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18604
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Discharge summary
|
report
|
Admission Date: [**2156-7-21**] Discharge Date: [**2156-7-23**]
Date of Birth: [**2133-11-23**] Sex: F
Service: Medicine, [**Location (un) **] Firm
HISTORY OF PRESENT ILLNESS: The patient is a 22-year-old
female who presented to the Emergency Department requesting
detoxification.
The patient had a recent admission to [**Hospital1 190**] for delirium tremens from [**7-7**] through [**7-13**] requiring an Intensive Care Unit stay for alcohol
withdrawal and pancreatitis (with a lipase of 2422).
The patient said that she started drinking on the day of
discharge ([**7-13**]) because of continued shaking, sweating,
and anxious feelings. She has been drinking two 40-ounce
beers and a half pint of vodka each day (the last time being
yesterday). The patient said that she had requested
detoxification, and her aunt brought her to the hospital;
however, she was unsure if she wanted to go ahead with
detoxification at the time of presentation.
She denied suicidal ideation. She said she has had increased
drinking frequency over the past four months, but did not
give a clear explanation as to why. She said she has
withdrawal symptoms each Sunday. She was unsure if she has
had any seizures in the past with her withdrawal. She said
several weeks ago she had a body shaking/jerking episode when
she cut down on her drinking. However, she was aware of the
episode the entire time, was not incontinent, and was able to
ease it by trying to relax.
She denies any history of physical or sexual abuse/being hit.
She also denies fevers, feeling ill, headache, abdominal
pain, nausea, vomiting, problems with her bowel or urine,
chest pain, cough, or shortness of breath. She does complain
of bilateral toe pain for one month without known cause or
injury.
In the Emergency Department, she was tremulous and said that
she could not tell dreams from reality. In the Emergency
Department, her blood pressure was controlled but her heart
rate did accelerate to the 130s. The patient remained
tremulous but did receive benzodiazepines and fluid
hydration.
PAST MEDICAL HISTORY:
1. Delirium tremens; hospital admission from [**7-7**] to [**7-13**]. The patient was admitted for alcohol withdrawal and
required Intensive Care Unit care including administration of
diazepam (per the CIWA protocol). She had no seizures but
did have acute pancreatitis with a lipase up to 2422 and an
amylase to 505. ALT up to 158, AST up to 408, and alkaline
phosphatase to 356.
2. Alcohol abuse; the patient reports drinking heavily in
the past four months without known cause or trigger. She
admits to drinking four to five 40-ounce beers each day in
addition to a half pint of vodka each day. Her alcohol abuse
has led to alcoholic hepatitis and alcoholic pancreatitis (as
documented in the past).
3. Recent pancreatitis from an admission from [**7-7**] to
[**7-13**]; lipase up to 2422.
4. Anemia.
5. Question of domestic abuse; as the patient was admitted
with multiple and extensive bruises over her body on the
admission on [**7-7**]. However, the patient denied physical
abuse by her boyfriend.
MEDICATIONS ON ADMISSION: None.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives with her boyfriend over
the past three and a half years. She recently attended a
computer education institute. She has a history of tobacco
use (half pack per day for the past 10 years). She has an
extensive history of alcohol abuse which has increased in the
past four months, but her alcohol use started at the age of
12. She most recently was drinking three to four 40-ounce
beers per day and a half pint of vodka.
SUBSTANCE ABUSE HISTORY: She admits to a history of crack
cocaine, ectasy, and mushroom use in the past; but not in the
past few years. She denies intravenous drug use.
FAMILY HISTORY: The patient reports having multiple family
members with drug problems. She is not in contact with her
parents or her two siblings.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed
temperature was 99.1, heart rate was 105, blood pressure was
110/62, respiratory rate was 17, and oxygen saturation was
99% on room air. In general, a tremulous young female who
was well-nourished. Alert and oriented times three. Awoken
easily. Somewhat agitated when alcohol abuse topics brought
up. Head, eyes, ears, nose, and throat examination revealed
pupils were equal, round, and reactive to light. Extraocular
muscles were intact. Normocephalic and atraumatic. The
mucous membranes were moist. The neck was supple. No
lymphadenopathy. Heart revealed tachycardia with a regular
rhythm. No murmurs, rubs, or gallops. The lungs were clear
to auscultation bilaterally. The abdomen revealed positive
bowel sounds in all four quadrants. Soft, nontender, and
nondistended. No masses. No hepatosplenomegaly. Extremity
examination revealed extremities were warm. No clubbing,
cyanosis, or edema. All toes were tender to touch
bilaterally. Sensation was intact to light touch, pinprick,
and proprioception. No gross abnormalities noted. Skin
examination revealed multiple blue/purple/yellow bruises on
her back and shins.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratory
data on admission revealed white blood cell count was 5.8
(differential revealed neutrophils of 42.2%, lymphocytes of
48.4%, monocytes of 5%, eosinophils of 3.8%, and basophils of
2.6%), hematocrit was 36.8, and platelet count was 689.
Electrolytes revealed sodium was 143, potassium was 4.2,
chloride was 106, bicarbonate was 22, blood urea nitrogen was
5, creatinine was 0.5, and blood glucose was 90. Calcium was
9.4, phosphate was 6.4, and magnesium was 2.3. Urine
toxicology was negative. Serum alcohol level was 394. Serum
benzodiazepines were positive. Serum aspirin, acetaminophen,
barbiturates, and tricyclic antidepressants were negative.
Urinalysis revealed specific gravity was 1.012; negative for
leukocytes, nitrites, blood, red blood cells, or white blood
cells. A few bacteria were present with 3 to 5 epithelial
cells. ALT was 103, AST was 187, alkaline phosphatase was
201, amylase was 118 (previous was 643), lipase was 737
(previous was 2422), and total bilirubin was 0.5.
HOSPITAL COURSE BY ISSUE/SYSTEM: In the Emergency
Department, the patient received multiple doses of Ativan
(totalling approximately 8 mg), librium 25 mg, and Valium 5
mg.
1. ALCOHOL WITHDRAWAL ISSUES: The patient was admitted to
the Medical Intensive Care Unit on [**7-21**] and was placed on
Valium to control her withdrawal symptoms; per the CIWA
protocol for delirium tremens prophylaxis given her history
of delirium tremens.
She continued to receive Valium 10 mg by mouth as needed;
however, this requirement did slowly decrease during her
hospital stay. On [**7-23**], she was transferred to the
medical floor for continued management of her alcohol
withdrawal symptoms. She did continue on the CIWA protocol.
The patient did receive thiamine, folate, and multivitamins
to replete any possible deficiencies.
The patient did initially refuse to speak with a social
worker, but was eventually seen by [**Name (NI) 2411**] [**Last Name (NamePattern1) 51086**] for an
addiction counseling consultation. Multiple options for
detoxification centers were discussed with the patient;
however, it was unclear if the patient was willing to admit
herself to one of these institutions for continued treatment
of her withdrawal symptoms.
The patient was often agitated and reluctant to interact with
the hospital staff. She became insistent on leaving the
hospital on [**7-23**]. A Psychiatry consultation was ordered
to assess the patient's competency to be discharged against
medical advice. Psychiatry did deem her to be competent to
make that decision.
The patient was given an extensive list of detoxification
centers that she could potentially go to over the weekend;
however, no free care beds were available at the time of the
patient's departure from the hospital. She was also given a
list of telephone numbers for centers related to the
management of alcohol abuse; including Alcohol Anonymous and
alcohol and drug referral hot lines. The patient said that
she had plans to attend a detoxification facility that coming
Monday.
She left against medical advice with her boyfriend on the
evening of [**7-23**] after a full explanation of the risks of
leaving the hospital given her current medical problems.
2. PANCREATITIS ISSUES: The patient presented with elevated
lipase levels; however, not to the extent of her previous
admission. They did continue to decrease during her hospital
stay. She did tolerate full meals without any nausea,
vomiting, or abdominal pain on [**7-23**]. The patient reported
never having any abdominal symptoms despite the evidence of
pancreatitis related to her extensive alcohol abuse.
3. ALCOHOLIC HEPATITIS ISSUES: The patient has a history of
elevated transaminases that had trended toward the normal
range but were still mildly elevated on [**7-23**]. She denied
any history of jaundice or a history of right upper quadrant
abdominal pain.
4. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: On admission, the
patient received intravenous fluids as well as folate,
thiamine, and multivitamins to replete any possible
deficiencies. The patient did eventually tolerate a full
house diet.
5. PSYCHOSOCIAL ISSUES: The patient said that her boyfriend
of three and a half years was supportive. However, she did
present with multiple bruises on her body on the prior
admission which were suggestive of possible physical abuse;
however, the patient denied this.
The patient did express some interest in attending a
detoxification facility. She was given information regarding
multiple centers in the area where she could go for
detoxification.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: The patient left against medical advice
but had no active symptoms related to pancreatitis or alcohol
withdrawal at the time of departure. She was medically
stable and deemed by Psychiatry to have the capacity to leave
against medical advice.
DISCHARGE DIAGNOSES:
1. Alcohol withdrawal.
2. Alcohol abuse.
3. Pancreatitis.
4. Transaminitis.
5. Anemia.
MEDICATIONS ON DISCHARGE: None.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was strongly advised to enter a
detoxification facility over the weekend. She was supplied
with a list of multiple local centers that could provide
detoxification for her; however, no free beds were available
on [**7-23**].
2. The patient did have a follow-up appointment scheduled
with Dr. [**First Name8 (NamePattern2) 7810**] [**Last Name (NamePattern1) 3315**] in [**Hospital6 733**] on [**8-9**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 24755**]
Dictated By:[**Last Name (NamePattern1) 1615**]
MEDQUIST36
D: [**2156-8-4**] 13:13
T: [**2156-8-12**] 14:00
JOB#: [**Job Number 51087**]
|
[
"291.81",
"577.0",
"303.90",
"285.9"
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icd9cm
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,166
| 133,124
|
33467
|
Discharge summary
|
report
|
Admission Date: [**2163-3-31**] Discharge Date: [**2163-4-7**]
Service: MEDICINE
Allergies:
Niacin / Latex / Formaldehyde
Attending:[**First Name3 (LF) 1436**]
Chief Complaint:
NSTEMI
Major Surgical or Invasive Procedure:
Cardiac Catheterizaiton
History of Present Illness:
[**Age over 90 **] Y F w/ hx of HTN, dyslipidemia, CAD s/p NSTEMI x2 in past 3
months, medically managed, systolic CHF w/ EF 25% s/p biV ICD,
and hx of GI bleed last year on ASA re-presented to [**Location (un) **] on
[**2163-3-27**] with recurrent SOB in acute CHF and NSTEMI. At [**Name (NI) **] pt
had another NSTEMI complicated by CHF exacerbation. Pt is
DNR/DNI and had previously not wanted an intervention but after
discussion with her physicians at [**Location (un) **] she agreed to reverse
her status to perform cardiac cath. She was transferred here for
cath on [**2163-4-1**] which showed the LAD had a 90% proximal stenosis
and a 90% distal stenosis; the D1 had a 70% lesion. The LCX
system had a small OM1 with 90% stenosis. The RCA was a small
vessel totally occluded in its distal portion. Successful
multivessel PCI of proximal and distal LAD and OM1 with bare
metal stents (2.0 X 23 mm X 2.0 X 12 mm Vision stents to distal
LAD and 2.0 X 18 mm Vision stent to proximal LAD postdilated to
2.5; 3.5 X 15 mm Vision stent to the OM with 3.5 X 12 mm kissing
balloon inflation in the LCX and OM1).
.
On the floor post-procedure, she was maintained on metoprolol,
lisinopril, atorvastatin, ASA, and Plavix. Her lisinopril was
titrated down on [**2163-4-2**] because of systolic blood pressure in
80s,at which time she also required a 250cc IVF bolus. Her
furosemide was held at this point given hypotension. She had a
HCT drop from 37 to 31 from [**4-1**] to [**4-2**], down to 29 on the
afternoon of [**4-2**]. Groin U/S nl and pelvic CT read pending.
.
On the day of transfer to the CCU team, she complained of
abdominal pain/tightness consistent with her anginal equivalent.
On the evening of transfer, she became acutely hypoxic with sats
to the mid 80's requiring a non-rebreather. Her SBP was in the
150s. ABG done showed 7.34/45/126. She was in acute respiratory
distress and uncomfortable, moaning in pain. Her exam had
wheezing and bronchospasm. Nebs were given and this improved.
ECG showed possible precordial ST elevations possibly changed
from baseline. CXR showed increase in vascular congestion. She
was given IV lasix 40mg x 2 and 2mg morphine IV. The cardiology
fellow came immediately and the attending was consulted.
Meanwhile, Nitro gtt, Morphine IV were initiated, as well as
heparin gtt. Labs were drawn which showed a slight elevation in
troponin from previous (0.43 from 0.36) but flat CK and CK/MB.
Discussions with the daughter about code status concluded
continued DNR/DNI with possible reversal if catheterization was
considered necessary. She is now being transferred for closer
observation to the CCU team.
.
After transfer, she reports improvement in symptoms. She has at
this point diureses 165cc from the IV lasix. She denies chest
pain/pressure, abdominal pain/pressure, shortness of breath, LH.
Past Medical History:
# HTN
# dyslipidemia
# CAD s/p NSTEMI x2 in past 3 months, medically managed
# CHF w/ EF 25% s/p biV ICD
# Peptic ulcer bleed [**10-28**] on full dose ASA
# TIA
Cardiac Risk Factors: Dyslipidemia, Hypertension
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. She has VNA services
since [**Month (only) 404**]. DNR/DNI.
Family History:
NC
Physical Exam:
(on admission)
VS - 68.8kg BP 109/62 HR 72 RR 18 SaO2 95RA
Gen: Elderly 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 8 cm.
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. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Pertinent Results:
admission labs:
[**2163-3-31**] 07:36PM GLUCOSE-138* UREA N-39* CREAT-1.1 SODIUM-134
POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-26 ANION GAP-13
[**2163-3-31**] 07:36PM estGFR-Using this
[**2163-3-31**] 07:36PM CALCIUM-9.2 PHOSPHATE-4.0 MAGNESIUM-1.9
[**2163-3-31**] 07:36PM WBC-10.2 RBC-3.57* HGB-11.3* HCT-32.3* MCV-90
MCH-31.6 MCHC-35.0 RDW-13.2
[**2163-3-31**] 07:36PM NEUTS-73.6* LYMPHS-18.9 MONOS-3.7 EOS-3.5
BASOS-0.4
[**2163-3-31**] 07:36PM PLT COUNT-231
[**2163-3-31**] 07:36PM PT-13.9* PTT-25.1 INR(PT)-1.2*
.
Cadiac cath ([**2163-4-1**]): 1. Coronary angiography in this right
dominant system demonstrated an LMCA without angiographically
apparent disease. The LAD had a 90% proximal stenosis and a 90%
distal stenosis; the D1 had a 70% lesion. The LCX system had a
small OM1 with 90% stenosis. The RCA was a small vessel totally
occluded in its distal portion. 2. Limited resting hemodynamics
revealed pulmonary hypertension and elevated right heart filling
pressures. 3. Successful multivessel PCI of proximal and distal
LAD and OM1 with bare metal stents.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Successful PCI of LAD and OM1 with bare metal stents.
.
Echo ([**2163-4-4**]): The left atrium is normal in size. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is top normal/borderline dilated. There is an apical
left ventricular aneurysm. There is moderate regional left
ventricular systolic dysfunction with distal akinesis, apical
dyskinesis. No masses or thrombi are seen in the left ventricle.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Right ventricular chamber size
and free wall motion are normal. The aortic arch is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. Significant pulmonic regurgitation is
seen. The end-diastolic pulmonic regurgitation velocity is
increased suggesting pulmonary artery diastolic hypertension.
There is an anterior space which most likely represents a fat
pad.
IMPRESSION: Moderate left ventricular focal dysfunction.
Moderate mitral regurgitation. Moderate pulmonary artery
systolic hypertension
Brief Hospital Course:
[**Age over 90 **] Y F w/ hx of HTN, dyslipidemia, CAD s/p NSTEMI x2 in past 3
months, medically managed, CHF w/ EF 25% s/p biV ICD, and hx of
GI bleed last year on ASA re-presented to [**Location (un) **] on [**2163-3-27**] with
recurrent SOB in acute CHF and [**Hospital 7792**] transferred to [**Hospital1 18**] for
cath on [**3-31**].
PCI here with right dominant system, LMCA without
angiographically apparent disease, 90% proximal stenosis and a
90% distal stenosis of the LAD; the D1 had a 70% lesion. The LCX
system had a small OM1 with 90% stenosis. The RCA was a small
vessel totally occluded in its distal portion. Pt had BMS to
proximal and distal LAD and OM1. Limited resting hemodynamics
revealed pulmonary hypertension and elevated right heart filling
pressures that improved s/p intervention (wedge high 20's to
teens after intervention).
On [**2163-4-2**], she was mildly hypotensive in the 80's, at which
time she was given a 250cc bolus. On [**2163-4-3**] in the early
morning, she complained of abdominal pain and tightness which
were consistent with her anginal equivalent. She became
hypertensive to the 150's systolic. She was started on a nitro
drip, morphine IV, and heparin drip but troponins were slightly
elevated (but flat CK/MB). She was transferred to the CCU for
monitoring where she was diuresed and again, she became slightly
hypotensive and required small fluid boluses. Her Lasix was held
on the day of transfer given hypotension. She was transferred
back to the cardiac floor after she was stabilized where the
team decided to increase ACEi in order to reduce afterload which
in turn should actually improve SBP --> blood pressure came up
allowing us to again use furosemide 20mg po bid. In addition
imdur was added back as it appeared that when she was ambulating
with PT she occasionally had anginal symtptoms that were relived
by rest. With this intervention she had no further CP and he
sbp remained in high 90s.
.
Please view problems [**Name (NI) 13744**] below:
# CHF w/ EF 25% s/p dual chamber ICD
- appears to be very close to euvolemic, some minimimal crackles
on exam --> resumed daily po lasix 20mg
- ACEi 10 mg in order to reduce afterload (actually increased bp
as we hoped it would)
- cont BB at 25 mg daily
.
# CAD s/p NSTEMI x3 in past 3 months now s/p BMS to LAD and OM1
- Discharged on toprol XL12.5mg [**Hospital1 **], atorvastatin 80mg daily,
ASA 325mg daily, Clopidogrel 75mg daily, lisinopril 10mg qday,
imdur 30mg daily
- ASA 325mg daily for continue for one month minimally; then
indefinitely at a dose of 75 to 162 mg/day (ACC/AHA/SCAI [**2160**]
guideline, Class 1 recommendation)
- Clopidogrel 75mg daily for at least one month, and ideally up
to 12 months although this pt may be at high risk of bleeding
and may preclude this (ACC/AHA/SCAI [**2161**] revison guidelines,
Class 1 recommendation)
- no chest pain even with ambulating prior to d/c
.
# Rhythm
- remained in sinus rhythm
- monitored for arrhythmias on tele
.
# HTN
- BB and ACEi as above
.
# Peptic ulcer bleed [**10-28**] on full dose ASA (but was on plavix
after that and did fine)
- continued PPI and pt had no signs of GIB in hosp.
.
# hx of TIA
- cont plavix and ASA
.
# dyslipidemia
- lipitor instead of simvastatin for pleotropic effects (per
PROVIT trial)
Medications on Admission:
HOME MEDICATIONS:
lisinopril 20mg po daily
prilosec 20mg po daily
plavix 75mg po daily
aspirin 81mg po daily
lasix 80mg po daily
imdur 30mg po daily
toprol XL 75mg po daily
Kcl 20 mEQ Po daily
zocor 10mg po daily
.
TRANSFER MEDICATION:
lisinopril 20mg po daily
plavix 75mg po daily
aspirin 325mg po daily
lasix 20mg po bid
toprol XL 50mg po daily
Kcl 20 mEQ Po daily
zocor 10mg po daily
lovenox 30mg SQ daily
nitroglycerin
Discharge Medications:
1. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
may repeat x2 every 5 minutes for a total of 3 tablets but if
use then please call 911 or go to nearest ED.
8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Primary Diagnosis:
# CAD s/p NSTEMI x3 in past 3 months no s/p BMS to OM1 and LAD
.
Secondary Diagnosis:
# Hypertension
# Hyperlipidemia
# CHF w/ EF 25% s/p biV ICD
# Peptic ulcer bleed [**10-28**] on full dose ASA
# TIA
Discharge Condition:
Stable, chest pain free
Discharge Instructions:
You were admitted to the hospital for chest pain and were found
to be having a heart attack. You were taken for a cardiac
catheterization and found to have occulusions of a number of
vessels. You had three stents placed to an artery called the
LAD. The hope is that this should improve your symptoms.
Please take medications as prescribed.
- Please continue to take plavix 75mg daily, prilosec 20mg
daily, imdur 30mg daily
- Please start taking aspirin 325mg daily instead of 81mg
- Please take lasix 20mg daily instead of lasix 80mg daily
- Please start taking 25mg toprol XL instead of toprol XL 75mg
daily
- Please take atorvastatin 80mg instead of zocor 10mg daily
- Please take lisinopril 10mg by mouth daily instead of 20mg
daily
- Please stop taking KCl
.
Please return to the hospital for any worsening chest pain,
shortness of breath, difficulty breathing.
Followup Instructions:
Please follow up with your PCP in the next 1-2 weeks (PCP:
[**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 58624**])
.
Please call Dr[**Name (NI) 52385**] office ([**Telephone/Fax (1) 40602**]) to schedule a
follow up in the next week.
|
[
"272.4",
"585.2",
"V45.02",
"410.71",
"533.70",
"414.01",
"403.90",
"428.0",
"428.43"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"00.66",
"00.41",
"88.52",
"99.20",
"88.55",
"00.48",
"36.06"
] |
icd9pcs
|
[
[
[]
]
] |
11725, 11788
|
6841, 10139
|
243, 269
|
12053, 12079
|
4422, 4422
|
12997, 13298
|
3576, 3580
|
10612, 11702
|
11809, 11809
|
10165, 10165
|
5516, 6818
|
12103, 12974
|
3595, 4403
|
10183, 10589
|
197, 205
|
298, 3142
|
11914, 12032
|
4438, 5499
|
11828, 11893
|
3164, 3375
|
3391, 3560
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,035
| 112,956
|
18066
|
Discharge summary
|
report
|
Admission Date: [**2156-8-17**] Discharge Date: [**2156-8-31**]
Date of Birth: [**2089-12-13**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Indomethacin / Actonel / Reglan / linezolid
/ meropenem / atenolol / biphosphates / macrolids / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug) / prazoles /
Prochlorperazine / risedronate sodium
Attending:[**First Name3 (LF) 3624**]
Chief Complaint:
Shortness of breath, chest pain
Major Surgical or Invasive Procedure:
Transesophageal echocardiogram [**2156-8-17**]
History of Present Illness:
66yoF with h/o chronic diastolic CHF (EF 70%),
severe/symptomatic AS (sp valvuloplasty [**2156-8-5**], gradient
46.44->29.4mmHg and valve area 1.0->1.23cm2, discharged on
[**2156-8-10**]), AFib not on Coumadin, liver/kidney transplant [**7-/2154**]
for ESRD [**3-11**] diabetic nephropathy and contrast induced
nephropathy as well as NASH, hip fracture s/p femoral nail
[**1-/2156**], DM on insulin who presents with increased SOB and chest
heaviness x 2 days.
Pt reports having chronic SOB associated with her aortic
stenosis. 2 weeks prior to arrival she had the valvuloplasty and
denied any improvement in her symptoms. She then returned home
with the same chronic SOB. One day prior to arrival she noted
increased SOB associated with chest heaviness in the middle of
the chest. Chest heaviness is worse with deep inspiration. Non
positional. She reports that her SOB is similar to prior
CHF/aortic stenosis episodes but her chest pain is new. Pt's SOB
worsening over the course of the day and went to PCPs office
this AM. She was initialy sent to [**Hospital 5871**] hospital.
While at [**Hospital 5871**] hospital, she was found to be in CHF per CXR
and given lasix 40mg IV with 800cc urine output. Also found to
have positive UA and given ceftriaxone. She was transferred to
[**Hospital1 18**] for further eval.
In the [**Hospital1 18**] ED, initial vitals were Temp: 100.2 ??????F (37.9 ??????C)
(Rectal), Pulse: 71, RR: 28, O2Sat: 98, O2Flow: 3,
Bedside u/s showed no evidence of pericardial effusion.
Labs and imaging significant for WBC 19 (81 Neut) PLT 634, HCT
31, Hb 9, MCV 103, lactate 2.7, Cr 1.9, trop 1.13. CK MB
pending. BNP 27,000.
Patient given lorazepam 1mg IV, vancomycin 1 g (OSH: lasix and
ceftriaxone)
Blood cultures and urine cultures were sent.
Vitals on transfer were 98.6, 74, RR 25, 129/55, 100% on 3L
Access: has a 20 g
Pt was transfered to the CCU for close care and for TEE.
On arrival to the CCU, patient is comfortable, denies any chest
pain or SOB, she says both have resolved. She reports that
ativan and lasix in the ED improved her CP and SOB.
Bedside TEE was performed and showed no acute dissection.
REVIEW OF SYSTEMS
Positive: urinary frequency
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or rigors
(does report feeling cool). 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 ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
severe aortic stenosis s/p aortic valvuloplasty in [**7-/2156**]
([**2156-8-6**] TTE showed [**Location (un) 109**] 0.9cm2, pressure gradient 34)
Atrial fibrillation
- High-degree AV block, s/p PPM [**2154-2-5**] ([**Company 1543**] Sensia DDD
pacemaker), now pacer dependent
- Diastolic heart failure, NYHA II-[**Last Name (LF) 1105**], [**First Name3 (LF) **] >70-75% on TTE [**5-/2155**]
- Moderate mitral annular calcification and mitral regurgitation
- Mild tricuspid regurgitation
- Moderate pulmonary hypertension
3. OTHER PAST MEDICAL HISTORY:
- Diabetes Mellitus Type 2, on Insulin, c/b retinopathy,
nephropathy, and neuropathy
- End-stage renal disease, [**3-11**] diabetes & contrast-induced
nephropathy, s/p cadaveric transplant [**2153-7-21**]
- Hx frequent MDR UTIs
- Dyslipidemia
- Hypertension
- Non-alcoholic steato-hepatitis cirrhosis (Stage IV, Grade 2),
c/b portal HTN, ascites, encephalopathy, grade I-II esophageal
varices s/p banding s/p TIPS [**8-/2152**], s/p OLTx [**2153-7-21**]
- Saphenous vein interposition graft repair of the hepatic
artery and harvesting of the left saphenous vein graft [**2154-3-14**],
Hepatic artery s/p stent [**2154-4-25**]
- [**3-/2155**]: Exploratory laparotomy, evacuation of intra-abdominal
blood, exploration of retroperitoneal hematoma, left
salpingo-oophorectomy for RP bleeding
- s/p VATS decortication [**11/2153**]
- Splenic vein thrombosis, no longer on coumadin
- Anemia
- Thrombocytopenia
- h/o C.diff
- h/o Seizures
- headaches ?[**3-11**] occipital neuralgia
- Meningioma, small left frontal lobe
- GERD
- OSA has CPAP at home but does not use
- Cervical DJD
- Dermoid cyst
- Right adrenal mass
- osteoporosis
- Status post cholecystectomy followed by tubal ligation
- Status post left oopherectomy
- Status post appendectomy
- ? Restless legs syndrome
- hypothyroid
- gout
- hip surgery, discharged [**2156-2-8**]
Social History:
Widowed, lives in [**Hospital3 **] facility in [**Hospital1 6930**], MA. Uses
a walker for ambulation. Has 4 children, 3 in MA, one in
[**State 3908**]. Previously worked as a nurse [**First Name (Titles) **] [**Last Name (Titles) **]. No tobacco,
alcohol or drugs ever
Family History:
father died of stroke, mother died of cerebral hemorrhage. Her
sister has diabetes.
Physical Exam:
Admission exam
VS: 97.9, HR 80, 141/79, RR 23, 99% 3L
GENERAL: NAD. Oriented x3. Mood, affect appropriate. Chronically
ill appearing
HEENT: NCAT. pale conjunctiva, PERRL, EOMI.
Neck: JVP difficult to assess since large neck.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. 2 systolic murmurs, one murmur heard at
right sternal border radiating to carotids late peaking, other
murmur is holosystolic at left sternal border. No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. few crackles in bases
bilaterally
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: radial 2+
Left: radial2+
MOST RECENT EXAM [**2156-8-30**]
VS - 98.2/98.6 134/58 (120s-150s/50s-70s) 73(60s-70s) 95% ra
I/O: 2 BMs last night.
BG: 75, 230, 208, 68
GENERAL: Well appearing female looks stated age. NAD. Speaking
in full sentences appropriately. AAOx3. Flat to depressed
affect.
HEENT: Upper dentures not in place. Moist mucous membranes. Non
distended JVP. Anicteric sclera. Poor dentition.
CARDIAC: Irregular, systolic ejection murmur best at RUSB, no
extra heart sounds.
LUNGS: Unlabored breathing. Good air flow. Minimal crackles at
bases b/l. No wheezing.
ABDOMEN: BS+, distended, soft, non-tender
EXTREMITIES: No Edema in the lower extremities. Warm.
NEUROLOGY: no Asterixis. A+Ox3. CN2-12 intact.
Pertinent Results:
Admission labs
[**2156-8-17**] 10:00PM BLOOD WBC-19.2* RBC-3.01* Hgb-9.6* Hct-31.0*
MCV-103* MCH-31.9 MCHC-30.9* RDW-18.6* Plt Ct-634*#
[**2156-8-17**] 10:00PM BLOOD Neuts-81* Bands-0 Lymphs-11* Monos-3
Eos-5* Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-6*
[**2156-8-17**] 11:10PM BLOOD PT-13.3* PTT-25.8 INR(PT)-1.2*
[**2156-8-17**] 10:00PM BLOOD Glucose-167* UreaN-51* Creat-1.9* Na-140
K-5.3* Cl-103 HCO3-22 AnGap-20
[**2156-8-17**] 10:00PM BLOOD ALT-10 AST-17 CK(CPK)-46 AlkPhos-101
TotBili-0.2
[**2156-8-17**] 10:00PM BLOOD CK-MB-2 cTropnT-1.13* proBNP-[**Numeric Identifier 21404**]*
Cardiac labs
[**2156-8-17**] 10:00PM BLOOD CK-MB-2 cTropnT-1.13* proBNP-[**Numeric Identifier 21404**]*
[**2156-8-18**] 04:10AM BLOOD CK-MB-2 cTropnT-1.20*
[**2156-8-19**] 05:15AM BLOOD CK-MB-3 cTropnT-0.64*
TACRLIMUS TREND:
[**2156-8-18**] 04:10AM BLOOD tacroFK-3.2*
[**2156-8-19**] 05:15AM BLOOD tacroFK-5.1
[**2156-8-20**] 05:00AM BLOOD tacroFK-6.1
[**2156-8-21**] 05:05AM BLOOD tacroFK-5.6
[**2156-8-22**] 05:00AM BLOOD tacroFK-6.6
[**2156-8-23**] 05:30AM BLOOD tacroFK-6.9
[**2156-8-29**] 05:05AM BLOOD tacroFK-5.1
[**2156-8-31**] 05:30AM BLOOD tacroFK-4.3*
DISCHARGE LABS ([**2156-8-30**])
[**2156-8-31**] 05:30AM BLOOD WBC-12.3* RBC-2.58* Hgb-8.5* Hct-27.5*
MCV-107* MCH-32.8* MCHC-30.7* RDW-18.2* Plt Ct-527*
[**2156-8-31**] 05:30AM BLOOD PT-10.0 PTT-29.0 INR(PT)-0.9
[**2156-8-31**] 05:30AM BLOOD Glucose-88 UreaN-54* Creat-1.5* Na-133
K-4.9 Cl-99 HCO3-23 AnGap-16
[**2156-8-31**] 05:30AM BLOOD ALT-14 AST-17 AlkPhos-106* TotBili-0.2
[**2156-8-31**] 05:30AM BLOOD Calcium-8.7 Phos-5.3* Mg-2.1
[**2156-8-31**] 05:30AM BLOOD tacroFK-4.3*
Micro:
[**8-17**] urine and blood cultures x2 negative
[**8-18**] MRSA negative
[**8-20**] urine culture negative
[**8-21**] urine culture pending
Studies:
[**2156-8-17**] TEE: Overall left ventricular systolic function is
normal (LVEF>55%). There are simple atheroma in the aortic root.
There are simple atheroma in the ascending aorta. There are
complex (>4mm) atheroma in the aortic arch. There are complex
(>4mm) atheroma in the descending thoracic aorta. No thoracic
aortic dissection is seen. There are three aortic valve
leaflets. The aortic valve leaflets are moderately thickened.
Significant aortic stenosis is present (not quantified). Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Moderate to severe (3+) mitral regurgitation
is seen. The tricuspid valve leaflets are mildly thickened. The
pulmonary artery systolic pressure could not be determined.
IMPRESSION: No evidence of aortic dissection. Atheroma
throughout aorta with small, calcified atheroma just above the
aortic sinus, complex atheroma in the arch and descending aorta.
Likely moderate to severe aortic stenosis with mild aortic
regurgitation. Moderate to severe mitral regurgitation
.
[**2156-8-17**] CXR: The lungs are well expanded and clear. The cardiac
silhouette is enlarged. The mediastinal silhouette and hilar
contours are normal. No pleural effusion or pneumothorax is
present. A left-sided pacer terminates with its leads in the
right atrium and right ventricle.
IMPRESSION: Mild cardiomegaly, but no acute intrathoracic
process.
.
[**2156-8-18**] bilateral LE U/S: No evidence of deep vein thrombosis in
either leg.
.
[**2156-8-19**] hip xray: FRONTAL VIEW OF THE PELVIS AND CONED-DOWN
VIEWS OF THE RIGHT HIP: The patient has a gamma nail construct
with proximal nail, intramedullary rod and interlocking screw
transfixing an intertrochanteric fracture which appears in
unchanged alignment with no evidence of hardware-related
complications. Fracture line is still visible but less
prominent compared to the most recent prior examination.
Vascular calcifications are noted. A coil is noted over
the left hip and along the left lower abdomen.
IMPRESSION:
Open reduction internal fixation of right intertrochanteric
femur fracture without evidence of hardware-related
complications and with fracture line less prominent compared to
the most recent prior examination.
[**2156-8-24**] CT pelvis: 1. Unchanged left chronic retroperitoneal
hematoma (but decreased from first sighting in [**Month (only) 956**] of
[**2155**]). This lesion contains some "entrapped" fat lobules and
should be followed to resolution to exclude an underlying
lesion. If seried, this could be followed by MRI.
2. Appearance of right femoral fracture and hardware.
3. Increased stranding and skin thickening with 2.7cm rounded
hematoma in left lower anterior abdominal/pelvic wall could
relate to recent injections and trauma to this site.
Correlation with exam findings is recommended.
4. Air in the bladder and transplant kidney collecting system
could relate to recent Foley catheterization.
Brief Hospital Course:
Ms [**Known lastname **] (goes by [**Doctor Last Name 8214**]) is a 66yoF with h/o severe aortic
stenosis (s/p valvuloplasty [**2156-8-5**]), diastolic congestive heart
failure (EF 70%), paroxysmal atrial fibrillation (not on
Coumadin), diabetes mellitus type 2, and End stage liver and
renal disease s/p liver/kidney transplant [**7-/2154**], who presented
with 2 days shortness of breath and pleuritic chest heaviness.
She is currently pain free with improvement in dyspnea.
Transesophageal echocardiogram showed no dissection. Now active
Suicidal ideation.
## acute diastolic CHF exacerbation - Patient complained of
dyspnea on exertion. Likely acute on chronic diastolic heart
failure (dCHF) exacerbation with volume overload in the setting
of severe Aortic Stenosis. BNP >[**Numeric Identifier **] (baseline 3,000-9,000) on
admission. Per OSH, pt's CXR showed pulmonary edema and she was
given lasix 40mg IV with good urine output. CXR here showed mild
pulmonary congestion. She was diuresed, weaned off oxygen, and
put back on her home dose of torsemide 20mg PO daily. She
remained euvolemic and was discharged at a weight of 86.4kg.
Also, she was restarted on home carvedilol 25mg [**Hospital1 **] and
lisinopril 5mg.
.
## Chest Pain with Troponin Elevation - likely secondary to
demand ischemia in setting of dCHF and left ventricular
hypertrophy/aortic stenosis. EKG is unchanged and CK-MB is
normal. She has 90% stenosis of LAD diagonal branch per [**8-5**]
cath report. A TEE was done in the CCU initially to r/o
dissection, and no dissection was found. Troponin trended down.
Because of mild persistant chest heaviness, and known 90%
stenosis per above, we trialed her on imdur 30mg daily which
improved her symptoms. This decrease in preload may facilitate
control of pulmonary edema as well. Given known CAD, we
continued [**Month/Year (2) **], Statin, [**Month/Year (2) **].
.
## Psych: Hx of depression, anxiety. Psych was consulted when
patient arrived to floors. Determined to be Section 12 as
patient was actively suicidal. Admits to trying to recently kill
herself w/ insulin and tylenol while at home. She was placed on
a 1 to 1 sitter. Psychiatry recommended inpatient psych unit and
ETC therapy. Venlafaxine was increased to 225mg and aripiprazole
were started. She continues on haldol. Ativan was given for
anxiety. She has not contraindications for inpatient
pyschiatric facility at this time.
.
## Urinary frequency and UA suggestive of UTI - h/o multi drug
including ESBL resistant E. coli and VRE UTI in the past. Had a
temperature of 100.4 on admission, though afebrile for the
remainder of the admission. She was empirically placed on
cefipime + tigacycline per ID recs, and received these for 2
days, but they were discontinued after urine culture came back
negative. Then started on Fosfomycin 3g once weekly for
suppressive therapy, per ID recs.
.
## h/o Renal/Liver Transplant - tacro was low, so we increased
tacrolimus to 1mg [**Hospital1 **], and resultant troughs were within goal
range. [**2156-8-28**] Trough was within Renal guidelines.
Recommendation to check Tacro Trough once weekly on Tuesdays.
Continued prednisone. Held Bactrim for PCP [**Name9 (PRE) **], given recent h/o
c diff. Has transplant f/u on [**2156-9-9**].
.
## Recent C DIFF infection: patient developed watery loose
stools on recent admission, C Diff PCR positive. She was started
on flagyl 500mg TID for total 14 day course to be completed [**8-24**]. However, on this admission had episodes of diarrhea with
increased frequency, so we started on PO vancomycin for 10 days,
completed on [**2156-8-31**], with improvement in her symptoms.
.
## Constipation - resolved with lactulose 15mL in AM, senna,
colace, miralax.
.
## DM type 2, insulin dependent: on lantus 25 U qhs, and used
HISS in house.
.
## Hypothyroidism: continued homed levothyroxine.
.
## Hx of seizure: continued on home keppra.
.
## POST DISCHARGE LABS
- Plan to check CBC & Chem7 & Tacro trough weekly on Tuesdays
.
CODE: full code
CONTACT INFO: [**Name (NI) **] [**Name (NI) **] (son) [**Telephone/Fax (1) 50001**], [**Telephone/Fax (1) 49733**]
============================================
TRANSITIONAL ISSUES
# Patient is stable and has no medical contraindications for
inpatient psychiatric facility
# Will need to f/u with cardiology to revaluate for AoValve
replacement as recent valvuloplasty does not seem to have
improved her functional status
# Check labs weekly including Tacro level, chem7, cbc
# Follow up imaging of left chronic retroperitoneal hematoma:
Per CT report, "This lesion contains some 'entrapped' fat
lobules and should be followed to resolution to exclude an
underlying lesion. If seried, this could be followed by MRI."
# Patient will need psychiatry follow up given her suicidal
ideation. ECT has been considered as therapy, as this has
reportedly worked in the past.
# Patient should follow up with her Cardiologist, Dr. [**First Name (STitle) 437**]
regularly given her diagnosis of heart failure and recent
exacerbation in the setting of AS. She should next be seen
1-2weeks into transfer to inpatient unit. Has appt for [**2156-9-20**]
at 1pm.
Medications on Admission:
1. Acetaminophen 325 mg PO Q6H:PRN pain
2. Albuterol-Ipratropium 2 PUFF IH Q6H:PRN SOB
3. Allopurinol 200 mg PO DAILY
4. Aspirin 325 mg PO DAILY
5. Atorvastatin 10 mg PO DAILY
6. Calcium Carbonate 500 mg PO DAILY
7. Carvedilol 25 mg PO BID
8. Docusate Sodium 100 mg PO BID
9. Clopidogrel 75 mg PO DAILY
10. Haloperidol 0.5 mg PO QAM
11. Haloperidol 1 mg PO HS
12. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
13. LeVETiracetam 500 mg PO BID
14. Levothyroxine Sodium 50 mcg PO DAILY
15. Multivitamins 1 TAB PO DAILY
16. PredniSONE 5 mg PO DAILY
17. Ursodiol 300 mg PO BID
18. Venlafaxine 75 mg PO DAILY
19. Vitamin D 400 UNIT PO DAILY
20. Lactulose 30 mL PO Q8H:PRN constipation
21. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
22. Lisinopril 5 mg PO DAILY
23. Torsemide 20 mg PO DAILY
24. HydrOXYzine 12.5-25 mg PO Q6H:PRN itching
hold for sedation
RX *hydroxyzine HCl 25 mg 0.5-1 tablet by mouth every 6 hours
Disp #*30 Tablet Refills:*0
25. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *Flagyl 500 mg 1 Tablet(s) by mouth every 8 hours Disp #*36
Tablet Refills:*0
26. Sarna Lotion 1 Appl TP QID:PRN pruitis
RX *Sarna Anti-Itch 0.5 %-0.5 % apply to skin four times a day
Disp #*1 Container Refills:*2
27. Tacrolimus 0.5 mg PO Q12H
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H:PRN pain
2. Albuterol-Ipratropium 2 PUFF IH Q6H:PRN shortness of breath
or wheezing
3. Allopurinol 200 mg PO DAILY
4. Aspirin 325 mg PO DAILY
5. Atorvastatin 10 mg PO DAILY
6. Calcium Carbonate 500 mg PO DAILY
7. Carvedilol 25 mg PO BID
8. Docusate Sodium 100 mg PO BID
9. Clopidogrel 75 mg PO DAILY
10. Haloperidol 0.5 mg PO QAM
11. Haloperidol 1 mg PO HS
12. HydrOXYzine 12.5-25 mg PO Q6H:PRN itching hold for sedation
13. Lactulose 30 mL PO Q8H:PRN constipation
14. LeVETiracetam 500 mg PO BID
15. Levothyroxine Sodium 50 mcg PO DAILY
16. Lisinopril 5 mg PO DAILY
17. Multivitamins 1 TAB PO DAILY
18. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
19. PredniSONE 5 mg PO DAILY
20. Sarna Lotion 1 Appl TP QID:PRN pruitis
21. Torsemide 20 mg PO DAILY
22. Ursodiol 300 mg PO BID
23. Vitamin D 400 UNIT PO DAILY
24. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
angina
consider to continue as outpatient, rec by Dr. [**First Name (STitle) 437**]
25. Glargine 10 Units Bedtime Insulin SC Sliding Scale using HUM
Insulin
26. Tacrolimus 1 mg PO Q12H You should have weekly Tacrolimus
levels drawn on Tuesdays to monitor your drug level.
27. Venlafaxine 225 mg PO DAILY
per Psych. Serotonin syndrome should be observed.
28. Aripiprazole 5 mg PO DAILY
29. Fosfomycin Tromethamine 3 g PO 1X/WEEK (MO)
Dissolve in [**4-11**] oz (90-120 mL) water and take immediately
30. Lidocaine 5% Patch 1 PTCH TD DAILY place on right hip please
31. Lorazepam 0.5 mg PO HS:PRN anxiety, insomnia hold for
sedation or RR < 12
MAX 1mg/ day
32. Polyethylene Glycol 17 g PO BID constipation
33. Senna 2 TAB PO BID
Discharge Disposition:
Extended Care
Discharge Diagnosis:
PRIMARY:
- acute on chronic diastolic congestive heart failure
exacerbation
- active suicidal ideation
SECONDARY:
- Liver/Renal transplant management
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 18**]. You came in for
worsening shortness of breath and chest pain. This was found to
be from volume overload, and we gave you water pills to get rid
of the extra fluid. Upon psychiatric [**Hospital1 2742**], it was later
determined that you pose a significant risk to yourself when
alone at home. The psychiatry team recommended inpatient
psychiatric admission for ECT, a treatment for depression that
you have had in the past.
You will be going to an inpatient psychiatric facility for
further mental health care.
The following changes have been made to your medications:
** INCREASE tacrolimus (immunosuppressant) to 1mg twice a day
(from 0.5mg twice a day)
** INCREASE Venlafaxine to 225 mg by mouth daily
** START Aripirazole 5mg by mouth daily
** START Imdur 30mg daily
** START Fosfomycin (antibiotic for UTI) 3gm/week on Mondays
indefinitely
** ADD Senna and Miralax to your daily treatment for
constipation
** STOP Flagyl (Metronidazole)
Followup Instructions:
Department: MEDICAL SPECIALTIES
When: TUESDAY [**2156-10-5**] at 11:20 AM
With: BONE DENSITY TESTING [**Telephone/Fax (1) 4586**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2156-9-20**] at 1 PM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: TRANSPLANT CENTER
When: THURSDAY [**2156-9-9**] at 10:20 AM
With: [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Please discuss with the staff at the facility a follow up
appointment with your PCP below when you are ready for
discharge.
Name: [**Last Name (LF) **],[**First Name3 (LF) **] S
Location: [**Hospital1 **] PRIMARY CARE
Address: [**Street Address(2) 20897**], [**Hospital1 **],[**Numeric Identifier 20898**]
Phone: [**Telephone/Fax (1) 20894**]
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]
Completed by:[**2156-9-1**]
|
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"008.45",
"244.9",
"V13.02",
"296.34",
"V58.69",
"V42.0",
"428.33",
"401.9",
"583.81",
"250.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
20164, 20179
|
12032, 17198
|
506, 554
|
20373, 20373
|
7267, 12009
|
21583, 22914
|
5578, 5664
|
18505, 20141
|
20200, 20352
|
17224, 18482
|
20524, 21560
|
5679, 7248
|
3385, 3908
|
435, 468
|
582, 3255
|
20388, 20500
|
3939, 5274
|
3299, 3365
|
5290, 5562
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,126
| 166,294
|
35898
|
Discharge summary
|
report
|
Admission Date: [**2108-2-7**] Discharge Date: [**2108-2-13**]
Date of Birth: [**2033-3-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Benadryl
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2108-2-8**] - CABGx4 (Left internal mammary->Left anterior
descending artery, Saphenous vein graft (SVG)->Diagonal artery,
SVG->obtuse marginal artery, SVG->Right coronary artery).
[**2108-2-7**] - Cardiac Catheterization
History of Present Illness:
74 yo male admitted to [**Hospital3 24768**] [**2108-2-6**] with recent
complaint chest discomfort with exertion and ETT yesterday with
chest pain at 3 minutes, and prolonged ST depression on ECG.
Transferred by Dr. [**Last Name (STitle) 24717**] for cardiac catheterization.
Past Medical History:
coronary artery disease, s/p CABG [**2108-2-8**]
Hyperlipidemia
hypertension
benign prostatic hyperplasia
Nephrolithiasis
left carotid endarterectomy
Cholecystectomy
back surgery
kidney stones
L rotator cuff surgery
Social History:
Social: wife deceased after longterm chronic illness with
patient primary caretaker; recently relocated to [**Doctor Last Name **],
from [**State **] State to be near family; Retired Naval Ship yard
worker.
Family History:
mother died 59 MI; father died [**Name2 (NI) 499**] ca, hx DM; sister well
Physical Exam:
well appearing 74 yo white male in NAD
Wt: 208 lbs Ht: 6'0"
VS: 51 15 L 167/54 R 153/63
Lungs: clear
Heart: S1/S2; no murmurs/gallops
Abdomen: RUQ incisional scar; +BS; soft non-tender; no masses
Extremities: no pedal edema
Pulses: C F DP PT
[**Name (NI) 167**] 2+ no bruit 2+ no bruit 1+ 1+
Left 2+ no bruit 2+ no bruit 1+ tr
Pertinent Results:
[**2108-2-7**] 11:07PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.028
[**2108-2-7**] 11:07PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.5
LEUK-NEG
[**2108-2-7**] 03:00PM ALT(SGPT)-19 AST(SGOT)-28 CK(CPK)-111 ALK
PHOS-64 AMYLASE-61 TOT BILI-1.1
[**2108-2-7**] 03:00PM GLUCOSE-113* UREA N-13 CREAT-0.8 SODIUM-138
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-29 ANION GAP-10
[**2108-2-7**] 03:00PM WBC-6.5 RBC-4.25* HGB-14.1 HCT-38.8* MCV-91
MCH-33.1* MCHC-36.2* RDW-13.3
[**2108-2-7**] Cardiac Catheterization
1. Selective coronary angiography of this right dominant system
revealed
three vessel coronary artery disease. The LMCA had a 60-70%
stenosis.
The LAD had an 80% mid vessel stenosis and filled distally via
collaterals. The Lcx had a 90% stenosis at its origin. The RCA
had a 30%
ostial stenosis and a 60-70% stenosis at the mid vessel.
2. Limited resting hemodynamics revealed mildly elevated left
sided
filling pressures with LVEDP of 16 mmHg. There was moderate
systemic
hypertension with a central pressure of 150/63 mmHg.
3. Left ventriculography revealed an EF of 55% without
significant
mitral regurtitation. Volumetric measurements were not made.
[**2108-2-8**] ECHO
The left atrium is dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (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) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Probable diastolic dysfunction. Mild mitral
regurgitation.
[**2108-2-8**] Carotid Duplex Ultrasound
1. 40-59% stenosis of the right internal carotid artery.
2. Less than 40% stenosis of the left internal carotid artery.
Brief Hospital Course:
Mr. [**Known lastname 81560**] was admitted to the [**Hospital1 18**] on [**2108-2-7**] for a cardiac
catheterization. As this revealed severe left main and three
vessel disease, the cardiac surgical service was consulted for
surgical management. Mr. [**Known lastname 81560**] was worked-up in the the
usual preoperative manner including a carotid duplex ultrasound
which showed a 40-59% stenosis of the right internal carotid
artery and less than 40% stenosis of the left internal carotid
artery. On [**2108-2-8**], Mr. [**Known lastname 81560**] was taken to the operating
room where he underwent coronary artery bypass grafting to four
vessels. Please see operative note for details. Postoperatively
he was taken to the intensive care unit for monitoring. By
postoperative day one, he had awoke neurologically intact and
was extubated. Beta blockade, aspirin and a statin were resumed.
Later on postoperative day one, he was transferred to the step
down unit for further recovery. He was gently diuresed towards
his preoperative weight. The physical therapy service was
consulted for assistance with his postopertative strength and
mobility. The patient did experience atrial fibrillation and
was started on amiodarone as well as coumadin. Rhythm did
convert to sinus before discharge. The patient made good
progress, and by POD 5 was found suitable for discharge to
rehab.
Medications on Admission:
Norvasc 10', ASA 81', atenolol 50', lipitor 20', neurontin
300''', paxil 20', diazepam 5 prn, ranitidine 150''
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
8. Paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Bimatoprost 0.03 % Drops Sig: One (1) Ophthalmic 1 DROP OU
QHS ().
10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day:
400mg 2x/day for 1 week, then 200mg 2x/day for 1 week, then
200mg/day until further instructed.
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 2 weeks.
Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
14. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day: dose
to change for goal INR 2-2.5 (a-fib).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
Clipper Home
Discharge Diagnosis:
coronary artery disease, s/p CABG [**2108-2-8**]
Hyperlipidemia
hypertension
benign prostatic hyperplasia
Nephrolithiasis
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 914**] in 1 month ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) **] in [**2-28**] weeks.
Please follow-up with Dr. [**Last Name (STitle) 24717**] in 2 weeks.
Completed by:[**2108-2-13**]
|
[
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"327.23",
"600.01",
"414.01",
"427.31",
"278.00",
"401.9",
"433.10",
"345.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.15",
"88.53",
"37.22",
"36.13",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7146, 7185
|
4106, 5489
|
283, 510
|
7351, 7358
|
1827, 4083
|
8135, 8404
|
1296, 1373
|
5651, 7123
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7206, 7330
|
5516, 5628
|
7382, 8112
|
1388, 1808
|
233, 245
|
538, 816
|
838, 1055
|
1071, 1280
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,106
| 184,652
|
49381
|
Discharge summary
|
report
|
Admission Date: [**2122-6-4**] Discharge Date: [**2122-6-13**]
Date of Birth: [**2041-12-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Insertion of Intraaortic balloon [**2122-6-4**]
Emergency Coronary Artery bypass grafts x3(LIMA-LAD,
SVG-OM1,SVG-LPDA), removal of intraaortic balloon [**2122-6-4**]
History of Present Illness:
This 80 year old white male has a history of Insulin dependent
diabetes mellitus, hyperlipidemia and Peripheral vascular
disease and has had a 2 week history of intermittent chest pain.
He saw his PCP yesterday and was admitted to [**Hospital **] Hospital
where he underwent cardiac cath today which revealed severe LM
disease. He was transferred to [**Hospital1 18**] for cardiac surgery.
Past Medical History:
Insulin dependent diabetes mellitus
Hyperlipidemia
Gastroesophageal reflux disease
Diabetic neuropathy
Benign Prostatic hypertrophy
Glaucoma
Peripheral vascular disease s/p right carotid endarterectomy
Social History:
Lives with his wife. Non [**Name2 (NI) 1818**], non drinker. Retired.
Family History:
noncontributory
Physical Exam:
Admission:
Pulse:65 Resp:16 O2 sat:
B/P Right:143/65 Left:
Height: Weight: 70kg
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x] Well-healed R carotid scar
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ []
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
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: sl. Left: no
Pertinent Results:
[**6-4**] Echo: Prebypass: The patient is on an IABP. The left atrium
is normal in size. Left ventricular wall thicknesses are 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. Moderate
(2+) mitral regurgitation is seen. There is no pericardial
effusion. Post bypass: patient on a Neo drip. The LV function is
preserved. There is Moderate MR. [**First Name (Titles) **] [**Last Name (Titles) **] observed. All
findings communicated to Dr [**Last Name (STitle) **]
[**6-4**] Carotid U/S: 1. Less than 40% stenosis in the left internal
carotid artery. 2. 0% stenosis in the right internal carotid
artery.
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname **] was transferred from
outside hospital to [**Hospital1 18**] for bypass surgery. Following
admission he remained pain free but given his critical left main
disease he was taken to the operating room. An intraaortic
balloon was first placed prior to induction and he then
underwent coronary artery bypass surgery. Please see operative
report. Due to bleeding around the balloon device, it was
removed and direct pressure held to control the site. Once
hemostasis was achieved he was brought to the CVICU in stable
condition for invasive monitoring. Within 24 hours he was weaned
from sedation, awoke neurologically intact and extubated. He
remained in the ICU for a couple days receiving Neo for
hemodynamic support. On post-operative day three he was
transferred to the telemetry floor for further care. Chest tubes
and epicardial pacing wires were removed per protocol. He had
some episodes of confusion/delirium and was started on Haldol.
Mr. [**Known lastname **] failed to void x 2 requiring foley to be replaced
twice. Foley is to remain until he sees his primary urologist.
Also had dysphagia and a bedside speech and swallow consult was
performed. He worked with physical therapy during his post-op
course for strength and mobility. He remains debilliated and
able to take steps with assist of 2 persons. Mr. [**Known lastname **] was
discharged to [**Location (un) 931**] House rehab in [**Location (un) **] on POD#9 with
follow-up appointments.
swallow eval [**6-12**]:
SUMMARY / IMPRESSION:
Patient was awake, alert and oriented during today's evaluation.
He did not p/w overt s/sx of aspiration during. Recommend
patient continue PO diet of ground solids and thin liquids, with
1:1 supervision. Alternate bites and sips. Continue to give
small pills whole and large pills crushed in puree as able.
Recommend nutrition consult as patient is at risk for decreased
PO. We will follow up with patient next week to see how he is
PO
tolerating diet.
This swallowing pattern correlates to a Dysphagia Outcome
Severity Scale (DOSS) rating of Level 3, Moderate Dysphagia
RECOMMENDATIONS:
1. Continue PO diet: ground solids and thin liquids
2. 1:1 supervision
3. Alternate bites and sips.
4. Continue to give small pills whole and large pills crushed
in
puree as able.
5. Recommend nutrition consult as patient is at risk for
decreased PO.
6. We will follow up with patient next week to see how he is PO
tolerating diet.
7. Q8 oral care
These recommendations were shared with the patient, nurse and
medical team.
____________________________________
[**First Name11 (Name Pattern1) 2331**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], M.S., CCC-SLP
Pager # [**Numeric Identifier 80118**]
Medications on Admission:
Lantus 25U qhs, Humalog SS, Proscar 5 mg PO daily, ASA 81 mg PO
daily, Flomax 0.8 mg PO daily, Lipitor 20 mg PO daily,
Lisinopril 5 mg PO daily, Lorazepam 0.5 mg 0.5 mg, Betoptic
0.25% 1gtt OU [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
9. Betaxolol 0.25 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
13. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID ().
14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 4 days: then decrease to daily on [**6-17**] for 1 week
then 200mg daily ongoing.
16. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
17. lantus
22 units at bedtime
18. humalog
humalog insulin per sliding scale fingerstick
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 931**] House Nursing & Rehabilitation Center - [**Location (un) 932**]
Discharge Diagnosis:
Coronary artery disease s/p Urgent Coronary Artery Bypass Graft
x 3
Insulin dependent diabetes mellitus
Hyperlipidemia
Gastroesophageal reflux disease
Diabetic neuropathy
Benign Prostatic hypertrophy
Glaucoma
Peripheral vascular disease s/p right carotid endarterectomy
Discharge Condition:
good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks from date of
surgery.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns [**Telephone/Fax (1) 170**]
8) Leave foley in until follow up with your urologist.
Followup Instructions:
Dr. [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
[**Hospital Ward Name 121**] 6 wound clinic in 2 weeks
Dr. [**Last Name (STitle) 40075**] in [**11-21**] weeks
Dr. [**First Name4 (NamePattern1) 56977**] [**Last Name (NamePattern1) 82932**] in 2 weeks
Please call for appointments
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2122-6-13**]
|
[
"411.1",
"458.29",
"530.81",
"293.0",
"250.60",
"424.0",
"787.20",
"401.9",
"V58.67",
"E878.1",
"996.09",
"788.20",
"357.2",
"414.01",
"272.4",
"600.01",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"36.15",
"39.61",
"37.61",
"97.44",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7420, 7534
|
2656, 5439
|
296, 463
|
7847, 7853
|
1893, 2633
|
8733, 9157
|
1210, 1227
|
5699, 7397
|
7555, 7826
|
5465, 5676
|
7877, 8710
|
1242, 1874
|
246, 258
|
491, 882
|
904, 1107
|
1123, 1194
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,202
| 151,488
|
4719
|
Discharge summary
|
report
|
Admission Date: [**2196-5-18**] Discharge Date: [**2196-5-28**]
Date of Birth: [**2121-5-9**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Lisinopril / Cephalosporins / Carbapenem /
Aztreonam / Shellfish / Zestril
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Heel ulcer
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This was a 75yo F with past medical history of CKD, diabetes
mellitus, and presumed PVD who presented with worsening right
foot pain. She reported that five days prior to arrival she had
cut her right heel with her fingernail while removing a
stocking. The area of the cut began to get progressively
painful and she began to have clear drainage from the area. She
denied any fever, purulence, or motor/sensory defects.
Nevertheless, progress pain led symptoms to interfere with her
ADL's as she has been dependent on a right foot/ankle brace
since her CVA and she was unable to wear this due to pain.
In the ED, initial vitals were T 96.2, P 56, BP 140/38, RR 18,
O2 99%RA. On physical exam a well defined area of erythema was
noted on R heel, as circular abrasion over lat aspect of R 5th
toe. Pulses were dopplerable. Labs were notable for WCC 14.0,
Hct 29.1 (baseline), Cr 2.1 (baseilne 1.2-1.6), lactate of 2.1.
Heel XR did not demonstrate signs c/w osteomyelitis. Podiatry
was consulted and recommended admission for IV antibiotics and
vascular work-up. Patient was given 1g IV vancomycin and
admitted to medicine. Vitals prior to transfer were 97.0 hr 56
146/50 20 100%.
On arrival to the floor, patient's vital signs were 95.7 195/47
62 18 100%RA. On review of systems, she denied fever, chills,
night sweats, headache, vision changes, rhinorrhea, congestion,
sore throat, cough, shortness of breath, chest pain, abdominal
pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
- Type II DM c/b nephropathy - followed at [**Last Name (un) **] by Dr. [**First Name4 (NamePattern1) 1726**]
[**Last Name (NamePattern1) 19862**]
- CKD II baseline 1.3-1.5
- HTN
- Foot ulcers - followed by Dr [**Last Name (STitle) **], question of vascular
disease in most recent note
- h/o CVA [**2182**]: residual right-sided weakness
- Anemia, Fe def and CKD: requiring infusions
- Hypothyroidism
- h/o hypercalcemia
- Malignant neoplasm of the skin
- Neurogenic bladder
Social History:
Lived independently. Smoked 29 pk yrs, quit in [**2167**]. No alcohol
or other drug use.
Family History:
+DM, HTN
Physical Exam:
ADMISSION
VS: 95.7 195/47 62 18 100%RA
GENERAL: Comfortable, NAD
HEENT: Sclera anicteric, PERRL, OP clear, MM dry
NECK: Supple, no JVD,
CV: RRR, no m/r/g
LUNGS: CTA b/l, no crackles, wheezes, rhonchi.
ABD: Soft, NTND. No HSM or tenderness.
EXTREMITIES: small abrasion at R heel w mild surrounding
erythema, no discharge, moderately painful on palpation; small
circular abrasion over lateral aspect of 5th digit, no
discharge, no surrounding erythema, mildly painful to palpation.
cool skin, but DP/PT 1+ equal bilaterally, appropriate
capillary refill
NEURO: AOx3, 4+/5 on R upper/lower extremities, 5+/5 on L
extremities
Pertinent Results:
===================
LABORATORY RESULTS
===================
On Admission:
WBC-14.0* RBC-3.16* Hgb-9.6* Hct-29.1* MCV-92 RDW-14.3 Plt
Ct-295
---Neuts-82.8* Lymphs-11.4* Monos-3.4 Eos-1.9 Baso-0.5
PT-11.6 PTT-24.8 INR(PT)-1.0
Glucose-152* UreaN-56* Creat-1.8* Na-139 K-5.1 Cl-109* HCO3-23
Calcium-10.3 Phos-5.7*# Mg-2.5
On Day of Demise:
WBC-14.5* RBC-2.79* Hgb-8.8* Hct-25.5* MCV-91 RDW-14.6 Plt
Ct-171
---PT-14.1* PTT-35.2* INR(PT)-1.2*
Glucose-106* UreaN-107* Creat-4.1* Na-133 K-6.6* Cl-94* HCO3-20*
ALT-350* AST-526* CK(CPK)-3792* AlkPhos-73 TotBili-0.2
CK(CPK)-[**Numeric Identifier 19863**]*
Calcium-7.5* Phos-14.1* Mg-2.5
==================
RADIOLOGY RESULTS
==================
Chest Radiograph [**2196-5-28**]:
FINDINGS: Support and monitoring devices are in standard
position, and
cardiomediastinal contours are unchanged. Multifocal poorly
defined nodules are again demonstrated in both lungs,
co-existing with coalescent areas of airspace opacity in the
perihilar and basilar regions. The latter have slightly improved
on the left but worsened on the right. The nodules are
consistent with an infectious etiology including fungal
organisms and septic emboli. The more confluent airspace
opacities could either be due to infection or co-existing
pulmonary edema. Left pleural effusion is small and not
appreciably changed.
R foot XR [**2196-5-18**]
1. No radiographic evidence of soft tissue ulcer or subcutaneous
edema.
2. Intact cortex surrounding the calcaneus without evidence of
acute
osteomyelitis. If clinical concern persists, suggest MRI or
nuclear medicine bone scan.
CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONS [**2196-5-19**]
1. Extensive atherosclerotic vascular disease with
mild-to-moderate bilateral
CFA stenosis, multifocal areas of narrowing in the bilateral SFA
and right
popliteal artery, and segment of moderate to severe narrowing in
the left
popliteal artery with patent bilateral three-vessel runoff.
2. Multiple subcutaneous fluid collections overlying the right
kidney.
3. Cholelithiasis without cholecystitis.
4. Left adrenal hyperplasia.
5. 3.1 cm possibly septated ovarian cyst. Given the patient's
age further
evaluation by MRI is recommended.
Brief Hospital Course:
This was a 75 y.o. female with DM, CKD, and PVD presenting with
right heel cellulitis and with course complicated by aspiration
pneumonia/pneumonitis and anuric acute renal failure.
1. Hypoxic Respiratory Failure: The patient developed increasing
oxygen requirement over hospital stay which was initially
thought to be due to volume overload in the context of holding
furosemide. She subsequently developed productive cough and
worsening hypoxia that continued to worsen despite
vanc/tigecycline/ and ciprofloxacin empiric treatment for
pneumonia. She was intubated with sputum cultures showing
multiple specise consistent with aspiration. She had an
esophageal balloon placed for help titrating PEEP but continued
to be hypoxic requiring 100% FiO2 at the time of her terminal
extubation on [**2196-5-28**]. Shortly after extubation the patient
become bradycardic and then asystolic. Family came to bedside.
Autopsy refused.
2) Acute on Chronic Renal Failure: The patient initially
presented with Cr 2.1 from 1.2-1.5 at baseline but quickly
improved with holding diuretics but unfortunately she developed
contrast induced nephropathy and anuric renal failure. Given
rising K and anuria discussion was had with the family on the
evening of [**5-27**] and the morning of [**5-28**] about initiating renal
replacement therapy. They did not feel she would want this
intervention given multiple other abnormalities and low
likelihood to return to previous standard of life.
Therefore,she was terminally extubated and passed away soon
afterward.
3) PVD/ Likely rhabdo: In the context of being intubated and
severe hypoxemia the patient's CK went to 20,000+ in the setting
of progressive renal failure suggestive of rhabdomyolysis.
Given very poor peripheral flow this was thought due to ischemia
due to PVD in the context of hypotension. Vascular was
consulted but patient was not stable enough for procedure and
given ultimate dismal prognosis she was extubated.
4)Cellulitis: Patient w R heel abrasion p/w localized
cellulitis. No signs of more serious infection on labs,
imaging. Pt received 5d doxycycline w improvement in WBC count
and redness. PVD likely contributing factor.
5) HTN: Patoent on multidrug outpatient regimen with poor
baseline control (SBP 150s). Her losartan was stopped at admit
given kidney injury. Other anti-hypertensive were stopped
around [**5-20**] as the patient's clinical status deteriorated.
INACTIVE
# Anemia: Patient w chronic microcytic anemia, likely [**1-13**]
chronic kidney disease. She was at her baseline Hct. Continued
iron sulfate, plan for outpatient procrit.
# CAD: Continued dipyridamole, lipitor. For medical clearance
for surgery, patient underwent nuclear stress w/o significant
abnormalities.
# CHF: Lasix held as above.
# Urinary retention: Continued oxybutynin
# DM: Continued standing lantus, SS humalog, glyburide,
metformin.
# Hypothyroidism: Continued levothyroxine.
On [**5-28**] in the context of progressive renal failure,
rhabdomyolysis, and need for large amount of ventilatory support
the patient's family elected to make her CMO. She was
terminally extubated.
Medications on Admission:
Oxybutynin Chloride 10mg daily
Lantus 10units qHS
Lasix 40Mg QOD
Atenolol 50Mg daily
Procrit weekly
Humalog SS
Vitamin D2 50,000 units weekly
Losartan 25mg [**Hospital1 **]
Norvasc 10mg daily
Dipyridamole 50Mg TID
Clonidine 0.1mg [**Hospital1 **]
Glucophage 500mg daily
Lipitor 10mg daily
Levothyroxine 50mcg daily
Glyburide 10mg qAM, 5mg qPM
Metamucil daily
MVI
Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
N/A. Patient deceased.
Discharge Disposition:
Expired
Discharge Diagnosis:
Pt expired
Discharge Condition:
Pt expired
Discharge Instructions:
Pt expired
Followup Instructions:
Pt expired
|
[
"438.89",
"729.89",
"682.7",
"788.20",
"728.88",
"428.33",
"917.3",
"507.0",
"780.09",
"799.02",
"250.40",
"584.9",
"E920.8",
"285.21",
"244.9",
"585.2",
"428.0",
"403.00",
"585.9",
"736.79",
"583.81",
"V49.86",
"518.81",
"E849.0",
"707.14",
"440.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"38.97",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
9085, 9094
|
5440, 8591
|
357, 364
|
9148, 9160
|
3223, 3282
|
9219, 9232
|
2553, 2564
|
9037, 9062
|
9115, 9127
|
8617, 9014
|
9184, 9196
|
2579, 3204
|
307, 319
|
392, 1931
|
3296, 5417
|
1953, 2430
|
2446, 2537
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,890
| 113,316
|
14394
|
Discharge summary
|
report
|
Admission Date: [**2190-6-5**] Discharge Date: [**2190-6-6**]
Service: #58
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 42654**] is a [**Age over 90 **] year-old
woman with a past medical history of hypertension, coronary
artery disease, status post myocardial infarction with
pacemaker, who presented with 35 minutes of generalized tonic
clonic activities suppressed by 15 mg of Valium. The patient
had reported been at her baseline in her usual state of
health, interactive, fluent until the day of admission when
she was last seen at 2:00 p.m. She had been resting in her
room and was found in convulsions at approximately 3:40 p.m.,
unresponsive with a systolic blood pressure of approximately
180 to 200. Emergency medical services arrived within twenty
minutes and she was given 5 mg of IM Valium followed by 10 mg
of intravenous before resolution of her symptoms. She was
reported at this time to hve copious secretions.
In the Emergency Room she was loaded with 1 gram of Dilantin
and intubated for airway protection. A left femoral central
line was initially placed and then removed secondary to a
hematoma, a right was later placed.
Per nursing home staff and family she had not been ill prior
to this. She had no history of prior seizures.
Upon admission to the Intensive Care Unit she was intubated
and not responsive.
PAST MEDICAL HISTORY: 1. Hypertension. 2. Tremor. 3.
Coronary artery disease status post myocardial infarction.
4. Left humerus fracture. 5. Hypercholesterolemia. 6.
Status post cataract surgery. 7. Status post pancreatic
surgery.
MEDICATIONS ON ADMISSION: 1. Effexor 37.5 mg po q day. 2.
Lipitor 10 mg po q day. 3. Monopril 20 mg po q day. 4.
Multivitamins. 5. Plavix 75 mg po q day. 6. Prevacid 15 mg
po q day. 7. Pericolace one tab po b.i.d. 8. Celebrex 100
mg po q day. 9. Senokot two tabs q.h.s.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs significant
for a temperature of 98.8. Blood pressure 150/75. Heart
rate 95, intubated, sating 100% on 40% FIO2. Oral mucosa
moist. No lymphadenopathy. Lungs with diffuse crackles. No
wheezing. Cardiac examination with a 2 out of 6 systolic
ejection murmur heard best at the apex. Regular rate and
rhythm. No rubs. No gallops. Abdomen soft, nontender,
nondistended with positive bowel sounds. She was moving all
four extremities. She had a large left groin hematoma not
firm or indurated. She had no active bleeding at the site.
Her right dorsalis pedis pulse was not palpable. Posterior
tibial was not dopplerable on the left. Her dorsalis pedis
pulse was dopplerable, but her posterior tibial pulse was not
palpable or dopplerable. Her skin was without rashes.
Neurologically she was intubated and sedated. She withdrew
mildly to all extremities on examination. She had positive
dolls eyes. No corneal reflex was noted upon initial
examination. She had a surgical pupil, both were reactive.
Her tone was slightly increased. She had mild intermittent
tremor of the chin and right upper extremity when she tried
to bring it midline. Reflexes were 1+ and symmetric at
biceps, triceps, brachial radialis bilateral in upper
extremities 1+ at patellar and Achilles. Her toes were up
going bilaterally.
Ventilator settings upon admission were pressor support of 10
and 5, 40% FIO2, respiratory rates in the 20s with tidal
volumes in the 300s. Arterial blood gas at this point was
7.37/46/187.
ADMISSION FILMS: CT of the head showing low attenuation with
white matter at the junction of the right MCA and PCA
territories. Lack of associated mass factor atrophy
suggesting a possible subacute watershed infarct. Without
prior films for comparison. Acuity was noted to be difficult
to ascertain.
LABORATORIES ON ADMISSION: White blood cell count of 8.0,
hematocrit 33.2, platelets 162, sodium 142, potassium 3.6,
chloride 104, bicarb 24, BUN 29, creatinine 1.1, glucose 151.
Urinalysis with no nitrites and no ketones.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit for monitoring. Left groin line placed
in the Emergency Department was discontinued secondary to
hematoma. She was transfused with 2 units of packed red
blood cells for a hematocrit drop in this setting. Post
transfusion hematocrit showed an appropriate bump. A groin
line was placed for access.
Dilantin level was therapeutic after an initial load in the
Emergency Department. Potassium, magnesium and calcium were
all repleted. She remained hemodynamically stable throughout
her Intensive Care Unit stay. She remained intubated during
her short stay in the Intensive Care Unit and extubation was
deferred secondary to transfer to the outside hospital. At
the time of discharge the patient remained intubated,
withdraws to painful stimulus in all extremities. Toes are
up going bilaterally and dolls eyes were intact.
She is to be transferred to [**Hospital3 **] Neurological step
down unit as all of her records are at [**Hospital3 **].
DISCHARGE DIAGNOSES:
1. Cerebrovascular accident.
2. Coronary artery disease.
3. Hypertension.
4. Hypercholesterolemia.
MEDICATIONS ON TRANSFER: Protonix 40 mg intravenous q.d.
Plavix 75 mg po/pngt q.d. Dilantin 100 mg po/pngt b.i.d.
Tylenol prn.
DISPOSITION: [**Hospital3 **] neurologic step down unit.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Name8 (MD) 4733**]
MEDQUIST36
D: [**2190-6-6**] 15:05
T: [**2190-6-9**] 07:14
JOB#: [**Job Number 42655**]
|
[
"434.91",
"345.3",
"412",
"401.9",
"V45.01",
"518.81",
"458.2",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5068, 5172
|
1628, 1946
|
4036, 5047
|
114, 1358
|
3821, 4018
|
5198, 5588
|
1381, 1601
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,136
| 161,435
|
19315
|
Discharge summary
|
report
|
Admission Date: [**2111-8-30**] Discharge Date: [**2111-9-7**]
Date of Birth: [**2041-12-3**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
Transfer from OSH for bleeding s/p liver bx of suspected HCC.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
69 yo M with alcoholic cirrhosis transferred from OSH s/p liver
biopsy on [**8-27**] c/b bleeding and hypotension. On [**8-27**] Pt became
hypotensive to the 50s (SBP) during a CT-guided liver bx of a R
liver lobe lesion discovered earlier on CT. Bx was completed
and tract was embolized with Gelfoam pledgets. f/u CT scan
revealed blood adjacent to liver and in pericolic gutter.
Repeat angiogram was done by IR without intervention. Pt
received a total of 3 u. pRBCs and 2 platelets with appropriate
HCT correction from 24 to 30 and improvement in vital signs.
Patient was transfered to ICU at [**Hospital6 **] and
received 3 additional u. of pRBCs and 3 of platelets. Pt
developed intermittent encephalopathy and was treated with
rifaximin and continued tx with lactulose. Pt was started on
doxycycline for SBP prophylaxis - he remained afebrile
throughout. Nadalol was held [**12-24**] hypotension. Creatinine
increased from ~1.5 baseline to 4.1 and on discharge with
decreased UOP (15/20mL/hr). O2 requirements increased over
course of stay likely [**12-24**] fluid overload and ARF - at time of
discharge, Pt was on 4 L O2 NC (sat 95%). Pt's tolerated regular
diabetic diet with daily BMs at mount hospital.
On presentation to [**Hospital1 18**] SICU; Patient c/o fatigue, 5 lb weight
loss, decreased urine, temperature intolerance to cold and
decreased appetite over past week, cough productive of "cloudy
sputum", midline abdominal pain, back pain, intermitent vomiting
x 1 week, diarrhea. Patient denies SOB, vision changes, DOE,
hemopysis, chestpain, dysuria, hematuria, hematchezia, joint
pain, HA, easy bruising or bleeding or parasthesias.
Past Medical History:
EtOH cirrhosis, diabetes, HTN, pulmonary HTN, chronic
gastropathy, Hx of esophageal varices, lower back pain.
Past Surgical History:
Basal cell excisions from b/l arms and ears, b/l cataract
surgery. CT guided needle biopsy R lobe liver mass. No Hx of
intra-abdominal surgeries.
Social History:
H/o alcohol abuse. Abstinent for 20 years. Denies smoking.
Family History:
Noncontributory.
Physical Exam:
On admission:
T: 98.2 P: 75 BP: 104/51 RR: 19 O2sat: 95% on 4L NC
Afebrile for >48 hours
General: awake, alert, NAD, on 4L NC
HEENT: NCAT, EOMI, no scleral icterus, R central line in place
Heart: RRR, NMRG
Lungs: right lung base decreased breath sounds, L base
inspirtatory crackles, normal excursion, no respiratory distress
Back: no CVAT
Abdomen: nonfocal diffuse tenderness, mild-moderate abdominal
distention with tympany, no rebound/guarding. postitive bowel
sounds. No splenomegaly
Neuro: strength intact/symmetric, sensation intact/symmetric
Extremities: WWP, no edema, no tenderness
Pyschiatric: normal judgment/insight, normal memory, normal
mood/affect
Pertinent Results:
[**2111-8-27**]
Liver biopsy:
POORLY-DIFFERENTIATED CARCINOMA WITH LYMPHOVASCULAR INVASION;
HEPATIC CIRRHOSIS.
THE FINDINGS WOULD BE CONSISTENT WITH A METASTATIC CARCINOMA OF
GASTROINTESTINAL, PANCREATICOBILIARY OR UROTHELIAL ORIGIN, OR A
PRIMARY CHOLANGIOCARCINOMA.
[**2111-8-30**] 02:00PM BLOOD WBC-9.0 RBC-2.79* Hgb-9.6* Hct-26.1*
MCV-94 MCH-34.3* MCHC-36.7* RDW-18.7* Plt Ct-61*
[**2111-8-30**] 10:03PM BLOOD WBC-7.6 RBC-3.11* Hgb-10.7* Hct-29.7*
MCV-96 MCH-34.4* MCHC-36.0* RDW-17.3* Plt Ct-53*
[**2111-8-31**] 01:49AM BLOOD WBC-7.6 RBC-3.21* Hgb-10.6* Hct-30.7*
MCV-96 MCH-33.1* MCHC-34.6 RDW-17.3* Plt Ct-61*
[**2111-8-31**] 09:51AM BLOOD WBC-8.3 RBC-3.19* Hgb-10.9* Hct-30.7*
MCV-97 MCH-34.1* MCHC-35.3* RDW-17.4* Plt Ct-58*
[**2111-8-31**] 10:18PM BLOOD WBC-7.4 RBC-3.03* Hgb-10.6* Hct-29.2*
MCV-97 MCH-34.9* MCHC-36.2* RDW-19.0* Plt Ct-43*
[**2111-9-1**] 02:32AM BLOOD WBC-7.0 RBC-3.08* Hgb-10.6* Hct-29.6*
MCV-96 MCH-34.3* MCHC-35.7* RDW-18.9* Plt Ct-57*
[**2111-9-1**] 12:34PM BLOOD WBC-9.7 RBC-3.39* Hgb-11.9* Hct-32.8*
MCV-97 MCH-35.0* MCHC-36.1* RDW-19.2* Plt Ct-68*
[**2111-9-2**] 02:13AM BLOOD WBC-6.9 RBC-3.25* Hgb-11.2* Hct-30.9*
MCV-95 MCH-34.4* MCHC-36.3* RDW-19.5* Plt Ct-59*
[**2111-9-2**] 12:23PM BLOOD WBC-6.6 RBC-3.31* Hgb-11.4* Hct-32.0*
MCV-97 MCH-34.5* MCHC-35.6* RDW-18.3* Plt Ct-63*
[**2111-9-3**] 02:00AM BLOOD WBC-10.9# RBC-3.73* Hgb-12.8* Hct-36.2*
MCV-97 MCH-34.2* MCHC-35.2* RDW-19.2* Plt Ct-65*
[**2111-9-3**] 07:54PM BLOOD WBC-9.7 RBC-3.74* Hgb-12.7* Hct-37.1*
MCV-99* MCH-34.0* MCHC-34.3 RDW-19.5* Plt Ct-55*
[**2111-9-4**] 01:31AM BLOOD WBC-10.2 RBC-3.88* Hgb-13.3* Hct-38.4*
MCV-99* MCH-34.2* MCHC-34.6 RDW-19.2* Plt Ct-57*
[**2111-8-30**] 02:00PM BLOOD PT-16.9* PTT-32.5 INR(PT)-1.5*
[**2111-8-30**] 10:03PM BLOOD PT-17.6* PTT-34.0 INR(PT)-1.6*
[**2111-8-31**] 01:49AM BLOOD PT-17.4* PTT-31.7 INR(PT)-1.6*
[**2111-8-31**] 09:51AM BLOOD PT-17.6* PTT-31.1 INR(PT)-1.6*
[**2111-8-31**] 10:18PM BLOOD PT-18.2* PTT-29.7 INR(PT)-1.6*
[**2111-9-1**] 02:32AM BLOOD PT-18.2* PTT-31.8 INR(PT)-1.6*
[**2111-9-1**] 12:34PM BLOOD PT-17.9* PTT-31.4 INR(PT)-1.6*
[**2111-9-2**] 02:13AM BLOOD PT-18.0* PTT-29.5 INR(PT)-1.6*
[**2111-9-2**] 12:23PM BLOOD PT-18.7* PTT-31.6 INR(PT)-1.7*
[**2111-9-3**] 02:00AM BLOOD PT-19.1* PTT-34.1 INR(PT)-1.7*
[**2111-9-3**] 07:54PM BLOOD PT-18.5* PTT-32.3 INR(PT)-1.7*
[**2111-9-4**] 01:31AM BLOOD PT-20.2* PTT-37.4* INR(PT)-1.8*
[**2111-8-30**] 10:03PM BLOOD Fibrino-273
[**2111-8-31**] 01:49AM BLOOD Fibrino-258
[**2111-8-31**] 09:51AM BLOOD Fibrino-319
[**2111-8-31**] 10:18PM BLOOD Fibrino-312
[**2111-9-1**] 12:34PM BLOOD Fibrino-319
[**2111-9-2**] 02:13AM BLOOD Fibrino-292
[**2111-9-2**] 12:23PM BLOOD Fibrino-277
[**2111-9-3**] 02:00AM BLOOD Fibrino-235
[**2111-8-30**] 02:00PM BLOOD Glucose-145* UreaN-112* Creat-4.7* Na-133
K-4.5 Cl-98 HCO3-17* AnGap-23*
[**2111-8-31**] 01:49AM BLOOD Glucose-127* UreaN-120* Creat-5.1* Na-134
K-4.2 Cl-99 HCO3-16* AnGap-23*
[**2111-9-1**] 02:32AM BLOOD Glucose-121* UreaN-136* Creat-5.9* Na-133
K-4.6 Cl-98 HCO3-15* AnGap-25*
[**2111-9-1**] 12:34PM BLOOD Glucose-136* UreaN-141* Creat-6.2*
Na-131* K-4.5 Cl-95* HCO3-14* AnGap-27*
[**2111-9-2**] 02:13AM BLOOD Glucose-142* UreaN-99* Creat-4.3*# Na-133
K-3.7 Cl-93* HCO3-20* AnGap-24*
[**2111-9-2**] 12:23PM BLOOD Glucose-157* UreaN-75* Creat-3.4* Na-130*
K-3.7 Cl-92* HCO3-22 AnGap-20
[**2111-9-2**] 06:02PM BLOOD Glucose-180* UreaN-79* Creat-3.0* Na-132*
K-3.9 Cl-95* HCO3-22 AnGap-19
[**2111-9-3**] 02:00AM BLOOD Glucose-173* UreaN-67* Creat-2.7* Na-132*
K-3.7 Cl-94* HCO3-24 AnGap-18
[**2111-9-3**] 01:39PM BLOOD Glucose-222* UreaN-49* Creat-2.1* Na-132*
K-4.0 Cl-93* HCO3-23 AnGap-20
[**2111-9-3**] 07:54PM BLOOD Glucose-204* UreaN-46* Creat-2.1* Na-131*
K-3.8 Cl-91* HCO3-23 AnGap-21*
[**2111-9-4**] 01:31AM BLOOD Glucose-227* UreaN-40* Creat-1.8* Na-131*
K-3.8 Cl-90* HCO3-25 AnGap-20
[**2111-9-4**] 03:55PM BLOOD Glucose-205* UreaN-31* Creat-1.5* Na-132*
K-3.7 Cl-93* HCO3-26 AnGap-17
[**2111-8-30**] 02:00PM BLOOD ALT-319* AST-344* LD(LDH)-301*
AlkPhos-166* Amylase-36 TotBili-10.0*
[**2111-8-31**] 01:49AM BLOOD ALT-278* AST-262* AlkPhos-156*
TotBili-12.3*
[**2111-9-1**] 02:32AM BLOOD ALT-223* AST-173* LD(LDH)-284*
AlkPhos-152* TotBili-15.2* DirBili-11.2* IndBili-4.0
[**2111-9-2**] 02:13AM BLOOD ALT-177* AST-135* AlkPhos-157*
TotBili-17.9*
[**2111-9-3**] 02:00AM BLOOD ALT-150* AST-140* AlkPhos-169*
TotBili-21.1*
[**2111-9-3**] 07:54PM BLOOD ALT-140* AST-150* AlkPhos-200*
TotBili-24.9*
[**2111-9-4**] 01:31AM BLOOD ALT-136* AST-153* AlkPhos-211*
TotBili-25.3*
[**2111-9-1**]
Liver US:
No detectable flow within the main, right or left portal vein,
which may indicate occlusive thrombosis or extremely slow flow.
[**2111-9-2**]
CT abdomen:
1. Portal vein thrombosis from the confluence with the superior
mesenteric vein extending to the proximal bilateral intrahepatic
branches.
2. The large heterogeneously-enhancing lesion in the right lobe
of the liver is most consistent with atypical hepatocellular
carcinoma or metastatic disease and less likely hypoperfusion.
3. Sequelae of portal venous hypertension including
splenomegaly, moderate ascites, and anasarca.
4. Right middle lobe infectious or inflammatory process.
Brief Hospital Course:
On [**2111-8-30**], the patient was admitted to the SICU on the
hepatobiliary surgery service after a liver biopsy complicated
by hemorrhage and acute renal failure. He was transfused 2u
PRBC and hct stabilized. On [**2111-8-31**], he was also transufsed
1pk platelets. He did not require additional transfusions. His
diet was advanced to regular. He became oliguric which did not
improve with furosemide. On [**2111-9-1**], a hemodialysis line was
placed and he was started on CVVH for fluid overload. On
[**2111-9-2**], he developed atrial fibrillation with RVR requiring
amiodarone gtt.
All of the above was in the setting of worsening liver failure.
His Tbili on presentation was 10.0 and continued to climb (it
was 25.3 on [**2111-9-4**], the last day it was checked). To workup
the cause of his worsening liver failure, a ultrasound was
performed on [**2111-9-1**] assessing the portal vasculature and
consistent with no flow in the portal vein. A CT scan on
[**2111-9-2**] suggested the cause of the portal venous obstruction
was malignancy, likely metastatic in origin. On [**2111-9-3**],
pathology results from [**Hospital6 **] from the liver biopsy
were consistent with undifferentiated malignancy and discussed
with the patient and his family (official pathology final report
from [**Hospital3 2568**] pending at time of this discharge summary).
Mr. [**Known lastname **], after discussion with his family and the palliative
care team at [**Hospital1 18**], decided upon DNR/DNI status and a slow
de-escalation of care. CVVH was discontinued on [**9-4**] and he
was transferred to the floor on [**2111-9-5**]. He was officially
made "comfort measures only" on [**2111-9-6**]. He expired at 9:01 PM
on [**2111-9-7**].
Medications on Admission:
- Humalong SS
- Lantus 46 u. QHS
- Prilosec OTC QD
- spironolactone PO BID
- Lactulose 10 g PO BID
- Nadolol 40 mg PO QD
- Lasix 40 mg PO QAM and 20 mg PO QPM
- Simvastatin 10 mg PO QHS
Discharge Disposition:
Expired
Discharge Diagnosis:
liver failure secondary to malignancy
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2111-9-8**]
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27,561
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52965
|
Discharge summary
|
report
|
Admission Date: [**2161-7-1**] Discharge Date: [**2161-7-9**]
Date of Birth: [**2084-1-29**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 21990**]
Chief Complaint:
hypotension, bradycardia, hypothermia
Major Surgical or Invasive Procedure:
Central line placement, Fluoro-guided Lumbar puncture
History of Present Illness:
77 yo female with h/o alzheimer's dementia, anemia, HTN,
arthritis, presented from [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] with lethargy,
bradycardia and hypotension. Apparently, pt was baseline at
sherillhouse until PM on [**7-1**] when she was noted to be brady to
40s and hypoT (SBP 80s). Pt was also noted to be less
interactive during the entire [**7-1**]. She was administered 1mg
atropine in the field which resulted in HR 40-50s. While in the
ED, patient received IVF with systolic 120s. Head CT negative,
CXR negative, UA negative. K of 6.7 for which she received
insulin, glucose, and kayexalate. ECG notable for first degree
AV block (? old) and bradycardia to 40s (new).
.
The patient was also started on empiric CTX, Vanc and Levaquin.
Cards fellow consulted re: pacer placement evaluaton.
.
Of note, pt has had previous admissions for delta MS [**First Name (Titles) **] [**Last Name (Titles) **]'s.
.
Apparently at baseline, the patient ambulates with a walker and
is talkative and interactive.
.
ROS: Unable to obtain as patient is non-communicative.
Past Medical History:
demenia
HTN
h/o CHF
anemia (being worked up presumably due to colonic polyps)
spinal stenosis
hyperlipidema
Social History:
Denies tobacco, ETOH, and illicit drug use. Daughter is legal
guardian (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]); lives at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **]
Family History:
[**Name (NI) 109170**], Sister--DM, [**Name (NI) 109171**], [**Name (NI) 109172**] of
leukemia
Physical Exam:
VS: Temp: unable to register, read as 88 in the ED via rectal
probe
SBP 50-140/30-57, HR 40-64; RR 5-12, O2 sat 90-95% 5L NC. 4.3L
in 590ccs out.
Gen - responsive early to sternal rub, opens eyes to voice
intermittently
HEENT - gurgly upper airway soudns, large amount of secretions
Neck - supple, No neck stiffness, flexing fully
Cor - very brady, S1 and S2, no murmurs
Chest - decreased BS at bases, minimal wheezing
Abd - soft, obese, non tender, good bowel sounds,
Vaginal exam: putrid smell, feculent vaginal secretions. no FB
found in vagina.
Ext - Bilateral pitting edema -
Neuro: responds to pain and opens eyes to voice intermittently.
non-verbal..
Pertinent Results:
[**2161-7-1**] 10:53PM GLUCOSE-94 NA+-143 K+-6.9* CL--113* TCO2-27
[**2161-7-1**] 10:40PM UREA N-40* CREAT-1.2*
[**2161-7-1**] 10:40PM CK(CPK)-78
[**2161-7-1**] 10:40PM CK-MB-NotDone cTropnT-0.01
[**2161-7-1**] 05:55PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2161-7-1**] 05:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2161-7-1**] 05:50PM LACTATE-1.2 K+-6.8*
[**2161-7-1**] 05:35PM GLUCOSE-85 UREA N-41* CREAT-1.4* SODIUM-138
POTASSIUM-6.7* CHLORIDE-108 TOTAL CO2-24 ANION GAP-13
[**2161-7-1**] 05:35PM estGFR-Using this
[**2161-7-1**] 05:35PM ALT(SGPT)-49* AST(SGOT)-37 CK(CPK)-59 ALK
PHOS-124* AMYLASE-93 TOT BILI-0.1
[**2161-7-1**] 05:35PM LIPASE-71*
[**2161-7-1**] 05:35PM cTropnT-0.01
[**2161-7-1**] 05:35PM CK-MB-NotDone
[**2161-7-1**] 05:35PM ALBUMIN-3.9 CALCIUM-9.7 PHOSPHATE-3.1
MAGNESIUM-2.2
[**2161-7-1**] 05:35PM WBC-4.5 RBC-2.89* HGB-9.2* HCT-28.8* MCV-100*
MCH-31.7 MCHC-31.7 RDW-16.4*
[**2161-7-1**] 05:35PM NEUTS-69.1 BANDS-0 LYMPHS-26.0 MONOS-3.2
EOS-1.2 BASOS-0.4
[**2161-7-1**] 05:35PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-OCCASIONAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL
STIPPLED-OCCASIONAL
[**2161-7-1**] 05:35PM PLT COUNT-160
[**2161-7-1**] 05:35PM PT-13.0 PTT-37.7* INR(PT)-1.1
Labs on discharge:
[**2161-7-9**] 05:33AM BLOOD WBC-7.4 RBC-3.35* Hgb-10.8* Hct-31.2*
MCV-93 MCH-32.2* MCHC-34.5 RDW-16.1* Plt Ct-219
[**2161-7-9**] 05:33AM BLOOD Neuts-58.9 Lymphs-33.3 Monos-5.1 Eos-2.3
Baso-0.4
[**2161-7-7**] 04:44AM BLOOD PT-12.0 PTT-34.9 INR(PT)-1.0
[**2161-7-9**] 05:33AM BLOOD Glucose-84 UreaN-28* Creat-1.3* Na-144
K-3.8 Cl-104 HCO3-32 AnGap-12
[**2161-7-8**] 08:07AM BLOOD Glucose-83 UreaN-29* Creat-1.3* Na-144
K-4.0 Cl-105 HCO3-33* AnGap-10
Cardiac enzymes:
ENZYMES & BILIRUBIN CK(CPK)
[**2161-7-8**] 08:07AM 89
Source: Line-PICC
[**2161-7-7**] 04:44AM 175*
Source: Line-PICC
[**2161-7-6**] 05:59AM 388*
Source: Line-a-line; @TROUGH
[**2161-7-5**] 05:57AM 560*
Source: Line-a-line
[**2161-7-4**] 11:41PM 551*
Source: Line-a-line
[**2161-7-4**] 05:17PM 456*
ADDED BUN AND CREA @ 20:21
[**2161-7-4**] 05:05AM 439*
Source: Line-a line
[**2161-7-3**] 03:31PM 360*
[**2161-7-3**] 04:13AM 154*
Source: Line-aline; @TROUGH
[**2161-7-2**] 10:10PM 143*
SLIGHTLY HEMOLYZED
[**2161-7-2**] 08:05AM 83
ADDED CHEM [**2161-7-2**] 10:10AM
[**2161-7-1**] 10:40PM 78
[**2161-7-1**] 05:35PM 59
Troponins:
[**2161-7-8**] 08:07AM BLOOD CK-MB-NotDone cTropnT-0.11*
[**2161-7-7**] 04:44AM BLOOD CK-MB-4 cTropnT-0.12*
[**2161-7-6**] 05:59AM BLOOD CK-MB-5 cTropnT-0.13*
[**2161-7-5**] 04:09PM BLOOD cTropnT-0.12*
[**2161-7-5**] 05:57AM BLOOD CK-MB-10 MB Indx-1.8 cTropnT-0.11*
[**2161-7-4**] 11:41PM BLOOD CK-MB-10 MB Indx-1.8 cTropnT-0.11*
[**2161-7-4**] 05:17PM BLOOD CK-MB-12* MB Indx-2.6 cTropnT-0.10*
[**2161-7-4**] 05:05AM BLOOD CK-MB-21* MB Indx-4.8 cTropnT-0.08*
[**2161-7-3**] 03:31PM BLOOD CK-MB-26* MB Indx-7.2* cTropnT-0.07*
[**2161-7-3**] 04:13AM BLOOD CK-MB-18* MB Indx-11.7* cTropnT-0.08*
[**2161-7-2**] 10:10PM BLOOD CK-MB-17* MB Indx-11.9* cTropnT-0.07*
[**2161-7-2**] 08:05AM BLOOD CK-MB-NotDone cTropnT-0.03*
Micro:
CSF;SPINAL FLUID SEROLOGY/BLOOD STOOL SWAB URINE All
EMERGENCY [**Hospital1 **] INPATIENT
[**2161-7-8**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
negative
[**2161-7-8**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2161-7-8**] URINE URINE CULTURE-PENDING
[**2161-7-8**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
Negative
[**2161-7-3**] CSF;SPINAL FLUID GRAM STAIN-FINAL;
FLUID CULTURE-FINAL;
FUNGAL CULTURE-PRELIMINARY;
ACID FAST CULTURE-PENDING;
VIRAL CULTURE-PENDING INPATIENT
[**2161-7-3**] CSF;SPINAL FLUID CRYPTOCOCCAL ANTIGEN-FINAL INPATIENT
negative
[**2161-7-2**] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-FINAL
INPATIENT negative
[**2161-7-2**] SWAB SMEAR FOR BACTERIAL VAGINOSIS-FINAL; WOUND
CULTURE-FINAL {GRAM NEGATIVE ROD(S)} INPATIENT
[**2161-7-1**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL negative
[**2161-7-1**] URINE URINE CULTURE-FINAL negative
[**2161-7-1**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL Negative
.
CT HEAD W/O CONTRAST [**2161-7-1**] 5:42 PM
IMPRESSION: No evidence of acute intracranial hemorrhage or mass
effect.
.
CHEST (PORTABLE AP) [**2161-7-1**] 5:11 PM
IMPRESSION: Mild cardiogenic edema as above. Followup
radiography after appropriate diuresis recommended to assess for
underlying infection.
.
ECHO
Conclusions:
The left atrium is elongated. 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>55%). Right ventricular chamber size
and free wall motion are normal. The right ventricular cavity is
dilated. Right ventricular systolic function is normal.
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. The left ventricular
inflow pattern suggests impaired relaxation. Tricuspid
regurgitation is present but cannot be quantified. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Brief Hospital Course:
A/P: 77F with Dementia, CHF anemia, who presented with
bradycardia, hypothermia, hypotension, hypoglycemia with delta
MS [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] house with unclear etiology, most likely transient
sepsis. She was admitted to ICU with code sepsis, placed on
pressors and IVFs for hypotension, d50 bolus for hypoglycemia.
.
# hypothermia: resolved with bair hugger, warm fluids on
admission and by time of discharge her temperature remained
wnl. ddx sepsis; hypothyroidism, myxedema coma, central
hypothalamic dysregulation (i.e due to a central ischemic event,
neurogenic shock), adrenal insufficiency. Broadly cover with
antibiotics during admission.TFTs showing sick euthyroid with
elevated TSH and normal free T4, Cortisol normalm, endocrine
consultants did not feel there was not an endocrine etiology.
Neurology was also consulted which did not feel there was an
acute neurologic event to trigger the events. Sepsis was another
possible etiology but urine, CSF and blood cx were
negative.there has been no sign of an infection: Urine, lumbar
and blood cultures are negative. Other possible etiologies for
her hypothermia included hypothyroidism- TSH was elevated but T4
was normal ruling out hypothyroidism.
.
# hypotension: admitted with hypotension, transfer to ICU on
sepsis protocol, was on pressors for 12 hours. Never intubated.
Initially on stress dose steroids rapidly wean off.
Unclear etiology given lack of infectous source that included,
negative chest x ray, negative U/A, negative urine and blood cx,
negative CSF cx. Adrenal insufficiency and neurogenic shock were
also considered. Endocrine consultants r/o adrenal insufficiency
or severe hypothyroidism.
On the floor, patient remained normotensive with no new
episodes.
.
#ID: Possible sources of infection included pneumonia, vs
rectovag fistual vs meningitis resulting in a septic picute. UA
clean. given CTX 2g IV, vanc in ED. Added flagyl to cover
anaerobes initially, but withdrawn after 1d. Also added
acyclovir for possible viral meningitis. Final blood cultures
results are neg, HSV PCR neg, urine culture neg, CSF no growth,
vaginal cultures neg, with no bacteria on gramstain. Following
the lack of a source and negative cultures, broad spectrum
antibiotics and and acyclovir were discontinued. Pt remained
afebrile till [**2161-7-8**] when patient was noted to have a single
rectal temp of 100.4, at that time a UA was checked and was only
notable for blood with 111 RBC no nitrite and few bacteria. No
new episodes of fever.
.
# delta MS.: The change in mental status appeared to be
delirium,however etiology is unclear. [**Name2 (NI) 430**] CT negative, tsh,
rpr wnl. B12, folate wnl. Patient was followed by neurology who
did not find any focal neural deficits. During her admission
especially after transfer from the ICU, she showed an improvment
in mental status. She is able to eat with assistance and able to
move to the chair from the bed with assistance. Over her stay,
she has become more alert and able to answer simple questions
and follows simple commands.
.
#Cardiology
Coronary Artery disease: No history of coronary artery disease,
cardiac enzymes were cycled and were found to be elevated. She
also had EKG changes- st drepression lateral leads and v4-v5-v6
in that setting. An Echo was performed showed no wall motion
abnormalities. She was seen by cardiology and it is presumed
that her elevated cardiac enzymes is secondary to demand
ischemia, especilly in the context of hypotension and no cardiac
history. A lipid panel was subsequently obtained which showed
LDL of 84, HDL of 80, trig 76, chol 179 and were within normal
limits.
.
Pump: In the MICU, after fluid resucitation, CXR showed fluid
overload with elevated CVP by catheterization. Length of stay
MICU fluid balance was 10 L positive. Pt has signs of congestive
failure, peripheral edema in extremities and crackles on lung
exam whcih have improved with diuresis while on the floor. Chest
xray was consistent with signs of pulmonary effusions. While on
the floor, gentle diuresis was done responding well to 20-40 IV
lasix/ day.
On they of discharge, patient sating 93-94% on RA. While on the
floor she has gone from 135.0 kg to 133.0ktg. Will advise
continued diuresis till baseline weight.
Rhythm: Pt presented with bradycardia and first degree AV block.
It was also in the setting of hypothermya. Atropine was given on
admission increasing HR from 40's to low 50's. On second day,
she developed t wave inversions on the lateral walls.
Patient remained with HR in the low 50's during her admission
but was able to maintained her BP adequately. Cardiiology was
consulted who felt that there were no need of any interventions
at this time. Reviewing prior EKg she had evidence of slow heart
rates.
#Hypertension: Given patient's history of hypotension and
persistent bradycardia no beta blocker was given. Also blood
pressure medications were held
.
# Heme: HCT drop on admission from 28.8 to 22 in the setting of
aggressive fluid resucitation although did have guiac + stool.
Hemolysis labs were negative. She received 5 U PRBC and her HCT
remained stable until day of discharge. HCT on day of discharged
31.2
.
#Hypoglycemia: no h/o diabetes. FS 28 when bradycardic. unclear
etiology, thought initially secondary to adrenal insufficiency
vs. sepsis. Responded to d50 now resolved normal blood sugars.
No other new episodes of hypoglycemia during rest of stay.
.
#Renal: does not have a h/o chronic renal insuff per records. Cr
1.4 on admission, pt pre-renal. improved to 1.2 with IVF. She
was hyperkalemic on admission, presumably due to ARF, resolved
with kayexylate. Currently Cr at 1.3 at discharge. Pt may have
suffered some renal damage from the hypotension. Should be
watched in the setting of diruesis. Pt will have a foley
catheter for evaluation of ins and outs and diuresis. As
patient returns to baseline weight post diuresis the foley can
be discontinued.
.
#Conjuctivitis: Patient given erythromycin ointment.
#FEN: Patient initially had an NG tube. After a satisfactory
speech and swallow evaluation and good PO intake, NGT was
discontinued. She is currently receiving soft foods, able to eat
with assistance. Nutrition has recommended pureed food with
supplements.
Pt has foley catheter for better in/outs recording. Consider d/c
once she is euvolemic.
#ppx: Patient received SC heparin for PE prophylaxis and a
proton pump inhibitor
#access: Patient initially had a right internal jugular line and
A line while in the ICU. PICC line on her right arm on transfer
to the floor.
Picc line discontinued on day of discharged.
Medications on Admission:
aricept 10 qhs
neurontin 300 1 cap [**Hospital1 **]
zyprexa 7.5 qhs
lasix 40mg qday
lidoderm 5% 1 patch x 12hr to back
naprosyn 500mg 1 tab qd
glucosamine 500mg 1 cap tid
tylenol 500mg 1 cap tid
duoneb
.
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4
times a day).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
Hypotension
Hypothermia
Mental status change
bradycardia
Non St elevation Myocardial Infarction.
Secondary:
Dementia
Discharge Condition:
Fair
Fair
Discharge Instructions:
You were admitted for hypotension, hypothermia, mental status
changes and bradycardia.
You had elevated cardiac enzymes but your echo showed no cardiac
wall abnormalities. More likely it was demand ischemia in the
setting of your acute ilness.
All cultures while in house remained negative.
You were in the Intensive Care Unit for 5 days and then transfer
to the regular floor.
Your blood pressure medications were discontinued.
You will still need to take your lasix at home.
Your aricept and pain medications were discontinued for now,
please talk to your physician about restarting them in the
future.
If you notice any changes in mental status, any hypothermia, any
fevers, nausea or vomitting that does not resolve, or any other
concering symptoms please call your PCP or come back to the
emergency room.
Followup Instructions:
Please make an appointment to see your PCP Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Phone
([**Telephone/Fax (1) 8417**] in 1 week.
Completed by:[**2161-7-12**]
|
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icd9cm
|
[
[
[]
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[
"89.61",
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icd9pcs
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[
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15371, 15467
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309, 364
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15629, 15642
|
2673, 4023
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|
1883, 1979
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15082, 15348
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15488, 15608
|
14853, 15059
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15666, 16479
|
1994, 2654
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4510, 8138
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232, 271
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4043, 4493
|
392, 1492
|
1514, 1625
|
1642, 1867
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,433
| 140,317
|
53385
|
Discharge summary
|
report
|
Admission Date: [**2176-7-30**] Discharge Date: [**2176-8-5**]
Date of Birth: [**2129-10-5**] Sex: F
Service: MEDICINE
Allergies:
Zosyn / Quinolones / Ceftriaxone / Flagyl / Keppra
Attending:[**First Name3 (LF) 4232**]
Chief Complaint:
Astma/COPD exacerbation
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 46yo F with spina bifida and paraplegia, MR, HTN,
asthma/COPD, h/o seizures who presented to the ED on [**2176-7-30**]
with SOB. The patient had URI and subjective fever of unclear
duration. In the ED she was sating 94% on continuous nebs.
Initially she was in severe respiratory distress, was unable to
speak, was using accessory muscles. Intubations was deffered
after improvement on continuous nebs. She was also given
morphine 4mg IV, solumedrol 125mg IV x1, azithro 500mg x1,
clinda 600mg x1, combivent followed by continuous albuterol
nebs.
In the MICU she was on continuous nebs for 30hrs. On the day
prior to flood admit she was weaned off to Q1 hr nebs and then
to Q4 hr nebs. She has no oxygen requirement. Her steroid
regimen has been changed from solumedrol to prednisone. She also
continues to be treated with clindamycin and azithromycin.
Additionally, she has had complaints of chest pain attributed to
work of breathing and cough. However, she was ruled out for an
MI. The patient had a non-gap acidosis that was attributed to
her [**Date Range 80011**]. Psych has been following the patient. She is now
therapuetic on phyenytoin. Holding atenolol and lisinopril
secondary to adequate blood pressures.
.
The day of transfer the patient had either a seizure or
pseudoseizure. Her Phenytoin level is currently therapeutic.
Past Medical History:
- spinal bifida
- paraplegia
- mild mental retardation
- psychogenic dysarthria and tremor
- [**Date Range 80011**]
- hypertension
- asthma/copd
- h/o VRE pyelonephritis
- GERD
- Depression
- genital herpes
- atopic dermatitis
- back pain
- uterine prolapse
- twins
- reported seizures and/or pseudoseizures, suggestion of
conversion d/o.
Social History:
Per report prior - She lives alone in an apartment in [**Location (un) 86**].
She is mostly wheelchair bound but is able to transfer
independently, she has no assistance at home "I don't want
strangers in my house." She identifies her boyfriend "[**Doctor Last Name 449**]" as
her emergency contact, gives permission for him to be contact[**Name (NI) **],
saying he lives at [**Name (NI) 4367**] [**Hospital3 400**]. [**Doctor Last Name 449**] calls her
every morning to encourage her to take her medication and visits
her every afternoon to evening. She misses doses of her
medications due to fatigue and forgetting. [**Doctor Last Name 449**] states she is
able to do all her ADLs. She has 2 twin 18 year old boys who
live with their aunt, she asks that they not be contact[**Name (NI) **].
-[**Name2 (NI) 1139**]: she smokes quantity unknown
-ETOH: drinks quantity unknown
-Drugs: according to prior notes, hx of cocaine abuse
Family History:
Unable to obtain - pt can not recall.
Physical Exam:
General: Alert, moderate distress
HEENT: Sclera anicteric, MMM, oropharynx clear, gaze
disconjugate
Neck: supple, JVP not elevated, no LAD
Lungs: wheezes b/l, limited chest movt
CV: Regular rate and rhythm, distant S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, tender around [**Name2 (NI) 80011**] wihoutout other sign of
inflammation, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2176-7-30**] 08:20PM BLOOD WBC-12.6*# RBC-4.03* Hgb-13.3 Hct-40.2
MCV-100* MCH-33.1* MCHC-33.2 RDW-13.2 Plt Ct-220
.
[**2176-8-2**] 05:05AM BLOOD WBC-10.6 RBC-3.00* Hgb-9.8* Hct-29.6*
MCV-99* MCH-32.6* MCHC-33.1 RDW-13.6 Plt Ct-192
.
[**2176-8-2**] 05:05AM BLOOD Glucose-98 UreaN-17 Creat-0.7 Na-139
K-4.7 Cl-107 HCO3-24 AnGap-13
.
[**2176-8-1**] 04:52AM BLOOD ALT-44* AST-25 AlkPhos-205* TotBili-0.3
.
[**2176-7-31**] 05:30PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2176-7-31**] 04:17AM BLOOD CK-MB-4 cTropnT-0.02*
[**2176-7-30**] 08:20PM BLOOD cTropnT-<0.01
.
[**2176-7-30**] 08:20PM BLOOD Phenyto-5.0*
[**2176-8-2**] 05:05AM BLOOD Phenyto-10.1
.
[**2176-7-31**] 04:17AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
[**2176-7-31**] 09:56PM BLOOD Type-ART Temp-37.1 Rates-/20 O2 Flow-10
pO2-91 pCO2-43 pH-7.30* calTCO2-22 Base XS--4 Intubat-NOT INTUBA
Comment-NEBULIZER
.
[**2176-7-31**] 12:56AM BLOOD Type-ART Temp-37.2 Rates-/28 O2 Flow-9
pO2-60* pCO2-39 pH-7.24* calTCO2-18* Base XS--10 Intubat-NOT
INTUBA
Labs on Discharge [**2176-8-5**]:
WBC-10.8 RBC-3.34* Hgb-11.0* Hct-33.5* MCV-100* MCH-32.9* Plt
Ct-220
Glucose-86 UreaN-14 Creat-0.8 Na-139 K-4.4 Cl-104 HCO3-29
Calcium-8.9 Phos-3.2 Mg-2.1
Other Studies:
[**2176-8-2**] CXR: Streaky density at the lung bases likely
representing
subsegmental atelectasis. This finding is somewhat more
pronounced than on
the earlier study.
[**2176-7-31**] EXG: Sinus rhythm with slowing of the rate as compared
with previous tracing of [**2176-7-31**]. The tracing is normal without
diagnostic interim change
[**2176-7-30**] Blood cultures x 2: No growth
Brief Hospital Course:
1) Respiratory Distress: When the patient arrived on the floor
she had oxygenation saturation in the high 90s on room air. We
stopped her clindamycin and azithromycin after reviewing her CXR
and feeling that pneumonia was not likely. Attempts were made to
rule out flu by the MICU team, but unable to obtain a sample
from the patient. We continued to wean her off her Ipratropium
and Albuterol nebs. The day prior to discharge the patient did
not need any nebulizer treatments. We had also started a
prednisone taper and the patient was tolerating that well. As an
outpatient she was to use the following prednisone taper:
Prednisone 40mg for 3 days [**8-6**] - [**8-8**]
Prednisone 20mg for 4 days [**8-9**] - [**8-12**]
Prednisone 10mg for 4 days [**8-13**] - [**8-16**]
Prednisone 5mg for 4 days [**8-17**] - [**8-20**]
The patient also had a follow up appointment with her PCP. [**Name10 (NameIs) **]
the day of discharge she stated that she was breathing well and
she was anxious to go home. We also recommended that she
continue using her home bronchodilator treatments.
.
2)History of seizures: The patient's Phenytoin level was sub
therapeutic on admission. She was started on her home dose and
her phenytoin level was therapeutic on discharge.
.
3)Psychiatric history: The patient's last diagnosis in recent
OMR note: Adjustment Disorder with Mixed Emotional Features &
Personality Disorder NOS. We continued her on her home regimen
of Citalopram and Quetiapine.
.
4) Chest Pain: After continuous nebulizer treatments and
difficulty breathing patient developed reproducible right sided
chest pain. She was ruled out for an MI with serial cardiac
enzymes. Her chest pain was likely musckuloskeletal. She was
initially treated with IV morphine but then weaned to Motrin
800mg TID.
.
5)Code: Full
Medications on Admission:
1. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): a stool softener.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): can stop taking this once you have good bowel movements.
8. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
9. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
10. Phenytoin Sodium Extended 100 mg Capsule Sig: Five (5)
Capsule PO HS (at bedtime).
11. Acetaminophen 500 mg Capsule Sig: Two (2) Capsule PO four
times a day as needed for pain: Can not exceed 4 grams per day
(taking only 4 times per day MAX)- CAN buy over the counter.
.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) 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. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
7. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
8. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
9. Phenytoin Sodium Extended 100 mg Capsule Sig: Five (5)
Capsule PO QHS (once a day (at bedtime)).
10. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 15 days: per taper:
From [**Date range (1) 109809**] take 4 tab (40mg) by mouth every day.
From [**Date range (1) **] take 2 tab (20mg) by mouth every day.
From [**Date range (1) **] take 1 tab (10mg) by mouth every day.
From [**Date range (1) 109810**] take 0.5 tab (5mg) by mouth every day. .
Disp:*26 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Health Systems
Discharge Diagnosis:
Primary Diagnosis:
1) COPD exacerbation
Secondary Diagnosis:
1) h/o spinal bifida
2) paraplegia
3) mild mental retardation
4) seizure disorder
Discharge Condition:
Stable, afebrile
Discharge Instructions:
You were admitted to the hospital for extreem shortness of
breath. You were first admitted to the intenstive care unit. You
were treated with continuous albulterol/ipratroprium nebulizers.
We decreased these treatments as your lungs improved. Please
continue to use your Advair 1 puff twice a day. We also treated
you with steriods, Prednisone. Please follow these intructions
for your prednisone:
1) Prednisone 40mg for 3 days [**8-6**] - [**8-8**]
2) Prednisone 20mg for 4 days [**8-9**] - [**8-12**]
3) Prednisone 10mg for 4 days [**8-13**] - [**8-16**]
4) Prednisone 5mg for 4 days [**8-17**] - [**8-20**]
You have developed some chest pain related to coughing. You can
take extra strength Motrin to relieve this pain.
While in the hospital you also developed your seizures. Please
make sure to take your Phenytoin 500mg by mouth at night.
Also your blood pressure was well controlled while you were in
the hospital. Do not take your blood pressure medications until
you see Dr. [**Last Name (STitle) **] on [**2176-8-8**] at 11:20am.
You will have home nursing, physical therapy, and social work to
help you with your needs once you leave the hospital.
Please seek medical care if you have shortness of breath, chest
pain, nausea, vomiting, diarrhea, fevers, chills, seizure, or
headache.
In summary the following changes have been made to your
medications:
1) Prednisone 40mg for 3 days [**8-6**] - [**8-8**]
2) Prednisone 20mg for 4 days [**8-9**] - [**8-12**]
3) Prednisone 10mg for 4 days [**8-13**] - [**8-16**]
4) Prednisone 5mg for 4 days [**8-17**] - [**8-20**]
5) Stop taking your lisinopril
6) Stop taking your Atenalol
Followup Instructions:
Please follow up with your primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) **]. An appointment has been made for you on [**2176-8-8**] at
11:20am. Their office is located on the [**Location (un) 10043**] of [**Location (un) 109811**]. Their number is [**Telephone/Fax (1) 2776**].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 4236**]
Completed by:[**2176-8-9**]
|
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icd9cm
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[
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|
2101, 3033
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,354
| 113,724
|
26780
|
Discharge summary
|
report
|
Admission Date: [**2123-1-24**] Discharge Date: [**2123-2-3**]
Date of Birth: [**2044-5-7**] Sex: M
Service: MEDICINE
Allergies:
Darvocet A500
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
ETOH withdrawl
Major Surgical or Invasive Procedure:
intubation [**1-24**], extubation [**1-25**]
EGD on [**2123-2-2**]
History of Present Illness:
78 yo M with PMHx of ETOH use and HTN, was transferred to our ED
from the OSH ED for management of frostbite of hands, knees and
feet. He was in his USOH until yesterday evening when he had a
few drinks in the bar, then was unable to open the door to his
house and fell asleep in his doorsteps last night. ? fall from
the porch. He woke this morning, got into the house, slept
some more, then woke up with increasing pain in his hands, feet
and knees. He presented to the OSH ED on [**2123-1-24**] where his work
up was significant only for the abovementioned frostbite, for
which he was trasnferred to the [**Hospital1 18**] ED.
.
In our ED, he was evaluated by plastics (conservative
management). He was also found to be withdrawing from ETOH
(tachycardic, hypertensive, hyperthermic and tremulous). He was
given a total of 30 mg of Valium. His respirations were noted
to be coarse, his O2 sat was 91% on RA, then 95% on a few liters
NC, then 100% on NRB. CXR showed bibasilar atelectasis vs PNA.
His Tm was 102 rectally during a withdrawal episode. He was
given empiric ABXs (Vanc and Levofloxacin) here (got Unasyn at
the OSH). Head CT neg.
.
For the first several hours of the ED stay he was found to have
no UOP. He got a total of 3.5 L fluids. Bladder scan showed
significant urinary retension. Foley was changed to 20F: he put
out 1 L (with some hematuria and clots), then his SBP dropped to
70s--> spont back up to 100s. Repeat CXR in the ED without
significant change. The pt then began to have coffee ground
emesis and the pt was intubated for airway protection (copious
oral secretions noted).
ROS prior to intubation: raspy voice; coughing up thick sputum;
loss of sensation in his fingers and his R great toe.
In the [**Hospital Unit Name 153**] [**2123-1-24**] pt initially hypotensive upon arrival w/ SBP
70s but responded to IVFs without pressor requirement. Pt had
[**Hospital1 **] dressing changes for his frostbite wounds and was by
plastics. He was extubated without complications on [**2123-1-25**].
Due to refusal to eat his NG tube was continued for medication
administration. As his ankle was notes to be painful, X-rays
were performed and showed ankle fracture - ortho was contact[**Name (NI) **]
for evaluation with plans to cast. Due to hypertension
metoprolol was started. Out of concern for cellulitis
associated with frostbite as well as to cover possible
aspiration pneumonia, Unasyn was initiated. Regarding bloody
emesis, hct remained stable, GI consulted with plan to perform
EGD once stable.
.
ROS prior to intubation: raspy voice; coughing up thick sputum;
loss of sensation in his fingers and his R great toe.
.
Meds in the ED: Dilaudid (3 mg IV); Fentanyl (100 mcg); Versed
(4 mg); Propofol gtt, Levofloxacin
Past Medical History:
Varicous veins
HTN
Social History:
ETOH of approx 5 beers per day; neg tobacco and illicit drugs
Family History:
NC
Physical Exam:
PE: 98.5 160/90 95 17 100% RA
HEENT: MMM
Neck: no JVD
CV: RRR; distant heart sounds
Lungs: CTA anteriorly
Ab: obese; + BS; no organomegaly; visible superficial veins;
redusible umbilical hernea
Extrem: escars B knees w/ surrounding erythema; moves all toes.
pulses by doppler only. hands with extensive blistering and
discolaration. loss of sensation distal to PIP all 5 digits B
and B great toes per chart; 2+ edema B LEs
.
Pertinent Results:
ABDOMEN ULTRASOUND: The liver is diffusely echogenic consistent
with fatty infiltration. No nodular outer contour is
appreciated. There is no intra or extrahepatic ductal
dilatation. The common bile duct measures 3 mm. The gallbladder
contains several stones. There is no gallbladder wall
thickening. There is a large cyst in the upper pole of the right
kidney, measuring up to 9 cm in diameter. A single thin
septation is seen within the cyst. The right kidney is otherwise
unremarkable. Two simple cysts are present within the left
kidney, with the largest at the lower pole measuring 1.8 cm in
diameter. The spleen is unremarkable. The pancreatic head is
normal.
IMPRESSION:
1. Echogenic liver consistent with fatty infiltration. Other
forms of liver disease and more advanced liver disease including
significant hepatic fibrosis/cirrhosis cannot be excluded on
this study.
2. Cholelithiasis.
.
RIGHT ANKLE: AP, oblique, and lateral views. Osseous detail is
obscured by the overlying cast. The distal fibular fracture is
again seen, with minimal distraction of the fracture fragments.
The ankle mortise is preserved. Pes planus is again noted.
Vascular calcifications are also again noted.
.
EGD ([**2123-2-2**]): ulceration of esophagus and stomache, antral
gastritis
.
ECHO:
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *5.7 cm (nl <= 4.0 cm)
Left Ventricle - Septal Wall Thickness: *1.4 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.4 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.7 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: >= 70% (nl >=55%)
Aorta - Valve Level: 2.2 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.7 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 2.0 m/sec (nl <= 2.0 m/sec)
INTERPRETATION:
Findings:
LEFT ATRIUM: Moderate LA enlargement.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Suboptimal
technical quality, a focal LV wall motion abnormality cannot be
fully
excluded. Hyperdynamic LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Mildly dilated ascending
aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets. No
valvular AS. The
increased transaortic gradient related to high cardiac output.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MR.
TRICUSPID VALVE: Tricuspid valve not well visualized.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Conclusions:
The left atrium is moderately dilated. There is mild symmetric
left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. 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 valve leaflets are mildly
thickened. There is no valvular aortic stenosis. The increased
transaortic gradient is likely related to high cardiac output.
No aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. No mitral regurgitation is seen. There is no
pericardial effusion.
Brief Hospital Course:
Briefly, this is a 78 yo with h/o ETOH abuse who presented with
frostbite on hands, broken right ankle, and hematemesis
secondary to stomach/esophageal ulcers and gastritis. On arrival
the pt was admitted to the [**Hospital Unit Name 153**] s/p intubation in the ED for
respiratory distress and airway protection.
.
1)ETOH abuse: He was written for CIWA protcol but never required
any valium. He was started on daily thiamine and folate. He
was started on metoprolol 12.5 mg po tid for likely both
underlying baseline HTN and perhaps minor withdrawl. Social work
was consulted
.
2)Respiratory Distress: Initially in the [**Name (NI) **] pt had appearance of
increased resp. distress but was satting at 100% on NRB;
subsequently was intubated for airway protection in the setting
of coffee ground emesis. Pt may have had another aspiration
event or had flash pulmonary edema s/p fluid resuscitation at
that time. The pt was extubated [**1-25**] without diffficulty,
satting 100% on 50% shovel mask. TTE showed some mild diastolic
dysfunction with EF >70%, mild symmetric LVH; perhaps explaining
flash edema on admission. Given mild rales on exam and 3L
positive fluid balance on HD3, the pt was given Lasix 20 mg IV
x1. Over the course of the hospitalization pt was diuresed with
good effect, no longer requiring supplemental oxygen.
.
3)Fever/Elevated WBC: WBC on admission 20.1 with 6%bands. WBC
on HD3 was down to 10 with no bands. Most likely source of fever
and elevated WBC was either ETOH withdrawl/stress demargination
vs. aspiration pneumonitis vs pneumonia vs skin infection in
light of frostbite. The pt was initially started on levo and
flagyl on admission; however Unasyn was started also on the
night of admission to cover the pts skin given his frostbite,
and levo/flagyl were discontinued given redundant coverage. Pts
wbc count returned to [**Location 213**], no fevers, was switched to
Augmentin for antibiotic prophylaxis against skin infection.
.
4)Ankle fracture: The pt c/o medial R ankle pain. XR on [**1-26**]
revealed oblique fx of distal fibula likely secondary to
eversion injury. Ortho was consulted and casted ankle. Knee
films obtained demonstrated no fracture at knee. Ortho team
suggested weight bearing as tolerated and follow up with Dr.
[**Last Name (STitle) **] 2 weeks from dicharge. Appointment made and listed in
discharge plan.
.
5)Stomach/esophagheal ulcers and gastritis: The pt had an
episode of coffee ground emesis in the ED. Hct remained stable
throughout course. On [**2123-2-2**] EGD performed and showed
stomach/gastric ulcers and gastritis. Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 2161**] and Dr. [**Last Name (STitle) **].
[**Doctor Last Name 3815**] of [**Hospital1 18**] GI department recommended protonix [**Hospital1 **] for 8
weeks followed by repeat EGD. Appointment made and listed in
discharge plan. Biopsies obtained and pending.
.
6)Frostbite: The pt sustained extensive frostbite injury to his
hands and fet with sensory loss distal to all PIPs and in his BL
1st toes. The pt was seen by plastics in the ED who recommended
xerofrom dressings [**Hospital1 **] and volar splints. The pt was covered
for potential infection with Unasyn which was switched to
Augmentin.
.
7Episode of Hypotension: The pt has one episode of hypotension
in the ED of unclear etiology, but self-limited (likely
contribution from sedatives received in the ED). His hypotension
quickly resolved with 1 L fluid bolus on admission to the [**Hospital Unit Name 153**]
and he never required pressors. In fact, the pt became
hypertensive by HD2.
.
8)Traumatic foley placement: Bleeding with foley placment
resolved. Four days prior to day of discharge foley removed, pt
voiding w/o difficulty.
.
9)Abdominal distension: Given unknown hx and alcohol abuse,
ultrasound obtained. LFTs normal. No ascities by ultrasound.
Liver with fatty infiltrations c/w alcoholic damage.
.
10) HTN: Difficult to control, typically 160-200/80-100 once off
ICU. Titrated up Lisinopril to max, Toprol started, Amlodopine
started ([**2123-2-2**]). Will need further titration at rehab.
.
Medications on Admission:
? Lisinopril
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
5. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 4 days.
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Ipratropium Bromide 0.02 % Solution Sig: one treatment
Inhalation Q6H (every 6 hours) as needed.
9. Albuterol Sulfate 0.083 % Solution Sig: one treatment
Inhalation Q6H (every 6 hours) as needed.
10. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
11. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
13. Toprol XL 200 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day. Tablet Sustained
Release 24HR(s)
14. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
16. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
frostbite
ankle fracture
CHF
GI bleed
Discharge Condition:
stable
Discharge Instructions:
Please call your PCP or return to emergency room with chest
pain, difficulty breathing, fever, increased pain in your hands.
Please call your PCP or return to emergency room with chest
pain, difficulty breathing, fever, increased pain in your hands.
Followup Instructions:
1) Regarding the ulcers in your stomach and esophagus, you will
need a repeat EGD to ensure that these have healed. You are
scheduled for [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2123-3-31**] 10:30; Place: SUITE GI ROOMS on the [**Hospital Ward Name 5074**] of [**Hospital1 **] Hospital.
2)Please follow up with the Plastic Surgeons. You have make an
appointment to be seen in two weeks phone number ([**Telephone/Fax (1) 65943**].
Completed by:[**2123-2-2**]
|
[
"530.19",
"786.09",
"531.90",
"428.30",
"E884.9",
"291.81",
"507.0",
"303.91",
"276.1",
"991.2",
"428.0",
"535.51",
"824.8",
"991.1",
"788.20",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
12682, 12761
|
7042, 11184
|
287, 355
|
12843, 12852
|
3758, 7019
|
13150, 13676
|
3288, 3292
|
11247, 12659
|
12782, 12822
|
11210, 11224
|
12876, 13127
|
3307, 3739
|
233, 249
|
383, 3149
|
3171, 3192
|
3208, 3272
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,362
| 135,878
|
8526
|
Discharge summary
|
report
|
Admission Date: [**2202-9-22**] Discharge Date: [**2202-9-30**]
Date of Birth: [**2133-5-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Respiratory failure
Major Surgical or Invasive Procedure:
Endotrachael intubation [**2202-9-21**] - [**2202-9-25**]
History of Present Illness:
69 year-old woman with history of DM2, CAD s/p CABG, paroxysmal
atrial fibrillation, PE in the past, on Coumadin and IVC filter
who presented as Outside Hospital transfer for hypoxemic,
hypercarbic respiratory failure.
She initially presented to [**Hospital3 **] on [**9-13**] after 3 days
of melena, and was found to have a Hct of 5.1 and INR of 3.66.
She was transfused 3 units pRBC, 2 units FFP. The next day she
had a desaturation to the mid 70's on room air, and had crackles
on exam, raising question of CHF exacerbation so she was started
on Bumetanide. By [**9-18**], she required a nonrebreather and was
started on a Lasix drip, with net negative fluid balance.
Despite diuresis she decompensated even more, requiring BiPAP,
and had worsening infiltrates on CXR which were concerning for
aspiration PNA vs ARDS. On [**9-20**], Vanc, Cipro, Imipenem/Cilastin
were started. She had worsening respiratory status so she was
intubated on [**9-21**] and transferred to [**Hospital1 18**] for further workup
and management.
Of note, her bicarb on admission was 35. Per family members, she
has a 40 pack-year history of smoking and she has some sort of
underlying lung disease.
TTE at OSH showed EF of 65%, no valve abnormalities; PA pressure
was 66mmHg. BNP 400.
Past Medical History:
-GI bleed attributed to hemorrhoids
-Hx PE, pulm HTN, on Coumadin and s/p IVC filter
-PAF on Coumadin
-CAD s/p CABG
-DMII
-peripheral neuropathy
-Hx TB (finished 1 yr treatment in [**7-29**])
-Hx meningitis
-Hx osteomyelitis of the spine
-Multiple lumbar compression fx
Social History:
40 pack-year history of cigarettes, no alcohol. Lives at
[**Hospital3 **] with husband. Wheelchair bound due to back pain
and fx's.
Family History:
Positive for CAD and DM
Physical Exam:
DISCHARGE PHYSICAL EXAM
Vitals: T: 98.5 BP:138/77 P:87 R:20 O2:95 on 2L
General: Alert, no acute distress
HEENT: Sclera anicteric, no nasal congestion, oropharynx clear
Neck: supple
Lungs: Scattered rales bilaterally decreased from yesterday, no
wheezes appreciated.
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur
appreciated. no rubs or gallops.
Abdomen: soft, non-distended, non-tender, bowel sounds present,
no rebound tenderness or guarding
Ext: No edema, 2+ distal pulses
Pertinent Results:
ADMISSION LABS
[**2202-9-23**] 12:21AM BLOOD WBC-5.9 RBC-3.55* Hgb-9.8* Hct-30.4*
MCV-86 MCH-27.6 MCHC-32.3 RDW-17.4* Plt Ct-262
[**2202-9-23**] 10:16AM BLOOD Neuts-71* Bands-0 Lymphs-13* Monos-7
Eos-9* Baso-0 Atyps-0 Metas-0 Myelos-0
[**2202-9-23**] 12:21AM BLOOD Glucose-113* UreaN-25* Creat-1.2* Na-146*
K-3.0* Cl-96 HCO3-39* AnGap-14
[**2202-9-23**] 12:21AM BLOOD ALT-9 AST-15 AlkPhos-57 TotBili-0.5
[**2202-9-23**] 12:10AM BLOOD Type-ART pO2-55* pCO2-50* pH-7.58*
calTCO2-48* Base XS-21
DISCHARGE LABS
Chem7: Na 146, K 3.0, Cl 96, bicarb 39, BUN 25, Cr 1.2, glu 113
[**2202-9-30**] 12:20PM BLOOD WBC-6.4 RBC-3.88* Hgb-10.3* Hct-33.0*
MCV-85 MCH-26.5* MCHC-31.1 RDW-17.6* Plt Ct-491*
[**2202-9-30**] 12:20PM BLOOD Plt Ct-491*
[**2202-9-30**] 12:20PM BLOOD Glucose-165* UreaN-11 Creat-0.9 Na-137
K-4.2 Cl-102 HCO3-28 AnGap-11
CT chest [**9-24**]
IMPRESSION:
1. Mild pulmonary edema with bibasilar consolidations, could be
atelectasis
however given out of proportions consolidations relative to
small effusions, the possibility of infection should be strongly
considered.
2. Low ET tube, extending up to the carina and just at the
proximal right
main stem bronchus.
4. Unchanged right adrenal mass, could be an adenoma.
5. Extensive vascular and coronary calcifications.
6. Multinodular thyromegaly.
Brief Hospital Course:
69 year-old woman who presented from outside hospital status
post GI bleed while supratherapeutic on Coumadin, whose course
was complicated by respiratory failure. The patient's
respiratory failure was from MRSA pneumonia causing ARDS. With
antibacterial treatment and volume management, the patient was
able to be extubated and weaned down on oxygen to her baseline
of requiring 2L 02 by nasal canula. She had no GI bleeding
during this hospitalization and her hematocrit remained stable.
Problem list:
# Respiratory failure [**2-23**] MRSA pneumonia causing likely ARDS
(PaO2:FiO2 being <200mmHg, bilateral infiltrates on CXR) on
underlying COPD. Heart failure was not likely a significant
factor given BNP 400 and TTE revealing normal pump function., as
well as TTE findings showing normal pump function of the heart.
She was treated initially with broad spectrum abx with vanco,
cipro, imipenem until sputum cultures grew MRSA. She was
narrowed to Vanco only to complete an 8-day course. She
returned back to her baseline oxygen use and was discharged on
2L oxygen.
# GI bleed, melena, tagged blood scan revealing bleed in left
colon: Melena suggests upper GI bleed such as PUD. Tagged blood
scan results indicate lower GI bleed such as AVM. Given no
active bleeding, [**Hospital **] clinic follow up and consider upper and
lower endoscopy for diagnostic evaluation.
# Diastolic heart failure, mild overload from not giving home
lasix. Patient given some gentle diuresis and restarted on home
dose of lasix. Euvolemic at the time of discharge.
# History of PE with IVC filter in place: Patient had both GI
bleeding and evidence of retroperitoneal bleed. In consultation
with the patient PCP and GI decided to not to restart
anticoagulation given the risk of bleeding.
# Paroxysmal atrial fibrillation: Patient was in normal sinus
rhythm throughout hospitalization. Metoprolol was continued.
# HTN: Patient was hypertensive in ICU and was continued on
Metoprolol and started on hydralazine. Hydralazine was
discontinued when patient was on the floor and Lisinopril was
started.
# COPD: Patient has history of COPD. On 2L home oxygen
chronically. She was continued on oxygen and given albuteral and
ipratropium nuebulizers as needed. She was at her baseline
oxygen use (2L) at time of discharge.
# Diabetes mellitus type 2: Patient was placed on sliding scale
insulin. Glucose was well-controlled throughout hospital course.
Medications on Admission:
Acetaminophen 1000 mg NG Q4H:PRN
Atrovent 2 puffs QID
Xanax 0.5mg q6H PRN agitation
Chlorhexidine to oral cavity daily
Cipro 400mg IV BID
Propofol
SSI Regular
Dilaudid 0.5mg IV q3H PRN:pain
Imipenem/Cilastin 500mg IV Q6H
Lopressor 2.5mg IV Q8H
Dronedarone 400mg PO BID
Prilosec 20mg NG [**Hospital1 **]
Paxil 10mg NG daily
Vancomycin 1.25g IV daily
Xopenex 2 puffs inh QID
Discharge Medications:
1. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
2. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for insomnia.
4. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO Q 12H (Every 12 Hours).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
11. Vitamin D 400 unit Capsule Sig: Two (2) Capsule PO twice a
day.
12. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2)
Inhalation four times a day as needed for shortness of breath or
wheezing.
13. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for dizziness.
14. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary Diagnoses:
- Respiratory failure
- Pneumonia, methicillin-resistent Staph aureus
- Gastrointestinal bleed
Secondary Diagnoses:
- Diabetes mellitus, type 2
- Diastolic heart failure
- Atrial fibrillation
- Hypertension
- Chronic obstructive pulmonary disease
- Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to [**Hospital1 69**]
([**Hospital1 18**]) after being found at an outside hospital to have
gastrointestinal bleeding, decreased blood counts, as well as
difficulty breathing. Because of the difficulty breathing, you
had a breathing tube placed and were transferred to [**Hospital1 18**] to the
ICU. You were found to have pneumonia and you were treated for
this. Your bleeding also stopped.
You were transferred to the floor where you finished your
antibiotics. The GI doctors saw [**Name5 (PTitle) **] and talked to Dr. [**Last Name (STitle) 6700**]
who believed you should not restart your Coumadin. In addition,
the GI doctors wanted to follow-up with you as an outpatient to
schedule a colonoscopy/endoscopy.
Please note the following changes to your medications:
** START Protonix 40 mg twice a day
** STOP Coumadin
Please continue to take all of your other medications as
prescribed.
Please keep all follow-up appointments and take all medications
as directed. If you notice bleeding, increase in fatigue,
shortness of breath, cough or fever, please return to Emergency
Department.
Followup Instructions:
Department: Primary Care
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M.
When: Thursday [**2202-10-7**] at 12 PM
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 6698**]
Phone: [**Telephone/Fax (1) 6699**]
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2202-10-13**] at 2:00 PM
With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11716**] [**Name8 (MD) 11717**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
|
[
"578.9",
"V45.81",
"428.0",
"357.2",
"427.31",
"482.42",
"276.3",
"250.60",
"496",
"518.81",
"V58.66",
"V12.51",
"428.32",
"414.00",
"787.91",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
8179, 8234
|
4027, 4521
|
334, 393
|
8570, 8570
|
2698, 4004
|
9888, 10577
|
2147, 2172
|
6896, 8156
|
8255, 8370
|
6499, 6873
|
8753, 9514
|
2187, 2679
|
8391, 8549
|
9543, 9865
|
275, 296
|
421, 1689
|
4535, 6473
|
8585, 8729
|
1711, 1982
|
1998, 2131
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,543
| 113,974
|
4420
|
Discharge summary
|
report
|
Admission Date: [**2187-10-28**] Discharge Date: [**2187-11-13**]
Date of Birth: [**2117-5-28**] Sex: F
Service: SURGERY
Allergies:
Bactrim / Amoxicillin / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
Abdominal wound infection
Major Surgical or Invasive Procedure:
[**2187-10-31**] Exploratory laparotomy; repair of gastric perforation;
chest tube insertion
History of Present Illness:
70-year-old female who had had undergone a splenectomy for
massive
splenomegaly 3 weeks ago. She returned with a smoldering
abdominal wound infection and illness; gastric juice pouring out
of the wound. She was admitted for evaluation and exploratin of
her wound.
Past Medical History:
-splenomegaly--as above.
-cholecystectomy
-ventral and inguinal hernia repair
-Hypertension
-Atrial fibrillation
-Chronic UTI
-Anemia
-Ovarian cysts
-Appendectomy
-TAH-BSO
.
Allergies: IV contrast, Bactrim, PCN
Social History:
SH: Married, works as a director of religious education for a
Catholic organization. No alcohol, tobacco or drugs.
Family History:
HTN
Pertinent Results:
[**2187-10-28**] 07:05PM CALCIUM-8.7 PHOSPHATE-4.2
[**2187-10-28**] 07:05PM WBC-20.3* RBC-2.65* HGB-7.7* HCT-26.0* MCV-98
MCH-28.9 MCHC-29.5* RDW-20.5*
[**2187-10-28**] 02:30PM ALT(SGPT)-14 AST(SGOT)-10 ALK PHOS-158*
AMYLASE-41 TOT BILI-1.5
[**2187-10-28**] 02:30PM cTropnT-<0.01
[**2187-10-28**] 02:30PM ALBUMIN-2.4* CALCIUM-8.6 PHOSPHATE-4.0
MAGNESIUM-2.4
[**2187-10-28**] 02:30PM PLT COUNT-650*
[**2187-10-28**] 02:27PM GLUCOSE-317* LACTATE-2.5* NA+-134* K+-5.4*
CL--97* TCO2-28
[**2187-11-10**] UNILAT UP EXT VEINS US LEFT
LEFT UPPER EXTREMITY VENOUS ULTRASOUND: Grayscale and Doppler
examination of the left internal jugular vein, axillary vein,
basilic vein and cephalic veins were performed. The left
cephalic vein is distended, non-compressible, with hypoechoic
intraluminal thrombus, and no flow. The left internal jugular
vein, axillary vein, and basilic veins demonstrate normal
compressibility, augmentability and respiratory variation and
flow.
IMPRESSION: Thrombosis of the left cephalic vein, likely acute.
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
Reason: eval for possible leakplease give oral contrast & infuse
con
[**Hospital 93**] MEDICAL CONDITION:
70 y/o female s/p open splenectomy with copious drainage from
abdominal wound
REASON FOR THIS EXAMINATION:
eval for possible leakplease give oral contrast & infuse
contrast into the 2 abdominal drains
CONTRAINDICATIONS for IV CONTRAST: None.
[**2187-11-8**] CT OF THE ABDOMEN AND PELVIS WITHOUT CONTRAST:
IMPRESSION:
1. Bilateral pleural effusions. The right pleural effusion has
increased in size since the prior study.
2. Overall, marked improvement in previously seen amount of gas
and fluid in the upper abdomen, now with expected post-surgical
changes. Streak artifact from the residual high- density barium
in the stomach and proximal small bowel makes it difficult to
determine whether the oral contrast is within or immediately
adjacent to the bowel lumen.
3. No frank contrast extravasation and no free intraperitoenal
air is seen.
4. Stable right groin hematoma.
Cardiology Report ECG Study Date of [**2187-11-2**] 1:05:50 AM
Baseline artifact. Atrial fibrillation with an average
ventricular response
about 95 per minute. Relatively low voltage diffusely.
Non-specific ST-T wave
changes. Compared to the previous tracing of [**2187-10-30**] atrial
fibrillation is now
seen. Clinical correlation is suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
95 0 96 350/411 0 64 0
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2187-11-13**] 08:50AM 13.37*1 2.65* 7.7* 25.1* 95 29.2 30.9*
18.8* 970*
Source: Line-PICC
1 VERIFIED
[**2187-11-12**] 03:01AM 15.14*1 2.52* 7.1* 24.0* 96 28.4 29.7*
19.0* 846*2
Source: Line-PICC
1 VERIFIED
2 FEW CLUMPS SEEN
[**2187-11-11**] 04:04AM 20.3* 2.70* 7.8* 25.7* 95 28.7 30.1*
18.7* 770*
Source: Line-Rt PICC
[**2187-11-10**] 02:47AM 18.1*1 2.56* 7.4* 24.2* 95 28.9 30.5*
18.4* 705*
Source: Line-PICC
1 CHECKED FOR NRBC
[**2187-11-9**] 03:24AM 20.8*1 2.75* 7.8* 25.8* 94 28.6 30.5*
18.0* 676*
Source: Line-Right PICC
1 CHECKED FOR NRBCS
[**2187-11-8**] 04:30AM 18.1*1 2.97* 8.4* 27.3* 92 28.4 30.8*
17.8* 610*
Source: Line-PICC
1 VERIFIED BY SMEAR
CHECKED FOR NRBC'S
[**2187-11-7**] 04:27AM 22.4* 3.25*# 9.5*# 29.9*# 92 29.1 31.6
18.0* 633*
Source: Line-CVL
[**2187-11-6**] 04:04AM 20.8*1 2.34* 6.4* 21.5* 92 27.5 30.0*
18.9* 640*
Source: Line-Left CVL
1 VERIFIED BY SMEAR
[**2187-11-5**] 02:02AM 22.7*1 2.51* 7.1* 22.9* 91 28.1 30.9*
18.8* 559*
Source: Line-CVL
1 CHECKED FOR NRBC'S
[**2187-11-4**] 04:40AM 22.0* 2.62* 7.3* 24.2* 92 28.0 30.3*
18.8* 563*
Source: Line-triple lumen
[**2187-11-3**] 04:37PM 18.7* 2.69* 7.5* 24.6* 92 27.9 30.5*
19.1* 547*
Source: Line-CVL
[**2187-11-3**] 05:35AM 18.0*1 2.51* 7.3* 23.6* 94 29.0 30.8*
19.5* 546*
Source: Line-triple lumen
1 VERIFIED BY SMEAR
[**2187-11-2**] 03:03AM 28.90*1 2.73* 7.9* 24.9* 91 29.0 31.8
19.5* 454*
Source: Line-arterial
1 CHECKED FOR NRBCS
[**2187-11-1**] 04:38AM 23.5*1 3.48* 10.0* 31.2* 90 28.8 32.1
19.5* 536*
1 CHECKED FOR NRBCS
[**2187-11-1**] 01:38AM 19.9*1 3.30*# 9.6*# 29.7*# 90#2 29.0 32.2
19.3* 499*
Source: Line-aline
1 CHECKED FOR NRBCS
2 VERIFIED
[**2187-10-30**] 09:25PM 13.3* 2.29* 6.5* 22.2* 97 28.5 29.5*
20.3* 648*
[**2187-10-30**] 05:35AM 11.5*1 2.23* 6.6* 22.5* 101* 29.6 29.3*
21.0* 640*
1 VERIFIED
[**2187-10-29**] 04:09AM 19.4* 2.45* 7.1* 24.5* 100* 28.8 28.8*
20.8* 606*
[**2187-10-28**] 07:05PM 20.3*1 2.65* 7.7* 26.0* 98 28.9 29.5*
20.5* 724*
1 VERIFIED BY SMEAR
[**2187-10-28**] 02:30PM 17.8*1 2.64* 7.7* 26.5* 100.2*#2 29.3
29.2* 20.7* 650*
1 VERIFIED BY SMEAR
2 ID CHECKED
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2187-11-13**] 08:50AM 88* 0 4* 4 4 0 0 0 0
Source: Line-PICC
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr
[**2187-11-13**] 08:50AM 1+ 2+ NORMAL 2+ NORMAL NORMAL
Source: Line-PICC
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2187-11-13**] 08:50AM VERY HIGH 970*
Source: Line-PICC
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino
[**2187-11-1**] 01:38AM 346#
Source: Line-aline
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2187-11-12**] 03:01AM 174* 29* 0.8 135 4.4 105 22 12
Source: Line-PICC
ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2187-11-12**] 03:01AM Using this1
Source: Line-PICC
1 Using this patient's age, gender, and serum creatinine value
of 0.8,
Estimated GFR = 71 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 70+ is 75 (mL/min/1.73
m2)
GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2187-11-10**] 03:20PM 8 21 832* 153* 31 0.9
Source: Line-picc
OTHER ENZYMES & BILIRUBINS Lipase
[**2187-11-10**] 03:20PM 30
Source: Line-picc
CPK ISOENZYMES CK-MB cTropnT
[**2187-10-30**] 09:25PM NotDone1 0.02*2
1 NotDone
CK-MB NOT PERFORMED, TOTAL CK < 100
2 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
[**2187-10-30**] 07:20PM NotDone1 0.012
1 NotDone
CK-MB NOT PERFORMED, TOTAL CK < 100
2 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
[**2187-10-30**] 10:25AM NotDone1 0.04*2
SAMPLE MODERATELY HEMOLYZED
1 NotDone
CK-MB NOT PERFORMED, TOTAL CK < 100
2 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
Cholest
[**2187-11-12**] 03:01AM 7.6* 3.9 2.1
Source: Line-PICC
HEMATOLOGIC calTIBC Ferritn TRF
[**2187-11-10**] 03:20PM 169* 1084* 130*
Source: Line-picc
LIPID/CHOLESTEROL Cholest Triglyc HDL CHOL/HD LDLcalc
[**2187-11-3**] 11:45AM 86 771 23 3.7 48
Source: Line-cvl
1 LDL(CALC) INVALID IF TRIG>400 OR NON-FASTING SAMPLE
ANTIBIOTICS Vanco
[**2187-11-6**] 04:04AM 23.8*1
Source: Line-Left CVL
1 UPDATED REFERENCE RANGE AS OF [**2186-9-27**] == REPRESENTS
THERAPEUTIC TROUGH
LAB USE ONLY HoldBLu
[**2187-10-28**] 02:30PM HOLD1
1 HOLD
DISCARD GREATER THAN 24 HRS OLD
Blood Gas
BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calTCO2 Base XS
[**2187-11-1**] 01:51AM ART 139* 41 7.41 27 1
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Lactate Na K Cl
calHCO3
[**2187-11-1**] 01:51AM 1.8
HEMOGLOBLIN FRACTIONS ( COOXIMETRY) Hgb calcHCT
[**2187-10-28**] 02:27PM 7.9* 24
CALCIUM freeCa
[**2187-11-1**] 01:51AM 1.07*
Blood Urine CSF Other Fluid Microbiology
Recent
Last Day Last Week Last 30 Days All Results Hide Comments
From Date To Date
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2187-11-13**] 08:50AM 13.37*1 2.65* 7.7* 25.1* 95 29.2 30.9*
18.8* 970*
Source: Line-PICC
1 VERIFIED
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2187-11-13**] 08:50AM 88* 0 4* 4 4 0 0 0 0
Source: Line-PICC
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr
[**2187-11-13**] 08:50AM 1+ 2+ NORMAL 2+ NORMAL NORMAL
Source: Line-PICC
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2187-11-13**] 08:50AM VERY HIGH 970*
Source: Line-PICC
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino
[**2187-11-1**] 01:38AM 346#
Source: Line-aline
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2187-11-12**] 03:01AM 174* 29* 0.8 135 4.4 105 22 12
Source: Line-PICC
[**2187-11-11**] 04:04AM 67* 32* 0.8 139 4.5 108 23 13
Source: Line-Rt PICC
[**2187-11-10**] 02:47AM 137* 38* 0.7 139 4.0 108 23 12
Source: Line-PICC
[**2187-11-9**] 03:24AM 95 40* 0.8 140 4.4 108 26 10
Source: Line-Right PICC
[**2187-11-8**] 04:30AM 79 43* 0.9 140 4.1 107 28 9
Source: Line-PICC
[**2187-11-7**] 04:27AM 99 39* 0.9 140 3.8 103 32 9
Source: Line-CVL
[**2187-11-6**] 04:04AM 50* 34* 0.8 139 3.5 102 35* 6*
Source: Line-Left CVL
[**2187-11-5**] 02:02AM 60* 31* 0.8 137 3.6 99 33* 9
Source: Line-CVL
[**2187-11-4**] 04:40AM 108* 27* 0.8 136 4.0 100 31 9
Source: Line-triple lumen
[**2187-11-3**] 05:35AM 170* 22* 0.8 135 4.7 103 29 8
Source: Line-triple lumen
[**2187-11-2**] 03:03AM 85 18 0.8 135 4.4 103 26 10
Source: Line-arterial
[**2187-11-1**] 04:38AM 188* 17 0.7 137 4.3 104 24 13
[**2187-11-1**] 01:38AM 188* 16 0.7 136 4.3 103 24 13
Source: Line-aline
[**2187-10-30**] 09:25PM 186* 19 0.9 134 4.8 100 27 12
[**2187-10-29**] 04:09AM 82 18 0.7 134 4.7 103 23 13
[**2187-10-28**] 07:05PM 268* 20 0.9 135 6.2*1 99 24 18
Brief Hospital Course:
She had previously been hospitalized in early [**Month (only) **] with
long history of splenomegaly with undefined non-malignant
hematologic abnormality, followed closely by Hematology/Oncology
for this. After much discussion with patient, family and her
providers the decision was made for therapeutic splenectomy. She
underwent successful splenic artery embolization on [**2187-10-9**] in
order to reduce the operative risk of splenectomy and on [**10-10**]
she underwent splenectomy. She was eventually discharged to home
with services. She returned with a smoldering wound infection
and illness, and then began to pour gastric juice out of the
wound. She was brought back to the operating room for
exploration of her wound and repair of gastric perforation.
Postoperatively she remained sedated and vented in the Surgical
ICU. TPN was started. She was eventually weaned and extubated
and was later transferred to the regular nursing unit. A VAC
dressing to her abdomen was later applied; the JP drains which
were placed intraoperatively have remained in place because of
continued high output. A regular diet was started and she is
tolerating this without difficulty. She was trialed on
Octreotide; this was eventually discontinued. IV antibiotics
will need to continue for an additional 2 days and then
discontinue; follow up with Dr. [**Last Name (STitle) **] in 1 week.
She underwent LUE ultrasound for swelling noted in her left arm
that was noted several days after central line removal; it did
reveal a thrombus in the cephalic vein. She was maintained on
tid Heparin. A right PICC line was placed eventually for
continued IV antibiotics.
Because of her deconditioned status she was evaluated by
Physical and Occupational therapy and it was recommended that
she go to an acute rehab following hospitalization.
Discharge Medications:
* Continue with IV antibioitcs for 2 more days *
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold fro SBP <110, HR <60.
4. Insulin Lispro 100 unit/mL Solution Sig: One (1) dose
Subcutaneous four times a day as needed for per siding scale:
See Attached sliding scale.
5. Ciprofloxacin 400 mg IV Q12H
6. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
7. Fluconazole 200 mg IV Q24H
8. Vancomycin 1000 mg IV Q 24H
9. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
10. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Gastric Perforation
Abdominal Abscess
Necrotizing Pancreatitis
Discharge Condition:
Good
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in 1 week, call [**Telephone/Fax (2) 19012**] for an
appointment.
You have an appointment with Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3749**], MD that
was scheduled for you prior to this hospitalization.
Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2187-11-21**] 1:00
|
[
"531.10",
"567.22",
"537.4",
"511.9",
"453.8",
"577.0",
"238.75",
"427.31",
"E878.6",
"998.31",
"998.12",
"401.9",
"998.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"52.59",
"44.63",
"99.04",
"88.72",
"99.15",
"93.59",
"38.93",
"34.09",
"96.33",
"44.61"
] |
icd9pcs
|
[
[
[]
]
] |
13666, 13732
|
10788, 12613
|
337, 432
|
13839, 13846
|
1133, 2292
|
13869, 14224
|
1109, 1114
|
12636, 13643
|
2329, 2407
|
13753, 13818
|
272, 299
|
2436, 10765
|
460, 726
|
748, 960
|
976, 1093
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,722
| 108,630
|
42988
|
Discharge summary
|
report
|
Admission Date: [**2178-5-21**] Discharge Date: [**2178-5-26**]
Date of Birth: [**2122-11-28**] Sex: F
Service: PSU
ADMISSION DIAGNOSIS: Absence bilateral breasts.
DISCHARGE DIAGNOSIS: Absence bilateral breasts.
HISTORY OF PRESENT ILLNESS: The patient has a history of
significant bilateral chest and upper body burns and is a
very pleasant 55-year-old female. She is seeking breast
reconstruction.
HOSPITAL COURSE: Patient was admitted on [**2179-5-20**], bilateral
free TRAM flap breast reconstruction was performed. This
proceeded uneventfully. By [**2178-5-26**], the patient was doing
well, ambulating, and tolerating p.o. and was ready for
discharge.
She will follow up next week in the Plastic Surgery center.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10418**], [**MD Number(1) 18192**]
Dictated By:[**Last Name (NamePattern4) 27436**]
MEDQUIST36
D: [**2178-6-18**] 07:27:54
T: [**2178-6-19**] 07:13:05
Job#: [**Job Number 18576**]
|
[
"709.2",
"V45.71",
"070.54",
"906.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"85.7"
] |
icd9pcs
|
[
[
[]
]
] |
209, 237
|
445, 1024
|
159, 187
|
266, 427
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,204
| 123,171
|
37059
|
Discharge summary
|
report
|
Admission Date: [**2197-11-1**] Discharge Date: [**2197-11-14**]
Date of Birth: [**2150-8-26**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
found collapsed at work
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
The pt is a 47 year-old woman who presents after collapsing
at work, found to have a large left basal ganglia hemorrhage.
According to the patient's husband, starting on [**10-29**] the
patient
began complaining of a severe, constant left sided headache. He
states that this was severe enough that she was unable to watch
the [**Company **] game with him on Sunday, and he also was having to
take care of the cooking and cleaning that she would normally
do,
because she was not feeling well. The headache persisted, but
this morning she was able to go to work. Around 9-10am she was
at work, and was found collapsed at her desk, and was noted to
not be moving her right arm. She was taken to [**Hospital3 3583**],
where she was intubated with etomidate, succinylcholine, versed
and vecuronium, presumably because of concerns about ability to
control her airway. She was initially found to have a blood
pressure of 195/112, however after intubation and starting
propofol she dropped as low as 114 systolic. She was briefly
started on neostigmine to then elevate her blood pressure,
however this was stopped on arrival to [**Hospital1 18**]. At [**Hospital 26580**]
Hospital
she had a head CT which showed a 2.5x6cm L basal ganglia
hemorrhage, with ~8mm midline shift. She was given 1g of IV
dilantin, and transferred to [**Hospital1 18**]
On arrival at [**Hospital1 18**], she was initially noted to be quite
agitated, moving all extremities. She was evaluated by
Neurosurgery, who found her to be localizing to pain, L>R, and
then because of the agitation recommended giving her vecuronium.
As she was determined to not be a surgical candidate, Neurology
was then consulted.
Intubated and sedated - unable to obtain ROS
Past Medical History:
- Depression
- Hx of diverticulitis
Social History:
Lives in [**Location 3320**] with her husband and 6 cats. Will
usually split a bottle of wine on Fridays and Saturdays, but
otherwise no EtOH. Quit smoking in [**2173**]. No illicits.
Family History:
Patient is adopted, family history unknown
Physical Exam:
Physical Exam:
Vitals: P:73 R: 16 BP:144/68 SaO2:100% - intubated
General: Intubated, on propofol and recently received vecuronium
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic - performed ~30 minutes after patient received
vecuronium for agitation. Reportedly previously was moving all
extremities, R>L, but was reported to be able to localize to
pain
with both right and left arms.
-Cranial Nerves: Pupils 6mm->4mm bilaterally. Negative
oculocephalics, corneals, gag.
-Motor/Sensory: Flaccid, no response to painful stimuli.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 0 0 0 0 0
R 0 0 0 0 0
Plantar response was mute bilaterally.
Pertinent Results:
[**2197-11-6**] 02:13AM BLOOD WBC-15.0* RBC-4.04* Hgb-13.7 Hct-39.4
MCV-98 MCH-33.9* MCHC-34.8 RDW-12.7 Plt Ct-379
[**2197-11-5**] 01:15AM BLOOD WBC-16.7* RBC-3.88* Hgb-12.9 Hct-36.5
MCV-94 MCH-33.1*# MCHC-35.2* RDW-12.9 Plt Ct-280
[**2197-11-6**] 02:13AM BLOOD Plt Ct-379
[**2197-11-3**] 01:56AM BLOOD PT-11.8 PTT-22.0 INR(PT)-1.0
[**2197-11-6**] 02:13AM BLOOD Glucose-158* UreaN-14 Creat-0.8 Na-142
K-3.6 Cl-99 HCO3-28 AnGap-19
[**2197-11-7**] 02:01AM BLOOD WBC-16.8* RBC-3.98* Hgb-12.9 Hct-37.7
MCV-95 MCH-32.3* MCHC-34.1 RDW-12.8 Plt Ct-391
[**2197-11-9**] 01:55AM BLOOD WBC-16.1* RBC-3.38* Hgb-11.2* Hct-34.0*
MCV-101* MCH-33.1* MCHC-32.9 RDW-12.8 Plt Ct-507*
[**2197-11-11**] 06:35AM BLOOD WBC-12.7* RBC-3.49* Hgb-11.4* Hct-34.6*
MCV-99* MCH-32.6* MCHC-32.9 RDW-13.1 Plt Ct-663*
[**2197-11-12**] 04:45AM BLOOD WBC-13.0* RBC-3.62* Hgb-11.9* Hct-35.1*
MCV-97 MCH-32.8* MCHC-33.9 RDW-13.0 Plt Ct-720*
[**2197-11-13**] 05:55AM BLOOD WBC-15.5* RBC-3.43* Hgb-11.3* Hct-32.9*
MCV-96 MCH-33.0* MCHC-34.3 RDW-13.2 Plt Ct-659*
[**2197-11-13**] 05:55AM BLOOD WBC-15.5* RBC-3.43* Hgb-11.3* Hct-32.9*
MCV-96 MCH-33.0* MCHC-34.3 RDW-13.2 Plt Ct-659*
[**2197-11-6**] 02:13AM BLOOD Neuts-81.2* Lymphs-11.6* Monos-4.9
Eos-1.4 Baso-1.0
[**2197-11-9**] 01:55AM BLOOD PT-13.2 PTT-22.5 INR(PT)-1.1
[**2197-11-10**] 06:10AM BLOOD PT-14.1* PTT-22.6 INR(PT)-1.2*
[**2197-11-11**] 06:35AM BLOOD Plt Ct-663*
[**2197-11-13**] 05:55AM BLOOD PT-16.9* PTT-27.0 INR(PT)-1.5*
[**2197-11-13**] 05:55AM BLOOD Plt Ct-659*
[**2197-11-9**] 01:55AM BLOOD Glucose-151* UreaN-28* Creat-0.7 Na-149*
K-3.8 Cl-108 HCO3-28 AnGap-17
[**2197-11-10**] 06:10AM BLOOD Glucose-144* UreaN-25* Creat-0.7 Na-153*
K-4.1 Cl-114* HCO3-26 AnGap-17
[**2197-11-11**] 06:35AM BLOOD Glucose-136* UreaN-19 Creat-0.6 Na-147*
K-3.5 Cl-110* HCO3-26 AnGap-15
[**2197-11-12**] 04:45AM BLOOD Glucose-124* UreaN-15 Creat-0.7 Na-145
K-3.3 Cl-108 HCO3-27 AnGap-13
[**2197-11-13**] 05:55AM BLOOD Glucose-114* UreaN-11 Creat-0.6 Na-143
K-3.7 Cl-109* HCO3-25 AnGap-13
[**2197-11-8**] 02:04AM BLOOD Calcium-9.1 Phos-3.6 Mg-2.3
[**2197-11-9**] 01:55AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.3
[**2197-11-10**] 06:10AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.5
[**2197-11-11**] 06:35AM BLOOD Mg-2.2
[**2197-11-10**] 06:10AM BLOOD TSH-2.9
[**2197-11-4**] 06:00AM BLOOD Vanco-5.5*
[**2197-11-2**] 02:08AM BLOOD Phenyto-11.5
[**2197-11-7**] 04:01PM BLOOD Type-ART pO2-81* pCO2-45 pH-7.49*
calTCO2-35* Base XS-9
[**2197-11-8**] 12:02AM BLOOD Type-ART pO2-72* pCO2-39 pH-7.50*
calTCO2-31* Base XS-6
[**2197-11-8**] 05:43AM BLOOD Type-ART pO2-108* pCO2-48* pH-7.46*
calTCO2-35* Base XS-8
[**2197-11-2**] 04:20AM BLOOD Glucose-134* Lactate-1.7 Na-139 K-3.8
Cl-109
[**2197-11-3**] 03:37AM BLOOD O2 Sat-98
[**2197-11-6**] 02:31AM BLOOD freeCa-1.17
[**2197-11-7**] 02:13AM BLOOD freeCa-1.19
[**2197-11-1**] 12:30PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.010
[**2197-11-5**] 04:07AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2197-11-10**] 12:13PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-7.0 Leuks-TR
[**2197-11-13**] 05:50PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2197-11-7**] 09:30AM URINE RBC-0-2 WBC-[**1-19**] Bacteri-FEW Yeast-NONE
Epi-0-2
[**2197-11-10**] 12:13PM URINE RBC-[**10-6**]* WBC-21-50* Bacteri-MANY
Yeast-NONE Epi-[**1-19**] TransE-<1
[**2197-11-10**] 09:27PM URINE RBC-[**4-26**]* WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0-2
Microbiology
Cl diff [**11-9**], [**11-10**], [**11-12**] - negative
Stool culture [**11-12**]- Pending at this time
[**2197-11-5**] 8:25 am SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2197-11-9**]**
GRAM STAIN (Final [**2197-11-5**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2197-11-8**]):
Commensal Respiratory Flora Absent.
STAPH AUREUS COAG +. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
[**2197-11-2**] 8:24 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2197-11-5**]**
GRAM STAIN (Final [**2197-11-2**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2197-11-5**]):
SPARSE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Blood culture [**11-2**], [**11-5**]- No growth
Urine culture [**11-2**]- No growth
Imaging:
CT/CTA [**2197-11-1**]:
1. Parenchymal hemorrhage involving the lateral aspect of the
left lentiform nucleus and external capsule, extending into the
left subinsular region. The hemorrhagic focus is noted to
dissect transependymally and appears within the left lateral
ventricle, with mass effect and rightward shift of midline
structures.
2. No evidence of extravasation at the margins of the
parenchymal hemorrhage, to specifically predict expansion.
3. There is no flow-limiting stenosis or occlusion in bilateral
internal
carotid arteries and vertebral arteries.
3. No evidence of AVM or vascular anomaly or aneurysm greater
than 2 mm. 4. No evidence of cerebral venous thrombosis.
CT [**11-2**]:
IMPRESSION:
1. Unchanged left basal ganglia hemorrhage with intraventricular
extent.
2. Similar mass effect, edema, and right subfalcine herniation.
3. Increased paranasal sinus opacification, which be
intubation-related.
CT [**11-4**]:
Left basal ganglia hemorrhage with extension into the left
lateral ventricle has slightly decreased in size. Persistent
surrounding vasogenic edema. There has been interval decrease in
mass effect on the left lateral ventricle. There is
approximately 7 mm of midline shift. Amount of blood in the left
lateral ventricle appears decreased however may be related to
evolution of blood products. There is no evidence of herniation.
The basal cistern and suprasellar cisterns appear patent. There
has been interval increase in opacification of the paranasal
sinuses with significant opacification of sphenoid sinuses,
ethmoid sinus air cells and maxillary sinuses, this is likely
sequelae of recent intubation. No osseous lesion to suggest
malignancy or infection is seen.
IMPRESSION:
Slightly smaller size of left basal ganglia hemorrhage with
extension into the left lateral ventricle.
CXR [**11-3**]
SINGLE AP PORTABLE VIEW OF THE CHEST
REASON FOR EXAM: Intubated patient in the SICU.
Comparison is made with prior study performed a day earlier.
There are low lung volumes. ET tube and NG tube remain in place
in standard
positions. Discoid atelectasis in the left mid lung has
resolved.
Bibasilar atelectases have improved in the left side. There is
no
pneumothorax or pleural effusion. Cardiomediastinal contours are
normal.
CXR [**2197-11-4**]:
Endotracheal tube is low in position, only 1.5 cm proximal to
the carina. NG tube is identified with its tip below the level
of the diaphragm. PICC line is identified on the right side,
which crosses the midline to terminate within the left
brachiocephalic vein at least 6 cm across the midline.
Cardiomediastinal silhouette and pulmonary vasculature are
within normal
limits. There is opacity in the retrocardiac region which is
somewhat hazy in appearance. This likely represents an
infectious process, less likely
atelectasis. Remainder of the lungs is clear. No pleural
effusions. No
pneumothorax.
CXR [**11-6**]
SEMI-UPRIGHT AP VIEW OF THE CHEST: The endotracheal tube
terminates 4.1 cm
above the carina. An orogastric tube terminates within the
stomach. Cardiac,
hilar and mediastinal contours are unchanged since [**2197-11-4**]. Mild
bibasilar atelectasis is unchanged. There is no pneumothorax or
pleural
effusion.
IMPRESSION: No significant radiographic change since [**11-4**], [**2196**].
CXR [**11-7**]
Comparison is made with prior study performed a day earlier.
Dobbhoff tube tip is in the stomach. ET tube is in a standard
position.
There are low lung volumes. Bibasilar atelectasis, greater on
the left side
has minimally increased. Cardiomediastinal contours are normal.
CXR [**11-13**]
FINDINGS: In comparison with the study of [**2196-11-15**], there is
ill-defined
opacification in the right apical region that cannot all be
explained by bony
structures. In view of the clinical history, an apical lordotic
view is
recommended to determine whether this represents a parenchymal
process.
There also is a vague suggestion of soft tissue prominence to
the left of the
superior mediastinum. It is unclear whether this is a true
finding or related
to slight differences in patient position.
.
Brief Hospital Course:
The pt is a 47 year-old woman with a history of depression and 2
days of headache, found to have a 2.5x6cm L basal ganglia
hemorrhage on CT. The patient was noted to have spontaneous
movements on the left, with minimal movement on the right. The
patient does not have a known history of hypertension, but did
have readings as high as 195/112 at [**Hospital3 3583**]. Given the
origin in the basal ganglia, would suspect this represents a
hypertensive hemorrhage. On further history the patient had
been complaining of a headache for 3 days prior to her being
found collapsed at work. She also was noted to have had a
particularly violent cough the last few days
Neuro
The patient was admitted to the neuro-ICU, she had been
intubated at the outside hospital. Given concern of
hydrocephalus she was started on aggressive diuresis with
mannitol and Lasix. The patient's wake full slowly improved.
She began to open her eyes on [**2197-11-6**]. She was closely
monitored for development of raised ICP. her condition gradually
improved, she had significant weakness on her right side both in
UE and LE on examination, however there was some improvement
over the course of her stay.She was later transferred to neuro
floor on [**11-11**] after successful extubation.
She was monitored on neuro floor for further care and was
evaluated by physical and occupational therapy for
rehabilitation.
The patient should have a follow up MRI with contrast in [**11-18**]
months after discharge to ensure that there is not an underlying
lesion which caused the initial hemorrhage. Neurosurgery
requested a head CT in one month to assess progression of
bleeding and hydrocephalus.
ID
Her course was complicated by a pneumonia. She was started on
Vanco/Zosyn on [**11-5**] and eventually grew out MS [**Last Name (Titles) **]. she was
later switched over to nafcillin given MSSA (COAG positive . she
completed her antibiotic course on [**11-13**]. Her repeat chest x ray
did not show appearance of new opacity. Clinically she did not
have fever.
She developed diarrhea since [**11-11**]. It was watery and her Cl
Diff toxin assays were negative ( 3 times). decision was made to
repeat stool toxin studies and stool culture which is still
pending. She was started on Flagyl 500 tid on [**11-14**] for a
duration of 1 week depending upon clinical response.
Pulmo
After extubation, she was noted to have mild stridor and she had
difficulty in getting voice out due to stridor. she was treated
with antiseptic and soothing throat sprays and racemic
epinephrine nebulization with good results and improvement in
her voice. she was seen by speech and swallow therapist who
suggested to start her on modified diet and advance her diet as
tolerated.
CVS
Over the course of her stay her blood pressure was well
controlled other than few episodes of HTN which later resolved,
and she did not require any antihypertensive agents.
General care
She was started initially on pneumonitis for DVT prophylaxis
which was later changed to heparin SC. She was treated with
miconazole powder for groin rash.
Physical exam at DC
Alert, awake, mildly inattentive, hoarse voice with aphasia,
(able to repeat intermittently; naming is inaccurate, paraphasic
errors; dysarthric but fluent)
Right facial droop , no clear field cut, and right hemiplegia
Pending Issues at Discharge:
1. She is on Flagyl PO for presumptive treatment of Cl
Diff,(stool negative times 3),started on [**11-14**], and is planned
for 1 week course, however this may be modified depending upon
clinical response.
2. Her HgbA1c is pending at discharge, she is not know to have
diabetes, however she has required standing NPH [**8-26**] and RI SS
at since admission.
3. Urine metanephrine pending at DC, done as a work up for
episodic HTN given her lack of prior history of hypertension.
4. She has been started on modified diet per speech and swallow
re cs, she has been eating nearly all her meals since this am.
We have not put an NGT, she should be monitored for calorie
intake and nutritional needs , if reqd, consider NG tube.
Medications on Admission:
- Citalopram
- Loestrin
- Ambien PRN
- Ibuprofen PRN
Discharge Medications:
1. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
2. Ipratropium Bromide 0.02 % Solution Sig: [**11-18**] Inhalation Q6H
(every 6 hours) as needed for sob, wheeze.
3. Oral Wound Care Products Gel in Packet Sig: One (1) ML
Mucous membrane TID (3 times a day).
4. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for T>100.4 or pain.
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days: For empiric treatment of C.Diff. .
7. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
8. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Two (2)
Subcutaneous twice a day: 10 units of NPH [**Hospital1 **]- to be titrated as
needed .
9. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection four times a day: Per Sliding Scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**]
Discharge Diagnosis:
Left basal ganglia hemorrhage, likely hypertensive
Pneumonia, treated
Discharge Condition:
Mental Status:Confused - sometimes
Level of Consciousness:Lethargic but arousable
Activity Status: Out of bed to chair, PT as tolerated
Discharge Instructions:
You were admitted after you were found collapsed at your desk at
work. You were initially taken to another hospital where a
breathing tube was placed to assist your breathing. An image of
your head was obtained and you wre found to have a bleed on the
left side, deep in your brain tissue. TO ensure that swelling
of your brain did not cause further damage, you were placed on
mannitol and lasix, two powerful diuretics. In addition your
hospital course was complicated by a pnemonia for which you
recieved antibiotics. You were then transfered out of ICU to
neurology floor for further care, where you were evaluated by
physical therapy.
Please take your meds as directed. please call 911 or your
doctor for any concerning symptoms.
Your Admission medications were as follows:
- Citalopram
- Loestrin
- Ambien PRN
- Ibuprofen PRN
***These medications were all discontinued
You should return in [**4-24**] weeks for an MRI to ensure there is no
other underlying cause of your bleed. You are also requested to
return in 1 month with a head CT to ensure there is not
worsening of the pressure in your brain.
Please take all medications as prescribed. Please call your
doctor if you experience any worsening of your symptoms or any
of the symptoms listed below please call yor doctor or return to
the nearest emergency room.
STUDIES PENDING AT DISCHARGE:
Urine metanephrine
Stool Culture
HbA1C
Followup Instructions:
Please follow up with
Scheduled Appointments :
1) Provider [**Name9 (PRE) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]
Date/Time:[**2197-11-28**] 2:30
2) Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 83554**], MD Phone:[**Telephone/Fax (1) 13266**]
Date/Time:[**2197-12-29**] 1:00
|
[
"431",
"342.91",
"781.94",
"692.9",
"784.3",
"786.1",
"787.21",
"311",
"482.41",
"348.5",
"348.4",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.93",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
19095, 19207
|
13839, 17178
|
341, 367
|
19321, 19321
|
3551, 13816
|
20909, 21279
|
2410, 2456
|
18027, 19072
|
19228, 19300
|
17948, 18004
|
19483, 20831
|
3253, 3532
|
2486, 3236
|
20845, 20886
|
278, 303
|
395, 2129
|
19335, 19459
|
2151, 2189
|
2205, 2394
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,176
| 107,835
|
1141
|
Discharge summary
|
report
|
Admission Date: [**2110-12-18**] Discharge Date: [**2110-12-21**]
Date of Birth: [**2045-3-5**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Ventricular tachycardia
Major Surgical or Invasive Procedure:
elective VT ablation
History of Present Illness:
a 65M with a history of inferior posterior MI s/p three vessel
CABG in [**2094**] with a large residual scar and recurrent VT who
underwent a VT ablation today. He had an initial event of VT
within a year of his MI and had an ICD placed at that time. He
did well until this past summer when his ICD fired twice, once
for Afib and once for VT. Today he underwent an extensive
ablation of his scar. At the end of the procedure he developed a
slow VT which was broken with lidocaine 150 mg IV x1. He was
started on mexilitine and transfered to the CCU for further
management. EKG NSR 82bpm RSR' c/w right intravenricular
conduction delay TWI V4-V6 when compared with [**2110-10-31**] EKG, no
significant changes are noted.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
-CABG: CAD, inferior lateral posterior MI treated with
thrombolytics in [**2094-3-9**] complicated by ventricular
tachycardia, subsequent three-vessel CABG in [**2094-3-9**] at
[**Hospital1 18**]. Anatomy unclear.
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: AICD implantation for ventricular tachycardia in
[**2094-6-9**] at [**Hospital1 18**], generator placement in [**2098**] upgraded device
due to battery depletion in [**2106-6-10**] with [**Company 1543**] AICD and
new RV lead
placement.
3. OTHER PAST MEDICAL HISTORY:
- Paroxysmal atrial fibrillation with evidence of inappropriate
firing of defibrillator.
- Hypertension.
- Hypercholesterolemia.
- Cardiomyopathy, EF 30% seen on echocardiogram in [**2107-5-10**].
- Moderate mitral regurgitation.
- Mild obesity.
- Obstructive sleep apnea treated with CPAP.
Social History:
- Married. He has two children from his first marriage. He is
self employed as a computer analyst
- Tobacco: Denies
- ETOH: One glass of wine twice a week
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission:
GENERAL: Middle aged male intubated and sedated.
HEENT:non injected sclera. no lymphadenopathy.
NECK: JVP not appreciated due to body habitus
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
CHEST: Well healed midline sternotomy and left pacer scars
LUNGS: CTAB in anterior fields, no rales, wheezes or rhonchi.
ABDOMEN: overweight, soft nondistended, liver border smooth,
normoactive bowelsounds.
EXTREMITIES: Right sheath in place, no drainage, no erythemia.
1+ pretibial edema to mid calf BL, no venous stasis changes.
SKIN: no rash
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
EKG
[**2110-12-19**] Normal sinus rhythm. Leftward axis at minus 25
degrees. Q waves in leads III, aVF and in leads V1-V2.
Non-specific ST-T wave changes in
leads I, II, aVL and V5-V6. Compared to the previous tracing of
[**2110-12-15**] no
diagnostic interval change.
.
Admission labs
[**2110-12-18**] 04:50PM BLOOD Hct-43.8
[**2110-12-18**] 07:00PM BLOOD Hct-43.4
[**2110-12-19**] 04:45AM BLOOD WBC-8.6 RBC-4.54* Hgb-15.1 Hct-42.3
MCV-93 MCH-33.2* MCHC-35.7* RDW-13.5 Plt Ct-167
[**2110-12-19**] 04:45AM BLOOD PT-13.2 PTT-22.3 INR(PT)-1.1
[**2110-12-18**] 07:00PM BLOOD Glucose-83 UreaN-15 Creat-0.6 Na-140
K-3.3 Cl-107 HCO3-27 AnGap-9
[**2110-12-19**] 04:45AM BLOOD Glucose-115* UreaN-14 Creat-0.7 Na-140
K-4.4 Cl-108 HCO3-24 AnGap-12
[**2110-12-19**] 04:45AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.1 Cholest-155
[**2110-12-19**] 04:45AM BLOOD Triglyc-307* HDL-40 CHOL/HD-3.9
LDLcalc-54
.
Discharge Labs
[**2110-12-21**] 06:10AM BLOOD WBC-7.2 RBC-4.54* Hgb-14.0 Hct-41.6
MCV-92 MCH-30.9 MCHC-33.8 RDW-13.6 Plt Ct-152
[**2110-12-20**] 05:40AM BLOOD PT-13.1 PTT-23.5 INR(PT)-1.1
[**2110-12-21**] 06:10AM BLOOD Glucose-95 UreaN-14 Creat-0.7 Na-144
K-4.2 Cl-107 HCO3-28 AnGap-13
[**2110-12-21**] 06:10AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.9
Brief Hospital Course:
65M with CAD s/p MI and CABG, CHF, HTN, HLD, VT s/p ablation
with recurrent VT admitted to the CCU after repeat ablpation and
intubation for airway protection.
.
# RHYTHM: Patient admitted for a repeat ablation of focus of
ventricular tachycardia. On the day of admission, patient went
to the cath lab and a focus was identified and ablated.
Immediatetly after ablation, patient entered a slow VT and was
intubated for airway protection. VT converted to sinus rhythm
with a lidocaine bolus and he was extubated without complication
on HD2. He remained in sinus rhythm for the remainder of his
hospitalization. He was started on mexilitine 150mg TID and
sotalol was increased to 120mg [**Hospital1 **]. Metoprolol XL 50mg PO Daily
was continued. Given risk of thromboembolism post VT ablation,
he was started on coumadin with a lovenox bridge. He will follow
up with [**Hospital1 **] anticoagulation and his PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 7325**]
for INR monitoring. He was started on lovenox with and he was
discharged with plan to follow up with Dr. [**Last Name (STitle) **] in EP
within 1 month.
.
# CORONARIES: CAD s/p MI and CABG x3 in [**2094**]. He was continued
on aspirin 325mg PO daily, simvastatin 80 daily, as well as
metoprolol as above.
.
# PUMP: CHF with EF 30%. Euvolemic on exam on admission to CCU.
He was continued on lisinopril 5mg PO Daily and metoprolol.
.
# Hypertension: Continued home metoprolol and lisinopril.
COMM: [**Name (NI) **] [**Name (NI) 1355**] (wife): [**Telephone/Fax (1) 7326**]
Medications on Admission:
- LISINOPRIL 5 mg PO daily
- METOPROLOL SUCCINATE 50 mg PO daily
- SIMVASTATIN 80 mg PO daily
- SOTALOL 80 mg PO BID
- ASPIRIN 325 mg PO daily
- ERGOCALCIFEROL (VITAMIN D2) 1,000 unit PO daily
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*3*
3. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*3*
4. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
5. mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours): 90 day Rx.
Disp:*270 Capsule(s)* Refills:*3*
6. sotalol 120 mg Tablet Sig: One (1) Tablet PO twice a day: 90
day Rx.
Disp:*180 Tablet(s)* Refills:*3*
7. Lovenox 100 mg/mL Syringe Sig: One (1) Subcutaneous twice a
day for 14 days: until INR > 2 for two consecutive days.
Disp:*28 syringes* Refills:*0*
8. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Outpatient Lab Work
Please have INR checked on Monday [**12-22**]
10. Outpatient Lab Work
INR Checks per protocol. Goal INR [**2-12**]. Bridge with Lovenox 100
mg [**Hospital1 **]. Indication: Afib, VT ablation. Contact:
[**Name (NI) 7327**],[**First Name3 (LF) **] R. Phone: [**Telephone/Fax (1) 7328**] Fax: [**Telephone/Fax (1) 7329**]
11. mexiletine 150 mg Capsule Sig: One (1) Capsule PO three
times a day: 30 day Rx.
Disp:*90 Capsule(s)* Refills:*2*
12. sotalol 120 mg Tablet Sig: One (1) Tablet PO twice a day: 30
day Rx.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Recurrent ventricular tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented for VT ablation for management of recurrent
ventricular tachycardia and admitted to the CCU afterwards for
monitoring. You were continued on sotalol at a higher dose, and
you were started on mexilitine. Please have your INR checked on
Monday.
Medication changes:
Sotalol INCREASED to 120mg twice a day.
Mexilitine STARTED at 150mg three times a day.
START Lovenox until INR > 2 for two consecutive days
START Coumadin 5mg daily
Please call your PCP to arrange for monitoring of your INR
(warfarin/Coumadin "level"). His contact info is:
[**Name (NI) 7327**],[**First Name3 (LF) **] R.
[**Location (un) 7330**], [**Location (un) **],[**Numeric Identifier 7331**]
Phone: [**Telephone/Fax (1) 7328**]
Fax: [**Telephone/Fax (1) 7329**]
Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up
more than 3 lbs.
Followup Instructions:
Please schedule follow up with Dr. [**Last Name (STitle) **] within 1 month.
His office number is [**Telephone/Fax (1) 7332**].
.
Please schedule follow up with your PCP [**Name Initial (PRE) 176**] 1 month. His
office number is [**Telephone/Fax (1) 7328**].
|
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|
[
[
[]
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,985
| 182,035
|
33867
|
Discharge summary
|
report
|
Admission Date: [**2201-6-20**] Discharge Date: [**2201-7-17**]
Date of Birth: [**2152-4-28**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Ciprofloxacin
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Mechanical Ventilation
ICU monitoring
PICC line placement X2
Central Line placement
History of Present Illness:
Mr. [**Known lastname 78266**] is a 49-year-old male with a history of APML s/p
induction and consolidation chemotherapy, who has been on a
maintenance program with 6 MP, then methotrexate, and ATRA, who
was found to have recurrent disease and was recently admitted
for MIDAM chemotherapy and discharged two days prior to
admission.
The patient reports having "really bad diarrhea" two days prior
to admission in the evening. He had two more episodes of
diarrhea on the evening prior to admission. He has had some
mild abdominal cramping/discomfort, but no abdominal pain. He
has had some intermittant nausea, but no vomiting. There is no
blood in his stool. He has also had pain near his anus for the
past 3 days which disappeared after he received his first
antibiotic infusion in clinic today. The patient came to clinic
for routine labs today. He was noted to be thrombocytopenic and
received a platelet transfusion. Afterward, his temperature
rose to 102 despite receiving acetaminophen prior. He had blood
cultures drawn both peripherally and from his PICC line. He
received 1 L normal saline and Aztreonam 2000mg IV infusion. On
arrival to the floor he was febrile to 102.5 and vancomycin and
flagyl were hung.
ROS: As above. Additionally notable for poor appetite and low
energy which are stable since his chemo and some intermittant
lightheadedness. Negative for headache, recent vision or
hearing changes, runny nose, sore throat, cough, shortness of
breath, chest pain, palpitations, BRBPR, dysuria, rashes,
myalgias, or arthralgias.
Past Medical History:
1. Acute promyelocytic leukemia
2. s/p cholecystectomy
3. irritable bowel syndrome
4. history of hypercholesterolemia
5. history of anal fissures
Social History:
Negative for tobacco, rarely drinks ETOH. He lives with his wife
and 6 yr old son. [**Name (NI) **] owns a seafood company and is a former
stock broker. He has no known chemical exposures. His only
foreign travel is to [**Location (un) 78267**]. He has a dog.
Family History:
His father died of prostate cancer and also had DM and heart
disease. He has a cousin with [**Name2 (NI) 499**] cancer. No known family with
leukemia or lymphoma.
Physical Exam:
VS: T 102.5, BP 138/74, HR 124, RR 20, 96% on RA
GENERAL: Middle-aged Caucasian male, appears tired, but
comfortable.
HEENT: Sclerae anicteric. PERRL, EOMI. Oropharynx is clear, no
exudates or erythema. No oral lesions. MMM.
NECK: No cervical, supraclavicular, or axillary lymphadenopathy.
HEART: Tachycardic, regular rhythm, normal S1, S2. No m/r/g.
LUNGS: CTAB. No crackles, wheezes or rhonchi.
ABD: Soft, obese, NTND. No HSM appreciated.
RECTAL: Peri-anal tissue with mild erythema near the anus, but
no obvious swelling, bleeding, or exudate. No tenderness to
palpation of the peri-anal tissues.
EXTREMITIES: No edema. 2+ DP pulses bilaterally. Right PICC
line with small amount of dried blood under dressing but no
tenderness to palpation.
SKIN: No rashes
NEURO: Alert and oriented x 3, CNII-XII grossly intact, language
appropriate, moves all extremities symmetrically.
Pertinent Results:
[**Hospital Unit Name 153**] Course Labs:
Labs on admission to [**Hospital Unit Name 153**]:
[**2201-6-22**] 12:00AM BLOOD WBC-0.1* RBC-3.49* Hgb-10.7* Hct-28.7*
MCV-82 MCH-30.7 MCHC-37.2* RDW-13.8 Plt Ct-7*
[**2201-6-22**] 12:00AM BLOOD Neuts-0* Bands-0 Lymphs-100* Monos-0
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2201-6-22**] 08:13PM BLOOD PT-21.6* PTT-48.2* INR(PT)-2.1*
[**2201-6-22**] 12:40PM BLOOD Glucose-104 UreaN-16 Creat-1.0 Na-130*
K-3.8 Cl-100 HCO3-16* AnGap-18
[**2201-6-22**] 12:00AM BLOOD ALT-419* AST-404* LD(LDH)-738* AlkPhos-63
TotBili-3.0* DirBili-1.1* IndBili-1.9
[**2201-6-22**] 08:50PM BLOOD Type-ART pO2-72* pCO2-32* pH-7.40
calTCO2-21 Base XS--3
.
Microbiology Data:
Blood:
Blood Culture, Routine (Final [**2201-6-26**]):
PROTEUS VULGARIS. FINAL SENSITIVITIES.
ESCHERICHIA COLI. FINAL SENSITIVITIES.
PROTEUS VULGARIS
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S =>16 R
.
Remaining blood cultures: negative or no growth to date.
.
Sputum:
[**2201-7-3**] Mini-BAL: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2201-7-5**]): NO
GROWTH.
.
GRAM STAIN (Final [**2201-6-29**]): <10 PMNs and <10 epithelial
cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
All other sputum cultures negative.
.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final [**2201-7-12**]): NEGATIVE for Pneumocystis jirovecii (carinii).
.
Urine: All urine cultures negative.
.
Peritoneal fluid: [**2201-7-11**] 2:53 pm PERITONEAL FLUID. GRAM STAIN
(Final [**2201-7-11**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO
MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): Pending
ACID FAST SMEAR (Final [**2201-7-12**]): NO ACID FAST BACILLI SEEN ON
DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): Pending
FUNGAL CULTURE (Preliminary): Pending
.
Misc:
CMV Viral Load (Final [**2201-6-26**]): CMV DNA not detected.
.
Imaging:
Serial CT scans:
CT W/CONTRAST [**2201-6-21**]: Inflammation associated with the
duodenum, extending along the retroperitoneum. Findings most
likely represent duodenitis. Perforated duodenal cannot be
excluded, although no extraluminal air is identified.
Pancreatitis with secondary duodenal inflammation is less
likely.
.
CT ABD/PELVIS W/O CONTRAST Study Date of [**2201-6-22**] 6:04 PM:
1. Progressed appearance of inflammation with increased ascites.
Stranding
is seen around the duodenum, right perinephric area and
pancreas. Regarding pancreatitis or renal pathology, recommend
correlation with labs since this may be a secondary inflammatory
process.
2. No conclusive evidence for perforation but given the
inflammatory changes around the duodenum, the appropriate
clinical setting, could consider a repeat scan in [**1-30**] hours to
evaluate for extravasation and perforation.
.
CT ABDOMEN/PELVIS W/O CONTRAST Study Date of [**2201-6-22**] 9:25 PM:
1. Extensive inflammatory change in the peritoneum and
retroperitoneum, with free fluid and stranding as previously,
though no evidence of extraluminal leak of oral contrast.
2. Increase of right pleural effusion
.
CT ABDOMEN/PELVIS W/O CONTRAST Study Date of [**2201-6-23**] 8:52:
1. Progression of intra-abdominal free fluid and minimal change
in the
overall degree of intra-peritoneal stranding. There is no
evidence of
extraluminal leak of contrast or obstruction.
2. Progression of right lung effusion and tree-in-[**Male First Name (un) 239**] opacities
which may be secondary to the diffuse process involving the
abdomen though should be
clinically correlated for possible infection in the setting of
neutropenia.
.
CT TORSO W/O CONTRAST [**2201-7-2**]:
1. Interval worsening of the consolidation of the bilateral
lower lobes. This finding may represent atelectasis, however,
superimposed infection cannot be excluded. There are small
bilateral pleural effusions.
2. Interval increase in the amount of ascites since the prior
exam with a
moderate amount now present.
.
CT ABDOMEN/PELVIS W/O CONTRAST Study Date of [**2201-7-10**]
1. Persistent [**Hospital1 **]-basilar, left greater than right, pulmonary
consolidations. This may represent atelectasis, however,
superimposed pneumonia cannot be excluded. Small bilateral
pleural effusions are improved.
2. Mild jejunal wall thickening is non-specific but could
reflect
opportunistic infection.
3. Persistent moderate intra- abdominal ascites, with no
evidence of loculated abscess formation.
.
UNILAT UP EXT VEINS US PORT LEFT Study Date of [**2201-7-7**]:
1. Thrombosis of the left basilic vein with no upstream
extension.
2. Hypoechoic well-defined mass of the right forearm measuring
1.8 cm.
Differentials include thrmbosed superficial vein and soft tissue
tumor.
.
Most recent portable CXR [**2201-7-12**]: There are low lung volumes
which slightly limits assessment, particularly in the lower
lungs which have some associated volume loss. NG tube is in the
stomach. Right upper quadrant clips are present. There is right
IJ line with tip in the SVC. There is no pneumothorax.
.
CT Head [**2201-7-15**]: 1. New right frontal hemorrhagic contusion
with probable small regions of adjacent subarachnoid hemorrhage.
Known external soft tissue swelling. No skull fractures. Close
follow up as clinically indicated.
Findings were discussed with Dr. [**First Name (STitle) **] on date of exam at 9:40
a.m.
This study done on [**2201-7-15**] at 03.43Am is available for review on
[**2201-7-15**] at 9.30am and wet rea dwas given to the physician as
mentioned above.
2. Small amount of fluid in the mastoid and petrous apices on
both sides, new since prior.
.
CT Head [**2201-7-16**]: 1. No interval change to right frontal
partially hemorrhagic contusion with small regions of adjacent
subarachnoid hemorrhage. F/u a sindicated clinically.
Other details above
.
Labs On Discharge:
[**Month/Day/Year 34887**]: WBC 4.9 HBG 9.6* HCT 27.7* Platelets 377
COAGS: PT 14.6* PTT 28.3 INR 1.3*
Chem 7: Gluc 91 BUN 16 Crn 0.8 NA 138 K 3.8 CL 101 HCO3 25
Brief Hospital Course:
In brief, Mr. [**Known lastname 78266**] is a 49-year-old male with a history of
APML s/p multiple rounds of chemotherapy who recently underwent
MIDAM chemotherapy, being treated with ATRA and was admitted
with febrile neutropenia and diarrhea and found to have GNR
sepsis and duodenitis.
.
# Febrile Neutropenia, GNR sepsis: The patient was initially
covered empirically with vancomycin, aztreonam, and flagyl with
concern for a GI source given his recent diarrhea and history of
anal fissures. He had no respiratory or urinary symptoms on
presentation and initial chest x-ray was negative for pneumonia.
Initial CT scan on [**6-21**] was concerning for duodenitis and the
patient's antibiotic regimen was broadened to include
ciprofloxacin and micafungin and [**5-2**] blood cultures from the
previous day were positive for gram negative rods. Overnight,
the patient's LFTs rose and he had multiple electrolyte
abnormalities that were corrected intravenously. Surgery was
consulted early on the morning of [**6-22**] given continued fevers
and worsening abdominal pain. An abdominal ultrasound was
obtained and showed no evidence of [**Last Name (un) **]-occlusive disease or
intrahepatic duct dilatation. The patient's LFTs continued to
rise during the day, his INR and PTT also rose, and additional
labs were concerning for DIC. The patient was transfused with
multiple units of platelets and also received PRBCs, FFP, and
vitamin K to try to correct his coagulopathy. The patient had
an episode of diarrhea on [**6-22**] that consisted of black-colored
liquid. He was placed on pantoprazole IV BID for GI bleeding.
A repeat CT scan in the evening with gastrograffin demonstrated
increased inflammation, but negative for duodenal perforation.
As his lactate was rising and his platelets remained very low
despite several transfusions in the context of a neutrophil
count of 0, he was then taken to the [**Hospital Unit Name 153**] for further
management. In route to the [**Hospital Unit Name 153**], a CT ABD was done which
showed extensive inflammatory changes in the peritoneum and
retroperitoneum. The cause was unclear but thought perhaps to
be related to his ATRA, which was held. Surgery followed him
and thought that there was no indication for surgical
management. Repeat CT the following day showed progression of
intra-abdominal free fluid and minimal change in the overall
degree of intra-peritoneal stranding. His abdomen continued to
be distended and tender, and he was increasingly short of breath
and hypoxic. He was eventually intubated for airway protection.
Blood cultures grew Proteus and E Coli from [**2201-6-20**]. He
underwent meropenem desensitization followed by meropenem
treatment. Empiric acyclovir at treatment doses was also
started. Filgrastim was also started for neutropenia. Patient
was followed by ID and started had the following courses of
antibiotics: Vanco ([**Date range (1) 19867**]), Linezolid ([**Date range (1) 78268**]),
Metronidazole ([**Date range (1) 34115**], [**Date range (1) 78269**]), Voriconazole ([**7-1**] ?????? [**7-9**]).
Neutropenia resolved as of [**7-1**]. Patient was treated for a total
of two weeks of Vancomycin and Meropenum following recovery of
his counts on [**2201-7-2**], consequently last day of therapy was
[**2201-7-16**]. Patient continued to have low grade fevers while on
Meropenum and Vancomycin. Infectious work-up involved mini-BAL
negative gram stain; multiple negative blood cultures and urine
cultures; negative B-glucan and Aspergillus; C. Diff negative X
3; diagnostic para negative gram stain and cultures negative.
.
# LUE DVT: During the workup for the patient's fever on
meropenem and vancomycin, the patient was found to have DVT in
the left upper extremity at the site of a PICC. Patient was
started on heparin drip and was initially started on coumadin,
but changed to lovenox. Low grade fevers felt to be secondary
to clot, and eventually resolved. On the night of [**2201-7-15**], the
patient fell standing up from the bed while on lovenox, see
below. Lovenox was discontinued. The decision was made not to
restart lovenox as the DVT was likely induced by the PICC
placement and small enough not to require long term
anticoagulation.
.
# Respiratory Distress: The patient was intubated in the
setting of abdominal distension and pain, no obvious primary
pulmonary process. The patient was successfully extubated on
[**2201-7-11**] using precedex.
.
# Thrombocytopenia: Initially related to the patient's recent
chemotherapy. He was initially transfused to keep his platelets
> 10K. Subsequently, however, he did not bump his platelets
appropriately to transfusion, likely as a result of DIC and his
acute illness, and given his GI bleeding, his transfusion
threshold was increased. Once his acute illness resolved, his
platelet count was maintained over the next week without
transfusions.
.
# Acute promyelocytic leukemia: The patient was initially
continued on ATRA per his home regimen, however, his dose was
reduced to 30 mg PO BID on the morning of [**6-22**] given the
worsening of his acute illness. In the [**Hospital Unit Name 153**], ATRA was
discontinued. The patient was instructed to discuss restarting
this medication with his primary oncologist Dr. [**First Name (STitle) **] on
discharge.
.
# Subarachnoid Hemorrhage: In the setting of anticoagulation
with Lovenox. The patient was given protamine and vitamin K.
Head CT showed small subarachnoid hemorrhage and Neurosurgery
was consulted. Repeat head CT the following day did not show
change in the hemorrhage. Neurosurgery recommended maintaining
platelet count > 60-70 and if < 100 should repeat head imaging.
The patient should follow up with Dr. [**Last Name (STitle) 548**] in 4 weeks with
repeat head CT at that time.
.
# History of anal fissures: The patient was continued on
Analpram.
.
# Dysuria: No evidence of UTI on UA or urine cultures. Started
following discontinuation of foley catheter. Most likely
traumatic in nature. Used lidojet and pyridium for symptomatic
relief.
Medications on Admission:
Docusate Sodium 100 mg [**Hospital1 **]
Hydrocortisone-Pramoxine [Analpram-HC] 2.5-1 % Cream, apply [**Hospital1 **]
prn anal fissure.
Lorazepam 0.5-1 mg Q4H prn anxiety, nausea
Nystatin 100,000 unit/mL Suspension, 5 mL QID prn thrush
Oxycodone 5 mg PO Q8H prn pain
Caphosol 30 cc PO QID prn mouth sores
Sennosides 8.6 mg [**Hospital1 **] prn constipation
ATRA 50 mg PO QAM, 40 mg PO QPM
Discharge Medications:
1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
2. Analpram-HC 2.5-1 % Cream Sig: One (1) Rectal once a day as
needed for pain.
3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for mouth pain, thrush.
4. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours
as needed for anxiety.
5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
6. Saliva Substitution Combo No.2 Solution Sig: One (1) ML
Mucous membrane QID (4 times a day) as needed for mouth sores.
7. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
8. 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.
9. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
Disp:*90 Capsule(s)* Refills:*2*
10. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
Disp:*3 Capsule(s)* Refills:*2*
11. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
Disp:*60 Tablet(s)* Refills:*2*
12. Phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
13. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary Diagnoses:
Gram Negative Rod Bacteremia
Acute Hepatitis from Drug Toxicity
Duodenitis/Colitis
Acute promyelocytic leukemia
Subarachnoid Hemorrhage
Deep Vein Thrombosis of the Upper Extremity.
.
Secondary Diagnoses:
Hypercholesterolemia
s/p Cholecystetomy
Discharge Condition:
The patient was afebrile and hemodynamically stable prior to
discharge.
Discharge Instructions:
You were admitted to [**Hospital1 18**] for evaluation of abdominal
distension. You were found to have an infection in your bowel
that infected your blood stream. You had a complicated hospital
course where you were treated with IV antibiotics for many days.
You had to be intubated and maintained on a mechanical
ventilator for a period of time because of your illness. You
were weaned off the ventilator and worked with physical therapy
to regain your strength. Your antibiotics were discontinued and
you will only need to continue on antibiotics for prophylaxis as
an outpatient.
.
You will need to follow up closely with your primary oncologist.
.
Medication Changes:
START Ursodiol 300 mg 3 times a day
START Acyclovir 200 mg Capsule Two (2) Capsules every 8 hours
START Fluconazole 200 mg Tablet Two (2) Tablet every day
START Famotidine 20mg twice a day
START Phenazopyridine 100 mg Tablet 3 times a day as needed
for pain with urination for 3 days
STOP ATRA (please discuss with Dr. [**First Name (STitle) **] when to restart this
medication)
.
If you experience chest pain, fevers, shortness of breath,
abdominal pain, diarrhea, constipation, worsening pain with
urination or any other concerning symptoms please seek medical
attention.
Completed by:[**2201-7-17**]
|
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63,364
| 173,749
|
50652
|
Discharge summary
|
report
|
Admission Date: [**2122-10-4**] Discharge Date: [**2122-10-9**]
Date of Birth: [**2045-1-21**] Sex: M
Service: MEDICINE
Allergies:
Bactrim / Sulfa (Sulfonamide Antibiotics) / Hayfever
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Hematochezia
Major Surgical or Invasive Procedure:
Colonoscopy with endovascular clipping of angioectasia
Colonoscopy
Capsule endoscopy
History of Present Illness:
This is a 77 y.o. male w/ Wegner's diverticulosis, AS, ESRD, and
multiple lower GI bleeds who presents with hematochezia. The
patient reports his recent medical history was notable for
development of some shortness of breath and wheezing over the
last few weeks in the setting of a viral illness. He was given
ipratroprium by his PCP with good improvement of his symptoms.
Then, today the patient awoke at around 7am and felt some
discomfort in his lower abdomen and a need to defecate, he
expected to pass gas but instead had a large bowel movement with
gross blood and clots. He has has multiple similar bowel
movements throughout the day. He denies any fevers or chills.
Endorses mild lower abdominal pain. No nausea or vomiting. No
diarrhea or symptoms preceding this. No presyncope, chest pain,
or current SOB.
He came into the ED this afternoon with these symptoms. In ED
initial vitals: T 98.7, P 75, BP 172/72, RR 18, O2 Sat 100%. He
had a right sided EJ placed and a 20 gauge IV. He did not have
any bloody bowel movements in the ED. He is being admitted to
the ICU due to a history of these bleeds becoming quite
fulminant (bled to a Hct of 17 during the previous one).
ROS: Negative for fevers, chills, night sweats, or unintentional
weight loss. He denies chest pain or SOB. No nausea or vomiting.
No hematemesis. He denies melena. No dysuria or hematuria. No
rashes or skin changes.
Past Medical History:
- Wegeners Disease
- ESRD on HD from ANCA-positive glomerulonephritis dx [**2112**] (on
HD through left arm fistula for one year)
- Gout
- Depression
- Hyperlipidemia
- Glaucoma
- h/o Septic thrombophlebitis
- h/o Cellulitis of the right upper extremity
- h/o Gastrointestinal bleed secondary to NSAID use
- h/o Diverticulitis
- s/p Left inguinal hernia repair
Social History:
Retired butcher. Lives with wife and oldest daughter. [**Name (NI) **] smoking
history. Denies any current alcohol use, or heavy use in the
past. No illicit drug use.
Family History:
Mother with diabetes, kidney disease. 3 brothers with heart
disease, one has had MI. Sister with diabetes. No family
history of cancer.
Physical Exam:
VS: T 97.3, HR 90, BP 189/81, RR: 22, O2sat 97% on RA
GEN: well appearing gentleman in NAD
HEENT: anicteric, MMM, OP without lesions or blood
RESP: CTA(B) with no wheezes, rhonchi, or rales, good air
movement bilaterally
CV: RRR, 3/6 systolic ejection murmur heard best at the left
upper sternal border, 2+ DP and radial pulses bilaterally, +
fistula in left upper extremity w/ thrill and bruit
ABD: Mildly TTP over lower quadrants, hyperactive bowel sounds,
soft, no masses or hepatosplenomegaly
EXT: no c/c/e, probable popliteal cyst left lower extremity
SKIN: no rashes or jaundice appreciated
NEURO: AAOx3, moving all extremities equally
Pertinent Results:
Initial Labs:
[**2122-10-4**] 04:00PM WBC-7.9 RBC-3.18* HGB-9.8* HCT-29.3* MCV-92
MCH-30.7 MCHC-33.4 RDW-16.2*
[**2122-10-4**] 04:00PM NEUTS-77.3* LYMPHS-12.8* MONOS-4.0 EOS-5.7*
BASOS-0.3
[**2122-10-4**] 04:00PM PLT COUNT-236#
[**2122-10-4**] 04:00PM PT-13.5* PTT-27.4 INR(PT)-1.2*
[**2122-10-4**] 04:00PM GLUCOSE-89 UREA N-47* CREAT-6.7*# SODIUM-136
POTASSIUM-4.2 CHLORIDE-96 TOTAL CO2-29 ANION GAP-15
[**2122-10-4**] 04:00PM cTropnT-0.10*
[**2122-10-4**] 09:51PM CK-MB-4 cTropnT-0.09*
.
HCT trend
[**2122-10-4**] 04:00PM Hct-29.3*
[**2122-10-4**] 09:44PM Hct-21.5*
[**2122-10-5**] 02:51AM Hct-26.0*
[**2122-10-5**] 11:36AM Hct-31.9*
[**2122-10-5**] 09:24PM Hct-31.9*
[**2122-10-6**] 04:00AM Hct-30.1*
[**2122-10-6**] 04:35PM Hct-30.5*
[**2122-10-6**] 10:49PM Hct-31.0*
[**2122-10-7**] 03:44AM Hct-31.2*
[**2122-10-7**] 07:45PM Hct-28.2*
[**2122-10-8**] 06:37AM Hct-30.2*
[**2122-10-9**] 06:24AM Hct-28.6*
.
Discharge Labs:
[**2122-10-9**] 06:24AM BLOOD WBC-6.2 RBC-3.19* Hgb-9.7* Hct-28.6*
MCV-90 MCH-30.3 MCHC-33.8 RDW-16.3* Plt Ct-212
[**2122-10-9**] 06:24AM BLOOD PT-13.5* PTT-25.8 INR(PT)-1.2*
[**2122-10-9**] 06:24AM BLOOD Glucose-95 UreaN-20 Creat-5.9*# Na-139
K-3.5 Cl-95* HCO3-33* AnGap-15
[**2122-10-9**] 06:24AM BLOOD Calcium-8.5 Phos-4.5 Mg-1.7
.
Imaging:
[**2122-10-4**] CXR: Moderate left and small right pleural effusion are
new. Aside from attendant atelectasis in the left lower lobe,
lungs are clear. Heart is normal size.
[**2122-10-5**] Colonscopy: A single medium angioectasia that was not
bleeding was seen in the cecum. A gold probe was applied for
tissue destruction successfully. One triclip was successfully
applied for the purpose of hemostasis. Protruding Lesions Grade
1 internal hemorrhoids were noted. Excavated Lesions Multiple
diverticula with medium openings were seen in the sigmoid colon.
Other No avms seen in ileum. Impression: Grade 1 internal
hemorrhoids. Diverticulosis of the sigmoid colon. Angioectasia
in the cecum (thermal therapy, endoclip). No avms seen in ileum.
Otherwise normal colonoscopy to cecum and ileum.
[**2122-10-6**] Tagged RBC scan: Active bleeding at a site within the
sigmoid colon with activity moving retro- and anterograde.
[**2122-10-6**]: Capsule endoscopy progress report: GI bleeding at the
distal ileum, fresh blood seen in thecolon as well.
[**2122-10-7**] Colonoscopy: Diverticulosis of the whole colon, Clip
seen in Cecum. Capsule seen in Cecum. Of note, capsule was noted
to be in cecum about 16 hours ago. Terminal Ileum could not be
intubated despite multiple attempts. Otherwise normal
colonoscopy to cecum.
[**2122-10-7**] CXR: The interpretation of this study is limited given
the presence of respiratory motion. A small right and moderate
left pleural effusions have improved. Cardiomediastinal contours
are unchanged. There is no evidence of pneumothorax or new lung
abnormalities. Opacity in the left lower lobe is a combination
of the pleural effusion and atelectasis.
Brief Hospital Course:
77 y.o. man with Wegner's granulomatosis and history of multiple
lower GIB's with known AVM's as well as diverticula and internal
hemorrhoids presenting with hematochezia.
1. Hematochezia: The patient presented with grossly bloody bowel
movements, from lower GI source, likely from angioectasias vs
diverticulosis. Initial HCT was 29, which was at/slightly above
baseline. The patient was hemodynamically stable. Of note,
following admission to the ICU, the patient had a presyncopal
event on the way to the bathroom. Vital signs measured
following event were within normal limits, but repeat Hct showed
decrease to 21.5. Initially resuscitated with 2 units pRBCc with
semi-emergent colonoscopy revealing no source of active
bleeding. An angioectasia was visualized and clipped, although
this was not felt to be the source of bleeding. Following
colonoscopy, capsule endoscopy was pursued to r/o bleed from
small bowel. On [**10-5**], patient complained of recurrent
hematochezia and tagged RBC scan performed. Tagged RBC scan
showed bleeding from sigmoid colon while capsule endoscopy
revealed hemorrhage at distal ileum. Given conflicting results
of imaging studies, a repeat colonoscopy was performed on [**10-7**]
which showed diverticulosis of the whole colon but no active
source of bleeding. The terminal ileum could not be intubated.
On [**2122-10-7**], the patient was felt to be stable for transfer to
the general medicine floor. The hematochezia appeared to be
self-limited, HCT was stable, and the last bloody bowel movement
was the evening of [**2122-10-6**]. His diet was slowly advanced, and
he was tolerating a regular diet prior to discharge. He was
initially placed on a PPI, but this was stopped prior to
discharge as the etiology of his bleeding was felt to be lower
and not upper GI source. Due to unclear etiology of the
hematochezia, the patient has been instructed to present to the
ED for emergent angio/CTA should the bleeding recur. He was
followed by both general surgery and GI during the admission,
and will follow up with GI as an outpatient. Total transfusion
requirement during hospital admission was 7U pRBC. The patient
remained hemodynamically stable through hospital course.
2. Pleural Effusion: The patient was noted to have mild hypoxia
with new O2 requirement of 2L NC on day of admission. CXR
[**2122-10-4**] showed new bilateral pleural effusions of unknown
etiology. Of note, the patient reported 1-2 weeks of orthopnea
and mild dyspnea when climbing stairs prior to admission.
Repeat CXR on [**2122-10-7**] showed improvement in small right and
moderate left pleural effusions. The patient's respiratory
status improved, and he was satting well on room air prior to
discharge. The most likely etiology of the pleural effusions is
fluid overload secondary to heart failure. Supporting evidence
includes a history of aortic stenosis with suboptimal ejection
fraction and improvement of pleural effusions seen on CXR
following hemodialysis. Diagnostic thoracentesis was considered
but deferred given improvement in effusions and resolution of
mild hypoxia. The patient should have repeat CXR in [**1-14**] weeks
following discharge to assess for interval change in pleural
effusions. If pleural effusions persist/increase, he may
benefit from diagnostic thoracentesis.
3. End Stage Renal Disease: ESRD secondary to ANCA-positive
glomerulonephritis diagnosed in [**2112**]. The patient continued to
have dialysis on M/W/F via left arm AVG. He received
supplemental IV vitamin D, and was also continued on sevelemer
and nephrocaps.
4. HTN: Home dose of valsartan was initially held in setting of
acute GI bleeding. Valsartan was restarted prior to discharge
once bleeding had resolved and HCT was stable.
5. Hyperlipidemia: Continued home statin.
6. Gout: Continued home allopurinol.
7. Glaucoma: Continued lantaprost drops.
8. Depression: Continued home paroxetine.
9. Probable popliteal cyst: The patient was noted to have a
probable popliteal cyst in his left lower extremity during the
admission. He denied any pain, and his range of motion in the
left knee was not limited. He should follow-up with his PCP for
further evaluation.
10. Code Status: The patient was a full code during this
admission.
Medications on Admission:
-Allopurinol 100 mg PO once a day.
-Cyanocobalamin 1000 mcg PO DAILY
-Paroxetine HCl 20 mg PO DAILY
-Simvastatin 20 mg PO QHS
-B Complex-Vitamin C-Folic Acid 1 mg PO DAILY
-Latanoprost 0.005 % Ophthalmic HS
-Valsartan 80 mg PO DAILY
-Pantoprazole 40 mg PO Q12H
-Sevelamer HCl 1600 mg PO TID W/MEALS
-Calcitriol 0.25 mcg PO once a day.
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
3. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
6. valsartan 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Lower Gastrointestinal Bleeding
End Stage Renal Disease
Secondary Diagnosis:
Hypertension
Possible popliteal cyst, left leg
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 1005**],
You were admitted to the hospital beause you had another episode
of bleeding from your lower gastrointestinal tract. You had
multiple studies done to try to figure out where this bleeding
was coming from, but there was no definite answer.
As you are aware, the next time this bleeding occurs, you should
inform the Emergency Room doctors that [**Name5 (PTitle) **] need to go straight
to the Interventional Radiology suite for an Angio procedure to
figure out where the bleeding is coming from.
You were also found to have pleural effusions (small fluid
collections at the bottom of your lungs) which do not seem to be
affecting your breathing at this time. Your primary care doctor
should arrange for you to have another Xray as an outpatient in
the next 1-2 weeks to see if the effusions are improving. If
not, your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] a procedure to get a
sample of that fluid to see what might be causing it.
You have a possible cyst behind your left knee that should be
evaluated by your primary care doctor next week.
The following changes have been made to your medications:
- Please STOP your pantoprazole and omeprazole for now
The rest of your medications are listed below.
Please be sure to keep all of your followup appointments as
listed below.
Followup Instructions:
Please be sure to keep all of your follow-up appointments as
listed below.
Name: [**Last Name (LF) **],[**First Name3 (LF) **] F.
Location: [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **]
Address: 545A CENTRE ST, [**Location (un) **],[**Numeric Identifier 6809**]
Phone: [**Telephone/Fax (1) 608**]
Appt: [**10-13**] at 1:50pm
Department: GASTROENTEROLOGY
With: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], M.D. [**Telephone/Fax (1) 463**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
***Dr.[**Name (NI) 13540**] office should contact you to make an
appointment. Please call [**Telephone/Fax (1) 463**] to make an appointment if
you have not heard from them by early next week.***
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,683
| 110,824
|
49311
|
Discharge summary
|
report
|
Admission Date: [**2127-12-12**] Discharge Date: [**2128-1-13**]
Date of Birth: [**2046-10-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4071**]
Chief Complaint:
Acute Exacerbation of Congestive Heart Failure
Major Surgical or Invasive Procedure:
central line placement
hemodialsys catheter placement
CVVH
History of Present Illness:
PCP: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. ([**Telephone/Fax (1) 103326**], [**Hospital3 103327**], Suite #202,
Briefly, 81 yo male with Hx of ischemic cardiomnypothy s/p CABG,
CHF (EF 30%), DM, and peripheral vascular disease s/p bipass
with graft on left femoral artery in [**Month (only) **]. Since discharge
from [**Hospital1 18**] in [**Month (only) 359**], he did not take any of his CHF meds, and
now returns increased swelling in his abdomen, legs. Orthopnea,
+DOE (can only walk to the bathroom, can not climb a flight of
stairs [**1-31**] to dyspnea) as well as 50lbs weight gain specially
over the last week. He finally came back to ED on [**12-15**] b/c
groin abscess and was initially admitted to vascular service.
The abcess was drained and he was started on nafcillin on [**12-15**].
He was then transferred to [**Hospital1 1516**] for diuresis on [**12-18**].
On the floor, he was started on a lasix gtt (5 -> 10 mg/hr) with
50-100cc output in 24hrs. He was given one dose of chlorthiazide
and loaded with digoxin. Creatinine was increased to 3.9 from
baseline of 1.5. Renal consulted for further eval of oliguria.
Urology also following because he was having urinary retention.
Foley placed (and then replaced) by urology but still not
draining adequately. He was given one dose of hyoscyamine
ungoing bladder spasm and per urology giving but can exacerbate
tachycardia (only recived one dose)
Given the poor response to lasix gtt, the CHF service has
requested transfer to CCU for pressors (milrinone) to see if he
will autodiurese with improved cardiac output.
Past Medical History:
# CAD: MI [**2106**]; s/p CABG 2 vessels [**2097**], s/p redo CABG 5 vessels
# CHF: ischemic cardiomyopathy, LVEF 35% by PMIBI [**8-1**]
# atrial fibrillation on coumadin
# DM type 2: c/b peripheral neuropathy
# hyperlipidemia
# HTN
# Anemia: baseline HCT 26-30
# COPD: no PFTs recently, started advair 1 month ago
# PVD: s/p redo fem-fem right to AK-popliteal with
8-mm PFT and right 2nd toe amputation on [**2123-7-30**]; s/p right
femoral BK-popliteal bypass with PTFE on [**2125-5-30**]. L Fem-[**Doctor Last Name **] w/
PTFE and 3rd L toe amputation [**9-5**]
# s/p Aortobifemoral bypass graft for abdominal aortic
aneurysm [**2118**]
# colon polyps s/p polypectomy
# internal hemorrhoids
Cardiac Risk Factors: + Diabetes, + Dyslipidemia, + Hypertension
Social History:
Social history is significant for the absence of current tobacco
use but significant past tobacco use. There is no history of
alcohol abuse. There is no family history of premature coronary
artery disease or sudden death. He worked as a bookeeper. Lives
with his wife.
Family History:
Non-contributory
Physical Exam:
T 96.3, Bp 84/37, RR 16 Hr 82 Afib , Sat 100%
General: non apparent distress,
HEENt: dry oral mucose, NO LAD. JVD up to the earlobe at 45
degrees
Lungs: few crackles in the bases.
CV: irregularly irregular. s1-s2 normal, ? s3. holosytolic
murmur RLSB
Abdomen: Distended, BS decreased, + ascitis. Non tender.
Extremities 3+ edema up to the thigh. 2nd and 3rd toe amputated
L and R. Distal pulses difficult to palpate given extensive
fluid accumulation. extremities warm.
L groin wound- gauze in place. no secretions. mild erythema.
L thigh wound- no secretion either.
R arm: mild erythmea forearm.
Neuro: Alert, oriented. responding appropiately to all
questions.
Pertinent Results:
[**2128-1-13**] 07:40AM BLOOD WBC-9.8 RBC-3.46* Hgb-9.5* Hct-29.7*
MCV-86 MCH-27.5 MCHC-32.1 RDW-15.6* Plt Ct-332
[**2128-1-6**] 07:50AM BLOOD WBC-14.0* RBC-2.60* Hgb-6.9* Hct-21.8*
MCV-84 MCH-26.7* MCHC-31.8 RDW-17.8* Plt Ct-377
[**2127-12-12**] 11:35PM BLOOD WBC-11.0 RBC-3.84* Hgb-10.5* Hct-31.7*
MCV-83 MCH-27.2 MCHC-32.9 RDW-16.5* Plt Ct-373#
[**2128-1-6**] 04:00PM BLOOD Neuts-84.3* Lymphs-8.6* Monos-5.7 Eos-0.8
Baso-0.5
[**2128-1-9**] 06:28AM BLOOD PT-15.7* PTT-35.2* INR(PT)-1.4*
[**2127-12-20**] 05:51AM BLOOD PT-35.9* PTT-53.7* INR(PT)-3.8*
[**2127-12-12**] 11:35PM BLOOD PT-19.8* PTT-40.1* INR(PT)-1.8*
[**2128-1-5**] 04:50PM BLOOD ESR-50*
[**2128-1-9**] 11:30AM BLOOD Ret Aut-2.6
[**2128-1-13**] 07:40AM BLOOD Glucose-85 UreaN-48* Creat-1.6* Na-142
K-3.9 Cl-103 HCO3-28 AnGap-15
[**2127-12-22**] 05:11AM BLOOD Glucose-44* UreaN-83* Creat-5.4* Na-134
K-5.1 Cl-94* HCO3-27 AnGap-18
[**2127-12-12**] 11:35PM BLOOD Glucose-119* UreaN-52* Creat-1.7* Na-138
K-2.8* Cl-96 HCO3-32 AnGap-13
[**2128-1-11**] 05:40AM BLOOD ALT-10 AST-27 AlkPhos-129* Amylase-44
TotBili-1.0 DirBili-0.6* IndBili-0.4
[**2128-1-10**] 05:42AM BLOOD ALT-9 AST-26 LD(LDH)-184 AlkPhos-121*
TotBili-1.9*
[**2128-1-8**] 03:17AM BLOOD CK(CPK)-334*
[**2128-1-7**] 09:04PM BLOOD CK(CPK)-404*
[**2128-1-11**] 05:40AM BLOOD Lipase-38
[**2128-1-7**] 02:45PM BLOOD Lipase-34
[**2128-1-8**] 03:17AM BLOOD CK-MB-3 cTropnT-0.19*
[**2128-1-7**] 09:04PM BLOOD CK-MB-3 cTropnT-0.20*
[**2128-1-7**] 02:45PM BLOOD CK-MB-4 cTropnT-0.20*
[**2128-1-7**] 11:37AM BLOOD CK-MB-3 cTropnT-0.23*
[**2128-1-13**] 07:40AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.1
[**2128-1-10**] 05:42AM BLOOD Albumin-3.2* Calcium-8.6 Phos-3.6 Mg-2.2
[**2128-1-10**] 05:42AM BLOOD Hapto-136
[**2127-12-21**] 04:22AM BLOOD Hapto-271*
[**2127-12-20**] 06:28PM BLOOD calTIBC-169* Ferritn-393 TRF-130*
[**2127-12-19**] 06:30AM BLOOD calTIBC-160* VitB12-904* Folate-18.4
Ferritn-343 TRF-123*
[**2127-12-18**] 08:11PM BLOOD %HbA1c-5.8
[**2127-12-19**] 06:30AM BLOOD Triglyc-52 HDL-29 CHOL/HD-2.8 LDLcalc-41
[**2127-12-21**] 01:16PM BLOOD TSH-11*
[**2128-1-5**] 04:50PM BLOOD T3-74* Free T4-1.1
ERYTHROPOIETIN 12.3 4.1-19.5 MU/ML
[**2128-1-10**] 02:37PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.014
[**2128-1-10**] 02:37PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2128-1-10**] 02:37PM URINE RBC-<1 /HPF WBC-3 Bacteri-NONE Yeast-NONE
Epi-<1 /HPF
[**2128-1-10**] 02:37PM URINE RBC-<1 /HPF WBC-3 Bacteri-NONE Yeast-NONE
Epi-<1 /HPF
CULTURE DATA:
URINE CULTURE (Final [**2128-1-9**]):
YEAST. 10,000-100,000 ORGANISMS/ML..
Blood Culture, Routine (Final [**2128-1-13**]): NO GROWTH.
Blood Culture, Routine (Final [**2128-1-10**]): NO GROWTH.
URINE CULTURE (Final [**2128-1-5**]): NO GROWTH.
URINE CULTURE (Final [**2127-12-27**]):
PSEUDOMONAS AERUGINOSA.
>100,000 ORGANISMS/ML. OF TWO COLONIAL MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM------------- 1 S
PIPERACILLIN---------- 32 S
PIPERACILLIN/TAZO----- 64 S
TOBRAMYCIN------------ <=1 S
GRAM STAIN (Final [**2127-12-13**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
WOUND CULTURE (Final [**2127-12-15**]):
STAPH AUREUS COAG +. MODERATE GROWTH.
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
PENICILLIN------------ =>0.5 R
TRIMETHOPRIM/SULFA---- <=0.5 S
Brief Hospital Course:
81 M h/o ischemic CHF (EF=25%), 1+MR, 3+TR, DM, PVD, admitted to
vascular service for left groin abcess s/p [**9-5**] fem-[**Doctor Last Name **] bypass,
transferred to CCU for management of CHF, with acute renal
failure with CVVH for volume removal then transferred to the
floor for further management.
Cardiovascular
1.Pump: The patient has Acute on chronic systolic CHF - he has
ischemic cardiomyopathy. His Last Echo [**12-17**] showed EF 20%-25%.
His most recent cath [**2127-9-25**] showed patent grafts, no
interventions done. He had a Lasix drip which was attempted
prior to transfer to CCU with no significant response. On
transfer to the CCU, he was given low dose milrinone x3 days,
with gross anasarca and oliguric renal failure, likely secondary
to CHF per renal, though he did have proteinuria. He had a swan
placed on [**12-21**], milrinone was stopped, and his CI and SVR [**12-22**]
initially concerning for septic shock 8h after milrinone was
stopped, though SBPs stablized off milrinone at SBP 120s and on
CVVH. The pt received CVVH [**Date range (1) 25254**] with net 27L removed.
Lasix drip was then started on [**12-29**] with low urine output.
Diuril was added Q12H hr with improved urine output. Renal
continued to follow the patient and he never required
hemodialysis. The patient was continued on a lasix gtt on the
floor with a net negative goal of approximately 2L a day, which
he maintained on the lasix gtt and the diuril IV BID. He
continued to have good diuresis, and he was eventually switched
to Lasix IV TID, then [**Hospital1 **]. He was transitioned to PO lasix
prior to discharge to rehab. His edema had markedly improved,
and his pulmonary exam was improved as well. His O2 sats were
>95% on room air. On [**2128-1-7**], the patient became hypotensive
with systolics in the 60s-70s. His WBC count had increased to
14, but he remained afebrile without any clear source of
infection. A CT abdomen/pelvis was done for a slowly decreasing
HCT which showed bilateral, but right greater than left psoas
hematoma. It was unclear whether there was active bleeding
since the scan was done without contrast given his renal
failure. He was transferred to the CCU for hypotension and
workup of possible sepsis/cardiogenic shock. In the CCU, the had
him on levophen shortly for shock. It was unclear whether this
was cardiogenic vs septic, but he was started and maintained on
Zosyn with improvement in his leukocytosis and his blood
pressure. He was weaned off the pressors, and his metoprolol
was up-titrated with good response. He was transferred back to
the floor where he remained stable, with normal BP, afebrile,
and improving leukocytosis. He will need to continue lasix PO,
as well as Toprol for his heart failure. He will also continue
low dose ACE-I with uptitration as tolerated by his creatinine.
At the time of discharge, he had mild crackles at the lower
bases and will likely need continue his lasix for a goal of even
to net negative 500 cc a day.
# Cardiac - ischemia: The patient has a history of CAD. He is
s/p CABG [**10-5**], no evidence of ischemia currently. He will need
to continue ASA 325 mg daily, Toprol, Rosuvastatin, and
Lisinopril.
# cardiac - rhythm: The patient initially in afib with HR in the
90s-130s. He received a dig load but then the digoxin was
stopped. He had a subtherapeutic INR, which then became
supratherapeutic, and the warfarin was held. His metoprolol was
up-titrated for improved HR control. In the beginning of
[**Month (only) 404**], the patient developed bilateral, spontaneous, psoas
hematomas with a decreasing HCT. The heparin drip was stopped,
and the warfarin was stopped as well. This is presumed
anti-coagulation failure with spontanous life threatening
bleeding, and given his high risk for fall as well, he should
not be on anti-coagulation unless later, his PCP or [**Name9 (PRE) 31931**]
feels another trial of anticoagulation should be initiated to
decrease his risk of stroke (high given age, DM, CHF). He will
need to continue the Toprol and ASA 325 mg daily.
# Acute renal failure - The patient's baseline creaitnine per
OMR was 1.0-1.2. During this hospitalization, he increaed up to
5.2 with oliguria thought to be due to poor forward flow from
his heart faliure. He had a foley placed, and had blood clots
so he had bladder irrigation as well. He was followed by urology
initially for the hematuria which grossly resolved. The patient
had CVVH for a few days while in the CCU for volume removal
given the poor UOP and elevated creatinine. Renal followed
closely, and he was initially on phosphate binders. At the time
of discharge, his creatinine had improved to 1.6. He will have
followup with Dr. [**Last Name (STitle) 118**] in [**Hospital 2793**] Clinic. He also developed a
UTI with pseudomonas which was treated with Cipro for 14 days.
His repeat urine cultures only grew yeast, but no UTI on UA. The
patient will be discharged with a foley, and while at rehab
should have bladder training to eventually remove the foley.
# Left groin abcess and recent RUE cellulitis. The patient had
a Cefazolin course which was completed on [**12-26**]. Vascular
surgery followed the patient, and his left groin abscess
improved. He was followed by wound care with their
recommendations. He should continue to have wound care while he
is in rehab. Also, he will follow up with Dr. [**Last Name (STitle) 1391**] after
discharge to evaluate his progress. He was afebrile at the time
of discharge with improvement in his abscess
# DM2: The patient's last HbA1c on [**2127-9-10**] was 6.9. He should
continue sliding scale insulin at rehab. His PCP should
followup whether any other agents should be used in the future.
# Anemia - The patient's baseline HCT is approx 30. He
initially had a decrease of his HCT, and CT scans did not show
evidence of RP bleed. It was thought to be likely dilutional.
He received multiple blood tranfusions during this
hospitalizaiton. Prior to inital planned discharge to rehab, he
developed bilateral psoas hematomas with a decreasing
hematocrit. His anticoagulation was stopped due to the
decreased HCT and hypotension, and he was given a unit of blood
in the CCU. His HCT stablized, and prior to discharge was at
his baseline. He also developed blood clots in the urine
earlier in his hospitalization. He had bladder irrigation with
improvement. At the time of discharge, he had no active
bleeding in his urine. He was guaiac negative during his
hospitalization.
# Peripheral Arterial Disease: The patient was admitted for
[**12-12**] for left groin abcess x 2 s/p fem-[**Doctor Last Name **] bypass [**2127-9-25**]. He
had an I&D, and received antibiotics during this
hospitalization. He received a 14 day course of Cefazolin with
improvement. At discharge, he was afebrile, and his groin
looked good. He will need continued wound care and followup
with Dr. [**Last Name (STitle) 1391**].
# Hematuria - The patient had difficulty urinating initially.
The bladder scan showed elevated PVR, though likely [**1-31**]
anasarca. Urology placed a foley [**12-17**] secondary to massive
edema. There were clots noted [**12-20**], and foley was replaced and
he was started on CBI, with resolution of clots. Now that he is
off anticoagulation, his hematuria has resolved. He will be
discharged with a foley, and that should eventually be removed
while in rheab.
# Hyperlipidemia: The patient will continue rosuvastatin. His
lipid panel showed HDL 29 and LDL 41.
#. CODE: DNR/DNI confirmed with patient and wife/HCP
#. Communication: wife and [**Name (NI) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 103328**]
#. Dispo: The patient will be transferred to [**Hospital **]
rehabilitation. He will be discharged with a foley catheter
which should be removed after bladder training. He will need
twice weekly electrolyte monitoring to evaluate his kidney
function and potassium levels. He should also have twice weekly
hematocrit checks. His goal I/O should be even to negative 500
cc daily and lasix titration accordingly.
Medications on Admission:
(on transfer from rehab):
albuterol nebulizer
Morphine [**2-2**] IV Q6H
Doccusate [**Hospital1 **]
Pantoprozole 40 daily
Fluticasone Salmeterol 100/50 [**Hospital1 **]
Rosuvastatin 10 mg
Hydralazine 25 Q8H
Spirolactone 25 PO daily
Insulin lantus 10 units +ss
Nafcillin 2 g IV Q6H
Ipratropium bromide neb
Metoprolol 50 [**Hospital1 **]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary Diagnosis: Left Femoral Abscess
Acute on Chronic Systolic Heart Failure
Urinary Tract Infection
Acute Kidney Injury
Anemia
Bilateral Psoas Hematomas
Secondary Diagnosis:
Diabetes Type 2
Hypertension
Atrial Fibrillation
Coronary Artery Disease
Peripheral Arterial Disease
Discharge Condition:
stable, hematocrit stable, blood pressure stable, rate
controlled, on room air
Discharge Instructions:
You were admitted to the hospital for a left groin abscess. You
were found to be severely fluid overloaded because you had not
been taking your lasix. You were in the ICU to have
hemodialysis to remove fluid. You had approximately 30-40
liters of fluid removal while you were in the hospital. You
also developed a urinary tract infection for which you were
treated with antibiotics. You had a prolonged hospital course,
with complications, but at the time of discharge, you were felt
safe to go to rehab for aggressive, inpatient rehabilitation.
You will no longer be on anticoagulation for your atrial
fibrillation given your spontanenous bleeding into your abdomen.
You will only continue aspirin.
Please take all medications as prescribed. Please keep all
scheduled appointments.
If you develop any of the following concerning symptoms, please
call your PCP or go to the ED: Fevers, chills, chest pain,
shortness of breath, worsening leg swelling, blood in the stool.
Followup Instructions:
Please call your PCP Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 87110**] to make a followup
appointment in the next 1-2 weeks.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2128-1-28**] 3:00
Please call Dr.[**Name (NI) 1392**] office to confirm your appointment
[**Telephone/Fax (1) 1393**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4074**]
|
[
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"728.89",
"427.31",
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"998.59",
"584.9",
"041.7",
"428.0",
"285.9",
"401.9",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93",
"39.95",
"86.04",
"38.95"
] |
icd9pcs
|
[
[
[]
]
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16943, 17022
|
8440, 16557
|
364, 425
|
17345, 17426
|
3909, 8417
|
18456, 18950
|
3190, 3208
|
17043, 17043
|
16583, 16920
|
17450, 18433
|
3223, 3888
|
278, 326
|
453, 2103
|
17221, 17324
|
17062, 17200
|
2125, 2887
|
2903, 3174
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,878
| 199,818
|
33280
|
Discharge summary
|
report
|
Admission Date: [**2142-8-21**] Discharge Date: [**2142-8-24**]
Date of Birth: [**2090-9-1**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril / Ampicillin
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
throat/mouth swelling
Major Surgical or Invasive Procedure:
Direct laryngoscopy
History of Present Illness:
51 YOM h/o DM, HTN and HLD presenting with increased throat
swelling, difficulty swallowing and voice change. Patient had
tooth ache starting approximately 1 week ago. On Saturday he
noted some submandibular swelling starting on Saturday. He went
to the dentist office yesterday and was prescribed amoxicillin.
He began to have chills last night and this morning noted
increased swelling with difficulty swallowing. He also noted a
change in his voice. He has had no difficulty breathing. He
denies any fevers. No n/v/d.
.
ED noted: Ludwig's angina.
ED Course: Initial Vitals: [**8-18**] 98.2 89 123/72 18 97% ra. Exam
was notable for woody submental fullness that is tender to
palpation,
Bilateral jugular chain LAD, Tooth #31 appearing decayed and
it is loose. Surrounding gingiva is mildly tender to palpation.
Labs noted to be CR 2.3 after 1 L IVF came down to 1.9.
Recieved Unasyn 3g /Clindamycin 600mgIV. ENT c/s: valecula,
base of tongue and cords okay. OMFS CS: got then panorex film,
but still needs CT after IVF hydration, no OR tonight, admit to
MICU will follow. Afebrile 85 117/71 18 94% RA. 2x PIV.
Past Medical History:
DM2, diet controlled
hypertension
hyperlipidemia
Social History:
He is from the United States. He is currently
employed by the State - Atheletic super at [**Hospital1 **]. He did smoke
- 37 year PPD. He drink alcohol moderatly. no IVDU.
Family History:
Noncontributory
Physical Exam:
At admission:
Vitals: T: 98 BP:130/77 P:79 R: 18 O2: 93% RA
General: in mild distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, LAD, submandibular swollen, tjm tenderness.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
At admission:
[**2142-8-21**] 05:10PM BLOOD WBC-11.7*# RBC-4.58* Hgb-14.0 Hct-39.7*
MCV-87 MCH-30.6 MCHC-35.3* RDW-13.1 Plt Ct-262
[**2142-8-21**] 05:10PM BLOOD Neuts-77.5* Lymphs-14.3* Monos-5.4
Eos-2.5 Baso-0.3
[**2142-8-22**] 06:26AM BLOOD PT-12.1 PTT-22.2 INR(PT)-1.0
[**2142-8-21**] 05:10PM BLOOD Glucose-225* UreaN-21* Creat-2.3*# Na-141
K-3.8 Cl-102 HCO3-22 AnGap-21*
[**2142-8-21**] 05:20PM BLOOD Lactate-1.2
[**2142-8-22**] 12:20AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
[**2142-8-22**] 12:20AM URINE RBC-<1 WBC-5 Bacteri-NONE Yeast-NONE
Epi-0
[**2142-8-22**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2142-8-22**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2142-8-22**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT
[**2142-8-22**] URINE URINE CULTURE-PENDING INPATIENT
[**2142-8-21**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2142-8-21**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**8-22**]: CT NECK W/CONTRAST (EG:PAROTIDS)
IMPRESSION:
1. No abscess or fluid collection in the floor of mouth, or
elsewhere.
2. Asymmetry of the parapharyngeal fat and adjacent palatine
tonsil may
represent early phlegmon; this finding should be correlated with
direct
visualization.
The study and the report were reviewed by the staff radiologist.
[**8-23**]: CXR
FINDINGS: The lung volumes are low. Borderline size of the
cardiac
silhouette. Tortuosity of the thoracic aorta. No pleural
effusions, no
pneumonia. No lung nodules or masses.
Brief Hospital Course:
51 y/o man with a PMH significant for DM (diet controlled), HLD
and HTN who presented to the ED on [**2142-8-21**] with throat swelling
and dysphagia.
.
# Ludwig's Angina: classic findings: He noted a tooth ache
about 1 week prior to admission that was accompanied by
submandibular swelling. For this he took 1600mg Ibuprofen TID
without relief. He went to the dentist on [**2142-8-20**] and was
prescribed Amoxacillin. The following day he noted dysphagia,
drooling, voice changes and chills and presented to the ED for
further evaluation.
.
In the ED VS were stable (T 98.2 HR 89 BP 123/72 RR 18 O2 Sat
97% RA). ENT noted a widely patent airway and OMFS was consulted
and panorex was obtained. OMFS felt there was bilateral jugular
chain LAD and tooth #31 was noted to be decaying with local
gingival erythema and swelling. He received IV Unasyn/Clinda and
was admitted to the MICU for Ludwig's Angina. CT neck was
obtained in the MICU that showed - no abscess or fluid
collection in the floor of mouth, or elsewhere. asymmetry of the
parapharyngeal fat and adjacent palatine tonsil may represent
early phlegmon; this finding should be correlated with direct
visualization. He was monitored overnight in the MICU and called
out to the floor on hospital day 2.
.
During his fisrt night on the floor, the MICU resident was paged
because of tongue swelling. He did not have stridor. There was a
question of whether he had angioedema from the unasyn. He was
given IV Dex 10mg (q8h), benadryl 50 IV x1, famotidine 20 IV x1
was given. He denied lip swelling, pruritis or rash. In the
morning, ENT evaluated his airway by laryngoscopy and felt that
the edema had worsened and was not characteristic of angioedema
as there was increased elevation of the floor of his mouth. His
antibiotics were changed to clinda IV and levofloxacin. The oral
surgeons were contact[**Name (NI) **] and extraction of the infected tooth was
recommended.
.
He was transferred to the ICU for closer monitoring of his
airway. On arrival he is breathing comofrtably without stridor.
He notes imporvement in the swelling that he attributes either
to steroids or the change in antibiotics. He is able to swallow
secretions without difficulty. He has only one allergy to
lisinopril and that was an episode of pancreatitis several years
ago. He again denies any sense of ithcy throat, lip swelling or
bronchospasm.
.
His ICU course was remarkable for dramatic improvement after the
steroids in terms of the face swelling. Also, patient noted
great improvement upon massaging of submandibular area and
resulting expression of green-colored, purulant material drained
from gum area adjacent to dental caries (spontaneous
decompression of absesss). ID saw him and advised a final
regimen of Clindamycin PO w/o steroids and no further
levofloxacin.
.
# ARF: pt has been taking 1600mg ibuprofen three times day for 4
days. decreased PO intake. This improved with IVF.
.
# DM2, diet controlled: diabetic diet. Blood sugars were
elevated [**1-10**] steroids.
.
# hypertension: continued norvasc/diovan
.
# hyperlipidemia: continued simvastatin
# Communication: Patient
# Code: Full (discussed with patient)
Transitions of care: his CXR from [**2142-8-23**] was concerning for
left apical opacity which deserves interval attention and
followup with primary care physician as an outpatient as well as
a PPD for Tuberculosis screening. Finally he was told to refrain
from NSAID use, and to see the oral surgeons for tooth
extraction as well as to f/u with he PCP [**Last Name (NamePattern4) **]: following her blood
glucose which was elevated [**1-10**] steroids.
Medications on Admission:
HOME MEDS:
Diovan 160 mg Tab Oral 1 Tablet(s) Once Daily
Amlodipine 10 mg Tab Oral 1 Tablet(s) Once Daily
Simvastatin 20 mg Tab Oral 1 Tablet(s) Once Daily
.
ALLERGIES: lisinopril
Discharge Medications:
1. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. chlorhexidine gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
Disp:*60 ML(s)* Refills:*0*
5. clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every
eight (8) hours for 14 days.
Disp:*42 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Submandibular space infection/cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with throat swelling. You were
evaluated by the Ear, Nose and Throat as well as Oral Maxofacial
Surgery services. There was a concern for neck space infection
related to an infected tooth. You were started on antibiotics
and steroids. Your condition improved.
Your kidney function was found to be low on admission, which was
likely due to taking a lot of ibuprofen in the setting of not
drinking enough fluids. Please stop taking ibuprofen until you
are seen by your primary care physician (PCP).
Your blood sugars were also elevated during this hospitalization
likely because you were on steroids but you should also check
with your PCP about this.
Please consider at this time that you may have an allergy to
penicillin and to consider getting testing for this as an
outpatient.
Finally, a chest x-ray done here at [**Hospital1 18**] showed an area of
possible scarring in the left upper lobe which is of uncertain
significance. Please ask your PCP to consider [**Name9 (PRE) 77267**]
another chest x-ray as well as test a PPD for potential latent
tuberculosis.
Please continue your home medications with the following
changes:
1. START taking clindamycin - an antibiotic
Please STOP:
-Nonsteroidal Anti-inflammatory medications (ie. ibuprofen)
until you see your primary care doctor
Followup Instructions:
Please schedule an appointment with oral surgery at [**Hospital 2082**] as soon as possible to have the tooth extraction.
If you cannot keep the appointment then he will be seen on 23rd
of [**Month (only) **] at 2pm. Contact Please call [**Telephone/Fax (1) 77268**] with any
questions for appointment sceduling.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2142-8-25**]
|
[
"584.9",
"401.9",
"799.02",
"E935.6",
"250.00",
"528.3",
"521.00",
"599.70",
"518.3",
"272.4",
"E932.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.42"
] |
icd9pcs
|
[
[
[]
]
] |
8261, 8267
|
3922, 7093
|
305, 327
|
8352, 8352
|
2341, 3899
|
9860, 10330
|
1763, 1780
|
7781, 8238
|
8288, 8331
|
7576, 7758
|
8503, 9837
|
1795, 2322
|
244, 267
|
355, 1480
|
8367, 8479
|
7114, 7550
|
1502, 1553
|
1569, 1747
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,002
| 189,478
|
3249
|
Discharge summary
|
report
|
Admission Date: [**2190-10-7**] Discharge Date: [**2190-10-19**]
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Periappendiceal abcess
Major Surgical or Invasive Procedure:
CT guided drainage of abcess
History of Present Illness:
This patient is an 89 year old female with a surgical history
significant for sigmoid cancer s/p LAR now presents with 3 day
history of progressive abdominal pain. Patient states that the
pain is constant, dull with intermittent jolts of sharp pain in
the RLQ. The patient states that she has never experienced a
pain like this before. She denies fevers, chills, nausea or
vomiting.
Past Medical History:
h/o sigmoid colon CA s/p resection in [**2178**]
CAD s/p 3-vessel CABG in [**2176**]
Chronic renal insufficiency (baseline Cr 1.1)
OA
DM2
HTN
Hearing aid
Cataracts
s/p hernia surgery
Social History:
The pt immigrated from [**Location (un) 6079**] in [**2176**]. She currently
lives alone at home but receives support from her daughter, who
is here today. She drank cognac or vodka about twice a day but
stopped about 3 years ago. No cigarette or substance use.
Family History:
Noncontributory
Physical Exam:
General: Awake and alert, Russian speaking only
CV: RRR
Lungs: bilateral wheezing noted on auscultation
Abdomen: soft, (+) tenderness RLQ, (+) rebound, no guarding,
NABS
Rectal: as per ED, heme (-)
Pertinent Results:
[**2190-10-7**] 08:15PM CK(CPK)-45
[**2190-10-7**] 08:15PM cTropnT-0.08*
[**2190-10-7**] 08:15PM CK-MB-NotDone
[**2190-10-7**] 02:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2190-10-7**] 02:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2190-10-7**] 02:50PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2190-10-7**] 12:25PM LACTATE-1.0
[**2190-10-7**] 12:20PM GLUCOSE-199* UREA N-34* CREAT-1.3* SODIUM-140
POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-25 ANION GAP-14
[**2190-10-7**] 12:20PM estGFR-Using this
[**2190-10-7**] 12:20PM ALT(SGPT)-10 AST(SGOT)-14 CK(CPK)-25* ALK
PHOS-78 TOT BILI-0.2
[**2190-10-7**] 12:20PM LIPASE-39
[**2190-10-7**] 12:20PM cTropnT-0.09*
[**2190-10-7**] 12:20PM CK-MB-3
[**2190-10-7**] 12:20PM ALBUMIN-3.5 CALCIUM-9.3 PHOSPHATE-2.5*
MAGNESIUM-2.0
[**2190-10-7**] 12:20PM WBC-8.9# RBC-3.28* HGB-8.3* HCT-26.3* MCV-80*
MCH-25.3* MCHC-31.6 RDW-13.4
[**2190-10-7**] 12:20PM NEUTS-89* BANDS-2 LYMPHS-5* MONOS-3 EOS-0
BASOS-1 ATYPS-0 METAS-0 MYELOS-0
[**2190-10-7**] 12:20PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
ELLIPTOCY-1+
[**2190-10-7**] 12:20PM PLT SMR-NORMAL PLT COUNT-231
Brief Hospital Course:
Pt is a 89 yo Russian-speaking only woman w/ a h/o DM, HTN, CAD
s/p 3-vessel CABG, and OA who was admitted [**2190-10-7**] for RLQ pain
[**1-9**] perforated appendicitis with a periappendiceal abscess. Pt
started on Levofloxacin and Flagyl. Abscess was drained
percutaneously and a RLQ pigtail cath was placed on [**10-8**] by
IR.[**10-8**] pt triggered for hypoxia and tachycardia on floor and
was transferred to SICU. CXR showed worsening pulmonary edema.
While in SICU experienced episodes of Afib and fluid overload.
Nephrology and Cardiology were consulted. Pt was rate
controlled and diuresed with improvements in breathing. She
received multiple modalities of repiratory support in the SICU.
Pt was transferred back to hospital floor when breathing and
sats improved on [**10-10**]. Cardiology recommended anticoagulation
in adidition to rate control based on pt's afib and thoracic
aorta thrombus noted on CT scan. Pt was advanced from NPO to
clear liquids [**10-10**], but coughed, raising concerns for
aspiration. Pt's oral and pharyngeal swallowing were evaluated.
Pt also developed L 3rd toe pain and erythema on [**10-13**] and
Rheumatology determined it to be gouty arhthritis. Pt's
symptoms and pain improved t/o hospitalization.
Pt's course has been complicated by elevated Cr (1.3 on
admission, up to 1.7 on [**10-10**],
now back down to 1.3; ? contrast-induced nephropathy) and
continued pulm edema (team has been giving free water through
IVF (due to pt's mental status) and lasix; her pulm status has
been improving). Echo showed EF 30-35%.
Medications on Admission:
Protonix
Lasix
Enalapril
Celebrex
Glyburide
Isordil
Lipitor
Digoxin
Nifedipine
Colace
Meclizine prn
Ambien prn
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
2. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every six (6)
hours as needed for fever or pain.
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig: One
(1) puff Inhalation twice a day.
5. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO QID (4 times
a day) as needed.
6. Lovenox 60 mg/0.6 mL Syringe Sig: One (1) injection
Subcutaneous twice a day.
Disp:*60 syringes* Refills:*2*
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
1. Perforated appendicitis
2. Peri-appendiceal abscess
Discharge Condition:
Good
Discharge Instructions:
Please call your surgeon or return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* 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.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
Followup Instructions:
Please call Dr.[**Name (NI) 15146**] office at [**Telephone/Fax (1) 10693**] to arrange for
your follow-up appointment.
Please contact Dr. [**Last Name (STitle) 3357**] your primary care doctor to discuss
long term anticoagulation and recent hospitalization.
Please call the Cardiology Clinic at [**Telephone/Fax (1) 62**] to discuss the
long term management of your atrial fibrillation.
|
[
"V10.05",
"428.30",
"276.0",
"416.8",
"041.04",
"041.02",
"427.31",
"585.9",
"540.1",
"428.0",
"599.0",
"584.9",
"366.9",
"403.90",
"799.02",
"518.81",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"38.93",
"38.91",
"93.90",
"88.01"
] |
icd9pcs
|
[
[
[]
]
] |
5234, 5304
|
2769, 4340
|
242, 273
|
5403, 5410
|
1443, 2746
|
6270, 6663
|
1192, 1209
|
4502, 5211
|
5325, 5382
|
4366, 4479
|
5434, 6247
|
1224, 1424
|
180, 204
|
301, 686
|
708, 894
|
910, 1176
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,199
| 120,030
|
49090
|
Discharge summary
|
report
|
Admission Date: [**2152-7-7**] Discharge Date: [**2152-7-11**]
Date of Birth: [**2081-8-7**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ampicillin
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Left upper lobe nodule
Major Surgical or Invasive Procedure:
[**2150-7-7**] Left thoracoscopy, wedge resection of left upper
lobe.
History of Present Illness:
The patient is a 70-year-old womanwith a nonischemic
cardiomyopathy and breast cancer now withd a ground-glass
opacity in the left upper lobe. This area was negative on PET
but was persistent and in fact increased slightly in size over
serial CT scanning.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Hypertension, Heart Failure
2. CARDIAC HISTORY:
-Cardiomyopathy: Dx'ed with nonischemic cardiomyopathy prior to
her breast cancer; echocardiogram here in [**2146**] showed LVEF of
<20%.
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None; normal coronary
arteries in [**2139**] per subsequent chart note
-PACING/ICD: None
-She denies any past frank MI.
3. OTHER PAST MEDICAL HISTORY:
Breast CA tx'ed w lumpectomy and sentinel node bx, whole breast
radiation 1-2 years ago
Asthma/COPD -takes Albuterol, Flovent, Advair at home PRN
Social History:
-Non smoker. No etoh. No illicit drugs. Lives alone in
apartment.
Family History:
No family history of early MI, non-contributory.
Physical Exam:
VS: T 99.1 HR 102 Resp> 18 O2 sat: 99%
General A+O NAD
Cardiac: RRR
Lungs: Mild crackles on the left
Abd: Lg. soft NT ND
Wound: CD+I
Pertinent Results:
[**2152-7-9**] 07:45AM BLOOD WBC-11.0 RBC-3.50* Hgb-10.0* Hct-30.8*
MCV-88 MCH-28.7 MCHC-32.6 RDW-13.8 Plt Ct-256
[**2152-7-7**] 11:28PM BLOOD WBC-17.1* RBC-3.57* Hgb-10.2* Hct-31.5*
MCV-88 MCH-28.5 MCHC-32.3 RDW-14.1 Plt Ct-286
[**2152-7-7**] 10:28PM BLOOD WBC-15.5* RBC-3.48* Hgb-9.9* Hct-30.8*
MCV-89 MCH-28.5 MCHC-32.2 RDW-14.1 Plt Ct-262
[**2152-7-7**] 03:08PM BLOOD WBC-18.7*# RBC-3.69* Hgb-10.5* Hct-33.9*
MCV-92 MCH-28.5 MCHC-31.0 RDW-13.3 Plt Ct-291
[**2152-7-9**] 07:45AM BLOOD Neuts-76.5* Lymphs-17.9* Monos-3.9
Eos-1.6 Baso-0.1
[**2152-7-9**] 07:45AM BLOOD Glucose-174* UreaN-17 Creat-1.2* Na-137
K-4.2 Cl-103 HCO3-25 AnGap-13
[**2152-7-7**] 11:28PM BLOOD Glucose-172* UreaN-19 Creat-1.5* Na-141
K-4.4 Cl-105 HCO3-26 AnGap-14
[**2152-7-7**] 10:28PM BLOOD Glucose-185* UreaN-20 Creat-1.7* Na-137
K-4.8 Cl-102 HCO3-24 AnGap-16
[**2152-7-7**] 03:08PM BLOOD Glucose-162* UreaN-15 Creat-1.2* Na-142
K-4.0 Cl-104 HCO3-30 AnGap-12
[**2152-7-9**] 07:45AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.2
[**2152-7-7**] 10:28PM BLOOD Calcium-8.1* Phos-5.7* Mg-2.5
[**2152-7-8**] 02:43AM BLOOD Type-ART pO2-158* pCO2-52* pH-7.31*
calTCO2-27 Base XS-0 Intubat-NOT INTUBA
[**2152-7-7**] 05:51PM BLOOD Type-ART pO2-131* pCO2-54* pH-7.29*
calTCO2-27 Base XS--1 Intubat-NOT INTUBA
[**2152-7-8**] 02:43AM BLOOD Glucose-174* Lactate-1.9
[**2152-7-8**] 02:43AM BLOOD freeCa-1.07*
[**2152-7-8**] 02:43AM BLOOD O2 Sat-99
Brief Hospital Course:
The patient is a 70-year-old woman who is now 3 years status
post right breast lumpectomy and sentinel node biopsy for Stage
I breast cancer. Also has nonischemic cardiomyopathy and now
ground-glass opacity in the left upper lobe. This area was
negative on PET but was persistent and in fact increased
slightly in size over serial CT scanning. admitted on [**2152-7-7**]
for Left thoracoscopy, wedge resection of left upper lobe.
Admitted to SICU for post op monitoring due to hypotension and
poor UO. Tolerating nasal cannula. Unable to resite positional A
line. Using vigileo. Received albumin overnight and UO improved.
POD #1 transfered to the floor. Labile o2 sats use of CPAP with
improvement. as activity increased so did o2 sats able to wean
off CPAP. Following UOP H/O Cardiomyopathy with EF of 20% IV
lasix cont. by [**7-10**] back on home dose. Adv. diet tol. well.
Chest tube removed CXR small left apical PTX. [**7-11**] Repeat cxr
un changed patient denies SOB D/C'd home.
Medications on Admission:
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - (Prescribed by Other
Provider) - 500 mcg-50 mcg/Dose Disk with Device - 1 puff
inhaled
twice a day
FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet -
Tablet(s) by mouth twice a day 3 tabs q am 2 tabs q pm
INSULIN ASPART [NOVOLOG] - (Prescribed by Other Provider) - 100
unit/mL Solution - 60 u q am 40 u qpm twice a day
ISOSORBIDE MONONITRATE - (Prescribed by Other Provider) - 30 mg
Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth twice a
day
LOPRESSOR - 50MG Tablet - ONE TABLET BY MOUTH TWICE A DAY
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 50 mg
Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth twice a
day
MONTELUKAST [SINGULAIR] - 10 mg Tablet - 1 Tablet(s) by mouth
nightly
PREDNISONE - 10 mg Tablet - 4 Tablet(s) by mouth daily 40mg x3
days, 30mg x3 days, 20mg x3 days, 10mg x 3 days, off on [**2152-4-12**]
RANITIDINE HCL [ZANTAC] - (Prescribed by Other Provider) - 150
mg Tablet - 1 Tablet(s) by mouth twice a day
TIZANIDINE - 4 mg Tablet - 0.5-1 Tablet(s) by mouth daily take
one half to one tablet at bedtime
VALSARTAN [DIOVAN] - (Prescribed by Other Provider) - 80 mg
Tablet - 1 Tablet(s) by mouth twice a day
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet -
Tablet(s) by mouth once a day
CALCIUM - (Prescribed by Other Provider) - 500 mg Tablet - 1
Tablet(s) by mouth once a day
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (OTC) - Dosage
uncertain
GLUCOSAMINE-MSM-CHONDROITIN [TRIPLEFLEX] - (OTC) - 500 mg-167
mg-400 mg Tablet - 1 Tablet(s) by mouth once a day
OMEGA-3 FATTY ACIDS-VITAMIN E [OMEGA-3 FISH OIL] - (OTC) -
1,000
mg-5 unit Capsule - 1 Capsule(s) by mouth once a day
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
8. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disk
with Device(s)
10. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a
day).
11. Insulin Regular Human 100 unit/mL Solution Sig: Four (4)
Injection four times a day.
12. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO once a day:
Lasix 120mg po q am.
13. Lasix 40 mg Tablet Sig: Two (2) Tablet PO once a day: 80 mg
po q pm.
Discharge Disposition:
Home
Discharge Diagnosis:
left upper lobe lung nodule
Discharge Condition:
Good
Discharge Instructions:
Please call Dr. [**First Name (STitle) **] with any questions or concerns.
[**Telephone/Fax (1) 2348**]
Call with fevers greater than 101.5 increased cough or
secretions and or any drainage or swelling or increased reddness
from incision.
You may shower but no tub bath or swimming. Do not use any
lotions or soap on incisions.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]/EYE LIST OR EYE SURGERY Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2152-8-3**] 8:15
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2152-8-4**] 9:20
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2152-8-4**] 10:00
Follow up appointment with Dr. [**First Name (STitle) **] on [**Telephone/Fax (1) 2348**]:
Completed by:[**2152-7-11**]
|
[
"786.03",
"512.1",
"493.20",
"413.9",
"401.9",
"788.29",
"998.81",
"278.00",
"428.42",
"428.0",
"518.5",
"997.5",
"162.3",
"425.4",
"E878.6",
"250.00",
"V10.3",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"32.20",
"03.90"
] |
icd9pcs
|
[
[
[]
]
] |
6945, 6951
|
2991, 3984
|
298, 370
|
7023, 7030
|
1569, 2968
|
7407, 7942
|
1349, 1400
|
5742, 6922
|
6972, 7002
|
4010, 5719
|
7054, 7384
|
1415, 1550
|
760, 1068
|
236, 260
|
398, 655
|
1099, 1249
|
677, 740
|
1265, 1333
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,471
| 112,557
|
39630
|
Discharge summary
|
report
|
Admission Date: [**2138-3-29**] Discharge Date: [**2138-4-11**]
Date of Birth: [**2111-9-19**] Sex: M
Service: MEDICINE
Allergies:
Cefepime
Attending:[**First Name3 (LF) 3963**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Sinus polyp biopsy, sinus wash and culture
History of Present Illness:
History of Present Illness:
.
26 yo man D +278 after single cord transplant for hypoplastic
MDS with h/o persistent pancytopenia thought to be [**3-20**]
myelosuppression from CMV + antivirals who is now admitted for
sepsis.
.
Patient was first diagnosed with with MDS in Fall [**2136**] when he
presented with pancytopenia. Initial MDS course was complicated
by mucor infection of the tongue with prolonged ICU course for
upper airway obsturuction, followed by pericoronitis as well as
perirectal abcess. Was subsequently managed with a single cord
transplant on [**2137-6-24**] with reduced intensity Flu/MEL/ATG
conditioning. Post transplant course c/b VRE + Coag neg staph
bacteremia [**6-/2137**] (treated with dapsone); CMV viremia [**7-/2137**],
c.diff infection [**10/2137**] (treated with 14 days oral vanc),
admission on [**10/2137**] for low grade temperature attributed to +CMV
viremia with prolonged IV ganciclovir --> oral Valgancyclovir
course; last admission 10/4-6 for neutropenic fever, CT chest
showed non specific minimal peribronchial ground-glass opacity
in the left lower lobe, treated with course of levofloxacine;
Saw ID [**12-12**] Valgancyclovir was stopped as CMV viral loads
remained negative since [**10-22**], was started on valacyclovir for
HSV/VZV PPx. He also continues oral Posiconazole for mucor and
monthly pentamidine nebs for PCP [**Name Initial (PRE) **] (most recent [**12-28**]).
.
Patient had > 97% donor on chimerism on peripheral blood from
[**2137-10-17**]. He has been intermitently leukopenic and neutropenic
throughout his illness with especially low white counts
generally ranging around 1000-3000 during the past 2 months.
This has been attributed to possible BM supression by CMV and/or
antiviral meds. Thrombocytopenia has been continous throughout
his illness and latley stable at ~ 25,000. Hct generally in the
high teens to low twenties. He also had had a stable
transaminitis for months which is attributed to drug effect +/-
hemochromatosis. Finally he is thought to be at low risk for GVH
and thus stopped immunosupressive meds in [**2137-9-16**] (was on
tacrolimus prior). Last neupogen was given on [**2138-3-27**].
.
Over the past several months, he has had recurrent PNAs and has
been followed in pulmonary clinic. In [**Month (only) 404**] he was found to
have fever and neutropenia and worsening tree-in-[**Male First Name (un) 239**] opacities,
particularly in
the left side. He was treated with meropenem, azithromycin and
oseltamivir. Repeat CT chest on [**3-4**] showed some resolution and
he was most recently seen in pulm clinic on [**2138-3-20**]. During this
visit he was in the midst of being treated for another pulm
infection with moxifloxacin.
.
Today pt called clinic because he reported feelings of malaise
and nausea and noted that he had a low grade fever. He went to
clinic and was found to have a fever of 103, Bp in 80's
systolic, HR of 140. He was started on meropenem and vancomycin
and started on maintenance fluids at 150cc/hr. WBC were 4.1
with 80%N.
Past Medical History:
-Hypoplastic MDS (deletion 7q and 13) - single cord transplant
on [**2137-6-24**] with reduced intensity Flu/MEL/ATG.
-Last chemo: Tacrolimus [**2138-10-5**], which was stopped after
clinical suspicion of GVH decreased
- Oral Mucor infection [**2136**]: infiltration into base of the
tongue with bleeding requiring intubation and IR guided ablation
of bleeding lingual artery. s/p excision by ENT. Complicated
hospital course involving multiple ICU stays for post-operative
laryngeal edema following intubation.
- C. difficile infection [**10/2136**]
- pericoronitis s/p extraction 4 teeth [**2137-1-24**]
- peri-rectal abscess s/p drainage [**2137-2-27**]
- Hemochromatosis
- Transaminitis (felt most likely multifactorial; contributions
by medications and hemochromatosis)
Social History:
-Moved from [**Country **] in [**2136**].
-lives with sister, brother-in-law, and their 2 children.
-He has no pet exposures.
-previously worked in warehouse packing boxes, has not worked
since [**35**]/[**2136**]. He has a history of working for an oil company in
[**Country **], though per reports worked mainly in office and had
only occasional exposure to factory environment.
-No significant tobacco history.
-Occasional alcohol use
-No illicit drug.
Family History:
Father died at age 73, per reports had "illness" and progressive
weakness. Mother died of stroke at age 60. No known family
history of cancer or bleeding disorders. Has 6 siblings who are
healthy.
Physical Exam:
Vitals: T:100.6 BP:95/60 P:104 R:20 O2: 98%
General: Alert, oriented, no acute distress, flat affect
HEENT: Sclera anicteric, PERRLA, MMM, OP clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, some basilar crackles
which clear with cough, no wheezes or ronchi
CV: tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: no focal deficits, motor [**6-21**] throughout, CNII-XII normal.
Pertinent Results:
[**2138-3-29**] 03:35PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2138-3-29**] 03:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2138-3-29**] 03:35PM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2138-3-29**] 10:15AM GLUCOSE-116* UREA N-14 CREAT-1.0 SODIUM-133
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-22 ANION GAP-14
[**2138-3-29**] 10:15AM estGFR-Using this
[**2138-3-29**] 10:15AM ALT(SGPT)-39 AST(SGOT)-62* LD(LDH)-319* ALK
PHOS-147* TOT BILI-0.6
[**2138-3-29**] 10:15AM ALBUMIN-4.1 CALCIUM-8.5 PHOSPHATE-3.1
MAGNESIUM-2.1
[**2138-3-29**] 10:15AM WBC-4.5# RBC-2.14* HGB-7.7* HCT-22.4*
MCV-104* MCH-35.9* MCHC-34.4 RDW-19.1*
[**2138-3-29**] 10:15AM NEUTS-80* BANDS-1 LYMPHS-14* MONOS-4 EOS-0
BASOS-0 ATYPS-1* METAS-0 MYELOS-0 NUC RBCS-3*
[**2138-3-29**] 10:15AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL
SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL
[**2138-3-29**] 10:15AM PLT SMR-VERY LOW PLT COUNT-21*
[**2138-4-3**] 04:08AM BLOOD WBC-2.8* RBC-2.14* Hgb-7.7* Hct-21.1*
MCV-99* MCH-36.2* MCHC-36.7* RDW-20.5* Plt Ct-43*#
[**2138-4-5**] 11:00AM BLOOD WBC-1.2*# RBC-1.98* Hgb-6.6* Hct-19.6*
MCV-99* MCH-33.2* MCHC-33.6 RDW-20.0* Plt Ct-26*
[**2138-4-8**] 11:00AM BLOOD WBC-6.0# RBC-2.76*# Hgb-9.4*# Hct-26.9*#
MCV-97 MCH-33.9* MCHC-34.8 RDW-18.9* Plt Ct-12*#
[**2138-4-11**] 05:32AM BLOOD WBC-2.0*# RBC-2.58* Hgb-8.8* Hct-25.4*
MCV-98 MCH-34.0* MCHC-34.6 RDW-19.1* Plt Ct-17*
[**2138-4-11**] 05:32AM BLOOD Neuts-42* Bands-0 Lymphs-25 Monos-30*
Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-1*
[**2138-3-30**] 09:20AM BLOOD Gran Ct-1206*
[**2138-3-31**] 03:44PM BLOOD Gran Ct-1533*
[**2138-4-1**] 09:45AM BLOOD Gran Ct-2378
[**2138-4-2**] 04:08PM BLOOD Gran Ct-[**2101**]*
[**2138-4-5**] 11:00AM BLOOD Gran Ct-492*
[**2138-4-8**] 11:00AM BLOOD Gran Ct-4800
[**2138-4-11**] 05:32AM BLOOD Gran Ct-860*
[**2138-4-11**] 05:32AM BLOOD Glucose-92 UreaN-14 Creat-0.8 Na-134
K-4.1 Cl-101 HCO3-23 AnGap-14
[**2138-4-3**] 04:08AM BLOOD ALT-36 AST-61* LD(LDH)-294* AlkPhos-136*
TotBili-0.5
[**2138-4-5**] 11:00AM BLOOD ALT-42* AST-76* LD(LDH)-262* AlkPhos-151*
TotBili-0.5
[**2138-4-8**] 11:00AM BLOOD ALT-48* AST-89* LD(LDH)-365* AlkPhos-162*
TotBili-0.6
[**2138-4-11**] 05:32AM BLOOD ALT-43* AST-79* LD(LDH)-296* AlkPhos-149*
TotBili-0.6
[**2138-4-11**] 05:32AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.0
[**2138-4-8**] 11:00AM BLOOD POSACONAZOLE-PND
[**2138-4-2**] 04:08PM BLOOD ADENOVIRUS PCR-Test Name
.
.
.
Blood cx [**2138-3-29**] - [**2138-4-3**]: No Growth
Sinus Aspirate x4 [**2138-4-2**]: no growth on bacteria/fungal cx
Resp Viral Swab: neg
Stool C.Diff negative x 2
Urine Cx: negative
CMV viral load: not detected
.
MRI Head/Sinus
IMPRESSION:
1. No evidence of intracranial, orbital, or dural extension.
2. Extensive opacification of all the sinuses with mucosal
thickening,
air-fluid levels, loculated air within the fluid collections,
and chronic
inflammatory changes. No bony destruction is visualized.
.
.
CT SINUS
IMPRESSION:
Extensive paranasal sinus disease with active secretions,
suggestive of acute
infection. The above findings appear significantly progressed
from [**2138-2-20**]
exam.
.
DIAGNOSIS:
.
R Middle Inferior Turbinate
Polypoid lesion, right inferior middle turbinate, biopsy:
- Polypoid fragments of sinonasal respiratory mucosa
with focal acute (neutrophilic) and chronic inflammation and
surface erosion.
- No definitive fungal organisms seen; see note.
Note: Special stains (PAS, PAS with Diastase, and GMS stains)
are negative for fungal organisms. Dr. [**Last Name (STitle) **]. Sepehr reviewed
frozen, permanent section, and special stain slides and concurs.
Drs. [**First Name (STitle) **] and [**Name5 (PTitle) **] were notified via emails on [**2138-4-3**]
at 5pm.
Clinical: History of oral mucormycosis, now with sinusitis,
polypoid tissue at inferior right middle turbinate.
Gross:
The specimen is received fresh labeled with the patient's name,
"[**Known lastname **], [**Known firstname 87416**]" and the medical record number. It consists of
fragments of tan pink soft tissue, measuring 0.9 x 0.8 x 0.2 cm
in aggregate. The specimen is submitted entirely for frozen
section evaluation. The frozen section diagnosis by Dr. [**Last Name (STitle) **].
Sepher is "Angioinvasive fungal elements, highly suspicious for
mucormycosis." The frozen section remnant is entirely submitted
in cassette A.
.
DISCHARGE
[**2138-4-11**] 05:32AM BLOOD WBC-2.0*# RBC-2.58* Hgb-8.8* Hct-25.4*
MCV-98 MCH-34.0* MCHC-34.6 RDW-19.1* Plt Ct-17*
[**2138-4-11**] 05:32AM BLOOD Neuts-42* Bands-0 Lymphs-25 Monos-30*
Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-1*
[**2138-4-11**] 05:32AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-1+ Stipple-OCCASIONAL Tear Dr[**Last Name (STitle) **]1+
Ellipto-1+
[**2138-4-11**] 05:32AM BLOOD Plt Smr-RARE Plt Ct-17*
[**2138-4-11**] 05:32AM BLOOD Gran Ct-860*
[**2138-4-11**] 05:32AM BLOOD Glucose-92 UreaN-14 Creat-0.8 Na-134
K-4.1 Cl-101 HCO3-23 AnGap-14
[**2138-4-11**] 05:32AM BLOOD ALT-43* AST-79* LD(LDH)-296* AlkPhos-149*
TotBili-0.6
[**2138-4-11**] 05:32AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.0
Brief Hospital Course:
26 yo man s/p single cord transplant ([**6-/2137**]) for hypoplastic
MDS c/b mucormycosis, CMV infection, c.diff and VRE bacteremia,
with persistent pancytopenia likely [**3-20**] myelosuppression from
CMV + antivirals, recently with recurrent PNA now admitted from
clinic with sepsis.
.
# Sinusitis/Sepsis: On admission, per SIRS criteria (fever of
103 and HR in 140s in clinic) pt met SIRS criteria. He was
hypotensive initially in clinic, but has been responsive to
fluids with BP stable in 110s systolic at time of admission.
All culture data (including sinus aspirates, blood, urine, NP
swab) was negative. The only obvious source of infection was
sinuses. CT and MR sinuses showed diffuse acute sinusitis. To
gather microbiological source, nasal swab was attained by our
colleagues in ENT, which was negative. Due to pt's history of
invasive mucormycotic infection without negative margins and pt
being on suppressive doses of posaconazole, more invasive
culture/biopsy data was pursued. Due to pt's request for
sedation, repeat ENT was done under conscious sedation in the
[**Hospital Unit Name 153**]. Four sinus aspirates and biopsy of polypoid lesion were
collected during ENT exam. The polypoid lesion was sent for
frozen path, and preliminary read came back positive for
invasive fungal infection. Before pt could be brought to OR for
debridement of this area, the final path report came back
revealing that the invasive fungal read was actually artifact
from frozen section. All fungal markers and stains were
negative, and final path was negative for fungal infection. Pt
was continued on IV broad spectrum antibiotics (dapto and [**Last Name (un) 2830**])
and posaconazole and ultimately transitioned to flagyl and
levaquin. He will continue these medications for a total of 3
weeks from day after ENT biopsy.
.
#Epistaxis: on day after ENT procedure, pt removed packing from
nose despite numerous warnings by staff not to take it out. He
was given afrin and started on amicar drip. ENT re-evaluated
pt, but he would not allow them to repack nose. Over the course
of the day, the bx site clotted and bleeding resolved. Amicar
was stopped.
.
# MDS, s/p BMT. Pt's valcyte dose was decreased to ppx dosing
at 900mg daily given negative CMV viral load. He was transfused
with platelets and PRBCs on numerous occasions during
hospitalization.
.
# transaminitis: stable. thought to be [**3-20**] to med effect or
hemochromatosis.
.
TRANSITIONAL:
- follow up in [**Hospital 3242**] clinic and in BMT [**Hospital **] clinic in 4 weeks
- continue levofloxacin and flagyl for three weeks from [**2138-4-3**]
Medications on Admission:
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth once a day
PENTAMIDINE [NEBUPENT] - (Prescribed by Other Provider) - 300 mg
Recon Soln - 300 mg inh once per month diluted in 6mg sterile
water; please give albuterol inhaler, 2 puffs, pre inhalation
POSACONAZOLE [NOXAFIL] - 200 mg/5 mL (40 mg/mL) Suspension - 10
ml Suspension(s) by mouth twice daily for 400 mg twice daily
URSODIOL - (Prescribed by Other Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **] nam; Dose
adjustment - no new Rx) - 300 mg Capsule - 1 Capsule(s) by mouth
twice a day
VALACYCLOVIR - 1,000 mg Tablet - 1 Tablet(s) by mouth daily
Medications - OTC
MULTIVITAMIN [DAILY MULTIPLE] - Tablet - 1 Tablet(s) by mouth
once a day
Discharge Medications:
1. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
2. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO Q24H
(every 24 hours).
3. posaconazole 200 mg/5 mL (40 mg/mL) Suspension Sig: Ten (10)
mL PO Q12H (every 12 hours).
4. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 14 days: until [**2138-4-24**].
Disp:*14 Tablet(s)* Refills:*0*
5. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 14 days: last day [**2138-4-24**].
Disp:*42 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Sinusitis
hypoplastic MDS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to hospital for sinusitis. We were concerned
that you might have an invasive fungal infection and had ENT
surgery take a biopsy from your sinus. There was no evidence of
fungal infection on your biopsy. We treated you with IV
antibiotics and transitioned you to oral antibiotic therapy. We
believe that you are now safe to home.
.
The following changes to your medications have been made:
1. Start Flagyl (metronidazole) 500mg by mouth every 8 hours
until [**2138-4-24**]
2. Start Levaquin 500mg by mouth every 24 hours until [**2138-4-24**]
3. change valgancyclovir to 900mg once daily
.
Please continue the rest of your home medications
Followup Instructions:
Department: BMT/ONCOLOGY UNIT
When: TUESDAY [**2138-4-15**] at 1 PM [**Telephone/Fax (1) 447**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: HEMATOLOGY/BMT
When: TUESDAY [**2138-4-15**] at 1:30 PM
With: [**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3885**], NP [**Telephone/Fax (1) 3886**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2138-4-15**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3884**], MD [**Telephone/Fax (1) 3237**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: HEMATOLOGY/ONCOLOGY Infectious disease clinic
When: [**2138-4-30**] 01:30p
With: Dr. [**Last Name (STitle) 724**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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10,377
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435
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Discharge summary
|
report
|
Admission Date: [**2136-2-28**] Discharge Date: [**2136-3-7**]
Date of Birth: [**2077-7-1**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Meperidine & Related / Codeine / Propoxyphene
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Dyspnea and pleuritic chest pain
Major Surgical or Invasive Procedure:
Transfusion of 1unit of pRBCs
History of Present Illness:
History of Present Illness: Ms. [**Known lastname **] is 58 year old female with
history of COPD, Systolic CHF (EF 45-50%), Bipolar disease,
Borderline Personality Disorder, severe pain, depression, RA,
and oxygen use (4L without a clear-cut rationale). She was
admitted today for chest pain and dyspnea.
.
Ms. [**Known lastname **] reports that she had the flu last week and began
experiencing diffuse chest pain (10+/10), a non-productive
cough, fatigue, and pain-associated dyspnea over the weekend
that differed in quality from her normal angina. The pain
intensitifed when she would breath deeply or cough and she had a
reported fever of 102.0, and she denied chills/sweats as well as
any radiating pain to her neck or arms. Ms. [**Known lastname **] did not take
her usual nitroglycerin, but instead called Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 575**], her pulmonologist who directed her to get a CXR at
the ED. Medical records indicate that she described her chest
pain to EMT as left-sided, stabbing, associated with pressure
and dyspnea -- similiar to her normal angina-like symptoms. Ms.
[**Known lastname **], however, disputes this characterization (along with
receiving any pain medications en-route or in the ED.
.
Ms. [**Known lastname **] also reports a worsening of her chronic diarhrea since
[**Last Name (LF) 2974**], [**1-19**]. She also reports that some blood in her
diarrhea since that time, but denies any change in her PO
intake, reporting that she had a proper dinner last night.
.
In the ED, Ms. [**Known lastname 3728**] vitals were BP: 115/63 & 102/53, HR: 107 &
90, RR: 16 & 20, O2 Sat: 100% 5L NC & 94% on 3L NC. She was
also afebrile. In the ED she received ASA (325 mg),
Nitroglycerin, Kcl (40mEq), Percocet (5/325), morphine (2mg IV),
and Levofloxacin (750mg). She denied any abdominal pain and
refused a guaiac exam. On physical exam, no wheezing. A CXR
identified multifocal bilateral airspace opacities and blunting
of the left costophrenic angle -- consistent with multifocal
pneumonia and a small parapneumonic effusion. Her EKG was
reassuring, and her cardiac enzymes (CK: 21) were negative. She
also had no events on telemetry and was reportedly chest pain
free before being transfered to [**Doctor Last Name **].
.
After being transferred to [**Doctor Last Name **], she complained of chest pain
and dyspnea, abdominal pain, and pain in the balls of her feet.
She also refused rectal guiac as well as an ABG. A second CXR
indicated that her cardiac sillihette was stable, that she had
multifocal pneumonia with multifocal hazy opacities in her RUL,
RML, and LLL as well as a blunted left costrophrenic angle.
Past Medical History:
COPD w/ Emphysema on CT scan; Decreased DLCO
Systolic CHF (EF 45%)
RA
Chronic Diarrhea of Unknown Etiology: atonic colon per pt.
per [**1-/2134**] note by her PMD and [**9-/2133**] note by Gastroenterology,
symptoms may be functional
Severe Pain, on Narcotics
Cigarette Smoking
Fibromyalgia
Migraine H/A
Anorexia; History of laxative and diuretic abuse
Oxygen Use (4L), without clear cut rationale per pulmonology
History of Breast Cancer; s/p resection x 4 lumps, No chemo or
radiation; Years ago per pt
History of Seizure disorder; Last in [**2126**]; ETOH Withdrawal
History of CVA: Many years ago
TAHBSO: [**2113**]; For cancer
History of [**Last Name (un) **] syndrome: Requiring inpatient decompression
.
PSYCHIATRIC HISTORY: (Per [**Last Name (un) **])
.
Bipolar Disorder
Borderline Personality Disorder
Attention Deficit Disorder
Depression
Multiple Prior Hospitalizations, Over 20 years ago
History of Suicide Attempt: Via OD; Over 20 Years Ago
Psychiatrist Dr. [**Last Name (STitle) 3704**] [**Telephone/Fax (1) 3715**], last visit unknown
Therapist unknown
FROM [**Telephone/Fax (1) **]:
- Diastolic CHF, EF 50%.
- COPD on 3.5L oxygen at home.
- Psychiatric disease including anorexia nervosa, past laxative
and diuretic abuse. Distant suicide attempt by overdose.
- Fibromyalgia.
- Arthritis.
- Seizure disorder, last seizure [**2126**] in the setting of EtOH
withdrawal.
- Breast CA s/p resection many years ago in Wisconson.
- Past Bell's palsy.
- CVA many years ago.
- Past TAHBSO for cancer in [**2113**].
- Chronic diarrhea.
- History of [**Last Name (un) 3696**] syndrome requiring inpatient
decompression.
- History of migraine headache.
PSYCHIATRIC HISTORY:
per [**Last Name (un) **], diagnosis of AN, borderline personality disorder and
poly substance abuse
- patient reports psychiatrist Dr. [**Last Name (STitle) 3704**] [**Telephone/Fax (1) 3715**], whom
she sees every few months for meds
- prior therpaist was [**Doctor First Name **] Aparcio, who she says stopped
seeing her 6 months ago. She says that " I begged and pleaded"
but that the therpaist let her go. No current therpaist
- reports mutiple prior psychiatric hospitalizations, but
deniesany in the last 20 years
- reports suicide attempt by OD over 20 years ago, nothing
recent per [**Doctor First Name **], certian notes indicate she had multiple SA and
hospitalizations in the past
Social History:
Reports that she is a recovering alcholic and addict, but
adamently denies ETOH and ilicit drug use for several years.
40-pack-year history of smoking, (still smokes occasionally).
Married for 20 years, alhough separated for 15 (per [**Doctor First Name **]).
Husband has multiple medical issues and is currently at a
nursing home.
Family History:
Mother & Sister: [**Name (NI) 3729**]
MOther: CAD, Breast Cancer
Father: Pancreatic [**Name (NI) 3730**], Lung Cancer
Physical Exam:
VS: T: 98.0 BP 91/48 HR: 122 reg RR 28 O2 sat 90% on 6L->98%
NRB->95% on 50% venti-mask
Gen: Anxious, Ill-appearing,
Cardiac: Increased rate, Normal S1 & S2, no m/r/g
Pulm: Diminished breath sounds bilaterally (anterior)
Abd: Refused
Ext: No edema
Neuro: A/O x 3. [**3-22**] motor strength LLE/RLE.
Pertinent Results:
[**2136-2-28**] 07:28PM CK(CPK)-19*
[**2136-2-28**] 07:28PM CK-MB-NotDone cTropnT-<0.01
[**2136-2-28**] 07:28PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG
[**2136-2-28**] 03:28PM URINE bnzodzpn-POS barbitrt-NEG cocaine-NEG
amphetmn-POS mthdone-NEG
[**2136-2-28**] 03:28PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2136-2-28**] 03:15PM LD(LDH)-132 TOT BILI-0.1 DIR BILI-0.1 INDIR
BIL-0.0
[**2136-2-28**] 03:15PM proBNP-8010*
[**2136-2-28**] 03:15PM IRON-9*
[**2136-2-28**] 03:15PM calTIBC-124* VIT B12-GREATER TH FOLATE-15.4
HAPTOGLOB-283* FERRITIN-228* TRF-95*
[**2136-2-28**] 03:15PM HCT-28.5*#
[**2136-2-28**] 12:48PM LACTATE-1.2
[**2136-2-28**] 10:40AM GLUCOSE-61* UREA N-24* CREAT-1.0 SODIUM-133
POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-25 ANION GAP-13
[**2136-2-28**] 10:40AM CK(CPK)-21*
[**2136-2-28**] 10:40AM cTropnT-<0.01
[**2136-2-28**] 10:40AM WBC-7.9 RBC-2.15* HGB-7.4* HCT-21.5* MCV-100*
MCH-34.4* MCHC-34.4 RDW-12.5
[**2136-2-28**] 10:40AM NEUTS-87.4* LYMPHS-10.1* MONOS-1.4* EOS-1.0
BASOS-0.1
[**2136-2-28**] 10:40AM PLT COUNT-306
[**2136-2-28**] 10:40AM FIBRINOGE-1005*#
[**2136-2-28**] 10:20AM HCT-24.9*
MICRO:
U/A: SpeGr: 1.006; pH: 7.0; Urobil Neg; Bili Neg; Leuk Neg; Bld
Neg; Nitr Neg; Prot Neg; Glu Neg; Ket Neg
IMAGES:
STRESS ECHO ([**1-25**]) Poor functional exercise capacity. No ischemic
ECG changes with 2D echocardiographic evidence of possible prior
myocardial infarction without inducible ischemia at the limited
achieved workload. Estimated pulmonary artery systolic pressures
were normal before and after exercise.
CXR ([**2-28**]; am) FINDINGS: PA and lateral views of the chest were
obtained. The cardiac silhouette is stable in appearance. There
is prominence of the right paratracheal stripe which is new
compared to the prior study and may reflect mediastinal
lymphadenopathy. There are multifocal hazy opacities noted
within the right upper lobe, right middle lobe, and left lower
lobe. There is blunting of the right costophrenic angle
suggestive of a small pleural effusion. The osseous structures
are intact. IMPRESSION: Multifocal bilateral airspace opacities
and blunting of the left costophrenic angle, the appearance of
which is consistent with multifocal pneumonia and a
small parapneumonic effusion. Interval development of prominence
of the right paratracheal stripe which may reflect reactive
mediastinal lymphadenopathy. A follow up CXR is recommended
following treatment.
CXR ([**2-28**];pm) FINDINGS: AP single view of the chest obtained
with patient in semi-upright position demonstrates again the on
next previous examination demonstrated multifocal parenchymal
densities in the pulmonary parenchyma preferentially in the
right upper lobe and left mid lung field and left lung base.
They persist practically unaltered. There is no evidence of
pneumothorax, and the lateral
pleural sinuses are only mildly blunted. Review of the next
preceding chest examination of [**2136-2-8**] showed
remarkable absence of any significant parenchymal densities at
that time. IMPRESSION: Bilateral multifocal extensive pulmonary
infiltrates consistent
with inflammatory processes. In light of patient's previous
diagnosis of COPD, consider also possibility of atypical edema
in particular as patient received large dose of fluid.
Brief Hospital Course:
This is a 58 year old female with history of COPD on 2-4L home
O2, Systolic CHF (EF 45-50%), Bipolar and Borderline Personality
Disorder admitted [**2135-2-27**] for chest pain and dyspnea after 5
days of viral syndrome with multi-focal pneumonia and
respiratory distress.
1) Chest Pain/Dyspnea: Patient has history of systolic CHF and
COPD - although according to pulm notes may not be obstructive
and may not actually need O2. At home on 4L NC at all times.
Reportes that chest pain differs from her usual anginal chest
pain and hurts more with deep breaths and coughing. In
addition, her EKG and cardiac enzyme levels suggested that a
myocardial infarction was not the source of her symptoms.
Likely her symptoms were caused by PNA (bibasilar multifocal
opacities on 2 CXRs) and exacerbated by getting fluids in the ED
(2L NS). Also, may in part, be attributed to anxiety as patient
has extensive psych history. Levo (750mg) was provided in the
ED and scheduled for [**2136-3-1**]. Upon arrival to the floor she
triggered immediately for low o2 sats on 4L NC and tachycardia.
She was put on venti mask and sats came up. It was felt she had
pulm edema given IVF in ED and CXR with possible edema. She
continued with tachycardia and it was thought this was a
combination of the CHF with BNP 8000 (highest in [**Month/Day/Year **] only 800s),
respiratory distress, and anxiety. She may also have taken her
home medications including adderall. Her room was searched and
these were taken from her. Got total of 30mg IV lasix over the
course of the late afternoon/evening as well as ativan and her
home dose of clonipin. HR came down to 120s. Overnight she
continued to have tachypnea with recurrently low O2 sats on 6L
NC so was placed on venti-mask. She continued to be tachycardic
all night with no improvement after ativan and confiscating her
adderall which she had been hiding in her room. An ABG revealed
hypoxia (PO2 61) without CO2 retention. She was given an extra
10mg IV lasix and put out total of 2.3L over the night.
In the am she continued to be tachypnic, hypoxic, and
tachycardic. She was started on IV vanc for empiric coverage of
HAP given recent hospitalizations. A repeat CXR did not show
pulm edema so no further lasix was given. She was started on
BIPAP. Repeat ABG with PO2 50s. She was transferred to the MICU
for respiratory distress and possible intubation. Of note she
did say she would take intubation "as a last resort". Would not
give us the phone numbers of next of [**Doctor First Name **] and in [**Name (NI) **] sister's
number is out of service.
She was transferred to the MICU where she was stabilized after
briefly being on BIPAP. A speech and swallow evaluation
confirmed that she was aspirating. The MICU team discussed with
her placing a PEG tube and she refused. She also pulled out an
NGT placed for feeding two times.
She came back to the floor and was satting 94% on 2L NC which
is her baseline. We attempted to convince her to comply with a
video swallow exam to rule out silent aspiration but the patient
refused. Given that she was high aspiration risk it was felt
that she should not eat, however, the patient threatened to
leave the hospital if she was not given food. Therefore, after
explaining her risk of choking and developing further
pneumonias, a compromise was reached. The patient had a
nectar-thickened diet while in house. She was set up with an
outpatient speech and swallow evaluation (including video
swallow) which she said she would comply with as long as we did
not try to evaluate her in the hospital. She was discharged with
"Thick-aid" to add to her liquids and will see the speech and
swallow team in one week for her evaluation. Her primary care
doctor will discuss these results with her.
2) Anemia: Patient with history of chronic inflammation (RA) as
well as gastritis likely from NSAIDs reports both bright and
dark blood in stool starting on [**Name (NI) 2974**]; attributes blood, in
part, to internal and external hemmorhoids and refused rectal
guiac on mulitple occasions. Normal MCV, low Fe, low TIBC, low
tranferrin and high ferritin suggestive of anemia of chronic
disease which is associated with both chronic inflammatory
processes and heart failure. Patient may be suffering from ACD
along with co-existing iron deficiency, requiring both iron
supplementation as well as addressing her underlying disorder.
Stool guaiacs were negative on the floor. Patient was consented
for blood transfusion but was not transfused given volume
overload and stable hcts while on floor.
In the MICU she was given 1unit pRBCs for a slightly lower hct
than previously. Her hct continued to be stable throughout her
stay. Her naproxen was held throughout her stay and she was
started on iron which she will take as an outpatient. Her
primary care doctor will follow her blood counts as an
outpatient.
3) Diarrhea: Patient has chronic history of diarrhea with a
question of laxative abuse and anorexia; Had some loose stools
on the floor even after medications were comfiscated and with
recent hospitalizations may have an infection. CDiff tests were
negative.
4) Pain Management/Psych issues: Unclear who is following her
for psych as an outpatient. Will likely need psych consult at
some point given medication regimen is likely not correct
regimen and she has off and on been refusing medical care.
Currently does have capacity per the medicine floor team's
assessment but may need formal capacity assessment in the
future. Also has h/o eating disorders and with laxative abuse
may need eating disorder team consult when more acute medical
issues resolved.
Medications on Admission:
ALBUTEROL - 90 mcg Aerosol - 1 to 2 puffs, QID
ALBUTEROL SULFATE - 0.83 mg/mL, QID
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg - 2 puffs inhaled [**4-22**]
times a day; PRN
AMPHETAMINE-DEXTROAMPHETAMINE - 20 mg Capsule, 1 Cap TID
BUTALBITAL-ACETAMINOPHEN-CAFF [FIORICET] - 50 mg-325 mg-40 mg
Tablet - 1 TAB Q Daily
CLONAZEPAM - 2 MG TABLET 1 TAB QID
FEXOFENADINE - 180 mg Tablet - I TAB Q Daily
FLUOXETINE - 20 mg Tablet - QID
FLUTICASONE - 50 mcg Spray 1 to 2 sprays [**Hospital1 **]
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose
Disk
with Device - 1 Inhalation [**Hospital1 **]
FOLIC ACID - 1 Tab Q Daily
FUROSEMIDE - 20 mg Tablet - 2 Tabs [**Hospital1 **]
HYDROCORTISONE ACETATE [ANUSOL HC-1] - 1 % Ointment - Q Bedtime
LIDOCAINE [LIDODERM] - 5 % (700 mg/patch) Adhesive Patch, 3
Patches on neck or back for 12 hours on/12 hours off
MISOPROSTOL [CYTOTEC] - 100 mcg Tablet - 2 Tabs [**Hospital1 **]
MULTIVITAMINS - SOLUTION - 1 Tab Q Daily
NAPROXEN - 500 mg Tablet - 1 Tab [**Hospital1 **]
NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 Tab every 5
minutes/3 doses PRN
OXYCODONE-ACETAMINOPHEN [PERCOCET] - 5 mg-325 mg Tablet - 1 Tab
QID
PANTOPRAZOLE - 40 mg Tablet, 1 Tab Q Daily
PERPHENAZINE - 8 mg Tablet - 1 Tab Q PM
POTASSIUM CHLORIDE - 20 mEq Tab 3 Tab [**Hospital1 **]
RALOXIFENE [EVISTA] - 60 mg Tablet - 1 Tab Q Daily
RISPERIDONE - 2MG Tablet - 1 Tab Q Daily
SULFASALAZINE - 500 mg Tablet - 2 Tab [**Hospital1 **]
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - 1 Inhalation Q Daily
TRAMADOL - 50 mg Tablet - 4 Tabs Q4-Q6
TRIAMCINOLONE ACETONIDE - 0.1 % Ointment - [**Hospital1 **]
Discharge Medications:
1. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours).
2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
4. Perphenazine 8 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. Risperidone 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Misoprostol 200 mcg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Fexofenadine 180 mg Tablet Sig: One (1) Tablet PO once a day.
8. Hydrocortisone Acetate 1 % Ointment Sig: One (1) Appl Rectal
QPM (once a day (in the evening)).
9. Sulfasalazine 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
10. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
Three (3) Adhesive Patch, Medicated Topical DAILY (Daily): On
for 12 hours, off for 12hours.
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
13. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) inh Inhalation once a day.
14. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO once a day.
15. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every six
(6) hours.
16. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab
Sublingual Q 5 mins as needed for chest pain for 3 doses.
17. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
18. Lasix 20 mg Tablet Sig: Two (2) Tablet PO twice a day.
19. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
20. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1)
inh Inhalation twice a day.
21. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
spray Nasal twice a day.
22. Fioricet 50-325-40 mg Tablet Sig: One (1) Tablet PO once a
day.
23. Amphetamine-Dextroamphetamine 20 mg Tablet Sig: One (1)
Tablet PO three times a day.
24. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation four times a day as needed for shortness
of breath or wheezing.
25. Thick-Aid Liquid Sig: AS DIR Topical three times a day:
Add to liquids to thicken prior to eating.
Disp:*1 months supply* Refills:*2*
26. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Three (3) Tab Sust.Rel. Particle/Crystal PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Aspiration PNA
Discharge Condition:
The patient was febrile, hemodynamically stable, and satting 98%
on 2L NC when she was discharged.
Discharge Instructions:
You were admitted to the hospital with pneumonia. We think you
got pneumonia from having food go down your windpipe when you
swallow. We have recommended that you not eat and have advised
you have a feeding tube instead. You have refused this treatment
and you have stated that you understand that you may get
pneumonia again if you eat.
Medication Changes:
START: Iron 325mg by mouth twice daily
STOP: Naproxen
Diet Changes: You have been advised to have a feeding tube
placed and no longer eat anything by mouth. You have refused the
feeding tube. We have thus advised that you eat only
nectar-thickened liquids. We have given you a prescription for
"Thick-Aid" which you can use to thicken your food.
Please call your doctor or come back to the hospital if you
develop shortness of breath, fevers, chills, chest pain,
confusion, weakness, or any other concerning symptoms.
Followup Instructions:
F/U CXR for mediastinal LAD in 6 weeks.
Please call your primary care doctor, Dr. [**Last Name (STitle) 3707**]
([**Telephone/Fax (1) 2205**]), for a follow up appointment in [**1-20**] weeks. She
will call you with the appointment time. She will listen to your
lungs and help you with setting up your swallowing doctor.
Please follow up with the speech pathologists ([**Telephone/Fax (1) 3731**]) who
will give you exercises for strenghthening your swallowing
muscles and test how you are swallowing. They will see you on
[**3-14**] at 1:00 pm in the [**Location (un) 591**], [**Hospital1 3732**]. [**Location (un) 470**] in the radiology department. Your
primary care doctor will discuss the results with you.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
Completed by:[**2136-3-7**]
|
[
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
19481, 19487
|
9739, 15378
|
350, 382
|
19546, 19647
|
6323, 9716
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20574, 21445
|
5868, 5988
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17071, 19458
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19508, 19525
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15404, 17048
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19671, 20010
|
6003, 6304
|
20030, 20551
|
278, 312
|
438, 3104
|
3126, 5502
|
5518, 5852
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,532
| 103,229
|
43241
|
Discharge summary
|
report
|
Admission Date: [**2141-11-11**] Discharge Date: [**2141-11-16**]
Date of Birth: [**2068-6-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
MI instent restenosis
Major Surgical or Invasive Procedure:
Percutaneous coronary intervention/drug eluting stent x2
History of Present Illness:
73 yom s/p CABG [**2125**], PCI/LCX (01), instent restenosis
w/brachytherapy balloon cutting ([**3-11**]) and instent restenosis
x2 stents ([**4-13**]) now with instent restnosis to LCx s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
[**Last Name (Prefixes) 10157**] to LCx and elevated right sided pressure on cath (PCWP
30). Patient also has extensive LAD disease -> LIMA-D1/LAD
(occluded proximally and subtotally occluded after LIMA
touchdown), RCA: SVG to RCA/PDA all occluded. LMain 60%. Has
previous EF 30-35% ([**4-13**]). No significant h/o arhythmia.
Patient reports approx 2 days of intermittent SSCP, squeezing
and [**12-11**] DOE. Denies orthopnea, PND, palpitations or syncope.
Of note, patient hasn't seen his PCP [**Last Name (NamePattern4) **] 4 yrs. Initially refused
taking statin and took only 30 days of Plavix after most recent
stent ([**4-13**]).
Past Medical History:
1. Hyperlipidemia
2. HTN
3. R CEA
4. CAD (CABG [**25**], stent [**36**], ballon cutting/brachy 02, stent
[**4-13**])
Social History:
15py tobacco history (quit at age 35)
no ETOH
lives with wife
Family History:
Fhx + for DM.
Physical Exam:
VS T 98.6 BP 130/70 HR 70 RR 16 O2sat 98%2L
NC
GEN: lying in bed
HEENT: PERRL, mmm, OP clear, no carotid bruit
CV: nl S1, S2 no murmurs/rubs/gallops appreciated
LUNG: CTA ant/lat
ABD: soft, NT, +BS
GROIN: no R femoral bruit or hematoma
EXT: 1+ DPP, nonedematous
NEURO: AOx3, nonfocal
Pertinent Results:
[**2141-11-11**] 12:25PM BLOOD WBC-8.9 RBC-3.53* Hgb-11.3* Hct-32.1*
MCV-91 MCH-32.0 MCHC-35.3* RDW-13.5 Plt Ct-177
Neuts-86.2* Bands-0 Lymphs-9.9* Monos-3.6 Eos-0.1 Baso-0.3
PT-14.5* PTT-27.1 INR(PT)-1.4
[**2141-11-11**] 12:25PM BLOOD Glucose-149* UreaN-49* Creat-2.3* Na-139
K-4.6 Cl-103 HCO3-23 AnGap-18
ALT-22 AST-17 AlkPhos-56 TotBili-0.8 Triglyc-98 HDL-36
CHOL/HD-3.4 LDLcalc-68
[**2141-11-11**] 12:25PM BLOOD CK(CPK)-99 cTropnT-1.08*
[**2141-11-12**] 02:56PM BLOOD CK-MB-13* MB Indx-7.3* cTropnT-1.18*
[**2141-11-12**] 10:08PM BLOOD CK-MB-13* MB Indx-6.6* cTropnT-1.19*
Calcium-9.2 Phos-3.9 Mg-2.3 freeCa-1.12
Iron-35* calTIBC-242* Ferritn-116 TRF-186*
CHEST (PORTABLE AP): Small vague density overlying the posterior
left 8th rib. Follow up with PA and lateral views is
recommended.
[**2141-11-11**] Cardiac Cath
COMMENTS:
1. Selective coronary angiography in this right dominant
circulation
demonstrated three vessel native coronary artery disease. The
LMCA had
diffuse 60% stenosis. The LAD with totally occluded proximally
and
subtotally occluded after the touchdown of the LIMA. The D1 was
without
any angiographically apparent flow limiting disease. The LCx had
a
proximal 80% instent restenosis. The more distal part of the
proximal
LCx stents were patent. OM1 and OM2 were without any flow
limiting
disease. The RCA was not engaged because it was known to be
previously
occluded.
2. The LIMA was without any flow limiting disease. The SVG was
not
engaged because it was known to be previously occluded.
3. Resting hemodynamics from right heart catheterization
demonstrated
moderately elevated right sided filling pressures (RVEDP
19mmHg). The
mean PCWP was severely elevated to 37mmHg and the tracing had
large v
waves. There was moderate to severe pulmonary arterial
hypertension. The
calculated cardiac output via the Fick method was 2.8 L/min with
a
cardiac index of 1.6.
4. successful prdilation using 2.5 X 20 mm Voyager balloon,
stenting
using 3.0 X 32mm and 3.0 X 12 cypher stents and post dilating
using 3.5 X 28 High sail ballon with lesion reduction from 90%
to 0% in
the mid CX and from 60% to 0% in the LMCA. The final angiogram
showed
TIMI III flow with no residual stenosis, no dissection or
embolisation.
(see PTCA comments)
FINAL DIAGNOSIS:
1. Severe three vessel native coronary artery disease.
2. Severely elevated PCWP with large v waves.
3. Severely depressed cardiac output.
4. Successful stenting of the CX/LMCA lesion.
[**2141-11-11**] ECHO
The left ventricular cavity is dilated. There is moderate to
severe regional left ventricular systolic dysfunction. Overall
left ventricular systolic function is moderately to severely
depressed with septal and apical hypokinesis although views are
technically suboptimal. The anterior wall may be hypokinetic but
is not fully visualized. Estimated LV ejection fraction ?30%.
Right ventricular chamber size and systolic function is probably
normal. The apex is not well seen; no apical thrombus seen but
cannot exclude. The aortic valve leaflets are mildly thickened.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate ([**12-11**]+) mitral
regurgitation is seen. There is an anterior space which most
likely represents a fat pad, though a loculated anterior
pericardial effusion cannot be excluded.
Compared with the prior study (tape reviewed) of [**2141-4-25**],
there is no
definite change (although current study is technically
suboptimal for
comparison.
[**2140-11-11**] EKG
Atrial fibrillation. Inferolateral wall myocardial infarction,
age
indeterminate. Probable left ventricular hypertrophy. Compared
to the previous tracing no significant change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
92 0 104 364/[**Telephone/Fax (2) 93154**]
Brief Hospital Course:
Mr. [**Known lastname 93155**] is a 73-year-old man with hypertension, peripheral
vascular disease, and coronary artery disease status post CABG
(`90), stent (`01 and `05), balloon/bracytherapy [**2137**] for
restenosis LCx now s/p 2 [**Year (4 digits) **] to restenosis site of LCx and
elevated filling pressures this admission.
.
##CARDIAC:
#Ischemia - 2 [**Year (4 digits) **] to LCx restenosis. Continue ASA, Plavix 75mg x
9 months. Restart Metoprolol XL 100 mg PO DAILY. Followed serial
EKGs and CE's. Started Lipitor 80mg. [**2141-11-12**]: Patient with 3/10
CP in AM, EKG showed 0.5-[**Street Address(2) 4793**] elevation isolated in V3.
Patient was started on heparin gtt for concern of ACS. Relieved
with Nitro gtt, CE's did not trend up, no further intervention
recommended.
.
#Pump - PCWP 30 indicating fluid overload, needing aggressive
diuresis. Patient received 100mg IV lasix s/p cath lab. Urgent
echocardiogram showed mod MR and no obvious flail leaflet. Nitro
ggt was titrated off and hydralazine was discontinued [**11-14**].
Patient was continued on imdur and started on lisinopril 10mg PO
QD.
.
#Rhythm - Patient is without history of afib. Patient went into
afib HR 89-90's, asymptomatic. Patient on IV heparin and started
on coumadin. Continued telemetry and serial EKG's.
.
##ARF: baseline 1.3, 2.3 on admission. likely [**1-11**] to decreased
perfusion. continue to reduce afterload, treat heart failure.
.
##Anemia: Baseline 38-40, 32.1->28.9. MCV 91. B12 wnl and iron
studies consistent with anemia of chronic disease. guiac'd
stool. No acute issues and no transfusions required. Deferred to
outpatient management.
.
##FEN: cardiac healthy 2g Na diet, replete lytes
.
##PPx: IV heparin, bowel regimen, PT consult
.
##Code: full
Medications on Admission:
1. ASA 325
2. amlodipine 5mg QD
3. metoprolol 50mg [**Hospital1 **]
4. captopril 25mg TID
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).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime:
Please start evening of [**2141-11-17**].
Disp:*60 Tablet(s)* Refills:*2*
8. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual q5 minutes: Please take 1 tablet as needed for chest
pain. [**Month (only) 116**] repeat dose after 5 minutes as needed up to 3 total
doses in 15 minutes.
Disp:*1 bottle* Refills:*2*
9. Outpatient Lab Work
Please go to [**Hospital3 **] admitting desk on Monday [**2141-11-20**]
between 9am-6pm to get your labs (INR/PT) drawn. Please have
results faxed to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1637**] Fax [**Telephone/Fax (1) 66123**].
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. STEMI/LCx restenosis
2. CHF
Secondary:
3. Hypertension
4. Hypercholesterolemia
5. Former tobacco use
Discharge Condition:
Good
Discharge Instructions:
Please take medications as prescribed. Continue to take aspirin
and plavix for AT LEAST 3 MONTHS. Please follow-up with your
cardiologist/PCP regarding any adjustment to your medications.
Please keep you follow-up appointments.
Please go to [**Hospital3 **] admitting and pick up lab slip on
Monday [**2141-11-20**] between 9am-6pm and get your labs drawn. Please
have your INR/PT results sent to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1637**] Fax
([**Telephone/Fax (1) 93156**].
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
Fluid Restriction: 1500cc.
Followup Instructions:
Please go to [**Hospital3 **] admitting and pick up lab slip on
Monday [**2141-11-20**] between 9am-6pm and get your labs drawn. Please
have your INR/PT results sent to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1637**] Fax
([**Telephone/Fax (1) 93156**].
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1637**], MD Phone:([**Telephone/Fax (1) 68572**] Date/Time:
[**2141-11-23**] 2:30pm Location: [**Street Address(2) **] [**Apartment Address(1) **], [**Hospital1 **], MA
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Phone:[**Telephone/Fax (1) 920**] Date/Time:
[**2140-12-18**] 4:15pm Location: [**Hospital Ward Name 23**] Clinical Center [**Location (un) **]
Completed by:[**2141-11-19**]
|
[
"E849.8",
"414.01",
"V45.81",
"996.72",
"E879.0",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.20",
"00.46",
"88.56",
"00.66",
"00.40",
"37.22",
"36.07"
] |
icd9pcs
|
[
[
[]
]
] |
9024, 9030
|
5717, 7472
|
339, 398
|
9188, 9195
|
1906, 4167
|
9883, 10669
|
1552, 1567
|
7612, 9001
|
9051, 9167
|
7498, 7589
|
4184, 5694
|
9219, 9860
|
1582, 1887
|
278, 301
|
426, 1315
|
1337, 1456
|
1472, 1536
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,303
| 175,726
|
46271
|
Discharge summary
|
report
|
Admission Date: [**2154-6-18**] Discharge Date: [**2154-7-3**]
Date of Birth: [**2084-5-9**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Antihistamines
Attending:[**First Name3 (LF) 5552**]
Chief Complaint:
Planned admission for ERCP to dilate post-stent stenosis of CBD
Major Surgical or Invasive Procedure:
ERCP
Biliary drain procedure by IR X 3
History of Present Illness:
70 year old female with a history of metastatic colon ca to
liver and lungs, admitted following ERCP to dilate post-stent
stenosis of CBD. Briefly Ms [**Name13 (STitle) 98372**] was diagnosed with
metastatic Colon cancer in [**2148**] and treated with resection and
5FU / Leucovorin. Unfortunately she had a recurrence in [**2152**]
with mets to liver and lungs. She has had multiple biliary
stents placed in the past for obstructive disease. Recently her
bilirubin has been elevated and she has undergone several ERCP's
with Dr [**Last Name (STitle) **] who was unable to remove all of the sludge
distal to the stents. Her chemotherapy regimen has been held for
the past several weeks due to the elevated bili and it was
recommended that she have the percutaneous biliary procedure
which was performed on [**6-6**]. She was then re-admitted on [**6-12**]
at which time IR replaced her percutaneous biliary drain.
.
According to the preliminary procedure documentation:
1. Previously placed metal stent was seen in the major papilla
with distal occlusion.
2. Cannulation of the biliary duct was performed with a balloon
catheter using a free-hand technique.
3. Cholangiogram showed partial stent occlusion with a normal
right hepatic system. The left hepatic system was dilated with
the external biliary drain in place.
4. Biliary Sludge was extracted from the biliary stent with a
balloon catheter.
.
ROS: Feels sleepy after procedure but otherwise well. No
f/c/n/v/SOB since recent discharge. Last BM today.
.
Past Medical History:
CVA on plavix, with residual deficit of dysarthria
Hypothyroidism
Pre-Diabetes
HTN
Patent foramen ovale
.
Onc Hx: Metastatic colon cancer; stage C when diagnosed in
[**8-/2148**] and treated with resection and 6 cycles of adjuvant 5-FU
and leucovorin. Recurrence in [**2152-12-14**] with liver and lung
metastasis. Had biliary stenting in [**12-18**]. Has been treated with
FOLFOX/Avastin since 1/[**2153**].
.
s/p chole
s/p hernia repair
Social History:
Patient lives at home with her husband. Now retired, but used to
work as a real estate and lead inspector for 20 years.
Prior history of smoking (roughly 10 ppy); quit 30 years ago. No
alchol use or illicit drugs.
Family History:
No FH of cancer
Physical Exam:
VS: Tc 98.7, BP 175/83, HR 57, RR 18, 97% on RA
GENERAL: obese woman, in NAD, resting comfortably in bed
HEENT: icteric sclerae; PERRLA
RESP: CTAB
CV: s1, S2, RRR, [**2-19**] sys murmur RUSB
ABD: hypoactive BS. obese. soft, nd, no HSM, no rebound.
Percutaneous drain in place with no evidence of erythema,
bleeding or drainage at site. Mildly TTP around perc drin site
EXT: Trace LE edema; no cyanosis or clubbing
Pertinent Results:
[**2154-6-17**] 10:00AM BLOOD WBC-7.4# RBC-3.56* Hgb-12.0 Hct-36.5
MCV-103* MCH-33.6* MCHC-32.8 RDW-14.1 Plt Ct-170
[**2154-7-3**] 12:00AM BLOOD WBC-8.3 RBC-3.02* Hgb-10.3* Hct-30.6*
MCV-101* MCH-34.2* MCHC-33.7 RDW-14.0 Plt Ct-226
[**2154-6-21**] 05:17PM BLOOD Neuts-73.5* Lymphs-19.8 Monos-5.3 Eos-1.0
Baso-0.4
[**2154-6-18**] 11:30AM BLOOD PT-15.6* INR(PT)-1.4*
[**2154-6-27**] 12:15AM BLOOD PT-18.3* PTT-42.8* INR(PT)-1.7*
[**2154-6-17**] 10:00AM BLOOD UreaN-6 Creat-0.6 Na-139 K-3.6 Cl-102
HCO3-25 AnGap-16
[**2154-7-3**] 12:00AM BLOOD Glucose-117* UreaN-6 Creat-0.5 Na-132*
K-3.8 Cl-97 HCO3-28 AnGap-11
[**2154-6-17**] 10:00AM BLOOD ALT-41* AST-79* LD(LDH)-149 AlkPhos-637*
TotBili-5.4* DirBili-3.6* IndBili-1.8
[**2154-6-21**] 05:00AM BLOOD ALT-34 AST-72* AlkPhos-496* TotBili-12.1*
DirBili-8.9* IndBili-3.2
[**2154-6-25**] 12:00AM BLOOD ALT-35 AST-77* AlkPhos-442* TotBili-10.2*
[**2154-7-3**] 12:00AM BLOOD ALT-24 AST-68* AlkPhos-435* TotBili-7.9*
[**2154-6-17**] 10:00AM BLOOD GGT-286*
[**2154-6-17**] 10:00AM BLOOD TotProt-7.0 Albumin-2.7* Globuln-4.3*
[**2154-7-3**] 12:00AM BLOOD Albumin-2.1* Calcium-7.9* Phos-3.0 Mg-2.2
[**2154-7-1**] 12:15AM BLOOD Osmolal-267*
[**2154-6-28**] 12:15AM BLOOD TSH-3.2
[**2154-6-25**] 12:00AM BLOOD CEA-4.2*
.
[**6-18**] ERCP
Procedures: Biliary Sludge was extracted from the biliary stent
with a balloon catheter.
Impression: 1. Previously placed metal stent was seen in the
major papilla with distal occlusion.
2. Cannulation of the biliary duct was performed with a balloon
catheter using a free-hand technique.
3. Cholangiogram showed partial stent occlusion with a normal
right hepatic system. The left hepatic system was dilated with
the external biliary drain in place.
4. Biliary Sludge was extracted from the biliary stent with a
balloon catheter.
.
[**6-19**] Tube cholangeogram
IMPRESSION: Successful placement of a 8.5-French right biliary
drainage tube, placed through the stent within the common bile
duct into the duodenum for internal drainage.
Successful replacement of pre-existing left biliary drainage
tube with a 6F nephrostomy catherter for external drainage.
.
[**6-21**] CXR
There is a large mass (4.7 x 5.7 cm) at the left lung apex.
Allowing for low inspiratory volumes, no CHF, focal infiltrate
or effusion is identified. The patient's numerous pulmonary
nodules are faintly visible. Drains noted over the upper
abdomen. No acute pneumonic infiltrate identified. Tip of right-
sided Port- A-Cath type catheter overlies the SVC/RA junction.
.
[**6-21**] EGD:
Impression: The esophagus was normal.
The stomach was normal with no blood within.
The ampullary area was examined using a duodenoscope. There was
a small mount of ooze around the previously placed metal stent.
The IR placed biliary stent could be seen within the metal
stent. There was no blood draining from the stent. The ooze was
flushed several times and seemed to be originating from the
periampullary area secondary to trauma from IR stent insertion
+/- metal stent change of position. The oozing had stopped by
the end of the procedure.
.
[**6-21**] GI Bleeding study:
INTERPRETATION: Following intravenous injection of autologous
red blood cells labeled with Tc-[**Age over 90 **]m, blood flow and dynamic
images of the abdomen for 90 minuteswere obtained. A left
lateral view of the pelvis was also obtained.
Dynamic blood pool images show increased uptake throughout
possibly small bowel seen only in the delayed images (60-90).
The precise cause of the increased uptake or the location cannot
be determined.
IMPRESSION:
Increased uptake possibly in the small bowel seen only in the
delayed images (60-90min) likely representing slow upper GI
bleeding.
.
[**6-25**] CT Abd/Pelvis:
CT ABDOMEN WITH IV CONTRAST: There are multiple lung nodules at
the lung bases. The largest is located within the left lower
lobe and measures 2.9 x 2.1 cm and previously measured 2.7 x 2.0
cm. A right upper lobe nodule has increased in size and now
measures 0.6 x 0.6 cm (series 4, image 1). The patient is status
post PTC and two catheters are seen within the liver entering
via frontal and right lateral approaches. There is a small
amount of perihepatic and perisplenic ascites. A common bile
duct stent is unchanged in appearance. The subcapsular mass in
the lateral right lobe which previously measured 2.1 x 2.2 cm is
now ill- defined, perhaps secondary to phase of contrast
administration, but measures approximately 2.2 x 1.2 cm. There
remains mild intrahepatic biliary dilatation, which has
decreased and an expected small amount of pneumobilia. There is
evidence of tumor extension up the porta hepatis encircling the
left portal vein, decreased compared to the prior study. Lymph
nodes within the porta hepatis, some with mucinous calcification
are unchanged.
A cystic lesion in an enlarged spleen is stable. Cysts in the
right kidney are also unchanged. The pancreas, right adrenal
gland, left kidney, and stomach are unremarkable. A new 1.6 x
1.0 cm left adrenal nodule likely represents metastasis. Small
retroperitoneal lymph nodes do not meet criteria for pathologic
enlargement. There is a small ventral hernia containing
unremarkable appearing mesentery.
CT PELVIS WITH IV CONTRAST: The rectum, bladder, and uterus are
unremarkable. There is mild sigmoid diverticulosis. There are no
enlarged lymph nodes and no free fluid within the pelvis.
BONE WINDOWS: No suspicious lytic or sclerotic foci.
IMPRESSION:
1. Interval progression of disease. New left adrenal lesion
suspicious for metastasis. Enlargement of right upper lobe
pulmonary nodule. The right lateral hepatic lesion is more
ill-defined but has likely mildly decreased in size as has tumor
extending up the porta hepatis.
.
[**6-26**] Cholangiogram:
IMPRESSION:
1. Bilateral cholangiograms performed demonstrate decompressed
system and right-sided biliary catheter retracted into the liver
parenchyma. The left- sided biliary catheter presents in good
position and drainage of the left- sided biliary ducts.
2. Successful exchange for right-sided biliary catheter for a 10
French biliary catheter, the pigtail was coiled in the duodenum.
.
[**6-30**] CXR
IMPRESSION:
1. Smaller apparent size of left apical mass, which may related
to technique. If detailed comparison for interval change is
desired, then PA and lateral radiographs could be helpful.
2. Bibasilar opacities, probably atelectasis
Brief Hospital Course:
A/P: 70 F metastatic colon ca admitted for for ERCP to dilate
post-stent stenosis of CBD.
# Hyperbilirubinemia: It was never completely clear why we were
unable to get her bilirubuin down further than we did. The CT
scan did not show progression of disease. ? [**2-15**] paraneoplastic
syndrome. However, after multiple ERCP/IR procedures (detailed
below), her bilirubin started to trend down by discharge.
- On [**6-18**], she underwent successful ERCP during which they
dilated the distal CBD stent stenosis. She was started on
Levofloxacin after this procedure.
- On [**6-19**], IR placed a drain to her R biliary system that was
also internalized to her duodenum. They also replaced her L-
biliary drain (this could not be internalized).
- On [**6-21**], she had a lg amt of marroon blood per rectum. A
bleeding scan suggested an upper-GI bleed. She was transferred
to the [**Hospital Unit Name 153**] and an EGD was performed which showed a slow bleed
from around the site of entry of the CBD into the duodenum,
thought to be secondary to prior procedures. The bleeding had
stopped by the end of th EGD. Her hct was stable and she did
not require any transfusions during her hospital course.
- On [**6-21**], the same day that she was transferred to the [**Hospital Unit Name 153**], she
spiked a fever to 101. CXR did not show a PNA and UA did not
show a UTI. Vanc/Zosyn were started with concern for biliary
source with possible catheter-site infection. On approximately
[**6-27**], Vancomycin was stopped and she was switched to unasyn,
based on sensitivities (her biliary fluid grew out enterococcus
and K. pneumoniae.) On [**6-30**], cipro was added based on new
sensitivity data for the K. pneumoniae and the fact that she
spiked a low-grade fever. She remained afebrile for the
remainder of her hospital course. On discharge, she was sent
out on augmentin and cipro to be taken ongoing.
- On [**6-26**], IR performed another cholangiogram as her bilirubin
was persistently elevated and her drains seemed only to be
intermittently draining. They increased her R drain to a 10 F
and showed that the L drain was working.
- Prior to d/c we also consulted Hepato-biliary surgery. They
stated that they could offer her a surgical procedure to attempt
to provide better drainage but based on the fact that here bili
began to trend down and her drains seemed to be working, she
decided to defer surgery for now. She will have a f/u
appointment w/ Dr. [**Last Name (STitle) **] as an outpatient.
- She is at very high risk for infection given her 2 biliary
drains.
.
# Hpothyroidism: cont armour
.
# HTN: atenolol held during her gi-bleed and for approx 6 days
after and re-started at a lower dose prior to d/c
- d/c of quinipril as did not seem to need it
.
# Metastatic colon cancer: tx per Dr. [**Last Name (STitle) 2036**] (Dr. [**Last Name (STitle) **] covering
initially and Dr. [**Last Name (STitle) **] took over her care prior to D/c)
- her colon cancer does not appear to be very agressive but she
likely cannot receive any further chemotherapy [**2-15**]
hyperbilirubinemia
- [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **] will continue to follow her bilirubin/CBC as
an outpatient.
.
Medications on Admission:
Plavix 75 mg once daily (held X 14 days), quinapril 60 mg daily,
Protonix 40 mg b.i.d., atenolol 50 mg once daily, citalopram 60
mg once daily, Armour 120 mg daily. Oxycodone 5 mg prn.
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Thyroid 120 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every
6 hours) as needed: titrate to [**2-16**] BM per day.
Disp:*1000 ML(s)* Refills:*1*
8. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever: not to exceed 2gm daily .
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Disp:*60 Tablet(s)* Refills:*2*
11. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
12. Outpatient Lab Work
Total Bilirubin to be drawn every Monday, Wednesday and Friday.
Please fax results to [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **], NP at ([**Telephone/Fax (1) 98373**].
13. Outpatient Lab Work
AST/ALT/Alk Phos/Albumin/CBC to be drawn every Monday. Please
fax results to [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **], NP at ([**Telephone/Fax (1) 98373**].
14. Daily Heparin port-a-cath flushes per [**Location (un) 511**] therapy
protocol
Disp: 2 week supply
Refills: 4
15. Daily Normal Saline Flushes Per [**Location (un) 511**] Therapy Protocol
Disp: 2 week supply
Refills: 4
16. Weekly 20 gauge [**3-17**] inch [**Doctor Last Name **] needles for weekly needle
changes
Disp: 2 week supply
Refills: 4
17. VAD Kits
Disp: 2 week supply
Refills: 4
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Health Services
Discharge Diagnosis:
Metastatic colon cancer
Hypertension
Hypothyroidism
Discharge Condition:
Hemodynamically stable. Ambulatory.
Discharge Instructions:
You were admitted for ERCP and IR biliary drain revision.
Please continue the antibiotics as instructed. We also
decreased your blood pressure medications as you did not need as
much as you were receiving.
.
Please seek medical attention immediately if you develop fever,
chills, nausea, vomiting, increased abdominal pain or any other
concerning symptoms.
Followup Instructions:
[**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **] will call you regarding your lab results and to
schedule follow-up w/ Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) 2036**].
.
Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (Hepato-biliary surgeon) office
to obtain the date and time of your appointment w/ him. Tel.
([**Telephone/Fax (1) 3618**].
.
Please make a follow-up appointment w/ Dr. [**Last Name (STitle) 2204**] within the
next 2 weeks. Tel [**Telephone/Fax (1) 2205**].
.
Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Date/Time:[**2156-1-20**] 4:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], MD Phone:[**Telephone/Fax (1) 1983**]
Date/Time:[**2156-1-20**] 4:00
|
[
"401.9",
"197.0",
"244.9",
"197.8",
"578.9",
"576.2",
"197.7",
"576.1",
"745.5",
"V10.05",
"996.79"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.98",
"87.54",
"00.33",
"45.13",
"51.84"
] |
icd9pcs
|
[
[
[]
]
] |
15015, 15090
|
9544, 12783
|
347, 388
|
15186, 15224
|
3113, 9521
|
15630, 16419
|
2645, 2662
|
13018, 14992
|
15111, 15165
|
12809, 12995
|
15248, 15607
|
2677, 3094
|
244, 309
|
416, 1933
|
1955, 2396
|
2412, 2629
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,055
| 187,650
|
51994+51995+52028
|
Discharge summary
|
report+report+report
|
Admission Date: [**2137-5-1**] Discharge Date: [**2137-5-9**]
Date of Birth: [**2073-8-12**] Sex: M
Service: CCU
NOTE: This is a dictation detailing the hospital events
between [**2137-5-1**] and [**2137-5-5**].
CHIEF COMPLAINT: The patient was transferred from [**Hospital3 6265**] for cardiac catheterization.
HISTORY OF PRESENT ILLNESS: The patient is a 63-year-old
male with a history of coronary artery disease, status post
2-vessel coronary artery bypass graft in [**2125**] (left internal
mammary artery to left anterior descending artery and
saphenous vein graft to posterior descending artery), and
status post myocardial infarction times four with positive
enzymes; however, the patient has declined cardiac
catheterization each time.
He was seen in consultation at his pulmonologist's office on
[**2137-4-30**] for evaluation of a cough for a 4-month
duration. The cough was characterized as constant,
productive of thick yellowish sputum with no associated
fevers, chills, nausea, vomiting, diarrhea, or diaphoresis.
Of note, the patient is an active smoker of approximately two
packs per day.
On evaluation in the Pulmonary Clinic he was diagnosed with
chronic obstructive pulmonary disease and felt to be in
congestive heart failure and transferred to [**Hospital3 3583**]
for admission. He was prescribed amoxicillin which was never
filled. At [**Hospital3 3583**], the patient was noted to be
normotensive with a blood pressure of 105/65, heart rate
of 100 with ventricular ectopy, and a respiratory rate of 22
with unlabored breathing. His electrocardiogram was sinus
tachycardia with ectopy, reactive airway disease, poor R wave
progression, and with nonspecific intraventricular conduction
delay. Clinically, he was felt to be in congestive heart
failure and volume overloaded and was admitted for management
of his congestive heart failure and a viral pneumonia.
Over the ensuing 24 hours he was diuresed, and on [**2137-5-1**], he was transferred to [**Hospital1 188**] for catheterization.
REVIEW OF SYSTEMS: Review of systems was positive for
decreased oral intake, cough (as stated above), and a
questionable history of chest pain that was intermittent and
not exertional.
In the cardiac catheterization laboratory, the patient had
the following findings: An arterial blood gas of 7.4, PCO2
of 48, and a PO2 of 67, atrial pressure was noted to be 14,
right ventricle 61/8, cardiac output of 3.22, cardiac index
of 1.58, pulmonary artery pressure of 60/34, with a mean
of 45, and a wedge of 39 to 40. Findings from angiography
included both grafts with 100% occlusions, 100% right
coronary artery occlusion, 100% left anterior descending
artery occlusion, a 98% left circumflex lesion, left
subclavian 100% lesion, perfusion maintained through
collaterals, and a left ventriculography was not performed.
Lasix 40 mg intravenously was given in the catheterization
laboratory times one. During catheterization, the patient
was noted to be hypotensive, and thus started on a dopamine
drip leading to a run of supraventricular tachycardia and
eventual hypertension, necessitating initiation of
nitroglycerin drip.
Upon arrival to the Coronary Care Unit the patient was noted
to be very agitated and having labored breathing. On
telemetry, his rhythm was significant for transitions between
supraventricular tachycardia and atrial fibrillation and
atrial flutter terminating in an unstable atrial fibrillation
rhythm with a progressive drop in blood pressure. Dopamine
was restarted. Given his hemodynamic instabilities, the
patient received direct current cardioversion times two with
no break in his atrial fibrillation. He was initiated on
amiodarone drip, and soon thereafter intubated given
worsening agitation, tachypneic, and in general grave
condition. His immediate pre-intubation arterial blood gas
had deteriorated to 7.22, with a PCO2 of 64, and a PO2
of 149. His blood pressure continued to drop, especially
after intubation with the use of propofol with his nadir at
37 for approximately five minutes. He fluid resuscitated and
switched to a Levophed drip. The patient was re-shocked at
360 joules and eventually converted to normal sinus rhythm
with improvement of his blood pressure. His first complete
hemodynamic numbers since arriving in the Coronary Care Unit
were notable for a pulmonary artery pressure of 78/33, a
cardiac output of 3.4, cardiac index of 1.61. These numbers
further deteriorated to a central venous pressure of 23,
pulmonary artery pressure of 73/39, a pulmonary capillary
wedge pressure of 40, a cardiac output of 2.6, a cardiac
index of 1.28, systemic vascular resistance of 1600
(consistent with cardiogenic shock). The patient was thus
started on milrinone for inotropic support as well as
maintained on Levophed with the addition of vasopressin for
pressor support.
PAST MEDICAL HISTORY:
1. Diabetes diagnosed eight years ago; on insulin times
three years. History of poor glycemic control.
2. Coronary artery disease, status post myocardial
infarction in [**2124**], coronary artery bypass graft in [**2125**],
myocardial infarction times three since, and two positive
stress tests with apparent report of fixed defects.
3. Chronic obstructive pulmonary disease, recently formerly
diagnosed, not home oxygen.
MEDICATIONS ON ADMISSION: (Medications as an outpatient
included)
1. Enteric-coated aspirin 325 mg p.o. q.d.
2. Rhinocort nasal spray.
3. Flovent 44 mcg 2 puffs b.i.d.
4. Robitussin-BM.
5. [**Doctor First Name **] 180 mg p.o. q.d.
6. Gemfibrozil 600 mg p.o. b.i.d.
7. Digoxin 250 mcg p.o. q.d.
8. Aldactone 50 mg p.o. q.d.
9. Insulin (70/30) 26 units q.p.m.
10. Amaryl 8 mg p.o. q.d.
11. Zestril 5 mg p.o. q.d.
SOCIAL HISTORY: As above, the patient is a smoker of two
packs per day.
FAMILY HISTORY: Family history positive for coronary artery
disease and diabetes.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on arrival to the Coronary Care Unit revealed weight
of 88 kg, blood pressure of 89/62 (on 40 mcg of
nitroglycerin), heart rate of 105 (with intermittent sinus
tachycardia), respiratory rate of 24 to 26, and an oxygen
saturation of 98% on face mask. In general, the patient was
an alert, agitated, white male lying in bed in mild distress.
Head, eyes, ears, nose, and throat examination revealed
normocephalic and atraumatic. Pupils were equally round and
reactive to light. Sclerae were anicteric. Neck was soft
and supple. Jugular venous pulse approximately 9 cm to 10
cm. Heart revealed distant heart sounds. No murmurs, rubs
or gallops. Lungs revealed distant breath sounds, rales at
the bases from the sides. No wheezes. Abdomen was soft,
nontender, and nondistended, normal active bowel sounds.
Extremities revealed trace edema. No calf tenderness or
cords. Right groin with an arteriovenous sheath in place,
and no hematoma.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory data
revealed a white blood cell count of 13, hematocrit of 43.4,
platelets of 245. PT of 16.2, PTT of 31.2, INR of 1.8.
Sodium of 136, potassium of 4.6, chloride of 96, bicarbonate
of 33, blood urea nitrogen of 25, creatinine of 0.6, blood
sugar of 64. Creatine kinase of 133, with a MB of 4.
Albumin of 3.4, calcium of 8.3, phosphorous of 4.1, magnesium
of 1.7.
RADIOLOGY/IMAGING: Cardiac catheterization with the
following findings: A right-dominant system revealing
3-vessel coronary artery disease; the left main coronary
artery was normal, the left anterior descending artery was
subtotally occluded after a large first diagonal, the left
circumflex was subtotally occluded proximally with late
filling of a large first obtuse marginal which collateralized
at the posterior descending artery, the right coronary artery
was occluded proximally, saphenous vein graft to posterior
descending artery was occluded, and the left internal mammary
artery to left anterior descending artery could not be
engaged because the left subclavian artery was occluded 3 cm
distal to its origin, but seemed to be filling the distal
left anterior descending artery via competitive flow on the
native vessel.
IMPRESSION: A 63-year-old male with coronary artery disease,
diabetes, and chronic obstructive pulmonary disease who was
transferred to the Coronary Care Unit in likely cardiogenic
shock in the setting of multivessel and graft coronary artery
disease.
HOSPITAL COURSE BY SYSTEM:
1. CARDIOVASCULAR: (a) Ischemia: The patient had cardiac
enzymes cycled with a peak creatine kinase of 378, with a MB
fraction within the normal range. The patient was not felt
to be having an acute coronary syndrome and was maintained
only on aspirin. Beta blockers and Lopressor could not be
utilized considering the patient's low blood pressure.
The Coronary Care Unit team consulted the Interventional
Cardiology Service, and the decision was made to pursue
revascularization of the left subclavian from which the left
internal mammary artery to left anterior descending artery
graft was coming off; although, the primary Coronary Care
Unit team felt that the benefit of such a procedure may be
minimal, they felt that intervention upon the left subclavian
may improve the patient's heart function and hemodynamics.
Lastly, the patient did not wish to be considered for
coronary artery bypass graft (as per his and his family's
wishes).
(b) Pump: The patient was noted to be in cardiogenic shock
on admission to the Coronary Care Unit and was maintained on
milrinone, Levophed, and vasopressin drip. The patient's
Swan numbers were monitored closely, and with noted
improvement the patient's vasopressin drip was discontinued
on hospital day two. Thereafter, the patient was maintained
on milrinone and Levophed drip which was slowly tapered to
off. In addition, the patient was placed on a Lasix drip for
diuresis in the setting of a markedly elevated wedge
pressure. The patient diuresed well with the Lasix drip
which was titrated from 1 mg to 25 mg per hour. However, the
Lasix drip was discontinued on hospital day three secondary
to hypotension.
An echocardiogram obtained on [**2137-5-2**] showed the left
ventricular cavity to be dilated, severe global left
ventricular hypokinesis, right ventricular systolic function
also appeared depressed, and ejection fraction was noted to
be between 10% and 20%. The patient continued to diuresis
well in spite of the stopping of his Lasix drip, and the
patient was also supplemented periodically with intravenous
Lasix times one to insure adequate diuresis.
(c) Rhythm: The patient remained in sinus rhythm after
being cardioverted, and the patient was maintained on an
amiodarone drip. However, on hospital day four, the patient
was noted to have an atrial tachycardia with likely
Wenckebach phenomenon, and the decision was made to
discontinue the amiodarone drip.
2. PULMONARY: As above, the patient was noted to be in
increasing respiratory distress and was intubated. The
patient was maintained on assist-control with frequent
arterial blood gas monitoring of his ventilation and
oxygenation status.
On hospital day four, in preparation for his upcoming cardiac
catheterization, a trial of weaning and extubation was
attempted; however, with the decreasing of the patient's
sedation and switching over to pressor support the patient
was not noted to take any spontaneous breaths. Therefore,
the decision was made to maintain the patient on
assist-control and to continue to lighten up his sedation.
In addition, the patient was noted to have purulent sputum
and was started empirically on Levaquin and Flagyl for a
likely pneumonia.
3. INFECTIOUS DISEASE: As above, the patient was started
empirically on Levaquin and Flagyl for a pneumonia. In
addition, blood cultures were notable for coagulase negative
Staphylococcus in the anaerobic bottle. The patient was
started on vancomycin. The patient was noted to have a
low-grade temperature and spiked to a temperature of 101.1 on
hospital day three.
In addition, the patient was noted to have a mild
leukocytosis with a high of 13.9.
4. RENAL: The patient's creatinine remained stable despite
the vigorous diuresis with Lasix. Therefore, during the time
frame which this dictation is commenting on, there were no
active renal issues.
5. HEMATOLOGY: The patient's hematocrit remained stable,
and there was no indication for transfusions. However, the
patient was noted to have elevated coagulation laboratories.
INR was noted to be 2.3 on hospital day four on no
anticoagulation. The etiology of this abnormal coagulation
was thought to be secondary to hepatic congestion secondary
to right-sided fluid overload.
6. ENDOCRINE: As above, the patient had a history of
diabetes with reportedly poor glycemic control. The patient
was maintained on a regular insulin sliding-scale as well as
being placed on a baseline NPH of 4 units subcutaneous b.i.d.
7. CODE STATUS: The patient's code status was full.
Once, again this has been a dictation detailing the hospital
events occurring between [**2137-5-1**] and [**2137-4-25**].
An Addendum detailing the further hospital course is to
follow.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 2139**]
Dictated By:[**Name8 (MD) 2054**]
MEDQUIST36
D: [**2137-5-9**] 00:25
T: [**2137-5-9**] 09:53
JOB#: [**Job Number 107638**]
Admission Date: [**2137-5-1**] Discharge Date:
Date of Birth: [**2073-8-12**] Sex: M
Service: CCU
This is an interval summary that will cover the period
[**2137-5-6**], through [**2137-5-17**].
HOSPITAL COURSE: (continued)
Ischemia - On [**2137-5-6**], the patient underwent repeat
catheterization with stents placed in the saphenous vein
graft to right coronary artery as well as to the left
subclavian arteries. The patient tolerated this procedure
well without complication and the patient was transferred
back to the CCU intubated on Levophed as well as Nordinone
pressors for blood pressure support.
Status post intervention, the patient's CK enzymes were
repeatedly cycled and did not show an elevation from a high
of 378 on [**2137-5-2**]. Postprocedure on [**2137-5-6**], the patient
had a CK of 196 which was not significantly changed over the
ensuing four days.
Status post procedure, the patient was continued on Aspirin
as well as Plavix. Plavix had been begun on [**2137-5-6**], at 300
mg and was then continued at 75 mg OGT q.d. There were no
further significant changes in the patient's ischemic heart
disease to this date from [**2137-5-6**], through the current date.
Pump - The patient was initially transferred from the
catheterization laboratory with a Swan catheter in place with
systolic blood pressure on the day after intervention ranging
between 99 and 104 and diastolic blood pressure ranging
between 54 and 61 with a MAP of 67 to 74. Pulmonary artery
pressure ranged between 57/61 to 31/34 with a central venous
pressure of 12 to 14 and a cardiac output of 4.7 with a
systemic vascular resistance of 936.
The patient was continued on Nordinone as well as Levophed
for blood pressure maintenance and did not require an
intra-aortic balloon pump status post procedure. The patient
was rapidly tapered off Nordinone and Levophed drips which
were both discontinued by [**2137-5-9**]. The patient for the
remainder of the dictated time period had systolic blood
pressure generally ranging in the mid 80 to mid 90 range.
The patient's Swan catheter was discontinued on or about
[**2137-5-9**], secondary to concerns surrounding possibility of
line sepsis. Swan numbers on [**2137-5-9**], with a blood pressure
of 88/52 and MAP of 64 showed a pulmonary artery pressure of
59/33 with a mean pulmonary artery pressure of 42 and a
central venous pressure of 12. Cardiac output was 4.1,
cardiac index 1.94, systemic vascular resistance of 976.
While the first dictated numbers were taken on Levophed and
Nordinone, the last dictated numbers were off these pressors.
The patient was known to have an ejection fraction of between
10 and 20% by echocardiography on [**2137-5-2**], and at the time
that this dictation covers initially the patient was noted to
be quite significantly volume overloaded with pitting edema
to or past the knees bilaterally and length of stay fluid
balance of between five and six liters positive.
The patient was aggressively diuresed with Lasix drip until
the night of [**2137-5-16**], when hypotension with systolic blood
pressure in the mid 70s necessitated stopping this Lasix drip
noting that the patient had become length of stay volume
status negative in the ensuing time. It was felt that the
patient on [**2137-5-17**], was essentially somewhat volume depleted
and, in fact, chest x-ray demonstrated resolving congestive
heart failure.
Rhythm - The patient has been in normal sinus rhythm for the
majority of this dictated time period. However, a thirty
beat run of ventricular tachycardia was noted at 4:00 a.m. on
[**2137-5-7**]. With the exception of one further eight beat run
of nonsustained ventricular tachycardia at 2200 hours on
[**2137-5-12**], no further significant runs of abnormal rhythms
were noted, though sparse ectopy was evident on telemetry,
decreasing during the course of this admission.
Please note that the most recent eight beat run of
nonsustained ventricular tachycardia occurred in the setting
of abnormal electrolytes which were later repleted. If the
patient affects a substantial recovery from his current state
might be considered for electrophysiology study should such
arrhythmias occur and at this time we are continuing to
monitor for them using telemetry.
Pulmonary - Congestive heart failure - As noted in greater
detail in the pump section of cardiovascular above, the
patient was initially on [**2137-5-6**], noted to be in significant
congestive heart failure with a chest x-ray read as follows:
congestive heart failure without evidence of pneumonia.
Later chest CT on [**2137-5-12**], did demonstrate continuing
congestive heart failure, however, by the chest x-ray of
[**2137-5-15**], [**2137-5-16**], and [**2137-5-17**], the congestive heart
failure was noted to be significantly improved. The patient
has not had difficulties with oxygenation during this
interval.
Pneumonia - As noted in the prior discharge summary for this
patient, the patient was originally admitted with a several
week history of cough and had been placed on antibiosis
including Vancomycin, Levofloxacin, Flagyl for possible
aspiration pneumonia. A chest CT performed on [**2137-5-12**],
demonstrated right paratracheal and precarinal
lymphadenopathy with the largest node in the prevascular
space measuring approximately 12 millimeters in short axis.
Additionally, bilateral air space opacities most prominent in
the lung apices and in the region of the left upper lobe and
lingula were noted concerning for multifocal pneumonia.
The patient was at that time and has continued to be febrile
and at the suggestion of infectious disease was begun on
Estrianam and Vancomycin for possibility of ventilator
acquired pneumonia. A sputum from [**2137-5-17**], is pending at
this time. One from [**2137-5-11**], showed greater than 25 PMNs
and less than 10 epithelial cells with no micro-organisms.
There was also noted to be gram negative rods on sputum gram
stain which was not later confirmed on culture. The patient
for this finding of gram negative rod on gram stain was
transiently covered for gram negative pneumonia with Ceptaz
added to the patient's regimen to cover for the possibility
of pseudomonal pneumonia. This was later discontinued when
culture failed to reveal pseudomonas or other gram negative
agents.
Pulmonary emboli - Again on the CT scan of [**2137-5-12**], the
patient was noted to have small bilateral lower lobe filling
defects consistent with small pulmonary emboli and the
patient was begun on Heparin shortly thereafter on which he
continues to this point with appropriate checks of partial
thromboplastin time and other coagulation studies. The
Heparin will be held for procedures such as tracheostomy
placement scheduled for [**2137-5-17**].
Ventilator status - The patient has been on endotracheal
intubation since [**2137-5-1**], and continues through the time of
this interval dictation summary with the plan for
tracheostomy today, [**2137-5-17**]. Repeated attempts have been
made to wean the patient off initial settings of assist
control with 650 by 14 with 40% FIO2 and 5 of PEEP. Over the
past week, attempts have been made to change the patient's
CPAP of pressure support with periods of resting on assist
control overnight to increase the strength of the patient's
respiratory muscles.
The patient at this time has not tolerated well attempts to
wean pressure support responding with tachypnea and
tachycardia to these efforts when pressure support is
decreased, however, he has been able to sustain a prolonged
period of CPAP plus pressure support on 10 and 5 with periods
of resting and the hope is that he will continue to move
towards weaning from the ventilation.
Pulmonology was consulted to assist in weaning this gentleman
from the ventilator and suggested a slow wean with attempts
to switch to pressure support ventilation and keep tidal
volume greater than 400 and respiratory rate less than 30
with a normal pH. They suggest weaning pressure support
level by greater than or equal to 2 centimeters per day.
Infectious disease - The patient has had multiple blood
cultures including blood cultures of fungal isolators as well
as urine cultures and sputum cultures sent for repeated
temperatures on every or almost every day during the period
of this dictation. Additionally, stool was sent for C.
difficile which was negative. To date, the sole positive
culture finding from blood culture on [**2137-5-8**], and [**2137-5-9**],
was coagulase negative Staphylococcus which was also
consistent with a blood culture from [**2137-5-1**]. The cultures
from the time following [**2137-5-9**], have failed to grow further
such organisms.
The patient on [**2137-5-6**], had multiple central lines including
a right IJ as well as a left subclavian, as well as a right
arterial line. Blood cultures on [**2137-5-9**], from the arterial
line showed two out of two bottles positive for
Staphylococcus coagulase negative while the blood cultures
drawn from other sites failed to demonstrate similar growth.
All central lines were discontinued due to concern
surrounding persistent fevers on or about [**2137-5-9**].
As noted above, infectious disease consultation was called
and suggested changing antibiosis from Levofloxacin and
Flagyl to Vancomycin and Ceptaz which had all at one time
been among the patient's antibiotic regimen to Estrianam and
Vancomycin for a twenty-one total day course. At the time of
this dictation, the patient is receiving Vancomycin for the
ninth consecutive day as well as Estrianam for the fifth
consecutive day, noting that the patient had previously been
on Vancomycin although it was discontinued as coagulase
negative Staphylococcus was felt by infectious disease at a
prior date to likely represent contaminant. At this time,
the source of the patient's fever remains uncertain and
consideration is being given to the possibility of that they
may represent drug fever. The plan is to resend white blood
cell count with differential in the morning and follow-up on
further infectious disease recommendations.
Hematology - The patient is currently on Heparin for
bilateral lower lobe small pulmonary emboli. The patient's
hematocrit has been more or less stable during the course of
this dictation in the low 30s with plan to transfuse should
the patient's hematocrit drop below 26.0.
Endocrine - The patient continues to be on regular insulin
sliding scale as well as NPH for diabetes mellitus type 2.
Renal - No issues at this time and creatinine stable.
FEN - The patient has been sustained on tube feeds by OG tube
to this date. Status post tracheostomy placement,
consideration should be given in consultation with the
patient's family for placement of percutaneous endoscopic
gastrostomy tube for further nutritional sustenance. As
noted above under cardiovascular, current opinion of the team
favors the possibility of the patient may be slightly
intravascularly volume depleted at this time, having been
over six liters positive for the stay during this interval.
We will at this time hold diuresis and plan for a goal of
even input and output.
Prophylaxis - The patient has been on pneumaboots as well as
Protonix as well as Colace and Senna for much of the course
of this interval. He is now maintained on Heparin drip for
small pulmonary emboli discovered at CT scan on [**2137-5-12**].
Gastrointestinal - The patient is continued on Reglan,
Protonix, Colace and Senna.
Code Status - Code status was changed in consultation with
the patient's family to "Do Not Resuscitate". Additionally,
the patient's family wishes that he not be reintubated should
he in the future status post extubation again develop
respiratory failure.
DISPOSITION: The patient's care will be assumed by Dr.
[**First Name (STitle) **] [**Name (STitle) **] in the ensuing days as medical intern who
will dictate further interval events at the time of
discharge.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2057**]
Dictated By:[**Name8 (MD) 2058**]
MEDQUIST36
D: [**2137-5-17**] 12:36
T: [**2137-5-18**] 14:06
JOB#: [**Job Number **]
cc:[**Last Name (NamePattern1) 107639**] Admission Date: [**2137-5-1**] Discharge Date: [**2137-5-23**]
Date of Birth: [**2073-8-12**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Patient is a 63-year-old male
with history of coronary artery disease, status post coronary
artery bypass graft in [**2125**] and three myocardial infarctions
since, with positive enzymes, with a declining of cardiac
catheterization each time. He was seen in consultation at
his pulmonologist's office on [**2137-4-30**] for evaluation
of cough of four months duration. Cough characterized as
constant, productive of thick yellow sputum with no
associated fever or chills, nausea, vomiting and diaphoresis.
The patient is an active smoker of two packs per day. Upon
evaluation at the Pulmonary Clinic, he was diagnosed with
chronic obstructive pulmonary disease and felt to be in
congestive heart failure and referred to [**Hospital3 3583**] for
admission. He was prescribed Amoxicillin which he never
filled.
At [**Hospital3 3583**], patient was noted to be normotensive with
blood pressure of 105/65. Heart rate of 100 with ectopy with
respiratory rate of 22 with unlabored breathing. His
electrocardiogram showed sinus tachycardia with ectopy with
nonspecific ventricular conduction delay. He was clinically
felt to be in congestive heart failure and volume overlay and
was admitted for medical management and congestive heart
failure and viral pneumonia. He was diuresed and then
transferred on [**2137-5-1**] to the [**Hospital6 649**] for cardiac catheterization.
At the catheterization laboratory, the patient had pulmonary
wedge pressure of 39 and 40 with cardiac index of 1.58. Both
of his vein grafts were totally occluded. He had 100% right
coronary artery lesions, as well as 100% left anterior
descending lesion, 98% left circumflex lesion, 100% left
subclavian stenosis. During the catheterization, the patient
was noted to have hypotensive and started on a dopamine drip
but leading to a run of supraventricular tachycardia and
eventual hypertension necessitating initiation of nitro drip.
Upon arrival to the Coronary Care Unit, the patient was noted
to be very agitated, having labored breathing. On telemetry,
he had transitions between supraventricular tachycardia and
atrial fibrillation and flutter, termination in unstable
atrial fibrillation rhythm in the end with progressive drop
in blood pressure. Dopamine was started. Patient was DC
cardioverted times two without effect on his atrial
fibrillation. He was initiated on an amiodarone drip and
subsequently intubated given worsening agitation, tachypnea
and general grave condition. His preintubation arterial
blood gases were 7.22, 64, 149. His blood pressure continued
to drop after intubation and started on a Levophed drip. He
was re-shocked and eventually converted to normal sinus
rhythm with improvement in blood pressure. The patient had a
PA catheter in place from his catheterization showing a
worsening picture consistent with cardiogenic shock. He was
started on milrinone, vasopressin in the Intensive Care Unit
as well.
PAST MEDICAL HISTORY:
1. Diabetes mellitus.
2. Coronary artery disease, status post myocardial
infarction in [**2124**], status post coronary artery bypass graft
in [**2125**], myocardial infarction times three since.
3. Chronic obstructive pulmonary disease.
4. History of tobacco use.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg q.d.
2. Rhinocort.
3. Flovent.
4. Robitussin.
5. [**Doctor First Name **] 180 mg q.d.
6. KCL 10 mEq q.d.
7. Gemfibrozil 600 mg b.i.d.
8. Digoxin 250 mcg q.d.
9. Aldactone 50 mg q.d.
10. Insulin.
11. Amaryl 8 mg q.d.
12. Zestril 5 mg q.d.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Significant for coronary artery disease and
diabetes mellitus.
PHYSICAL EXAM ON ADMISSION: Blood pressure 89/62. Heart
rate 105. Respiratory rate 24. O2 saturation 98% on 100%
face mask. General: Alert, agitated in mild distress.
Head, eyes, ears, nose and throat exam: Jugular venous
pressure at 9-10 cm, PRL. Pulmonary: Distant breath sounds,
rales at bases, anteriorly no wheeze. Cardiovascular exam:
Distant, no murmurs, rubs or gallops. Abdominal exam:
Positive bowel sounds, soft, nontender, nondistended.
Extremity exam: Trace ankle edema, no calf tenderness or
cords. Right groin with baby sheaths in place. No hematoma.
LABORATORY VALUES ON ADMISSION: Significant for white blood
cell count of 13, hematocrit of 43.4, INR 1.8, BUN of 25,
creatinine of .6, CK of 133.
INITIAL ASSESSMENT: This is a 63-year-old male with coronary
artery disease, diabetes mellitus and chronic obstructive
pulmonary disease here with subacute congestive heart failure
and bacterial pneumonia in the setting of ongoing poorly
controlled diabetes mellitus, now intubated, status post
hypotension, post catheterization.
HOSPITAL COURSE: The patient had a prolonged stay in the
Intensive Care Unit with issues as outlined below culminating
in the decision by the family to withdraw care followed by
the death of the patient on [**2137-5-23**]. Active medical
issues are outlined as below.
1. Cardiovascular: The patient was weaned off of pressors
and continued on aspirin and Plavix.
2. Infectious Disease: The patient started to spike
continuous fevers up to 105 degrees during the last two weeks
of his hospitalization. No source of infection could be
located. The patient was placed on broad spectrum
antibiotics without effect.
3. Pulmonary: The patient's fevers made it difficult for
him to be weaned off the ventilator. This was also
complicated by discovery of bilateral PEs on a chest CT.
CONDITION ON DISCHARGE: The patient expired on [**2137-5-23**].
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Fevers of unknown source.
3. Failure to wean off of ventilator.
4. Diabetes mellitus.
5. Chronic obstructive pulmonary disease.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 2064**] 12-ABZ
Dictated By:[**Name8 (MD) 2061**]
MEDQUIST36
D: [**2137-8-19**] 14:35
T: [**2137-8-19**] 14:35
JOB#: [**Job Number 46158**]
|
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icd9cm
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[
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[
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[
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248, 332
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25886, 28819
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30136, 30584
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28841, 29111
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5776, 5833
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31400, 31441
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,581
| 129,164
|
1364
|
Discharge summary
|
report
|
Admission Date: [**2130-7-14**] Discharge Date: [**2130-7-24**]
Date of Birth: [**2053-7-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Cough, hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 8291**] is a 76 year-old gentleman with history of CAD s/p
CABG [**2121**], PVD, HTN, COPD, U/L RAS and asthma who had presented
to the ED with 2 days of productive cough and SOB. In the ED he
was febrile to 103.8, RR 22, O2 sat was 85% on RA which improved
to 98 % on 100% NRB. With NRB, ABG was 7.47/33/195. Given
tachypnea and general appearance, patient was started on CPAP
which provided symptomatic relief. CXR was done in ED with
showed evidence of CHF +/-PNA. He was treated with combivent
nebs x2, ceftriaxone 1 g x1, azithromycin 250 mg x 1, lasix 40
mg IV x 2, levaquin 500 mg IV x1, vancomycin I g x 1, morphine 4
mg x 1, ASA supp 600 mg x1, tylenol 1300 mg PR x1, and nitro
paste 1 inch.
.
In the MICU, patient was breathing more comfortably and reported
interval improvement in his symptoms. COPD flare/PNA/CHF were
treated with Ceftriaxone, Azithromycin, Lasix 80 mg IV x 1 and
supportive nebulizers. By the morning, he was weaned down to 2L
nasal cannula.
.
Of note, patient has undergone a right TPT/PT lesion with
atherectomy on [**2130-7-5**] complicated by groin hematoma with
extension into penis and scrotum. U/S did not reveal fistula or
pseudoaneursym.
.
On transfer to the floor, patient reported that his breathing
status was better, still felt short of breath but nowhere near
when he had come in last night. Had eaten full meal, denied
abdominal or urinary complaints. Reported that his lower
extremity edema was better, but still persisted.
Past Medical History:
1. CAD s/p 3 vessel CABG around [**2121**] without further cardiac
issues
2. HTN
3. COPD -patient unsure of this diagnosis
4. BPH s/p turp
5. Second degree AV block s/p PPM
6. Hyperlipidemia
Social History:
Lives with his son. Remote history of 20 year smoking a pipe and
cigars. Rare alcohol use. No IVDA. Retired art teacher.
Family History:
Noncontributory.
Physical Exam:
PHYSICAL EXAMINATION:
Vitals: Tc 96.6; Tm 98.0; BP 130/61 (96-135/41-70); HR 61-84
sinus; RR 20-25; O2 Sat 95-99% 2L NC
GEN: NAD, sitting in chair, speaking [**4-22**] word sentences, using
some accessory muscles of respiration
HEENT: PRRL. EOMI. MMM. OP clear.
CV: Distant HS (difficult to hear [**1-19**] wheezing). No appreciable
abnormal sounds
LUNGS: + Diffuse expiratory and inspiratory wheeze, prolonged
expiratory phase. Coarse breath sounds diffusely. Decent air
entry.
ABD: obese. soft, NT/ND. BS normoactive.
EXT: 1+ edema to mid-calf. DPs symmetric, diminished. Chronic
venous stasis changes. PT pulses [**Hospital1 2824**] than DP.
GU: + ecchymosis pubic symphysis to scrotum, foley in place
Pertinent Results:
[**2130-7-14**] 03:13PM LACTATE-2.6*
[**2130-7-14**] 03:32PM PT-13.3* PTT-23.5 INR(PT)-1.2*
[**2130-7-14**] 03:32PM PLT COUNT-427
[**2130-7-14**] 03:32PM POIKILOCY-1+ MICROCYT-1+
[**2130-7-14**] 03:32PM NEUTS-90.7* LYMPHS-3.8* MONOS-5.2 EOS-0.3
BASOS-0.1
[**2130-7-14**] 03:32PM WBC-20.0* RBC-3.96* HGB-11.9* HCT-32.5*
MCV-82 MCH-30.1 MCHC-36.7* RDW-14.0
[**2130-7-14**] 03:32PM CALCIUM-9.0 PHOSPHATE-4.6* MAGNESIUM-2.3
[**2130-7-14**] 03:32PM CK-MB-14* MB INDX-4.8 proBNP-4882*
[**2130-7-14**] 03:32PM cTropnT-0.32*
[**2130-7-14**] 03:32PM CK(CPK)-293*
[**2130-7-14**] 03:32PM GLUCOSE-108* UREA N-55* CREAT-2.1* SODIUM-135
POTASSIUM-4.3 CHLORIDE-93* TOTAL CO2-22 ANION GAP-24*
[**2130-7-14**] 04:09PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2130-7-14**] 04:09PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2130-7-14**] 04:09PM URINE UHOLD-HOLD
[**2130-7-14**] 04:09PM URINE HOURS-RANDOM CREAT-157 SODIUM-27
[**2130-7-14**] 04:35PM TYPE-ART PO2-195* PCO2-33* PH-7.47* TOTAL
CO2-25 BASE XS-1
[**2130-7-14**] 10:34PM CK-MB-15* MB INDX-5.8 cTropnT-0.34*
[**2130-7-14**] 10:34PM CK(CPK)-258*
[**2130-7-14**] 10:34PM GLUCOSE-96 UREA N-57* CREAT-2.1* SODIUM-138
POTASSIUM-3.4 CHLORIDE-96 TOTAL CO2-25 ANION GAP-20
.
Imaging Studies
1. CXR [**2130-7-14**]
Findings consistent with CHF.
.
2. CXR [**2130-7-15**]
Stable CHF with possible left lower lobe pneumonia.
Brief Hospital Course:
Patient is a 76 year-old gentleman with PMHx CAD s/p CABG, PVD,
HTN, COPD/Asthma who presented with PNA/CHF exacerbation/COPD
flare. The following issues were addressed during hospital
admission.
.
# Cough/SOB/fever/leukocytosis
Given tachypnea and oxygen desturation on room air, patient was
admitted to the medical ICU for overnight monitoring. He did
well on a non-rebreather and BIPAP overnight, and was quickly
transitioned to nasal cannula once his underlying respiratory
issues were addressed. Dyspnea was thought to be secondary PNA,
COPD flare, and CHF exacerbation, the latter two precipitated by
infection. Patient was treated for community acquired PNA with
10 days of antibiotics; for CHF exacerbation, patient was placed
on low sodium diet, diuresed with Lasix; and for COPD flare,
patient was treated with short course of steroids and adjuncitve
nebulizers/inhaled steroids. He was weaned off of oxygen with an
oxygen saturation of 94-97% on room air. After treatment,
patient remained afebrile and hemodynamically stable throughout
his hospital stay. Patient exhibited leukocytosis on discharge,
and this was attributed to steroids administration. CBC should
be checked in [**1-20**] days to ensure it does not continue to rise.
Patient was afebrile without any new localizing sources of
infection. On discharge, a chest CT ordered to f/u a ground
glass appearance on CXR showed multiple areas of consolidation
and emphysema. Aspiration cannot be ruled out. Pt. will need
outpatient speech and swallow study.
.
# ARF: Baseline 1.1
On admission, patient's creatinine was 2.1. This was thought to
be due to both dehydration and ? post-obstructive component from
groin hematoma (patient with history of peripheral
cath/intervention). Foley was placed by urology and creatinine
improved to 1.3 on discharge. Creatinine should be checked in
[**1-20**] days to ensure it continues to normalize. Medications were
renally dosed and NSAIDS were avoided.
.
# Groin hematoma
Patient with known groin hematoma following recent peripheral
revascularization procedure. Ultrasound was done which was not
concerning for pseudoaneurysm or fistula. Continued to improve
by exam.
.
# Anemia
Patient guiaic positive on exam. Hct remained stable during
hospital stay. On colonoscopy in [**2125**], adenomatous polyps were
found and repeat colonoscopy was recommended in 3 years, for
which patient is overdue. Outpatient PCP was notified that a
colonoscopy needs to be scheduled in the near future and pt.
will f/u with PCP [**Last Name (NamePattern4) **] [**2130-7-24**] . Iron was low; transferrin and
saturation were not checked in acute setting of pulmonary
process, but should be re-checked and managed accordingly (i.e.
iron supplementation, f/u colonoscopy) as outpatient.
.
# CARDIAC
No chest pain/angina issues. EKG without changes, paced rhythm.
Trop of 0.34 in the setting of creatinine of 2.1 - per cards
curbside in ED, most likely [**1-19**] demand ischemia and ARF. Patient
was continued on ASA, statin, plavix. Patient was not on BB due
to underlying COPD/Asthma. Outpatient [**Last Name (un) **] (Candesartan) was
restarted at 4 mg and titrated up to 16 mg with good effect.
.
# HTN: BP well controlled on Diltiazem and Candesartan.
.
# PVD
Continued ASA, plavix
.
# Hypothyroidism
Continued Levothyroxine 50 mcg Po QD. TSH was elevated at 4.9,
FT4 was within norml limits. Should be re-checked once acute
issues resolve.
.
# FEN:
Electrolytes were repleted as necessary. He was maintained on
low salt, cardiac healthy diet, with fluid restriction to 1.5
liters
.
# FULL CODE
.
# COMMUNICATION: Son [**Name (NI) **], cell [**Telephone/Fax (1) 8292**], home [**Telephone/Fax (1) 8293**]
Medications on Admission:
MEDICATIONS AT HOME:
ASA 325 mg Po QD
Diltiazem SR 240 mg PO QD
Plavix 75 mg Po QD
Levothyroxine 50 mcg Po QD
Atorvastatin 20 mg Po QD
Colace 100 mg Po BID:PRN
Albuterol inh [**12-19**] pufs Q6H PRN
Fluticasone nasal spray PRN
Salmeterol 50 mcg/dose Q12H
Fluticasone 100 mcg 2 puffs [**Hospital1 **]
Discharge Medications:
1. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
Disp:*qs Disk with Device(s)* Refills:*2*
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs * Refills:*2*
6. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed.
Disp:*qs * Refills:*0*
10. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
Inhalation every six (6) hours as needed.
Disp:*qs * Refills:*0*
11. Candesartan 16 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home with Service
Facility:
[**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 1268**]
Discharge Diagnosis:
Primary
1. Dyspnea [**1-19**] PNA/CHF/COPD
Secondary
1. CAD s/p CABG
2. PVD
3. HTN
4. Unilateral renal artery stenosis
Discharge Condition:
Stable
Discharge Instructions:
1. Take all medications as prescribed
2. Make all follow-up appointments
3. Contact your provider or report to the Emergency Department
if you develop shortness of breath, fevers, chills or any other
concerning signs/symptoms
Followup Instructions:
You have a follow-up appointment with Dr. [**First Name (STitle) 1313**] scheduled for
[**Last Name (LF) 766**], [**2130-7-24**] at 3:30 PM.
Please keep your previously scheduled appointments:
Provider: [**Name10 (NameIs) **] CALL Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2130-9-19**]
10:00
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2130-11-15**]
10:30
|
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icd9cm
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4497, 8195
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329, 335
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59,903
| 110,458
|
37032
|
Discharge summary
|
report
|
Admission Date: [**2171-5-6**] Discharge Date: [**2171-6-8**]
Service: MEDICINE
Allergies:
Zosyn
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
fever, hypoxia, hypotension
Major Surgical or Invasive Procedure:
1. Tracheostomy
2. PICC line
3. Mechanical ventilation/intubation
History of Present Illness:
[**Age over 90 **] yo F with h/o dementia, CVA with residual left sided
paralysis who presents from a NH with fevers and hypoxia. Per NH
records and family report, pt was found to be febrile to 103F,
hypoxic to 88% on RA today and was noted to have a cough.
Daughter believes that pt has been "sick" for at least a week as
she has been less conversant and responsive. She has also
noticed shallow, rapid breathing that occasionally improves
after neb treatments. A CXR was reportedly done at the NH on
Monday that was negative. However, she had increasing mouth
secretions and by Wednesday the daughter believes the [**Name (NI) **] started
the pt on an antibiotic for PNA, although this is not listed on
the transfer paperwork. Yesterday evening, the patient was noted
to have a fever and hypoxia and was transported to ED for eval.
.
In the ED, initial vitals T 102, HR 111, BP 120/63, RR 20s, O2
sat 100% NRB -> 90% RA -> 99% 6L NC. Labs notable for WBC 8.1
with 77.3%N, lactate 1.7, Na 150, BUN 36, Cr 0.9, UA negative.
CXR with small to moderate right pleural effusion with
underlying infection that could not be excluded. Given 4L IVFs
with improvement in HR to 80s; however, BP trended down as low
as 86/38. RIJ TLC placed and started on levophed gtt at 0.04
mcg/kg/min with BPs to 116/66. Also given vancomycin 1 gm IV X
1, zosyn 4.5 gm IV X 1, tylenol 1 gm PR, albuterol nebs and
admitted to [**Hospital Unit Name 153**] for further care. Per ED discussion with
family, pt is DNR but ok to intubate for now if necessary.
.
ROS could not be performed with patient as not responding to
questions or commands in Mandarin.
Past Medical History:
h/o CVA with L sided paralysis but contractures in all 4
extremities, PEG
Dementia
HTN
CHF, unclear if systolic or diastolic
Spinal stenosis
Sciatica
h/o peptic ulcer
Hypothyroidism
Osteoporosis
Rheumatoid Arthritis
h/o PNA, UTIs
MRSA carrier
Social History:
Widowed. Mandarin speaking. Per family, has resided in NH since
CVA 3-4 years ago. Speaks occasionally in very short sentences
to daughter but per [**Name (NI) **] and [**Name (NI) **] notes, pt mostly aphasic and
non-verbal. No h/o tobacco but significant second hand smoke
exposure. No illicits, EtOH.
Family History:
non-contributory
Physical Exam:
Admission physical exam:
T 98.2 BP 94/40 HR 87 RR 22-27 O2 sat 97% 4L NC
Gen - elderly female in no apparent distress, not responsive to
commands in Mandarin. Briefly opens eyes to sternal rub. Lying
on left side
HEENT - sclerae anicteric, difficult to assess MM as pt not
cooperative with opening mouth. Cannot assess JVP due to RIJ
TLC.
CV - RRR, no m/r/g appreciated
Lungs - Decreased BS at right base without clear crackles
appreciated, exam is limited by pt not taking deep breaths
Abd - Soft, mod distended, + BS, PEG in place with surrounding
denuded area with macerated tissue. PEG dressing c/d/i.
Ext - no LE edema but edema noted in UEs with L > R. WWP with 1+
pulses distally.
Neuro - lethargic, briefly opens eyes to sternal rub. No
spontaneous movement of any 4 extremities. All 4 extremities
with contractures. Increased tone of RUE. LUE flaccid. [**12-25**]+ DTRs
b/l. Upgoing toe on left, equivocal on right. Unable to assess
remaining neurologic exam due to MS.
Skin - no rashes appreciated
Pertinent Results:
LABS ON ADMISSION:
[**2171-5-6**] 12:20AM BLOOD WBC-8.1 RBC-3.19* Hgb-9.6* Hct-30.5*
MCV-96 MCH-30.1 MCHC-31.5 RDW-15.0 Plt Ct-287
[**2171-5-6**] 12:20AM BLOOD Neuts-77.3* Lymphs-17.6* Monos-2.5
Eos-1.8 Baso-0.6
[**2171-5-5**] 10:30PM BLOOD PT-11.9 PTT-21.0* INR(PT)-1.0
[**2171-5-5**] 10:30PM BLOOD Glucose-103 UreaN-36* Creat-0.9 Na-150*
K-3.9 Cl-114* HCO3-29 AnGap-11
[**2171-5-6**] 03:46AM BLOOD Albumin-2.5* Calcium-6.3* Phos-3.0 Mg-2.1
Iron-49
.
.
.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2171-6-5**] 04:51AM 12.8* 2.89* 8.7* 26.7* 92 30.0 32.4 16.5*
994*
Source: Line-PICC
[**2171-6-4**] 04:32AM 13.1* 2.80* 8.3* 26.4* 94 29.7 31.5 16.5*
1002*
Source: Line-picc
[**2171-6-3**] 03:16AM 12.6* 2.83* 8.4* 26.9* 95 29.5 31.1 16.3*
1019*1
Source: Line-PICC
[**2171-6-2**] 02:08AM 8.9 2.84* 8.4* 26.8* 94 29.7 31.5 16.1*
967*
Source: Line-PICC
[**2171-6-1**] 04:03AM 10.2 2.81* 8.4* 26.8* 96 30.0 31.3 16.4*
993*
Source: Line-PICC
[**2171-5-31**] 04:24AM 8.0 2.67* 7.9* 25.6* 96 29.5 30.8* 16.4*
919*
Source: Line-PICC
[**2171-5-30**] 04:15AM 11.4* 2.84* 8.4* 26.9* 95 29.4 31.1 16.8*
971*
.
.
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2171-6-5**] 04:51AM 95 14 0.7 138 3.1* 96 33* 12
Source: Line-PICC
[**2171-6-4**] 12:42PM 3.9
Source: Line-pic
[**2171-6-4**] 04:32AM 105 13 0.6 139 3.8 99 32 12
Source: Line-picc
[**2171-6-3**] 03:16AM 102 12 0.7 134 3.7 98
Source: Line-PICC
[**2171-6-2**] 02:08AM 118* 10 0.7 137 3.6 101 28 12
Source: Line-PICC
[**2171-6-1**] 08:02AM 3.8
Source: Line-left picc
[**2171-6-1**] 04:50AM GREATER TH1
Source: Line-PICC
[**2171-6-1**] 04:03AM 112* 9 1.1 132* 7.6*2 101 25 14
Source: Line-PICC
[**2171-5-31**] 04:30PM 9 1.1 138 3.7 100 30 12
Source: Line-PICC
[**2171-5-31**] 04:24AM 116* 8 1.1 141 3.8 100 29 16
Source: Line-PICC
[**2171-5-30**] 04:50PM 115* 8 1.3* 138 3.6 99 32 11
Source: Line-PICC
[**2171-5-30**] 04:15AM 100 9 1.2* 138 3.7 97 32 13
.
.
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2171-5-30**] 04:15AM 4 22 100 0.2
Source: Line-PICC
[**2171-5-29**] 03:54AM 8 22 98 0.2
.
.
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2171-6-5**] 04:51AM 8.2* 2.4* 2.0
Source: Line-PICC
[**2171-6-4**] 04:32AM 8.1* 2.3* 2.0
Source: Line-picc
[**2171-6-3**] 03:16AM 8.0* 2.2* 2.0
Source: Line-PICC
[**2171-6-2**] 02:08AM 8.1* 2.5* 2.2
Source: Line-PICC
[**2171-6-1**] 04:03AM 7.8* 3.4 2.3
.
.
BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calTCO2 Base XS AADO2 REQ O2 Intubat Vent Comment
[**2171-6-4**] 01:09PM [**Last Name (un) **] 32*1 53* 7.45 38* 10
NOT INTUBA2
[**2171-6-3**] 01:09PM MIX 32*1 51* 7.43 35* 7
[**2171-6-2**] 11:18AM [**Last Name (un) **] 37.23 /19 40 PND PND PND PND
PND TRACH MASK
[**2171-6-1**] 01:47AM [**Last Name (un) **] 54*1 44 7.45 32* 5
[**2171-5-31**] 10:17PM [**Last Name (un) **]
GREEN-TOP/4
[**2171-5-31**] 11:01AM [**Last Name (un) **] 37*1 53* 7.41 35* 6
[**2171-5-30**] 02:15PM ART 37.75 /24 [**Telephone/Fax (2) 83491**] 7.51* 36*
9 INTUBATED
[**2171-5-30**] 02:06PM [**Last Name (un) **] 37.76 /24 [**Telephone/Fax (2) 83492**] 7.59*7 35*
11 INTUBATED SPONTANEOU8 GREEN TOP
[**2171-5-28**] 05:52PM ART 88 44 7.47* 33* 7
[**2171-5-15**] 09:19PM CENTRAL VE9 39*1 56* 7.31* 30
0
[**2171-5-11**] 04:58PM ART 98 38 7.39 24 -1
[**2171-5-9**] 12:42PM CENTRAL VE9
[**2171-5-8**] 08:07PM ART 37.710 14/0 [**Telephone/Fax (2) 83493**]* 39 7.35
22 -3 431 73 INTUBATED CONTROLLED
[**2171-5-8**] 05:58PM ART 127* 55* 7.22*11 24 -5
[**2171-5-6**] 04:12AM MIX
[**2171-5-6**] 02:54AM ART 36.8 /23 89 46* 7.38 28 0
NOT INTUBA2
.
.
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Lactate
[**2171-5-11**] 04:58PM 2.5*
[**2171-5-9**] 12:42PM 1.8
[**2171-5-9**] 04:25AM 3.0*
[**2171-5-8**] 08:07PM 1.8
[**2171-5-8**] 05:58PM 5.1*1
[**2171-5-6**] 02:54AM 1.2
[**2171-5-5**] 10:52PM 1.7
.
.
PLEURAL
PLEURAL ANALYSIS WBC RBC Polys Lymphs Monos
[**2171-5-8**] 10:59AM 72* [**Numeric Identifier **]* 88*1 4* 8*
25 CELL DIFFERENTIAL
PLEURAL CHEMISTRY TotProt Glucose LD(LDH)
[**2171-5-8**] 10:59AM 0.0 75 40
ASCITES
ASCITES ANALYSIS WBC RBC Polys Lymphs Monos Macroph Other
[**2171-5-28**] 03:09PM 218* 39* 11* 26* 0 62*1 1*2
PIGMENT LADEN CELLS PRESENT
ATYPICAL CELLS,REFER TO CYTOLOGY
REVIEWED BY [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 21496**],MD ON [**2171-5-29**]
ASCITES CHEMISTRY TotPro Glucose Creat LD(LDH) Amylase TotBili
Albumin
[**2171-5-28**] 03:09PM 3.0 94 1.0 160 13 0.2 1.3
.
.
Date 6 Specimen Tests Ordered By
All [**2171-5-5**] [**2171-5-6**] [**2171-5-8**] [**2171-5-9**] [**2171-5-14**]
[**2171-5-24**] [**2171-5-28**] [**2171-6-1**] [**2171-6-2**] [**2171-6-3**] All
BLOOD CULTURE BLOOD CULTURE NOT PROCESSED Influenza A/B by DFA
MRSA SCREEN PERITONEAL FLUID PLEURAL FLUID SPUTUM STOOL URINE
All EMERGENCY [**Hospital1 **] INPATIENT
[**2171-6-3**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2171-6-2**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
INPATIENT
[**2171-6-1**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{STAPH AUREUS COAG +, GRAM NEGATIVE ROD(S), GRAM NEGATIVE ROD
#2, YEAST} INPATIENT
[**2171-6-1**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2171-6-1**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2171-6-1**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2171-5-28**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL; ANAEROBIC CULTURE-FINAL; FUNGAL
CULTURE-PRELIMINARY; ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PRELIMINARY INPATIENT
[**2171-5-24**] URINE URINE CULTURE-FINAL {ESCHERICHIA COLI}
INPATIENT
[**2171-5-24**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2171-5-14**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS} INPATIENT
[**2171-5-9**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2171-5-9**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2171-5-9**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2171-5-9**] BLOOD CULTURE NOT PROCESSED INPATIENT
[**2171-5-8**] PLEURAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL;
ANAEROBIC CULTURE-FINAL INPATIENT
[**2171-5-6**] Influenza A/B by DFA DIRECT INFLUENZA A ANTIGEN
TEST-FINAL; DIRECT INFLUENZA B ANTIGEN TEST-FINAL INPATIENT
[**2171-5-6**] URINE Legionella Urinary Antigen -FINAL INPATIENT
[**2171-5-6**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS} INPATIENT
[**2171-5-5**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **]
[**2171-5-5**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY
[**Hospital1 **]
[**2171-5-5**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY
[**Hospital1 **]
OTHER:
[**2171-5-6**] 03:46AM BLOOD calTIBC-189* VitB12-852 Folate-GREATER TH
Ferritn-177* TRF-145*
[**2171-5-6**] 03:46AM BLOOD TSH-2.2
[**2171-5-6**] 03:46AM BLOOD Free T4-1.1
.
URINE:
[**2171-5-5**] 10:25PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.022
[**2171-5-5**] 10:25PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
.
MICRO:
Bl cx - no growth to date
Urine legionella - negative
Influenza DFA - negative
Sputum culture ([**2171-6-1**]):
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Please contact the Microbiology Laboratory ([**5-/2468**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
GRAM NEGATIVE ROD(S). MODERATE GROWTH.
GRAM NEGATIVE ROD #2. RARE GROWTH.
YEAST. SPARSE GROWTH.
Urine culture ([**2171-6-1**]): YEAST. 10,000-100,000 ORGANISMS/ML
C. diff toxin: negative
.
CARDIOLOGY:
TTE ([**5-6**]):
Conclusions
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%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). 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. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. The
estimated pulmonary artery systolic pressure is normal. There is
an anterior space which most likely represents a fat pad.
IMPRESSION: Normal biventricular cavity sizes with preserved
global biventricular systolic function. Mild aortic
regurgitation. No significant pericardial effusion. Increased
PCWP.
CLINICAL IMPLICATIONS:
Based on [**2168**] 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.
.
RADIOLOGY:
CXR:
The heart is moderately enlarged and the aortic contour is
tortuous. Vascular calcifications are seen along the aorta and
in
the right neck. Additionally, rounded calcification along the
right
mediastinal contour is atypical for lymph node calcification and
may also represent vascular calcification. There is small to
moderate right pleural effusion with adjacent atelectasis,
although right lower lung infection cannot be excluded. There
may also be tiny left pleural effusion with some atelectasis.
The upper lungs are grossly clear, without evidence of pulmonary
edema. Degenerative changes are noted along the thoracic spine.
IMPRESSION:
1. Marked cardiomegaly, without evidence of pulmonary edema.
2. Right pleural effusion with atelectasis, although right
basilar infection cannot be excluded.
.
Port CXR post line - RIJ terminating in appropriate position, no
PTX
.
Final Report
REASON FOR EXAM: Pulmonary edema. Acquired pneumonia.
Comparison is made with prior study performed [**2171-6-3**].
Tracheostomy tube is in standard position. Large right and small
to moderate
left pleural effusion are unchanged. Cardiomediastinal contours
are partially
visualized and unchanged. Mild interstitial edema seen in the
left lung is
stable. There is no pneumothorax. Opacity in the left base is
unchanged
likely atelectasis.
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
Approved: WED [**2171-6-5**] 12:02 PM
.
.
CT Abdomen
HISTORY: [**Age over 90 **]-year-old woman with history of CVA, dementia,
hospital-acquired
pneumonia, status post tracheostomy, now with emesis for four
days. A GJ
tube. Distended abdomen on exam. The patient underwent exchange
of the GJ
catheter earlier today.
COMPARISON: None.
TECHNIQUE: MDCT axial images were obtained from the lung bases
to the pubic
symphysis following administration of 50 mL of Optiray
intravenous contrast
that was hand injected via the left upper extremity PICC line.
Multiplanar
coronal and sagittal reformatted images were generated.
CT ABDOMEN WITH INTRAVENOUS CONTRAST: There is a moderate right
and small
left pleural effusion, with underlying atelectasis. There is
fluid within the
distal esophagus. The gastrostomy balloon is located within the
stomach, and
the jejunostomy catheter terminates in the jejunum.
The liver is normal. The gallbladder is decompressed. The spleen
is not
enlarged. The pancreas, adrenals and kidneys are unremarkable.
There are dilated proximal small bowel loops and decompressed
diatal lops
are seen, however contrast progresses into the decompressed
loops consistent
with a partial obstruction.
There is a moderate amount of ascites within the abdomen and
pelvis. The
greater omentum is abnormal, with nonspecific soft tissue
infiltration. This
may be related to recent procedure/tube placement and reactive,
but in the
absence of recent instrumentation could be seen with neoplasm.
The abdominal aorta is normal in caliber, with dense vascular
atherosclerotic
calcifications.
CT PELVIS WITH INTRAVENOUS CONTRAST: The uterus is not
identified. Two low-
density ovoid soft tissue foci measuring up to 2.3 cm in
diameter (2:66) in
the left hemipelvis, one represents the ovary which contains a
cystic mass.
There is a Foley catheter in the urinary bladder, which is
decompressed. The
rectum and sigmoid colon are unremarkable.
There is diffuse soft tissue stranding consistent with anasarca.
BONE WINDOWS: There are severe compression deformities of L2,
T11 and T9,
with resultant narrowing of the spinal canal, most severely at
T9 and T11.
Heterotopic ossification arises from the anterior aspect of the
intertrochanteric region of the left femur is likely
post-traumatic in
etiology.
IMPRESSION:
1. Partial small bowel obstruction with transition point in the
right lower
quadrant.
2. Left ovarian cystic mass with thickening of the omentum and
ascites is
concerning for ovarian carcinoma, The ovarian mass could be
further evaluated
with ultrasound. Alternatively, diagnostic paracentesis could be
performed
3. Moderate right and small left pleural effusions.
4. Fluid in the distal esophagus.
5. G-tube balloon in the stomach, and jejunostomy catheter
terminating in the
jejunum.
6. Compression deformities of T9, T11 and L2 with resultant
narrowing of the
spinal canal, significantly at T9 and T11.
Revised report was discussed with Dr. [**Last Name (STitle) **] at 9:30AM on [**2171-5-28**]
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name8 (NamePattern2) 7722**] [**Last Name (NamePattern1) 7723**]
Approved: TUE [**2171-5-28**] 9:32 AM
.
.
Brief Hospital Course:
[**Age over 90 **] female with h/o CVA, dementia, RA who presented with fever
and hypoxia to the ICU [**2171-5-6**]. She was started on Vanc, Zosyn
and Levofloxacin for Health Care associated pneumonia vs.
aspiration PNA. Hemodynamically she was stable and transferred
to the general medicine floor [**2171-5-7**]. On the general medicine
floor patient was continued for treatment of HAP, had G tube
replaced to a GJ tube and thoracentesis to eval effusion.
Patient received lasix for diuresis. On the floor patient's
blood pressure ranged from 92-141/56-87, was re-started on
outpatient B-blocker and started on lasix diuresis. She was
afebrile, pulse 97-118, 94-99 on 2 L. At 1830 [**2171-5-8**] patient
was found to be tachypneic (RR 40s) and ABG demonstrated CO2 55,
pH 7.22 and lactate of 5.1. Patient was consequently intubated,
required phyenlepineprine for pressor support and transferred to
the [**Hospital Unit Name 153**]. [**Hospital 153**] hospital course according to problem list as
below. The patient was ultimately discharged with comfort
measures.
Respiratory distress: Patient known HAP PNA, large effusion and
diastolic CHF. Acute episode requiring intubation most likely
related to aspiration. Patient with poor urine output, did not
respond to lasix and dopamine drip support. Continued Zosyn and
Vancomycin for total 8 days treatment ([**Date range (1) 83494**]) of HAP.
Scopolamine patch to decrease oral secreations. Continued
albuterol, ipratropium nebs prn for wheezing. From [**Date range (1) 11734**],
patient was stable on ventilator, however experienced some
apneic events due to oversedation and was responsive to narcan.
On [**5-22**], after much discussion with HCP and family, Mrs. [**Known lastname **],
recieved a tracheostomy by thoracic surgery. On [**5-23**] crepitus
was noted around the trach site, thoracic surgery consulted,
resolved without intervention. Mrs. [**Known lastname **] was gradually weaned off
the vent from [**5-22**] to [**5-31**] using MMV overnight due to apnea and
PS during most of the day. On [**5-28**], she had a possible
aspiration event after GJ tube replacement, however, she was
monitored for infection/fever, which did not develop. A sputum
culture from the trach revealed MRSA, however, the trach is
likely colonized. Before discharge, Mrs. [**Known lastname **] was tolerating her
tracheostomy mask well with no signs of respiratory distress or
infection. However, upon discharge after repeated lengthy
discussions with her family, it was determined that Ms. [**Known lastname **] was
to be treated with comfort measures, so her trach was capped,
and started on morphine, ativan, and continued on albuterol nebs
while breathing on room air. She was discharged comfortable and
breathing room air in the high 80 percents.
Abdominal Distension: Patient noted to have abdominal distension
on admission to [**Hospital Unit Name 153**]. KUB on [**5-9**] with no obstruction, bowel
regimen increased. Pt noted to have increasingly decreased
bowel sounds over next week, however portable supine on [**5-24**]
showed no obstruction. GJ tube replaced by IR on [**5-27**], with
subsequent emesis and drainage of gastric contents out of tract.
CT scan abdomen showed properly placed GJ tube, ascites and
ovarian mass. Diagnostic paracentesis cytology consistent with
adenocarcinoma. G tube placed to suction and J tube to gravity.
She was started on tube feeds until she started to drain dark
brown mildly heme-positive material from her gastric tube. It
was unclear if the drainage was either coffee ground emesis or
feculent material from obstruction. She remained NPO at
discharge due to comfort measures. Her G-tube was to gravity and
J tube clamped.
Allergic Reaction: On [**5-13**], day 7 of Zosyn treatment, Mrs. [**Known lastname **]
developed a rash on her torso that was maculopapular and
erythematous. The rash ultimately spread to her upper and lower
extremities, sparing her feet, palms and face. Froom [**Date range (1) **],
the rash progressed to blister/bullae-like lesions, then began
weepy before crusting and desquamating. Zosyn and Vancomycin
were stopped due to concern of allergy and it is thought that
the reaction most likely from Zosyn and not Vancomycin. The
rash was treated with supportive care and sulfadine creme to
prevent super-infection. Due to insensible losses, fluids were
repleated as needed. At time of discharge, rash resolved with
minimal desquamation.
Hypotension: Most likely combination of septic shock (related to
HAP) and cardiac failure (see below). Lactate elevated on
admission, trended downward. Patient was slowly weaned off
pressor support. No aggressive fluid resucitation due to
overload on exam and CXR. Over course of ICU stay, Mrs. [**Known lastname **] had
intermittent hypotension, usually related to over-sedation.
When sedation weaned, blood pressure returned to her normal.
Mrs. [**Known lastname **] ultimately tolerated Lasix gtt started on [**5-28**] later
transition to Q8 boluses, to diurese excess fluid off with a
goal of negative 1 liter/day. Upon discharge she was not on any
diuretics with the aim of comfort measures.
Cardiac Failure: EF demonstrated new regional wall abnormality
and worsened MR, troponin and CK negative. EKG no ST elevation.
Most likely suffered strain related to acute respiratory event.
Held outpatient BB and CCB due to low blood pressure and due to
comfort measures at discharge it is not recommended that any of
her outpatient medications be restarted.
Anemia: Decreased to 24 from 29. Drop most likely related to IVF
and possible suppression for sepsis. Iron studies consistent
with anemia of chronic disease. Patient required no
transfusions.
UTI: Urine with yeast on [**5-9**], foley was changed. On [**5-24**], pt
became hypotensive and tachycardic, remained afebrile. Urine
grew E. Coli, completed course of Bactrim.
Rheumatoid arthritis: Held azathioprine in setting of acute
infection and due to comfort measures at discharge it is not
recommended that any of her outpatient medications be restarted.
Osteoporosis: Continued outpatient calcium and vitamin D and due
to comfort measures at discharge it is not recommended that any
of her outpatient medications be restarted.
Goals of care: Ongoing discussion with family goals of care and
patient's quality of life. After trying many interventions for
her multiple medical problems, the patient seemed unlikely to
recover. Her daughter decided to switch from DNR to DNR/DNI with
no escalating care including pressors. After more repeated
conversations, it was determined that Ms. [**Known lastname **] goal of care
would be to maximize comfort measures. The ICU team then
withdrew invasive measures such as ventilation through
tracheostomy, and plans for any future G tube use. She was
started on morphine, ativan, and continued on albuterol nebs for
comfort. The remainder of her home medicines and medicines in
the hospital were discontinued.
Medications on Admission:
Fleet enema daily prn
Natural tears 1 ddrop q4h prn
Lacrilube ointemnt qhs
Levothyroxine 125 mcg daily
Calcium carbonate 500 mg [**Hospital1 **]
Vitamin D 400 units daily
Prevacid 15 mg tab daily
Aricept 10 mg daily
Multi-delyn liquid 5 ml daily
KCL 10 meq qMon,Wed,Fri
Metoprolol tartrate 25 mg daily
Vitamin C 500 mg (5ml) [**Hospital1 **]
Reglan 5 mg/5ML 10 ML tid
Scopolamine patch 1.5 mg/72hr behind ear q72h
Amlodipine 5 mg daily
Lasix 20 mg tab qod
Azathioprine 25 mg daily
Duoneb qid and q2h prn
Tylenol 650 mg prn
Docusate 100 mg [**Hospital1 **] prn
Milk of Magnesia 30 ml prn
Dulcolax 10 mg PR prn
Tube feeds: Jevity 1.2 at 60 ml/hr for 15 hrs off at 8am and on
at 5pm. 30 ml H2O flush before and after medss via G tube. 300
ml H20 flushes q4h
Discharge Medications:
1. Morphine Concentrate 5 mg/0.25 mL Solution Sig: 5-10 mg PO
Q2H:PRN as needed for Pain or dyspnea.
Disp:*15 mL* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 3005**] Hospice
Discharge Diagnosis:
Primary:
pneumonia
small bowel obstruction secondary to ovarian cancer
acute renal failure secondary to hypovolemia now resolved
.
Secondary:
-asthma
-dementia /Alzheimers type
-gait disorder
-dysphagia
Discharge Condition:
comfortable, afebrile, stable vitals, extubated, NPO,
nonambulatory
Discharge Instructions:
You were admitted to the ICU for respiratory distress, probable
pneumonia, and small bowel obstruction secondary to ovarian
cancer. You were treated with antibiotics and you were intubated
due to difficulty breathing. You eventually had to have a tube
placed in your trachea since you were intubated for such a long
time. After several repeated discussions with your family it was
decided that you would be provided with measures to maximize
your level of comfot, but that we would discontinue attempts for
invasive care and escalation of care. We also discontinued use
of your feeding tube due to the small bowel obstruction.
.
You should not take any of your usual home medicines since you
are now being medicated only for your own comfort. The only
medicine that we will prescribe you is liquid morphine that you
should take as needed for pain or until you have achieved
comfort.
.
Please take all medications as prescribed.
Please do not hesitate to return to the hospital if you have any
concerning symptoms.
Followup Instructions:
none
|
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icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.04",
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"96.6",
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icd9pcs
|
[
[
[]
]
] |
25845, 25903
|
17902, 24888
|
239, 306
|
26150, 26220
|
3631, 3636
|
27282, 27290
|
2569, 2587
|
25694, 25822
|
25924, 26129
|
24914, 25671
|
26244, 27259
|
2627, 3612
|
12878, 17879
|
172, 201
|
334, 1965
|
3650, 12855
|
1987, 2232
|
2248, 2553
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,838
| 163,802
|
18409
|
Discharge summary
|
report
|
Admission Date: [**2175-5-28**] Discharge Date: [**2175-6-20**]
Date of Birth: [**2124-4-3**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
Hematemasis
Major Surgical or Invasive Procedure:
TIPS (transjugular intrahepatic portosystemic shunt) x 2
History of Present Illness:
Mr. [**Known lastname 1744**] is a 51 yo male with NASH cirrhosis, and grade IV
esophageal varices, who was transferred from [**Hospital3 44339**] Hospital
in [**Location (un) 3441**], NY with hematemesis. He was initially diagnosed with
liver failure in [**2172**]. The pt was doing well until [**2175-5-23**] when
he developed melena, followed by hematemesis on [**5-24**]. He
presented to [**Hospital3 44339**] Hospital in NY. He was started on
octreotide, pantoprazole and vitamin K. EGD there showed large
esophageal varices, which were banded x 2 on [**5-24**]. After
recurrent hematemesis, repeat EGD on [**5-26**] again showed large
varicies with clot and pt was banded X 4 at that time. Pt was
started on Vasopressen and pantoprazole gtt along with nitro gtt
for BP control. He was then transferred to [**Hospital1 18**] MICU on [**2175-5-28**]
for further evaluation & possible TIPS procedure.
.
Past Medical History:
- NASH
- DM type 2
- reported non-occlusive (partially) thrombus in portal vein
- internal hemorrhoids
- history of thrombocytopenia and splenomegaly
- pancytopenia
- Arthritis
- diverticulosis
Social History:
Married with 2 healthy children. wife is a nurse.
Works as sales coordinator for [**Last Name (un) 34699**] [**Location (un) **].
Smokes one ppd x28 years.
No Etoh, drank only socially prior to dx of NASH.
No IVDU, no tatoos.
Family History:
Father died at age 79 of complications of DM, CAD, AAA.
Mother alive at 83.
No siblings.
Physical Exam:
VITALS: 98.7, HR: 65, BP: 146/77, 96% RA.
GEN: pleasant, conversant, in NAD
HEENT: no JVD, no LAD, PERRL, anicteric
CV: s1s2, no r/g/m, rrr
CHEST: ctab
ABD: soft, nt, obese, hepatomegaly, no fluid wave or shifting
dullness noted, +BS
EXT: no c/c/e, wwp, 2+ dp pulses B
NEURO: no asterixis, a&O x 3, no focal deficits noted
Pertinent Results:
admission labs:
[**2175-5-28**] 10:57PM BLOOD WBC-3.3* RBC-2.96*# Hgb-9.1*# Hct-25.4*#
MCV-86 MCH-30.6 MCHC-35.6* RDW-16.9* Plt Ct-35*
[**2175-5-28**] 10:57PM GLUCOSE-195* UREA N-20 CREAT-0.6 SODIUM-127*
POTASSIUM-3.6 CHLORIDE-98 TOTAL CO2-23 ANION GAP-10
[**2175-5-28**] 10:57PM ALT(SGPT)-26 AST(SGOT)-33 LD(LDH)-172 ALK
PHOS-59 AMYLASE-14 TOT BILI-3.0* DIR BILI-1.2* INDIR BIL-1.8
.
CXR: [**2175-5-29**] IMPRESSION:
1. Probable bilateral pleural effusions.
2. Patchy asymmetrical right perihilar opacities, which may be
due to asymmetrical pulmonary edema, aspiration, or atelectasis.
Given the technical limitations of the study, a repeat
radiograph with improved technique is recommended when the
patient's condition permits.
.
Abd U/S [**2175-5-29**]:
Limited study. Heterogeneous echogenic liver consistent with
known cirrhosis. Splenomegaly. Normal hepatopetal flow in portal
veins. Partially occlusive thrombus cannot be excluded. Small
amount of ascites. No fluid pocket suitable for nonguided or
ultrasound- guided paracentesis.
.
Duplex doppler abd/pelv s/p TIPS: patent tips with appropriate
velocities
Brief Hospital Course:
1. Bleeding varices: Upon original admission to the MICU, Mr.
[**Known lastname 50682**] Hct remained stable and he had no further hematemasis
or melena. Abd U/S with dopplers showed normal hepatopetal flow
in portal veins, but the study was limited by pt's body habitus
and could not rule out partial obstruction. A small amount of
ascites was also noted.
As the patient remained stable, he was transferred to the
floor, where he was awaiting elective TIPS when he was found
down on [**2175-6-2**] with a large amount of melena and dark red blood
per rectum, hypotensive to 87/palp at that time. He was
transferred back to the MICU, given PRBCs, Cordis was placed, pt
was intubated, and emergent TIPS was performed. Due to excessive
variceal bleeding, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] tube was placed. In the unit the
pt remained hypotensive and was put on neosynephrine, which was
eventually weaned. The pt was extubated on [**6-4**] (intubated 2
days total). He began treatment with lactulose for mild
encephalopathy, which was titrated to [**12-29**] BMs per day and
continued throughout the remainder of his stay. He has
continued to have some melena and small blood per rectum but
stable hct. EGD [**6-5**] showed no active bleed. RUQ U/S [**6-5**] showed
patent TIPS. Head CT showed no sign of bleed s/p fall.
In the MICU on [**6-8**] he had an episode of hematemesis and a
repeat EGD was performed which revealed a bleeding ulcer at
prior banding site. A proximal band was placed and the pt was
electively intubated for airway protection until [**6-15**]. He had a
revision of his TIPS with alcohol embolization of new varix. At
that time he was hypotensive requiring levophed for two days.
Since that time his hct remained stable. He began to show signs
of hepatic encephalopathy with hallucinations and confusion and
was continued on lactulose at increased frequencies (up to q2h)
titrated for [**12-29**] BMs daily. He was transferred to the floor.
He stopped having hallucinations, and confusion resolved to a
somewhat mild confusion which remained throughout the remainder
of his stay. Pt was oriented x 3 and answered questions
appropriately, but seemed to use as few words as possible to
potentially mask his underlying confusion. He was seen by OT
before discharge, who recommended that he be supervised 24 hours
a day. This was discussed with his wife, [**Name (NI) 717**], before
discharge, who felt strongly that she and her children could
watch him and they did not want other services at home for him.
I instructed [**Doctor First Name 717**] to contact either Dr. [**Last Name (STitle) **] in NY or
myself if she were to require such services in the future.
The pt was discharged on lactulose with instructions to
titrate to [**12-29**] BMs daily. His wife [**Name (NI) 717**] seems quite reliable
and will be able to titrate accordingly. He will call Dr. [**Last Name (STitle) 497**]
for follow up within 1-2 weeks of discharge.
2. NASH cirrhosis - The pt had no signficant ascites on U/S for
tap, remained afebrile throughout his stay, and received a 14
day course of levofloxacin prophylactically against the
development of SBP. Although his diuretics were held during
much of his stay, his Lasix was restarted after his second
discharge from the MICU. The pt was discharged on his home
doses of Lasix and spironolactone to prevent accumulation of
ascites. The pt remains on the transplant list and will
continue to see both Dr. [**Last Name (STitle) **] in NY and Dr. [**Last Name (STitle) 497**].
3. HTN: Prior to his TIPS procedure, the pt's BP was controlled
with Nadolol. After a large GI bleed that sent the pt back to
the MICU, he was very hypotensive (70s/palp). His nadolol was
stopped. It was not restarted after TIPS procedure. S/p TIPS x
2, the pt's BP remained stable without antihypertensives and he
is discharged without further prescriptions for HTN. His BP
should be followed as an outpt.
4. DM2 - Pt's outpatient metformin was held and his glucose was
controlled with regular insulin slide scale. He will restart
metformin 500mg PO BID as an outpt.
.
5. FEN - Once his hematocrit was stable, the pt ate a slowly
advancing diabetic diet without event. On his second return to
the floor, he was found to have a very low potassium which was
aggressively repleted.
6. PT/OT - Mr. [**Known lastname 1744**] was seen by PT during his stay and he was
able to walk with them slowly, including up and down stairs. He
was also seen by OT who recommended 24 hour supervision given
his mild encephalopathy. As mentioned above, his wife refused
home services and stated that she and her children would be able
to watch Mr. [**Known lastname 1744**] at all times given that she is home from
work with Family Medical Leave privileges, and their teenage
children are home for the summer. She will call Dr. [**Last Name (STitle) **] or
myself should the situation change and she requires services in
the future.
7. Code status - full code.
8. Dispo - Mr. [**Known lastname 1744**] was discharged to home in [**Location (un) 3441**], NY without
services and with instructions to call Dr. [**Last Name (STitle) 497**] within [**11-27**]
weeks for follow up.
Medications on Admission:
Home:
Nadolol 30/20 mg every other day
Glucophage
Protonix 40mg PO daily
Ursadiol 300
Reglan 10 QID
Vit E
Metfomin 500mg PO BID
MVI
.
On Transfer:
Octretide 500 mcg
Vasopressin 0.3 units/min
Protonix gtt
Ngt gtt
Discharge Medications:
1. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Lactulose 10 g/15 mL Syrup Sig: Two (2) tablespoons PO every
4-6 hours: please take 2 tablespoons (30 ml) of lactulose every
4 hours, or as needed to have [**12-29**] BMs per day. Disp:*6 L*
Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Non-Alcoholic Steatohepatitis cirrhosis with bleeding esophageal
varices
Discharge Condition:
Fair
Discharge Instructions:
If you have bloody sputum or vomit, black stools or bloody
stools, feel lightheaded or weak, you have increased confusion,
or have fever or abdominal pain please call Dr. [**Last Name (STitle) **] or go
to the Emergency room.
Please continue to take your lactulose so that you have [**12-29**]
bowel movements per day. Lactulose may be increased or decreased
in frequency accordingly.
Please follow up with Dr. [**Last Name (STitle) 497**].
Followup Instructions:
Provider: [**Name10 (NameIs) 497**],[**Name11 (NameIs) **] [**Telephone/Fax (1) 2422**] Call to schedule
appointment within two weeks of discharge
If you decide you would like OT services at home, please call
the hospital and have them page Dr. [**Last Name (STitle) 31478**], who will work
with the case manager to set it up for you.
Completed by:[**2175-6-25**]
|
[
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"285.1",
"571.5",
"456.20",
"789.5",
"V49.83",
"250.00",
"572.3",
"572.2",
"996.74"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"39.1",
"39.50",
"99.29",
"45.13",
"96.71",
"44.44",
"42.33",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9471, 9477
|
3348, 8593
|
278, 337
|
9594, 9600
|
2203, 2203
|
10091, 10460
|
1753, 1844
|
8855, 9448
|
9498, 9573
|
8619, 8832
|
9624, 10068
|
1859, 2184
|
227, 240
|
365, 1275
|
2219, 3325
|
1297, 1493
|
1509, 1737
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,977
| 165,755
|
502
|
Discharge summary
|
report
|
Admission Date: [**2159-12-29**] Discharge Date: [**2160-1-6**]
Date of Birth: [**2090-1-18**] Sex: F
Service: MEDICINE
Allergies:
Losartan / Aspirin / Lisinopril-Hctz
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
fever, hypotension
Major Surgical or Invasive Procedure:
trans-esophageal echocardiogram
History of Present Illness:
69F with h/o ESRD on HD, PE (PEA arrest), recent admit for
sepsis of unclear etiology from [**Date range (2) 4167**], presenting to
ED with fever Tm 102, hypotension, decreased appetite and
lethargy per son. Pt has had loose stools x 2 in the past few
days with hypomagnesemia and hypophosphatemia receiving PO
repletion w/o benefit. Pt received empiric Abx coverage of
Vanc/Cefepime/Levaquin/Flagyl at [**Hospital **] Rehab prior to transfer.
.
Recent hospitalization notable for intubation for airway
protection in setting of obtundation, no clear source of
infection. Micro data remarkable for yeast and VRE in urine for
which pt received 7d Fluconazole and 14d course of Linezolid (LD
[**2159-12-27**]). Pt intermittently on Flagly, Cefepime until culture
data remained negative. Also failed [**Last Name (un) **] stim and was on stress
dosed steroids. No evidence of infection in sputum, blood, or
CSF. CT Abd/Pel unremarkable. PICC removed and tunneled HD
catheter changed over wire on [**2159-12-18**] (from [**10-15**]). A new PICC
was inserted prior to discharge on [**12-18**].
.
In ED, Tm 102, tachy 110-120, BP dropped to 82/17 intermittently
then improved to normal, tachypneic 22-28, 99% RA. Received Gent
x 1, Fluconazole 400mg IV x1. ROS: denies any pain or
localizable symptoms at this time. Per sons' report pt;s mental
status has improved greatly from this morning.
Past Medical History:
1. Type 2 diabetes mellitus
2. Diabetic nephropathy resulting in ESRD for which she is on
HD Mon, Wed, and Fri.
3. Status post left femur fracture
4. Hyponatremia
5. Hypercholesterolemia
6. Unsteady gait
7. Cataracts
8. Back pain
9. Hypertension
10.Anemia of chronic disease
11. S/P L shoulder hemiarthroplasty following a left humeral
fracuture in [**10/2159**]- Course was complicated by a PEA arrest
secondary to PE. [**11-24**] new humerus fracture
12. PE [**2159-10-27**] leading to PEA arrest
13. Hospitalization [**11-24**] for Sepsis (negative work-up) treated
empricially with Vanc
14. h/o C-diff [**2159-11-22**], Urine citrobacter (tx w/Cipro)
Social History:
Lives with son who is very involved and well informed regarding
her care needs. Non smoker. No EtOH
Family History:
Noncontributory
Physical Exam:
PE: Tm 102, 119/60, [**1-2**], 80, 93-100% 3LNC
GEN: A&O x 2 (person and place), sleepy but arousable
HEENT: anicteric bilateral cataracts, EOMI, OP clear, no teeth
CV: reg rate, distant S1, S2, no MRG
PULM: clear with decreased BS at bases.
ABD: obese, NT/ND, NABS
EXT: anisarca, DP pulses dopplerable, thick white discharge from
vagina. LLE lateral ankle ulcerations dressed without evidence
of purulent drainage. Dry gangrene of toes B. Able to dorsi-flex
feet, LUE swollen with surgical scar over shoulder. RUE good
ROM.
NEURO: CN II-XII intact, able to follow simple commands. Toes
down-going
BACK:minimal skin breakdown new buttocks. No ulcers.
Pertinent Results:
Admission Labs:
[**2159-12-29**] 03:13PM BLOOD WBC-14.1*# RBC-3.15* Hgb-9.7* Hct-30.5*
MCV-97 MCH-30.8 MCHC-31.8 RDW-21.4* Plt Ct-166
[**2159-12-29**] 03:13PM BLOOD Neuts-67.2 Lymphs-22.8 Monos-6.7 Eos-2.8
Baso-0.6
[**2159-12-29**] 03:13PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+
Macrocy-3+
[**2159-12-29**] 03:13PM BLOOD PT-13.9* PTT-21.7* INR(PT)-1.3
[**2159-12-29**] 03:13PM BLOOD Plt Ct-166
[**2159-12-29**] 03:13PM BLOOD Glucose-216* UreaN-16 Creat-2.5*# Na-144
K-4.7 Cl-107 HCO3-24 AnGap-18
[**2159-12-29**] 03:13PM BLOOD ALT-13 AST-36 LD(LDH)-519* AlkPhos-108
Amylase-22 TotBili-0.4
[**2159-12-29**] 03:13PM BLOOD Albumin-2.9* Calcium-8.3* Phos-1.5*#
Mg-1.3*
[**2159-12-30**] 04:58AM BLOOD CRP-163.7*
[**2160-1-1**] 07:42PM BLOOD PTH-268*
.
[**2159-12-30**] 12:17 am URINE Site: CATHETER
**FINAL REPORT [**2160-1-3**]**
URINE CULTURE (Final [**2160-1-3**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Trimethoprim/Sulfa sensitivity testing confirmed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing E. coli and Klebsiella species.
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| PSEUDOMONAS AERUGINOSA
| |
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R 8 S
CEFTAZIDIME----------- =>64 R 4 S
CEFTRIAXONE----------- R
CEFUROXIME------------ 32 R
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ <=1 S =>16 R
IMIPENEM-------------- <=1 S 4 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- 8 S <=4 S
TOBRAMYCIN------------ =>16 R =>16 R
TRIMETHOPRIM/SULFA---- <=1 S
.
[**12-29**] CT Head: FINDINGS: There is no acute intracranial
hemorrhage, shift of normally midline structures, or
hydrocephalus. Mild degree of cerebral atrophy, stable in
appearance. Hypodensities are seen in the periventricular white
matter surrounding both right and left frontal horns, within the
left thalamus, and in the right basal ganglia. These are all
stable in appearance. Osseous structures and soft tissues are
normal. Mucosal thickening within the ethmoid air cells and
right maxillary sinus is unchanged.
IMPRESSION:
No acute intracranial hemorrhage.
.
[**12-29**] CXR: FINDINGS: There is no interval change when compared
to the prior study. There is no evidence of pneumothorax. The
lines are in stable position. The cardiac and mediastinal
contours are stable. There is apparent widening of the
mediastinal contour, which is secondary to vascular structures
and fat based on prior CT from [**2159-12-12**].
IMPRESSION: No evidence of pneumothorax.
.
[**12-31**] TEE: Conclusions:
1. The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler.
2.Left ventricular wall thickness, cavity size, and systolic
function are
normal (LVEF>55%). Regional left ventricular wall motion is
normal.
3.Right ventricular chamber size and free wall motion are
normal.
4.There are simple atheroma in the aortic arch and the
descending thoracic aorta.
5.The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No masses or vegetations are seen on
the aortic valve. Mild to moderate ([**1-21**]+) central aortic
regurgitation is seen.
6.The mitral valve leaflets are structurally normal. No mass or
vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen.
7.No vegetation/mass is seen on the pulmonic valve.
IMPRESSION: No evidence of endocarditis. Mild-moderate aortic
regurgitation.
.
[**1-1**] CXR: IMPRESSION: Stable chest radiograph with no evidence
of infiltrates or effusions.
.
[**1-4**] Humerus/Femur Plain Films:
LEFT HUMERUS: There is a displaced and mildly comminuted distal
periprosthetic fracture of the humerus. A previous a left
proximal humerus arthroplasty is well positioned. There is
diffuse osteopenia.
LEFT FEMUR: There is little change from [**12-6**] of the
supracondylar distal femur fracture with associated callus
formation. In addition, three displaced femoral neck fracture
appears unchanged though is incompletely evaluated on this femur
study and is limited by osteopenia and body habitus.
IMPRESSION: New periprosthetic humerus fracture. I confirmed
that the housestaff were aware of these findings.
Brief Hospital Course:
69F w/ESRD, recent sepsis of UNK source, presenting with fever
and sepsis.
.
1. Sepsis: This is a patient who has had multiple past
admissions for sepsis. Possible etiology included lines, urine,
wounds, pneumonia, etc. This was considered most likely to be
urosepsis, likely secondary to poor hygeine given that the
patient is incontinent of stool and likely her infection
resulted from GI pathogens entering the urine. Wounds and
osteomyelitis were also considered as possibilities, but her
surgical wound from past ortho procedure was clean and did not
appear infected. A new PICC line was placed and her initial
femoral line was removed. Blood cultures from an outside
facility grew enterobacter and klebsiella. Urine culture here
at [**Hospital1 18**] grew klebsiella and pseudomonas. Initially, the
patient was covered broadly with cefipime, linezolid, and
flagyl. Once sensitivities became available, antibiotics were
changed to cefipime/gent. A TEE was negative for vegetations.
Subsequent blood cultures were all negative, and repeat urine
cultures were also negative. Antihypertensives were held in the
setting of sepsis and were not resumed due to low-normal BP.
Stress dose steroids were started on admission and stopped on
[**1-2**]. The possibility of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-vesicular fistula was raised
as a possible explanation of recurrent urosepsis. The patient
had a CT abdomen on a recent previous admission that showed no
evidence of such a fistula, so repeat imaging was not done.
Plan is for cefipime and gentamicin to be continued for 10 more
days to complete a 2 week course of both.
.
2. ESRD: Renal followed throughout hospital course. Patient had
HD M-W-F. Phos binders were held due to low phos. Can consider
restarting if phos increases. Patient received epogen with
dialysis.
.
3. Altered Mental Status: Likely this was due to sepsis. Mental
status returned to baseline.
.
4. Fractures: Orthopedics evaluated the patient while
hospitalized, and repeat films of the humerus and femur were
obtained. The patient is not an operative candidate at this
time, so fractures have been managed non-operatively with pain
control. LUE was kept in a sling, non-weight bearing. Patient
is bed-bound.
.
5. h/o RLL PE (resulting in PEA arrest): Patient is on coumadin
at home. Coumadin was held for procedures (TEE, etc.) and was
restarted prior to discharge. She was on a heparin drip while
off her coumadin. Goal INR is [**2-22**]. Patient slightly below goal
on day of discharge. INR should be checked after discharge and
coumadin dose adjusted as needed.
.
6. Htn: Home metoprolol dose was held in the setting of sepsis.
It was not restarted prior to discharge as her BP remained
low-normal without medication. BP should be checked after
discharge and BB restarted as needed.
.
7. CHF: EF 55% with MR. HD was continued M-W-F to regulate
volume status. I/O followed closely.
.
8. DM: FS QID, ISS continued. Glargine 8U hs continued.
.
9. Skin Breakdown: Secondary to prolonged bed rest, DM2, PVD.
The patient had consistently dopplerable pulses. Wound care and
nutrition were consulted to make recommendations as well.
.
10. Anemia: BL 29-33. No evidence of acute blood loss. Epogen
given at HD.
Medications on Admission:
1. Ascorbic Acid 500 mg PO BID
2. Folic Acid 1 mg
3. Zinc Sulfate 220 mg qd
4. Acetaminophen 325 mg PO Q4-6H prn
5. Papain-Urea [**Telephone/Fax (3) 3335**] unit-mg/g Ointment Sig: One (1) Appl
Topical DAILY (Daily).
6. Ipratropium Bromide q4hrs
7. Calcium Acetate 667 mg TIDWM
8. Metoprolol 25 TID
10. Insulin, GLargine 8U at HS
11. Warfarin 2 mg qHS
12. Linezolid 600 mg IV Q12H LD [**2159-12-27**] (PICC)
Discharge Medications:
1. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Papain-Urea [**Telephone/Fax (3) 3335**] unit-mg/g Ointment Sig: One (1) Appl
Topical DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever or pain.
6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
7. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
9. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
10. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15)
units Subcutaneous at bedtime.
11. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: as
directed Subcutaneous four times a day: Please resume insulin
sliding scale.
12. Gentamicin 40 mg/mL Solution Sig: Eighty (80) mg Injection
dosed by level for 10 days: Please check a gentamicin level
after each HD treatment and dose gentamicin for levels <2.
Thanks.
13. Cefepime 1 g Recon Soln Sig: One (1) gram Injection once a
day for 10 days: Please give dose after HD on HD days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Primary Diagnoses:
urosepsis with enterobacter and klebsiella in blood cultures,
klebsiella and pseudomonas in urine
end stage renal disease, on hemodialysis
Secondary Diagnoses:
history of PE
hypertension
CHF
diabetes type II
anemia, secondary to ESRD
Discharge Condition:
stable
Discharge Instructions:
1. If you experience fever, chills, confusion or change in
mental status, abdominal pain, shortness of breath, or other
concerning symptoms, please contact your doctor or return to the
emergency room for evaluation.
2. Please take all medications as prescribed.
- antibiotics cefipime and gentamicin are to be continued fro 10
more days to complete a course of 2 weeks.
- we have held the calcium acetate because the [**Hospital6 4168**] level
was low on admission. Please have your doctor [**First Name (Titles) 4169**] [**Last Name (Titles) 4168**]
levels and consider restarting.
- We have held the metoprolol because of low blood pressure.
Discuss with your doctor whether this should be restarted.
3. Please attend all followup appointments.
- Please make an appointment to followup in Infectious Disease
clinic within 2 weeks. Please call ([**Telephone/Fax (1) 4170**].
Followup Instructions:
Please make an appointment to followup in Infectious Disease
clinic within 2 weeks. Please call ([**Telephone/Fax (1) 4170**].
|
[
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"041.89",
"785.4",
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icd9cm
|
[
[
[]
]
] |
[
"00.14",
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icd9pcs
|
[
[
[]
]
] |
13349, 13414
|
8287, 10163
|
315, 349
|
13711, 13720
|
3281, 3281
|
14648, 14779
|
2577, 2594
|
12042, 13326
|
13435, 13593
|
11597, 12019
|
13744, 14625
|
2609, 3262
|
13614, 13690
|
257, 277
|
377, 1764
|
5668, 8264
|
3297, 5659
|
10178, 11571
|
1786, 2443
|
2459, 2561
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,420
| 148,722
|
31568
|
Discharge summary
|
report
|
Admission Date: [**2110-6-26**] Discharge Date: [**2110-7-4**]
Date of Birth: [**2042-12-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Nausea/vomiting
Major Surgical or Invasive Procedure:
LIJ CVL placement
TIPS revision
History of Present Illness:
Mr. [**Known lastname 74228**] is 67 yo male with PMH significant for NASH
cirrhosis complicated by portal hypertensive gastropathy and was
recently admitted for an upper and lower GI bleeding for which
he required admission ([**Date range (1) **]) and urgent TIPS placement on
[**6-18**]. After the TIPS he had no further episodes of bleeding. He
did develop mild pulmonary edema which responded to diuresis. He
did develop a progressive hyperbilirubinemia which was found to
be largely indirect and was thought to be likely hemolysis in
the setting of receiving blood transfusions. His TIPS was
evaluated prior to discharge with an ultrasound which showed
that the TIPs was patent and then he was discharged home.
He then presented to the ED the following day ([**6-26**]) with new
onset nausea and vomiting. His bilirubin was also noted to
elevated to 33.2 from 22.6 at the time of her last discharge.
There was concern for a biliary leak given her recent TIPs
procedure and the plan was for TIPs reduction. Per the
radiologist, the attempt to reduce the shunt with a stent was
not successful so it was pulled out. There was approximately
200-400cc of blood loss during this time. He was then
transferred to the MICU for closer monitoring.
Past Medical History:
1)NASH cirrhosis - Child's class B evaluated for TIPS and OLT by
Dr. [**Last Name (STitle) 497**] in [**7-3**] (by report Dr. [**Last Name (STitle) 497**] recommended TIPS, family
did not want to proceed)
2)Portal Hypertensive Gastropathy, chronic GI bleeding, leading
to transfusion-dependent anemia
3)Iron Deficiency Anemia
4)NIDDM
5)CAD
6)HTN
7)CVA [**2102**]
8)Systolic CHF
9)Hypothyroidism
Social History:
Divorced male, lives alone, quit smoking in [**2091**]. No
significant EtOH history.
Family History:
Non-contributory
Physical Exam:
vitals T 98.4 BP 125/55 AR 85 RR 20 O2 sat 97 NRB
Gen: Somnolent but awakens to voice, jaundiced
HEENT: MMM, scleral icterus
Lungs: Poor air movement at bases, +wheezes
Heart: RRR, 2/6 systolic murmur at the RUSB and apex, radiating
to both neck and axilla
Abdomen: Soft, NT/ND, +BS
Extremities: 1+ bilateral edema, 2+ DP/PT pulses bilaterally,
LIJ in place
Neuro: Oriented x 3
Pertinent Results:
Labs:
.
CBC WBC RBC Hgb Hct MCV MCH MCHC RDW Plt
[**2110-7-4**] 05:58AM 9.5 2.15 7.5 20.1 93 34.8 37.3 24.2 115
[**2110-6-27**] 06:15AM 4.0 2.79 9.6 27.2 97 34.3 35.3 23.2 58
[**2110-6-26**] 10:00AM 4.6 3.13 10.6 30.3 97 33.7 34.9 23.0 63
.
LFTs:
ALT AST LDH CK(CPK) AlkPhos Amylase
TotBili
[**2110-7-4**] 05:58AM
41.2*
Source: Line-cvl
[**2110-7-3**] 04:47AM 56* 132* 246 94
44.2*
SPECIMEN ICTERIC
[**2110-7-2**] 05:49AM
47.3*
ICTERIC
[**2110-7-1**] 04:30AM 62* 171*
42.8*
Source: Line-LIJ
[**2110-6-30**] 04:16AM
39.6*
Source: Line-LIJ
[**2110-6-29**] 04:28AM
41.8*
Source: Line-aline
[**2110-6-28**] 03:56PM
42.0*
Source: Line-LIJ
[**2110-6-27**] 06:15AM 85* 214* 305* 79
32.5*
[**2110-6-26**] 10:00AM 87* 208* 314* 88
33.2*
.
Studies:
.
[**2110-6-26**] Ultrasound: Patent TIPS, with appropriate direction of
flow. Velocities within the main portal vein and TIPS are mildly
increased in comparison to the baseline exam from [**2110-6-22**]
suggesting interval growth of intimal hyperplasia.
.
[**2110-6-30**] TIPS redo: Placement of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 74229**] covered stent into the
existing Wallstent. Decrease in portosystemic gradient from 11
mmHg to 8 mmHg.
.
[**2110-7-1**] MRI: No focal liver lesions identified. Findings
consistent with cirrhosis and portal hypertension. Right greater
than left pleural effusions. Infrarenal abdominal aortic
aneurysm measuring 3.5 cm.
.
[**2110-7-3**] HIDA Scan: Insufficient study to exclude/diagnose biliary
leak in the setting of vicarious excretion related to hepatic
failure.
Brief Hospital Course:
1)NASH cirrhosis: Patient presented with acute decline in
hepatic function as evidenced by rising direct bilirubinemia
along with worsening INR. Likely due to TIPs shunt diversion
away from liver resulting in relative hypoperfusion and
depressed function. His lasix and aldactone were initially held
given hypotension; but they were restarted at time of transfer
to the liver service. He was continued on lactulose and
rifaximin for his hepatic encephalopathy. TIPS revision was
unsuccessful. Liver failure progressed. Pt underwent evaluation
for liver transplant. Cardiac evaluation revealed pt has
multiple cardiac issues that would make him inelibible for
transplant. Pt and family were notified that he would not be
eligible for transplant. With progression of liver failure
palliative care and hospice were consulted. Pt was scheduled to
return home with hospice services. However, pt expired the
evening prior to his scheduled discharge.
.
2)Hypotension: Patient presented with nausea and vomiting and
was noted to have a significant rise in his bilirubin. On
previous admission he underwent TIPs on [**6-18**] and was then
discharged on [**6-25**]. Ultrasound prior to discharge showed patency
of the TIPs. On this admission, given his rising bilirubin, he
was taken to IR and stent placement was attempted through the
RIJ without success. EBL was approximately 200-400cc. He was
then transferred to the MICU for closer monitoring. Upon
transfer to the MICU he was significantly hypotensive 2/2 blood
loss in the setting of his coagulopathy. An emergent LIJ central
line was placed and he received 5 units pRBCs, 2 units FFPs, and
1 unit of platelets. During his stay in the MICU, despite a rise
in his bilirubin, his hematocrit remained stable. He was taken
back to IR once he was hemodynamically stable which showed that
his TIPs was patent and a biliary stent was placed in hopes to
prevent further rising of his bilirubin. Pt was then transfered
to the liver service with blood pressure stable at baseline.
.
3)CHF: Recent ECHO on [**6-25**] showed mild systolic dysfunction with
EF 45-50%. He is on Lasix and Aldactone as an outpatient. He
received additional doses of IV lasix in the setting of
receiving multiple blood products. At time of transfer to the
liver service, he was restarted on home diuretic regimen.
.
4)Pleural effusion: Patient noted to have R sided pleural
effusion on chest x-ray. Likely [**12-28**] underlying liver disease and
systolic dysfunction.
.
5)Type 2 DM: Patient is on Glyburide as an outpatient but this
regimen was held during his inpatient stay. He was placed on an
insulin sliding scale with close monitoring of his blood sugars.
.
6)Hypothyroidism: Levothyroxine was initially held but then
restarted once he was medically stable.
Medications on Admission:
Medications on transfer:
Neutra-Phos 1 PKT PO BID
Pantoprazole 40 mg PO Q12H
Docusate Sodium 100 mg PO BID:PRN
Furosemide 40 mg PO DAILY
Rifaximin 400 mg PO TID
Insulin SC
Lactulose 30 mL PO TID
Spironolactone 100 mg PO DAILY
Levothyroxine Sodium 125 mcg PO DAILY
Ursodiol 300 mg PO BID
Medications at home:
Levothyroxine 125mcg PO daily
Pantoprazole 40mg PO Q12
Lactulose 30cc PO TID
Furosemide 40mg PO daily
Spironolactone 100mg PO daily
Rifaximin 400mg PO TID
Glyburide 5mg PO daily
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
NASH cirrhosis
pHTN gastropathy
UGIB
anemia
DMt2
Discharge Condition:
Pt expired
Discharge Instructions:
Pt expired
Followup Instructions:
None
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
|
[
"428.22",
"571.5",
"578.9",
"572.2",
"511.9",
"250.00",
"571.8",
"E878.8",
"998.2",
"998.11",
"537.89",
"428.0",
"244.9",
"285.1",
"572.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"00.40",
"99.04",
"39.90",
"88.64",
"39.50",
"00.45",
"38.93",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
7647, 7656
|
4293, 7081
|
331, 364
|
7749, 7761
|
2604, 4270
|
7820, 7949
|
2173, 2191
|
7618, 7624
|
7677, 7728
|
7107, 7107
|
7785, 7797
|
7416, 7595
|
2206, 2585
|
276, 293
|
392, 1636
|
7132, 7395
|
1658, 2054
|
2070, 2157
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,826
| 142,288
|
49324
|
Discharge summary
|
report
|
Admission Date: [**2179-12-20**] Discharge Date: [**2179-12-24**]
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 317**]
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
[**First Name3 (LF) **] placement
History of Present Illness:
[**Age over 90 **] yo female with HTN presents with increasing fatigue and
lethargy over the past few days and was found in the ED to have
both an NSTEMI by elevated troponin and complete heart block.
She had and unwitnessed fall this morning, and used her first
responder call to get help. She refused to come to the hospital,
but had progressive weakness throughout the day. Her family
brought her into the emergency department, where an ECG was not
concerning for acute ischemia but did demonstrate complete heart
block. Then, her first set of cardiac enzymes came back with a
CK of 224, MB of 5, and Tn of 0.16. She also had a head CT
negative for bleed or subacute infarct and a C-spine negative
for fracture, but with incidental prelim read of R. partially
calcified meningioma.
.
Per her son, the pt is very functional. She lives by herself,
shops for herself, plays bridge 3x week. She has a functional
limit of walking about 20 feet. Denies SOB, CP, URI sxs, change
in bowel habits. possible dysuria.
Past Medical History:
- HTN
- hearing loss
- left blind eye (s/p zoster infect at [**Age over 90 **]yo)
- zoster
- Hiatal hernia
- distant h/o UTI ([**2164**])
- h/o falls
Social History:
Lives by herself in [**Hospital3 **]. She does her ADLs (cooks
cleans). Has children in area. No tobacco history. Plays bridge
2-3 times a week.
Family History:
Non-contributory
Physical Exam:
Gen: elderly woman, appearing younger than stated age, sleeping
flat on back with minimal snoring.
VS: T 96 HR 31 BP 158/38 (69) RR 23 O2sat 95% on 5L (88% on 2L)
skin: small hemangioma on left mandible, no rashes
HEENT: right pupil reactive 3to2mm, left eye with scarred
sclera, Dry mucous membranes, palatine torus in OP
Lungs: CTAB anteriorly
Cardiac: Bradycardic, distant sounds, no m/r/g
Extremities: 1+ pulses DPs, warm, trace edema in shins.
Neuro: arousable, appropriate, falls asleep easily, moving all 4
symmetrically
Pertinent Results:
[**2179-12-20**] 09:40PM BLOOD WBC-8.0 RBC-3.50* Hgb-11.6* Hct-31.6*
MCV-90 MCH-33.2* MCHC-36.8* RDW-14.4 Plt Ct-162
[**2179-12-24**] 07:45AM BLOOD WBC-8.2 RBC-3.32* Hgb-10.6* Hct-30.7*
MCV-93 MCH-32.0 MCHC-34.6 RDW-14.5 Plt Ct-217
[**2179-12-20**] 09:40PM BLOOD Glucose-118* UreaN-28* Creat-1.1 Na-128*
K-5.4* Cl-95* HCO3-21* AnGap-17
[**2179-12-21**] 05:13AM BLOOD Glucose-108* UreaN-26* Creat-0.8 Na-133
K-3.2* Cl-100 HCO3-23 AnGap-13
[**2179-12-24**] 07:45AM BLOOD UreaN-15 Creat-0.7 K-3.7
[**2179-12-21**] 05:13AM BLOOD calTIBC-234* VitB12-467 Folate-9.2
Ferritn-348* TRF-180*
[**2179-12-21**] 05:13AM BLOOD Triglyc-53 HDL-61 CHOL/HD-2.2 LDLcalc-65
.
TTE [**2179-12-22**]:
1. The left atrium is mildly dilated. 2.There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Overall left ventricular systolic function is low
normal (LVEF 50-55%).
3.Right ventricular chamber size is normal. Right ventricular
systolic
function is normal. 4.The ascending aorta is mildly dilated.
5.The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No aortic regurgitation is seen. 6.The
mitral valve leaflets are mildly thickened. Physiologic mitral
regurgitation is seen (within normal limits). 7.There is mild
pulmonary artery systolic hypertension. 8.There is no
pericardial effusion.
Brief Hospital Course:
Extremely healthy [**Age over 90 **]F with HTN here with fatigue, found to be
in complete heart block and with elevated cardiac enzymes. She
had a [**Age over 90 4448**] placed on [**2179-12-21**].
.
#Heart block -- She was found in the emergency department to be
in complete heart block, though with preserved blood pressures
and mentating well so was brought to the CCU where a temporary
pacing wire was placed fluoroscopically in the RV without
difficulty. This remained in overnight, on VVI setting, with
all beats paced, until the next morning when she was taken to
the EP lab, and a [**Company 1543**] Sigma DR [**Last Name (STitle) 4448**] was placed by
cephalic access and set at DDD. She did fine following the
procedure with minimal discomfort at the pocket site with no
evidence of infection or hematoma. She was discharged witha
prescription to complete five days of post-procedural
antibiotics.
.
#Coronary artery disease -- She came in with an elevated
troponin, minimally elevated CK (220's), but a negative CK-MB.
As such, this was felt to not represent an ACS or any type of
cardiac ischemia in any of its multitudinous forms. After the
pacer was placed, these enzymes trended down, and it was felt
the initial modest elevation was probably secondary to transient
poor flow from her heart block in the setting of poor renal
function, as altough her Cr is not that high, her clearance is
quite poor (given her age, height, and weight). Aspirin,
simvastatin, and irbesartan were continued.
.
#Fall -- She had a mechanical fall at home, likely from being
generally weak. She did not have a syncopal event by her
description, though given the heart block, this was certainly
our main concern. She had a full trauma evaluation in the ED
that demonstrated no fractures or head bleed.
.
#Chronic renal disease -- She may have some mild renal
insufficiency from longstanding hypertension. However, she
probably has age related renal insufficiency. Her creatinine
clearance is in the mid 30's range, and her medications were
dosed as such.
Medications on Admission:
-amlodipine 5mg daily
-irbisartan 150mg daily
Discharge Medications:
1. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO daily ().
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours) for 2 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Complete heart block
Secondary:
- HTN
- hearing loss
- left blind eye (s/p zoster infect at [**Age over 90 **]yo)
- zoster
- Hiatal hernia
- distant h/o UTI ([**2164**])
- h/o falls
Discharge Condition:
Good, with resolution of fatigue, in normal paced rhythm
Discharge Instructions:
You were admitted for heart block, a problem with your heart's
ability to beat normally; for this, a [**Year (4 digits) 4448**] was placed that
is now helping your heart beat at a regular rate and rhythm.
.
Call your doctor or return to the emergency department for chest
pain, lightheadedness, loss of conciousness, shortness of
breath, bleeding, fevers, chills, or other concerning symptoms.
.
Take medications as below and follow-up as described.
Followup Instructions:
Please see your cardiologist, Dr. [**Last Name (STitle) **], in the next 1-2 weeks;
his office has been contact[**Name (NI) **] and will contact you about an
appointment. If you do not hear from them by next week, call
[**Telephone/Fax (1) 10012**] to make an appointment.
.
Please see your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], in the next 1-2 weeks; call
[**Telephone/Fax (1) 608**] to make an appointment.
.
You need to be seen in the device clinic in the [**Hospital Ward Name 23**]
building, as below:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2179-12-29**]
11:00
|
[
"426.0",
"276.1",
"585.9",
"285.9",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.83",
"37.72"
] |
icd9pcs
|
[
[
[]
]
] |
6150, 6216
|
3607, 5665
|
224, 260
|
6442, 6501
|
2235, 3584
|
6999, 7646
|
1652, 1670
|
5762, 6127
|
6237, 6421
|
5691, 5739
|
6525, 6976
|
1685, 2216
|
177, 186
|
288, 1299
|
1321, 1472
|
1489, 1636
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,098
| 165,511
|
52935
|
Discharge summary
|
report
|
Admission Date: [**2123-12-27**] Discharge Date: [**2124-1-4**]
Date of Birth: [**2049-9-10**] Sex: F
Service: CARDIOTHOR
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is a 74-year-old
female admitted from [**Hospital3 **] on the [**12-26**]
with ST elevation MI (troponin 2.7). She was transferred to
[**Hospital1 69**] for cardiac
catheterization which revealed a three vessel coronary artery
disease with good targets and right sided aortic
arch.
PAST MEDICAL HISTORY:
1. Chronic back pain.
2. Asthma.
3. Infrarenal abdominal aortic aneurysm 3.3 cm.
4. History of transient ischemic attacks (carotid ultrasound
one year ago revealed 50% bilateral stenosis).
5. Hypertension.
6. Hypercholesterolemia.
7. Status post right mastectomy.
8. Status post bilateral renal endarterectomy.
9. Chronic renal insufficiency (creatinine approximately
2.0).
10. Diverticulosis.
PHYSICAL EXAMINATION: ABFS. Cardiovascular: Regular rate
and rhythm, III/VI systolic ejection murmur at second
intercostal space. Pulmonary: Clear to auscultation
bilaterally. Abdomen: Positive bowel sounds, no
hepatosplenomegaly. Extremities: No cyanosis, clubbing or
edema. Neuro: No focal abnormalities.
HOSPITAL COURSE: Patient was admitted to the C-MED Service
where an echo showed that the patient has an ejection
fraction of 60 to 65%, left atrial dilation with regional
left ventricular wall motion abnormalities and 2+ mitral
regurgitation. The patient was placed on Nitrodrip titrated
to pain.
A carotid ultrasound revealed right internal carotid stenosis
40 to 59% and left internal carotid stenosis less than 40%.
The patient was brought to the Operating Room on [**2123-12-29**] where a coronary artery bypass graft times four vessels
was performed. The LIMA was brought to the LAD, SVG to the
PDA, SVG to OM, SVG to diagonal. The patient's coronary
artery bypass was 72 minutes and cross clamp was 59 minutes.
The patient was transferred on Dobutamine, Neo-Synephrine and
Propofol drip and was subsequently transferred to the
Cardiothoracic ICU. Postoperative day #1, the patient's
filling pressures remained low despite a cardiac index of
approximately 1. The patient was weaned off Neo-Synephrine
and Dobutamine with increase in volume and maintained her
blood pressure to approximately 90s to 100s.
Subsequently on postoperative day #2, filling pressures were
increased with increased volume and cardiac index improved.
The patient was weaned off the Dobutamine completely. ICU
postoperatively was also complicated by delirium which
resolved before transfer to the floor on postoperative day
#4. The patient was stable on the floor and Foley and
epicardial pacing wires were all discontinued.
The patient progressed quite nicely saturating at 92% on room
air and maintained her heart rate in the 80s to 90s in sinus
rhythm with no complications. The patient remained motivated
in therapy and continued aggressive pulmonary toilet. On
postoperative day #6, the patient was discharged in good
condition to rehab.
DISCHARGE STATUS: To rehab.
DISCHARGE DIAGNOSIS: Coronary artery disease, status post
coronary artery bypass graft times four.
DISCHARGE MEDICATIONS:
1. Fexofenadine 60 mg p.o. q. day.
2. Metoprolol 50 mg p.o. b.i.d.
3. Aspirin 325 p.o. q.d.
4. Zantac 150 mg p.o. q. day.
5. Colace 100 mg p.o. b.i.d.
6. Albuterol inhalers p.r.n.
7. Vioxx 25 mg p.o. b.i.d.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 14176**]
MEDQUIST36
D: [**2124-1-4**] 14:34
T: [**2124-1-4**] 16:56
JOB#: [**Job Number 109124**]
|
[
"401.9",
"272.0",
"997.1",
"493.90",
"427.31",
"593.9",
"414.01",
"293.0",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.22",
"36.13",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
3217, 3711
|
3115, 3194
|
1245, 3093
|
931, 1227
|
172, 482
|
504, 908
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,694
| 144,807
|
5387
|
Discharge summary
|
report
|
Admission Date: [**2155-10-30**] Discharge Date: [**2155-11-11**]
Date of Birth: [**2072-2-1**] Sex: F
Service: NEUROLOGY
Allergies:
Lactose Intolerance
Attending:[**First Name3 (LF) 1032**]
Chief Complaint:
Progressive Ptosis, Dysarthria, and Dysphagia
Major Surgical or Invasive Procedure:
* Administration of IVIG
History of Present Illness:
PER ADMITTING RESIDENT:
The patient is an 83 year old right handed woman with a
history of myasthenia [**Last Name (un) 2902**] diagnosed 10 years ago previously
on
Mestinon who presents with a 1 month history of progressively
worsening ptosis, dysarthria, and over the past week dysphagia
with both solids and liquids. She is accompanied today by her
son.
The patient reports that starting 1 months ago, she developed
left ptosis. She saw ophthomology for this without diagnosis.
The
ptosis became progressively worse, and then 2 weeks ago she
developed dysarthria. Her son realized that her symptoms may be
due to mysathenia. Then 1 week ago she felt weak all over and
developed dysphagia with solid foods, and reports she hasn't
eaten anything (even soup) for the past 1 week. Last Monday (3
days PTA), her son found some 5 year old Mestinon in the
cabinet,
and said it wasn't brown or clumpy so he crushed a 60 mg tablet
to give to his mother. She got 1 pill on Monday, 2 pills on
Tuesday, and 2 pills on Wednesday. On Monday, she did get slight
improvement in her dysarthria and ptosis after receiving the
Mestinon. Yesterday she started choking with liquids, also. She
says her symptoms are constant, and do not necessarily get worse
as the day progresses. Her symptoms are similiar to the ones she
had 10 years ago at the time of diagnosis of MG. Her symptoms
have been getting progressively worse over the past 1 month.
Because of this, she walked into the [**Hospital 878**] clinic last
Monday
to try to see a neurologist, but everyone was busy so she wasn't
able to be seen. She was seen by Dr. [**Last Name (STitle) 21900**] and Dr. [**Last Name (STitle) 1206**] in
[**Hospital 878**] Clinic today. On exam, she had ptosis, dysphagia for
liquids and choked with 1 oz of water, and fatigable proximal
muscle weakness. She was sent to the ED for neurology admission.
On ROS, she denies diplopia or SOB. She denies numbness, blurry
vision, or headache. She has had a nonproductive cough for the
past few days, but denies fevers/chills, diarrhea, or
pain/burning on urination.
Past Medical History:
Myasthenia [**Last Name (un) 2902**], diagnosed 10 years ago when she presented
with
dysarthria, dysphagia, and ptosis with Tensilon test and EMG
indicating MG, son says [**Name (NI) 21901**] were "abnormal" at Dr.[**Name (NI) 21902**]
office, was given plasmapheresis c/b LUE DVT, not currently on
medications but previously on mestinion which she stopped 5
years
ago due to diarrhea (which she says is due to lactose in the
formulation and not a mestinon side effect itself), has had no
flares since diagnosis, has never been intubated
Idiopathic colitis
Diverticulosis
Temporomandibular joint disease with secondary migraine
headaches
Lower GI bleed
Lactose intolerant
.
PSH
s/p bilateral total hip replacement
s/p bladder suspension
s/p appendectomy
Social History:
She lives independently, and her daughter lives nearby. She is
widowed.
She is a former ED nurse [**First Name8 (NamePattern2) **] [**Last Name (Titles) 189**].
She enjoys playing bridge.
HABITS
She denies cigarette, EtOH, and illicit drug use.
Family History:
All 4 of her children have arthritis.
Physical Exam:
ON ADMISSION:
VS: temp 98.2, HR 95, bp 142/73, RR 22, SaO2 98% on RA, NIF -10
Genl: Awake, alert, NAD. Can count to 41 in one breath.
HEENT: Sclerae anicteric, injection of her left lower inner
eyelid, oropharynx clear
CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops
Chest: CTA bilaterally anteriorly and laterally, no wheezes,
rhonchi, rales
Abd: +BS, soft, NTND abdomen
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive, says [**Doctor Last Name 1841**]
backwards. Speech is fluent with normal repetition; naming
intact. + dysarthria. No right-left confusion. No evidence of
apraxia or neglect.
Cranial Nerves: Pupils equally round and reactive to light, 5 to
3 mm bilaterally. Visual fields are full to confrontation.
Extraocular movements intact bilaterally without nystagmus. No
diplopia. Sensation intact V1-V3. Left>right ptosis which
worsens
on sustained upgaze. Facial movement symmetric. Hearing intact
to
finger rub bilaterally. Palate elevation symmetric.
Sternocleidomastoid and trapezius full strength bilaterally.
Tongue midline, movements intact.
Motor: Normal tone bilaterally. No observed myoclonus,
asterixis,
or tremor. No pronator drift.
[**Doctor First Name **] Tri [**Hospital1 **] WE FE FF IP H Q DF PF TE
R 5 5 5 5 5 5 3* 5 5 5 5 5
L 5 5 5 5 5 5 3 5 5 5 5 5
*Her IP is giveway weakness from her prior hip surgeries.
She has decrement of left deltoid strength to 4- after
repetitive
stimulation.
She has 4- neck flexor strength, normal neck extensors.
Sensation: Intact to pinprick, position sense, and cold
sensation
throughout. No extinction to DSS.
Reflexes: 2+ and symmetric in biceps, brachioradialis, triceps,
knees, and ankles. Toes downgoing bilaterally.
Coordination: Finger-nose-finger, finger-to-nose, fine finger
movements, and [**Doctor First Name **] normal.
Gait: Deferred
Pertinent Results:
Admission Lab Data:
.
WBC-9.0 RBC-4.70 HGB-13.9 HCT-42.2 MCV-90 PLT-203
GLUCOSE-98 UREA N-17 CREAT-1.0 SODIUM-141 POTASSIUM-3.5
CHLORIDE-98 TOTAL CO2-30 ANION GAP-17
CALCIUM-9.8 PHOSPHATE-4.1 MAGNESIUM-2.2
.
URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-40
BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG
.
Discharge Lab Data;
WBC 7.3
HCT 29.0
Direct Coombs test positive
Haptoglobin 68
LDH 291
Fe 196
TIBC 224
Ferritin 614
Brief Hospital Course:
The patient is an 83 year old right handed woman with a history
of myasthenia [**Last Name (un) 2902**] diagnosed 10 years ago previously on
Mestinon who presents with a 1 month history of progressively
worsening ptosis, dysarthria, and over the past week dysphagia
with both solids and liquids. Initially she was admitted to the
ICU. Once it was determined that she was stable, she was
transferred to the general neurology floor. After transfer to
the floor, she had an episode of hypoxia, with O2 sats down to
89% on room air. Her sats came up with 2 L of oxygen. She
received albuterol and atrovent nebs. Chest X-ray was clear.
After this she was maintained comfortably on room air. CT chest
showed no evidence of thymoma. Her NIFs and VC were followed
frequently and stable. She was started on mestinon 60 mg q4h
with a good clinical response. This was decreased to q8h after
patient reported diarrhea. She completed a 5-day course of IVIG
(plasmapheresis was deferred due to her complication of
thrombosis in the past). Her blood type was A+ and her CBC was
followed daily. Her HCT dropped from 42 on admission to a nadir
of 24.0. While this was thought to be partially dilutional,
there was concern for hemolysis as her LDH was elevated (291)
and haptoglobin had decreased to 68 from 125 and her direct
Coombs test was positive. She received one unit of PRBCs and
her hematocrit remained stable between 27-30 for the three days
prior to discharge. Given our concern, we would recommend
should the patient require further IVIG treatments in the
future, her HCT should be watched closely and it should be
ensured that anti-A titers of future IVIG batches should be <
1:8. She was guaiac negative and iron studies were
unremarkable. She was followed by physical therapy and speech
and swallow services during her hospitalization and will be
discharged home with VNA to monitor her CBC. In discussion with
Dr. [**Last Name (STitle) 1206**], patient will discharged on her mestinon as well as
prednisone 10 mg, increasing to 20 mg in one week. Further
adjustments will be made upon follow-up. She will also have VNA
monitor her CBC, reticulocyte count, and coags and results will
be faxed to her PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 3646**].
Medications on Admission:
None
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
2. Pyridostigmine Bromide 60 mg/5 mL Syrup Sig: One (1) PO Q8H
(every 8 hours).
Disp:*90 Tabs* Refills:*2*
3. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day: 1
tab daily for one week, then increase to 2 tabs daily. .
Disp:*60 Tablet(s)* Refills:*2*
4. Outpatient Lab Work
CBC. Please draw twice per week for next two weeks.
5. Folic acid 1 mg daily
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
myasthenia [**Last Name (un) 2902**]
Discharge Condition:
Able to count to 33 in one breath. Mild left ptosis with
sustained upgaze over 30 seconds. Full strength throughout.
Sensation intact to all modalities. Coordination intact. Gait
with normal initiation and stride, steady.
Discharge Instructions:
Please follow up with your PCP as well as Dr. [**Last Name (STitle) 1206**] (neurology
attending) as scheduled. Continue your medications as
prescribed and please continue frequent blood draws to monitor
your hematocrit as this had been low at the time of discharge.
Followup Instructions:
Dr. [**First Name (STitle) 3646**] (PCP) [**Telephone/Fax (1) 21903**].
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1206**] (neurology). [**Hospital1 18**] [**Hospital Ward Name 516**] [**Hospital Ward Name 23**]
Building, [**Location (un) **]. An appointment has been scheduled for you
on Friday, [**11-21**] at 9:30 AM. The office can be reached at ([**Telephone/Fax (1) 21904**].
Please continue blood draws as directed below.
Also, you may use warm compresses to your left eye daily as
needed. If your eye does not improve in the next 2-3 days
please discuss this with your PCP or you may benefit from
opthomological evaluation.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD, [**MD Number(3) 1041**]
|
[
"791.9",
"V45.89",
"787.91",
"562.10",
"285.9",
"271.3",
"358.01",
"346.90",
"524.60",
"V12.51",
"V43.64",
"799.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.14"
] |
icd9pcs
|
[
[
[]
]
] |
8855, 8930
|
6020, 8309
|
328, 354
|
9011, 9239
|
5563, 5997
|
9555, 10340
|
3529, 3569
|
8364, 8832
|
8951, 8990
|
8335, 8341
|
9263, 9532
|
3584, 3584
|
243, 290
|
382, 2471
|
4300, 5544
|
3598, 3967
|
4006, 4284
|
3991, 3991
|
2493, 3249
|
3265, 3513
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,665
| 194,834
|
32866
|
Discharge summary
|
report
|
Admission Date: [**2145-4-18**] Discharge Date: [**2145-4-27**]
Service: CARDIOTHORACIC
Allergies:
Penicillins / Indocin / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
pre-syncope, CP, DOE
Major Surgical or Invasive Procedure:
AVR(#23 StJude epic tissue)[**4-20**]
History of Present Illness:
84 yo F with known AS who presented to OSH in [**2-9**] with near
syncopal episode. Ruled out for MI. Cath showed normal
coronaries, moderate AS and MR. She was referred for surgery.
Past Medical History:
PMH:AS/MR COPD, chronic AF, HTN, arthrits, Glaucoma, Gput,
PSH: Appy, CCY, Thyrois [**Doctor First Name **], Fibroid excision, Cataract [**Doctor First Name **]
Social History:
retired
20 pack year tobacco history, quit 25 years ago
no current etoh
Family History:
NC
Physical Exam:
Admission:
HR 84 RR 14 BP 112/70
Lungs bibasilar rales
Heart Irregular 6/6 systolic murmur
Abdomen benign
Extrem warm, trace BLE edema
bilateral superficial varicosities
Discahrge:
VS T 97 HR 80 AFib BP 133/70 RR 20 O2sat 96% 2LNP
Gen NAD
Neuro A&Ox3, non-focal exam
Pulm course rhonchi throughout, no rales. + end expiratory
wheezes
CV irreg-irreg, no murmur. Sternum stable. Minimal
erythema(1cm)sternal incision
Abdm soft, NT/+BS
Ext warm, 1+ pedal edema bilat
Pertinent Results:
[**2145-4-18**] 05:48PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2145-4-18**] 05:48PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2145-4-18**] 06:00PM PT-15.4* PTT-26.0 INR(PT)-1.4*
[**2145-4-18**] 06:00PM PLT COUNT-229
[**2145-4-18**] 06:00PM WBC-9.3 RBC-4.95 HGB-15.1 HCT-44.5 MCV-90
MCH-30.5 MCHC-33.9 RDW-12.4
[**2145-4-18**] 06:00PM ALBUMIN-4.0 CALCIUM-9.7 PHOSPHATE-3.0
MAGNESIUM-2.1
[**2145-4-18**] 06:00PM LIPASE-32
[**2145-4-18**] 06:00PM ALT(SGPT)-16 AST(SGOT)-23 LD(LDH)-223 ALK
PHOS-84 AMYLASE-57 TOT BILI-0.6
[**2145-4-18**] 06:00PM GLUCOSE-159* UREA N-13 CREAT-0.9 SODIUM-142
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-25 ANION GAP-15
[**2145-4-27**] 05:05AM BLOOD WBC-8.5
[**2145-4-26**] 06:00AM BLOOD WBC-12.4*# RBC-3.33* Hgb-10.2* Hct-30.4*
MCV-91 MCH-30.8 MCHC-33.7 RDW-12.3 Plt Ct-210
[**2145-4-27**] 05:05AM BLOOD PT-24.3* INR(PT)-2.4*
[**2145-4-26**] 06:00AM BLOOD Plt Ct-210
[**2145-4-26**] 06:00AM BLOOD Glucose-96 UreaN-13 Creat-0.8 Na-136
K-4.3 Cl-100 HCO3-31 AnGap-9
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2145-4-23**] 10:46 AM
CHEST (PORTABLE AP)
Reason: eval pleural effusions
[**Hospital 93**] MEDICAL CONDITION:
84 year old woman s/p AVR
REASON FOR THIS EXAMINATION:
eval pleural effusions
PROCEDURE: Chest portable AP on [**2145-4-23**].
COMPARISON: [**2145-4-21**] and [**2145-4-20**].
HISTORY: 84-year-old woman status post AVR, evaluate for pleural
effusion.
FINDINGS: There is slight increase in the right pleural effusion
which is small. Persistent moderate left pleural effusion is
unchanged. Mild cardiomegaly is again noted. No pulmonary edema.
Status post cardiothoracic surgery with median sternotomy wires
with no complications.
IMPRESSION:
1. Stable left moderate pleural effusion.
2. Slight increase of the small right pleural effusion.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 11004**] [**Name (STitle) 11005**]
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: FRI [**2145-4-23**] 8:16 PM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 76511**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 76512**]
(Complete) Done [**2145-4-20**] at 12:04:26 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2060-5-9**]
Age (years): 84 F Hgt (in): 65
BP (mm Hg): 124/72 Wgt (lb): 204
HR (bpm): 54 BSA (m2): 2.00 m2
Indication: Intra-op TEE for AVR, and MVR
ICD-9 Codes: 427.31, 440.0, 441.2, 424.1
Test Information
Date/Time: [**2145-4-20**] at 12:04 Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Suboptimal
Tape #: 2008AW01-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.0 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.3 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.6 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.2 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.9 cm
Left Ventricle - Fractional Shortening: 0.31 >= 0.29
Left Ventricle - Ejection Fraction: 55% >= 55%
Left Ventricle - Stroke Volume: 55 ml/beat
Left Ventricle - Cardiac Output: 2.99 L/min
Left Ventricle - Cardiac Index: *1.50 >= 2.0 L/min/M2
Aorta - Annulus: 2.3 cm <= 3.0 cm
Aorta - Sinus Level: 3.3 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 3.0 cm <= 3.0 cm
Aorta - Ascending: *4.0 cm <= 3.4 cm
Aorta - Arch: 3.0 cm <= 3.0 cm
Aorta - Descending Thoracic: *3.4 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *2.8 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *32 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 21 mm Hg
Aortic Valve - LVOT pk vel: 0.83 m/sec
Aortic Valve - LVOT VTI: 16
Aortic Valve - LVOT diam: 2.1 cm
Aortic Valve - Valve Area: *0.8 cm2 >= 3.0 cm2
Mitral Valve - Peak Velocity: 1.0 m/sec
Mitral Valve - Mean Gradient: 2 mm Hg
Mitral Valve - Pressure Half Time: 48 ms
Mitral Valve - MVA (P [**2-3**] T): 4.5 cm2
Findings
LEFT ATRIUM: Moderate LA enlargement. Mild spontaneous echo
contrast in the body of the LA. Mild spontaneous echo contrast
in the LAA. Depressed LAA emptying velocity (<0.2m/s) No
thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No
ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Normal regional LV systolic function. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic
function.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Moderately dilated ascending
aorta. Focal calcifications in ascending aorta. Normal aortic
arch diameter. Simple atheroma in aortic arch. Mildly dilated
descending aorta. Complex (>4mm) atheroma in the descending
thoracic aorta.
AORTIC VALVE: Three aortic valve leaflets. Moderately thickened
aortic valve leaflets. Severe AS (AoVA <0.8cm2). Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. No MS. Mild (1+) MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The rhythm appears
to be atrial fibrillation. See Conclusions for post-bypass data
The post-bypass study was performed while the patient was
receiving vasoactive infusions (see Conclusions for listing of
medications).
Conclusions
PRE-BYPASS:
1. The left atrium is moderately dilated. Mild spontaneous echo
contrast is seen in the body of the left atrium. Mild
spontaneous echo contrast is present in the left atrial
appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s). No thrombus is seen in the left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%).
3. Right ventricular chamber is mildly enlarged and free wall
motion is normal.
4. The ascending aorta is moderately dilated. There are simple
atheroma in the aortic arch. The descending thoracic aorta is
mildly dilated. There are complex (>4mm) atheroma in the
descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. There is severe aortic valve
stenosis (area <0.8cm2). Trace aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. MR did not increase despite
provocative maneuvers such as volume loading, phenylephrine drip
and trendelenburg position.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is
being paced
1. A well-seated bioprosthetic valve is seen in the aortic
position with normal leaflet motion and gradients (mean gradient
= 15 mmHg). No aortic regurgitation is seen.
2. Biventricular function is preserved.
3. Aorta is intact post decannulation
4. MR is still mild
5. Other findings are unchanged
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician [**Last Name (NamePattern4) **] [**2145-4-21**] 15:34
Brief Hospital Course:
She was admitted preoperatively for IV heparin as she stopped
her coumadin for surgery. She underwent PFTs, and then was taken
to the operating room on [**4-20**] where she underwent an AVR,
please see OR report for details. In summary she had AVR with
#23 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Epic pericardial valve. She tolerated the operation
well and was transferred to the ICU in stable condition. She did
well in the immediate post-operative period, her anesthesia was
reversed she was weaned from the ventilator and extubated the
night of surgery. She was given 48 hours of vanocmycin as she
was in the hospital preoperatively. She was transferred to the
floor on POD #2. She was restarted on coumadin for atrial
fibrillation. She remained in the ICU for aggressive pulmonary
toilet and was transferred to the floors on POD... She developed
sternal drainage associated with minimal erythema without fever
or white count, antibiotics were initiated. The drainage
dissipated after one day, she remained without fever or elevated
white count. She was ready for discharge to rehab on POD7.
Medications on Admission:
Atacand 8', Digoxin 0.125', Diltiazem CD 240', Lasix 20',
Coumadin, Colace 100', Xalatan gtts, Albuterol MDI, Flonase 50",
Advair 250/50", Ativan 1-prn, Tylenol 500"", Loratadine 10', MVI
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY
(Daily): target INR 2-2.5.
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
11. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
15. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
16. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed.
17. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q6H (every 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
AS s/p AVR
PMH:MR, COPD, chronic AF, HTN, arthrits, Glaucoma, Gput,
PSH: Appy, CCY, Thyrois [**Doctor First Name **], Fibroid excision, Cataract [**Doctor First Name **]
Discharge Condition:
Stable
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (STitle) 1057**] 2 weeks
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**Last Name (Prefixes) **] 4 weeks
Completed by:[**2145-4-27**]
|
[
"428.32",
"424.1",
"427.31",
"424.0",
"365.9",
"443.9",
"428.0",
"496",
"V15.82",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.60",
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
12460, 12490
|
9552, 10675
|
284, 324
|
12704, 12713
|
1335, 2554
|
827, 831
|
10914, 12437
|
2591, 2617
|
12511, 12683
|
10701, 10891
|
12737, 13003
|
13054, 13205
|
846, 1316
|
224, 246
|
2646, 9529
|
352, 536
|
558, 721
|
737, 811
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,843
| 172,579
|
20558
|
Discharge summary
|
report
|
Admission Date: [**2126-1-7**] Discharge Date: [**2126-1-16**]
Date of Birth: [**2086-5-14**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Intractable epilepsy left temporal lobe.
Major Surgical or Invasive Procedure:
Awake left temporal lobectomy with electroencephalogram
recording for identification of speech area.
History of Present Illness:
39yo Brazilian man with a past medical history of refractory
complex partial epilepsy, followed by Dr. [**Last Name (STitle) 52089**], who
presented for left temporal lobectomy. Post operatively pt was
noted to have right sided weakness of the face, arm and leg. The
deficits on examination were consistent with a deep, subcortical
lesion, nearby the region of the surgery. The possibilities
include post-operative inflammation and edema causing vascular
compression and infarct in the deep matter on the left-side.
Past Medical History:
Past Medical History:
-Refractory complex partial epilepsy, as mentioned above. The
patient has undergone an extensive evaluation that is
well-described in his most recent discharge summary from
[**2125-11-7**]. past seizures are associated with altered
consciousness, inability to speak and understand, extension of
the right arm with opening and closing of the fist, and
lip-smacking without aura. Episodes last for 30 seconds to 1
minute, without premonitory aura, but often with post-ictal
sleepiness.
-History otherwise negative
Social History:
Used to work as a painter and in a pizza parlor before,
currently does not work. Lives w/ wife and two children (8 and 4
yo, healthy) in [**Location (un) 2251**], MA. He does not smoke tobacco, drink
alcohol or use illicit substances. He emigrated from [**Country 4194**] in
[**2116**].
Family History:
No family history of seizures.
Physical Exam:
Prior to OR pt A/O x3, following all commands, slightly
perseverative speech, MAE with equal strength. PERRLA.
Post operative:
A/A&Ox3,speech conversant/perseverative, PERRLA @3, EOMI, face
asymmetric with slight R.nasolabial flattening, MAE with
significant RUE/LE weakness, +gag/cough. tongue deviates to left
Pt afebrile, hemodynamically stable.
Pertinent Results:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
8.6 4.04* 12.5* 36.6* 91 31.0 34.2 12.7 381
Chemistry
Glucose UreaN Creat Na K Cl HCO3 AnGap
100 17 0.9 141 4.0 107 23 15
ESTIMATED GFR (MDRD CALCULATION) estGFR
Calcium Phos Mg
8.8 3.3 2.2
CT HEAD W/O CONTRAST; -76 BY SAME PHYSICIAN
Reason: S/P L TEMP LOBECTOMY
Field of view: 25
[**Hospital 93**] MEDICAL CONDITION:
39 year old man with decreased R sided mvmt s/p L temp lobectomy
REASON FOR THIS EXAMINATION:
bleed
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 39-year-old male with concern for postoperative
hemorrhage.
COMPARISON: Non-contrast head CT, [**2126-1-7**] at 16:10.
TECHNIQUE: Non-contrast head CT.
FINDINGS: Again demonstrated is prior left frontal craniectomy.
There is regional soft tissue scalp swelling and emphysema.
There remains pneumocephalus underlying the craniectomy site and
layering along the left frontal convexity. Several small locules
of gas remain in the left temporal lobe at the surgical site.
Post-surgical edema at the resection site is similar. A left
subdural hematoma at the surgical site has not appreciably
changed. Maximal thickness is estimated at 7 mm. There remains
shift of the septum pellucidum to the right by approximately [**4-16**]
mm, indicating subfalcine herniation but not appreciably
changed. The ventricular system is stable in configuration and
size compared to the study at 16:10 today. No new areas of
intracranial hemorrhage are seen. There is no new major vascular
territorial infarction. Paranasal sinuses and mastoid air cells
remain clear. The mastoids are congenitally under pneumatized.
IMPRESSION: No appreciable change in appearance of the brain
compared to prior study on [**2126-1-7**] at 16:10. The left subdural
hematoma measuring 7 mm maximal thickness. Post-surgical changes
and pneumocephalus. Unchanged rightward subfalcine herniation by
about 5-6 mm.
NOTE ON ATTENDING REVIEW:
Subtle hypodensity in the left capsuloganglionic region.
MR HEAD WITH DWI is more sensitive in the detection of acute
stroke and should be considered.
MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST
Reason: Vasospasm or infarctMRI/MRA/MRV please
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
39 year old man with R hemiplegia s/p L temporal lobectomy
REASON FOR THIS EXAMINATION:
Vasospasm or infarctMRI/MRA/MRV please
CONTRAINDICATIONS for IV CONTRAST: None.
ROUTINE MRI OF THE BRAIN WITHOUT AND WITH GADOLINIUM. ROUTINE
MRA OF THE BRAIN USING 3D TIME-OF-FLIGHT TECHNIQUE. ROUTINE MRV
OF THE BRAIN USING 3D TIME-OF-FLIGHT TECHNIQUE.
HISTORY: Right hemiplegia status post left temporal lobectomy.
Evaluate for vasospasm or infarction.
Comparison is made with prior MRI from [**2125-12-6**] and prior CT
from the day prior.
Again noted are changes from a left temporal lobectomy with an
overlying extra-axial hematoma, likely in the subdural location
which is grossly unchanged compared to yesterday's CT scan. The
postoperative cavity contains a subacute layering hemorrhage ,
which appears to have slightly increased since the prior study.
There is approximately 6 mm of left to right shift. There is
also an acute infarction in the left posterior limb of internal
capsule/lateral thalamus.
A small amount of subarachnoid hemorrhage is also noted in both
convexities.
Bilateral mastoid opacification is seen.
MRA of the circle of [**Location (un) 431**] demonstrates patency of the anterior
and posterior circulations. There is a slight decrease in
caliber of left inferior M2 branches compared to the right,
raising the possibility of vasospasm.
The right distal vertebral artery is not visualized and may be
congenitally or developmentally hypoplastic/occluded proximally.
MRA of the neck can be performed for further evaluation if
clinically indicated.
MRV of the brain demonstrates no evidence for venous sinus
thrombosis.
IMPRESSION:
Acute infarction in the left posterior limb of internal
capsule/lateral thalamus.
Postoperative sequela in the left temporal lobe with layered
hemorrhage in the postoperative cavity which appears slightly
larger than on the prior CT scan.
Stable midline shift.
There is a slight decrease in caliber of left inferior M2
branches compared to the right, raising the possibility of
vasospasm.
Stable left-sided subdural hematoma.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 54985**]Portable TTE
(Complete) Done [**2126-1-9**] at 12:13:27 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 742**]
[**Hospital1 18**]-Division of Neurosurgery
[**Hospital Unit Name 18400**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2086-5-14**]
Age (years): 39 M Hgt (in):
BP (mm Hg): 99/52 Wgt (lb): 180
HR (bpm): 43 BSA (m2):
Indication: ? Thrombus.
ICD-9 Codes: 424.2
Test Information
Date/Time: [**2126-1-9**] at 12:13 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) **],
RDCS
Doppler: Full Doppler and color Doppler Test Location: West
SICU/CTIC/VICU
Contrast: None Tech Quality: Adequate
Tape #: 2008W007-0:28 Machine: Vivid [**6-18**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.1 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.3 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.6 m/s
Left Atrium - Peak Pulm Vein D: 0.5 m/s
Right Atrium - Four Chamber Length: 4.2 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.0 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.7 cm
Left Ventricle - Fractional Shortening: 0.33 >= 0.29
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Left Ventricle - Lateral Peak E': 0.16 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': 0.09 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 4 < 15
Aorta - Sinus Level: 2.8 cm <= 3.6 cm
Aorta - Arch: 2.6 cm <= 3.0 cm
Aortic Valve - Peak Velocity: 1.1 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 0.5 m/sec
Mitral Valve - A Wave: 0.3 m/sec
Mitral Valve - E/A ratio: 1.67
TR Gradient (+ RA = PASP): <= 25 mm Hg <= 25 mm Hg
Pulmonic Valve - Peak Velocity: 1.1 m/sec <= 1.5 m/sec
Findings
LEFT ATRIUM: Normal LA size. No thrombus/mass in the body of the
LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum. No ASD by 2D or color Doppler. Normal IVC
diameter (<2.1cm) with >55% decrease during respiration
(estimated RAP (0-5mmHg).
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). No LV
mass/thrombus. No resting LVOT gradient. No VSD.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. No 2D or Doppler evidence of distal
arch coarctation.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No
masses or vegetations on aortic valve.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. [**Name13 (STitle) **]
mass or vegetation on mitral valve.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. No mass or vegetation on tricuspid valve. Normal PA systolic
pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is normal in size. No thrombus/mass is seen in
the body of the left atrium. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is 0-5
mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%) No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3)
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. No mass or vegetation is seen on
the mitral valve. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2126-1-9**] 14:26
Cardiology Report ECG Study Date of [**2126-1-9**] 7:25:32 AM
Marked sinus bradycardia with prominent U waves. Consider
hypokalemia.
Compared to tracing #1 the U waves are more prominent.
TRACING #2
Read by: [**Last Name (LF) **],[**First Name3 (LF) **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
38 142 96 [**Telephone/Fax (2) 54986**]2
Brief Hospital Course:
39 yo Brazilian man with a past medical history of refractory
complex partial epilepsy, followed by Dr. [**Last Name (STitle) 52089**], who is
s/p left temporal lobectomy on [**1-7**]. Pt was noted to have right
sided weakness of the face, arm and leg
several hours post-operatively. After further workup of CT/CTA,
MR/MRA of head and neck, pt was diagnosed as having thalmic
stroke. Stroke neurology consulted on the patient. Further
imaging was obtained as presented above in this note. Pt's
strength has improved. He is able to lift his arm with moderate
weakness 4-/5, improved bicep/tricep strength 4/5 in both muscle
groups. Speech improving with increased fluency, minimal word
finding difficulty, minimal perseveration. Pt following all
commands with some repetition of command required.
Pt started on ASA per neurology request at day 7.
Pt continues to improve, working with PT/OT. Stable at d/c to
rehab.
Medications on Admission:
unknown
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
7. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
8. Zonisamide 100 mg Capsule Sig: Four (4) Capsule PO HS (at
bedtime).
9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
13. Topiramate 100 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Intractable epilepsy left temporal lobe.
Left thalamic infarct
Right hemipareis
Discharge Condition:
Stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY
?????? Have a 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,
excessive bending
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
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, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) 739**] TO BE SEEN IN 4 WEEKS.
YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2126-1-16**]
|
[
"E878.8",
"342.90",
"348.4",
"997.02",
"345.51",
"784.3",
"434.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.53"
] |
icd9pcs
|
[
[
[]
]
] |
13449, 13522
|
11416, 12334
|
360, 463
|
13646, 13655
|
2313, 2702
|
15040, 15346
|
1893, 1925
|
12392, 13426
|
4599, 4658
|
13543, 13625
|
12360, 12369
|
13679, 15017
|
1940, 2294
|
279, 322
|
4687, 11393
|
491, 1010
|
1054, 1571
|
1587, 1877
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,758
| 131,132
|
10233+56124
|
Discharge summary
|
report+addendum
|
Admission Date: [**2143-8-7**] Discharge Date: [**2143-8-12**]
Date of Birth: [**2100-8-8**] Sex: M
Service: PURPLE GENERAL SURGERY
HISTORY OF PRESENT ILLNESS: This is a 42 year-old male with
a past medical history significant for a C8 radiculopathy who
presented with subacute right flank pain. He underwent CT
scan [**7-29**], which demonstrated a 5 by 23 cm low density
mass in the right hepatic lobe. Repeat ultrasound [**7-31**]
confirmed that this was a cystic structure. He then
underwent ultrasound guided aspiration of this liver cystic
fluid, which had about 4.5 liters of brownish fluid with a
culture positive for coag negative staph. The cavity
appeared to be fibrotic with some septations with possible
risk of malignancy. The patient as a result was scheduled
for elective fenestration of the cyst by laparoscopy.
PAST MEDICAL HISTORY: Degenerative disease of the cervical
spine, compression of the left C8 root, mild stenosis of
C6-C7. Hepatitic cyst. Status post appendectomy. Status
post tonsillectomy.
MEDICATIONS: None.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is a financial vice president.
Occasional alcohol. No tobacco. No intravenous drug use.
HOSPITAL COURSE: The patient was admitted to the hospital on
[**2143-8-7**]. He underwent laparoscopic fenestration of
hepatic cyst, which had to be converted to an open procedure
due to bleeding. The patient had tolerated the procedure
well and the only complication was of vein evulsion off the
ICC. Please see the operative note dated [**2143-8-7**] for
full details of this procedure. Intraoperatively the patient
received 7 liters of crystalloid and a unit of packed cells.
Estimated blood loss was approximately a liter. He was
transferred to the Intensive Care Unit for serial abdominal
examinations and serial hematocrits and telemetry.
Intraoperatively the patient's hematocrit decreased from a
preoperative value of 40 to 25. He received 1 unit of packed
red blood cells. Postoperatively, the patient's hematocrit
was 34 and remained stable with a hematocrit prior to
discharge of 32. The patient was hemodynamically stable
throughout the entire time of his admission. He had
abdominal pain initially, which was controlled with a
morphine PCA. He had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**] [**Last Name (NamePattern1) 1662**] drain placed
intraoperatively with an output of over 100 cc per day of
serosanguinous fluid. His drain continued to put out copious
amounts and there was concern about being able to actually
discontinued the bulb suction drain. At the time of
dictation that decision has not been made.
The rest of his postoperative course is otherwise
unremarkable. He is stable to tolerate a regular diet and
ambulate without difficulty. He remained hemodynamically
stable.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient will be discharged to home.
DISCHARGE MEDICATIONS: 1. Percocet one to two po q 4 to 6
hours prn.
DISCHARGE DIAGNOSES:
1. Status post open fenestration of a hepatic cyst.
2. Status post IVC repair.
INSTRUCTIONS: The patient is to follow up with Dr. [**Last Name (STitle) **]
one week from the day of discharge. Further instructions
regarding the patient's drain will be provided to the patient
upon discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**]
Dictated By:[**Last Name (NamePattern1) 2682**]
MEDQUIST36
D: [**2143-8-10**] 04:53
T: [**2143-8-12**] 10:49
JOB#: [**Job Number 34102**]
Name: [**Known lastname 5984**], [**Known firstname **] Unit No: [**Numeric Identifier 5985**]
Admission Date: [**2143-8-7**] Discharge Date: [**2143-8-12**]
Date of Birth: [**2100-8-8**] Sex: M
Service:
ADDENDUM: Mr. [**Known lastname **] continued to progress well, however, on
postoperative day #3 complained of significant fatigue,
weakness and he, in addition, continued to have significant
JP drain output in the 200's. Postoperative day #4 the
patient also continued to complain of crampy lower abdominal
pain. He was given a Dulcolax suppository with some relief.
He was, however, able to tolerate a regular diet without
nausea and vomiting. Postoperative day #5 the patient
continued passing flatus and was much more comfortable and
able to care for himself at home. His JP drain output
continued to be in the 200's, 290 on the day prior to
discharge. Hematocrit was checked on the JP drainage output
which was 2 and additional serum hematocrit was checked which
was 28.2. He, throughout, remained hemodynamically stable
and afebrile and was deemed stable for discharge home on
postoperative day #5.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: The patient will be discharged to home
with his JP drain in place after having received JP drain
teaching. He will be discharged without services.
DISCHARGE INSTRUCTIONS: The patient is to follow-up with Dr.
[**Last Name (STitle) **] for wound check and drain removal in one week.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 206**], M.D. [**MD Number(1) 207**]
Dictated By:[**Last Name (NamePattern1) 5986**]
MEDQUIST36
D: [**2143-8-12**] 13:38
T: [**2143-8-16**] 09:45
JOB#: [**Job Number 5987**]
|
[
"573.8",
"V64.4",
"998.11",
"998.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.32",
"50.29"
] |
icd9pcs
|
[
[
[]
]
] |
3056, 4788
|
2987, 3035
|
1247, 2869
|
5013, 5399
|
178, 853
|
876, 1109
|
1126, 1229
|
4813, 4988
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,428
| 151,842
|
16893
|
Discharge summary
|
report
|
Admission Date: [**2116-11-9**] Discharge Date: [**2116-11-14**]
Date of Birth: [**2095-5-6**] Sex: F
Service: MEDICINE
Allergies:
Sulfamethizole / Zosyn / Penicillins
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
SOB, respiratory distress, MICU call-out
Major Surgical or Invasive Procedure:
Coronary Catheterization
Hemodialysis
History of Present Illness:
21 year old woman with a history of ESRD on HD, SLE, lupus
nephritis, BOOP, h/o pericarditis, was admitted for SOB,
respiratory distress-using accessory muscles to breath. Also
found to have HTN urgency BP 183/139. She was recently admitted
on [**11-2**] with similar complaints of increasing DOE and SOB.
She received HD w/removal of 4L on prior admission w/improvement
in her symptoms. Her HTN was also managed w/HD and increasing
her BB to Toprol XL 200mg daily, increasing her Lisinopril to
40mg daily, and was due to have HD on Saturday following d/c
home. She did receive HD on saturday, however only 1kg removed
when 3kg are usually removed. She also admits to eating very
salty foods over the weekend. She presented to ED w/ increasing
SOB.
.
ED course: Initial VS T97.8 P103 BP183/139 R50 90% on RA, 100%
w/NRB and nebs. CXR was consistent with fluid overload. She was
started on BiPAP 12/8 and a nitro gtt. EKG was unchanged. Renal
service aware.
.
MICU course: Pt was stabilized in the ED initially with
BiPap->NC->RA after HD session this AM. She remained
hypertensive, though it has improved to 150s/100s. Once her
vital signs were stable, she was called out to the floor.
.
Currently, pt is without complaints. No chest pain/dyspnea. No
palpitations. She notes that she has had progressively worse
DOE, PND and orthopnea to the point where she sleeps upright
most of the time.
.
Past Medical History:
-Hypertension
-ESRD, dx [**12-6**] presumed [**1-2**] "ANCA-associated" pathology ?lupus
-> HD T,TH,Sat since [**1-6**]
-BOOP of unclear etiology diagnosed during [**2116-5-13**] admission
-h/o pericarditis c/b pericardial effusion w/o tamponade
-h/o Right lower extremity myositis NOS
-HSV Type 1 infection
.
Social History:
She is no longer working or going to school, but plans to go
back to school in [**Month (only) 404**]. She used to work as a waiter with
[**Last Name (un) 47587**] Puck catering. She was a former student at [**First Name4 (NamePattern1) 392**]
[**Last Name (NamePattern1) 1688**]. She reports no tobacco or alcohol use and reports no
other drug use.
Family History:
Sister with lupus. Mother with asthma, cousin with [**Name2 (NI) 14165**] cell
trait; no other issues. No history of bleeding diatheses.
Physical Exam:
VS: 97.6, 140/120, 76, 18, 96% RA
GEN: young woman laying in bed in NAD
HEENT: PERRL, Anicteric sclera, mild injected conjunctiva,
extremely poor dentition with multiple bilateral dental caries.
RESP: CTA B, no wheezes, rales, ronchi
CV: regular, prominent S2, ?S4, no m/g/r
ABD: Soft ND/NT +BS, no rebound/guarding
EXT: No peripheral edema, 2+DP pulses b/l
NEURO: A&Ox3, CNII-XII intact
.
Pertinent Results:
[**2116-11-14**] 07:45AM BLOOD WBC-4.6 RBC-4.37 Hgb-11.4* Hct-35.3*
MCV-81* MCH-26.1* MCHC-32.3 RDW-17.6* Plt Ct-259
[**2116-11-12**] 06:30AM BLOOD Neuts-50.5 Lymphs-30.3 Monos-7.6
Eos-10.6* Baso-1.0
[**2116-11-12**] 06:30AM BLOOD ESR-3
[**2116-11-10**] 03:55PM BLOOD Ret Aut-1.1*
[**2116-11-14**] 07:45AM BLOOD Glucose-111* UreaN-50* Creat-8.9*#
Na-132* K-4.5 Cl-98 HCO3-21* AnGap-18
[**2116-11-14**] 07:45AM BLOOD Albumin-3.6 Calcium-8.7 Phos-5.1* Mg-2.1
[**2116-11-11**] 01:10AM BLOOD VitB12-617 Folate-18.4
[**2116-11-10**] 03:55PM BLOOD TSH-2.8
[**2116-11-12**] 03:10PM BLOOD HCG-<5
[**2116-11-10**] 05:34AM BLOOD ANCA-WEAKLY POS
[**2116-11-12**] 03:10PM BLOOD RheuFac-4
[**2116-11-12**] 03:10PM BLOOD C3-91 C4-44*
.
[**11-9**]: Portable CXR: IMPRESSION: Findings consistent with severe
congestive heart failure. Small bilateral pleural effusions.
Follow up radiographs after treatment to ensure no underlying
infection are recommended.
.
[**11-10**]: CT chest w/o contrast: IMPRESSION:
1. Limited study for the assessment of pulmonary vasculature.
2. Very faint patchy ground-glass opacity in bilateral lungs,
which can represent minimal residual disease from the previously
noted airspace consolidations. However, no new interstitial
changes or consolidation.
3. Persistent lymphadenopathy in the right paratracheal, left
axilla, with small pericardial effusion.
.
[**11-12**]: Cardiac cath- FINAL DIAGNOSIS:
1. No angiographically apparent coronary artery disease.
2. Normal left and right sided filling pressures. Normal
pulmonary
arterial and systemic arterial pressures. No evidence of
constritive or
restrictive phsiology. Low normal cardiac index.
3. Successful endomyocardial biopsy.
.
[**11-13**]: Echo INTERPRETATION:
Conclusions:
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is moderate global left
ventricular hypokinesis. Overall left ventricular systolic
function is moderately depressed. Right ventricular chamber size
is normal. Right ventricular systolic function is 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.
The pulmonary artery systolic pressure could not be determined.
There is a very small pericardial effusion. There are no
echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2116-11-13**],
the pericardial effusion is now slightly smaller. Left
ventricular systolic function appears similar to slightly
improved.
.
Cardiac MR: Impression:
1. Mild symmetric LV hypertrophy with severely increased LV
mass.
2. Mildly dilated left ventricular cavity size with moderate
global hypokinesis. The LVEF was moderately depressed at 39%. No
MR evidence of myocardial scarring.
3. Normal right ventricular cavity size and function. The RVEF
was mildly depressed at 46%.
4. The indexed diameters of the ascending and descending
thoracic aorta were normal. The main pulmonary artery diameter
index was mildly increased.
5. Normal coronary artery origins with no evidence of anomalous
coronary arteries, and normal signal characteristics of all
visualized vessel segments.
6. Small circumferential pericardial effusion. No evidence of
pericardial constriction found.
Brief Hospital Course:
21 yo F w/ESRD on HD, SLE, lupus nephritis, BOOP, h/o
pericarditis, p/w SOB/respiratory distress in setting of dietary
indiscretion and insufficient fluid removal at HD. Hospital
course by problem below:
.
?Vasculitis- h/o weakly positive ANCA, +[**Doctor First Name **], +anti-Ro, renal
disease, pericardial disease and heart failure of unknown
etiology point to possible rheumatologic etiology to tie things
together. rheum consulted, recommended consulting cards to eval
vessels with cath- L and R cath prelim read with no
abnormalities. Will need to f/u endomyocardial biopsies.
Considered possible FNA/biopsy of lingular granuloma for
pathology- discussed with radiology resident, location not ideal
for CT-guided biopsy; potentially okay for VATS- deferring for
now as pt stable. Formal audiology testing to r/o involvement of
Wegener's considered- Pt's hearing normalized over hospital
course. Based on high probability of overlap syndrome of
Sjogren's (+anti-Ro, dental caries, conjunctival injection,
swelling of cheeks, though no c/o of dry eyes/dry mouth) and SLE
(+[**Doctor First Name **], renal disease, ?pericardial disease, +family history),
started prednisone 30 daily and plaquenil 400 daily. Will taper
prednisone to 10 daily over 2 weeks and f/u with rheumatology
clinic.
.
Hypertension: BP initially elevated in setting of volume
overload. Normalized after increasing metoprolol to 100 tid.
Resumed home meds post HD to control BP (amlodipine, metoprolol,
and lisinopril), increased metoprolol dose from 75 to 100 tid.
During and after cath, BP extremely well controlled even without
BP meds. Instructed pt to use BP machine that she has at home to
decide when to use BP meds. If SBP<100, not to use. If>100, use
meds. Educated pt on symptoms of hypotension. Etiology for drop
in BP unclear given intervention of prednisone and plaquenil
started after BP normalized.
.
Respiratory Distress: She's had several recent admissions for
the same symptoms of volume overload, pulmonary edema in setting
of dietary indiscretion and possibly inadequate volume removal
at HD. CXR initially clearly c/w severe CHF and pulmonary edema.
Improved s/p HD, Without O2 requirement on d/c. Renal team
communicated with pt's HD center to ensure proper HD.
.
CV: As above, cath done. Repeat TTE with EF 35-40%, resolving
pericardial effusion, thick ventricular walls; Cardiac MRI done
[**11-13**], to be f/u by cardiology and rheumatology as outpt.
.
ESRD on HD: Pt non-compliant w/diet precipitating volume
overload also insufficient removal of volume at HD center on
saturday. Renal fellow aware. Will now resume normal HD
schedule. Continued renagel. Nutrition consult provided diet
education
.
Depression: Continued celexa
.
DISPO: Discharged home with appropriate follow-up with ENT for
possible lip biopsy, Ophtho for eye exam, Dentist for oral care,
Rheum for med management, Cards for f/u cardiac MRI, and PCP for
general management.
Medications on Admission:
MEDS on Admission:
1. Amlodipine 10 mg Daily
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule daily
3. Sevelamer 800 mg 1 Tablet PO TID
4. Aspirin 81 mg daily
5. Citalopram 20 mg daily
6. Lisinopril 40 mg daily
7. Toprol XL 200 mg daily
.
MEDS on Transfer to floor from ICU:
1. Heparin sc tid
2. Acetaminophen 325-650 mg PO Q4-6H:PRN fever, pain
3. Lisinopril 40 mg PO DAILY
4. Amlodipine 10 mg PO DAILY
5. Metoprolol 75 mg PO TID
6. Aspirin 81 mg PO DAILY
7. Nephrocaps 1 CAP PO DAILY
8. Citalopram Hydrobromide 20 mg PO DAILY
9. Sevelamer 800 mg PO TID
10. Dolasetron Mesylate 12.5 mg IV Q8H:PRN Nausea
11. Ambien 5 mg PO HS:PRN
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
For blood pressure. Do not take if your systolic (top number)
pressure is less than 100.
Disp:*30 Tablet(s)* Refills:*2*
2. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
For blood pressure. Do not take if your systolic (top number)
pressure is less than 100.
Disp:*60 Tablet(s)* Refills:*2*
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
7. Metoprolol Tartrate 50 mg Tablet Sig: Five (5) Tablet PO TID
(3 times a day): For blood pressure. Do not take if your
systolic (top number) pressure is less than 100.
Disp:*180 Tablet(s)* Refills:*2*
8. Hydroxychloroquine 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. Prednisone 10 mg Tablet Sig: 1-3 Tablets PO DAILY (Daily):
Take 30mg daily for 5 days, 20mg daily for 5 days, and then 10mg
daily after that .
Disp:*30 Tablet(s)* Refills:*2*
10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever, pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Vasculitis NOS, Possible Lupus/Sjogren's Overlap Syndrome
Secondary Diagnoses:
1. ESRD on HD
2. CHF EF 35-40%
3. HTN
Discharge Condition:
Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
You should adhere to a 2 gm sodium diet.
.
Check your blood pressure before you take your blood pressure
medications. If the systolic (top) pressure is less than 100, DO
NOT take your blood pressure medication. This could cause
serious life-threatening consequences
.
Don't forget to make the follow-up appointments below.
.
Call your PCP or return to the ED if you have:
*fever/chills/night sweats
*difficulty breathing/chest pain
*nausea/vomiting
Followup Instructions:
EAR, NOSE & THROAT-
You will need to schedule an appointment for a lip biopsy for
the diagnosis of Sjogren's syndrome by calling [**Telephone/Fax (1) 41**]. If
you encounter any problems, call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 11679**] (number
below) to help you make the appointment.
.
DENTIST APPOINTMENT-
Self-scheduled for [**2116-11-18**]
.
RHEUMATOLOGY APPOINTMENT-
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 6405**] [**Name (STitle) 6406**] Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2116-12-2**] 8:00
.
CHF (HEART FAILURE) APPOINTMENT-
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. Phone:[**Telephone/Fax (1) 4451**]
Date/Time:[**2116-12-2**] 9:40
.
OPHTHALMOLOGY (EYE) APPOINTMENT-
Provider: [**Name10 (NameIs) 6131**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2116-12-21**]
3:15
.
PRIMARY CARE PHYSICIAN [**Name9 (PRE) **]
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2116-12-30**] 2:30
.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2116-11-17**]
|
[
"403.91",
"425.4",
"710.2",
"516.8",
"582.81",
"710.0",
"428.0",
"447.6",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"37.25",
"37.23",
"88.52",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
11540, 11546
|
6456, 9401
|
337, 377
|
11729, 11738
|
3084, 4486
|
12308, 13549
|
2518, 2657
|
10081, 11517
|
11567, 11567
|
9427, 9432
|
4503, 6433
|
11762, 12285
|
2672, 3065
|
11668, 11708
|
257, 299
|
405, 1800
|
11586, 11647
|
9446, 10058
|
1822, 2134
|
2150, 2502
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,669
| 172,308
|
50299
|
Discharge summary
|
report
|
Admission Date: [**2113-8-18**] Discharge Date: [**2113-8-22**]
Date of Birth: [**2041-5-12**] Sex: M
Service: MEDICINE
Allergies:
Azithromycin / Penicillins
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
hyperkalemia, urosepsis, acute on chronic renal failure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 72 yo male with h/o developmental delay, nonverbal at
baseline, seizure disorder, dementia, CRF secondary to urinary
retention/obstruction and hydronephrosis (baseline Cr 1.4-1.5)
and DMII who now presents from group home with hyperkalemia (K
7.7) observed at PCP's office yesterday. Per group home PCA,
patient has been in good spirits, no more agitated or sleepy
than usual; has had good PO intake. No fevers/chills. No
vomiting, but did have large loose bowel movement prior to
coming to ED which is not his baseline. No black or bloody
stools. PCA also notes intermittent hypotension with a couple of
blood pressure readings of 85/46 and 109/57 at the group home.
At baseline, straight caths 3x/day for chronic
obstuction/retention. Also, has a stage IV decub ulcer which is
followed by Dr. [**First Name (STitle) 805**] at [**Hospital 1263**] hospital and managed with a
wound vac.
.
In the ED, initial vs were: 97.8 66 127/57 20 100% on RA. On
exam, pt appeared comfortable, lungs clear. Urine in catheter
cloudy. UA showed WBC>182, lg leuk, many bact. Blood cx were
sent. Pt was given Vanc 1g and Cefepime 2 g. Labs showed K
7.0, Cr 2.8, BUN 147. Pt was given 10U insulin, with D50 [**1-8**]
amp. Also, was given calcium gluconate and kayexelate 30 g. EKG
showed NSR, no peaked T waves or ST changes. Lactate was 1.5. A
VBG showed pH 7.16 pCO2 30 pO2 105 bicarb 11. On transfer, VS
were T 95.8 HR 81 BP 122/57 RR 32 O2 sat 100% RA.
.
Upon arrival to the ICU, initial VS were T94.1 HR66 BP 118/44
RR26 O2 sat 97% on RA. Patient was alert and following commands.
(+) Per HPI; Unable to obtain further ROS as patient is non
verbal at baseline.
Past Medical History:
DIABETES MELLITUS
SEIZURE DISORDER
MENTAL RETARDATION
Dementia w/ agitation
DVT (provoked RUE, diagnosed [**2-16**] treated w/ 3 months of
coumadin)
CKD Stage 3 (attributed to diabetic nephropathy, obstructive
hydronephrosis)
URINARY INCONTINENCE
Hypothyroidism
Osteoporosis
Hypertension
Anemia of chronic disease
Social History:
Lives at group home. Does not smoke, does not drink alcohol. No
drug history.
Family History:
Non-contributory.
Physical Exam:
Physical Exam on Admission:
Vitals: T: 94.1 BP: 118/44 P: 66 R: 26 18 O2: 97% on RA
General: Alert, non verbal, but following simple commands, 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; + upper airway sounds
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mildly distended, non-tender, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: Foley
Ext: atrophied musculature, warm, well perfused, 2+ pulses, no
clubbing, cyanosis or edema
Pertinent Results:
Labs on Admission:
[**2113-8-17**] 11:59AM WBC-11.8* RBC-2.90* HGB-7.9* HCT-25.3*
MCV-87# MCH-27.3# MCHC-31.2 RDW-17.4*
[**2113-8-17**] 11:59AM NEUTS-75.3* LYMPHS-17.1* MONOS-5.8 EOS-1.5
BASOS-0.3
[**2113-8-17**] 11:59AM PHENYTOIN-1.6*
[**2113-8-17**] 11:59AM TSH-4.4*
[**2113-8-17**] 11:59AM %HbA1c-7.4* eAG-166*
[**2113-8-17**] 11:59AM ALBUMIN-3.1*
[**2113-8-17**] 11:59AM ALT(SGPT)-18 AST(SGOT)-13
[**2113-8-17**] 11:59AM UREA N-130* CREAT-2.5*# SODIUM-138
POTASSIUM-7.7* CHLORIDE-117* TOTAL CO2-12* ANION GAP-17
[**2113-8-18**] 11:35AM GLUCOSE-338* UREA N-147* CREAT-2.8*
SODIUM-138 POTASSIUM-7.0* CHLORIDE-120* TOTAL CO2-10* ANION
GAP-15
.
Imaging
.
CXR [**8-18**]: Single portable chest radiograph demonstrates
unremarkable
mediastinal, hilar and cardiac contours. The lungs are clear.
The left
costophrenic angle is not well seen but this is stable compared
to [**2113-2-7**] and likey reflects overlying soft tissue. No
pleural effusion or pneumothorax is evident.
IMPRESSION: No acute intrathoracic process.
.
CT abdomen/pelvis w/o contrast:(prelim read)
1. Thickened bladder wall, related to underdistension with
multiple foci of air within the bladder likely related to recent
instrumentation, although infection cannot be excluded.
2. Moderate hydroureteronephrosis, likely related to neurogenic
bladder is
unchanged. Thickening of the ureteric walls (right greater than
left) with
peri-ureteric stranding may be related to chronic reflux.
However, a
retrograde ureterogram or brushings may be considered if
clinically
appropriate.
3. Mild left lower lobe tree-in-[**Male First Name (un) 239**] opacities likely represents
an early
infection or sequelae of aspiration.
4. Small non-obstructive stones in the right renal parenchyma
and in an upper calyx in the left kidney.
.
EKG: NSR at 71 bpm. No ST-T-wave changes. No peaked T waves.
Similar to prior.
.
Brief Hospital Course:
72 yo male with h/o developmental delay, nonverbal at baseline,
seizure disorder, dementia, CRF secondary to urinary
retention/obstruction and hydronephrosis (baseline Cr 1.4-1.5)
and DMII who now presents from group home with hyperkalemia and
likely urosepsis.
# Urosepsis: Patient w/ h/o urinary retention and obstuction c/b
hydronephrosis and multiple UTIs. Typically self caths [**3-10**]
times/day and is followed by Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] urology. Cystogram in
[**2-16**] w/thickened trabeculated wall suspicious for a neurogenic
bladder. In past, UTIs have grown klebsiella ([**4-17**]; resistant to
macrobid) and proteus ([**3-17**]; amp, bactrim, cipro resistant)
previously treated with cipro and cefpodoxime respectively.
Given obstructive pathology and h/o self catheterization patient
has multiple risk factors for UTI. Low blood pressures were
suggestive of possible septic involvement, as was hypothermia w/
temp of 94.1. Received 1 L NS in ED with improvement in
pressures. Patient was initially treated with Cefepime and
Vancomycin, renally dosed. Urine culture was consistent with
contamination and blood cultures were no growth at the time of
discharge. He was transitioned to Cefpodoxime one day prior to
discharge and remained normothermic. He will complete a total of
ten days of antibiotics and follow-up with Urology as an
outpatient.
# Acute on chronic renal failure: Thought to be secondary to
obstruction vs. ATN in setting of relative hypotension. Unlikely
to be pre-renal as patient with reportedly good PO intake and
urine sodium of 44. Fena = 1.7 more suggestive of intrinsic
etiology such as ATN. Elevated BUN of 147 on presentation is
much higher than prior presentations, unclear why; no suggestion
of GI bleed. Muscle mass not significant, but patient does take
beneprotein supplements 6x day in group home which could account
for part of the elevation. Medications were renally dosed and
home ACE-I was held. Urine output was monitored carefully and
was robust. CT abdomen/pelvis was obtained to assess for
?retained stone, but only small, non obstructive stones were
visualized. Renal function returned to baseline prior to
discharge.
# Hyperkalemia: Likely secondary to [**Last Name (un) **] as well as recent
addition of lisinopril to regimen. Only on 2.5 mg daily, which
was started in response to borderline hypertension. No EKG
changes. Received calcium gluconate in ED. Improved w/ insulin
and kayexelate. Home Lisinopril was held at discharge.
# Metabolic acidosis, non-gap: Venous pH of 7.16 on presentation
with bicarb of 10 and hyperchloremia. Ddx includes renal acid
retention in setting of [**Last Name (un) **] vs. GI losses though no history of
vomiting. HCO3 normal at discharge.
# DMII: Blood sugar normal on presentation though trended down
with insulin in ED. Hgb A1c on check by PCP prior to admission
was 7.4. Patient was on Lantus 18 units qAM and sliding scale at
home; this was decreased to 16u on the day of discharge in
response to a morning FSBG of 54.
# Seizure Disorder- Recent Dilantin level checked by PCP low at
1.6. Presumably taking as prescribed at group home, but unclear
why level would be so low. Patient was loaded with 1g of
phenytoin IV and had his dose increased to 100 mg PO BID. A
repeat level should be checked in one week at his follow-up PCP
[**Name Initial (PRE) 648**].
# Anemia- History of anemia of chronic disease; on darbopoietin
at home once weekly. Hct was overall stable throughout this
admission.
# Stage IV Sacral Decubitus Ulcer- Has been followed by Dr.
[**First Name (STitle) 805**] at [**Hospital 1263**] hospital and treated w/ wound vac. Per group
home PCA, wound vac has had questionable results. Wound care
consult was obtained and recommended discontinuing wound vac
while in the hospital and resuming upon return to nursing home.
If wound does not begin to show signs of healing, could consider
evaluation for underlying osteomyelitis.
# H/O HTN: Pressures usually in the 140s, admitted
w/hypotension. His ACE-I was held at discharge; further
evaluation deferred to the outpatient setting.
# H/o dementia, developmental delay w/ agitation: At baseline
mental status currently. Following basic commands, but
non-verbal. Continued home Risperidone.
Medications on Admission:
darbepoetin 60 mcg/mL SC once a week
insulin glargine 18 units once a day
levothyroxine 75 mcg once a day
lisinopril 2.5 mg once a day
lorazepam [Ativan] 0.5 mg as needed for anxiety
phenytoin sodium extended 100 mg once a day
risperidone 0.5 mg at bedtime
acetaminophen 650 mg every four hours as needed for pain or
fever
ascorbic acid 500 mg twice a day
bismuth subsalicylate [Kaopectate] every six hours as needed for
for diarrhea
calcium carbonate-vitamin D3 [Calcium 500 With D] 500 mg (1,250
mg)-400 unit twice a day
dextromethorphan-guaifenesin every six hours as needed for cough
ferrous sulfate 325 mg (65 mg iron) once a day
insulin regular human [Novolin R] sliding scale
multivitamin once a day
polyvinyl alcohol-povidone [Refresh] 1.4 %-0.6 % Dropperette
1 drop in each eye once a day as needed for eye irritation
sennosides-docusate sodium [Doc-Q-Lax] 8.6 mg-50 mg Tablet 2
tablets once a day for constipation
thickening [**Doctor Last Name 360**], topical no.1 Liquid 4 tablespoon every four
hours
zinc oxide 25 % Paste use as directed with each diaper change
.
Allergies: Azithromycin/Penicillins
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
3. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. risperidone 1 mg/mL Solution Sig: One (1) mg PO HS (at
bedtime).
5. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: 1250
(1250) mg PO BID (2 times a day).
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
8. dextromethorphan-guaifenesin 10-100 mg/5 mL Liquid Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
9. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: Three
[**Age over 90 **]y Five (325) mg PO DAILY (Daily).
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. phenytoin sodium extended 100 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day).
12. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for agitation.
13. cefpodoxime 100 mg Tablet Sig: Four (4) Tablet PO Q12H
(every 12 hours) for 7 days.
Disp:*56 Tablet(s)* Refills:*0*
14. polyvinyl alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for itching, discomfort.
15. insulin glargine 100 unit/mL Cartridge Sig: Sixteen (16)
units Subcutaneous at bedtime.
16. Kaopectate (bismuth subsalicy) 262 mg/15 mL Suspension Sig:
One (1) dose PO every six (6) hours as needed for diarrhea.
17. darbepoetin alfa in polysorbat 60 mcg/0.3 mL Syringe Sig:
One (1) dose Injection once a week.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **]
Discharge Diagnosis:
Urosepsis
Acute on chronic renal failure
Hyperkalemia
Discharge Condition:
Mental Status: Non verbal
Level of Consciousness: Alert.
Discharge Instructions:
You were admitted with a urinary tract infection, poor kidney
function and electrolyte imbalance. You were treated with
antibiotics and IVFs with good response. You will need to
complete a total of ten days of antibiotics and are being
discharged on Cefpodoxime.
Aside from the addition of an antibiotic, your Lisinopril was
stopped (due to hyperkalemia) and your Phenytoin was increased
to twice a day (due to a low serum level on admission). Due to a
low blood sugar on the morning of discharge, your Lantus was
decreased to 16u from 18u. No other changes were made to your
home medications.
Followup Instructions:
Department: BIDHC [**Location (un) **]
When: MONDAY [**2113-8-28**] at 1 PM
With: [**First Name11 (Name Pattern1) 3295**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3296**] [**Last Name (NamePattern1) 3297**], MD [**Telephone/Fax (1) 608**]
Building: 545A Centre St. ([**Location (un) 538**], MA) None
Campus: OFF CAMPUS Best Parking:
Department: SURGICAL SPECIALTIES
When: MONDAY [**2113-9-4**] at 8:45 AM
With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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icd9cm
|
[
[
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icd9pcs
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[
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|
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74,444
| 146,236
|
32536
|
Discharge summary
|
report
|
Admission Date: [**2138-9-26**] Discharge Date: [**2138-10-1**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 15716**] is an 84 year old female with CAD s/p CABG on [**2138-7-29**],
AS, recently discharged from [**Hospital1 18**] on vanco for MRSA pneumonia
who now presents with worsening shortness of breath and
increasing oxygen requirements. She reports ongoing productive
cough though her cough is weak. She denies fevers, chills, chest
pain. She reports stable PND. She is unable to comment on
orthopnea. She denies diarrhea, constipation, dysuria. She
reports that she remains mostly in bed following her previous
admission for pneumonia.
.
Of note patient has a history of PE, but is anticoagulated with
coumadin for A. fib (INR 4.5 on admission).
.
In the ED, vitals were 97.9, HR 74, BP 106/48, 100% on 3LNC. In
ED, she got vanco, cefepime, lasix. Her blood pressure fell to
80/32 after receiving lasix 20 IV, but responded to a fluid
bolus. She was admitted to the MICU due to frequent suctioning
requirements. She was evaluated by cardiac surgery who
recommended admission to medicine.
Past Medical History:
Diastolic Congestive Heart Failure
Aortic Stenosis
Coronary Artery Disease
History of Pulmonary Embolus
Sjogren's Syndrome
Osteoporosis
Kyphosis
Compression Fractures
Cataract Surgery
Colonic polypectomies
Social History:
She is widow and lives alone, but has been at rehab since
surgery. She does not drink or smoke. She has three children.
She is retired from office work. Walk with walker at baseline
Family History:
Mother died of "heart attack" at age 68
Physical Exam:
VS: HR 84, BP 102/35, 96% on 6LNC, RR 22
Gen: frail, chonically ill appearing elderly female, tachypneic
HEENT: EOMI, dry mucous membranes
CV: RRR, 2/6 systolic murmur present and LUSB
Pulm: poor inspiratory effort, diffuse rhonchi, + kyphosis
Abd: soft, NT, ND, bowel sounds present
Ext: bilaterally 2+ peripheral edema, warm extremities
Pertinent Results:
Admission Labs:
139 | 106 | 33 /
---------------- 115
4.7 | 24 | 1.0 \
.
Baseline Cr 0.9
.
.. \ 10.3 /
16.8 ----- 274
.. / 32.2 \
.
Baseline Hct 30 - 33
.
Diff: 96.%N, 1.8%L, 1.4%M, 0.3%E, 0.1%B
.
PT 42.5
PTT 29.4
INR 4.5
.
BNP 4965 (no priors for comparison)
.
CK 48
TroponinT 0.05
.
Imaging:
CXR. [**2138-9-26**].
Retrocardiac opacity along with atelectasis and left basal
effusion, likely a combination of atelectasis and pneumonic
consolidation. Atelectasis is also seen in the right mid-zone.
Superimposed mild CHF. Followup AP and lateral radiographs are
recommended for further evaluation.
.
Echo. [**2138-9-29**].
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. A bioprosthetic
aortic valve prosthesis is present. The transaortic gradient is
higher than expected for this type of prosthesis. Mild to
moderate ([**11-20**]+) 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.] The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2138-8-4**],
the gradient across the prosthetic aortic valve has increased
and the aortic regurgitation is also increased. Estimated
pulmonary artery pressure also increase. TEE may be recommended
to further evaluate AVR.
CT Chest. [**2138-9-27**].
IMPRESSION:
1. Improvement in non-hemorrhagic left pleural effusion, now
small.
Improvement of left lower lobe collapse.
2. Change in location and overall increased multifocal
pneumonia, now more in the right lower lobe, less marked in
right upper lobe, right middle lobe and left lower lobe.
3. Moderate cardiomegaly. Prior sternotomy for AVR. Extensive
atherosclerotic calcifications.
4. Enlargement of main pulmonary artery, suggesting pulmonary
hypertension.
5. Left adrenal adenoma.
6. Kyphosis and unchanged multiple compression fractures.
Brief Hospital Course:
In summary, Ms. [**Known lastname 15716**] is an 84 year old female with CAD, AS,
diastolic CHF admitted with a worsening shortness of breath
likely due to worsening aspiration pneumonia and CHF.
.
Pneumonia. Ms. [**Known lastname 15716**] was was recently discharged from [**Hospital1 18**]
with pneumonia, treated with levaquin and 14 day course of
vancomycin for MRSA PNA completed on [**9-18**]. She presented on
this admission with leukocytosis, though denies fevers or
chills. She had significant secretions, requiring deep
suctioning due to patients poor cough. She was treated with
Vanco/Zosyn and deep suctioning and her pneumonia improved.
CHF. Patient had LE edema, shortness of breath. She did not
tolerate diuresis ddut to low blood pressures. An echo revealed
high pressure gradients across her recently (2 months prior)
replaced aortic valve suggesting and malfunctioning valve. It
was recommended that she undergo TEE, but given her tenuous
respiratory status and her wishes to remain DNI, this was not
pursued.
H/o PE. Patient was anticoagulated for PE from 6 months prior
and anticoagulated for A. fib. However, developed significant
epistaxis due to frequent deep suctioning requiring reversal of
anticoagulation. She was continued on amiodarone and remained
in NSR during hospital stay.
Epistaxis. Patient required frequent nasal suctioning. She
developed significant epistaxis with aspiration of blood. Her
INR was therapeutic for A. fib and h/o PE. This was reversed
with FFP and vitamin K. She was evaluated by ENT and nasal
packing was placed.
CAD. S/p CABG on [**2138-7-29**]. No evidence of a cardiac event during
hospital stay. She was continued on aspirin, simvastatin,
metoprolol during hospital stay. Lisinopril was held due to
hypotension.
During hospital stay, patient became progressively more
tachypneic. She had evidence of CHF but did not tolerate
diuresis due to hypotension. She was treated wtih vancomycin
and zosyn for PNA and her pneumonia symptoms seemed to improved.
She developed worsening shortness of breath, and ABG revealed
significant hypercarbia, likely due to tiring, worsening
pulmonary edema and pneumonia. She did not respond to lasix
bolus or lasix drip. After disucssion with patient and family,
the decision was made to make patient comfortable. She was
given morphine for SOB. Her family was at her bedside when she
passed away.
.
DNR/DNI, confirmed with patient
Medications on Admission:
Magnesium Hydroxide prn constipation
Omeprazole 20 mg [**Hospital1 **]
Tramadol 50 mg PO Q6H prn
Bacitracin Zinc 500 [**Hospital1 **]
Amiodarone 200 mg daily
Bisacodyl 5 mg [**Hospital1 **] PRN
Simvastatin 20 mg daily
Robitussin PRN
Lorazepam 0.5 PO TID prn
Albuterol Sulfate Q6H prn
Atrovent PRN
KCl 30 meq daily
Metoprolol tartrate 25 [**Hospital1 **]
Sucralfate 1 gram [**Hospital1 **]
Lisinopril 2.5 mg Tablet
Coumadin 2.5 mg daily
Ferrous Sulfate 325 mg daily
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
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|
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|
281, 287
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1572, 1758
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,996
| 119,476
|
48229
|
Discharge summary
|
report
|
Admission Date: [**2171-1-12**] Discharge Date: [**2171-1-15**]
Date of Birth: [**2119-8-3**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 5188**]
Chief Complaint:
fevers, rigors
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 51y.o. man, with a history of recently
diagnosed diverticulitis, who presented to the [**Hospital1 18**] emergecy
room with rigors. The rigors developed on the evening of
admission and were accompanied by fever, hypotension and
tachycardia. The patient reported an approximately 3 mo history
of dull, aching epigastric/perumibilical pain. Abd/pelvis CT on
[**12-19**] showed sigmoid diverticulitis, (as well as a liver
hemagioma) and the patient was treated with a course of
antibiotics. He denied any change in bowel habits, nausea and
vomiting.
Past Medical History:
[**Doctor Last Name 9376**] syndrome
Diverticulitis
Sinusitis
Social History:
Reports no EtOH or tobacco use. He is a psychiatrist.
Family History:
non-contributory
Physical Exam:
VS:103.0 max, 102.2 current, 120, 81/52, 24, 97%RA
General:A&O, with rigors, tachypnic
CV:tachycardic, regular rhythm, S1,S2
Pulm:CTA B
Abd: soft, non-distended, non-tender, +BS
Rectal:guaiac negative
Pertinent Results:
imaging:
CHEST PORT. LINE PLACEMENT [**2171-1-12**] 6:15 AM
No acute cardio-pulmoanry process. The tip of the central line
is projected over the SVC. There is a small pocket of air
projected over the medial aspect of the left hemidiaphragm, this
is not visulised on the most recent CT of [**2171-1-12**]
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2171-1-12**] 4:42 AM
IMPRESSION: No son[**Name (NI) 493**] evidence of acute cholecystitis.
Right liver lobe hemangioma.
CT ABDOMEN W/CONTRAST [**2171-1-12**] 2:55 AM
IMPRESSION: Persistent sigmoid colonic diverticulitis with no
significant interval change compared to [**2170-12-19**]. No evidence of
perforation
CHEST (PA & LAT) [**2171-1-12**] 1:51 AM
IMPRESSION:
No acute cardiopulmonary process.Possible small focus of
subdiaphragmatic free air. Subsequent CT of the abdomen and
pelvis showed no free air.
CHEST (PORTABLE AP) [**2171-1-13**] 4:47 AM
IMPRESSION:Increased plate-like atelectasis right mid lung zone.
Increased patchy airspace opacity left perihilar-left mid and
lower lung zone. These findings could represent evolving
pneumonia. Mild congestive failure
[**2171-1-11**] 11:55PM PT-12.9 PTT-26.1 INR(PT)-1.1
[**2171-1-11**] 11:55PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2171-1-11**] 11:55PM NEUTS-92.0* BANDS-0 LYMPHS-4.9* MONOS-1.3*
EOS-1.7 BASOS-0
[**2171-1-11**] 11:55PM ALT(SGPT)-148* AST(SGOT)-68* ALK PHOS-60
AMYLASE-98 TOT BILI-1.3
[**2171-1-11**] 11:55PM LIPASE-41
[**2171-1-11**] 11:55PM GLUCOSE-91 UREA N-18 CREAT-1.2 SODIUM-139
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-26 ANION GAP-16
[**2171-1-12**] 01:55AM LACTATE-1.8
[**2171-1-12**] 03:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2171-1-12**] 06:30AM WBC-13.0* RBC-4.25* HGB-12.6*# HCT-36.3*
MCV-85 MCH-29.5 MCHC-34.6 RDW-14.0
[**2171-1-12**] 06:30AM GLUCOSE-130* UREA N-13 CREAT-1.1 SODIUM-140
POTASSIUM-4.0 CHLORIDE-111* TOTAL CO2-20* ANION GAP-13
[**2171-1-12**] 06:30AM CALCIUM-7.1* PHOSPHATE-1.5* MAGNESIUM-1.8
[**2171-1-12**] 06:49AM HGB-12.9* calcHCT-39 O2 SAT-94
[**2171-1-12**] 06:49AM LACTATE-1.9
Brief Hospital Course:
The patient was admitted to the sugery service from the
emergency department after presenting with fevers, rigors,
tachycardia and hemodynamic instability with significant
hypotension requiring pressor support. CT showed previously seen
divericulitis and liver hemagioma, but no other significant
findings. The patient was admitted directly to the ICU for
pressors, fluid resuscitation, and close monitoring. He required
pressors for until the afternoon of hospital day one when they
were weaned to 0 after good BP response to fluid resuscitation.
Early that evening his SBP dropped back into the 80s but soon
stabilized. The patient was transferred from the ICU to a
surgical floor on [**1-13**] where he continued to do well.
Hemodynamic instability: The patient was admitted with a blood
pressure as low as 75/48. He required neosynephrine and
aggressive fluid resuscitation to raise his pressure. He was
tachycardic to 130 beats per minute. With the above treatment
his BP and HR returned to a normal range.
ID: The patient presented with fever of unknown origin. He was
finishing an out-patient antibiotic regimen for diverticulitis.
On admission he was started on broad spectrum empiric antibiotic
therapy. An ID consult was called. The ID team recommended
pan-culturing and continuation of broad spectrum antibiotics. A
hepatitis panel and EBV screen were also sent on ID's
recommendation.
GI/Nutrition:The patient was made NPO on admission. On [**1-14**] he
was advanced to a clear liquid diet in the morning and a regular
diet in the afternoon which he tolerated well.
The patient was discharged to home on HD#4, tolerating a regular
diet, vital signs stable. No definitive source of
fever/infection was found during hospital course. Labs/cultures
pending on discharge will be followed up when the patient
returns for his follow-up appointments.
Medications on Admission:
cipro
flagyl
nasonex
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 weeks.
Disp:*42 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
fevers
hemodynmaic instability with pressor requirement
Discharge Condition:
Good. Tolerating a regular diet. Pain well controlled.
Discharge Instructions:
Please call your physician or return to the emergency department
if you experience any of the following:
* You experience lightheadedness or dizziness.
* 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 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:
Please call Dr. [**Last Name (STitle) 5182**] to schedule an appointment for 2
weeks. The office number is ([**Telephone/Fax (1) 15350**].
You will also need a follow up chest x-ray that we will schedule
for you.
Please make an appointment with your primary care physician.
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]
|
[
"780.6",
"473.9",
"458.8",
"562.11",
"228.04",
"785.0",
"277.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5783, 5789
|
3582, 5448
|
329, 336
|
5889, 5946
|
1355, 3559
|
7013, 7399
|
1101, 1119
|
5519, 5760
|
5810, 5868
|
5474, 5496
|
5970, 6990
|
1134, 1336
|
275, 291
|
364, 929
|
951, 1014
|
1030, 1085
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,140
| 122,120
|
44061
|
Discharge summary
|
report
|
Admission Date: [**2143-3-5**] Discharge Date: [**2143-3-8**]
Service: MEDICINE
Allergies:
Aspirin / Sulfonamides / Analgesic, Salicylate And Barbiturate
Co
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a [**Age over 90 **] year old ([**Age over 90 595**] speaking) woman with
history of AFIb, CHF (EF40-45%), PVD, CAD, CKD presenting with
sudden onset of shortness of breath. Of note the patient was
discharged from [**Hospital1 18**] on [**2143-2-13**] after an admission for
influenza and UTI and acute on chronic renal failure. She was in
her usual state of health when she woke up this morning short of
breath. She states that she had pain in her bilateral upper
abdomen that has now resolved. She denied pain in her chest.
Of note her PCP had just increased her lasix from 40 mg daily
alternating with 20 mg daily to 40 mg daily.
In the ED her initial vital signs were [**Age over 90 **]F 91 170/79 94%
(100%neb). An ekg was read as unchanged from prior. She was
transiently on BiPaP in the ED then weaned to 3L NC.
She received lasix, ceftiaxone, and levofloxacin.
Past Medical History:
# Coronary disease
# History of deep venous thrombosis.
# Peripheral vascular disease.
# Chronic renal insufficiency, status post left nephrectomy,
1.4-1.9 baseline
# Infiltrating ductal breast cancer dx'd [**2132**] s/p excisional
biopsy and tamoxifen x5 years
# Diabetes.
# COPD versus asthma.
# ? gout
#. Anemia
# CHF - [**2137**] echo shows EF 40 - 45%
# paroxysmal atrial fibrillation
Social History:
Lives with duaghter, who is primary caretaker. They have a
visiting nurse. [**First Name (Titles) 482**] [**Last Name (Titles) 595**], very little English.
Family History:
Non-contributory
Physical Exam:
AF, VSS, on room air
Gen -- elderly, NAD
HEENT -- unremarkable
Heart -- regular
Lungs -- sparse basilar crackles
Abd -- soft, nontender, +BS
Ext -- right 2nd PIP erythema, swelling (improving)
Pertinent Results:
Admission:
[**2143-3-5**] 10:35AM BLOOD WBC-7.8# RBC-4.38# Hgb-12.3 Hct-37.7
MCV-86 MCH-28.0 MCHC-32.6 RDW-14.6 Plt Ct-243#
[**2143-3-5**] 08:30PM BLOOD PT-39.5* PTT-31.1 INR(PT)-4.3*
[**2143-3-5**] 10:35AM BLOOD Glucose-119* UreaN-42* Creat-2.1* Na-140
K-5.0 Cl-104 HCO3-22 AnGap-19
[**2143-3-5**] 10:35AM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier **]*
[**2143-3-5**] 10:35AM BLOOD cTropnT-0.02*
[**2143-3-5**] 08:30PM BLOOD CK-MB-2 cTropnT-0.03*
[**2143-3-6**] 04:17AM BLOOD Calcium-9.2 Phos-3.4 Mg-1.9
[**2143-3-5**] 10:40AM BLOOD Lactate-1.2 K-5.2
[**2143-3-5**] 11:00AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2143-3-5**] 11:00AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2143-3-5**] 11:00AM URINE RBC-21-50* WBC-[**1-23**] Bacteri-FEW Yeast-NONE
Epi-0-2
===============================
Discharge:
BLOOD cx negative
[**2143-3-7**] 06:10AM BLOOD WBC-5.4 RBC-3.52* Hgb-9.9* Hct-30.6*
MCV-87 MCH-28.1 MCHC-32.4 RDW-14.8 Plt Ct-162
[**2143-3-7**] 06:10AM BLOOD PT-30.4* PTT-30.0 INR(PT)-3.1*
[**2143-3-8**] 06:10AM BLOOD Glucose-114* UreaN-62* Creat-2.7* Na-142
K-4.4 Cl-106 HCO3-22 AnGap-18
===============================
FINGER(S),2+VIEWS RIGHT [**2143-3-7**] 1:55 PM
FINDINGS: There is soft tissue swelling over the index digit of
the right hand. There is loss of the joint space. There is a
dorsal osteophyte extending from the distal end of the middle
phalanx. aint curvilinear calcification is seen along the volar
aspect of the finger. No well-corticated erosion and no
characteristic gouty tophus is identified to confirm the
presence of gout. The differential diagnosis includes svere OA,
gout, and septic arthritis, and gout.
IMPRESSION: Focused view of the index digit of the right hand
demonstrates loss of joint space , cortical irregularity, dorsal
osteophyte and curvilinear soft tissue calcification. Remainder
of the hand is not available for comparison. Differential
includes sever osteoarthritis, septic arthritis, and gout.
================================
CHEST (PORTABLE AP) [**2143-3-5**] 10:44 AM
FINDINGS: Single AP upright portable chest radiograph is
obtained. Patient is slightly rotated to her left somewhat
limiting exam. Bilateral pleural effusions are noted with
increasing bibasilar atelectasis. There may be mild pulmonary
vascular congestion. The heart size is stably enlarged.
Mediastinal contour is unremarkable. There is atherosclerotic
calcification along the aortic knob. Diffuse osteopenia is
noted.
IMPRESSION:
Possible mild congestion with small bilateral pleural effusions.
Cardiomegaly.
Brief Hospital Course:
[**Age over 90 **] year old woman with hx of CAD, CHF, CKD presenting with acute
shortness of breath and hypoxia now markedly improved with
diuresis and transient NIPPV.
# Hypoxia: likely acute pulmonary edema in setting of poorly
controlled hypertension or potentially afib with RVR supported
by CXR findings, marked improvement with diuresis and NIPPV. no
sign of pneumonia. taking coumadin for hx of Afib so low prob
for PE. low risk for ACS in absence of chest pain or ischemic
EKG changes. minimally bronchospasmtic and minimal cough so COPD
exacerbation unlikely
- gradual diuresis (lasix 40 mg po bid) initially, changed to
home dose Lasix (alternating 40mg qday with 20 mg qday) after
BUN/Crt rise.
- recommended daily weights as outpatient
- discussed dietary compliance with patient and her family
- continued ACEi, beta-blocker, and nitrates
- hold aspirin given hx of allergy
- home dose bronchodilators
- low salt/heart healthy/DM diet
# right 2nd PIP destructive osteoarthritis -- Evaluated by
rheumatology. Short prednisone burst prescribed given
contraindication for NSAIDs with renal disease. She continued
Tylenol. She and her family were advised the prednisone may
worsen her heart failure and to return to the ED with any
shortness of breath or difficulty. The rheumatologists advised
tapping her joint, but she declined.
# Chronic kidney disease: Cr near her baseline
- renally dosed meds
- add-on Ca-phos
Medications on Admission:
Docusate Sodium 100 mg [**Hospital1 **]
Fluticasone-Salmeterol 250-50 mcg/Dose [**Hospital1 **]
Levalbuterol HCl neb q6h
Ipratropium Bromide neb q6prn
Acetaminophen 650 mg q6
Senna 8.6 mg [**Hospital1 **]
Cholecalciferol 400 unit daily
Lisinopril 5 mg DAILY
Metoprolol Succinate 150 mg daily
Ergocalciferol (Vitamin D2) 50,000 unit twice weely
Furosemide 40 mg alternating 20 mg daily
Warfarin 1 mg daily
Insulin Lispro
Seroquel 25 mg qhs
Mom[**Name (NI) 6474**] 50 mcg NU daily
Isosorbide Dinitrate 30 mg TID
Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Isosorbide Dinitrate 10 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO every other
day.
8. Glipizide 5 mg Tablet Sig: [**11-21**] Tablet PO twice a day.
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO every other day.
10. Warfarin 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
1. acute systolic heart failure
2. right 2nd finger destructive osteoarthritis
Discharge Condition:
stable, on room air, ambulating with a walker.
Discharge Instructions:
You were hospitalized with heart failure and pulmonary edema
(fluid leaking in your lungs). Please drink no more than 2
liters of fluid per 24 hours and avoid more than 2 grams of salt
(pre-packaged food, soup, pickles) per day. Take all your
medications. Call your primary physician with
questions/concerns. Return to the hospital with fever greater
than 101, chest pain, shortness of breath or other alarming
symptoms.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14290**], OD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2143-3-29**]
1:00
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2143-7-23**] 11:00
Call Dr. [**Last Name (STitle) **],[**First Name3 (LF) 1730**] J. [**Telephone/Fax (1) 250**] for a follow up
appointment as soon as possible.
|
[
"715.34",
"584.9",
"427.31",
"428.0",
"428.23",
"V10.3",
"585.4",
"403.90",
"250.00",
"496",
"285.21",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7606, 7692
|
4713, 6149
|
278, 285
|
7815, 7864
|
2051, 4690
|
8337, 8791
|
1805, 1823
|
6709, 7583
|
7713, 7794
|
6175, 6686
|
7888, 8314
|
1838, 2032
|
231, 240
|
313, 1201
|
1223, 1615
|
1631, 1789
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,179
| 161,447
|
18163
|
Discharge summary
|
report
|
Admission Date: [**2182-10-7**] Discharge Date: [**2182-10-16**]
Date of Birth: [**2117-4-2**] Sex: M
Service: CARDIAC SURGERY
HISTORY OF PRESENT ILLNESS: This is a 65 year-old gentleman
with known coronary artery disease who has had a myocardial
infarction in the past who was in his usual state of health
until two weeks ago and began feeling poorly after that. He
went to his doctor's office when he developed substernal
chest pain. The patient ruled in for a myocardial infarction
and was transferred to [**Hospital1 69**]
for further evaluation.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Cerebrovascular accident status post left carotid
endarterectomy with residual right sided weakness.
3. Peptic ulcer disease.
4. Hypertension.
5. Hypercholesterolemia.
6. Chronic neck and shoulder pain.
PREOPERATIVE MEDICATIONS:
1. Lipitor.
2. Aspirin 81 mg po q day.
3. Lopressor 25 mg po q day.
4. Aleve prn.
ALLERGIES: No known drug allergies.
HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] on [**10-7**] and was taken to the
cardiac catheterization laboratory, which showed an ejection
fraction of 45%, 70% left main stenosis, 90% osteal left
anterior descending coronary artery stenosis, 80% proximal
left circumflex and 80% obtuse marginal one stenosis and 80%
right coronary artery stenosis. Angiography of the bilateral
iliac arteries showed severe diffuse disease of the distal
aorta, common iliac and an occlusive right common femoral
artery.
The patient was referred to cardiac surgery for operative
treatment of his disease. The patient also had carotid
ultrasounds performed, which showed completely occluded right
internal carotid artery, left internal carotid artery,
carotid artery and external carotid artery, however, the
patient had patent vertebral arteries. The patient was
admitted to the Cardiology Service and had a preoperative
neurological evaluation for his severe carotid stenosis and
his residual weakness. During the time of his neurological
evaluation the patient also developed an upper
gastrointestinal bleed, which required a 3 unit transfusion.
A gastrointestinal consult was obtained. An
esophagogastroduodenoscopy was performed, which showed mild
erythema and friability in the stomach body and antrum
compatible with mild gastritis. No old blood or active
bleeding noted in the stomach. Erythema, congestion and
friability in the proximal bulb compatible with duodenitis.
Erosions in the proximal bulb. No old blood or active
bleeding lesions noted in the duodenum, otherwise normal
esophagogastroduodenoscopy to the third part of the duodenum.
The patient was started on proton [**Month (only) 4581**] inhibitors. With the
upper gastrointestinal bleed the patient was admitted to the
Coronary Care Unit due to the severity of his coronary artery
disease and need for blood transfusion.
Due to the patient's ongoing issues it was decided that the
patient would return to the Cardiac Catheterization
Laboratory for stenting of his iliac arteries and placement
of an intraaortic balloon [**Last Name (LF) 4581**], [**First Name3 (LF) **] on [**10-9**] he was taken
to the Cardiac Catheterization Laboratory. The patient had a
stent placed in his left iliac artery with good return of
blood flow. The patient also had been noted to have a 90%
lesion of his left subclavian artery. The patient had a
stent placed in his left subclavian artery and the patient
had an intraaortic balloon [**Month (only) 4581**] placed. The patient was
transported back to the Coronary Care Unit in stable
condition. It was decided on [**10-10**] that the patient was
stable to go to the Operating Room as there was no further
interventions that could be performed on his carotid
arteries. The patient was taken to the Operating Room on
[**10-10**] for an off [**Month (only) 4581**] coronary artery bypass graft times
one with Dr. [**Last Name (STitle) 70**]. The patient had left internal
mammary coronary artery to left anterior descending coronary
artery performed. The patient tolerated the procedure well
and was transferred to the Intensive Care Unit in stable
condition, weaned and extubated from mechanical ventilation.
On his first postoperative evening he remained on an
intraaortic balloon [**Last Name (STitle) 4581**]. The patient required small amounts
of neo-synephrine to maintain adequate blood pressure. On
postoperative day number one the patient was taken to the
Cardiac Catheterization Laboratory where he had percutaneous
transluminal coronary angioplasty and stent to his left main,
left circumflex ostium and proximal left circumflex. The
patient tolerated this procedure well and was transferred
back to the Intensive Care Unit in stable condition. The
intraaortic balloon [**Last Name (STitle) 4581**] was removed after the patient
returned from the cardiac catheterization laboratory without
difficulty. Hemostasis was easily obtained and the patient's
pulses in his distal lower extremities remained palpable.
The patient's pulmonary artery catheter was removed on
postoperative day number two. The patient began ambulating
with physical therapy. Due to his preoperative right lower
et weakness it was determined the patient would benefit from
a stay at short term rehab. The patient was started on a low
dose beta blocker and intravenous Lasix. On postoperative
day number four the patient was transferred from the
Intensive Care Unit to the floor, continued to ambulate with
physical therapy, required moderate amount of assistance from
physical therapy. The patient's pacing wires were removed
without difficulty on postoperative day number five and on
postoperative day number six the patient was deemed stable
for discharge to rehab facility.
CONDITION ON DISCHARGE: Temperature max 99.5. Pulse 92
sinus rhythm. Blood pressure 125/64. Respiratory rate 16.
Room air oxygen saturation 95%. The patient's weight on
[**10-16**] is 66.7 kilograms. Preoperatively the patient's weight
was 73 kilograms. Neurologically the patient is awake, alert
and oriented times three sitting in a chair out of bed.
Neurologically the patient has right upper and lower
extremity weakness, however, the patient has full range of
motion in his extremities just strength weakness. Heart is
regular rate and rhythm. S1 and S2 without murmurs, rubs or
gallops. Lungs are clear to auscultation bilaterally,
decreased left lower base. Abdomen positive bowel sounds,
soft, nontender, nondistended. Sternal incision Steri-Strips
are intact. The incision is clean and dry. There is no
erythema or drainage. Sternum is stable. His extremities
are warm and well perfuse with no edema.
LABORATORY DATA: White blood cell count 11.7, hematocrit
29.1, platelets count 439, sodium 140, potassium 4.5,
chloride 101, bicarb 32, BUN 16, creatinine 0.9, glucose 136.
Chest x-ray from [**10-14**] showed left lower lobe atelectasis,
no effusion.
DISCHARGE STATUS: The patient is discharge to rehab in
stable condition.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Status post coronary artery bypass graft times one off
[**Month/Year (2) 4581**], left internal mammary coronary artery to left anterior
descending coronary artery.
3. Status post percutaneous transluminal coronary
angioplasty stent times three.
4. Peripheral vascular disease.
5. Status post percutaneous transluminal coronary
angioplasty stent to left common iliac artery. Status post
stent to proximal left subclavian artery.
6. Upper gastrointestinal bleed due to gastritis.
DISCHARGE MEDICATIONS:
1. Enteric coated aspirin 325 mg po q day.
2. Plavix 75 mg po q day.
3. Percocet 5/325 one to two po q 4 hours prn.
4. Tylenol 65 mg po/pr q 6 hours prn.
5. Colace 100 mg po b.i.d.
6. Protonix 40 mg po q day.
7. Lopressor 75 mg po b.i.d.
8. Lipitor 10 mg po q day.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 1541**]
MEDQUIST36
D: [**2182-10-16**] 11:15
T: [**2182-10-16**] 12:00
JOB#: [**Job Number 50224**]
|
[
"997.3",
"535.01",
"440.8",
"438.89",
"518.0",
"440.20",
"410.71",
"412",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.61",
"88.48",
"99.20",
"88.56",
"45.13",
"37.22",
"39.50",
"36.01",
"88.53",
"39.90",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7062, 7580
|
7603, 8182
|
1008, 5785
|
865, 990
|
177, 576
|
598, 839
|
5810, 7041
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,809
| 140,210
|
17227
|
Discharge summary
|
report
|
Admission Date: [**2121-6-3**] Discharge Date: [**2121-6-18**]
Date of Birth: [**2056-10-31**] Sex: M
Service: #58
HISTORY OF PRESENT ILLNESS: This 64 year-old white male was
transferred to [**Hospital1 69**] from
[**Hospital **] Hospital. He was admitted there on [**2121-5-27**] after
presenting to the Emergency Department with complaints of
seven days of weakness, fatigue and shortness of breath. He
had undergoing a low anterior colon resection on [**3-27**] for
rectosigmoid carcinoma and his postop course from that was
apparently uneventful. On [**4-26**] he received 2 units of packed
cells when he was found to be anemic with a hematocrit of 27.
In the Emergency Department he was significantly dehydrated
with acute renal failure with a BUN of 56 and a creatinine of
3.1. Intravenous fluids resuscitation precipitated pulmonary
edema requiring emergency intubation. He was given Lasix
with no response. His white blood cell count in the
Emergency Room was [**Numeric Identifier 15362**]. He was admitted to the Coronary
Care Unit for sepsis and respiratory failure and required
large amounts of fluid. He had a significant murmur and
there was evidence of anterolateral ST depression on the
electrocardiogram. His troponin was 10.9. He was started on
Unasyn and Levaquin and was then diuresed. A Swan was placed
and revealed a cardiac index of 1.9 and he was placed on
Dopamine and his cardiac index increased to 2.9. An
echocardiogram revealed mitral valve vegetation, mitral valve
prolapse with a large mobile anterior leaflet vegetation,
which flopped into the antrum and moderate mitral
regurgitation. An abdominal CT was performed, which revealed
no evidence of significant intraabdominal fluid collection or
other anatomical abnormalities. He was started on tube
feeds. Gentamycin was added. He had blood cultures, which
were positive for strep Viridans and was sensitive to
Penicillin and Ceftriaxone. His creatinine did continue to
improve with a creatinine of 2.1 on hospital day number five.
He remained in pulmonary edema, remained intubated and he was
transferred for further treatment.
PAST MEDICAL HISTORY: Significant for status post lower
anterior resection for large invasive rectosigmoid carcinoma
in [**3-27**] at [**Hospital **] Hospital, status post inguinal hernia
repair 20 years prior to admission. History of
diverticulitis.
MEDICATIONS AT HOME: Nexium q.d.
ALLERGIES: No known drug allergies.
MEDICATIONS ON TRANSFER:
1. Unasyn 3 grams intravenous q 8 hours.
2. Levaquin 500 mg intravenous q day.
3. Epogen 10,000 units subq q week.
4. ________ albumin with Lasix q 12 hours.
5. Heparin 5000 units subq b.i.d.
6. Morphine prn.
7. Ativan prn.
8. Dopamine drip at 2 mg per kilograms per minute.
SOCIAL HISTORY: He does not smoke cigarettes and drank in
the past, but has not had a drink in one month.
FAMILY HISTORY: Unremarkable.
REVIEW OF SYSTEMS: As above.
PHYSICAL EXAMINATION: He is a thin white male intubated.
Vital signs were stable. His temperature was 98.8. His HEENT
examination normocephalic, atraumatic. Extraocular movements
intact. Oropharynx benign. Neck was supple. Full range of
motion. No lymphadenopathy or thyromegaly. Carotids 2+ and
equal bilaterally without bruits. Lungs have rhonchi on the
left. His cardiovascular examination is regular rate and
rhythm with a [**2-27**] holosystolic murmur. Abdomen was slightly
distended and nontender with a well healed surgical scar.
Extremities were without clubbing, cyanosis or edema.
Neurological examination was nonfocal.
HOSPITAL COURSE: He was transferred to the CSRU. He was
seen by dental who had a limited examination due to the ET
tube, but saw no evidence of dental infection. He was seen
by cardiology. ID also saw him and they recommended
discontinued Levofloxacin and continuing the Unasyn. He
remained in the unit and transesophageal echocardiogram
revealed severe mitral regurgitation with partial flail
leaflets and a 1.8 by 1.1 cm vegetation. He had a balloon
placed and that remained in and on [**6-6**] he underwent a
coronary artery bypass graft times four with left internal
mammary coronary artery to the left anterior descending
coronary artery, reverse saphenous vein graft to the right
coronary artery, obtuse marginal and diagonal and a mitral
valve replacement with a #29 Mosaic porcine valve. The cross
clamp time was 146 minutes, total bypass time 164 minutes.
He was transferred to the CSRU on Propofol in stable
condition. He remained intubated and was on neo and Propofol
on postop day one. He was switched at that point to
Ampicillin 2 grams intravenous q 6 hours and that was
recommended to have a four week course. His balloon was
removed on postoperative day number one and he remained on a
pressure support wean. He was extubated on postoperative day
three. He did have a hoarse voice and difficulty swallowing.
He was fed with tube feeds. He had a bedside swallowing
evaluation, which they felt he was aspirating, so he was kept
NPO and on tube feeds. He continued to progress very well,
although he was markedly fatigue and weak. He did go into
atrial fibrillation on postop day five. He converted with
Amiodarone and Lopressor. He did continue to have frequent
bursts of atrial fibrillation that would be very short and he
eventually was anticoagulated. He was seen by EP who
recommended the Amiodarone and they wanted upon discharge for
him to have [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor while he was having his
Amiodarone load for two weeks following discharge.
Eventually he was transferred to the floor on postoperative
day number six and he continued to slowly improve. He did
have another swallowing evaluation and they felt he could
have nectar thick liquids and regular food, which he was slow
to eat at first due to loss of appetite, but has been
improving with that. He also requires Boost pudding and
thick shakes. He was on heparin and Coumadin, slowly
anticoagulated. His pacing wires were discontinued. He
continued to improve and on postop day number twelve was
transferred to rehab in stable condition.
LABORATORIES ON DISCHARGE: White blood cell count 11,600,
hematocrit 38.9, platelets 285, sodium 140, potassium 4.1,
chloride 107, CO2 23, BUN 27, creatinine 1.1, blood sugar 91,
PT 40.4, INR 1.4.
MEDICATIONS ON DISCHARGE:
1. Ampicillin 2 grams intravenous q 6 hours for twelve more
days.
2. Colace 100 mg po b.i.d.
3. Percocet one to two po q 4 to 6 hours prn for pain.
4. He will receive 5 mg of Coumadin tonight and then should
be dosed to keep his INR between 2 and 2.5.
5. Aspirin 81 mg po q.d.
6. Nystatin swish and swallow 5 cc oral q.i.d.
7. Amiodarone 600 mg po q.d. for four more days and then
decrease to 400 mg po for three weeks and then decrease to
200 mg po q.d.
[**Last Name (STitle) 34081**]be transferred to [**Hospital3 7665**] with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of
Hearts monitor for two weeks. The strip should be sent to
Dr. [**Last Name (STitle) 73**] at the [**Hospital1 69**].
He will also have an appointment with him in one month
following discharge and needs an appointment with Dr.
[**Last Name (STitle) 38409**] in one to two weeks after discharge and with Dr. [**Last Name (Prefixes) 2545**] in four weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 48286**]
MEDQUIST36
D: [**2121-6-18**] 11:33
T: [**2121-6-18**] 12:31
JOB#: [**Job Number 48287**]
|
[
"428.0",
"427.31",
"414.01",
"745.5",
"421.0",
"458.2",
"787.2",
"511.9",
"041.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"35.23",
"36.13",
"37.22",
"39.61",
"88.56",
"88.72",
"37.61",
"96.72",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
2911, 2926
|
6425, 7650
|
3618, 6213
|
2426, 2477
|
2980, 3600
|
6228, 6399
|
2946, 2957
|
165, 2150
|
2502, 2786
|
2173, 2404
|
2803, 2894
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,933
| 183,577
|
8370+55934
|
Discharge summary
|
report+addendum
|
Admission Date: [**2111-7-29**] Discharge Date: [**2111-9-2**]
Date of Birth: [**2055-3-2**] Sex: F
Service: MEDICINE
Allergies:
Cipro / Doxycycline / Paxil / Quinine / Compazine / Levaquin /
Lithium / Cefepime
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
NG tube placement
PICC line placement
Endoscopy
History of Present Illness:
56 yo with cirrhosis [**3-16**] [**Last Name (LF) 29580**], [**First Name3 (LF) **] 30-40 (idiopathic)
transferred from [**Hospital1 **] bacteremic and hypotensive. She
states that she was feeling well up until 3 days ago when she
started having lightheadedness nausea and vomiting, her
lightheadedness was worse upon standing up and worse in the a.m.
The day of her admission she was told that her blood pressure
was low. In addition she had one peripheral IV and further
access could not be obtained, she had a PICC line which was
removed two days prior as she had blood cultures that were S.
epidermidis.
.
In addition the patient states that she has had dysuria and
suprapubic pain for 3 days, with mid back pain (not flank pain)
which felt like UTI symptoms to her.
.
Recently had a 2 month hospital stay from [**Month (only) **] to may of this
year for diarrhea/abd pain/and melena. MR enterography showed
colonic edema c/w portal hypertension. She underwent EGD, during
which she aspirated and required intubation and ICU stay with
levophed and vanc/zosyn. She improved and was extubated. She
also has SBO, for which she went to the OR for lysis, resection,
and placement of an ileoostomy on [**2111-5-15**]. Her GI function
improved. She had some seizure activity while in the ICU, for
which her seizure meds were titrated successfully. She received
a PICC for nutrition and was transferred to [**Hospital **] rehab.
.
In the ED: initial VS were T 97.9 HR 90 BP 82/49 RR 20 O2 97%
RA.
She was noted to have new ARF w/ a Cr of 3.3, baseline is
normal. She was given 4L of NS IVF. A R IJ central line was
placed using sterile technique. CVP was noted to be [**11-23**] and
BPs were still in the 80s systolic so she was started on
levophed which was uptitrated to 0.08 prior to transfer to the
ICU.
.
VS upon transfer to the ICU: T 98.0 HR 84 BP 84/48 RR 18 sating
96% on 4L by nasal cannula.
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 and partial SBOs, most recent [**2-20**]
# Concern for GI dysmotility syndrome pending further workup
# 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 [**2-17**]: 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
# [**2111-2-7**] repair of abdominal fascial defect/ascites leak
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 [**3-16**]
disability for RSD.
Family History:
Father with CAD, died age 55yo.
Physical Exam:
On admission -
VITAL SIGNS: T 97.4 HR 69 BP 143/59 RR 18 100% Bipap (FiO2
100%, [**11-16**])
GEN: dyspneic at end of sentences, working to breath
HEENT: anicteric, OP - no exudate, no erythema, unable to see
JVP secondary to anatomy
CHEST: bilateral rales to top of lungs, expiratory wheezes
CV: RRR, nl S1, S2, no m/r/g
ABD: NDNT, soft, obese, NABS
EXT: [**3-17**]+ pitting edema to bilateral knees
NEURO: A&O x 3
DERM: no rashes
.
On D/c
.
Vitals: 98.8 155/53 109, 24, 96%2L
GENERAL: Pleasant, thin woman in NAD, appearing older than
stated age
HEENT: Normocephalic, atraumatic. No conjunctival pallor. Mild
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. Systolic
murmur grade [**4-17**]
LUNGS: Mild bibasilar crackles, no wheezes or rhonchi
ABDOMEN:Hypoactive bowel sounds Soft, persistent lower quadrant
tenderness, ND. Ostomy in placedraining dark black liquid stool
. Enterocutaneous Fistula with mild erythema, no tenderness,
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
Pertinent Results:
ADMISSION LABS:
================
[**2111-7-29**] 06:30PM WBC-7.3 RBC-3.62* HGB-10.7* HCT-30.5* MCV-84
MCH-29.5 MCHC-35.0 RDW-17.1*
[**2111-7-29**] 06:30PM NEUTS-79.8* BANDS-0 LYMPHS-5.2* MONOS-2.8
EOS-12.1* BASOS-0.2
[**2111-7-29**] 06:30PM PLT SMR-LOW PLT COUNT-98*
[**2111-7-29**] 05:20PM PT-12.5 PTT-35.4* INR(PT)-1.0
[**2111-7-29**] 04:30PM GLUCOSE-145* UREA N-83* CREAT-3.3*#
SODIUM-127* POTASSIUM-4.2 CHLORIDE-86* TOTAL CO2-25 ANION GAP-20
[**2111-7-29**] 04:30PM ALT(SGPT)-38 AST(SGOT)-57* CK(CPK)-37 ALK
PHOS-836* TOT BILI-2.2*
[**2111-7-29**] 04:30PM cTropnT-0.04*
[**2111-7-29**] 04:30PM CK-MB-NotDone
[**2111-7-29**] 04:30PM CALCIUM-7.1* MAGNESIUM-1.9
[**2111-7-29**] 06:39PM LACTATE-1.6
[**2111-7-29**] 10:30PM URINE RBC-0 WBC-[**4-16**] BACTERIA-FEW [**Month/Day (1) **]-MOD
EPI-0
[**2111-7-29**] 10:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR
[**2111-7-29**] 10:30PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.022
[**2111-7-29**] 10:58PM ALBUMIN-2.4*
[**2111-7-29**] 10:58PM CK-MB-NotDone cTropnT-0.04*
[**2111-7-29**] 10:58PM CK(CPK)-14*
[**2111-7-29**] 11:01PM LACTATE-1.3
OSH MICROBIOLOGY:
[**Hospital1 **] Rehab culture results:
2/4 bottles from PICC line 6.15: staph species
(in addition to the already known [**3-16**] PICC cultures from [**7-26**]
and [**2-13**] peripheral cultures from [**7-26**]). PICC line catheter tip-
no growth. Wound (sinus tract / fistula)- Klebsiella pneumo-
they will fax us sensitivities
STUDIES:
========
[**7-29**] PORTABLE CXR
FINDINGS: Single upright portable chest radiograph is obtained.
The lungs
are clear bilaterally. Overlying EKG wires are noted.
Cardiomediastinal
silhouette is unremarkable. Bony structures are intact. A TIPS
is noted in
the right upper quadrant as is the IVC filter and a right upper
quadrant
surgical clip.
IMPRESSION: No acute intrathoracic process.
[**7-30**] TTE
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-10mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). The estimated cardiac index is normal (>=2.5L/min/m2).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No masses or vegetations are seen on
the aortic valve, but cannot be fully excluded due to suboptimal
image quality. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No mass or vegetation is seen on
the mitral valve. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is
borderline pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of [**2110-10-30**],
the findings are similar. No vegetations identified, but the
quality of images was not optimal.
[**7-30**] RENAL U/S
FINDINGS: The study is compared to recent CT from [**2111-6-19**].
The right
kidney measures 8.5 cm. The left kidney measures 9.9 cm. There
is no
hydronephrosis, mass, or stone. The bladder is decompressed
around a Foley
catheter. It cannot be fully evaluated.
IMPRESSION: Small right kidney. No hydronephrosis.
[**7-31**] CT ABDOMEN/PELVIS
IMPRESSION:
1. Overall, minimally changed study since [**2111-6-19**].
Specifically,
anasarca, splenomegaly, and pleural effusions are relatively
stable.
2. Retained contrast in the lower esophagus and distended
stomach. Please
monitor/suction as clinically approriate for possibly reflux.
[**8-7**] Doppler Abdominal U/S
Limited ultrasound of the right upper quadrant demonstrates no
intrahepatic biliary ductal dilatation. The common bile duct may
be slightly dilated. There is no ascites. Allowing for
limitations of technique, the TIPS is occluded. The left portal
vein demonstrates hepatopetal flow. The main portal vein is
patent with hepatopetal flow. The left hepatic artery is
unremarkable. The background liver parenchyma is diffusely
abnormal c/w provided history of sarcoid and unchanged from
prior studies.
IMPRESSION:
1. Chronic occluded TIPS and reversal of flow in the left portal
vein.
2. Possible slight dilatation of the common bile duct.
[**8-7**] PICC placement
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided
5 French
double-lumen PICC line placement via the left brachial venous
approach. Final internal length is 41 cm, with the tip
positioned in SVC. The line is ready to use.
[**8-10**] Head CT w/o contrast
There is no evidence of hemorrhage. Chronic encephalomalacia in
the right frontal lobe is unchanged. Coils at the right middle
cerebral
artery bifurcation are unchanged, with regional streak artifact
limiting
evaluation in the right middle cranial fossa. There is no sign
of mass, mass effect, edema, or new infarction. Ventricles and
sulci are unchanged in size and configuration. There are some
aerosolized secretions in the sphenoid sinus. Paranasal sinuses
are otherwise normally aerated.
IMPRESSION: No acute intracranial process.
[**8-14**] Bilateral Upper Extremity U/S
IMPRESSION: Old DVT in one of the two right brachial veins. No
evidence of
new DVT.
[**8-16**] Unilateral Lower Extremity U/S
IMPRESSION: No right lower extremity deep vein thrombosis
[**8-17**] EKG
Sinus tachycardia. Non-specific T wave abnormalities. Borderline
low voltage.
DC labs
Brief Hospital Course:
56 y.o. F with a h/o cirrhosis secondary to hepatic sarcoid,
multiple SBOs and recent ex-lap. Her hospital course was
protracted, below is a summary by chronological problem.
# Sepsis: Likely sources are staph epidermidis from PICC line
and VRE in urine. Patient initially needed low dose levophed to
keep MAP>60 after IVF boluses, but this vasopressor was quickly
weaned off. Stress dose steroids were also started as the
patient is chronically on prednisone 10 mg daily. These were
then tapered and planned return to home dose on [**8-1**]. Per ID,
she was started on meropenem and linezolid and continued on
these while in the ICU. Patient had VRE growing at OSH, as well
as Staph epi in the blood, but no VRE or Staph epi were isolated
inhouse. Murmur heard on exam; thus, echo completed and without
vegetations. Also, given multiple SBOs and enterocutatneous
fistula, surgery was consulted and recommended non-urgent CT
scan to evaluate. CT abd/pelvis was performed to rule out
perinephric abscess, which was negative for abscess or any other
intrabdominal pathology. Initial urinary cultures grew only
[**Last Name (LF) 23087**], [**First Name3 (LF) **] patient was treated with 3 days of fluconazole.
Meropenem and Linezolid were changed to vancomycin only to
complete a total of 8 day course of antibiotics for line sepsis.
This resolved during the hospitalization
# Acute renal failure: Per rehab notes, her Cr has been
increasing and lasix (home medication) had been held. Cr was 1.5
on [**2111-7-15**]. Renal ultrasound negative. Likely elevated in
setting in sepsis and hypotension. Cr trended and renally dosed
medications. The patient was discharged with a Cr of 1.2 that
was stable at 1.3 for the 10 days prior to d/c
# Gastroparesis: Persistent nausea and vomiting. Standing IV
antiemetics as well as IV ativan. NGT placed on [**7-31**] for
decompression and later removed by patient. No obvious SBO on
abdominal CT. Gradually advanced diet to soft foods and Reglan,
patient tolerated until aspiration on [**8-17**]. This was a
significant problem this hospitalization. After returning from
the ICU, having recovered from the sepsis, she had an aspiration
event of bilious emesis. She returned to the ICU, was intubated
and treated for the chemical pneumonitis with coverage for
aspiration pna. She return to the floor with an uncompromised
respiratory status. On the floor, she continued to have
intermittent episodes of emesis. During one episode 5 days prior
to d/c, an NGT was placed. Ultimately, it fell out and the pt
reufsed all further NGT placement. She was started on Cisapride
and these gradually faded with resolution by the time of d/c
# Ostomy output: Had large quantity of secretory ostomy output.
Improvement after octreotide and tincture of opium added.
Nevertheless, this was a serious problem this hospitalization.
It was managed with octreotide until the pt refused that
medication [**3-16**] the pain of injection and cholestyramine. We
replaced lost fluids with NS and TPN.
# Urinary tract infection: Had Klebsiella in urine and received
Meropenem and then Bactrim for a total 6 day course of
antibiotic treatment.
# History of seizures: Continued Keppra and Dilantin. Secondary
to gastroparesis and malabsorption, she requires the phenytoin
suspension formula. [**3-16**] to N/V the pt was discharged on IV
Keppra and Phosphenytoin.
# Liver failure from Sarcoidosis: s/p TIPS and TIPS revision,
most recent EGD [**4-20**] w/ esophagitis (on PPI) but no varicies or
portal gastropathy. No apparent history of SBP. On transplant
list. No history of cirrhosis.
# Itching - the pt has progressive, intractable pruritis likely
[**3-16**] TPN cholestasis. This was managed with creams,
cholestyramine, rifampin and naltrexone. Only the naltrexone
worked, so that was what she was d/c'd on.
# GI Bleed - the pt became to bleed, first with emesis on
[**2111-8-31**] and then from the ostomy on [**2111-9-1**]. The bleed was
brisk and red followed by melanotic. She was transfused with
three units. The pt consented to endoscopy but no bleed was
found. Still, the pt and the family agreed that her wishes were
to go home regardless of GI bleed.
# CMO/Home with Hospice - ultimately, the pt decided after
several lengthy discussions with the hepatology teams,
palliative care, social work and case management as well as the
family that she would like to go home with hospice. We arranged
that her treatments would all be symptom related, including
itching, pain, ostomy output, seizures, gastroparesis and
anxiety. She was discharged in stable condition to home per her
wishes
Medications on Admission:
-Rifaximin 400 mg TID
-Reglan 5mg IV q12 hrs
-esomeprazole 40mg daily
-combivent inhaler
-dronabinol 2.5mg po bid
-ambien 10mg po qhs
-tylenol 650mg po q6hrs prn
-MSIR 30mg po q6hrs prn
-Miconazole powder topically [**Hospital1 **]
-Regular insulin sliding scale (201-250 give 4 units)
-Camphor-Menthol 0.5-0.5 % Lotion
-Citalopram 20 mg PO DAILY
-Metoprolol Tartrate 25 mg PO TID
-Zolpidem 10 mg PO HS prn
-Ursodiol 300 mg PO TID
-Prednisone 10 mg PO DAILY
-Levothyroxine 100 mcg PO DAILY
-Phenytoin 100 mg PO TID
-Levetiracetam 500 mg PO BID
-Ondansetron HCl 4 mg Q8H prn
-Linezolid 600mg IV x 1 ? started [**7-25**]
-Zosyn 2.25g IV Q 6hrs [**2111-7-29**]
-Atarax 50mg po q6hrs prn itch
Discharge Medications:
1. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML
Intravenous PRN (as needed) as needed for line flush.
2. Fosphenytoin 50 mg PE/mL Solution Sig: One [**Age over 90 1230**]y
(150) mg Injection Q8H (every 8 hours).
Disp:*[**Numeric Identifier 22475**] mg* Refills:*2*
3. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
4. medication
1) Naltrexone 5.25 mg by mouth daily, disp: qs 30 days
2) Cisapride 10 mg by mouth QID, take home meds
5. Opium Tincture 10 mg/mL Tincture Sig: Ten (10) Drop PO Q6H
(every 6 hours) as needed for high ostomy output.
Disp:*60 mL* Refills:*0*
6. Levetiracetam 500 mg/5 mL Solution Sig: Five Hundred (500) mg
Intravenous Q12H (every 12 hours).
7. Levothyroxine 200 mcg Recon Soln Sig: Fifty (50) mcg from
Recon Soln Injection DAILY (Daily).
8. Sodium Chloride 0.9 % 0.9 % Syringe Sig: Ten (10) ML
Injection once a day as needed for line flush.
9. Metoclopramide 5 mg/mL Solution Sig: Ten (10) mg Injection
Q8H (every 8 hours).
10. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: 8-16 mg
Injection Q8HRS ().
11. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
12. Methylprednisolone Sodium Succ 40 mg/mL Recon Soln Sig:
Eight (8) mg from Recon Soln Injection Q24H (every 24 hours).
13. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day).
14. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) Packet PO
DAILY (Daily).
15. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) patch
Transdermal once a week.
Disp:*qs 30 days * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Old [**Hospital **] Hospice
Discharge Diagnosis:
Primary: Line sepsis
Secondary: Hepatic sarcoidosis, cholestasis, Recurrent small
bowel obstruction, intractable nausea and vomitting, GI bleed,
intractable pruritis
Discharge Condition:
afebrile, hemodynamically stable
Discharge Instructions:
You were admitted to the hospital for a line infection. You had
a long course thereafter with aspiration and pneumonia, severe
nausea and vomitting, itching, difficulties keeping up with your
ostomy output and bleeding from your ostomy. Ultimately, you
decided that you wanted to go home. We worked to ensure that you
received the medications and services that you needed at home.
.
Followup Instructions:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 29557**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 3183**]
Completed by:[**2111-9-8**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 5164**]
Admission Date: [**2111-7-29**] Discharge Date: [**2111-9-2**]
Date of Birth: [**2055-3-2**] Sex: F
Service: MEDICINE
Allergies:
Cipro / Doxycycline / Paxil / Quinine / Compazine / Levaquin /
Lithium / Cefepime
Attending:[**First Name3 (LF) 3727**]
Addendum:
The discharge summary incorrectly refers to the patient's
discharge condition as deceased. In fact, she was alive at the
time of discharge. She left the hospital according to her
wishes, happily. There was an outpouring of support from the
many staff who have cared for her over the years. Ultimately,
the patient did pass a few days after discharge.
Discharge Disposition:
Home With Service
Facility:
Old [**Hospital 5165**] Hospice
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3728**] MD, [**MD Number(3) 3729**]
Completed by:[**2111-9-22**]
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44,723
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29072
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Discharge summary
|
report
|
Admission Date: [**2149-10-10**] Discharge Date: [**2149-10-14**]
Date of Birth: [**2089-7-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
Dermabond injection of gastric varix
TIPS revision
History of Present Illness:
Mr. [**Known lastname 52**] is a 60 y/o man with cryptogenic cirrhosis and known
gastric fundal varices transferred from [**Hospital6 33**]
with hematemesis. Patient felt nauseated on day of admission and
spit up small amt of blood at home. Initial BP on EMS arrival
was in the 80s with HR in the 110s. At that time, he was taken
to [**Hospital1 34**] where he received 4 U PRBCs and 2 U FFP and platelets. He
was treated with IV protonix and octreotide gtt. No endoscopy
was performed as his bleeding had stopped and no ultrasound was
done of his liver/TIPS. He was transferred to [**Hospital1 18**] after 1 day
for further care.
Of note, per wife, the patient has had 3 other admissions to
[**Hospital6 33**] in the past month for hematemesis. [**9-17**]:
endoscopy showed possible [**Doctor First Name **]-[**Doctor Last Name **] tear. [**9-27**]: had
hematemesis requiring 6 units RBCs. EGD showed no active
bleeding, but cautery was performed. [**10-3**]: self-limited
bleeding, no endoscopy performed.
On arrival to the ICU, the patient is somnolent but arousable to
voice. Not answering questions. Accompanied by wife who reports
he was more somnolent today and was given PR lactulose X 1 prior
to transfer. She reports that he becomes encephalopathic when he
misses his lactulose.
Past Medical History:
1) Cryptogenic cirrhosis c/b ascites, gastric varices, hepatic
encephalopathy s/p TIPS in [**2147**]
2) h/o nephrolithiasis
Social History:
Lives with wife. [**Name (NI) **] alcohol, prior smoker (quit > 30 years ago).
Family History:
NC
Physical Exam:
VS: T 97.2 BP 143/74 HR 124 RR 22 O2 96% on room air
GEN: somnolent but arousable to voice, does not answer questions
reliably (consistently answers "yes")
HEENT: pupils large but reactive bilaterally, sclerae anicteric,
MM slightly dry, op clear
RESP: grossly clear without wheezes or rhonchi
CV: RRR, normal S1, S2
ABD: distended but soft, nontender to palpation throughout, +
fluid wave, hypoactive bowel sounds
EXT: dp pulses 2+ bilaterally, no edema
SKIN: no rash
NEURO: alert, not oriented, not reliably answering questions,
face symmetric, PERRL, tongue midline, moving lower extremities
in hip flexion, bilateral hand grip intact, no hyperreflexia, no
clonus, no appreciable asterixis on exam
Pertinent Results:
[**2149-10-10**] 09:04PM BLOOD WBC-4.2 RBC-3.72* Hgb-11.4* Hct-32.6*
MCV-88# MCH-30.7 MCHC-35.1* RDW-18.7* Plt Ct-109*
[**2149-10-12**] 09:21AM BLOOD WBC-5.8 RBC-3.55* Hgb-10.7* Hct-30.7*
MCV-86 MCH-30.2 MCHC-35.0 RDW-17.3* Plt Ct-63*
[**2149-10-14**] 06:40AM BLOOD WBC-4.4 RBC-3.40* Hgb-10.6* Hct-29.2*
MCV-86 MCH-31.1 MCHC-36.1* RDW-18.2* Plt Ct-78*
[**2149-10-10**] 09:04PM BLOOD PT-17.5* PTT-31.1 INR(PT)-1.6*
[**2149-10-14**] 06:40AM BLOOD PT-17.6* PTT-37.6* INR(PT)-1.6*
[**2149-10-10**] 09:04PM BLOOD Glucose-170* UreaN-17 Creat-1.3* Na-146*
K-3.9 Cl-114* HCO3-16* AnGap-20
[**2149-10-14**] 06:40AM BLOOD Glucose-93 UreaN-10 Creat-0.9 Na-139
K-3.4 Cl-109* HCO3-26 AnGap-7*
[**2149-10-10**] 09:04PM BLOOD ALT-22 AST-34 LD(LDH)-235 AlkPhos-79
TotBili-4.0*
[**2149-10-14**] 06:40AM BLOOD ALT-19 AST-31 LD(LDH)-216 AlkPhos-69
TotBili-3.9*
[**2149-10-11**] 12:12PM BLOOD Lactate-2.5*
[**2149-10-12**] 03:46PM BLOOD Lactate-1.9
Abd Doppler U/S ([**10-11**]):
IMPRESSION:
1. Patent TIPS with decreased velocities within the TIPS
compared to prior
study with low to no flow demonstrated in the left portal vein.
2. Cirrhosis, cholelithiasis and persistent significant ascites.
Abd Doppler U/S ([**10-12**]):
The main portal vein velocity measures approximately 51 cm/s and
demonstrates wall-to-wall flow. Wall-to-wall flow is
demonstrated within the TIPS stent with velocities ranging from
78 cm/s in the proximal, 137 cm/s in the mid, and 121 cm/s in
the distal portions of the TIPS shunt. These have increased when
compared to prior exam.
Brief Hospital Course:
Upon arrival to [**Hospital1 18**] on [**10-10**], he was noted to be developing
encephalopathy. Late that night, he had an episode of brisk
hematemesis, requiring 6 units RBCs and 2 units FFP. He was
intubated for airway protection. EGD was performed and showed
gastric fundal varices with an area of ulceration, injected with
5 ml dermabond, but no active bleeding. A 7 day course of cipro
was started for infection prophylaxis. The following day, his
TIPS was found to have poor flow on U/S, so he underwent TIPS
revision, with resultant improvement in flows. His hematocrit
stabilized after the transfusion, and he was extubated, then
transferred out of the ICU. His octreotide drip was stopped at
that time, after an approximately 3 day course. His mental
status gradually improved to becoming alert and oriented x3.
Prior to discharge, he had been restarted on his home lactulose,
rifaximin (dose increased), lasix, and spironolactone. He was
also started on metoprolol, later switched to nadolol 20mg
daily, for variceal bleeding prophylaxis. He may need this dose
increased, but was started low due to asymptomatic SBPs in the
90s. He had no recurrence of GI bleeding after the episode on
[**10-10**].
Medications on Admission:
Lactulose 30 mL daily to twice daily
Spironolactone 50 mg [**Hospital1 **]
Lasix 40 mg daily
Protonix 40 mg daily
Rifaximin 200mg daily
Discharge Medications:
1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO three
times a day: Please adjust as needed to achieve [**3-25**] loose stools
daily.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
7. Nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Gastric variceal bleeding
Secondary: Cryptogenic cirrhosis
Discharge Condition:
Hemodynamically stable
Discharge Instructions:
You were admitted to [**Hospital1 18**] with bleeding from an enlarged vein
in your stomach. This was treated with a glue injection, and you
also required blood products due to your bleeding. Your TIPS was
opened wider to help prevent future bleeding, but this increases
the risk of developing confusion. You blood counts have been
stable over the past 3 days, so we will discharge you home.
Please take all medications as prescribed and go to all follow
up appointments. We have made the following medication changes:
- Increased your rifaximin dose.
- Started ciprofloxacin, which prevents infections in the
setting of a GI bleed. You will need to take this for 2 more
days.
- Started nadolol, a beta-blocker that helps prevent recurrence
of variceal bleeding.
If you develop any nausea, vomiting, bleeding, bloody stools,
dizziness, confusion, or any other concerning symptoms, please
seek medical attention or come to the ER immediately.
Followup Instructions:
Please call [**Hospital1 18**] radiology at ([**Telephone/Fax (1) 6713**] to schedule an
ultrasound of your TIPS in 2 months.
Please call the [**Hospital1 18**] liver clinic at ([**Telephone/Fax (1) 1582**] to schedule
an appointment for 2 months.
Please call your primary care doctor, [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **], at
[**Telephone/Fax (1) 36012**] to arrange a follow up appointment.
Completed by:[**2149-10-14**]
|
[
"456.1",
"571.5",
"518.81",
"572.3",
"456.8",
"578.9",
"280.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"39.49",
"38.93",
"44.43",
"96.71",
"96.04",
"99.07",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
6409, 6415
|
4268, 5479
|
330, 383
|
6528, 6553
|
2702, 4245
|
7545, 8004
|
1962, 1966
|
5665, 6386
|
6436, 6507
|
5505, 5642
|
6577, 7077
|
1981, 2683
|
7097, 7522
|
279, 292
|
411, 1703
|
1725, 1850
|
1866, 1946
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,118
| 110,586
|
55104
|
Discharge summary
|
report
|
Admission Date: [**2172-8-18**] Discharge Date: [**2172-8-21**]
Date of Birth: [**2133-4-11**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 16851**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
39M with history of alcohol abuse and withdrawal seizures found
by [**Location (un) **] FD in hotel room with abdominal pain and coffee
ground emesis all over the room. pt reports that last drink was
4 days ago. Brought to [**Hospital3 **] where patient had
witnessed seizure. Intubated for airway protection and altered
mental status. CT head negative at [**Hospital1 **]. Patient had coffee
ground emesis prior to intubation. K 2.3 at OSH. CK 3000. Sent
to [**Hospital1 18**] for further eval. Received ceftraixone, vanc and flagyl
for presumed aspiration PNA.
In the ED, initial VS were: T: 97.6 P: 72, RR: 16, BP: 107/68,
Rhythm: NSR, O2Sat: 100, O2Flow: (Intubation). In the ED he was
given 2L NS and 40 K. Started on IV pantoprazole and IV profopol
was continued. WBC 14 with left shirt (N:96). Na126 K 2.3
HCO3:38, Mildly AST/ALt (80/45), lipase 39. ABG 7.51/51/260/38
Preliminary read of CXR revealed ?R middle lobe atelectasis vs
consolidation. CT scan abd without contrast RML, RLL and LLL
consolidations and no acute intraabdominal or intrapelvic
process.
Past Medical History:
ETOH Abuse
ETOH withdrawl sz
Social History:
Heavy ETOH, denies illicts
Family History:
no early CAD
Physical Exam:
Admission exam:
General: intubated sedated 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: R base significantly decreased BS, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU:foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred. Neurologic: Responds to: Not assessed, Movement: Not
assessed, Tone: Not assessed
DISCHARGE:
General: no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear,
Neck: supple, no LAD
CV: Regular rate and rhythm, no murmurs, rubs, gallops
Lungs: CTAB
Abdomen: soft, non-distended, bowel sounds present, no
tenderness to palpation, Ext: Warm, well perfused, 2+ pulses, no
clubbing, cyanosis or edema
Neuro: alert, answering questions appropriately, moving all
extremities
Pertinent Results:
Admission Labs:
[**2172-8-18**] 01:00AM BLOOD WBC-14.0* RBC-4.80 Hgb-14.0 Hct-39.8*
MCV-83 MCH-29.1 MCHC-35.1* RDW-14.2 Plt Ct-142*
[**2172-8-18**] 01:00AM BLOOD Neuts-96* Bands-0 Lymphs-3* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2172-8-18**] 01:00AM BLOOD PT-10.6 PTT-22.6* INR(PT)-1.0
[**2172-8-18**] 01:00AM BLOOD Glucose-124* UreaN-29* Creat-1.1 Na-126*
K-2.3* Cl-79* HCO3-38* AnGap-11
[**2172-8-18**] 01:00AM BLOOD ALT-45* AST-80* AlkPhos-62 TotBili-0.7
[**2172-8-18**] 05:32AM BLOOD ALT-36 AST-65* CK(CPK)-1378* AlkPhos-50
TotBili-0.6
[**2172-8-18**] 01:00AM BLOOD Albumin-3.6 Calcium-7.4* Phos-3.8 Mg-2.2
[**2172-8-18**] 01:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2172-8-18**] 01:12AM BLOOD Type-ART Rates-16/ Tidal V-400 PEEP-5
FiO2-100 pO2-260* pCO2-51* pH-7.51* calTCO2-42* Base XS-15
AADO2-403 REQ O2-70 -ASSIST/CON Intubat-INTUBATED
[**2172-8-18**] 01:12AM BLOOD Lactate-1.2
Brief Hospital Course:
39 y/o w/etoh abuse and withdrawal seizures found with coffee
ground emesis and intubated at OSH for airway protection s/p
seizure. Transferred first to [**Hospital Unit Name 153**], then to medicine for
continued care.
Active issues:
#Altered mental status requiring intubation: Pt was intubated
for airway protection s/p seizure. Most likely etiology was
alcohol withdrawal given his hx of withdrawal seizures. Pt was
extubated without complication and mental status improved. Pt
initially on a CIWA scale. Did not receive any benzos for
greater than 48hr prior to discharge.
#Metabolic alkalosis: Most likely [**3-12**] to vomiting. Resolved with
IVF during ICU stay.
#EtOH withdrawal: CIWA and benzos as above
#Leukocytosis: pt with left shift and consolidations on Chest CT
most likely represents aspiration pneumonitis vs aspiration
pneumonia. Started on vanc/CTX/flagyl in ED and changed to
Unasyn/Azithro in [**Hospital Unit Name 153**]. to complete 5 day course on [**8-22**].
#Elevated CK to 3000: most likely from immobility and
dehydration. Improved with IV fluids.
#?coffee ground emesis: guaiac positive gastric secretions.
[**Doctor First Name **] [**Doctor Last Name **] tear from history of vomiting is most likely.
Other diagnoses include gastritis and PUD. Hct remained stable
during ICU stay. GI was consulted who recommended PPI [**Hospital1 **], daily
Hct, no further bleeding and thus no EGD performed during
admission.
HTN: pt developed persistent HTN during stay with SBP steady in
150s. As pt with oustide PCP and does not know his name, contact
information or location, poor history of follow up, and no
desire to arrange [**Hospital1 18**] PCP, [**Name10 (NameIs) **] not start medication.
Instructed him to follow up with PCP to start [**Name9 (PRE) **] regimen.
Medications on Admission:
none
Discharge Medications:
1. acetaminophen 325 mg tablet Sig: Two (2) tablet PO Q6H (every
6 hours) as needed for back pain.
2. amoxicillin-pot clavulanate 875-125 mg tablet Sig: Two (2)
tablet PO twice a day for 4 days.
Disp:*8 tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
alcoholic seizure, high blood pressure
Discharge Condition:
Alert and oriented. No signs or symptoms of withdrawl.
Ambulating without difficulty.
Discharge Instructions:
Avoid alcohol. You will need to discuss starting a medication
for blood pressure with your primary doctor.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in [**Hospital1 1474**] within 2 weeks.
|
[
"724.2",
"275.41",
"482.9",
"780.39",
"311",
"276.3",
"287.5",
"530.7",
"291.81",
"V49.87",
"276.1",
"276.8",
"507.0",
"303.92",
"V60.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5776, 5782
|
3668, 3889
|
328, 340
|
5865, 5953
|
2705, 2705
|
6108, 6196
|
1553, 1567
|
5525, 5753
|
5803, 5844
|
5496, 5502
|
5977, 6085
|
1582, 2686
|
266, 290
|
3904, 5470
|
368, 1441
|
2721, 3645
|
1463, 1493
|
1509, 1537
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,659
| 173,499
|
38478
|
Discharge summary
|
report
|
Admission Date: [**2109-4-17**] Discharge Date: [**2109-5-3**]
Date of Birth: [**2033-4-9**] Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
s/p fall while intoxicated
Major Surgical or Invasive Procedure:
Tracheostomy
PEG
History of Present Illness:
This is a 77 year old man with known alcoholism, who had
presented to OSH on [**4-16**] for alcohol intoxication. He had left
the hospital AMA, but returned to [**Location **] after falling and hitting
his head and developing headaches. At OSH, he was agitated and
stopped following commands and was intubated for airway
protection. Head CT showed bilateral SDH. C-spine CT showed
unstable C6 fracture. He was transfered to [**Hospital1 18**] for further
care.
Past Medical History:
HTN
Social History:
+ETOH
Family History:
unknown
Physical Exam:
PE: On Admission
T 98.1 P 110 BP 150/77 R 24 SaO2 100%
Gen: intubated, sedated
HEENT: 4 cm laceration at occiput, extraocular muscles not able
to be tested, corneal and gag reflexes intact
Pupils: [**2-12**] b/l, sluggish
Neck: Supple.
Neuro:
Mental status: intubated, sedated
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3to2
mm bilaterally, sluggish.
III, IV, VI: not tested
V, VII: no facial droop
VIII: not tested
IX, X: gag reflex intact
[**Doctor First Name 81**]: not tested
XII: not tested
Motor: No spontaneous movements, no withdrawal to painful
stimuli
PE on Discharge: eyes open spontaneously, moves all 4
extremities spontaneously, follows commands, trach and PEG
Pertinent Results:
CT HEAD [**4-17**]
1. Multifocal subdural and subarachnoid hemorrhage, as detailed
above,
without significant mass effect. Small left frontal subcortical
white matter hemorrhage, which could be related to diffuse
axonal injury. This appears unchanged compared to prior study,
though note is made that the time interval elapsed was less than
three hours.
2. Subgaleal hematoma at the vertex posteriorly, without
underlying fracture.
3. Extensive periventricular and deep white matter
hypodensities, of
uncertain etiology at this young age, some of which appear
chronic, and others indeterminate in chronicity. Some of the
latter could correspond to
nonhemorrhagic diffuse axonal injury. Mild enlargement of the
ventricles and sulci for age also indicates chronic pathology.
Recommend MRI with and
without contrast for further evaluation when the patient is
stable.
CT C-spine [**2109-4-17**]:
1. No evidence for cervical spine fracture. Findings on the
previous
examination performed at [**Hospital6 3105**] were
secondary to motion artifact.
2. Emphysema, subpleural parenchymal opacities and pleural
scarring in the
imaged upper thorax. If there are no prior studies to confirm
stability, then follow-up chest CT is recommended.
CT Torso [**2109-4-17**]:
1. Lower back hematoma without intraperitoneal or
extraperitoneal bleed.
2. No osseous fractures.
3. Bilateral adrenal lesions are not well characterized in this
not
multiphasic study. They may represent adenomas but associated
hematoma can not be ruled out.
Left Elbow X-ray [**2109-4-17**]:
No definite acute fracture.
right 4th digit X-ray [**2109-4-17**]:
1) No evidence of acute fracture.
2) Soft tissue swelling in addition to possible tiny foreign
bodies in palmar soft tissues the right fourth digit.
CT head [**2109-4-18**]:
1. Increase in degree of subdural hematoma and subarachnoid
blood products.
2. Developing right temporoparietal contusion.
3. Additional periventricular hypodensities as well as volume
loss unexpected for patient's age appears unchanged.
CT head [**2109-4-20**]:
1. Stable subarachnoid hemorrhage and stable thin subdural
hematomas, with
interval increase in intraventricular blood products. This may
represent
redistribution rather than new hemorrhage. The ventricles remain
stable in
size, without evidence of developing hydrocephalus.
2. Redemonstration of right temporoparietal parenchymal
contusion.
3. Atrophy and chronic small vessel infarcts, unchanged from
prior study and likely chronic.
CT head [**2109-4-21**]:
1. Stable appearance of diffuse subarachnoid hemorrhage and
subdural
hematomas. Stable appearance of intraventricular blood products.
No new
areas of acute hemorrhage.
2. The ventricles remain stable in size and configuration with
no evidence of hydrocephalus.
3. Stable appearance of right temporoparietal parenchymal
contusion.
CXR [**2109-4-23**]:
In comparison with the study of [**4-21**], the tip of the endotracheal
tube lies approximately 6 cm above the carina and is situated at
the lower
clavicular level. The tip of the Dobbhoff tube extends to the
upper stomach, where it crosses the bottom of the image. Central
catheter extends to about the junction between the
brachiocephalic vein and SVC.
Hyperexpansion of the lungs is again seen without convincing
evidence of
congestive failure or acute pneumonia.
Brief Hospital Course:
Patient was admitted to the neurosurgery service from the ED
after being transferred from an OSH, where he had recently been
discharged and subsequently fell. He was intoxicated upon
presentation to the OSH. His head CT showed a right SDH along
the tentorium and a left SDH in the frontal/parietal region. He
was intubated for agitation and admitted to the ICU. With
sedation off he was moving all extremities, without eye opening.
His pupils were sluggish but reactive. He had +corneal
reflexes bilaterally as well as a cough. The patient was started
on dilantin for seizure prophylaxis and he was on Q1 hour neuro
checks in the ICU.
On [**4-19**] he was noted to be hyponatremic to 123. He required a 3%
drip which slowly corrected the problem and he was put on salt
tabs. His sodium was monitored and ultimately salt tabs were
dc'd.
He had been on dilantin for seizure prophylaxis and after 2
weeks this was discontinued. he never had seizure. he had aso
been on ativan for CIWA scale prophylaxis.
He was extubated on [**4-21**] but he quickly needed reitubation for
copious secretions and though did not have a pneumonia on CXR,
he did grew out STAPH AUREUS COAG + in sputum on [**4-23**] he was
started on Vancomycin to be continued until [**2109-5-4**]. He had PICC
line placed for IV antibiotic administration. He was also found
to have UTI [**4-30**] and was started on 10day course of Cipro.
His mental status improved on a daily basis and he was moving
all extremities and following intermittent commands. He had a
couple trials at extubation but required re-intubation and
ultimately he was trached on [**2109-4-26**]. He also had PEG placed for
nutrition on [**4-27**]. He was able to be transferred to stepdown
unit on [**2109-4-29**]. He has had issues with hypertension and
medication required titration for control. Also overnight on
[**4-30**] into [**5-1**] he had an episode of atrial fibrillation with RVR
requiring lopressor/diltiazem/digoxin. A cardiology consult was
obtained for this. PT/OT/Speech all evaluated pt and felt
appropriate for rehab. Speech also was able to place a speaking
valve on his trach on [**5-1**] after which he was able to verbalize
that he was in a hospital. On [**5-2**] he was deemed fit for
discharge to rehab with a hospital level of care and on [**5-3**] was
dischargerd to [**Hospital3 **]
Medications on Admission:
unknown
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Multivitamins Tablet, Chewable Sig: One (1) Tablet PO
DAILY (Daily).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day) as needed for DVT prophy.
5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
6. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q4H (every 4 hours) as needed for
wheeze.
7. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q4H (every 4 hours) as needed for
wheeze.
8. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
9. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
11. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
12. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QTHUR (every Thursday).
13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
16. Ondansetron 4 mg IV Q8H:PRN nausea/vomiting
17. Metoclopramide 10 mg IV Q6H
18. Metoprolol Tartrate 5 mg IV Q4H:PRN tachycardia
19. Vancomycin 1250 mg IV Q 12H GPC pneumonia +MRSA Duration: 7
Days
last day [**5-4**]
20. HydrALAzine 10 mg IV Q6H:PRN sbp>180, hr>110
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
Right Subdural Hematoma
Left Frontoparietal Subdural Hematoma
Vertex Subgaleal hematoma
Bilateral Adrenal Lesions
Lumbar Subcutaneous hematoma
Right 4th digit cellulitis
Subpleural lung nodules
Pneumonia
UTI
Respiratory distress requiring reintubations
Poor nutrition
Discharge Condition:
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
?????? Take your 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.
Followup Instructions:
??????Please call ([**Telephone/Fax (1) 2726**] to schedule an appointment with Dr.
[**Last Name (STitle) 548**], 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.
You will need to follow up in the hand clinic 1 week after
discharge for your fourth finger cellulitis. The number is ([**Telephone/Fax (1) 77358**].
You will need to follow up with your PCP [**Last Name (NamePattern4) **] [**1-16**] months for an
incidental finding of lung nodules on CT imaging.
Completed by:[**2109-5-3**]
|
[
"041.12",
"518.5",
"851.00",
"291.81",
"303.91",
"E888.9",
"599.0",
"401.9",
"922.31",
"253.6",
"681.00",
"482.41",
"427.31",
"110.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.72",
"86.27",
"31.1",
"86.04",
"38.93",
"43.11",
"96.71",
"38.91",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
9151, 9225
|
5008, 7369
|
301, 320
|
9537, 9656
|
1643, 4985
|
10067, 10696
|
881, 890
|
7427, 9128
|
9246, 9516
|
7395, 7404
|
9680, 10044
|
905, 1152
|
1526, 1624
|
235, 263
|
348, 815
|
1203, 1512
|
1167, 1187
|
837, 842
|
858, 865
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,963
| 131,561
|
28581
|
Discharge summary
|
report
|
Admission Date: [**2146-11-12**] Discharge Date: [**2146-11-30**]
Date of Birth: [**2067-5-31**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Painless jaundice, increasing fatigue
Major Surgical or Invasive Procedure:
Exploratory laparotomy, common bile duct excision.
[**2146-11-16**] Roux-en-Y choledochojejunostomy to the bifurcation of
the
right and left hepatic ducts. Lymph node biopsy.
History of Present Illness:
Patient presents with painless jaundice of one weeks duration,
weight loss and noting decreasing appetite and energy since [**Month (only) 116**]
of this year. 20 pound weight loss in the last few months.
Denies nausea and vomiting abdominal pain but does have
non-specific bloating. Family noted increasing yellow appearance
of skin in the last week. Denies fever or chills
Past Medical History:
Hypertension
Atrial fib
BPH
Social History:
Lives alone
Recent tobacco use
Occ ETOH
Family History:
Non-contributory
Physical Exam:
On Admission:
VS: 97.9, 133/106, HR 81, 20, 99%
Gen: NAD, Skin Icteric, AxOx3
EOMI, PERRLA
Resp: CTA bilaterally
Card: Regular, S1S2, no M/R/G
Abd: Soft, Non-tender, non-distended, + BS
Skin: Warm, dry, icteric
Extr: No edema
Pertinent Results:
On Admission:\
[**2146-11-12**] 08:30AM UREA N-16 CREAT-1.3* SODIUM-139 POTASSIUM-3.9
CHLORIDE-104 TOTAL CO2-24 ANION GAP-15
[**2146-11-12**] 08:30AM ALT(SGPT)-87* AST(SGOT)-70* ALK PHOS-272*
AMYLASE-65 TOT BILI-19.7*
[**2146-11-12**] 08:30AM LIPASE-57
[**2146-11-12**] 08:30AM WBC-4.2 RBC-4.66 HGB-14.4 HCT-44.3 MCV-95
MCH-30.9 MCHC-32.6 RDW-14.9
[**2146-11-12**] 08:30AM PLT COUNT-220
[**2146-11-12**] 08:30AM PT-16.0* PTT-32.1 INR(PT)-1.5*
On Discharge: PT/INR 19.5/1.9 on 7.5 mg Coumadin
Brief Hospital Course:
Patient admitted with painless jaundice, weight loss.
On [**2146-11-12**] ERCP was performed with sphincterotomy and stent
placement across the CHD/CBD stricture that was seen. Concerning
for neoplastic process. Bile duct brushings taken are positive
for malignant cells consistent with poorly differentiated
adenocarcinoma.CT performed on [**11-14**] showed cholangiocarcinoma at
the common hepatic duct-cystic duct confluence and on [**2146-11-16**]
patient underwent Exploratory laparotomy, common bile duct
excision. Roux-en-Y choledochojejunostomy to the bifurcation of
the right and left hepatic ducts.
Patient initially admitted post-op to the SICU. Cardiology
consult for history of Afib, not currently treated with
anticoagulation d/t difficulty with controlling INR.
Cardiology continued to follow throughout admission as patient
in and out of Afib. Given short term Digoxin, but this will not
be continued.
Transferred from SICU on POD 3, advancing diet, rate controlled
on beta blocker.
Roux study on [**11-21**] showed patent anastomosis with free passage
of contrast into the jejunum and mild dilation of the
intrahepatic biliary system.
Seen on [**2146-11-22**] by Heme-onc who made recommendations as to
ongoing treatment as needed in the future. Patient has stated he
would like to pursue treatment. Outpatient clinic appointment is
scheduled for [**12-5**] at 10 AM with Dr [**Last Name (STitle) **].
Blood pressures remained low during hospitalization, requiring
adjustments to, and short term holding of beta blockers. Resumed
for discharge. Proscar D/C'd. To restart Flomax for BPH
JP drain had very high outputs, often greater than a liter
during the hospitalization and required repletion with Albumin
and fluid boluses.
On [**11-23**], patient was found to have Left hand weakness. Neuro
consult immediate for stroke protocol, head CT obtained with no
evidence of bleed. Head MRI obtained subsequently showed No
evidence of acute infarction, but there is evidence of old
infarct involving the left occipital lobe. Patient was started
on IV heparin, and will be anticoagulated with heparin on long
term basis. Left hand weakness resolved quickly after it started
and it was determined this was most likely a TIA. No more events
were noted during the hospitalization.
Cardiac Echo on [**11-24**] showed no cardiac source of embolus
identified.
Carotid Doppler obtained, has 60-69% R. Internal Carotid
stenosis.
Vascular was also consulted, who are in agreement with managing
this with anti-coagulation (Coumadin and aspirin) at this time.
It is scheduled to be re-evaluated in 6 months, but may be done
sooner if patient with continuing symptoms.
PICC line placement was attempted, however, this was
unsuccessful. This was for the ongoing potential for fluid
management, however, the drain output will be managed by
limiting output to 300 cc, emptying only 3 times daily, and
allowing reabsorption of any excess.
Patient almost to anticoagulation goal of [**3-11**] INR by discharge
on [**2146-11-30**]. Will continue on 7.5 mg Coumadin daily, have INR
checked and results faxed to [**Hospital 1326**] clinic who will, for now
manage Coumadin therapy. He will also be maintained on Aspirin
daily.
Will D/C to [**Hospital1 1501**] ([**Location (un) 68876**], [**Location (un) **] [**Location (un) 3844**]) for
rehab.
Appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 766**] [**12-5**]
Medications on Admission:
Proscar, Diovan, Zocor
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q3H (every 3 hours) as needed for pain.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO ONCE (Once):
Monitor INR, draw Thursday [**12-1**] and fax results to
[**Telephone/Fax (1) 697**].
8. Flomax 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO once a day: for BPH.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] nsg and rehab
Discharge Diagnosis:
[**2146-11-12**] CBD brushings: Positive for malignant cells consistent
with poorly differentiated adenocarcinoma.
Probable TIA
Atrial fibrillation
Discharge Condition:
Stable
Discharge Instructions:
Please call [**Telephone/Fax (1) 673**] to Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] if patient develops
fever, chills, abdominal pain, increasing abdominal girth or
weight gain greater than 3 pounds in a 2 day period. Also
monitor for change in drainage in JP bulb that is currently
light yellow/green. Call for bloody or dark green bilious
dranaige in bulb.
Only empty JP bulb once per shif. Goal is to have output at 300
cc/day and patient to reabsorb some of the
Dressing change once daily to insertion site of pigtail
drain/Roux tube on abdomen
Followup Instructions:
Appointment [**12-5**] at 11:30 with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD
Please call ([**Telephone/Fax (1) 7394**] to arrange a follow-up appointment
with neurology, Dr. [**Last Name (STitle) **], in 6 months. Call [**Telephone/Fax (1) 327**] to
arrange for a repeat carotid ultrasound for the same day, in the
morning.
Completed by:[**2146-11-30**]
|
[
"401.9",
"435.9",
"427.31",
"600.00",
"574.10",
"585.9",
"276.52",
"272.0",
"305.1",
"576.2",
"155.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.14",
"45.91",
"51.85",
"51.87",
"51.22",
"87.54",
"40.11",
"99.04",
"38.93",
"51.69",
"51.36",
"51.37",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
6200, 6261
|
1869, 5310
|
353, 530
|
6453, 6462
|
1338, 1338
|
7087, 7472
|
1059, 1077
|
5383, 6177
|
6282, 6432
|
5336, 5360
|
6486, 7064
|
1092, 1092
|
1808, 1846
|
276, 315
|
558, 934
|
1351, 1794
|
956, 985
|
1001, 1043
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,505
| 144,658
|
53637
|
Discharge summary
|
report
|
Admission Date: [**2127-3-16**] Discharge Date: [**2127-3-25**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3043**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
colonoscopy with biopsy
History of Present Illness:
Mr. [**Known lastname 437**] is an 86 year-old Mandarin (dialect) speaking man with
a remote history of unknown abdominal surgery and no other known
past medical history who presents with RUQ abdominal pain. Per
son, the pain began this AM after breakfast with intermittent,
sharp, severe and lasting 5-6 minutes. He had another episode
early afternoon while son present. His son noted that the
severe pain was accompanied by shallow breathing and
lightheadedness, along with chills and rigors, so called EMS.
.
In the ED, initial VS were: T 99.3, P 93, BP 146/62, RR 22,
O2sat 99 RA. On exam, abd with RUQ tenderness but benign; stool
guaiac negative. Temp spiked to 102.6 in ED with accompanying
rigors; pt given tylenol followed by ibuprofen with
defervescence. Labs notable for a Hct 19.9 (33.4 in [**2117**]), MCV
84 with iron 14 and ferritin 14; platelets, hapto, and
fibrinogen nl. Lactate initially 5.6. He was given 2 units
pRBC and 1.5L NS IVF with normalization of his ST depessions and
improvement in lactate to 1.5. 1st set cardiac enzymes
negative. U/A with 3-5 RBC and WBC, mod bact, 0-2 epis. FAST
scan was negative for bleed. CT torso showed probably left
renal collecting system transitional cell ca causing partial
obstruction with complex fluid around the left kidney likely
representing fornix rupture. There was also focal transverse
colon wall thickening concerning for neoplasm with hypodense
liver lesions and cystic duct enhancing lesion concerning for
mets. Liver u/s showed normal GB and liver masses. Bcx x 2 and
Ucx sent. Patient was started on cipro 400mg IV and flagyl 500mg
IV initially, then broadened to ceftriaxone 1gm IV. He also
received pantoprazole 40mg IV. On transfer, VS: T 99.3, BP
106/56, P 59, RR 18, O2sat 100%RA.
.
On the floor, pt reports that abdominal pain is much improved
and minimal currently. He denies any early satiety or decreased
appetite. Prior to today, no fevers, chills, night sweats. He
has had occasional BRB on toilet paper and does describe
dark-colored stools but denies frank hematochezia otherwise.
Per son, weight loss of only [**4-7**] lbs in past 10 years. No
known colonoscopy in past.
Past Medical History:
"Low blood pressure" per pt
S/p unknown abdominal surgery (?colectomy) per son
Social History:
Widowed, lives alone. Retired chef. Originally from [**Country 5142**].
- Tobacco: H/o tobacco use x "many years," quit >20 years ago
per son
- Alcohol: Occasional, no h/o EtOH abuse per son.
- Illicits: Denies.
Family History:
No known h/o cancer.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: Minimal bibasilar rales, otherwise clear.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Soft, mild R paraumbilical tenderness w/o guarding or
rebound, non-distended, bowel sounds present
GU: Foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AAO x 3, CN II-XII intact, strength 5/5, sensation to LT
intact, no pronator drift, toes downgoing on Babinski.
Pertinent Results:
Admission labs:
[**2127-3-16**] 04:20PM NEUTS-90.9* LYMPHS-4.1* MONOS-4.8 EOS-0
BASOS-0.1
[**2127-3-16**] 04:20PM WBC-9.5 RBC-2.38*# HGB-5.9*# HCT-19.9*#
MCV-84 MCH-24.9*# MCHC-29.7*# RDW-14.6
[**2127-3-16**] 04:20PM GLUCOSE-133* UREA N-19 CREAT-1.1 SODIUM-140
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-22 ANION GAP-20
Tumor markers:
[**2127-3-16**] 04:20PM CEA-416* PSA-6.0* AFP-1.9
CT torso:
1. Urothelial thickening and enhancement within the left renal
collecting
system, concerning for transitional cell carcinoma, which
results in mild left
hydronephrosis. 9-mm left para-aortic lymph node is suspicious
for metastatic
involvement.
2. Complex left perinephric fluid collection demonstrates
progressive
enhancement, and may be secondary to forniceal rupture.
3. Multiple hepatic metastases.
4. Area of focal wall thickening and narrowing in the transverse
colon may be
due to peristalsis, but underlying neoplasm is not excluded.
Correlation with
colonoscopy is recommended.
5. Focal enhancement of the cystic duct, possibly due to
metastasis, but may
be inflammatory as well.
6. Severe emphysema with 3-mm right upper lobe nodule.
Brief Hospital Course:
86 yo man with no significant PMH other than unclear and remote
abdominal surgery p/w RUQ abdominal pain, found to have anemia
to Hct 19 and CT torso findings suggestive of metastatic disease
.
# Metastatic colon cancer: The patient had imaging findings
consistent with a primary colon or transitional renal cell
carcinoma with evidence of metastasis to the liver. He had a
significantly elevated CEA level. The gastrointestinology
service was consulted. Colonoscopy with biopsy revealed likely
adenocarcinoma. A family meeting was held to inform the patient
and his family of the diagnosis and treatment options. Oncology
and surgery consulting services provided more information about
what they could offer. Palliative care assisted with decision
making. Arrangements were made to follow up in oncology clinic
for likely initiation of capecitabine. _________
.
# Anemia:. He was transfused a total of 4 units of pRBC with an
appropriate increase in hematocrit. He remained hemodynamically
stable, and Hct did not fall again.
.
#Abdominal pain: Resolved soon after admission.
.
# Dynamic ST-depressions: The patient has no known history of
CAD. ST changes occurred in the setting of tachycardia secondary
to fever or abdominal pain with normalization following improved
rate control. Cardiac enzymes were trended and were normal. TTE
done later in the admission for surgical risk planning showed an
essentially normal heart.
.
# RUL nodule: 3mm nodule could represent metastatic disease but
nonspecific.
.
# COPD: Significant smoking history with CT chest findings
consistent with emphysema. O2 Sats ranged 88-92% on RA. He was
given nebulizers as needed.
OB
Medications on Admission:
none
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for hypoxia/sob.
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for hypoxia/sob.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) **]
Discharge Diagnosis:
primary: metastatic colon cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital because of abdominal pain. You were
found to have low blood counts. You received blood
transfusions. A CT showed that you have many lesions in your
liver. Colonoscopy showed that this is due to metastatic colon
cancer. You spoke with the oncologists and arranged to follow
up with them in clinic to begin chemotherapy.
No medications were added this hospitalization.
Followup Instructions:
Please follow up in oncology clinic and with your primary care
doctor:
|
[
"584.9",
"211.3",
"153.0",
"198.0",
"492.8",
"794.31",
"276.2",
"458.9",
"518.4",
"197.7",
"V66.7",
"560.89",
"285.1",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.25",
"45.42"
] |
icd9pcs
|
[
[
[]
]
] |
6661, 6744
|
4655, 6328
|
277, 302
|
6821, 6821
|
3482, 3482
|
7393, 7466
|
2859, 2882
|
6383, 6638
|
6765, 6800
|
6354, 6360
|
6971, 7370
|
2897, 3463
|
223, 239
|
330, 2508
|
3499, 4632
|
6836, 6947
|
2530, 2611
|
2627, 2843
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,827
| 151,461
|
37002
|
Discharge summary
|
report
|
Admission Date: [**2110-9-12**] Discharge Date: [**2110-9-17**]
Service: CARDIOTHORACIC
Allergies:
Benzodiazepines / Methylhydrocortisone
Attending:[**First Name3 (LF) 3948**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
[**2110-9-15**] flex bronch.
History of Present Illness:
Ms. [**Known lastname **] is an 85 female who presents for placement of a
Y-stent with stent trial. Patient presented to [**Hospital6 **] from [**Hospital **] rehab for respiratory failure. While at
[**Hospital6 2561**] she was transferred to the ICU and placed
on intermittent BIPAP for O2 saturations of ~70%.
Patient was recently admitted to [**Hospital 8**] hospital [**2110-7-18**] for
hip fracture and while admitted was intubated for respiratory
failure secondary to collapse of the right lung thought to be
due
to pneumonia. Patient has since been discharged and readmitted
to the the hospital due to shortness of breath and respiratory
distress secondary to TBM.
This admission she is to have a Y-stent placed to perform a
trial
to determine if placement will improve her respiratory
Past Medical History:
She has right hip fracture, right upper lung collapse from mucus
plugging as mentioned above, COPD, diabetes mellitus type 2,
congestive heart failure, history of recurrent angina, chest
pain, diastolic dysfunction, hypertension, hyperlipidemia, she
sustained a stroke in [**2081**] with residual left lower extremity
weakness, she has intermittent vertigo and anxiety.
Social History:
The patient has a healthcare proxy, which is her granddaughter,
[**Name (NI) 553**], which makes all her healthcare decisions. Her phone
number is [**Telephone/Fax (1) 83438**]. The patient currently transfers from
the rehab center, but otherwise, she lives with
her daughter, [**Name (NI) **]. [**Name2 (NI) **] code status is not discussed in full,
but she is currently full code for now.
Family History:
Noncontribitory
Pertinent Results:
[**2110-9-15**] 07:00AM BLOOD WBC-7.6 RBC-3.34* Hgb-9.1* Hct-29.7*
MCV-89 MCH-27.3 MCHC-30.8* RDW-15.9* Plt Ct-259
[**2110-9-14**] 07:55AM BLOOD WBC-7.1 RBC-3.26* Hgb-9.1* Hct-29.4*
MCV-90 MCH-27.9 MCHC-31.0 RDW-16.6* Plt Ct-250
[**2110-9-13**] 02:00AM BLOOD WBC-5.9 RBC-3.02* Hgb-8.4* Hct-26.8*
MCV-89 MCH-27.7 MCHC-31.2 RDW-16.4* Plt Ct-285
[**2110-9-12**] 08:39PM BLOOD WBC-6.3 RBC-2.99* Hgb-8.7* Hct-26.3*
MCV-88 MCH-29.2 MCHC-33.1 RDW-16.2* Plt Ct-295
[**2110-9-15**] 07:00AM BLOOD Glucose-146* UreaN-15 Creat-0.6 Na-141
K-4.3 Cl-99 HCO3-34* AnGap-12
[**2110-9-14**] 07:55AM BLOOD Glucose-182* UreaN-16 Creat-0.6 Na-140
K-4.4 Cl-99 HCO3-36* AnGap-9
[**2110-9-13**] 02:00AM BLOOD Glucose-124* UreaN-23* Creat-0.6 Na-140
K-4.8 Cl-97 HCO3-37* AnGap-11
[**2110-9-12**] 08:39PM BLOOD Glucose-99 UreaN-24* Creat-0.6 Na-140
K-4.8 Cl-98 HCO3-38* AnGap-9
[**2110-9-15**] 07:00AM BLOOD Calcium-9.8 Phos-3.6 Mg-1.7
[**2110-9-14**] 07:55AM BLOOD Calcium-9.6 Phos-3.7 Mg-1.7
[**2110-9-13**] 02:00AM BLOOD Calcium-10.0 Phos-3.8 Mg-2.0
Brief Hospital Course:
Ms. [**Known lastname **] is an 85 female who presents for placement of a
Y-stent with stent trial. Patient presented to [**Hospital3 60734**] from [**Hospital **] rehab for respiratory failure. While at
[**Hospital6 2561**] she was transferred to the ICU and placed
on intermittent BIPAP for O2 saturations of ~70%.
Patient was recently admitted to [**Hospital 8**] hospital [**2110-7-18**] for
hip fracture and while admitted was intubated for respiratory
failure secondary to collapse of the right lung thought to be
due to pneumonia. Patient has since been discharged and
readmitted to the the hospital due to shortness of breath and
respiratory
distress secondary to TBM.
This admission she is to have a Y-stent placed to perform a
trial to determine if placement will improve her respiratory
status. Admitted to [**Hospital Ward Name 121**] 9-some confussion overnight with drop
in O2 sats-given nebs NRB and haldol with good response.
[**2110-9-15**] patient taken for Flex bronch distal malasia with thick
secretions L>R. Unable to stent. Plan to treat
Medically-Mucomyst/albeuterol/spiriva/atrovent.
CT-Airways:IMPRESSION: No significant tracheobronchial
collapsibility or evidence of malacia. Small right tracheal
diverticulum with mild bronchiectasis and left lower
lobe mucous plugging.Complete collapse of the right middle lobe
and near complete collapse of the left lower lobe and lingula
with a moderately large left pleural effusion. Pleural nodule in
the right lower lobe with pleural thickening in the
right lung base may be a sequela of recent inflammation or
infection. Severe thoracic kyphosis. No definite air trapping
Medications on Admission:
ALBUTEROL SULFATE 2.5 mg/3 mL (0.083 %) Solution for
Nebulization
- four times a day
ATORVASTATIN [LIPITOR] - 20 mg by mouth once a day
INSULIN GLARGINE [LANTUS] - 100 unit/mL Cartridge - 6 units once
a day sq
IPRATROPIUM BROMIDE 0.2 mg/mL(0.02 %) Solution - four times a
dy
LACTULOSE - Dosage uncertain
LISINOPRIL - 2.5 mg Tablet - Tablet(s) by mouth once a day
MECLIZINE - Dosage uncertain
METFORMIN - 1,000 mg Tablet - Tablet(s) by mouth twice a day 08
am and 1700 pm
METOPROLOL SUCCINATE - 25 mg Tablet Sustained Release 24 hr -
Tablet(s) by mouth once a day 37.5 mg
MIRTAZAPINE - 15 mg Tablet - Tablet(s) by mouth at bedtime 7.5
mg
NITROGLYCERIN - Dosage uncertain
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - Capsule(s)
by
mouth once a day
POTASSIUM CHLORIDE [K-DUR] - 20 mEq Tab Sust.Rel.
Particle/Crystal - Tab(s) by mouth once a day 40 meq
Medications - OTC
ASPIRIN - 81 mg Tablet - Tablet(s) by mouth once a day
CALCIUM CARBONATE-VITAMIN D2 [LIQUID CALCIUM 600-VITAMIN D] - -
1,200 mg-400 unit Capsule -
Capsule(s) by mouth
CYANOCOBALAMIN - 1,000 mcg
Tablet Sustained Release - Tablet(s) by mouth once a day
DOCUSATE SODIUM - 100 mg Capsule - Capsule(s) by mouth once a
day
GLYCERIN (ADULT) - Dosage uncertain
GUAIFENESIN - 400 mg Tablet - Tablet(s) by mouth twice a day
1200
mg
MULTIVITAMIN,TX-MINERALS [MULTI-VITAMIN HP/MINERALS] -
(Prescribed by Other Provider) - Dosage uncertain
Discharge Medications:
1. Insulin sliding scale
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular Regular Regular Regular
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-60 mg/dL 1 amp D50 1 amp D50 1 amp D50 1 amp D50
61-150 mg/dL 0 Units 0 Units 0 Units 0 Units
151-200 mg/dL 2 Units 2 Units 2 Units 2 Units
201-250 mg/dL 4 Units 4 Units 4 Units 4 Units
251-300 mg/dL 6 Units 6 Units 6 Units 6 Units
301-350 mg/dL 8 Units 8 Units 8 Units 8 Units
351-400 mg/dL 10 Units 10 Units 10 Units 10 Units
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Lisinopril 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
8. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for Pain.
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB, wheezing.
13. Acetylcysteine 20 % (200 mg/mL) Solution Sig: 1-2 MLs
Miscellaneous TID (3 times a day).
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation TID (3 times a day).
15. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 15967**] Facility - [**Hospital1 8**]
Discharge Diagnosis:
COPD,diabetes mellitus type 2, congestive heart failure, history
of
recurrent angina, chest pain, diastolic dysfunction,
hypertension, hyperlipidemia, she sustained a stroke in [**2081**]
with residual left lower extremity weakness, she has
intermittent vertigo and anxiety.
Discharge Condition:
Stable
Discharge Instructions:
Please call Dr. [**Last Name (STitle) 83439**] with any questions or concerns
[**Telephone/Fax (1) 7769**].
Call with fever greeater than 101.5
Call with increased cough, shortness of breath or secretions.
Followup Instructions:
Please call Dr. [**Last Name (STitle) **] office for a follow up appointment with
in next week [**Telephone/Fax (1) 7769**].
Call your primary care physician for [**Name Initial (PRE) **] follow up appointment
with in the next week or two.
Completed by:[**2110-9-17**]
|
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icd9cm
|
[
[
[]
]
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[
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] |
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[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,258
| 168,110
|
39595
|
Discharge summary
|
report
|
Admission Date: [**2160-7-16**] Discharge Date: [**2160-7-29**]
Date of Birth: [**2081-9-23**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 16115**]
Chief Complaint:
hyponatremia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
78yo woman whose PMH includes DMII, HTN, RA, and recent
diagnosis of pancreatic cancer with liver metastases, s/p ERCP
with biliary stent on [**7-10**], p/w fatigue, near fall, found to
have hyponatremia to 117.
Home has [**4-20**] stairs in front of building that she must go up and
down for ADLs. Today while attempting with help of husband and
son [**Name (NI) **], legs very wobbly and weak while descending the
stairs. On way back up the stairs, legs buckled from underneath
her. Husband and [**Name2 (NI) **] able to hold her up and get her to
elevator and to her apartment, then to chair. Once in chair,
felt better. No LOC, no head strike, no aura, no change in
behavior or focal neurologic findings reported. Period of
weakness lasted ~10 minutes. Called EMS, to ED.
In the ED, initial VS were:
97.0 90 118/70 18 99%
Labs were notable for Na of 117. UA notable for 15 WBC, few
bacteria, large leuks. EKG performed, unrevealing for acute
event. Neurological exam was performed which was fully intact
except for foot drop on the left (chronic).
Received 1.25 L of NS. Na bumped to 120.
On transfer to ICU, vitals were: 98 136/67 p77 sat 100 ra
In the [**Hospital Unit Name 153**], patient relays similar history. Says has had poor
appetite and fatigue over past month, worse in the last week.
Also has had a cough recently, productive occasionally of clear
sputum, which her son thinks is [**1-17**] PND. But denies numbness,
paresthesias, fevers/chills, chest pain, palpitations, dyspnea,
chest pressure, abdominal pain, diarrhea, constipation, bloody
stools, dysuria, polyuria, urinary frequency, or incontinence.
Past Medical History:
?????? Pancreatic adenocarcinoma dx [**6-/2160**]
?????? HISTORY OF BASAL CELL CARCINOMA
?????? ARTHRITIS - RHEUMATOID
?????? HYPERTENSION - ESSENTIAL
?????? FOOT DROP
?????? THYROID NODULE
?????? Toxic Multinodul Goiter
?????? Type 2 Diabetes Mellitus
?????? Fatty Liver/NASH
?????? Urinary Tract Anomaly
?????? Osteopenia
?????? Hypercholesterolemia
?????? Colonic adenoma
?????? Constipation, chronic
Social History:
Former account manager at [**Company 87377**]. Lives at home with her husband,
previously independent with ADLs. Son, [**Name (NI) **], is her healthcare
proxy and very involved in her care. Former smoker but quit 10
years ago. Denies alcohol use or IVDU.
Family History:
Her daughter has [**Name2 (NI) 499**] cancer and mother had brain tumor.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, 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, no tenderness to palpation, no rebound or guarding
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.
Discharge exam:
T 98.1 105/67 HR 87 RR 20 98% RA
General: Alert, oriented, pleasant, no acute distress
HEENT: Sclera anicteric, 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, no tenderness to palpation, no rebound or guarding
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.
Pertinent Results:
[**2160-7-16**] 06:50PM BLOOD Glucose-208* UreaN-7 Creat-0.4 Na-117*
K-3.8 Cl-84* HCO3-23 AnGap-14
[**2160-7-16**] 09:35PM BLOOD Glucose-124* UreaN-6 Creat-0.5 Na-120*
K-3.9 Cl-89* HCO3-23 AnGap-12
[**2160-7-17**] 12:23AM BLOOD Glucose-100 UreaN-5* Creat-0.5 Na-125*
K-3.4 Cl-90* HCO3-24 AnGap-14
[**2160-7-16**] 06:50PM BLOOD WBC-11.8* RBC-3.68* Hgb-11.4* Hct-34.0*
MCV-92 MCH-31.0 MCHC-33.6 RDW-13.8 Plt Ct-274
[**2160-7-17**] 12:23AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.4*
[**2160-7-16**] 09:35PM BLOOD Osmolal-254*
.
[**2160-7-18**] RUQ US
IMPRESSION:
1. Appropriately positioned CBD stent. No intrahepatic bile
duct dilation.
2. Unchanged 8 mm dilated pancreatic duct.
3. Unchanged numerous hepatic masses.
.
[**2160-7-18**] CXR
CONCLUSION:
Mild left lower lobe opacities have improved since the morning.
This is
mostly due to atelectasis or aspiration. There is no new
consolidation.
CT torso:
1. Interval progression of hepatic metastases, more numerous
and confluent
since [**2160-6-20**]. Continued occlusion of superior mesenteric
vein.
2. New moderate intra-abdominal ascites and increase in pelvic
ascites. New
small bilateral pleural effusions.
3. Right colonic edema, could relate to reactive changes in the
setting of
new ascites, although colitis cannot be entirely excluded.
4. Slight increase in size of the known infiltrative pancreatic
head/uncinate
process mass with continued encasement of the superior
mesenteric artery
resulting in narrowing but no evidence of occlusion. Unchanged
mesenteric
lymphadenopathy.
5. New nodular density in left lower lobe may relate to
subsegmental
atelectasis given new bilateral pleural effusions. Attention at
followup
imaging.
6. Equivocal filling defect in a left lower lobe pulmonary
artery,
inadequately evaluated on this examination which is not targeted
for
evaluation of the pulmonary vasculature. A tiny pulmonary
embolus cannot be
excluded. Further evaluation could be obtained with repeat
chest CTA if
clinically indicated.
CXR [**2160-7-26**]:
FINDINGS: The PICC line projects over the right atrium and
should be pulled
back 1-2 cm to be in the SVC- done.
Brief Hospital Course:
78yo previously functional woman with DMII, HTN, RA, recently
diagnosed with pancreatic ca with liver mets, last admitted
[**Date range (1) 20941**] for ERCP with stent placement to relieve N/V come in
this admission for poor po intake and weakness, found to have a
Na=117 and unexplained leukocytosis.
# Hypovolemic hyponatremia:
The etiology of the patients hyponatremia was likely due to
nause and vomiting and poor po intake. The patient presented
with a serum sodium of 117. She had no neurologic symptoms. She
was given 1.25L normal saline in the ED and her sodium rose to
120. She was admitted to the MICU where PO intake was encouraged
and supplemented with IVF. On the morning of [**7-17**] her serum
sodium was 127, so IVF were stopped. Later that morning it was
122, so 500cc NS were given. She remained without neurologic
symptoms but remained with decreased po intake and intermittent
N/V. She continued to receive intermittent IV fluids throughout
her hospitalization. A PICC was placed prior to discharge to
allow outpatient IV fluids as well. Given that she had a normal
mental status and was without pain or discomfort it was felt
that this may allow more quality time with her family. The
patient and her family were made aware of the potential risks,
including infection and clot.
# Mild hypothyroidism in setting of multinodular goiter s/p I
131
TSH was found to be elevated and her free T4 was at the lower
limits of normal. The patient had been on synthorid in past for
a short period of time. Endocrine was consulted and they rec'd
synthroid 50, and outpatient Endo at [**Location (un) 2274**] to be scheduled while
patient is at [**Hospital3 13990**].
# Anorexia with intermittent N/V: Persisted despite recent
biliary stent placement. RUQ US showed no significant change
from prior, and stent confirmed to be in proper position. Along
with elevated transaminases, ALP, and total bilirubin, symptoms
are attributed to significant tumor burden.
# Pancreatic ca with liver metastases: Pt was to start
chemotherapy on [**7-18**] but she is too weak and deconditioned, with
intermittent N/V as above. Her [**Location (un) 2274**] oncologist Dr [**Last Name (STitle) **] [**Name (STitle) **]
was notified and agreed to hold off on chemotherapy. She is
being sent home on a bridge to hospice. CT torso final read
showed equivocal left lower lobe opacity in branch of pulmonary
artery, could not rule out PE. Clinical picture not consistent
with PE, and after discussion, did not pursue additional
imaging. Patient has follow up with her oncologist, Dr. [**First Name (STitle) **], on
[**2160-8-7**] at 1 p.m.
# Leukocytosis with cough: Pt developed cough, mostly
nonproductive, prior to her hospitalization for ERCP. CXR was
repeated after hydration and raised possibility of LLL
infiltrate, so she was started empirically on ceftriaxone &
azithromycin on [**7-18**]. Her antibiotics coverage was narrowed to
augmentin/azithromycin and then discontinued when repeat CXR
showed no infiltrate. The ERCP team was informed of her elevated
t. bili on [**2160-7-20**] and they elected to follow it and did not feel
as though another stent was indicated at this time. Repeat
bilirubin, UA, and C.difficile were unrevealing. Symptoms
resolved with time.
Goals of Care: The patient was made DNR/DNI and will be
discharged to [**Hospital3 13990**] Health Care Center for continued
symptomatic care.
Medications on Admission:
1. Atenolol 50 mg PO DAILY
hold for SBP < 100, HR < 55
2. Bacitracin Ointment 1 Appl TP [**Hospital1 **]
To right side of back of head.
3. Calcium Carbonate 500 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. GlipiZIDE 5 mg PO QPM
6. GlipiZIDE 5 mg PO QAM:PRN FS > 200
Takes this in the morning only if FS is elevated.
7. Omeprazole 20 mg PO DAILY
8. Ondansetron 4 mg PO Q8H:PRN nausea
9. PredniSONE 5 mg PO DAILY
10. Prochlorperazine 10 mg PO Q6H:PRN nausea
11. Senna 1 TAB PO BID:PRN constipation
Discharge Medications:
1. Omeprazole 20 mg PO DAILY
2. Ondansetron 4 mg PO Q8H:PRN NAUSEA
3. PredniSONE 5 mg PO DAILY
4. Prochlorperazine 10 mg PO Q6H:PRN NAUSEA
5. Senna 1 TAB PO BID:PRN CONSTIPATION
6. Cepacol (Menthol) 1 LOZ PO PRN cough
7. Docusate Sodium 100 mg PO BID
8. Guaifenesin-CODEINE Phosphate [**4-24**] mL PO HS:PRN cough
9. Levothyroxine Sodium 50 mcg PO DAILY
10. 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.
11. Metoprolol Succinate XL 50 mg PO DAILY
Hold for HR<60, SBP<100
12. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
13. GlipiZIDE 5 mg PO DAILY
TAKE MORNING DOSE ONLY IF GLUCOSE >200
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 13990**] Health Care Center - [**Location (un) 5110**]
Discharge Diagnosis:
# hypovolemic hyponatremia
# weakness with recurrent falls
Secondary diagnoses:
# pancreatic ca with liver metastases
# s/p ERCP with biliary stent [**2160-7-10**]
# DM type II controlled without complications
# hypertension
# rheumatoid arthritis
# chronic left foot drop
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 [**Hospital1 18**] with complaints of weakness and
falls. You were found to have a low sodium which was treated
with IV fluids and supportive care. As part of your laboratory
work up your were found to have low thyroid hormone. You were
started on low dose thyroid hormone supplements. You also
received a few days of antibiotics while we were investigating a
possible pneumonia, but these were stopped when a repeat chest
X-[**Hospital1 **] showed no evidence of pneumonia. Your sodium has remained
somewhat low, and it will be important for you to continue to
keep up with drinking fluids as an outpatient. You may need
occasional treatments with IV fluids as well, for which a PICC
line was placed.
Followup Instructions:
Name: [**Hospital1 **], [**Name8 (MD) **] MD
Specialty: Hematology/Oncology
When: [**8-7**] at a 1 p.m.
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3468**]
|
[
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
10911, 11005
|
6215, 9637
|
318, 325
|
11323, 11323
|
4042, 6192
|
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|
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|
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|
3392, 4023
|
266, 280
|
353, 1985
|
11338, 11482
|
2007, 2413
|
2429, 2688
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,380
| 136,515
|
52873
|
Discharge summary
|
report
|
Admission Date: [**2126-6-2**] Discharge Date: [**2126-6-9**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name8 (NamePattern2) 812**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
85 yo F with a past medical history of afib, avr/mvr, SSS s/p
pm, CHF presents with altered mental status. History obtained
from family as patient is altered at the time of his exam.
Patient lives in an attached apartment with her son [**Name (NI) **], and
has reportedly been more fatigued over the last 2 days.
Yesterday she was found going to sleep at 4pm, which is
apparently unlike her. This morning, she was found ironing while
in a seated position, which is apparently unlike her because she
generally enjoys ironing and always stands up. Throughout this
time, patient had been interactive, lucid and with baseline
mental status. She was reporting some mild dyspnea, and a horase
voice, but denied dysuria, chest pain, palpitations, and
syncope. Family reports poor po intake over the last several
weeks, and that patient has been overall discouraged with need
for two hospitalizations in the last 6 weeks.
.
In the ER, patient was found to have oxygen saturation of 68% at
triage and was brought back to the ED core. She was placed on
Bipap and was initially agressive, but became progressively more
somnolent. CXR, per ED interpretation, was concerning for right
sided consolidation. EKG was reportedly at baseline. Family
decided to make patient DNR/I, with decision to treat with
antibiotics, but without central lines, pressors or invasive
procedures. Patient received 1 L NS, Vancomycin 1 g IV x1, Zosyn
4.5 g IV x1, and Vitamin K 10 mg IVx1 for an elevated INR at 12.
On transfer, VS were 113/47, 48, 100% on Bipap 12/5 with an FiO2
100%.
.
In the ICU, patient is sedated and only grimaces to verbal and
mechanical stimuli.
Past Medical History:
- Mechanical MVR, AVR, and tricuspid repair with [**Last Name (un) 3843**] ring
in [**2109**]
- Rheumatic heart disease
- CHF LVEF = 35-40 %
- Moderate-to-severe tricuspid regurgitation.
- Chronic atrial fibrillation
- Sick sinus syndrome s/p pacemaker [**2107**]
- Hypertension.
- Recurrent urinary tract infections
- Status post total abdominal hysterectomy, right inguinal
and femoral hernia repair.
- COPD - FEV1 in [**2109**] 0.87 38% predicted, no prior ABGs in OMR
- Long term short term memory loss, per family, going back to
[**2105**]
Social History:
(per OMR)
- Tobacco: Denies
- etOH: Social only
- Illicits: Denies
Family History:
Multiple relatives with rheumatic heart disease
Physical Exam:
General: wearing bipap, somnolent with minimal response to
sternal rub
HEENT: Sclera anicteric, dry MM, oropharynx clear, Pupils
symmetric and reactive to light
Neck: supple, JVP 8 cm
Lungs: scattered rhonchi right base, no crackles or wheezing
CV: Regular rate and rhythm, normal S1 + S2, 4/6 SEM
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place with clear urine
Skin: + tenting
Ext: chronic venous stasis changes bilaterally, 2+ LE edema to
knees
Pertinent Results:
Admission Labs:
[**2126-6-2**] 04:10PM BLOOD WBC-10.6# RBC-4.50 Hgb-13.5 Hct-43.4#
MCV-96 MCH-30.0 MCHC-31.1 RDW-15.3 Plt Ct-159
[**2126-6-2**] 04:10PM BLOOD Neuts-84.6* Lymphs-11.0* Monos-3.6
Eos-0.2 Baso-0.7
[**2126-6-2**] 04:10PM BLOOD PT-97.0* PTT-35.8* INR(PT)-12.0*
[**2126-6-2**] 04:10PM BLOOD Glucose-156* UreaN-50* Creat-1.8* Na-144
K-5.4* Cl-103 HCO3-29 AnGap-17
[**2126-6-2**] 04:10PM BLOOD ALT-21 AST-35 LD(LDH)-410* AlkPhos-62
TotBili-0.6
[**2126-6-2**] 04:10PM BLOOD proBNP-[**Numeric Identifier 109030**]*
[**2126-6-2**] 04:10PM BLOOD Albumin-4.5
[**2126-6-2**] 04:10PM BLOOD Digoxin-1.2
[**2126-6-2**] 05:02PM BLOOD Type-ART Tidal V-270 FiO2-100 pO2-360*
pCO2-85* pH-7.19* calTCO2-34* Base XS-1 AADO2-284 REQ O2-53
Intubat-NOT INTUBA
[**2126-6-2**] 04:14PM BLOOD Lactate-2.1*
U/A:
[**2126-6-2**] 04:20PM URINE Color-Amber Appear-Hazy Sp [**Last Name (un) **]-1.020
[**2126-6-2**] 04:20PM URINE Blood-MOD Nitrite-NEG Protein-150
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-4* pH-6.5 Leuks-TR
[**2126-6-2**] 04:20PM URINE RBC-[**5-16**]* WBC-[**5-16**]* Bacteri-MANY
Yeast-NONE Epi-[**5-16**] TransE-[**5-16**]
[**2126-6-2**] 04:20PM URINE CastHy-0-2
[**2126-6-2**] 04:20PM URINE AmorphX-MOD
Cardiac Enzymes:
[**2126-6-3**] 03:28AM BLOOD CK(CPK)-40
[**2126-6-2**] 04:10PM BLOOD cTropnT-0.07*
[**2126-6-3**] 03:28AM BLOOD CK-MB-4 cTropnT-0.05*
Radiology:
CXR ([**2126-6-2**]) - IMPRESSION:
1. Increased regions of consolidation in the right lung, which
may indicate infection. Followup chest radiograph after
appropriate therapy is indicated to exclude underlying pulmonary
mass.
2. Stable severe cardiomegaly.
CT Head ([**2126-6-2**]) - IMPRESSION:
1. No acute intracranial abnormalities. Specifically, no acute
intracranial hemorrhage.
2. Mild chronic microvascular ischemic disease.
Echo ([**2126-6-3**]) - The left atrium is moderately dilated. The
right atrium is markedly dilated. The right atrial pressure is
indeterminate. Left ventricular wall thicknesses and cavity size
are normal. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is low normal (LVEF
50-55%). Right ventricular chamber size and free wall motion are
normal. [Intrinsic right ventricular systolic function is likely
more depressed given the severity of tricuspid regurgitation.] A
mechanical aortic valve prosthesis is present. The aortic valve
prosthesis appears well seated, with normal disc motion and
transvalvular gradients. Trace aortic regurgitation is seen.
[The amount of regurgitation present is normal for this
prosthetic aortic valve.] A mechanical mitral valve prosthesis
is present. The mitral prosthesis appears well seated, with
normal disc motion and transvalvular gradients. No mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal functioning mitral and aortic valve
mechanical prostheses. Moderate pulmonary artery systolic
hypertension. Moderate tricuspid regurgitation. Compared with
the prior study (images reviewed) of [**2124-2-23**], left ventricular
systolic function has improved and the estimated pulmonary
artery systolic pressure is now lower.
.
Portable CXR [**2126-6-7**]:
Compared with earlier the same day, there ay be mild increase in
the degree of vascular plethora. Otherwise, I doubt significant
interval change. Again seen is bibasilar collapse/consolidation.
Pacemaker with tip in enlarged RV and prosthetic heart valve
noted.
.
ECG [**2126-6-7**]:
Atrial fibrillation. Left axis deviation is probably due to left
anterior
fascicular block but consider also possible prior inferior
myocardial
infarction. Probable prior anterior wall myocardial infarction.
ST-T wave
abnormalities are non-specific. Clinical correlation is
suggested. Since the previous tracing of [**2126-6-2**] axis appears
further leftward and delayed R wave progression is more
prominent.
Brief Hospital Course:
85 yo F with a past medical history of afib, avr/mvr, SSS s/p
pm, CHF who presented with fatigue, was found to have hypoxia to
68% at triage, and progressively worsening mental status in the
ER.
.
#. Pneumonia: Patient with R infiltrate on CXR with relative
leukocytosis and recent AMS which may secondary to
infection/PNA. Initially treated broadly with vanco/zosyn and
then narrowed to CAP treatment with CTX/Azithro. She was placed
on BiPAP, given her hypercapnia and poor respiratory status.
However, ultimately BiPAP was stopped [**1-8**] facial skin breakdown.
Given the patient's poor clinical appearance at that time, her
antibiotics were broadened back to HCAP and aspiration PNA
coverage, with vancomycin, cefepime, and cipro. Ultimately, the
patient's clinical status improved, and she was weaned down to
nasal cannula. She was called out to the floor on [**2126-6-5**] and
initially showed clinical improvement in terms of oxygen
requirements. Was kept at goal oxygen saturation of 88-92% in
setting of chronic CO2 retaining. She remained at goal with
1-2L oxygen via nasal cannula until night of [**2126-6-7**] when she
was found to be tachypneic with RR 50s. Labs revealed
respiratory acidosis and metabolic alkalosis with HCO3 41; ABG
pH 7.41, pO2 54, pCO2 65. We were preparing for transfer to ICU
for re-initiation of bipap but due to lack of ICU beds, she was
kept on floor with nasal cannula increased to 6L O2. Patient's
family was called and upon discussion with palliative care
consult, decided to change code status from DNI/DNR to CMO.
After discussion with family, all antibiotics were discontinued.
Patient was kept comfortable with morphine, scopolamine, and
lorazepam. She passed on [**2126-6-9**] with her family at the
bedside.
.
#. Altered mental status: Unclear precipitant, but likely
influenced by hypercarbia and pneumonia. [**Month (only) 116**] also have had some
confusion from mild uremia and UTI (although UA dirty). Given
elevated INR, head CT was done which was negative for acute
bleed. ACS seemed less likely as EKG was at baseline, but
troponin was mildly elevated in the setting of renal
dysfunction. Pneumonia was treated as above, but mental status
continued to wax/wane. Mental status transiently improved
somewhat after patient received trazodone to help sleep but
thereafter worsened upon onset of respiratory distress (see
above).
.
#. Respiratory acidosis: Likely acute on chronic respiratory
acidosis, given delta pH inappropriately small for change in
CO2. Unclear if altered mental status was causing retention of
CO2, or if altered mental status was created by [**Name Initial (PRE) 109031**].
Patient had history of low FEV1, but was a nonsmoker and had no
spirometry for the last 15 years. Son, however, reported long
term second hand smoke exposure so may have had some component
of obstruction based on prior smoke exposure. No prior ABG was
available for comparison but we started albuterol and
ipratropium nebs for possible obstruction. Pneumonia was treated
as above but ultimately patient passed due to worsening
respiratory distress.
.
#. Goals of care: On presentation, family aware that patient had
acute on subacute decline, and understood that patient would not
want artificial life support for extended period of time.
Patient had previously expressed desire to be DNR/I. Family
opted to treat all reversible processes, but did not want CVL,
mechanical ventilation, or invasive procedures. The patient's
pneumonia was treated as above. However, clinical status
deteriorated and upon discussion with family and palliative care
consult, family decided to make patient comfort measures only.
All antibiotics, anticoagulation, labs, and vitals were stopped
at that time.
.
# Supratherapeutic INR: Patient had been placed on coumadin for
atrial fibrillation. On admission, INR was elevated to 12, may
be secondary to poor nutrtion or medicine malcompliance.
Received 10mg IV vitamin K in the ED and subsequently INR
decreased to 2.2 which was subtherapeutic for her AVR and MVR.
She was then started on heparin drip for bridging and coumadin
was re-started. When patient was made CMO, all anticoagulation
was discontinued.
.
# CKD: Since [**2126-1-7**], baseline Cr 1.4 - 2. Cr 1.8 on admission,
likely secondary to prerenal etiology given dry appearance. Cr
improved to 1.0 with IV hydration.
.
# UTI: Patient had history of multiple UTIs. UA was positive
with 6-10 WBC, many bacteria, and trace leuks (although it did
have epithelials). Urine culture grew 10,000-100,000
ORGANISMS/ML of group B strep. Patient's broad spectrum
antibiotic regimen for pneumonia would have also covered urinary
pathogens.
.
# CHF: Patient had been off lasix for several weeks. Lasix was
initially held during hospital course because she appeared dry
on exam and had history of minimal po intake. BNP 25,000 but
there were no priors for comparison. EKG unchanged from prior.
Repeat TTE showed moderate TR and moderate pulmonary HTN
improved from prior. On [**2126-6-6**] patient showed increasing
tachypnea and had crackles on exam; she improved with 20mg IV
lasix.
.
#. Afib: Patient had been rate controlled on digoxin, which was
held during hospital course. She was anticoagulated as above.
On [**2126-6-7**], telemetry showed several runs of V-tach (the longest
run being 18 beats) but HR remained in the 80s and no
intervention was pursued at the time.
.
# SSS: No acute issues. Patient had pacemaker.
Medications on Admission:
1. Digoxin 125 mcg daily
3. Coumadin 3 mg daily
4. Furosemide 40 mg daily [ON HOLD since may]
5. Moexepil 15 mg daily [ON HOLD since may]
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **] MD, DMD [**MD Number(2) 821**]
Completed by:[**2126-7-18**]
|
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"424.2",
"416.8",
"507.0",
"790.92",
"428.22",
"287.5",
"348.30",
"427.1",
"585.9",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
13097, 13106
|
7401, 9178
|
291, 297
|
13157, 13166
|
3254, 3254
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13222, 13390
|
2634, 2684
|
13065, 13074
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13127, 13136
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12902, 13042
|
13190, 13199
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2699, 3235
|
4476, 7378
|
230, 253
|
325, 1965
|
3270, 4459
|
9193, 12876
|
1987, 2534
|
2550, 2618
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,872
| 119,357
|
44928
|
Discharge summary
|
report
|
Admission Date: [**2136-5-14**] Discharge Date: [**2136-5-28**]
Date of Birth: [**2058-6-25**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
PICC/Midline placement
History of Present Illness:
77 year old female with hx of ILD, depression for many years
presents with shortness of breath and hypoxia at pulmonary
clinic. Patient states she has been SOB since an argument with
her friend on [**5-12**]. She did endorse feeling "more sick" over the
last 7 days with increased SOB, DOE, cough, and white sputum
production. Denies F/C, chest pain, nausea, vomiting, or
diarrhea. In [**Hospital **] clinic Sat 85% in triage, 68% in the exam room
-> 97% on 4L n.c. (sat was 98% at the last clinic visit in
7/[**2135**]). No wheezing.
.
In the ED, initial VS were: 100.2 105 125/75 28 100
Patient was given levofloxacin, Hypoxic on RA but came up to 98%
with 3L O2
Vitals on transfer were 100.2 94 120/99 20 100% on 3L.
.
Review of systems:
(+) Per HPI - also notable for dark stools in recent past (~
months)
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied chest pain or tightness, palpitations. Denied
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias.
Past Medical History:
- Hypertension.
- Diabetes.
- Arthritis-pain in all joints.
- Carpal tunnel syndrome.
- Depression and anxiety-apparently since [**2086**].
- Interestitial lung disease diagnosed 7/[**2135**].
Social History:
Currently works at a day care occasionally. She has
granddaughter in [**Name (NI) 86**] and 2 daughters in [**Name (NI) 6482**] (cannot
recall phone #s). Lives by herself in [**Hospital3 **]. Denies
[**Male First Name (un) 1554**].
Family History:
Mother died age 24 from apparent poisoning, father died at 90s
of old age
Physical Exam:
Vitals: T: 99.6 BP: 122/70 P: 102 R: 22 O2: 93% 3L
General: Alert, oriented x 3, but forgetful of medications and
some daily events, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Diffuse fine crackles more prominent at bases.
CV: tachy, reg rhythm, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission labs:
[**2136-5-14**] 07:00PM BLOOD WBC-6.4 RBC-4.54 Hgb-10.5* Hct-34.5*
MCV-76* MCH-23.0* MCHC-30.3* RDW-12.8 Plt Ct-331#
[**2136-5-14**] 07:00PM BLOOD Neuts-76.3* Lymphs-16.3* Monos-4.8
Eos-2.2 Baso-0.3
[**2136-5-14**] 07:00PM BLOOD Glucose-103* UreaN-11 Creat-0.7 Na-139
K-4.3 Cl-99 HCO3-31 AnGap-13
[**2136-5-14**] 07:00PM BLOOD CK(CPK)-74
[**2136-5-14**] 07:00PM BLOOD CK-MB-NotDone proBNP-347
[**2136-5-14**] 07:00PM BLOOD cTropnT-<0.01
[**2136-5-14**] 07:00PM BLOOD Iron-15*
[**2136-5-14**] 07:00PM BLOOD calTIBC-174* Ferritn-609* TRF-134*
Serologies:
[**2136-5-20**] 05:55AM BLOOD ANCA-PND
[**2136-5-20**] 05:55AM BLOOD [**Doctor First Name **]-PND
[**2136-5-20**] 05:55AM BLOOD RheuFac-PND
[**2136-5-20**] 05:55AM BLOOD HIV Ab-PND
[**2136-5-20**] 05:55AM BLOOD ANGIOTENSIN 1 - CONVERTING [**Last Name (un) **]-PND
[**2136-5-20**] 05:55AM BLOOD ANTI-JO1 ANTIBODY-PND
[**2136-5-20**] 05:55AM BLOOD RNP ANTIBODY-PND
[**2136-5-20**] 05:55AM BLOOD RO & [**Name Prefix (Prefixes) **]-[**Last Name (Prefixes) 21195**]
[**2136-5-20**] 05:55AM BLOOD SCLERODERMA ANTIBODY-PND
[**2136-5-20**] 05:55AM BLOOD SM ANTIBODY-PND
STUDIES:
[**5-14**] ECG: Sinus tachycardia. Left axis deviation. Possible left
ventricular hypertrophy. ST-T wave abnormalities. No previous
tracing available for comparison.
.
[**5-14**] CXR: Interval progression of interstitial lung disease.
Limited
evaluation for superimposed pneumonia.
.
[**5-17**] CTA:
1. Baseline pulmonary fibrosis with likely superimposed
infectious process. Differential diagnosis includes viral,
mycoplasma, or H. influenza bacterial pneumonia.
2. Increased hilar, axillary, and mediastinal lymphadenopathy
compared to
[**2135-5-11**].
3. No pulmonary embolism.
4. Large hiatal hernia is stable since [**2135-4-20**].
.
[**5-18**] CXR: Left PICC terminates within the body of the right
atrium.
Widespread diffuse lung abnormalities are not appreciably
changed since the recent study.
.
[**5-20**] CXR: No significant change.
.
[**5-21**] CXR: Severe UIP-related changes make exclusion of
superimposed
infection difficult. Clinical correlation is advised.
.
[**5-22**] Sputum cytology: NEGATIVE FOR MALIGNANT CELLS.
.
[**5-23**] CXR: Stable severe UIP related changes. No evidence of
supervening
pneumonia.
.
[**5-24**] CXR: There are low lung volumes. There has been no interval
change in
diffuse reticular opacities of the lower lungs. The
cardiomediastinal
silhouette and hilar contours are normal. The distal tip of left
PICC
projects at the cavoatrial junction. No pneumothorax or new
opacity is noted.
.
Brief Hospital Course:
77 yo woman with hx of ILD by CT scan in [**4-/2132**] p/w hypoxia,
cough, radiologic evidence of pulmonary infection. Respiratory
status worsening with increasing oxygen requirement and frequent
desaturations
.
# Hypoxia/Pneumonia: Imaging on admission was limited for
evaluation of acute processes on background of chronic
interstitial disease. She was started empirically on
levofloxacin for CAP coverage. She continued to spike fevers and
vancomycin/cefepime were added, out of concern for HCAP, given
participation in adult day care center, where fellow attendees
were reportedly sick. Her O2 saturation worsened during her time
on the floor. One day prior to transfer to the MICU, she was
desatting regularly, with minimal exertion or intervention. Even
with coughing, her O2 sats were < 80%. She was seen by the
pulmonary team, who recommended holding further invasive
evaluation (e.g. bronch/BAL) until goals of care were further
clarified with the family. Steroids were also held, given
ongoing fevers. On the morning of transfer, she triggered for
hypoxia to an O2 sat of 48% while sitting in bed. Her O2 sats
initially improved with non-rebreather, but she continued to
desaturate to the 70s with minimal movement, and was
subsequently transferred to the MICU. In the MICU, pt initialy
had a high O2 requirement but never required intubation or
non-invasive assisted ventilation. Fluid status was monitored
closely and roughly 1-2 L of fluid was diured with prn lasix
over several days. O2 was weaned to 4L shovel mask on transfer
back to the floor. The patient's oxygenation and overall
respiratory status was stable for the remainder of her
hospitalization.
.
# Weakness: Believed to be multifactorial, with dyspnea and
malnutrition as contributing factors. She was to be discharged
to a rehabilitation facility for further physical therapy.
.
# Tachycardia: Early in the patient's stay on the floor, she had
multiple episodes of narrow complex tachycardia, likely SVT. She
responded well to 10 mg IV diltiazem each time. She was
monitored on telemetry. She was started on standing diltiazem,
and her heart rate/rhythm were subsequently well controlled,
despite her frequent hypoxic events. HR remained well
controlled in high 90s to low 100s in the ICU. The night prior
to discharge, she also had a brief run of tachycardia that
self-resolved and did not recur after her usual dose of
dilatiazem. She was discharged on sustained-release diltiazem,
for ease of administration.
.
# Microcytic Anemia: The patient had an iron study profile
consistent with anemia of chronic inflammation, but may have had
an iron deficiency component as well. She had reportedly refused
colonoscopy as an outpatient in the past. Her hematocrit was
stable throughout the hospitalization. She did not require blood
transfusion.
.
# Type 2 DM: The patient reportedly takes metformin as an
outpatient, but her fingersticks were generally under excellent
control on the floor. She was treated with an insulin sliding
scale. She was discharged on an insulin sliding scale, given her
ongoing course of glucocorticoid therapy.
.
# Chronic polyarticular arthritis: Stable at baseline. She was
continued on her home celecoxib
.
# HTN: BP was generally well controlled. When she was started on
standing diltiazem, her home amlodipine was discontinued.
.
# Code: Full code at time of transfer to MICU. In the ICU the
patient was made DNR/DNI after discussion with her HCP.
Medications on Admission:
(Per email from outpatient provider):
amlodipine 5 mg tablet, Sig: 1 tab(s) orally once a day
simethicone 80 mg tablet, chewable, Sig: 1 tab(s) orally 4 times
a day (after meals and at bedtime)
Tylenol 500 mg tablet, Sig: 2 tab(s) orally qid prn
ferrous sulfate 325 mg enteric coated tablet, Sig: 1 tab(s)
orally once a day
Senokot 8.6 mg tablet, Sig: 2 tab(s) orally once a day (at
bedtime)
Robitussin-AC 10 mg-100 mg/5 mL syrup, Sig: 10 mL orally q 4 hrs
prn
Protonix 40 mg enteric coated tablet, Sig: 1 tab(s) orally
bedtime
Flonase 0.05 mg/inh spray, Sig: 1 spray(s) intranasally once a
day
multivitamin with iron Multiple Vitamins with Iron tablet, Sig:
1 tab(s) orally once a day
calcium and vitamin D combination 600 mg-200 units tablet, Sig:
1 tab(s) orally daily
metformin 500 mg tablet, Sig: 1 tab(s) orally once a day (in the
morning)
Vitamin D3 400 intl units tablet, Sig: 2 tab(s) orally once a
day
Tylenol with Codeine #3 300 mg-30 mg tablet, Sig: 1 tab(s)
orally bedtime
Senokot 187 mg tablet, Sig: 1 tablet orally 2 times a day
Wellbutrin SR 150 mg tablet, extended release, Sig: 1 tab(s)
orally 2 times a day
Claritin 10 mg tablet, Sig: 1 tab(s) orally once a day
desipramine 25 mg tablet, Sig: 1 tab(s) orally hs
clonazepam 1 mg tablet, Sig: 1 tab(s) orally q hs
Discharge Medications:
1. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
2. Celecoxib 200 mg Capsule Sig: One (1) Capsule PO daily ().
3. Desipramine 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
6. Prednisone 50 mg Tablet Sig: One (1) Tablet PO once a day:
[**Date range (1) 76542**]: 50 mg/day.
[**Date range (1) 96099**]: 40 mg/day.
[**Date range (1) 11621**]: 30 mg/day.
[**Date range (1) 34960**]: 20 mg/day.
[**Date range (1) 49148**]: 10 mg/day.
OFF.
7. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for indigestion,
bloating.
9. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO four times a
day as needed for fever or pain.
10. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO once a day as
needed for constipation.
12. Guaifenesin AC 10-100 mg/5 mL Liquid Sig: Ten (10) mL PO
every four (4) hours as needed for cough.
13. Flonase 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal once a day as needed for cold symptoms.
14. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO BID (2 times a day).
16. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
17. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
19. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Six Hundred
(600) mg Miscellaneous Q 8H (Every 8 Hours).
20. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Nebulizer Treatment Inhalation Q6H
(every 6 hours) as needed for SOB/Wheezing.
21. Ipratropium Bromide 0.02 % Solution Sig: One (1) Nebulizer
treatment Inhalation Q6H (every 6 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
Pneumonia
Interstitial lung disease
Tachycardia
.
Secondary:
Hypertension.
Diabetes Mellitus
Arthritis-pain in all joints.
Carpal tunnel syndrome.
Depression, anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Ms. [**Known lastname 3501**],
.
You were admitted with a pneumonia. You continued to have
difficulty breathing despite antibiotic therapy and you required
a stay in the intensive care unit. You were started on
intravenous, then oral steroids for your lung disease. You will
continue taking steroids for some time, and slowly decrease your
dose. You are being discharged to a rehab facility where you can
work on getting stronger.
.
The following medication changes have been made:
-Started DILTIAZEM Sustained Release, 180 mg tabs, one tab by
mouth, once daily
-Discontinued AMLODIPINE
-Started PREDNISONE, with dose to be tapered as follows:
[**Date range (1) 76542**]: 50 mg/day
[**Date range (1) 96099**]: 40 mg/day
[**Date range (1) 11621**]: 30 mg/day
[**Date range (1) 34960**]: 20 mg/day
[**Date range (1) 49148**]: 10 mg/day
OFF. Please discuss this further with [**First Name8 (NamePattern2) 4457**] [**Last Name (NamePattern1) 10686**] or your other
outpatient provders
-Started SULFAMETHOXAZOLE-TRIMETHORPIM Single Strength tabs, one
tab by mouth once daily. You should continue taking this as long
as you are taking the PREDNISONE.
-Started CALCIUM CARBONATE 500 mg tabs, TWO tabs by mouth twice
daily
-Stopped METFORMIN
-Started INSULIN SLIDING SCALE (See attached sheet). You should
continue to have your blood sugar closely monitored and treated
with insulin while you are taking the PREDNISONE, as it can
elevate your blood glucose levels.
-Started ACETYLCYSTEINE 600 mg by mouth every eight hours
-Started ALBUTEROL nebulizer, one nebulizer treatment every six
hours as needed for shortness of breath or wheezing.
-Started IPRATROPIUM nebulizer, one nebulizer treatment every
six hours as needed for shortness of breath or wheezing
Followup Instructions:
Pt is in an [**Hospital3 **] facility within [**Hospital1 **]-JP. The providers
will see her as soon as she is back home.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
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"280.9",
"250.00",
"553.3",
"486",
"799.02",
"518.81",
"263.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12218, 12291
|
5196, 8658
|
275, 300
|
12511, 12511
|
2601, 2601
|
14461, 14680
|
1951, 2026
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12687, 14438
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2041, 2582
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1069, 1470
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232, 237
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328, 1050
|
2617, 5173
|
12526, 12663
|
1492, 1686
|
1702, 1935
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,982
| 153,024
|
46110
|
Discharge summary
|
report
|
Admission Date: [**2105-7-26**] Discharge Date: [**2105-8-7**]
Date of Birth: [**2038-8-1**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 9002**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
66 year old woman with metastatic (lung, liver, bone)
endometrial adenocarcinoma that has been refractory to multiple
chemotherapeutic agents, CM/CHF (EF 20%) s/p ICD, BiV pacer,
Afluter/Atrial fibrillation, CKD, HTN, OSA with recent change in
her code status how now presents with worsening DOE, malaise,
tachypnea, air hunger, unable to speak in full sentences to the
ED. She is on home O2 of [**3-12**] L NC.
She was apparently in USOH until 2 weeks ago, when she began to
experience increasing SOB, in setting of anxity episodes. Family
reports increasing weight and LE edema in setting of not
elevating her LEs. They have also noted a cough, productive of
white/yellow sputum over the past few weeks, though per patient
this has been unchanged for several months. There have been no
recent changes in her medications. She has not had other
infectious symptoms. She c/o of chronic insomnia and often of
anxiety w/ episodes of dyspnea.
She only recently, 6mo ago, started using BiPAP regularly, which
has
been uncomfortable for her. There have been no recent changes
in her medications. At time of interview on the floor, she
denies CP, diaphoresis, fever, night sweats but has occasional
chills.
In the ED, initial VS were: 98.8 77 116/65 20 100 on 6 LNC. She
was started on BiPAP, EKG showed LVH (apparently unchanged from
prior). She was started on nitro gtt, was given lasix 80mg IV x1
(UOP ~ 200cc), Vancomycin 1g, Cefepime 2g and Levofloxacin 500mg
for suspected PNA (CXR w/ volume overload and "unable to r/o LLL
PNA."
.
Of note, during [**2105-7-2**] meeting with Oncology ([**Doctor Last Name 6401**]/
[**Doctor Last Name **]) after a discussion regarding an incurable
nature of her cancer and her refractoriness to treatments a
recommendation was not to pursue further chemotherapy as her
"numerous medical comorbidities would preclude her participation
in any ongoing clinical trials" a decision was made to pursue
hospice care. Patient remained in hospice care until [**2105-7-22**]
when she reversed her code status to full after a discussion
with her other two sons (recently arrived to help take care of
her and hospice nursing staff). Apparently her major concern
re: intubation had been fear of not being sedated, once it was
explained to her that she would be sedated, she agreed to
intubation and resuscitation. She apparently was able to
communicate her understanding of difficulty with extubation, but
would like to defer that decision to her children once she is
intubated and can not be extubated.
Of note, on last discharge from [**Hospital Unit Name 196**] for HF ([**2105-5-25**]), her
weight was 136.9kg with Cr of 1.5.
Past Medical History:
- Metastatic Endometrial Adenocarcinoma to lung, liver, bone
- HTN
- BiV pacer placed in [**2099**]
- Atrial fibrillation/flutter
- Dilated cardiomyopathy EF ~ 20%, non-ischemic diagnosed prior
to cancer, ICD in place, last shock [**2105-6-17**] (for aflutter w/
1:1 conduction, HR in 220-240s)
- Chronic Kidney Disease
- Morbid Obesity
- Gout
- Osteoarthritis
- Complex obstructive sleep apnea and [**Last Name (un) 6055**]-[**Doctor Last Name **] breathing
(Auto SV settings 13-16 cm over 9 cm. 3 L oxygen during the day
and 8 at night).
Social History:
Lives alone in an apartment with home VNA and PT. Sons and
grandchildren live nearby and help.
-Tobacco history: Smoked for 20 years but quit 30 years ago.
-ETOH: none
-Illicit drugs: none
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS: 97.4, 126/59, 82, 24, 94% 3L NC
GEN: anxious, obese female in mild respiratory distress
HEENT: NC/AT, PERRLA, EOMI, anicteric sclera with pale
conjunctivae, MMM, clear oropharynx
Neck: supple + large circumference, JVD elevated to 9-10cm
CV: RRR, nl S1/S2, no mrg
PULM: Rales to mid lung fields bilaterally
ABD: obese, soft, NT/ND with +BS
EXT: 2+ LE edema, tender to palpation in upper thigh and below
knee, 2+ UE pulses, no clubbing/cyanosis, warm and well perfused
Neuro: AAOx3, CNs II-XII grossly intact, decreased strength in
lower extremities with intact sensation
Psych: Avoids eye contact, very anxious, difficult to focus on
conversation
Pertinent Results:
[**2105-7-26**] 09:30PM BLOOD WBC-10.1 RBC-2.80* Hgb-8.0* Hct-26.0*
MCV-93 MCH-28.6 MCHC-30.8* RDW-16.8* Plt Ct-308
[**2105-8-1**] 05:30AM BLOOD WBC-13.9* RBC-3.16* Hgb-9.1* Hct-29.9*
MCV-95 MCH-28.8 MCHC-30.4* RDW-18.1* Plt Ct-315
[**2105-8-7**] 05:20AM BLOOD WBC-11.7* RBC-3.12* Hgb-9.1* Hct-29.1*
MCV-93 MCH-29.3 MCHC-31.4 RDW-18.7* Plt Ct-227
[**2105-7-26**] 09:30PM BLOOD PT-13.3 PTT-30.6 INR(PT)-1.1
[**2105-7-27**] 03:00AM BLOOD Ret Aut-3.4*
[**2105-7-26**] 09:30PM BLOOD Glucose-112* UreaN-55* Creat-2.1* Na-143
K-3.6 Cl-91* HCO3-40* AnGap-16
[**2105-8-1**] 05:30AM BLOOD Glucose-88 UreaN-58* Creat-2.8* Na-140
K-5.0 Cl-92* HCO3-35* AnGap-18
[**2105-8-4**] 05:39AM BLOOD Glucose-91 UreaN-68* Creat-3.5* Na-141
K-3.4 Cl-92* HCO3-38* AnGap-14
[**2105-8-7**] 05:20AM BLOOD Glucose-110* UreaN-76* Creat-3.6* Na-140
K-3.2* Cl-91* HCO3-40* AnGap-12
[**2105-7-26**] 09:30PM BLOOD proBNP-5934*
[**2105-7-27**] 04:15PM BLOOD Calcium-9.1 Phos-3.7 Mg-1.8
[**2105-8-7**] 05:20AM BLOOD Calcium-9.6 Phos-4.5 Mg-2.2
[**2105-7-27**] 03:00AM BLOOD Mg-1.7 Iron-45
[**2105-7-27**] 03:00AM BLOOD calTIBC-208* Ferritn-495* TRF-160*
[**2105-7-27**] 03:00AM BLOOD Digoxin-2.2*
[**2105-7-27**] 05:25AM BLOOD Type-ART pO2-75* pCO2-64* pH-7.48*
calTCO2-49* Base XS-20 Intubat-NOT INTUBA Vent-CONTROLLED
[**2105-7-27**] 02:07AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.008
[**2105-7-27**] 02:07AM URINE RBC-0-2 WBC-0 Bacteri-NONE Yeast-NONE
Epi-<1
[**2105-8-2**] 04:35PM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.018
[**2105-8-2**] 04:35PM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-6.0 Leuks-MOD
[**2105-8-2**] 04:35PM URINE RBC->1000* WBC-71* Bacteri-FEW Yeast-NONE
Epi-0 TransE-1
[**2105-8-4**] 04:16PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
[**2105-8-4**] 04:16PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
[**2105-8-4**] 04:16PM URINE RBC-39* WBC-5 Bacteri-FEW Yeast-NONE
Epi-0 TransE-<1
[**2105-8-2**] 04:35PM URINE Hours-RANDOM UreaN-401 Creat-171 Na-39
K-84 Cl-12 TotProt-164 Phos-40.8 Mg-2.2 Prot/Cr-1.0*
[**2105-7-27**] 02:07AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
MICRO
.
Blood Culture x 2, (Final [**2105-8-1**]): NO GROWTH.
Legionella Urinary Antigen (Final [**2105-7-28**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
URINE CULTURE (Final [**2105-7-31**]): NO GROWTH.
.
IMAGING
.
Chest x-ray ([**2105-7-26**]):
IMPRESSION:
1. Low lung volumes with persistent and possibly worsened
central pulmonary
vascular congestion, with blurring of the vascular borders,
concerning for
CHF. Enlarged cardiac silhouette persists.
2. Multiple pulmonary nodules, consistent with metastatic
disease, better
assessed on CT.
.
Chest x-ray ([**2105-8-4**]):
FINDINGS: In comparison with the study of [**7-29**], there is a
little overall change. The multiple metastatic nodules are again
seen throughout both lungs in a patient with substantial
enlargement of the cardiac silhouette and a pacemaker device in
place. It is very difficult to evaluate the pulmonary
vascularity, though there does not appear to be frank pulmonary
edema. Areas of opacification at the bases have apparently
decreased since the prior study.
.
Renal ultrasound ([**2105-8-2**]):
IMPRESSION: Normal renal ultrasound.
.
EKG: Sinus rhythm with A-V conduction delay. Left ventricular
hypertrophy with secondary repolarization abnormalities.
Compared to the previous tracing of [**2105-5-21**] findings are
similar.
Brief Hospital Course:
# Hypoxic respiratory failure: Patient was initially admitted to
the ICU. She has baseline O2 requirement of 3-4L and is on
BiPAP at home. Her baseline dyspnea is multifactorial: CHF, OSA
w/ [**Last Name (un) 6055**]-[**Doctor Last Name 6056**] respirations, innumerable lung metastases and
restrictive lung disease (obesity). Pt was volume overloaded on
CXR at admission, clinical exam of decompensated CHF.
Exacerbating [**Doctor Last Name 360**] unclear. [**Name2 (NI) **] history and lack of fever or
white count made infectious etiology less likely. Most likely
exacerbating factors were PE (given burden of malignancy) and
viral bronchitis. She was assisted on BiPAP of 5 with PEEP 8 and
FiO2 of 100%, which was decreased to 40%. She was started on a
Lasix drip overnight after arrival to the unit and was doing
much better in the morning after admission ([**7-27**]). By the
morning, she was on her home O2 requirement. At that point, she
was transitioned to Lasix boluses for diuresis. Although she
received cefepime and levofloxacin in the ED, she was not
continued on any antibiotics. Urine legionella antigen, blood
cultures, and urine culture were sent and were negative, despite
some appearance of bacteria on the urinalysis. Upon transfer to
the general medical floor, her respiratory status was stable and
unchanged. She continued to require her home dose of oxygen
(3-4L) and would use BiPAP overnight with oxygen saturations in
the mid 90%s. With further diuresis, her lung and lower
extremity exam findings seemed to improve.
.
# Acute on Chronic Systolic heart failure / renal failure: Last
TTE showed EF 20%. Upon transfer the floor, she was
transitioned from Lasix drip/boluses to fluid-restriction +
high-dose Lasix [**Hospital1 **] + metolazone with continued effective
diuresis. The Heart Failure team was consulted and recommended
switching Lasix to torsemide 80mg for more gradual diuresis.
This change seemed to correspond with an increased creatinine
over the 2 days of treatment, so all diuretics were held. At
this point, it was unclear if the patient had been overdiuresed
or if there was still fluid overload with poor forward flow
secondary to heart failure. A repeat urinalysis was sent to
investigate intrinsic renal causes of decreased kidney function,
but the Renal team did not express any concerns about the
presence of blood or the urine sediment. The FeNa and FeUrea
seemed to indicate a pre-renal cause. The diuretics were held
and she was given a fluid challenge, with no effect on the
rising creatinine. Since she still seemed fluid overloaded on
exam, gentle diuresis of Lasix 120mg daily was started.
Creatinine began to trend down, as low as 2.9, along with
improvement in her exam. The day before admission, the
creatinine bumped back to 3.6 but she remained asymptomatic and
it was felt that with close follow-up, she could return home. At
home, she will skip the 1st day of Lasix but then continue her
Lasix 120mg daily + metolazone 5mg only as needed for increasing
edema or shortness of breath, with close follow-up by Dr. [**Last Name (STitle) **].
Her digoxin was discontinued because of her renal dysfunction.
She was nearly 10L negative over this hospital stay.
.
# Hypochloremic metabolic alkalosis: Multifactorial etiology -
(1) contraction alkalosis from aggressive diuresis, and (2)
likely chronic CO2 retainer with metabolic compensation.
Initial blood gas in MICU showed elevated PaCO2 of 64 and a pH
of 7.48, with HCO3 40. She was started on acetazolamide 500 mg
IV TID, and her K+ was repleted as needed. HCO3 levels remained
stable throughout her time on the floor and her acetazolamide
was gradually discontinued because this increased level was
thought to be her new baseline, given her chronic CO2 retention.
.
# Anxiety / restless legs: Patient was started on ativan PRN in
the ICU. On the floor, she was given clonazepam PRN and started
on ropinirole with mild improvement. Sometimes restless legs
can be caused by iron deficiency, so the patient was transfused
twice over this hospital visit with some effect.
.
# Anemia: Patient was transfused two units of pRBCs during this
hospital stay some symptomatic improvement. Her chronic anemia
is likely a combination of iron deficiency, ACD (low TIBC, high
ferritin) and BM suppression (reticulocyte index of 0.96) in
setting of malignancy. Stools were guaiac negative and
hematocrit was stable. No evidence of an active bleed. Her
iron supplementation home regimen was continued.
.
# Paroxysmal Afib/flutter: The patient was continued on
amiodarone, metoprolol, and aspirin. Not on Coumadin. EKGs
taken did not reveal current arrhythmia. Her amiodarone dosed
was changed to once daily upon discharge.
.
# Metastatic endometrial carcinoma / goals of care: Patient
previously undergoing palliative chemotherapy, but resistant to
multiple treatments. She is not a candidate for further chemo
based on co-morbidities. Goals of care were discussed at length
with her during this visit and she is still undecided about her
code status. She does not seem to have full insight into her
condition and is quite anxious about her lack of mobility and
dependence on others for help. Since there was some question
about non-compliance with Lasix because she was incontinent, we
have decided to leave her Foley in with the intention of
re-visiting the issue in a week. We have reconciled her
medications so that she is only taking those that will improve
her symptoms and allow her to be comfortable. She will continue
with hospice care upon discharge, with a re-evaluation of her
code status in the near future.
.
Medications on Admission:
1. Amiodarone 200mg [**Hospital1 **]
2. Lasix 120 in the morning and 80 in the afternoon.
3. Metoprolol 100 b.i.d.
4. Aspirin 81.
5. Ferrous sulfate.
6. Metolazone 5 mg prn worsening edema.
7. Allopurinol 200mg QD
8. Digoxin 0.125 mg.
9. Prilosec 20mg.
10. Senna/docusate
11. Benzonatate pearls 200mg TID
12. Prochloperazine 10mg TID prn
13. Clonopin 0.5mg HS prn
14. Albuterol HFA prn
15. Atrovent 1 puff Q6H prn
16. Oxycodone 5mg prn pain Q4H
17. Tylenol prn
Discharge Medications:
1. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
3. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
6. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
9. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for Anxiety, sleep, restless leg.
10. Benzonatate 100 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
12. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: One
(1) puff Inhalation every six (6) hours.
13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain/fever.
15. Prochlorperazine Edisylate 5 mg/mL Solution Sig: One (1)
Injection Q6H (every 6 hours) as needed for nausea.
16. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
17. Ropinirole 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
18. Metolazone 5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for worsening edema or shortness of breath.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary diagnosis:
Congestive Heart Failure exacerbation
Acute on chronic renal failure
Secondary diagnosis:
Metastatic endometrial carcinoma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It was a pleasure treating you at [**Hospital1 1170**]. You were admitted because of weight gain, increasing
lower leg swelling, and you were having trouble breathing
normally. While you were here, we gave you medicine that helped
to get rid of the fluid that you were retaining in your body,
causing your shortness of breath and swelling. We changed these
medications a few times as we worked out the best plan to ensure
you would not retain too much fluid and that your kidneys would
function well. You were also very anxious during your hospital
stay and had trouble keeping your legs still. We prescribed you
a new medication called ropinirole (Requip) to help you with
this.
During your stay here, we took the opportunity to speak with you
about your goals of medical care. Your physicians will continue
to control your symptoms with your medications, but will do
their best to keep you off of medications that make you feel
unwell. Please continue to think about the level of care you
would want in an emergency situation and your physicians will
discuss this further with you at your frequent follow-up visits.
We will be leaving the catheter in your bladder for at least one
more week. When you regain some of your strength at home, the
hospice nurses will decide with you if it is a good idea to keep
the catheter in or if it can be taken out.
We have made the following changes to your medications:
START Furosemide 120mg by mouth daily
START Amiodarone 200mg by mouth daily
START Ropinirole 0.5mg by mouth daily
START Metolazone 5mg by mouth daily as needed for worsening
edema or shortness of breath.
Please do not take your Lasix tomorrow. You may then restart it
at the dose above. Hospice care will arrange to have labs drawn
in 1 week and these results will be followed up by Dr. [**Last Name (STitle) **].
Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up
more than 3 lbs.
It is very important to follow-up with your physicians closely
so they can keep an eye on your symptoms to make sure you do not
need to come back to the hospital.
Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2105-8-13**] at 3:25 PM
With: [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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40,310
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36854
|
Discharge summary
|
report
|
Admission Date: [**2144-12-24**] Discharge Date: [**2144-12-31**]
Date of Birth: [**2103-12-5**] Sex: M
Service: MEDICINE
Allergies:
Vincristine
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Endotracheal extubation
History of Present Illness:
*Per OSH records as patient could not provide limited history
while intubated and sedated*
41 yo gentleman with h/o acromegaly and diffuse large B-cell
lymphoma (s/p admission at [**Hospital1 18**] from [**2144-7-11**] to [**2144-11-12**])
who was transferred from [**Hospital6 5016**] following episode
of altered mental status early today that led to intubation for
airway protection. Patient had a head CT performed at [**Hospital 40796**] which was reported as showing right temporal and
parietal edema and small foci of hemorrhage, though the images
were not sent with the patient upon transfer to [**Hospital1 18**]. According
to discharge paperwork from [**Hospital3 **] today, the patient
originally presented to the hospital on [**2144-12-21**] with
intractable nausea and vomiting of 5 days duration. While at
[**Hospital3 **], the patient had several abdominal films as well as
an upper GI series which were reportedly unremarkable.
Physicians were concerned that there was a central cause of
nausea and attempted head imaging, which the patient initially
refused. Late on night of [**2144-10-23**], patient was found to be
minimally responsive with head turning to right and arms flexed
to chest. As he had received nortriptyline, there was initial
concern for a dystonic reaction and 50 mg IV diphenhydramine was
pushed. There was no improvement in his mental status following
that intervention and he was intubated for ariway protection and
head CT was then performed with results as above. Transfer to
[**Hospital1 18**] was requested given patient's decline in mental status
requiring intubation.
Of note, patient was recently admitted to [**Hospital6 5016**]
on [**12-14**] with hypercalcemia and a pseudomonas infection of stage
IV pressure ulcer. He completed antibiotic course of
ceftazidime, daptomycin, and azithromycin.
Unknown level of ambulation immediately prior to presentation to
[**Hospital6 5016**] on [**2144-12-21**]; however, at time of discharge
from [**Hospital1 18**] on [**2144-11-12**], he could stand and walk about 10 feet.
A recent neurology note from [**2144-12-4**] assessed his IP strength
as being 1 on the right and 0 on the left. He was assessed as
having "residual severe paraparesis due to combination of
deconditioning and vincristine toxic polyneuropathy, and
question of critical illness polyneuropathy/myopathy."
REVIEW OF SYSTEMS:
*extremely limited due to intubated and sedated status of
patient*
Past Medical History:
1) Diffuse Large B-Cell Lymphoma, Stage IVB with CNS
involvement:
- hospitalization from [**2144-7-11**] - [**2144-11-12**]
- oringinally had Bell's Palsy, urinary retention, and LE
weakness; transferred to [**Hospital1 **] with labs suggestive of tumor lysis
syndrome
- bone marrow biopsy demonstrated Burkitt-like high grade
lymphoma
- imaging showed lymphangitic spread to lung, stomach, ureters
- severe scrotal swelling felt to be due to tumor involvement
- LP demonstrated malignant cells.
- first treated with hyper-CVAD systemically and intrathecal
chemotherapy with MTX and cytarabine starting the first week of
[**Month (only) 205**]
- then treated with R-[**Hospital1 **] alternating with HD MTX. Vincristine
was stopped due to concern that it might be causing severe
polyneuropathy
- treatment complicated by mucositis and pancytopenia requiring
neupogen
- now in remission
2) Pituitary Macroadenoma
3) Acromegaly
4) h/o Respiratory Failure with ARDS requiring mechanical
ventilation [**2144-7-12**] to [**2144-7-30**] -- did well with PSV, had
large TV (700-800) and MV (>10)
5) h/o Mycoplasma hominis PNA treated with cipro and doxy
6) Sinus Tachycardia with PVCs -- had significant work-up with
TSH, TTE. Felt to be physiologic given lymphoma, infection,
acromegaly.
7) Lower extremity paraparesis attributed to leptomeningeal
involvement of his lymphoma, vincristine toxicity, and critical
care myopathy.
- received IVIG for possible paraneoplastic syndrome, but
stopped b/c of low IgA
8) h/o DVT [**2144-8-15**], plan for at least 6 months of lovenox
9) Stage IV Sacral ulcer, required surgical debridements
10) h/o Bell's Palsy -- unclear if [**2-17**] acromegaly or Burkitt's
11) Constipation requiring aggressive bowel regimen
12) Peripheral neuropathy
13) h/o keratitis and right corneal ulcer, Cx grew coag neg
staph, s/p right lid approximation
14) h/o Diffuse Joint Pain thought to be from acromegaly, on
methadone
15) h/o right tibial fracture
Social History:
Brother incarcerated in [**Name (NI) 3844**]. Patient has a 19 yr old
son in [**Name (NI) **]. Prior to his recent hospitalization, he was
living in automobile. Discharged to [**Hospital1 **] on [**2144-11-12**] and
currently living at Wood Mill Skilled Nursing Facility.
Tobacco: 2.5 packs X 25 years
EtOH: unknown
IVDA/other illicit drug use: previously denied
Family History:
Non-contributory per prior records.
Physical Exam:
VS: T 97, HR 94, BP 155/96, RR 17, O2Sat 100% (AC Vt 600, FiO2
50%, f 16, PEEP 5)
GEN: NAD, appears cachectic, intubated and sedated
HEENT: Left pupil reactive 3 -> 2 mm, right pupil sluggish 4 mm,
right eyelid surgical changes, generous tongue, oral mucosa dry,
ET tube in place, generous chin, frontal bossing
NECK: No [**Doctor First Name **], no JVP elevation
PULM: Significant pectus carinum, CTAB anteriorly
CARD: RR, nl S1, nl S2, no M/R/G
ABD: Thin, BS+, epigastric scar, soft, non-distended,
non-tympanitic
EXT: Minimal BLE pitting, markedly enlarged hands and feet
SKIN: No rashes, approximately 4 x 5 cm sacral ulcer without
visible exudates, but with undermining of superficial skin
NEURO: Sedated, was seen to be moving both upper extremities
non-purposefully while briefly off sedation, muscle tone is
normal bilaterally in upper and lower extremities
Pertinent Results:
Admission labs:
6.7>11.4/33.2< 202
WBC remained WNL during ICU course with value up to 7.9 as of
[**12-27**], Hct increased to 37.6, Platelets remained stable
N85, L9.2, M4.2, E1.4, B0.3
PT 15.9, PTT 31.5, INR 1.4
142/3.2/109/25/5/0.4<90, remained stable during ICU course as of
[**12-27**]
ALT 9, AST 15, LDH 489 (increased to 796 as of [**12-28**]), AlkPhos
72, Amylase 17, TB 0.3, Lipase 11
Alb 3.6, Ca 8.0, Phos 0.8 (repleted to 2.2, then required repeat
repletion), Mg 1.9
TP 6.0, Osm 280
PTH 133
PEP pending
b2micro pending
ABG: 7.44/33/205
UA 3 WBC, 5 RBC, <1 epi, neg nitrite
LP CSF [**12-25**]
Tube 1: 183 WBC, 13 RBC, 2 polys, 98 other
Tube 4: 300 WBC, 4 RBC, 1 poly, 99 other
TP: 463 Glucose 1 LDH 1459
PEP pending
HSV pending
flow pending
cultures:
[**12-24**] urine neg
[**12-24**], 13 blood pending
[**12-25**] sputum: coag + staph
[**12-25**] CSF Cryptococcal neg, culture NGTD
[**12-27**] urine NGTD
CT head [**12-24**]
1. Limited study due to patient motion despite five repeat
attempts.
2. Round mild densities in the temporal lobes, and possibly
increased density interdigitating with the sulci. Note
additional history obtained of Burkitt's lymphoma. The findings
may relate to lymphoma involvement, less likely parenchymal and
subarachnoid hemorrhage, though not quite as dense as typical
hemorrhage products, especially in temporal lobes.
3. Enlarged pituitary gland, better evaluated on recent MR
pituitary.
These findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4011**] at 9:00 p.m.
[**2144-12-24**], at which time MRI had been ordered and the patient had
been brought for MRI.
[**12-25**] MRI, MRV, MRA head
1. Diffuse leptomeningeal enhancement and FLAIR hyperintensity
involving the right greater than left temporal and parietal
lobes, with more focal areas of parenchymal abnormality in the
temporal lobe, also right greater than left. Differential
diagnostic considerations primarily include recurrent lymphoma
(especially given the patient's history of Burkitt's lymphoma)
as well as a meningoencephalitis such as herpes encephalitis,
although other viral or bacterial meningoencephalitides could
also result in a similar appearance.
2. Areas of decreased diffusion corresponding to the
leptomeningeal disease with additional foci involving the right
thalamus and right hippocampus, which may represent acute
infarcts, although they may be related to lymphomatous
involvement versus infectious process given the findings above.
Hypoxic injury would be a less likely differential
consideration.
3. Suboptimal MRA and MRV given patient motion. There is no
definite
evidence of venous thrombosis, although the sigmoid sinuses and
the visualized internal jugular veins are suboptimally
evaluated.
4. No evidence of a hemodynamically significant stenosis on the
MRA of the
head, although irregularity at the anterior communicating artery
raises the possibility of a small aneurysm. This was
suboptimally evaluated given the degree of patient motion. At
the time of followup imaging, the MRA sequence could be
repeated.
5. Pituitary adenoma, not significantly changed since the prior
examination when accounting for differences in technique,
although dedicated imaging of the sella was not obtained today.
[**12-25**]
TTE
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 0-10mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. There is probably mild
global left ventricular hypokinesis (LVEF = 45-50 %). No masses
or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size is
normal. with borderline normal free wall function. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
a small pericardial effusion. There are no echocardiographic
signs of tamponade.
Compared with the prior study (images reviewed) of [**2144-8-13**],
the LVEF is less vigorous. The pericardial effusion is slightly
larger but still with no evidence for overt tamponade.
[**12-27**] Chest Xray
The endotracheal tube is no longer visualized. This is a rotated
film. There is bilateral lower lobe subsegmental atelectasis.
The right
Port-A-Cath is unchanged.
[**12-28**] CT Head
Relatively stable vasogenic edema in the temporal lobes as well
as leptomeningeal hyperdensity and hyperdensity in the left
temporal lobe. Question of increased hypodensity in the mid
brain, recommend correlation with MRI to exclude the possibility
of ischemia.
[**12-29**] Chest Xray
As compared to the previous radiograph, there is no relevant
change. No evidence of pneumothorax, no pleural effusion. Mild
retrocardiac atelectasis. No focal parenchymal opacity
suggesting pneumonia, no overhydration.
Brief Hospital Course:
41 year old gentleman with h/o acromegaly and high grade B-cell
lymphoma (s/p admission at [**Hospital1 18**] from [**2144-7-11**] to [**2144-11-12**])
who was transferred from [**Hospital6 5016**] following episode
of altered mental status early on day of admission, [**12-24**], that
led to intubation for airway protection.
#. Lymphoma: He initially presented to [**Hospital6 5016**] with
nausea and vomiting. On admission here, an LP was done that
showed a high opening pressure (49) and multiple atypical cells
concerning for recurrent CNS lymphoma. He was started on
high-dose Decadron and was followed by Medical Oncology,
Neuro-oncology, and Radiation Oncology. His presenting symptoms
were considered a consequence of his worsening lymphoma. Given
his previous treatments with intrathecal chemotherapy, he was
not considered a candidate for chemotherapy. He began
palliative full brain XRT on [**2144-12-28**]. His clinical condition
deteriorated and his respiratory status worsened and he was only
able to have one treatment. On [**2144-12-29**] a discussion with the
health care proxy led to Mr. [**Known lastname **] being made comfort measures
only. He died on [**2144-12-31**] at 4:40pm.
#. Altered mental status: His AMS was most likely caused by
recurrent CNS lymphoma and increased intracranial pressure. He
was initially treated with Acyclovir for HSV, however this was
stopped due to low clinical suspicion. His mental status did not
improve off sedation. His mental status deteriorated to the
point where he was not responsive, likely related to his CNS
lymphoma and increased ICP.
#. Endotracheal intubation/extubation: He was intubated for
airway protection at an OSH prior to admission. He
self-extubated two days after admission without complication.
He remained off ventilatory support and became hypoxic three
days prior to death but was made comfort measures only.
#. Pneumonia: At admission, he spiked a temperature, had copious
secretions and a consolidation in the RUL on chest x-ray.
Vancomycin and Cefepime were started on [**12-25**] for a planned 8
day course, which was stopped early when the goals of care were
changed.
#. Acromegaly and Pituitary Macroadenoma: He had a history of a
pituitary adenoma and surgical resection had been planned for
future. This was deferred due to his poor clinical status.
#. Sacral decubitus ulcer: He had a stage IV sacral ulcer with
recent pseudomonal infection. It appeared uninfected on
admission and was followed by the wound care team.
#. Code Status: He was initially full code during this
hospitalization, but after he clinically worsened with severe
alteration in mental status, he was made DNR/DNI and eventually
comfort measures only.
#. Emergency Contact: [**Name (NI) **] [**Last Name (NamePattern1) 40169**] (Health Care Proxy): Primary
ph [**Telephone/Fax (1) 83235**], Secondary ph [**Telephone/Fax (1) 83236**]
Medications on Admission:
MEDS ON TRANSFER:
1) Metoprolol 12.5 mg PO BID
2) Furosemide 20 mg PO BID (on hold)
3) Nitroglycerin 0.3 mg SL PRN chest pain
4) Morphine 2 mg IV PRN chest pain
5) Citalopram 20 mg DAILY
6) Pregabalin 50 mg [**Hospital1 **]
7) Nortriptyline 25 mg QHS
8) Tizanidine 2 mg Q12H
9) Lorazepam PRN
10) Polyethylene glycol DAILY
11) Senna 8.6 mg two tabs [**Hospital1 **]
12) Docusate sodium 100 mg TID
13) Bisacodyl 10 mg oral DAILY
14) Lactulose 30 mL Q6H:PRN constipation
15) Acetaminophen 650 mg Q4H:PRN pain or fever
16) Maalox plus 30 mL Q4H:PRN 17) Ondansetron 4 mg IV Q6H:PRN
nausea
17) Magnesium hydroxide 10 mL Q6H:PRN dyspepsia
18) Lovenox 90 mg Q12H (on hold)
19) Multivitamins DAILY
20) Clotrimazole 10 mg QID
21) Miconazole topical QID:PRN
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnosis:
Cardiopulmonary Arrest
Hypoxia
Central nervous system lymphoma
Secondary Diagnosis:
Acromegaly
Pituitary adenoma
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
[
[]
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14898, 14907
|
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|
303, 328
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15084, 15093
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6141, 6141
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5202, 5239
|
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14094, 14094
|
15117, 15126
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356, 2725
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15032, 15063
|
6157, 11125
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14947, 15011
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12386, 14068
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2834, 4805
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4821, 5186
|
14112, 14843
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,482
| 171,787
|
53157
|
Discharge summary
|
report
|
Admission Date: [**2170-9-1**] Discharge Date: [**2170-9-3**]
Date of Birth: [**2106-7-14**] Sex: M
Service: NEUROLOGY
Allergies:
latex gloves / Percocet
Attending:[**First Name3 (LF) 11344**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
This is a 63 year old man with a history of generalized
tonic-clonic seizures since [**3-10**] followed by Dr. [**Last Name (STitle) **], CAD,
diabetes and hypertension who presents minimally responsive with
a witnessed seizure by EMS. History obtained from wife with son
as [**Last Name (LF) 109463**], [**Name (NI) **] staff and medical record.
The patient was evidently in his usual state of health recently
with the exception of a severe frontal headache, nausea and
dizziness that brought him to the ED on [**7-18**]. LP and CT head
were
unconcerning at that time. His wife awoke this morning and found
him laying on his side, holding his phone, groaning softly with
eyes open. She says he looked 'frozen' but was not shaking. His
eyes were gazing forward and not rolled back. There was no
urinary incontinence. She immediately called EMS. As they
arrived
she witnessed fine amplitude shaking of all extremities and his
head flexing backward. This lasted 5 minutes. Report from EMS is
that he had another episode en route that involved arm shaking
(unclear which side), lasting 2 minutes and stopped with 2mg of
ativan. His BS at that time was in the 120s and his BP was
200/110. He received another 1 mg of ativan on arrival to the
ED.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, He was noted to have a
O2 saturation of 93% on NC and not protecting his airway well so
he was intubated in the ED.
With regards to his prior seizure history, Mr. [**Known lastname 11791**] had his
first seizure in [**2168-2-29**] which was generalized tonic clonic.
He also presented with hypertension at that time. He had a full
workup including MRI and LP which did not show any cause for his
new onset seizures. His EEG showed only frontal intermittent
rhythmic delta activity (FIRDA) and slowing at that time. He had
a CTA (presented as Code stroke) which showed a 1-2mm aneurysm
at
the anterior communicating artery. He was initially placed on
Keppra 1000mg [**Hospital1 **] but then was changed to Lamictal 150mg [**Hospital1 **] by
Dr. [**Last Name (STitle) **] due to patient's complaint of daytime sleepiness,
headache, neck stiffness and difficulty swallowing while on
Keppra. He had a generalized seizure while on keppra due to
medication noncompliance. He has not had any seizures on
Lamictal. His wife thinks he has not been missing any doses of
his medications.
Past Medical History:
Coronary Artery Disease
Hypertension
Type II Diabetes Mellitus
Dyslipidemia
Chronic Renal Insufficiency
Gastroesophogeal Reflux Disease
Left Shoulder Arthritis/Rotator Cuff Injury
History of Detached Retina
Social History:
Lives with wife. Several children, present at bedside. Smoked a
few cigs/day for 2-3 years, stopped in [**2117**]. Works at [**Hospital1 18**] in
environmental services. He only rarely drinks beer once in a
while for holidays. No recreational drugs.
Family History:
Parents with CAD in their 70s.
Physical Exam:
ADMISSION EXAM:
Vitals: BP 200/110 HR 95 O2 sat 93%
General:
HEENT: NC/AT, no tongue laceration
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: (after 3mg atican) Minimal grimace with sternal
rub. GCS 6 (no eye opening or verbal response)
-Cranial Nerves:
PERRL 3 to 2mm and brisk. No abnormal eye movements
No facial asymmetry noted
-Motor/Sensory: Normal bulk, tone throughout. No rythmic
movements or tremors. Withdraws all four extremities to pain. No
spontaneuos movement.
-DTRs:
[**Name2 (NI) **] Tri Pat Ach
L 2 2 2 0
R 2 2 2 0
Plantar response was mute bilaterally.
DISCHARGE EXAM:
MSE intact- alert, oriented, attentive, language intact
CN intact, no nystagmus
MOTOR: no pronator drift, full throughout
[**Last Name (un) **]: intact to light touch, no extinction to DSS
COORD: intact FNF
GAIT: steady, normal base and stride.
Pertinent Results:
[**2170-9-1**] 08:30AM BLOOD WBC-5.4 RBC-4.63 Hgb-14.5 Hct-45.9
MCV-99* MCH-31.2 MCHC-31.5 RDW-12.4 Plt Ct-220
[**2170-9-1**] 08:30AM BLOOD Glucose-222* UreaN-19 Creat-1.5* Na-142
K-4.6 Cl-101 HCO3-16* AnGap-30*
[**2170-9-1**] 08:30AM BLOOD ALT-21 AST-24 AlkPhos-100 TotBili-0.3
[**2170-9-2**] 03:24AM BLOOD Albumin-4.0 Calcium-8.7 Phos-2.6* Mg-2.3
CXR:
Endotracheal and orogastric tube tips are in standard positions.
Low lung
volumes with streaky opacities in the lung bases, likely
atelectasis.
Possible trace right pleural effusion.
HEAD CT:
1. No evidence of an acute intracranial process. The known
aneurysm could be
assessed by CTA, if indicated.
2. Chronic right frontal sinusitis with inspissated secretions
or fungal
colonization.
Brief Hospital Course:
The patient was intubated for airway protection prior to ICU
admission. He had no further clinical seizures, and EEG
initially showed beta activity from medication effect but no
epileptiform activity. EEG improved over first 24 hours with no
evidence of seizure activity. He had been loaded with Dilantin,
and this was allowed to trend down. He was continued on Lamictal
monotherapy, since it was believed that noncompliance triggered
his seizures. On discussion with patient and family, it seems
that he often forgets morning dose because of work schedule.
They believed that once daily dosing would improve compliance,
so he was switched to Lamictal XR.
He has an appt already set up with Dr. [**First Name (STitle) 3322**] [**Name (STitle) **] in 3 weeks.
Medications on Admission:
1. Simvastatin 60 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. MetFORMIN (Glucophage) 250 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
hold for SBP <100 or Hr <50
5. Lisinopril 2.5 mg PO DAILY
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. LaMICtal 150 mg [**Hospital1 **]
Discharge Medications:
1. Simvastatin 60 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. MetFORMIN (Glucophage) 250 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
hold for SBP <100 or Hr <50
5. Lisinopril 2.5 mg PO DAILY
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. LaMICtal XR *NF* (lamoTRIgine) 300 mg Oral daily
RX *lamotrigine [Lamictal XR] 300 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
epilepsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
neuro status: normal exam
Discharge Instructions:
You were admitted for seizures. You required intubation
(breathing tube) because you could not protect your airway after
the seizures. We believe the reason you had seizures was missing
doses of your medication. You need to take your seizure medicine
regularly as prescribed and not miss doses.
To make this easier, we will switch your lamotrigine (Lamictal)
to an extended release formula that you only need to take once a
day.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 8222**], MD Phone:[**Telephone/Fax (1) 857**]
Date/Time:[**2170-9-24**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2170-10-24**] 10:20
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14290**], OD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2171-7-22**]
11:30
|
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"V45.81",
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] |
icd9cm
|
[
[
[]
]
] |
[
"89.19",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
6700, 6706
|
5168, 5929
|
292, 305
|
6759, 6759
|
4400, 4940
|
7389, 7822
|
3274, 3307
|
6273, 6677
|
6727, 6738
|
5955, 6250
|
6936, 7366
|
3779, 4119
|
3322, 3651
|
4135, 4381
|
245, 254
|
333, 2759
|
4949, 5145
|
6774, 6912
|
2781, 2990
|
3006, 3258
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,279
| 157,231
|
11888
|
Discharge summary
|
report
|
Admission Date: [**2188-12-26**] Discharge Date: [**2188-12-28**]
Service: MEDICINE
Allergies:
Cephalosporins
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
107 russian only speaking felmale with diastolic congestive
heart failure, hypertension who presents with acute onset
shortness of breath (SOB). She resides at [**Hospital **] rehab. she had
an episode of SOB at 4 pm today and was sent to the ER. her VS
at that time were 128/42 70 30 94/ra. She had no fevers. Per
further history the patient reports some trouble with
swallowing.
.
In ER VS 90/40 70 32 100/ra.cxr showed persistent retrocard
opacity. she recd CTX and azithro x 1. she c/o resp distress in
ER and said she felt like she was dying. hence she was put on
CPAP for some time. she felt better w/ it. she was weaned to 40%
venti mask.
Past Medical History:
#. Diastolic CHF
- EF 70-80% Echo [**2182**]
#. HTN
#. Osteoarthritis
s/p displaced femoral neck fracture
s/p left [**Doctor Last Name 17113**] hemiarthroplasty
#. Cholelithiasis
#. Vertigo
#. Macular degeneration
#. Large left frontal meningioma
Social History:
The patient is currently a resident at [**Hospital **] Rehab. At baseline
she is able to walk with 2 person assist. She feeds herself if
her meals are prepared, ground solids. She is generally
dependent on others for most ADL.
Tobacco: None
ETOH: None
Illicits: None
Family History:
NC
Physical Exam:
VS: afebrile, satting well on room air.
GEN: NAD, awake, alert
HEENT: EOMI, PERRL, sclera anicteric, conjunctivae clear, OP
moist and without lesion
NECK: Supple, no JVD
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp were unlabored, no accessory muscle use. mild
crackles bibasilar
ABD: Soft, NT, ND, no HSM
EXT: No edema
SKIN: No rash
Pertinent Results:
CBC:
[**2188-12-26**] 10:45PM BLOOD WBC-3.6* RBC-2.43* Hgb-8.5* Hct-22.5*
MCV-92 MCH-35.0* MCHC-37.9* RDW-15.8* Plt Ct-194
[**2188-12-28**] 09:45AM BLOOD WBC-3.2* RBC-2.87* Hgb-9.8* Hct-26.4*
MCV-92 MCH-34.2* MCHC-37.3* RDW-16.9* Plt Ct-185
Chemistry:
[**2188-12-26**] 03:36PM BLOOD Glucose-102 UreaN-57* Creat-1.2* Na-140
K-3.7 Cl-96 HCO3-30 AnGap-18
[**2188-12-28**] 09:45AM BLOOD Glucose-187* UreaN-49* Creat-1.3* Na-139
K-3.1* Cl-98 HCO3-29 AnGap-15
[**2188-12-28**] 09:45AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.3
Cardiac Enzymes:
[**2188-12-26**] 03:36PM BLOOD CK(CPK)-25*
[**2188-12-26**] 10:45PM BLOOD CK(CPK)-22*
[**2188-12-26**] 03:36PM BLOOD cTropnT-0.01
[**2188-12-26**] 10:45PM BLOOD cTropnT-<0.01
BNP:
[**2188-12-26**] 03:36PM BLOOD CK-MB-NotDone proBNP-4240*
CXR: IMPRESSION: Persistent retrocardiac opacity, which could
represent atelectasis, although pneumonia is not excluded.
Cardiomegaly with prominance of the pulmonary vascularity, but
no overt congestive heart failure.
Brief Hospital Course:
107 russian only speaking F w/ dCHF, HTN p/w acute onset SOB.
.
#SOB: Patient minimally desatted and was placed on CPAP
overnight initially. She was initially given antibiotics, but
the lack of fever, white count and [**Male First Name (un) **] CXR fiondings made
pneumonia unlikely and the antibiotics were continued. The next
day she was weaned to room air. She remained satting well on
room air. She did desat overnight once and responded to 2L NC.
In the morning again she was weaned to room air. Current
thinking is small aspiration event or mucous plugging. She was
placed on aspiration precautions.
.
# Persistent retrocardiac opacity: Unlikely to represent
pneumonia as unchanged over time. More likely atelectasis.
Small pleural effusion.
.
#h/o Meningioma: cont home dialntin
.
# anemia: per previous notes, egd and colon deffered. She was
given one unit of blood slowly and her hematocrit responded
appropriatly.
.
# dCHF: She was continued on her home dose of lasix. She was
given one extra dose of lasix 20mg with her transfusion. As the
patient did not appear clinically volume overloaded and her labs
were trending towards being dry (Cr. up from 0.8 on previous
admission to 1.2). The decision was made to hold her lasix.
Would check her labs in [**1-20**] days to see if Creatinine trending
down. If not she may benefit from some IV fluids. If she
starts to appear volume overloaded would restart her lasix at
20mg daily and uptitrate as needed.
.
# FEN: reg diet.
.
# Access: PIV
.
# PPx: heparin SC
.
# Code: DNR/DNI
.
# Medication changes: Stopped lasix.
Medications on Admission:
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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3)
Capsule PO DAILY (Daily).
10. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
2. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
9. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Shortness of breath
Discharge Condition:
Stable on room air
Discharge Instructions:
You were admitted because of shortness of breath. You were
placed on posative airway pressure. The next morning you were
able to breath well on room air again. We think that you
aspirated some food into your lungs. Please be very careful
when you are eating. Always sit up and take small bites.
Remember to chew frequently. Have people help you eat.
You lasix was stopped for concern that you may be getting a
little dehydrated. Please continue to eat and drink. Your
doctor may decide to restart your lasix if it looks like you are
holding on to more water.
No other medication changes were made.
Please return to the hospital or call your doctor if you have
temperature greater than 101, shortness of breath, worsening
difficulty with swallowing, chest pain, abdominal pain,
diarrhea, or any other symptoms that you are concerned about.
Followup Instructions:
PCP
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
|
[
"584.9",
"276.51",
"225.2",
"793.1",
"428.0",
"786.05",
"E944.4",
"362.50",
"294.8",
"715.90",
"V45.89",
"280.0",
"780.4",
"428.32",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6153, 6218
|
2882, 4434
|
228, 235
|
6282, 6303
|
1865, 2380
|
7202, 7331
|
1485, 1489
|
5356, 6130
|
6239, 6261
|
4496, 5333
|
6327, 7179
|
1504, 1846
|
2397, 2859
|
4454, 4470
|
185, 190
|
263, 913
|
935, 1184
|
1200, 1469
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,842
| 105,745
|
40050
|
Discharge summary
|
report
|
Admission Date: [**2119-1-17**] Discharge Date: [**2119-1-21**]
Date of Birth: [**2087-4-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Mid scapular to lower back to RT testicular pain
beginning two says ago.
Major Surgical or Invasive Procedure:
none this admission
(Major Surgical or Invasive procedures: [**2119-1-9**] Replacement of
Ascending aorta with 28mm Gelweave graft)
History of Present Illness:
81yo white male who presented [**1-9**] to
RI VAH w/ acute onset upper back pain then radiating to
legs/testicles. CT revealed Type A dissection and transferred
here after diversion of LifeFlight from [**Hospital1 2025**]. He underwent
uneventful interposition tube graft repair and did well
postoperatively. The right kidney was not perfused from the true
lumen and was avascular on US as well after surgery. His admit
creatinine was 1.6 and 1.5 at discharge.
He had significant pain issues during his stay and called last
night w/ above pain but not taking meds. he had AF on transfer,
but stable Vital Signs. Non constrast CT at VA this AM shows
usual postop
changes. Toradol at VAH relieved his pain.
The aorta was abnormal appearing at surgery and Rheumatology and
ID were consulted. Cx were all negative and this was felt to
likely be Ehlos-Danler Type IV (also consistent w/ path report).
Past Medical History:
Remote stroke after rodding, no residual
Left deep vein thrombophlebitis
Chronic low back pain
Obstructive sleep apnea
Sinusitis- completed course antibiotics/prednisone
s/p Lumbar laminectomies
s/p femoral rodding
h/o tympanic membrane surgeries
Social History:
15pk year history (active smoker)
heavy ETOH until 2years ago
disabled from back pain
Family History:
noncontributory
Physical Exam:
Pulse: Resp:16 O2 sat: 98%
B/P Right: 120/70 Left:122/70
Height: Weight:
General:WDWN in NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur
Abdomen: Soft [x] non-distended [x] non-tender xbowel sounds +
[x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit Right:n Left:n
Pertinent Results:
[**2119-1-17**] 12:50PM GLUCOSE-94 UREA N-13 CREAT-1.3* SODIUM-135
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-28 ANION GAP-11
[**2119-1-17**] 03:10AM PT-15.0* PTT-25.6 INR(PT)-1.3*
[**2119-1-17**] 12:50PM WBC-14.6* RBC-2.90* HGB-8.5* HCT-25.4* MCV-88
MCH-29.4 MCHC-33.6 RDW-14.5
[**2119-1-17**] CT chest abd pelvis
Wet Read: WWM [**First Name8 (NamePattern2) **] [**2119-1-17**] 9:02 AM
1. Type B (DeBakey III) Aortic dissection from just dist to LSCA
to bilat
CIAs. High attenuation small L pleural effusion with irregular
margins prox
desc thoracic aorta. Suspect leak, pre- rupture.
2. Thrombosed R renal artery resulting in right renal infarction
- stable c/w
[**2119-1-9**] CT. L kidney perfused, LRA supplied by true lumen and
patent. Remaining
major mesenteric vessels supplied by false lumen and well
opacified.
3. Significant fluid with minimal locules of air surround
ascending aorta -
presumed post op (reportedly 1 wk post repair), superinfection
not excluded.
Small focus of extravasation ~[**2-9**] o'clock at distal anastomosis
(se 2 im 29),
2nd focus posteriorly at 6 o'clock on se 2 im 28. Leak
suspected.
Scrotal ultra sound
IMPRESSION: No intratesticular mass and no signs of torsion.
Prominent left
spermatic cord with fatty component and possible mild left
varicocele;
however, these findings are not considered clinically
significant since the
patient complains of pain on the right.
[**2119-1-19**]
CTA chest abd pelvis
IMPRESSION:
1. Stable post-operative appearance of aortic repair with
contrast leak at
the distal anastomosis in the ascending arch as seen on prior.
2. Residual type B aortic dissection originating from just
distal to the left
subclavian artery, where it is fenestrated and extending
distally as far as
the bilateral common iliac arteries. There is associated
infarction of the
right kidney as seen on prior.
3. Cardiomegaly and bilateral simple pleural effusions without
evidence of
pulmonary congestion.
Brief Hospital Course:
Mr. [**Known lastname 48587**] was admitted to the CVICU for blood pressure
control and hemodynamic monitoring. The CTA x 2 showed stable
post-operative findings: 1. Stable post-operative appearance of
aortic repair with question of contrast leak at the distal
anastomosis in the ascending arch as seen on prior CTA. Vascular
surgery was also consulted and followed Mr. [**Known lastname 88053**] care
during his hospital course and he will be seen in follow up by
vascular surgery. Once blood pressure control was achieved with
oral agents, Mr. [**Known lastname 48587**] was transferred form the ICU to the
stepdown unit. At the time of discharge on HD5 his pain was
controlled with analgesics and his blood pressure was adequately
controlled. All discharge instructions and follow up
appointments were advised. He was cleared for discharge to home.
Medications on Admission:
Lopressor 37.5mg [**Hospital1 **],Percocet
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
4. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
Disp:*45 Tablet(s)* Refills:*0*
5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
7. losartan 25 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Type A Aortic dissection s/p Replacement of ascending aorta
Postop UTI
Past medical history:
Remote stroke
Chronic low back pain
Obstructive sleep apnea
s/p Lumbar laminectomies
s/p femoral rodding
h/o tympanic membrane surgeries
Discharge Condition:
alert and oriented x3
No testicular pain
gait steady
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**]
Keep your systolic (top number) blood pressure less than 130. If
your blood pressure is higher than 130, please call the cardaic
surgery office at [**Telephone/Fax (1) 170**] for instructions.
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on Wednesday [**2-1**] at 1:00 ([**Hospital Ward Name **]
2A)
vascular surgery: Please call Dr.[**Name (NI) 7446**] office
[**Telephone/Fax (1) 1237**] to schedule a follow up appointment to be seen in
one month with a CT scan.
*** Cardiologist: Please ask Dr. [**Last Name (STitle) **] for a referral to a
cardiologist and make appt for 4 weeks
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office from genetic testing at [**Hospital1 11900**] of [**Location (un) 86**] will be calling you on Monday to arrange an
appointment. His office phone is ([**Telephone/Fax (1) 77621**].
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) **] in [**4-11**] 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:[**2119-1-24**]
|
[
"338.18",
"305.1",
"427.31",
"451.19",
"441.03",
"593.81",
"996.1",
"E849.8",
"327.23",
"787.01",
"724.2",
"427.89",
"996.62",
"608.9",
"789.09",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6213, 6269
|
4471, 5324
|
384, 518
|
6543, 6598
|
2491, 4448
|
7635, 8665
|
1839, 1856
|
5417, 6190
|
6290, 6361
|
5350, 5394
|
6622, 7611
|
1871, 2472
|
271, 346
|
546, 1449
|
6383, 6522
|
1735, 1823
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,312
| 157,618
|
44479
|
Discharge summary
|
report
|
Admission Date: [**2113-7-8**] Discharge Date: [**2113-8-2**]
Date of Birth: [**2074-11-28**] Sex: F
Service: SURGERY
Allergies:
Penicillin V
Attending:[**Doctor First Name 5188**]
Chief Complaint:
abdominal pain, n/v
Major Surgical or Invasive Procedure:
Exploratory laparotomy, abdominal "wash out", enterorrhaphy.
History of Present Illness:
38F POD#3 s/p lap b/l tubal ligation and 1 month post-partum
presents with persistent abdominal pain, nausea and vomitting
since the night of her operation. She reports taking ibuprofen
and percocet, with little help and not being able to tolerate
much po. Pt also reports subjective fevers and chills. Patient
reports brown spotting is ongoing with foul a smell. She
complains of chest pain without SOB. Denies difficulty with
urination but endorses +constipation/obstipation since surgery.
Upon arrival to ED, patient was found to tachycardic to the
150s,
ill-appearing, and had an episode of coffee-ground emesis.
Continues to complain of abdomen pain and overall unwell.
Past Medical History:
gastritis, MDD, brain tumor, age 11 (spont resolution), chronic
migraines, Bell's palsy
Social History:
partner [**Name (NI) **], works at [**Name (NI) **] as project manager, tobacco
quit 5.5 yrs ago, denies EtOH or drug use
Family History:
NC
Physical Exam:
98.8, HR 150s on initial presentation, to 120 following fluid,
106/82, 44
ill-appearing, but awake, alert, and oriented
tachy
fast, shallow breaths with poor insp effort, but clear
soft, distended, + voluntary guarding, diffusely TTP, no
rebound,
no bs.
incision sites c/d/i
guiac +, no masses
Brief Hospital Course:
The patient presented to the ED s/p lap b/l tubal ligation 3
days ago. She now presents with perforated viscus diagnosed on
CT scan and septic. She was made NPO with NGT/IVF/Foley/ABX. She
was taken emergently to the operating room and underwent
Exploratory laparotomy, abdominal "wash out" and enterorrhaphy.
She was transferred to the floor on East Surgery service. NGT
was kept in and return of bowel function was awaited. Bowel
function was very very slow to return and multiple attempts at
removing the NGT were unsuccessful. Pt had multiple CT scans to
evaluate for obstruction. Fluid collections were identified and
she was taken to Interventional Radiology on post-op day 6 where
two 8 French pigtail catheters were placed on either side to
drain collections of pus. The OB/GYN service followed her
throughout her admission and on [**2113-7-25**] a vaginal drain was
placed by IR to drain a pelvic fluid collection. Her NGT was
removed and her nausea was controlled with multiple antiemetics,
and she was able to take small amounts of regular food. She is
being discharged with cycled TPN as well.
Medications on Admission:
none
Discharge Medications:
1. Simethicone 80 mg Tablet, Chewable Sig: [**1-20**] Tablet, Chewables
PO QID (4 times a day) as needed for nauesa.
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
3. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
Two (2) Adhesive Patch, Medicated Topical DAILY (Daily).
5. Hydromorphone (PF) 1 mg/mL Syringe Sig: [**1-20**] Injection Q4H
(every 4 hours) as needed for pain.
6. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
7. Metoclopramide 10 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
8. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q8H (every
8 hours) as needed for anxiety.
9. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] TCU - [**Location (un) 701**]
Discharge Diagnosis:
Perforated viscus after tubal ligation.
Discharge Condition:
Stable. Tolerating regular food. Pain controlled on PO meds.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
Home services will be provided for wound care, drain care and
physical therapy.
Followup Instructions:
Call Dr.[**Name (NI) 6045**] office at [**Telephone/Fax (1) 5189**] for follow-up
appointment in 1 week.
Provider: [**First Name8 (NamePattern2) 3679**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 95321**] Date/Time:[**2113-8-10**]
11:15
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2113-9-21**]
2:50
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]
|
[
"998.59",
"038.9",
"995.92",
"998.2",
"584.9",
"567.22",
"346.90",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.73",
"54.11",
"99.15",
"38.93",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
3797, 3873
|
1672, 2786
|
293, 356
|
3957, 4022
|
5293, 5813
|
1334, 1338
|
2841, 3774
|
3894, 3936
|
2812, 2818
|
4046, 5270
|
1353, 1649
|
233, 255
|
384, 1067
|
1089, 1178
|
1194, 1318
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,981
| 170,730
|
27507
|
Discharge summary
|
report
|
Admission Date: [**2158-4-27**] Discharge Date: [**2158-5-2**]
Date of Birth: [**2111-6-10**] Sex: M
Service: MEDICINE
Allergies:
Lasix
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
transfer from OSH, GI bleed
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy (EGD) with banding of 3 esophageal
varices
History of Present Illness:
46YO male with ETOH cirrhosis known varices with hx UGIB from ?
esophagitis, hx partial portal vein thrombosis [**8-26**] who
presented to [**Hospital **] Hospital with hematemesis on 4/. Pt was
eating dinner/drinking ETOH and began having nausea and vomting.
He vomited 2 x times each with "2 cups of blood". Hours later
he vomited a 3rd time and "passed out" for "1 minute" injuring
his head in the process. He then called 911. On arrival to ED
his HR was 106 and his BP was 60/40. Per reports, his initial
Hgb was 10.1/Hct 31.1 and INR 2.4. He had an NG lavage with
bloody return that cleared after 500cc lavage. He was given IV
fluids and PRBCS. A left facial lac was repaired. The next day
he had EGD with significant blood in the stomach and bleeding
from dieulafoys vs varix but no convincing fundic varices. In
total he has received 6units PRBCs and 9 units of FFP. He was
started on octreotide gtt. He was started on levofloxacin for
SBP prophylaxis with GI bleed. On [**4-27**] he was transfered to
[**Hospital1 18**] ICU for futher management.
On arrival, pt is mentating well and HD stable. He has no pain.
Denies fever, cough, SOB, CP,abd pain. He reports only have one
bowel movement in past 3 days (unsure if it had blood). He
denies having itchiness
Past Medical History:
-ETOH cirrhosis with known portal HTN and hx Grade I varices and
gastropathy
-partial portal vein thrombosis [**8-26**]
-hx alcoholic hepatitis
-hx upper GI bleed from distal esophagitis
-hx ascites with 2 large volume paracentesis (8liters each time
per patient) in [**Month (only) 216**] and [**2157-9-22**]
-recent lower GI bleed from hemorrhoids (pt reports recent
colonoscopy)
-iron deficiency anemia
-umbilical hernia with recent reduction in ED
-depression
Social History:
Patient lives alone, he was employed as an electrician as
recently at 7/05. hx [**Last Name (un) 20934**]
he is divorced and has no children
He is actively drinking ETOH, he reports usually drinking about
6pack of beer and 1pint of whiskey each day
he has distant history of polysubstance use including cocaine,
acid, THC. His last cocaine use was over 10 years ago
Family History:
alcoholism in mother and aunt
Physical Exam:
no distress, cooperative, tire-appearing
VS: 99.4 77 136/66 15 97%RA
HEENT: laceration on left side of face (intact) slight icterus,
EOMI, mild moderately dry MM
Neck: supple, -LAD, JVP not elevated
lungs: CTA bilaterally
heart: RRR -murmurs, -rubs
abd: soft +spleen tip, mild distension, RUQ fullness but liver
edge difficult to appreciate, mild RUQ tenderness of palpation
-fluid wave + BS
ext: -edema, -tremor
neuro: CN intact, -asterixis,
skin: diffuse erythematous rash + blanching on back and upper
chest
Brief Hospital Course:
54 year old M with ETOH cirrhosis, history of partial portal
vein thrombosis, ascites, anemia presenting with hematemesis,
weakness/lightheadedness, transient confusion/lethargy and EtOH
abuse. The following is a summary of his hospital course by
problem.
.
# Gastrointestinal bleed: On admission to the outside hospital,
an NG lavage was positive which cleared after 500 cc Normal
Saline. An emergent EGD was done which showed a Dieulafoy vs.
gastric varix without active signs of bleeding. No intervention
was done, and he was started on IV octreotide, protonix and
levofloxacin for spontaneous bacterial peritonitis prophylaxis
and transferred to [**Hospital1 18**]. On admission to [**Hospital1 18**], his hematocrit
was monitored in the MICU and found to be stable at 30,
requiring no further transfusions. His INR was found to be
elevated to 1.6, and he was given 3 days of Vitamin K with
minimal improvement in INR but no further bleeding. His
levofloxacin was changed to cipro. The liver team was
consulted, and they initially planned an EGD on [**4-28**], but then
deferred until after the weekend because of altered mental
status. His octreotide was changed to octreotide SQ on [**4-29**] and
he was transferred out to the floor. His hct was stable in the
ICU at 30. On [**5-1**], he was noted to have a bloody stool which
cleared by his next stool. His hematocrit remained stable.
According to his outside records, he received a flexible
sigmoidoscopy to the proximal transverse colon on [**2158-3-10**] at
[**Hospital **] Hospital by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 67282**] which showed large red
and injected appearing external hemorrhoids with noninflamed
internal hemorrhoids, but otherwise normal. No further workup
was pursued, and he had no further rectal bleeding. His EGD
showed 3 cords of grade II varices at the lower third of the
esophagus and middle third of the esophagus, to which 3 bands
were successfully placed, as well as granularity, friability and
petechiae in the whole stomach compatible with portal
hypertensive gastropathy with multiple petechiae. He was
scheduled to follow-up with Dr. [**Last Name (STitle) **] of the Liver Center in
2 weeks at which time a follow-up EGD would be scheduled for
rebanding.
- continue soft diet for 3 days
- continue cipro 500 mg [**Hospital1 **] for 3 more days
- continue omeprazole 40 mg QD
.
#. Mental status - The patient was noted to have transient
change in mental status in the MICU which was thought to be
secondary to encephalopathy due to liver failure vs. alcohol
withdrawl vs. medication sedation from his CIWA scale. He was
started on lactulose TID which was discontinued at discharge
because he had developed diarrhea and his mental status had
cleared. He was continued on his CIWA scale and his scores were
consistently 0 by time of discharge, with discontinuation of the
scale on the day prior to discharge.
.
#. Cirrhosis - The patient had a right upper quadrant ultrasound
on [**4-28**] which showed changes consistent with a cirrhotic liver,
patent portal veins with normal hepatopetal directional flow,
and RUQ ascites not amenable to drainage. He finished a 5 day
course of ciprofloxacin for spontaneous bacterial peritonitis
prophylaxis and was started on nadolol 10 mg once daily for
portal hypertension. He was also started on lactulose for
possible hepatic encephalopathy that was discontinued when his
mental status cleared and also secondary to diarrhea.
.
#. Diarrhea - As a result of starting the lactulose, the patient
developed diarrhea. Given that he was on ciprofloxacin, a c.
diff was checked and found to be negative. He had drops in his
potassium and magnesium secondary to the diarrhea, so his
lactulose was discontinued.
.
#. EtOH abuse - The patient is an active drinker despite being
in AA and other support groups. He denies [**Last Name 3545**] problem. [**Name (NI) **]
was placed on a diazepam and then ativan CIWA scale which was
eventually discontinued when his CIWA scales remained
consistently zero. An addictions consult was called, and he
stated that he was unwilling at this time to go to an inpatient
program. He was given the name and number of CAB evening
program in [**Hospital1 3597**] as he is getting his DUI mandatory treatment
there. He refused to call while in house.
- Continue multivitamin, folate, thiamine
.
#. Thrombocytopenia - The patient was noted to be
thrombocytopenic on this admission. His platelet counts
steadily improved during this admission, and were stable in the
high 50s to 70s at time of discharge. His initial platelet
count of 31 was felt to be secondary to a consumptive component
with his active bleeding and also likely secondary to cirrhosis.
A HIT antibody was negative.
.
#. Recent fall - This was felt likely to be secondary to
hypovolemia from GI bleeding. There was no evidence of ICH at
OSH. A PT consult was called and they felt that there was no
need for outpatient PT.
Medications on Admission:
Colace 100mg [**Hospital1 **]
prilosec
Metamucil QD
Anusol cream PR [**Hospital1 **]
iron sulfate (recently d/c'd)
zoloft
Discharge Medications:
1. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] (2
times a day).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
5. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. Nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Grade 2 esophageal varices
Portal hypertension
Portal gastropathy
Cirrhosis
Alcohol abuse
Pancytopenia
Discharge Condition:
hemodynamically stable, A&O x3, CIWA 0
Discharge Instructions:
1. PLEASE stop drinking. Please follow-up with your alcohol
cessation program this Thursday as planned.
2. Please take all medications as prescribed.
3. Please keep all follow-up appointments.
4. Please seek medical attention if you develop nausea,
vomiting, black or bloody stools, abdominal pain, chest pain,
shortness of breath, change in your mental status, alcohol use
or have any other concerning symptoms.
5. Please eat a soft, low salt diet for the next 3 days, then
you may eat a regular, low salt diet.
Followup Instructions:
1. Please make a follow-up appointment with Dr. [**Last Name (STitle) 39527**] [**Name (STitle) **]
at [**Telephone/Fax (1) 51033**] for within the next week.
2. You have an appointment at the liver center in [**Hospital1 **] [**Last Name (NamePattern1) 439**] [**Location (un) **] of the [**Hospital Unit Name **]
with Dr. [**First Name (STitle) **] [**Name (STitle) **] for [**2158-5-17**] Wednesday at 2:10 PM ([**Telephone/Fax (1) 16686**]. You will also be scheduled for a repeat
esophagogastroduodenoscopy (EGD) for repeat banding of your
varices in 3 weeks. They will arrange that for you at your
appointment on [**5-17**].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2158-5-17**]
|
[
"303.91",
"285.1",
"456.20",
"571.1",
"276.52",
"287.5",
"577.0",
"571.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33"
] |
icd9pcs
|
[
[
[]
]
] |
9104, 9110
|
3153, 8156
|
293, 365
|
9257, 9298
|
9860, 10616
|
2563, 2595
|
8329, 9081
|
9131, 9236
|
8182, 8306
|
9322, 9837
|
2610, 3130
|
226, 255
|
393, 1674
|
1696, 2162
|
2178, 2547
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,111
| 197,728
|
20757
|
Discharge summary
|
report
|
Admission Date: [**2136-4-19**] Discharge Date: [**2136-4-30**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
ST-elevation myocardial infarction
Major Surgical or Invasive Procedure:
Cardiac catheterization with bare metal stent to LAD
History of Present Illness:
Pt is 87 yo [**First Name3 (LF) 8230**] speaking m with HTN, dyslipidemia, who
began having chest pain and back pain at his nursing home at 1
pm. He had elevated CK, and abnormal EKG so he was brought to
the [**Hospital1 18**] ED at 2 AM. He received 2 SL ntg's prior to arrival.
.
In the ED, EKG showed anterolateral ST elevations, trop 11.3. He
was given ASA 325mg PO prior to arrrival, then plavix 600mg PO,
heparin gtt, and integrillin gtt. He was brought to the cath
lab, found to have a 95% mid LAD lesion, thrombectomy was
performed, and a BMS was placed to the LAD.
.
Pt currently has no complaints and denies CP/SOB.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
*** Cardiac review of systems is notable for absence of dyspnea
on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle
edema, palpitations. He does have history of syncope and falls.
.
Past Medical History:
HTN
Dyslipidemia
s/p R hip arthroplasty
h/o syncope
h/o falls
L eye enucleation
dementia
.
Cardiac Risk Factors: Dyslipidemia, Hypertension
.
Cardiac History: none
.
Pacemaker/ICD: none
Social History:
Quit smoking >20 yrs ago. No EtOH. Was a farmer in [**Country 651**] before
coming here several decades ago; has 9 children.
Family History:
Non-contributory in this 87 year old man
Physical Exam:
S: T 94.6, BP 101/52 , HR 60, RR 16, O2 97 % on 2L NC
Gen: elderly male, somnolent, NAD. dry MM. Arousable to loud
voice, responds only intermittently to commands. A&O only to
name.
HEENT: L eye enucleation.
Neck: Supple.
CV: PMI located in 5th intercostal space, midclavicular line.
Distant heart sounds. RRR, 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: soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: all 4 ext cool. RLE with purple color compared to LLE.
Skin: RLE with purple color compared to LLE.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit;
dopplerable DP/PT
[**Name (NI) 2325**]: Carotid 2+ without bruit; Femoral 2+ without bruit;
dopplerable DP/PT
MEDICAL DECISION MAKING
.
EKG (at NH): NSR @ 73, LAD, QW II, III, V1-V6, STE I, II, III,
aVF, V2-V6, TWI aVL, TWF V4-V6
.
EKG ([**Hospital1 18**], pre-cath): no change from OSH.
.
EKG ([**Hospital1 18**], post-cath): NSR @ 84, LAD, QW II, III, V1-V6, STE I,
II, III, aVF, V2-V6 (more pronounced V3-V6), TWI aVL, TWF V4-V6
.
TELEMETRY demonstrated: NSR
.
CARDIAC CATH performed on [**2136-4-19**] demonstrated:
LAD: 95% thrombotic mid, moderate diffuse distal disease
LCX: ectopic off right cusp with 80% proximal (small vessel),
diffuse disease in OM
RCA: 40% mid, 70% mid PDA
Export thrombectomy of mid LAD followed by bare metal stenting.
Pertinent Results:
OSH labs: ALT 73, AST 486, WBC 10.4, CK 3781.
.
.
[**2136-4-19**] 02:00AM cTropnT-11.3*
[**2136-4-19**] 08:01AM CK-MB-240* MB INDX-8.1* cTropnT-20.05*
[**2136-4-19**] 03:33PM CK-MB-98* MB INDX-5.0
[**2136-4-19**] 03:33PM CK(CPK)-[**2097**]*
.
[**2136-4-19**] 06:36AM TYPE-ART PO2-131* PCO2-37 PH-7.43 TOTAL
CO2-25 BASE XS-1
[**2136-4-19**] 09:14PM LACTATE-1.7
[**2136-4-19**] 09:14PM TYPE-[**Last Name (un) **] PO2-50* PCO2-42 PH-7.37 TOTAL CO2-25
BASE XS-0
[**2136-4-19**] 10:48PM O2 SAT-63
.
[**2136-4-19**] 02:00AM WBC-14.9* RBC-4.73 HGB-14.7 HCT-45.2 MCV-96
MCH-31.1 MCHC-32.6 RDW-14.4 PLT COUNT-215
[**2136-4-19**] 08:01AM WBC-13.1* RBC-4.10* HGB-12.9* HCT-38.9*
MCV-95 MCH-31.5 MCHC-33.1 RDW-14.8// NEUTS-83.4* LYMPHS-9.6*
MONOS-6.4 EOS-0.5 BASOS-0.2
[**2136-4-19**] 03:33PM WBC-10.8 RBC-3.95* HGB-12.3* HCT-37.4* MCV-95
MCH-31.2 MCHC-32.9 RDW-14.5 PLT COUNT-175
.
[**2136-4-19**] 02:00AM GLUCOSE-110* UREA N-28* CREAT-1.0 SODIUM-136
POTASSIUM-5.1 CHLORIDE-101 TOTAL CO2-19* ANION GAP-21*
[**2136-4-19**] 08:01AM GLUCOSE-121* UREA N-26* CREAT-0.8 SODIUM-135
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-23 ANION GAP-15
[**2136-4-19**] 08:01AM ALT(SGPT)-78* AST(SGOT)-481* LD(LDH)-1337*
CK(CPK)-2959* ALK PHOS-66 TOT BILI-1.2
[**2136-4-19**] 08:01AM ALBUMIN-3.7 CALCIUM-8.6 PHOSPHATE-3.1
MAGNESIUM-2.2 CHOLEST-137
[**2136-4-19**] 08:01AM TRIGLYCER-31 HDL CHOL-67 CHOL/HDL-2.0
LDL(CALC)-64
.
[**2136-4-19**] 08:01AM ACETMNPHN-NEG
.
[**2136-4-19**] 09:45AM URINE COLOR-Yellow APPEAR-Clear SP
[**Last Name (un) 155**]->=1.035
[**2136-4-19**] 09:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
.
.
Brief Hospital Course:
.
[**Known firstname **] [**First Name8 (NamePattern2) 1255**] [**Known lastname 20451**] was an 87 year old man who presented to [**Hospital1 18**]
with an anterolateral STEMI, likely evolving for a time prior to
admission. During cardiac catheterization he was found to have
95% mid LAD thrombotic lesion, which was stented with a bare
metal stent. In the night after the procedure, he was febrile
and hypotensive, required pressors, and having put in a right
internal jugular Cordis, his Swan numbers suggested cardiogenic
shock with septic contribution. His blood cultures remained
negative but he was treated empirically for possible
hospital-acquired pneumonia (given earlier nursing home stay)
with piperacillin-tazobactam and vancomycin. He improved
somewhat from a hemodynamic point of view, improving his
apparent forward flow, and remaining afebrile after the first
days of his admission.
.
However, his mental status waxed and waned and he did have some
problems with sundowning; as the admission went on, it became
also clear that he became less responsive and more confused when
dopamine was turned off, including agitation that was only
mildly responsive to anti-psychotic treatment (olanzapine) and
required soft restratints for a time to prevent the patient from
pulling out his lines. We pulled his Foley, dressed his RIJ line
so that he could not pull it, and restarted dopamine which had
the effect of reducing his agitation.
.
We continued to make efforts to communicate with the patient
through a [**Name (NI) 8230**] interpreter and through his family.
Additionally, several members of the medical staff (a resident
and the palliative care consulting attending, as well as a
cardiology fellow assisting with a heart failure consult) were
able to have basic communication with him by speaking some
Mandarin, which the patient appeared to be able to understand.
Unfortunately, whether in [**Name (NI) 8230**] or Mandarin, the patient was
not entirely coherent even at this best, and was not able to
communicate much in the way of history or description of current
state; his family members said they were understanding as little
as a quarter of what he was trying to say.
.
Two echocardiograms early in the admission ([**4-19**] and [**4-20**])
showed diminished ejection fraction (the second showing
LVEF=35%), and apical and mid-left ventricular akinesis, as well
as moderate-to-severe AR and mild-to-moderate MR. It is likely
that his valvular disease decreased his forward flow more than
his LVEF would indicate, given that his cardiac output when
measured by Swan was generally quite low, and he was
dopamine-dependent for most of the admission. We found that even
when we attempted to reduce afterload in conjunction with
reducing dopamine, his mental status deteriorated and he became
barely responsive when not on dopamine during the second week of
his admission. Additionally, in consideration of the possibility
of hospice we contemplated theophylline and Sinemet as
substitutes for dopamine, but ultimately it became clear that he
would either require dopamine or have comfort care. The relation
between dopamine and mental status was effectively demonstrated
by two attempts to wean off dopamine in which mental status
markedly declined, and then revival of interactivity and
lessening of agitation when dopamine was restarted.
We discussed goals of care with the family, emphasizing that we
did not expect any significant recovery from his cardiac injury.
Palliative care was consulted and the palliative care attending
physician also discussed goals of care with the family on [**4-25**]. They understood the difficulties of his medical situation
but hoped to delay changing goals of care until other members of
the family could arrive. They did, however, agree to make Mr
[**Known lastname 20451**] DNR/DNI in the meantime. The cardiac care unit team agreed
to this plan and emphasized trying to maintain adequate
perfusion and mental status until more of the family could be
present over the weekend.
.
By the night of [**4-28**], most of the far-flung family had
arrived, and a large family meeting was conducted with all
family members, in which we emphasized that we did not expect Mr
[**Known lastname 20451**] to be able to function without dopamine, and pointed out
that we expected either a rapid decline without dopamine or a
slow but unpredictable (and possibly just as rapid) decline even
with more aggressive critical-care-level care, including
dopamine. Even before dopamine was stopped, Mr [**Known lastname 20451**] was having
increased episodes of apnea, and for the last two days had a
need for oxygen by nasal cannula.
.
After deliberation, and after another of the patient's nine
children was able to arrive from a flight from [**State 8842**] on the
morning of the 25th, the family and the medical and nursing
teams all agreed that the most appropriate plan of care was
comfort measures while the patient could be in the presence of
his family. Dopamine and other medications were discontinued and
morphine was started.
.
Mr [**Known lastname 20451**] died in the cardiac care unit in the morning of [**2136-4-30**],
having been surrounded by many members of his large extended
family for his last days. Before we turned off dopamine and for
a short time afterwards, Mr [**Known lastname 20451**] had clearly been able to
register and recognize his family's presence, and indeed
appeared to rally considerably in their presence, before fading
from consciousness as his cardiac and respiratory function
gradually slowed and lost effectiveness in the absence of
dopamine and other cardiac medications. Morphine was used and
appeared to be successful in preventing and treating respiratory
distress, pain and discomfort.
.
.
Medications on Admission:
MEDICATIONS (at NH):
Lisinopril 10mg daily
MVI
Famotidine 20mg [**Hospital1 **]
Colace 100mg [**Hospital1 **]
Metoprolol 12.5mg [**Hospital1 **]
Senna 2 tabs qhs
MOM 30ml prn
Fleet enema daily prn
Tylenol with codeine 300/30 q4h prn
Maalox 30ml q4h prn
.
MEDICATIONS (on transfer from cath lab):
Plavix 75mg daily
ASA 325mg daily
.
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Death caused by acute-on-chronic systolic and diastolic heart
failure secondary to STEMI.
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
[
"414.01",
"401.9",
"428.0",
"997.3",
"294.8",
"998.59",
"486",
"038.9",
"272.4",
"410.01",
"428.43",
"995.92",
"584.9",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"88.56",
"00.66",
"37.23",
"36.06",
"00.40",
"00.45"
] |
icd9pcs
|
[
[
[]
]
] |
11360, 11369
|
5168, 10950
|
297, 351
|
11502, 11511
|
3452, 5145
|
11563, 11698
|
1917, 1959
|
11332, 11337
|
11390, 11481
|
10976, 11309
|
11535, 11540
|
1974, 3433
|
223, 259
|
379, 1550
|
1572, 1759
|
1775, 1901
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,924
| 180,451
|
2681+55395
|
Discharge summary
|
report+addendum
|
Admission Date: [**2198-1-26**] Discharge Date: [**2198-2-6**]
Date of Birth: [**2129-4-3**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 10488**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
thrombolysis
History of Present Illness:
68 y/o with severe CAD with acute onset of chest pain and sob.
Pt report that since Monday he has been holding his ASA and
plavix in preparation for an upcoming hernia repair. on monday
he had a mild episode of CP / SOB and briefly resumed ASA /
plavix. Last evening at 730 he became fatigued. He awoke at 3am
with SOB (PND) and chest pain described as substernal presure.
It improved with 2 SL NTG and he reported to sleep. He again
awoke at 7am with SOB. While he was preparing to go to the ED,
he developed [**10-1**] non-radiating substernal pressure and severe
SOB. Also had a pleuritic aspect to the pain. He was profoundly
diaphoretic. Symptoms feel similar to previous cardiac pain. It
was minimally responsive to SL NTG at that time. The patient had
been holding his blood thinners because of an upcoming
procedure.
.
On arrival to the ED VS 96.5, 115/89, HR 60s-70s, 20, 98% 3L.
Shortly after arrival he became hypotensive to 81/51 but was
fluid responsive. CTA chest relieved a saddle PE and heparin gtt
was started. Recieved 3 L IVF. Received zofran 4mg IV and
morphine 2mg IV x 1.
Past Medical History:
# CAD s/p multiple PCIs: details below
# Diastolic CHF: EF 55% on [**9-30**] echo
# Hypertension
# Diabetes
# Hyperlipidemia
# Hypothyroidism
# GERD
# NASH
# Appendectomy
# Chronic back pain
# ED
# acoustic neuroma
# s/p appy
.
Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension
.
Percutaneous coronary interventions:
-- [**2182**]: anatomy unknown
-- [**7-/2194**]: Successful POBA and direct bare metal stenting of the
RCA.
-- [**8-/2194**]: One vessel coronary artery disease (known 2 vessel
CAD with LCA not injected). PTCA of the instent occlusion of
the distal RCA.
-- [**12/2194**]: POBA of the RCA and successful stenting of the Ramus.
-- [**7-/2195**]: Stenting of the distal AVG LCX. Stenting of the OM2-3
origin disease. Stenting of the proximal RI disease. All were
drug eluting stents.
-- [**9-/2195**]: PTCA and stenting of the AVG LCX (with a 2.5x15 mm
Xience DES) and proximal RI (with 3.0x16 mm Taxus DES).
-- [**5-/2196**]: 50-60% mid LAD, 80% distal LAD; 90% stent restenosis
at origin OM1; 40-50% distally; 90% restenosis of OM2. POBA with
cutting and kissing balloon.
Social History:
Spanish speaking only. Originally from [**Location (un) 13366**]. Married,
lives with wife and daughter. Currently retired.
Smoking: He has never smoked.
Alcohol: No alcohol in the last two years, though did drink
heavily in the past.
Drugs: He denies any illegal substance use.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. Family history otherwise
non-contributory.
Father died of an MI at age 83.
Mother died of an MI at age 78.
Physical Exam:
Admission physical exam
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
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps
Pertinent Results:
.
Echo [**2198-1-26**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). The right
ventricular cavity is moderately dilated with severe global free
wall hypokinesis. There is appearance of RV apical sparing
([**Last Name (un) 13367**] sign), worrisome for acute pulmonary hypertension
from pulmonary embolism. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Dilated and hypokinetic right ventricle, c/w acute
pulmonary hypertension. Small, underfilled left ventricle with
normal global and regional systolic function.
Compared with the prior study (images reviewed) of [**2196-5-27**], RV
systolic dysfunction is new. Findings discussed with Dr.
[**Last Name (STitle) **] at 0950 hours on the day of the study.
.
CTA chest [**2198-1-26**]
IMPRESSION:
1. Saddle embolus involving the bifurcation of the main
pulmonary artery and with extensive clot burden in the left
lung, specifically involving the left lower lobe segmental and
subsegmental arteries. Extensive thrombus is also present in the
ascending and descending portions of the right pulmonary artery.
Scattered bilateral segmental and subsegmental thrombi are
present.
2. Evidence of right heart strain with enlargement of the right
ventricle and loss of the normal right convex configuration of
the interventricular septum.
3. No evidence of pulmonary infarction.
.
[**2198-1-26**] LENIs
IMPRESSION:
No evidence of deep venous thrombosis.
.
CXR [**1-29**]-Portable AP chest radiograph was reviewed in comparison
to [**1-26**] and 5 chest radiograph. Heart size is normal.
Mediastinal position, contour and width are unremarkable. Lungs
are clear. No new consolidations to suggest interval development
of infection or pulmonary infarct has been demonstrated. No
pneumothorax is seen.
.
EKG [**1-26**] Sinus rhythm. Non-specific intraventricular conduction
delay. Non-specific T wave flattening in the precordial leads.
RSR' pattern in lead V1. Compared to tracing #3 T wave
flattening is new.
.
[**2198-1-26**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2198-1-26**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
[**2198-1-26**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
.
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2198-2-1**] 07:10 4.3 4.20* 11.8* 36.4* 87 28.1 32.4 16.1* 150
[**2198-1-31**] 07:15 5.1 4.27* 12.2* 35.4* 83 28.5 34.4 16.1*
142*
[**2198-1-30**] 07:30 6.3 4.67 13.1* 39.6* 85 28.1 33.2 16.2* 170
[**2198-1-29**] 04:51 3.9* 4.30* 12.0* 36.1* 84 27.8 33.2 16.2*
110*
[**2198-1-28**] 17:17 35.0*
[**2198-1-28**] 05:54 5.9 4.23* 12.2* 36.0* 85 28.8 33.8 16.3*
130*
[**2198-1-27**] 21:38 4.6 4.14* 11.7* 35.3* 85 28.2 33.1 16.2*
125*
Source: Line-PIV
[**2198-1-27**] 04:53 4.8 3.99* 11.5* 33.9* 85 28.8 33.9 16.3*
124*
[**2198-1-26**] 16:02 5.3 4.02* 11.6* 34.1* 85 28.8 34.0 16.3*
113*
[**2198-1-26**] 08:20 7.3 4.31* 12.2* 36.3* 84 28.3 33.6 16.0* 169
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2198-1-26**] 08:20 39.7* 54.3* 3.6 1.4 0.9
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2198-2-1**] 07:10 150
[**2198-2-1**] 07:10 27.0* 31.7 2.6*
[**2198-1-31**] 07:15 142*
[**2198-1-31**] 07:15 17.2* 27.4 1.5*
[**2198-1-30**] 12:15 14.3* 27.4 1.2*
[**2198-1-30**] 07:30 170
[**2198-1-29**] 04:51 110*
[**2198-1-29**] 04:51 13.1 72.7* 1.1
[**2198-1-28**] 23:04 72.0*
heparin dose: 1500
[**2198-1-28**] 17:17 75.2*
heparin dose: 1500
[**2198-1-28**] 09:24 48.0*
heparin dose: 1350
[**2198-1-28**] 05:54 130*
[**2198-1-28**] 05:54 13.5* 36.7* 1.2*
[**2198-1-28**] 02:10 38.8*
Source: Line-PIV L hand
[**2198-1-27**] 21:38 125*
Source: Line-PIV
[**2198-1-27**] 21:38 12.6 55.5* 1.1
Source: Line-PIV
[**2198-1-27**] 04:53 124*
[**2198-1-27**] 04:53 79.9*
[**2198-1-26**] 21:16 99.6*
[**2198-1-26**] 16:02 113*
[**2198-1-26**] 16:02 13.1 113.5*1 1.1
[**2198-1-26**] 08:20 169
[**2198-1-26**] 08:20 12.3 20.4*2 1.0
NOTIFIED [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] 510P [**1-26**]
VERIFIED BY REPLICATE ANALYSIS
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino
[**2198-1-28**] 05:54 148*
[**2198-1-28**] 02:10 159
Source: Line-PIV L hand
INHIBITORS & ANTICOAGULANTS Heparin
[**2198-1-28**] 02:10 <0.11
Source: Line-PIV L hand
<0.1
VERIFIED BY REPLICATE ANALYSIS
LAB USE ONLY
[**2198-2-1**] 07:10
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2198-2-1**] 07:10 183*1 16 1.0 140 4.5 105 26 14
LFT ADDED [**2-1**] @ 13:40
[**2198-1-31**] 07:15 175*1 12 0.8 137 4.2 104 24 13
[**2198-1-30**] 07:30 141*1 13 0.9 138 3.8 103 25 14
[**2198-1-29**] 04:51 227*1 11 0.9 138 3.9 104 23 15
[**2198-1-28**] 05:54 128*1 12 0.8 139 3.6 106 21* 16
[**2198-1-27**] 21:38 201*1
Source: Line-PIV
[**2198-1-27**] 04:53 140*1 13 0.5 140 3.9 108 24 12
[**2198-1-26**] 08:20 274*1 15 0.9 139 3.7 108 18* 17
BNP ADDED 12:39PM
IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES
ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2198-1-26**] 08:20 Using this1
BNP ADDED 12:39PM
Using this patient's age, gender, and serum creatinine value of
0.9,
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 60-69 is 85 (mL/min/1.73
m2)
GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2198-2-1**] 07:10 PND PND PND PND
LFT ADDED [**2-1**] @ 13:40
[**2198-1-31**] 07:15 77* 47* 95 0.4
[**2198-1-30**] 07:30 90* 51* 330*
[**2198-1-29**] 04:51 84* 39 270* 89 0.5
[**2198-1-28**] 05:54 1351
[**2198-1-27**] 15:20 1732
MODERATELY HEMOLYZED SPECIMEN
[**2198-1-27**] 04:53 1451
[**2198-1-26**] 23:28 1581
[**2198-1-26**] 21:00 1691
[**2198-1-26**] 16:02 1561
NEW REFERENCE INTERVAL AS OF [**2196-12-26**];UPPER LIMIT (97.5TH %ILE)
VARIES WITH ANCESTRY AND GENDER (MALE/FEMALE);WHITES 322/201
BLACKS 801/414 ASIANS 641/313
HEMOLYSIS FALSELY ELEVATES CK.
NEW REFERENCE INTERVAL AS OF [**2196-12-26**];UPPER LIMIT (97.5TH %ILE)
VARIES WITH ANCESTRY AND GENDER (MALE/FEMALE);WHITES 322/201
BLACKS 801/414 ASIANS 641/313
CPK ISOENZYMES CK-MB cTropnT proBNP
[**2198-1-28**] 05:54 3 0.04*1 565*2
[**2198-1-27**] 15:20 5 0.03*1 1230*2
MODERATELY HEMOLYZED SPECIMEN
[**2198-1-27**] 04:53 6 0.05*1
[**2198-1-26**] 23:28 7 0.07*1 1406*2
[**2198-1-26**] 21:00 7 0.08*1
[**2198-1-26**] 16:02 6 0.12*3
[**2198-1-26**] 08:20 <0.014
LIGHT GREEN
[**2198-1-26**] 08:20 112
BNP ADDED 12:39PM
CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
REFERENCE VALUES VARY WITH AGE, SEX, AND RENAL FUNCTION;AT 35%
PREVALENCE, NTPROBNP VALUES; < 450 HAVE 99% NEG PRED VALUE;
>1000 HAVE 78% POS PRED VALUE;SEE ONLINE LAB MANUAL FOR MORE
DETAILED INFORMATION
NOTIFIED [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] AT 0526 [**2198-1-26**]
CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
<0.01
CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2198-2-1**] 07:10 9.4 3.9 2.0
LFT ADDED [**2-1**] @ 13:40
[**2198-1-31**] 07:15 9.2 3.7 1.9
[**2198-1-30**] 07:30 9.8 3.3 2.1
[**2198-1-29**] 04:51 9.3 3.4 1.9
[**2198-1-28**] 05:54 9.1 3.1 1.9
[**2198-1-27**] 04:53 8.7 3.1 1.9
LAB USE ONLY GreenHd
[**2198-1-26**] 23:28 HOLD1
HOLD
DISCARD GREATER THAN 4 HOURS OLD
Blood Gas
BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2
Comment
[**2198-1-26**] 08:26 GREEN TOP
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Lactate
[**2198-1-26**] 16:09 2.7*
[**2198-1-26**] 08:26 5.1*1
MRI spine ([**2198-2-4**]): Status post left-sided L4-5 laminectomy. No
evidence of disc protrusion or nerve root compression, but the
left L4 and L5 nerve roots are surrounded by postoperative scar.
There is hyperintensity in the L4-5 disc on the long TR images,
but no enhancement of the disc after contrast administration.
This most likely reflects surgical changes, with infection far
less likely given the lack of disc enhancement.
Brief Hospital Course:
#Acute PE: convincing explanation for acute SOB and CE.
Radiographic evidence of a saddle embolus. Echocradiogram with
RV hypokinesis; however, patient remained hemodynamically
stable. The patient's LENIs showed no evidence of DVT. The
patient was started on an anticoagulation regimen with a heparin
gtt. After a day in the ICU, the patient began to expeience new
onset substernal pain/pressure. After contacting his
cardiologist, Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] and conferring with his colleague,
Dr. [**First Name (STitle) **] [**Name (STitle) **], the patient was started on tPA, which he
handled without any neurological complications. Following
administration of tPA, the patient's chest pain/pressure
resolved. The patient was then placed on Lovenox anticoagulation
therapy with coumadin. Pt remained hemodynamically stable after
discharge from ICU. He is likely going to require at least 6
months of anticoagulation. Pt will also need to ensure age
appropriate cancer screening and hypercoagulation work up in the
outpatient setting. Repeat echo can be considered in the
outpatient setting.
.
#h.o severe CAD s/p PCI-now off plavix per patient's
cardiologist Dr. [**Last Name (STitle) 911**]. Pt on asa, BB, statin, [**Last Name (un) **]. Pt taken off
plavix for now given current anticoagulation. He should f/u with
Dr. [**Last Name (STitle) 911**] as outpt after DC.
.
#DM 2 controlled. DM diet, FS QID, HISS while in house with [**Hospital1 **]
75/25 insulin. He can resume metformin after discharge.
.
#chronic diastolic CHF, but acute R.heart strain due to PE. Pt
continued on bb/asa as above. [**Last Name (un) **] was restarted on [**1-31**] and lasix
restarted?????
.
#Hypertension: Patient was restarted on many of his home
medications after several days in the ICU in which his blood
pressure first stabilized, then began to rise. No new
antihypertensive agents were added. Lasix????? BB, [**Last Name (un) **]
continued.
.
#Cough-CXR without infiltrate or failure. NO leukocytosis or
other signs of overt heart failure. Improved. Pt given incentive
spirometer and benzonatate.
.
#back pain-Pt reported sharp back pain similiar to chronic pain
which he has experienced since his back surgery. Pt typically in
L.buttock now in R.buttock. Pt without neurologic deficits. He
was given increased oxycodone 5-10mg q4 prn pain, tylenol prn,
heat/ice packs prn, added lidocaine patch. His pain did not
appropriately respond, and so pain service was consulted. They
initially tried neurontin, but this caused nausea, and then
tried pregabalin 50 mg qhs, which reduced his pain. We tried to
increase to pregabalin 50 mg [**Hospital1 **], but this resulted in some
dizziness. Ultimately, his pain regimen is oxycontin 10 mg po
bid, pregabalin 50 mg po qhs, valium prn, lidoderm patch,
tylenol, and oxycodone 5-10 mg po q4h prn. MRI of spine was done
with no acute process including bleed, mass, or infection; known
post-surgical changes on left were seen. PT evaluated him and
thought he was safe for discharge home with services.
.
#mild transaminitis-Pt with h.o NASH. On statin. Has been mildly
elevated in the past. trended downward to normal. Continue
statin given h.o severe CAD.
-trend and monitor LFTs. Will DC statin if continues to rise.
Could be somewhat congestive given R.heart strain from PE.
.
#thrombocytopenia/anemia. T.penia resolved this am. Pt on
coumadin. Hit ab checked in ICU and negative. Pt with mild
normocytic anemia. Is on anticoag but did not display signs of
active bleeding. Hct 36 and platelets 214 on discharge.
.
#hypothyroidism-continued home levothyroxine.
.
FEN:DM, cardiac diet
.
DVT PPx:coumadin/lovenox
.
GERD: Continued home H2 blocker.
Medications on Admission:
ASA 325mg QD
Plavix 75mg QD
Diovan 80mg QD
Metoprolol Succinate 200mg QD
Furosemide 20mg 1.5 tablets QD
NTG SL pRN
Metformin 850 [**Hospital1 **]
Levothyroxin 100mg QD
Insulin
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
acute pulmonary embolism
acute musculoskeletal back pain
.
CAD
diastolic heart failure
DM2
hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with chest pain and shortness of breath and
found to have a large blood clot in your lungs. You were
initially admitted to the ICU. For this, you were given a blood
thinning medication with good effect. Then, you were started on
additional blood thinning medication-lovenox and coumadin.
.
You had a flare of your back pain while you were here. You were
given pain medication and xray shows only degenerative changes.
This was followed up by an MRI of your spine, which showed some
known surgical changes on the right side, and degenerative
changes, but no acute infection or bleed.
.
You should make sure that you have routine health screening for
your age such as colonoscopy.
.
Medication changes:
1.Coumadin, to be continued for at least 6 months
2.Stool softeners
3.Pain medications: lidoderm patch, oxycontin, lyrica, tylenol,
oxycodone as needed, and valium as needed
.
Please take all of your medications as prescribed and follow up
with the appointments below.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs. Your discharge weight is 82 kgs (180.5 lbs).
Followup Instructions:
Department: [**Hospital3 249**]
When: FRIDAY [**2198-2-23**] at 10:10 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7212**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PAIN MANAGEMENT CENTER
When: MONDAY [**2198-3-12**] at 3:10 PM
With: [**Name6 (MD) 13368**] [**Last Name (NamePattern4) 13369**], MD [**Telephone/Fax (1) 1652**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
Note: This was the first available appt they had but you have
been placed on the cancellation list. If anything sooner
becomes available, the office will call you directly.
Name: [**Known lastname 1989**],[**Known firstname **] Unit No: [**Numeric Identifier 1990**]
Admission Date: [**2198-1-26**] Discharge Date: [**2198-2-6**]
Date of Birth: [**2129-4-3**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1991**]
Addendum:
Upon transfer to the floor on [**2198-1-30**], lasix was initially held
on the theory that the pt was still preload dependent. It was
not restarted during the hospital course, given that the patient
was euvolemic throughout the remainder of his stay, with roughly
stable weights, no shortness of breath, and no edema. Given that
his vital signs were stable on discharge, he may be restarted as
an outpt on low-dose lasix (e.g., 20 mg po daily).
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. metoprolol succinate 200 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
4. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual as directed.
5. metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day.
6. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.
8. Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: One (1)
Subcutaneous twice a day.
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*qs Tablet(s)* Refills:*0*
10. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
Disp:*qs Capsule(s)* Refills:*0*
12. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*qs Adhesive Patch, Medicated(s)* Refills:*2*
14. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) as needed for back pain.
Disp:*30 Tablet(s)* Refills:*0*
15. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for severe pain.
Disp:*30 Tablet(s)* Refills:*0*
16. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H
(every 4 hours) as needed for pain/fever.
Disp:*qs Tablet(s)* Refills:*0*
17. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
Disp:*60 Tablet Extended Release 12 hr(s)* Refills:*2*
18. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
Disp:*qs * Refills:*0*
19. pregabalin 25 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 42**] VNA
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 1992**] MD [**MD Number(2) 1993**]
Completed by:[**2198-2-7**]
|
[
"338.29",
"564.09",
"429.9",
"401.9",
"518.0",
"244.9",
"721.3",
"287.5",
"414.01",
"V58.67",
"V45.82",
"428.0",
"250.00",
"553.9",
"607.84",
"338.19",
"530.81",
"459.0",
"V58.61",
"571.8",
"272.4",
"415.19",
"785.59",
"428.32",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
21483, 21698
|
12335, 16069
|
314, 329
|
16502, 16502
|
3706, 12312
|
17800, 19415
|
2894, 3089
|
19438, 21460
|
16373, 16481
|
16095, 16272
|
16653, 17352
|
3104, 3687
|
17372, 17777
|
264, 276
|
357, 1453
|
16517, 16629
|
1475, 2579
|
2595, 2878
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,976
| 152,143
|
35678
|
Discharge summary
|
report
|
Admission Date: [**2185-1-8**] Discharge Date: [**2185-1-11**]
Date of Birth: [**2123-8-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
LUQ pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
61M with history of HTN, HL, unknown to [**Hospital1 22160**] transferred to
our ED from [**Hospital3 **] with LUQ pain. His pain level their
was requiring high levels of narcotics. He also was noted to be
in renal failure with hyperkalemia. He underwent a CT abd
without contrast (due to ARF) there which did not reveal an
acute process. Due to his high pain levels, ARF and enlarged
mediastinum on CXR he was sent here for MRI due to concern for
aortic dissection.
.
In our ED initial VS 97.4 106/67 104 16 97% on 15L NRB. He was
hypoxic to 74% on RA, NRB replaced, sats returned to high 90s.
He had an elevated BUN/Cr, hyperkalemia to 6. Was given
insulin/dextrose/CaGluconate/Kayexelate. No hyperkalemic ECG
changes. ECG was noted to be unremarkable with negative MB and
trop. He had a WBC of 17.8 with a left shift. Negative
LFTs/Lipase. AP CXR in our ED, fairly poor study due to body
habitus, did suggest a LLL. This could also be seen on OSH CT.
Had a bedside u/s of LUQ on ED, noted to be a poor study, no
acute etiology/pericardial effusion visualized. Lactate was WNL.
OSH d-dimer reported as WNL. He received azithromycin,
ceftriaxone for PNA. 2mg of dilaudid for pain control in
addition to aformentioned hyperkalemia tx. He got 3L of IVF.
Refused foley. At time of s/o no UOP. Had 3 18g PIVs prior to
transfer. He was transferred to the MICU service for his hypoxia
as well as being somewhat hypotensive, with systolic BPs in high
80s. He was reported as initially somnolent, thought to be due
to narcotics at OSH (morphine 18mg + Dilaudid 4mg), when pain
controlled was comfortable, when narcotics wore off was SOB,
grunting, tachycardic.
VS at time of transfer were: Afebrile 89/50 96% on NRB 18 HR 97
.
On arrival to MICU pt c/o [**4-3**] pleuritic LUQ pain. Reported
several days of myalgias and mild cough. Denied
fevers/sweats/chills/sputum production/sick
contacts/n/v/diarreha/melena or other complaints.
.
Past Medical History:
HTN
HL
Obesity
PTSD
Enlarged prostate
Social History:
Former marine, was in [**Country 3992**]. Retired chef, lives with wife. [**Name (NI) **]
tobacco, occasional marijuana, no other illicits. Rare EtOH. +
chewing tobacco history, quit over the summer.
Family History:
unable to obtain
Physical Exam:
Vitals: T: BP:98/59 P:96 R:15 O2: 99% 15L NRB
General: Somnolent, rousable. NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Thick, unable to appreciate JVP
Lungs: Decreased BS b/l L>R, sl crackles at bases.
CV: Tachy, regular, distant. Pulsus 25mmhg. BPs 110/70 b/l
Abdomen: Obese, mildly tense. + BS. No rebound or guarding. No
pain with palpation or LUQ. Guaiac - in ED.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2185-1-8**] 02:40AM BLOOD WBC-17.8* RBC-4.79 Hgb-14.8 Hct-44.9
MCV-94 MCH-30.9 MCHC-33.0 RDW-13.7 Plt Ct-265
[**2185-1-8**] 02:40AM BLOOD Neuts-88.8* Lymphs-6.0* Monos-4.6 Eos-0.4
Baso-0.1
[**2185-1-8**] 02:40AM BLOOD PT-13.5* PTT-24.4 INR(PT)-1.2*
[**2185-1-8**] 02:40AM BLOOD Glucose-143* UreaN-50* Creat-4.3* Na-143
K-6.0* Cl-105 HCO3-24 AnGap-20
[**2185-1-8**] 02:40AM BLOOD AST-17 CK(CPK)-176* AlkPhos-86
TotBili-0.5
[**2185-1-8**] 02:40AM BLOOD Lipase-33
[**2185-1-8**] 02:40AM BLOOD CK-MB-4 proBNP-137
[**2185-1-8**] 02:40AM BLOOD cTropnT-<0.01
[**2185-1-8**] 07:59AM BLOOD CK-MB-8 cTropnT-<0.01
[**2185-1-8**] 11:15PM BLOOD CK-MB-10 MB Indx-1.6 cTropnT-<0.01
[**2185-1-8**] 02:40AM BLOOD Albumin-4.3 Calcium-8.7 Phos-7.4* Mg-2.1
[**2185-1-8**] 07:29AM BLOOD D-Dimer-3169*
[**2185-1-8**] 07:53AM BLOOD Type-ART pO2-266* pCO2-56* pH-7.23*
calTCO2-25 Base XS--4
[**2185-1-8**] 07:53AM BLOOD Lactate-0.8 K-5.5*
.
Echo - The left atrium is normal in size. No atrial septal
defect is seen by 2D or color Doppler. There is mild symmetric
left ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
.
Outside hospital CT (read by our radiologist) - IMPRESSION: 1.
No acute abdominal/pelvic pathology identified. While
non-contrast evaluation of the aorta is unremarkable, evaluation
for dissection is limited without contrast.
2. Moderately enlarged prostate.
.
[**2185-1-8**] - chest x-ray
IMPRESSION: While atelectasis may represent a componet of the
bibasilar
opacity, pneumonia cannot be excluded; particularly on the left.
.
[**2185-1-10**] Renal U/S
1. No evidence of obstruction, renal mass, or nephrolithiasis.
2. Blood flow demonstrated to the right, equivocal on the left,
although this may be technical in etiology.
.
[**2185-1-10**] LENI
No evidence for deep vein thrombosis in the bilateral common
femoral,
superficial femoral or popliteal veins.
Brief Hospital Course:
This is a 61M with HTN, HL who presents with severe LUQ pain,
acute on chronic renal failure and a possible pneumonia.
.
# Respiratory distress: Transfered from [**Hospital 81171**] hospital hypoxic
with a respiratory acidosis, likly from splinting, underlying
OSA, and narcotics. His pulmonary process may have also
contributed. PNA was suspected given opacities on CXR, high WBC
and several days of malaise despite being afebrile. Influenza
and legionella negative. His story is also concerning for PE,
but negative LENI, and his conditon improved on antibiotics.
CTA was considered by impossible with renal failure, and VQ scan
not useful with possible pneumonia. On discharge he is
currently saturating well, not requiring O2 while resting. Will
continue abx outpatient, sputum and blood cultures pending.
Day #1 post discharge- pts blood cultures 2/4 were positive for
Gram positive rods (cornebacterium and propiobacterium). Pt was
called and was feeling well. The flora were felt to be most
likely secondary to a skin contaminate and given pts clinical
improvment, no adjustment to his antibiotics was felt necessary.
He was instructed to make an appointment with his new PCP
[**Name Initial (PRE) 176**] 1 week for follow up. The PCP office was updated and
sent a discharge summary. Pt was notified to return to the ER if
ongoing fevers, chills, lightheadedness, or worsening of his
symptoms.
.
# LUQ pain. Likely secondary to LLL PNA vs PE. Lipase normal,
pancreas normal on CT non-contrast, guaiac negative so less
concerned for PUD/diverticulitis. CEs negative with no ischemia
on ECG. D-dimer elevated which is concerning for PE but pain and
oxygenation has greatly improved and LENI negative as noted
above. On discharge pt is without chest pain.
.
#Pulsus parodoxus. Pt admitted to MICU with tachycardia,
hypotension, large pulsus on exam. Admitted physicians
considered pericardial effusion vs hypotension and tachycardia
due to sepsis or PE. TTE was negative for effusion. His pulse
has normalized with improved blood pressure.
.
# Acute on Chronic Renal Failure - atrophic kidneys on CT, has
chronic kidney disease, baseline Cr 2.1, now 2.5 down from 4.4.
Renal ultrasound was normal making post renal obstruction and
renal artery dissection less likely. Likely cause is pre-renal
from hypotension in setting of PNA. Pt's urine output was
minimal admission and normalized, with excellent output off
foley by discharge.
.
# HTN - on lisinopril/HCTZ at home, which was for now given
renal failure. His pressures improved from original hypotensive
state on admission. Discharged on home regimen.
.
# HL ?????? Continued simvastatin 20mg
.
# Anemia- Mild, normocytic, new after admission and rehydration.
This is most likely [**12-27**] hemodilution. Recommend outpatient
follow up if persistent.
.
# PTSD- Continued home dose of bupropion, citalopram and
clonazepam.
.
# OSA: Obstructive Sleep Apnea- Chronic, was given CPAP with
home machine, but pt refused treatment during parts of stay.
# Hx of duodenal ulcers - continued therapy with ranitidine
Medications on Admission:
Bupropion 200mg PO bid
Simvastatin 20mg PO qhs
Lisinopril-HCTZ 20/12.5mg 2tabs PO daily
Ranitidine 150mg PO BID
Clonazepam 1mg PO qhs
Citalopram 20mg PO qhs
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Bupropion 100 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO BID (2 times a day).
5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Lisinopril-Hydrochlorothiazide 20-12.5 mg Tablet Sig: One (1)
Tablet PO once a day.
7. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses
-Acute on Chronic Renal Failure
-Lobar pneumonia
-Hypoxia with respiratory depression
Secondary Diagnoses:
-Hypertension
-Hyperlipidemia
-Post Traumatic Stress Disorder
-Obstructive Sleep Apnea
Discharge Condition:
Hemodynamically stable, ambulating on RA, tolerating PO
Discharge Instructions:
You were transferred to the [**Hospital 18**] hospital from [**Hospital3 **]
due to difficulty breathing and severe pain.
At the [**Hospital1 18**], your difficulty breathing required a short stay in
the intenstive care unit but you did very well and were able to
go to a normal floor in under 2 days. Based on your history,
your physical exam and several differnt laboratory and imaging
studies it seems most likely you had a pneumonia, a lung
infection. You have been improving greatly on antibiotics.
.
You were given the following antibitoics. Azithromycin for 5
days (you completed the course in the hospital) and cefpodoxime.
You will continue this medication for 5 more days when you go
home.
Based on the studies we performed, we know you have had [**Last Name **]
problem with you heart, and it is very unlikely you had a blood
clot to your lungs.
The other medical problem you experienced in the hospital was
kidney failure. Your kidneys stopped makeing urine, probably
because you were sick with an infection. After a few days your
kidney function improved to your normal level. However, you
should be aware that you have had a degree of renal disease for
a long time.
Also, please try and rest and drink plenty of fluids for the
next several days. Please make your follow up appointments as
noted below.
Contact a medical provider if you experience any of the
following:
-Sudden shortness of breath
-Chest pain or pressure
-High fever
-8 hrs or more with no urine
-Any other concerning symptoms
Followup Instructions:
Pleaes call your Primary Care Doctor, Doctor [**Doctor Last Name **] for an
appointment within 1-2 weeks at ([**Telephone/Fax (1) 80083**].
Please call and get an appointment with a nephrologist. You can
ask your PCP to refer you.
|
[
"600.00",
"585.9",
"272.4",
"584.9",
"327.23",
"458.9",
"278.00",
"309.81",
"427.89",
"530.81",
"403.90",
"532.70",
"486",
"276.7",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9463, 9469
|
5500, 8579
|
322, 328
|
9725, 9783
|
3086, 5477
|
11350, 11586
|
2583, 2601
|
8787, 9440
|
9490, 9594
|
8605, 8764
|
9807, 11327
|
2616, 3067
|
9615, 9704
|
274, 284
|
356, 2288
|
2310, 2349
|
2365, 2567
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,079
| 151,604
|
826
|
Discharge summary
|
report
|
Admission Date: [**2177-5-14**] Discharge Date: [**2177-5-17**]
Date of Birth: [**2146-7-21**] Sex: F
Service: SURGERY
Allergies:
Dilaudid
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
ventral hernia
Major Surgical or Invasive Procedure:
umbilical and ventral hernia repair
History of Present Illness:
30yo female currently on HD, had PD catheter removed in [**Month (only) 116**]
[**2176**], with ongoing complaint of pain from an umbilical hernia.
Past Medical History:
- ESRD since [**2174-8-29**], currently on HD via tunneled line
- Peritonitis [**8-7**]
- Type I DM complicated by neuropathy and nephropathy
- Bilateral cataract surgeries
- Ventral Hernia
Social History:
- Lives with her mother, + tobacco history, social ETOH,
marijuana use noted in history
Family History:
DM type II, otherwise NC
Physical Exam:
upon admission:
Gen - NAD, AOx3
CV - RRR, S1/S2 appreciated
Chest - CTAB
Abdomen - soft, nontender, nondistended, well healed PD cath
removal site left abdomen, normal bowel sounds
Ext - no C/C/E
Pertinent Results:
upon admission:
WBC-7.9 RBC-3.72* Hgb-10.9* Hct-34.8* MCV-94 MCH-29.2 MCHC-31.2
RDW-18.1* Plt Ct-239
Glucose-78 UreaN-21* Creat-6.4*# Na-144 K-3.6 Cl-104 HCO3-30
AnGap-14
Calcium-8.4 Phos-3.3 Mg-2.1
[**2177-5-17**] 07:30AM BLOOD WBC-7.1 RBC-3.83* Hgb-11.4* Hct-36.3
MCV-95 MCH-29.9 MCHC-31.5 RDW-17.8* Plt Ct-253
[**2177-5-17**] 04:40AM BLOOD Glucose-122* UreaN-20 Creat-8.5*# Na-140
K-3.9 Cl-100 HCO3-24 AnGap-20
Brief Hospital Course:
The patient was admitted to the West-1 surgery for scheduled
ventral/umbilical herniorrhaphy on [**2177-5-14**], which went well
without complication (please refer to Operative Note for
details). In the PACU, the patient experienced significant pain
control issues as well as nausea and emesis. After
stabilization and improvement in symptoms, the patient was
transferred to the inpatient floor in stable condition.
Neuro: The patient received dilaudid with adequate pain control,
however patient experienced nausea likely related to narcotic
analgesia. She was transitioned to oxycodone during her
admission after improvement in surgical site pain.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI/GU/FEN: Post-operatively, diet was advanced when appropriate
and tolerated. Patient's intake and output were closely
monitored, and IV fluid was adjusted when necessary.
Electrolytes were routinely followed, and repleted when
necessary. Patient underwent scheduled hemodialysis while an
inpatient.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection.
Endocrine: Post-operatively, the patient's blood sugar levels
were monitored and a sliding scale implemented.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Carvedilol 12.5 mg [**Hospital1 **], Sensipar 30 mg Tdaily, Furosemide 60 mg
daily, Novolog
100 unit/mL Solution per sliding scale QID, Glargine 100 unit/mL
Solution
15 units qhs- fluctuates with appetite and blood sugars,
Lisinopril 20 mg daily, Oxycodone 5 mg Tablet [**11-30**] every four (4)
hours as needed for pain Sevelamer HCl 800 mg TID with meals,
Travoprost (Benzalkonium) [Travatan]
0.004 % Drops 1 gtt ou hs, Aspirin 81 mg daily, B complex
Vitamins daily, Folic Acid 1 mg daily,
Discharge Medications:
1. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. B Complex Vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
11. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
12. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
13. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous once a day.
14. Novolog 100 unit/mL Solution Sig: follow sliding scale
Subcutaneous four times a day.
15. Epogen 10,000 unit/mL Solution Sig: One (1) ml Injection
once a week.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Dialysis [**Location (un) **]
Discharge Diagnosis:
ESRD
Ventral hernia repair
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call Dr.[**Name (NI) 670**] office [**Telephone/Fax (1) 673**] if you have any of
the warning signs listed below.
Continue with your usual dialysis schedule
No heavy lifting/straining
No driving while you are taking pain medication
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2177-5-30**] 3:40
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2177-6-13**] 10:40
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 5808**] Date/Time:[**2177-7-4**]
10:40
Completed by:[**2177-5-21**]
|
[
"553.20",
"403.91",
"250.61",
"250.41",
"585.6",
"357.2",
"553.1",
"V45.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"53.69",
"53.41"
] |
icd9pcs
|
[
[
[]
]
] |
5394, 5475
|
1530, 3622
|
282, 319
|
5546, 5546
|
1091, 1093
|
5960, 6422
|
833, 860
|
4168, 5371
|
5496, 5525
|
3648, 4145
|
5697, 5937
|
875, 877
|
228, 244
|
347, 496
|
1107, 1507
|
5561, 5673
|
518, 710
|
726, 817
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,419
| 131,290
|
14623
|
Discharge summary
|
report
|
Admission Date: [**2196-7-23**] Discharge Date: [**2196-7-31**]
Date of Birth: [**2122-12-18**] Sex: M
Service: Cardiac Surgery
CHIEF COMPLAINT: Third degree heart block and inferior
myocardial infarction.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 29721**] is a 72 year-old man
with a history of hypertension, hypercholesterolemia and
acute myocardial infarction who was transferred from [**Hospital 189**]
[**Hospital 107**] Hospital to the cardiology service for bradycardia
and heart block with symptomatic syncope. Two days prior to
his transfer to [**Hospital1 69**] he
experienced several episodes of dizziness and syncope. He
was standing at the kitchen counter when he felt the counter
spinning and lost consciousness and fell to the floor. It
was unwitnessed and he reports coming to in about a minute.
This happened approximately two other times that day and
eventually reported to the local Emergency Room. There he
was found to have complete heart block with relative
hypotension and temporary pacing wires were placed. He also
had cardiac enzymes that were consistent with ST segment
elevation myocardial infarction. [**Doctor Last Name **] they also attempted
cardiac catheterization but were not successful. The
following day he was transferred to [**Hospital1 190**] for electrophysiologic evaluation.
PAST MEDICAL HISTORY: Is notable for the following. 1)
hypertension, 2) myocardial infarction in [**2187**], 3)
hypercholesterolemia, 4) tobacco abuse, quit 12 years ago.
MEDICATIONS ON TRANSFER: 1) Enalapril 10 mg p.o. q.d., 2)
Norvasc 5 mg p.o. q.d. which was started on the day prior to
transfer. 3) aspirin 325 mg p.o. q.d., 4) Lipitor 20 mg p.o.
q.h.s. which was started on the day prior to transfer, 5)
Ancef 1 gram intravenous q. 8, 6) Xanax 0.5 mg p.o. q 6 hours
p.r.n., 7) Tylenol 2 tablets q 3 hours p.r.n. The patient is
not allergic to any medications.
SOCIAL HISTORY: The patient is a retired plumber who lives
with his wife. [**Name (NI) **] smoked one pack of cigarettes per day of
50 years, quitting 12 years ago. He has a sister with
coronary artery disease who is status post coronary artery
bypass graft and in her 80s.
PHYSICAL EXAMINATION: His temperature is 100, his blood
pressure is 125/52, heart rate is in the 80s to 90, oxygen
saturation is 94 percent on room air. In general he is a
youthful appearing older man in no acute distress. Head,
eyes, ears, nose and throat: he is normocephalic,
atraumatic. Oropharynx is clear. His neck is supple. There
is a right internal jugular line in place for pacing.
Cardiovascular: he has regular rate and rhythm but with
frequent ectopy. Lungs are clear to auscultation
bilaterally. Abdomen is soft, nontender, nondistended with
normal active bowel sounds. Extremities have palpable pulses
and no edema. Neurologically he is awake and oriented times
three and language and comprehension are intact. Extraocular
movements are intact. Pupils equal, round, reactive to
light. Patient's palate and tongue are midline with normal
movement. Strength is 5 out of 5 and his deep tendon reflexes
are intact and his toes are downgoing.
LABORATORY STUDIES AT OUTSIDE HOSPITAL: White blood cell
count was 6.5, hematocrit was 43, platelets were 130, BUN 13,
creatinine 1.0, HDL cholesterol was 31, LDL cholesterol is
164, total cholesterol is 218. Troponin is 5.4.
HOSPITAL COURSE: The patient was admitted to cardiology
service with the diagnosis of acute inferior myocardial
infarction and bradycardia with third degree heart block. He
was paced with temporary packing wires. He was taken to the
cardiac catheterization laboratory where he was found to have
80 percent left main disease and was referred for coronary
artery bypass grafting.
An incidental finding on the catheterization was a right
internal iliac moderate calcification and proximal iliac
aneurysm approximately 3.5 cm in diameter. His abdominal
aorta was normal.
On [**2196-7-25**] patient was taken to the operating room
where he had off pump coronary artery bypass grafting time
two. His grafts are LIMA to LAD and saphenous vein graft to
OM. As summarized above the indications for his operation
were unstable angina and emergent conduction abnormalities.
Postoperatively he was taken intubated to the cardiac surgery
Intensive Care Unit on NeoSynephrine and Propofol drips. He
remained intubated overnight and his NeoSynephrine was gently
weaned. The following morning he was extubated without [**Last Name **]
problem and his pressor requirement was soon weaned
completely off. He did have an isolated episode of AV
dissociation overnight and the electrophysiology team
concluded that a conduction study was necessary. By the
second postoperative day he had been transferred to the
floor, appeared to be in a sinus rhythm with 1:1 conduction
and did not appear to be experiencing any further conduction
abnormalities. He had a transthoracic echocardiogram that
demonstrated some moderate right ventricular free wall
hypokinesis and moderate 1 to 2+ mitral regurgitation. By the
third postoperative day the patient was taken to the
electrophysiology laboratory where he had a study that
revealed inducible ventricular tachycardia. For this reason
he had an internal cardiac defibrillator and pacemaker
implanted. The patient's procedure itself was unremarkable.
He did receive 48 hours of antibiotic afterwards.
The remainder of the [**Hospital 228**] hospital course was relatively
unremarkable. His chest tubes and Foley were discontinued in
normal fashion. His temporary pacing wires were discontinued
after his electrophysiology intervention. By the patient's
fifth postoperative day he was nearing the time of discharge
but was found to desaturate to approximately 85 percent when
ambulating with physical therapy. For this reason he was
kept for another day. His diuresis was continued and by the
date of his discharge he was maintaining his saturations
adequately well and met all the criteria to be discharged
home.
On [**2196-7-31**] he was discharged home in stable condition
in the care of his family. He was instructed to follow up in
[**Hospital **] Clinic in one week. Their phone number is
[**Telephone/Fax (1) 21817**]. In addition he is to see his primary care
physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 43109**] in one to two weeks. He is
also to see his cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1147**] in two to
three weeks and to follow up with Dr. [**Last Name (STitle) 1537**] in four weeks.
Patient is discharged on the following medications: 1)
Lopressor 25 mg b.i.d., 2) Plavix 75 mg p.o. q.d. times three
months. 3) enteric coated aspirin 325 mg q.d., 4) Colace 100
mg b.i.d., 5) Lipitor 20 mg p.o. q.d., 6) Lasix 20 mg p.o.
b.i.d. times seven days, 7) potassium chloride 20 mEq p.o.
b.i.d. times seven days, 8) Serax 15 mg p.o. q.h.s. p.r.n.
9) Tylenol 650 mg p.o. q 4 to 6 hours p.r.n. 10) ibuprofen
400 mg p.o. q 4 to 6 hours p.r.n. 11) Percocet 5/325 1 p.o.
q 4 to 6 hours p.r.n.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease and left main disease, now
Status post coronary artery bypass graft times two.
2. Complete heart block, now status post pacemaker
insertion.
3. Inducible ventricular tachycardia, now status post
internal cardiac defibrillator insertion.
4. Inferior wall myocardial infarction.
5. Hypertension, controlled.
6. Hypercholesterolemia.
7. Prior tobacco abuse.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 9638**]
MEDQUIST36
D: [**2196-7-31**] 13:06
T: [**2196-7-31**] 13:16
JOB#: [**Job Number 43110**]
|
[
"401.9",
"440.0",
"426.0",
"442.2",
"410.41",
"443.9",
"427.1",
"414.01",
"426.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"88.47",
"88.53",
"36.11",
"39.50",
"37.23",
"88.42",
"37.94",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
7177, 7901
|
3422, 7156
|
2231, 3404
|
167, 229
|
258, 1358
|
1558, 1930
|
1381, 1532
|
1947, 2208
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,452
| 162,611
|
38535
|
Discharge summary
|
report
|
Admission Date: [**2135-12-9**] Discharge Date: [**2135-12-13**]
Date of Birth: [**2060-4-24**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 28286**]
Chief Complaint:
Lightheadedness
Major Surgical or Invasive Procedure:
Pacemaker placement
History of Present Illness:
75 yo female history of HTN, HL, CAD s/p MI, and chronic afib on
warfarin transferred to the CCU for CHB in the setting of
chronic afib. Her afib has been notoriously hard to control
with high doses of atenolol and diltiazem twice daily.
.
For the past 48 hours, she has felt extreme lightheadedness,
nausea, and weakness in bilateral legs and in the center of her
low back. She reports shortness of breath without chest pain.
Her shortness of breath is improved with laying flat. She
reported palpitations today followed by lightheadedness. She
denies losing consciousness. She denies taking an extra dose of
nodal blockade today. Her last doses were this morning. She
was seen at the [**University/College **] Atrius today where they sent her to
NWH ED. There she was given glucagon with no response except
subsequent nausea and vomiting. She was transferred to [**Hospital1 18**]
and admitted to [**Hospital Ward Name 121**] 3 where EKG revealed some wide QRS
complexes concerning for a lower junctional rhythm. She was
tranferred to the CCU for further monitoring.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative. She had her flu shot a
few weeks ago at her annual well visit.
.
Cardiac review of systems is notable for paroxysmal nocturnal
dyspnea and presyncope. She reports the absence of chest pain,
dyspnea on exertion, orthopnea, ankle edema, or syncope. She
denies any history of CHF, diabetes, or stroke.
.
Past Medical History:
1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY: Coronary artery disease, inferior
myocardial infarction in [**2123**] with angioplasty and stenting of
RCA
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: none
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- Aortic valve insufficiency
- Atrial Fibrillation, CHADS = 2, previously hard to control
- Hyperlipidemia, not currently on therapy: previously on simva,
taken off b/c off dilt, then on crestor but intolerant due to
nausea
- Hypertension
- Fatty liver
- Obesity
- Colonic polyps
- Esophageal Reflux
- Osteopenia
- Anxiety
- Arthritis in hands
- S/p right total knee replacement [**11-10**], left knee TKR [**12-12**]
- Right ankle surgery with hardware [**1-14**]
- Ovarian cyst removal
- Tubal Ligation
- Tonsillectomy as a child
Social History:
Lives alone in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] in Marlbourough for over 55 people. Has
a maltese name [**Last Name (un) **]. Performs all of her own iADL's and ADL's
independently including driving.
- Tobacco history: 1-1.5 ppd for 25 years, quit [**2103**]
- ETOH: 2 drinks per night at 5pm with friends
- Illicit drugs: None.
Family History:
- Mother: multiple strokes
- Father: MI at 79, d.84
- Brother: MI at 55
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.6, 38, 112/52, 24, 95% 4LNC
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple without JVD. No bruits.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Irregularly irregular and bradycardic. Normal S1, S2. No
m/r/g. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: +BS, soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
BACK: no rashes, no reproducible pain or tenderness
EXTREMITIES: wwp, no c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+
PT 2+
NEURO: CN 2-12 intact, 5/5 strength in UE and LE
.
DISCHARGE PHYSICAL EXAM:
VS: Temp 98.3, HR 72-81, RR 18, BP 129-164/79-108, O2 sat 96% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: Conjunctiva were pink, no pallor or cyanosis of the oral
mucosa.
NECK: Supple without JVD. No bruits.
CARDIAC: Irregularly irregular. Normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4. Left pacer site with no ecchymosis,
mild swelling and tenderness. Dressing with no bleeding.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: +BS, soft, NTND. No HSM or tenderness.
BACK: no rashes, no reproducible pain or tenderness
EXTREMITIES: wwp, no c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+
PT 2+
NEURO: CN 2-12 intact, 5/5 strength in UE and LE
Pertinent Results:
ADMISSION LABS:
[**2135-12-9**] 06:38PM GLUCOSE-106* UREA N-23* CREAT-0.9 SODIUM-137
POTASSIUM-4.8 CHLORIDE-103 TOTAL CO2-21* ANION GAP-18
[**2135-12-9**] 06:38PM WBC-8.5 RBC-3.97* HGB-13.3 HCT-38.9 MCV-98
MCH-33.5* MCHC-34.2 RDW-13.8
[**2135-12-9**] 06:38PM PT-21.5* INR(PT)-2.0*
.
PERTINENT LABS:
[**2135-12-10**] 06:15AM BLOOD CK-MB-1 cTropnT-<0.01
[**2135-12-9**] 06:38PM BLOOD CK-MB-1 cTropnT-<0.01
.
DISCHARGE LABS:
CXR [**12-10**]
IMPRESSION:
1. The heart is borderline enlarged given AP technique. The
aorta is
somewhat unfolded and tortuous. The lungs are grossly clear with
the
exception of linear opacity at the right base which likely
reflects
subsegmental atelectasis. No pulmonary edema, pneumothorax, or
pleural
effusions are appreciated.
Brief Hospital Course:
ASSESSMENT AND PLAN: 75 year old female with history of HTN, HL,
CAD s/p MI, and chronic afib on warfarin presented with
lightheadedness and nausea found to have complete heart block on
EKG.
.
# symptomatic bradycardia: The patient presented with
symptomatic bradycardia in atrial fibrillation, and was found to
have a heart rates in the 30-40s. All of the patient's home
nodal blockade medications, including Atenolol 100 mg [**Hospital1 **] and
dilt 180 mg [**Hospital1 **], were held on admission. The patient was also
given glucagon, which did not really have much effect on her
heart rates. The patient was ruled out for MI with negative
cardiac enzymes. Her bradycardia could be secondary to
worsening conduction delays due to aging. The patient had pacer
pads placed; she also had one episode of hypotension, which
responded to a 500cc NS bolus. The patient was also seen by EP
and it was decided that a pacemaker should be placed. The
patient has a CHADS of 2 and her coumadin was held prior to the
procedure, but was restarted the night prior to the procedure.
Throughout the hospitalization, the patient's heart rate trended
up and the morning prior to the procedure, the patient's heart
rates were in the 70-80s. The patient had the pacemaker placed
on [**2135-12-12**], and tolearated the procedure well. Post procedure,
she was started on Vancomycin while in patient, and she was
discharged on Keflex 500 mg QID for another two days. The
patient also had a post procedure CXR the morning after
procedure, which was normal. She was also instructed to wear a
sling at night for one week post procedure. She will follow up
as an outpatient in device clinic, as well as following up with
Dr. [**First Name (STitle) **] as an outpatient.
.
# atrial fibrillation: The patient has been in slow atrial
fibrillation while in the CCU. Her home medications included
Dilt 180 mg [**Hospital1 **] and Atenolol 100 mg [**Hospital1 **]. As her medications
began to wash out, the patient's heart rates began to increase.
She still had her pacemaker placed and the patient was
discharged on her home nodal agents, without any changes made in
her medication. She will follow up with Dr. [**First Name (STitle) **] as an
outpatient and medication titration will be done as needed. Her
coumadin was restarted.
.
# CAD: The patient has a history of MI in [**2123**] with RCA stent.
She was ruled out for MI as the cause of her symptomatic
bradycardia. We continued the patient on ASA during this
hospitalization, however, the patient's lisinopril was held
because she was a little bit hypotensive. The patient's beta
blocker was also held because of her bradycardia.
.
# PUMP: The patient appeared euvolemic on exam, and does not
have any history of heart failure. Strict I/Os were measured
and daily weights were followed. The patient's Lisinopril and
beta blocker were held.
.
Chronic Issues:
# GERD: The patient was continued on her home ranitidine.
# Insomnia: The patient was continued on her home lorazepam
# IBS: The patient's florastor was restarted upon discharge.
.
Transitional Issues:
- depending on the patient's heart rate/symptoms, consider
titrating down her nodal agents in the outpatient setting.
However, now that she has the new pacemaker, she should no
longer have bradycardic episodes.
- Echo revealed moderate MR, will need repeat TTE in one year.
Medications on Admission:
- Lorazepam 0.5 mg qhs PRN insomnia
- Ranitidine HCl 150 mg QHS
- Warfarin 2.5 mg four days per week, 1.25 three days per week
- Atenolol 100 mg [**Hospital1 **]
- Diltiazem HCl 180 mg [**Hospital1 **]
- Lisinopril 10 mg Daily
- Florastor
- NITROGLYCERIN 0.4MG prn CP - never used
- ASPIRIN 81MG daily
- MULTIVITAMIN [**Last Name (un) **] CAPSULE PO (MULTIVITAMINS) 1 po qd
- CALCIUM CARBONATE TABLET 650MG PO as directed
Discharge Medications:
1. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Days
(Tues/Wed/Fri/Sun).
4. warfarin 2.5 mg Tablet Sig: 0.5 Tablet PO Days
(Mon/Thurs/Sat).
5. atenolol 100 mg Tablet Sig: One (1) Tablet PO twice a day.
6. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO twice a day.
7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Florastor 250 mg Capsule Oral
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. calcium carbonate 650 mg calcium (1,625 mg) Tablet Sig: One
(1) Tablet PO once a day.
12. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO three
times a day for 5 days.
13. oxycodone 5 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
14. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 2 days.
Disp:*8 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis:
atrial fibrillation
AV nodal dysfunction
symptomatic bradycardia
.
secondary diagnosis:
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
chest pain free.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you while you were hospitalized
at [**Hospital1 18**]. You were admitted to the hospital because you were
feeling very light-headed, and you were found to have a heart
rate that was very low. We gave you medications that would help
counter the effects to some of your home medications. We also
had the doctors [**First Name (Titles) 1023**] [**Last Name (Titles) **] with heart rates see you, and it
was decided to go ahead and insert a pacemaker into your chest
to make sure that your heart rate does not become too slow.
..
You had the pacemaker placed and it is working properly. You
tolerated the procedure well. Please wear the sling at night for
a week. You will also take an antibiotic for 2 days to prevent
an infection at the pacer site. Please call Dr. [**First Name (STitle) **] for any
increase in swelling, pain, redness or bleeding at the pacer
site. No lifting more than 5 pounds with your left arm for 6
weeks, no driving for one week.
.
We made the following changes to your medicines:
1. Start acetaminophen (tylenol) extra strength 2 tablets three
times a day for pain. YOu can take an oxycodone as needed if the
pain is not relieved by the acetaminophen.
2. START Cephalexin (Keflex) four times a day for the next 2
days to prevent an infection at the pacer site.
Followup Instructions:
Name: [**Last Name (un) 85715**],[**Last Name (un) **] F. MD
Location: [**Location (un) 2274**] [**University/College **] -Primary Care
Address: [**Hospital1 3470**], [**University/College **],[**Numeric Identifier **]
Phone: [**Telephone/Fax (1) 85716**]
Appt: [**12-19**] at 3:20pm
.
Location: [**Location (un) 2274**]-[**Location (un) **]--Dept of Cardiology/Device Clinic
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2258**]
Appt: [**12-20**] at 4pm
.
Name: [**Last Name (LF) **], [**Name8 (MD) 2922**] MD
Location: [**Location (un) 2274**] [**University/College **] -Cardiology
Address: [**Hospital1 3470**], [**University/College **],[**Numeric Identifier **]
Phone: [**Telephone/Fax (1) **]
Appt: [**1-4**] at 11:40pm
|
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31,226
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31101
|
Discharge summary
|
report
|
Admission Date: [**2113-12-4**] Discharge Date: [**2113-12-5**]
Date of Birth: [**2035-6-1**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
elective right carotid angiography and possible stenting
Major Surgical or Invasive Procedure:
Carotid angiography and stent placement
History of Present Illness:
78 yo female with known coronary artery and peripheral [**First Name3 (LF) 1106**]
disease, status post AMI and LAD, LCX and left carotid
revascularizations in [**Month (only) 205**], now referred for right carotid
angiography and possible revascularization.
.
The patient states that she had been in her usual state of
health, and is now here for elective
angiography/revascularization. In [**8-12**], the patient had an
anterior STEMI and was taken to the cath lab at [**Hospital1 **], where
she was found to have an 80%
proximal LAD stenosis, an 80-90% LCX stenosis, an 80% RCA
stenosis and a 60-70% ramus stenosis. Given her 3 vessel
disease.
she was transferred to [**Hospital1 18**] for evaluation by CT surgery for
possible CABG A carotid ultrasound was done as part of her
evaluation and she was found to have 80-90% bilateral carotid
stenosis, making her a poor surgical candidate. She was also
found to have poor conduits due to prior vein stripping. She was
therefore referred for percutaneous intervention.
.
On [**2113-8-23**], she returned to the cath lab for a successful
thrombectomy, angioplasty and stenting of her proximal LAD with
a
2.5 x 18mm Cypher DES. Carotid angiography revealed bilateral
high grade carotid stenosis. She had a 90% Mid LCX stenosis and
a
60% proximal Ramus stenosis that were not intervened upon at
that
time. (RCA disease not reported in cath report)
.
She returned again to the cath lab on [**2113-8-24**] for carotid
angiography. This revealed a 99 % left internal carotid artery
stenosis and a 60% right internal carotid artery stenosis. She
was also found to have an 80% right subclavian artery stenosis.
She underwent a successful left internal carotid intervention
with placement of a [**7-14**] x 30mm acculink stent. A 6F angioseal
was
placed to her right femoral artery at that time.
.
The patient??????s post procedure course was complicated by a GI
bleed
with a hct drop from 28 to 23.5. She was treated with 2 units of
PRBC??????s. A colonoscopy was significant for rectal polyps,
external
hemorrhoids and diverticulosis of the entire colon.
.
The patient returned again to the cath lab on [**2113-11-1**] and had a
3.0 x 18mm Cypher stent placed to the mid circumflex and a 2.5 x
8mm Cypher to the OM1. A 3.5 x 18mm Cypher DES was also placed
to the mid RCA.
.
The patient was admitted to the CCU after her angiography and
revascularization of her right cartoid. She had a 7-10x30mm
Acculink
stent posted with a 4.5mm balloon to 16atms. Excellent result
with
normal flow down vessel and 10% residual. Post procedure; the
patient is doing well. She is without complaints. She denies
chest pain, shortness of breath, weakness or dumbness in the
extremeties, dysarthria, or visual changes. The patient was
already blind in her left eye. Her SBPs have been in the
90s-110s.
.
On review of symptoms, she denies any prior history of stroke,
TIA, amurosis fugax, deep venous thrombosis, pulmonary embolism,
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 paroxysmal
nocturnal dyspnea, orthopnea, palpitations, syncope or
presyncope. Of note, the patient reports chronic LE edema for
which she is taking a "water pill."
Past Medical History:
CARDIAC HISTORY:
Percutaneous coronary intervention, in anatomy as follows:
stenting of proximal LAD with a 2.5 x 18mm Cypher DES
3.0 x 18mm Cypher stent placed to the mid circumflex and a 2.5 x
8mm Cypher to the OM1.
A 3.5 x 18mm Cypher DES was also placed to the mid RCA.
left internal carotid placement of a [**7-14**] x 30mm acculink stent.
.
PAST MEDICAL HISTORY:
CAD s/p anterior MI/LAD stent [**8-12**]
GI bleed [**8-12**] post LAD and carotid intervention
Left carotid artery stenosis, s/p stent [**8-12**]
Hypertension
Hyperlipidemia
Macular degeneration-Left Eye Blindness
Varicose veins s/p remote bilateral lower extremity vein
stripping
Morbid obesity
Degenerative joint disease
Remote appendectomy
Remote hysterectomy
Social History:
Married, lives at home with her husband. Retired. Daughter,
[**Name (NI) 1785**] is very involved in patient??????s care The patient does not
drink any alcohol. She denies history of drug use. She currently
does not smoke; but has a 40+ pack year history. Currently has
[**Location (un) 1110**] VNA
Family History:
Her Father had a heart attack at age 64. There is no family
history of premature coronary artery disease or sudden death.
Physical Exam:
VS: T 97.3, BP 102/39 , HR 58 , RR 20, O2 96% on RA
Gen: elderly obese female in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. right pupil 3 mm, left pupil 1
mm, non reactive, EOMI. Conjunctiva were pink, no pallor or
cyanosis of the oral mucosa.
Neck: Supple with JVP 6-8 cm
CV: RRR, normal S1, S2. No S4, no S3.
Chest:Resp were unlabored, no accessory muscle use. Clear
anteriorly. No crackles, wheeze, rhonchi.
Abd: Obese, soft, NTND. No abdominial bruits.
Ext: 1+ BLE edema, chronic venous stasis changes. No femoral
bruits. right groin central line in place, no tenderness, no
hematoma, no thrill.
Pulses:
Right: Carotid 2+ without bruit; 1+ DP, 2+ PT
[**Name (NI) 2325**]: Carotid 2+ with bruit; 1+ DP, 2+ PT
Pertinent Results:
[**2113-12-5**] 05:43AM BLOOD WBC-5.5 RBC-3.53* Hgb-10.4* Hct-31.8*
MCV-90 MCH-29.4 MCHC-32.5 RDW-13.9 Plt Ct-173
[**2113-12-5**] 05:43AM BLOOD Plt Ct-173
[**2113-12-5**] 05:43AM BLOOD Glucose-86 UreaN-26* Creat-0.9 Na-139
K-4.1 Cl-112* HCO3-23 AnGap-8
[**2113-12-5**] 05:43AM BLOOD CK(CPK)-77
[**2113-12-4**] 08:51PM BLOOD CK(CPK)-61
STUDIES:
CATHETERIZATION:
PTCA COMMENTS: Initial angiography revealed a 90% focal
stenosis of
the right internal carotid artery. We planned to perform
PTCA/stenting
to this lesion. Heparin was commenced prophylactically. A 6F
Shuttle
sheath was inserted into the right common carotid. A 6.5mm
AccuNet
filter was deployed distally. The lesion was predilated with a
2.5mm
balloon and then stented with a [**8-15**] x30mm Acculink stent posted
with a
4.5mm balloon to 16atms. Excellent result with 10% residual and
normal
flow down vessel. The filter was retrieved without difficulty
and no
evidence of embolic debris. The patient was stable at end of
procedure
with no neurlogical symptoms.
.
COMMENTS:
1. The LCCA is normal. The previous left internal carotid stent
is
patent.
2. The RCCA is normal. The right ICA has a focal 90% lesion with
post-stenotic dilatation. The ICA fills the ipsilateral MCA/ACA
and
cross fills the contralaterl ACA.
3. Successful PTA and stenting of right ICA with a 7-10x30mm
Acculink
stent posted with a 4.5mm balloon to 16atms. Excellent result
with
normal flow down vessel and 10% residual. Patient left cathlab
in stable
condition with no neurological sequelae.
FINAL DIAGNOSIS:
1. Focal 90% stenosis of right ICA
2. Patent left ICA stent
3. Successful PTA and stenting of right ICA with 7-10x30mm
stent.
Brief Hospital Course:
78 yo female with CAD, peripheral arterial disease,
hypertension, and hyperlipidemia presents for elective right
carotid angiography and revascularization now s/p stent
placement of R carotid
.
# s/p R carotid stenting: The patient had 7-10x30mm Acculink
stent posted with a 4.5mm balloon to 16atms in the right
carotid. Dr. [**First Name (STitle) **] had an SBP goal for the patient of 100-180.
Her SBP tended to stay in the low 100s, but occasionally dipped
down into the low 90s and upper 80s. With normal saline boluses
of 250-500 cc, the patient maintained her SBP>100. She had no
neurological deficits noted on exam. She had no change in
mental status. At discharge, she was able to ambulate without
difficulty at her baseline level. She tolerated the procedure
well and there were no immediate complications. She will
followup with Dr. [**First Name (STitle) **] in one month, and follow up with her
PCP this week for a BP check. She will need to continue her
aspirin and plavix indefinitely or until determined by her
cardiologist. She will also need to restart her
anti-hypertensive medications as well.
.
# CAD: The patient is s/p stenting of proximal LAD with a 2.5 x
18mm Cypher DES
3.0 x 18mm Cypher stent placed to the mid circumflex and a 2.5 x
8mm Cypher to the OM1. A 3.5 x 18mm Cypher DES was also placed
to the mid RCA. These were all done on prior admissions. The
patient was chest pain free during this hospitalization, and she
will con't ASA, plavix, statin, and anti-hypertensives after
discharge.
.
# Hyperlipidemia: The patient will continue her outpatient
statin dose.
.
# H/o GIB: The patient's HCT remained stable during this
hospitalization.
Medications on Admission:
Aspirin 325mg daily in the am
Plavix 75mg daily in the am
Atenolol 25mg daily in the am
Triamterene/hctz 37.5/25mg daily in the am
Lipitor 80mg [**2-7**] tablet daily in the pm
Xalatan 0.005% 1 gtt OU qHS
Cosupt 1gtt OU [**Hospital1 **]
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day:
restart on [**2113-12-7**].
7. Triamterene-Hydrochlorothiazid 37.5-25 mg Tablet Sig: One (1)
Tablet PO once a day: restart [**2113-12-7**].
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Primary Diagnosis: Right Carotid Angiography and Stent Placement
Secondary Diagnosis:
Coronary Artery Disease
Peripheral Arterial Disease
Hypertension
Hyperlipidemia
Discharge Condition:
stable
Discharge Instructions:
You were admitted for elective right carotid angiography and
intervention. You had a stent placed in your right carotid
artery because of a blockage. You tolerated the procedure well.
You had a slightly low blood pressure that responsed well to IV
fluids. You were discharged home without any complications.
Please hold your blood pressure medications and restart them on
[**2113-12-7**]. Please take all other medications as prescribed.
Please go to all appointments as scheduled.
If you develop any of the following concerning symptoms, please
call Dr [**First Name (STitle) **]: chest pain, shortness of breath, weakness or
numbness in the extremities, sudden loss of vision, difficulty
speaking, or headaches.
Followup Instructions:
Appointment made with your PCP [**Last Name (NamePattern4) **] [**2113-12-8**] at 12:15 PM
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6403**], MD Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2114-1-4**] 9:30
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2114-1-4**]
10:30
Provider: [**Last Name (NamePattern5) 7224**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2114-1-4**]
1:00
|
[
"278.01",
"362.50",
"V45.82",
"412",
"414.01",
"V70.7",
"272.4",
"443.9",
"715.90",
"433.10",
"V12.79",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"00.45",
"00.61",
"00.63"
] |
icd9pcs
|
[
[
[]
]
] |
10151, 10210
|
7532, 9217
|
371, 413
|
10420, 10429
|
5827, 7364
|
11198, 11676
|
4895, 5018
|
9505, 10128
|
10231, 10231
|
9243, 9482
|
7381, 7509
|
10453, 11175
|
5033, 5808
|
275, 333
|
441, 3805
|
10317, 10399
|
10250, 10296
|
4198, 4563
|
4579, 4879
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,016
| 175,342
|
19731
|
Discharge summary
|
report
|
Admission Date: [**2168-11-3**] Discharge Date: [**2168-11-16**]
Date of Birth: [**2089-3-16**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**Last Name (NamePattern1) 4659**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Open cholecystectomy
Ventral herniorraphy
placement of swan-ganz catheter
respiratory failure
History of Present Illness:
79yF p/w acute onset of epigastric/Right sided abdominal pain
for 18 hours. Pt awoke with constant burning pain and nausea
and vomiting x7. Pain radiated to right side of back. Last BM
1 day PTA.
Past Medical History:
Colectomy for colon Ca [**2167**]
HTN, CAD, h/o pericarditis
Psoriasis
Social History:
Denies tobacco and EtOH
Family History:
Mother-CAD died age 76
Physical Exam:
On addmission:
98.6 92 181/60 18 95RA
A&Ox3, Russian speaking
neck supple w/o LAD, PEARL, EOMI
CTAB
RRR
abd soft/obese, midline scar w/ ventral hernia, reducible. +RUQ
TTP and +[**Doctor Last Name **] sign.
Rectal: guaic negative
est: warm w/o CCE
Pertinent Results:
[**2168-11-3**] 02:45PM BLOOD WBC-15.0*# RBC-4.27 Hgb-13.0 Hct-38.2
MCV-89 MCH-30.5 MCHC-34.2 RDW-13.0 Plt Ct-315
[**2168-11-15**] 04:39AM BLOOD WBC-12.5* RBC-3.25* Hgb-9.7* Hct-29.5*
MCV-91 MCH-29.7 MCHC-32.7 RDW-13.8 Plt Ct-454*
[**2168-11-3**] 02:45PM BLOOD Neuts-73* Bands-12* Lymphs-12* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2168-11-15**] 04:39AM BLOOD Neuts-61 Bands-2 Lymphs-23 Monos-7 Eos-0
Baso-0 Atyps-7* Metas-0 Myelos-0
[**2168-11-3**] 02:45PM BLOOD Plt Smr-NORMAL Plt Ct-315
[**2168-11-15**] 04:39AM BLOOD Plt Smr-HIGH Plt Ct-454*
[**2168-11-3**] 02:45PM BLOOD Glucose-163* UreaN-18 Creat-0.8 Na-138
K-4.2 Cl-98 HCO3-25 AnGap-19
[**2168-11-15**] 04:39AM BLOOD Glucose-122* UreaN-11 Creat-1.0 Na-143
K-3.2* Cl-100 HCO3-34* AnGap-12
[**2168-11-3**] 02:45PM BLOOD ALT-14 AST-25 LD(LDH)-206 AlkPhos-90
Amylase-90 TotBili-0.6
[**2168-11-7**] 02:32AM BLOOD ALT-54* LD(LDH)-190 AlkPhos-94 Amylase-34
TotBili-0.3
[**2168-11-3**] 02:45PM BLOOD Lipase-25
[**2168-11-7**] 02:32AM BLOOD Lipase-14
[**2168-11-5**] 05:56PM BLOOD CK-MB-4 cTropnT-<0.01
[**2168-11-6**] 05:45AM BLOOD CK-MB-3
[**2168-11-3**] 02:45PM BLOOD Calcium-9.1 Phos-2.9 Mg-1.9
[**2168-11-15**] 04:39AM BLOOD Calcium-8.4 Phos-3.6 Mg-1.7
[**2168-11-5**] 06:15PM BLOOD freeCa-1.15
[**2168-11-11**] 03:45AM BLOOD freeCa-1.14
Brief Hospital Course:
Pt admitted to surgery through ED. To OR on [**2168-11-4**] for
cholecystectomy, converted to open and ventral hernia repair.
Pt taken to PACU in good condition, extubated with JP drains x2.
[**11-5**]: L SCV PA catheter placed. Pt was extubated and
transferred to the SICU on POD1 when pt demonstrated respiratory
distress, low UOP, and elevated TBili. Pt was reintubated,
cardiac enzymes were negative, and multiple boluses given--pt
required almost 12 Liters including intra-op fluids. GI ERCP
was consulted, decision to follow LFTs w/ plan to ERCP if LFTs
increased. LFTs normalized throughout stay. Pt on dopamine for
blood pressure support. Dopamine weaned to off on POD4, and put
on CPAP on same day. Swab from wound bed grew pan-sensitive
E.coli, on levo/fagyl. POD5 pt self extubated, maintained
oxygenation and did not require re-intubation. PA cath changed
to 3 lumen CVL. POD6 pt removed NGT, started on sips. Advanced
to regular diet w/o incident. Pt discharged to rehab for PT and
strengthening before returning home.
Medications on Admission:
Toprol 25 QD
Norvasc 5 QD
Discharge Medications:
1. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for
7 days.
Disp:*14 Capsule(s)* Refills:*0*
and home meds
Discharge Disposition:
Extended Care
Facility:
Meadowbrook - [**Location (un) 2624**]
Discharge Diagnosis:
1. Acute and chronic cholecystitis.
2. Cholelithiasis, cholesterol type
Discharge Condition:
Good
Discharge Instructions:
Please resume your home medications. Take all new medications
as prescribed.
You may shower, but keep the wound dry. The staples will remain
unitl your follow up visit.
You may resume your regular diet. You may resume your regular
activities, but no heavy lifting (> a gallon of milk) for 6
weeks, unless directed otherwise.
Please call your physician if you experience increased pain,
fever (>101.5), inability to eat or drink, foul discharge from
your wound, or other symptoms concerning to you.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **].
An appointment has been made for [**11-24**] at 4:00pm.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**]
|
[
"276.6",
"401.9",
"553.21",
"518.5",
"574.01",
"V10.05",
"276.52",
"574.11",
"696.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"53.51",
"51.22",
"96.71",
"89.64",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
3796, 3861
|
2411, 3457
|
295, 391
|
3977, 3984
|
1086, 2388
|
4536, 4790
|
770, 794
|
3534, 3773
|
3882, 3956
|
3483, 3511
|
4008, 4513
|
809, 1067
|
241, 257
|
419, 619
|
641, 713
|
729, 754
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,380
| 127,994
|
13113
|
Discharge summary
|
report
|
Admission Date: [**2194-9-17**] Discharge Date: [**2194-9-24**]
Date of Birth: [**2124-6-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
SOB/edema
Major Surgical or Invasive Procedure:
s/p CABG x2(Lima->LAD/SVG->PDA)/MVR (#29mm ST.[**Male First Name (un) 923**] Epic Porcine)
History of Present Illness:
70yo F with 3-4 week hx of worsening SOB/LE edema admitted to
[**Hospital3 **]. Further workup revealed [**Hospital3 **]/4+MR and right
pulmonary artery embolus/(negative DVT).She was started on
Lovenox and transferred to [**Hospital1 18**] for surgical consultation for
MVR/CABG with Dr.[**Last Name (STitle) **].
Past Medical History:
CHF
Severe MR
[**First Name (Titles) **]
[**Last Name (Titles) **]
Osteoporosis
remote (L)wrist FX
s/p (L)Hip replacement
s/p (L)triple cmpd FX
Social History:
+social ETOH
+former tobacco,40PY
Family History:
Brother had MI at 63yo
Physical Exam:
DISCHARGE PE:
VSS: 98.7, 97/54, p:68, 95% R/A O2SAT
General: pleasant, anxious, A&Ox3
CVS: RRR, no m/r/g
Lungs:CTA
ABD: benign
EXT:warm, (B) 1+LE edema
wounds: Sternal incsion C/D/I, No [**Doctor Last Name **]/click, stable sternum
Pertinent Results:
[**2194-9-23**] 05:25AM BLOOD WBC-11.5* RBC-3.20* Hgb-9.8* Hct-28.9*
MCV-90 MCH-30.7 MCHC-34.1 RDW-15.8* Plt Ct-105*#
[**2194-9-17**] 07:38PM BLOOD WBC-8.2 RBC-4.08* Hgb-12.5 Hct-37.1
MCV-91 MCH-30.7 MCHC-33.8 RDW-14.6 Plt Ct-211
[**2194-9-23**] 05:25AM BLOOD PT-13.3 PTT-28.9 INR(PT)-1.1
[**2194-9-17**] 07:38PM BLOOD PT-15.4* PTT-36.2* INR(PT)-1.4*
[**2194-9-23**] 05:25AM BLOOD Glucose-108* UreaN-25* Creat-1.3* Na-129*
K-4.5 Cl-94* HCO3-26 AnGap-14
[**2194-9-17**] 07:38PM BLOOD Glucose-154* UreaN-20 Creat-1.3* Na-140
K-4.3 Cl-95* HCO3-31 AnGap-18
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 40043**]Portable TTE
(Complete) Done [**2194-9-18**] at 2:21:53 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 1112**] W.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2124-6-27**]
Age (years): 70 F Hgt (in): 63
BP (mm Hg): 102/70 Wgt (lb): 134
HR (bpm): 77 BSA (m2): 1.63 m2
Indication: Preoperative assessment. Mitral valve disease.
ICD-9 Codes: 424.1, 424.0, 424.3, 424.2
Test Information
Date/Time: [**2194-9-18**] at 14:21 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) **], MD
Test Type: Portable TTE (Complete)
3D imaging. Son[**Name (NI) 930**]: [**Name2 (NI) 8154**] Bzymek, RDCS
Doppler: Full Doppler and color Doppler Test Location: [**Location 13333**]/[**Hospital Ward Name 121**] 6
Contrast: None Tech Quality: Adequate
Tape #: 2008W056-0:42 Machine: Vivid [**8-18**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *6.0 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *7.2 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *6.5 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *6.5 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 5.6 cm
Left Ventricle - Fractional Shortening: *0.14 >= 0.29
Left Ventricle - Ejection Fraction: 27% >= 55%
Left Ventricle - Lateral Peak E': 0.10 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.08 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 13 < 15
Aorta - Sinus Level: 2.8 cm <= 3.6 cm
Aorta - Ascending: *3.5 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.2 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 1.2 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A ratio: 2.00
Mitral Valve - E Wave deceleration time: 156 ms 140-250 ms
Mitral Valve - [**Last Name (un) **]: 0.40 cm2
TR Gradient (+ RA = PASP): *27 to 46 mm Hg <= 25 mm Hg
Pericardium - Effusion Size: 0.7 cm
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Marked LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.
LEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV
cavity. Severe global LV hypokinesis. Severely depressed LVEF.
[Intrinsic LV systolic function likely depressed given the
severity of valvular regurgitation.] No resting LVOT gradient.
RIGHT VENTRICLE: Mildly dilated RV cavity. Moderate global RV
free wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Mildly dilated
ascending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.
MITRAL VALVE: Eccentric MR jet. Effective regurgitant orifice is
>=0.40cm2. Severe (4+) MR. LV inflow pattern c/w restrictive
filling abnormality, with elevated LA pressure.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Moderate [2+] TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Mild PR. The end-diastolic PR velocity is increased c/w PA
diastolic hypertension.
PERICARDIUM: Small pericardial effusion.
Conclusions
The left atrium is markedly dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated. There
is severe global left ventricular hypokinesis. Overall left
ventricular systolic function is severely depressed. [Intrinsic
left ventricular systolic function is likely more depressed
given the severity of valvular regurgitation.] Quantitative (3D)
LVEF = 27 %. The right ventricular cavity is mildly dilated with
moderate global free wall hypokinesis. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. Trace aortic regurgitation is seen. An eccentric,
posterioly directed jet of severe 4+) mitral regurgitation is
seen. The effective regurgitant orifice is >=0.40cm2 The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. The tricuspid
valve leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. The end-diastolic pulmonic regurgitation
velocity is increased suggesting pulmonary artery diastolic
hypertension. There is a small pericardial effusion.
IMPRESSION: Severely depressed left ventricular function. Severe
mitral regurgitation. Depressed right ventricular function.
Moderate pulmonary artery systolic pressure.
Electronically signed by [**Name6 (MD) **] [**Name8 (MD) **], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2194-9-18**] 16:00
[**Known lastname **],[**Known firstname **] G [**Medical Record Number 40044**] F 70 [**2124-6-27**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2194-9-23**] 9:04
AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2194-9-23**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 40045**]
Reason: tamponade
[**Hospital 93**] MEDICAL CONDITION:
70 year old woman s/p MVR/CABG
REASON FOR THIS EXAMINATION:
tamponade
Final Report
HISTORY: Post cardiac surgery.
FINDINGS: In comparison with study of [**9-21**], the Swan-Ganz
catheter has been
removed. Persistent atelectatic changes at the left base. Little
change in
the appearance of the heart and lungs otherwise.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: TUE [**2194-9-23**] 10:30 AM
Imaging Lab
Brief Hospital Course:
[**2194-9-19**] mrs. [**Known lastname 8389**] was taken to the OR by Dr.[**Last Name (STitle) **] and underwent
CABGx 2(LIMA->LAD/SVG->PDA)/MVR (#29mm ST.[**Male First Name (un) 923**] Epic porcine).
Please refer to Dr.[**Name (NI) 3502**] operative report for further
details.She was transferred to the CVICU intubated, requiring
Propofol, Amiodarone, Epinephrine,Milrinone, and Levophed drips
to optimize her cardiac output and hemodynamic stability. In
addition an IABP was inserted intraoperatively to assist
cardiac function off bypass. Over the next 24-48hours, the drips
were weaned off and the IABP was discontinued.She had a brief
burst of atrial fibrillation and with Amiodarone conversion to
oral dosing, her rhythm converted to sinus and has remained in
sinus. POD#3 All lines and tubes were discontinued in a timely
fashion. Due to anemia, HCT 23.2 she was transfused 1 u PRBcs;
Beta-blocker and a statin were initiated; ACE-I will need to be
reevaluated as an outpt. due to inability to start during this
admission, as BP would not tolerate. She was transferred to the
SDU. She was started on Coumadin for her PE diagnosed at the
OSH. The remainder of her postoperative course was essentially
unremarkable. She progressed well and on post-operative day 5
she was discharged to a rehab for further strength, endurance
and increase in daily activities. She was instructed on the
neccessary followup appointments.
Medications on Admission:
-at Home:
Fosamax
-On TX from OSH:
NTG prn
MSO4 prn
ASA 325 (1)
NTG 1" (4)
Lopressor 12.5 (2)
Colace 100(2)
Lovenox 60(2)
Lasix 40 (2)
Captopril 6.25(3)
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
take 400mg (2 tablets) for one week and then taper down to 200mg
(1 tablet) daily.
Disp:*60 Tablet(s)* Refills:*0*
7. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day:
titrate for an INR goal of 2.5-3 for pulmonary embolism.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital 2203**] [**Hospital **] Nursing Home - [**Location (un) 2203**]
Discharge Diagnosis:
-s/p CABG x2(Lima->LAD/SVG->PDA)/MVR (#29mm ST.[**Male First Name (un) 923**] Epic
Porcine)
-PE
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr. [**Last Name (STitle) 13175**] (Cardiologist) in [**2-12**] weeks. Please call for
appointment
Please establish a primary care provider and see him or her as
soon as possible.
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2194-9-24**]
|
[
"599.0",
"414.01",
"416.8",
"427.31",
"397.0",
"585.9",
"428.0",
"285.9",
"415.19",
"424.0",
"V43.64",
"428.22",
"733.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.23",
"37.61",
"36.11",
"36.15",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10538, 10640
|
7797, 9224
|
331, 424
|
10780, 10787
|
1293, 7236
|
11299, 11720
|
1002, 1026
|
9429, 10515
|
7276, 7307
|
10661, 10759
|
9250, 9406
|
10811, 11276
|
1041, 1041
|
1055, 1274
|
282, 293
|
7339, 7774
|
452, 768
|
790, 935
|
951, 986
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,946
| 176,771
|
54577
|
Discharge summary
|
report
|
Admission Date: [**2100-7-14**] Discharge Date: [**2100-7-21**]
Date of Birth: [**2016-5-13**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Dyspnea, pneumonia, Acute on Chronic CHF exacerbation
Major Surgical or Invasive Procedure:
Diagnostic and Therapeutic thoracentesis of right hemithorax
History of Present Illness:
Patient is an 84yo male with PMH of systolic CHF (EF 40%, with
recent TTE 30%), esophageal CA s/p gastroesophagectomy, CAD s/p
CABGx4, admitted for hypoxia, increasing SOB, now with transfer
to the MICU for hypoxia and hypotension. He was recently
admitted for an aspiration PNA and discharged on Augmentin. He
was then readmitted, and started on Vanc/ZOsyn and flagyl
briefly for HCAP. He continues to have a leukocytosis despite
abx. He had tapped pleural effusion that is transudative,
thought to be [**2-10**] CHF. He had a repeat TTE which showed
worsening EF from 40% to 30%. He was being diuresed with IV
lasix 40mg [**Hospital1 **], with inital improvement in hypoxia. However,
this was limited by now worsening renal failure. He is making
only ~300cc of urine in the last hour. His hospitalization has
also been complicated by hypernatremia, likely [**2-10**] decreased
free water access, not given back free water yet. This evening,
he became hypotensive to 82/56, mentating well A&Ox3, hypoxic 6L
NC with 55% facemask at 97%?. He had been hypoxic the evening
prior, with desats to 81% on 4LNC, iwht improvement with duonebs
& facemask. Since 0300 on the morning prior to transfer, pt was
on on 4LNC + 50%FM. For the hypotension, he was bolused 250ccx2
and then 500cc later this evening, with minimal BP response. A
code discussion was had between the patient and his daughter,
and the decision was made to reverse his code status to full
code.
.
Currently, he feels SOB, but that it has not changed in the last
couple of hours. He says that he started to feel worse this
afternoon after the thoracentesis was done. He denies any chest
pain or pain anywhere else. He has had a dry, non-productive
cough.
.
ROS: As above. last BM was today, brown per pt report. He also
always feels cold, which is unchanged.
Denies fever, chest pain, productive cough, abdominal pain,
diarrhea, bloody or black bowel movements.
Past Medical History:
CAD s/p CABGx4 ([**2085**])
systolic CHF (EF 40% on echo [**2099-1-19**])
Esophageal CA s/p chemo, radiation, gastroesophagectomy [**2088**]
PUD, GERD, Barrett's, h/o GI bleed
HTN
BPH
depression
narcolepsy
osteoarthritis
microvascular strokes without sequelae
h/o C. diff colitis
spinal stenosis
Social History:
Per medical floor team history
The patient does not smoke any cigarettes but did during WWII
and the Korean War. He smoked a pipe/day until his CABG in [**2085**].
He
drinks a glass of red wine per day. He is currently living
alone while his wife is in rehab. They have no children together
but wife does from a previous marriage. His stepdaughter [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] is very involved in his care.
Family History:
Notable for cardiac disease in mother and father (died of heart
disease age 45). Brother died recently of complications
secondary to DM.
Physical Exam:
On admission:
VS - Temp 98.8F, BP140/70 , HR88 , R20 , O2-sat 93% 4LNC
GENERAL - comfortable, appropriate, cachectic
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear,
palate raises evenly
NECK - supple, no thyromegaly, JVD 3cm above sternal notch
LUNGS - prominent rhonchi throughout lung fields, breath sounds
heard at bases but difficult to discern level with prominent
rhonchi
HEART - RRR, no M/R/G
ABDOMEN - NABS, scaphoid, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - 2+ pitting edema bilaterally
SKIN - dry scale over feet with black pinpoint lesion of right
great toe
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, diffusely weak
Pertinent Results:
On admission:
.
[**2100-7-14**] 01:53PM BLOOD WBC-17.6*# RBC-2.80* Hgb-9.3* Hct-27.6*
MCV-98 MCH-33.3* MCHC-33.9 RDW-14.2 Plt Ct-226
[**2100-7-14**] 01:53PM BLOOD Neuts-91.3* Lymphs-5.4* Monos-2.7 Eos-0.4
Baso-0.3
[**2100-7-14**] 01:53PM BLOOD Glucose-86 UreaN-42* Creat-2.3* Na-144
K-4.4 Cl-108 HCO3-29 AnGap-11
[**2100-7-14**] 01:53PM BLOOD proBNP-[**Numeric Identifier **]*
[**2100-7-15**] 05:50AM BLOOD Albumin-2.0* Calcium-7.8* Phos-3.8 Mg-1.8
[**2100-7-15**] 08:40AM BLOOD Vanco-30.4*
.
On day of death:
.
[**2100-7-21**] 02:49AM BLOOD WBC-25.0* RBC-2.54* Hgb-8.1* Hct-24.8*
MCV-98 MCH-32.0 MCHC-32.9 RDW-15.3 Plt Ct-153
[**2100-7-21**] 02:49AM BLOOD Glucose-58* UreaN-66* Creat-4.5* Na-150*
K-4.0 Cl-110* HCO3-22 AnGap-22*
[**2100-7-21**] 02:49AM BLOOD Calcium-8.0* Phos-6.0* Mg-2.3
Brief Hospital Course:
Patient is an 84yo male with PMH of Esophageal CA s/p
gastroesophagectomy with stomach pull-through, CAD s/p CABGx4,
and CHF with previous ejection fraction of 40% who presented
from rehab with acute shortness of breath from acute on chronic
CHF exacerbation, and aspiration pneumonia. Patient was recently
hospitalized for aspiration pneumonia, and chronically aspirates
even when following recommendations from speech and swallow
recommendations. Pt was transferred to the MICU for hypoxia and
hypotension. Hypoxia was attributed to multifactorial etiology
of pulmonary edema from heart failure, pleural effusions and
pneumonia. He was persistently hypotensive, in part likely [**2-10**]
hypovolemia, but mostly thought to be secondary to systolic
heart failure. A code discussion was had with the family and pt
was made DNR/DNI with the decision not to pursue invasive
treatments with lines, pressors, etc. During the admission he
was made CMO and expired.
.
#. Shortness of breath/cough: Given patient's history of
aspiration event in the past with worrisome s+s eval and history
of acutely worsening dyspnea, patient likely had another
aspiration event. Concern for aspiration pneumonia vs.
aspiration pneumonitis. HCAP and atypical pneumonia remain
possibilities as well and were treated. He was also in heart
failure. Discussion was held with the patient and family, and
given the irreversibility of his heart failure and acute
worsening of his condition, he was made CMO and expired 7 days
after admission.
.
#. ARF: Patient with BUN/Cr suggestive of prerenal azotemia.
Possibly due to poor forward-flow in setting of CHF
exacerbation. However, worsening with diuresis. Creatinine
continued to worsen until his death.
Medications on Admission:
tylenol 650mg PO Q4H prn pain or fever
MOM 30ml po daily daily prn constipation
Zofran 4mg po Q4H prn nausea
ferrous sulfate 325mg po daily
finasteride 5mg po daily
opium tincture 10mg/5 drops po q6h prn dumping syndrome
carvedilol 6.25mg po bid
aspirin 81mg po daily
mirtazapine 7.5mg
omeprazole 40mg po daily
amoxicillin 500/125mg PO q12H (3 more days to completion)
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Aspiration pneumonia
Acute on chronic CHF exacerbation
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
"401.9",
"584.9",
"V10.03",
"V45.81",
"414.00",
"276.0",
"530.81",
"347.00",
"600.00",
"V49.86",
"507.0",
"311",
"428.23",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
7009, 7018
|
4825, 6556
|
358, 421
|
7117, 7126
|
4011, 4011
|
7178, 7184
|
3170, 3308
|
6977, 6986
|
7039, 7096
|
6583, 6954
|
7150, 7155
|
3323, 3323
|
265, 320
|
449, 2372
|
4025, 4802
|
2394, 2691
|
2707, 3154
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,467
| 129,697
|
52977
|
Discharge summary
|
report
|
Admission Date: [**2133-4-17**] Discharge Date: [**2133-5-8**]
Service: CARDIOTHORACIC
Allergies:
Penicillins / Heparin Agents
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Fatigue, anorexia
Major Surgical or Invasive Procedure:
[**2133-4-27**] Mitral Valve Repair(26 millimeter ring) and Two Vessel
Coronary Artery Bypass Grafting utilizing left internal mammary
to left anterior descending and vein graft to obtuse marginal
History of Present Illness:
This is a 86 year old female with PMH significant for known
CAD(prior IMI [**2111**]), who was transferred from OSH after episode
BRBPR, weakness/malaise, acute renal insufficiency,
hyperkalemia, and elevated cardiac enzymes. She was in her USOH
(which is occasional weakness and she reports recent difficulty
ambulating due to "soreness") until this past week when she felt
weaker than usual. At the OSH, her BP was found to be 80s
systolic to 115. CK was 257 in the setting of this hypotension
and MB was 20 with a Troponin of 1.24. She was transferred from
the ER to the CCU for ?NSTMI and transient hypotension and
weakness. On arrival to [**Hospital1 18**] she was found to be
hemodynamically stable, mentating well with no symptoms. She was
subsequently transferred to the floor. The patient additionally
relates one week of lethargy, with her ??????legs weak,?????? but it
appears often that she has found it more difficult to get out of
bed. On detailed ROS, she denies any feverishness, and relates 2
days of diarrhea ??????but I didn??????t see any blood!?????? No cough /
dysuria, or other concern for infection.
Past Medical History:
CAD - as above
History of Complete AV block following IMI - s/p PPM
Hypertension
Hypercholesterolemia
GERD with Hiatal Hernia
Anemia
?History of GIB
s/p Cataract Surgery
s/p Appy
s/p Tonsillectomy
Social History:
Lives in [**Location 86**] area with family. No tobacco nor alcohol abuse
per report. Never married. No children. She is a retired
accountant.
Family History:
Father died of MI at age 52
Physical Exam:
VS BP 110/55, P70, R20.
Gen: Overweight female in no distress. Pleasant and conversant.
HEENT: Oropharynx benign
Neck: Supple, no JVD. Filateral carotid bruits noted.
CV: S1 S2 with II/VI HSM, consistent with TR. Regular rhythm.
Lungs: Posterior wheezes and crackles, R>L bases on posterior
auscultation.
Abd: Soft, NT/ND.
Ext: Warm, trace edema
Neuro: Alert and oriented. No focal deficits noted. CN 2-12
intact.
Pertinent Results:
[**2133-4-17**] 09:27PM GLUCOSE-134* UREA N-56* CREAT-1.7* SODIUM-140
POTASSIUM-5.1 CHLORIDE-112* TOTAL CO2-16* ANION GAP-17
[**2133-4-17**] 09:27PM ALT(SGPT)-112* AST(SGOT)-128* LD(LDH)-408*
CK(CPK)-241* ALK PHOS-87 AMYLASE-197* TOT BILI-0.3
[**2133-4-17**] 09:27PM LIPASE-279*
[**2133-4-17**] 09:27PM CK-MB-17* MB INDX-7.1* cTropnT-1.40*
[**2133-4-17**] 09:27PM ALBUMIN-3.6 CALCIUM-8.1* PHOSPHATE-4.5
MAGNESIUM-2.1 IRON-23*
[**2133-4-17**] 09:27PM calTIBC-317 HAPTOGLOB-349* FERRITIN-94
TRF-244
[**2133-4-17**] 09:27PM TSH-1.9
[**2133-4-17**] 09:27PM WBC-12.0* RBC-3.22* HGB-9.2* HCT-27.2* MCV-84
MCH-28.5 MCHC-33.9 RDW-14.0
[**2133-4-17**] 09:27PM NEUTS-82.2* LYMPHS-11.9* MONOS-5.5 EOS-0.5
BASOS-0
[**2133-4-17**] 09:27PM PLT COUNT-252
[**2133-4-17**] 09:27PM PT-12.0 PTT-23.1 INR(PT)-1.0
[**2133-4-17**] 09:27PM RET AUT-1.7
[**2133-5-8**] 02:54AM BLOOD WBC-12.3* RBC-3.22* Hgb-9.8* Hct-28.5*
MCV-89 MCH-30.3 MCHC-34.2 RDW-23.1* Plt Ct-16*#
[**2133-5-8**] 01:22PM BLOOD PT-26.3* PTT-83.7* INR(PT)-2.7*
[**2133-5-8**] 02:54AM BLOOD Fibrino-412*
[**2133-5-8**] 02:54AM BLOOD Glucose-80 UreaN-29* Creat-0.9 Na-127*
K-4.8 Cl-92* HCO3-19* AnGap-21*
[**2133-5-8**] 02:54AM BLOOD ALT-175* AST-168* LD(LDH)-962*
AlkPhos-101 Amylase-106* TotBili-21.3*
[**2133-5-8**] 01:25PM BLOOD Type-ART pO2-121* pCO2-30* pH-7.20*
calTCO2-12* Base XS--14
[**2133-5-6**] 06:43AM BLOOD HEPARIN DEPENDENT ANTIBODIES - Positive
Brief Hospital Course:
Ms. [**Known lastname 109217**] was admitted under cardiology with NSTEMI. An
echocardiogram on [**4-18**] showed 3+ mitral regurgitation and
mild LV dysfunction with an LVEF of 45%. Her recent myocardial
infarction was most likely the result of transient hypotension
which also resulted in acute renal insufficiency and hepatic
ischemia. She remained guaiac negative and her liver and renal
function gradually improved. She remained pain free on medical
therapy. Colonoscopy on [**4-22**] was only notable for small
internal hemorrhoids, otherwise normal. She subsequently
underwent cardiac catheterization on [**4-23**] which revealed
biventricular diastolic dysfunction and severe three vessel
coronary artery disease which included left main disease. Based
upon the above results, cardiac surgery was consulted for
surgical revascularization and potential mitral valve
repair/replacement. Further evaluation included dental clearance
and carotid non invasive studies which showed only mild disease
of internal carotid arteries. Her preoperative course was
otherwise uneventful and she was cleared for surgery.
On [**4-27**], Dr. [**Last Name (STitle) **] performed a mitral valve repair and
coronary artery bypass grafting. Following the operation, she
was brought to the CSRU in stable condition. Her postoperative
course was complicated by acute renal failure and mesenteric
ischemia. She required CVVHD and underwent subtotal colectomy
and terminal ileum colon resection on postoperative day three.
Abdominal arteriogram at time of colectomy confirmed severe
spasm of the superior mesenteric artery and findings consistent
with low flow state. She remained in critical condition. TPN was
started for nutritional support. She continued to require CVVHD
and inotropic support. Her platelet count dropped as low as 16k
and she was diagnosed with heparin induced thrombocytopenia with
a postive heparin PF4 antibody assay. Her thrombocytopenia was
multifactorial in etiology. She was eventually started on
Bivalirudin to prevent thromobotic complications. Despite
medical therapies, her clinical status progressively
deteriorated. She became acidotic with no improvement in renal
and liver function. She became more and more pressor dependent
and displayed no signs of improvment. After discussions with the
family, it was decided to make her a DNR. She eventually expired
on [**5-8**].
Medications on Admission:
Diovan 160 mg qd
Inderal ? qd
Lipitor 10 mg po qd
ASA 81 mg qod
Prilosec 40 mg po qd
Spirolactone 25 mg qd
Discharge Medications:
Not applicable
Discharge Disposition:
Home
Discharge Diagnosis:
Postoperative Cardiogenic Shock with Mesenteric ischemia,
Postoperative Liver and Renal Failure, Heparin Induced
Thrombocytopenia, s/p Mitral Valve Repair and Coronary artery
bypass grafting
Discharge Condition:
Expired
Discharge Instructions:
Not applicable
Followup Instructions:
Not applicable
Completed by:[**2133-6-11**]
|
[
"V64.41",
"424.0",
"557.0",
"397.0",
"276.7",
"785.59",
"585.9",
"410.71",
"038.9",
"998.12",
"284.8",
"416.8",
"428.0",
"414.01",
"570",
"280.0",
"518.5",
"401.9",
"286.6",
"995.94",
"584.5",
"530.81",
"997.4",
"V53.31",
"412",
"455.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"37.23",
"96.72",
"88.42",
"00.13",
"99.15",
"99.04",
"88.72",
"99.05",
"88.56",
"36.11",
"45.73",
"35.12",
"39.61",
"39.95",
"54.21",
"45.23",
"46.21"
] |
icd9pcs
|
[
[
[]
]
] |
6530, 6536
|
3940, 6333
|
259, 457
|
6770, 6779
|
2487, 3917
|
6842, 6887
|
2008, 2037
|
6491, 6507
|
6557, 6749
|
6359, 6468
|
6803, 6819
|
2052, 2468
|
202, 221
|
485, 1612
|
1634, 1832
|
1848, 1992
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,483
| 162,745
|
4682
|
Discharge summary
|
report
|
Admission Date: [**2196-1-12**] Discharge Date: [**2196-1-15**]
Date of Birth: [**2131-9-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 64 yo M with metastatic lung cancer who presents
with acute worsening of his dyspnea over the last 2 days. They
note that while in the last 7 days he has had persistent mental
status changes thought secondary to an increase in oxycontin. As
well over the last few days he has had poor PO intake and
nausea. He has been more hypoxic and has had episodes of
shortness of breath. And the home 02 monitor showed 02 sats in
the 70-80s despite being on his home 02 of [**5-10**] liters.
.
.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
melena, hematochezia, chest pain, shortness of breath,
orthopnea, PND, lower extremity oedema, cough, urinary
frequency, urgency, dysuria, lightheadedness, gait unsteadiness,
focal weakness, vision changes, headache, rash or skin changes.
Past Medical History:
PMH:
resection of a nonsmall cell lung
cancer in the right upper lobe at [**Hospital6 **] in [**2188**]
Social History:
lives with wife
Family History:
Non-contributory
Physical Exam:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
.
Pertinent Results:
[**2196-1-12**] 11:45PM PO2-27* PCO2-47* PH-7.24* TOTAL CO2-21 BASE
XS--8
[**2196-1-12**] 05:10PM GLUCOSE-148* UREA N-100* CREAT-4.3*#
SODIUM-138 POTASSIUM-6.1* CHLORIDE-101 TOTAL CO2-18* ANION
GAP-25*
[**2196-1-12**] 05:10PM estGFR-Using this
[**2196-1-12**] 05:10PM ALT(SGPT)-1068* AST(SGOT)-1159* LD(LDH)-1573*
CK(CPK)-263* TOT BILI-0.5
[**2196-1-12**] 05:10PM LIPASE-24
[**2196-1-12**] 05:10PM cTropnT-0.04*
[**2196-1-12**] 05:10PM CK-MB-5
[**2196-1-12**] 05:10PM CALCIUM-8.1*
[**2196-1-12**] 05:10PM HAPTOGLOB-339*
[**2196-1-12**] 05:10PM WBC-4.7 RBC-2.57* HGB-7.6* HCT-23.0* MCV-90
MCH-29.6 MCHC-33.1 RDW-15.3
[**2196-1-12**] 05:10PM NEUTS-80* BANDS-1 LYMPHS-15* MONOS-3 EOS-0
BASOS-1 ATYPS-0 METAS-0 MYELOS-0
[**2196-1-12**] 05:10PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-2+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL SCHISTOCY-1+
BURR-1+
[**2196-1-12**] 05:10PM PLT SMR-VERY LOW PLT COUNT-27*#
[**2196-1-12**] 05:10PM PT-21.9* PTT-32.9 INR(PT)-2.1*
[**2196-1-12**] 05:09PM LACTATE-3.1*
[**2196-1-12**] 05:09PM HGB-8.0* calcHCT-24
Brief Hospital Course:
Patient was admitted to the [**Hospital Unit Name 153**] in the context of evolving
dyspnea secondary to terminal cancer. The family immediately
decided to make the patient's treatment priority comfort
measures. The decision was accepted by the medical staff. The
patient was made comfortable with Morphine and outpatient home
hospice was arranged. It was the wish of the family to have the
patient transferred home as soon as possible. The patient's
discharge was accelerated once his comfort on Morphine was
assured.
Medications on Admission:
AMLODIPINE [NORVASC] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth daily
CLONAZEPAM [KLONOPIN] - (Prescribed by Other Provider) - 0.5 mg
Tablet - 1 Tablet(s) by mouth twice a day
DEXAMETHASONE - 4 mg Tablet - 2 tabs Tablet(s) by mouth [**Hospital1 **]
beginning 24 hrs prior to chemo Take for 3 days//6 doses
ESOMEPRAZOLE MAGNESIUM [NEXIUM] - (Prescribed by Other Provider)
- 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth
once daily
FEXOFENADINE - 60 mg Tablet - 1 Tablet(s) by mouth Twice daily
LISINOPRIL - (Prescribed by Other Provider) - Dosage uncertain
METOPROLOL SUCCINATE - 25 mg Tablet Sustained Release 24 hr - 1
Tablet(s) by mouth twice a day
OXYCODONE [OXYCONTIN] - 10 mg Tablet Sustained Release 12 hr - 1
Tablet(s) by mouth twice a day
OXYCODONE-ACETAMINOPHEN [PERCOCET] - 5 mg-325 mg Tablet - [**2-4**]
Tablet(s) by mouth q4-6h prn pain
OXYCONTIN - - 10 mg po twice a day
OXYGEN - - Concentrator and LOX portable for ambulation; 2-3L
via nasal cannula; Dx: COPD; O2 sat 96% on 2L
PROCHLORPERAZINE EDISYLATE [COMPAZINE] - 10 mg Tablet - 1
Tablet(s) by mouth q8 h as needed for nausea Take on the night
after chemo and then for 2-3 days as needed
SIMVASTATIN [ZOCOR] - (Prescribed by Other Provider) - 20 mg
Tablet - 1 Tablet(s) by mouth daily
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - One capsule inhaled daily Use with
HandiHaler device
Medications - OTC
ASPIRIN [ECOTRIN] - (Prescribed by Other Provider) - 325 mg
Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily
DOCUSATE SODIUM [COLACE] - (OTC) - Dosage uncertain
IBUPROFEN - (OTC) - 800 mg Tablet - 1 Tablet(s) by mouth three
times a day
MISC NATURAL PRODUCT NASAL [PONARIS] - (OTC) - Dosage uncertain
SENNA - (OTC) - Dosage uncertain
Discharge Medications:
1. Morphine Concentrate 20 mg/mL Solution Sig: 10 to 30 mg PO
Q1H as needed for shortness of breath or wheezing.
Disp:*60 mL* Refills:*0*
2. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q2H as needed
for pain: sublingual.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Hospice of the [**Hospital3 **]
Discharge Diagnosis:
Metastatic Lung Cancer
Hypoxic Respiratory Failure
Acute Renal Failure
Thrombocytopenia
Discharge Condition:
Discharged home in critical condition to hospice care. Descision
made to make patient comfort measures only.
Discharge Instructions:
You were seen for difficulty breathing. The decision was made
to be discharged home with hospice services.
Followup Instructions:
None
Completed by:[**2196-1-17**]
|
[
"300.00",
"518.81",
"496",
"287.5",
"584.9",
"162.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5916, 5978
|
3262, 3782
|
323, 330
|
6110, 6221
|
2158, 3239
|
6377, 6413
|
1411, 1429
|
5636, 5893
|
5999, 6089
|
3808, 5613
|
6245, 6354
|
1444, 2139
|
276, 285
|
358, 1234
|
1256, 1361
|
1377, 1395
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,708
| 170,081
|
13453+56454
|
Discharge summary
|
report+addendum
|
Admission Date: [**2108-5-11**] Discharge Date: [**2108-5-23**]
Date of Birth: [**2041-8-27**] Sex: M
Service: MEDICINE
Allergies:
Penicillamine / Ciprofloxacin / Vancomycin / Insulins / Lithium
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Epistaxis and hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
66 yo male with complicated medical hx, chronic nursing home
resident, with frequent aspiration pna (last noted on cxr
4/3/6). Per staff at HRC, has been an outbreak of Influenza A
at the facility and thus patient was started on oseltamivir as a
precaution. Patient was doing well on levoflox for asp pna
until 6:30 am when he had a temp of 102. He also started to
have epistaxis and hemoptysis after picking his nose. His O2
sats were noted to be 87% on RA at that time.
In the ED, treated with flagyl, (had levo today already), vanco
ordered but held due to patient's known allergy. Also given
tylenol per G-tube.
ROS: Denies SOB, + cough, denies CP, fevers (other than this
am), chills, muscle pain, diarreha. Has been using tube feeds
since he keeps aspirating POs. Per nurses at [**Hospital 100**] Rehab he was
taking honey thick liquids po but this past week was changed
back to NPO due to aspirating.
Past Medical History:
Wilson's disease, bipolar disease, hx SI, hs Pica,
bronchiectasis, atrial fibrillation, coronary artery disease,
history of pancreatitis, status post Billroth II for peptic
ulcer disease, chronic renal insufficiency baseline cr 1.9-2.4,
status post mitral valve replacement, status post a
cholecystectomy. He has had an exploratory laparotomy,status
post bowel resection for obstruction. He is also status post
partial colectomy. He is also status post gastrostomytube
placement. S/P R hip fracture and THR. Cataracts. Anemia. Had
flu shot this year,pneumovax [**2106-10-4**]. **MRSA/VRE**
Social History:
Lives at [**Hospital3 **] Center, no EtOH use, no tobacco
use
Family History:
Non-contributory.
Physical Exam:
PE: 98.7 110/61 99 18 96% 3Lnc
Gen: pleasant, hard of hearing, sitting in bed, nad
HEENT: mmm, blood in OP, string of blood from nares, blood clot
appears to be coming into OP from nose, prrl, anicteric sclera
CV: tachy 3/6 sem at apex
Pulm: crackles rll
Abd: G tube in place, nt/nd
Ext: trach lower extrem edema
Neuro: a/o, no focal deficits
Pertinent Results:
[**2108-5-17**] ECHO - 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. The mitral valve leaflets are mildly thickened. Moderate
(2+) mitral regurgitation is seen. Compared with the findings of
the prior study of [**2104-2-11**], there has been no significant change.
[**2108-5-18**] CXR - No pneumothorax. Equivocal overinflation of
endotracheal tube cuff. Otherwise, no change given differences
in patient position
[**2108-5-19**] CXR - The patient has been extubated since the earlier
chest x-ray this morning at 5:30 a.m. The left-sided chest tube
has been fractured retracted several centimeters. The left-sided
pneumothorax is again noted and appears similar to the prior
chest x-ray earlier today.
[**2108-5-19**] CXR - Left-sided small pneumothorax.
[**2108-5-20**] CXR - There is interval decrease in the left pleural
effusion and left pneumothorax. There continues to be a small
left pleural effusion and increased retrocardiac opacity
consistent with volume loss/infiltrate/ effusion. There is
ill-defined opacity projecting over the right lower and mid
lung, likely representing layering effusion. Left subclavian
line with tip in the superior vena cava is unchanged.
[**2108-5-21**] CXR - A left chest tube is present unchanged in position
from five hours prior. A side port overlies the left chest wall
external to the pleural space. Small left pneumothorax is more
prominent than previous. Bilateral moderate-sized pleural
effusions are still present (right greater than left).
Retrocardiac opacity may be secondary to atelectasis. Right
perihilar opacity is unchanged. Left-sided central venous
catheter tip overlies the brachiocephalic vein near the SVC
junction, allowing for rotation.
[**2108-5-21**] CXR - Small left apical pneumothorax. Side port of chest
tube external to the pleural space
[**2108-5-23**] CXR - No pneumothorax. Partial clearing of pulmonary
edema in the right lung with persistent bibasilar
consolidations.
Labs:
[**2108-5-11**] 06:39PM LACTATE-1.5
[**2108-5-11**] 06:25PM WBC-6.0 RBC-3.47* HGB-9.9* HCT-29.0* MCV-83#
MCH-28.6 MCHC-34.3 RDW-15.8*
[**2108-5-11**] 06:25PM NEUTS-79.3* LYMPHS-11.8* MONOS-7.7 EOS-0.4
BASOS-0.7
[**2108-5-11**] 06:25PM MICROCYT-1+
[**2108-5-11**] 06:25PM PLT COUNT-162#
[**2108-5-11**] 06:25PM BLOOD WBC-6.0 RBC-3.47* Hgb-9.9* Hct-29.0*
MCV-83# MCH-28.6 MCHC-34.3 RDW-15.8* Plt Ct-162#
[**2108-5-12**] 07:25AM BLOOD WBC-6.2 RBC-3.61* Hgb-9.9* Hct-31.2*
MCV-86 MCH-27.4 MCHC-31.7 RDW-15.8* Plt Ct-206
[**2108-5-22**] 04:02AM BLOOD WBC-16.7* RBC-3.44* Hgb-10.1* Hct-29.5*
MCV-86 MCH-29.2 MCHC-34.2 RDW-17.2* Plt Ct-350
[**2108-5-23**] 04:53AM BLOOD WBC-15.3* RBC-3.72* Hgb-10.9* Hct-32.8*
MCV-88 MCH-29.3 MCHC-33.2 RDW-17.6* Plt Ct-370
[**2108-5-22**] 04:02AM BLOOD Neuts-96* Bands-0 Lymphs-1* Monos-3 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-1*
[**2108-5-23**] 04:53AM BLOOD PT-15.0* PTT-37.4* INR(PT)-1.3*
[**2108-5-19**] 05:47AM BLOOD Glucose-139* UreaN-29* Creat-1.6* Na-141
K-3.2* Cl-111* HCO3-22 AnGap-11
[**2108-5-20**] 04:36AM BLOOD Glucose-124* UreaN-33* Creat-1.4* Na-147*
K-2.6* Cl-114* HCO3-23 AnGap-13
[**2108-5-22**] 09:53PM BLOOD K-3.3
[**2108-5-23**] 04:53AM BLOOD Glucose-107* UreaN-35* Creat-1.6* Na-149*
K-3.5 Cl-113* HCO3-24 AnGap-16
[**2108-5-21**] 09:58PM BLOOD ALT-42* AST-40 LD(LDH)-198 AlkPhos-288*
TotBili-0.4
[**2108-5-16**] 01:51AM BLOOD Lipase-37
[**2108-5-21**] 09:58PM BLOOD Albumin-3.3* Calcium-8.5 Phos-1.7* Mg-2.2
[**2108-5-14**] 05:50AM BLOOD calTIBC-260 Ferritn-204 TRF-200
[**2108-5-17**] 03:03AM BLOOD calTIBC-166* Hapto-319* Ferritn-185
TRF-128*
[**2108-5-16**] 01:51AM BLOOD Triglyc-201* HDL-16 CHOL/HD-5.7
LDLcalc-35
[**2108-5-17**] 02:24AM BLOOD Cortsol-5.4
[**2108-5-17**] 03:03AM BLOOD Cortsol-13.1
[**2108-5-17**] 03:03AM BLOOD Cortsol-16.5
[**2108-5-11**] 06:39PM BLOOD Lactate-1.5
[**2108-5-15**] 04:57AM BLOOD Lactate-1.8
[**2108-5-15**] 09:55PM BLOOD Lactate-1.6
Brief Hospital Course:
The patient is a 66 yo male with complicated medical hx, recent
aspiration pna on levoflox as outpatient, living at HRC where
there has been a recent Influenza outbreak, presenting
w/epistaxis after picking his nose as well as fever,
desaturation, and continued cough.
New O2 requirement/Increasing WBC/Worse CXR - The patient
originally was requiring 30% O2 shovel mask on admission. Nasal
swab demonstrated influenza A positive and continued oseltamivir
- 75mg daily x 5 days which he had been started on at his
nursing home. He was started on levo/flagyl for possible
superimposed aspiration/bacterial pneumonia. On hospital day
#4, the patient spiked a low grade fever, had increasing O2
requirements, and a rising WBC. There was concern a worsening
superimposed bacterial pneumonia. His antibiotics were switched
to zosyn/vanco. He has a history of MRSA and VRE. The
following evening, the patient continued to experience oxygen
desaturation and his respiratory status worsened. He was
transferred to the ICU. He was intubated for respiratory
distress. Unfortunately, during subclavian line placement, the
patient developed a small left apical pneumothorax. The
Thoracic Surgery team placed a chest tube that was drained on
suction. Eventually it was clamped and removed on [**2108-5-22**]. A
repeat CXR shows a small pneumothorax that has not increased in
size. The patient was started treated with stress dose steroids
for inappropriate response to cotrosyn stimulation testing. The
patients sputum grew G+ cocci and he was started on vancomycin.
When the cultures returned MSSA he was switched to oxacillin.
He will need to complete a 14 day course ([**5-23**] is day #6).
Hypernatremia - The patient sodium began to increase during his
course in the ICU. We felt that he had a free water deficit and
increased the free water flushes to 300mL with his tube feeds.
If his sodium continues to rise he will need free water (D5W)
repletion at [**Hospital 100**] Rehab or an increase in his free water
boluses.
Swallowing - The speech and swallow team saw the patient in the
ICU 1 day prior to discharge to [**Hospital 100**] Rehab. They felt it was
unsafe to perform a speech and swallow exam in Mr [**Known lastname 7796**] while he
was acutely ill. He should have a repeat swallowing evaluation
when he is clinically better at [**Hospital 100**] Rehab.
Abdominal Pain - unclear etiology; exam was benign.
Epistaxis - by the time the patient was transferred from the ER
to the floor the bleeding had stopped. He was maintained on
humidafied O2 to prevent further bleeding.
Bipolar disorder and Wilsons disease - The patient was
continued on his home meds clonazepam, olanzapine, buproprion,
lamotragine. [**Hospital1 18**] does not carry trientine (copper chelator
for Wilson's) so we substituted with zinc sulfate 220mg tid
while in house.
Orthostatic hypotension - We continued the patient on his home
doses of midodrine and fludrocort while also givine Metoprolol
for patient's underlying CAD.
CRI - currently Cr at baseline (1.9-2.4).
Code - FULL CODE
Medications on Admission:
tylenol, ibuprofin, Esomeprazole, Fludrocortisone 0.1mg daily,
guiafenesin/codine, lamotrigine 25mg [**Hospital1 **], levoflox 500mg daily
started 4/4/6, metoprolol 50mg tid, midodrine 5mg tid,
olanzapine 10mg daily, oseltamvir 75mg daily started 4/6/6,
sucralfate, trientine 250mg [**Hospital1 **], coombivent, trimethobenzamide
prn, hydrocortisone rectally prn.
Discharge Medications:
1. Bupropion 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
4. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) treatment
Inhalation Q4-6H (every 4 to 6 hours) as needed.
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
10. Oxacillin 2 g Recon Soln Sig: Two (2) mg Intravenous every
six (6) hours for 8 days.
11. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q4-6H (every 4 to 6 hours) as needed.
12. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4)
Puff Inhalation Q6H (every 6 hours).
13. Olanzapine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
14. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
MSSA Pneumonia
Influenza A
Pneumothorax
Discharge Condition:
Stable; has short episodes of transient desaturations.
Otherwise oxygenating well. Afebrile.
Discharge Instructions:
--Please take all medications as prescribed. You will need to
complete a course of antibiotics for pneumonia (another 8 days).
--Please return to the ER for increasing fevers, difficulty
breathing, shortness of breath.
Followup Instructions:
--Please follow up with your primary care doctor within 1 week.
His number is [**Telephone/Fax (1) 14943**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Name: [**Known lastname 1264**],[**Known firstname 77**] S Unit No: [**Numeric Identifier 7336**]
Admission Date: [**2108-5-11**] Discharge Date: [**2108-5-23**]
Date of Birth: [**2041-8-27**] Sex: M
Service: MEDICINE
Allergies:
Penicillamine / Ciprofloxacin / Vancomycin / Insulins / Lithium
Attending:[**First Name3 (LF) 1807**]
Addendum:
The patients central line (left subclavian line) was placed on
[**2108-5-16**]. Please remove after his course of antibiotics.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - Acute Rehab
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1809**]
Completed by:[**2108-5-23**]
|
[
"518.82",
"487.0",
"296.80",
"512.1",
"427.31",
"585.9",
"482.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.71",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
12512, 12736
|
6461, 9555
|
346, 352
|
11359, 11455
|
2417, 6438
|
11723, 12489
|
2010, 2029
|
9970, 11179
|
11296, 11338
|
9581, 9947
|
11479, 11700
|
2044, 2398
|
285, 308
|
380, 1298
|
1320, 1914
|
1930, 1994
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,117
| 113,057
|
17157
|
Discharge summary
|
report
|
Admission Date: [**2156-6-17**] Discharge Date: [**2156-6-24**]
Date of Birth: [**2104-4-22**] Sex: M
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: Patient is 52-year-old gentleman
with slurred speech in the morning of admission in the
shower, then fell, and had a seizure witnessed by his wife.
Taken to an outside hospital. He is unresponsive,
decerebrate posturing, and intubated at the outside hospital.
Transferred to [**Hospital1 69**] for
further management.
Head CT scan shows large right frontal intracranial
hemorrhage.
PAST MEDICAL HISTORY: Hypertension.
PAST SURGICAL HISTORY: Unknown.
ALLERGIES: Patient has no known allergies.
MEDICATIONS: Aspirin.
PHYSICAL EXAMINATION: On physical exam, the patient was
intubated, unresponsive. Right pupil was fixed and dilated.
Left pupil was 3 mm and nonreactive. Patient's chest was
clear to auscultation. Cardiac: S1, S2, no murmurs, rubs,
or gallops. Abdomen is soft, nontender, nondistended,
positive bowel sounds. Extremities: Cool, positive pedal
pulses. Neurologic examination: No eye opening, pupils
right was fixed and nonreactive, 3 nonreactive, no corneals.
Bilateral decerebrate posturing in the upper with minimal
withdraw on the lowers.
Patient was taken immediately to the OR, where he underwent a
right frontal craniotomy for excision of hematoma, then
underwent a diagnostic arteriogram which showed a right MCA
aneurysm which was not treated.
Postoperative, his pupils were 3.5 mm bilaterally and
nonreactive. He was intubated with no sedation. He had weak
corneal on right and left side and there was flexure
posturing in the upper extremities bilaterally. Continued on
Dilantin. Had a repeat head CT scan, which showed
hydrocephalus and a vent drain was placed on [**2156-6-18**]. He
remained in the Intensive Care Unit with no change in his
mental status, decerebrate posturing. The family was
notified of his poor prognosis and poor outcome.
Patient was made comfort measures only and expired on
[**2156-6-24**]. Patient was referred to the Organ Bank for organ
donation, however, the patient did not progress to asystole
within the two hour period specified by the hospital policy,
and therefore organ donation was not carried out. Patient
expired on [**2156-6-24**].
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2156-9-6**] 11:12
T: [**2156-9-16**] 11:39
JOB#: [**Job Number 48141**]
|
[
"431",
"437.3",
"V66.7",
"482.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.39",
"02.2",
"88.41",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
616, 695
|
718, 1054
|
169, 554
|
1079, 2551
|
577, 592
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,980
| 148,469
|
18555
|
Discharge summary
|
report
|
Admission Date: [**2176-9-25**] Discharge Date: [**2176-10-4**]
Date of Birth: Sex: M
Service: General Surgery
DIAGNOSES:
1. Mesenteric venous thrombosis with bowel ischemia and
infarction.
2. Congestive heart failure.
3. Respiratory failure.
4. Sepsis.
5. Tetralogy of Fallot.
6. Down syndrome.
7. Paget disease.
8. Chronic conjunctivitis.
9. Seizure disorder.
10. Peripheral vascular disease.
CHIEF COMPLAINT: Respiratory failure with mesenteric
thrombosis.
HISTORY OF PRESENT ILLNESS: The patient is a 37-year-old
gentleman with Down syndrome and tetralogy of Fallot who
presented to [**Hospital 1562**] Hospital from his group care facility
on [**2176-9-22**], with complaints of diarrhea, nausea, vomiting
and acute abdominal pain x 48 hours. He was initially
admitted to the medical floor but acutely desaturated and
went into respiratory failure. He required intubation and
was transferred to the ICU. He had bilateral pulmonary
infiltrates. He was started empirically on intravenous
antibiotics and began spiking temperatures and his abdominal
pain worsened. He started passing bright red blood per
rectum and a CT scan was performed, which demonstrated
mesenteric venous thrombosis. He had a hematocrit drop from
43 to 29 and he was transfused for supportive therapy. His
respiratory status deteriorated and he was transferred to the
[**Hospital1 69**] for further tertiary
care on [**2176-9-25**].
PAST MEDICAL HISTORY:
1. Down syndrome.
2. Congenital heart disease.
3. Tetralogy of Fallot.
4. Paget disease.
5. Chronic conjunctivitis.
6. Seizure disorder.
7. Mental retardation.
8. Depression.
9. Peripheral vascular disease.
PAST SURGICAL HISTORY: None could be elicited, as the
patient was not responsive.
MEDICATIONS ON ADMISSION:
1. Dilantin.
2. Ativan.
3. Colace.
4. Aspirin.
5. Valium.
6. Multivitamin.
7. Bacitracin.
8. Lasix.
9. Digoxin.
10.Claritin.
11.Tinactin.
12.Penicillin.
13.Zoloft.
14.Protonix.
15.Vancomycin.
ALLERGIES: GENTAMICIN EYE DROPS causing rash.
SOCIAL HISTORY: He lives in a group home and he is
profoundly retarded and nonambulatory, nonverbal and
frequently combative. He does not drink or smoke.
PHYSICAL EXAMINATION: His temperature is 101.8, heart rate
88, blood pressure 104/54, he is saturating 96 percent on
assist control with 100 percent FiO2. Generally, he was
sedated, intubated and nonresponsive. His head was
normocephalic. His mucous membranes were dry and he had
nasogastric tube and an endotracheal tube. Reflexes could
not be elicited. His chest had coarse breath sounds
bilaterally with diminishment at the bases. He was without
wheezes or crackles. His heart was regular rate and rhythm
with a 4/6 systolic murmur. His abdomen was distended and
soft. He had no bowel sounds. He had anasarca with pitting
edema in both extremities. His white blood cell count was
11.2. His hematocrit 32, his platelet count 159, 87
neutrophils, no bands, 9 lymphocytes. Sodium was 150,
potassium was 3.8, chloride was 114, bicarbonate 27, BUN 23,
creatinine 0.9 and glucose 96. His calcium was 8.1,
magnesium was 1.8, phosphorus was 2.2. AST 44, ALT 20,
alkaline phosphatase 77, amylase 73, lipase 13, albumin 2.1,
and total bilirubin 0.4. Blood cultures were taken and a
urine culture was taken. His PT was 16.8 and INR 1.8. His
ABG was pH 7.33, pO2 of 136 and pCO2 of 60. Lactate of 1.
Chest x-ray showed bilateral fluffy infiltrates about
pneumoperitoneum.
CT scan was reviewed from the outside hospital and
demonstrated mesenteric venous thrombosis with bowel wall
thickening and ascites.
CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted
on [**2176-9-25**], started on intravenous heparin and broad-
spectrum antibiotics. His condition initially improved and
then did plateau. A central line was placed for access for
parenteral nutrition and he was started on parenteral
nutrition. The patient continued to have heme-positive stool
and his hemodynamics secondary to his tetralogy of Fallot and
his ischemia did not improve. Cardiology consult, Vascular
consult and Infectious Disease consult were all obtained.
The patient's condition stabilized but did not significantly
improve over the course of approximately 1 week. After
detailed discussions with the patient's family, it was
decided that no surgery would be performed in the event that
the bowel declared itself as being infarcted rather than
merely ischemic. The patient was transferred to the Medical
Service for supportive therapy. The patient continued with
lack of improvement and the [**Location (un) 511**] Organ Bank was
contact[**Name (NI) **] and the patient was chosen for donation. On
[**2176-10-4**], the patient was taken to the operating room. He
was extubated and declared dead and his organs were
harvested.
DATE OF DEATH: [**2176-10-4**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 18475**]
Dictated By:[**Last Name (NamePattern4) 9859**]
MEDQUIST36
D: [**2176-12-17**] 14:47:01
T: [**2176-12-17**] 23:06:56
Job#: [**Job Number 50984**]
|
[
"276.2",
"276.0",
"507.0",
"428.0",
"789.5",
"745.2",
"557.0",
"518.82",
"452"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.04",
"96.72",
"88.47",
"88.49",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
1802, 2044
|
1716, 1776
|
3658, 5147
|
2224, 3629
|
455, 504
|
533, 1461
|
1483, 1692
|
2061, 2201
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,795
| 170,060
|
1875
|
Discharge summary
|
report
|
Admission Date: [**2138-7-30**] Discharge Date: [**2138-8-12**]
Service: MEDICINE
Allergies:
Ciprofloxacin / Naprosyn / Metoprolol / Amlodipine / Sulfa
(Sulfonamides) / Verapamil / Nsaids
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
dysuria, fever
Major Surgical or Invasive Procedure:
EGD and Colonoscopy
History of Present Illness:
82yo F with PMH significant for CHF, CAD, type II DM, PVD, and
CRI (Cr ranged from 1.4 to 3.3 in last 4 months) who presents
with hypotension in setting of recurrent UTI. Pt first developed
sx od dysuria 1 week ago and gave UA/urine cx to VNA for
testing. Since then, has had persistent dysuria and her baseline
incontinence, but no f/c/rigors/n/v/change in her back pain.
This AM, her daughter noted that the patient was "breathing
funny" while she was sleeping and when Ms. [**Known lastname 3142**] [**Last Name (Titles) 5058**], she
felt she was breathing harder so she went to the ER.
.
Per the ER, the patient was sent there in f/u for a positive
urine culture. On arrival to the ER, Ms. [**Known lastname 3142**] had a temp of
102, BP 122/80, HR 88. However, she quickly became hypotensive
to 77/40. Labs revealed a lactate of 2.8 and code sepsis was
initiated. She never had alteration in her mental status,
tachycardia, or respiratory distress. She had a central line
placed without incident and was given 1L of NS and 1u pRBC with
improvement in her SBP to 90s. She was then transferred to the
[**Hospital Unit Name 153**] for further management.
.
Of note, the ER resident considered further imaging of the
patient's spine given her h/o of low back pain, recurrent UTIs
and the question of epidural abscess raised during her last
hospitalization earlier this month. She never obtained imaging
as discussed at that time. On physical exam, the ER resident
found decreased rectal tone, trace guaiac + stool, and saddle
anesthesia. However, the patient is unable to fit in the MRI
scanner on the [**Hospital Ward Name 517**], is claustrophobic, and has refused
MRI in the past. A CT of the spine w/ contrast was not performed
given her rising Cr (1.9).
.
ROS:
dysuria x 1 week -> urine cx
denies f/c, denies wt loss/night sweats
denies CP/palp
+ SOB (baseline), walks 10 ft before getting inc pain
(?claudication)
denies n/v/d
+ urinary incontinence (chronic), denies bowel incontinence
+ constipation -> able to have BM this AM
denies increased back pain, well controlled on tylenol
Past Medical History:
1. diastolic CHF (EF 38% on cardiac cath with an akinetic
posterobasal wall, a severely hypokinetic inferior wall, and
moderately hypokinetic anterobasal, anterolateral, and apical
walls, and mild MR) Echo [**2138-4-3**]: LVEF>55%
2. CAD: Cath: DES to mid-LCX, OM1, and mid-LAD in [**1-12**]-during
cath
3. DMII c/b peripheral neuropathy
4. OA
5. IBS
6. PVD s/p right popliteal to DP bypass
7. Chronic venous insufficiency
8. Urinary incontinence
9. Hx uterine cancer s/p TAHBSO
10. Hx breast cancer s/p lumpectomy
11. Hx TIAs
12. Cervical radiculopathy
13. Benzodiazepine dependence
Social History:
Quit smoking >20 years ago. 20-40 pack year history. Lives at
home with two daughters on the [**Location (un) 448**]. Widowed. Denies
alcohol use. She is Irish in descent. She ambulates with a
walker at home. Worked in a shipyard during WWII.
Family History:
Mother died in 60's w/CAD.
Physical Exam:
VS - Tm 102, Tc 96.7, BP 100/30 (78-122/22-60), HR 70s, RR 18,
sats 94-95% on RA, CVP 9-11
Gen: WDWN obese elderly F in NAD, appears younger than stated
age.
HEENT: NCAT. Sclera anicteric, PERRL, EOMI. OP clear, no
exudates or erythema. No JVD appreciated, though R IJ in place.
Dsg is c/d/i. No LAD.
CV: RR, normal S1, S2. II/VI SEM best heard at LUSB. No r/g.
Resp: Crackles at bases bilaterally, but no wheezes or rhonchi.
Abd: Soft, NTND. + BS. No organomegaly.
Ext: Chronic venous stasis changes/erythema bilaterally to
shins. + pitting edema up to mid shin bilaterally. Could not
feel DP pulses. 2+ radial pulses bilaterally. Feet warm, dry. No
c/c. Point tenderness over S1/L5 vertebrae, w/o radiation.
Neuro: CN II-XII grossly intact, AAOx3. STrength 4+/5 in UE and
LE bilaterally, both distally and proximally. DTR 1+ at patella
bilaterally. Toes downgoing bilaterally. Decreased rectal tone,
but no evidence of saddle anesthesia. Sensation intact to light
touch and pin throughout saddle distribution.
Pertinent Results:
[**2138-7-30**] 09:52PM HGB-9.4* calcHCT-28 O2 SAT-83
[**2138-7-30**] 09:33PM GLUCOSE-54* UREA N-56* CREAT-1.6* SODIUM-138
POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-30 ANION GAP-12
[**2138-7-30**] 09:33PM CALCIUM-9.0 PHOSPHATE-4.0 MAGNESIUM-2.3
[**2138-7-30**] 09:33PM WBC-8.8 RBC-2.97* HGB-9.3* HCT-25.6* MCV-86
MCH-31.3 MCHC-36.2* RDW-15.6*
[**2138-7-30**] 09:33PM NEUTS-65.8 LYMPHS-25.8 MONOS-5.5 EOS-2.7
BASOS-0.3
[**2138-7-30**] 09:33PM PLT COUNT-282
[**2138-7-30**] 05:01PM COMMENTS-GREEN TOP
[**2138-7-30**] 05:01PM LACTATE-1.3
[**2138-7-30**] 05:01PM HGB-8.8* calcHCT-26 O2 SAT-93
[**2138-7-30**] 04:19PM TYPE-MIX COMMENTS-GREEN TOP
[**2138-7-30**] 04:19PM GLUCOSE-119* LACTATE-2.1*
[**2138-7-30**] 04:19PM HGB-8.7* calcHCT-26 O2 SAT-97
[**2138-7-30**] 02:15PM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.013
[**2138-7-30**] 02:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2138-7-30**] 02:15PM URINE RBC-0 WBC-21-50* BACTERIA-MANY
YEAST-NONE EPI-0
[**2138-7-30**] 02:15PM URINE HYALINE-0-2
[**2138-7-30**] 01:59PM GLUCOSE-164* LACTATE-2.8* K+-4.4
[**2138-7-30**] 01:40PM GLUCOSE-170* UREA N-60* CREAT-1.9* SODIUM-136
POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-29 ANION GAP-14
[**2138-7-30**] 01:40PM CK(CPK)-65
[**2138-7-30**] 01:40PM CK-MB-NotDone cTropnT-0.03*
[**2138-7-30**] 01:40PM CALCIUM-9.2 PHOSPHATE-4.0 MAGNESIUM-2.2
[**2138-7-30**] 01:40PM WBC-9.5 RBC-2.74*# HGB-8.7* HCT-24.2*# MCV-88
MCH-31.7 MCHC-35.9* RDW-15.3
[**2138-7-30**] 01:40PM NEUTS-68.2 LYMPHS-26.6 MONOS-4.3 EOS-0.7
BASOS-0.2
[**2138-7-30**] 01:40PM PLT COUNT-295
[**2138-7-30**] 01:40PM PT-12.4 PTT-28.0 INR(PT)-1.1
CXR: No evidence of CHF or increase in cardiac size.
L ankle XR: There is medial and lateral malleolar soft tissue
swelling without signs for fractures or dislocations. Extensive
vascular and soft tissue calcifications are seen throughout the
ankle. The talar dome is intact. There is enthesopathy at the
attachment of the Achilles tendon and a plantar spur present.
Colonoscopy: Normal colonoscopy to cecum
Additional notes: The efficiency of colonoscopy in detecting
lesions was discussed in detail with the patient. It was
explained that colon cancer and colon polyps may on rare
occasions be missed during a colonscopy. The attending was
present during the entire procedure Routine Post-Procedure
orders. No source of bleeding found, may follow up with
outpatient capsule endoscopy.
EGD: Normal EGD to second part of the duodenum
Additional notes: The attending was present for the entire
procedure. Routine post-procedure orders. No source of bleeding.
Follow up with outpatient capsule endoscopy.
Brief Hospital Course:
# SEPSIS: Unclear why sepsis protocol was initiated, given that
lactate was only 2.8, but patient improved since its initiation.
Patient has pseudomonal UTI and back pain. Treated for
urosepsis, probable pyelonephritis. Improved on cefepime and
completed 2 week course. Had a UA on discharge that was checked
showing continued pyuria, but had just completed 2 weeks of
antibiotics. She will need a repeat UA and UCx followed up in
the next week as an outpatient. She should follow up with her
urologist.
.
# DECREASED RECTAL TONE: Unclear etiology, however exam appears
stable from earlier this month and clinical history does not
support an acute change. Most optimal study, after talking with
both neurology and radiology, would be MRI. If not MRI, then CT
of spine w/ contrast. Very little utility in CT of the spine w/o
contrast in this situation. Since her neuro exam appeared
stable, decision was made to hold off on attempting imaging as
patient refused MRI. She is willing to have an outpatient open
MRI however. She had no other neurologic deficits during her
hospital stay.
# UTI: Pansensitive Pseudomonas from OSH cx. Given levofloxacin
and vanco in ER, though has reported allergy to levofloxacin
(quinolones). Switched to cefepime, given pansensitive organism
and the fact that pt has tolerated cephalosporins in the past.
Unclear why pt has h/o recurrent UTIs (h/o pansensitive E.Coli
and Klebsiella UTIs as well). Was followed by urology 2 yrs ago,
had cystoscopy that was not significant for any anatomical
abnormalities, no increased bladder volumes and post-void
residuals suggestive of overflow incontinence. Follow up with
urologist. Will need follow up UA as outpatient in next week.
.
# CRI: Baseline is somewhat unclear given fluctuating levels
over the last year (Cr has been anywhere from 1.4 to 3.3). On
admission was 1.9 and now down to 1.3. Diuretics restarted and
remained on same home medications.
.
# HTN: Will continue coreg (for CHF/CAD). Diuretics held
initially then restarted when sepsis resolved.
.
# CAD: Has h/o multivessel disease s/p multiple stents. Troponin
now 0.03, CK 65. Story not c/w angina or ischemia, but
hypotension may have caused some mild demand ischemia. EKG w/o
any acute changes.
- cont ASA, bblocker, plavix, lipitor, nitrate, bumex
.
# CHF: Cont. Imdur/bumex
.
# DM TYPE II: Last HgbA1C was 7.8 in [**4-12**]. On NPH [**Hospital1 **] + HISS at
home. Pt with low blood sugars on admission to 57, low blood
sugar this am in 50s c symptoms of "hot flashes." Improved to
70s after eating breakfast. Restarted home insulin.
.
# ANEMIA: Pt's baseline Hct in low 30s, noted to be 24.7 in ER,
Guaiac positive, given 1U pRBC. Pt. with persistently low hct in
26-28 range with no symptoms but persistently guiac positive
stool. Had EGD and colonoscopy that did not reveal any source of
bleeding as an inpatient. Pt's hct remained stable in this
range, and GI recommended f/u for outpt. capsule study. She can
follow up with Dr. [**Last Name (STitle) 2161**] for this.
.
# OA/CHRONIC PAIN: Stable on home regimen. No acute increase in
pain requirement currently.
.
# URINARY INCONTINENCE: Ongoing problem. GU w/u neg to date. No
PVR, no anatomic abnormalities (though pyelogram not done yet).
Last urology appt was in [**9-11**].
- tolterodine [**Hospital1 **] and detrol LA
.
# HYPOTHYROIDISM: Dx in [**6-11**], TSH was 4.5, corrected to 1.4 in
[**4-12**] on levothyroxine.
- cont levothyroxine at home dose
.
# H/O UTERINE/BREAST CANCER: Currently not active issues. XR on
[**6-22**] no signs of bony or metastatic disease.
.
# FEN:
- IVF boluses to keep SBP >90 or CVP 8-12
- check lytes [**Hospital1 **], replete prn
- regular [**Doctor First Name **], low salt, heart healthy diet
.
# ACCESS:
- RIJ placed [**7-30**], PICC- pulled at d/c
.
# PPX:
- heparin SC
- PPI
- bowel regimen
.
# CODE: FULL, confirmed by HCP on [**7-30**].
.
# COMM: HCP [**Name (NI) **] [**Name (NI) 3142**] [**Telephone/Fax (1) 10462**] or cell [**Telephone/Fax (1) 10463**]
.
Medications on Admission:
1. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: as dir as
dir Subcutaneous twice a day: 25 untis sc qam and 15 units sc
qpm.
2. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: as dir as
dir Subcutaneous four times a day: Sliding scale humalog, please
resume your regular scale.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
4. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual QID (4 times a day) as needed for
prn stomach cramps.
9. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day). Disp:*120 Tablet(s)* Refills:*2*
10. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for SOB, wheezing.
12. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
16. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
18. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
19. Bumetanide 2 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
20. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8PM ().
Disp:*480 Capsule(s)* Refills:*2*
21. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
22. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
26. Detrol LA 4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO once a day.
27. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
28. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO once a day.
29. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Discharge Medications:
1. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: as dir as
dir Subcutaneous twice a day: 25 untis sc qam and 15 units sc
qpm.
2. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: as dir as
dir Subcutaneous four times a day: Sliding scale humalog, please
resume your regular scale.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
4. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual QID (4 times a day) as needed for
prn stomach cramps.
9. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
10. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for SOB, wheezing.
12. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
16. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
18. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
19. Bumetanide 2 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
20. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8PM ().
Disp:*480 Capsule(s)* Refills:*2*
21. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
22. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
23. Phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
24. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day).
Disp:*qs 2 weeks* Refills:*2*
25. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*qs 1 week* Refills:*2*
26. Detrol LA 4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO once a day.
27. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
28. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO once a day.
29. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
30. open MRI
Please have a lumbosacral spine MRI done to r/o spinal stenosis.
31. Outpatient Lab Work
CBC to be done [**8-13**] or [**8-14**] and results faxed to PCP.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Sepsis due to Pyelonephritis
Occult Gastrointestinal Bleeding
Discharge Condition:
stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500cc
Please continue your regular medications. Please have your blood
count checked either [**8-13**] or [**8-14**]. You will need to have a follow
up spinal open MRI. Please also follow up with your PCP
regarding your low blood count and blood in your stool.
Followup Instructions:
1.Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**]
Date/Time:[**2138-8-25**] 10:00
2. Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], M.D. Date/Time:[**2138-8-25**] 12:00
3. Please have your Hematocrit checked by the nurse [**8-13**] or [**8-14**]
to make sure these are stable.
4. Please also arrange with your PCP to have an open MRI of your
L and S spine
|
[
"578.9",
"428.30",
"250.60",
"V10.42",
"715.90",
"585.9",
"038.9",
"440.20",
"724.5",
"428.0",
"401.9",
"244.9",
"995.92",
"V10.3",
"357.2",
"590.80",
"459.81",
"V12.59",
"458.9",
"723.4",
"564.1",
"285.8",
"V45.82",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"99.04",
"45.13",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
16680, 16751
|
7173, 11187
|
317, 339
|
16857, 16866
|
4421, 7150
|
17295, 17750
|
3345, 3373
|
13692, 16657
|
16772, 16836
|
11213, 13669
|
16890, 17272
|
3388, 4402
|
263, 279
|
367, 2460
|
2482, 3068
|
3084, 3329
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,805
| 123,287
|
18703+18704
|
Discharge summary
|
report+report
|
Admission Date: [**2132-7-21**] Discharge Date: [**2132-7-23**]
Date of Birth: [**2071-8-26**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old
female who was watching television with her husband on [**7-21**] when she then fell to the floor and was unresponsive.
Her husband then performed CPR and called paramedics. The
paramedics then arrived, placed external defibrillator on the
patient. The patient was shocked three times. The patient
then regained normal sinus rhythm and was sent to [**Hospital6 3426**]. At [**Hospital6 33**] the patient was intubated
and transferred to [**Hospital1 69**]. The
patient has no previous medical problems. Upon admission,
the patient was intubated.
PHYSICAL EXAMINATION: Physical examination was significant
for an obese, somewhat agitated and combative patient. On
physical examination, her head and neck examination revealed
pupils were equally round and reactive. Her extraocular
movements were intact. She was anicteric. Her neck was not
evident for jugular venous distention. Her lung examination
was clear to auscultation anteriorly and laterally. Her
cardiac examination revealed a regular rate and rhythm, S1,
S2. No murmurs, rubs or gallops. On abdominal examination,
she was obese. Her abdomen was non-distended, non-tender and
she had normoactive bowel sounds. Extremity examination
showed intact pulses bilaterally, no clubbing, cyanosis or
edema but did show a left ganglionic cyst. Her neuro
examination was nonfocal. She moved all four limbs equally.
RADIOLOGY: Patient had a head CT which was negative. She
had a chest x-ray which was negative except for a small
calcification which may be significant for a tooth.
LABORATORY: Patient's Chem-7: Sodium 141, potassium 4.1,
chloride 103, bicarb 29, BUN 20, creatinine 1.3, glucose 163.
Patient's initial CBC: White count 13.8, hemoglobin 13.3,
hematocrit 38.4, platelets 270. Her PT 13.0, PTT 23, 8, INR
1.1. Patient's d-dimer less than 500. Urinalysis was
negative. Troponin of 0.1, CK MB 13, MB index of 1.8%
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**]
Dictated By:[**Last Name (NamePattern1) 6289**]
MEDQUIST36
D: [**2132-7-23**] 15:35
T: [**2132-7-23**] 17:56
JOB#: [**Job Number 51282**]
Admission Date: [**2132-7-21**] Discharge Date: [**2132-7-24**]
Date of Birth: [**2071-8-26**] Sex: F
Service: CCU
HISTORY OF THE PRESENT ILLNESS: The patient is a 60-year-old
female who was previously healthy who had an episode where
her eyes rolled back in her head and became unresponsive
while watching television with her husband. [**Name (NI) **] husband
performed CPR and called the paramedics who then found the
patient to be in V fib. The patient received three shocks,
regained normal sinus rhythm and was brought to the [**Hospital6 3622**] where she was intubated. The patient was then
transferred to [**Hospital6 256**] where she
was started on heparin, Plavix, and aspirin.
PHYSICAL EXAMINATION ON ADMISSION: Upon admission, the
patient's vital signs revealed that she weighed 106
kilograms, temperature 97.9, respirations 22, blood pressure
114/52, and she was saturating at 100% on 80 FI02. The
patient's examination revealed that she was obese, agitated,
combative, not interactive on admission. Head and neck: Her
pupils were equally round and reactive to light. The
extraocular movements were intact. She was nonicteric. Her
neck was thick, no JVD, was supple. No lymphadenopathy.
Chest: Clear to auscultation anteriorly and laterally.
Cardiac: Regular rate and rhythm, S1, S2, no rubs, no
gallops, no murmurs. Abdomen: Obese, nontender,
nondistended, normoactive bowel sounds, no organomegaly.
Extremities: She had 2+ distal pulses bilaterally, no
clubbing, cyanosis or edema. She did have left ganglionic
cyst. Neurologic: Grossly nonfocal. She moved all four
extremities equally.
LABORATORY/RADIOLOGIC DATA: Upon admission, the patient had
a troponin of 0.13, CK 507, white count 8.7. She had a
D-dimer that was less than 500. Her U/A was negative. Her
Chem-7 had a sodium of 140, potassium 3.7, chloride 105,
bicarbonate 23, BUN 20, creatinine 0.9, glucose 159. A
follow-up white count revealed a white count of 13.8,
hematocrit 38.4, platelets 269,000. Her PTT was 38.2, INR
1.2.
CT of the head was negative.
Her EKG revealed normal sinus rhythm, rate in the 70s, no ST
segment elevation.
HOSPITAL COURSE: The patient remained in the CCU where at
that time she was sent for cardiac catheterization which
revealed clean coronary arteries. She then received an
echocardiogram which showed good left ventricular function
with no wall motion abnormalities. On further review of her
chest x-ray, a small calcified area was noted which may be
consistent with a tooth. The patient then underwent
bronchoscopy and a small lesion was removed which appeared to
be a tooth possibly secondary to intubation. The lesion was
sent for pathology.
The same day, the patient was also sent to the EP laboratory
with successful placement of ICD. The patient was also
extubated with good 02 saturations. The following day, the
patient was sent to the floor where he did well, was able to
tolerate a p.o. diet and continued to have good 02
saturations on room air. PT and OT were consulted who
recommended that the patient should have home OT therapy but
did not require a rehabilitation facility. Neurobehavior was
also contact[**Name (NI) **] for involvement with possible mental status
changes secondary to anoxic injury from her V fib.
CONDITION ON DISCHARGE: Good. She was able to ambulate well
with good p.o. intake. Her neurological examination was
nonfocal. She was oriented to person, time, and place. She
was fully conversant. The patient was discharged on
[**2132-7-24**].
FOLLOW-UP: The patient was given appropriate follow-up with
[**Hospital 29890**] Clinic. She was also given Cardiology
follow-up with Dr. [**Last Name (STitle) **] as well as follow-up with the
Device Clinic for her ICD. The patient was also setup for
home occupational therapy. No cardiac medications other than
a statin were indicated for a patient with no other cardiac
disease. The patient was told to follow-up with her
appropriate appointments and further therapy could be done at
that time. The patient was told that if she had any bleeding
at the site of her ICD, had any lightheadedness, chest pain,
palpitations, shortness of breath, or any other concerning
symptoms that she should return to the Emergency Department
for further evaluation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Last Name (NamePattern4) 30868**]
MEDQUIST36
D: [**2132-7-28**] 06:31
T: [**2132-8-5**] 20:37
JOB#: [**Job Number 51283**]
|
[
"E849.0",
"427.41",
"E915",
"934.1",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"98.15",
"33.22",
"37.23",
"96.71",
"37.94",
"37.26",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
4553, 5675
|
765, 3104
|
160, 742
|
3119, 4535
|
5700, 6963
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,569
| 138,644
|
13459
|
Discharge summary
|
report
|
Admission Date: [**2177-5-15**] Discharge Date: [**2177-5-26**]
Date of Birth: [**2106-8-2**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Heparin Agents / Morphine / Tylenol
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
GIB, mental status changes
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
The patient is a 70 year old female with a history of diabetes
mellitus type 2, ESRD on hemodialysis and cirrhosis presenting
to an outside hospital with mental status changes. She was
brought in by her family due to increasing confusion after
dialysis yesterday. Her daughter was not aware of dark stools
until she presented to the hospital.
.
In the OSH ED, her ammonia level was 123 and she was given
lactulose. NG lavage failed x 2 so she was given ativan and
versed for conscious sedation and a third NG lavage attempt
returned negative. Her Hct was 29.9 and she remained
hemodynamically stable. A right subclavian line was placed and
she was given Protonix. She was transferred to [**Hospital1 18**] ED because
most of her medical care is here.
.
In the [**Hospital1 18**] ED, her Hct was 30.5. Her SBP remained in the 130s
and HR in the 80s. She was lethargic and not oriented but
maintained O2 sats in the high 90s on room air so was not
intubated. She had 2 episodes of melanotic stools while in the
ED. Given the conscious sedation she received at the OSH, she
was given Narcan with no effect. GI was made aware and given her
hemodynamic stability, plans were made to scope her tomorrow.
Past Medical History:
Diabetes type 2
ESRD on HD Q M,W,F
s/p infection in left knee
h/o MRSA/C.diff
cirrhosis due to NASH and Tylenol toxicity; has not made
outpatient appointments in several months (daughter says they
have always been on dialysis days and can't make both
appointments)
?h/o Seizure, on [**Hospital1 13401**]
h/o CHF (diastolic dysfxn; EF>55% last TTE [**8-8**])
s/p ORIF for left distal femur fracture on [**2176-1-23**]
HIT (Ab positive [**2-8**])
large ulcer seen on endoscopy at OSH ~2 years ago per daughter
Social History:
lives at home with daughter. [**Name (NI) **] ETOH/TOB/illicit drugs.
Family History:
non-contributory
Physical Exam:
VS: T: 95.8; HR: 85; BP: 131/47; RR 15; O2 96% RA
GEN: elderly woman, lying in bed, confused, responsive to voice
HEENT: PERRL bilat, EOMI bilat, +icteric sclerae, MMM, OP w/
dried blood
CV: RRR, normal s1s2, [**4-8**] sys murmur @ LUSB, no S3/S4
CHEST: CTAB
ABD: NABS, obese, soft, ND, no masses, no ascites
EXT: no c/c/e; AV fistula on left arm
NEURO: A&Ox1, unable to cooperate with full neuro exam, moves
extremities on command, sensory/motor exam grossly intact bilat,
no asterixis, no myoclonus.
Pertinent Results:
[**2177-5-15**] 06:00PM GLUCOSE-137* UREA N-31* CREAT-4.3* SODIUM-142
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-26 ANION GAP-16
[**2177-5-15**] 06:00PM ALT(SGPT)-10 AST(SGOT)-27 ALK PHOS-149*
AMYLASE-57 TOT BILI-3.6*
[**2177-5-15**] 06:00PM LIPASE-28
[**2177-5-15**] 06:00PM ALBUMIN-2.7* CALCIUM-9.7 PHOSPHATE-5.1*
MAGNESIUM-2.4
[**2177-5-15**] 06:00PM AMMONIA-133*
[**2177-5-15**] 06:00PM WBC-4.7 RBC-2.97* HGB-10.0* HCT-30.5*
MCV-103* MCH-33.8* MCHC-33.0 RDW-20.3*
[**2177-5-15**] 06:00PM NEUTS-79.5* LYMPHS-12.3* MONOS-5.6 EOS-2.5
BASOS-0.2
[**2177-5-15**] 06:00PM HYPOCHROM-1+ ANISOCYT-2+ MACROCYT-3+
[**2177-5-15**] 06:00PM PLT COUNT-65*
[**2177-5-15**] 06:00PM PT-16.3* PTT-33.6 INR(PT)-1.5*
.
portable CXR: Mild cardiogenic hydrostatic edema. No definite
pneumonia.
.
Abdominal ultrasound with dopplers:
1. On this technically limited study, no color Doppler flow was
demonstrated in the portal vein, consistent with either
extremely low or absent portal venous flow.
2. Cirrhosis with associated splenomegaly.
3. Gallstones.
.
Abdominal CT scan:
1. Limited evaluation of the portal vein. No gross filling
defects within the main portal vein to suggest thrombus. If
there is further clinical concern about portal vein thrombosis a
duplex Doppler ultrasound of the liver is recommended.
2. Moderate to large right pleural effusion.
3. Cirrhosis, collateralization, and splenomegaly, all
consistent with portal hypertension.
4. 2 mm nonobstructing right renal stone.
.
.
[**12/2176**] Fistulogram:
A fistulogram was performed and demonstrated the venous outflow
to the level of the right atrium. An area of tight stenosis was
demonstrated at the outflow cephalic vein in the arm, associated
with some collaterals. Patent central veins.
.
1. Left AV fistulogram demonstrating patent superior vena cava,
left
brachiocephalic, and left subclavian veins.
2. Multiple collaterals were seen in the area of the axilla, as
well as tight stenosis in the outflow of the cephalic vein.
3. Successful dilation with a 6 mm balloon at the level of
stenosis with mild improvement of the venous outflow.
4. Unsuccessful attempts to opacify the arterial side of the
fistula due to patient discomfort
Brief Hospital Course:
1. Altered mental status: likely hepatic encephalopathy in the
setting of GI bleed. She had an elevated ammonia at the outside
hospital and was treated with lactulose. The patient responded
well and was at her baseline mental status at discharge.
.
2. GI Bleed: the patient underwent EGD which demonstrated
gastric angioectasias/watermelon stomach. Her hematocrit
trended down and she was transfused 2 units prbcs and was
maintained on an octreotide drip, [**Hospital1 **] PPI and sucralfate. She
underwent second EGD for APC, which was successful. She was
transitioned to twice daily PPI and low dose propranolol.
H.pylori negative.
.
3. Portal vein thrombosis: positive by ultrasound, negative by
CT scan of the abdomen. Not a candidate for anticoagulation.
.
4. End stage renal disease: the patient was followed by the
renal team and dialyzed by her regular schedule while inpatient.
Per the patient's daughter, the outpatient dialysis unit said
the patient needed a fistulogram. She had the fistulogram
performed [**2177-5-26**].
.
5. Bacteremia: the patient had [**2-6**] positive gram positive rod
blood culture. No fever, no leukocytosis from admission. She was
treated initially with Zosyn/Vancomycin and her central line
needed to be removed. The line was removed [**2177-5-23**] and had no
growth. The patient will continue Vancomycin with Hemodialysis
until [**2177-5-27**].
.
6. DM: the patient was continued on her home dose of Lantus and
SSI.
.
7. Diastolic dysfunction: evidence of edema on initial chest
x-ray, but not hypoxic. The patient was maintained on her home
Lasix dose and further fluid management was done by
hemodialysis.
.
8. Disposition: the patient was discharged to rehabilitation
after a prolonged hospitalization. She will follow up with her
PCP and primary hepatologist as an outpatient.
Medications on Admission:
[**Month/Day/Year 13401**] 500mg qd
Protonix
Lasix 40mg qd
Lantus 12U SC
Discharge Medications:
1. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): titrate to [**4-6**] bowel movements per day.
2. Sevelamer 400 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
3. Levetiracetam 250 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Propranolol 10 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): hold for sbp <100, hr <60.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO three times a day.
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
9. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day) as needed.
10. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime.
11. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig:
variable units Subcutaneous four times a day: per sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Primary:
Gastric angioectasias
Hepatic encephalopathy
Gram positive rod bacteremia
Secondary:
End stage renal disease
End stage liver disease from NASH
Diabetes mellitus type 2, complicated
MRSA
Clostridium difficle
Seizure disorder
Diastolic dysfunction
HIT
Discharge Condition:
Stable, on room air, baseline mental status. Stable hematocrit X
5 days.
Discharge Instructions:
You were admitted with bleeding from your stomach. Please
return to the ED if you vomit blood, have blood per rectum,
abdominal pain, chest pain, shortness of breath or an inability
to tolerate your medications.
Followup Instructions:
-Please see your PCP [**Name Initial (PRE) 176**] 2 weeks of rehabilitation discharge.
Dr. [**First Name (STitle) 3077**] [**Telephone/Fax (1) 40793**] to discuss your hospitalization and have
your labs checked.
.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2177-7-4**] 8:00
|
[
"403.91",
"599.0",
"428.0",
"345.90",
"287.5",
"585.6",
"428.30",
"573.3",
"537.9",
"537.83",
"571.5",
"572.2",
"250.00",
"456.20",
"286.9",
"790.7",
"572.3",
"008.45"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"99.04",
"39.95",
"38.93",
"44.43",
"96.34"
] |
icd9pcs
|
[
[
[]
]
] |
8002, 8049
|
4991, 5002
|
331, 336
|
8353, 8428
|
2757, 4968
|
8690, 9049
|
2201, 2220
|
6944, 7979
|
8070, 8332
|
6846, 6921
|
8452, 8667
|
2235, 2738
|
265, 293
|
364, 1565
|
5017, 6820
|
1587, 2097
|
2113, 2185
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,980
| 134,279
|
10904
|
Discharge summary
|
report
|
Admission Date: [**2120-12-4**] Discharge Date: [**2120-12-15**]
Date of Birth: [**2067-2-15**] Sex: M
Service: CT SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old
male with a history of coronary artery disease status post
multiple percutaneous transluminal coronary angioplasties
with stents. He was symptom-free for two weeks status post
the last stent. Since then, he has had progressive angina
and occasional angina at rest. No history of orthopnea,
paroxysmal nocturnal dyspnea, or lower extremity edema.
Denies atrial fibrillation or transient ischemic attack. No
claudication.
PAST MEDICAL HISTORY: Noncontributory.
MEDICATIONS: Aspirin 325 mg once daily, Lopressor 25 mg
twice a day, Protonix 40 mg once daily, Lipitor 20 mg once
daily, Norvasc 5 mg once daily.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Cardiac: Regular rate and rhythm,
Grade I/VI systolic murmur. Pulmonary: Clear to
auscultation bilaterally. Abdomen: Soft, nontender,
nondistended. Extremities: No edema.
HOSPITAL COURSE: The patient was brought to the operating
room on [**2120-12-5**], where a coronary artery bypass graft x 4
was performed. Left internal mammary artery went to left
anterior descending, saphenous vein graft to diagonal,
saphenous vein graft to obtuse marginal I, saphenous vein
graft to obtuse marginal III. The pericardium was left open.
An arterial line and right internal jugular with a Swan-Ganz
catheter were placed. Two atrial wires as well as two
mediastinal tubes and one pleural tube were placed. His EBB
equals 98 minutes, XTL equals 66 minutes.
Postoperatively, the patient was transferred to the Intensive
Care Unit, where he was rapidly extubated. On postoperative
day one, his mediastinal and pleural tubes were removed. He
was kept in the Intensive Care Unit for aggressive pulmonary
toilet on postoperative day two. On postoperative day two,
the patient was noted to have tachycardia and diaphoresis
despite albuterol nebulizers and pain control. He began to
become hypoxemic. A chest x-ray revealed a consolidation
with pneumonia, for which levofloxacin and vancomycin were
started. The patient was reintubated and was once again
stable. A TTE performed at that time revealed right
ventricular hypokinesis and mild mitral regurgitation. No
pericardial effusion, and the left ventricular ejection
fraction was preserved.
The patient was stable on the ventilator. He was on a
Neo-Synephrine and propofol drip. Tube feeds were started
also on postoperative day two. The patient's hematocrit fell
to 23 on two occasions, for which he received two units of
packed red blood cells each time. The ventilator began to be
weaned on postoperative day three, and on postoperative day
four, the patient was extubated again. The Neo-Synephrine
drip was also weaned.
The patient was stable in the Intensive Care Unit, and was
transferred to the floor on [**2120-12-11**], in the evening.
This is now postoperative day seven. On the floor, he was
slow with ambulation, but eventually improved significantly.
He was tolerating a regular diet, and levofloxacin and
vancomycin were discontinued. Laboratories were stable, with
a hematocrit of 32.3, white count 5.8, potassium 4.2, BUN 21,
creatinine .7.
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS: Lopressor 25 mg twice a day, lasix
20 mg twice a day, potassium chloride 20 mEq twice a day,
Colace 100 mg twice a day, aspirin 325 mg once daily, Plavix
75 mg once daily, Lipitor 20 mg once daily, Protonix 20 mg
once daily, Tylenol and percocet one to two tablets by mouth
every four to six hours as needed.
DISCHARGE STATUS: Home.
FO[**Last Name (STitle) 996**]P: With primary care physician in three weeks,
follow up with Dr. [**Last Name (Prefixes) **] in four weeks.
DISCHARGE DIAGNOSIS:
1. Status post coronary artery bypass graft x 4
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 1308**]
MEDQUIST36
D: [**2120-12-13**] 14:40
T: [**2120-12-14**] 03:44
JOB#: [**Job Number 35463**]
|
[
"305.1",
"424.0",
"401.9",
"997.3",
"996.72",
"414.01",
"411.1",
"272.4",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"33.23",
"37.22",
"36.15",
"96.71",
"36.13",
"88.56",
"88.72",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
3366, 3843
|
3864, 4166
|
1081, 3306
|
883, 1062
|
174, 628
|
652, 859
|
3332, 3341
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,248
| 198,550
|
17763
|
Discharge summary
|
report
|
Admission Date: [**2162-4-5**] Discharge Date: [**2162-4-8**]
Date of Birth: [**2113-12-20**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: This is a 48-year-old male with
cardiac risk factors of gender, hypercholesterolemia, and
tobacco use, who presented to [**Hospital3 3834**] after
experiencing three days of chest pain prior to admission. He
described it as substernal pressure, which felt like
heartburn. He denied nausea, diaphoresis, palpitations. He
seemed to improve with activity. He admitted to nocturnal
awakening, though no shortness of breath. He states he had a
similar episode approximately 20 years ago which resolved
with a H2 blocker. He had syncope approximately 15 years
ago, felt flushed. Approximately six weeks ago, he felt
lightheaded without syncope. He denies PND or orthopnea.
At presentation to the [**Hospital3 3834**], his blood pressure
was decreased to the 80s to 90s with nitroglycerin. He was
transferred to [**Hospital1 **] for cardiac
catheterization. Catheterization demonstrated right dominant
system, 30% left circumflex, total occlusion of the right
coronary artery and mid region which was Angio-Jetted and
then stented with 2.75 x 32 mm and 3.0 x 15 mm stents. There
were distal emboli in the PDA and RPL. A left ventriculogram
revealed mitral regurgitation, pulmonary capillary wedge of
19, P.A. of 13/12, RV of 42/5, RA of 13, cardiac output of
4.76, cardiac index of 2.21. His case was complicated by
decreased breath sounds requiring dopamine drip. He was
transferred to the CCU with an Aggrastat drip.
REVIEW OF SYSTEMS: Night sweats on the end of [**2162-11-10**], negative for fevers, positive for chills at that time.
Denies amaurosis fugax. Denies dysarthria or asymmetric
weakness. Positive cough, nonproductive, no melena, no
bright red blood per rectum, no hematuria. Negative for poor
healing. Positive claudication.
PHYSICAL EXAM ON PRESENTATION TO THE CCU: Heart rate 90
regular, blood pressure 91/54 on dopa 5 mcg/kg. Sating 98%
on 2 liters, respiratory rate 16, 98 kg. He was lying
supine, breathing comfortably. Pupils are equal, round, and
reactive bilaterally. Extraocular muscles are intact.
Oropharynx is clear and dry. Carotids are 2+ without bruits.
Neck: No jugular venous distention while supine. Lungs are
clear to auscultation bilaterally. Heart: Regular, rate,
and rhythm, normal S1, S2, no S3, S4, or murmur. Abdomen:
No pulsatile mass, negative hepatomegaly, nontender.
Extremities: DP decreased on the right, trace DP and PT
pulses on the left 1+, no edema, clubbing. Right groin with
a 5 French arterial line. Left groin with a 6 French
arterial sheath. Neurologic: No facial droop. Tongue
midline. Palate upgoing symmetrically. Moves all four
extremities symmetrically.
Electrocardiogram at 8 am: AVR with ST elevation of 4 mm.
At 9:50 am, he was sinus at 86 beats per minute, PR 140, QRS
92, QTC at 44, normal axis, 1-[**Street Address(2) 1766**] elevations in II, III,
and aVF, III greater than II, ST depressions in I and aVL.
LABORATORIES: White count 11.8, hematocrit 37.5, platelets
111, MCV of 88, neutrophils 84%, bands 4, lymphocytes 7, INR
of 1, PTT of 21, PT of 11.7. Sodium 138, potassium 4.1,
chloride of 105, bicarb 21, BUN 13, creatinine 1.6, glucose
of 126, calcium of 8, albumin of 3.5, bilirubin of 0.9, and
alkaline phosphatase 74, ALT of 84, AST of 250, CK of 1493,
CK MB of 135, index of 9.1, troponin-I of 28.
HOSPITAL COURSE: This was a 48-year-old gentleman with
inferior myocardial infarction admitted to the CCU on Dopa
drip due to hypotension status post RCA Angio-Jet and stent
x2. There is a concern that he had right ventricular
involvement because of the hypotension post nitroglycerin at
the outside hospital. The patient was continued on Aggrastat
for about 18 hours. He was continued on aspirin, Plavix,
Lipitor, and he was counseled on smoking cessation given a
nicotine patch. The enzymes were continued and cycled until
a downward trend.
A beta blocker was held initially due to the hypertension.
During catheterization laboratory, the patient was also noted
to have VT. He was not shocked. His electrolytes were
monitored closely, there were no further episodes. Patient
was also on a proton-pump inhibitor.
The day of admission the patient was initiated on low dose
beta blocker. The following day he was started on a low dose
ACE inhibitor. The dopamine came off the day after admission
as well, and he had no difficulty maintaining pressure.
Patient was .............. that day.
Postcatheterization course was complicated by a temperature
of 101.3, as well as decreased platelets. A HIT antibody was
sent which was negative. Due to the cough and the fever, the
patient was initiated on levofloxacin. Patient also had
diarrhea at that time. Clostridium difficile was sent since
he had been on antibiotics previously. Stool, sputum, and
blood cultures, as well as urine cultures all remained
negative, and the patient remained afebrile after that one
event.
Patient continued to do well, and stated that he would
followup closely with his PCP due to the fever with unknown
source. The patient was discharged status post inferior
myocardial infarction, status post right coronary artery
stent x2. Patient was scheduled to followup with PCP.
FOLLOW-UP INSTRUCTIONS: The patient was instructed to
followup with Dr. [**Last Name (STitle) 11493**] of Cardiology and his PCP both within
one week of discharge.
DISCHARGE INSTRUCTIONS: He was instructed to continue to
take his temperature q day, and if he should have any
symptoms of chills or night sweats.
PROCEDURES: Cardiac catheterization with stent of totally
occluded right coronary artery x2 stents.
DISCHARGE CONDITION: Improved and stable.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg q day.
2. Plavix 75 mg q day x9 months.
3. Atorvastatin 20 mg q day.
4. Nicotine patch.
5. Carvedilol 3.125 [**Hospital1 **].
6. Lisinopril 5 q day.
7. Nitroglycerin 0.3 mg sublingual prn.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Name8 (MD) 8876**]
MEDQUIST36
D: [**2162-5-13**] 17:58
T: [**2162-5-14**] 05:44
JOB#: [**Job Number 49345**]
|
[
"428.0",
"427.1",
"410.41",
"458.2",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"36.06",
"36.01",
"37.22",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
5790, 5812
|
5835, 6307
|
3500, 5351
|
5542, 5768
|
1612, 3482
|
164, 1592
|
5376, 5517
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
731
| 173,234
|
256
|
Discharge summary
|
report
|
Admission Date: [**2152-3-16**] Discharge Date: [**2152-3-22**]
Date of Birth: [**2073-11-29**] Sex: F
Service: MEDICINE
Allergies:
Gemfibrozil
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
Ms. [**Known lastname 931**] is a 78 year-old woman with h/o HTN, hyperchol,
CHF, ESRD (not yet on HD) who was transfered from [**Hospital **] [**Hospital 2538**] for management of NSTEMI.
.
The patient describes 2 types of pain. The first pain is a R
sternal pain that occurs while eating and is usually relieved
with physical massage. She reports having this pain for years.
.
The second type of pain started 2 days ago, but has not recurred
now for more than 24 hours. She reports having epigastric
chest pain 2 days prior to admission that lasted for a whole
day. She also noted pain in her R arm at the same time. Denies
associated N/V, diaphoresis, or sob. No recent change in
weight, LE swelling, or PND. Patient did have some mild cough
with yellow productive sputum, but no f/c. She also c/o chronic
lightheadedness that she attributes to her medication along with
some intermittent vertigo. Patient otherwise denies any
myalgias/arthralgias. She continues to urinate, no
dysuria/hematuria, intermittent constipation. She also has
chronic insominia. Her exercise capacity consists of [**12-14**] a
block, limited by fatigue. Patient told her daughter about the
pain, who then contact[**Name (NI) **] patient's PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2539**]. PCP referred
the patient to [**Hospital1 **] [**Location (un) 620**] ED for evaluation.
.
Upon arrival to the OSH ED, labs revealed Cr 2.7; CK 301; CKMB
59; Trop T 1.46; EKG was unchanged. Elevated cardiac enzymes
were confirmed with CK of 317, troponin 1.68 with no prior
baseline. She was started on a heparin gtt, ASA 325, Lopressor
5 mg IV x 1. Patient was then transferred to [**Hospital1 18**] for further
managment.
.
Currently, patient feels well, denies CP/SOB.
Past Medical History:
CVA ([**8-16**]; MRI showing left internal capsular defect, little
residual effect)
ESRD still not on HD - Cr 3.0 (1.7-6.0) - followed by Dr. [**Last Name (STitle) **]
Congestive Heart Failure (ECHO [**9-27**] [**Hospital1 1474**], technically
limited showed mild concentric LVH with EF at 60%, ?pericardial
effusion (size unspecified)
s/p right renal artery stent ([**9-15**]) by Dr. [**Last Name (STitle) 911**]
Hypertension
Hypercholesterolemia,
Hypothyroidism
Depression
Degenerative Joint Disease
TAH-BSO/repair of umbilical hernia for benign ovarian mass
(path=fibroma [**4-14**])
Social History:
Former light smoker (ages 25-73); quit 4 yrs ago. No history of
EtOH or other drugs. Formerly worked as a paralegal. Now living
in public senior housing in [**Hospital1 1474**]. Mother of two--one
daughter lives nearby.
Family History:
Notable for diabetes and renal failure in a brother.
Physical Exam:
VS: 97.8 - 130/59 - 60 - 16 - 98% 2L
Gen: elderly female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple; JVP flat.
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. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NT, ND.
Ext: No c/c/e. No femoral bruits.
Pulses: 2+ femoral, 2+ DP/PT pulses
.
Pertinent Results:
LABS ON ADMISSION:
[**2152-3-16**] 09:30PM BLOOD WBC-8.3 RBC-4.00* Hgb-13.0 Hct-36.3
MCV-91 MCH-32.5* MCHC-35.8* RDW-13.8 Plt Ct-186
[**2152-3-16**] 09:30PM BLOOD Neuts-64.2 Lymphs-21.7 Monos-6.2 Eos-7.4*
Baso-0.5
[**2152-3-16**] 09:30PM BLOOD PT-13.1 PTT-127.1* INR(PT)-1.1
[**2152-3-16**] 09:30PM BLOOD Plt Ct-186
[**2152-3-16**] 09:30PM BLOOD Glucose-87 UreaN-30* Creat-2.5* Na-142
K-3.4 Cl-109* HCO3-21* AnGap-15
[**2152-3-16**] 09:30PM BLOOD ALT-18 AST-49* CK(CPK)-317*
[**2152-3-16**] 09:30PM BLOOD CK-MB-54* MB Indx-17.0* cTropnT-1.68*
[**2152-3-17**] 06:42AM BLOOD ALT-13 AST-40 CK(CPK)-239*
[**2152-3-17**] 06:42AM BLOOD CK-MB-38* MB Indx-15.9* cTropnT-1.88*
[**2152-3-18**] 05:05AM BLOOD CK(CPK)-518*
[**2152-3-18**] 05:05AM BLOOD CK-MB-58* MB Indx-11.2* cTropnT-3.53*
[**2152-3-19**] 07:15AM BLOOD CK(CPK)-351*
[**2152-3-20**] 05:25AM BLOOD CK(CPK)-152*
[**2152-3-16**] 09:30PM BLOOD Calcium-9.9 Phos-2.4* Mg-2.5
[**2152-3-17**] 02:45PM BLOOD %HbA1c-5.6
.
CARDIAC CATHETERIZATION [**2152-3-17**] (PRELIMINARY REPORT)
1. Selective coronary angiography revealed two vessel coronary
artery disease. The left main coronary artery was short with no
angiographically apparent flow limiting stenoses. The LAD had
moderate diffuse disease with a 70% stenosis in the mid vessel
and a 70% stenosis at the origin of the first diagonal. The LCX
had an OM1 upper pole with a 99% stenosis and slow flow. The
LCX had a 70% stenosis in the mid vessel. The RCA was small in
caliber and had no angiographically apparent flow limiting
stenoses.
2. Limited resting hemodynamics were performed upon entry.
Systemic arterial pressure was moderately elevated (aortic
pressure was 160/73mmHg).
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
.
CT ABDOMEN [**2152-3-17**] (PRELIMINARY REPORT)
1. Small hemorrhagic pericardial effusion.
2. Small bilateral pleural effusion.
3. No evidence of reteroperitoneal bleed.
4. Diffuse atherosclerotic disease.
5. Atrophic kidneys. Not significantly changed form CT from [**4-14**], [**2148**].
.
ECHO [**2152-3-17**]
The left ventricular cavity size is normal. LV systolic function
appears depressed with lateral hypokinesis (regional wall motion
not fully assessed). Right ventricular chamber size is normal.
Right ventricular systolic function is normal. There is a small
pericardial effusion. There are no echocardiographic signs of
tamponade.
.
CXR [**2152-3-20**]: (PRELIMINARY REPORT)
2 views of the chest compared to a single view done 4 days
earlier. There are no focal infiltrates or definite effusions.
Mediastinum and bony structures are unchanged including findings
consistent with rotator cuff disease involving the right
shoulder. There is also marked aortic tortuosity and prominence,
this is also unchanged. Over the cervical prevertebral area,
there is a superimposed air which likely represents the trachea
as well as the piriform sinuses. Please correlate clinically in
this patient with fever.
.
CT chest (non-contrast): 1. Extensive aortic and coronary
atherosclerosis with suspected descending thoracic aorta
dissection and intraluminal thrombus, stable. This study is not
dedicated to evaluation of the vascular system and additional
examination might be considered.
2. Right lower lobe atelectasis and small pleural effusions.
Brief Hospital Course:
Mrs. [**Known lastname 931**] is a 78 year-old woman with a history of
hypertension, hypercholesterolemia, congestive heart failure,
end stage renal disease (not yet on hemodialysis) who was
transfered from [**Hospital **] [**Hospital3 628**] for management of NSTEMI.
.
# NSTEMI: The patient was diagnosed with a non-ST elevation MI
at the outside hospital. She underwent cardiac catheterization
on [**2152-3-17**] showing 2 vessel disease(LAD 70%, D1 70%; LCx 70%, OM1
99%). During cath, the cardiologists were unable to cross the
LCx/OM1 lesion with the wire. CT surgery was called for
evaluation of possible surgical revascularization given the
inability to perform PCI. Plavix was held given this
consideration of surgical revascularization in the future. She
was continued on aspirin and statin. The patient was not on a
betablocker as an outpatient; however, this was not started
initially after cath due to hypotension (see below). Her
hypotension resolved, and a beta blocker was started. Because
of ongoing fevers and clinical pneumonia, CABG was deferred and
the pt was discharged home with instructions to follow-up with
CT surgery for CABG in several weeks.
.
# HYPOTENSION: Approximately 2 hours after catheterization, the
patient was noted to have an asymptomatic low blood pressure of
74/47. IV fluid bolus was started immediately with some
response and her SBP rose to the mid-80's. The cardiology team,
including the interventional cardiology attending, and the
attending of record were present to evaluate the patient. A
stat bedside echo was done given concern for
dissection/perforation since there was difficulty attempting to
cross LCx/OM lesion during cath. This echo revealed a small
amount of fluid in pericardial space; however, there was no
evidence of tamponade. The patient was given Atropine given due
to concern for vagal response since she still had a femoral
sheath in place. She responded to this medication with good
response in her blood pressure (SBP rose from the 80's to
100's); however, this was only a transient response. A stat
hematocrit was sent given concern for retroperitoneal bleeding.
This value was stable was stable. She was given a total 1.5L
bolus of normal saline. The patient was then transferred to the
CCU for further management.
.
On arrival to the CCU, her BP continued to fall, and more
atropine was given (total 1.2mg) along with a dopamine infusion
for augmentation of blood pressure. A triple lumen catheter was
placed in her right femoral vein, and 2 units of PRBCs were
transfused. She was taken for an emergent CT abdomen once her
MAP was consistently above 65 while on dopamine drip.
Neosynephrine was added for a short period en route to CT, but
was titrated off during the scan. This CT scan of the abdomen
and pelvis was negative for a retroperitoneal bleed. On return
to the CCU, an arterial line was placed. The pt. became somewhat
delerious and agitated and was given Haldol 1mg x2 and 0.25 mg
lorazepam x2 for sedation.
.
She did well overnight with improvement in her blood pressure.
Dopamine was titrated off at 12am (total duration approximately
4 hours). After weaning dopamine, the patient maintained her
blood pressure well in the range of 104-143/50-76.
.
The etiology of her hypotension was thought to be secondary to a
vagal response due to her femoral sheath. Once her blood
pressure stabilized, she was started on a low dose betablocker.
She remained with normal blood pressure throughout the remainder
of her stay.
.
# FEVER: The patient spiked temperature overnight on [**2152-3-19**]. She
denied all infectious symptoms. Her WBC count was normal. UA
was negative, blood cultures show no growth to date. CXR did
not show evidence of pneumonia, however pt had adventitious lung
sounds on exam. She continued to spike fevers for several days,
and then became mildly hypoxic, so she was started on
levofloxacin for presumed pneumonia.
.
# END STAGE RENAL DISEASE: The patient is not yet on
hemodialysis. During this admission, her creatinine bumped
slightly from 2.4 to 2.8. Her FeNa was less than 1%. She was
likely prerenal with a component of contrast nephropathy from
the catheterization. Her creatinine promptly improved from 2.8
back to her baseline of 2.4.
.
# HYPERLIPIDEMIA: She was placed on lipitor 80mg daily given her
NSTEMI.
.
# HTN: She is on norvasc as an outpatient. This was held
initially due to her hypotension. She was later started on a
low dose of metoprolol given her NSTEMI, and her norvasc was
discontinued. Her ACEI was also held both during the admission
and upon discharge due to her renal dysfunction and upcoming
CABG.
.
# DEPRESSION: She was continued on Zoloft.
.
# HYPOTHYROIDISM: She was continued on her outpatient dose of
levothyroxine.
.
# CODE: she was originally DNR/DNI, however after further
discussion with the pt, she decided to be Full Code.
.
Medications on Admission:
Aspirin 325 daily
Plavix 75 daily,
levothyroxine 88 mcg daily
Norvasc 5 mg daily
Zoloft 50 mg daily
simvastatin 10 mg daily
Aranesp 25 mcg every month
benazepril 10 mg daily
PhosLo 667 mg t.i.d.
vitamin C and vitamin E daily.
Zantac prn
Calcitriol 25 mcg qMWF
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Aranesp 25 mcg/mL Solution Sig: Twenty Five (25) mcg
Injection once a month.
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).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*2*
10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 10 days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Community VNA
Discharge Diagnosis:
Primary diagnosis: Non-ST Elevation Myocardial Infarction
Secondary diagnoses:
Hypotension
End Stage Renal Disease
Stable small aortic dissection
Discharge Condition:
Stable. No chest pain.
Discharge Instructions:
Please call your doctor or return to the emergency room if you
experience chest pain, difficulty breathing, palpitations,
dizziness, weight gain, leg swelling, or any other concern.
.
Take your medications as prescribed. The following changes were
made to your medications: you should stop taking plavix, you
should take lipitor instead of simvastatin, you should stop
taking your benazepril, and you were started on metoprolol. You
should complete a 10 day course of levofloxacin for pneumonia.
.
Please attend all follow-up appointments.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) 914**] (Cardiac surgery) on
Wednesday [**2152-3-29**] @ 2:30. [**Hospital **] Medical Office Building [**Hospital Unit Name **]
[**Telephone/Fax (1) 170**]. Please also follow-up with your PCP in the next 7
days, as some of your medications may need to be adjusted. You
also have the following appointments scheduled:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 41**]
Date/Time:[**2152-4-5**] 11:15
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2152-5-3**] 11:30
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2152-7-19**] 11:30
Completed by:[**2152-3-22**]
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icd9cm
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[
[
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icd9pcs
|
[
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[]
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13138, 13182
|
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|
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|
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13422, 13964
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3047, 3587
|
13283, 13352
|
233, 245
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336, 2109
|
13222, 13262
|
3625, 5294
|
2131, 2722
|
2738, 2961
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,450
| 141,365
|
5677
|
Discharge summary
|
report
|
Admission Date: [**2175-10-1**] Discharge Date: [**2175-10-14**]
Date of Birth: [**2132-12-29**] Sex: M
Service: MEDICINE
Allergies:
hydrochlorothiazide
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Fever and Diaphoresis
Major Surgical or Invasive Procedure:
[**2175-10-3**] Endotracheal intubation
[**2175-10-5**] Tracheostomy
[**2175-10-11**] J tube placement
[**2175-10-12**] Bronchoscopy
History of Present Illness:
Mr. [**Known lastname 7716**] is a 42 year old gentleman with a history of
pilocytic astrocytoma (at age 2), multiple CVAs, and a medullary
cavernoma with persistent right hemiparesis, epilepsy, and
aspiration who presents with with diaphoresis and fevers to
100.2 at home. He states that he has increased frequency of
cough after being given a G tube 3 weeks prior due to recurrant
aspiration pneumonia and difficulty swallowing, but that the
cough has not worsened in the past few days. He feels otherwise
well with no sensation of fevers/chills or increased sweating,
but was brought into the ED due to concern from his group home
caretaker.
Regarding his feedings, he gets them from 8pm to 5pm every day.
They have been unable to increase the rate due to gastric
residuals with feeding. The patient notes regurgitation 2-3x a
day with a sensation of food coming up into his chest and
sometimes into the back of his throat and into his mouth. He
cannot be for certain whether the coughing is associated with
his feedings. Pt is without any complaints including chest
pain, shortness of breath, dizziness, abdominal pain, nausea,
vomiting, dysuria, or new swelling. He reports being constipated
without a normal BMs for the past 4-5 days. He has + flatulence
and minimal burping. He was given an enema yesterday with
minimal stool output.
Past Medical History:
Medullary cavernoma in [**4-13**] at site of radiation
Epilepsy (absence, complex partial, and generalized seizures)
Cerebellar pilocytic astrocytoma resection at age two s/p
brainstem radiation
Presumed radiation-induced vasculopathy with multiple strokes
Strokes: Left internal capsule/thalamus [**2167**], left posterior
cerebellum, left cerebellar peduncle [**10/2169**], TIA with facial
droop, followed by Dr. [**Last Name (STitle) 1693**]
Presumed XRT-induced bilateral hearing loss
Hypertension
Hyperparathyroidism
Bilateral Kidney Stones (thought to be due to parathyroidism,
not
Topamax use)
Hypercalcemia
Osteopenia
Social History:
He lives in a group home, and during the week goes to sports
program, gateway arts, and massage. He uses a wheelchair to get
around since his strokes, but does walk with assistance at his
sports class. He denies cigarette or EtOH use.
Family History:
There is no family history of seizures. His sister died of
multiple myeloma.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS - 98.3 HR 104 BP 123/74 RR 20 96% on 3 LNC
GENERAL: Well-appearing man, not acutely distressed. Speaking
comfortably in full sentences
HEENT: Mucous membranes semi-dry. No cervical lymphadenopathy.
Soft palate elevates symetrically
HEART: Heart sounds distant, RRR, normal S1 S2
LUNGS: Clear to auscultation but limited by poor air movement
due to poor respiratory effort. No evidence of respiratory
distress or accessory muscle requirement.
ABDOMEN: Soft and nontender except at the insertion of the
G-tube. He does have a G-tube in position with scabing. No
erythema or exudates. Mildly distended (likely secondary to
constipation). + bowel sounds in all 4 quadrants
EXTREMITIES: He does not have any edema of his lower
extremities, + distal pulses, warm and well perfused.
NEURO: EOMI, pupils are equal and reactive. No facial weakness.
There is right hemiplegia.
DISCHARGE PHYSICAL EXAM
PHYSICAL EXAM:
VS - Tmax 98 Tcurr 98 BP 112/80 HR 81 RR 18 100% pm 35%FM
GENERAL - NAD, comfortable, appropriate
HEENT - Sclerae anicteric, MMM
LUNGS - Mild coarse breath sounds throughout, good air movement,
resp unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - Soft and nontender. G-tube in place with no erythema
or exudates. Non-distended. + bowel sounds in all 4 quadrants
EXTREMITIES - He does not have any edema of his lower
extremities, + distal pulses, warm and well perfused.
Pneumoboots in place.
NEURO - awake, A&Ox3, Right hemiplegia
Pertinent Results:
ADMISSION LABS:
[**2175-10-1**] 01:30PM BLOOD WBC-20.8*# RBC-4.46* Hgb-14.3 Hct-41.6
MCV-93 MCH-32.0 MCHC-34.3 RDW-12.9 Plt Ct-238
[**2175-10-1**] 01:30PM BLOOD Neuts-89.1* Lymphs-4.6* Monos-5.9 Eos-0.2
Baso-0.2
[**2175-10-1**] 01:30PM BLOOD Plt Ct-238
[**2175-10-1**] 01:30PM BLOOD Glucose-111* UreaN-32* Creat-1.2 Na-143
K-4.2 Cl-107 HCO3-25 AnGap-15
[**2175-10-3**] 08:45PM BLOOD ALT-102* AST-99* CK(CPK)-274 AlkPhos-131*
TotBili-0.8
[**2175-10-3**] 08:45PM BLOOD CK-MB-2 cTropnT-<0.01
[**2175-10-1**] 01:30PM BLOOD Calcium-9.8 Phos-2.7# Mg-1.9
[**2175-10-1**] 01:30PM BLOOD D-Dimer-792*
[**2175-10-3**] 03:10PM BLOOD Type-ART Temp-37.5 pO2-55* pCO2-31*
pH-7.40 calTCO2-20* Base XS--3 Intubat-NOT INTUBA Comment-SIMPLE
FAC
IMAGING:
[**10-1**] CTA CHEST W&W/O C&RECONS, NON-CORONARY and CT ABD & PELVIS
WITH CO
1. Right middle, right lower, and left lower lobe consolidations
compatible with pneumonia.
2. No pulmonary embolism.
3. No acute intra-abdominal process.
4. Bladder trigone thickening may represent focal inflammation,
less likely malignancy.
[**10-1**] CHEST XRAY
FINDINGS: There is opacification of the right lower lobe seen
both on frontal and lateral radiographs. In addition, the right
heart border is obscured, worsened from [**2175-9-9**]. There is no
pleural effusion or pneumothorax. The heart size is normal.
The left lung is clear.
IMPRESSION: Right middle and lower lobe pneumonia, possibly due
to recurrent aspiration.
[**10-4**] PORTAL AP CHEST XRAY
IMPRESSION: AP chest compared to [**9-2**] through [**10-3**]:
Tip of the endotracheal tube is no less than 7 cm from the
carina. It could
be safely advanced 2 cm for more secured seating. Nasogastric
tube passes into the stomach and out of view. Bibasilar
pneumonia has not changed appreciably overnight. There is no
pneumothorax or pleural effusion. Cardiomediastinal and hilar
silhouettes are normal.
[**10-5**] ECG:
Sinus rhythm. Right bundle-branch block. Non-specific
repolarization
abnormalities. Compared to the previous tracing of [**2175-10-3**] the
quality of the tracing has improved somewhat. Otherwise,
findings are similar.
DISCHARGE LABS:
[**2175-10-14**] 03:22AM BLOOD WBC-12.8* RBC-3.68* Hgb-11.6* Hct-34.0*
MCV-92 MCH-31.5 MCHC-34.1 RDW-14.1 Plt Ct-357
[**2175-10-14**] 03:22AM BLOOD Plt Ct-357
[**2175-10-14**] 03:22AM BLOOD Glucose-100 UreaN-15 Creat-1.1 Na-137
K-3.7 Cl-104 HCO3-21* AnGap-16
[**2175-10-14**] 03:22AM BLOOD Calcium-9.1 Phos-3.0 Mg-2.0
Brief Hospital Course:
Mr. [**Known lastname 7716**] is a 42 year old gentleman with a history of
pilocytic astrocytoma (at age 2), multiple CVAs, and a medullary
cavernoma hemorrhage with persistent right hemiparesis,
epilepsy, and aspiration who presents with low grade fever,
found to have likely aspiration pneumonia on CXR and chest CT.
He deteriorated with hypoxia and was intubated and then recieved
a tracheostomy.
#MRSA Pneumonia: The patient has a history of aspiration
pneumonia given swallow dysfunction related to prior
neurological disease. On the night of [**2175-10-3**], he desaturated
to the high 70s. Given his concerning respiratory status which
is unlikely to improve since it is due to neurologic dysfunction
of pharyngeal muscles, he was transferred to MICU, intubated and
a tracheostomy was performed [**10-5**]. CT scan suggestive of
consolidations consistent with pneumonia. We initiated tube
feeds on the night of [**2175-10-5**] which he seemed to tolerate
without obvious regurgitation. However, there was continued
concern over oral secretions and his tracheostomy cuff was left
inflated. Speech/swallow felt it would be best to avoid placing
a speaking valve until his respiratory condition resolved in the
short term. He completed an 8 day course of Vancomycin for HCAP.
Elevated WBC has resolved on discharge and he has remained
afebrile for several days.
#RLL Collapse: On [**2175-10-12**] Pt began exhibiting worsening O2
saturations down to the high 70s on 35%TM. Attempted aggressive
respiratory suction with minimal removal of mucus. Chest XRay
done on the bedside showed right middle and lower lobe collapse
most likely attributable to a mucus plug. He was transferred to
the MICU for bronchoscopy which successfully removed mucus plug
and reinflated his RLL. Post brochoscopy CXR showed reinflation
of RLL. Following the procedure his O2 requirement improved and
is respiratory status returned to baseline. He did require
aggressive mucus suctioning to prevent further plugging.
#Tube Feeds: We initially stopped tube feeds due to concern of
regurgitation on admission along with aspiration of oral
secretions. We contact[**Name (NI) **] and consulted both speech/swallow and
nutrition for appropriate recommendations to optimize his G tube
feeding. Per their recommendations, we continued with 16 hrs
cycled feeds with Fibersource HN Oral liquid 100 ml/hr g tube
and Ranitidine 15 mg/ml syrup 150 mg by mouth twice a day. Per
speech/swallow we initiated mouth rinses every 4 hours to
prophylactically prevent oral secretion aspiration pneumonia.
IR was able to successfully convert his G tube to a GJ tube
without complications on [**2175-10-11**].
#Obstructive sleep apnea: Suspected by PCP and from prior
inpatient stays he had reports of snoring and nighttime
desaturations. After his trach was placed, these resolved and
he was more alert during the daytime.
#Transaminitis: Bilirubin not elevated, but AST/ALT above
baseline. Felt most likely due to drug effect, especially from
the pip-tazo. Trended down after pip-tazo was stopped. Patient
remained asymptomatic thoughout.
CHRONIC ISSUES:
#Hx Stroke / Cavernoma Hemorrhage / Seizure Disorder: Stable
neurologic exam during admission. Had been in [**Hospital3 **]
for PT and speech/[**Hospital3 22701**]. Continued prednisone 17.5 mg
daily with plan to taper by 2.5 mg weekly for cerebral edema.
Per PCP, [**Name10 (NameIs) **] had a clinical decline when this was tapered too
quickly in the past. Also, for risk modification of further
strokes, continued Simvastatin 80 mg daily, cilostazol 100 mg
[**Hospital1 **], Aspirin 81 mg daily. For headaches and neurologic
function, continued topiramate 200 mg [**Hospital1 **], and trileptal 1500 mg
[**Hospital1 **].
#Hx right bundle branch block (RBBB): Unclear cause. Patient
remains asymptomatic from a cardiac perspective.
#Hypothyroidism: Stable. Continued levothyroxine 88 mcg daily.
#Hypertension: Stable. Continued Amiloride 5 mg daily.
#Hyperparathyroidism: Stable. Continued Cinacalcet 30 mg [**Hospital1 **].
#Depression: Stable. Continued citalopram 40 mg daily.
#Maintanence: Patient received flu shot at last discharge visit
1 week ago. Recieved pneumococcal vaccine this admission.
TRANSITIONAL ISSUES:
#Please taper prednisone dose by 2.5mg per week. Can stop
Bactrim once dose is below 10mg per week.
#Consideration for down-sizing of his trach so that he can have
a speaking valve and consider eating per goals of care of the
patient
#Pt needs suctioning in order to prevent mucus plugging. Mucus
plugging is frequent but usual responds to respiratory therapy
maneuvers. Consider increasing nebulized saline frequency.
#Pt is DNR but can be intubated
#Please see discharge paperwork for patient's outpatient follow
up appointments
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver[**Name (NI) 581**].
1. Amiloride HCl 5 mg PO QAM
2. Cinacalcet 30 mg PO BID
3. Citalopram 40 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Oxcarbazepine 1500 mg PO BID
7. PredniSONE 17.5 mg PO DAILY
8. Simvastatin 80 mg PO DAILY
9. Topiramate (Topamax) 200 mg PO BID
10. Vitamin D 1000 UNIT PO DAILY
11. Vitamin E 400 UNIT PO DAILY
12. Ranitidine (Liquid) 150 mg PO BID
13. Aspirin 81 mg PO DAILY
14. Miconazole Powder 2% 1 Appl TP TID:PRN diaper rash
15. Docusate Sodium (Liquid) 100 mg PO BID
per peg tube
16. lactobacillus rhamnosus GG *NF* 10 billion cell Oral daily
17. Fibersource HN *NF* (nutritional supplement - fiber) Oral
daily
Tubefeeding: Fibersource HN Full strength;
Starting rate: 100 ml/hr; Do not advance rate Goal rate: 100
ml/hr
Cycle?: Yes, when at goal Cycle start: 1900 Cycle end: 1100
Residual Check: q4h Hold feeding for residual >= : 250
Flush w/ 30 ml water q8h
18. cilostazol *NF* 100 mg Oral [**Hospital1 **]
19. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Medications:
1. Amiloride HCl 5 mg PO QAM
2. Aspirin 81 mg PO DAILY
3. cilostazol *NF* 100 mg Oral [**Hospital1 **]
4. Cinacalcet 30 mg PO BID
5. Citalopram 40 mg PO DAILY
6. Docusate Sodium (Liquid) 100 mg PO BID
per peg tube. Hold for loose stools
7. FoLIC Acid 1 mg PO DAILY
8. Levothyroxine Sodium 88 mcg PO DAILY
9. Miconazole Powder 2% 1 Appl TP TID:PRN diaper rash
10. Oxcarbazepine 1500 mg PO BID
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. PredniSONE 15 mg PO DAILY
Please decrease this dose by 2.5mg per week
13. Simvastatin 80 mg PO DAILY
14. Topiramate (Topamax) 200 mg PO BID
15. Vitamin D 1000 UNIT PO DAILY
16. Vitamin E 400 UNIT PO DAILY
17. lactobacillus rhamnosus GG *NF* 10 billion cell Oral daily
18. Fibersource HN *NF* (nutritional supplement - fiber) 0
ORAL DAILY
Tubefeeding: Fibersource HN Full strength;
Starting rate: 100 ml/hr; Do not advance rate Goal rate: 100
ml/hr
Cycle?: Yes, when at goal Cycle start: 1900 Cycle end: 1100
Residual Check: q4h Hold feeding for residual >= : 250
Flush w/ 30 ml water q8h
19. Ranitidine (Liquid) 150 mg PO BID
20. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN sob/ wheeze
21. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob/ wheeze
22. Sulfameth/Trimethoprim SS 1 TAB PO DAILY prophylaxis
Can stop taking after prednisone dose is below 10mg daily
23. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
24. Acetaminophen 650 mg PO Q8H:PRN pain
25. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **]
26. Medication
Nebulized saline [**Hospital1 **]
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Chronic aspiration pneumonia due to stroke
Mucus plugging
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 7716**],
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
for difficulty breathing and found to have pneumonia most likely
from aspirating food. You required intubation with a breathing
tube to assist breathing and a tracheostomy was placed to help
prevent further complications. You were treated with
antiobiotics for you pneumonia and it improved.
While you were recovering, you became short of breath due to a
mucuc plug which caused collapse of your lung. We re-inflated
your lung and your breathing returned to [**Location 213**].
We have made no changes in your medications. Please decrease you
dose of predisone by 2.5 mg per week after leaving the hospital.
Followup Instructions:
Department: [**Hospital3 249**]
When: TUESDAY [**2175-10-24**] at 2:10 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2175-10-26**] at 1 PM
With: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3172**] [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: MONDAY [**2175-11-27**] at 3:30 PM
With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 1694**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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[
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2481, 2717
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9,887
| 104,667
|
44960+44961+45077
|
Discharge summary
|
report+report+report
|
Admission Date: [**2170-1-24**] Discharge Date: [**2170-2-3**]
Service:
HISTORY OF THE PRESENT ILLNESS: This is a [**Age over 90 **]-year-old female
who reportedly was found by her family member after falling,
questionable syncope. When she was brought to the ED for
evaluation, she was found to have a large hematoma on her
right knee and leg. She was under evaluation in the ED when
her heart rate dropped to the 40s with no compromise in her
blood pressure initially and her mentation was clear.
However, her heart rate then drifted into the 20s and 30s and
her systolic blood pressure dropped to 80. She was then
given Atropine 0.5 times two and transcutaneous paced rhythm
strip revealed a high-degree AV block. She was then
transvenous paced. Her systolic blood pressure was slow at
63. She was rapidly transfused 3 units of packed red blood
cells, 1 unit of platelets, and IV fluids. She was then
started on Neo and her blood pressure rose to the 130s. She
was intubated for airway protection.
A bedside cardiac echocardiogram revealed no pericardial
fluid. An ultrasound of the abdomen revealed fluid in
[**Location (un) 6813**] pouch. CT of the abdomen revealed fluid in the
right upper quadrant. Her leg films were negative for
fracture. Head CT was normal. She was noted to develop
facial and neck petechiae with questionable transfusion
reaction. She was given Benadryl, Solu-Medrol, and 2 grams
of ceftriaxone.
A chest x-ray revealed CHF. She was given 20 mg of Lasix.
She was then transferred to the CCU for closer monitoring.
PAST MEDICAL HISTORY:
1. PVD.
2. CAD.
3. Hypertension.
4. PAF.
5. CHF.
6. Vasovagal syncope.
7. Osteoarthritis.
8. COPD.
9. Hypothyroidism, status post thyroidectomy.
10. Right hip fracture.
11. Right total hip replacement.
12. Renal artery stenosis.
ALLERGIES: She is allergic to codeine which causes a rash
and penicillin and theophylline.
ADMISSION MEDICATIONS:
1. Metoprolol 25 twice a day.
2. Lisinopril 20 once a day.
3. Plavix 75.
4. Flovent.
5. Risedronate 5 once a day.
6. Pravastatin 20 once a day.
7. Clonidine 0.1 twice a day.
8. Albuterol.
9. Folic acid.
10. Levothyroxine 25 micrograms.
11. Aspirin 81 once a day.
12. Calcitriol 0.25 once a day.
13. Digoxin 0.125.
14. Lasix 80 Monday, Wednesday, and Friday, 40 Tuesday,
Thursday, Saturday, and Sunday.
15. Multivitamin.
16. Calcium carbonate.
17. Colace.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Her heart
rate was 65-69, blood pressure 153/68, MAP 97% on room air.
Those were taken while on Neo. Her ventilator was set at AC
500/14, 40%, PEEP of 5. She was intubated and sedated. She
had petechiae predominantly on her eyelids. Heart: Distant
heart sounds, regular rate and rhythm. Lungs: Clear
anteriorly with a few bibasilar crackles. Abdomen: Soft,
benign, with positive bowel sounds. Extremities: She had a
large hematoma of the right knee anterior skin. The calves
were soft. Her pulses were Dopplerable.
LABORATORY STUDIES: White count 9.5, hematocrit 29.4, down
from 36.3, platelets 154,000. Sodium 139, creatinine 4.7,
chloride 111, bicarbonate 21, BUN 26, creatinine 0.5, glucose
113.
HOSPITAL COURSE: The patient's blood pressure seemed to
tolerate her native heart rhythm of a 2:1 to 3:1 block
initially. The transvenous pacing was discontinued. She was
able to be weaned off Neo.
A pacemaker was placed the following day. She was also noted
to have an unstable hematocrit requiring blood transfusions,
although her hematoma seemed stable. A chest x-ray revealed
that she had large bilateral pleural effusions. A
thoracentesis was performed demonstrating grossly bloody
fluid, approximately 600 cc was drained from this. The
effusion seemed to remain stable after drainage.
She was extubated on [**2170-1-26**] with no difficulties. It
appeared that the leads of the pacemaker were slightly
misplaced and they were repositioned under fluoroscopy.
Since that time, she had [**Last Name **] problem with her pacemaker.
A HIDA scan was obtained to evaluate the fluid collection
adjacent to the gallbladder. It was negative for
cholelithiasis or cholecystitis.
A chest CT was obtained following the drainage of the pleural
fluid. This revealed bibasilar atelectasis and mild CHF.
Additionally, after the fluid was drained she had a
preliminary echocardiogram which revealed no pericardial
effusion and an EF of 60-65%, left atrium normal in size,
left ventricular wall thickness and cavity normal, mitral
valve not well seen. There seemed to be a trivial
pericardial effusion but no electrocardiographic signs of
tamponade. It was thought perhaps that this could be
attributable to the hemothorax that she had developed.
However, it remained stable for the remainder of her
hospitalization and no further action was needed.
She was then transferred to the floor. She was noted to be
fairly inactive, developing a cough. A chest x-ray was
consistent with probable pneumonia. She was started on
Levaquin. There was concern for hospital-acquired pneumonia.
However, the culture data was unavailable at the time of this
dictation. She was maintained on Levaquin without further
evidence of culture data to add a second [**Doctor Last Name 360**] or possibly a
pseudomonal [**Doctor Last Name 360**].
Additionally, her Cordis catheter tip grew Staphylococcus
coagulase-negative from the culture tip. She was then
started on vancomycin. A midline PICC was placed because of
her recent device placement. She was maintained on
vancomycin for 14 days.
She was seen by Physical Therapy who felt that she would
likely benefit from a [**Hospital 3058**] rehabilitation stay. She
was screened and the details of this will be addended in the
next discharge summary as well as the discharge dictation.
At the time of this dictation, her hematocrit was still
slightly trending downward from previous values. It was
unclear if this could be attributed to her natural window
after blood transfusion where she would even out to her
resting hematocrit or if this is continued bleeding. The
results of this will also be addressed in the discharge
addendum.
DR [**First Name8 (NamePattern2) 251**] [**Name (STitle) **] 12.191
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2170-2-3**] 12:09
T: [**2170-2-3**] 13:40
JOB#: [**Job Number **]
Admission Date: [**2170-1-24**] Discharge Date: [**2170-2-6**]
Service: CCU
This dictation will cover the remainder of the patient's stay
in hospital after [**2170-2-3**]. The patient continued
to do well on the floor. She remained afebrile. Her
hematocrit remained stable. She was restarted on aspirin.
On the 24th the patient was slightly volume overloaded and
received Lasix po.
DISCHARGE DIAGNOSES:
1. Multiple hematomas post fall.
2. Two to one and three to one heart block status post
pacemaker placement.
3. Hospital acquired pneumonia.
4. Staph line related bacteremia.
5. Hemothorax.
6. Non Q wave myocardial infarction.
7. Peripheral vascular disease.
8. Coronary artery disease.
9. Hypertension.
10. History of paroxysmal atrial fibrillation.
11. History of congestive heart failure.
12. History of vasovagal syncope.
13. Osteoarthritis.
14. Chronic obstructive pulmonary disease.
15. Hypothyroidism, status post thyroidectomy.
16. History of right hip fracture.
17. History of right total hip replacement.
18. Renal artery stenosis.
DISCHARGE MEDICATIONS: Aspirin 325 mg po q day, Vancomycin
500 mg intravenous q 24 hours until [**2-11**]. Levofloxacin
250 mg po q 24 hours until [**2-11**], Miconazole powder 2%
applied t.i.d. under arms and breasts, Simethicone 40 to 80
mg po q.i.d. prn, Oxycodone 5 mg po q 3 h prn, Lopressor 75
mg po b.i.d., Oxycontin 10 mg po q 12 h, Tylenol 325 to 650
mg po q 4 to 6 hours prn, Dulcolax 10 mg pr q.h.s. prn,
Albuterol inhaler two puffs q.i.d. prn, Atrovent inhaler two
puffs q.i.d. prn, Colace 100 mg po b.i.d., Captopril 25 mg po
t.i.d., multivitamin one tablet po q day, Levothyroxine 25
micrograms po q day, folic acid 1 mg po q day, Pravastatin 20
mg po q day, Protonix 40 mg po q day.
DISCHARGE CONDITION: Stable.
DISCHARGE FOLLOW UP: The patient is being discharged to a
rehab facility. She will continue to be seen by her primary
care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 11679**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Last Name (NamePattern1) 4066**]
MEDQUIST36
D: [**2170-2-5**] 01:16
T: [**2170-2-5**] 13:34
JOB#: [**Job Number 96146**]
Admission Date: [**2170-1-24**] Discharge Date: [**2170-2-6**]
Service: CCU
ADDENDUM
HOSPITAL COURSE: On the day of discharge, the patient was
restarted on Lasix 80 mg q.Monday, Wednesday, Friday, and 40
mg p.o. q.Tuesday, Thursday, Saturday, and Sunday. We also
asked the rehabilitation facility to check the patient's CBC
and CHEM10 three days after discharge.
The remainder of the discharge medications and discharge
diagnosis remains the same.
FOLLOW-UP: The patient is being discharged to a
rehabilitation facility. She will continue to be followed by
her primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 11679**]. She will follow-up
with the [**Hospital **] Clinic in six months time.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Last Name (NamePattern1) 222**]
MEDQUIST36
D: [**2170-2-6**] 11:00
T: [**2170-2-6**] 11:10
JOB#: [**Job Number 96352**]
|
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icd9cm
|
[
[
[]
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[
"96.04",
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icd9pcs
|
[
[
[]
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] |
8173, 8192
|
6789, 7450
|
7474, 8151
|
8802, 9705
|
1946, 2432
|
8204, 8784
|
2447, 3177
|
1591, 1923
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,638
| 183,321
|
27409
|
Discharge summary
|
report
|
Admission Date: [**2158-5-11**] Discharge Date: [**2158-5-30**]
Date of Birth: [**2121-1-19**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
nausea, vomiting ,epigastric pain for 3 days
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 37 year old male with a history of recurrent
pancreatitis treated by Dr. [**Last Name (STitle) 59756**], who presented to [**Hospital1 18**] on
[**2158-5-10**] with 3 days of nausea, vomiting, and severe epigastric
pain. Denies any fevers, but he has had chills. Last drank
EtOH one week ago. No changes in bowel movements or urination.
Past Medical History:
pancreatitis, HIV, lap chole
Social History:
NC
Family History:
NC
Physical Exam:
VS- Temp 96.3, HR 98, BP 103/51, RR 18, SO2 100%
Gen- NAD, anicteric
Lungs: CTA b/l
Heart: RRR, S1S2
Abd: soft, ND, mild epigastric tenderness, no rebound or
guarding, no hernias or masses palpated
Rectal: guiac neg, normal tone
Neuro: AxOx3
Pertinent Results:
CHEST (PORTABLE AP)
Reason: Acute drop in O2 sat after large volume resuscitation, ?
ove
[**Hospital 93**] MEDICAL CONDITION:
37 year old man w/ pancreatitis
REASON FOR THIS EXAMINATION:
Acute drop in O2 sat after large volume resuscitation, ?
overload
INDICATION: 37-year-old man with pancreatitis and hypoxia.
PORTABLE SEMI-UPRIGHT FRONTAL RADIOGRAPH. Comparison is made to
study done at 8:30 p.m. last night.
Lung volumes are reduced. There are bilateral pleural effusions
and associated discoid atelectasis in both lower lobes and the
lingula. There is no definite CHF. There has been interval
placement of an NG tube with resultant decompression of gastric
distension seen on the prior study. ET tube is stable in
position.
IMPRESSION:
Bilateral pleural effusions and associated atelectasis. No CHF.
CT ABD W&W/O C; CT PELVIS W/CONTRAST
Reason: * acute/chronic pancreatitis protocol, evaluate for
pancreat
Field of view: 39 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
37 year old man with pancreatitis, acute on chronic
REASON FOR THIS EXAMINATION:
* acute/chronic pancreatitis protocol, evaluate for pancreatic
abscess/necrosis/mass*
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 37-year-old man with pancreatitis, acute on chronic.
TECHNIQUE: Multidetector axial images of the abdomen and pelvis
were obtained with oral and without and with IV contrast.
Coronal and sagittal reformatted images were obtained.
CT ABDOMEN: There are moderate bilateral pleural effusions and
associated bilateral lower lobe atelectasis. The liver is
unremarkable. The patient is status post cholecystectomy. The
pancreas is boggy in appearance, and there is decrease in the
expected contrast enhancement. There is a significant amount of
peripancreatic fluid. The spleen is normal in appearance;
however, the splenic vein appears occluded. The adrenal glands
and kidneys are unremarkable. There is a low attenuation focus,
which measures 7 x 3.6 cm with a thin-walled, which likely
represents a pseudocyst either within the lesser sac or within
the gastric wall. In either case, it is exerting external
compression on the stomach. A nasointestinal feeding tube is
identified with the tip in the third portion of the duodenum.
There is a significant amount of inflammatory exudate and fluid
tracking along the paracolic gutters. There is thickening of the
wall of the upper portions of the upper right and left and
transverse colon. Multiple small mesenteric lymph nodes are
identified.
CT PELVIS: Foley catheter and air are noted in the bladder. The
prostate, seminal vesicles and rectum are unremarkable. There
are scattered sigmoid diverticula. A rectal tube is noted. There
is a moderate amount of fluid in the pelvis. There is no pelvic
or inguinal lymphadenopathy. Diffuse cutaneous stranding is
noted.
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
lesions.
IMPRESSION:
1. Large boggy pancreas with significant associated inflammatory
exudate consistent with pancreatitis. Decreased perfusion of the
pancreas is worrisome for necrosis. In addition, there is a
large fluid collection with apparent thin wall consistent with a
pseudocyst either gated in the lesser sac or within the gastric
wall. This exerts mass effect on the stomach.
2. Splenic vein occlusion.
3. Wall thickening of the transverse colon and upper portions of
the right and left colon consistent with colitis secondary to
peripancreatic inflammation.
4. Moderate bilateral pleural effusions and bilateral lower lobe
atelectasis.
5. Moderate amount of free fluid in the abdomen.
Brief Hospital Course:
The patient is a 37 year old male who was admitted to [**Hospital1 18**] on
[**2158-5-10**] with acute pancreatitis. He was admitted to the ICU and
received aggressive fluid resuscitation. He was kept NPO. An
NG tube, Foley, A-line and CVL were placed. A chest X-ray was
unremarkable. His creatinine was elevated at 3.7. His WBC was
16. He had transaminitis (ALT 166, AST 260), his amylase was
500 and his lactate was 3.5. On HD 2, he was intubated. His
AST was 2064 and his ALT was 724. His total bilirubin and
alkaline phosphatase were normal. He received Hydromorphone for
pain and Lorazepam for anxiety. Imipenem was started
empirically. That night he required a phenylephrine drip for
hypotension. An OG tube was placed and bilious material
returned. He had new left lower lobe atelectasis on CXR. A RUQ
ultrasound was unremarkable for gallstones, but did show
evidence of liver cirrhosis. On HD 3, he was febrile to 101.
His WBC was down to 6.6. His creatinine was down to 2.7. His
lactate was down to 1.7. His ALT, AST, and amylase were
trending down. A CXR showed improved pulmonary edema, however
he did have bilateral effusions. Tube feeds were started via
his Dobbhoff. Fentanyl and midazolam were used for sedation.
His LFTs continued to trend down. On HD 4, his Dobbhoff was
placed post-pyloric under fluoroscopy. On HD 5, a CT scan
showed a large boggy pancreas with significant associated
inflammatory exudate consistent with pancreatitis. Decreased
perfusion of the pancreas was worrisome for necrosis. In
addition, there was a large fluid collection with apparent thin
wall consistent with a pseudocyst either gated in the lesser sac
or within the gastric wall. Also, there was evidence of splenic
vein occlusion. In addition, there was wall thickening of the
transverse colon and upper portions of the right and left colon
consistent with colitis secondary to peripancreatic
inflammation, and moderate bilateral pleural effusions and
bilateral lower lobe atelectasis. We decided that no
intervention was necessary at this time, as there was no
evidence of pancreatic necrosis. On HD 6, Lopressor was used as
needed for tachycardia. His tube feeds were increased, but were
one half strength. On HD 7, this patient was transferred to the
gold surgery service under the care of Dr. [**Last Name (STitle) **].
The patient remained intubated until HD 15. He was sedated on
Fentanyl and Versed. He was agitated at times requiring Haldol
with good effect. The patient was having difficulty weaning off
the vent and a Trach was discussed if unable to wean. HD 10 he
spike to 104.4 and treated with Tylenol and cooling blankets.
Blood cultures were negative. He continued on Imipenem and
Fluconazole. HD 11 he was tried on CPAP but desaturated and
became tachypneic and had to be put on Assist-control on a rate.
He was opening eyes spontaneously, but unable to follow commands
or track and was tachycardic when anxious.
HD 15 he was extubated. Tube feedings were held due to abdominal
pain and then Dobbhoff tube feedings were restarted. He was
transferred to the floor on HD 18 where he progressed well. He
began a regular diet and had no shortness of breath. He had a CT
of his pancreas/splenic vein and was discharged home in good
condition.
Medications on Admission:
Lopressor
Xanax
Cholestyramine
Discharge Medications:
1. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*qs Tablet(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*qs Tablet(s)* Refills:*2*
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
7. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO QIDWMHS (4 times a day
(with meals and at bedtime)).
Disp:*qs Cap(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatitis
Discharge Condition:
Good
Discharge Instructions:
come to the emergency room if you have fever >101.4F, nausea or
vomiting, shortness of breath,
-do not drive while taking pain medications
-take a stool softener while taking pain medications
-take your usual home medicines
-no heavy lifting >10lbs for 6 weeks
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in [**3-4**] weeks. Call ([**Telephone/Fax (1) 15807**] to schedule an appointment.
Completed by:[**2158-5-30**]
|
[
"305.00",
"276.7",
"300.00",
"458.9",
"577.0",
"275.2",
"401.9",
"577.1",
"427.31",
"276.2",
"275.41",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.05",
"96.6",
"87.69",
"33.22",
"38.93",
"38.91",
"96.07",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8923, 8929
|
4723, 8011
|
358, 364
|
8986, 8993
|
1113, 1204
|
9303, 9470
|
832, 836
|
8092, 8900
|
2105, 2157
|
8950, 8965
|
8037, 8069
|
9017, 9280
|
851, 1094
|
274, 320
|
2186, 4700
|
392, 744
|
766, 796
|
812, 816
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,132
| 158,940
|
18495
|
Discharge summary
|
report
|
Admission Date: [**2131-5-15**] Discharge Date: [**2131-7-5**]
Date of Birth: [**2092-12-24**] Sex: F
Service: MEDICINE
Allergies:
Latex / Adhesive Tape / Magnesium Sulfate / Cyclosporine
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
mini-MUD non-myeloablative transplant with campath
Major Surgical or Invasive Procedure:
Lumbar Puncture
Intubation
CVVHD
History of Present Illness:
38 year old female with relapsed Nodular-Sclerosing Hodgkin's
lymphoma s/p autoSCT being admitted for a nonmyelablative (mini)
allogeneic transplant from a MUD. She has been feeling well
recently. She does note baseline shortness of breath from
pulmonary involvement of disease, but no oxygen requirement. She
has been increasing her activity with improvement in her
respiratory status. She denies any bleeding including blood in
urine or stool, epistaxis or gum bleeding. No recent fevers,
nausea, vomiting, or abdominal pain. She has had chronic sciatic
pain for which is on narcotics and that may have been a little
worse today. She also had an episode of diaphoresis today.
Past Medical History:
Oncology History: Diagnosed with Hodgkin's lymphoma, nodular
sclerosing) in [**2123**]. The patient initially was treated with
Adriamycin, bleomycin, vinblastine, dacarbazine with subsequent
disease recurrence. Transplant was deferred at that time, and
the patient received four cycles of CEPT. She also received
radiation therapy as part of initial treatment for six weeks.
She had an autologous [**Year (4 digits) 3242**] in 4/[**2128**]. In [**2-/2130**] (about one year
post transplant) a CT evaluation revealed recurrent disease in
her chest and abdomen. Anterior mediastinal adenopathy was in
the field of prior radiation. She underwent a biopsy of her
anterior mediastinal adenopathy that revealed recurrent
Hodgkin's lymphoma. She was then treated with CEPP chemotherapy.
She had a variable response to CEPP and was started most
recently on Rituxan and Vinblastine and then just completed 3rd
course of ICE. PET/CT done in [**2-/2131**] still shows some FDG avid
lesions in lung.
.
PAST MEDICAL HISTORY:
1. Hodgkin's lymphoma with the details described above.
2. Splenectomy in [**2126**].
3. History of herpes zoster.
4. History of Phen-Phen use.
5. Previous history of clot in left SVC. She was on Coumadin
for a period of time but this has been held due to her low
platelet count.
6. Paralyzed vocal cords.
Social History:
[**Known firstname **] is single, and lives with the father of
her 11-year-old son. She denies tobacco or alcohol use. She has
worked occasionally at a convenient store.
Family History:
Significant for her mother who passed away from
a myocardial infarction. Her father was diagnosed recently with
pancreatic liver and colon cancer of unknown primary.
Physical Exam:
Temp 98.4 HR 92 BP 106/55 RR 20 94% RA
GEN: NAD, ECOG 1
HEENT: bald with wig, PERRL, EOMI, anicteric sclerae, MMM, OP
clear
NECK: supple, no LAD
CV: S1S2 RRR. NO MRG
LUNGS: L side decreased breath sounds [**11-28**] way up, decreased BS R
base, crackles above L base, crackles above R base
ABD: soft, NT/ND. +BS
EXT: No clubbing, cyanosis, or edema
Pertinent Results:
[**2131-5-15**] WBC-7.14 RBC-2.93* Hgb-9.5* Hct-28.6* MCV-98 MCH-32.6*
MCHC-33.4 RDW-23.2* Plt Ct-30*# Neuts-90* Bands-0 Lymphs-0
Monos-10 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-3*
Gran Ct-3850
[**2131-5-16**] 07:00AM BLOOD PT-11.8 PTT-25.3 INR(PT)-1.0
[**2131-5-15**] Glucose-83 UreaN-8 Creat-0.5 Na-137 K-3.5 Cl-101
HCO3-26 TotProt-5.5* Albumin-3.4 Globuln-2.1 Calcium-8.7
Phos-2.4* Mg-1.5*
[**2131-5-15**] ALT-27 AST-21 LD(LDH)-297* AlkPhos-138* TotBili-0.4
DirBili-0.2 IndBili-0.2
[**2131-5-16**] MRI L-spine:
IMPRESSION:
1. No abnormal epidural soft tissue or abnormal epidural fluid
collections.
2. No evidence of spinal canal or neural foraminal narrowing.
3. Extensive retroperitoneal adenopathy that is better assessed
on a recent PET CT.
.
[**5-17**] CXR
IMPRESSION: Apparent slight enlargement of bilateral pleural
effusions, left greater than right, which may be accentuated by
lower lung volumes on the current study.
.
[**5-18**] CXR
IMPRESSION: AP chest compared to [**4-4**] through [**5-17**].
Left hemidiaphragm is chronically significantly elevated and the
resultant left lower lobe is chronically collapsed. Moderate
left pleural effusion was little changed between [**4-4**] and [**5-16**], but has increased subsequently. Right lung is clear.
Mediastinum remains shifted to the left inferiorly and
superiorly to the right. The tips of bilateral central venous
lines project over the SVC. No pneumothorax.
.
[**5-22**] CT chest w/o contrast
IMPRESSION:
1. New, extensive consolidation within the left lung. The
differential diagnosis includes infection or marked radiation
pneumonitis.
2. Increase in small-to-moderate left partially loculated
pleural effusion with possible component of pleural thickening.
The differential diagnosis includes parapneumonic
effusion/empyema, or neoplastic involvement of the pleura.
3. Marked increase in left chest wall and breast edema could
represent post- radiation change or lymphatic obstruction. No
significant interval change in left chest wall and mediastinal
masses, although comparison is difficult due to technique.
4. Mild pulmonary edema.
5. Questionable new nodule in right middle lobe, difficult to
assess due to motion artifact in this area. Attention to this
region is recommended on followup.
.
[**5-23**] CXR
IMPRESSION:
1. Increased left pleural effusion resulting in complete
opacification of the left hemithorax.
2. Resolution of pulmonary edema.
.
[**5-30**] CXR
IMPRESSION: Mild improvement in left upper lung aeration.
.
[**6-1**] CXR
IMPRESSION:
1. Stable bilateral effusions and bibasilar atelectasis.
2. Improving aeration, left upper lobe.
.
[**6-14**] CT w/o contrast of chest, abdomen and pelvis
IMPRESSION:
1. Improving left lung aeration.
2. Unchanged left chest wall and breast edema secondary to
lymphatic obstruction or post- radiation change.
3. Multiple mediastinal and chest wall masses, relatively
unchanged, but new pulmonary nodules in the right middle lobe
are identified. No fluid collections in the abdomen or pelvis,
or other definite evidence.
.
[**2131-6-14**] CT head w/o contrast
IMPRESSION: Bilateral frontal subcortical white matter
hypodensity, more prominent on the left. The findings are
potentially concerning for leukoencephalopathy, although, in the
appropriate clinical setting, could represent
subacute-to-chronic borderzone infarcts. MRI of the brain
without and with gadolinium is recommended for further
evaluation.
.
[**6-15**] MR brain w/ gad
IMPRESSION:
White matter edema in the left frontal region, predominantly
posteriorly. No abnormal enhancement noted. These findings could
be due to an area of lymphomatous involvement (though it is more
common to see contrast enhancement at such involvements); other
differential diagnosis to be considered are progressive
multifocal leukoencephalopathy, encephalitis.
.
Brief Hospital Course:
ASSESSMENT AND PLAN: 38 year-old female with refractory and
recurrent Hodgkin's lymphoma, status post auto-[**Month/Year (2) 3242**] in [**2128**],
asplenic, and status post multiple chemotherapeutic regimens,
s/p Mini allo-MUD [**Year (4 digits) 3242**] on [**2131-5-22**].
.
Hodgkins Lymphoma: She had a response to ICE and it was felt
that her disease burden was low enough to allow the SCT. Her
donor is a male who is CMV positive with blood type A+. She is
CMV positive, her blood type is O+. Her conditioning regimen
consisted of Campath, fludarabine, and Cytoxan. Her POC
remained in place during her transplant given her history of
chest wall edema and the risk of poor healing. Her Mini
allo-MUD [**Date Range 3242**] occurred on [**2131-5-22**]. She was initially started on
Cyclosporine for GVHD prophylaxis but she subsequently developed
ARF requiring HD so this was stopped and high-dose
Methylprednisolone was started in place. The pt was also started
on clotrimazole, nystastin, and ursodiol for prophylaxis and
given a dose of aerisolized pentamadine and then bactrim for PCP
[**Name Initial (PRE) 1102**]. During the [**Hospital **] hospital course, methylrednisolone
was tapered due to concerns for steroid induced myopathy
contributing to pt's respiratory failure. A CT chest continued
to show progression of the pt's lymphoma, and given the pt's
high tumor burden and poor prognosis, lack of further options
for treatment, and persistent respiratory failure, the decision
was made during a family meeting to make the pt [**Name (NI) 3225**].
.
Respiratory Failure: The pt was intubated on [**6-1**] due to
desaturation, tachypnea, increased work of breathing on a 15L
non-rebreather. The decision was made to perform an elective
intubation. The pt was extubated on [**6-11**] but was reintubated
again the day after for hypercarbia, increased work of
breathing, and sedation needs beyond those that were safe off of
the vent. During the remaining hospital course, the pt was
unable to be weaned off of the vent. Possible contributing
steroid induced myopathy was considered and methylprenisilone
was tapered. The pt had no increased secretions suggestive of
infection, however completed a course of vancomycin and cefipime
for empiric tx of VAP and was placed on voriconazole for fungal
coverage. Myopathy of critical illness was also a likely
contributing factor to the pt's inability to be weaned off of
the vent. Furthermore, the pt was grossly positive during her
length of stay which also likely contributed to inability to
wean off vent. Fluid was taken off the patient during CVVHD as
BPs would tolerate. The pt was scheduled to go to the OR for a
trach placement when she had a precipitious drop in WBC, likely
[**12-28**] myelosuppression from bactrim. The trach placement was also
put on hold as the family had decided to make the pt [**Name (NI) 3225**].
.
Mental status changes: The pt began to develop mental status
changes that were noted during sedation weaning. A LP done by IR
on [**6-20**] was significant for a bloody tap not concerning for
bacterial infection; however all viral cultures eventually came
back no growth. The pt was started on acyclovir, bactrim for
empiric toxo treatment. CT and MRI of brain were both concerning
for PML/encephalitis/toxicity from chemotherapy. A repeat MRI
showed decreased instensity of parietal lobe abnormality; per
neurology, pt's mental status changes likely [**12-28**] reversible
luekoencephalopathy. The pt never fully recovered to her
baseline mental status in spite of sedation weaning as
tolerated.
.
ARF: [**12-28**] cyclosporine which caused HUS/TTP. The pt was placed on
pheresis X 4 days with positive results. HD catheter was placed
by renal and CVVHD was subsequently begun to help remove fluid
off pt as BP tolerated. The pt had several episodes of
hypotension during CVVHD and was unable to be transitioned to HD
during hospital course.
.
Hypothyroidism: on IV levothyroxine during hospital stay.
.
Diarrhea: Had 2 days of diarrhea during course but was c diff
negative X 3 and it did not persist
.
Fever: On admission to [**Name (NI) 153**], pt febrile with source possibly
being L breast cellulitis/UTI/pulmonary infectious process/high
tumor burden. No clear source was ever isolated, and pt
subsequently defeversced.
.
Breast pain: before intubation, she complained of chronic L
breast swelling, erythema and pain; thought to be secondary to
LN involvement and chest-wall mass; inflammation swelling seemed
to correlate to volume status. Breast pain and swelling
subsequently resolved during hospital course.
.
FEN: Pt switched to TPN once intubated with electrolytes
repleted in TPN. RISS. PEG placement was scheduled to be done in
OR; however was put on hold given pt's precipitous drop in WBC
and subsequent family decision to make pt [**Name (NI) 3225**].
.
PPx: No heparin SC given [**12-28**] thrombocytopenia, on pneumoboots,
PPI. Mouth care.
.
Dispo: Given pt's grave prognosis, high tumor burden, lack of
further treatment options, and persistent respiratory failure, a
family meeting led by Dr. [**First Name (STitle) **] was held in which the family
decided to make the pt [**Name (NI) 3225**]. The pt was removed from the vent and
subsequently passed away [**12-28**] cardiopulmonary arrest.
Medications on Admission:
MS Contin 60mg tid
Vicodin 10 mg/325 mg q4-6h prn or Percocet 5/325 1-2 tabs q4-6h
prn
MSIR 30 mg q4-6h prn
Levothyroxine 100mcg qd
Acyclovir 400mg [**Hospital1 **]
Bactrim DS MWF
Decadron 1 mg [**Hospital1 **]
Celexa 20 mg qd
potassium chloride 60 mEq qd
Protonix 40 mg qd
Xanax 0.25mg t.i.d. p.r.n.; Epogen subcu q. weekly.
Discharge Medications:
None.
Discharge Disposition:
Expired
Discharge Diagnosis:
Hodgkin's lymphoma
Cardiopulmonary Arrest
Respiratory Failure
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2131-7-17**]
|
[
"276.6",
"E933.1",
"458.21",
"585.9",
"370.34",
"285.22",
"518.81",
"584.9",
"V45.79",
"996.85",
"286.9",
"611.0",
"276.1",
"362.81",
"201.52",
"799.02",
"300.00",
"287.4",
"724.5",
"244.9",
"V12.51",
"288.0",
"276.2",
"599.0",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"41.05",
"99.04",
"99.15",
"38.93",
"33.22",
"99.05",
"96.04",
"03.31",
"39.95",
"38.95",
"00.92",
"96.72",
"99.07",
"99.25",
"99.71",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
12813, 12822
|
7100, 12407
|
375, 409
|
12928, 12937
|
3224, 7077
|
12989, 13159
|
2666, 2835
|
12783, 12790
|
12843, 12907
|
12433, 12760
|
12961, 12966
|
2850, 3205
|
285, 337
|
437, 1119
|
2153, 2461
|
2477, 2650
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,157
| 167,598
|
35192
|
Discharge summary
|
report
|
Admission Date: [**2183-10-4**] Discharge Date: [**2183-10-20**]
Date of Birth: [**2121-7-1**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
Left chest tube placement
History of Present Illness:
61 yo F transferred from referring hospital s/p fall with ?LOC;
was able to call EMS on her own. She complained of facial
swelling. She was found by EMS to have a BP of 260/140, facial
swelling, and EtOH on breath. She was taken to an area hospital
where found to have extensive SQ emphysema, left rib fractures
and left PTX. A left chest tube was placed and she was intubated
due to combativeness, and was transferred to the [**Hospital1 18**] for
further care.
Past Medical History:
EtOH abuse
HTN
Chronic back pain
Hypothyroid
Social History:
EtOH abuse
Lives with husband
Family History:
Noncontributory
Physical Exam:
Upon admission:
T 98.8F, P 89, BP 149/99, R 14, Sat 100% on vent.
Gen: Pt intubated, sedated, collared, agitated prior to
increased sedation moving all 4s.
HEENT: PERRL
Neck: nl to inspection, palp, auscultation
Chest: extensive SQ air, decreased breath sounds on L, chest
tube in place on L, L-sided bruising.
CV: RRR
Abd: soft, nt, nd, + bs. Guaiac neg.
MSK: no signs of fracture.
Skin: Crepitus over chest, neck, arms.
Neuro: moving all 4. Sedated.
Psych: agitated on arrival
Pertinent Results:
[**2183-10-15**] 04:20PM BLOOD WBC-10.0 RBC-3.09* Hgb-10.6* Hct-31.6*
MCV-103* MCH-34.3* MCHC-33.4 RDW-14.1 Plt Ct-489*
[**2183-10-4**] 01:55AM BLOOD WBC-16.2* RBC-3.53* Hgb-12.5 Hct-36.9
MCV-105* MCH-35.4* MCHC-33.9 RDW-13.6 Plt Ct-250
[**2183-10-15**] 04:20PM BLOOD Neuts-74.3* Lymphs-19.9 Monos-3.5 Eos-1.9
Baso-0.3
[**2183-10-4**] 01:55AM BLOOD Neuts-96.3* Lymphs-2.2* Monos-1.1*
Eos-0.2 Baso-0.1
[**2183-10-11**] 02:51AM BLOOD PT-15.6* PTT-29.2 INR(PT)-1.4*
[**2183-10-4**] 01:55AM BLOOD PT-13.8* PTT-22.9 INR(PT)-1.2*
[**2183-10-16**] 08:00PM BLOOD Glucose-129* UreaN-11 Creat-0.7 Na-145
K-3.6 Cl-109* HCO3-28 AnGap-12
[**2183-10-4**] 01:55AM BLOOD Glucose-177* UreaN-14 Creat-0.6 Na-138
K-3.1* Cl-107 HCO3-21* AnGap-13
[**2183-10-5**] 01:50AM BLOOD ALT-10 AST-19 AlkPhos-49 TotBili-0.3
[**2183-10-16**] 08:00PM BLOOD Calcium-8.3* Phos-3.8 Mg-2.2
[**2183-10-15**] 04:20PM BLOOD VitB12-1469* Folate-GREATER TH
[**2183-10-4**] 11:17AM BLOOD calTIBC-311 Ferritn-122 TRF-239
[**2183-10-15**] 04:20PM BLOOD TSH-1.0
[**2183-10-10**] 03:43AM BLOOD Type-ART Temp-36.6 FiO2-100 pO2-116*
pCO2-47* pH-7.39 calTCO2-30 Base XS-3 AADO2-580 REQ O2-92
Intubat-NOT INTUBA Comment-NEBULIZER
[**2183-10-4**] 02:25AM BLOOD Type-ART pO2-158* pCO2-54* pH-7.23*
calTCO2-24 Base XS--5
[**2183-10-4**] 10:28PM BLOOD K-3.0*
[**2183-10-4**] 08:37AM BLOOD Na-141 K-3.8
[**2183-10-4**] 08:37AM BLOOD freeCa-1.10*
RADS:
Pelvic U/S: Neither ovary is visualized. No adnexal mass. Low
attenuation structure may have represented bowel.
- CT Head [**2183-10-4**] 1. No acute intracranial abnormality. 2.
Extensive gas subcutaneously and dissecting along the fascial
planes of the head and neck.
- CT C-spine [**10-4**]: 1. Fracture involving the left articular
process of C7, with also minimally displaced fractures involving
the inferior articular facet at C6. 2. Interspace widening at
C6-7, with concern for ligamentous injury. An MRI is recommended
for further evaluation to evaluate for any cord injury or
ligamentous injury. 3. Degenerative disk disease with canal
narrowing at multiple levels due to disk bulges, protrusions,
and osteophytes.
- CT abd & pelvis [**10-4**]: 1. Diffuse subcutaneous emphysema as
described above. In addition, there is pneumomediastinum and a
small left pneumothorax. Given the presence of pneumomediastinum
any, as yet unknown mechanism of injury, injury to the airway or
esophagus cannot be completely excluded. Clinical correlation
and correlation with outside studies is suggested. 2. Acute left
rib fractures as described above. Compression fracture of T9,
chronicity indeterminate.
3. Left lower lobe collapse. 4. Partially calcified left adrenal
mass, which is not fully characterized. Differential
considerations include such entities as prior hemorrhage or
partially calcified myelolipoma or neoplasm. MRI is suggested
for further evaluation.
5. Cystic pancreatic lesion and prominence of the pancreatic
duct. MRCP is
suggested for further evaluation. 6. Bilateral hypodense renal
lesions too small to characterize. These could be assessed with
MRI or ultrasound.
7. No evidence of solid abdominal organ injury. 8. 2 cm left
adnexal cyst. Right ovary is not well visualized. Pelvic
ultrasound is recommended for further evaluation.
- MR [**Name13 (STitle) 2853**] [**10-6**]: 1. Anterolisthesis, grade 1, of C2 on 3 and
C4 on 5. No prevertebral soft tissue swelling. Anterior and
posterior longitudinal ligaments appear intact. 2. Fluid
anterior to the upper cervical vertebral bodies which may be due
to intubation. 3. Degenerative joint disease as described above.
- Pleural aspirate [**10-10**]: Technically successful
ultrasound-guided percutaneous placement of pigtail catheter
into moderate left pleural effusion, with initial aspiration of
20 cc of fluid. Sample sent for microbiology. Procedure
discussed afterward with Dr. [**Last Name (STitle) **].
Micro:
[**10-7**] Sputum GS:staphA coag(+), mod growth, MSSA
[**10-7**] BCx: staphA coag(+) MSSA
[**10-7**] UrineCx: Enterococcus >100,000
Brief Hospital Course:
She was admitted to the Trauma Service and taken to the Trauma
ICU for close monitoring. She remained sedated on Fentanyl and
Versed and was vented. On [**10-5**] she self extubated and was re
intubated for airway protection as she was tremulous,
diaphoretic, and slurred speech when extubated. She was placed
on a CIWA scale and required large quantities of Ativan for EtOH
withdrawal. She was hypertensive and was started on Metoprolol.
She developed increased respiratory secretions. Sputum cultures
and blood cultures grew MSSA and a urine culture grew
enterococcus, Nafcillin was then started. Her c-spine was
cleared clinically; the CT showed stable c-spine
anterolisthesis. An MRI confirmed the anterolisthesis and showed
that there was no ligamentous injury.
On [**10-10**] her sedation was decreased and she was extubated. She
became increasingly agitated and required a large amounts of
Valium. She did not require re-intubation. She developed a
loculated right pleural effusion which was drained with a
pigtail catheter that was left in place. The pigtail was
self-pulled on [**10-12**]; she did not develop further respiratory
compromise.
She was later transferred to the floor where her agitation
continued she was disoriented. The benzodiazepines were weaned
and she was started on Zyprexa which helped tremendously. She
became more cooperative and was able to work with Physical
therapy.
Social work was closely involved with her from early admission
as there were questionable reports of domestic abuse at home.
The [**Location (un) 6598**] Elder Services was contact[**Name (NI) **] and were aware of her
situation and prepared to assist upon discharge. She was
counseled on her alcohol abuse and was offered information on
inpatient alcohol treatment centers for which she was agreeable
to participate. She was discharged to her cousins home with
instructions for follow up.
Medications on Admission:
tramadol 50'''', fioricet 1'''', lexapro 10', fluoxetine 20',
ambien cr 12.5', levothyroxine 125', lisinopril 10', prilosec
20'
Discharge Medications:
1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Chlordiazepoxide HCl 25 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
4. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
9. Dicloxacillin 250 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) for 10 days.
Disp:*40 Capsule(s)* Refills:*0*
10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
12. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q6H (every 6 hours) as needed for headache.
Disp:*60 Tablet(s)* Refills:*0*
13. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
14. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for constipation.
15. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily): Remove old patch before applying new
one.
Disp:*30 Patch 24 hr(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Fall
Left pneumothorax
Left rib fractures 4,5,6,11
Subcutanoeus emphysema
Bacteremia
Pneumonia
Urinary tract infection
Discharge Condition:
Good
Discharge Instructions:
AVOID alcohol and/or other illicit drugs as they put you at very
high risk for future injuries.
Return to the Emergency room for fevers, chills, productive
cough, shorness of breath, chest pain, rib pain not relieved
with the pain medication prescribed, nausea, vomiting, diarrhea
and.or any other sypmotms that are concerning to you.
Followup Instructions:
Follow up in 2 weeks with Provider: [**Name10 (NameIs) 2194**],[**Name11 (NameIs) 900**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 6429**]
Call to schedule appointment.
Follow up with the [**Location (un) 6598**] Elder Services as instructed for the
social issues that were addressed during your hospital stay. You
have indicated that you have their contact numbers.
Follow up with your primary care doctor in the next week, you
[**First Name8 (NamePattern2) **] [**Doctor First Name **] to call for an appointment.
Completed by:[**2183-10-22**]
|
[
"511.9",
"041.04",
"303.91",
"958.7",
"807.04",
"244.9",
"041.11",
"599.0",
"790.7",
"291.0",
"E888.9",
"997.31",
"860.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.72",
"34.91",
"34.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
9307, 9313
|
5549, 7446
|
323, 351
|
9480, 9486
|
1506, 5526
|
9870, 10431
|
974, 991
|
7624, 9284
|
9334, 9459
|
7472, 7601
|
9510, 9847
|
1006, 1008
|
275, 285
|
379, 843
|
1022, 1487
|
865, 911
|
927, 958
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,431
| 163,793
|
9941
|
Discharge summary
|
report
|
Admission Date: [**2154-7-2**] Discharge Date: [**2154-7-6**]
Date of Birth: [**2103-9-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Decrease exercise tolerance
Major Surgical or Invasive Procedure:
[**2154-7-3**] - Minimally Invasive Mitral Valve Repair (34mm [**Doctor Last Name 405**]
ring), PFO closure.
[**Last Name (NamePattern4) 15255**] of Present Illness:
The patient is a 50-year-old gentleman who was diagnosed with
severe mitral regurgitation. He has been followed by serial
echo's with the most recent showing 4+ MR. The patient was
referred to Dr. [**Last Name (Prefixes) **] for repair or replacement. The
patient understood the risks and benefits of the procedure
and wished to proceed.
Past Medical History:
MVP/MR
[**First Name (Titles) 15421**] [**Last Name (Titles) 33309**]
[**Last Name (Titles) **]
Pulmonary nodule on CT (Stable)
Social History:
Works in window treatments. 2 drinks weekly. Quit smoking 20
years ago. Lives with wife.
Family History:
Father with CAD
Physical Exam:
GEN: WDWN in NAD
SKIN: Warm, Dry, No C/C/E
HEENT: NCAT, PERRL, Anicteric sclera. Needs root canal
LUNGS: Clear
HEART: RRR, IV/VI holosystolic murmur
ABD: BEnign
EXT: No varicosities, pulses 2+, no edema
Pertinent Results:
[**2154-7-3**] ECHO
The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque. The
aortic valve leaflets (3)appear structurally normal with good
leaflet excursion and no aortic regurgitation. There is no
pericardial effusion.
[**2154-7-3**] CXR
Bibasilar atelectasis. No pulmonary edema.
[**2154-7-5**] 07:25AM BLOOD WBC-8.8 RBC-3.62* Hgb-11.4* Hct-32.4*
MCV-89 MCH-31.5 MCHC-35.2* RDW-13.4 Plt Ct-118*
[**2154-7-5**] 07:25AM BLOOD Plt Ct-118*
[**2154-7-5**] 07:25AM BLOOD Glucose-116* UreaN-12 Creat-0.8 Na-135
K-4.3 Cl-100 HCO3-26 AnGap-13
[**Last Name (NamePattern4) 4125**]ospital Course:
Mr. [**Known lastname 33310**] was admitted to the [**Hospital1 18**] on [**2154-7-2**] for elective
surgical management of his mitral valve disease. His surgery was
delayed one day due to a surgical emergency. He was taken to the
operating room on [**2154-7-3**] where he underwent a minimally invasive
mitral repair using a 34mm [**Doctor Last Name **] ring and patent foramen
ovale closure. Postoperatively he was taken to the cardiac
surgical intensive care unit for monitoring. He awoke
neurologically intact and was extubated. On postoperative day
one he was transferred to the cardiac surgical step down unit
for further recovery. Aspirin and beta blockade were started. He
was gently diuresed towards his preoperative weight. The
physical therapy service was consulted for assistance with his
postoperative strength and mobility. He continued to make steady
progress and was discharged home on postoperative three. He will
follow-up with Dr. [**Last Name (Prefixes) **], his cardiologist and his primary
care physician as an outpatient.
Medications on Admission:
Lisinopril 20mg QD
Advair
Clarinex
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 7 days.
Disp:*14 Capsule, Sustained Release(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 10 days.
Disp:*20 Capsule(s)* Refills:*0*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed for 3 weeks.
Disp:*60 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:*2*
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
MVP/MR
[**First Name (Titles) **]
[**Last Name (Titles) **]
Pulmonary nodule
s/p Root canal
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) You may wash you incision and pat dry. No swimming or bathing
until it has healed.
5) No lotions, creams or powders to wound until it has healed.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 1290**] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with cardiologist Dr. [**First Name (STitle) 437**] in [**1-28**] weeks.
Follow-up with primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in 2 weeks.
([**Telephone/Fax (1) 33311**].
Call all providers for appointments.
Completed by:[**2154-8-15**]
|
[
"745.5",
"401.9",
"793.1",
"493.90",
"429.5",
"512.1",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.32",
"39.61",
"35.12",
"35.71",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
4239, 4290
|
309, 817
|
4426, 4433
|
1345, 1946
|
4837, 5220
|
1090, 1107
|
3129, 4216
|
4311, 4405
|
3069, 3106
|
4457, 4814
|
1122, 1326
|
1997, 3043
|
242, 271
|
839, 968
|
984, 1074
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,499
| 102,556
|
46212+46213
|
Discharge summary
|
report+report
|
Admission Date: [**2159-1-1**] Discharge Date: [**2159-1-2**]
Date of Birth: [**2099-8-27**] Sex: F
Service: SURGERY
Allergies:
Phenothiazines
Attending:[**Doctor First Name 5188**]
Chief Complaint:
ventral hernia x 2
Major Surgical or Invasive Procedure:
ventral hernia repair with mesh
History of Present Illness:
59F s/p TAH with infraumbilical incisional hernia & painful
epigastric hernia. No GI symptoms or concern for incarceration.
CT revealed nonobstructed hernias. Patient presented for
elective repair
Past Medical History:
TAH
HTN
^chol
depression
Social History:
noncontrib
Family History:
noncontrib
Physical Exam:
AVSS
NAD
RRR
CTA B
Soft obese NT ND
Palp nonreducible midline epigastric & infraumb incisional
hernias
No CCE
Pertinent Results:
Fasting fingerstick levels: 160-180
[**2159-1-1**] 08:42PM BLOOD %HbA1c-PND [Hgb]-PND [A1c]-PND
Brief Hospital Course:
[**1-1**]: Uncomplicated hernia repair with mesh. Patient admitted
for overnight observation given extension of incision to repair
markedly weakened fascia between hernias. 2 subcutaneous JP
drains left to drain possible seroma.
During routine postop check 6 hours after skin closure, patient
was lethargic given excessive narcotic administration. She was
transferred to [**Hospital Unit Name 153**] for close respiratory monitoring while
narcotics wore off. foley placed for failure to void.
fingersticks 160-180, HBA1C sent (still pending)
[**1-2**]: foley DC'd in AM. given oxycodone without narcosis.
diet advanced & sent home with drain instruction.
Medications on Admission:
norvasc
triamterene
lipitor
premarin
celexa
trazodone prn
Discharge Medications:
norvasc
triamterene
lipitor
premarin
celexa
trazodone prn
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): use while taking percocets.
Disp:*60 Capsule(s)* Refills:*2*
3. Motrin 800 mg Tablet Sig: One (1) Tablet PO three times a
day: take with meals for the next 5 days.
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
ventral incisional & epigastric hernias
hypertension
depression
hypercholesterolemia
hyperglycemia (perioperative vs new onset diabetes mellitus)
Discharge Condition:
good
Discharge Instructions:
Diet as tolerated. Drain your JP drains as directed. No
bathing (showers okay - pat wound dry), no driving if taking
narcotics, and no strenuous activity.
Continue all of your preoperative medications. You may take
motrin or tylenol to minimize your narcotic requirement. You
should take an OTC stool softener like colace while using
percocets to prevent constipation.
Contact your MD if you develop fevers>101, redness or drainage
from your surgical wound, increasing abdominal pain, inability
to tolerate PO's, or if you have any questions or concerns
whatsoever.
Followup Instructions:
Contact [**Name2 (NI) 54841**] office at [**Telephone/Fax (1) 5189**] to arrange a
follow up appointment in 1 week.
You should follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], in [**4-8**] weeks
to discuss your high blood sugars.
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]
Completed by:[**2159-1-2**] Admission Date: [**2159-1-6**] Discharge Date: [**2159-1-11**]
Date of Birth: [**2099-8-27**] Sex: F
Service: SURGERY
Allergies:
Phenothiazines / Compazine
Attending:[**Doctor First Name 5188**]
Chief Complaint:
Abdominal Pain
Nausea
Vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
59F s/p ventral hernia repair [**2159-1-1**] returns [**1-5**] for
abdominal pain, nausea and vomiting.
Past Medical History:
TAH
HTN
^chol
depression
Social History:
noncontributory
Family History:
noncontributory
Physical Exam:
Admission Physical Exam
97.4 78 164/55 18 100%
AOx3, NAD
RRR
CTAB
Soft, NT, Wound Clean
Right JP serosanguinous
Pertinent Results:
Admission Labs
-------------------
[**2159-1-5**] 02:25PM BLOOD WBC-10.1 RBC-4.36 Hgb-12.4 Hct-35.7*
MCV-82 MCH-28.4 MCHC-34.7 RDW-13.3 Plt Ct-321
[**2159-1-5**] 02:25PM BLOOD Neuts-77.8* Lymphs-16.6* Monos-2.9
Eos-1.5 Baso-1.3
[**2159-1-5**] 02:25PM BLOOD PT-12.5 PTT-27.1 INR(PT)-1.1
[**2159-1-5**] 02:25PM BLOOD Glucose-116* UreaN-13 Creat-0.7 Na-140
K-3.3 Cl-105 HCO3-22 AnGap-16
[**2159-1-5**] 02:25PM BLOOD ALT-17 AST-19 AlkPhos-62 Amylase-99
TotBili-0.6
[**2159-1-5**] 02:25PM BLOOD Calcium-9.2 Phos-1.4*# Mg-1.7
[**2159-1-5**] 02:33PM BLOOD Lactate-2.3*
Discharge Labs
--------------------
[**2159-1-9**] 06:55AM BLOOD WBC-8.7 RBC-4.03* Hgb-11.3* Hct-33.0*
MCV-82 MCH-28.2 MCHC-34.4 RDW-13.3 Plt Ct-307
[**2159-1-9**] 06:55AM BLOOD Plt Ct-307
[**2159-1-11**] 06:40AM BLOOD Glucose-117* UreaN-7 Creat-0.6 Na-139
K-3.9 Cl-106 HCO3-25 AnGap-12
[**2159-1-11**] 06:40AM BLOOD Calcium-8.4 Phos-3.0 Mg-1.9
ABDOMEN (SUPINE & ERECT) (Admission)
Reason: supine and erect films for air fluid levels
[**Hospital 93**] MEDICAL CONDITION:
59 year old woman with hernia surgery 5 days ago, now w/ acute
onset lower abd pain and bilious vomiting
REASON FOR THIS EXAMINATION:
supine and erect films for air fluid levels
INDICATION: 59-year-old female five days status post hernia
repair, now with acute lower abdominal pain. Evaluate.
COMPARISON: CT abdomen and pelvis dated [**2158-7-7**].
SUPINE AND UPRIGHT ABDOMINAL X-RAY: Gas and stool are seen
throughout the colon to the level of the rectum. A few small
bowel loops within the left mid abdomen are mildly dilated with
scattered air-fluid levels on the upright film. There is no free
air under bilateral hemidiaphragms. [**Location (un) 1661**]- [**Location (un) 1662**] drains are
seen in the left lower pelvis. S-shaped thoracolumbar scoliosis
is incidentally noted.
IMPRESSION: Nonspecific bowel gas pattern with mildly dilated
loops of small bowel could represent early or partial
obstruction.
Brief Hospital Course:
[**Known firstname **] [**Known lastname 98250**] was evaluated in the emergency department at
[**Hospital1 18**] on [**2159-1-5**]. WBC was 10.1 and a KUB was unremarkable. She
was admitted to the surgery service under the care of Dr.
[**Last Name (STitle) 5182**] for further observation. She was given a GI
cocktail, regular diet, and Percocet for pain.
At HD 2 she had worsening nausea. KUB showed evidence of bowel
obstruction. She was made NPO, an NGT was placed, IV fluids were
started, and she was given IV Lopressor for blood pressure
control.
At HD 4 an abdominal/pelvic CT scan was completed which showed
small bowel obstruction. She remained afebrile. She had return
of bowel function with +flatus/stool.
At HD 5 her NGT was discontinued due to + bowel function and low
output. Her diet was advanced to clears which she tolerated
well. Her home medications were restarted.
At HD 6 she was tolerating a regular diet. She was afebrile and
continued with bowel function. She was discharged home in good
condition. Her abdominal JP drain remained. She was to follow
up with Dr. [**Last Name (STitle) 5182**] in one week.
Medications on Admission:
norvasc
triamterene
lipitor
premarin
celexa
trazodone prn
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Ventral Hernia Repair
Small Bowel Obstruction
Discharge Condition:
Good
Discharge Instructions:
Please return or contact for:
* Fever (>101 F) or chills
* Inability to pass gas or stool
* Abdominal Pain
* Inability to urinate or dark urine
* Redness or drainage at incisions
* Nausea or vomiting
* Removal or misplacement of drain
* Any other concerns
Please continue any home medications as prescribed.
You may shower. Gently wash incision site and pat dry. Do not
remove the steri-strips (small paper strips at incision) as they
will fall off on their own. No tub baths or immersion for two
weeks.
No lifting over 20 pounds or abdominal stretching exercises for
4 weeks. Please do not drive while taking pain medication.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 5182**] in 1 week. Please call for
an appointment. The number is ([**Telephone/Fax (1) 15350**].
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]
Completed by:[**2159-1-15**]
|
[
"401.9",
"788.20",
"272.0",
"780.79",
"560.9",
"E878.8",
"311",
"997.4",
"553.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"53.69"
] |
icd9pcs
|
[
[
[]
]
] |
7431, 7437
|
6179, 7322
|
3794, 3801
|
7531, 7538
|
4203, 5202
|
8216, 8500
|
4033, 4050
|
1696, 2174
|
5239, 5344
|
7458, 7510
|
7348, 7408
|
7562, 8193
|
4065, 4184
|
3724, 3756
|
5373, 6156
|
3829, 3935
|
3957, 3983
|
3999, 4017
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,860
| 188,546
|
51392
|
Discharge summary
|
report
|
Admission Date: [**2161-12-11**] Discharge Date: [**2161-12-15**]
Date of Birth: [**2105-7-21**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Iodine; Iodine Containing / Versed / Fentanyl
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
elective pericardial drainage
Major Surgical or Invasive Procedure:
pericardiocentesis
History of Present Illness:
56 yo female with h/o metastatic breast cancer(dx [**2143**]) s/p XRT
and more recently chemo (FU/LCV), dyslipidemia, chronic
pericardial effusion presents with worsening SOB for elective
pericardial drainage.
Pt has progressive DOB over the past 2 months. Pt is only able
to walk 10 strides or 5 steps prior to getting SOB. Pt has
long-standing pericardial effusion with slow progression in size
over the last year. Associated fatigue. Denies SOB at rest,
orthopnea, PND, CP, palpitations
Recently admitted from [**12-2**] for similar symptoms of worsening
DOE. During that admission chest CT and echo were performed
which showed moderate sized circumferential pericardial effusion
extending 1.7 cm posterior and lateral to the left ventricle,
2.0 cm around the right ventricular free wall, 1.7 cm around the
right atrium without echocardiographic signs of tamponade.
Cardiology wasn't sure if dyspnea was of cardiac etiology. The
patient was discharged with instructions to follow up with echo
in [**3-10**] weeks.
Past Medical History:
1. Breast Ca-metastatic to spine, pelvis, lung (Dx 22 yrs ago)
s/p BMT [**2151**]; recurrence [**2158**]; finished cycle 7 (week 3 of 5) of
FU/leucovorin with zometa
2. Dyslipidemia
3. Narrow angle glaucoma s/p Laser eye surgery
4. Cholecystectomy [**2151**]
Social History:
Married to husband of 35 years; lives at [**Location 106547**] any tobacco
use; [**3-10**] glasses of wine/month; no illicit drug use
Family History:
Father-deceased at 87, CAD
Mother-deceased at 80, CVA/HTN
Sisters-both alive, one with narcolepsy, one with glaucoma
Physical Exam:
VS: T 96.5, p78, 104/70, rr22, 100%2L
HEENT: PERRL, EOMI, MMM
Neck: non-elevated JVP
CVS: soft heart sounds, RRR, nl s1 s2, no m/g/r
Chest: R porta-cath, pericardial drain in place
Lungs: CTA anteriorly
Abdomen: soft, NT, ND, +BS
Extremities: right groin swan in place, no edema bilaterally, 2+
DP
Pertinent Results:
[**2161-12-11**] 10:00AM WBC-4.3 RBC-2.98* HGB-11.3* HCT-32.4*
MCV-109* MCH-37.8* MCHC-34.9 RDW-16.3*
[**2161-12-11**] 10:00AM PLT COUNT-187
[**2161-12-11**] 10:00AM PT-13.1 PTT-34.2 INR(PT)-1.1
.
[**2161-12-11**] 10:00AM GLUCOSE-86 UREA N-15 CREAT-1.0 SODIUM-140
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-26 ANION GAP-12
[**2161-12-11**] 12:00PM OTHER BODY FLUID TOT PROT-5.5 GLUCOSE-90
LD(LDH)-226 AMYLASE-54 ALBUMIN-3.4
.
[**2161-12-11**] 01:45PM TYPE-ART PO2-146* PCO2-50* PH-7.33* TOTAL
CO2-28 BASE XS-0 INTUBATED-NOT INTUBA
[**2161-12-11**] 01:45PM HGB-10.1* calcHCT-30 O2 SAT-98
.
[**2161-12-11**] 12:00PM OTHER BODY FLUID WBC-350* RBC-1200* Polys-5*
Lymphs-13* Monos-70* Mesothe-6* Macro-6*
[**2161-12-11**] 12:00PM OTHER BODY FLUID TotProt-5.5 Glucose-90
LD(LDH)-226 Amylase-54 Albumin-3.4
[**2161-12-11**]: Negative gram stain
.
[**2161-12-11**]: pre-procedure TTE
Conclusions:
1. Left ventricular wall thickness, cavity size, and systolic
function are
normal (LVEF>55%). Regional left ventricular wall motion is
normal.
2. The aortic valve leaflets (3) are mildly thickened. Mild (1+)
aortic
regurgitation is seen.
3. The mitral valve appears structurally normal with trivial
mitral
regurgitation.
4. There is a moderate sized pericardial effusion. The effusion
appears
circumferential. There are no echocardiographic signs of
tamponade.
5. Compared with the findings of the prior study (tape reviewed)
of [**2161-12-1**],
there has been no significant change.
.
[**2161-12-11**]: post-procedure TTE
Conclusions:
1. Left ventricular wall thickness, cavity size, and systolic
function are
normal (LVEF>55%).
2. There is no pericardial effusion.
3. Compared with the findings of the prior study (tape reviewed)
of [**2161-12-11**],
the pericardial effusion is gone.
.
[**2161-12-11**]: CXR:
no evidence of pneumomediastinum or other complications
post-pericardiocentesis
Brief Hospital Course:
1. Pericardial effusion: On admission, pt was taken to cardiac
cath, where pericardiocentesis was performed. 410cc of
straw-colored fluid was removed. Hemodynamics during the
procedure were as follows: RA 2, RV 30/2/7, PCW 13, CO 3.74, CI
2.37. No tamponade physiology. Several minutes post-procedure,
pt became agitated and stridorous without evidence of laryngeal
edema or tongue swelling. Treated with IV solumedrol, benadryl,
pepcid, and versed with improvement in stridor. The drain was
pulled on [**12-12**] without event. The patient then developed
pericarditis after the drain was pulled with manifested itself
as [**11-15**] chest pressure, mainly pleurtic, and an EKG with PR
depressions and ST scooping. She also had elevations in her CK,
but a negative MB and negative troponins and therefore not from
myocardial destruction. She was given ibuprofen and morphine
for pain. On discharge, she no longer needed either. The
cytology will need to be follow ed up as an outpatient.
2. Dyspnea: Since significant removal of pericardial fluid
occurred an the patient's DOE did not improve, the effusion is
likely not related to her DOE. Continue to work this up as an
outpatient.
3. Hypercholesterolemia: statin was continued.
4. Coagulopathy: The patient's PTT increased throughout her stay
until day before discharge. There was no evidence that she was
in DIC. Her values normalized prior to discharge. This can be
followed as an outpatient.
Medications on Admission:
Paxil 20mg qd
Oscal/Vit D 500 tid
Lipitor 40mg qd
Xanax 1mg qhs
Zometa q4wk IV
FU/Leukovorin qwk
Discharge Medications:
1. Hydromorphone HCl 2 mg Tablet Sig: One (1) Tablet PO Q2H
(every 2 hours) as needed.
2. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
4. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
6. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for chest pain.
7. Zometa 4 mg/5 mL Solution Sig: One (1) Intravenous once a
month.
Discharge Disposition:
Home
Discharge Diagnosis:
pericardial drain
pericarditis
metastatic breast cancer
Discharge Condition:
good
Discharge Instructions:
Call Dr. [**Last Name (STitle) **] if you experience chest pain again. You may
take over the counter ibuprofen for your chest pain.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4053**], RN Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2161-12-16**] 9:00
Provider: [**Name Initial (NameIs) 4426**] 2 Date/Time:[**2161-12-16**] 9:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4053**], RN Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2161-12-21**] 9:00
|
[
"423.9",
"198.89",
"197.0",
"285.9",
"V10.3",
"198.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
6441, 6447
|
4232, 5689
|
349, 370
|
6547, 6553
|
2320, 4209
|
6733, 7204
|
1868, 1987
|
5836, 6418
|
6468, 6526
|
5715, 5813
|
6577, 6710
|
2002, 2301
|
280, 311
|
398, 1419
|
1441, 1701
|
1717, 1852
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,462
| 194,590
|
10958
|
Discharge summary
|
report
|
Admission Date: [**2162-11-10**] Discharge Date: [**2162-12-2**]
Date of Birth: [**2099-11-27**] Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Rising bilirubin
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 62 year old male with a history of multiple
myeloma s/p multiple treatments, including numerous chemotherapy
regimens, Autologous transplant in [**3-/2156**], mini-MUD allogeneic
transplant in [**9-/2159**], and DLI x4, most recently on [**2162-9-6**],
presenting from clinic after his bili was found to be
increasing.
.
Of note, Mr. [**Known lastname **] was recently admitted for DLI in [**Month (only) 216**], and
during that admission was found to have GVHD of the liver on
biopsy. He was started on MMF and prednisone and was being
managed as an outpatient. However, his numbers continue to rise,
and he now appears to have eye and skin involvement. He was
recently seen by ophthamology and started on drops for GVHD of
the eye. He has, blurry vision in the left eye, grittiness and
photosensitivity, but limited pain. His skin feels like "its
burning down his legs."
.
Otherwise, he feels well. He denies any nausea, vomiting,
diarrhea (one loose stool yesterday), fever, chills, itchiness.
His appettite is improving. He denies any pain. He is otherwise
asymtpomatic.
Past Medical History:
PAST ONCOLOGIC HISTORY:
# [**8-/2155**]: Diagnosed with multiple myeloma after admission for
ARF (creatinine 3.0), anemia, hypercalcemia, Bence-[**Doctor Last Name **]
proteinuria, multiple lytic lesions, and 20-22% BM involvement.
# [**10/2155**]: VAD x4
# [**12/2155**]: Micro fracture of right hip, s/p IM rodding R femur
# [**12/2155**]: Pulse Cytoxan
# [**1-/2156**]: Cytoxan for stem cell mobilization
# [**3-/2156**]: Autologous stem cell transplant
# [**1-/2157**]: Enrolled in dendritic cell fusion vaccine protocol
(04-240) after demonstrating progressive disease
# [**12/2157**]: Thalidomide max dose 200 mg/day, stopped due to
increasing Bence [**Doctor Last Name **] protein
# [**3-/2158**]: Velcade/dexamethasone x2 cycles with disease
progression
# [**5-/2158**]: Cytoxan/dexamethasone
# [**6-/2158**]: XRT to left hip and femur
# [**6-/2158**]: Revlimid/dexamethasone x2 cycles on expanded access
and continued on this through [**6-/2159**] (stopped for pancytopenia)
# [**9-/2159**]: Admitted for allogeneic stem cell transplant
(mini-MUD)
with Campath as conditioning regimen. Donor = A antigen
mismatch.
# [**11/2160**], [**12/2160**]: DLI c/b GVHD --> disease stability. Started
Revlimid at low dose, then found to have plasmacytoma in frontal
bone.
# [**4-/2162**]: MRI C-spine shows extensive myelomatous infiltration
of left lateral mass of C1 with cortical breakthrough; radiation
to c-spine, frontal mass; started on Velcade, steroids.
# [**2162-6-1**]: DLI (3rd infusion), weekly Velcade
# [**2162-8-23**]: Increased Velcade to twice weekly
# [**2162-8-28**]: Admitted for [**Last Name (un) **], resolved with hydration
# [**2162-9-6**]: DLI (4th infusion)
.
PAST MEDICAL HISTORY:
# Coronary Artery Disease
- stenting x2 in [**2157**]
# DVT
- during auto transplant
# GERD
- decreased in severity recently
# Hypertension
- has been less of an issue
- now on Amlodipine alone
# Hypothyroidism
# Osteoporosis
# Compression fracture
# Depression
# C diff infection
.
PAST SURGICAL HISTORY:
# Rod internal fixation of the right hip
- Fracture in [**2155-12-15**].
# Open cholecystectomy
Social History:
SOCIAL HISTORY:
He worked as a general contractor prior to his illness. He is
married and has two children.
Tobacco: Never smoked.
Alcohol: Drank alcohol socially prior to chemo, none since.
Drugs: Denies illicit drug use.
.
Family History:
FAMILY HISTORY:
His mother died of myocardial infarction at age 59.
His maternal uncle died of myocardial infarction at age 65.
His father is alive at 86 with CAD s/p recent CABG and valve
surgery.
.
Physical Exam:
Vitals: T: 97.3 BP: 160/80 P: 54 R: 20 O2: 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera icteric, MMM, oropharynx clear, no mucositis, left
eye erythematous, PERRL, EOMI
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi, few bibasilar crackles
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, palpable liver tip
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis, 2+
pitting edema bilaterally
Skin: erythema along the back of his neck and back, as well as
jaundice
Neuro: CNII-XII in tact, 5/5 strength, normal gait
Pertinent Results:
Admission labs:
[**2162-11-10**] 12:30PM BLOOD WBC-5.0 RBC-3.18* Hgb-11.2* Hct-34.4*
MCV-108* MCH-35.3* MCHC-32.6 RDW-23.6* Plt Ct-113*
[**2162-11-10**] 12:30PM BLOOD Neuts-88* Bands-0 Lymphs-6* Monos-6 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2162-11-10**] 12:30PM BLOOD Plt Smr-LOW Plt Ct-113*
[**2162-11-10**] 07:00PM BLOOD PT-13.7* PTT-26.3 INR(PT)-1.2*
[**2162-11-10**] 12:30PM BLOOD UreaN-26* Creat-0.7 Na-139 K-3.2* Cl-107
HCO3-26 AnGap-9
[**2162-11-10**] 12:30PM BLOOD ALT-411* AST-195* LD(LDH)-287*
AlkPhos-646* TotBili-12.5* DirBili-9.9* IndBili-2.6
[**2162-11-10**] 12:30PM BLOOD Calcium-8.0* Phos-2.3* Mg-1.7
CHEMISTRIES:
[**2162-11-26**] 12:30AM BLOOD Glucose-123* UreaN-39* Creat-0.8 Na-129*
K-3.6 Cl-101 HCO3-20* AnGap-12
[**2162-12-1**] 06:24PM BLOOD Glucose-117* UreaN-72* Creat-1.4* Na-144
K-3.1* Cl-118* HCO3-15* AnGap-14
[**2162-11-9**] 11:20AM BLOOD ALT-385* AST-155* LD(LDH)-253*
AlkPhos-639* TotBili-10.6* DirBili-8.5* IndBili-2.1
[**2162-11-23**] 01:30AM BLOOD ALT-207* AST-74* LD(LDH)-329*
AlkPhos-655* TotBili-29.0*
[**2162-12-1**] 05:41AM BLOOD ALT-146* AST-74* AlkPhos-659*
TotBili-27.3*
[**2162-11-15**] 12:00AM BLOOD PEP-HYPOGAMMAG IgG-321* IgA-10* IgM-38*
[**2162-11-30**] 11:09AM BLOOD PEP-HYPOGAMMAG IgG-476* IgA-15* IgM-29*
[**2162-12-1**] 06:24PM BLOOD b2micro-5.8*
[**2162-11-12**] 09:16AM BLOOD Cyclspr-LESS THAN
[**2162-11-20**] 10:30AM BLOOD Cyclspr-239
[**2162-11-24**] 09:30AM BLOOD Cyclspr-388
[**2162-12-1**] 05:41AM BLOOD Cyclspr-248
[**2162-11-30**] 12:07PM BLOOD Lactate-2.6*
[**2162-12-1**] 02:22PM BLOOD Lactate-4.5*
[**2162-12-1**] 02:22PM BLOOD Type-ART pO2-39* pCO2-23* pH-7.38
calTCO2-14* Base XS--9
CBC:
[**2162-11-9**] 11:20AM BLOOD WBC-4.7 RBC-3.14* Hgb-10.8* Hct-33.0*
MCV-105* MCH-34.4* MCHC-32.7 RDW-23.5* Plt Ct-108*
[**2162-11-26**] 05:06PM BLOOD WBC-3.6* RBC-2.49* Hgb-9.2* Hct-27.6*
MCV-111* MCH-36.9* MCHC-33.4 RDW-26.0* Plt Ct-44*
[**2162-12-1**] 06:24PM BLOOD WBC-0.4* RBC-2.09* Hgb-7.7* Hct-23.2*
MCV-111* MCH-36.7* MCHC-33.0 RDW-24.7* Plt Ct-61*#
IMAGES:
DUPLEX DOP ABD/PEL LIMITED Study Date of [**2162-11-11**] 8:07 AM
The appearance of the liver is unchanged compared to the prior
study. The
hepatic veins, portal veins, and hepatic artery are patent.
Intrahepatic
biliary ducts are not dilated. The CHD measures 1.9 mm in
diameter.
The patient is status post cholecystectomy.
IMPRESSION: No evidence of biliary obstruction.
CHEST (PORTABLE AP) Study Date of [**2162-11-30**] 3:21 PM
IMPRESSION: Worsening pneumonia in the left lung, now involving
the basal
segments of the left lower lobe. Apparent increase in right
lower lung opacity which may reflect pneumonia. Small bilateral
pleural effusions, possibly increased on the left. Diffuse bony
changes compatible with known multiple myeloma.
CT CHEST W/O CONTRAST Study Date of [**2162-11-22**] 10:51 PM
IMPRESSION:
Left upper and lower lobe acute pneumonia.
CT CHEST W/O CONTRAST Study Date of [**2162-11-26**] 9:36 AM
IMPRESSION:
1. Worsening of left lower lobe pneumonia especially superior
segment.
2. Additional infectious sites in left upper lobe/right lung
base unchanged.
3. Small effusions/atelectasis unchanged.
MR HEAD W & W/O CONTRAST Study Date of [**2162-11-26**] 5:43 PM
IMPRESSION:
1. No evidence of acute infarct, mass effect, or hydrocephalus.
2. No enhancing brain lesions.
3. Multiple calvarial lesions consistent with patient's history
of multiple
myeloma.
4. New extensive opacification of bilateral mastoid air cells
and middle
ears. Clinical correlation recommended.
Brief Hospital Course:
ASSESSMENT AND PLAN: 62 year old male with a pmh of Multiple
Myeloma with multiple therapies and auto and allo tx s/p dli x4
most recently in [**Month (only) 216**], now with GVHD of the liver and skin.
.
# GVHD: Mr. [**Known lastname **] was recently admitted in [**Month (only) 216**] for DLI. In
[**Month (only) 359**] he was found to have GVHD of the liver on biopsy. He was
discharged on prednisone and MMF. He was being managed as an
outpatient, but appeared to have eye involvement and skin
involvement. His bilirubin continued to rise and was 12.5 on
admission. We started him on solumedrol 30mg IV BID,
cylosporine 50mg [**Hospital1 **], and continued him on his MMF and
budesonide. A RUQ ultrasound was done and showed no evidence of
thrombosis or obstruction. He required a switch from PO to IV
cyclosporin because he was not registering a detectable level
while on PO. It was thought to be in the setting of absorption
issues with active GVHD. He was started on 100mg IV BID and
reached a peak level of 388 on [**2162-11-24**]. Hepatology was
consulted in the setting of his acutely elevated bilirubin (peak
29.0 on [**11-23**]) without response to IV steroids, MMF, and CSA. His
transaminases began to downtrend [**11-18**], and initially thought the
bilirubin would lag for 4-5 days. However, it continued to
remain elevated in the mid to high 20s. At that point he had a
fever and was diagnosed with a left lower lobe pneumonia. The
continued elevation in bilirubin was thought to be in part
caused by infection. He had been on acyclovir, atovaquone, and
micafungin ppx. In light of his fever, he was started on
cefepime and vancomycin. He was found to have a pneumonia on
chest x-ray (see below). Liver recommended a re-biopsy of the
liver, which was scheduled, and ultimately postponed on the
afternoon of [**11-30**] because he went into a-fib with RVR and was
transferred to the unit.
.
# Multifactorial Metabolic Encephalopathy: Overnight from
[**Date range (1) **], Mr. [**Known lastname **] became acutely confused, and began having
hallucinations, confusion, word finding difficulty with severe
asterixis. Possible etiologies of his encephalopathy were CSA
toxicity (peak level of 388 at the time of his change in MS)
hepatic encephalopathy, polypharmacy, infection, and worsening
primary disease (myeloma). His CSA was decreased and eventually
stopped on [**2162-11-27**] and levels were followed. He was started on
lactulose, and his other possible psychoactive medications were
held. His infection was being treated with cefepime (which
switched to meropenem on [**11-30**]) vancomycin and micafungin, which
was changed to ambisome on [**12-1**]. He had an LP done on [**11-28**]
which had elevated protein, but no white or red cells. Viral
PCRs were sent and were unremarkable. He remained altered on
transfer to the ICU, without a clear etiology.
.
# Pneumonia: On [**11-22**] Mr. [**Known lastname **] [**Last Name (Titles) 28316**] a fever, and a chest x-ray
revealed a new left lower mid lung field pneumonia. A CT scan
was done and showed a superior left lower lobe pneumonia. He was
started on cefepime and vancomycin, and was continued on
treatment with micafungin. ID was consulted as well as
pulmonology. He underwent bronchoscopy to evaluate for fungal
pneumonia. His galactomanan came back negative from his BAL, and
his beta-glucan could not be interpreted because of his
bilirubin level. He had a repeat chest CT scan on [**11-26**] because
of his change in mental status, and it showed an interval
increase in size of his left lower lobe pneumonia. He
maintained oxygen saturations of greater than 95% on RA. His
fever curve decreased and he defervesced (although he remained
on high levels of immunosuppression). On [**11-30**] he went into
a-fib with RVR, and a chest x-ray was checked to evaluate for
fluid overload as possible cause of his RVR. The chest x-ray
showed a worsening of his pneumonia. He was transferred to the
ICU for further management [**11-30**]. His initial bronchoscopy had
abnormal plasma cells reported.
.
# A-Fib with RVR: He does not have any history of atrial
fibrillation, and on [**11-30**] he was noted to be tachycardic to
113, and irregular. An EKG was checked and he was in a-fib with
RVR at 139 BPMs. He was put on telemetry and found to be
consistently between 140-160 BPMs. 5mg IV metoprolol x 3 was
given with no effect. A lactate was checked and found to be 2.6.
He became hypotensive to 95/60 transiently. His BP remained
110-130/60-75. He was transferred to the ICU for further
management shortly thereafter.
.
# Multiple Myeloma: Status post DLI #4. His imuunoglobulin
levels were all low, and his disease was thought to have been
under good control. However, the abnormal plasma cells on BAL
were concerning. Similarly, the elevated protein in his CSF
raised suspicion for CSF involvement, although there were no
cells.
.
# Hypertension: He was initially continued on his home dose of
amlodipine 5mg PO daily which was subsequently increased to
10mg. Ultimately it was held in the setting of his liver
dysfunction.
.
# Pain: Pain from his multiple myeloma was controlled on
Oxycontin 30mg [**Hospital1 **] and oxydcodone for breakthrough pain, which
was his home regimen. He was tapered off of his oxycontin and
was not requiring any pain medication as his pain level was
zero. He was given stool softeners for constipation.
[**Hospital Unit Name 153**] course
Patient presented with atrial fibrillation with RVR not
responsive to IV beta blockade. He was initially given IV
diltiazem followed by initiation of ditiazem drip and digoxin
load. Afib became rate controlled on this regimen with HR <100
consistently. His mental status was significantly compromised,
differential included cyclosporin toxicity and/or worsening
hepatic encephalopathy secondary to GVHD. His cyclosporin was
held during his [**Hospital Unit Name 153**] course. Lactulose was stopped and
rifaximin was started. He was continued on mycophenalate and
steroids. Despite continuation of broad spectrum antibiotics
for his worsening bilateral mulitfocal pneumonia, he developed
worsening hypoxic respiratory failure and was intubated.
Bronchoscopy was completed which showed gram negative rods for
which tobramycin (for double negative coverage) and
ciprofloxacin (atypical coverage) were added to his vancomycin
and meropenum. He was also switched from micafungin to
amphotericin for empiric fungal coverage. His beta 2
microglobulin levels were high, but no plasma cells were seen on
BAL. He became pancytopenic and neutropenic after intubation
and was started on neupogen and received several transfusions of
platelets. Despite this treatment he progressed into septic
shock and required full doses of phenylephrine and levophed.
With worsening pressures, his family voiced that he would not
have wanted to continue with aggressive treatment considering
his grave prognosis. He was terminally extubated the evening of
[**2162-12-2**] and passed away 30 minutes later with cardiopulmonary
collapse. His family was at his bedside at the time of death.
The family was called regarding grief counseling services (phone
for counseling [**Telephone/Fax (1) 35567**]), and his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 35568**] was notified
of his passing.
Medications on Admission:
1. mycophenolate mofetil 500 PO TID
2. acyclovir 400 mg PO Q12H
3. amlodipine 5 mg PO DAILY
4. atovaquone 1500 PO Daily
5. budesonide 3 mg Capsule, Sust. Release PO BID
6. folic acid 1 mg PO DAILY
7. gabapentin 200 mg PO TID
8. levothyroxine 50 mcg PO DAILY
9. lorazepam 0.5 mg 1-2 Tablets PO every four (4)hours as needed
for insomnia.
10. neomycin-polymyxin-HC 3.5-10,000-1 mg-unit/mL-% Drops 4 Drop
Otic [**Hospital1 **]
11. omeprazole 20 mg PO DAILY
12. oxycodone 30 mg Tablet Sustained Release PO Q12H
13. oxycodone 5 mg Tablet PO Q4 hours as needed for pain.
14. prednisone 30 mg Tablet PO DAILY
15. sertraline 50 mg PO DAILY
16. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-16**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
17. White petroleum-mineral oil -lacrilube 1 dab QID
18. dexamethasone 0.5 mg/5 mL Elixir Sig: Five (5) ML PO TID
19. triamcinolone acetonide 0.1 % OintmentAppl TID as needed for
rash
20. docusate sodium 100 mg PO BID as needed for constipation
21. senna 8.6 mg PO BID as needed for daily BMs
Discharge Disposition:
Expired
Discharge Diagnosis:
N/A
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2162-12-3**]
|
[
"518.81",
"244.9",
"V13.51",
"E879.8",
"427.31",
"584.9",
"276.1",
"V87.41",
"401.9",
"284.1",
"414.01",
"368.8",
"379.8",
"038.9",
"293.0",
"785.52",
"348.31",
"733.00",
"996.85",
"V45.82",
"995.92",
"V66.7",
"782.4",
"279.53",
"572.2",
"486",
"709.8",
"286.9",
"203.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"33.24",
"96.04",
"38.91",
"03.31",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
16788, 16797
|
8333, 15686
|
294, 300
|
16844, 16849
|
4788, 4788
|
16901, 17071
|
3845, 4031
|
16818, 16823
|
15712, 16765
|
16873, 16878
|
3472, 3569
|
4046, 4769
|
238, 256
|
328, 1437
|
4804, 8310
|
3166, 3449
|
3601, 3813
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,632
| 128,414
|
34193
|
Discharge summary
|
report
|
Admission Date: [**2105-12-4**] Discharge Date: [**2105-12-14**]
Date of Birth: [**2041-10-9**] Sex: F
Service: MEDICINE
Allergies:
Cefaclor
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
bipap
History of Present Illness:
HPI: Mrs. [**Known lastname 8840**] is a 64 yo F with PMH of stage III lung non
small cell lung cancer, undergoing chemotherapy (last treatment
[**11-19**]), with seven days of worsening dyspnea. She was found by
a neighbor on the morning of admission in respiratory distress
and she was taken to [**Hospital3 2737**] by ambulance. She reports
that she has been taking azithromycin for the past four days
with no improvement and has also been taking prednisone 60mg
daily.
.
She was initially taken to [**Hospital3 **] where she was treated
with vancomycin and moxifloxacin due to concern for post
obstructive pneumonia. She was given Solumedrol 80mg IV q8
hours. She was also found to have an NSTEMI and was started on
a heparin gtt. She was reportedly hypotensive and was started
on a levophed drip as well at 2mcg/kg. She had an
echocardiogram which showed EF of 35%.
.
In the ED HR 120 BP 122/83 RR 20 99% BIPAP. She was given
Solumedrol 125mg IV x1 for COPD exacerbation. In addition she
was given levofloxacin 750mg IV and aztreonam 1gm IV x1.
Past Medical History:
nonsmall cell lung cancer diagnosed, [**2099**]. Status post lung
resection (followed by Dr. [**Last Name (STitle) **]
Stage IA Hodgkin's disease in [**2091**]. Status post radiation.
Mild hypothyroidism.
Mild elevated cholesterol.
COPD - emphysema (followed by Dr. [**Last Name (STitle) **]
history of MRSA and pseudomonas pneumonia.
Her last episode was in [**2105-2-27**].
-s/p metal stent placed in her bronchus intermedius due to
extrinsic compression of her tumor
Social History:
lives alone, has a sister who is very involved, h/o tobacco
abuse, no current alcohol or smoking.
Family History:
Her mother was diagnosed with [**Name (NI) 2481**]
disease. There is a history of cerebrovascular accident in her
father. There is no history of cancer in the family.
Physical Exam:
On admission:
VS: T97.2 HR 124 BP 122/94 RR 16 95% on 70% Bipap 15/5
Gen: Awake and alert, answering all questions appropriately,
able to speak in [**3-1**] word sentences
HEENT: NC AT BIPAP mask in place
CV: unable to auscultate over lung sounds
Lungs: diffuse wheezing, rhonchi over right lung
Abd: obeses, multiple old surgical scars, no tenderness, BS+
Ext: no significant edema
Pertinent Results:
[**2105-12-4**] 07:20PM BLOOD WBC-42.2* RBC-3.79* Hgb-11.6* Hct-35.7*
MCV-94 MCH-30.7 MCHC-32.6 RDW-20.9* Plt Ct-355
[**2105-12-4**] 07:20PM BLOOD Neuts-54 Bands-15* Lymphs-13* Monos-11
Eos-0 Baso-0 Atyps-1* Metas-2* Myelos-4* NRBC-4*
[**2105-12-4**] 07:20PM BLOOD PT-15.0* PTT->150* INR(PT)-1.3*
[**2105-12-4**] 07:20PM BLOOD Glucose-107* UreaN-21* Creat-1.7* Na-144
K-4.5 Cl-106 HCO3-23 AnGap-20
[**2105-12-4**] 07:20PM BLOOD CK(CPK)-612*
[**2105-12-4**] 07:20PM BLOOD cTropnT-0.21*
[**2105-12-5**] 02:50AM BLOOD CK-MB-16* MB Indx-2.7 cTropnT-0.21*
[**2105-12-6**] 05:00AM BLOOD CK-MB-5 cTropnT-0.07*
[**2105-12-4**] 08:53PM BLOOD Type-ART FiO2-50 pO2-65* pCO2-46* pH-7.35
calTCO2-26 Base XS-0 Intubat-NOT INTUBA Comment-MASK VENTI
.
Cultures:
Blood cultures [**2105-12-4**]: negative
Urine cultures [**2105-12-6**], [**2105-12-9**]: yeast > 100,000 colonies
Urine legionella [**2105-12-5**]: negative
.
Chest X-ray [**2105-12-4**]: Large right hilar mass consistent with the
known neoplasm, along with post-obstructive pneumonic
consolidation in the right lower lobe. Small bibasal effusions
are present
.
Chest CT [**2105-12-5**]: 1. Worsening disease in the right lung with
enlarging tumor causing new marked narrowing and obstruction of
multiple right bronchi, as well as multiple enlarging
mediastinal lymph nodes.
2. New ground glass and more consolidative opacities in the
right upper lobe, right lower lobe, and to a lesser degree left
lower lobe that suggest postobstructive multifocal pneumonia.
Brief Hospital Course:
Ms. [**Known lastname 8840**] was admitted with shortness of breath. She had a
chest x-ray which showed a large right hilar mass and a
post-obstructive pneumonia. She was treated with vancomycin,
Zosyn and levofloxacin. She was given standing nebs and given
steroids to treat her COPD. She was weaned off the Levophed on
arrival to the MICU and did not require additional pressors for
hypotension throughout her course. She alternated between bipap
and a non-rebreather face mask for oxygenation. She did not
wish to be intubated. Her primary oncologist was contact[**Name (NI) **] and
recommended a repeat chest CT, radiation oncology consult and IP
consult for possible symptom relief. Radiation oncology was
consulted and stated that additional radiation would not be
likely to improve her symptoms and could make her temporarily
worse. She had also received prior mediastinal radiation for
her Hodgkin's disease in the past. Interventional pulmonology
was consulted and did not feel that her disease was amenable to
additional procedures for palliation. Her pulmonologist was
contact[**Name (NI) **] for additional assistance.
.
On admission, she had elevated cardiac enzymes which peaked at
0.21. This was believed to be demand ischemia in the setting of
severe hypoxia and early sepsis. She was given aspirin and
Lipitor for this. She did not complain of chest pain during
this admission. She had acute renal failure on admission with a
creatinine of 1.7 which improved to her baseline of 0.8 with IV
fluids and was felt to be related to dehydration.
.
Ms. [**Known lastname 8840**] continued to receive antibiotics, steroids and nebs
to treat her symptoms. She had a chest CT to further evaluate
her disease. She was supported with oxygen for comfort via a
bipap and non-rebreather. Palliative care was consulted and saw
this patient for several days. She was clear that she did not
wish to be intubated and wanted to be kept comfortable with
medications. She wished to continue antibiotics, steroids and
nebs. She was put on morphine PRN and then a Morphine drip as
she requested it more often. She died peacefully on [**2105-12-4**].
Medications on Admission:
-Vitamin D
-Advair 500/50 1 puff [**Hospital1 **]
-folic acid 1mg daily
-furosemide 80mg daily
-xopenex 3ml Neb Q4 hours
-famotidine 1-2 tabs prn
-levoxyl 25mcg daily
-ondansetron 8mg q6 hours prn
-KCL 10mEq daily
-prednisone 60mg daily
-zoloft 100mg [**Hospital1 **]
-spiriva daily
-effexor XR 150mg SR daily
-zyrtec 10mg daily prn
benadryl 25mg q12 hours prn pruritis
-oxycodone 5mg q6h prn pain
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnosis:
1. Non-Small Cell Lung Cancer
Secondary Diagnoses:
2. COPD
3. NSTEMI
4. Acute Renal Failure
Discharge Condition:
pt expired
Discharge Instructions:
pt expired
Followup Instructions:
pt expired
|
[
"428.21",
"162.8",
"410.71",
"V15.3",
"276.51",
"491.21",
"311",
"V66.7",
"V58.65",
"599.0",
"117.9",
"272.0",
"244.9",
"428.0",
"486",
"V10.72",
"V87.41",
"518.81",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
6764, 6773
|
4121, 6287
|
278, 285
|
6928, 6940
|
2588, 4098
|
6999, 7012
|
1999, 2169
|
6735, 6741
|
6794, 6794
|
6313, 6712
|
6964, 6976
|
2184, 2184
|
6865, 6907
|
231, 240
|
313, 1374
|
6813, 6844
|
2198, 2569
|
1396, 1867
|
1883, 1983
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,820
| 163,945
|
28972
|
Discharge summary
|
report
|
Admission Date: [**2167-10-29**] Discharge Date: [**2167-10-31**]
Date of Birth: [**2119-1-15**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Upper endoscopy
Colonoscopy
History of Present Illness:
Mr. [**Known lastname 13469**] is a 48 yo male with h/o ETOH cirrhosis with varices,
DM, HTN who initially presented on [**10-29**] with BRBPR, melena, and
coffee ground emesis x 5days. Of note he was last banded in
[**8-30**] but failed to return for follow-up. Two days PTA the
patient noted loose BMs mixed with blood with increasing
frequency. Of note, he had been drinking alcohol during this
time. In the ED, he was tachycardic with HRs to 140s and
orthostatic. No report of chest pain, nausea, or SOB. His Hct
had dropped to 16.7 from 29.9 on [**2167-9-8**]. He received 4 L of NS
w/ SBPs stable in 110s-130s and HRs in 100s. He also received 1
unit PRBCs in the ED. He was also started on an Octreotide gtt,
Protonix IV, and Ceftriaxone IV which was done. The patient was
transferred to the MICU for closer monitoring.
Past Medical History:
1)Diabetes mellitus
2)EtOH Cirrhosis
3)Esophageal varices: 4 cords of grade II varices, s/p banding
[**8-30**]
4)portal hypertensive gastropathy.
5)Diverticulosis
6)h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] tear ([**11-30**])
7)Hypertension
8)Anemia- baseline Hct = 34
9)Tobacco use
10)Depression
Social History:
Drinks daily, roughly 5 8 oz glasses of gin and 40 oz of beer.
1ppd, 35 pack year hx. Lives with wife. [**Name (NI) **] works at night as a
BU custodian. Remote history of cocaine use 15 years prior, but
has not used since then and has never used IV drugs.
Family History:
Mother died at age 59 from end-stage renal disease. She also had
a history of diabetes. Father alive at age 64. The patient
states he has some issue with his prostate, but is unclear what
this is. The patient's son died of end-stage renal disease at
the age of 23. The son also had a history of juvenile diabetes.
The patient has two other children, a son aged 21 and daughter
aged 15, both of whom are healthy and a brother with diabetes
mellitus.
Physical Exam:
vitals T 99.4 BP 117/74 AR 60-80 RR 12-15 O2 sat 99% RA
Gen: Pleasant male, lying in bed
HEENT: Mild scleral icterus, MMM
Heart: RRR, no m,r,g
Lungs: CTAB
Abdomen: soft, NT/ND, no evidence of ascites, +hepatomegaly
Extremities: No edema, 2+ DP/PT pulses bilaterally
Neuro: No asterixis
Pertinent Results:
Laboratory results:
[**2167-10-28**] 11:10PM BLOOD WBC-14.0*# RBC-2.07*# Hgb-6.7*#
Hct-19.8*# MCV-96 MCH-32.2* MCHC-33.6 RDW-18.1* Plt Ct-216#
[**2167-10-31**] 09:30AM BLOOD WBC-8.0 RBC-3.50* Hgb-11.0* Hct-31.6*
MCV-90 MCH-31.3 MCHC-34.7 RDW-17.5* Plt Ct-110*
[**2167-10-28**] 11:10PM BLOOD PT-19.5* PTT-31.0 INR(PT)-1.8*
[**2167-10-31**] 09:30AM BLOOD PT-17.1* PTT-33.3 INR(PT)-1.5*
[**2167-10-31**] 09:30AM BLOOD Plt Ct-110*
[**2167-10-31**] 09:30AM BLOOD Glucose-161* UreaN-9 Creat-0.9 Na-130*
K-3.5 Cl-96 HCO3-28 AnGap-10
[**2167-10-28**] 11:10PM BLOOD ALT-45* AST-199* AlkPhos-100 TotBili-2.5*
[**2167-10-28**] 11:10PM BLOOD Calcium-7.7* Phos-3.8 Mg-1.5*
Relevant Imaging:
1)Endoscopy ([**10-29**]): Grade B esophagitis in the lower third of
the esophagus compatible with reflux esophagitis. Varices at the
lower third of the esophagus. Granularity and mosaic appearance
in the whole stomach compatible with portal hypertensive
gastropathy
2)Colonoscopy ([**10-29**]): Large rectal varices were found. The
procedure was otherwise normal to cecum.
Brief Hospital Course:
Mr. [**Known lastname 13469**] is a 48M with history of ETOH abuse, anemia,
cirrhosis, DMII, GIB, diverticulosis, grade 2 esophageal
varices, prior [**First Name4 (NamePattern1) 329**] [**Last Name (NamePattern1) **] tear who presents with BRBPR,
melena, and coffee ground emesis.
1)GI Bleed: Patient initially presented with BRBPR with Hct drop
to 16 from baseline~30. Underwent and EGD which showed portal
gastropathy & erosive gastritis; also underwent colonoscopy
which showed nonbleeding rectal varice. Did not require any
banding. Received total of 4u pRBCs during hosptial stay. Hct at
baseline at time of discharge. He was maintained on PPI [**Hospital1 **].
2)Acute renal failure: Patient presented with Cr~1.7 on
admission. Elevated from baseline of 0.9 likely prerenal in
setting of blood loss and hypovolemia. Cr returned to baseline
quickly after receiving blood and IVFs since her admission.
3)Type 2 DM: Patient on an oral hypoglycemic as outpatient but
was held during his hospital stay. Blood sugars were monitored
closely and he was placed on an insulin sliding scale. He was
restarted on oral regimen at time of discharge.
4)ETOH cirrhosis: Patient has known cirrhosis secondary to ETOH
use. LFT profile at baseline. Also has coagulopathy which is
likely due to underlying liver disease; did not receive any FFP
during hospital stay. Received Ceftriaxone in ED for empiric SBP
treatment but was changed to Cipro at time of discharge for 2
week course. Also underwent an abdominal ultrasound to evaluate
patency of vessels which showed adequate flow through portal
vessels.
5)Alcohol abuse: Patient was reported to be consuming alcohol
prior to admission. He was ordered for CIWA scale but has not
received any doses.
Medications on Admission:
Glipizide 5 mg daily
Protonix 40 mg daily
Sulcrafate 1 gram QID
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
5. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 12 days.
Disp:*24 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Lower gastrointestinal bleed
Acute renal failure
Secondary diagnoses:
Alcoholic cirrhosis
Type 2 Diabetes
Discharge Condition:
Stable
Discharge Instructions:
1)You were admitted to the hospital because of a lower
gastrointestinal bleed. You underwent both an endoscopy and
colonoscopy which showed some inflammation in your esophagus and
a varice in your rectum. Your blood count is now stable at
discharge.
2)Please take all medications as listed in the discharge
instructions.
3)You are being discharged on an antibiotic called Cipro which
your must take for 2 weeks until [**2167-11-12**]. Your diabetic
medications have also been restarted.
4)Please schedule a follow-up appointment with your primary care
physician and liver doctor within 1-2 weeks after being
discharged from the hospital.
5)If you experience any fevers, chills, chest pain, shortness of
breath, abdominal pain, bleeding from your gastrointestinal
tract, please return to the emergency department.
Followup Instructions:
Please schedule a follow-up appointment with your primary care
physician and liver doctor within the next 1-2 weeks after
leaving the hospital.
|
[
"303.90",
"275.41",
"276.52",
"535.40",
"571.2",
"455.6",
"456.21",
"584.9",
"572.3",
"276.2",
"530.11",
"285.1",
"250.00",
"578.1",
"286.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"99.04",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
6066, 6072
|
3679, 5421
|
279, 309
|
6242, 6251
|
2601, 3262
|
7116, 7263
|
1830, 2280
|
5536, 6043
|
6093, 6162
|
5447, 5513
|
6275, 7093
|
2295, 2582
|
6183, 6221
|
234, 241
|
3280, 3656
|
337, 1165
|
1187, 1540
|
1556, 1814
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,187
| 180,680
|
47678
|
Discharge summary
|
report
|
Admission Date: [**2148-9-23**] Discharge Date: [**2148-9-29**]
Date of Birth: [**2084-9-11**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Percocet / Percodan
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
Posterior decompression and fusion L1-L4
History of Present Illness:
Ms. [**Known lastname 100712**] has a long history of back pain. She has
attempted conservative therapy but has failed. She now presents
for surgical intervention.
Past Medical History:
Anxiety, Arthritis: Lumbar, right knee, Depression, Diabetes,
High cholesterol, Vit D deficiency, Sciatica
Social History:
Denies
Family History:
N/C
Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles
Pertinent Results:
[**2148-9-27**] 06:40AM BLOOD WBC-8.9 RBC-3.21* Hgb-8.9* Hct-27.1*
MCV-84 MCH-27.6 MCHC-32.7 RDW-14.7 Plt Ct-242
[**2148-9-26**] 05:20AM BLOOD WBC-12.3* RBC-3.26* Hgb-9.2* Hct-27.4*
MCV-84 MCH-28.4 MCHC-33.8 RDW-14.9 Plt Ct-204
[**2148-9-25**] 01:58AM BLOOD WBC-13.2* RBC-3.76* Hgb-10.4* Hct-31.4*
MCV-84 MCH-27.7 MCHC-33.2 RDW-15.4 Plt Ct-237
[**2148-9-24**] 02:12AM BLOOD WBC-10.4 RBC-3.63* Hgb-10.1* Hct-29.6*
MCV-82 MCH-27.9 MCHC-34.1 RDW-15.3 Plt Ct-255
[**2148-9-27**] 06:40AM BLOOD Plt Ct-242
[**2148-9-25**] 01:58AM BLOOD Plt Ct-237
[**2148-9-27**] 06:40AM BLOOD Glucose-174* UreaN-11 Creat-0.9 Na-137
K-4.1 Cl-97 HCO3-33* AnGap-11
[**2148-9-25**] 01:58AM BLOOD Glucose-128* UreaN-10 Creat-1.0 Na-139
K-3.6 Cl-102 HCO3-26 AnGap-15
[**2148-9-24**] 02:12AM BLOOD Glucose-119* UreaN-13 Creat-0.9 Na-141
K-3.9 Cl-106 HCO3-26 AnGap-13
[**2148-9-27**] 06:40AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.1
Brief Hospital Course:
Ms. [**Known lastname 100712**] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2148-9-23**] and taken to the Operating Room for total laminectomy of
L1, L2, L3, revision laminectomy of L4, fusion L1-L4 and
instrumentation L1-L4. Please refer to the dictated operative
note for further details. The surgery was without complication
and the patient was transferred to the PACU in a stable
condition. TEDs/pnemoboots were used for postoperative DVT
prophylaxis. Intravenous antibiotics were given per standard
protocol. Initial postop pain was controlled with a PCA. A
bupivicaine epidural pain catheter placed at the time of the
posterior surgery remained in place until postop day one. She
was kept NPO until bowel function returned then diet was
advanced as tolerated. The patient was transitioned to oral pain
medication when tolerating PO diet. Foley was removed on POD#2
from the second procedure. She was fitted with a lumbar
warm-n-form brace for comfort. Physical therapy was consulted
for mobilization OOB to ambulate. Hospital course was otherwise
unremarkable. On the day of discharge the patient was afebrile
with stable vital signs, comfortable on oral pain control and
tolerating a regular diet.
Medications on Admission:
BUPROPION HCL, BUSPAR, CLONAZEPAM, DICLOFENAC SODIUM - 75 mg
ERGOCALCIFEROL (VITAMIN D2), FLUTICASONE - 50 mcg Spray,
Suspension - 2 sprays to each nostril daily, GABAPENTIN
[NEURONTIN], METFORMIN - 500 mg Tablet - 1 Tablet(s) by mouth
twice a day, SERTRALINE 50 mg Tablet, SIMVASTATIN - 80 mg Tablet
CALCIUM, MULTIVITAMIN, OMEGA-3 FATTY ACIDS [FISH OIL]
Discharge Medications:
1. Buspirone 5 mg Tablet Sig: Three (3) Tablet PO TID (3 times a
day).
Disp:*270 Tablet(s)* Refills:*2*
2. Clonazepam 0.5 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
Disp:*270 Tablet(s)* Refills:*2*
3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
4. Sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
5. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
Disp:*120 Capsule(s)* Refills:*2*
7. Bupropion HCl 100 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
Disp:*100 Tablet(s)* Refills:*0*
11. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
12. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Lumbar stenosis/spondylosis
Discharge Condition:
Stable- awake and alert- ambulating idependently with walker
Discharge Instructions:
Ambulate as tolerated/ keep dressings clean and dry
Physical Therapy:
Ambulate as tolerated- walker for support as needed
Treatments Frequency:
Keep dressings clean and dry
Followup Instructions:
10 days in office
Completed by:[**2148-10-14**]
|
[
"780.57",
"272.0",
"300.4",
"V45.4",
"721.3",
"285.1",
"250.00",
"V43.64",
"268.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.79",
"81.07",
"78.69",
"81.63",
"81.37",
"84.52"
] |
icd9pcs
|
[
[
[]
]
] |
5191, 5247
|
2162, 3392
|
294, 337
|
5319, 5382
|
1242, 2139
|
5603, 5653
|
702, 707
|
3798, 5168
|
5268, 5298
|
3418, 3775
|
5406, 5458
|
722, 1223
|
5476, 5528
|
5550, 5580
|
245, 256
|
365, 532
|
554, 662
|
678, 686
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,450
| 153,185
|
12984
|
Discharge summary
|
report
|
Admission Date: [**2170-12-19**] Discharge Date: [**2170-12-27**]
Date of Birth: [**2113-1-29**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Ceftriaxone
Attending:[**First Name3 (LF) 1828**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Pt is a 57 y.o female with no prior PMH who presentns with
R.upper CP,cough, weakness, and poor po intake. She presented to
[**Location (un) 620**] where she was found to have hypotension (baseline in
90's, have ARF (cr 3.8) and CT/CXR finding of RUL consolidation,
with multiple opacities in both lobes and extensive adenopathy.
Pt was given azithromycin and CTX and transferred to [**Hospital1 18**] ED.
.
Time Pain Temp HR BP RR Pox
+ 19:33 5 97.4 97 88/49 20 98
recent vitals: 93 97/50 22 98% 2L
AT [**Hospital1 18**] [**Name (NI) **], pt was given levaquin and thought to have been
given ~5L IVF. Pt with 2 PIVs (18 and 20). Spiked to 101 in ED.
Per pt, she reports fever to 101, chills, all over headache, ST
starting fri night. She then developed fatigue and weakness, dry
cough, rhinorrhea and nauseas 2 days ago. She denies
photophobia, blurred vision, new neck stiffness, paresthesias,
weakness. However, she does report constant, sharp R.upper chest
pain that is worse with movement, but not associated with
sob/LH/diaphoresis/radiation/palp. Headache and CP are relieved
by NSAIDs. She denies abd
pain/n/v/d/c/melena/brbpr/dysuria/joint pain/skin rash. She
reports she has been lying in bed since saturday and is thirsty.
She reports travel to [**Location (un) 20309**], Az end [**Month (only) **]-beg [**Month (only) **] and that she
received the H1N1 ~1.5 wks ago. She reports recent increases in
NSAID use.
Past Medical History:
GERD
Social History:
Lives at home with 2 sons and daughter. +smoking history, quit 1
month ago, smoked since 15yrs, denies ETOH, drug use, husband
died 1.5 [**Name2 (NI) 1686**] ago.
.
Family History:
father died from MI/cancer, mother hemorrhagic brain lesion.
Physical Exam:
VITAL SIGNS:
T.97.1, BP 101/37, HR 98, sat 95% on 2L
.
PHYSICAL EXAM
GENERAL: Pleasant, able to speak in full sentences, NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. dry MM. OP clear. Neck Supple, No
LAD, No thyromegagly, supple.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP=not elevated.
LUNGS: b/l ae, decreased BS, RUL and RML, no w/c/
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**11-24**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2170-12-19**] 09:34PM LACTATE-1.4
[**2170-12-19**] 08:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2170-12-19**] 08:30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2170-12-19**] 08:30PM URINE RBC-0-2 WBC-[**5-2**]* BACTERIA-FEW
YEAST-NONE EPI-0-2 TRANS EPI-0-2
.
cxr-Portable AP chest radiograph was reviewed with no prior
studies
available for comparison. There is right upper lobe atelectasis
with questionable right hilar mass that potentially may
represent Golden S sign suggesting central obstruction due to
mass. The right lower lobe and the left lung are unremarkable.
Minimal bibasilar atelectasis is present. Note is madethat the
costophrenic sulci were not included in the field of view
bilaterally. Thus a significant amount of pleural effusion
cannot be excluded. Cardiomediastinal silhouette otherwise is
unremarkable. A further evaluation with chest CT with contrast
is recommended. Findings were
discussed with Dr. [**Last Name (STitle) 3271**] over the phone by Dr. [**Last Name (STitle) **] at
the
time of dictation with the recommendation to proceed with chest
CT
.
CT chest-IMPRESSION:EXTENSIVE RIGHT UPPER LOBE CONSOLIDATION AS
WELL AS AREAS OF MULTIFOCAL OPACITIES IN THE SUPERIOR SEGMENT OF
THE RIGHT LOWER LOBE AND TO A LESSER EXTENT IN LEFT UPPER AND
LEFT LOWER LOBE. THE FINDINGS ARE CONCERNING FOR WIDESPREAD
INFECTION. GIVEN THE PRESENCe OF SOME DEGREE OF ATELECTASIS EVEN
IN THE ABSENCE OF DEMONSTRATION OF OBSTRUCTIVE AIRWAYS CENTRAL
OBSTRUCTING MASS WITH PARTIAL ATELECTASIS CAN NOT BE EXCLUDED.
EXTENSIVE LYMPHADENOPATHY IS PRESENT WHICH POTENTIALLY [**Month (only) **] BE
REACTIVE TO THE INFECTIOUS PROCESS. FOLLOW-UP OF THE PATIENT IN
2 TO 3 WEEKS WITH CHEST RADIOGRAPH WITH RECOMMENDATION OF
IMPROVEMENT OF THE ABOVE DESCRIBED FINDINGS IS RECOMMENDED. IF
PATIENT CLINICALLY IS IMPROVING AND THE CHEST RADIOGRAPHS SHOWS
IMPROVEMENT THEN EVALUATION WITH CHEST CT IN 3
MONTHS IS RECOMMENDED. OTHERWISE FURTHER EVALUATION WITH
BRONCHOSCOPY
WOULD BE CONSIDERED.
Brief Hospital Course:
Ms. [**Known lastname **] is a 57 year old woman with a history of GERD who
presented to [**Location (un) 620**]-ED with antecedent URI symptoms, taking
ibuprofen, found to be febrile, hypotensive, with multifocal
pneumonia and acute renal failure. She was transferred to the
[**Hospital1 18**] [**Hospital Ward Name 332**] ICU and was treated with aggressive volume
resuscitation (9-10 L) but averted intubation and pressor
support. She was treated with Unasyn, Vanco and Levofloxacin
empirically. She ruled out for influenza by DFA and her rapid
viral screen/culture was also negative. Legionella antigen was
negative. Her renal function rapidly improved. She developed
atrial fibrillation with rapid ventricular response (CHADS score
= 0). A TTE showed normal function. She was treated with
diltiazem for rate control and converted to normal sinus rhythm.
She was transferred out of the ICU on [**12-20**] where she has
continued to have fevers and feel generally unwell. Unasyn was
discontinued. Consideration of discontinuing Vancomycin was
made, but due to concerns re: her fever, it was stopped
transiently but resumed shortly therafter. A CT of the chest
was ordered and showed no obvious changes from prior. It did
show an incidentally noted enlarged right lobe of her thyroid
for which outpatient ultrasound is recommended. She has not
been able to produce sputum, despite attempts with inducing it.
ID recommended Vanc/Levo and Ceftriaxone on [**12-24**]. She received 1
dose of ceftriaxone and developed a rash and lip swelling. This
was discontinued. She was been continued on the levoflox and
vancomycin. On [**12-26**], given persistently negative cultures and
inability to produce sputum, Vanco was d/c'd in consultation
with Infectious disease. She had mildly abnormal LFTs and a RUQ
ultrasound was obtained. Preliminarily it showed no
abnormalities. Towards the end of her hospitalization she was
noted to run low bps in the range of 80/50 at the lowest,
asymptomatic, but dltiazem was persistently being held and so
the decision was made to discharge her not on the diltiazem.
Medications on Admission:
protonix-1 Tablet, Delayed Release (E.C.)(s) Twice Daily
(ordered [**Hospital1 **], but insurance only covers QD)
Clonazepam 0.5 mg Tab Oral
1 Tablet(s) Once Daily, at bedtime, as needed
Discharge Medications:
1. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
2. protonix-1 Tablet, Delayed Release (E.C.)(s) Twice Daily
(ordered [**Hospital1 **], but insurance only covers QD)
3. Clonazepam 0.5 mg Tab Oral
1 Tablet(s) Once Daily, at bedtime, as needed
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia, bacterial
Afib with RVR
GERD
Enlarged Thyroid (right lobe)
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted with a severe pneumonia. You were given
antibiotics and will need to complete a course of levofloxacin x
6 more days (until [**1-2**])
.
Please do NOT take ibuprofen or other NSAIDs due to your recent
kidney failure.
Followup Instructions:
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: Internal Medicine-Primary Care
Date/ Time: [**2170-12-31**] 11:00am
Location: [**Street Address(2) 39796**], [**Location (un) 13588**] MA
Phone number: [**Telephone/Fax (1) 31529**]
- You should have a follow-up ultrasound of your thyroid as an
outpatient. This can be arranged by Dr. [**Last Name (STitle) **]
[**Name (STitle) 39797**] atrial fibrillation episod with Dr. [**Last Name (STitle) 39798**]
|
[
"038.9",
"584.9",
"530.81",
"240.9",
"V15.82",
"799.02",
"791.9",
"276.8",
"995.92",
"427.31",
"482.9",
"785.52",
"E930.5",
"693.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7790, 7796
|
5101, 7223
|
316, 323
|
7910, 7910
|
2983, 5078
|
8315, 8808
|
2031, 2094
|
7460, 7767
|
7817, 7889
|
7249, 7437
|
8055, 8292
|
2109, 2964
|
269, 278
|
379, 1804
|
7924, 8031
|
1826, 1832
|
1848, 2015
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,597
| 176,783
|
19507
|
Discharge summary
|
report
|
Admission Date: [**2178-2-11**] Discharge Date: [**2178-4-9**]
Date of Birth: [**2103-2-27**] Sex: F
Service: CSU
[**First Name8 (NamePattern2) **] [**Known lastname **] is a 74-year-old woman with known aortic stenosis
followed by serial echocardiograms referred to [**Hospital1 346**] for an outpatient catheterization on
[**2178-1-14**]. The echo at that time showed no coronary disease
with an aortic valve area of 0.5 cm with a mean gradient of
45, an EF of 59 percent, an LVEDP of 10, aortic valve heavily
calcified. She had no coronary disease. Right common iliac
stenosis of 70 percent and subtotal left common iliac
stenosis.
HISTORY OF PRESENT ILLNESS: Patient with known aortic
stenosis followed with serial echocardiograms.
Echocardiogram from one year prior to catheterization showed
an aortic valve area of 0.75 cm2. Repeat echo done in
[**12/2177**] showed left ventricular hypertrophy with significant
aortic calcification and aortic valve area of 0.4 to 0.5 cm2
with a peak gradient of 70 mm/Hg. Patient states dyspnea
with exertion, such as climbing a flight of stairs. No
complaints of angina.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Aortic stenosis.
4. Hiatal hernia.
5. PVD with aortoiliac disease.
6. Arthritis.
7. Degenerative disc disease.
8. Stress incontinence.
PAST SURGICAL HISTORY:
1. Right hip replacement in [**2165**].
2. Right carpal tunnel release over 15 years ago.
3. Cesarean sections in the past.
ALLERGIES: Patient has no known drug allergies.
MEDICATIONS: Her medications prior to catheterization
include:
1. Lipitor 10 mg q.d.
2. Ditropan 5 mg b.i.d.
3. Omeprazole 20 mg q.d.
4. Avapro 300 mg q.d.
5. Hydrochlorothiazide 25 mg q.d.
6. Vitamin B supplements.
7. Multivitamin.
8. Calcium carbonate.
9. Glucosamine.
SOCIAL HISTORY: Lives with daughter and son-in-law in
[**Name (NI) 3320**], [**State 350**]. Planning to move to [**Doctor First Name 26692**]
following aortic valve surgery. Denies alcohol use. Denies
tobacco use. Denies any other recreational drug use.
FAMILY HISTORY: Father died of an MI in his 80s and
patient's mother died in her 90s.
REVIEW OF SYMPTOMS: No diabetes, no thyroid disease, no CVA,
no TIA, no seizures, no peptic ulcer disease, no
hematochezia, no melena, no COPD, no asthma, no fevers,
chills, sweats, or constitutional systems. Posterior PVD,
pain in thighs with walking; relieved with rest.
LABORATORY DATA: White count 6.8, hematocrit 35.9, platelets
242, PT 12.9, INR 1.1. Sodium 139, potassium 4.2, chloride
105, CO2 24, BUN 28, creatinine 0.6, glucose 105. ALT 13,
AST 17, alkaline phosphatase 62, amylase 56, direct bilirubin
0.1, albumin 4.0.
Chest x-ray showed mild enlargement of the cardiac silhouette
with no evidence of CHF.
EKG: A left bundle branch block at a rate of 80 with Q wave
in Lead III as well as V2 through 3, an ST depression in Lead
I, aVL, and V6.
UA was pending, and dental clearance was provided by the
patient prior to surgery.
PHYSICAL EXAMINATION: Height 5 feet, 0 inches, weight 146
pounds. Vital signs: Heart rate 85, blood pressure 137/68,
respiratory rate 14, O2 saturation 100 percent on room air.
General: Lying comfortably in bed. HEENT: Pupils equally
round and reactive to light with extraocular movements
intact; anicteric, noninjected. Mucous membranes moist.
Normal mucosa. No erythema or exudates. Neck is supple; no
lymphadenopathy or thyromegaly; no JVD, with a radiating
murmur. Respiratory: Clear to auscultation bilaterally.
Cardiac: Regular rate and rhythm; S1, S2 with a III/VI
blowing murmur. Abdomen is soft, nontender, nondistended
with normoactive bowel sounds. Extremities are warm with no
clubbing, cyanosis, or edema; no varicosities. Pulses:
Carotid 2 plus with murmur bilaterally, radial 2 plus
bilaterally, femoral 1 plus with a dressing on the right, and
dorsalis pedis by Doppler bilaterally. Neurologically:
Alert and oriented times three and nonfocal exam.
Patient was a direct admission to the Operating Room on
[**2178-2-11**] where she underwent aortic valve replacement.
Please see the OR report for full details.
In summary, the patient had a difficult operative course.
She had an aortic valve replacement with a #19 mosaic valve.
Her bypass time was 93 minutes with a cross clamp time of 66
minutes. The patient showed evidence of right heart failure
following a wean from the bypass pump. Her chest was left
open with a rubber [**Doctor Last Name **] and she was transferred from the
Operating Room to the Cardiothoracic Intensive Care Unit. At
the time of transfer the patient's mean arterial pressure was
96. Her CVP was 17 with a PAD of 19. She was in a sinus
tachycardia at 130 beats per minute with Levophed at 0.4
mcg/kg per minute, milrinone at 0.75 mcg/kg per minute,
Amiodarone at 1 mg per minute, Neo-Synephrine at an
undisclosed dose, epinephrine at 0.5 mcg/kg per minute,
Vasopressin at 2.4 units per minute, and Lidocaine at 2 mcg
per minute as well as propofol at 30 mg per hour.
Upon arrival in the Intensive Care Unit the patient was
placed on a _______ infusion as well as Ativan and Fentanyl
infusions.
On postoperative day one the patient remained hemodynamically
unstable, and she returned to the Operating Room, at which
time a right ventricular assist device was placed. Please
see the OR report for full details.
In summary, the patient had an RVAD placed, and following the
procedure she was again returned to the Cardiothoracic
Intensive Care Unit, again, with an open chest. Over the
next several days the patient remained in critical condition
in the Cardiothoracic Intensive Care Unit. She remained
paralyzed and sedated with full ventilatory support. She was
slowly weaned from her vasoactive medications. She had flow
rates of 4 to 4.5 liters per minute with her right
ventricular assist device. She was seen by the Renal Service
to assist in fluid removal. Additionally, the patient was
seen by the Heart Failure Service for assist in patient care
management.
On postoperative day seven the patient returned to the
Operating Room, at which time she had her chest closed. On
postoperative day eight the patient was brought to the
Cardiac Catheterization Lab for a diagnostic catheterization
which showed a tight right coronary artery lesion which was
stented at that time. Please see the cath report for full
details. Following the stenting to the RCA the patient
returned to the Cardiothoracic Intensive Care Unit. She
remained hemodynamically stable with her RVAD in place and
the paralytics were slowly weaned to off so that by
postoperative day nine all paralytics had been weaned off.
By that point the patient had also been weaned from her
epinephrine, significantly weaned from her Pitressin. The
milrinone had been weaned down. The Lidocaine had been
discontinued, and the Levophed was also weaned to off.
Patient did well over the next several days. However, she
was noted to have an elevated white blood cell count. She
was pancultured and Infectious Disease was consulted at that
time. By [**2178-2-27**] the patient was beginning to have an
ARDS type picture by chest x-ray, and at that time she was
bronched by the Interventional Pulmonary Service. The
bronchoscopy showed diffuse blood in the airways with
bleeding from the right upper lobe. Following the bronch the
patient's Heparin was discontinued. The patient remained
stable over the next several days with good right ventricular
assist device flows. She was further weaned from her
cardioactive IV medications, and on [**2178-3-3**] she again
returned to the Operating Room, at which time her right
ventricular assist device was removed. Please see the OR
report for full details.
Following RVAD removal the patient was again transferred to
the Cardiothoracic Intensive Care Unit. At that time, she
had two new mediastinal tubes, mean arterial pressure of 92
with a CVP of 19. She was in a sinus rhythm at 110 beats per
minute with milrinone at 0.75 mcg/kg per minute, epinephrine
at 0.5 mcg/kg per minute, Levophed at 2 mcg/kg per minute,
Vasopressin at 1.2 units per hour, Amiodarone at 0.5 mg per
hour, and propofol at 30 mg per hour. Again, the patient's
chest was left open with a rubber [**Doctor Last Name **] in place.
The patient did well over the next three postoperative days,
and on [**2178-3-6**] she again returned to the Operating Room,
at which time her chest was closed. Patient tolerated the
closure well. Following closure she was returned again to
the Cardiothoracic Intensive Care Unit. She had a mean
arterial pressure of 92. She was in a sinus rhythm at 106
beats per minute with a CVP of 23 and PAD of 24. Her
Levophed had been weaned off, milrinone is at 0.75 mcg/kg per
minute, epinephrine at 0.6 mcg/kg per minute, Vasopressin at
0.6 units per hour, Amiodarone at 0.5 mg per hour, as well as
an insulin and Ativan drip. In addition to the services that
had been previously consulted at this point, Plastic Surgery
and the Intensivist Service had also been consulted.
Over the next week the patient continued to make slow
progress at weaning from her vasoactive IV medications as
well as slow progress in weaning from the ventilator. She
continued to be followed by the Infectious Disease Service as
her white count had been greater than 20 since the
implantation of the right ventricular assistive device.
On [**2178-3-8**] a culture of the [**MD Number(3) 52953**] was positive for
yeast. It turned out to be [**Female First Name (un) 564**] Torulopsis glabrata.
Following identification the patient was switched from
Fluconazole to caspofungin. During this period the patient's
sedation was also discontinued. She continued to make
progress, weaning from the ventilator. However, she remained
too weak to adequately protect her airway, and on [**2178-3-23**]
she again was brought to the Operating Room, at which time
she underwent tracheostomy. Please see the OR report for
full details. In summary, she had a 7 mm percutaneous Portex
trach with a small amount of superficial bleeding.
Following placement of the tracheostomy the patient returned
to the Cardiothoracic Intensive Care Unit, and over the next
two days, started on trach collar trials, which she tolerated
well. Patient did exceedingly well with her trach collar
trials. She was spending most of the day off of the
ventilator, only being rested at night.
On [**2178-3-27**] she had a video swallow evaluation which she
passed. At that point her tube feeds were changed to be
cycled in the nighttime hours only, and she was able to take
oral food during the course of the daytime. Additionally,
the patient was noted to have some sternal wound drainage.
She was seen by the Plastic Surgery Service for incision.
Distal incision was superficially debrided and a VAC dressing
applied. However, by [**2178-4-2**] the incision showed necrotic
tissue in the base of the wound and her sternum was felt to
be unstable. At that point she was brought to the Operating
Room for additional sternal debridement as well as a pec flap
advancement and closure.
Following her sternal debridement the patient was again begun
on trach collar trials, and within two days she was
successfully weaned from the ventilator and has been without
ventilator support since [**2178-4-3**].
The patient's oral diet was advanced over the next week with
shorter and shorter periods of tube feed cycles at night, and
by [**2178-4-8**] she was on a full oral diet. Also on
[**2178-4-8**] the patient's trach was downsized to a number 6
Portex fenestrated cuff.
It is felt at this time that the patient will be ready for
transfer to [**Hospital 4820**] rehabilitation center within the next
day. At this time the patient's physical exam is as follows.
Vital signs: Temperature 97.7, heart rate 91, sinus rhythm,
blood pressure 128/53, respiratory rate 22, O2 saturation 99
percent on 35 percent trach collar.
LABORATORY DATA: White count 10.7, hematocrit 31, platelets
290, sodium 138, potassium 4.4, chloride 102, CO2 27, BUN 29,
creatinine 0.4, glucose 84.
PHYSICAL EXAMINATION: Neurologically alert and oriented
times three; moves all extremities, although remains weak.
Breath sounds clear to auscultation bilaterally. Cardiac:
Regular rate and rhythm. Sternal incision clean, dry, and
intact. Abdomen is soft, nontender, with positive bowel
sounds. Extremities are warm with no edema.
DISCHARGE DIAGNOSES:
1. Aortic stenosis status post aortic valve replacement with
number 19 mosaic valve.
2. Hypertension.
3. Hypercholesterolemia.
4. Peripheral vascular disease.
5. Arthritis.
6. Degenerative disc disease.
7. Stress incontinence.
8. Hiatal hernia.
9. Right hip replacement.
10. Right carpal tunnel release.
11. Cesarean section.
12. Right heart failure.
13. Status post right ventricular assist device
placement and removal.
14. Status post tracheostomy.
15. Status post sternal debridement and pec flap
advancement and closure.
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg q. day.
2. Albuterol one to two puffs q. 4 hours as needed.
3. Miconazole powder t.i.d. as needed.
4. Pantoprazole 40 mg q.d.
5. Potassium chloride 20 mEq b.i.d.
6. Amiodarone 200 mg q.d.
7. Plavix 75 mg q.d.
8. Fluconazole 200 mg q.d.
9. Captopril 100 mg t.i.d.
10. Lasix 20 mg b.i.d.
11. Colace 150 mg b.i.d.
12. Ceftazidime 1 gram q. 8 hours times three weeks.
13. Bisacodyl suppository, one, q.d. as needed.
14. Benadryl 25 mg q. h.s. as needed.
15. Acetaminophen 325 to 650 mg q. 4 hours for a
temperature greater than 38.0 C.
16. Toprol XL 25 mg q.d.
DISCHARGE INSTRUCTIONS:
1. Patient is to have follow up with Dr. [**Last Name (STitle) **] of the Plastic
Surgery Service in one week.
2. Rehabilitation center is to call [**Telephone/Fax (1) **] for an
appointment.
3. She also is to have follow up with Dr. [**Last Name (STitle) 70**] in six
weeks, to call [**Telephone/Fax (1) **] for an appointment.
4. Follow up with Dr. [**First Name (STitle) **] of the Infectious Disease
Service on [**2178-5-18**] at 9:30 a.m.; please call [**Telephone/Fax (1) **]
for directions.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] M.D. [**MD Number(1) 75**]
Dictated By:[**Doctor Last Name 52954**]
MEDQUIST36
D: [**2178-4-8**] 21:10:52
T: [**2178-4-8**] 23:46:55
Job#: [**Job Number 52955**]
|
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"428.0",
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"786.3",
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"427.41",
"427.5",
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] |
icd9cm
|
[
[
[]
]
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[
"37.22",
"39.61",
"83.82",
"96.72",
"37.64",
"88.55",
"36.01",
"35.21",
"31.1",
"99.62",
"37.65",
"34.79",
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icd9pcs
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[
[
[]
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2104, 3025
|
12504, 13052
|
13109, 13698
|
13722, 14495
|
1369, 1826
|
12169, 12483
|
689, 1143
|
1165, 1346
|
1843, 2087
|
13077, 13086
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,107
| 121,572
|
27000
|
Discharge summary
|
report
|
Admission Date: [**2110-8-21**] Discharge Date: [**2110-8-28**]
Date of Birth: [**2028-12-19**] Sex: M
Service: MEDICINE
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending:[**First Name3 (LF) 3063**]
Chief Complaint:
Fever
Diarrhea
Septic Shock
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt was recently diagnosed with a urinary tract infection on
[**2110-8-19**] and started on Ciprofloxacin. He was also was diagnosed
with C. difficile at his rehab on [**2110-8-14**] and was on Flagyl. Of
note, the patient was admitted from [**2110-7-14**] to [**2110-7-16**] for
right testicular pain consistent with epididymitis thought to be
related to repeated instrumentation of urethra and chronic
indwelling catheterization. A CT scan of abdomen and pelvis was
done due to concern for Fournier's gangrene but was negative.
His pain was managed with morphine and tylenol. He was started
on vancomycin, flagyl, and levofloxacin. His urinalysis was
"positive" and antibiotics were changed to ceftriaxone. He was
discharged on a 14-day course of cefpodoxime that ended on
[**2110-7-28**]. Subsequently had a positive urine culture that was
that was started with treatment with Cipro. Additionally, C.
Diff assay was positive [**2110-8-14**], for which pt was started on
Flagyl. Of note, a UTI diagnosed on [**2110-8-6**] was resistent to
Levofloxacin and Bactrim. There is also a note from his Atrius
urologist that in the past 2 months he had a 3 mm calculus with
R side stent placement, with a planed ureteroscopy in the
future.
Past Medical History:
- DMII
- Hypotonic hyposensitive bladder with urinary retention and
chronic indwelling foley
- Afib not on coumadin
- Cerebral palsy
- sCHF but could not find recent echo in system
- HTN
- HL
Social History:
Patient is a limited historian. Lives in [**Location 66367**] facility.
Wheelchair bound. Non-smoker. Does not drink alcohol.
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM:
Vitals: 100.2 110 142/55 37 98% RA
General: Elderly male sitting comfortably in his chair. Awake,
alert, oriented, no acute distress.
HEENT: Tounge deviation to the left, mild slurring of speech,
edentulous, dry mucus membranes with white inspissated mucus
present, EOMI, PERRL
Neck: supple, JVP not elevated, RIJ in place
CV: Irregularly irregular, no murmurs, rubs, or gallops
Lungs: Mild expiratory wheezes, minimal rhonchi c/w some
secretions, no crackles
Abdomen: soft, non-tender, minimal distention, bowel sounds
present
GU: foley in place
Ext: warm, well perfused, 1+ pulses
Neuro: AAOx3, patient diffusely weaker on the right versus left
(chronic finding per patient report)
.
DISCHARGE EXAM:
VS: T 97.8, Tm 98.8, BP 130/70, HR 72, RR 16, O2 97% RA, BGlu
190
I/O: [**2047**]/3900/No BM on record
General: Elderly male lying in bed. Awake, alert, oriented, no
acute distress.
HEENT: Tounge deviation to the left, mild slurring of speech,
edentulous, inspissated mucus on uvula
Neck: supple, RIJ in place, no LAD, no JVD
CV: Irregularly irregular, no murmurs, rubs, or gallops
Lungs: No respiratory distress, CTAB
Abdomen: soft, non-tender, minimal distention, bowel sounds
present, no CVA tenderness
GU: foley in place
Ext: warm, well perfused, 1+ pulses, no edema b/l, SCDs in place
bilaterally
Neuro: AAOx3, patient diffusely weaker on the right versus left
(chronic finding per patient report)
Pertinent Results:
[**2110-8-21**] 03:30AM BLOOD WBC-19.4*# RBC-3.51* Hgb-10.4* Hct-30.5*
MCV-87 MCH-29.5 MCHC-34.0 RDW-14.8 Plt Ct-231
[**2110-8-21**] 01:15PM BLOOD WBC-17.6* RBC-3.22* Hgb-9.8* Hct-28.4*
MCV-88 MCH-30.4 MCHC-34.4 RDW-15.0 Plt Ct-222
[**2110-8-21**] 03:30AM BLOOD Neuts-89.2* Lymphs-4.6* Monos-5.6 Eos-0.5
Baso-0.2
[**2110-8-21**] 01:15PM BLOOD Neuts-89.6* Lymphs-5.4* Monos-4.6 Eos-0.1
Baso-0.2
[**2110-8-21**] 03:30AM BLOOD Plt Ct-231
[**2110-8-21**] 01:15PM BLOOD PT-14.1* PTT-30.3 INR(PT)-1.3*
[**2110-8-21**] 03:30AM BLOOD Glucose-281* UreaN-20 Creat-1.0 Na-129*
K-4.1 Cl-96 HCO3-21* AnGap-16
[**2110-8-21**] 01:15PM BLOOD Glucose-250* UreaN-16 Creat-0.8 Na-134
K-3.8 Cl-104 HCO3-20* AnGap-14
[**2110-8-21**] 03:30AM BLOOD ALT-13 AST-16 CK(CPK)-32* AlkPhos-72
TotBili-0.3
[**2110-8-21**] 03:30AM BLOOD CK-MB-1 cTropnT-0.04*
[**2110-8-21**] 03:30AM BLOOD Albumin-3.7
[**2110-8-21**] 01:15PM BLOOD Calcium-7.7* Phos-1.9* Mg-1.1*
[**2110-8-21**] 03:30AM BLOOD Digoxin-0.7*
[**2110-8-21**] 03:42AM BLOOD Lactate-3.8*
[**2110-8-21**] 05:50AM BLOOD Lactate-3.2*
[**2110-8-21**] 01:29PM BLOOD Lactate-1.8
[**2110-8-21**] 01:29PM BLOOD O2 Sat-65
.
RELEVANT LABS:
[**2110-8-22**] 03:25AM BLOOD WBC-9.2 RBC-2.76* Hgb-8.3* Hct-24.3*
MCV-88 MCH-30.2 MCHC-34.3 RDW-15.0 Plt Ct-181
[**2110-8-22**] 03:25AM BLOOD Glucose-181* UreaN-12 Creat-0.8 Na-134
K-3.3 Cl-106 HCO3-21* AnGap-10
[**2110-8-22**] 03:25AM BLOOD CK(CPK)-44*
[**2110-8-22**] 03:25AM BLOOD CK-MB-3 cTropnT-0.07*
[**2110-8-22**] 03:25AM BLOOD Calcium-7.3* Phos-2.5* Mg-2.0
[**2110-8-22**] 06:46AM BLOOD Vanco-10.4
[**2110-8-22**] 03:37AM BLOOD Type-[**Last Name (un) **] Temp-37.9 pO2-124* pCO2-40
pH-7.33* calTCO2-22 Base XS--4 Comment-GREEN TOP
[**2110-8-23**] 08:50AM BLOOD calTIBC-229* Ferritn-799* TRF-176*
[**2110-8-25**] 06:15AM BLOOD WBC-6.5 RBC-3.00* Hgb-9.1* Hct-26.0*
MCV-87 MCH-30.5 MCHC-35.2* RDW-15.1 Plt Ct-273
[**2110-8-26**] 05:50AM BLOOD Glucose-202* UreaN-9 Creat-0.9 Na-138
K-3.8 Cl-106 HCO3-26 AnGap-10
[**2110-8-23**] 08:50AM BLOOD CK-MB-2 cTropnT-0.05*
[**2110-8-26**] 05:50AM BLOOD Calcium-7.9* Phos-2.2* Mg-1.8
[**2110-8-25**] 06:15AM BLOOD Digoxin-0.2*
.
DISCHARGE LABS:
[**2110-8-28**] 05:49AM BLOOD WBC-9.7 RBC-3.28* Hgb-10.1* Hct-29.0*
MCV-88 MCH-30.7 MCHC-34.8 RDW-15.9* Plt Ct-362
[**2110-8-28**] 05:49AM BLOOD Glucose-165* UreaN-12 Creat-0.9 Na-139
K-4.1 Cl-102 HCO3-29 AnGap-12
[**2110-8-28**] 05:49AM BLOOD Calcium-9.0 Phos-3.8 Mg-1.7
.
IMAGING:
[**2110-8-21**] @ 0329 - CXR - IMPRESSION: Mild pulmonary edema though
no consolidation.
[**2110-8-21**] @ 0630 - CXR - IMPRESSION:
1. New central venous catheter terminating in the mid SVC.
2. Stable mild interstitial pulmonary edema.
[**2110-8-21**] @ 1309 - ABD XR - IMPRESSION: Bowel gas pattern
consistent with ileus. No evidence of obstruction or toxic
megacolon.
[**2110-8-21**] @ 1659 - ABD CT W/ & W/O CONTRAST - IMPRESSION:
1. Mild colitis involving the cecum.
2. Renal stent in proper position.
3. There is no evidence of pyelonephritis.
4. New bilateral pleural effusions.
5 Unchanged 1.3 cm left adrenal lesion that is indeterminate
by CT size
criteria, however, it most likely represents a lipid poor
adenoma.
6. Foley catheter balloon in the prostate.
7. Non-obstructing 2mm right renal calculus.
[**2110-8-22**] - ECHO - IMPRESSION: The left atrium is elongated. The
estimated right atrial pressure is 5-10 mmHg. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). There is no ventricular septal
defect. The right ventricular cavity is mildly dilated with
borderline normal free wall function. There is abnormal
diastolic septal motion/position consistent with right
ventricular volume overload. 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
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is an anterior space which
most likely represents a prominent fat pad.
[**2110-8-25**] - CXR - REASON FOR EXAM: Assess right PICC after power
flush. Comparison is made with prior study performed one hour
earlier. Left PICC tip is difficult to visualized, can be
followed to the cavoatrial junction. There is no pneumothorax
or pleural effusion. There are no other interval changes.
.
MICRO:
[**2110-8-21**] 3:30 am BLOOD CULTURE
**FINAL REPORT [**2110-8-27**]**
Blood Culture, Routine (Final [**2110-8-27**]):
KLEBSIELLA PNEUMONIAE.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
353 5861C
[**2110-8-21**].
Aerobic Bottle Gram Stain (Final [**2110-8-24**]): GRAM NEGATIVE
ROD(S).
[**2110-8-21**] 3:30 am URINE Site: CATHETER
**FINAL REPORT [**2110-8-25**]**
URINE CULTURE (Final [**2110-8-25**]):
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
sensitivity testing performed by Microscan. MEROPENEM
<=1 MCG/ML.
CEFEPIME >16 MCG/ML. SULFA X TRIMETH >2 MCG/ML.
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
sensitivity testing performed by Microscan. MEROPENEM
<=1 MCG/ML.
CEFEPIME >16 MCG/ML. SULFA X TRIMETH >2 MCG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- =>32 R 16 I
CEFAZOLIN------------- =>32 R =>32 R
CEFEPIME-------------- R R
CEFTAZIDIME----------- 4 S 4 S
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM------------- S S
NITROFURANTOIN-------- <=32 S 32 S
TOBRAMYCIN------------ =>16 R 8 I
TRIMETHOPRIM/SULFA---- R R
[**2110-8-21**] 3:45 am BLOOD CULTURE # 2.
**FINAL REPORT [**2110-8-24**]**
Blood Culture, Routine (Final [**2110-8-24**]):
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 4 S
CEFTRIAXONE----------- 16 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
Anaerobic Bottle Gram Stain (Final [**2110-8-21**]):
Reported to and read back by [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] @ 1725 ON [**8-21**]
- [**Numeric Identifier 66368**].
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final [**2110-8-23**]): GRAM NEGATIVE
ROD(S).
[**2110-8-21**] 6:30 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2110-8-24**]**
MRSA SCREEN (Final [**2110-8-24**]): No MRSA isolated.
[**2110-8-22**] 2:30 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2110-8-28**]**
Blood Culture, Routine (Final [**2110-8-28**]): NO GROWTH.
[**2110-8-26**] 12:29 pm URINE Source: Catheter.
**FINAL REPORT [**2110-8-27**]**
URINE CULTURE (Final [**2110-8-27**]):
YEAST. >100,000 ORGANISMS/ML..
Brief Hospital Course:
Mr. [**Known lastname 66369**] is an 81M with DMII, chronic indwelling Foley due
to urinary retention, cerebral palsy, atrial fibrillation not
anti-coagulated presents with septic shock
.
# Septic Shock: The patient was aggressively fluid resucitated
in the ED and ICU per rivers protocol; he was briefly on
norepinephrine in the ED, but had weaned by the time he arrived
to the ICU. U/A findings (reported "pus" in the Foley initially)
as well as recent instrumention and stenting in the past 2
months, with what appears per records to be several rounds of
UTIs pointed to an etiology of urosepsis. Of note, CT Abd
revealed right ureteral stent, nonspecific perinephric stranding
unchanged from [**2110-7-16**]. As such, the patient initially in the
ICU was covered with Vancomycin IV, Cefepime IV, Vancomycin PO,
and IV Metronidazole to cover potential lung, urine, and colonic
srouces, with a plan to wean antibiotics on the floor. He was
subsequently found to have Klebsiella Pneumonia in the blood,
and was narrowed to Cefepime IV, Vancomycin PO, and IV
Metronidazole. Urine Cx from OSH grew Klebsiella Pneumonia ESBL+
sensitive to cefepime, but urine culture from here grew two
different strains of K. Pneumonia resistant to cefepime. Due to
resistance panel, a PICC line was placed and a 10d course of IV
Meropenem 500mg q6 was started, beginning on [**8-26**] and expected
to go on until the evening of the 14th. We did not consult
urology since pt has an outpt appt and is doing OK clinically.
.
# C. difficile diarrhea: Patient has fever, WBC > 15. Also > age
65 years old. He has evidence of sepsis and elevated serum
lactate (> 2.5), which may be from sepsis from a urinary source.
He does thus meet criteria severe C. difficile criteria per
[**Hospital1 18**] guidelines. As such, he was started on vancomycin 500 mg
PO q 6 hr, and reduced to 125 mg PO q 6 hr, then to PO
metronidazole. Due to other infections, will continue flagyl for
1w post other abx. He will continue metronidazole 500mg TID
until 1 week after the Meropenem has been d/c'ed'
# Bradycardia: patient was bradycardic to 40s, asymptomatic, on
metoprolol succinate. This was discontinued and the digoxin
will be used for rate control. The rates were in the 60s-70s on
discharge.
.
# Hyponatremia: Likely hypovolemic in the setting of diarrheal
loses, patient endorses thirst and has dry MM. Resolved after
fluid resucitation.
.
# Mild metabolic acidosis: Likely secondary to fluid
resustication with NS and and diarrheal losses. Resolved.
.
# Atrial fibrillation: Patient is CHADS2 of > 2, has not elected
to be on coumadin. We continued ASA in house. Off metorpolol due
to bradycardia. On digoxin for rate control.
.
# Normocytic, normochromic anemia: Unclear etiology, stable from
prior admission
.
# DM2: Blood sugars consistently were in the 300's at the
beginning of the admission, so a standing bedtime dose of Lantus
was added to his sliding scale. Also, his sliding scale was
adjusted accordingly throughout the hospital course.
.
# Congestive heart failure: There is no ECHO on file at [**Hospital1 18**] or
atrius but per reports, patient has history of ? heart failure.
An ECHO was ordred prior to his discharge from the ICU, results
above. EKG done on [**8-23**] showed asymmetric t-wave inversions in
V1, meaning possible left heart strain. Given his cardiac
history, findings of edema and lung sounds, and the fluid
recussitation, the most likely reason for the strain was the NS
bolus during septic shock. The pt was given IV lasix with
resolution of his edema and lung findings.
.
# Transitional Issues
- 10d course of IV Meropenem 500mg q6. Day 1 = [**8-26**]. Day 10 =
[**9-5**] stop in evening
- PO Metronidazole 500mg TID. D/C 1 week after meropenem is
stopped = [**9-12**]
- PICC line in place, will be removed when completes the course
of antibiotics
PENDING STUDIES:
None
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from [**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **].
1. Ciprofloxacin HCl 250 mg PO Q12H
Planned for [**Hospital1 **] for 5 days, started [**8-19**] end [**2110-8-24**]
2. Senna 2 TAB PO BID:PRN constipation
3. traZODONE 25 mg PO HS:PRN insomnia
4. Biscolax *NF* (bisacodyl) 10 mg Rectal Daily:PRN constipation
5. Milk of Magnesia 30 mL PO DAILY:PRN constipation
6. Acetaminophen 500 mg PO Q6H:PRN fever,pain
7. Aspirin 325 mg PO DAILY
8. Calcium Carbonate 500 mg PO BID
9. Digoxin 0.25 mg PO EVERY OTHER DAY
10. Furosemide 20 mg PO DAILY
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Metoprolol Succinate XL 25 mg PO DAILY Hold for SBP< 100, HR
<60
13. Multivitamins 1 TAB PO DAILY
14. Omeprazole 20 mg PO DAILY
15. Simvastatin 10 mg PO QHS
16. Timolol Maleate 0.5% 1 DROP BOTH EYES [**Hospital1 **]
17. Vitamin D 400 UNIT PO BID
18. Loratadine *NF* 10 mg Oral Daily
19. Finasteride 5 mg PO DAILY
20. Tamsulosin 0.4 mg PO HS
21. MetRONIDAZOLE (FLagyl) 500 mg PO TID Daily
22. GlipiZIDE 10 mg PO BID
23. Lisinopril 5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN fever,pain
2. Aspirin 325 mg PO DAILY
3. Calcium Carbonate 500 mg PO BID
4. Digoxin 0.25 mg PO EVERY OTHER DAY
On even days, start [**2110-8-21**]
5. Furosemide 20 mg PO DAILY
6. Lisinopril 5 mg PO DAILY
7. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
Continue until 1 week after meropenem has been discontinued,
[**2110-9-12**]
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*45 Tablet Refills:*0
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Senna 2 TAB PO BID:PRN constipation
11. Simvastatin 10 mg PO QHS
12. Timolol Maleate 0.5% 1 DROP BOTH EYES [**Hospital1 **]
13. Vitamin D 400 UNIT PO BID
14. Meropenem 500 mg IV Q6H Duration: 8 Days
last dose [**2110-9-5**] 6pm
RX *meropenem 500 mg every six (6) hours Disp #*30 Vial
Refills:*0
15. Biscolax *NF* (bisacodyl) 10 mg Rectal Daily:PRN
constipation
16. Finasteride 5 mg PO DAILY
17. GlipiZIDE 10 mg PO BID
18. Loratadine *NF* 10 mg Oral Daily
19. MetFORMIN (Glucophage) 1000 mg PO BID
20. Milk of Magnesia 30 mL PO DAILY:PRN constipation
21. Tamsulosin 0.4 mg PO HS
22. traZODONE 25 mg PO HS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name **] house
Discharge Diagnosis:
Primary Dx: Urosepsis
Secondary Dx: C. Diff, Atrial fibrillation, Urinary Tract
Infection, Type 2 Diabetes, 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:
Dear Mr. [**Known lastname 66369**],
It was a pleasure taking care of you during your hospitalization
at [**Hospital1 18**]. You were admitted for urosepsis. The fevers you were
experiencing were secondary to bacteria from your urinary tract
infection invading your bloodstream. You also had a C.Diff
infection in your gastrointestinal system. This lead to your
diarrheal episodes.
You were treated with antibiotics for both the urosepsis and
C.Diff infections. Please continue to monitor your symptoms, and
notify your primary care physician if they worsen.
The following changes were made to your medications:
-take meropenem 500mg every 6 hrs through [**2110-9-5**]
-take flagyl 500mg every 8 hours through [**2110-9-12**]
-stop metoprolol succinate
Good luck in your recovery.
Followup Instructions:
Please follow up with your urologist at the previously made
appointment.
Department: PAT PREADMISSION TESTING
When: TUESDAY [**2110-9-23**] at 10:15 AM
With: PAT-PREADMISSION TESTING [**Telephone/Fax (1) 2289**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Completed by:[**2110-8-29**]
|
[
"250.00",
"596.51",
"428.33",
"343.9",
"427.89",
"428.0",
"276.2",
"038.49",
"285.9",
"785.52",
"995.92",
"788.29",
"008.45",
"V49.86",
"276.1",
"599.0",
"427.31",
"V46.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
17861, 17918
|
11635, 15514
|
335, 342
|
18095, 18095
|
3457, 5591
|
19080, 19449
|
1981, 2000
|
16701, 17838
|
17939, 18074
|
15540, 16678
|
18271, 19057
|
5607, 11612
|
2015, 2717
|
2733, 3438
|
268, 297
|
370, 1605
|
18110, 18247
|
1627, 1820
|
1836, 1965
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,594
| 140,204
|
43298
|
Discharge summary
|
report
|
Admission Date: [**2183-11-21**] Discharge Date: [**2183-12-12**]
Date of Birth: [**2135-11-1**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Dilantin
Attending:[**First Name3 (LF) 17683**]
Chief Complaint:
s/p fall, left femur fracture [**11-20**]
Major Surgical or Invasive Procedure:
[**11-24**] ORIF of distal femur with 4 screws
[**11-27**] ex lap with colectomy, small bowel resection for ischemic
bowel, right chest tube for pneumothorax
[**12-9**] ex lap, intraop TEE, transdiaphragmatic preicardial window
for cardiac tamponade
History of Present Illness:
48 F c h/o renal transplant c renal insufficiency (on
cyclosporine, cellcept, and prednisone), morbid obesity, and
mitral regurgitation who slipped and had controlled fall in
bathroom on [**2183-11-20**] pm. She was taken to [**Hospital1 18**] and found to
have distal femur fracture with CT showing intra-articular
fragment of distal femur with fragments. She was scheduled to go
to OR on [**2183-11-21**] but it was cancelled per request of
anesthesiology until medical clearance has been given.
.
Per earlier note, pt has been without other complaints and has
been in her usual state of health. She denied fevers, chills,
abdominal pain, dysuria, cough, diarrhea, headache, sinus
pressure, bleeding, melena, and change in urine output. She
lives at home and is fully independent. She is able to climb few
flights of stairs without getting short of breath.
Past Medical History:
1. heterotopic living-related Kidney transplant -94'
(glomerulonephritis)
2. Bacterial endocarditis in [**2174**] with persistent mitral valve
murmur and aortic stenosis by TTE
3. Morbid obesity (400lbs)
4. s/p appendectomy
6. OSA
7. Hypercholesterolemia
8. h/o sz
9. HTN
Social History:
occasional EtOH, no tobacco
Family History:
N/C
Physical Exam:
BP 143/65 HR 60 RR 16 O2sat 100% on vent
Gen: obese, intubated and sedated
HEENT: ETT
CV: RRR, 4/6 SEM heard best at apex
Pulm: CTAB
abd: obsese, soft, NABS
ext: left knee dressed and in immobilizer
Pertinent Results:
Echo([**2-26**]): EF >55%, mod to severe MR with mitral annular
calcifications (poor study)
.
[**2183-11-20**] 11:45PM WBC-23.0*# RBC-3.18* HGB-8.9* HCT-28.9*
MCV-91 MCH-28.0 MCHC-30.8* RDW-15.1
[**2183-11-20**] 11:45PM GLUCOSE-110* UREA N-82* CREAT-1.5* SODIUM-141
POTASSIUM-5.5* CHLORIDE-105 TOTAL CO2-20* ANION GAP-22*.
.
TTE ([**11-24**]) Conclusions:
1. The left atrium is moderately dilated. The left atrium is
elongated.
2.There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%).
3. Right ventricular chamber size is normal. Right ventricular
systolic function is normal.
4.The aortic valve leaflets are moderately thickened. No aortic
insufficiency seen.
5.The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
6.There is moderate pulmonary artery systolic hypertension.
7.There is no pericardial effusion. There is an anterior space
which most likely represents a fat pad, though a loculated
anterior pericardial effusion cannot be excluded.
Compared with the findings of the prior report (tape unavailable
for review) of [**2180-2-28**], the aortic stenosis is more severe.
No echocardiographic evidence of endocarditis seen.
.
CT femur ([**11-21**]): communicated intercondylar intra-articular
fracture of distal femur with intra-articular fragments.
.
CXR ([**11-22**]): Peribronchial cuffing, without evidence for focal
infiltrate. Prominent left hilum for which further evaluation by
cross sectional imaging is recommended, to exclude
lymphadenopathy.
.
RENAL ULTRASOUND: The transplanted kidney measures 11.5 cm.
There is no evidence of stones, masses or hydronephrosis. There
is mild increased echogenicity of the renal parenchyma. There is
normal venous flow with the areterial resistive indices in the
range of 0.72 to 0.85.
.
EKG: NSR @ 100, N axis, N intervals, no ST/T abnormalities;
small Q waves in II, III, and aVF.
.
CT chest ([**11-26**]): No structural abnormality identified
corresponding to the reported findings on radiograph, Minimal
faint ground-glass opacities within the posterior right upper
lobe. These are nonspecific in appearance and of unclear
clinical significance. If clinically warranted, three-month
followup CT of the chest can be performed to ensure resolution.
.
CT abd ([**11-27**]):
1. Diffuse dilation of large and small bowel containing air and
fluid levels. There is no evidence of mechanical small-bowel
obstruction, and the findings could indicate enteritis/colitis.
Pseudomembranous colitis may occasionally present with a
distended and fluid filled colon.
2. Diverticulosis of the sigmoid and descending colon with
probable mild or early diverticulitis of the sigmoid colon. No
evidence of extraperitoneal gas or drainable fluid collection.
3. Bowel malrotation without evidence of volvulus or
small-bowel obstruction.
4. Diminutive size of mesenteric arterial vessels as well as
IVC may reflect low volume status/dehydration. Clinical
correlation is requested.
5. Focal hypodensity in the interpolar region of the transplant
kidney is of uncertain significance.
6. Fat containing anterior abdominal hernia.
Brief Hospital Course:
A/P: 48 F s/p renal transplant on several immunosupressive meds,
moderate mitral regurgitation ([**2-26**] SBE), and morbid obesity who
presents s/p mechanical fall with left distal femur fracture
found to be febrile with leukocytosis.
.
# Ischemic bowel: Onset of abdominal pain on morning of [**11-27**],
progressive throughout the day, developed peritoneal signs in
the evening. Also had associated nausea, tachypnea,
constipation, and later developed vomiting. Had gap acidosis
that had worsened on morning of [**11-27**], but only slightly elevated
lactate. By evening, began to appear toxic, repeat WBC of 36.
Surgery consult called and was concerned for ischemic bowel as
well. CT scan showed dilated loops of small and large bowel
without obvious transition point, but no free fluid/air and no
thickened bowel wall. Clinical picture, however, prompted
Surgery team to perform ex lap and portion of ileum was found to
be ischemic and was resected. End ileostomy placed. She was
transferred to the SICU for postop management. Unclear what the
etiology is: low flow state vs. distal embolic event. Also
unclear if initial picture of leukocytosis and fever was related
to her bowel ischemia. Postopreatively she improved but
developed GI bleed and underwent EGD, which showed crusty
esophageal lacerations, which were positive for HSV, and
gastritis. This improved on acyclovir and protonix drip. Her
status improved until the [**12-9**] when she acutely decompensated
with elevated lactic acid and bas deficit of 18. TTE suggested
cardiac tamponade but was extremely limited due to body habitus.
She was taken to the operative room for ex lap, which was
negative. Intraoperative TEE showed pericardial tamponade
physiology and a transdiaphragmatic pericardial window was
performed. Her blood pressure improved immediately and she was
taken back to the ICU.
.
# ID/Fevers: On presentation to the hospital had WBC of 23 and
was febrile but had no localizing signs or symptoms. Blood
cultures were negative. One urine culture growing Gardenerella,
subsequent cultures negative. Fevers resolved, WBC improved.
Taken to ORIF with perioperative antibiotics. L hilar fullness
on CXR, CT without structural abnormality or sign of infection.
LLE wound without signs of infection. Continued to be afebrile
throughout her stay on the medicine floor, but leukocytosis
worsened on [**11-27**]. Found to have ischemic bowel as above. Sh was
started and continued on broad spectrum antibiotics and
antifungal therapy during the remainder of her hospital stay.
From her first postoperative bowel movement clostridium
difficile was cultured. This was treated with flagyl iv as well
as vancomycin enemas. She continued to be afebrile with
decreasing white count over her hospital stay.
.
3) ESRD s/p Tx: Was stable on immunosuppresant therapy with
cyclosporine, mycophenolate, and prednisone, was sustained on
immunosuppressant therapy. Cyclosporine level adequate
throughout her stay. BUN/Cr initially slightly elevated, thought
to be prerenal. Renal US unremarkable. Transplant service
following. During her ICU stay, the immunosuppression was
decreased so that she could fight her sepsis. She was continued
only on hydrocortisone iv.
.
4) Femur fracture: s/p left ORIF of distal femur with 4 screws
placed. Transferred to Medicine service post-op for w/u of
leukocytosis. Ortho continued to follow with wound care. LLE
kept in immobilizer. The incision was healing well.
.
5) Cards:
a. AS: Valve area 0.9. No regular cardiology follow up per
patient. Not an acute issue, will be cautious with volume and
antihypertensives. No nitrates.
- will arrange for outpatient Cardiology f/u
b. CAD: No previous ischemic cardiac history. Will continue
Lipitor.
c. Pump: preserved EF by recent TTE; euvolemic by exam
d. HTN: On dilt, metoprolol and valsartan as outpatient, will
continue regimen.
e. TEE: ([**12-1**])
f. Afib, RVR: [**11-30**], attempt electric cardioversion w/o success.
Started on amiodarone drip, controlled rate.
.
6) Obesity/OSA: Respiratory failure.
.
7) Anemia: Likely ACD + femur fracture + post-op losses. 1500cc
EBL from ORIF, received 4U PRBC intraop. Received overall 6
units PRBC more over her hospital stay for GI bleed, sepsis and
ICU anemia.
.
8) FEN: She was kept NPO on TPN during her hospital stay.
.
9) PPx: Lovenox (renally dose as above) and pneumaboot to R leg,
PPI.
.
10) Code status: FULL
.
Hospital Course: After her second ex lap with pericardial window
her condition improved for 2 days. On [**12-12**], she became acutely
unstable with worsening ABGs. She was placed on pressors and
full support. After several long family meetings, the family
agreed to make her DNR. Mrs. [**Known lastname 93258**] expired on the evening of
[**2183-12-12**]. Autopsy was not wished by the family.
Medications on Admission:
1. valsartan 160 mg Qday
2. allopurinol 100 mg [**Hospital1 **]
3. atenolol 50 mg Qday
4. Lasix 80 mg Qday
5. Morphine prn
6. Lipitor 10 mg Qday
7. Colace 100 mg [**Hospital1 **]
8. Diltiazem 240 mg Qday
9. hydromorphone PCA
10.Cellcept [**Pager number **] mg [**Hospital1 **]
11.cyclosporine 125 mg [**Hospital1 **]
12.Prednisone 10 mg Qday
13. Lovenox 40 mg SQ Qday
Discharge Medications:
None
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Left femur fracture
Ischemic bowel
Right pneumothorax
Sepsis
Multi-system organ failure
Discharge Condition:
The patient expired.
Discharge Instructions:
None
Followup Instructions:
None
[**Name6 (MD) 843**] [**Name8 (MD) 844**] MD [**MD Number(1) 845**]
Completed by:[**2183-12-19**]
|
[
"584.5",
"327.23",
"285.1",
"420.90",
"751.4",
"780.39",
"578.9",
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"821.21",
"785.52",
"512.1",
"278.01",
"054.9",
"038.3",
"557.0",
"E927",
"996.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.14",
"96.6",
"46.21",
"99.62",
"45.16",
"45.73",
"79.35",
"54.12",
"38.93",
"96.72",
"96.07",
"99.15",
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"89.64",
"88.72",
"39.95",
"34.04",
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] |
icd9pcs
|
[
[
[]
]
] |
10637, 10652
|
5359, 9794
|
327, 579
|
10784, 10806
|
2067, 5336
|
10859, 10992
|
1825, 1830
|
10608, 10614
|
10673, 10763
|
10216, 10585
|
9811, 10190
|
10830, 10836
|
1845, 2048
|
246, 289
|
607, 1469
|
1491, 1764
|
1780, 1809
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,162
| 123,954
|
48739
|
Discharge summary
|
report
|
Admission Date: [**2114-1-28**] Discharge Date: [**2114-2-2**]
Date of Birth: [**2057-2-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1572**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
Transesophageal Echocardiography on [**2114-1-31**]
History of Present Illness:
Mr. [**Known lastname 62215**] is a 56 year old male s/p renal xplant '[**90**] (b/l Cr
3.0), AVR for AS '[**09**] p/w 2-3 weeks of gradual dyspnea on
exertion and orthopnea. His exercise tolerance has drastically
decreased as well. He was previously able to walk 1 mile
5x/week, however recently he has become dyspneic with walking
from the bed to the bathroom. He notes that the shortness of
breath has been gradually increasing and has made it difficult
for him to sleep. He went to see his Cardiologist for these
complaints last week. His symptoms persisted until last night
when he had to sleep sitting up secondary to shortness of breath
with lying flat. He also reports a nonproductive cough and
denies fevers. He had increased LE edema, although attributes
this to his Nifedipine which has historically resulted in LE
edema. This AM prior to presentation he was unable to ambulate
around the house without dyspnea. He had no chest pain.
In the ED on arrival his VS were BP 209/125, HR 86, O2sat 77% on
RA. Exam was notable for ??. He was given 100mg IV lasix and
started on Bipap. He was given 20mg IV hydralazine and started
on a nitro gtt. He put out 500cc of urine in the 2 hours in the
ED. CXR showed evidence of heart failure. A bedside US showed no
evidence of pericardial effusion but ? global hypokinesis. Labs
were notable for Cr 2.9 which is his baseline, BNP 70,000. EKG
with sinus rhythm no ST or TW changes.
On transfer to the CCU, the patient is saturating 97% on NRB. He
is comfortable.
Past Medical History:
s/p renal transplant [**2090**], baseline creatinine 3.0
AVR [**2110**], bovine valve
Prostate CA s/p XRT
Melanoma on neck s/p resection
Hypertension
Hyperlipidemia
Gout
Social History:
No tobacco use. He has not had any alcohol in three years.
Family History:
There is no family history of premature coronary artery disease
or sudden death. His father had an MI at later age.
Physical Exam:
VS BP 146/114, HR 96, RR 19, O2sat 99% on NRB
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate. Conversant without use of accessory muscles.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 10 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal s1, s2. 2/6 systolic ejection murmur at apex. No
thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Poor air movement.
Bilateral rales
Abd: Soft, NTND. No HSM or tenderness. + abdominal hernia.
Ext: [**12-1**]+ ankle edema bilaterally. No femoral bruits.
Pertinent Results:
[**2114-1-28**] 02:50PM BLOOD WBC-10.7 RBC-3.94* Hgb-11.9* Hct-34.8*
MCV-89 MCH-30.2 MCHC-34.2 RDW-15.6* Plt Ct-322
[**2114-1-29**] 04:20AM BLOOD WBC-8.7 RBC-3.21* Hgb-9.9* Hct-28.3*
MCV-88 MCH-30.8 MCHC-35.0 RDW-15.5 Plt Ct-239
[**2114-2-2**] 05:30AM BLOOD WBC-6.6 RBC-3.12* Hgb-9.1* Hct-27.7*
MCV-89 MCH-29.2 MCHC-32.9 RDW-15.2 Plt Ct-286
[**2114-2-2**] 05:30AM BLOOD ESR-63*
[**2114-1-28**] 02:50PM BLOOD Glucose-124* UreaN-86* Creat-2.9* Na-133
K-9.0* Cl-103 HCO3-17* AnGap-22*
[**2114-1-30**] 07:17PM BLOOD Glucose-131* UreaN-108* Creat-3.8* Na-140
K-3.9 Cl-108 HCO3-22 AnGap-14
[**2114-2-2**] 05:30AM BLOOD Glucose-89 UreaN-113* Creat-3.4* Na-139
K-4.0 Cl-109* HCO3-20* AnGap-14
[**2114-1-28**] 02:50PM BLOOD CK-MB-9 cTropnT-0.19* proBNP-GREATER THAN
70,000
[**2114-1-29**] 04:20AM BLOOD CK-MB-7 cTropnT-0.29*
[**2114-1-30**] 04:51AM BLOOD CK-MB-NotDone cTropnT-0.30*
CXR ([**1-28**]): There is cardiomegaly with hilar congestion and
alveolar opacities compatible with pulmonary edema. Small
bilateral pleural effusions are also noted.
TTE ([**1-29**]): Severe LVH with moderate LV dilatation. Moderate to
severe global LV hypokinesis with inferior akinesis.
Bioprosthetic AVR with very high gradients (mean 49). Unable to
assess if vegetation or thrombus on aortic valve. At least
moderate mitral regurgitation (UNDERestimated due to shadowing).
Diastolic dysfunction with moderate pulmonary artery systolic
hypertension. Compared with the prior study (images reviewed) of
[**2114-1-9**], overall LV systolic function has decreased
significantly. The gradient across the aortic prosthesis is
slighlty higher. The other findings are similar.
Renal transplant U/S ([**1-29**]): 1. No hydronephrosis of the renal
transplant.
2. Unremarkable renal transplant Doppler examination with only
slightly
elevated resistive indices but unremarkable waveforms.
3. Atrophy of both the native kidneys which make them unable to
be imaged on this exam.
TEE ([**1-31**]): The left atrium and right atrium are normal in cavity
size. There is mild regional left ventricular systolic
dysfunction with inferior wall hypokinesis. Overall left
ventricular systolic function is mildly depressed (LVEF= 40-45
%). There are simple atheroma in the descending thoracic aorta.
A bioprosthetic aortic valve prosthesis is present. The
prosthetic aortic valve leaflets are thickened. There is
moderate to severe aortic valve stenosis (area 0.8 cm2) by
planimetry. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Thickened and calcified bioprosthetic aortic valve
struts and leaflets. Moderate to severe prosthetic aortic valve
stenosis.
Brief Hospital Course:
1) Acute on chronic systolic and diastolic heart failure:
Elevated BNP, history and exam consistent with CHF. Likely
precipitated by AS and HTN, and TTE showed worsened systolic
function (which improved after diuresis) and increased aortic
valve gradient. He also had a slightly elevated troponin likely
in the setting of demand given normal CK-MB. He was diuresed
with lasix IV in 100mg boluses with improvement in symptoms and
was weaned off oxygen. He was restarted on his home dose of
160mg PO lasix daily, although this made the patient appear
volume depleted so was decreased to 80mg daily.
2) Hypertensive emergency: No evidence of renal artery stenosis
on doppler study. Initially required a nitroglycerin drip.
Hydralazine was used for intermittent hypertensive episodes. He
was restarted on clonidine 0.1mg PO BID, nifedepine 60mg CR was
switched from qam to qhs, metoprolol and valsartan continued,
and lisinopril stopped secondary to cough. His BP was well
controlled after these changes.
3) Acute on chronic renal failure s/p renal transplant: Baseline
creatinine 3.0. Had bump to 3.8. Transplant renal ultrasound was
unremarkable. Nephrology was consulted and felt this was due to
his chronic nephropathy and volume shifts. His immunosuppresant
regimen, calcitriol, and sensipar were continued and his
creatinine was trending down at discharge. Renagel was added per
nephrology recommendations.
4) Aortic valve stenosis: TEE showed mod-severe AS with a valve
area of 0.8. He will likely need valve replacement and was seen
by cardiac surgery, but surgery will be scheduled for a
subsequent admission. He was instructed to follow up with Dr.
[**Last Name (STitle) **] in 3 weeks. He will likely need chest CT and cardiac
cath prior to AVR per Dr. [**Last Name (STitle) **].
5) Blurred vision left eye: started in last few weeks per pt.
Opthamology saw pt and noted a blurred optic disc. They
recommended continuing ASA 81 mg, checking ESR (63), and f/u
with optho in 2 weeks (booked).
Medications on Admission:
Allopurinol 100mg [**Hospital1 **]
Calcitriol 0.5mcg 5 days/week
Sensipar 30mg [**Hospital1 **]
Sandimmune 1 cap daily
Aranesp 1 subq inj every two weeks
Lasix 160mg daily
Guanfacine 1mg [**Hospital1 **]
Lisinopril 40mg daily
Metoprolol 50mg [**Hospital1 **]
CellCept 500mg [**Hospital1 **]
Nifedipine 60mg daily
Prednisone 5mg every day
Simvastatin 60mg daily
Tamsulosin 0.4mg daily
Diovan 320mg daily
Zolpidem 1 tab hs
Vitamin C 250mg daily
Multivitamin
* Recently completed Lupron
Discharge Medications:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QHS (once a day (at bedtime)).
4. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO 5
DAYS/WEEK ().
8. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
9. Simvastatin 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
10. Ascorbic Acid 250 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO DAILY (Daily).
11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Cyclosporine 100 mg Capsule Sig: One (1) Capsule PO QAM
(once a day (in the morning)).
15. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
17. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*180 Tablet(s)* Refills:*3*
18. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
19. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
20. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO
three times a day.
Disp:*270 Tablet(s)* Refills:*3*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Primary:
Systolic Congestive Heart Failure
Aortic Stenosis
Mitral Regurgitation
Hypertension
.
Secondary:
s/p renal transplant
Discharge Condition:
Stable, afebrile, oxygen saturations mid 90s on room air
Discharge Instructions:
You had some trouble breathing with activity and some fluid
retention in your legs. We gave you some intravenous furosemide
and your blood presure medicines were adjusted. An ECHO showed
that your aortic valve is narrowed and not working well. You
were seen by the nephrologists here as well. Dr. [**Last Name (STitle) 65483**] talked
to you about surgery to fix your aortic valve.
.
Medicine changes:
1. Clonidine 0.1 mg twice daily was added back
2. Furosemide was decreased to 80 mg daily
3. Renagel was added
4. We stopped your lisinopril since it may have been giving you
a cough
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day
or 6 pounds in 3 days. Please also call Dr. [**Last Name (STitle) **] if you notice
that you have increasing shortness of breath, fevers, chest
pain, nausea, increasing fatigue or any other concerning
symptoms.
Adhere to 2 gm sodium diet
Followup Instructions:
Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 6937**] to schedule an
appointment within the next week.
Please call the office of Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 170**] to make in
appointment in approximately 2-3 weeks.
Ophthomology: Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 253**] on [**2-15**], [**2113**] at 3:00pm [**Hospital Ward Name 23**] 5.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2114-2-28**] 1:30
Provider: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 3217**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2114-4-10**] 1:30
|
[
"285.9",
"403.90",
"585.9",
"V10.85",
"424.1",
"272.4",
"V42.0",
"V10.82",
"368.8",
"428.43",
"428.0",
"274.9",
"V43.3",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
10172, 10235
|
5878, 7881
|
342, 396
|
10406, 10465
|
3108, 5855
|
11419, 12173
|
2223, 2341
|
8415, 10149
|
10256, 10385
|
7907, 8392
|
10489, 11396
|
2356, 3089
|
283, 304
|
424, 1937
|
1959, 2130
|
2146, 2207
|
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