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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
7,548
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49976
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Discharge summary
|
report
|
Admission Date: [**2110-4-6**] Discharge Date: [**2110-4-11**]
Date of Birth: [**2036-5-23**] Sex: F
Service: Neurology
CHIEF COMPLAINT: Right-sided weakness.
HISTORY OF PRESENT ILLNESS: This is a 73-year-old
right-handed woman with history of multiple vascular risk
factors, PFO, Raynaud's, and Sjogren's, who presents with
acute onset of right-sided weakness. She went to bed feeling
well at 11 p.m. She then got up at 2 a.m. to urinate when
she noted that she was walking unsteadily almost falling to
the floor. The patient retrospectively thought her right
side was weak, but had not thought much of it at 2 a.m.
because she was sleepy. She then woke up at 6 a.m. with
right-sided weakness and dysarthria. She denies any
diplopia, dysphagia, visual changes, headache, numbness, or
tingling. As of 6 a.m., she noted that her voice had gotten
increasingly softer.
Of note, patient was discontinued on her statin medications
secondary to muscle cramps. Her blood pressure has been in
the range to 170s systolically and sugars in the 300s.
REVIEW OF SYSTEMS: On review of systems, the patient denies
any fever, chills, nausea, vomiting, headache, neck pain,
numbness, tingling, visual changes, hearing changes, chest
pain, dysuria, hematuria, diarrhea, bright red blood per
rectum, or bowel or bladder problems. She has abdominal
cramps and shortness of breath at baseline. She also has
vertigo secondary to her Meniere's disease.
PAST MEDICAL HISTORY:
1. Sjogren's disease.
2. Raynaud's.
3. Diabetes mellitus.
4. Hypothyroidism secondary to thyroid removal for
hyperthyroidism.
5. Pernicious anemia.
6. Colon cancer status post resection.
7. Seizure disorder sustained after a trauma to the left
temporal lobe 25 years ago with two generalized tonic-clonic
seizures in her life, now controlled with phenobarbital.
8. [**Doctor Last Name **] mal seizure with lip smacking and isolating every
four months.
9. SIADH with Meniere's disease.
10. Polycystic ovarian syndrome with hysterectomy.
11. Endometriosis.
12. Fracture left patella.
13. Status post cataract operation bilaterally.
FAMILY HISTORY: Son has [**Name2 (NI) 1557**] [**Doctor Last Name **] variant of
Guillain-[**Location (un) **] syndrome.
SOCIAL HISTORY: The patient lives at home and performs all
of her activities of daily living independently. Her son
lives next door. She is a retired saleswoman for [**Company 2892**].
There is no history of alcohol or drug abuse. She quit
smoking at age 37 with a 30-pack year history before that.
MEDICATIONS AT HOME:
1. Plavix 75 mg a day.
2. Meclizine 25 mg a day.
3. Percocet [**1-3**] tablet every four hours prn pain.
4. Tramadol 50 mg p.o. q.4h. prn pain.
5. E-Vista 60 mg p.o. q.d.
6. Celebrex 200 mg p.o. b.i.d.
7. Aspirin 81 mg p.o. q.d.
8. Phenobarbital 60 mg p.o. q.a.m. and 120 mg p.o. q.p.m.
9. Synthroid 150 mcg p.o. q.d.
10. Nifedipine control release 30 mg p.o. q.d.
11. Prevacid 50 mg p.o. q.d.
12. Fludrocortisone 0.1 mg p.o. q.d.
13. Quinapril 40 mg p.o. b.i.d.
14. Azathioprine 75 mg p.o. b.i.d.
15. Prednisone 10 mg p.o. q.d.
ALLERGIES: Codeine causes vomiting.
EXAM UPON ADMISSION: Temperature 97.2, blood pressure
203/92, pulse 88, respiratory rate 22, and 100% on 2 liters
of nasal cannula. Generally: A pleasant female in no acute
distress. Neck is supple without carotid bruits. Heart has
regular rate and rhythm with no murmurs or gallops. Lungs
are clear to auscultation bilaterally. There is no clubbing,
cyanosis, or edema on extremities.
On neurologic exam, the patient is awake and alert,
cooperative with exam. She has normal affect. She is
oriented to person, place, and date. She is able to series
subtractions. She is fluent with good comprehension,
repetition. Naming is intact. There is no dysarthria or
paraphasic errors. There is no apraxia or neglect. [**Location (un) **]
is intact. On cranial nerve exam, the patient's pupils are
equal, round, and reactive to light 2.5 to 2 mm bilaterally.
Unable to view the fundus. Visual fields are full to
confrontation. Extraocular eye movements are intact
bilaterally without nystagmus. Facial sensation is intact
and symmetric. She has a right upper motor and facial droop.
Hearing is intact to finger rub bilaterally. Palatal
elevation and sensation is intact and symmetric. She has a
weak cough and a soft voice. Sternocleidomastoids are normal
bilaterally. Right trapezius is 0/5. Tongue is midline
without vesiculations. On motor exam, patient has normal
bulk bilaterally. She has decreased tone on the right side.
There is minimal movement at the right shoulder and hip, but
otherwise is 0/5 on the right arm and leg. Left side has
full power at 5/5. On sensory exam, she is intact to light
touch, pinprick, temperature, vibration, and proprioception.
On the reflex exam, she is [**1-5**] in the right upper extremity
and [**2-5**] in the left upper extremity. There are no reflexes
in the right leg. The left patella is [**2-5**] and left plantar
is [**1-5**]. Grasp reflex is absent. Toes are downgoing in the
left, but upgoing on the right. She has normal
finger-to-nose-to-finger test on coordination test. Gait was
not assessed due to the severe right-sided weakness.
LABORATORIES UPON ADMISSION: White count 4.6, hematocrit
39.6, platelets 360. INR 1.1. PTT 23.9, PT 12.7.
Urinalysis shows positive nitrites, 1000 glucose, [**3-7**] white
cells, and [**3-7**] red cells, [**6-12**] epithelial cells. Chemistry:
sodium is 137, potassium 4.4, chloride 105, bicarbonate 19,
BUN 22, creatinine 0.8, glucose 164. CK is negative.
Troponin is negative.
MRI/MRA shows left corona radiata infarct in the posterior
aspect of the left lateral ventricle. There were no occluded
vessels on the MRA.
HOSPITAL COURSE:
1. Ischemic cerebrovascular infarction: It was not known
whether the patient's stroke was secondary to her underlying
connective tissue disease or vasculitis process. An
angiogram was performed showing no evidence of vasculitis. A
lumbar puncture was performed, which was normal, showing 0
white cells, 1 red cell, 36 protein, and glucose of 138.
There was no evidence of vasculitis on the lumbar puncture
results.
Given these findings, it was felt that she had infarction
secondary to her underlying connective tissue disease. Her
aspirin was increased from 81 to 325 mg a day. She was continued
on her Plavix. Her cholesterol was checked and found to be
elevated at 228 with triglyceride 183, HDL 67, LDL 124. She
was then started on simvastatin 10 mg a day.
Given that she had a history of PFO, lower extremity Dopplers
were obtained, but there was no evidence of a clot. She was
also ruled out for a myocardial infarction and put on
telemetry, which showed no atrial fibrillation.
Hypercoagulable workup was done. The factor VIII, C3, C4,
lupus, antithrombin-III, protein-C, [**Doctor First Name **], and protein-S were
all normal. The beta-2 glycoprotein antibody and
anticardiolipin antibody, prothrombin mutation, factor V
Leiden were all pending upon discharge. If her
anticardiolipin or beta-2 glycoprotein antibody becomes
positive, it is most likely she needs to be anticoagulated
with Coumadin. She was not given anticoagulation during this
hospital course because those results were still pending.
Carotid ultrasound and transthoracic echocardiogram was not
performed on this admission given that she had one done back
in [**2110-2-2**].
2. Rheumatology: Sjogren's and Raynaud's disease as
mentioned above, angiogram and lumbar puncture did not
support any evidence of vasculitis. This was done in light
of the fact that she had a slightly elevated ESR of 46.
Rheumatology was consulted and they asked for a hepatitis B
and C antibody and antigen, which were all negative.
Rheumatoid factor was 317 and C-reactive protein was 7.3.
Her [**Doctor First Name **] was positive at titer 1:1280. SPEP and C3, C4, and
RPR were all done and found to be normal. Cryoglobulin and
UPEP were still pending upon discharge.
Patient also has underlying chronic infiltrative lung disease
secondary to her rheumatological disease. A chest x-ray was
performed showing a right lower lobe opacity. A CT of the
chest was done to further delineate this finding. However,
the CT of the chest showed no evidence of pulmonary embolism
or changes from her prior CT of the chest.
For her Sjogren's and Raynaud's, she was initially put on
methylprednisolone 30 mg twice a day and that was weaned down
to prednisone 10 mg a day. Rheumatology also recommended
restarting her nifedipine to prevent any vasospasm.
3. Infectious disease: Patient was screened for MRSA and
VRE, which were both negative. Urinalysis that was done
later did show evidence of a urinary tract infection. Urine
cultures grew Enterococcus that were susceptible to
levofloxacin. She was treated with a seven-day course of
levofloxacin.
DISCHARGE DIAGNOSES:
1. Left thalamic/corona radiata cerebrovascular ischemic
infarct.
2. Sjogren's.
3. Raynaud's.
4. Urinary tract infection.
DISCHARGE MEDICATIONS:
1. Prednisone 10 mg p.o. q.d.
2. Nifedipine 40/20/40 mg a day.
3. Aspirin 325 mg a day.
4. Plavix 75 mg a day.
5. Levofloxacin 500 mg p.o. q.d. x7 day course.
6. Protonix 40 mg a day.
7. Simvastatin 10 mg a day.
8. Azathioprine 75 mg p.o. b.i.d.
9. Synthroid 150 mcg a day.
10. Phenobarbital 120 p.o. q.p.m. and 60 mg p.o. q.a.m.
11. Tramadol 50 mg p.o. q.4h. prn.
12. Hydrocodone/acetaminophen 1-2 tablets p.o. q.4-6h. prn.
13. Meclizine 25 mg p.o. q.d.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To rehabilitation center.
FOLLOWUP: The patient is to followup with Dr. [**Last Name (STitle) 3057**] in
Rheumatology, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in Neurology, Dr. [**Last Name (STitle) 2146**] in
Pulmonology, and her primary care doctor.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 5930**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 6125**]
Dictated By:[**Last Name (NamePattern1) 4270**]
MEDQUIST36
D: [**2110-4-11**] 07:20
T: [**2110-4-11**] 07:30
JOB#: [**Job Number 104360**]
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68,402
| 173,121
|
40022
|
Discharge summary
|
report
|
Admission Date: [**2112-11-7**] Discharge Date: [**2112-11-15**]
Date of Birth: [**2043-3-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
PCP: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
CC:[**Hospital6 88030**]
Major Surgical or Invasive Procedure:
percutaneous intraabdominal drain for biloma
percutaneous cholecystostomy
central venous line placement x2
axillary arterial line placement
History of Present Illness:
Mr. [**Known lastname 22159**] is a 69 M with a medical history notable for
previous partial gastrectomy and peripheral vascular disease
transferred from [**Hospital6 302**] with an intra-abdominal
fluid collection concerning for a biloma.
In reviewing Mr. [**Known lastname 88031**] large chart from the OSH, there are a
few conflicting pieces of information. Below is what was
collected from interview with the patient and on review of the
OSH records.
He originally presented to [**Hospital6 302**] the first week of
[**Month (only) 359**] with abdominal pain and vomitting. He reported
intermittent epigastric pain not associated with food or BM,
typically a [**5-23**]. He had no similar abdominal pain in the past.
His evaluation at that time reportedly revealed the following: a
HIDA scan with delayed gall bladder emptying but no definite
obstruction, an abdominal MRI with a mildly distended gall
bladder with no evidence of stone, an elevated lipase, and a CT
scan with evidence of acute pancreatitis. He was diagnosed with
acalculous cholecystitis and discharged on 2 weeks of Augmentin.
He reports feeling well after discharge but noted recurrent
abdominal pain and loose, watery bowel movements. He was
re-admitted to [**Hospital6 302**] on [**2112-11-1**] for these
symptoms. His evaluation revleaed an albumin of 1.5, negative C
diff toxin, a TTE with LVEF 60-65% and normal RV function, a PE
CT that revealed a left lower lobe PE (diagnosed on the day of
transfer), and a CT abdomen that revealed a large, loculated
fluid collection behind the liver with persistent gall bladder
dilation and a stricture of the common hepatic duct. For the
above CT findings, he had an ERCP on [**11-3**] that revealed
contrast accumulation adjacent to the gall bladder consistent
with a bile leak; a stent was placed in the common hepatic duct
though there was no obvious obstruction there. A repeat CT scan
on [**11-5**] revealed interval improvement in the fluid collection
and incidental findings of a left lower lobe air bronchogram
(started on Zosyn for presumed pneumonia) and left kidney
perfusion defects concerning for infarct.
Medications on transfer:
- Atenolol 25mg daily
- Lactobacillus
- Protonix 40mg IV twice daily
- Zosyn 3.375g IV q6 hours
- Crestor 5mg daily
- Flomax 0.4mg daily
- Aspirin 81mg and Plavix 75mg daily (on hold since [**11-3**])
- Morphine for pain
- Zofran for nausea
- Oxazepam 10mg qhs
- Percocet as needed for pain
Review of Systems: Prior to the above Mr. [**Known lastname 22159**] tells me he
felt well and was independent at home. Over the last month he
noted no fevers, chills, or night sweats. Appetite is poor and
his weight is down. No SOB, cough, or chest pain. No urinary
symptoms. Other systems reviewed in detail and all otherwise
negative.
Past Medical History:
- Either gastric or esophageal cancer s/p resection with
parital gastrectomy, chemotherapy and radiation (approximately 5
years ago).
- Hypertension
- Coronary artery disease and patient reports no MI or
revasculariztion procedures
- Peripheral vascular disease s/p revascularization procedure
[**8-/2112**]
Social History:
He is independent and lives with his girlfriend. [**Name (NI) **] smokes [**1-16**]
ppd and drinks occasional alcohol.
Family History:
He believes his sister had her gall bladder removed but he is
unsure. No other history of gall bladder disease or malignancy.
Physical Exam:
Vital Signs: T 96.2, P 93, BP 121/76, 94% on RA.
Physical examination:
- Gen: Thin male with anasarca. Appears in NAD.
- HEENT: Sclera anicteric. He often talks with his right eye
closed but is able to open it.
- Neck: Supple.
- Chest: He is very weak and unable to participate in a full
lung exam. He appears to be moving air well anteriorly but
decreased breath sounds at the bases. No wheezes.
- CV: PMI normal size and not displaced. Regular rhythm. Normal
S1, S2. He has a harsh, systolic murmur at the base that is
somewhat high-pitched. No radiation. JVP 6 cm.
- Abdomen: Normal bowel sounds. His abdomen is firm. No
tenderness with deep palpation of all quadrants.
- Extremities: diffuse LE edema, [**2-17**]+; also with swelling and
weeping of UE
- Neuro: Alert, oriented x3. Good fund of knowledge about
medical care over the last month. Able to discuss current events
and memory is intact. CN 2-12 intact. English is his second
language but he is fluent. Speech and language are otherwise
normal. He moves all extremities but he is unable to sit up
without full assistance.
- Psych: Appearance, behavior, and affect all normal.
Pertinent Results:
Latest available labs:
[**2112-11-14**] 08:27PM BLOOD WBC-9.6 RBC-2.45* Hgb-6.9* Hct-21.1*
MCV-86 MCH-28.2 MCHC-32.8 RDW-16.1* Plt Ct-130*#
[**2112-11-14**] 04:00AM BLOOD Neuts-82* Bands-0 Lymphs-11* Monos-6
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2112-11-14**] 04:00AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-1+
Target-OCCASIONAL Schisto-1+
[**2112-11-14**] 08:27PM BLOOD PT-22.7* PTT-63.6* INR(PT)-2.1*
[**2112-11-11**] 05:00AM BLOOD Fibrino-417*
[**2112-11-10**] 08:22PM BLOOD FDP-10-40*
[**2112-11-14**] 08:27PM BLOOD Glucose-181* UreaN-17 Creat-0.4* Na-140
K-3.4 Cl-106 HCO3-25 AnGap-12
[**2112-11-14**] 04:00AM BLOOD ALT-21 AST-18 AlkPhos-81 TotBili-1.1
[**2112-11-14**] 08:27PM BLOOD Calcium-7.3* Phos-3.4 Mg-2.0
[**2112-11-11**] 12:55PM BLOOD Hapto-32
[**2112-11-8**] 07:00AM BLOOD Triglyc-44 HDL-9 CHOL/HD-3.4 LDLcalc-13
[**2112-11-7**] 02:15AM BLOOD CEA-1.8
[**2112-11-14**] 06:02AM BLOOD Vanco-29.9*
[**2112-11-14**] 04:25AM BLOOD Type-[**Last Name (un) **] pO2-44* pCO2-37 pH-7.43
calTCO2-25 Base XS-0
[**2112-11-14**] 04:22AM BLOOD Lactate-1.4
[**2112-11-14**] 04:22AM BLOOD freeCa-1.07*
[**2112-11-11**] 01:33PM BLOOD O2 Sat-97
CT head: [**2112-11-14**]
Right MCA and ACA territory infarction with significant mass
effect resulting in leftward subfalcine herniation, right uncal
herniation and concern for impending cerebellar tonsillar
herniation. Entrapment of the left lateral ventricle. Diffuse
sulcal effacement. Emergent neurosurgery consult recommended.
CT torso: [**2112-11-10**]
1. Progressive worsening multifocal consolidations involving the
right upper, middle and lower lobes concerning for pneumonia. In
the setting of the contrast within the esophagus and layering on
the cords, concern for
aspiration pneumonia is high.
2. Pulmonary embolism of the left posterior basal segmental
artery.
3. Interval worsening of the lobulated effusion on the right
with layering
over the major fissure. The appearance of this effusion is
concerning for
exudative process.
4. Interval drainage of the perihepatic fluid collection.
Persistent
gallbladder distention, gallbladder wall edema, but
decompression of
intrahepatic bile ducts with stent post ERCP. Heterogeneous
enhancement of the liver concerning for cholangitis. Small
amount of residual perihepatic fluid tracking inferior to the
gallbladder and in periportal spaces. Further attenuation of
left portal vein riases question of thrombosis.
5. Increase in the degree of ascites within the abdomen without
evidence of peritoneal enhancement or thickening to suggest
diffuse
infection/inflammation. Intermesenteric fluid pocket in the
right mid-to-lower abdomen has slight peritoneal thickening and
may be a developing collection.
6. Chronic ischemia to bilateral upper poles of the kidneys,
from radiation.
7. Bilateral superficial femoral artery occlusions stable since
the outside hospital studies.
Brief Hospital Course:
69 y/o male with CAD, PVD, and past history of gastroesophageal
CA s/p partial gastrectomy transferred from [**Hospital6 302**]
after recent ERCP with concern for an infected bile leak and
possible ruptured gallbladder. He was admitted to the wards and
received an ultrasound-guided aspiration and drainage of
perihepatic collection by IR on [**2112-11-7**]. He developed
respiratory failure with new infiltrate in right mid and lower
lung, initially thought to be due to hospital acquired
pneumonia, started on vancomycin and zosyn which targeted both
his respiratory failure and his possible biliary infection.
Upon arrival to the ICU he was suctioned and due to low oxygen
saturations, tachypnea, and increased work of breathing, he was
intubated. An axillary a-line was placed and he was started on
pressor support (levophed). He was continued on antibiotics
with improvement of his infiltrate over the course of several
days.
His percutaneous biliary collection drain continued to put out
frank pus throughout his stay. He had a paracentesis at the
time of his percutaneous drain placement. Peritoneal cultures
grew yeast. Micafungin cultures were added. His PICC was
removed and blood cultures were positive for yeast on [**2112-11-9**].
CT abd/pelvis was completed which showed persistent gallbladder
distention and gallbladder wall edema. He was followed by ERCP
and surgery throughout admission. Surgery team was concerned
about potential malignancy of his biliary tree and recommended
considering ERCP for brushings.
Of note he had an incidental pulmonary embolus in left posterior
basal segmental artery for which he was initially placed on a
heparin drip. However, his platelets dropped significantly and
due to concern for HITT, his heparin was stopped and was started
on agatroban. HITT Ab negative on [**2112-11-14**] at which time
agatroban was held.
Due to concern for gallbladder necrosis and worsening fluid
collection in and around his gallbladder, percutaneous drain was
placed on [**2112-11-14**]. Platelets and FFP were given before the
procedure for elevated coag studies (was on agatroban). There
were no immediate complications of the surgery.
During the afternoon of [**2112-11-14**] he was seen by opthalmology who
dilated his pupils and examined for evidence of candidal
opthalmic involvement, of which none was found. After exam his
pupils remained fixed and dilated and remained so throughout the
afternoon despite clearance of dilating medications. Sedation
had been stopped early in the morning and throughout the day he
was not responsive to painful stimuli, he did not have a cough
or gag, and he was persistently breathing above the vent rate
settings. Neurologic exam revealed fixed gaze with head turning
which was particularly concerning for brain stem lesion. CT
head was ordered and showed right MCA and ACA territory
infarction with significant mass effect resulting in leftward
subfalcine herniation, right uncal herniation and concern for
impending cerebellar tonsillar herniation. Neurosurgery was
consulted urgently who saw the patient and reviewed his films.
They determined that due to the extensive size of his infarct
territory, midline shift and evidence of herniation that his
current stroke was not compatible with life. There was no
neurosurgical intervention that would change outcome. Family
was called and they came to the hospital. Met with family and
decided that due to grave prognosis, patient would have wanted
to be extubated and made comfort measures only. He was
extubated on [**2112-11-15**] at 0445. 25 minutes later he became apneic
and asystolic and was pronounced at 0510. He passed peacefully
in the company of his loving family at the bedside.
The family declined autopsy. Organ bank was notified prior to
extubation and after discussion of his case declined him for
organ donation secondary to fungemia and history of
gastroesophageal cancer. Admitting notified. Death certificate
signed.
Medications on Admission:
-patient unable to confirm all medication names and doses-
Augmentin 875mg [**Hospital1 **]
Aspirin 81mg qday
Atenolol 25mg qhs
Pletal 100mg [**Hospital1 **]
Plavix 75mg qday
Lorazepam 1mg TID PRN
Ranitidine 150mg [**Hospital1 **]
Simvastatin 20mg qday
Oxazepam 10mg qhs PRN
Percocet PRN pain
Tramadol q6h PRN pain
Discharge Disposition:
Expired
Discharge Diagnosis:
cardiopulmonary arrest, cerebral edema secondary to right MCA
and ACA stroke, sepsis with fungemia, bile leak s/p ERCP,
emphysematous gallbladder
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
Completed by:[**2112-11-15**]
|
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icd9cm
|
[
[
[]
]
] |
[
"33.24",
"38.97",
"54.91",
"51.01",
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"96.04",
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icd9pcs
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[
[
[]
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12525, 12534
|
8162, 12160
|
445, 586
|
12723, 12733
|
5213, 6405
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12790, 12830
|
3911, 4038
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12555, 12702
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12186, 12502
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12757, 12767
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4053, 4103
|
4125, 5194
|
3103, 3423
|
277, 407
|
614, 2756
|
6414, 8139
|
2782, 3084
|
3446, 3759
|
3775, 3895
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,163
| 178,334
|
16192
|
Discharge summary
|
report
|
Admission Date: [**2102-5-6**] Discharge Date: [**2102-5-16**]
Date of Birth: [**2021-6-14**] Sex: M
Service: MEDICINE
Allergies:
Horse Blood Extract
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
80 yo M with PMH significant for ESRD on HD, CAD s/p
CABG x 3 COPD.Patient discharged 2 weeks ago from [**Hospital1 18**] after
he had a L subclavian stent placed. He presented to ED today
from [**Hospital3 **] where he c/o of cough , SOB weakness,
fatigue and low grade fever x 1 week. He was diagnosed with
influenza A 1 week ago.
.
In ED he was found to be very tachypneic RR 35 % and SpO2 100%
on a NRB mask. CxR with hyperinflated lung and interstitial
infiltrates. Patient had a CTA of chest to rule out PE after
which ,while he was back in the ED, he developed an episode
of SVT. Patient's BP remained stable. VBGs : 7.09/89/95/26 .He
was given 1 lt NS, Levaquin , Flagyl ,Lasix 80 mg , solumedrol
125 mg and bronchodilators. He was intubated and transferred to
MICU.
Renal was consulted for emergent hemodyalisis. They considered
there was no indication due to patient's abnormal heart rhythm.
Cardiology -was consulted , no indication for revascularization.
Recommended treating respiratory acidosis.
Past Medical History:
ESRD [**3-10**] HTN nephrosclerosis on HD
CAD s/p CABG X 3 in [**2082**]
PVD s/p mult revasculazations in [**12-10**] and [**2-10**].
CHF (EF 50%)
Hypercholesterolemia
Carotid Artery Stenosis s/p L CEA [**2087**]
COPD
h/o prostate CA on lupron (PSA undetectable)
Restless Leg Syndrome
Depression
Legally blind [**3-10**] macular degeneration
R inguinal hernia
Social History:
He is a former smoker one-half pack per day for
30 years quit 22 years ago. He has former alcohol abuse, quit
in
[**2070**]. He is a former elementary and [**Male First Name (un) 1573**] high school teacher.
Denies EtOH.Retired middle school teacher.functional status . He
uses a rolling walker at baseline.
Family History:
Mom DM
Father prostate ca
SIster breast ca
Physical Exam:
T 98.5 (102.5 ax in ED) BP 105/56 HR 72
AC TV 500 RR 20 PEEP 5 FiO2 0.6
ABGs 7.27/45/186/22
Gen - elderly, chronically ill, pale appearing male in NAD,
Skin - diffuse ecchymosis in abdomen and forearms
HEENT - tube @ 23 cm sclerae anicteric, slightly dry MM, OP
clear, LAD, neck ,supple
CV - RRR, +s1/s2, II/VI systolic murmur over LSB and apex
Lungs - limited by poor inspiratory effort, decreased BS b/l,
bilateral wheezing
Abd - Soft, NT, slightly distended, normoactive BS
Ext - no LE edema, DP pulses not appreciated but feet warm to
touch, has R forearm fistula
Neuro - not tested, sedated.
Pertinent Results:
EKGs :
-upon arrival : sinus rhythm, RBBB.
-During episode of SVT: left axis deviation, wide complex
tachycardia, small P waves in DII
-post SVT : RBBB
.
-CxR: hyperinflated lungs , bilateral interstitial infiltrates.
CTA chest:
.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. New nodular opacities in the right lower lobe and right
upper lobe with resolution of the left upper lobe opacity
previously seen. The rapidity of these changes are more
suggestive of an infectious or inflammatory process. However,
continued followup to ensure resolution is recommended.
3. Increased density and reticulated appearance to the
vertebral bodies, likely related to renal osteodystrophy.
4. Cardiomegaly and coronary artery disease and more diffuse
atherosclerosis
Brief Hospital Course:
#Respiratory Failure: most likely respiratory failure is
pneumonia in the setting of a patient with a very poor lung
function, as determined by previous PFTs and current CxR.
Additional V/Q mismatch is likely related to a PNA considering
he has fever, cough , secretions and a 2 opacities in RML and
RLL ,c/w multifocal PNA. Was extubated soon after intubation and
has been weaning off of O2.
-s/p course of azithro for possible legionella (legionella ag
negative) and continuing on zosyn for GN's and vanco for gm
positives (and enterococcus in urine).
.
#Respiratory Acidosis: Patient's ABGs c/w acute respiratory
acidosis, probably related to COPD with probably with
?hypoventilation?, muscular fatigue due to hypoxemia?
pHs improved after patient intubated and then remained fine
after extubation.
.
#PNA: Patient has fever, elevated WBC, infiltrate on CT.
Etiology unclear.
-sputum studies, Urine Legionella Ag negative. DFA for influenza
A and B negative.
-covering with Zosyn (to cover Pseudomonas considering patient
has bronchieactasis on CT and comes from rehab), Zithromax for
Legionella x 5 days (completed [**5-11**]). Vanco considering he has hx
of influenza infection, could have staph PNA.
-blood cultures neg
--remained afebrile through [**5-16**]. white count elevated but
otherwise no significant signs of infection, most likely due to
steroids. white count stabilized at discharge, minimal O2
requirement.
.
#COPD: Patient has histoty of severe COPD. Was initially given
solumedrol 80 tid which is being tapered. switched to prednisone
and tapered to zero at discharge.
-Continue nebs
-taper steroids quickly
.
#SVT: Patient had episode of SVT in ED. EKG in MICU has remained
within NSR. Per Cardiology, no signs of ischemia.
-Continue following EKG.
-added metoprolol
.
#CP pt c/o one episode of CP on am [**5-15**] with some rate related ST
changes, relieved with BB, Morphine and SLNTG, Enzymes negative
x 3. no recurrence.
.
#Borderline BP: Patients BP has remained systolic 105- 110s
unclear baseline. BP prior to intubation with systolic near
130-150s. Lactate elevated on admission. Most likely related to
hypoperfusion
-Initially held BP meds - now restarting with strict holding
parameters.
.
#CAD:
- Patient on ASA, Plavix, statin. BB added back and going back
up to home dose slowly.
- troponins were flat.
.
#ESRD: pt makes very little urine. HD scheduled for Mon, Wed,
Fri.
-Continue Phoslo and give Epo during dyalisis
-Follow Vanc levels in dialysis.
.
#Lung nodule: seems to have improved per new CT.
-Follow up after PNA has resolved.
.
#Coagulopathy: patient has elevated PTT and PT. D dimer elevated
but no evidence of DIC.
.
#Code status: Discussed with wife extensively who states pt is
definitely DNR/DNI now even though this had been reversed for
the intubation earlier on this admission. Wife is HCP and states
pt has been declining lately and they are prepared if he
declines further to make him CMO.
Medications on Admission:
Plavix 75 mg qd
ASA 325 mg qd
Metoprolol 37.5 mg tid
NTG 0.3 mg sl PRN
Lipitor 40 mg qd
Fluticasone 50 mcg qd
Albuterol nebulizer q 6 h
Combivent inhaler
Ipatropium inhaler
Citalopram 40 mg qd
Tamsulosin/Flomax 0.4 qd
Stool softeners
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
pneumonia
Discharge Condition:
good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet. wigh yourself. you were treated in
the hospital for pneumonia which resolved. you are to return to
the rehab facility and resume all your other medications. follow
all instructions. return to the hospital for any chest pain or
shortness of breath.
Followup Instructions:
follow up with your doctor in the next two weeks.
|
[
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"272.0",
"V45.81",
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icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"96.6",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7408, 7478
|
3539, 6488
|
282, 289
|
7532, 7539
|
2747, 3516
|
7937, 7990
|
2065, 2110
|
6772, 7385
|
7499, 7511
|
6514, 6749
|
7563, 7914
|
2125, 2728
|
239, 244
|
317, 1339
|
1361, 1722
|
1738, 2049
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,090
| 121,590
|
33813
|
Discharge summary
|
report
|
Admission Date: [**2187-5-9**] Discharge Date: [**2187-5-18**]
Date of Birth: [**2119-11-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Aspirin / Ibuprofen / Motrin
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Tracheobronchomalacia.
Major Surgical or Invasive Procedure:
[**2187-5-9**] Flexible bronchoscopy with bronchoalveolar lavage of
the right lower lobe, right thoracotomy, right upper lobe wedge
resection, thoracic tracheoplasty with mesh; right mainstem
bronchoplasty and bronchus intermedius bronchoplasty with mesh;
left mainstem bronchoplasty with mesh.
History of Present Illness:
Mr. [**Known lastname 78172**] is a 67-year-old gentleman who has had cough,
dyspnea and recurrent pulmonary infections. He was found to have
severe tracheobronchomalacia
on bronchoscopy. He had a stent trial and responded favorably in
terms of his cough and dyspnea.
Past Medical History:
Recurrent pneumonias, asthma, BPH, sinusitis, status post left
meniscectomy of the left knee, status post TURP, status post
three sinus surgeries, status post tonsillectomy, status post
ankle plating, status post vasectomy, status post recurrent
inguinal hernia repairs.
Social History:
A 34-pack-year smoker, discontinued 32 years ago. Occupation:
Retired insurance [**Doctor Last Name 360**] and carpenter. Lives with his family.
He occasionally drinks beer, and he had exposure history to
asbestos while in the Navy.
Family History:
Mother had heart failure. His father had COPD
and a question of neck cancer.
Physical Exam:
General: 67 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR, normal S1,S2 no murmur/gallop or rub
Resp: decreased breath sounds otherwise clear
GI: bowel sounds positive, abdomen soft non-tender/non-distended
Extr: warm no edema
Incision: right thoracotomy site clean/dry intact
Neuro: non-focal
Pertinent Results:
[**2187-5-17**] WBC-8.0 RBC-3.59* Hgb-11.0* Hct-32.4* Plt Ct-381
[**2187-5-10**] WBC-8.5 RBC-3.99* Hgb-12.2* Hct-36.9* Plt Ct-229
[**2187-5-18**] BLOOD PT-14.2* PTT-30.3 INR(PT)-1.2*
[**2187-5-17**] Glucose-120* UreaN-17 Creat-1.0 Na-134 K-4.7 Cl-100
HCO3-28
[**2187-5-10**] Glucose-125* UreaN-22* Creat-1.0 Na-137 K-4.7 Cl-104
HCO3-26
[**2187-5-12**] Blood Culture, Routine (Final [**2187-5-18**]): NO GROWTH.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2187-5-17**]
CT CORONARY ANGIOGRAPHY
FINDINGS:
CT coronary angiography revealed a right dominant system with
normal origins and orientations of the left and right main
coronary arteries. The right coronary artery was technically
difficult to evaluate due to artifact from cardiac motion and
change as well as a high heart rate during the examination.
There is apparent noncalcified plaque in the proximal and mid
course of the right coronary artery. There is a short left main
coronary artery, and there is nonobstructive calcified plaque in
the proximal as well as mid LAD. Similarly, there is mixed
plaque in a patent D1. There is also minimal nonobstructive
mixed plaque in the LCX.
CT cine images of left ventricle showed normal wall motion. The
left ventricular end-diastolic volume was 220 cc, the
end-systolic volume was 178 cc, the stroke volume was 42 cc, and
the ejection fraction was 19%. The coronary calcium score was
294 Agatston with bulk of the calcium in LAD.
CONCLUSION:
Global cardiac dysfunction with an ejection fraction of 19%.
Very limited evaluation of the right coronary artery due to
motion artifact and a very high heart rate during the
examination. Within these limitations, there is nonobstructive
mixed plaque seen in the right coronary artery as well as the
left anterior descending coronary artery.
There are multiple calcified pleural plaques and multifocal
areas of pleural thickening consistent with prior asbestos
exposure. There are scattered ill- defined ground-glass
opacities in the left upper lobe which are new since the scan of
[**2187-2-22**] and most likely are consistent with an infectious or
inflammatory etiology. There is a small right basal effusion.
There are several scattered mediastinal lymph nodes with the
largest measuring 15 x 14 mm in a pretracheal location.
There are bilateral pulmonary emboli. There is no aortic
dissection. The coronary arteries arise from the normal expected
anatomic location.
There is a small hiatus hernia. The visualized liver and spleen
appear unremarkable.
CONCLUSION:
1. Multiple bilateral pulmonary emboli with no aortic dissection
and normal origin of the coronary arteries.
2. Calcified pleural plaques and pulmonary nodules along with
pleural thickening consistent with asbestos exposure.
3. Ground-glass opacities in the left upper lobe, most likely
infectious or inflammatory, however, a followup chest CT would
be helpful to ensure complete resolution of these pulmonary
opacities given the background emphysema and prior asbestos
exposure.
Brief Hospital Course:
Mr. [**Known lastname 78172**] was admitted on [**2187-5-9**] underwent Flexible
bronchoscopy with bronchoalveolar lavage of the right lower
lobe, right thoracotomy, right upper lobe wedge resection,
thoracic tracheoplasty with mesh; right mainstem bronchoplasty
and bronchus intermedius bronchoplasty with mesh; left mainstem
bronchoplasty with mesh.
He was extubated in the operating room and taken to the SICU for
further management with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**] drain, foley and Epidural
managed by the acute pain service. On POD [**Street Address(2) 78173**]
130's, required increase in epidural rate for better pain
control which dropped his BP requiring pressors and IV fluid
boluses. He was on a clear liquid diet which he tolerated. On
POD #2 the epidural was decreased and given IV Dilaudid for
pain. He was weaned off the pressors. His oxygen requirements
increased, HR remained ST 130's and not responding to IV
Lopressor. His cardiac enzymes were negative. He was gently
diuresed, aggressive pulmonary toileting was continued. He
developed AFib and was administered an amiodarone bolus/drip and
converted to SR. On POD #3 the epidural was removed and his pain
was managed with a Dilaudid PCA with good control. His
oxygenation improved, the CXR revealed atelectasis. On POD #4
the foley was removed, the [**Doctor Last Name 406**] drain was removed. Cardiology
was consulted who recommended amiodarone PO for 1 month, an
echocardiogram which revealed an EF of 20-25% and severe global
left ventricular hypokinesis with moderate to severe mitral
regurgitation and moderate left ventricular dilatation. Mild
pulmonary artery systolic hypertension with preserved right
ventricular systolic function. Given the above findings a
cardiac CTA angiogram was done and an incidental finding of
multiple bilateral pulmonary emboli were found which he was
started on Lovenox and Coumadin. His coronary arteries were
normal. He was discharged to home with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of hearts monitor
and will follow-up with cardiology as an outpatient. He will
follow-up with Dr. [**Last Name (STitle) **] in 2 weeks, and his PCP will
manage his Coumadin
Medications on Admission:
flonase, tessalone [**Last Name (un) **], benadryl, MVI, Zyflo, singular,
fosamax, advair, vitamin D2, mucinex
Discharge Medications:
1. Zileuton 600 mg Tab, Multiphasic Release 12 hr Sig: Two (2)
Tab, Multiphasic Release 12 hr PO bid ().
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/headache.
8. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
start [**2187-5-24**].
Disp:*30 Tablet(s)* Refills:*2*
12. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day
for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
13. Outpatient Lab Work
INR check sunday [**2187-5-20**] then 2-3 times weekly or directed by
Dr. [**Last Name (STitle) 78174**].
phone: [**Telephone/Fax (1) 75671**]
Fax: [**Telephone/Fax (1) 78175**]
14. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
15. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12 ().
Disp:*12 * Refills:*2*
16. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
17. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
Discharge Disposition:
Home With Service
Facility:
VNA and Hospice of Northern [**Hospital1 **]
Discharge Diagnosis:
severe asthma, recurrent PNA, chronic sinusitis, nasal polyps,
GERD, osteoporosis,
tracheobronchomalacia s/p tracheobronchoplasty
post-operative atrial fibrillation
EF 20-25%
bilateral subsegmental pulmonary emboli
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] if you develop chest
pain, shortness of breath, fever, chills, green or brown
productive cough, redness or drainage from your chest incision.
You are on new heart medications and cholesterol lowering
medication as well as a blood thinner called coumadin. Your PCP
[**Last Name (NamePattern4) **]. [**First Name (STitle) **] will be managing your coumadin medication. You will
need to have frequent blood monitoring of this medication. INR
levels will be checked and then your doctor will advise you
regarding the dosing of your coumadin.
You will have your INR blood work drawn on Sunday.
Lovenox 80 mg twice daily: continue until INR 2.0 or greater
then stop
Followup Instructions:
You have a follow up appointment with DR. [**Last Name (STitle) **] on the
[**Hospital Ward Name **] [**Hospital Ward Name **] Clinical center [**Location (un) **] [**2187-6-7**] at 2pm.
Please arrive 45 minutes prior to your appointment and report to
the [**Location (un) 470**] radiology for a chest xray.
You have a follow up appointment with Dr. [**Last Name (STitle) **] and Dr.
[**Last Name (STitle) **] (cardiologists)[**Telephone/Fax (1) 6197**] [**2187-6-7**] at 11:40am [**Hospital Ward Name 23**]
7 [**Hospital Ward Name **]
Completed by:[**2187-5-21**]
|
[
"E879.8",
"427.32",
"997.1",
"493.90",
"427.89",
"415.11",
"519.19",
"E878.8",
"427.31",
"425.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.48",
"33.24",
"32.29",
"31.79",
"03.90"
] |
icd9pcs
|
[
[
[]
]
] |
9242, 9317
|
4990, 7234
|
319, 618
|
9576, 9583
|
1967, 4967
|
10358, 10926
|
1480, 1560
|
7395, 9219
|
9338, 9555
|
7260, 7372
|
9607, 10335
|
1575, 1948
|
256, 281
|
646, 916
|
938, 1211
|
1227, 1464
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,285
| 103,640
|
35731
|
Discharge summary
|
report
|
Admission Date: [**2200-12-6**] Discharge Date: [**2200-12-12**]
Date of Birth: [**2172-7-18**] Sex: F
Service: MEDICINE
Allergies:
Adhesive Pads
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
palpitations, anxiety
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is 28 year old female with PMH of HCV who presented to
the ED with a chief complaint of anxiety, palpitations, and
abdominal pain. Per patient, she has been using GHB every [**12-31**]
hours for the past 1.5 weeks until Tuesday at 5pm, when she ran
out. She subsequently presented to [**Hospital3 68**] a few hours
later with symptoms of anxiety, mild SOB, palpitations that she
attributed to GHB withdrawal, which had not abated at home with
Phenibut. Per her, she was admitted to the ICU at [**Location (un) **] for 3
days. She is unclear on the management and states she does not
remember the first two; however, she received infrequent
medication, is unclear on the treatment, and was sent home
without medical management or follow-up. She states she was
discharged earlier today.
.
After discharge, she found two 0.5mg of ativan in her car, which
she took because of anxiety. She states she infrequently takes
ativan, and none in the last two weeks before day of admission.
She continued to have worsening anxiety and palpitations at
home, as well as epigastric sharp abdominal pain, muscle
"clenching", and panic-like symptoms. Therefore, she presented
to the [**Hospital1 18**] ED.
.
In the emergency department, initial vitals: 97.6 145 149/95 12
99. She was given 10mg of IV valium with resultant drop in her
HR to 105. Her abdominal pain subsided with benzo
administration. She continued to be anxious, so phenobarbital
was started. A total of 150mg was given, but then it was
stopped because increased anxiety and muscle tremors. At the
time of signout, she was sleeping. Neurological exam was
described as nonfocal. Labs were notable for a normal chem 7,
WBC of 13.9 (N 79, L 15.6, M 4.5, E 0.8, Bas 0.2) but otherwise
normal CBC, HCG negative, and tox screen negative for asa, etoh,
acetaminophen, benzos, barbiturates, and tricyclics. Toxicology
was called and plan to see her in the AM. Phone recs included
benzos and then phenobarbital if needed. Indication for ICU
admission was risk of respiratory depression from receiving
phenobarbital.
.
Prior to transport, vitals were:
98.9 120 117/84 18 99%RA
.
REVIEW OF SYSTEMS:
(+)ve: as per HPI
(-)ve: fever, chills, night sweats, loss of appetite, fatigue,
chest pain, rhinorrhea, nasal congestion, cough, sputum
production, hemoptysis, dyspnea, orthopnea, paroxysmal nocturnal
dyspnea, nausea, vomiting, diarrhea, constipation, hematochezia,
melena, dysuria, urinary frequency, urinary urgency, focal
numbness, focal weakness, myalgias, arthralgias
Past Medical History:
1. Hepatitis C, genotype 3a, not currently treated.
2. Renal calculi.
Social History:
She is with a steady monogamous relationship for the past 2
years. She works as a waitress at Stephanie's [**Location (un) 81267**]. She smokes 10 cigarettes a day. She drinks alcohol
about 1x per month. She does recreational intranasal cocaine
about twice monthly. She reports IVDU twice in the past about 2
yrs ago. She reports she feels safe at home and denies
physical/emotional abuse.
Family History:
Her mother has a brain tumor. No history of substance abuse.
Uncle with aneurysm.
Physical Exam:
Admission:
98.6 105 121/81 13 96%RA
.
.
PHYSICAL EXAM
GENERAL: Pleasant, well appearing, in NAD though slightly
anxious
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: tachycardic, regular. Normal S1, S2. No murmurs, rubs
or [**Last Name (un) 549**]. No JVD
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 intact. Preserved sensation
throughout. 5/5 strength throughout. [**11-29**]+ reflexes, equal BL.
Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2200-12-6**] 08:40PM PLT COUNT-308
[**2200-12-6**] 08:40PM NEUTS-79.0* LYMPHS-15.6* MONOS-4.5 EOS-0.8
BASOS-0.2
[**2200-12-6**] 08:40PM WBC-13.9* RBC-5.18 HGB-15.3 HCT-44.2 MCV-85
MCH-29.6 MCHC-34.7 RDW-13.1
[**2200-12-6**] 08:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2200-12-6**] 08:40PM HCG-<5
[**2200-12-6**] 08:40PM estGFR-Using this
[**2200-12-6**] 08:40PM GLUCOSE-109* UREA N-22* CREAT-0.8 SODIUM-138
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-22 ANION GAP-18
Chest film IMPRESSION: No acute cardiopulmonary abnormality
[**2200-12-8**] 06:25AM BLOOD WBC-6.5 RBC-5.02 Hgb-14.6 Hct-42.9 MCV-85
MCH-29.1 MCHC-34.1 RDW-12.8 Plt Ct-272
[**2200-12-8**] 06:25AM BLOOD Glucose-93 UreaN-18 Creat-0.9 Na-138
K-4.7 Cl-102 HCO3-29 AnGap-12
[**2200-12-7**] 04:46AM BLOOD ALT-30 AST-26 CK(CPK)-73 AlkPhos-59
TotBili-0.8
[**2200-12-7**] 04:46AM BLOOD TSH-0.80
[**2200-12-6**] 08:40PM BLOOD HCG-<5
[**2200-12-6**] 08:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2200-12-7**] 04:46AM URINE opiates-NEG cocaine-NEG amphetm-NEG
EKG: Baseline artifact is present. Sinus tachycardia. Otherwise,
normal tracing. Compared to the previous tracing the rate is
slower and the ST-T wave changes are less apparent.
Brief Hospital Course:
28 year old female presenting with agitation and tachycardia
with known GBL use, presemted with GBL withdrawl.
.
#. Tachycardia/agitation: Patient was initially managed in the
ICU for airway monitoring/precautions, and was placed on a CIWA
scale, on which she scored infrequently. Cocaine and opiates
were negative on urine tox screen. Thiamine, magnesium, and
folate were given. TSH was normal. Seroquel was held.
Pt's severe anxiety and significant tachycardia were likely due
to significant GBL withdrawl. She was managed with a CIWA
scale, however this did not seem to adequately capture her
symptoms of withdrawl, which included anxiety and tachycardia
primarily, but also included sweats and occas palpitations. As
pt seems to have significant anxiety at baseline, and pt claimed
to be self-medicating for anxiety, Psychiatry was consulted for
assistance. Pt was started on scheduled Valium which was
gradually tapered. Pt had significant improvement in symptoms
with scheduled valium, and her withdrawl symptoms gradually
decreased. Her tachycardia appeared to be the most consistent
sign of her withdrawl, and at the time of discharge, her
tachycardia had resolved. She was monitored on telemetry
throughout the hospitalization.
Social work was consulted as well, and between Social Work and
Psychiatry, pt was provided extensive resources for Psychiatry
and Social Work follow up as an outpatient. Pt was discharged
with 2 additional days of Valium taper.
.
#. HCV: diagnosed in [**Month (only) 956**], followed by Dr. [**Last Name (STitle) 696**] at
[**Hospital1 18**]. Not currently being treated. Likely too early in
disease to have developed fibrosis. No stigmata of chronic
liver disease. Liver function tests, albumin, and coag studies
were normal. She will follow up with Dr. [**Last Name (STitle) **] as an outpt.
.
.
CODE STATUS: full
Medications on Admission:
seroquel 100mg qhs
Ativan 0.5mg 1-2 tabs prn
Discharge Medications:
1. Diazepam 5 mg Tablet Sig: One (1) Tablet PO as directed for 2
days: Take 1 tab every 6 hours on [**12-12**]; then 1 tab every 8 hours
on [**12-13**]; then discontinue.
Disp:*6 Tablet(s)* Refills:*0*
2. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily): you may purchase over the counter.
3. Multivitamin Tablet Sig: One (1) Tablet PO once a day:
you may purchase over the counter.
Discharge Disposition:
Home
Discharge Diagnosis:
# GBL withdrawl
# Anxiety
Secondary
Hepatitis C
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted for GBL withdrawl, and you were treated with a
valium taper with improvement in your symptoms. You were
followed by Psychiatry and Social Work, who have helped you
obtain outpatient follow up.
It is extremely important that you remain off of all drugs and
alcohol, and follow up with your outpatient providers.
Please finish the Valium taper as prescribed.
Followup Instructions:
Please schedule a follow up appointment with your primary care
provider, [**Name10 (NameIs) **] keep the appointments that you scheduled with
Psychiatry and social work.
|
[
"728.85",
"070.70",
"292.0",
"785.0",
"300.01",
"305.62",
"304.60"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8057, 8063
|
5645, 7515
|
297, 303
|
8156, 8156
|
4335, 5622
|
8700, 8873
|
3410, 3494
|
7610, 8034
|
8084, 8135
|
7541, 7587
|
8301, 8677
|
3509, 4316
|
2512, 2888
|
236, 259
|
331, 2493
|
8170, 8277
|
2910, 2981
|
2997, 3394
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,567
| 146,736
|
35556
|
Discharge summary
|
report
|
Admission Date: [**2132-10-29**] Discharge Date: [**2132-11-8**]
Date of Birth: [**2096-12-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Morphine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Pacemaker erythema
Major Surgical or Invasive Procedure:
[**2132-10-29**] - Removal of infected pacemaker defibrillator, attempted
removal of pacing leads.
[**2132-10-30**] - Repair of left common femoral artery and repair of
left common femoral vein.
[**2132-10-30**] - 1. Removal of infected pacemaker leads by median
sternotomy.
2. Repair of laceration to the superior vena cava and innominate
vein with bovine pericardial patch.
History of Present Illness:
This is a 35 year old male with PMH significant for hypertrophic
cardiomyopathy, paroxysmal atrial fibrillation, complete heart
block, ASD (repaired in [**2093**]), multiple pacemaker surgeries,
s/p AICD revision on [**2132-9-24**] here at [**Hospital1 18**] admitted [**2132-10-21**] for
infection at the pacemaker site. An ultrasound of the
pacemaker pocket revealed a small rim of fluid. However, it
was decided that the risk of seeding the pacemaker site by
placing a needle through the overlying cellulitis to drain the
fluid outweighed the benefits. Therefore, a left sided PICC was
placed [**10-23**] and the patient was discharged to hotel on [**2132-10-24**]
with VNA services to administer vancomycin 1500mg IV twice
daily. Patient presented to holding area on [**10-28**] to follow up
with cardiologist an decision made to
explant hardware.
Past Medical History:
ASD repair [**2097**] at age 14 months
Hypertrophic Cardiomyopathy
Complete Heart Block
Pacemaker placement [**2114**], [**2130**] with repositioning [**1-31**] and [**3-2**]
Paroxysmal Atrial fibrillation
Lumbar Discitis [**3-/2132**] requiring 6 weeks of IV antibiotics
Laminectomy [**2121**]
Lung Mass, biopsy negative for malignancy
Migraine
Anxiety
GERD
Vasectomy
Social History:
He is married and lives with his wife [**Name (NI) **] and 2 children. He
works as a network engineer in upstate NY. He does not smoke and
rarely drinks alcohol.
Family History:
Father with Hypertrophic Cardiomyopathy diagnosed
at age 52 along with a brother who was diagnosed at age 31.
Physical Exam:
Physical Exam
(VS from inpt scanned record [**10-1**])
Pulse: 70 Resp: 18 O2 sat: 95%
B/P 106/72
Height: 71 inches Weight: 195 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [xx] non-tender [x] bowel
sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None []
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:
[**2132-10-30**] ECHO
PRE CPB
The left atrium is markedly dilated. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium or
left atrial appendage. The right atrium is moderately dilated.
No atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is severely depressed (LVEF=
XX %). The right ventricular cavity is mildly dilated with
severe global free wall hypokinesis. There are three aortic
valve leaflets. The aortic valve leaflets are mildly thickened
(?#). There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen.
POST CPB:
Unchanged RV systolic function (Still severely depressed).
Unchanged LV systolic function.(EF 15-20%) (On Epinephrine and
milrinone)
TR is now mild
No other change
[**2132-10-30**] CT Scan
1. Thrombus identified within the left internal jugular vein.
The right
internal jugular vein remains patent, although please note that
ultrasound is more sensitive.
2. Extensive fat stranding and lymph nodes within the left
supraclavicular
area. ICD wires are identified traversing this area and entering
the SVC.
NOTE ADDED AT ATTENDING REVIEW: The heterogeneous density in the
left jugular vein may be contrast mixing, rather than clot. The
junction of the left jugular with the SVC is poorly seen, and no
opacification is seen surrounding the ICD leads. Although poorly
visualized, this may indicate thrombosis along this segment. The
right jugular and subclavian veins appear patent.
[**2132-11-7**] 4:39 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
Clostridium DIFFICILE TOXIN A & B TEST
(Final [**2132-11-8**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
WOUND CULTURE (Final [**2132-11-8**]):
Mixed bacterial types (>= 3 colony morphologies) isolated.
Abbreviated work-up performed Isolate(s) identified and
susceptibility testing performed because of concomitant
positive
blood culture(s).
Comparison of the susceptibility patterns may be helpful
to assess
clinical significance.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >15 colonies.
Please contact the Microbiology Laboratory ([**7-/2429**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 2 S
[**2132-11-8**] 06:07AM BLOOD WBC-13.9* RBC-3.58* Hgb-10.9* Hct-33.2*
MCV-93 MCH-30.6 MCHC-32.9 RDW-21.4* Plt Ct-165
[**2132-10-28**] 12:40PM BLOOD WBC-5.1 RBC-4.37* Hgb-13.1* Hct-39.7*
MCV-91 MCH-30.0 MCHC-33.0 RDW-13.8 Plt Ct-145*
[**2132-11-8**] 06:07AM BLOOD PT-18.2* PTT-30.4 INR(PT)-1.6*
[**2132-10-28**] 12:40PM BLOOD PT-15.2* INR(PT)-1.3*
[**2132-11-8**] 06:07AM BLOOD UreaN-59* Creat-7.2*# Na-135 Cl-95*
HCO3-18*
[**2132-10-28**] 12:40PM BLOOD Glucose-86 UreaN-12 Creat-0.9 Na-142
K-4.0 Cl-108 HCO3-23 AnGap-15
[**2132-11-8**] 06:07AM BLOOD ALT-131* AST-50* LD(LDH)-521*
CK(CPK)-251* AlkPhos-55 Amylase-39 TotBili-30.5*
[**2132-10-28**] 12:40PM BLOOD ALT-52* AST-31 LD(LDH)-174 AlkPhos-74
Amylase-35 TotBili-1.1
[**2132-11-8**] 06:07AM BLOOD Albumin-4.6 Calcium-8.6 Phos-5.6* Mg-2.8*
[**2132-11-8**] 11:22AM BLOOD Type-ART Temp-35.8 pO2-68* pCO2-28*
pH-7.38 calTCO2-17* Base XS--6 Intubat-INTUBATED
[**2132-10-29**] 01:59PM BLOOD Type-ART pO2-88 pCO2-29* pH-7.49*
calTCO2-23 Base XS-0 Intubat-INTUBATED
Brief Hospital Course:
Mr. [**Known lastname 80943**] was admitted to the [**Hospital1 18**] on [**2132-10-29**] for removal of
an infected pacer lead and pacer pocket. Vancomycin was
continued per the infectious disease service for the infection.
He was taken to the operating room where he underwent removal of
the infected pacemaker defibrillator and attempted removal of
pacing leads. The leads were unable to be removed. He returned
to the operating room on [**2132-10-30**] and underwent removal of
infected pacemaker leads through a median sternotomy on CPB
(groin cannulation). He required repair of the superior vena
cava and innominate vein with bovine pericardial patch. The
vascular surgery service was consulted intraoperatively for
repair of the left common femoral artery and left common femoral
vein due to the urgent femoral cannulation. Please refer to
operative note for further surgical details. Postoperatively he
was taken to the CVICU. He required high doses of several
pressors (epi 0.3, vasopressin 3.6, levophed, milrinone) to
maintain an adequate blood pressure/hemodynamics. He began to
spike fevers to 104 and showing signs of septic shock.
Vancomycin was continued and zosyn was added. ID continued to
follow postoperatively with recommendations for antibiotics. His
liver and renal function began to deteriorate and CVVH was
initiated (Total bilirubin up to 28, creatinie bump to 5).
Amiodarone was initiated for atrial fibrillation. Cultures from
the generator pocket grew staph aureus, vancomycin was continued
and the zosyn was stopped. We then had to stop CVVH as the R
groin Quinton was clotting (we could not use citrate because of
his liver function), but the pt responded faily well to lasix.
Over the next two days, we made some progress as the patient was
completely weaned off the epi and milrinone. He started to
defervesce as well and his WBC normalized. His respiratory
status was stable on >80% FiO2 and the CXR was pristine. However
a repeat Echo on [**11-6**] showed still severly depressed/dilated
RV, and lung V/Q SCAN was performed to investigate his sat of
90% on 100% (although we thought that part of it was at least
due to shunting / abnormal venous connection). The ScAn was a
low probability for PE. By [**11-7**] we had to resume nitric oxide
and go back up on Levophed, vasopressin (to 3.6), and milrinone
o.25 (which with his creatinine of 8 is almost equivalent to
0.675). His respiratory status deteriorated with decreasing
sats around 88%, and new B/L pleural effusions on CXR. He
continued to spike temps to the 102.2 range. Contact was made
with [**Hospital1 336**] for transfer re: possible RVAD - Tranplant. CVVH was
restarted last PM for volume removal, in addition, he had an
increasing pressor requirement/worsening hypoxemia and Nitric
Oxide was restarted. Chemical paralysis with Cisatracurium was
initiated for increased ventilatory needs over the past 24
hours. Several amps of Sodium Bicarbonate required for
correction of his combined metabolic/respiratory
acidosis.Epicardial V-wires threshold this AM=8 mAmp.However,
hemodynamic stability is actually improved with his own
junctional escape rhythm in the 40s. Mr.[**Known lastname 80943**] is currently
critically ill with septic shock, tenuous cardiovascular
hemodynamics with severe RV failure, early ARDS-like picture in
acute renal failure requiring CVVH. He is being transferred to
[**Hospital1 336**] for possible RVAD-transplant. Attending physicians and
family in agreement of plan.
Medications on Admission:
Zolpidem 10, Quinapril 2.5, Famotidine 40 [**Hospital1 **], Paroxetine HCl
20, Vancomycin 1500 [**Hospital1 **] 7 days, Sotalol 120 [**Hospital1 **], Lorazepam 1 Q8
PRN
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml
PO BID (2 times a day).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
3. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: 1-2 MLs Mucous
membrane [**Hospital1 **] (2 times a day).
4. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
5. Norepinephrine Bitartrate 1 mg/mL Solution Sig: One (1)
Intravenous INFUSION (continuous infusion).
6. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection TITRATE TO (titrate to desired clinical effect (please
specify)).
7. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation every four (4) hours as needed for wheezing.
8. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
9. Vasopressin 20 unit/mL Solution Sig: One (1) Injection
INFUSION (continuous infusion).
10. Fentanyl Citrate (PF) 50 mcg/mL Solution Sig: One (1)
Injection INFUSION (continuous infusion).
11. Midazolam 5 mg/mL Solution Sig: One (1) Injection INFUSION
(continuous infusion).
12. Vancomycin 1000 mg IV PRN level<20
please check Vanco Level daily
13. Pantoprazole 40 mg IV Q12H
14. Milrinone 0.25 mcg/kg/min IV INFUSION
15. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
16. Piperacillin-Tazobactam 4.5 g IV Q8H
17. Cisatracurium Besylate 0.06-0.30 mg/kg/hr IV TITRATE TO
adequate paralysis
Patient should be ventilated and sedated prior to initiating
NMBAs.
18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
ASD repair [**2097**] at age 14 months
Hypertrophic Cardiomyopathy
Complete Heart Block
Pacemaker placement [**2114**], [**2130**] with repositioning [**1-31**] and [**3-2**],
most recent pocket revision [**2132-9-24**] (Device: [**Company 1543**] Virtuoso)
Paroxysmal Atrial fibrillation
Lumbar Discitis [**3-/2132**] requiring 6 weeks of IV antibiotics
Laminectomy [**2121**]
Lung Mass, biopsy negative for malignancy
Migraine
Anxiety
GERD
Vasectomy
Discharge Condition:
critical
Discharge Instructions:
transfer to outside facility
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **]
Completed by:[**2132-11-8**]
|
[
"530.81",
"276.1",
"V15.1",
"473.9",
"518.5",
"300.00",
"453.82",
"998.11",
"998.2",
"276.4",
"285.1",
"560.1",
"998.0",
"995.92",
"426.11",
"428.0",
"V45.01",
"486",
"E870.0",
"V45.02",
"287.4",
"346.90",
"570",
"746.84",
"E878.1",
"998.12",
"584.5",
"426.0",
"V12.53",
"038.11",
"999.2",
"997.5",
"785.52",
"996.61",
"997.4",
"576.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.31",
"33.23",
"39.61",
"39.95",
"39.32",
"39.64",
"96.72",
"96.6",
"39.56",
"37.89",
"37.77",
"99.61"
] |
icd9pcs
|
[
[
[]
]
] |
12246, 12261
|
6912, 10411
|
295, 673
|
12758, 12769
|
2940, 3725
|
12846, 12929
|
2148, 2259
|
10630, 12223
|
12282, 12737
|
10437, 10607
|
12793, 12823
|
2274, 2921
|
236, 257
|
701, 1559
|
1581, 1952
|
1968, 2132
|
3735, 6889
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,753
| 121,343
|
126+55191
|
Discharge summary
|
report+addendum
|
Admission Date: [**2168-4-5**] Discharge Date: [**2168-4-20**]
Date of Birth: [**2127-1-17**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor Last Name 1350**]
Chief Complaint:
Transferred from OSH intubated with progressive loss of
function. Found to have cerivcal discitis, epidural abscess,
pharangeal abscesses and bacteremia.
Major Surgical or Invasive Procedure:
[**2168-4-5**] C5-T1 lami for epidural abscess - White
[**2168-4-8**] ACDF, posterior I&D
[**2168-4-11**] C3-T1 PISF, L ICBG, Incisional Vac
[**4-14**] Trach and PEG
[**4-18**] Right PICC line placement
History of Present Illness:
HPI: 41M h/o IVDA with 3d progressive neck and upper back pain
and 1d of rapidly progressive UE/LE weakness, numbness.
Progressive symptosm [**4-7**] with epidural abscess on MRI
Past Medical History:
Not Known
Social History:
Living with a friend. [**Name (NI) 1351**], no children. On SSI benefits for
asthma and neuropathy. Smokes occasional cigarettes, no EtOH.
Family History:
Parents with DM. Father with [**Name2 (NI) 499**] CA.
Physical Exam:
Trach in place
Anterior, Posterior, ICBG wounds clean and dry
C5 3/5 strength
C6 3/5 strength
SITIL grossly BUE and BLE
C7-S1 No demonstrated motor
Pertinent Results:
[**2168-4-5**] 04:56PM TYPE-ART PO2-95 PCO2-34* PH-7.45 TOTAL CO2-24
BASE XS-0
[**2168-4-5**] 04:56PM freeCa-1.04*
[**2168-4-5**] 08:13AM URINE COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.032
[**2168-4-5**] 08:13AM URINE BLOOD-SM NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-1 PH-6.0 LEUK-NEG
[**2168-4-5**] 08:13AM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-<1
[**2168-4-5**] 08:13AM URINE AMORPH-MOD
[**2168-4-5**] 07:40AM TYPE-ART PO2-280* PCO2-53* PH-7.39 TOTAL
CO2-33* BASE XS-6
[**2168-4-5**] 07:40AM GLUCOSE-196* LACTATE-1.0
Brief Hospital Course:
The patient was taken to the OR rapidly for decompression of his
spinal cord. His procedures are as follows:
[**2168-4-5**] C5-T1 lami for epidural abscess - White
[**2168-4-8**] ACDF, posterior I&D
[**2168-4-11**] C3-T1 PISF, L ICBG, Incisional Vac
[**4-14**] Trach and PEG
He was seen by PT, infectious disease, Speach and Swallow,
Trauma ICU team, Dr. [**Last Name (STitle) 1007**] and Dr. [**Last Name (STitle) 1352**] of the spine team,
the PICC placement team and ENT for managment of his complex
spinal cord issues. He was discharged from the ICU to the floor
on [**2168-4-18**] and received his picc line. He was discharged in
stable condition on heparin DVT prophylaxis and IV Nafcillin via
his PICC with follow up with Spine and Infectious Disease. He
was discharged to spinal cord rehab.
Medications on Admission:
No Known
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
nausea.
2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.
3. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
4. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
5. Nafcillin 2 g IV Q6H epidural abcess
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
7. 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.
8. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
9. Lorazepam 0.5-2 mg IV Q2-4 HOUR PRN agitation
hold for rr<10 or somnolence
10. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
11. Quetiapine 200 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
12. Methadone 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
13. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
15. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
16. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for nausea.
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
19. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours): Tolerated in house.
20. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
MSSA bacteremia with C5-C7 epidural abscess, discitis
C6 level (C5 3/5 strength, C6 3/5 Strength).
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:
Discharge diagnosis: MSSA bacteremia with C5-C7 epidural abscess
Prescribed Antibiotic Information
1.) Nafcillin 2 g IV q 6 hrs ([**4-10**] -
laboratory monitoring required
weekly CBCd, BMP, LFT's, ESR, CRP
Other medications of note for drug inteactions, other oral
antibiotics taken in conjunction etc.
access changes
comments
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]
All questions regarding outpatient antibiotics should be
directed
to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**]
Daily wound checks - Hip Bone graft, Anterior and Posterior
Cervical Spine wounds
Physical Therapy:
OOB WBAT
C collar for oob activities
Treatments Frequency:
daily wound checks
Agressive spinal cord rehab
anticipated 6-8 weeks of Nafcillin via PICC
Followup Instructions:
PLease follow up with ID in 1 month. See above instructions for
weekly labs to be faxed to the [**Hospital **] clinic.
Please follow up with Dr. [**Last Name (STitle) 1007**] in 2 weeks.
Name: [**Known lastname 76**],[**Known firstname 126**] Unit No: [**Numeric Identifier 127**]
Admission Date: [**2168-4-5**] Discharge Date: [**2168-4-20**]
Date of Birth: [**2127-1-17**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor Last Name 147**]
Addendum:
The patient was seen by psychiatry who felt that his suicidal
ideation did not pose an immediate threat to safety. The
patient was very encouraged by his improving exam on the day of
discharge. Psychiatry also recommended titrating his methadone
for pain control but he is comfortable this morning and the dose
was not changed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Location (un) 42**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 148**] MD [**MD Number(2) 149**]
Completed by:[**2168-4-20**]
|
[
"E915",
"478.24",
"305.90",
"518.83",
"721.1",
"041.11",
"722.71",
"344.00",
"493.90",
"519.4",
"324.1",
"V62.84",
"401.9",
"934.1",
"790.7",
"730.08"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.05",
"81.63",
"80.99",
"03.09",
"81.03",
"02.94",
"84.51",
"81.02",
"96.72",
"88.72",
"33.24",
"31.1",
"81.62",
"96.6",
"43.11",
"03.4",
"77.79"
] |
icd9pcs
|
[
[
[]
]
] |
6883, 7108
|
1942, 2748
|
473, 678
|
4935, 4935
|
1331, 1919
|
5949, 6860
|
1093, 1148
|
2807, 4699
|
5132, 5757
|
2774, 2784
|
5111, 5111
|
1163, 1312
|
5775, 5812
|
5834, 5926
|
279, 435
|
706, 887
|
4950, 5087
|
909, 920
|
936, 1077
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,784
| 197,204
|
1834+1835
|
Discharge summary
|
report+report
|
Admission Date: [**2116-1-6**] Discharge Date: [**2116-1-9**]
Date of Birth: [**2036-1-27**] Sex: M
Service: MEDICINE
Allergies:
Allopurinol / Aspirin / Lopressor
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
79yo M patient with Afib on coumadin, CAD, CHF, s/p PPM, DM2, w/
known cirrhosis (cryptogenic vs NASH) and multiple admits for
hepatic encephalopathy, admitted with altered MS. [**Name13 (STitle) **] wife he
was at his baseline mental status the day prior to admission.
Intitial review of symptoms was not obtainable given altered
mental status. He was somnolent, in no acute distress.
Presenting exam and vital signs as below.
Past Medical History:
1. Cryptogenic cirrhosis likely NASH.
2. CHF with an EF of 35% from [**2112**].
3. CAD status post stent x2.
4. AFib status post DDD pacer.
5. Hypertension.
6. history of CVA.
5. Diabetes, HbA1c [**6-23**]: 6.5
6. history of confusion, multiple admissions for hepatic
encephalopathy
7. history of multiple UTIs
8. history of pancytopenia.
9. Eosinophilic syndrome
10. Iron deficiency anemia, known trace pos stools.
11. Upper GI bleed.
12. Diverticulosis, grade II internal hemmorroids (cscope [**2110**])
13. Chronic renal insufficiency 1.2-1.6 at baseline.
14. s/p Left Total knee replacement
15. history of Gout
Social History:
Lives with his wife; daughter and son-in-law assist them. Worked
for the City of [**Location (un) **]. Was in the Army for 21 years. Denies
past or present tobacco usedenies alcohol consumptiondenies IV
drug use.
Family History:
His father with a MI at age 60. Two brothers with [**Name2 (NI) **] and
diabetes.
Physical Exam:
GEN: Moaning, eyes closed--> open to voice. unable to follow
commands
VS: 97, 110/70, 80, 22, 96% RA
HEENT: anicteric, dry mm, op clear
NECK: flat JVP, no [**Doctor First Name **]
CV: irreg, irreg, no murmers
Pulm: CTA b/l
ABD: s, nt, nd, no ascites, no HSM
EXT: trace edema, no cyanosis
Neuro: unable to assess
Pertinent Results:
[**2116-1-6**] 01:34PM TYPE-ART TEMP-36.7 RATES-16/16 O2-96 O2
FLOW-2 PO2-220* PCO2-26* PH-7.50* TOTAL CO2-21 BASE XS-0
AADO2-456 REQ O2-76 INTUBATED-NOT INTUBA
[**2116-1-6**] 01:34PM LACTATE-1.6
[**2116-1-6**] 01:00PM AMMONIA-217*
[**2116-1-6**] 12:43PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2116-1-6**] 12:43PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-7.0
LEUK-NEG
[**2116-1-6**] 12:43PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2116-1-6**] 11:45AM GLUCOSE-257* UREA N-30* CREAT-1.6* SODIUM-142
POTASSIUM-4.6 CHLORIDE-111* TOTAL CO2-21* ANION GAP-15
[**2116-1-6**] 11:45AM ALT(SGPT)-25 AST(SGOT)-31 ALK PHOS-147*
AMYLASE-55 TOT BILI-0.8
[**2116-1-6**] 11:45AM LIPASE-72*
[**2116-1-6**] 11:45AM ALBUMIN-3.8
[**2116-1-6**] 11:45AM TSH-0.77
[**2116-1-6**] 11:45AM DIGOXIN-0.5*
[**2116-1-6**] 11:45AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2116-1-6**] 11:45AM WBC-4.0 RBC-3.95* HGB-12.2* HCT-35.9* MCV-91
MCH-30.9 MCHC-34.0 RDW-16.3*
[**2116-1-6**] 11:45AM NEUTS-75.1* LYMPHS-16.5* MONOS-4.6 EOS-3.4
BASOS-0.4
[**2116-1-6**] 11:45AM ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+
[**2116-1-6**] 11:45AM PLT COUNT-201
[**2116-1-6**] 11:45AM PT-19.4* PTT-35.4* INR(PT)-2.4
________________________________________________________________
[**2116-1-9**] 05:40AM BLOOD WBC-3.8* RBC-3.32* Hgb-10.1* Hct-29.1*
MCV-88 MCH-30.4 MCHC-34.7 RDW-15.9* Plt Ct-160
[**2116-1-9**] 05:40AM BLOOD Plt Ct-160
[**2116-1-9**] 05:40AM BLOOD Glucose-139* UreaN-17 Creat-1.1 Na-141
K-3.8 Cl-113* HCO3-20* AnGap-12
[**2116-1-8**] 05:33AM BLOOD ALT-22 AST-28 AlkPhos-134* TotBili-1.2
[**2116-1-7**] 07:00AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.0
[**2116-1-6**] 11:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
_______________________________________________________
CT HEAD W/O CONTRAST
TECHNIQUE: Noncontrast head CT.
FINDINGS: No intracranial mass lesion, hydrocephalus, or shift
of normally midline structures is present. Low attenuation focus
in the right cerebellar hemisphere is consistent with a chronic
infarction. Low attenuation areas in the right temporal lobe
adjacent to the posterior portion of the sylvian fissure is also
consistent with chronic infarction. No acute intracranial
hemorrhage is seen. The prominence of the sulci is consistent
with atrophy. The surrounding osseous and soft tissue structures
are unremarkable.
IMPRESSION: No acute intracranial pathology, including no sign
of intracranial hemorrhage. Chronic infarcts as described above.
Brief Hospital Course:
79yo M patient with Afib on coumadin, CAD, CHF, s/p PPM, DM2, w/
known cirrhosis (cryptogenic vs NASH) and multiple admits for
hepatic encephalopathy presenting with Altered Mental Status,
dehydration, and acute renal failure.
## CONFUSION/ HEPATIC ENCEPHALOPATHY:
Altered mental status in patient w/ known cirrhosis (cryptogenic
vs NASH) w/ recurrent episodes of hepatic encephalopathy.
Improved to baseline mental status with lactulose suggesting
that encephalopathy is the likely diagnosis. Infectious and
neuro work up was negative including a negative head CT, CXR,
and urine analysis. No clinical or biochemical evidence of
infection. Regarding etiology, the patient reported that prior
to admission, he would take lactulose on average once a day,
rather than the recommended 3 times a day administration, [**1-29**]
feeling "tired of" repetitivive stooling. Given his
self-administration of medications, there was sufficient concern
for a recurrent cycle of hepatic encephalopathy and dehydration.
As such, we felt short term supervised setting is appropriate.
Patient should continue lactulose with a goal of 4 bowel
movements a day. He should be monitored for signs of
dehydration with frequent volume loss from stool.
## ACUTE ON CHRONIC RENAL INSUFFICIENCY: Likely pre-renal
azotemia secondary to volume depletion. Resolved w/ hydration.
Creatinine at baseline of 1.1 on discharge
## Systolic CHF: This patient had an EF of 35% in [**2112**].
Hypovolemic clinically on initial presentation w/ no evidence of
CHF. Initially held Lasix/spironolactone until volume repleat.
Patient will re-initiate these medication on [**2116-1-10**] as he has
demonstrated ability to take in adequate po to offset volume
losses in stool. Held digoxin and Lisinopril w/ presenting
ARF. Digoxin re-initiated [**1-9**], Lisinopril should be added back
on [**1-10**].
## MILD RESPIRATORY ALKALOSIS: on presenting ABG. Likely acute
on chronic [**1-29**] hepatic failure and altered MS. Improved w/
lactulose as above. No respiratory compromise throughout
admission.
## CAD: s/p PCI in past. His EKG demonstrated Afib with LBBB and
intermittent pacing w/o concerning signs for ischemia. He was
continued on Plavix and aspirin.
## AFIB: known afib on coumadin and digoxin and has a DDD pacer.
His INR is therapeutic on Coumadin home regimen. No bleed on
Head CT. His digoxin was intially held as above. His coumadin
was continued however held on [**1-9**] as INR was 3.9. Daily INR
checks at extended care facility until therapeutic. Goal INR
[**1-30**]. His pre-admission coumadin dosing was as follows:
Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO 5X/WEEK
(MO,TU,TH,FR,SA).
Warfarin Sodium 1 mg Tablet Sig: Three (3) Tablet PO 2X/WEEK
([**Doctor First Name **],WE).
## ANEMIA: chronic dz, iron deficiency. HCT 35--> 29.1 since
admit following hydration. HCT near baseline. No evidence of
bleed. COntinued on iron supplementation
## DIABETES: Insulin sliding scale. Should restart Glyburide
2.5 mg po bid on [**1-10**]
## FEN: diabetic/low sodium diet/ cardiac health. does not need
low protein diet as there is no hard evidence to support such
diet and it may contribute to malnutrition.
Needs close monitoring of fluid balance with goal IN=OUT. This
is difficult in the face of losses while stooling, and then
decreased po while lethargic. His EF is 35% so caution with
IVF. He is also on lasix and spironolactone.
COMM: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10254**] = daughter ([**Telephone/Fax (1) 10255**]
[**First Name4 (NamePattern1) **] [**Known lastname **] = son ([**Telephone/Fax (1) 10256**]
Medications on Admission:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO 5X/WEEK
(MO,TU,TH,FR,SA).
9. Warfarin Sodium 1 mg Tablet Sig: Three (3) Tablet PO 2X/WEEK
([**Doctor First Name **],WE).
10. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO twice a
day.
Disp:*1080 ML(s)* Refills:*0*
11. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
Discharge Medications:
1. Lasix 20 mg Tablet Sig: Three (3) Tablet PO once a day: start
[**1-10**].
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): titrate to 4 bowel movements a day.
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): hold if NPO.
7. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): start [**1-10**].
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
start [**1-10**].
9. insulin sliding scale
per flow sheet
10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
Courtyard - [**Location (un) 1468**]
Discharge Diagnosis:
## ALTERED MENTAL STATUS SECONDARY TO HEPATIC ENCEPHALOPATHY:
## ACUTE ON CHRONIC RENAL INSUFFICIENCY FAILURE
## VOLUME DEPLETION SECONDARY TO NEGATIVE FLUID
BALANCE/INSENSIBLE
LOSSES/DAIRRHEA
## CIRRHOSIS(cryptogenic vs NASH)
## SYSTOLIC CONGESTIVE HEART FAILURE
## RESPIRATORY ALKALOSIS
## CAD
## ATRIAL FIBRILLATION
## ACUTE ON CHRONIC RENAL INSUFFICIENCY FAILURE
## ANEMIA: chronic dz, iron deficiency
Discharge Condition:
A+O x 3, in no respiratory distress
Completed by:[**2116-1-9**] Admission Date: [**2116-1-10**] Discharge Date: [**2116-1-21**]
Date of Birth: [**2036-1-27**] Sex: M
Service: MEDICINE
Allergies:
Allopurinol / Aspirin / Lopressor
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
Colonoscopy
Angiography
Esophagastroduodenoscopy
History of Present Illness:
Patient is a 49 year old gentleman with a history of cryptogenic
cirrhosis, hepatic encephalopathy, coronary artery disease,
cardiomyopathy, atrial fibrillation on warfarin who presented to
the emergency room on [**2116-1-10**] with a lower GI bleed. On
presentation hematocrit was 24, INR was 4.9. The patient was
transfused one unit of PRBC and 2 bags of FFP. A repeat
hematocrit was 21. He then got 5 units of PRBC, vitamin K,
proplex and 10 L of IVF. Colonoscopy [**2116-1-10**] showed non-bleeding
diverticula throughout the colon with blood in the whole colon.
No rectal varices. EGD showed 3 cords of grade I varices
starting 33 cm from the incisors in the GE junction and lower
third of the esophagus. The patient's course was complicated by
demand ischemia. He was seen by cardiology consult with a
recommendation for medical management.
.
Patient felt well upon transfer to medical service with no
complaints other than weakness. Denies shortness of breath,
chest pain. Reports some mild abdominal discomfort with
palpation.
MEDICATIONS ON TRANSFER to medical svc from the ICU:
Protonix 40 IV bid
Digocin 0.125 daily
Diltiazem 30 po qid
Fentanyl patch 75 mcg/hr q72
morphine sulfate 1-5 mg prn
Insulin sliding scale
Past Medical History:
1. Cryptogenic cirrhosis likely NASH.
2. CHF with an EF of 35% from [**2112**].
3. CAD status post stent x2.
4. AFib status post DDD pacer ('[**12**] for symptomatic bradycardia,
intrinsic rhtythm is Afib/flutter).
5. Hypertension.
6. history of CVA.
5. Diabetes, HbA1c [**6-23**]: 6.5
6. history of confusion, multiple admissions for hepatic
encephalopathy
7. history of multiple UTIs
8. history of pancytopenia.
9. Eosinophilic syndrome
10. Iron deficiency anemia, known trace pos stools.
11. Upper GI bleed.
12. Diverticulosis, grade II internal hemmorroids (cscope [**2110**])
13. Chronic renal insufficiency 1.2-1.6 at baseline.
14. s/p Left Total knee replacement
15. history of Gout
Social History:
Lives with his wife; daughter and son-in-law assist them. Worked
for the City of [**Location (un) **]. Was in the Army for 21 years. Denies
past or present tobacco usedenies alcohol consumptiondenies IV
drug use.
Family History:
His father with a MI at age 60. Two brothers with [**Name2 (NI) **] and
diabetes.
Physical Exam:
VS: Tm 99.8 Tc 97.5 BP 119/60 (83-124/38-60) HR 75 (75-106)
RR 18-20 O2 sat 100% on 2L
I/O: 2143/4055 net -1900
GEN: Obese, pale, weak appearing man, sitting up in bed, dozing
in NAD. Breathing comfortably on room air.
HEENT: PERRL, EOMI, sclera anicteric. Dry MM. Some erythema of
the posterior pharynx.
NECK: No LAD, no thyromegly. No JVD.
LUNGS: Clear anteriorly with some upper airway sounds.
CV: Irregularly irregular with no MRG.
ABD: Soft, NT, ND, minimal BS.
Ext: 3+ pitting edema to the groin and to the shoulders
bilaterally.
Neuro: Alert and oriented to "hospital", "[**2115-12-28**]" but not
to city. No asterixis. Speech is slow but clear.
Pertinent Results:
[**2116-1-10**] 10:40AM WBC-5.4 RBC-2.23*# HGB-6.8*# HCT-20.1*#
MCV-90 MCH-30.7
MCHC-34.0 RDW-16.3*
[**2116-1-10**] 10:40AM NEUTS-83.3* LYMPHS-12.5* MONOS-3.3 EOS-0.8
BASOS-0.1
[**2116-1-10**] 10:40AM PLT COUNT-217
[**2116-1-10**] 10:40AM FIBRINOGE-283#
[**2116-1-10**] 10:40AM CALCIUM-7.3* PHOSPHATE-2.6* MAGNESIUM-1.8
[**2116-1-10**] 10:40AM GLUCOSE-219* UREA N-23* CREAT-1.3* SODIUM-142
POTASSIUM-5.0 CHLORIDE-115* TOTAL CO2-19*
ANION GAP-13
[**2116-1-10**] 10:40AM ALT(SGPT)-16 AST(SGOT)-28 ALK PHOS-94 TOT
BILI-1.3
[**2116-1-10**] 10:40AM PT-16.9* PTT-34.1 INR(PT)-1.8
_
_
_
_
_
_
_
_
_
________________________________________________________________
[**2116-1-10**] 03:40PM CK-102 CK-MB-11* MB INDX-10.8* cTropnT-0.12*
[**2116-1-10**] 09:16PM CK-209* CK-MB-27* MB INDX-12.9* cTropnT-0.46
[**2116-1-11**] 2:36 AM CK-196 TnT 0.62
[**2116-1-11**] 5:41 AM CK-191 TnT 0.70
[**2116-1-11**] 9:07 PM CK-96 TnT 0.61
[**2116-1-12**] 3:05 AM CK-95 TnT 0.44
___________________________________
COMPLETE BLOOD COUNT Hct
[**2116-1-13**] 10:07AM 27.3*
[**2116-1-13**] 04:47AM 28.9*
[**2116-1-13**] 02:27AM 27.0*
[**2116-1-12**] 06:44PM 31.3*
[**2116-1-12**] 11:42AM 30.8*
[**2116-1-12**] 03:05AM 31.8*
[**2116-1-11**] 09:08PM 30.1*
[**2116-1-11**] 05:53PM 31.2*
[**2116-1-11**] 01:40PM 31.5*
[**2116-1-11**] 10:54AM 31.8*
[**2116-1-11**] 05:41AM 29.9*
[**2116-1-11**] 02:36AM 29.4*
[**2116-1-10**] 10:00PM 34.3*
[**2116-1-10**] 06:30PM 37.1*
[**2116-1-10**] 03:40PM 32.5*
[**2116-1-10**] 01:45PM 27.8*#
[**2116-1-10**] 10:40AM 20.1*#1
_________________________________
[**2116-1-13**] 4:47 AM WBC 4.1 HGB 9.8* HCT 28.9* MCV 89 PLT 114
[**2116-1-13**] 4:47 AM PT 14.3* PTT 31.2 INR 1.3
[**2116-1-13**] 4:47 AM GLU 102 BUN 22* CREAT 1.2 NA 143 K 3.8 CL 115*
HCO3 23
[**2116-1-13**] 4:47 AM CA 7.8* PHOS 3.4 MG 2.1 DIG 1.2 LACTATE 1.7
FREECA 1.16
_
_
_
_
_
_
_
_
_
________________________________________________________________
CXR [**2116-1-10**]:
IMPRESSION:
1) Endotracheal tube in good position approximately 1-2 cm above
the carina.
2) Interval worsening in cardiopulmonary status when compared
with prior chest x-ray dated [**2116-1-6**].
_
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
LIMITED ABDOMINAL ULTRASOUND [**2116-1-10**]: A limited exam was
performed due to the patient's acute clinical status. Images
show patency of the portal vein and hepatopetal flow. The right
and left hepatic veins are patent. There is a small to moderate
amount of ascites.
IMPRESSION: Patent hepatopetal flow within the portal vein.
Small to moderate amount of ascites.
[**2116-1-17**] 05:39AM BLOOD WBC-4.2 RBC-3.58* Hgb-10.7* Hct-31.5*
MCV-88 MCH-29.9 MCHC-34.0 RDW-16.2* Plt Ct-121*
[**2116-1-16**] 10:30AM BLOOD WBC-3.6* RBC-3.44* Hgb-10.5* Hct-30.8*
MCV-89 MCH-30.6 MCHC-34.2 RDW-16.2* Plt Ct-120*
[**2116-1-15**] 02:22PM BLOOD Hct-30.9*
[**2116-1-15**] 05:33AM BLOOD WBC-3.6* RBC-3.37* Hgb-10.5* Hct-30.1*
MCV-89 MCH-31.0 MCHC-34.8 RDW-15.9* Plt Ct-120*
[**2116-1-14**] 06:00PM BLOOD Hct-32.4*
[**2116-1-14**] 01:04PM BLOOD Hct-35.3*
[**2116-1-14**] 04:51AM BLOOD WBC-3.9* RBC-3.49* Hgb-10.6* Hct-31.5*
MCV-90 MCH-30.4 MCHC-33.7 RDW-16.1* Plt Ct-117*
[**2116-1-14**] 01:52AM BLOOD Hct-30.3*
[**2116-1-13**] 10:07AM BLOOD Hct-27.3*
Brief Hospital Course:
79 year old man with a history of cryptogenic cirrhosis, hepatic
encephalopathy, CAD, CHF, s/p PPM, DM2, Afib who presented with
an acute LGIB from diverticulosis complicated by hypovolemic
shock in the setting of supratherapeutic INR (4.9); SICU course
complicated by:
- intubation for airway protection. post extubation ABG;
7.36/39/194
- hypovolemic shock [**1-29**] severe blood loss anemia (requiring
10Units
PRBC, vit K, 6U FFP, 10 Liters IVF)
- medically managed demand ischemia/NSTEMI ([**1-10**]-->peak CK 209,
peak MB 27, peak Trop T 0.7)
- Afib; rate controlled on Diltiazem (new to this admit), + dig
(last level 1.2 on [**1-12**])
- moderate to severe anasarca; [**1-29**] volume rescucitation (abd US
[**1-10**] w/ small
ascites, patent hepatopetal flow in portal vein)
- Colonoscopy [**1-10**]; non-bleeding diverticula throughout colon
No rectal varices
- EGD; showed 3 cords of non-bleeding grade I varices in lower
esophagus
## LGIB w/ massive blood loss anemia c/b Hypovolemic Shock:
Numerous non-bleeding diverticula seen on colonoscopy felt to be
source. EGD showed Grade I varices with no sign of bleed.
Patient has received a total of 10 U of PRBC and 6 bags of FFP
to for goal hct > 30 and INR < 1.5. No evidence of ongoing
bleed. HCT stable for 1 week before discharge. Held aspirin,
coumadin, plavix, NSAIDS.
## CIRRHOSIS c/b RECURRENT HEPATIC ENCEPHALOPATHY:
known cirrhosis (cryptogenic vs NASH) w/ propensity for
recurrent encephalopathy (usually in the setting of lactulose
noncompliance at home). lactulose and spirinolactone had been
initially held in the setting of hypovolemic shock/massive blood
loss anemia, however where reinstituted later in course once
hemodynamically stable. Paitent clearly demonstrates [**Doctor Last Name 688**]
mental status if at least 3 bowel movements are not acheived in
a given day. His encephalopathy rapidly clears with increased
bowel movments.
## MODERATE/SEVERE ANASARCA: Once hemodynamics were stabilized,
he was diuresed approximatley 2 liters a day w/ 30IV [**Hospital1 **] of
Lasix. K+ and Mg+ were repleted once a day. Renal function
remained stable. Will need transition to po lasix at rehab.
## DYSRHYTHMIA: underlying AFib. frequent episodic AFIB w/ Rapid
ventricular response during course that improved w/ titrating
doses of diltiazem. Electrophysiology service interogatted
pacemaker funstion that was capturing well and functioning
appropriately. set VVI at 70. Digoxin was continued during his
stay and the dose was increased. [**Month (only) 116**] need additional dilt at
rehab pending HR.
## SYSTOLIC CHF:
EF of 35% Hypervolemic clinically post resuscitaion w/ weaned
supplemental O2 requirement after diuresis. Lisinopril was
re-instituted for afterload reduction.
## CAD c/b NSTEMI:
s/p NSTEMI with resolving CK/TnT (peaked on [**1-10**]). s/p PCI in
past. His EKG demonstrated Afib w/ RVR, no pacing during
NSTEMI. Cardiology consulted and recommended medical management.
Held Plavix and aspirin given GIB. Diltiazem and
digoxin for AFib rate control. Refrain from BB as per OMR notes
intolerant in past.
## MULTI-FACTORIAL ANEMIA
chronic dz + iron deficiency + blood loss anemia this admit [**1-29**]
GIB. Baseline HCT 29-30. Transfused to a goal hct of 30 given
recent NSTEMI. Held coumadin as above.
## DIABETES MELLITUS TYPE 2:
Held glyburide until assured of good po intake. Treated w/
insulin sliding scale
## CHRONIC KIDNEY DISEASE:
creatinine at baseline, monitor closely as diuresing
## FEN
diabetic/low sodium diet/ cardiac healthy
replete lytes as diuresing aggressively
## Prophylaxis
--PPI
--pnuemoboots
## WOUND CARE
scrotal erythema/edema without open wounds
--appreciate wound care recs
--gentle foam cleansing to scrotum/pat dry/aloe to scotum and
bilateral groins/towel scrotal elevation
##COMM: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10254**] = daughter
([**Telephone/Fax (1) 10255**] (home)
([**Telephone/Fax (1) 10257**] (work)
([**Telephone/Fax (1) 10258**] (cell)
[**First Name4 (NamePattern1) **] [**Known lastname **] = son ([**Telephone/Fax (1) 10256**]
## CODE: FULL
Medications on Admission:
1. Lasix 20 mg Tablet Sig: Three (3) Tablet PO once a day: start
[**1-10**].
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): titrate to 4 bowel movements a day.
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): hold if NPO.
7. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): start [**1-10**].
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
start [**1-10**].
9. insulin sliding scale
per flow sheet
10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Discharge Medications:
1. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
2. Sliding Scale
Regular insulin sliding scale
3. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day.
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Lactulose 10 g/15 mL Syrup Sig: Forty Five (45) ML PO TID (3
times a day).
7. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
9. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
10. Furosemide 30 mg IV DAILY (transition to po when
appropriate)
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
## LOWER GI BLEED
## HYPOVOLEMIC SHOCK SECONDARY TO MASSIVE BLOOD LOSS ANEMIA
## CIRRHOSIS c/b RECURRENT HEPATIC ENCEPHALOPATHY
## MILD ANASARCA
## SYSTOLIC CHF
## CAD c/b NSTEMI
## AFIB
## MULTI-FACTORIAL ANEMIA
## DIABETES MELLITUS TYPE 2
## CHRONIC KIDNEY DISEASE
Discharge Condition:
stable hematocrit and hemodynamics. no evidence of further GIB
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500ml/day
Follow up appointments as follows:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 9119**] [**Name12 (NameIs) 9120**] MEDICINE (PRIVATE) Where: ADULT
MEDICINE UNIT [**Hospital3 **] HEALTHCARE - 1000 [**Location (un) **] - [**Location (un) 2352**],
[**Numeric Identifier 9121**] Phone:[**Pager number **] Date/Time:[**2116-2-5**] 4:30
Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2116-2-6**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 127**] Date/Time:[**2116-2-6**] 3:30
Followup Instructions:
scrotal erythema/edema without open wounds
--appreciate wound care recs
--gentle foam cleansing to scrotum/pat dry/aloe to scotum and
bilateral groins/towel scrotal elevation
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 9119**] [**Name12 (NameIs) 9120**] MEDICINE (PRIVATE) Where: ADULT
MEDICINE UNIT [**Hospital3 **] HEALTHCARE - 1000 [**Location (un) **] - [**Location (un) 2352**],
[**Numeric Identifier 9121**] Phone:[**Pager number **] Date/Time:[**2116-2-5**] 4:30
Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2116-2-6**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 127**] Date/Time:[**2116-2-6**] 3:30
Completed by:[**2116-1-21**]
|
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icd9cm
|
[
[
[]
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[
"45.23",
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icd9pcs
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[
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23504, 23576
|
17610, 21825
|
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|
23887, 23951
|
14194, 17587
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13417, 13501
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23975, 24791
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13516, 14175
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11083, 11112
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11228, 12457
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12479, 13171
|
13187, 13401
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,127
| 186,328
|
2182
|
Discharge summary
|
report
|
Admission Date: [**2194-1-23**] Discharge Date: [**2194-2-3**]
Date of Birth: [**2117-3-7**] Sex: M
Service: ,
HISTORY OF PRESENT ILLNESS: The patient is a 76 year old
male who recently underwent a surveillance colonoscopy that
was unable to be completed secondary to a large adenoma at
the hepatic flexure. It was decided that due to inability to
complete a polypectomy at that time that the patient should
undergo a right hepatic colectomy.
PAST MEDICAL HISTORY:
1. Diabetes mellitus
2. Prostatectomy.
3. Artificial urinary sphincter.
4. Agoraphobia.
5. Osteoarthritis.
6. Alcohol use.
HOME MEDICATIONS: Celexa.
ALLERGIES: Include sulfa.
PHYSICAL EXAMINATION: In general, the patient is [**Year (4 digits) 3584**] and
oriented in no acute distress. HEENT: Within normal limits.
Chest is clear to auscultation bilaterally. Cardiac is
regular rate and rhythm. Abdomen is soft, nontender; there
is a reducible left inguinal hernia and a well healed low
midline scar. Rectal with no mass; guaiac negative.
Extremities with two plus dorsalis pedis and posterior
tibials bilaterally.
HOSPITAL COURSE: The patient was admitted to the hospital
on [**2194-1-23**] and was taken directly to the Operating Room
where an extended right colectomy, initially laparoscopic
which turned open, was performed.
The patient initially did well postoperatively, receiving a
morphine PCA for pain control. He was initially n.p.o. and
he did require magnesium for hypomagnesemia postoperatively.
On postoperative day one, since the patient complained of
some mild confusion, although appeared relatively [**Name2 (NI) 3584**],
although only slightly disoriented. On postoperative day
two, the patient began to become agitated and it became
evident with further questioning of the patient's family that
the patient had a significant alcohol history and was placed
on a CIWA scale and Ativan for delirium tremens prophylaxis.
Later on postoperative day two, it became evident that the
patient was beginning to go into florid delirium tremens with
tachycardia and ST depressions on EKG associated with his
tachycardia. He was transferred to the Surgical Intensive
Care Unit for closer monitoring as well as an increased
treatment with Ativan drip. Lopressor was used to control
the patient's heart rate. Ativan, folate, thiamine and
multivitamin were also used to treat his alcohol withdrawal.
A head CT scan was ordered to rule out any other organic
cause of pathology which was, in fact, negative.
The patient was ruled out for myocardial infarction although
he did have spiked enzyme elevations associated with his ST
depression. While in the Intensive Care Unit, the patient
developed a fever. A sputum sample was sent showing a growth
of E. coli and Staphylococcus aureus which was felt at this
time to be an aspiration type pneumonia.
The patient was started on Levofloxacin for this infection.
A number of attempts were tried to wean the patient off the
ativan although each time the patient's heart rate would
increase.
A Neurology consultation was requested but it was recommended
that we start a long term benzodiazepine such as valium,
which was done to aid in decreasing the patient's ativan
drip. This was eventually successful and approximately on
postoperative day nine, the patient suddenly became clear
again. His Valium then was slowly weaned.
The patient was tested on p.o. nutrition which he tolerated
and was slowly advanced as tolerated, although while in-house
he was left on a soft diet secondary to aspiration
precautions.
While in-house, the patient was visited by the Urology Team
who discontinued the patient's Foley catheter and his
artificial urinary sphincter.
On [**2194-2-3**], the patient was doing well and would like to
go home. We are going to send him home today with ten days
of Levofloxacin. He will follow-up with Dr. [**Last Name (STitle) 1888**] in two to
three weeks. He can observe a regular diet and continue his
home medications.
[**Last Name (NamePattern4) 1889**], M.D. [**MD Number(1) 1890**]
Dictated By: [**Name6 (MD) **] [**Last Name (NamePattern4) 11618**], M.D.
MEDQUIST36
D: [**2194-2-3**] 08:40
T: [**2194-2-5**] 19:39
JOB#: [**Job Number 11619**]
|
[
"998.2",
"997.3",
"196.0",
"153.8",
"507.0",
"560.1",
"998.11",
"997.4",
"211.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"45.73",
"45.93",
"45.79",
"50.61"
] |
icd9pcs
|
[
[
[]
]
] |
1139, 4278
|
635, 672
|
696, 1120
|
158, 464
|
486, 616
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,670
| 185,268
|
47495
|
Discharge summary
|
report
|
Admission Date: [**2130-9-12**] Discharge Date: [**2130-9-27**]
Service: CARDIOTHORACIC
Allergies:
Theophylline / Fosamax
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest discomfort, at OSH ruled in for MI
Major Surgical or Invasive Procedure:
[**2130-9-20**] cabg x3 (LIMA to LAD, SVG to OM, SVG to PDA)
History of Present Illness:
Per transfer note after hand-off from outside hospital:
"87 year old woman with DM, HTN, + CHOL with intermittent chest
discomfort over the past month. Admitted to [**Hospital3 417**]
yesterday with increasing chest discomfort. EKG with evidence of
evolving anterior MI. Troponin peaked at .9 from 6pm last
evening, .58 this morning. No further chest pain. Received
plavix 600mg yesterday, lovenox last evening, Aspirin. No pain
since admission. Transfer direct to cath lab."
.
Accordingly, she was transferred for cardiac catheterization and
echocardiogram, after which she was admitted to the [**Hospital1 1516**] service
of [**Hospital1 18**].
.
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. Denies recent fevers, chills or rigors.
She denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Per patient, has been having a "few weeks" of being lethargic,
starting to sit down and do nothing more and more. Also having
some chest pain and dyspnea on exertion with increasing
frequency. Chest pain is "pressure across my chest".
.
More distantly pt notes that has had history of falls; children
took away her car more than a year ago.
Past Medical History:
NIDDM, HTN, + CHOL, osteoarthritis
NSTEMI
.
Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension
Social History:
Social history is significant for the absence of current or
history of tobacco use. There is no history of alcohol abuse;
very occasional single drink at social gatherings in past. There
is no family history of premature coronary artery disease or
sudden death.
Family History:
Family history includes mother with heart problems but died at
89; father had MI but died of cerebral hemorrhage; sister died
of lung CA at 55; two other sisters, one has dementia and lives
in [**Hospital1 1501**]; one has various issues but no heart problems pt is aware
of.
Physical Exam:
VS - bp 142/69, hr 65, rr 22, O2 94% RA
5'0" 165#
Gen: Elderly woman in NAD. Oriented to self, day, date and year;
"hospital"--"the biggest one in [**Location (un) 86**]"--with prompting "Be--"
says, "it has a girl's name"--recognition when I state "[**Hospital1 **]". Mood, affect appropriate. Some vagueness and
imprecision in history.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Somewhat dry
tongue. No xanthalesma.
Neck: Supple with JVP not appreciated; soft mobile mass at R
mandibular region, 4 cm x 3 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. Systolic ejection murmur [**2-14**] >at base. 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 abdominal bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ DP 1+ PT 1+
Left: Carotid 2+ DP 1+ PT 1+
Pertinent Results:
[**2130-9-12**] 08:35PM POTASSIUM-3.7
[**2130-9-12**] 08:35PM MAGNESIUM-2.0
.
[**2130-9-13**] 06:35AM BLOOD WBC-7.3 RBC-4.39 Hgb-12.1 Hct-36.8 MCV-84
MCH-27.5 MCHC-32.9 RDW-15.0 Plt Ct-174
[**2130-9-13**] 06:35AM BLOOD Neuts-74.2* Lymphs-17.5* Monos-4.1
Eos-3.6 Baso-0.6
[**2130-9-13**] 06:35AM BLOOD Plt Ct-174
.
[**2130-9-13**] 06:35AM BLOOD PT-10.9 PTT-23.8 INR(PT)-0.9
.
[**2130-9-13**] 06:35AM BLOOD Glucose-81 UreaN-23* Creat-1.1 Na-141
K-3.7 Cl-102 HCO3-32 AnGap-11
[**2130-9-13**] 06:35AM BLOOD ALT-18 AST-24 AlkPhos-57 Amylase-68
TotBili-0.5
[**2130-9-13**] 06:35AM BLOOD Lipase-17
[**2130-9-13**] 06:35AM BLOOD Albumin-3.4 Calcium-9.8 Phos-3.2 Mg-2.1
Cholest-154
[**2130-9-13**] 06:35AM BLOOD Triglyc-175* HDL-48 CHOL/HD-3.2
LDLcalc-71
TELEMETRY demonstrated: 4 beat run of NSVT; 14 beat run of
irregular tachycardia c/w SVT, ?brief a fib.
2D-ECHOCARDIOGRAM performed on [**9-12**]: "The left atrium is
elongated. There is mild to moderate regional left ventricular
systolic dysfunction with apical akinesis. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is mild functional
mitral stenosis (mean gradient 3mmHg) due to mitral annular
calcification. Trivial mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion."
CARDIAC CATH performed on [**9-12**] demonstrated: [formal report
pending, written report in chart:] diffuse 3 vessel disease
[**2130-9-13**] - Carotid Series Complete
IMPRESSION: There is a less than 40% right ICA stenosis and less
than 40% left ICA stenosis with antegrade flow in both vertebral
arteries.
[**2130-9-15**] - CT CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST:
CONCLUSION:
1. Indeterminate ground glass opacities in both lungs may be
infectious or inflammatory, and can be followed up with a chest
CT in three months to assess stability/clearance.
2. Prominence of pulmonary arteries, with the main pulmonary
artery measuring 35 mm.
3. Extensive atherosclerotic disease is present in the coronary
arteries and the aorta.
4. Left renal hypodensity is not fully assessed on this
examination.
HEMODYNAMICS: stable while here, some slightly high BPs
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 100420**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 100421**] (Complete)
Done [**2130-9-20**] at 11:35:54 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2043-1-22**]
Age (years): 87 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: cabg
ICD-9 Codes: 786.05, 786.51, 799.02, 440.0, 424.1, 424.0
Test Information
Date/Time: [**2130-9-20**] at 11:35 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW-:1 Machine: [**Pager number **]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aorta - Descending Thoracic: *2.7 cm <= 2.5 cm
Aortic Valve - Valve Area: *1.4 cm2 >= 3.0 cm2
Mitral Valve - MVA (P [**12-13**] T): 2.1 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). Moderately
thickened aortic valve leaflets. Mild (1+) AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. Severe
mitral annular calcification. Trivial MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
Pre-CPB: No spontaneous echo contrast is seen in the left atrial
appendage. LV systolic fxn is good. Right ventricular chamber
size and free wall motion are normal. There are simple atheroma
in the descending thoracic aorta. . The aortic valve leaflets
are moderately thickened. Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are moderately thickened. Peak
Mitral gradient is 7.6. There is severe mitral annular
calcification. Trivial mitral regurgitation is seen. There is no
pericardial effusion.
Post-CPB: Preserved biventricular systolic fxn. Trace MR. 1+AI.
Aorta intact. Other parameters as prebypass.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician
?????? [**2125**] CareGroup
Brief Hospital Course:
ASSESSMENT AND PLAN, AS REVIEWED AND DISCUSSED IN
MULTIDISCIPLINARY ROUNDS
Patient is an 87 year old woman with NIDDM, HTN,
hypercholesterolemia, now presenting with weeks-long history of
chest pain and dyspnea on exertion and an NSTEMI diagnosed at
outside hospital; she was transferred to [**Hospital1 18**] for further
evaluation and treatment planning.
#. Coronary artery disease.
Coronary angiography demonstrated 3 vessel disease, the most
important of which was diffuse blockages of the LAD. An
echocardiogram demonstrated a 40% EF and several areas of
hypokinesis. The patient was written for PRN nitroglycerin, as
well as high-dose statin, aspirin, and diuresis. The cardiac
surgery service was consulted. Based on their recommendations,
we ordered a cardiac MRI study which showed viable myocardium;
additionally, we ordered a non-contrast chest CT which showed
diffuse atherosclerosis of the aorta. Surgical planning
proceeded, and the risks and benefits of surgery were discussed
at length with the patient and her children. The ultimate
decision was to proceed with coronary artery bypass. While
awaiting for surgery and plavix wash out, she experienced
multiple episodes of non-sustained v-tach on telemetry and the
night prior to CABG was started on a heparin drip for [**7-21**] chest
pain with T-wave inversions in the lateral leads.
#. Heart failure.
On arrival, she was euvolemic or slightly dehydrated by exam.
She got fluids for 6 hours post procedure on the day of
admission. Her EF was 40%. This was judged likely to be the
result of ischemic heart failure. She had crackles on exam and
was gaining weight during the early part of her admission. We
began diuresis, eventually accelerating to a goal of one liter
negative per day. She received metoprolol and losartan. As
above, the decision about surgery was to proceed and
accordingly, the plan for her heart failure going forward was
medical management.
#. Urinary incontinence
She had been on detrol in the past to good effect, but was
recently changed to another med for insurance reasons. The [**Hospital1 18**]
formulary, on the other hand, provides detrol, and this was
given to her to good effect during this admission. Urinary
incontinence was not a [**Last Name 16423**] problem.
.
#. DM
She used glyburide as an outpatient; we used an insulin sliding
scale to achieve tight control during hospitalization.
.
#. FEN
She received a heart healthy diet and electrolytes were checked
daily and repleted as necessary. Except after her procedure, IV
fluids were not used because of heart failure.
.
#. Access:
PIV
.
#. PPx:
Heparin SC
Bowel regimen
.
#. Code:
Full (discussed with patient).
.
Underwent cabg x3 with Dr. [**Last Name (STitle) **] on [**9-20**]. Transferred to the
CVICU in stbale condition. Extubated on POD #1 and gentle
diuresis started as well as titrated beta blockade.Went into A
fib on POD #2 and treated with amiodarone.Pacing wires and chest
tubes removed. Periodic bursts of A Fib, but ultimately
transferred to the floor on POD #5 to begin increasing her
activity level. Cleared for discharge to rehab on POD #7. Pt.
is to make all followup appts. as per dicharge instructions.
Medications on Admission:
TRANSFER MEDICATIONS:
Asa 81mg (additional 3 Aspirin 81mg this morning)
plavix 600mg last evening
75mg today
cardizem 120mg
colace
lovenox 80mg (last dose 8pm last evening)
lasix 20mg
glyburide (held this morning)
vicodin daily
cozaar 50mg
lopressor 25mg [**Hospital1 **]
NTP
nortriptyline
zocor
maxide
.
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 2 days, then 200 mg daily ongoing.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months.
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Nortriptyline 10 mg Capsule Sig: Four (4) Capsule PO HS (at
bedtime).
8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 7 days: then 40 mg daily ongoing.
11. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
7 days: then 20 mEq daily ongoing; hold for K > 4.5.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
CAD s/p cabg x3
NSTEMI
NIDDM
HTN
elev. chol.
osteoarthritis
postop A Fib
PSH: bladder suspension, hysterectomy
Discharge Condition:
stable
Discharge Instructions:
SHOWER DAILY and pat incisions dry
no lotions, creams, or powders on any incision
no driving until cleared by surgeon and PCP
no lifting greater than 10 pounds for 10 weeks
call surgeon for fever greater than 100.5, redness, or drainage
Followup Instructions:
see Dr. [**Last Name (STitle) 1057**] in [**12-13**] weeks
see Dr. [**Last Name (STitle) **] in [**1-14**] weeks
see Dr. [**Last Name (STitle) **] in 4 weeks
Completed by:[**2130-9-27**]
|
[
"410.71",
"401.9",
"997.1",
"250.80",
"788.30",
"E878.2",
"276.51",
"428.31",
"428.0",
"427.31",
"414.01",
"427.1",
"715.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"36.15",
"39.61",
"37.22",
"88.56",
"88.53",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
14222, 14288
|
9595, 12783
|
277, 343
|
14444, 14453
|
3729, 8585
|
14739, 14928
|
2279, 2556
|
13139, 14199
|
14309, 14423
|
12809, 12809
|
14477, 14716
|
8634, 9572
|
2571, 3710
|
197, 239
|
12831, 13116
|
371, 1857
|
1879, 1984
|
2000, 2263
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,099
| 142,437
|
52241
|
Discharge summary
|
report
|
Admission Date: [**2133-10-10**] Discharge Date: [**2133-10-13**]
Date of Birth: [**2074-3-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
59 y/o male presented to outside hospital after 3 days of chest
discomfort, lightheadedness, unsteady gait, scapular pain.
Major Surgical or Invasive Procedure:
Emergency CABG X 2(SVG>LAD, SVG>OM), PFO closure, Repair left
femoral artery, removal IABP, LVAD placement [**Date range (1) 108059**]
History of Present Illness:
59 y/o male presented to outside hospital after 3 days of chest
discomfort, lightheadedness, unsteady gait, scapular pain. He
initially saw a chiropractor for this pain, symptoms persisted,
so he went to the ED. ECG showed AMI, troponin 5.5, Chest,
abdomen & head CT scans done which were all essentially
negative. He was transferred to [**Hospital1 18**] for emergent cardiac
catheterization. He had a cardiac arrest on the cath table
during procedure. He was emergently placed on ECMO for
transport to the OR.
Past Medical History:
DM-2
HTN
Neuropathy
Depression
Shoulder pain
Social History:
former smoker
ETOH ?
Family History:
unknown
Physical Exam:
Admitted to cardiac surgery service after emergent CABG
Pertinent Results:
[**2133-10-13**] 12:06PM BLOOD Hgb-11.3* Hct-30.7*
[**2133-10-13**] 05:07AM BLOOD WBC-21.8* RBC-3.57* Hgb-11.2* Hct-30.1*
MCV-84 MCH-31.5 MCHC-37.3* RDW-15.4 Plt Ct-131*
[**2133-10-13**] 05:34AM BLOOD PTT-56.3*
[**2133-10-13**] 05:07AM BLOOD Glucose-172* UreaN-42* Creat-2.1* Na-135
K-4.7 Cl-101 HCO3-24 AnGap-15
[**2133-10-11**] 04:56AM BLOOD UreaN-36* Creat-2.2* Na-142 K-3.3 Cl-110*
HCO3-23 AnGap-12
[**2133-10-13**] 05:07AM BLOOD ALT-99* AST-280* LD(LDH)-1584* AlkPhos-93
Amylase-20 TotBili-1.8*
[**2133-10-11**] 09:09AM BLOOD ALT-110* AST-553* LD(LDH)-1571*
AlkPhos-38* Amylase-20 TotBili-1.1
[**2133-10-10**] 05:30PM BLOOD cTropnT-4.82*
Brief Hospital Course:
Pt. was transferred to [**Hospital1 18**] for emergent cardiac
catheterization. He had a cardiac arrest on the cath table
during procedure. He was emergently placed on ECMO for
transport to the OR. Underwent emergent CABGX 2, removal of
IABP, LVAD placement, PFO repair. Post-op he was transported to
the Cardiac surgery recovery unit in critical condition. He
remained on Levophed, Vasopressin, Epinephrine, Milrinone gtts,
with acceptable hemodynamic parameters, on full vent. support.
He was weaned from propofol, and has awakened, moves all
extremities, and follows most commands. He had a post-op left
pleural chest tube placed for an effusion. He is on PCV, 60%
O2, Vt 550, RR 20, +12 PEEP. Lasix drip was initiated for
aggressive diuresis. TEE on [**2133-10-12**] showed minimal LV ejection,
and the decision was made to transfer him to [**Hospital3 1563**]
Hospital for evaluation for long-term VAD/Heartmate, or possible
heart transplant.
Medications on Admission:
Darvocet N-100 [**3-13**]/day
Neurontin 600mg [**Hospital1 **]
Lisinopril 20mg daily
Lipitor 10mg daily
Celebrex 200mg daily
Prozac 20-30mg daily
Humulin NPH insulin 30 U Q AM & Q PM
Humalog 10 Units Q AM & Q PM
Discharge Medications:
1. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Epinephrine 1 mg/mL Solution Sig: One (1) Injection INFUSION
(continuous infusion).
5. Norepinephrine Bitartrate 1 mg/mL Solution Sig: One (1)
Intravenous INFUSION (continuous infusion).
6. Vasopressin 20 unit/mL Solution Sig: One (1) Injection
TITRATE TO (titrate to desired clinical effect (please
specify)).
7. Morphine Sulfate 2-8 mg IV Q2H:PRN pain
8. Furosemide 10 mg/mL Solution Sig: Fifteen (15) mg/hr
Injection INFUSION (continuous infusion).
9. Levofloxacin 250 mg IV Q24H
10. Pantoprazole 40 mg IV Q24H
11. Milrinone 0.26-0.5 mcg/kg/min IV INFUSION
12. Potassium Chloride 20 mEq / 50 ml SW IV PRN
k+ < 4.0
13. Vancomycin HCl 750 mg IV Q 12H
14. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: 1000 (1000) u Intravenous ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Acute MI
renal failure
DM
Discharge Condition:
Critical
Discharge Instructions:
ICU care
Followup Instructions:
as indicated
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2133-10-13**]
|
[
"V58.67",
"272.0",
"745.5",
"427.5",
"414.01",
"458.29",
"250.00",
"410.11",
"785.51",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.23",
"39.61",
"96.04",
"35.71",
"37.66",
"96.72",
"39.31",
"97.44",
"99.05",
"37.61",
"99.07",
"36.12",
"99.04",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
4255, 4270
|
1974, 2930
|
402, 539
|
4340, 4351
|
1307, 1951
|
4408, 4544
|
1207, 1216
|
3192, 4232
|
4291, 4319
|
2956, 3169
|
4375, 4385
|
1231, 1288
|
240, 364
|
567, 1085
|
1107, 1153
|
1169, 1191
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,712
| 166,011
|
51569
|
Discharge summary
|
report
|
Admission Date: [**2154-3-29**] Discharge Date: [**2154-4-30**]
Date of Birth: [**2084-11-16**] Sex: M
Service: MEDICINE
Allergies:
Ambien / Beta-Blockers (Beta-Adrenergic Blocking Agts)
Attending:[**Last Name (NamePattern1) 1171**]
Chief Complaint:
weakness, left ankle pain, swollen legs
Major Surgical or Invasive Procedure:
None
History of Present Illness:
69 yo m with hx of systolic [**Last Name (LF) 19874**], [**First Name3 (LF) **] 15-20%, s/p CABG x2, s/p
MVR and tricuspid valve annuloplasty ring, PAF, and ITP who
presents with increased weakness and difficulty ambulating due
to left ankle pain. The patient states that he started to feel
weak about four days ago. He rose from his bed and noticed that
he felt very weak. Of note, he had difficulty walking on his
left ankle and it was very limited by pain. He did note
increased swelling in his legs and abdomen, however, his scale
did not show any weight gain. He claims that he's taking
Coumadin 5 mg only. He denies orthopnea, PND, dyspnea, fevers,
chills, cough, n/v, black tarry stools, bright red blood per
rectum, headache, blurry vision.
.
He was recently admitted [**Date range (1) 45928**] for a heart failure
exacerbation. His INR at that time was elevated. He was diuresed
aggressively and sent home. He presented once again to the
hospital because he had an elevated INR>20 and in the ER, he was
also found to be in acute on chronic renal failure. His lasix
and aldactone were held at the end of admission and he was given
vitamin K to reverse his INR. He was sent home with a normal INR
and had an INR check and f/u with cardiology. Cardiology started
him on lasix and aldactone and kept the rest of his medications
the same.
.
Since the patient could not walk, he came to the hospital. In
the ER, his vital signs were T: 99.5, BP: 116/77, HR: 96, RR:
18, O2 sat: 100% RA. The patient had a CXR which showed mild
pulmonary vascular congestion with small bilateral pleural
effusions and a retrocardiac opacity likely represents
atelectasis, although underlying infection cannot be excluded.
His INR was also found to be elevated >20. He had xrays of his
left ankle and tibia which showed "no acute fracture." EKG
showed atrial fibrillation at 98 bpm with LVH, intraventricular
conduction delay and overall no changes from prior. The patient
received Lasix 20 mg IV and Vitamin K 10 mg PO and was
transferred to the floors.
.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. 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
-Coronary Artery Disease, [**2128**] CABG LIMA to LAD, SVG to rPDA and
SVG sequential graft to OM1 and OM2; [**2151**] CABG SVG to rPDA
-Chronic systolic CHF EF 15-20%
-Severe tricuspid regurgitation s/p Tricuspid valve annuloplasty
ring [**2151**]
-Severe mitral regurgitation s/p porcine MVR [**2151**]
-Paroxysmal atrial fibrillation on coumadin, s/p cardioversion
[**9-2**], h/o bradycardia with beta blocker
-PAD s/p bilateral carotid endarterectomy
-ITP
-Pancreatic cysts (likely IPMN)
-h/o cholestatic jaundice in [**2151**] (thought secondary to drug
reaction, since resolved, had 2 liver biopsies)
Social History:
Divorced. Lives alone. 2 children. Tries to follow 2g Na diet
with 50 ounce fluid restriction. Lives alone. He is retired.
Former ETOH abuse [**2150**] and denies current ETOH use and denies
illicit drug use.
Family History:
Mother with hyperlipidemia and died of coronary artery disease
in her 60s. There is no family history of premature coronary
artery disease or sudden death.
Physical Exam:
Admission Physical Exam:
Vitals: T: 97.7, BP: 114/75, HR: 83, RR: 20, O2 sat: 96% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP elevated to ear, no LAD
Lungs: Clear to ausculatation bilaterally. No w/r/c.
CV: Irregular rhythm. Normal rate. normal S1 + S2, loud systolic
murmur at LLSB.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, 2+ peripheral edema to the
knee bilterally. Brusing on left ankle with tenderness to
palpation. Cool left foot, difficult to assess pulses due to
edema in left foot. Sensation intact.
Pertinent Results:
Admission laboratories:
[**2154-3-29**] 04:39PM BLOOD WBC-7.3 RBC-4.47* Hgb-12.2* Hct-36.1*
MCV-81* MCH-27.3 MCHC-33.7 RDW-17.8* Plt Ct-171
[**2154-3-29**] 04:39PM BLOOD Neuts-86.5* Lymphs-6.6* Monos-5.6 Eos-0.8
Baso-0.5
[**2154-3-29**] 04:39PM BLOOD PT->150* PTT-55.3* INR(PT)->20.2*
[**2154-3-30**] 12:05AM BLOOD Fibrino-428*#
[**2154-3-29**] 04:39PM BLOOD Glucose-97 UreaN-63* Creat-2.2* Na-126*
K-5.3* Cl-87* HCO3-23 AnGap-21*
[**2154-3-30**] 05:45AM BLOOD ALT-84* AST-138* AlkPhos-107 TotBili-3.1*
DirBili-1.7* IndBili-1.4
[**2154-3-30**] 03:12PM BLOOD Calcium-8.8 Phos-3.9 Mg-2.6
---------------
CXR: IMPRESSION:
1. Mild pulmonary vascular congestion with small bilateral
pleural effusions.
2. Retrocardiac opacity likely represents atelectasis, although
underlying infection cannot be excluded.
Ankle/tibia Xray: IMPRESSION: No acute fracture.
Brief Hospital Course:
# Acute exacerbation of systolic heart failure: The patient
presents with fluid overload, especially in the lower
extremities. He has been compliant with his lasix and aldactone.
He noticed his legs swelling, but he said his weight hasn't
increased. He has been keeping to his fluid restriction. The
patient was started on his home lisinopril. The patient was
started on lasix boluses, however his hypotension limited his
diuresis. Since he was hypotensive to SBP: 80s-90s, his
lisinopril was decreased to 2.5 mg. He was started on a lasix
drip for more gentle diuresis, which proved ineffective with
even I&Os. He was admitted to the CCU with the intention of
ionotrope assisted diuresis in the setting of persistent
hypotension. Vigorous diuresis was achieved with aggressive
lasix drip without the need for ionotropes with the patient
found to be asymptomatic from stable blood pressures in the 90s
systolic. His lisinopril was held as this worsened his
hypotension. The patient was transferred out of the CCU to the
cardiac floor. His lasix drip was continued with further
diuresis. The patient's weight plateaued, so metalozone was
started which assisted with his diuresis. Low dose captopril
(3.125 mg TID) was added. Any attempt to uptitrate the captopril
caused hypotension. The was switched to Lasix IV pushes and then
to torsemide in which the patinet continued to gain weight.
Since there was difficulty in diuresing the patient, the patient
was transferred to the CCU for ionotropic assisted diuresis. In
the CCU, his lasix gtt was increased, and his urine output
subsequently increased. He was subsequently transfered back to
the cardiology floor were lasix gtt was continued with good
response. Once his weight reached his dry weight of <140 lbs,
lasix gtt and metolazone were stopped, he was started on
torsemide 40 mg and continued on spironolactone 25 mg [**Hospital1 **]. His
weight on discharge was 138 lbs.
.
# Acute on chronic renal failure: The patient presented with a
creatinine of 2.2, higher than his baseline of 1.2. Was on
aldactone 25 and Lasix 40 mg PO at home. This was thought to
represent pre-renal azotemia given his low ejection fraction and
CHF exacerbation. With aggressive diuresis (as above), his
creatinine improved to baseline. On the floor, the patient was
continued on the lasix drip and again developed acute renal
failure with his Cr increasing to 1.5-1.6 and stabilizing in
that range.
.
# Coagulopathy: The patient presented with an INR above 20.2.
His elevated INR was likely due to hepatic congestion secondary
to CHF. The patient was given Vitamin K 10 mg IV in the ER and
his INR corrected to 1.8. He continued his warfarin for a goal
of [**2-27**] thereafter.
.
# Bioprosthetic mitral valve: The patient presented with an
elevated INR to 20.2. He was given Vitamin K 10 mg in the
emergency room and his INR corrected to 1.8. At that point, he
was started on a heparin drip along with warfarin. Since a
heparin gtt was not indicated, it was stopped and he continued
coumadin for a goal INR of [**2-27**].
.
# Hypervolemic hyponatremia: Hyponatremia in the setting of CHF,
likely high ADH state given low cardiac output. The patient was
fluid restricted and diuresis was achieved (as above). His Na
continued to be low ranging from 126-130 but the patient
remained asymptomatic.
.
# Left lower extremity pain: The patient presented with LLE pain
in the setting of an elevated INR. Xrays of the ankle and tibia
were negative. Ortho evaluated the patient and felt his pain was
likely related to cellulitis (though no leukocytosis or fever)
and possibly a hematoma. He had no signs of compartment
syndrome. He was started on cefazolin on [**3-31**] for treatment of
cellulitis. His leg pain did not improve while on cefazolin, so
it was discontinued on [**4-7**]. With time, his lower extremity pain
resolved, so it was likely related to a hemarthrosis vs. lower
extremity edema.
.
# Runs of Vtach: The patient has a long history of runs of Vtach
and PVCs. Patient has been refusing pacer since has pancreatic
mass which needs to be followed by [**Month/Year (2) 4338**]. He continued to have
runs of Vtach but all non-sustained.
.
# Clot in nose: Patient with bilateral nose clots in the setting
of anticoagulation and thrombocytopenia. The patient had a
nosebleed earlier during his admission and was prescribed
affrin. He continued to use the affrin over three days and the
primary team was unaware. Once the primary team realized that
the patient had been using affrin longer than the prescribed
amount, it was discontinued. The patient was found to have
bilateral ulcerated septums. ENT recommended refraining from
affrin use and the nasal mucosa should heal. In addition, ENT
recommended gentle irrigation with saline and saline mist
hydration, and this was done. After this episode he had no more
issues with epistaxis.
.
# Microcytic Anemia: Patient with falling Hct from admission.
The patient was guiaic negative x 3. He most likely had an
anemia due to bone marrow suppression and continued phlebotomy.
There were no signs of bleeding. His Hct remained stable ranging
from 25-28.
.
# Thrombocytopoenia: The patient has a history of ITP was noted
to have thrombocytopenia on admission. The patient had heparin
during this admission and a prior admission to the hospital.
Both heparin induced thrombocytopenia and ITP were ruled out.
His thrombocytopenia likely related to bone marrow supporession.
It remained stable ranging from 130-160's.
.
# Cholestatic Transaminitis: This was thought to be due to
hepatic congestion, as a result of CHF exacerbation. It resolved
after diruesis. Had no RUQ tenderness or epigastric discomfort.
Medications on Admission:
1. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual PRN as needed for chest pain: Take one tablet for
chest pain. Can repeat up to 2 times. At that point, call your
doctor.
[**Last Name (Titles) **]:*30 tablets* Refills:*0*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Calcium Oral
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Oral
6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
7. Lasix 40 mg PO
8. Aldactone 25 mg PO
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
11. Captopril 12.5 mg Tablet Sig: 0.25 Tablet PO TID (3 times a
day).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
Extended care facility
Discharge Diagnosis:
Primary:
-acute on chronic systolic heart failure
-atrial fibrillation
-acute on chronic renal failure
Secondary:
-ventricular arrhythmias
-thrombocytopenia
-anemia
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 827**]. You came into the hospital because your left leg
hurt. You were found to have a worsening of your heart failure
(increased water), acute kidney failure and a high INR (Coumadin
level).
.
While on lasix, you had low blood pressures, so you needed
closer monitoring. You were transferred to the cardiac intensive
care unit so that we could keep a closer eye. You did well while
in the intensive care unit and were subsequently transfered to
the cardiology floor where you continued with your diuresis.
Once you reached your goal weight of less than 140 pounds the
lasix drip was stopped and you were transitioned to oral
diuretics. You continued to do well and you weight was 138 on
discharge. Your INR reached the goal of [**2-27**] once we increased
your coumadin to 4 mg daily. Your kidney function improved with
treatement of your CHF but this never returned to your previous
baseline. Please have your PCP follow up your renal function
once you are discharged from the rehabilitation facility.
.
Since you have a history of congestive heart failure, you should
weigh yourself every morning. Call your doctor if weight goes up
more than 3 lbs. You should only drink 1.5 liters of fluid per
day and stick to a 2 gram ([**2144**] mg) salt/sodium diet.
Followup Instructions:
Appointment #1
MD: Dr [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**]
Specialty: Cardiology
Date/ Time: [**5-20**] at 3pm
Location: [**Hospital Ward Name 516**], [**Location (un) 11633**], [**Location (un) 436**]
Phone number: [**Telephone/Fax (1) 62**]
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2154-6-11**] 2:35
Provider: [**First Name11 (Name Pattern1) 2295**] [**Last Name (NamePattern4) 11222**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2154-7-10**] 2:00
|
[
"584.9",
"427.31",
"287.5",
"427.1",
"V42.2",
"682.6",
"V45.81",
"280.9",
"V58.61",
"585.9",
"428.0",
"414.00",
"276.1",
"403.90",
"428.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12877, 12926
|
5489, 11178
|
364, 371
|
13136, 13136
|
4611, 5466
|
14654, 15275
|
3727, 3885
|
11802, 12854
|
12947, 13115
|
11204, 11779
|
13317, 14631
|
3925, 4592
|
2461, 2840
|
285, 326
|
399, 2442
|
13151, 13293
|
2862, 3484
|
3500, 3711
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,608
| 105,328
|
42031
|
Discharge summary
|
report
|
Admission Date: [**2192-7-2**] Discharge Date: [**2192-7-9**]
Service: MEDICINE
Allergies:
fentanyl / OxyContin
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
corevalve placement
Major Surgical or Invasive Procedure:
[**2192-7-3**] Corevalve placement
History of Present Illness:
Ms. [**Known lastname 91257**] is a [**Age over 90 **]yo caucasian female with h/o CAD s/p LAD
stent in [**2184**] and known aortic stenosis. She reports worsening
shortness of breath after ambulating [**1-23**] block, though noteable
for limited activity due to multiple ortho procedures
necessitating cane. She denies chest pain, lightheadedness, or
syncopal episodes, but admits fatigue with doing usual household
activities and shortness of breath when reaching up. She was
seen
in consultation for surgical aortic valve replacement and was
deemed not a surgical candidate due to her history of Childs A
liver disease. She has continued on medical therapy alone and
both patient and family report worsening fatigue and shortness
of
breath of late. She now also admits to chest discomfort after
walking 50 feet, and with light housework. After informed
consent, she was screened for the Corevalve/TAVR. She met all
inclusion criteria and did not meet any exclusion criteria.
Warfarin was held 4 days prior to admission.
Today, she was taken to the OR and corevalve procedure was
completed under general anesthesia. She had successful placement
of the corevalve device with post-placement TEE in the OR
showing trace peri-valvular aortic regurgitation and also 1+
mild central aortic regurgitation. She recieved 3500 ml of IVF
with production of >1100 cc of urine during the case. Also
recieved 20 mEq of K repletion and 1 unit of pRBCs because of
estimated blood loss of 100 cc at the groin access sites. Was
sedated with propofol and had a muscle relaxant at the start of
the case only.
She was noted to have ST depressions on telemetry during the
case in a V5 lead and then ST elevations when the lead was
changed to V1 position. An EKG on arrival to the CCU showed new
LBBB with expected ST elevations in V1-V3 and ST depressions in
V5-6. She arrives to the CCU intubated and sedated although
opens eyes to voice. Her right femoral groin site is oozing and
left groin site still has femoral sheath in place.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY: STEMI [**2184**] s/p PCI
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: DES to LAD [**2184**]
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- aortic stenosis
- Hep C (2/2 blood transfusion [**2155**])
- spinal stenosis
- osteoarthritis
- cataract extraction
- choley
- liver bx
- bilateral TKA's (right x2)
- bilateral THA's (twice each)
- left leg shorter than right (congenital)
- skin cancer right mandible area, s/p excision
Social History:
Lives with her husband in their daughter's home. Seven steps to
enter. Walks with cane due to multiple ortho issues, husband
frail. [**Name2 (NI) 4084**] smokers, occasional EtOH, denies illicits.
Daughter - [**Name (NI) 391**] [**Name2 (NI) **] ([**Telephone/Fax (1) 91258**])- -Kensington,NH. Sons x
2 ([**Name2 (NI) 2498**], MA, [**Location (un) 61361**], CO)
Family History:
noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.7, BP 140-190/60s HR 66-76 sinus, RR 14, O2 sat > 98%
CMV PEEP 5, FiO2 50%
GENERAL: frail elderly female, intubated and sedated
HEENT: NCAT. Sclera anicteric. PERRL, 1 mm bilaterally.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
No xanthalesma.
NECK: lying flat, no JVD appreciated
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. II/VII holosystolic murmur, No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. CTAB,
no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Femoral 2+ radial 2+ DP 2+ PT 2+
Left: Femoral 2+ radial 2+ DP 2+ PT 2+
.
DISCHARGE PHYSICAL EXAM:
VS: Tm 98.2 HR 70 BP 145/59 RR 16 O2 100%RA I/O 1460/2300
Weight 56.6kg
GENERAL: Elderly woman in chair. NAD
HEENT: PERRLA, no ertyhema, MMM, no LAD, JVD non elevated
CHEST: CTABL
CV: S1,S2. RRR, [**2-27**] midpeaking systolic murmur with crisp S2
ABD: Soft, NT, ND, NABS, No rebound or guarding. No HSM, No
[**Doctor Last Name **] sign. BM this am
EXT: wwp, no edema. Bilteral groin sites clean and dry
NEURO: CNII-XII intact. [**5-26**] strenth throughout
SKIN: No rashes
PSYCH: Calm, pleasant
Pertinent Results:
ADMISSION LABS:
[**2192-7-2**] 01:10PM BLOOD WBC-5.6 RBC-4.44 Hgb-13.6 Hct-41.0 MCV-92
MCH-30.5 MCHC-33.1 RDW-13.4 Plt Ct-175
[**2192-7-2**] 01:10PM BLOOD PT-11.0 PTT-29.1 INR(PT)-1.0
[**2192-7-3**] 04:06PM BLOOD Fibrino-191
[**2192-7-2**] 01:10PM BLOOD Glucose-90 UreaN-22* Creat-0.7 Na-142
K-4.1 Cl-104 HCO3-31 AnGap-11
[**2192-7-2**] 01:10PM BLOOD ALT-48* AST-48* CK(CPK)-141 AlkPhos-71
TotBili-0.6
[**2192-7-2**] 01:10PM BLOOD proBNP-3666*
[**2192-7-3**] 05:02PM BLOOD Calcium-7.7* Phos-2.6* Mg-1.5*
[**2192-7-2**] 01:10PM BLOOD Albumin-4.3
[**2192-7-3**] 12:46PM BLOOD Type-ART pO2-425* pCO2-35 pH-7.50*
calTCO2-28 Base XS-4 Intubat-INTUBATED Vent-CONTROLLED
[**2192-7-2**] 11:39AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2192-7-2**] 11:39AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
.
MICRO:
[**7-2**] URINE CULTURE NEGATIVE
.
IMAGING:
[**2192-7-5**] POST-COREVALVE ECHO:
LEFT ATRIUM: Marked LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter
or pacing wire is seen in the RA and extending into the RV.
LEFT VENTRICLE: Mild symmetric LVH. Mild (non-obstructive) focal
hypertrophy of the basal septum. Small LV cavity. Normal
regional LV systolic function. Overall normal LVEF (>55%). TDI
E/e' >15, suggesting PCWP>18mmHg. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Aortic CoreValve. AVR well seated, normal
leaflet/disc motion and transvalvular gradients. No AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Moderate mitral annular calcification. Mild thickening of mitral
valve chordae. [**Male First Name (un) **] of the mitral chordae (normal variant). No
resting LVOT gradient. Calcified tips of papillary muscles. Mild
to moderate ([**1-23**]+) MR. [Due to acoustic shadowing, the severity
of MR may be significantly UNDERestimated.]
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is markedly dilated. There is mild symmetric
left ventricular hypertrophy. There is mild (non-obstructive)
focal hypertrophy of the basal septum. The left ventricular
cavity is small. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. An aortic
CoreValve prosthesis is present. The aortic valve prosthesis
appears well seated, with normal leaflet/disc motion and
transvalvular gradients. No aortic regurgitation is seen. The
mitral valve leaflets are moderately thickened. Mild to moderate
([**1-23**]+) mitral regurgitation is seen. [Due to acoustic shadowing,
the severity of mitral regurgitation may be significantly
UNDERestimated.] There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Biatrial abnormality. Well-seated, normally
functioning aortic CoreValve. Mild symmetric left ventricular
hypertrophy with preserved global and regional biventricular
systolic function. Increased left ventricular filling pressure.
Mild to moderate mitral regurgitation. Mild pulmonary artery
systolic function.
Compared with the prior study (images reviewed) of [**2192-6-7**], a
well-seated, normally functioning aortic CoreValve prosthesis is
now present. The severity of pulmonary artery systolic
hypertension has decreased from moderate to mild.
Brief Hospital Course:
Ms. [**Known lastname 91257**] is a [**Age over 90 **] year old female with history of coronary
artery disease (CAD) status post drug eluding stent (DES) to
LAD, Childs class A liver disease and known critical aortic
stenosis ([**Location (un) 109**] < 0.6) demonstrating worsening symptoms who was
admitted to the CCU after elective corevalve procedure. She did
well post-operatively.
ACTIVE ISSUES:
# Critical symptomatic aortic stenosis: Underwent corevalve
procedure on [**2192-7-3**], no immediate complications. Intubated for
the procedure and then extubated without issues. Recieved
plavix load with 300 mg prior to procedure and then was
continued on 75 mg daily. Intraoperatively, was noted to have
ST changes on telemetry and post-procedure 12-lead EKG
demonstrated new left bundle branch block (LBBB) with expected
ST changes. However, this spontaneously resolved within a few
hours. For the first 48 hours post-operatively, she had labile
blood pressures and required alternating nitroglycerin drip and
phenylephrine drip for hyper and hypotension respectively. This
variability resolved and her blood presures were stable from
120-150s for several days before discharge. Was discharged on
aspirin 81 mg daily, plavix 75 mg daily, metoprolol succinate 50
mg daily, and valsartan 80 mg daily.
# hypertension: Periprocedurally her pressures were labile and
she was initially hypertensive to the 240s and required a nitro
drip to lower her BP. She subsequently became hypotensive and
the nitro was discontinued and neosynephrine was started. After
about 48 hours post procedure, her pressures normalized and her
home anti-hypertensive medications were slowly re-introduced and
uptitrated. At the time of discharge, she was on valsartan 80mg
PO Daily and Metoprolol Succinate 50 mg daily.
CHRONIC ISSUES:
# CAD: Not an active issue during this hospital stay. Her home
medications were initially held periprocedurally, but slowly
restarted when her pressures stabilized. She will be discharged
on aspirin 81mg, plavix 75mg, valsartan 80mg PO Daily, and
metoprolol succinate 50 mg dialy.
# mobility is impaired due to multiple surgeries: TKR, spinal
stenosis, congenital leg length deformity. Physical therapy saw
patient and recommended short term Rehab for improved ambulation
and strength training. The patient was screened by PT and will
be discharged to rehab. We will continue pain control with with
tylenol and oxycodone prn.
# Childs class A liver disease: Due to hep C but has never been
treated for hepC. no history of decompensations and no symptoms
or signs during this admission.
Transitional Issues:
# Physical Therapy as per Rehab
# CONTACT: [**Name (NI) 391**] [**Name2 (NI) **] ([**Telephone/Fax (1) 91258**])
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Metoprolol Tartrate 50 mg PO BID
2. Valsartan 80 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Calcium Carbonate 500 mg PO DAILY
5. Vitamin D Dose is Unknown PO DAILY
6. Multivitamins Dose is Unknown PO DAILY
7. Vitamin E Dose is Unknown PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 500 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Valsartan 80 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Vitamin E 200 UNIT PO DAILY
7. Clopidogrel 75 mg PO DAILY
Start: In AM day of surgery. Do not give if direct aortic
approach
8. Docusate Sodium 100 mg PO BID:PRN constipation
9. Metoprolol Succinate XL 50 mg PO DAILY
hold for sbp<100 or hr<50
10. Senna 1 TAB PO BID:PRN constipation
11. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
Langdon Place of [**Location (un) **], NH
Discharge Diagnosis:
PRIMARY DIAGNOSIS
aortic stenosis
CAD s/p LAD stenting ([**2184**])
hypertension
hyperlipidemia
hepatitis C from transfusions in [**2155**]
spinal stenosis
osteoarthritis
cholecystectomy [**2171**]
bilateral total knee replacements
bilateral total hip replacements x 2
congenital left leg shorter than right
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 91257**],
You were admitted to the hospital for an elective procedure for
severe symptomatic aortic stenosis, a narrowing of the aortic
valve. You had a percutaneous transcatheter aortic valve
replacement with the corevalve procedure. You went through this
successfully and afterwards the ultrasound of your heart showed
improved flow across the aortic valve and decreased pressures.
You received 1 unit of packed red blood cells during your stay
and had no complications. You have progressed nicely and are now
ready for discharge.
The following changes were made to your medications:
- START taking clopidogrel (plavix) 75 mg daily to help prevent
clots
- CHANGE metoprolol to long acting. Now you are taking
metoprolol succinate 50 mg daily
You should keep all of the follow-up appointments listed below.
You should bring your medications to each appointment so that
your doctors [**Name5 (PTitle) **] update their records and adjust the doses as
needed.
Please refer to the additional discharge information sheets
provided. Important to note is:
1. Weigh yourself daily - notify doctor if you should gain more
that 3 lbs in 2 days, or 5 lbs in 5 days.
2. Inspect your groin sites daily to monitor for infection
(redness, drainage, pain)
It was a pleasure taking care of you.
Followup Instructions:
Please make sure you have follow up appointment with Dr. [**Last Name (STitle) **]
in clinic within the next two weeks.
Please follow up with your primary care doctor after you are
discharged from Rehab.
|
[
"V10.83",
"424.1",
"458.29",
"070.54",
"V43.65",
"724.00",
"416.8",
"401.9",
"426.3",
"V43.64",
"755.30",
"276.52",
"V45.82",
"276.3",
"571.5",
"272.4",
"412",
"V70.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.05"
] |
icd9pcs
|
[
[
[]
]
] |
12054, 12122
|
8394, 8782
|
246, 283
|
12475, 12475
|
4701, 4701
|
13999, 14207
|
3279, 3296
|
11548, 12031
|
12143, 12454
|
11178, 11525
|
12658, 13976
|
3336, 4158
|
2439, 2557
|
11036, 11152
|
187, 208
|
8797, 10205
|
311, 2329
|
4717, 8371
|
12490, 12634
|
2588, 2879
|
10221, 11015
|
2351, 2419
|
2895, 3263
|
4183, 4682
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,097
| 111,866
|
26263
|
Discharge summary
|
report
|
Admission Date: [**2103-10-13**] Discharge Date: [**2103-10-19**]
Date of Birth: [**2028-4-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 29767**]
Chief Complaint:
nausea, weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
75 yo with h/o severe HTN, DMII, CRI, h/o prostate cancer s/p
chemo/XRT, left [**First Name3 (LF) 6024**], presents from home with nausea and weakness
since morning of admission and constant emesis on DOA. Patient
was unable to tolerate po and did not take any of his
medications including anti-hypertensives or insulin on DOA. In
the ED: SBP 220's, tachy at 100-125, given hydralazine. The
patient was actively vomiting. LBBB demonstrated on EKG old, but
patient had a troponin of 0.1 (CK/MB flat). Blood sugars
elevated in 400's with anion gap 27, ketones/glucose in urine,
lactate 4.4. Insulin gtt started and femoral line placed as
unable to get other access. He was given empiric Vanco and
ceftriaxone and transferred to the MICU for further management.
In the MICU, insulin gtt was weaned when AG closed and BG < 250.
IV hydration was continued. Troponin trended down. ASA and
metoprolol were given, but no heparin b/c suspicion of
thromboembolic event was low. HTN was treated with home doses.
Lactate improved and there was NGTD on cultures. ARF resolved.
.
ROS: No fevers, chills, (+) cough, abdominal pain. No CP, SOB.
Past Medical History:
-DMII
-Prostate CA, s/p chemo/radiation
-s/p Left [**Name (NI) 6024**], pt sustained injury wading through water while
living in [**Location (un) 5770**] during Hurricane [**Doctor First Name 3064**], was admitted to
hospital in [**Location (un) 36413**], as well as to hospitals in [**Name (NI) 86**] (pt does
not recall which)
-Hypothyroidism
-HTN
-Depression, coping after Hurricane and [**Name (NI) 6024**]
-Iron deficiency anemia
-H/o aspiration pna, with h/o MRSA in sputum??
[**Hospital 65041**] medical records, as pt recently moved to [**Location (un) 86**] area
Social History:
Lives at home with wife. Quit tobacco but smoked 1.5 ppd x many
years. Originally from [**Country 3594**] but moved to U.S. at age 6. Used
to live in [**Location (un) 5770**], but left after Hurricane [**Name (NI) 3064**], wife
is here in [**Name (NI) 86**] with him. Previously a cook, however no longer
working. Twin brother recently died. No EtoH or IDU.
Family History:
Wife had nausea/vomiting/diarrhea a week prior to the patient's
admission.
Physical Exam:
ADMISSION TO MICU: PHYSICAL EXAM:
95.6 120 205/82 23 97% RA
awake, alert to self, "hospital", "Saturday", could not state
month
MM dry
JVP flat
RR, tachycardic, nl S1, S2
Abd s/nt/nd, no rebound/guarding
L [**Name (NI) 6024**], RLE thin, no edema
.
TRANSFER TO FLOOR:
Vitals: T afeb HR 76 BP 184/63 RR 14 97%RA
Gen: awake, alert, oriented to self, "hospital" and date;
slurred speech
HEENT: PERRL, EOMI, anicteric, OP clear, MMM
Neck: JVP flat
CV: RR, tachy, nl S1/S2, early systolic murmur LLSB; late
non-radiating crescendo systolic murmur at apex
Pulm: CTAB although exam limited by poor compliance
Abd: (+) BS, soft, ND/NT, no rebound or guarding
Ext: L [**Name (NI) 6024**], RLE thin, warm, no edema; 2+ distal pulses
Pertinent Results:
[**2103-10-13**] EKG:
Sinus rhythm
Possible left atrial abnormality
Left anterior fascicular block
Intraventricular conduction defect
LVH with secondary ST-T changes
Since previous tracing, no significant change
.
[**2103-10-15**] Renal U/S:
1. No downstream evidence of renal artery stenosis.
2. Bilateral renal cysts. No hydronephrosis or solid mass.
3. Bilateral pleural effusions.
.
[**2103-10-17**] LUE U/S:
No evidence of DVT.
.
[**2103-10-17**] HEAD CT:
IMPRESSION: No acute intracranial process
.
[**2103-10-18**] HEAD MRI/MRA:
No stroke. Evidence of small vessel disease.
.
[**2103-10-13**] 11:48PM GLUCOSE-231* UREA N-23* CREAT-1.6*
SODIUM-150* POTASSIUM-3.4 CHLORIDE-116* TOTAL CO2-22 ANION
GAP-15
[**2103-10-13**] 11:48PM CK(CPK)-165
[**2103-10-13**] 11:48PM CK-MB-7 cTropnT-0.12*
[**2103-10-13**] 11:48PM CALCIUM-8.3* PHOSPHATE-0.8*# MAGNESIUM-1.8
[**2103-10-13**] 09:45PM GLUCOSE-394* UREA N-23* CREAT-1.6*
SODIUM-147* POTASSIUM-3.1* CHLORIDE-112* TOTAL CO2-18* ANION
GAP-20
[**2103-10-13**] 08:29PM ACETONE-LARGE
[**2103-10-13**] 08:28PM GLUCOSE-426* LACTATE-4.4*
[**2103-10-13**] 07:00PM GLUCOSE-459* UREA N-25* CREAT-1.9*
SODIUM-146* POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-17* ANION
GAP-31*
[**2103-10-13**] 07:00PM ALT(SGPT)-9 AST(SGOT)-16 CK(CPK)-127 ALK
PHOS-78 AMYLASE-131* TOT BILI-0.4
[**2103-10-13**] 07:00PM CK-MB-6 cTropnT-0.10*
[**2103-10-13**] 07:00PM NEUTS-92.9* LYMPHS-5.7* MONOS-1.3* EOS-0.1
BASOS-0.1
[**2103-10-13**] 07:00PM WBC-20.2*# RBC-4.39* HGB-12.1* HCT-34.9*
MCV-79* MCH-27.5 MCHC-34.7 RDW-15.3
Brief Hospital Course:
Mr. [**Known lastname 52213**] was found to be in DKA on admission which may have
been secondary to gasteroenteritis and subsequent decreased
insulin use. In the MICU, an insulin drip was initiated and was
weaned when his anion gap closed and blood glucose was < 250.
His blood glucose was in the 100-200 range when he was
transferred to the floor. He was started on an insulin regimen
consisting of 6 NPH [**Hospital1 **] and 3 Humalog with meals. Humalog
sliding scale was provided for additional coverage QID. The
patient's NPH was converted to Lantus upon discharge to the
nursing home.
.
The patient had an elevated blood pressure on admission and
remained difficult to control. Renal ultrasound/doppler did not
reveal renal artery stenosis. He was transitioned to Labetolol.
Metoprolol and amlodipine were discontinued. TSH was also within
normal limits.
.
The patient also appeared to have left-sided facial weakness and
dysarthria when he arrived on the floor. It was unclear when
this started, but his wife reported that he did have some
trouble speaking at home during the week prior to admission.
Given the pooling of secretions and dysphagia, head CT was done
to rule out a stroke. CT of the head was negative as well as
subsequent brain MRI/MRA. Speech and swallow consultation was
also obtained. His facial weakness and dysphagia improved to his
reported baseline within 24 hours after initiating levaquin for
a presumed UTI.
.
As above, Mr. [**Known lastname 52213**] was started on Levaquin for a presumed UTI
because he was having intermittent fevers. His blood cultures
showed no growth to date on discharge. His chest xray also
demonstrated [**Hospital1 **]-basilar opacities that possibly represented
aspiration pneumonia or pneumonitis. Aside from [**Hospital1 **], he was
otherwise assymptomatic.
.
The patient had a troponin leak on admission. This was likely
related to cardiac strain. ASA and metoprolol were given per his
home regimen, but heparin was not started given low suspicion of
thromboembolic event. He was also found to have ARF on
admission, but creatinine had returned to baseline on discharge.
.
The patient experienced a mechanical fall on the day prior to
discharge after trying to ambulate from the bathroom to bed
without any assistance. He slipped on the floor and hit his head
on a plastic sharps container mounted on the wall. There were no
external signs of trauma on exam and his neurologic exam was at
baseline.
.
The patient was discharged to [**Hospital **] [**Hospital **]
Rehabilitation facility where Dr. [**Last Name (STitle) 1699**] will follow-up with
him.
Medications on Admission:
MEDICATIONS ON ADMISSION:
?insulin 70/30
lisionopril 40mg qd
lantus ?15U qday
toprol 300mg qday
flomax 0.4mg qday
hydralazine 60mg [**Hospital1 **]
norvasc 5mg po qd
dulcolax
?simvastatin 10mg qd
.
MEDICATIONS ON TRANSFER FROM MICU
-Insulin SS
-Acetaminophen 325-650 PO q4-6h PRN pain
-Amlodipine 5mg PO BID
-ASA 325 PO qD
-Anzemet 12.5-25mg IV q8h PRN nausea
-Heparin 5000U SC TID
-Hydralazine 50mg PO QID
-Lisinopril 40mg PO qD
-Metoprolol 100mg PO TID
-Pantoprazole 40mg IV qD
-Prochlorperazine 10mg IV q6h PRN nausea
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
Tablet(s)
6. Labetalol 200 mg Tablet Sig: One (1) Tablet PO Q 12H (Every
12 Hours).
7. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Lantus 100 unit/mL Solution Sig: 0.12 mL Subcutaneous qam:
Please start in the morning on [**2103-10-20**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) **]
Discharge Diagnosis:
DKA
Hypertension
Discharge Condition:
Stable. Nausea resolved. Afebrile. Walks with assistance.
Discharge Instructions:
Please return to ED or call your doctor [**First Name (Titles) **] [**Last Name (Titles) **] > 101.5, severe
nausea/vomiting, intractable headache or pain or any other
concerning symptoms.
.
Please take all medications as prescribed.
.
Please follow-up with all appointments as scheduled.
Followup Instructions:
Dr. [**Last Name (STitle) 1699**] will see you next week at [**Hospital **] [**Hospital **]
Rehabilitation.
|
[
"309.9",
"272.0",
"V10.46",
"511.9",
"584.9",
"V58.67",
"787.2",
"785.0",
"V15.81",
"250.12",
"280.9",
"414.01",
"403.91",
"244.9",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8906, 8976
|
4914, 7530
|
334, 341
|
9037, 9097
|
3328, 3784
|
9435, 9546
|
2485, 2561
|
8101, 8883
|
8997, 9016
|
7582, 8078
|
9121, 9412
|
2610, 3309
|
278, 296
|
369, 1499
|
3793, 4891
|
1521, 2094
|
2110, 2469
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,861
| 142,285
|
22411
|
Discharge summary
|
report
|
Admission Date: [**2129-5-8**] Discharge Date: [**2129-5-11**]
Date of Birth: [**2105-5-5**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Dilaudid
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: The Pt. is a 24y/o F with a PMH of Type I DM, diagnosed at
the age of 16y.o with greater than 20 admissions for DKA over
the past four years admitted with elevated blood sugars and
chest tightness.
The patient was recently admitted on [**3-10**] to [**3-15**] with similar
symptoms. She was treated with fluids and insulin, and was seen
by the [**Last Name (un) **] consult service. She was switched to insulin
glargine 33 units at bedtime, with a sliding scale with meals.
She now follows at Upoms Corner for her DM management. Pt
reports her FS had ranged from 150-200 until 1 weeks prior to
admission. Over the past two days her FS have ranged in the
300s. Pt reports recent yeast infection, treated with diflucan,
otherwise denies illness. No fever/chills. No N/V/D. No URI sx.
Earlier today she brought her mother to an OSH [**Name (NI) **] after her
mother had fallen. The Pt then reports developing Chest
tightness and shortness of breath and came to the [**Hospital1 18**] ED. She
states she has not eaten all day today, reports poor po intake
over the past several days. Her FS at noon prior to coming to ED
was 235. She states she currently takes Lantus 31U nightly, has
not missed any doses. No recent medication changes. Denies EtOH,
denies IVDU. The patient reports symptoms of chest pain for two
hourse prior to arrival to ED with associated shortness of
breath and nausea. Pt reports these symptoms are her typical,
starting with gasping for air, then followed by chest
tightntess. Not changed with exertion. Symptoms most frequently
occur during times of stress, rarely occur at rest.
.
On arrival to the ED Vitals T 98.9, HR 131, BP 114/69, RR 18, O2
sat 100% RA. Cardiac enzymes were cycled with 1st set negative.
UA negative for evidence of infection. Labs demonstrated DKA
with anion gap of 24 and glucose of 551 and the pt was give
insulin 10 unit bolus and started on gtt at 6u/hr. Repeat labs
demonstrated glucose of 296 with AG of 19. She received 4L NS
total. Dilaudid 1mg X2 and zofran 4mg X1.
Past Medical History:
-Diabetes Type I: diagnosed age 16 in [**2120**] after her first
pregnancy. Most recent Hgb A1C 12.7 % ([**7-/2128**]), followed at
[**Last Name (un) **] but concern for compliance.
- Stage I diabetic nephropathy
- Anxiety/panic attacks
- Depression
- H. Pylori [**6-/2128**]
- Hyperlipidemia
- S/P MVA [**5-4**] - lower back pain since then. Per patient
received oxycodone from her primary provider
[**Name Initial (PRE) **] [**Name10 (NameIs) 58252**]
[**Name Initial (NameIs) **] G2P1Ab1, s/p miscarriage in 06/00 3rd trimester, s/p C-section
in [**2122**], not menstruating secondary to being on Depo-Provera
shots
- Genital Herpes
Social History:
She was born and raised in [**Location (un) 669**] but currently lives in her
own appartment. She is currently unemployed and received
disability. She has a 5 year old son. [**Name (NI) **] mother and sisters
live nearby. She denies tobacco, alcohol or illicit drug use.
Family History:
Her grandmother had type I diabetes. Otherwise
non-contributory.
Physical Exam:
Vitals AF, VSS
Gen: alert and oriented X3, NAD
CV: RRR nl S1/S2, no MRG, flat JVP
Resp: CTAB, no W/R/R
Abd: soft, NT/ND, NABS
Ext: no edema
Skin: no rashes, no lesions
Neuro: speech spont and fluent, moving all ext, non-focal
Pertinent Results:
Admission:
[**2129-5-8**] 02:57PM WBC-6.0 RBC-4.49 HGB-12.5 HCT-39.2# MCV-87
MCH-27.8 MCHC-31.8 RDW-12.4
[**2129-5-8**] 02:57PM NEUTS-62.5 LYMPHS-34.7 MONOS-2.0 EOS-0.4
BASOS-0.5
[**2129-5-8**] 02:57PM PLT COUNT-228
[**2129-5-8**] 02:57PM CALCIUM-9.8 PHOSPHATE-4.0 MAGNESIUM-2.0
[**2129-5-8**] 02:57PM CK(CPK)-95
[**2129-5-8**] 02:57PM CK-MB-NotDone
[**2129-5-8**] 02:57PM cTropnT-<0.01
[**2129-5-8**] 02:57PM GLUCOSE-551* UREA N-21* CREAT-1.2*
SODIUM-132* POTASSIUM-4.8 CHLORIDE-96 TOTAL CO2-12* ANION
GAP-29*
[**2129-5-8**] 05:45PM WBC-5.9 RBC-4.45 HGB-12.5 HCT-39.6 MCV-89
MCH-28.1 MCHC-31.6 RDW-12.1
[**2129-5-8**] 05:45PM NEUTS-72.2* LYMPHS-25.5 MONOS-1.5* EOS-0.5
BASOS-0.3
[**2129-5-8**] 05:45PM PLT COUNT-145* LPLT-1+
[**2129-5-8**] 05:45PM ACETONE-SMALL
[**2129-5-8**] 05:45PM GLUCOSE-296* UREA N-19 CREAT-0.9 SODIUM-137
POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-11* ANION GAP-23*
[**2129-5-8**] 05:45PM CALCIUM-8.3* PHOSPHATE-2.9
[**2129-5-8**] 08:00PM GLUCOSE-209* UREA N-15 CREAT-0.9 SODIUM-138
POTASSIUM-4.2 CHLORIDE-114* TOTAL CO2-10* ANION GAP-18
[**2129-5-8**] 08:00PM CALCIUM-7.5* PHOSPHATE-2.6* MAGNESIUM-1.7
=================
CXR - AP UPRIGHT CHEST: The cardiac, mediastinal, and hilar
contours are normal. The lungs are clear. Pulmonary vascularity
is normal. There are no pleural effusions. There are no
pneumothoraces. Osseous structures are unremarkable.
IMPRESSION: No acute cardiopulmonary process.
=================
Discharge:
[**2129-5-11**] 06:20AM BLOOD WBC-6.6 RBC-4.32 Hgb-12.5 Hct-38.3 MCV-89
MCH-28.9 MCHC-32.6 RDW-12.3 Plt Ct-203
[**2129-5-8**] 11:49PM BLOOD PT-11.8 PTT-25.0 INR(PT)-1.0
[**2129-5-11**] 06:20AM BLOOD Glucose-137* UreaN-16 Creat-0.8 Na-139
K-3.8 Cl-103 HCO3-25 AnGap-15
[**2129-5-9**] 11:57AM BLOOD CK-MB-2 cTropnT-<0.01
[**2129-5-8**] 11:49PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2129-5-8**] 02:57PM BLOOD cTropnT-<0.01
[**2129-5-11**] 06:20AM BLOOD Calcium-9.5 Phos-4.6* Mg-1.9
[**2129-5-8**] 11:57AM BLOOD %HbA1c-11.0*
[**2129-5-8**] 11:49PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2129-5-8**] 03:15PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.032
[**2129-5-8**] 03:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2129-5-8**] 03:22PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Brief Hospital Course:
A/P: Pt is a 24y/o F with PMH of labile Type 1 DM admitted with
DKA.
#. DKA - Pt with multiple admissions in recent past with DKA. AG
on admission was 24 which corrected following 4L NS and insulin
gtt. No clear inciting cause, however pt does report poor po
intake over past several days. No evidence of infection.
[**Last Name (un) **] consulted and gave recommendations for inpatient and
outpatient/discharge insulin regimens. She was instructed to
use Lantus 31 units qhs and a humalog sliding scale. She had
early morning hypoglycemia related to pm humalog administration
so was instructed to not use more than 5 units sliding scale
humalog with her pm dose. Depression may play a role in her
insulin noncompliance at home, and psychiatry evaluation may be
beneficial.
#. Chest Tightness/Dyspnea - Pt reports similar sx in past. Sx
worse with stressful situations, no excertional symptoms. Sx not
worse with respiration. D-dimer negative. CXR negative. Cardiac
enzymes negative. Pain spontaneously resolved prior to
discharge.
.
#. Hyperlipidemia - continued zetia
.
#. Stage I Diabetic Nephropathy - continued lisinopril
.
#. Hx Panic D/O/Depression - not currently on medications,
previously on Prozac but pt dc'd. - strongly advised outpatient
psychiatry follow up.
.
Medications on Admission:
Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. Insulin Glargine 100 unit/mL Cartridge Sig: One (1) 33
Subcutaneous at bedtime.
6. Novolog 100 unit/mL Cartridge Sig: One (1) units Subcutaneous
four times a day: Please use sliding scale as provided. .
Discharge Medications:
1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Lantus 100 unit/mL Solution Sig: Thirty One (31)
Subcutaneous at bedtime.
6. Humalog 100 unit/mL Solution Sig: One (1) units Subcutaneous
QAC, QHS: per sliding scale, do not take more than 5 units for
your nighttime dose. if BG 121-160 take 2 units, 161-200 take 4
units, if 201-240 take 6 units, if 241-300 take 8 units, if
301-340 take 10 units, if 341-400 take 12 units, if greater than
400 call your primary physician.
Discharge Disposition:
Home
Discharge Diagnosis:
1. diabetic ketoacidosis
2. DM1
3. depression
Discharge Condition:
stable
Discharge Instructions:
You were hospitalized with diabetic ketoacidosis. Please take
the insulin as prescribed. Check your blood sugar before meals
and before you go to sleep. If you have symptoms of
hypoglycemia (lightheaded, sweaty, nausea, headache), please
take glucose tabs, drink juice. Call your doctor if your
glucose is greater than 400. Return to the emergency department
if you are unable to eat, drink, have fever greater than 101,
confusion, or other concerning symptoms.
Followup Instructions:
Please see your primary care physician as soon as possible on
discharge.
You have an appointment with your [**Last Name (un) **] physician on [**Name9 (PRE) 2974**].
|
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icd9cm
|
[
[
[]
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[] |
icd9pcs
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[
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18,614
| 160,003
|
22204
|
Discharge summary
|
report
|
Admission Date: [**2152-11-29**] Discharge Date: [**2152-12-1**]
Service: MEDICINE
Allergies:
Penicillins / Iodine; Iodine Containing / Sulfa (Sulfonamides) /
Buspar / Haldol / Levaquin / Sulfamethoxazole/Trimethoprim /
Trazodone / Percocet
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Tracheal mass
Major Surgical or Invasive Procedure:
[**2152-11-29**]: Flexible bronchoscopy with phototherapy.
[**2152-12-1**]: bronchoscopy with tracheal mass debridement. There was
no evidence of any necrosis in that area, which suggest that
there is probably more granulation as compared to more tumor.
Tumor excission was done with the use of the microdebrider.
There was also evidence of severe malacia of trachea, especially
due to anterior movement of the posterior wall in the area
posterior to the tracheostomy tube. Complete patency was
accomplished.
History of Present Illness:
83 w/metastastic thyroid cancer metastatic to lung, bone,
trachea (s/p thryoidectomy 95/98), s/p iodine treatment,
resection), also with history of [**Last Name (un) **]-[**Location (un) **] and paralyzed
right hemidiaphram. Who presents for photofrin debridement (ie
photofrin placed on [**11-27**], activation occured on [**11-29**] and plan
for OR on [**2152-12-1**]). Patient had admission [**Date range (1) 57944**] when
tracheal obstrcution noted and debridement occured at that time
as well.
Past Medical History:
throid cancer, mets, thyroidectomy, history of iodine
treatments, cataract, a-fib on coumadin, ulcerative colitis,
bilateral dvt, greefield filter, mitral regurgitation, asthma,
history of PEG removed, hypertension, ocular migraines, normally
on trach support at night.
Physical Exam:
98.8, 80, 124/78, 24, 96% on vent
GENL: frail appearing elderly female
HEENT: trach in place, no increased JVP
Lungs: course breath sounds diffusely
CV: RRR no M/R/G appreciated
ABF: soft, NT, ND
Ext: no c/c/e
Pertinent Results:
[**2152-12-1**] 07:03AM BLOOD Plt Ct-182
[**2152-12-1**] 07:03AM BLOOD Glucose-112* UreaN-17 Creat-0.6 Na-140
K-3.9 Cl-103 HCO3-30* AnGap-11
[**2152-11-29**] 03:45PM BLOOD ALT-12 AST-34 AlkPhos-85 TotBili-0.5
[**2152-12-1**] 07:03AM BLOOD Calcium-8.8 Phos-4.4 Mg-1.9
Brief Hospital Course:
She was admitted to the MICU for bronchoscopy with phototherapy
to tumor on [**2152-11-29**] and then debridement of tumor s/p
phototherapy on [**2152-12-4**]. She tolerated the procedure well and
was tolerating being off the ventilator for several hours prior
to discharge. She was kept on her outpatient regiment of
medications.
Medications on Admission:
albuterol, asacol, coumadin 2.5 mg po daily, lovenox, zantac 150
mg po qday, dur q day, ranitidine, levoxyl 131 daily
Discharge Medications:
1. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO once a day.
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
4. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours).
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed.
7. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Please have your INR checked and check with your PCP
regarding dosing.
8. Lovenox 60 mg/0.6mL Syringe Sig: One (1) Subcutaneous twice
a day for 6 days.
Disp:*8 8* Refills:*1*
9. K-Dur 10 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab
Sust.Rel. Particle/Crystal PO once a day.
10. Levoxyl 137 mcg Tablet Sig: One (1) Tablet PO once a day.
11. M-Vit Tablet Sig: One (1) Tablet PO once a day.
12. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day.
13. Calcium + Vitamin D 600-200 mg-unit Tablet Sig: One (1)
Tablet PO twice a day.
Discharge Disposition:
Home With Service
Facility:
Infusion and Respiratory Services of Westrn MA
Discharge Diagnosis:
Metastatic thyroid cancer
S/P photofrin therapy and bronchoscopy with tracheal mass
debridement
thyroidectomy, history of iodine treatments, cataracts, atrial
fibrillation on coumadin, ulcerative colitis, bilateral deep
venous thromboses, [**Location (un) **] filter, mitral regurgitation,
asthma, removal of feeding tube, hypertension, ocular migraines,
normally on trach support at night
Discharge Condition:
Stable
Discharge Instructions:
Please follow up with your PCP [**Name Initial (PRE) 176**] 1 week.
VNA will draw INR on Monday, [**2152-12-4**]. Fax results to your PCP
so he can advise you on coumadin dose.
Take lovenox as directed until you are told to stop by your PCP.
[**Name10 (NameIs) 57945**] to the ED if you experience shortness of breath, cough up
blood.
Followup Instructions:
Follow up with Dr. [**Name (NI) **] in 1 month
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 57946**] Call to schedule
appointment
|
[
"V44.0",
"285.9",
"244.0",
"197.3",
"493.90",
"424.0",
"198.5",
"401.9",
"V10.87",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.5",
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icd9pcs
|
[
[
[]
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] |
3925, 4002
|
2237, 2569
|
368, 880
|
4436, 4444
|
1946, 2214
|
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4023, 4415
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|
1716, 1927
|
315, 330
|
908, 1408
|
1430, 1701
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,354
| 120,396
|
44536
|
Discharge summary
|
report
|
Admission Date: [**2154-12-11**] Discharge Date: [**2154-12-26**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Altered mental status, hypoxia
Major Surgical or Invasive Procedure:
Tracheostomy and trach tube placement [**12-24**]
History of Present Illness:
Mr. [**Known lastname 95403**] is an 87 yo man with a recent stroke with
persistent R near-hemiplegia s/p PEG placement, DM2, CKD
(baseline Cr 1.6-2) who presented from his nursing home today
minimally repsonsive.
.
Upon arrival to the ED, he remained minimally responsive and was
intubated for airway protection. His initial VSs were 98.1, 84,
96/53, 80, 94%. A CXR demonstrated a questionable new opacity at
the right base. A U/A was suggestive of UTI, and he was covered
broadly for both UTI and PNA with vancomycin, ceftazadime and
levofloxacin. A central line was placed.
.
No further history was available. Among the pt's outside records
were lab reports indicating that his Cr was 2.1 on [**12-9**] and had
risen to 4.2 on [**12-11**].
Past Medical History:
- Diabetes mellitus
- Chronic kidney disease, Cr 1.6-2
- Hypertension
- dyslipidemia
- Aortic insufficiency
- Thoracic aortic aneurysm
- Osteoarthritis.
- First degree A-V delay
- GERD
- BPH
- Nephrolithiasis
- Cataracts
- Ventral hernia
- History of malaria
- Baseline chronic anemia
- s/p PEG tube placement [**10/2154**]
Social History:
No smoking, occasional alcohol, no drug use.
Family History:
non-contributory
Physical Exam:
VS: Temp: 96.9 BP: 109/47 HR: 100 RR: 16 O2sat 100%
GEN: sedated, intubated
HEENT: PERRL, L eye cloudy, anicteric, MM dry
NECK: supple, no jvd
RESP: CTA b/l anteriorly with good air movement throughout
CV: tachycardic, S1 and S2 wnl, no m/r/g
ABD: G-tube without surrounding erythema, ND, NABS, soft, no
masses or hepatosplenomegaly
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
Pertinent Results:
[**2154-12-11**] 06:00PM WBC-13.5* RBC-3.65* HGB-10.8* HCT-32.1*
MCV-88# MCH-29.6 MCHC-33.7 RDW-14.8
[**2154-12-11**] 06:00PM NEUTS-70.0 LYMPHS-25.1 MONOS-3.6 EOS-1.3
BASOS-0.2
[**2154-12-11**] 06:00PM PT-15.2* PTT-26.9 INR(PT)-1.3*
[**2154-12-11**] 06:00PM PLT COUNT-192
.
[**2154-12-11**] 06:00PM GLUCOSE-147* UREA N-120* CREAT-4.3*#
SODIUM-156* POTASSIUM-4.7 CHLORIDE-116* TOTAL CO2-32 ANION
GAP-13
[**2154-12-11**] 06:00PM ALT(SGPT)-17 AST(SGOT)-16 LD(LDH)-177
CK(CPK)-160 ALK PHOS-93 AMYLASE-160* TOT BILI-0.2 LIPASE-29
.
[**2154-12-11**] 06:17PM LACTATE-1.3
.
[**2154-12-11**] 06:50PM URINE RBC-[**2-5**]* WBC-21-50* BACTERIA-MOD
YEAST-NONE EPI-<1
[**2154-12-11**] 06:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-SM
[**2154-12-11**] 06:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2154-12-11**] 06:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
.
Cardiology Report ECG Study Date of [**2154-12-13**] 6:44:40 PM
Sinus rhythm with borderline sinus tachycardia. Brief pause -
probably due to non-conducted atrial premature beat. Borderline
first degree A-V delay. Left atrial abnormality. Left anterior
fascicular block. Since the previous tracing of [**2154-12-11**] atrial
ectopy is present.
.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
99 0 100 350/418 0 -59 56
==========================
On discharge:
.
RECENT STUDIES
[**12-26**] Chest x-ray
FINDINGS: In comparison with the study of [**12-24**], the patient has
taken a much better inspiration. The opacification at the right
base almost completely cleared and the hemidiaphragm is sharply
seen. Mild increased opacification persists at the left base.
The cardiac silhouette remains somewhat enlarged and there is
indistinctness of pulmonary vessels that could be a
manifestation of vascular congestion.
.
Tracheostomy tube and PICC line remain in place.
.
RECENT LAB VALUES:
[**2154-12-26**] 03:47AM BLOOD WBC-11.5* RBC-3.03* Hgb-8.8* Hct-26.3*
MCV-87 MCH-28.9 MCHC-33.2 RDW-14.7 Plt Ct-240
.
[**2154-12-26**] 03:47AM BLOOD PT-14.5* PTT-39.6* INR(PT)-1.3*
[**2154-12-26**] 01:55PM BLOOD Glucose-188* UreaN-46* Creat-2.4* Na-137
K-3.8 Cl-106 HCO3-27 AnGap-8
[**2154-12-26**] 01:55PM BLOOD Calcium-7.7* Phos-3.6 Mg-2.1
.
[**2154-12-25**] 04:43PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2154-12-25**] 04:43PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
.
MICROBIOLOGY: C diff toxin +
Brief Hospital Course:
A/P: 87 yo man with recent stroke with persistent
near-hemiplegia and PEG placement, DM2, CKD presents from NH
with delirium, acute renal failure, ? PNA and ? UTI.
.
# Hypoxemic respiratory failure: Mr [**Known lastname 95403**] was intubated for
airway protection and hypoxemia on arrival. His x-ray was read
as a possible right lower lobe pneumonia, and then evolved with
perihilar opacities. He was started on levofloxacin, ceftazidime
and vancomycin to treat a healthcare-associated pneumonia (given
recent nursing home residence) and possible UTI. By the 12th
(day [**2-4**]) his x-ray was no longer showing a clear opacity, but
he remained ventilator dependent with copious oral and pulmonary
secretions. He was titrated down to FiO2 of 0.40, pressure
support of 10 and PEEP of 5 by the 14th, and has been on these
settings since then.
.
Despite multiple spontaneous breathing trials, his RSBI never
declined to a level in which extubation appeared reasonable.
Accordingly, after discussion with his family, he had a bedside
tracheostomy on [**12-24**] and was on a trach tube thereafter; still,
his vent settings remained the same and he remained unable to
tolerate spontaneous breathing trials. In the last two days of
his admission we started 4x/daily trach mask trials for 20-30
minutes as tolerated in order to see whether this would help his
pulmonary condition. We also began to more aggressively diurese
him (see below) which appeared to help resolve edema seen on his
x-ray although his clinical condition did not change
substantially in the short term. Hopefully with further diuresis
he can wean from the vent as there is no clear other reason he
should not be able to.
.
# C. difficile infection. On the night before discharge, Mr
[**Name13 (STitle) 95404**] was noted to have foul-smelling mucoid stool, and C.
diff was sent. This returned positive, and flagyl was started.
This was likely caught very early in the infection, which was
most likely secondary to C. diff regrowth soon after the
discontinuation of his 14 day course of levo/ceftaz/vanco for
pneumonia, which had likely depleted much of his normal flora.
[**12-26**] is day 1 of 14 for treatment of this.
.
# Altered mental status: He was lethargic and unresponsive on
arrival. We considered several possible etiologies including
toxic/metabolic encephalopathy, uremia, hypernatremia, PNA, UTI,
and meningitis. His BUN was remarkably high (baseline at last
d/c was 20), though he had no pericardial rub on exam.
Hypernatremia likely [**1-4**] volume depletion. His neck was supple
on exam. A CT head was negative for new processes although it
did show an old pontine infarct. A clear etiology was not
identified since his infection and hypernatremia were both
treated in the first days of his admission; his mental status
appeared to clear somewhat although it was difficult to tell
(particularly in the setting of requiring mechanical
ventilation) what his baseline was and whether he had returned
to it. He had some clearly lucid periods in which he was able to
shake his head or nod in response to questions and even
occasionally to attempt to mouth words, though on the day of
discharge he was arousable and tracked and registered his
examiners but did not clearly answer questions. (He had received
a one-time dose of ativan in the night prior.) Whether he might
continue to have improvement as other aspects of his health
improve is not clear. We would suggest low-dose Haldol if his
agitation continues. We have been attempting to avoid sedation
in order to try to work further towards weaning from the vent.
.
# Acute renal failure: Mr [**Last Name (Titles) 95405**] creatinine was quite
elevated from baseline on arrival at 4.3, with a BUN of 120; we
hydrated him aggressively and saw a progressive improvement in
his creatinine over the next several days. His urine from his
inital presentation grew out coag-negative staph, resistant to
oxacillin and levofloxacin but sensitive to the vancomycin we
had started by that time. We judged the initial presentation of
renal failure to be most likely secondary to volume depletion
given BUN/Cr ratio and the strong possibility of falling behind
on intake at the nursing home in the setting of an acute
illness. We held his lisinopril and other antihypertensives, and
dosed medicines renally as appropriate.
.
His creatinine rose again in the last three days of admission
(to 2.4 on [**12-26**]) in the setting of gentle efforts at diuresis,
with the hope of getting his pulmonary and peripheral edema to
resolve. We consulted the renal team which agreed with further
efforts at diuresis, and we increased our doses of lasix, which
we titrated to a fluid balance of even to -500 cc/day, although
we only actually achieved a negative fluid balance on the last
day of admission. He will likely need further increasingly
aggressive diuresis if he does not begin to autodiurese more
vigorously, and will likely need furosemide plus another [**Doctor Last Name 360**].
.
# Hypernatremia: He was hypernatremic on arrival; this corrected
with consistent hydration and free water boluses in his tube
feeds.
.
# s/p CVA: Per neuro d/c summary, "at the time of discharge he
could withdraw his right leg slightly, with plegia in the right
arm and a right facial droop, as well as dysarthria. AS now is
sedated, unable to perform adequate neuro exam.
- continue clopidogrel, atorvastatin
.
# Leukocytosis: Likely [**1-4**].
.
# DM: We held his PO hypoglycemics. We kept him on an insulin
sliding scale, and also added glargine for baseline level.
.
# Anemia: He has most recently been written for an outpatient
dose of 40 mcg of Aranesp every other week, likely [**1-4**] CKD. We
held this during this admission but this could be restarted. He
received a unit of packed red blood cells on [**12-14**] for a
hematocrit of 21.4 which was dropping in the setting of
aggressive hydration (a source of bleeding was not identified
then or in retrospect). He also received a unit of packed red
blood cells on [**12-25**] for a hematocrit of 21.9, with the
expectation that this would continue to drop, he would be
leaving the ICU soon, and evaluation of his post-transfusion
stability would be helpful before transfer. Otherwise his
hematocrit transfusion criteria could be <21.
.
# GERD: lansoprazole 30 daily
.
# F/E/N: IVF. Repleted lytes PRN. Tube feeds; we changed this
during the last two days of his admission to reduce his total
fluid volume, and on discharge he was on Replete w/fiber, full
strength; with a goal rate of 65 ml/hr. His albumin did decline
during this admission although the contribution of nutrition vs
acute illness was difficult to know, and should be followed
after discharge.
.
# PPx: Bowel regimen (should hold with diarrhea), sq Heparin
.
# Access: Right subclavian central line, PIVs
.
# Dispo: To a rehabilitation facility with ventilator capacity
.
# Code Status: full (confirmed with daughter, [**Name (NI) 2431**])
.
Medications on Admission:
Aranesp
Amlodipine 10 daily
Atorvastatin 40 daily
Clopidogrel 75 daily
Vitamin D 1000 daily
Ferrous sulfate 325 daily
Glipizide 10 daily
Lisinopril 7.5 mg daily
Metoprolol 50 [**Hospital1 **]
Acetaminophen prn
Omeprazole 20 [**Hospital1 **]
Senna 2 tabs [**Hospital1 **]
Insulin
.
Discharge Medications:
1. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One Hundred (100) mg
PO BID (2 times a day): hold for diarrhea.
4. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily).
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily): hold for
diarrhea.
8. Metoclopramide 10 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)) as needed for for
regurgitation/high residuals.
9. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: 1-2 Puffs Inhalation
Q6H (every 6 hours).
10. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2)
Puff Inhalation QID (4 times a day).
11. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection TID (3 times a day).
12. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever or pain: notify physician if
patient has fever.
13. Metronidazole 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3
times a day).
14. Clopidogrel 75 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
15. Ferrous Sulfate 300 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO DAILY
(Daily).
16. Sodium Chloride 0.9% Flush 3 mL IV DAILY:PRN
Peripheral IV - Inspect site every shift
17. 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.
18. Haloperidol Lactate 5 mg/mL Solution [**Last Name (STitle) **]: 0.25 mg Injection
Q4H (every 4 hours) as needed for agitation.
19. plan for diuresis
Consider continuing diuresis with furosemide 100-160 up to [**Hospital1 **]
to reach fluid balance goal of -500 cc/day
20. Aranesp (Polysorbate) 40 mcg/0.4 mL Syringe [**Hospital1 **]: One (1)
injection Injection every other week.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Pneumonia, pulmonary edema, C. diff infection
Discharge Condition:
Stable
Discharge Instructions:
You are being discharged to the [**Hospital3 95406**], where your care can continue.
See below for instructions to providers.
Followup Instructions:
Key issues for discharge:
* Attempt to further diurese patient who gained considerable
fluid weight during his ICU admission; this may also improve
respiratory status.
* Weaning from vent as tolerated
* Treatment of C. diff infection; day 1 of 14 day course of
metronidazole is [**12-26**]
* Ongoing evaluation of mental status; not clear what new
baseline will be at this point.
.
He has the following appointments:
RENAL FOLLOW-UP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2155-1-6**] 4:00
Completed by:[**2154-12-26**]
|
[
"369.60",
"553.20",
"530.81",
"285.21",
"E944.4",
"307.9",
"599.0",
"585.9",
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"366.9",
"782.3",
"438.19",
"518.81",
"438.20",
"272.4",
"008.45",
"403.90",
"250.40",
"438.83",
"041.19",
"441.2",
"600.00",
"784.5",
"426.3",
"V55.4",
"486",
"424.1",
"276.0",
"584.5",
"426.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"31.1",
"96.6",
"96.72",
"97.02",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
14301, 14367
|
4575, 6774
|
295, 347
|
14457, 14466
|
1992, 3434
|
14642, 15242
|
1545, 1563
|
11879, 14278
|
14388, 14436
|
11573, 11856
|
14490, 14619
|
1578, 1973
|
3448, 4552
|
225, 257
|
375, 1120
|
6789, 11547
|
1142, 1467
|
1483, 1529
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,033
| 106,376
|
42981
|
Discharge summary
|
report
|
Admission Date: [**2186-3-20**] Discharge Date: [**2186-3-25**]
Date of Birth: [**2148-4-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
altered mental status.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
37 y/o male patient with Type I DM, HTN, gastroparesis, ESRD on
HD who presents to ED with hypertensive urgency. The patient
came to the ED with his usual nausea, vomiting, abdominal pain
and was found to be hypertensive to 267/171, HR 102. History is
difficult to obtain from patient d/t somnolence and lack of
desire to participate in interview. He was given ativan a total
of 2 mg of Ativan, 4 mg of dilaudid, labetolol 20 mg IV x 3 and
hydralazine 20 mg IV x 1 with good response (BP at one point
down to 83/58). He recieved 2L NS, Clonidine 0.2mg, Metoprolol
25mg, and Nifedipine XL 30mg. He also received Anzamet. His BP
stabalized and his nausea and abd pain improved.
.
Of note, the patient is admitted to hospital ~3 times every
month
for similar complaints with last admission [**Date range (1) 92782**]. In the
past, he has eloped prior to formal discharge
Past Medical History:
1. DM type I
2. ESRD on hemodialysis started [**2-/2184**] on Tu, Th, Sat
3. Severe autonomic dysfunction with multiple hospitalizations
for hypertensive emergency, gastroparesis, and orthostatic
hypotension.
4. History of esophageal erosion, MW tear
5. CAD with 1-vessel disease (50% stenosis D1 in [**7-/2181**]), normal
stress
[**11/2182**]
6. hx of Foot Ulcer
7. h/o clot in AV graft x2 ([**Month (only) 958**] and [**2185-8-13**])
Social History:
Denies alcohol or tobacco use. Endorses occassional marijuana
use. Lives with his [**Hospital1 **] mother and their three children.
Family History:
His father recently died of ESRD and diabetes. His mother is in
her 50s and has hypertension. He has two sisters, one with
diabetes, and six brothers, one with diabetes.
Physical Exam:
per Dr. [**First Name8 (NamePattern2) 915**] [**Last Name (NamePattern1) 916**]
Vitals: 97.5, 157/82, 83, 16, 96% 2L
General: sleepy, arouses to voice but limited participation with
physical exam
HEENT: PERRL, left pupil smaller than right, pt will not
participate in EOMI, sclera anicteric, MM dry, No OP lesions
Neck: Supple, no JVD
CV: RRR, nl S1, S2, 2/6 systolic murmur at LUSB
Lungs: CTAB post
Chest: HD line in place without erythema
Abd: Soft, ND, nontender, + BS, no guarding, no rebound,
multiple well healed scars
Ext: no c/c/e, left arm with fistula with good thrill
Skin: no rashes
Pertinent Results:
admit EKG: Sinus rhythm. Early repolarization, no other change
from prev
Admission labs:
137 97 47
--------------< 287
4.2 23 8.3
Ca: 9.2 Mg: 2.0 P: 2.3 D
.
13.1
11.3 >----< 166
40.2
N:90.9 Band:0 L:5.3 M:3.4 E:0.2 Bas:0.2
PT: 21.4 PTT: 32.8 INR: 2.1
.
Trends:
WBC: 11.3 - 7.6
INR: 2.1 - 2.3 - 2.4 - 3.0 - 3.7 - 1.3
CK: [**Telephone/Fax (3) 92783**]
CKMB: 4 - 7 - 8
Trop: 0.21 - 0.33 - 0.36
Urine tox neg
Serum tox neg
.
Micro:
NGTD
.
Rads:
[**3-21**]: Head CT: No definite intracranial hemorrhage or mass
effect.
[**3-22**]: Head MRI: FINDINGS: No intracranial mass lesion,
hydrocephalus, shift of normally midline structures, minor or
major vascular territorial infarct is apparent. The signal
intensities of the brain parenchyma are normal. Specifically, no
increased T2 signal is seen in the parietal or occipital regions
to suggest posterior reversible encephalopathy. The surrounding
osseous and soft tissue structures are unremarkable. Major
vascular flow patterns are normal.
IMPRESSION: Unremarkable MRI of the brain.
Brief Hospital Course:
37 yo M with Type I DM, HTN, gastroparesis, ESRD on HD who
presented to ED with hypertensive urgency. Upon presentation it
was unclear when last time was that patient took meds, but
hypertension likely d/t inability to take meds in setting of
N/V. Also contribution of autonomic dysfunction. No evidence of
active end organ damage. His outpt meds were restarted and his
BP improved. Remainder of hospital course by problem:
.
# Mental Status Change - On day following admission, the patient
was found to be diaphoretic, confused, and had repetition of
speach saying only "dilaudid." A trigger was called and given
the acuteness of this change, he was transferred to the ICU.
DDx included possible toxic metabolic vs. HTN/hypotension.
Electrolytes and CBC were unchanged. There were no signs of
infection. CE were cycled and there was no acute EKG changes.
CT of head without bleed or mass. MRI brain was negative. His
mental status improved over the following three days and he was
at his reported baseline for at least 24h prior to discharge.
.
# AV fistula/Access - patient with h/o clotted fistula and with
very difficult peripheral access. His [**Month/Day (4) **] was held for two
nights in anticipation of possible portacath placement. He also
received vit k 1mg IV x1 on [**3-23**]. However, the procedure was
delayed and it was determined to be done as an outpatient. His
[**Month/Day (4) **] was held at discharge until after his port placement
scheduled for the following week. During his stay he had a
right femoral line placed, which was removed prior to discharge.
.
# Hypertension - patient with wild swings in BP. As above, was
hypertensive initially. We treated with his home meds.
.
# DM - We continued his home regimen of NPH 5u [**Hospital1 **] and HISS. He
had wild swings in his blood glucose with the lowest recorded in
the 20s. He was aware, and he improved with an amp of D50.
.
# Cards Vasc: After altered ms, EKG with unchanged ant ST elev
(likely J point elevation). Trop were mildly elevated. No
chest pain at this time. CK/MB stable.
- cont asa, bblocker
.
# ESRD - on HD and followed by renal. We continued calcium
acetate and HD as scheduled.
.
# Access - As above. He had a femoral line which was removed
prior to dispo. He is in need of a portacath given his frequent
admissions and difficult access.
.
FEN - DM/Renal diet
.
PPx - [**Hospital1 **], PPI, ambulating
.
Full Code
Medications on Admission:
1. Metoclopramide 10 mg q6hrs
2. Metoprolol 75tid
3. Calcium Acetate 667 mg Capsule PO TID
4. Ativan 1 mg Tablet Sig: One (1) Tablet PO q6h prn.
5. Dilaudid 4 mg PO q3-4hr prn.
6. Clonidine 0.3 mg/24 hr Patch Weekly
7. Clonidine 0.2 mg Tablet PO TID
8. Warfarin 1.5 mg PO DAILY
9. Nifedipine 30 mg Tablet Sustained Release PO daily
10. Pantoprazole 40 mg Tablet, Delayed Release
11. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
12. Humalog SS
13. Insulin NPH 2 UNITS Subcutaneous twice a day.
Discharge Medications:
1. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO every six
(6) hours.
2. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
3. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Ativan 1 mg Tablet Sig: One (1) Tablet PO every six (6) hours
as needed for agitation.
5. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q3-4H (Every
3 to 4 Hours) as needed.
6. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QFRI (every Friday).
7. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8. Warfarin 1 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
9. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Humalog 100 unit/mL Solution Sig: variable units
Subcutaneous four times a day: use sliding scale as directed.
13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Two (2)
units Subcutaneous twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- hypertensive urgency
- altered mental status
- DMI
- ESRD on HD
Secondary:
- autonomic dysfunction
- s/p esophageal erosion
- hx of CAD
- hx of foot ulcerations
- h/o clot in AV graft x2
Discharge Condition:
fair
Discharge Instructions:
You were admitted to the hospital with hypertensive urgency.
You developed altered mental status and were monitored in the
ICU. You had a head CT and MRI which were negative. You
remained on hemodialysis.
.
Please take your medications as instructed. Please contact your
PCP if you experience shortness of breath, chest pain, worsening
abdominal pain, fevers, or chills.
.
We are holding your [**Hospital1 **] for your surgery. Do not take your
[**Hospital1 **] until you discuss when to restart it with your primary
care physician or nephrologist.
.
Please return on Tuesday [**2186-3-28**] at 12:30 to have your portacath
placed by surgery. It is very important for you to keep this
appointment.
Followup Instructions:
please return on Tuesday [**2186-3-28**] at 12:30pm for your portacath
placement. Please have nothing to eat since midnight the night
prior.
.
Please contact your PCP for an appointment within the next two
weeks. Please followup with your nephrologist as scheduled.
Completed by:[**2186-3-25**]
|
[
"403.01",
"536.3",
"337.1",
"585.6",
"414.01",
"250.63"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7944, 7950
|
3747, 4145
|
338, 344
|
8192, 8199
|
2673, 2746
|
8949, 9248
|
1870, 2041
|
6734, 7921
|
7971, 8171
|
6205, 6711
|
8223, 8926
|
2056, 2654
|
276, 300
|
4173, 6179
|
372, 1242
|
3157, 3724
|
2762, 3148
|
1264, 1703
|
1719, 1854
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,219
| 155,528
|
358
|
Discharge summary
|
report
|
Admission Date: [**2170-8-20**] Discharge Date: [**2170-8-25**]
Date of Birth: [**2096-8-16**] Sex: M
Service:
CHIEF COMPLAINT: Bright red blood per rectum.
HISTORY OF PRESENT ILLNESS: This is a 74-year-old gentleman
with a history of bleeding, internal hemorrhoids, status post
cauterization seven days prior to admission who was started
on Plavix three days prior to admission. He was admitted to
the medical Intensive Care Unit for bright red blood per
rectum. The patient said the bleeding started suddenly at 2
o'clock PM on the day of admission with passing large clots
and bright red blood per rectum. This was not associated
with abdominal pain, nausea, fevers, chills, diarrhea. The
patient reports he has bright red blood per rectum on a daily
basis, this is basically self-limited.
REVIEW OF SYSTEMS: The patient complains of severe rectal
pain. No complaints of chest pain, dyspnea, short of breath
or dysuria.
In the emergency department, the patient continued to have
profuse bright red blood per rectum and was transfused two
units of packed red blood cells. His blood pressure had
decreased, systolic blood pressure in the 80's which was
corrected by fluid boluses. Colonoscopy revealed an actively
bleeding internal hemorrhoid which was ligated.
PAST MEDICAL HISTORY:
1. Internal hemorrhoids.
2. Diverticula and polyp seen on [**6-21**] colonoscopy.
3. Chronic renal insufficiency with a baseline creatinine of
2 to 3 thought to be secondary to hypertensive glomerulus
scleras.
4. Atrial fibrillation.
5. Cerebrovascular accident on [**7-22**].
6. Obstructive sleep apnea intolerance of CPAP.
7. Hypercholesterolemia.
8. Anemia.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Plavix 75 mg p.o. q day.
2. Diovan 80 mg p.o. q day.
3. Allopurinol 100 mg p.o. q day.
4. Zantac.
5. Lipitor.
6. Epoetin 10,000 units q week.
7. Iron.
SOCIAL HISTORY: The patient lives with his wife. Quit
smoking several years ago, no alcohol, no intravenous drug
use.
PHYSICAL EXAMINATION: On admission temperature was 97.4,
blood pressure 192/47, heart rate 16 sating 100% on two
liters nasal cannula. General: Alert and oriented times
three. Some discomfort in the rectal area. Head, eyes,
ears, nose and throat: Pupils are equal, round, and reactive
to light and accommodation. Extraocular movements intact.
Dry mucous membranes. Neck: Supple, no lymphadenopathy or
jugular venous distention. Pulmonary: Clear to auscultation
bilaterally. Cardiac: Bradycardiac. Regular. S1 and S2.
No murmurs, rubs or gallops. Abdomen: Obese, nontender.
Normal active bowel sounds, no organomegaly. Extremities:
No cyanosis, clubbing or edema. 2+ dorsalis pedis pulses
bilaterally. Skin: Several nevi. Cranial nerves 2 through
12 intact. Upper and lower extremity strength 5/5
bilaterally.
LABORATORY on admission white cell count 8.3, hemoglobin 9.8,
hematocrit 29.7, platelets 157, sodium 142, potassium 4.0.
Chloride 107, bicarbonate 23, BUN 54, creatinine 4.7, glucose
152. AST 15, ALT 11, alk phos 86, Left ventricular
hypertrophy 189, amylase 92, lipase 52, total bilirubin 1.1,
magnesium 2.0, phosphorus 4.0, calcium 8.9. Urinalysis:
Positive for moderate blood, 100 protein.
HOSPITAL COURSE:
1. Gastrointestinal bleed. The patient admitted with
gastrointestinal bleed from internal hemorrhoids, status post
ligation in the emergency department. The patient received a
total of 5 units packed red blood cells in the emergency
department and medical Intensive Care Unit. By [**9-20**] the
patient was having only trace bleeding and hematocrit has
stabilized. Upon transfer to the floor on [**9-20**] hematocrit
continued to be monitored closely. On the morning of [**9-21**]
the patient had a drop in hematocrit from 26.9 to 24.6 and
received one more unit of packed red blood cells. Throughout
the remainder of the stay the patient's hematocrit was stable
and he did not require further transfusions.
2. Change in mental status. In the medical Intensive Care
Unit, the patient received Ambien, Morphine, and Tylenol for
control of rectal pain. After receiving these medications
the patient became confused with orientation only to his self
on [**2170-9-20**]. It was hypothesized that the Morphine was the
most likely cause of the patient's change in mental status.
The Morphine was discontinued and the patient was given
Tylenol for pain control. Other possible causes of change in
mental status that were considered included Intensive Care
Unit psychosis which was unlikely the short amount of time
the patient spent in the unit. In addition, an underlying
infection was considered but the patient remained afebrile
and without an elevated white blood count. After being taken
off the Morphine and having his pain controlled only with
Tylenol the patient's mental status changes resolved.
3. Acute on chronic renal failure. The patient was increased
in creatinine from baseline. Most likely secondary to
hyperperfusion in the setting of his gastrointestinal bleed.
A renal ultrasound was obtained which did not show any
hydronephrosis or post obstructive problems. His creatinine
is trending down following intravenous hydration and p.o.
intake.
4. Atrial fibrillation. The patient is currently off
anti-coagulation given his gastrointestinal bleed. At this
time, anti-coagulation will be held until the patient follows
up with surgery in two weeks. At that time, if the patient
is cleared by surgery, Neurology and the Stroke Team
recommend long-term anti-coagulation for the patient with a
goal INR of 2 to 3.
5. Hypertension. The patient's anti-hypertensive was held
on admission given his hypotension from the severe
gastrointestinal bleed. It was later held due to the
patient's chronic renal failure. The patient will be
restarted on his [**Last Name (un) **] today. Blood pressure has been trending
upward and his creatinine is trending down to baseline.
6. Fluid, Electrolytes and Nutrition. The patient
tolerating a house diet. Electrolytes have been corrected as
needed.
7. Prophylaxis. The patient was on Unna boots for deep vein
thrombosis prophylaxis throughout the hospitalization. He
was continued on a bowel regimen to avoid constipation. The
patient was continued on PPI.
CONDITION ON DISCHARGE: Stable.
STATUS: The patient will be discharged to a rehabilitation
facility.
DISCHARGE DIAGNOSIS:
1. Gastrointestinal bleed from internal hemorrhoids, status
post ligation.
2. Mental status changes, not otherwise specified, now
resolved.
3. Paroxysmal atrial fibrillation.
4. Hypertension.
5. Anemia.
6. Chronic renal insufficiency.
7. Acute renal insufficiency.
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. twice a day.
2. Epoetin 10,000 units subcutaneously one time per week.
3. [**Doctor Last Name **] 8.6 mg one tab p.o. twice a day.
4. Pantoprazole 40 mg p.o. four times a day.
5. Allopurinol 100 mg p.o. q day.
6. Valsartan 80 mg p.o. q day.
7. Acetaminophen 325 mg one to two tabs p.o. q 4 to 6 hours
p.r.n.
FOLLOW-UP: The patient should follow-up with PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 216**]
at earliest convenience.
The patient will follow-up with Dr. [**First Name (STitle) **] from Behavioral
Neurology on [**2170-9-27**] at 10:00.
The patient should follow-up with Dr. [**Last Name (STitle) 1888**] in two weeks.
Please call [**Telephone/Fax (1) 160**] to make an appointment.
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2170-9-24**] 13:52
T: [**2170-9-24**] 16:03
JOB#: [**Job Number 3252**]
|
[
"285.1",
"403.91",
"584.9",
"427.31",
"455.2",
"780.57",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"49.45"
] |
icd9pcs
|
[
[
[]
]
] |
6726, 7604
|
6430, 6703
|
3267, 6304
|
2045, 3250
|
841, 1296
|
149, 179
|
208, 821
|
1318, 1901
|
1918, 2022
|
6329, 6409
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,038
| 162,358
|
42163
|
Discharge summary
|
report
|
Admission Date: [**2112-11-3**] Discharge Date: [**2112-11-7**]
Date of Birth: [**2044-11-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Asymptomatic
Major Surgical or Invasive Procedure:
[**2112-11-3**] Replacement of ascending aorta with a 30-mm Dacron tube
graft using deep hypothermic circulatory arrest
History of Present Illness:
68-year-old otherwise healthy gentleman with newly diagnosed
prostate cancer ([**Doctor Last Name **] score 7) this past [**Month (only) 205**] and scheduled
to have a prostatectomy on [**2112-10-20**]. As part of the
preoperative workup for his prostate cancer, he underwent a CT
which was noted to have a dilated ascending aorta and a
thoracoabdominal aneurysm both measuring near 6.0 cm in
diameter. Given the above findings, he has been referred for
surgical evaluation.
Past Medical History:
Prostate cancer
Hypertension
Cardiomegally (Told as young adult)
Right hand and bilateral knee cramping treated with prednisone
since [**Month (only) 205**]
Social History:
Retired multiple jobs
Lives with spouse
[**Name (NI) 1139**] 40 pack year history
ETOH < 1 drink a week
Family History:
mother with hypertension
Physical Exam:
Pulse: 79SR Resp: 16 O2 sat: 97%
B/P Right: 125/80 Left: 152/95
Height: 72" Weight: 208
General: WDWN in NAD
Skin: Warm, Dry and intact. No C/C/E
HEENT: NCAT, PERRLA, EOMI, sclera anicteric, OP benign. Teeth in
good repair.
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR, No M/R/G
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] No Edema
Varicosities: None noted on standing. Some small spider
varicosities noted.
Neuro: Grossly intact [X]
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit None appreciated
Pertinent Results:
[**2112-11-3**] ECHO
PRE-BYPASS: Transgastric images deferred due to resistance past
basal short axis view of the left ventricle. No spontaneous echo
contrast is seen in the body of the left atrium or left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The ascending aorta is
severely dilated. The aortic arch is mildly dilated. There are
complex (>4mm) atheroma in the aortic arch. The descending
thoracic aorta is moderately dilated. There are complex (>4mm)
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. There is no
pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the
results at time of surgery.
POST-BYPASS: The patient is A paced. The patient is on no
inotropes. Biventricular function is unchanged. Aortic
insufficiency is unchanged. Mitral regurgitation is unchanged.
There is an ascending aortic tube graft originating from the
sinotubular junction.
[**2112-11-5**] 04:20AM BLOOD WBC-10.9 RBC-3.71* Hgb-10.5* Hct-32.2*
MCV-87 MCH-28.3 MCHC-32.6 RDW-13.9 Plt Ct-118*
[**2112-11-7**] 04:15AM BLOOD PT-15.6* INR(PT)-1.5*
[**2112-11-7**] 04:15AM BLOOD UreaN-28* Creat-0.7 Na-140 K-4.2 Cl-103
[**2112-11-7**] 04:15AM BLOOD Mg-2.0
Brief Hospital Course:
He was admitted to the [**Hospital1 18**] on [**2112-11-3**] for surgical management
of his ascending aortic aneurysm. He was taken to the operating
room where he went an ascending aorta replacement using a
Gelweave tube graft. Please see operative note for details.
Postoperatively he was taken to the intensive care unit for
monitoring. Over the next several hours, he awoke neurologically
intact and was extubated. He continued to progress and was
started on betablockers and diuretics on post operative day one.
He continued to do well and was transferred to the floor to
begin increasing his activity level. Beta blockade titrated and
he was gently diuresed toward his preop weight. Chest tubes and
pacing wires removed per protocol. Went into A Fib and was
started on amiodarone and coumadin. Converted on POD #3 and
coumadin sopped prior to discharge. Continued to make good
progress and cleared for discharge to home with VNA on POD #4.
All f/u appts were advised.
Medications on Admission:
Atenolol 50mg daily
Prednisone 2mg daily
Bicalutamide 50mg daily
Discharge Medications:
1. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain or fever .
Disp:*50 Tablet(s)* Refills:*0*
7. prednisone 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*1*
8. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): through [**11-9**] 400 mg [**Hospital1 **].
Disp:*120 Tablet(s)* Refills:*2*
9. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 2 weeks.
Disp:*14 Tablet, ER Particles/Crystals(s)* Refills:*0*
10. bicalutamide 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
11. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*1*
12. amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days: [**11-10**] through [**11-16**].
Disp:*14 Tablet(s)* Refills:*0*
13. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
starting [**11-17**] ongoing until evaluated by cardiologist.
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Ascending aortic aneurysm s/p replacement
postop atrial fibrillation
thoracoabdominal aortic aneurysm
Prostate cancer
Hypertension
Right hand and bilateral knee cramping treated with prednisone
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema:1+
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound check :Cardiac surgery office [**Hospital **] medical building [**Hospital Unit Name **] [**Telephone/Fax (1) 170**] [**11-15**] @ 10:30 AM
Surgeon: Dr [**Last Name (STitle) 914**] [**Name (STitle) 766**] [**12-13**] @ 1:45 PM
Cardiologist: Dr [**Last Name (STitle) **] [**12-2**] @ 9:45 AM ( [**Location (un) 620**] office)
Urologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3748**] [**11-23**] @ 2:30 pm [**Hospital Ward Name 23**] 3
Vascular: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] [**12-8**] @ 9:45 AM [**Hospital Ward Name **] Bldg, [**Hospital Unit Name 17173**]
Please call to schedule appointments with your:
Primary Care Dr. [**Last Name (STitle) 22552**] [**Telephone/Fax (1) 4475**] in [**2-23**] 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:[**2112-11-7**]
|
[
"287.5",
"401.9",
"427.31",
"729.82",
"441.7",
"E849.7",
"285.9",
"E878.2",
"V15.82",
"443.9",
"997.1",
"185"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"38.45"
] |
icd9pcs
|
[
[
[]
]
] |
6634, 6683
|
3789, 4764
|
323, 447
|
6921, 7095
|
2053, 3766
|
7984, 9015
|
1271, 1297
|
4880, 6611
|
6704, 6900
|
4790, 4857
|
7119, 7961
|
1312, 2034
|
271, 285
|
475, 952
|
974, 1133
|
1149, 1255
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,988
| 133,642
|
26077
|
Discharge summary
|
report
|
Admission Date: [**2102-1-11**] Discharge Date: [**2102-1-27**]
Date of Birth: [**2028-8-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Neck pain
Major Surgical or Invasive Procedure:
[**2102-1-17**]: Occiput to C6 fusion, Halo placement
History of Present Illness:
The patient is a 73 year old man with PMH mild CF per family who
was admitted to orthopedic spine surgery on [**2102-1-11**] from rehab
for stabilization of a type 2 dens fracture (first noted on xray
on [**2101-12-14**] in ED). His sodium on admission was 129, down from
142 in [**12-9**]. For the first several days he was placed in a halo
and given morphine for pain control. On [**1-16**], he was seen by
medicine consult for preop eval of continued hyponatemia (Na
127). Urine lytes at that time were c/w SIADH and free water
restriction to 1 L was suggested (although cannot tell if this
was done), along with changing from 1/2 NS to NS. He was also
found to have a UTI and was started empirically on cipro. He
went to the OR [**1-17**] for occiput to C6 fusion. He transiently
required pressor support post-op. On [**1-18**], his cipro was changed
to bactrim for ESBL Klebsiella. He was again seen by medicine
consult who emphasized free water restriction. He was extubated
[**1-19**] and transferred to the floor on [**1-20**]. He was maintained on
NS at 80 cc/hr during this time. His sodium peaked at 131 on
[**1-19**], then trended down to 125 on [**1-22**] so medicine was
reconsulted. They again suggested free water restriction to 1 L.
They also recommended stopping all IVFs. On [**1-23**], the IVFs were
stopped and he was put on 1500 cc free water restriction. On
[**1-24**], his sodium increased from 123 to 125.
.
ROS: He denies confusion, dizziness, thirst. He denies fevers,
chills, sweats. He denies shortness of breath, chest pain. He
does note a cough productive of yellow, brown sputum
Past Medical History:
Cerebral palsy
HTN
Hyperlipidemia
L hip surgery
BPH
UTI's
Social History:
NA
Family History:
NA
Physical Exam:
Gen:Well appearing, comfortable, sitting in chair in NAD. In
halo.
HEENT: Pupils 2-3 mm , mod. reactive to light. left lateral gaze
- sluggissh. Sclera anicteric. Conjunctiva not pale. MMM. No OP
lesions.
[**Month/Year (2) **]: good [**Month/Year (2) **] turgor.
CV: RRR with no m/r/g
Lungs: bibasilar crackles, dull at right base
Abd: soft, NT, ND active BS, no hepatosplenomegly.
Ext: 1+ edema in upper extremities bilaterally, no edema in
lower extremities.
Neuro: A and O x self and hospital. Wiggles fingers and toes,
does not follow commands completely (unclear baseline MS)
Pertinent Results:
[**2102-1-11**] 09:00PM GLUCOSE-149* UREA N-12 CREAT-0.6 SODIUM-129*
POTASSIUM-4.6 CHLORIDE-95* TOTAL CO2-22 ANION GAP-17
[**2102-1-11**] 09:00PM CALCIUM-9.1 PHOSPHATE-3.0 MAGNESIUM-1.9
[**2102-1-11**] 09:00PM WBC-8.0 RBC-4.04* HGB-12.8* HCT-37.1* MCV-92
MCH-31.8 MCHC-34.6 RDW-14.3
[**2102-1-11**] 09:00PM PLT COUNT-543*
[**2102-1-11**] 09:00PM PT-13.4* PTT-25.1 INR(PT)-1.2*
Brief Hospital Course:
Hospital Course until [**2101-1-23**] when the patient was transferred
to medicine. The patient was admitted to the orthopaedic service
on [**2102-1-11**] for definitive treatment of his C1/C2 fracture. He
was placed in halo traction on [**2102-1-12**]. Lateral films were
obtained daily and the weight was added in increments until the
fracture pulled into alignment. The weight was 2lbs on [**2102-1-12**]
and 4 lbs, 7 lbs, 9 lbs on [**2-14**], and [**1-15**], respectively.
The patient tolerated this well with no change in his motor or
sensory function. He was evaluated by the medical team for
clearance for the OR. He was also seen by urology for placement
of his foley. On [**2102-1-17**] the patient went to the operating room
for occiput to C6 fusion and iliac crest graft. He tolerated
the procedure well. It was decided to leave the patient
intubated because the patient was prone for the long procedure.
He was extubated on [**2102-1-18**] without incident. He was found to
have a UTI and was started on bactrim on [**2102-1-18**] for ESBL
Klebsiella. A bedside swallowing evaluation was done on [**2102-1-19**]
and the patient was placed on aspiration precautions. On [**2102-1-20**]
he was doing well and was called out of the unit to the floor.
Pincare was done daily to the halo pinsites. His INR was found
to be 3.2 and he was given 2 units of FFP on [**2102-1-20**]. The
patient found to have low sodium and medicine was reconsulted.
Hospital Course post-transfer to medicine.
#Hyponatremia: Repeat urine lytes and serum osmolality was sent.
These numbers seemed consistent with SIADH but the picture was
clouded by the amount and different types of IVFs (NS and [**12-5**]
NS)that the patient received. Upon transfer, all IVFs were
stopped and the patient was placed on 1000 cc free water
restriction. A chest xray was done to evaluate for pulmonary
process as etiology of SIADH as the patient had a productive
cough but the chest xray did not suggest an acute
cardiopulmonary process. The following morning his sodium
decreased from 125 to 122 so Renal was consulted. Repeat urine
lytes were sent along with SPEP/UPEP (which were pending at the
time of discharge), cholesterol and TSH (which were normal) in
order to evaluate for paraproteinemia or other source of
euvolemic hyponatremia. Since the patient was asymptomatic and
his sodium remained in mid 120s, he was not started on further
therapy such as hypertonic saline or lasix. Renal felt that it
could take weeks for his sodium to improve on free water
restriction and that it was safe to transfer the patient to
rehab on 1000 cc free water restriction with frequent monitoring
of sodium levels. His sodium was stable 125-126 from [**1-22**] -
discharge.
.
#Hypotension - Upon transfer the patient's BPs were
85-100/50s-60s. He was asymptomatic with these pressures. A
random cortisol was sent which was 26. His lopressor dose was
held initially and restarted at a lower dose. His systolic blood
pressures remained 100-110 on this dose.
.
#Anemia - The patients hematocrits remained in 28-30 range
post-op. Iron studies were sent which were notable for low iron,
low TIBC and normal ferritin. These values were c/w anemia of
chronic disease.
#Post-Op Ortho - The patients halo was evaluated daily by ortho.
It caused stage 2 ulcers on his chest so the halo was adjusted
and duoderm was placed on these wounds. His posterior incision
developed some erythema around the staples. The staples were
removed and a small red area was noted by ortho which was
concerning for infection. He was started on keflex for this
?wound infection per ortho.
#UTI - He was started on Bactrim for ESBL Klebsiella UTI. His
repeat UA with foley was notable for continued inflammatory
cells + bacteria and yeast. His foley was changed and a repeat
urine culture was sent (pending at discharge). He was discharged
on 7 more days of Bactrim for 14 day course.
Medications on Admission:
Toprol XL 100 daily
Gemfibrozil 600 mg [**Hospital1 **]
Flomax 0.4 mg daily
Duragesic 50 mg q 72 hours
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) syringe
Injection [**Hospital1 **] (2 times a day) for 3 weeks.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
5. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain: for breakthrough
pain. Tablet(s)
8. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
9. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-5**]
Drops Ophthalmic PRN (as needed).
10. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) as needed for super Klebsiella,
ICU for 7 days.
11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID
(4 times a day).
14. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 10 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
C1-C2 instability, odontoid fracture
Hyponatremia
Discharge Condition:
Stable
Discharge Instructions:
Please keep incision clean and dry. Pincare daily to pinsites.
If you notice any increased redness, discharge, swelling,
prescribed. Please follow up as below. Call with any
questions.
Pin care [**Hospital1 **]
-Please check incision over L hip daily, watch for signs of
infection.
-Please check [**Hospital1 **] daily under brace for decub.
-Please have wound care nurse [**First Name (Titles) 11197**] [**Last Name (Titles) **] for further breakdown.
On discharge the patient's sodium was 125 (It was
Pin care [**Hospital1 **]
-Please check incision over L hip daily, watch for signs of
infection.
-Please check [**Hospital1 **] daily under brace for decub.
-Please have wound care nurse [**First Name (Titles) 11197**] [**Last Name (Titles) **] for further breakdown.
On discharge the patient's sodium was 125 (It was stable from
125-126 since [**2102-1-22**]). It could take several weeks to increase
with strict free water restriction <1000 cc/day.
-Please check sodium daily in order to ensure that it is stable.
If it decreases to <120, he may need further therapy with hypert
Pin care [**Hospital1 **]
-Please check incision over L hip daily, watch for signs of
infection.
-Please check [**Hospital1 **] daily under brace for decub.
-Please have wound care nurse [**First Name (Titles) 11197**] [**Last Name (Titles) **] for further breakdown.
On discharge the patient's sodium was 125 (It was stable from
125-126 since [**2102-1-22**]). It could take several weeks to increase
with strict free water restriction <1000 cc/day.
-Please check sodium daily in order to ensure that it is stable.
If it decreases to <120, he may need further therapy with
hypertonic saline or lasix.
Followup Instructions:
Provider: [**Name10 (NameIs) 5865**] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2102-2-1**] 9:40
Provider: [**Known firstname **] [**Last Name (NamePattern1) 1972**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2102-2-1**] 10:00
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"707.05",
"343.9",
"285.29",
"V15.88",
"707.8",
"806.00",
"041.3",
"272.4",
"401.9",
"E888.9",
"286.9",
"253.6",
"458.29",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.41",
"81.01",
"96.71",
"99.05",
"81.03",
"81.63",
"02.94",
"99.07",
"03.53",
"77.79"
] |
icd9pcs
|
[
[
[]
]
] |
8669, 8766
|
3171, 7100
|
324, 380
|
8860, 8869
|
2760, 3148
|
10617, 10968
|
2139, 2143
|
7253, 8646
|
8787, 8839
|
7126, 7230
|
8893, 10594
|
2158, 2741
|
275, 286
|
408, 2021
|
2043, 2103
|
2119, 2123
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,482
| 193,950
|
50013
|
Discharge summary
|
report
|
Admission Date: [**2148-12-23**] Discharge Date: [**2148-12-30**]
Date of Birth: [**2097-4-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Codeine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Exertional angina
Major Surgical or Invasive Procedure:
s/p Redo sternotomy/Replacement of asc. and hemi-arch aorta(28mm
gelweave) [**2148-12-25**]
History of Present Illness:
This 51M is s/p CABGx2 in [**2137**] and presented to the ED on [**12-23**]
with exertional chest pain. He has a known ascending aortic
aneurysm of 4.9 cm. He was cathed and admitted to the CCU.
Past Medical History:
- CAD s/p MI and CABG in [**2138**] (LIMA-LAD, RIMA-RCA), PTCA [**9-2**]
showed 100% native vessel occlusion with patent grafts, MIBI
[**8-5**] with fixed defect.
- EtOH abuse
- Remote head trauma '[**18**]
- Hypercholesterolemia
- History of seizure disorder (?EtOH vs. head trauma)
- HTN
- s/p skin graft to leg following MVA
Social History:
Married ten years ago, was living in [**Location (un) 3844**]. Wife died 5
months ago, patient moved back to [**Location (un) 86**]. Funeral director.
Living part time in funeral home and with his sister-in-law.
Drinks 6-12 pack/day each day, [**12-3**] pack/day tobacco use, both
for nearly 30 years.
Family History:
positive for early CAD
Mother - died of MI at 59.
Father - died at 61 of "MI and cancer.'
Physical Exam:
Gen: Thin, [**Male First Name (un) 4746**], appears older than stated age, in NAD
HEENT: NC/AT, PERLA, EOMI, oropharynx benign, carotids 2+=bilat.
without bruits
Lungs: Clear to A+P
CV: RRR without R/G/M
Abd: +BS, soft, nontender without masses or hepatosplenomegaly
Ext: no C/C/E, pulses 2+= bilat. throughout
Neuro: nonfocal
Pertinent Results:
[**2148-12-30**] 05:50AM BLOOD WBC-4.1 RBC-3.94* Hgb-11.3* Hct-32.4*
MCV-82 MCH-28.6 MCHC-34.8 RDW-13.7 Plt Ct-322
[**2148-12-29**] 12:36AM BLOOD PT-12.3 PTT-28.4 INR(PT)-1.1
[**2148-12-30**] 05:50AM BLOOD Glucose-106* UreaN-6 Creat-0.4* Na-134
K-3.7 Cl-98 HCO3-28 AnGap-12
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2148-12-29**] 11:08 AM
CHEST (PORTABLE AP)
Reason: eval subq air
[**Hospital 93**] MEDICAL CONDITION:
51 year old man s/p redo sternotomy/repl. asc. and hemiarch and
ct removal
REASON FOR THIS EXAMINATION:
eval subq air
INDICATION: Postop chest tube removal re-evaluation.
COMPARISON: [**2148-12-27**]
FINDINGS:
Extensive subcutaneous emphysema persists and is not
significantly different. There are no new patchy consolidations,
and overall there is no significant interval change compared to
prior. No PTX noted.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4347**]
Cardiology Report ECHO Study Date of [**2148-12-25**]
*** Report not finalized ***
PRELIMINARY REPORT
PATIENT/TEST INFORMATION:
Indication: Intra-op TEE for Ascending Aorta Aneurysm Repair.
Redo surgery for placement of coronary sinus catheter and
pulmonary artery vent
BP (mm Hg): 110/70
HR (bpm): 72
Status: Inpatient
Date/Time: [**2148-12-25**] at 12:09
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW02-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **]
MEASUREMENTS:
Left Ventricle - Ejection Fraction: 40% (nl >=55%)
Aorta - Ascending: *4.5 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.0 m/sec (nl <= 2.0 m/sec)
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement. Good (>20 cm/s) LAA ejection
velocity. All
four pulmonary veins identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Dynamic
interatrial septum.
Left-to-right shunt across the interatrial septum at rest. Small
secundum ASD.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Moderately
depressed LVEF.
LV WALL MOTION: Regional LV wall motion abnormalities include:
mid
anteroseptal - hypo; mid inferoseptal - hypo; septal apex -
hypo;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Moderately dilated aortic sinus. Focal calcifications in
aortic root.
Moderately dilated ascending aorta. Focal calcifications in
ascending aorta.
Mildly dilated aortic arch. Simple atheroma in aortic arch.
Moderately dilated
descending aorta Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. No AS. Mild (1+) AR.
MITRAL VALVE: No MS. Mild (1+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure. The patient appears to be in sinus rhythm. Results
were personally
post-bypass
data
Conclusions:
PRE-BYPASS:
The left atrium is mildly dilated. A left-to-right shunt across
the
interatrial septum is seen at rest. A small secundum atrial
septal defect is
present.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size
is normal. Overall left ventricular systolic function is
moderately depressed.
With LVEF of 40%
Right ventricular chamber size and free wall motion are normal.
The aortic root is moderately dilated athe sinus level. The
ascending aorta is
moderately dilated. The aortic arch is mildly dilated. There are
simple
atheroma in the aortic arch. The descending thoracic aorta is
moderately
dilated. There are simple atheroma in the descending thoracic
aorta. There are
three aortic valve leaflets. There is no aortic valve stenosis.
Mild (1+)
aortic regurgitation is seen.
Mild (1+) mitral regurgitation is seen.
There is no pericardial effusion.
POST-BYPASS:
Ascending aortic contour is suggestive of well placed graft .
Normal RV systolic function.
Overall LVEF 40%.
Mild AI, MR.
[**Name13 (STitle) **] PHYSICIAN:
Brief Hospital Course:
The patient went from the ED directly to the cath lab and the 2
grafts(LIMA->LAD, RIMA->RCA) were patent. He had a thoracic
aneurysm without evidence of dissection and mild pulm. HTN. He
continued having chest pain and had a CTA of chest which showed
a slight increase in size of aneurysm to 5.1 cm with a
dissection of the ascending aorta. Cardiac surgery was
consulted and a TEE was performed which revealed no clear Type A
dissection but possible focal ulceration and moderate AI.
On [**12-25**] he underwent Redo sternotomy/Replacement of the
ascending and hemi arch aorta(28 mm Gelweave graft) by Dr.
[**Last Name (STitle) **]. The cross clamp time was 63 mins., total bypass time
was 98 mins., and circ. arrest time was 13 mins. He was
transferred to the CSRU on stable condition on Epi, Neo, and
Propofol in stable condition. He was extubated on POD#1 and was
transferred to the floor. His chest tubes were removed and
later that night he developed severe subcutaneous emphysema. He
was transferred back to the CSRU and had a right chest tube
placed. This was not effective and was d/c'd. The following
morning he had 14 gauge angiocaths placed in the ant. chest
bilaterally and this helped with the subcutaneous air. He
continued to progress and was transferred back to the floor on
POD#4. He continued to progress and was discharged to home on
POD# 5.
Medications on Admission:
Protonix 40mg PO daily
Lipitor 80 mg PO daily
Lopressor 25 mg PO BID
Plavix 75 mg PO daily
ASA 325 mg PO daily
Lisinopril 5 mg PO daily
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily) for 7 days.
Disp:*7 Patch 24HR(s)* Refills:*0*
8. Nicotine 7 mg/24 hr Patch 24HR Sig: One (1) Transdermal once
a day for 14 days: Start after 14mg patches finished.
Disp:*14 patches* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Aortic dilitation
s/p CABG
HTN
^chol.
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 1 month.
Do not lift more than 10 lbs. for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use powders, lotions, or creams on wounds.
Call our office for temp>101.5, sternal drainage.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 665**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 1290**] for 4 weeks.
Completed by:[**2148-12-31**]
|
[
"441.7",
"998.81",
"V45.81",
"780.39",
"416.9",
"412",
"E878.4",
"272.0",
"401.9",
"414.00",
"447.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"37.23",
"88.56",
"39.61",
"34.04",
"38.45"
] |
icd9pcs
|
[
[
[]
]
] |
8996, 9002
|
6043, 7416
|
308, 402
|
9084, 9092
|
1770, 2161
|
9420, 9597
|
1316, 1408
|
7602, 8973
|
2198, 2273
|
9023, 9063
|
7442, 7579
|
9116, 9397
|
2852, 6020
|
1423, 1751
|
251, 270
|
2302, 2826
|
430, 628
|
650, 980
|
996, 1300
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,877
| 166,690
|
12444
|
Discharge summary
|
report
|
Admission Date: [**2135-1-21**] Discharge Date: [**2135-1-26**]
Date of Birth: [**2075-2-14**] Sex: M
CHIEF COMPLAINT: Liver nodule.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 59-year-old man
with a history of colon cancer that now presents with a
sigmoid colectomy in [**2132-8-22**] for a T3-N0 grade 2
adenocarcinoma of the colon. Since that time he has had a
recent rise in his CEA. Recent CT scan of the chest, abdomen
and pelvis in [**2134-11-23**] demonstrated a 2 mm nodule in the
left lower lobe of the lung that was unchanged from previous
CT's in both [**2131**] and in [**2132**]. However, the abdominal CT
demonstrated ill defined low attenuation mass near the porta
He is now referred for caudate lobe resection.
PAST MEDICAL HISTORY: Significant for the following:
Adenocarcinoma of the colon as described above. Adult onset
diabetes mellitus. Hypertension. Hypercholesterolemia.
Status post sigmoid colectomy.
ALLERGIES: Eggs.
MEDICATIONS: Lipitor 10 mg po q day, Glucophage 1000 mg po q
day, Zestril 8 mg po q day, Aspirin 81 mg po q day,
Nortriptyline 10 mg po q day, Vitamin E 400 IU po q day,
Centrum Silver po q day.
PHYSICAL EXAMINATION: His blood pressure was 146/76, heart
rate 88, temperature afebrile and weight 186 lbs. In general
he is well developed and a well nourished male in no acute
distress. His skin is normal. His head, eyes, ears, nose
and throat demonstrates no scleral icterus. His oropharynx
was clear. Neck was supple without lymphadenopathy or
thyromegaly. His carotids are 2+ and 4+ without bruit. His
lungs are clear to auscultation bilaterally. Heart has a
regular rate and rhythm with a normal S1 and S2. There is no
murmur, rub or gallop. Abdomen demonstrates a well healed
low midline incision, there is no hepatosplenomegaly, masses,
tenderness or incisional hernia. His extremities are without
peripheral edema and neurologically he is grossly intact.
LABORATORY DATA: In [**2134-10-23**] sodium 138, potassium 5.2,
chloride 99, CO2 25, BUN 18, creatinine 0.8, glucose 189,
calcium 9.5, AST 30, ALT 41, alkaline phosphatase 71, total
bilirubin 0.5 and albumin 4.2.
HOSPITAL COURSE: The patient was admitted to the general
surgery service and on [**2135-1-21**] was taken to the operating
room. There, he had a right hepatic lobectomy,
cholecystectomy, wedge biopsy of the left lobe, needle biopsy
of the left lobe and intraoperative ultrasound. During his
operation he was transfused with one unit of packed red blood
cells. Postoperatively he was taken to the surgical
Intensive Care Unit where he was extubated on the evening of
his operation. The remainder of his hospitalization is
dictated by systems.
1. Neurologic: The patient had pain control with an
epidural that contained both Dilaudid and Bupivacaine. He
did not receive total analgesia with this and because of his
discomfort on postoperative day #1, the acute pain service
bolused his epidural while he was still in the surgical
Intensive Care Unit. He became markedly hypotensive with
this and required several hours of vasopressive support with
a Neo-Synephrine drip. Subsequent to this time, his epidural
was no longer used, he started to take po and he was
maintained with oral Percocet. His epidural catheter was
discontinued without incident on the second postoperative day
and patient continued to receive adequate analgesia with oral
Percocet throughout the remainder of his hospitalization.
2. Cardiopulmonary: Other than the episode of hypotension
that he experienced from his epidural, the patient had no
other acute cardiopulmonary events. He was stable on the
floor for several days and his Zestril was restarted prior to
his discharge. His Aspirin continued to be held at the time
of his discharge and will need to be restarted once the
patient follows up as an outpatient. He had access with a
right internal jugular central venous line that was kept in
place until the date of his discharge. It was discontinued
without incident prior to his leaving.
3. GI: On the evening of his operation, the patient's
transaminases were markedly elevated as we expected them to
be with an ALT of 2,220 and an AST of [**2041**]. The following
day these had decreased to an ALT of 1822 and an AST of 1439,
however, because these were not decreasing as quickly as we
expected them to, the patient had an ultrasound of his liver.
The study was limited but the hepatic artery, hepatic vein
and portal vein were felt to demonstrate adequate blood flow.
Throughout the remainder of the patient's hospitalization,
his liver enzymes continued to trend downward. By the date
of the patient's discharge his ALT had decreased to 431 and
his AST was 97. His alkaline phosphatase had consistently
remained in the 60-100 range and his total bilirubin was
steady at 1.7. He did have [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drains that had
been placed intraoperatively with the medial drain placed
inferior to the liver and the lateral drain placed adjacent
to his liver. These continued to put out several hundred cc
per day and the patient was discharged home with both of them
in place. He was educated as to their care and maintenance
and instructed to measure the output and consistency of the
drains.
4. Fluids, Electrolytes & Nutrition: The patient was
started on po on the afternoon of his first postoperative day
and by the following day was tolerating Percocet without any
problems. His diet was subsequently advanced on the third
postoperative day and his Glucophage was restarted. The
patient continued to tolerate a regular diet up until the
time of his discharge. He did require some sliding scale
insulin. During this time his blood sugars remained in the
180-200 range which we felt were acceptable in the acutely
postoperative patient. For the entire hospitalization he
also received intravenous Zantac for stress ulcer
prophylaxis. He was not discharged home on this.
5. Infectious Disease: The patient received intravenous
Unasyn during his operation and for the first two
postoperative days. Subsequent to this time it was
discontinued. The patient did continue to have problems with
fever during his postoperative course. On the third
postoperative day he had a maximum temperature of 102
degrees. He was pancultured for this and all studies proved
to be negative. It was ultimately felt that his fever was
atelectatic as he had diminished breath sounds in his right
base and was limited by pain on taking a deep breath. The
patient was not discharged home on any antibiotic therapy.
Surgical pathology of his intraoperative specimen revealed
that he had a normal gallbladder with two lymph nodes
demonstrating no evidence of malignancy. In addition, he had
a liver needle biopsy that demonstrated macro and micro
vesicular steatosis with no evidence of malignancy. His
wedge biopsy demonstrated a bile duct adenoma and his
resected portion of liver demonstrated adenocarcinoma that
was moderately differentiated, consistent with a colorectal
primary. The margins of this were 2 mm from the ink
resection margin and there is no vascular invasion seen.
On [**2135-1-26**] the patient was discharged home in stable
condition in the care of his family. He had [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**]
drains in place and was instructed in proper care for them at
home.
DISCHARGE MEDICATIONS: He was discharged home on the
following medications: Lipitor 10 mg po q day, Glucophage
1,000 mg po q day, Zestril 5 mg po q day, Multivitamin,
Vitamin E, Nortriptyline 10 mg po q day, Percocet [**11-24**] po q
4-6 hours prn. The patient was not restarted on Aspirin. As
stated above, this needs to be restarted upon follow-up. The
patient verbalized understanding of all of his discharge
instructions and was told to follow-up with Dr. [**Last Name (STitle) **] in
approximately one week.
DISCHARGE DIAGNOSIS:
1. Metastatic colonic adenocarcinoma, now status post right
hepatic lobectomy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366
Dictated By:[**Last Name (NamePattern1) 9638**]
MEDQUIST36
D: [**2135-2-8**] 13:00
T: [**2135-2-10**] 19:25
JOB#: [**Job Number 38656**]
|
[
"V10.05",
"401.9",
"272.0",
"197.7",
"250.00",
"458.2",
"571.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.3",
"50.11",
"51.22",
"50.12",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7495, 7990
|
8011, 8357
|
2197, 7471
|
1209, 2179
|
136, 151
|
180, 766
|
789, 1186
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,410
| 196,975
|
54155
|
Discharge summary
|
report
|
Admission Date: [**2200-8-12**] Discharge Date: [**2200-8-21**]
Date of Birth: [**2167-8-10**] Sex: F
Service: [**Company 191**] East Medical Service
HISTORY OF PRESENT ILLNESS: Miss [**Known lastname 3647**] is a 33-year-old
female with history of Crohn's disease status post two
intestinal resection surgeries, multiple perirectal
abscesses, fistula operations with the most recent being [**2200-7-4**] and a history of non adherence to medications in the
setting of an extensive psychiatric history, who was sent to
the Emergency Room from her primary care physician's office
after presenting with a [**5-9**] week history of fevers up to 102,
loose bowel movements up to 15 a day and chest pain and
orthostatic lightheadedness, has also a one week history of
bilious vomiting and decreased po intake. Chest pain is
described as pressure like with a [**2209-8-12**] severity,
substernal location without radiation, alleviated by drinking
ice water and by bowel movements. Not exertional, lasts
greater than a day at the time and has been having this chest
pain for greater than 30 days. No palpitations. In the
Emergency Room temperature was 99.7, blood pressure 81/58
with heart rate of 140 that responded with 5 liters of IV
fluids to 115/64 with heart rate of 110. Subsequently her
blood pressure dropped to 64/39 with a heart rate of 128 and
was started on IV Levophed and transferred to the MICU for
continuing care.
PAST MEDICAL HISTORY: Arthritis secondary to Crohn's,
chronic renal insufficiency with baseline creatinine of 1.5
to 2.1. This is felt secondary to Lithium use in the past.
Obesity. Depression. Anxiety. Obsessive compulsive
disorder. PTSD. Schizo-affective disorder. Status post TAH
BSO and Crohn's disease diagnosed at age 11 years, status
post an ileocecal resection in [**2182**] and a right hemicolectomy
in [**2181**], status post an ileocolectomy in [**2193**] for stricture
and enteroenteral fistula. Status post some multiple
perirectal surgeries for abscesses and fistulas with the last
one being [**2200-7-4**]. Also a history of non adherence to
medications per the OMR.
ALLERGIES: Penicillin and Depakote.
MEDICATIONS: Zyprexa, Seroquel, Neurontin, Pentasa,
Prednisone. Of note the patient denies taking Pentasa or
Prednisone for approximately 1-3 months.
FAMILY HISTORY: Notable for the mother having hypertension
and a paternal grandfather with history of [**Name (NI) 4522**] disease.
SOCIAL HISTORY: She lives with a 9-year-old daughter and her
mother. Lives close to the hospital. Denies any tobacco,
alcohol or IV drug use.
REVIEW OF SYSTEMS: Notable for fever, palpitations, black
stool but no hematemesis or coffee grounds, no shortness of
breath or cough, no urinary symptoms. There is clear
drainage from the perirectal wound with some mild chronic
perirectal discomfort. She also notes a 30 lb weight loss
over the 6 weeks prior to admission.
PHYSICAL EXAMINATION: Temperature 99.7, heart rate 135,
blood pressure 110/80, heart rate 14, O2 saturation 99%,
weight 90 kg. In general this is a pleasant female in no
apparent distress, lying on side in the MICU bed. HEENT:
Normocephalic, atraumatic, sclera anicteric, mucus membranes
dry. Neck is supple, no lymphadenopathy or JVD is noted.
Chest is clear to auscultation bilaterally. Cardiovascular,
tachycardic and regular with no murmurs. Abdomen soft,
slightly distended, nontender with positive bowel sounds,
palpable liver edge one fingerbreadth below the right
costovertebral junction at the midclavicular line. Back, no
CVA tenderness, left perirectal lesion with minimal clear
drainage, no fluctuants noted. Positive skin tag vs
hemorrhoids noted. Extremities, no clubbing, cyanosis or
edema. Further extremity exam deferred by patient.
LABORATORY DATA: WBC 13.7 with 86% neutrophils, 0 bands, 8%
lymphs, hematocrit 31.7, MCV 79, platelet count 569,000,
sodium 134, potassium 4, chloride 96, CO2 21, BUN 13,
creatinine 2.4, glucose 124, ALT 10, AST 19, alkaline
phosphatase 192, amylase 66, total bilirubin 0.3, calcium
8.8, potassium 6.4, magnesium 1.9. Urinalysis showed 38 WBC,
trace protein, moderate bacteria. An abdominal, pelvic CT
with po contrast showed mucosal thickening at the hepatic and
splenic flexures with focal areas of fatty infiltration, no
free fluid or lymphadenopathy noted. Consistent with
progression of her Crohn's disease since a prior study of
[**2200-6-2**]. EKG showed sinus tachycardia at 133 beats per
minute with normal axis, poor R wave progression in the
anterior leads, flattening and T wave inversions new compared
with EKG of [**2200-6-13**].
HOSPITAL COURSE: Miss [**Known lastname 3647**] is a 33-year-old female with a
history of Crohn's disease, admitted to [**Hospital1 190**] initially to the Medical Intensive Care Unit
for weight loss, lightheadedness, chest pain, increasing
diarrhea in the setting of radiologic evidence for
progression of her Crohn's disease.
1. GI: Miss [**Known lastname **] symptoms were consistent with an
exacerbation of her Crohn's disease. A GI consult was
obtained with the recommendations of continuing her Pentasa
and starting a two week course of Cipro and Flagyl. She was
made npo and started TPN and IV Solu-Medrol drip at 2 mg per
hour. There was discussion at that time about starting
Remicade, however, it was felt best to be deferred given her
multiple perirectal abscesses and a questionable infection at
that site. On hospital day #3 she was taken to the operating
room for an examination under anesthesia and excision of skin
tag. There were no signs of active infection at the time and
showed a well healing surgical scar from prior drainage of
perirectal abscesses. On hospital day #4 she was switched to
po from IV Solu-Medrol drip to po Prednisone after the
surgery. Again, on hospital day #4 after surgery and after
stabilization of her cardiovascular status she was
transferred to the regular floor and continued treatment for
Crohn's disease. Throughout the hospital course she was
started on TPN and continued with Pentasa, Cipro/Flagyl and
po Prednisone. On hospital day #6 at the suggestion of the
GI consult team, she was taken for flexible sigmoidoscopy
which showed ulceration erythema with lesion and cobblestone
pattern in the descending colon, rectum and sigmoid colon
compatible with a Crohn's disease. Over the subsequent three
days prior to hospital discharge, the patient was started on
fluid intake which she advanced slowly over the course of
three days. Over that time she was decreased in the volume
of TPN that she received with no increase of her bowel
movements. At the time of hospital discharge she was noting
[**7-11**] bowel movements that were watery and light brown in
color. This was prior very dark, bloody bowel movements.
She was not having any abdominal pain with meals and no
fevers or chills overnight. She was discharged to home with
a follow-up with her new primary care provider, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], on
[**8-27**] at 1:30 p.m. She was asked to continue Cipro and Flagyl
for a two week total dosage. She was asked to continue
steroid with a taper, continue her Prednisone at 40 mg po q d
in a taper of 5 mg a week and continue her Pentasa as an
outpatient. In addition, she has a follow-up appointment
with GI, Dr. [**Last Name (STitle) 2987**], two weeks after discharge.
2. Cardiovascular: The patient presented with profound
hypertension to systolic blood pressure of 80's and was
started on Levophed. It was felt her hypotension was a
combination of hypovolemia, anemia, and possible sepsis. She
was supported well with IV fluids and antibiotics. By
hospital day #2 her blood pressure and heart rate responded
well such that the Levophed was discontinued. By hospital
day #2 her blood pressure and heart rate were stable and IV
fluids were continued only at maintenance levels. She had no
EKG changes throughout the course and no further episodes of
chest pain or hypotension throughout the rest of her hospital
course.
3. ID: Miss [**Known lastname **] profound hypertension and tachycardia
was thought also possibly consistent with a sepsis type
picture in the setting of a Crohn's flare. She was started
on Flagyl 500 mg IV tid and Ciprofloxacin 200 mg IV bid.
This was maintained through her hospital course. She had an
elevated white count, as high as 13.7 during hospital course
and it was felt secondary to Solu-Medrol. She had several
stool studies done throughout the course of her hospital
course, however, all stool studies were negative. At the
time of hospital discharge the patient was switched to po
Cipro/Flagyl and was asked to continue those for two week
total course. She was afebrile with a normal white count at
the time of hospital discharge.
4. Hematologic: Miss [**Known lastname 3647**] presents to the hospital with
hematocrit of 31.7, it fell subsequently over the course of
two days to 23.9, however, this was in the setting of several
liters of IV fluids and it was felt secondary to dilutional
effects from the IV fluids. On hospital day #2 she received
two units of packed red blood cells with appropriate response
in her hematocrit to 28.3. This was felt to be approximately
her baseline and her hematocrit was followed through the
duration of her hospital course and was stable. At the time
of discharge her hematocrit was 28.9 and stable.
5. Chronic renal insufficiency: Miss [**Known lastname 3647**] has history of
chronic renal insufficiency felt secondary to Lithium use in
the past. Her baseline creatinine is reportedly 1.5 to 2.0.
At the time of admission her creatinine of 2.4 was felt
secondary to profound hypovolemia. Her creatinine returned
to baseline with hydration and at the time of discharge was
back to baseline level of 1.4. She will continue to have
this followed as an outpatient with Dr. [**First Name (STitle) **].
6. Psychiatry: Miss [**Known lastname 3647**] carries a psychiatric diagnoses
of depression, anxiety, OCD, PTSD, schizo-affective disorder.
On hospital day #3 she was continued on her outpatient
medications of Seroquel and Zyprexa. On hospital day #2
psychiatry team was consulted and it was felt that she had
chronic psychiatric disorder that involved psychotic features
in the past. She appeared currently stable with no evidence
of active depression, hypomania, mania, psychosis,
suicidality or other psychiatric disturbances. The issue of
medication non compliance was addressed and Miss [**Known lastname 3647**]
[**Last Name (Titles) 2771**] the non compliance to the side effects of
abdominal pain and vomiting. She appeared agreeable to
taking her necessary medications if she tolerates them.
Throughout the course of her hospitalization she was
continued on her Zyprexa and Seroquel without any psychiatric
events and at discharge she did not appear depressed or
particularly anxious. She denied any suicidal or homicidal
ideation. She was to follow-up with her outpatient
psychiatrist.
Miss [**Known lastname 3647**] is discharged to home in good condition with
follow-up with Dr. [**First Name (STitle) **], her primary physician, [**Last Name (NamePattern4) **] [**8-27**] at
1:30 p.m. and a follow-up appointment with Dr. [**Last Name (STitle) 2987**],
gastroenterology, two weeks after discharge.
DISCHARGE MEDICATIONS: Prednisone 40 mg po q d, then taper 5
mg per week, Ciprofloxacin 500 mg po bid times 6 weeks, then
Ciprofloxacin 500 mg po q d times 6 weeks, Flagyl 500 mg po
tid times four weeks, Pentasa 1,000 mg po qid. All
medications that were taken prior to hospitalization were
continued.
DISCHARGE DIAGNOSIS:
1. Crohn's disease exacerbation.
2. Chronic renal insufficiency.
3. Depression.
4. Anxiety.
5. [**11-8**]. PTSD.
7. Schizo-affective disorder.
8. Obesity.
9. Medication non compliance.
10. Arthritis secondary to Crohn's.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Last Name (NamePattern1) 14434**]
MEDQUIST36
D: [**2200-9-18**] 16:00
T: [**2200-9-23**] 07:59
JOB#: [**Job Number **]
|
[
"276.5",
"280.9",
"458.9",
"555.1",
"584.9",
"786.59",
"296.7",
"455.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"49.03",
"99.15",
"45.24",
"49.93"
] |
icd9pcs
|
[
[
[]
]
] |
2350, 2467
|
11411, 11692
|
11713, 12206
|
4670, 11387
|
2964, 4652
|
2633, 2941
|
196, 1449
|
1472, 2333
|
2484, 2613
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,671
| 159,595
|
32588
|
Discharge summary
|
report
|
Admission Date: [**2151-12-30**] Discharge Date: [**2152-1-2**]
Date of Birth: [**2093-3-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
Fever, cough
Major Surgical or Invasive Procedure:
Central Venous Line placement - R internal jugular vein
History of Present Illness:
received INH x 8 months, and recent bronch during admission for
pna ([**Date range (1) 75968**] at [**Hospital1 **]) on last day of 6-day course of
augmentin who presents with R-sided chest pain, productive
cough, temp x 1 day.
In the ED, initial VS were T 100.4 BP 120/66 HR 115 satting 100%
on 2L NC. He was initially stable, although ill-appearing, but
then spiked fever to 101.8 around 4am, so abx (vanc/levo/zosyn)
were started. He then became hypotensive to 70s systolic;
received 3L NS with BP up to high 80s systolic, which is near
his baseline, and he was mentating well. Pt was very reluctant
to have a central line, so got fluid boluses through 2 PIVs. VS
at 6am: 99.5, 91, 85/60, 16, 100% 2L. Then, prior to transfer at
730am, SBP was back down to 70s, so ED placing central line to
start levophed.
ROS: The patient denies any chills, weight change, nausea,
vomiting, abdominal pain, diarrhea, constipation, melena,
hematochezia, chest pain, orthopnea, PND, lower extremity
oedema,urinary frequency, urgency, dysuria, lightheadedness,
gait unsteadiness, focal weakness, vision changes, headache,
rash or skin changes. He does report a low grade temperature
around 99.4 prior to admission and worsening cough for the last
day, non-productive in nature. He does have occasional right
sided chest pain related to his cough, though not pleuritic.
Past Medical History:
- squamous cell lung cancer T3, N2 s/p L pneumonectomy [**2-/2151**]
after chemo and XRT; bronchoscopy on [**12-22**] revealed erythema and
abnormal appearance in the L bronchial stump suggesting
recurrent disease. Recent PET shows some FDG avidity along the
pneumonectomy suture line with a comment about a foci of avidity
in the AP window area. There is also circumferential uptake
around the pneumonectomy cavity. There is also a note of poor
anatomic delineation without a contrast CT. There was also FDG
avidity between the right atrial appendage and the left
ventricular outflow track without anatomic correlate. No
definite bony lesions, no subdiaphragmatic lesions. Dr [**Last Name (STitle) 3274**]
is his oncologist and last note indicates they are considering
radiation therapy.
- a-flutter s/p ablation in [**11/2151**]; not anticoagulated [**1-17**]
bleeding problems while on coumadin for PE in the past
- PE [**11-20**]
- multiple PNAs, most recently in [**12-24**]
- + PPD, treated with INH x8 months (completed in [**4-21**])
- COPD: FEV1 of 1.55 liters or 48% of predicted, an FVC of 2.38
liters or 53% of predicted, and an FEV1/FVC ratio of 55%
Social History:
Patient is divorced and lives with his two daughters. Only rare
alcohol use and prior tobacco use (roughly 70 pack years); he
quit smoking approximately a year ago just prior to be diagnosed
with lung cancer. He was born in [**Country 5881**] and came to the U.S.
roughly forty years ago.
Family History:
Father died of laryngeal cancer. Does not know what his mother
died from.
Physical Exam:
On Presentation:
Vitals: T: BP: HR: RR: O2Sat:
GEN: Ill-appaering, NAD
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, dry MM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline, LIJ in place
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs diffuse wheezing, referred breath sounds on the
left, no rales or rhonchi
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.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
IMAGING:
CT CHEST:
Brief Hospital Course:
MICU COURSE:
58M with squamous cell lung CA, h/o recurrent/?post obstructive
pna, also h/o PE, who presented to the ED with fever, cough,
and hypotension. He was treated with vancomycin, levofloxacin
and cefepime.
# Sepsis: Patient met SIRS criteria with fever and hypotension
in ED. Likely source was pneumonia based on symptoms of cough, R
sided chest pain. Patient had completed course of Augmentin day
prior to admission after admission for PNA at which time he was
initially treated with vanc/zosyn. During that admission, AFB
titers were normal, PCP smear was negative, sputum cultures were
negative. Symptoms worsened the day prior to admission after
completing antibiotic course. On admission his CXR unremarkable.
CTA showed no focal infiltrate, No PE but did show ground glass
opacities. Patient initially required pressors but was quickly
weaned off when he got to the ICU. He was treated with
vancomycin, levofloxacin and cefepime for broad coverage. DFA
was negative, blood cultures were negative and urine culture was
negative. He remained afebrile and normotensive and was
transferred to the floor. He was transitioned to PO
levofloxacin. We considered doing a thoracentesis to evaluate
for empyema, but after speaking with the patient's throacic
surgeon (who reviewed the CT scan) it felt that empyema was
highly unlikely. The patient remained afebrile for >48 hours
and was d/c'd home and asked to follow up with the infectious
disease clinic.
.
# A-flutter, s/p ablation: In sinus rhythm on admission.
Diltizem & flecainide held on admission [**1-17**] hypotension but were
restarted after patient was weaned off pressors. Patient was
monitored on telemetry and remained in normal sinus rhythm for
the remainder of his hospitalization.
.
# Squamous cell lung cancer: Status post L pneumonectomy now
with evidence of local recurrence as confirmed by biopsy during
admission at [**Location (un) 620**]. Primary oncologist is Dr. [**Last Name (STitle) 3274**] was is
aware of admission. His oncologist, thoracic surgeon and
primary team felt that the patient should recover from his acute
illness and his treatment will be decided upon as an outpatient.
.
# COPD: Continued outpatient medications including albuterol,
advair, and spiriva. Albuterol/ipratropium nebs as needed.
.
Medications on Admission:
ALBUTEROL - inhaled four times a day as needed
DILTIAZEM HCL - 120 mg Capsule, Sust. Release daily
FLECAINIDE - 100 mg Tablet [**Hospital1 **]
FLUTICASONE-SALMETEROL - 250 mcg-50 mcg/Dose [**Hospital1 **]
GABAPENTIN - 800 mg [**Hospital1 **] twice a day
OMEPRAZOLE - 20 mg daily
OXYCODONE - 5 mg q4h prn pain
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule
INH daily
ASPIRIN - 325 mg daily
DOCUSATE SODIUM - 100mg [**Hospital1 **]
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed.
3. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for apin.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
9. Flecainide 50 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12
hours).
10. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
11. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
12. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
sepsis
lung cancer
atrial fibrillation
Discharge Condition:
good.
Discharge Instructions:
You were admitted to the hospital with fever and low blood
pressure. You did not appear to have pneumonia, although you
have had recurrent pneumonias lately. You should finish a
course of levofloxacin. We have not changed any of your
medications.
Please call your doctor if you have fevers, chills,
light-headedness, passing out episodes, or any other concerning
symptoms.
You should follow-up with Dr. [**Last Name (STitle) 3274**] in clinic in the next [**12-17**]
weeks, and you should be seen in the Infectious [**Hospital 2228**] Clinic
in the next 1-2 weeks for evaluation of recurrent pneumonias.
Followup Instructions:
Please call Dr.[**Name (NI) 3279**] office to set up a follow-up
appointment next week.
.
Please call the infectious disease clinic at [**Telephone/Fax (1) 457**] and
ask for the urgent care clinic. They will help you set up an
appointment for early this week to discuss your recurrent
pneumonias.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
|
[
"V15.82",
"162.2",
"795.5",
"V46.2",
"196.9",
"038.9",
"995.91",
"496",
"V12.51",
"427.32",
"458.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8198, 8204
|
4130, 6439
|
328, 385
|
8287, 8295
|
4086, 4107
|
8952, 9365
|
3282, 3357
|
6935, 8175
|
8225, 8266
|
6465, 6912
|
8319, 8929
|
3372, 4067
|
276, 290
|
413, 1772
|
1794, 2959
|
2975, 3266
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,904
| 185,539
|
50338
|
Discharge summary
|
report
|
Admission Date: [**2198-4-3**] Discharge Date: [**2198-4-10**]
Date of Birth: [**2126-2-17**] Sex: F
Service: NEUROSURGERY
Allergies:
Dilantin Kapseal
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
T7-8 lesion
Major Surgical or Invasive Procedure:
[**4-4**] T5-9 laminectomy and mass resection at T7-8
History of Present Illness:
This is a 72 year old right handed female with a history of left
frontal lobe atypical meningioma grade II s/p resection (Dr
[**Last Name (STitle) **] and radiation in [**2192**] with chronic incontinence and
executive function difficulties subsequently,
now presents with progressive worsening of RLE weakness.
Reportedly, the patient began having difficulty with balance in
association with more frequent falls back in [**2196-10-18**]. The gait
instability was also associated with increased incontinence. Due
to these symptoms, the patient was seen by neuro-oncology for
workup of possible recurrent meningioma. She underwent an MRI
(head), which was negative for recurrence. She subsequently saw
a neuromuscular neurologist for evaluation of persistent
weakness,
and was noted to have decreased power in the right leg with
decreased sensation in the left leg, with no accurate sensory
level. An MRI of the C-spine and L-spine in addition to an XR of
the thoracic spine were obtained. The cervical spine MR [**First Name (Titles) 654**] [**Last Name (Titles) 104941**] and canal narrowing, but no cord impingement.
Following these appointments, she had progressive worsening of
the RLE weakness. She became unable to bear any weight on R leg
and cannot ambulate without full assist.
She denies fevers/chills, nausea/vomiting, headache, dizziness,
vertigo, visual disturbance, dysarthria, dysphagia, or tinnitis.
Past Medical History:
thyroidectomy for cancer [**2183-8-29**];
uterine and transverse colon polypectomy for adenoma [**2183**];
basal cell carcinoma nasal bridge and left lower lip [**2188**];
GERD, hypothyroidism, hypertension.
Social History:
Lives with her husband and daughter, no ETOH or tobacco.
Sister very much involved with her care.
Family History:
NC
Physical Exam:
At time of discharge:
BUE full strength
BLE exam limited to pain and patient effort, but antigravity
throughout.
Pertinent Results:
[**4-5**] C/T Spine MRI:
1. MR OF THE C-SPINE: Multilevel, multifactorial degenerative
changes, with moderate canal stenosis at C5-6, at C6-7 and
mild-to-moderate at C4-5 level from disc osteophyte complex and
ligamentum flavum thickening, with effacement of the CSF space
and deformity on the cord at C5-6 and C6-7 levels ventrally
along with moderate-to-severe foraminal narrowing, with possible
impingement on the nerves in this location.
2. Area of altered signal intensity in the posterior spinous
soft tissues and in the posterior epidural space, with
displacement of the cord anteriorly, this may relate to a
combination of blood products, recent surgical
changes/inflammatory changes. To correlate with surgical
details. While there is anterior displacement of the cord, the
appearance of the cord is significantly improved compared to the
preoperative study when it was significantly compressed. Small
focus of T2 signal intensity in the cord at T8 level may relate
to edema/myelomalacia, less likely infarct and a small focus of
this was seen on the prior study, however, this appears more
prominent on the present study. Again, to correlate clinically
to assess the significance of this finding. Consider close
followup to assess
stability/progression and evaluation for any residual tumor.
Urine Culture [**4-3**] proteus mirabilis
Urine Culture [**4-9**] pending at time of discharge
Brief Hospital Course:
Ms. [**Known lastname 104942**] presented to [**Hospital1 18**] Neurosurgery on [**4-3**] for a
conventional angiogram to assess vasculature surrounding her
T7-8 lesion. The angiogram showed no large feeders of the
thoracic lesion and she was prepared for resection on [**4-4**]. She
went to the operating room and underwent a T5-9 laminectomy and
t7-8 mass resection on the mornign of [**4-4**]. She tolerated the
procedure well and was trasnferred to the ICU for further care.
On the morning of [**4-5**] she was noted to have no spontaneous
movement of her RLE or movement to command. She withdrew the RLE
to noxious however. She also was noted to only be able to
perform grip to command on the RUE and minimally withdrew to
noxious otherwise. She underwent a Cervical and Thoracic spine
MRI on [**4-5**] which showed multiple ares of degenerative chnages
without cord impingement and post-operative chnages. She was
cleared for transfer to the floor.
On [**4-6**] she remained neurologically stable. PT and OT were
consulted for assistance with discharge planning. She had some
pain and ultram was prescribed on [**4-7**]. Her srength continued to
improve. Her Foley was removed on [**4-8**] and urinalysis was
ordered as her urine was cloudy. On [**4-10**], patient was placed on
IV ceftriaxone for proteus UTI. She wull continue antibiotics
for 3 days and was discharged to rehab later that day.
Medications on Admission:
levothyroxine, lisinopril, colace, senna, bisacodyl, heparin,
protonix, dexamethasone
Discharge Medications:
1. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. alendronate 70 mg Tablet Sig: One (1) Tablet PO QSAT (every
Saturday).
4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TID (3 times a day).
9. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, T>38.5.
11. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. insulin regular human 100 unit/mL Solution Sig: Two (2)
units Injection ASDIR (AS DIRECTED): see sliding scale.
14. dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO q6hours () for
2 days.
15. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours) for 3 days: please
d/c after last dose on [**4-11**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
T7-8 meningioma
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
?????? Do not smoke.
?????? Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery.
?????? If you have steri-strips in place, you must keep them dry for
72 hours. Do not pull them off. They will fall off on their own
or be taken off in the office. You may trim the edges if they
begin to curl.
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
?????? Limit your use of stairs to 2-3 times per day.
?????? Have a friend or family member check your incision daily for
signs of infection.
?????? Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
?????? Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
?????? 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:
?????? Pain that is continually increasing or not relieved by pain
medicine.
?????? Any weakness, numbness, tingling in your extremities.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
?????? Fever greater than or equal to 101?????? F.
?????? Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **] to be seen in 4 weeks.
??????You willnot need x-rays/CT-scan prior to your appointment.
Completed by:[**2198-4-10**]
|
[
"225.4",
"599.0",
"788.30",
"V15.88",
"244.0",
"721.0",
"458.29",
"336.3",
"V10.83",
"438.0",
"530.81",
"401.9",
"V10.87",
"041.6",
"781.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.94",
"03.4",
"88.42",
"88.49"
] |
icd9pcs
|
[
[
[]
]
] |
6667, 6737
|
3739, 5145
|
292, 348
|
6797, 6914
|
2312, 3716
|
8612, 8839
|
2159, 2163
|
5281, 6644
|
6758, 6776
|
5171, 5258
|
6938, 8589
|
2178, 2293
|
241, 254
|
376, 1795
|
1817, 2027
|
2043, 2143
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,719
| 123,790
|
32959
|
Discharge summary
|
report
|
Admission Date: [**2144-4-3**] Discharge Date: [**2144-4-7**]
Date of Birth: [**2109-12-13**] Sex: M
Service: SURGERY
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Splenic laceration
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 76677**] is a 34M well known to Dr. [**Last Name (STitle) **]. He has a
history of chronic pancreatitis with pancreatic pseudocyst. He
had a follow up CT scan on [**2144-4-3**] which revealed a grade III
splenic laceration. He states he had a traumatic fall 1.5 weeks
ago.
Past Medical History:
1. Chronic pancreatitis since [**2129**] due to EtOH abuse, admitted 4
times for exacerbations, with pseudocysts
2. Portal Vein thrombus
3. Diabetes mellitus
4. HTN
5. s/p shoulder and ankle surgeries
Social History:
He lives with his wife and 18 month old daughter. [**Name (NI) **] denies
tobacco and recreational drug use other than occasional
marijuana. He quit drinking alcohol 4 years ago.
Family History:
Non-contributory
Physical Exam:
On Discharge:
VS: Afebrile, vital signs stable
Gen: no acute distress
Chest: RRR, lungs clear
Abd: soft, nontender, nondistended
Ext: 2+ pulses, no edema
Pertinent Results:
[**2144-4-2**] 10:08PM BLOOD WBC-4.6 RBC-2.74*# Hgb-7.8*# Hct-23.1*#
MCV-84 MCH-28.4 MCHC-33.8 RDW-16.6* Plt Ct-153
[**2144-4-3**] 05:02AM BLOOD WBC-5.4 RBC-3.16* Hgb-9.6* Hct-26.9*
MCV-85 MCH-30.3 MCHC-35.6* RDW-16.0* Plt Ct-142*
[**2144-4-3**] 09:37AM BLOOD Hct-26.6*
[**2144-4-3**] 12:48PM BLOOD Hct-27.3*
[**2144-4-3**] 04:54PM BLOOD Hct-27.3*
[**2144-4-3**] 08:00PM BLOOD Hct-26.9*
[**2144-4-3**] 11:46PM BLOOD Hct-27.2*
[**2144-4-4**] 04:16AM BLOOD WBC-4.4 RBC-3.44* Hgb-9.9* Hct-29.6*
MCV-86 MCH-28.9 MCHC-33.5 RDW-15.5 Plt Ct-161
Brief Hospital Course:
Mr. [**Known lastname 76677**] was transferred from a referring hospital with a
grade III splenic laceration. He was directly admitted to the
ICU. His hematocrit on arrival was 23.1. He was tranfused with
2 units of packed RBCs. He was given no anti-coagulation. His
post-transfusion hematocrit was stable in the range of
26.9-29.7. After 2 nights in the ICU, he was transferred to the
floor in good condition and started on a clear liquid diet. He
was slowly advanced to a regular diet which he tolerated. His
pain was well controlled on oral percocet. He was noted to have
splenic vein thrombosis secondary to his pancreatitis. A
vascular surgery consult was obtained to evaluate for timing of
a splenic artery embolization. He was given Pneumococcus, H.
flu, and N. meningitidis vaccines on [**4-6**]. Dr.[**Name (NI) 7446**]
office will schedule his splenic artery embolization next week.
He is discharged in good condition.
Medications on Admission:
famotidine, viokase, tricor, fentanyl TD, glipizide, percocet
Discharge Medications:
famotidine, viokase, tricor, fentanyl TD, glipizide, percocet
Discharge Disposition:
Home
Discharge Diagnosis:
Chronic alcoholic pancreatitis
Pancreatic pseudocyst
Splenic laceration
Splenic vein thrombosis
Discharge Condition:
Good
Discharge Instructions:
Call your physician or return to the Emergency Department if you
experience:
- fever > 101.5
- chills
- increasing abdominal pain not relieved by your medication
- inability to eat or drink
- persistent nausea or vomiting
- if your have signs of bleeding: feeling lightheaded/faint,
rapid heart rate greater than 100 beats per minute
You will be given percocet for pain. Resume all of your home
medications.
Followup Instructions:
Dr.[**Name (NI) 7446**] office (Vascular surgeon) will call you and
arrange for you to have your splenic artery embolized. If you
do not hear from them by Friday, call his office at ([**Telephone/Fax (1) 18152**] to schedule your operation.
Follow up with Dr. [**Last Name (STitle) **] in [**3-17**] weeks. Call his office at
([**Telephone/Fax (1) 2363**] to schedule your appointment.
|
[
"285.9",
"289.59",
"577.2",
"E885.9",
"401.9",
"250.00",
"452",
"865.03",
"577.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
2969, 2975
|
1829, 2771
|
287, 294
|
3115, 3122
|
1267, 1806
|
3580, 3972
|
1060, 1078
|
2883, 2946
|
2996, 3094
|
2797, 2860
|
3146, 3557
|
1093, 1093
|
1107, 1248
|
229, 249
|
322, 621
|
643, 845
|
861, 1044
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,129
| 181,231
|
41642
|
Discharge summary
|
report
|
Admission Date: [**2156-11-23**] Discharge Date: [**2156-11-27**]
Date of Birth: [**2088-7-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2156-11-23**] Coronary artery bypass grafting x2, with the left
internal mammary artery to the left anterior descending coronary
artery and reversed saphenous vein single graft from the aorta
to the posterior descending coronary artery
History of Present Illness:
68 year old gentleman with known coronary artery disease who was
experiencing exertional chest pain over the past several months.
A cardiac catheterization was performed [**2156-10-12**] which revealed
severe in stent restenosis and two vessel coronary disease.
Given the progression of his disease and aggressive instent
restenosis that has occurred, he has now been referred for
surgical revascularization.
Past Medical History:
- Coronary artery disease (Multiple stents and angioplasty in
past - see below)
- Non-insulin dependent diabetes mellitus
- Hyperlipidemia
- Hypertension
- Erectile dysfunction
- Obesity
Past Surgical History:
- s/p Supraglottic laryngectomy [**2133**] - Squamous cell cancer
- s/p Appendectomy
Past Cardiac Procedures:
- Stent RCA [**2147-4-19**]
- Restenosis RCA [**7-21**] s/p brachytherapy and stent.
- Cypher DES in RCA10/11/04
- Cypher DES to mid RCA secondary to restenosis [**2151-4-23**]
- Cypher stent to mid/distal LAD
- S/P PTCI of RCA and PROMUS stent to proximal and distal RCA
[**2153**]
Social History:
Race: Caucasian
Last Dental Exam: 2 months ago
Lives with: Wife
Contact: Phone #
Occupation: Attorney
Cigarettes: Smoked no [] yes [X] Hx: Smoked for approx 25 yrs.
Quit in [**2133**].
ETOH: < 1 drink/week [] [**1-26**] drinks/week [X] >8 drinks/week [X] 2
glasses of wine/day
Illicit drug use: Denies
Family History:
+Premature coronary artery disease
GM(mother side) MI @62, GM(father side) died from MI in 40's,
Brother with MI @48
Physical Exam:
Pulse: 74 Resp: 18 O2 sat: 100%
B/P Right: 120/78 Left: 121/81
Height: 5'7" Weight: 223 lbs
General: Well-developed obsese male in no acute distress
Skin: Dry [X] intact [X] healed incision on upper abd from mole
excision. Healed scars on b/l palms from burn injury as infant.
HEENT: PERRLA [X] EOMI [X] Raspy voice secondary to laryngeal
surgery
Neck: Supple [X] Full ROM [X] multiple healed incisions on neck
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur [] grade ______
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema -
Varicosities: None [X] superficial
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Discharge Exam:
VS; T: 98.9 HR: 84 SR BP: 97/60 Sats: 99% RA
General: 68 year-old male in no apparent distress
HEENT: normocephalic, weak voice at baseline
Card: RRR normal S1,S2 no murmur
Resp: decreased breath sounds otherwise clear
GI: obese, abdomen soft non-tender
Extr:warm 1+ edema
Incision: sternal and LLE clean dry intact
Neuro: awake, alert oriented
Pertinent Results:
[**2156-11-23**] Echo: PRE-CPB:1. The left atrium is normal in size. No
spontaneous echo contrast is seen in the left atrial appendage.
No thrombus is seen in the left atrial appendage. 2. No atrial
septal defect is seen by 2D or color Doppler. There is a
lipomatous intraatrial septum (normal varient)
3. Left ventricular wall thicknesses and cavity size are normal.
4. Right ventricular chamber size and free wall motion are
normal. 5. The ascending, transverse and descending thoracic
aorta are normal in diameter and free of atherosclerotic plaque.
There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. 6. There are three
aortic valve leaflets. There is no aortic valve stenosis. No
aortic regurgitation is seen. 7. The mitral valve appears
structurally normal with trivial mitral regurgitation. Dr.
[**Last Name (STitle) 914**] was notified in person of the results.
POST-CPB: On infusion of phenylephrine. A pacing for slow sinus
with first degree AV block. Preserved biventricular systolic
function with LVEF = 65%. MR is 1+. The aortic contour is normal
post decannulation.
CXR: [**2156-11-26**]:
Lateral view shows a small layering right pleural effusion and a
retrosternal air and fluid collection which would not be visible
on prior frontal bedside films and are probably not clinically
significant as this is early after surgery. The heart size is
top normal, increased slightly since the earlier postoperative
studies, but the pulmonary vasculature is normal and there is no
edema. Subsegmental atelectasis at the right lung base is also
unlikely to be of any clinical significance.
[**2156-11-27**] WBC-10.5 RBC-3.26* Hgb-10.3* Hct-30.3* MCV-93 MCH-31.6
MCHC-34.0 RDW-12.7 Plt Ct-262
[**2156-11-23**] WBC-19.3*# RBC-3.78* Hgb-11.5* Hct-34.9* MCV-92
MCH-30.6 MCHC-33.1 RDW-12.4 Plt Ct-216
[**2156-11-27**] Glucose-128* UreaN-17 Creat-0.8 Na-135 K-4.6 Cl-97
HCO3-30
[**2156-11-23**] UreaN-17 Creat-0.9 Na-136 K-4.2 Cl-108 HCO3-25 AnGap-7*
[**2156-11-27**] Mg-2.3
Brief Hospital Course:
Mr. [**Known lastname **] was a same day admit after undergoing pre-operative
work-up as an outpatient. On [**11-23**] he was brought to the
operating room where he underwent a coronary artery bypass graft
x 2. Please see operative report for surgical details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. Later this day he was weaned from sedation,
awoke neurologically intact and extubated. On post-op day one he
was started on beta-blocker and diuretics and diuresed towards
his pre-op weight. Later this day he was transferred to the
step-down unit for further recovery. Chest tubes and epicardial
pacing wires were removed per protocol. He worked with physical
therapy for strength and mobility. He continued to make good
progress with no setbacks and was discharged home [**2156-11-27**].
Medications on Admission:
Aspirin 325mg daily
Plavix 75mg daily
Toprol XL 50mg daily
Viagra 50mg prn
Lisinopril 40mg daily
Zocor 40mg daily
Famotidine 20mg daily
Metformin ER 500mg twice daily
Folic acid daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
8. metformin 500 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO twice a day.
Disp:*60 Tablet Extended Rel 24 hr(s)* Refills:*2*
9. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO twice a day.
Disp:*60 Tablet Extended Release 24 hr(s)* Refills:*2*
10. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*10 Tablet(s)* Refills:*1*
11. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO once a day for 10 days.
Disp:*10 Tablet Extended Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 2
Past medical history:
- s/p Multiple stents and angioplasty
- Non-insulin dependent diabetes mellitus
- Hyperlipidemia
- Hypertension
- Erectile dysfunction
- Obesity
- s/p Supraglottic laryngectomy [**2133**] - Squamous cell cancer
- s/p Appendectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Provider: [**Name10 (NameIs) **] CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2156-12-7**]
10:00
Location: [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Surgeon: Dr. [**Last Name (STitle) 914**] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2156-12-27**] 1:45
Location: [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Cardiologist: Needs referral
Please call to schedule appointments with your
Primary Care physician once you are established 4-5 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2156-11-27**]
|
[
"413.9",
"414.01",
"401.9",
"V17.3",
"272.4",
"V45.82",
"V10.21",
"V15.82",
"250.00",
"278.00",
"784.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7797, 7855
|
5393, 6239
|
321, 561
|
8211, 8419
|
3340, 5370
|
9342, 10150
|
1981, 2100
|
6473, 7774
|
7876, 7937
|
6265, 6450
|
8443, 9319
|
1231, 1625
|
2115, 2957
|
2973, 3321
|
271, 283
|
589, 999
|
7959, 8190
|
1641, 1965
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,387
| 128,679
|
50579
|
Discharge summary
|
report
|
Admission Date: [**2144-10-4**] Discharge Date: [**2144-10-5**]
Date of Birth: [**2083-9-30**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 61-year-old female
with insulin dependent-diabetes mellitus, hypertension,
obesity, and porcine AVR placed [**10/2141**], who is transferred to
[**Hospital1 69**] from [**Hospital1 **] with a
variceal bleed for urgent TIPS procedure. The patient was
admitted to outside hospital on [**10-2**] complaining of
lightheadedness, dry heaves, black stools x2 days. She was
initially managed on the floor, but then transferred to the
ICU at outside hospital after gross hematemesis. Her
hematocrit was 23.4 on admission, on [**8-20**] it was 39.5.
Over the following two days at the outside hospital, she
received 7 units of red cells and hematocrit increased to 34.
She was scoped at the outside hospital and was found to have
gastric varices at the gastroesophageal junction, which they
were unable to band. On day of transfer to [**Hospital3 **], the
patient had runs of NSVT without chest pain. She is noted to
current jelly stools and bright red blood through her
nasogastric tube. Her blood pressures dropped and patient
was transfused multiple units of packed red blood cells and
started on Neo and Vaso. She also received vitamin K for an
elevated INR. She is intubated outside hospital for airway
protection. On transfer, the patient's blood pressures were
110/70, hematocrit 26.4. She was actively bleeding from the
rectum. On transfer, she immediately began getting packed
cells, FFP, platelets, and fluids. Blood pressures were
stable.
Patient also had an ultrasound which also did not demonstrate
a patent portal vein secondary to body habitus, and therefore
I wanted to wait on her procedure. She had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] tube
placed by GI. Position was confirmed by chest x-ray. She
was to go to CTA to evaluate portal vein.
PAST MEDICAL HISTORY:
1. Insulin dependent-diabetes mellitus.
2. Hypertension.
3. AVR [**10/2141**] (porcine).
4. Obesity.
5. GERD.
6. Chronic lower extremity rash x7 years.
7. Fibromyalgia.
8. Mental illness.
ALLERGIES: Betadine.
ON TRANSFER MEDICATIONS:
1. Ativan.
2. Protonix 40 IV q.d.
3. RISS.
4. Vasopressin.
5. Lopressor.
6. Lasix.
7. Neo-Synephrine.
8. Propofol.
SOCIAL HISTORY: The patient lives in public housing. She is
widowed and has several children. Never smoker and never
drinker per report.
FAMILY HISTORY: Positive for CAD.
PHYSICAL EXAMINATION: Afebrile, blood pressure 119/68, heart
rate 90, respirations 15, and O2 100%. The patient was on AC
600/15, FIO2 of 70%, PEEP of 5. Obese pale female, not
jaundiced. Pupils are equal, round, and reactive to light.
Neck is obese and supple. Heart: Regular, rate, and rhythm,
S1, S2, 2/6 systolic murmur left upper sternal border.
Coarse breath sounds bilaterally, distended firm abdomen.
Positive bowel sounds, fresh blood and clots on her bed.
Dark maroon in color, 2+ pitting edema to the knees.
Hematocrit on arrival 26.4, INR of 2.3, ionized calcium 0.7.
HOSPITAL COURSE:
1. GI bleed: After the [**Last Name (un) **] tube was placed and
confirmed to be in good position, the patient had a CTA which
demonstrated only very small left portal vein and her other
branches were not visualized. When the patient returned from
her CTA, she had a rebleed from both above and below. Blood
pressure dropped and patient remained on Neo and Vaso. Her
heart rate also began to drop to the 40s, and she became
hypotensive 60s/40s. A code was called at approximately 2
a.m. and Epinephrine and atropine were given with good
response in heart rate. Patient received greater than 10
units of PRBCs as well as platelets, FFP, and IV fluids. A
Cordis was placed for better fluid resuscitation. Patient
was also started on dopo, which subsequently was weaned off.
The IR team and Anesthesia was called for an urgent TIPS,
however, due to patient's worsening pulmonary status on the
ventilator due to the aggressive fluid resuscitation as well
as persistent hypotension, the family decided to treat for
comfort only. Patient died morning following admission.
Patient passed away at 08/18 at 9 a.m. Family was present
and decided not to request an autopsy.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**Last Name (NamePattern1) 8141**]
MEDQUIST36
D: [**2145-1-12**] 14:22
T: [**2145-1-13**] 07:32
JOB#: [**Job Number 105289**]
|
[
"276.2",
"571.5",
"570",
"452",
"280.0",
"518.81",
"785.59",
"578.0",
"456.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.06",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
2492, 2511
|
3116, 4540
|
2534, 3099
|
2218, 2334
|
156, 1959
|
1981, 2196
|
2351, 2475
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,012
| 122,132
|
28626
|
Discharge summary
|
report
|
Admission Date: [**2112-9-19**] Discharge Date: [**2112-9-23**]
Date of Birth: [**2043-2-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Cefaclor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Progressive chest pain with exertion
Major Surgical or Invasive Procedure:
CABG X 3 (LIMA > LAD, SVG>OM, SVG>PDA) on [**2112-9-19**]
History of Present Illness:
This 69 year old man has a history of CAD and diabetes. The
patient and his wife report that approximately ten years ago he
underwent cardiac catheterization at [**Hospital 1474**] hospital for
complaints of chest pain where he was found to have CAD (see
below). He was managed conservatively and has been on medication
over the past ten years. Although a cath report from [**Hospital 1474**]
hospital mentions that the patient has undergone prior
angioplasty, the patient and wife state that this is inaccurate.
He has not had follow up with a cardiologist in over 10 years
and
has not undergone stress testing since his initial diagnosis of
CAD.
The patient reports that after starting medication ten years
ago,
his symptoms improved significantly. Over the past 6-8 months,
his chest discomfort has increased in frequency.
Presently, he has daily episodes of chest pain. His discomfort
is
felt in the middle of the chest and occurs at rest but also with
exertion. Often these symptoms occur in the middle of the night
after coming back from the bathroom. He will find that he must
sit on the side of the bed for 10-15 minutes before they will
resolve spontaneously. He has not used nitroglycerin but has
taken Gaviscon on occasion with relief. Over the past several
weeks, his chest discomfort has been accompanied by nausea and
dry heaves. He denies shortness of breath, increased fatigue, or
diaphoresis. His primary care provider had been treating him
with Nexium which
the patient reports has been ineffective. He recently saw a
gastroenterologist who referred him to cardiology. EKG has been
notable for lateral ST depression. He was referred for cardiac
catheterization which revealed 3VD. He is now preop for CABG.
Past Medical History:
Hypercholesterolemia
HTN
CAD
Diabetes
Hyperlipidemia
Appendectomy
? GERD
Hiatal hernia
Alcohol abuse
Social History:
Heavy tobacco use. >100pack year history and continues to smoke
1 pack every 4 days.
+ ETOH (6-8 beers per day)
Social History: Patient is married with three adult daughters.
[**Name (NI) **]
is retired. His wife and daughter will accompany him to the
procedure. His wife can be reached by cell phone at
[**Telephone/Fax (1) 69266**].
Family History:
Family History: Brother with CABG in his 60's.
Physical Exam:
62 SR 116/67 95% RA
GEN: NAD
HEART: RRR, No murmur
LUNGS: diminished BS bilaterally
ABD: Benign
EXT: 2+ pulses throughout. Warm, no varicosities
NEURO: Nonfocal.
Pertinent Results:
[**2112-9-22**] 06:30AM BLOOD Hct-27.5*
[**2112-9-21**] 06:20AM BLOOD WBC-13.1* RBC-3.44* Hgb-10.3* Hct-29.8*
MCV-87 MCH-30.0 MCHC-34.6 RDW-13.6 Plt Ct-229
[**2112-9-21**] 06:20AM BLOOD Plt Ct-229
[**2112-9-19**] ECHO
PRE-BYPASS:
The left atrium is mildly dilated. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. There is mild symmetric left ventricular hypertrophy
with normal cavity size and systolic function (LVEF>55%).
Resting regional wall motion abnormalities include apical
hypokinesis. Right ventricular chamber size and free wall motion
are normal. There are complex (>4mm) atheroma in the descending
thoracic aorta. 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. Trivial mitral regurgitation is seen. There is no
pericardial effusion.
POST_BYPASS:
Preserved biventricular systolic function. Overall LVEF 55%
Aortic contour is intact Trace MR,TR and PI
[**2112-9-20**] CXR:
1. New very small left apical pneumothorax following chest tube
removal.
2. Slight worsening of basilar atelectasis and new small
effusions.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on 828/06 for surgical
management of his coronary artery disease. He was taken directly
to the operating room where he underwent coronary artery bypass
grafting to three vessels. Postoperatively he was taken to the
cardiac intensive care unit for monitoring. By postoperative day
one, Mr. [**Known lastname **] had awoke neurologically intact and was
extubated. Wires and drains were removed per protocol. He was
then transferred to the step down unit for further recovery. Mr.
[**Known lastname **] was gently diuresed towards his preoperative weight. The
Physical therapy service was consulted for assistance for his
postoperative strength and mobility. Beta blockade, aspirin,
plavix and a statin were resumed. Mr. [**Known lastname **] continued to make
steady progress and was discharged home on postoperative day
four. He will follow-up with Dr. [**Last Name (STitle) **], his cardiologist and
his primary care physician as an outpatient.
Medications on Admission:
Admission Medications:
Lipitor 20mg daily every morning
Isosorbide 20mg three times a day
Atenolol 50mg once daily every morning
Glyburide 10mg twice a day (held [**2112-9-8**])
Norvasc 10mg daily every morning
Nexium 40mg twice a day
Aspirin 81mg daily every morning
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
2. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO twice
a day for 7 days.
Disp:*14 Packet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
10. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
CAD
DM
GERD
Discharge Condition:
good
Discharge Instructions:
may shower, no bathing or swimming for 1 month
no creams, lotions or powders to any incisions
no lifting > 10# for 10 weeks
Followup Instructions:
with Dr. [**Last Name (STitle) **] in 4 weeks
with Dr. [**Last Name (STitle) **] in [**2-26**] weeks
with Dr. [**Last Name (STitle) **] in [**2-26**] weeks
Completed by:[**2112-9-30**]
|
[
"401.9",
"553.3",
"512.1",
"E849.7",
"305.00",
"272.0",
"E878.2",
"250.00",
"414.01",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6758, 6813
|
4211, 5222
|
312, 372
|
6869, 6876
|
2870, 4188
|
7048, 7235
|
2639, 2672
|
5541, 6735
|
6834, 6848
|
5248, 5248
|
6900, 7025
|
5271, 5518
|
2687, 2851
|
236, 274
|
400, 2130
|
2152, 2254
|
2398, 2607
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,058
| 157,633
|
1874
|
Discharge summary
|
report
|
Admission Date: [**2187-12-12**] Discharge Date: [**2187-12-19**]
Date of Birth: [**2116-2-26**] Sex: M
Service:
CHIEF COMPLAINT: Carcinoma of the colon.
HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old
male admitted for elective transverse colectomy for carcinoma
of the colon which was diagnosed after recent colonoscopy
done for heme positive stool.
PAST MEDICAL HISTORY: 1. Coronary artery disease status
post myocardial infarction in [**2177**] and [**2180**]. Status post LV
aneurysm repair. 2. History of
ventricular tachycardia status post ICD placement. 3.
Hypertension. 4. Hypercholesterolemia. 5. Congestive
heart failure with an ejection fraction of 17% and mild
mitral regurgitation. 6. Status post polypectomy of the
colon. 7. Status post transurethral resection of prostate.
8. Chronic obstructive pulmonary disease. 9. Gout. 10.
Chronic renal insufficiency.
PAST SURGICAL HISTORY: 1. Status post coronary artery
bypass grafting in [**2180**]. 2. Status post ICD placement. 3.
Status post polypectomy of the colon. 4. Status post
transurethral resection of prostate.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
MEDICATIONS ON ADMISSION: Lasix 160 mg b.i.d., Amiodarone
200 mg q.d., KCl 20 mEq t.i.d., Lovastatin 40 mg q.d.,
Zaroxolyn 25 mg Monday, Wednesday, and Friday, Allopurinol
200 mg q.d.
HOSPITAL COURSE: The patient underwent transverse colectomy
by Dr. [**Last Name (STitle) **] on [**2187-12-12**]. His intraoperative
course was unremarkable. He was admitted to the Intensive
Care Unit postoperatively for close management because of his
cardiac status. He did relatively well there and was
transferred to the floor after a couple of days. From
thereon, his postoperative course was routine, and he was
started on p.o., and his bowel function returned. He is now
tolerating a regular diet and is being discharged to
rehabilitation.
DISCHARGE MEDICATIONS: Percocet [**11-28**] tab p.o. q.4-6 hours
p.r.n., all preoperative medications.
FOLLOW-UP: With Dr. [**Last Name (STitle) **] in the clinic.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Awaiting discharge to rehabilitation.
DISCHARGE DIAGNOSIS: Carcinoma of colon status post
transverse colectomy.
[**Name6 (MD) 843**] [**Name8 (MD) 844**], M.D. [**MD Number(1) 845**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2187-12-19**] 09:51
T: [**2187-12-19**] 09:50
JOB#: [**Job Number 10461**]
|
[
"496",
"593.9",
"414.00",
"401.9",
"211.3",
"560.89",
"568.0",
"424.0",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.59",
"45.74"
] |
icd9pcs
|
[
[
[]
]
] |
1943, 2087
|
2201, 2507
|
1206, 1365
|
1383, 1919
|
949, 1179
|
151, 176
|
205, 385
|
408, 925
|
2112, 2179
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,313
| 177,158
|
24079
|
Discharge summary
|
report
|
Admission Date: [**2169-4-7**] Discharge Date: [**2169-4-21**]
Date of Birth: [**2125-7-22**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / ciprofloxacin / Percocet / clindamycin /
Levofloxacin / Sulfa(Sulfonamide Antibiotics) / meropenem /
Allopurinol
Attending:[**First Name3 (LF) 3967**]
Chief Complaint:
blasts on peripheral smear
Major Surgical or Invasive Procedure:
Bronchoscopy with BAL - no immediate complications
History of Present Illness:
43 yo F with SLE, ESRD on HD MWF, thyroid cancer, GERD and HTN
who is referred to the ED after blood work showed a white count
of 30k with 22% blasts and smear consistent with acute leukemia.
.
Patient reports two weeks ago labs showed low platelets. Repeat
labs on [**2169-4-3**] with worsening thrombocytopenia and elevated
wbc's with 70% blasts. Patient referred to Dr. [**First Name (STitle) 4223**] of
[**Location (un) **] who obtained labs today which showed WBC 32.5, Hb 8.7,
PLT 31, 22% blasts and smear consistent with acute leukemia.
Dr. [**First Name (STitle) 4223**] sent patient to [**Hospital1 18**].
.
Patient has no complaints and has been feeling well. She does
note easy bruisability. Patient denies any cough, shortness of
breath or chest pain. No abdominal pain or headache. No recent
fever however was febrile in the ED to 101.2. Denies any
nausea, vomiting or diarrhea. Patient was dialyzed today. Of
note patient received 1gm of vancomycin on [**2169-3-31**], [**2169-4-3**] and
[**2169-4-5**] due to a small abrasion on her left foot.
.
ED: 101.2 104 142/75 16 98%RA; oxycodone 5mg, ativan 1mg,
allopurinol 100mg; heme consulted and performed bone marrow bx
.
ROS: as per HPI, 10 pt ROS otherwise negative
Past Medical History:
SLE in remission
ESRD on HD (M/W/F) with AVF on chronic AC
THYROID CANCER s/p total thyroidectomy
GERD
HTN
anxiety
Chronic LBP
RLS
Social History:
Lives alone; sister, [**Name (NI) 21457**] and brother-in-law live next door.
On disability. Quit tobacco 12 years ago. Rare etoh. No
illicits.
Family History:
No fhx of leukemia. Mother with ovarian cancer. Father with
renal cancer.
Physical Exam:
Admission Physical Exam:
VS: 99 130/96 63 15 97%RA
Appearance: alert, NAD, tearful
Eyes: eomi, perrl, anicteric
ENT: OP clear s lesions, mmm, no JVD, neck supple
Cv: +s1, s2 -m/r/g, no peripheral edema, 2+ dp/pt bilaterally
Pulm: clear bilaterally
Abd: soft, nt, nd, +bs
Msk: 5/5 strength throughout, no joint swelling, no cyanosis or
clubbing
Neuro: cn 2-12 grossly intact, no focal deficits
Skin: no rashes, left forearm fistula with palpable thrill, left
heel with healing abrasion
Psych: appropriate, pleasant
Heme: no cervical [**Doctor First Name **]
Pertinent Results:
[**2169-4-7**] 08:15PM PLT SMR-VERY LOW PLT COUNT-37*
[**2169-4-7**] 08:15PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-2+ MICROCYT-1+ POLYCHROM-1+ OVALOCYT-1+ BURR-1+
TEARDROP-OCCASIONAL
[**2169-4-7**] 08:15PM NEUTS-1* BANDS-0 LYMPHS-7* MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 OTHER-92*
[**2169-4-7**] 08:15PM WBC-42.3* RBC-2.82* HGB-9.3* HCT-28.9*
MCV-103* MCH-32.8* MCHC-32.0 RDW-22.5*
[**2169-4-7**] 08:15PM HAPTOGLOB-133
[**2169-4-7**] 08:15PM CALCIUM-8.5 PHOSPHATE-2.0* MAGNESIUM-1.8 URIC
ACID-2.9
[**2169-4-7**] 08:15PM ALT(SGPT)-15 AST(SGOT)-29 LD(LDH)-362* ALK
PHOS-77 TOT BILI-0.4
[**2169-4-7**] 08:15PM estGFR-Using this
[**2169-4-7**] 08:15PM GLUCOSE-109* UREA N-14 CREAT-5.2* SODIUM-136
POTASSIUM-4.1 CHLORIDE-92* TOTAL CO2-38* ANION GAP-10
[**2169-4-7**] 08:45PM LACTATE-1.3
[**2169-4-7**] 09:13PM FIBRINOGE-346
[**2169-4-7**] 09:13PM PT-20.3* PTT-32.0 INR(PT)-1.9*
.
[**2169-4-7**] OSH Labs:
.
32.5> 8.7/27.3 <31 22% blasts
.
[**2169-4-3**] OSH Labs:
.
26> 9.7/28.7 <44 70% blasts
.
[**2169-3-6**] OSH Labs:
.
5.37> 11/33 <73
.
[**2169-4-7**] Pa/Lat CXR: No acute cardiopulmonary process.
.
[**2169-4-9**] CT abdomen/pelvis:
1. Nodular opacities in the left lower lung with additional
small
ground-glass opacities bilaterally may represent infection.
Chest CT
recommended for further assessment given infectious symptoms.
2. Abdominal wall varices of indeterminate etiology.
3. Splenomegaly.
4. Coronary artery calcification
.
[**2169-4-9**] CT chest without contrast:
1. Left upper lung parenchymal consolidation likely pneumonia.
2. Multiple ground-glass and mixed solid and ground-glass
opacities in
bilateral lungs may be infectious in etiology although the
differential
includes neoplasm. A short-term (<3 month) repeat chest CT
should be
performed post-treatment to document resolution.
2. Extensive coronary artery calcifications
3. Mediastinal lymph nodes may be reactive.
4. Right subpectoral node. Recommend correlation with mammogram.
5. Small bilateral pleural effusions with adjacent compressive
atelectasis.
6. Chest wall collateral vessels. Coarse calcification in the
SVC could
relate to chronic thrombus.
Brief Hospital Course:
43 yo F with SLE, ESRD on HD MWF, thyroid cancer, GERD and HTN,
admitted with gram negative sepsis and acute leukemia, found to
have AML. Hospital Course complicated by Tumor Lysis Syndrome,
Febrile Neutropenia with Enterobacter Bacteremia, mucositis,
delirium, agitation. With the patient clearly declining despite
best efforts at recovery, the patient was made CMO by her
healthcare proxy. The patient expired on [**2169-4-21**].
#Acute myeloid leukemia: Patient with rapidly rising WBC count
on admission despite therapy with hydrea. She underwent CT
chest that showed hilar and pretracheal lymphadenopathy, likely
consistent with leukemia, although possibly related to
infection. Labs consistent with early tumor lysis syndrome.
The patient was started on daily dialysis for tumor lysis
syndrome. Given tumor lysis syndrome prior to initiation of
chemotherapy, she was transferred to the ICU for leukophoresis
to decrease WBC count burden prior to initiating chemotherapy.
WBC count decreased from 78 to 28 with leukophoresis, and the
patient became more awake with decreased peripheral cyanosis.
She was initiated on 7+3 and was transitioned back to the BMT
floor. On the floor, she completed 7+3, the patient's course
was complicated by gram negative bacteremia, mucositis and
delirium and agitation. S/p chemotherapeutic regimen, patient
still had a significant number of blasts in peripheral blood,
signifying a very poor prognosis.
# Mucositis: significant mucositis, requiring patient to be NPO,
placed on TPN, and oral medications to be switched to IV
medications. Also with e/o stridor, likely from mucosal
sloughing, crusting and bleeding. ENT consulted on pt and did
endoscopy of pharynx, confirming structural defect. Dilaudid
PCA was initiated for symptomatic relief.
# Agitation / delirium: On approximately hospital day #12,
patient had significant agitation and delirium, likely secondary
to difficulty in achieving equilibrium with new IV medications,
in the setting of severe mucositis. The patient was treated
with dilaudid, clonazepam and ativan.
#Neutropenic fever: Patient febrile on admission to 101.7. On
admission, she was found to have gram negative bacteremia with
enterobacter cloacae. She also had ground glass opacities on
CT. Patient with hypoxia and mild hypotension (to SBP 92 from
130s), concerning for developing sepsis. She was placed on
vancomycin and meropenem on admission. She was then broadened
to posaconazole to cover for possible pulmonary fungal
infection. She underwent bronchoscopy with BAL to further
evaluate her ground glass opacities. 4 days into admission, the
patient developed a firey-erythematous blanching rash on her
back, that spread to cover her trunk and proximal thighs.
Antibiotics were changed to daptomycin, aztreonam, and ambisome
out of concern for drug rash. The rash gradually improved.
#ESRD on HD MWF: Followed by renal throughout admission.
Patient with chronic left arm fistula, on coumadin at home for
fistula thrombosis prevention - this was discontinued on
admission for impending chemotheraphy-related coagulopathy. On
admission, the patient was dialyzed on her regular MWF schedule.
With increasing tumor burden, she experienced tumor lysis
syndrome with hyperkalemia to 6.7, and received 2 extra sessions
of dialysis for electrolyte correction. She was continued on
home renagel. She was started on allopurinol on admission.
However, it was discontinued, as it likely caused LFT elevations
and may have been responsible for the patient's rash.
# Transaminitis: The patient developed worsening transaminits
on admission, attributed to drug effect in the setting of
initiation chemotherapy and allopurinol. The patient had no
right upper quadrant pain, and right upper quadrant ultrasound
was negative for obstruction. Allopurinol was discontinued, and
transaminitis improved, making it the likely culprit of her
laboratory abnormalities.
# Rash: Early in admission, the patient developed a fiery-red
blanching rash on her back that spread to the remainder of her
torso and proximal thighs. Antibiotics were switched as above,
and allopurinol was discontinued. The patient was evaluated by
dermatology who felt the rash was likely a drug rash from
meropenem or allopurinol. Slowly, the rash improved.
Dermatology was consulted to assist in her care.
#HTN: Patient with a history of hypertension on labetalol. The
patient became borderline hypotensive on admission, and
labetalol was held.
#Chronic LBP: On oxycontin, oxycodone, and neurontin at home.
#Hypothyroidism: Chronic. The patient was continued on home
synthroid.
#GERD: chronic. The patient was continued on home omeprazole.
#RLS: Chronic. The patient was continued on home requip.
#Anxiety: Patient with chronic anxiety, worsened acutely in the
setting of new diagnosis. On home clonazepam. Transitioned to
ativan on admission, given potential for nausea with chemo. She
was followed by social work for coping.
Medications on Admission:
Coumadin 2.5 mg alternating with 5mg daily
Levothyroxine 0.125 mg 1 tab daily -> PLEASE CLARIFY DOSE IN AM
OxyContin CR 10 mg [**Hospital1 **]
oxycodone 5 mg PRN
Requip 1mg qhs
Neurontin 300 mg qhs
Ativan 2 mg 1 tab [**Hospital1 **] prn
Renagel 800 mg 3 tab tid
Klonopin 1 mg [**Hospital1 **]
pravastatin 40 mg daily - d/c'ed 2 weeks ago due to low
platelets
Omeprazole 20mg daily
Labetalol 2 tabs qhs - PLEASE CLARIFY DOSE IN AM
Lidoderm patch prn
Discharge Disposition:
Expired
Discharge Diagnosis:
primary cause of death: cardiorespiratory failure
secondary causes of death: AML, ESRD, delirium, lupus
Discharge Condition:
expired
[**Name6 (MD) **] [**Last Name (NamePattern4) 3974**] MD, [**MD Number(3) 3975**]
|
[
"995.91",
"724.2",
"710.0",
"530.81",
"582.81",
"300.00",
"348.30",
"693.0",
"403.91",
"277.88",
"287.5",
"611.72",
"205.00",
"333.94",
"585.6",
"276.7",
"528.01",
"285.22",
"038.49",
"E944.7",
"780.61",
"V49.86",
"482.9",
"041.85",
"V10.87",
"244.0",
"288.00",
"790.4",
"790.7",
"338.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"99.25",
"38.97",
"99.72",
"29.11",
"33.24",
"41.31",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
10461, 10470
|
4950, 9961
|
413, 466
|
10618, 10739
|
2750, 4927
|
2073, 2150
|
10491, 10597
|
9987, 10438
|
2190, 2731
|
347, 375
|
494, 1738
|
1760, 1893
|
1909, 2057
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,841
| 167,440
|
14117
|
Discharge summary
|
report
|
Admission Date: [**2149-5-22**] Discharge Date: [**2149-5-27**]
Date of Birth: [**2077-11-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
Lung cancer with malignant airway obstruction of right upper
lobe and right bronchus intermedius.
Major Surgical or Invasive Procedure:
[**2149-5-23**] 1. Rigid bronchoscopy using the black Dumon rigid
bronchoscope.
2. Flexible bronchoscopy.
3. Transbronchial needle aspiration of mediastinal lymph
node #7 (blind).
1. Mechanical and cryoprobe-assisted tumor debridement in
the right bronchus intermedius.
2. Balloon dilatation of the right bronchus intermedius up
to 12 mm.
3. Deployment of a 12 x 20 mm metallic stent in the
bronchus intermedius.
History of Present Illness:
The patient is a 71 yo F w/a perported history of smoking who is
being transferred from [**Hospital3 **] for a right hilar mass
that is obstructing the right [**Hospital1 **]. A few weeks prior to
admission, per report, the patient developed increased
SOB/wheezing/cough, was treated with augmentin for presumed CAP
without relief. Per report, the patient also c/o weight loss,
fatigue, decreased appetite. Given the lack of symptom
improvement, she went to [**Hospital **] Hosp on [**5-20**] and was admitted
there after CXR in the ED revealed R hilar mass. CT chest
w/contrast confirmed the presence of a 5.5 x 6.5 cm mass in the
right hilum obstructing the right [**Hospital1 **] and extending into the
right upper lobe, subcarinal adenopathy, subcentimeter axillary
nodes, and parenchymal changes within the superior segment of
the RLL concerning for either inflammatory of lympahngitic
spread of tumor.
The patient at [**Hospital1 **] was taken for bronchoscopy, that revealed
near complete obstruction of the right [**Hospital1 **] with a large tumor,
and mild-moderate obstruction of the RUL bronchus; multiple bx
taken from the right [**Hospital1 **] tumor with minimal bleeding controlled
by 10 mL of 1/10K lido/epi. The patient was kept intubated for
concern with respiratory and possibly hemodynamic instability;
then
transferred to [**Hospital1 18**] via MD/MD discussion.
Past Medical History:
DM, HTN, hyperlipidemia, COPD, asthma, anxiety d/o, depression,
CAD s/p stent to RCA [**2136**], hx epistaxis
Social History:
lives independently, has supportive daughter, + 30-35 pack year
history. Denies EtoH, drug use; apparently quit smoking 1 mo
PTA.
Family History:
non-contributory
Physical Exam:
VS: T: 98.4 HR: 71 SR BP: 119/66 Sats: 93% RA
General: sitting up no apparent distrss
HEENT: normocephalic, mucus membranes moist
Neck: supple
Card: RRR
Resp: audible wheezes, bilateal experitory > inspirtory wheezes
GI: benign
Extr:warm no edema
Neuro: non-focal
Pertinent Results:
[**2149-5-26**] WBC-7.1 RBC-4.23 Hgb-11.7* Hct-35.9* MCV-85 MCH-27.6
MCHC-32.5 RDW-14.7 Plt Ct-304
[**2149-5-25**] WBC-5.9 RBC-3.97* Hgb-11.5* Hct-33.1* MCV-83 MCH-28.9
MCHC-34.7 RDW-15.0 Plt Ct-305
[**2149-5-22**] WBC-8.0 RBC-2.97* Hgb-7.9* Hct-24.2* MCV-82 MCH-26.7*
MCHC-32.7 RDW-15.4 Plt Ct-341
[**2149-5-26**] Neuts-89.3* Lymphs-9.7* Monos-1.0* Eos-0 Baso-0.1
[**2149-5-26**] Glucose-156* UreaN-31* Creat-1.0 Na-143 K-4.0 Cl-102
HCO3-28 AnGap-17
[**2149-5-22**] Glucose-143* UreaN-25* Creat-0.8 Na-142 K-4.3 Cl-106
HCO3-30 AnGap-10
[**2149-5-26**] Albumin-3.8 Calcium-9.5 Phos-4.1 Mg-1.9
CXR: [**2149-5-25**] Clearing of subsegmental atelectasis. Persistent
right hilar
enlargement.
[**2149-5-24**] Slight interval improvement in partial atelectasis in
the right
mid lung. Bronchial stent in place. Right hilar mass
redemonstrated
[**2149-5-22**] Intubated, no pneumothorax, right-sided hilar mass.
Brief Hospital Course:
Mrs. [**Known lastname 42058**] was transferred from [**Hospital3 2737**] intubated
for airway obstruction secondary to right hilar mass obstructing
the right bronchus intermedius.
She was taken to the operating room on [**2149-5-23**] for flexible,
rigid bronchoscopy with tumor debridement and metal stent
placement. She tolerated the procedure and was transferred back
to the SICU and extubated later that evening. Aggressive
pulmonary toilet, IV steroids, and nebulizers were continued for
COPD exacerbation. She was transfused with 2 units of PRBC for a
HCT of 23 to HCT 32. She remained in the SICU for respiratory
observation and on [**2149-5-25**] was transferred to the floor. The IV
antibiotics were continued. The foley was removed. She was
started on a diabetic diet. On [**2149-5-26**] the IV steroids were
converted to a PO wean. Inhalers increased. Her respiratory
status improved with RA oxygen saturation of 93-95%. She was
discharged to home on [**2149-5-27**] and will follow-up with her
oncologist and Dr. [**Last Name (STitle) **] as an outpatient.
Medications on Admission:
"albuterol nebs", atacand 32 daily, hctz 12.5 daily, coreg 3.125
[**12-27**]
tab HS, iron pills daily, metformin 500 twice daily, MV daily,
paxil 10 daily
crestor 15 daily, ambien 5 HS
Discharge Medications:
1. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Carvedilol 3.125 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
7. Rosuvastatin 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*1 * Refills:*2*
10. Prednisone 10 mg Tablet Sig: Six (6) Tablet PO tonight.
11. Prednisone 10 mg Tablet Sig: Four (4) Tablet PO twice a day
for 2 days.
12. Prednisone 10 mg Tablet Sig: Four (4) Tablet PO once a day
for 5 days.
13. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day
for 7 days.
14. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*62 Tablet(s)* Refills:*0*
15. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation twice a day.
Disp:*1 disk pak* Refills:*2*
16. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing: use spacer.
Disp:*1 inhaler* Refills:*3*
Discharge Disposition:
Home With Service
Facility:
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 2256**]
Discharge Diagnosis:
Central airway obstruction
Discharge Condition:
stable
Discharge Instructions:
Call Dr.[**Name (NI) 5070**] office [**Telephone/Fax (1) 7769**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, cough or sputum production
-Steroid taper as ordered
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in [**1-29**] weeks call for an appointment
[**Telephone/Fax (1) 7769**]
Follow-up with your oncologist
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
Completed by:[**2149-6-3**]
|
[
"250.00",
"414.01",
"196.1",
"162.2",
"300.4",
"V45.82",
"491.21",
"486",
"272.0",
"305.1",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.91",
"32.01",
"33.79",
"40.11"
] |
icd9pcs
|
[
[
[]
]
] |
6579, 6679
|
3827, 4908
|
420, 856
|
6750, 6759
|
2896, 3804
|
6996, 7287
|
2574, 2592
|
5144, 6556
|
6700, 6729
|
4934, 5121
|
6783, 6973
|
2607, 2877
|
282, 382
|
884, 2277
|
2299, 2410
|
2426, 2558
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
448
| 125,279
|
17203
|
Discharge summary
|
report
|
Admission Date: [**2136-4-25**] Discharge Date: [**2136-5-6**]
Date of Birth: [**2067-6-19**] Sex: M
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 68 year old
right handed man who, a couple of days prior to admission,
was [**Location (un) 1131**] a paper and developed blurry vision and felt
lightheaded with bilateral arm heaviness. He tried to pick
up a coffee cup with both hands but his arms felt weak. He
tried to stand but again his legs felt weak and he could not
move well. He felt lightheadedness. He called 911 and says
his speech was slurred. He could understand what was being
said to him. This episode came on suddenly and resolved
within one hour.
He had a similar episode of this approximately three weeks
prior that occurred while walking when he felt lightheaded at
that time as well.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Chronic obstructive pulmonary disease.
3. Left femoral-popliteal bypass.
4. Pneumonia.
5. Vertigo.
6. Headache.
7. Benign prostatic hypertrophy.
8. Status post appendectomy.
9. Status post tonsillectomy.
MEDICATIONS:
1. Zestril 30 mg p.o. q. day.
2. Hydrochlorothiazide 25 mg p.o. q. day.
3. Lipitor 10 mg p.o. q. day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Smokes two packs of cigarettes per day
since age of eight. Takes two to three drinks of alcohol per
day. Has a second marriage currently.
PHYSICAL EXAMINATION: On physical examination, the patient
is afebrile, vital signs are stable. He is awake and alert;
he answers questions appropriately with fluent speech.
Memory registers three out of three. Recall three out of
three at five minutes. No right to left confusion. No
apraxia. Face is symmetric without ptosis. Extraocular
muscles are intact. Pupils 4 to 3 bilaterally. The
patient's upper extremities were full strength. Left lower
extremity full strength as well.
LABORATORY: An MRI / MRA was done that showed right
vertebral artery stenosis.
White blood cell count 8.5, hematocrit 47, platelets 162.
Sodium 133, BUN 27, creatinine 1.1.
HOSPITAL COURSE: The patient was admitted to Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) **] Service. He underwent an angiogram on [**4-27**]. This
showed intracranial stenosis of the right V4 vertebral
segment.
This was discussed with the patient. The risks and benefits
of this procedure were explained to the patient. He wished
to proceed.
Preoperative diagnosis again was right intracranial vertebral
artery stenosis.
Procedure that the patient underwent was:
1. Cerebral angiogram.
2. Angioplasty and stent deployment within the right
vertebral artery stenosis segment.
This operation was performed by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1132**] and was
characterized by a prolonged decreased right vertebral flow
because of the need for the guide catheter to be high enough in
the neck to allow PTA balloon and stent navigation to the site
of stenosis.
The patient awoke with right arm and leg hemiplegia. A STAT
head CT scan was performed to rule out hemorhhage and that
was negative.
Over the next couple of hours, the patient recovered
excellent strength in the right arm and leg back to normal
baseline strength, a finding most consistent with relative
reversible hypoperfusion of his brainstem intra-procedurally
because of the guide catheter position.
The patient was continued on heparin, Plavix and aspirin post
procedure. The heparin was discontinued on [**5-3**]. The
patient's arterial sheath was also discontinued on [**5-3**].
The patient did well. He was transferred out of the
Intensive Care Unit.
He was continued on aspirin and Plavix and did well on the
floor and was stable for discharge to home on [**2136-5-6**].
DISCHARGE INSTRUCTIONS:
1. The patient will follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1132**] in one
month.
DISCHARGE MEDICATIONS: The patient will be discharged on all
his preoperative medications.
1. Zestril 30 mg p.o. q. day.
2. Hydrochlorothiazide 25 mg p.o. q. day.
3. Lipitor 10 mg p.o. q. day.
4. He will also be discharged on Plavix 75 mg p.o. q. day.
5. Add aspirin 325 mg p.o. q. day.
It has been explained to the patient the absolute necessity
that he take these medications every day.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Name8 (MD) 48241**]
MEDQUIST36
D: [**2136-5-5**] 19:09
T: [**2136-5-5**] 19:24
JOB#: [**Job Number 48242**]
|
[
"998.12",
"496",
"443.9",
"997.09",
"578.0",
"433.30",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"96.34",
"39.50",
"39.90"
] |
icd9pcs
|
[
[
[]
]
] |
3947, 4559
|
2112, 3785
|
3809, 3923
|
1446, 2093
|
169, 849
|
871, 1263
|
1281, 1422
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,807
| 146,492
|
2597
|
Discharge summary
|
report
|
Admission Date: [**2174-7-10**] Discharge Date: [**2174-7-14**]
Date of Birth: [**2124-8-13**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Codeine / Bee Pollens / Tobramycin
Attending:[**First Name3 (LF) 6701**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 13100**] is a 48M with a PMH s/f HIV (last CD4 > 800),
chronic pain on narcotics, recent TKA on [**2174-5-19**] complicated by
two subsequent hospitalizations for erythema and drainage of the
wound who presents to the ED with AMS and hypoxia. Following his
TKA he was placed on lovenox for 4 weeks to be followed by full
dose asa for 3 weeks. He was readmitted on [**5-26**] for erythema and
pain and given IV antibiotics. Cultures never showed any growth
and he was given keflex for prophylaxis. He was readmitted on
[**2174-6-8**] for a small area of dehiscence and again was initially
given IV abx until cultures were negative and was then
discharged on Keflex. He states that he completed his lovenox
shots on [**6-5**].
.
A few days prior to presentation on [**7-10**] he began to feel more
lethargic. Yesterday expreianced altered mental status with
mental slowing and decreased awareness of enviroment.
.
In the ED he was found to be oriented x 1 (off from baseline)
and hypoxic to 88% on RA and 89% on ventimask. BP was in the
90s and improved to 120s after 2 L IVF. Head CT was normal. CXR
was obtained which was read as possible atalectasis followed by
CTA that showed pulmonary embolus in left upper lobe segmental
branch with b/l patchy opacity likely atelectasis, but cant
exclude aspiration. He was given cefipime, vancomycin, and
levofloxacin. Sputum cx was not obtained. He was also started on
heparin gtt. He was placed on nonrebreather 100% and his sats
improved to 90%. He was transferred to the ICU for oxygen
requirement and AMS.
.
On the floor, his vital signs HR:83 BP:121/69 RR:14 SpO2:99% on
4L NC
.
Review of systems:
(+) Per HPI and wet productive cough for two days and a new band
like pain in lower chest since yesterday
(-) Denies fever, chills, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
shortness of breath, or wheezing. Denies palpitations. Denies
nausea, vomiting, diarrhea, constipation, abdominal pain, or
changes in bowel habits. Denies dysuria, frequency, or urgency.
Past Medical History:
1. HIV: Last CD4 count [**11/2172**] 1200, viral load undetectable
2. Depression/anxiety
3. Chronic myofascial pain syndrome: Managed at [**Doctor Last Name 1193**] pain
center
4. Seizure disorder
5. L TKA for osteoarthritis in [**2174-5-19**] complicated by
infections
Social History:
Remote smoking history, 8 years from age 22-30. Non-drinker, no
IVDU. Acquired HIV through sexual intercourse. Homosexual.
Lives with a roomate, does not work, is on disability.
Family History:
non-contributory
Physical Exam:
Vitals: T:98 BP:140/73 P:84 R:13 O2:100% on 4L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Poor inspiratory effort. Symmetric breath sounds, 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, left knee with 20 cm scar
and suprapatellar 2x1 cm area of dehiscence without erthema or
purulent drainage, no clubbing, cyanosis or edema
Pertinent Results:
CXR: no acute intracranial abnormality
.
CTA: pulmonary embolus in left upper lobe segmental branch. b/l
patchy opacity likely atelectasis, but cant exclude aspiration.
also b/l hilar and mediastinal lymph nodes.
.....
[**2174-7-10**] 06:10AM BLOOD WBC-12.5*# RBC-3.80* Hgb-11.8* Hct-35.0*
MCV-92 MCH-31.0 MCHC-33.7 RDW-14.2 Plt Ct-245#
[**2174-7-10**] 04:29PM BLOOD WBC-11.1* RBC-3.48* Hgb-10.7* Hct-32.0*
MCV-92 MCH-30.8 MCHC-33.5 RDW-14.3 Plt Ct-225
[**2174-7-11**] 04:55AM BLOOD WBC-5.8 RBC-3.31* Hgb-10.4* Hct-30.8*
MCV-93 MCH-31.5 MCHC-33.9 RDW-14.1 Plt Ct-233
[**2174-7-12**] 06:25AM BLOOD WBC-4.6 RBC-3.47* Hgb-10.7* Hct-31.5*
MCV-91 MCH-30.8 MCHC-34.0 RDW-14.1 Plt Ct-235
[**2174-7-13**] 06:55AM BLOOD WBC-5.0 RBC-3.60* Hgb-11.0* Hct-32.2*
MCV-89 MCH-30.6 MCHC-34.2 RDW-14.0 Plt Ct-250
[**2174-7-14**] 06:45AM BLOOD WBC-4.4 RBC-3.96* Hgb-12.0* Hct-35.8*
MCV-90 MCH-30.3 MCHC-33.5 RDW-14.1 Plt Ct-291
.
[**2174-7-10**] 06:10AM BLOOD Neuts-78.4* Lymphs-14.7* Monos-4.2
Eos-2.4 Baso-0.3
[**2174-7-10**] 04:29PM BLOOD Neuts-77.0* Lymphs-15.8* Monos-4.2
Eos-2.9 Baso-0.1
[**2174-7-11**] 04:55AM BLOOD Neuts-51.4 Lymphs-37.4 Monos-5.8 Eos-5.0*
Baso-0.4
[**2174-7-12**] 06:25AM BLOOD Neuts-42.6* Lymphs-46.4* Monos-6.0
Eos-4.7* Baso-0.2
.
[**2174-7-10**] 06:10AM BLOOD PT-11.7 PTT-25.8 INR(PT)-1.0
[**2174-7-10**] 04:29PM BLOOD PT-13.2 PTT-111.0* INR(PT)-1.1
[**2174-7-11**] 04:55AM BLOOD PT-12.4 PTT-66.3* INR(PT)-1.0
[**2174-7-12**] 06:25AM BLOOD PT-12.5 PTT-34.5 INR(PT)-1.1
[**2174-7-13**] 06:55AM BLOOD PT-14.0* PTT-35.8* INR(PT)-1.2*
[**2174-7-14**] 06:45AM BLOOD PT-17.0* PTT-37.4* INR(PT)-1.5*
.
[**2174-7-10**] 06:10AM BLOOD Glucose-100 UreaN-6 Creat-1.1 Na-134
K-4.5 Cl-93* HCO3-34* AnGap-12
[**2174-7-10**] 04:29PM BLOOD Glucose-110* UreaN-6 Creat-0.9 Na-139
K-4.2 Cl-99 HCO3-33* AnGap-11
[**2174-7-11**] 04:55AM BLOOD Glucose-92 UreaN-6 Creat-0.9 Na-136 K-4.3
Cl-97 HCO3-33* AnGap-10
[**2174-7-12**] 06:25AM BLOOD Glucose-92 UreaN-8 Creat-0.9 Na-131*
K-4.3 Cl-93* HCO3-33* AnGap-9
[**2174-7-13**] 06:55AM BLOOD Glucose-86 UreaN-8 Creat-0.9 Na-126*
K-3.9 Cl-91* HCO3-27 AnGap-12
[**2174-7-14**] 06:45AM BLOOD Glucose-85 UreaN-10 Creat-1.0 Na-131*
K-3.9 Cl-96 HCO3-26 AnGap-13
.
[**2174-7-10**] 04:29PM BLOOD CK(CPK)-69
[**2174-7-10**] 04:29PM BLOOD CK-MB-1 cTropnT-<0.01
.
[**2174-7-12**] 06:25AM BLOOD Mg-1.9
[**2174-7-10**] 04:29PM BLOOD Calcium-9.0 Phos-2.4* Mg-1.8
[**2174-7-11**] 04:55AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.0
.
[**2174-7-12**] 06:25AM BLOOD Osmolal-271*
[**2174-7-13**] 06:55AM BLOOD Osmolal-260*
[**2174-7-13**] 06:55AM BLOOD TSH-2.2
.
[**2174-7-10**] 06:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
Time Taken Not Noted Log-In Date/Time: [**2174-7-10**] 6:23 am
BLOOD CULTURE
**FINAL REPORT [**2174-7-16**]**
Blood Culture, Routine (Final [**2174-7-16**]): NO GROWTH.
.
[**2174-7-10**] 7:40 am URINE Site: CLEAN CATCH
**FINAL REPORT [**2174-7-11**]**
URINE CULTURE (Final [**2174-7-11**]): NO GROWTH.
.
[**2174-7-10**] 4:29 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2174-7-13**]**
MRSA SCREEN (Final [**2174-7-13**]): No MRSA isolated.
.
[**2174-7-12**] 11:34 am SWAB Source: L knee.
GRAM STAIN (Final [**2174-7-12**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Brief Hospital Course:
Mr. [**Known lastname 13100**] is a 48M with a PMH s/f HIV (last CD4 > 800),
chronic pain on narcotics, recent TKA who presents to the ED p/w
AMS and hypoxia. Now found to have a PE.
.
.
#Hypoxia - Patient was found to be hypoxic in the ED. This could
best be explained by a PNA or PE. A CXR was c/w atelectasis and
a CT-A shouwed evidence of PE, with question of aspiration. In
the absence of a reported or suspected aspiration event and
afebrile status aspiration PNA is unlikely. However, he does
have an elevated WBC count and slight left shift at 78%N
possibly consistent with CAP. He was started on Levofloxacin and
continued to be afebrile. Blood cultures and urine
culturesnegative.
He was titrated on Heparin to therapeutic levels and continued
on Lovenox bridge to coumadin for tx of PE. Pt was no longer
hypoxic at time of discharge. Rx were faxed to pharmacy. Pt
given detailed instruction for follow up and self adminstration
of lovenox.
.
#Hyponatremia - Pt with downtrending Na levels since discharge
from MICU. Nephrology consulted and hyponatremia attributed to
pulmonary injury [**1-18**] PE and chronic pain. He was placed on fluid
restriction and high protein diet to increase Urine osm and free
water diuresis. Stable at time of discharge.
.
#L TKA - Surgery on [**2174-5-19**] complicated by two repeat
admissions on [**5-26**] and [**6-8**] for suspected wound infection and
dehiscence and treated with Keflex, never culture positive.On
exam the wound appears to be closing by secondary intention of
2cm by 1cm
and no drainage or purulence noted. wound care includes saline
and dry dressing for now. Repeat wound gram stain show likely
skin contamination and cultures negative.
.
#HIV - Stable on home regimen. Continued on Reyataz and Epzicom
.
#Seizure disorder - stable on home regimen. Continued Depakote
ER
.
#Depression/Anxiety - stable on home regimen. cContinued on
Citalopram and clonazepam
.
#Chronic Myofascial pain syndrome - Managed at [**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**]
Center. Discontinue home Ibuprofen, Tramadol, Piroxicam and
Endocet as these meds increase likelihood of GIB on
anticoagulation. He was started on opioids for pain control and
acetaminophen.
Medications on Admission:
Divalproex 750 SR [**Hospital1 **]
Pregabalin 75 mg [**Hospital1 **]
Piroxicam 20 mg Q day
Clonazepam 4 mg TID
Citalopram 20 mg TID
Tizanidine 2 mg QHS
Docusate 100 mg [**Hospital1 **]
Trazodone 100 mg PO Q HS
Atazanavir 200 mg [**Hospital1 **]
Lamivudine 150 mg PO Q DAY
Abacavir 600 mg Q day
Oxycodone 5 mg [**12-18**] tabsQ3
ASPIRIN 325 MG q DAY
Discharge Medications:
1. Atazanavir 200 mg Capsule Sig: One (1) Capsule PO twice a
day.
2. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO once a day.
3. Lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
5. Divalproex 250 mg Tablet Sustained Release 24 hr Sig: Three
(3) Tablet Sustained Release 24 hr PO BID (2 times a day).
6. Pregabalin 75 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
8. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*0*
9. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*0*
10. Enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q12H
(every 12 hours).
Disp:*20 syringes* Refills:*0*
11. Citalopram 20 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
12. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
13. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for anxiety.
14. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
Disp:*240 Tablet(s)* Refills:*0*
15. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
17. Senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day as
needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
18. Alcohol Pads Pads, Medicated Sig: One (1) Topical every
twelve (12) hours: use before administering lovenox injections.
Disp:*1 box* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Pulmonary Embolus
Right knee infection [**1-18**] TKA
Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with complaints of confusion
and decreased oxygen level. You were admitted to the Intensive
Care unit for IV antibiotics and a chest CT scan showed a blood
clot in your lung vessels. You were started on blood thinners to
dissolve the clot and transferred to the general medicine [**Hospital1 **]
once you began to improve.
.
You were changed from IV heparin to lovenox shots while
continued on your coumadin. You will be discharged home on
Coumadin and VNA will assist in educating you on your
medications.
Please also have your blood drawn every other day for 1 week
after discharge to check your INR (coumadin levels).
.
Please continue to limit your fluid intake to 1200ml per day.
Please eat a high protein diet. This is important to keep your
sodium in normal range.
.
The following changes were made to your medications:
STARTED Enoxaparin Sodium 100 mg SC Q12H
STARTED Warfarin 5 mg taken orally once daily
STARTED Levofloxacin 500mg taken orally once daily x 5 days
STARTED Tylenol 1000mg up to 4 times daily
STARTED OxycoDONE (Immediate Release) 10 mg up to 4 times daily
STOPPED Ibuprofen
STOPPED Ultram
STOPPED Piroxicam
STOPPED Aspirin
Please continue your other home medications.
.
Please follow up with the physician listed below:
Followup Instructions:
PCP [**Name Initial (PRE) **]: Friday, [**7-15**] at 10:10AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13105**],MD
Location: [**Location (un) **] ASSOCIATES OF [**Hospital1 **] HEALTH
Address: [**Street Address(2) **], 2ND FL, [**Location (un) **],[**Numeric Identifier 2900**]
Phone: [**Telephone/Fax (1) 5723**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6708**]
|
[
"729.1",
"682.6",
"E878.1",
"041.04",
"998.59",
"V58.61",
"415.19",
"300.4",
"253.6",
"486",
"345.90",
"V08"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11761, 11819
|
7357, 9596
|
331, 337
|
11930, 11930
|
3652, 7238
|
13385, 13852
|
2961, 2979
|
9995, 11738
|
11840, 11909
|
9622, 9972
|
12081, 13362
|
2994, 3633
|
2037, 2454
|
270, 293
|
7270, 7285
|
365, 2018
|
7321, 7334
|
11945, 12057
|
2476, 2747
|
2763, 2945
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,761
| 199,994
|
10570
|
Discharge summary
|
report
|
Admission Date: [**2188-7-7**] Discharge Date: [**2188-7-17**]
Date of Birth: [**2130-3-24**] Sex: F
Service: MICU-ACOVE
HISTORY OF PRESENT ILLNESS: The patient is a 58 year old woman
with multiple medical problems including congestive heart
failure, chronic obstructive pulmonary disease, sleep apnea, cor
pulmonale with right heart failure, obesity, and end-stage renal
disease requiring hemodialysis. The patient has had recent
admissions at the [**Hospital1 69**] in
[**Month (only) 956**] and [**Month (only) 958**] of this year, most notably for a line
infection. Two days prior to admission, the patient's son noted
increasing somnolence. The patient underwent hemodialysis on
[**2188-7-7**], and was subsequently noted to be more somnolent by
her [**Hospital6 407**]. As such, she was referred back
to the [**Hospital1 69**] for further
management.
PAST MEDICAL HISTORY:
1. Morbid obesity.
2. Congestive heart failure; last echocardiogram [**1-/2188**],
with marked right ventricular dilation; left ventricular
function 58 to 55%, four plus tricuspid regurgitation with
severe pulmonary hypertension.
3. Chronic obstructive pulmonary disease.
4. Obstructive sleep apnea; the patient does not use BiPAP
at home and has known right heart failure and cor pulmonale.
5. Hypertension.
6. History of atrial flutter not currently anti-coagulated.
7. Chronic renal insufficiency on hemodialysis.
8. Peripheral vascular disease.
9. Multiple urinary tract infection, most recent being a
Klebsiella and E. coli in [**Month (only) 958**] of this year.
MEDICATIONS AT HOME:
1. Protonix 40 mg p.o. q. day.
2. Amiodarone 200 mg p.o. q. day.
3. Neurontin 300 mg p.o. q. day.
4. Nephrocaps 1 tablet p.o. q. day.
5. Vioxx 12.5 mg p.o. q. day p.r.n.
6. Tums 500 mg p.o. three times a day with meals.
7. Prozac 20 mg p.o. q. day.
8. Remeron 7.5 mg p.o. q. h.s.
9. Albuterol MDI.
10. Atrovent MDI.
11. Flovent 44 micrograms two puffs twice a day.
12. The patient also uses home O2.
ALLERGIES: The patient has a reported allergy to Demerol,
unknown effect. The patient is also allergic to nuts
resulting in anaphylaxis.
SOCIAL HISTORY: The patient has a 70 pack year history of
tobacco use. She also notes ethanol abuse. She is married;
she is bed and wheelchair bound secondary to deconditioning.
She has a [**Hospital6 407**] and has family members
assist her activities of daily living. The patient has
refused rehabilitation in the past.
PHYSICAL EXAMINATION: On admission, temperature 99.4 F.,
pulse of 86; blood pressure 101/40; respiratory rate of 19
with an oxygen saturation of 93%, with mechanical ventilation
FIO2, 30%, pressure support 5, PEEP of 5. The patient was
somnolent but arousable to noxious stimuli. Her HEENT
examination was unremarkable with pupils equal, round and
reactive to light. Sclerae anicteric. Extraocular movements
are intact. Mucous membranes dry without oral lesions. Her
neck was supple, obese. A right IJ catheter was in place.
It was difficult to assess jugular venous distention.
Carotids were two plus without bruits. Her heart sounds were
distant but regular in rate and rhythm without notable
murmurs, rubs or gallops. Normal S1 and S2. Her lungs had
bibasilar crackles, right greater than left. No wheezes were
noted. Her abdomen was obese, soft, with diffuse mild
tenderness. Her extremities had no cyanosis, clubbing or
edema. She had a 2 cm by 3 cm ulceration on the right
lateral aspect of her shin, with a question of purulent
drainage. On neurologic examination, she was oriented to
place only. Reflexes were symmetric bilaterally.
LABORATORY: On admission, white blood cell count 14.4,
hematocrit 33.5, platelets 175, MCV of 102. Sodium 138,
potassium 4.1, chloride 101, bicarbonate 23, BUN 19,
creatinine 3.1, glucose 94. Calcium of 9.0, phosphorus of
3.4, magnesium of 1.5, free calcium of 1.32. Differential on
the white blood cell count is as follows: 77% polys, 7
bands, 9 lymphs, 5 monos, 2 eosinophils.
Initial arterial blood gas is as follows: pH 7.19, pCO2 of
69, pO2 of 43. Chest x-ray showed increased interstitial
lung markings in the lower lung zones, hilar fullness, mild
congestive heart failure, question of infiltrate.
EKG was normal sinus rhythm at a rate of 65, borderline right
axis deviation with right bundle branch block. Mild ST
depression in the precordial leads. No significant changes
from prior EKG of [**2188-5-15**].
SUMMARY OF HOSPITAL COURSE: In the Emergency Department, the
patient was found to be afebrile and hypotensive with systolic
blood pressure in the 70s. The patient was given fluid
resuscitation and with 1.2 liters, subsequent chest x-ray showed
mild congestive heart failure. Her white blood cell count was
noted to be elevated at 14.4 with a left shift. As such, she was
started on antibiotics of broad-spectrum, including Vancomycin,
Levofloxacin and Flagyl. Arterial blood gas was 7.19/69/43. The
patient was started on Dopamine after placement of a right IJ
catheter and transferred to the Intensive Care Unit for further
management.
The patient was intubated for her progressively worsening
acidosis with repeat arterial blood gas of 7.17, 68, 64.
After intubation, the patient's next arterial blood gas was
7.22, 54, 102. Cultures were taken including blood, sputum
and of the wound. Only colonizing organisms were noted from
the right shin wound culture, including Methicillin resistant
Staphylococcus aureus.
Given her previous history of resistant Klebsiella and E.
coli, the patient's antibiotic coverage was changed to Meropenem
for renal dosing and Vancomycin. The patient was then continued
on a ten day course of these antibiotics with good response. It
was believed that the patient most likely suffered from a
pneumonia and, on [**2188-7-12**], the patient self-extubated. The
patient subsequently developed stridor and was started on
steroids and re-intubated. The patient continued to do well and,
on [**2188-7-13**], pressors were weaned off, and the patient was
subsequently extubated and then transferred to the floor on
[**2188-7-14**], to complete her ten day course of antibiotic.
The patient continued to convalesce well and on [**2188-7-17**], was
discharged to home without change in any of her prior
medications.
DISCHARGE DIAGNOSES:
1. Pneumonia.
2. Sepsis.
SECONDARY DIAGNOSES:
Congestive heart failure.
Chronic obstructive pulmonary disease.
Obstructive sleep apnea.
Morbid obesity.
Hypertension.
Peripheral vascular disease.
End-stage renal disease on hemodialysis.
Atrial arrhythmia, currently in sinus rhythm.
DISCHARGE MEDICATIONS:
1. Amiodarone 200 mg p.o. q. day.
2. Neurontin 300 mg p.o. q. day.
3. Protonix 40 mg p.o. q. day.
4. Tums 500 mg p.o. three times a day with meals.
5. Nephrocaps one tablet p.o. q. day.
6. Prozac 20 mg p.o. q. day.
7. Remeron 7.5 mg p.o. q. h.s.
8. Albuterol MDI.
9. Atrovent MDI.
10. Flovent 44 micrograms, two puffs three times a day.
11. Vioxx 25 mg p.o. q. day p.r.n.
DISCHARGE INSTRUCTIONS:
1. The patient is to continue with her home O2 at
approximately two liters.
2. She is scheduled for hemodialysis on Monday, Wednesday
and Friday.
3. She is to follow-up with her primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) **], in approximately one week. Dr. [**Last Name (STitle) 34780**] contact
information is as follows: Telephone number [**Telephone/Fax (1) 34781**];
address [**Street Address(2) **], [**Location (un) 3786**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Last Name (NamePattern1) 9348**]
MEDQUIST36
D: [**2188-7-17**] 10:59
T: [**2188-7-17**] 11:30
JOB#: [**Job Number **]
cc:[**Last Name (NamePattern1) 34782**]
|
[
"518.81",
"585",
"397.0",
"428.0",
"486",
"427.32",
"496",
"416.9",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"39.95",
"38.91",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
6347, 6375
|
6656, 7038
|
7062, 7819
|
1604, 2155
|
6396, 6633
|
4499, 6326
|
2505, 4470
|
170, 882
|
904, 1583
|
2172, 2482
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,645
| 109,514
|
32413
|
Discharge summary
|
report
|
Admission Date: [**2115-11-21**] Discharge Date: [**2116-1-13**]
Date of Birth: [**2046-3-31**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
69 year old female admitted from outside hospital with right
upper quandrant abdominal pain. Status post ERCP and
sphicterotomy where a stone was removed. Febrile and elevated
white count now.
Major Surgical or Invasive Procedure:
Status post placement of two retroperitoneal drains on [**11-16**] and
[**11-22**].
History of Present Illness:
HPI: 69F h/o chronic steroid use (initially prenisone 60mg
daily, now tapered to 2.5mg daily.for uveitis and retinitis who
initially presented to [**Hospital3 17921**] Center on [**11-9**] with
severe back pain radiating to the RUQ and epigastric region that
started at 11AM the same day of presentation. She reported
vomiting and nausea associated with the pain. She was thought to
have acute calculus cholecystitis after US (gallstones and
thickened gallbladder wall with dilated CBD) and underwent ERCP
on [**2115-11-11**] which was reported as a successful sphincterotomy
and removal of diminutive stone material. Her initial admission
WBC was 9.6 on admission and on transfer was 18.8. She continued
to have persisitent fevers post-procedure and a CT scan done on
[**11-14**] demonstarted a large retroperitoneal fluid collection. On
[**11-16**], she underwent IR drainage with placement of a drain in
her retroperitoneal fluid collection with drainage of dark brown
fluid, which later cultures [**Female First Name (un) 564**]. Fluid analysis had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
2253, prot 2.6, glucose 4, LDH 5945. Her initial LFTs had AST
661, ALT 521, AP 390, Albumin 3.8. Last LFTs [**11-21**] AP 362, AST
22, ALT 25, T.bili 0.4, [**Doctor First Name **] 104, lip 467. It was decided that
the patient continued fevers, rising WBC, and presistent fluid
collection, the patient was transferred to [**Hospital1 18**].
Past Medical History:
Hypertension
Uveitis
Retinitis
Social History:
Positive for tobacco in past.
Occasional alcohol use
Married lives with husband in [**Name (NI) 3844**]
Family History:
NC
Physical Exam:
T: 99.0 (102.2) P: 90-112 R: 18 95% RA BP: 140-150/60-70 Wt:
67.1kg FS 130-170
General: Nausea, spitting into bucket.
HEENT: ?Oral thrush with adherent white coating on the anterior
tongue.
Neck: {X}WNL
Cardiovascular: {X}WNL
Respiratory: {X}WNL
Back: 2 RP drain sites clean and dry.
Gastrointestinal: Hypoactive bowel sounds. Tender to palpation
in
the RUQ.
Genitourinary: {X}WNL
Musculoskeletal: {X}WNL
Skin: {X}WNL
Neurological: Left eye visual field deficits as at baseline.
Psychiatric: {X}WNL
Heme/Lymph: {X}WNL
Other: Right subclavian site clean and dry, nontender, no
erythema.
Pertinent Results:
[**2115-12-1**] 10:10AM BLOOD WBC-21.1*# RBC-3.77*# Hgb-10.8*#
Hct-33.4*# MCV-89 MCH-28.6 MCHC-32.3 RDW-15.5 Plt Ct-732*
[**2115-11-29**] 09:15AM BLOOD WBC-13.5* RBC-3.11* Hgb-9.0* Hct-26.5*
MCV-85 MCH-28.8 MCHC-33.7 RDW-15.2 Plt Ct-485*
[**2115-11-27**] 05:25AM BLOOD WBC-12.7* RBC-3.09* Hgb-9.0* Hct-26.9*
MCV-87 MCH-29.2 MCHC-33.6 RDW-15.2 Plt Ct-570*
[**2115-11-22**] 12:04AM BLOOD WBC-20.7* RBC-3.37* Hgb-10.0* Hct-30.0*
MCV-89 MCH-29.6 MCHC-33.2 RDW-15.2 Plt Ct-584*
[**2115-12-2**] 03:41AM BLOOD Neuts-86.9* Lymphs-6.8* Monos-5.1 Eos-1.1
Baso-0.1
[**2115-12-2**] 03:41AM BLOOD Plt Ct-469*
[**2115-11-22**] 12:04AM BLOOD PT-13.8* PTT-29.6 INR(PT)-1.2*
[**2115-12-2**] 03:41AM BLOOD Glucose-127* UreaN-17 Creat-0.6 Na-134
K-4.9 Cl-105 HCO3-19* AnGap-15
[**2115-11-28**] 05:00AM BLOOD Glucose-122* UreaN-15 Creat-0.6 Na-130*
K-4.0 Cl-100 HCO3-21* AnGap-13
[**2115-11-22**] 12:04AM BLOOD Glucose-120* UreaN-15 Creat-0.6 Na-130*
K-4.3 Cl-96 HCO3-23 AnGap-15
[**2115-12-2**] 03:41AM BLOOD ALT-12 AST-24 LD(LDH)-219 AlkPhos-439*
Amylase-206* TotBili-0.3
[**2115-11-22**] 12:04AM BLOOD ALT-30 AST-28 AlkPhos-352* Amylase-140*
TotBili-0.5
[**2115-12-2**] 03:41AM BLOOD Albumin-2.2* Calcium-8.4 Phos-4.0 Mg-1.6
[**2115-11-22**] 12:04AM BLOOD Albumin-2.9* Calcium-8.0* Phos-3.6 Mg-2.2
Iron-16*
[**2115-11-29**] 10:48AM BLOOD Osmolal-278
[**2115-11-28**] 05:00AM BLOOD TSH-7.7*
[**2115-11-28**] 03:15PM BLOOD T4-7.3 T3-77* calcTBG-0.99 TUptake-1.01
T4Index-7.4
[**2115-11-29**] 12:45PM BLOOD Cortsol-34.6*
[**2115-12-2**] 04:09AM BLOOD Type-ART pO2-91 pCO2-30* pH-7.46*
calTCO2-22 Base XS-0
Brief Hospital Course:
This is a 69 year old female admitted from [**Hospital3 17921**]
Center in [**Location (un) 5450**] NH. The patient originally presented on
[**2115-11-9**] to [**Hospital3 17921**]
Center with severe back pain radiating to the right upper
quadrant and epigastric
area. She had associated nausea and vomiting. Ultrasound
revealed gallstones
and a thickened gallbladder wall with a dilated common bile duct
thought consistent with acute calculus cholecystitis. She was
started on cipro and flagyl on [**2115-11-9**], continued until
[**2115-11-17**]. On [**2115-11-11**] the patient underwent ERCP with reported
successful sphinterotomy and removal of diminutive stone
material. Patient's course was then complicated by an increasing
white count and fever. Abdominal CT revealed a large
retroperitoneal fluid collection. Placement of two
retroperitoneal drains on [**11-16**] and [**11-22**] were done.
[**2115-11-22**] - [**2115-11-30**] Patient continued to be febrile with nausea
and vomiting. Nasogastric tube inserted and left in for
decompression. Patient pancultured several times. Infectious
disease (ID) consulted. Intravenous antibiotics continued per
ID's recommendations. Patient experienced loose stool, cultures
sent for c. difficile. Patient became hyponatremic; thyroid
studies done showing a high thyroid stimulating hormone.
Endocrine consulted. [**2115-11-25**] CT of abdomen repeated showing a
decrease in the fluid collection. Nasogastric tube discontinued
on [**2115-11-29**]. Specimen obtained from drains and grew [**Female First Name (un) 564**],
MRSA and coag - staph. Patient was able to get out of bed and
ambulate.
Admitted to SICU:
On [**2115-12-1**] Patient became tachycardic with oxygen desaturation
to the 80's. Readmitted to SICU for respiratory distress and
intubated, then underwent CT Torso. This was negative for
pulmonary embolism. Chest xray did reveal enlarging effusions
and bilateral atelectasis with scattered opacities.
[**2115-12-2**] Drain of retroperitoneal fluid collection replaced.
[**2115-12-3**] Patient extubated and then reintubated for desaturations
and pulmonary edema.
[**2115-12-4**] Patient diuresised, [**12-4**] CXR: Interval improvement of
b/l pulmonary edema
On [**12-6**] patient had an abdominal CT - IMPRESSION: Improved
appearance of retroperitoneal fluid collections with
appropriately placed catheters. No new developing abscess.
Decreased but persistent pleural effusions and atelectasis.
[**2115-12-7**] Patient was extubated.
[**2115-12-8**] Patient reintubated with CXR revealing pulmonary edema
and bilateral pleural effusions.
[**2115-12-10**] Patient went back to the operating room for:
1. Incision and debridement of retroperitoneal abscess.
2. Tracheostomy tube placement.
[**2115-12-11**] - [**2115-12-15**]
Patient was weaned from ventilator to cpap.
Dobhoff tube placed for tube feedings.
CT of abd/pelvis on [**2115-12-15**] - Continued small fluid collection
interdigitating within the right retroperitoneum with
appropriately placed surgical and pigtail drainage catheters as
described. The collections are not significantly changed,
although they are slightly decreased in size when compared to
prior study. No new collections.
Enlarging pleural effusions and new biapical airspace disease,
likely developing pneumonia/aspiration.
[**2115-12-16**] L lung effusion drained for 900cc.
labetatol drip weaned to off.
[**2115-12-18**] Discontinued aztreonam and flagyl
[**2115-12-20**] WBC 10.1, all cultures negative.
Lasix drip being weaned.
Tube feeds at goal and tolerating well
Off ventilator, on trach collar mist with good oxygention.
[**2115-12-20**] - [**2115-12-24**]
Respiratory - Trach changed to PMV, good saturations with trach
mist.
Lasix changed to standing dose
Antibiotics changed to vancomycin and capsofungin
[**2115-12-23**] Patient went to CT, had retroperitoneal catheter
replaced with 12 french catheter with resulting drainage of 5cc
of purulent fluid. Catheter left in place.
[**12-24**] - CXR done - FINDINGS: Feeding tube is again seen with tip
off the film, past the second portion of the duodenum.
Tracheostomy tube is unchanged. Catheter in the right mid
abdomen is unchanged. The alveolar and interstitial infiltrates
are not significantly changed. There is a small left effusion
that is slightly larger than on the film from three days ago.
There continues to be retrocardiac opacity consistent with
volume loss/infiltrate/effusion.
[**2115-12-24**] - Patient transferred to floor.
[**2115-12-25**] - Discharge planning begun for rehab.
Physical therapy consult for chest PT and strengthening
Psych. consult - assessment and support
Consult to speech and swallow for evaluation and treatment.
L wrist ulcer from old IV site - healing, adaptik with dry
sterile dressing daily.
[**2115-12-27**] Family meeting with spouse, daughter, son, and Dr.
[**Last Name (STitle) **]. Plan discussed regarding further treatment and
course. Swallow study done. Started thin liquids. Out of bed to
chair. Continued physical therapy. Will get abd. CT on [**2115-12-31**]
and possible discharge to rehab. in one week.
[**Date range (1) 75676**]/08 Out of bed daily with physical therapy. Patient c/o
nausea, kub + stool throughout colon.
[**2115-12-31**] CT of Abd. -
IMPRESSION:
1. Persistent 4.2 x 2.5-cm rim-enhancing fluid collection in
the
retroperitoneum superior to the right kidney with pigtail
catheter that has
been partially retracted. Although the pigtail catheter lies at
the superior
portion of this lesion, re-manipulation may be helpful if the
catheter is not
draining. Please correlate clinically.
2. Improving bilateral pleural effusions and atelectasis.
Small pericardial
effusion.
3. Pneumobilia and air within the gallbladder. Please
correlate with any
recent manipulation.
[**2116-1-1**] - Pigtail drain discontinued.
[**2116-1-3**] - [**2116-1-12**] Patient continued to improve with complaints of
intermittent nausea. Bowel regimen began and medication
administration spaced out. Tube feedings weaned to just at night
and then discontinued. Patient placed on soft diet with calorie
counts and supplements. Patient also complained of trouble
sleeping, Psychiatry suggested Remeron at night for sleep. She
is now at 15mg and is sleeping better. On [**2116-1-10**] penrose drains
removed. Beta blockers weaned from 150mg tid to 50mg tid.
Current issues:
1. Surgical follow up - will return for abdominal CT and
appointment with Dr. [**Last Name (STitle) **] in [**3-3**] weeks.
2. Nausea/nutrition - will continue to encourage oral intake at
rehab. with the addition of high calorie supplements in between
meals.
3. Insomnia - Continue Remeron 15mg q HS.
4. Mobility - Will continue physical therapy at a more intense
level at [**Hospital1 **].
5. Antibiotics - As infectious disease recommended, we will
continue vancomycin and capsofungin until 2 weeks post
discontinuation of penrose drains. ([**2116-1-24**])
Medications on Admission:
Omeprazole 20 qd
prednisone eye drop
cosopt eye drops (both in left eye)
nystatin
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection [**Hospital1 **] (2 times a day).
2. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
3. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic DAILY (Daily).
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1)
ML Intravenous DAILY (Daily) as needed.
10. Caspofungin 70 mg Recon Soln Sig: Fifty (50) Recon Soln
Intravenous Q24H (every 24 hours): Discontinue on [**2116-1-24**].
11. Famotidine(PF) in [**Doctor First Name **] (Iso-os) 20 mg/50 mL Piggyback Sig:
Twenty (20) mg Intravenous Q24H (every 24 hours).
12. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous Q 24H (Every 24 Hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
s/p biliary perforation from ERCP s/p placement of two
retroperitoneal drains
Retroperitoneal abscess complicated by respiratory failure.
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or return to the emergency room if you
have any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
Followup Instructions:
Your follow up appointment with Dr. [**Last Name (STitle) **] is 1 pm Friday
Febuary 1st, [**Location (un) 10043**] [**Hospital Ward Name 23**] Building.
You are to have an abdominal CT on the [**Hospital Ward Name **] [**Hospital Ward Name 23**]
building, [**Location (un) **]. You are to arrive at 9:45m, your CT is
scheduled for 10:45. You must have nothing to eat 3 hours prior
to CT.
Completed by:[**2116-1-13**]
|
[
"518.81",
"577.0",
"511.9",
"514",
"V09.0",
"599.0",
"482.41",
"998.2",
"998.59",
"567.38",
"E870.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"96.71",
"96.6",
"96.04",
"38.93",
"54.3",
"31.1",
"54.0",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
12735, 12814
|
4466, 11427
|
466, 551
|
12996, 13005
|
2856, 4443
|
13868, 14289
|
2229, 2233
|
11559, 12712
|
12836, 12975
|
11453, 11536
|
13030, 13845
|
2248, 2837
|
233, 428
|
580, 2038
|
2060, 2092
|
2108, 2213
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,732
| 180,948
|
8056
|
Discharge summary
|
report
|
Admission Date: [**2140-5-13**] Discharge Date: [**2140-5-17**]
Date of Birth: [**2091-8-28**] Sex: M
Service: CCU
CHIEF COMPLAINT: Left upper quadrant pain.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 14779**] is a 48 year old man
with a significant past medical history who presents to his
primary care physician on the day of admission with a one
week history of fever and malaise. The patient had home
temperatures of 101.0 F., on [**5-7**], which briefly improved
over the next few days; however, then again on [**5-9**], the
patient began feeling poorly with aches and fevers. Denies
upper respiratory or gastrointestinal symptoms.
The day prior to admission, the patient did note some slight
stomach ache with some dry heaves. On the morning of
admission, he had worsening malaise. The patient noted an
episode of sharp upper left quadrant pain exacerbated by
laying on his left side, after which the patient said he had
feelings of being slightly nauseated and anxious and as he
was walking to the bathroom, fell to the floor. The patient
denies trauma. He had brief loss of consciousness, no
confusion, no incontinence.
After this episode, the patient went to see his primary care
physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) 679**], and was found to have hematuria in the
office and was referred to the Emergency Room.
In the Emergency Room, the patient underwent an abdominal CT
scan and was noted to have a large pericardial effusion. He
underwent further evaluation for this finding by
echocardiogram which demonstrated tamponade physiology. The
patient was brought to the Cardiac Catheterization Laboratory
for emergent pericardiocentesis which was performed, and 450
cc. of bloody fluid removed, with suction bulb drain left in
place. The patient was noted to have hemodynamics including
pulmonary artery pressure of 26/15 with a wedge of 15, right
atrium 13, right ventricle 25/9. Cardiac output 2.7 with an
index of 1.5, which improved to a cardiac index of 2.4 after
removal of fluid.
Of note, the patient denies any history of chest pain; no
shortness of breath and reports stable recent exercise
tolerance for which at baseline he is able to walk flights of
stairs without limitations.
The patient denies prior tuberculosis exposure and has no
risk factors. He has no travel history. The patient does
note sick contacts with his wife and daughter.
PAST MEDICAL HISTORY:
1. Kidney stones; two prior episodes treated with pain
relief.
2. Health maintenance including a within normal limits
colonoscopy within the past two years, demonstrating only
hemorrhoids.
3. Stress test in [**2139-9-6**] for costochondritis type
chest pain which demonstrated at 100% of maximum heart rate
eleven minutes of [**Doctor First Name **] protocol. The patient stopped for
fatigue with no ischemic EKG changes, within normal limit
hemodynamic response.
MEDICATIONS: None. Occasional Tylenol, Motrin, Sudafed.
FAMILY HISTORY: Mother status post mastectomy. Father is
85 years old with a history of a gland removed in his
abdomen. Brother who is healthy. Positive coronary artery
disease in his uncles.
SOCIAL HISTORY: The patient works in giftware sales. No
occupational exposures. No tobacco. Drinks a few drinks per
week. No illicit drugs. He has two daughters, ages 11 and
18 and a son 26. He lives with his wife and children.
ALLERGIES: To contrast dye given for prior CT scan.
REVIEW OF SYSTEMS; No vision changes, no upper respiratory
system symptoms; positive slight nausea, positive sharp left
upper quadrant pain; no diarrhea; no constipation. No
melena, no bright red blood, no urinary frequency, no burning
or frank hematuria. No rashes, no joint pain, no weight
loss. The patient reports a stable weight of 133. Night
sweats only with fevers.
Of note, the patient does report two prior febrile illnesses
in [**Month (only) 1096**] and [**Month (only) 956**] of the past year with five to six
days of fevers and aches.
PHYSICAL EXAMINATION: Temperature 100.5 F.; blood pressure
111/59; pulse 101; respiratory rate 22; O2 saturation 98% on
room air. In general, pleasant middle aged man lying in bed
in no acute distress. HEENT: Normocephalic, atraumatic.
Pupils are equal, round and reactive to light. Extraocular
muscles are intact. Oropharynx with white coating on tongue.
Throat clear, no exudates. Neck supple, no jugular venous
distention, no anterior or posterior supraclavicular,
axillary or left inguinal lymphadenopathy. Cardiovascular is
regular rate, no murmur. Positive tachycardia. Pulmonary is
clear to auscultation bilaterally anteriorly. Abdomen is
normoactive bowel sounds, soft, nondistended, Liver:
Nontender, palpable 2 centimeters below the costal margin.
Spleen not palpable with minimal epigastric left upper
quadrant tenderness. Extremities with no edema.
Neurological is alert, oriented and appropriate. Non-focal.
LABORATORY: White blood cell count 18.3, hematocrit 42.6,
platelets 448. Sodium 143, potassium 4.7, chloride 101,
bicarbonate 27, BUN 21, creatinine 1.2, glucose 115. ALT 45,
AST 31, alkaline phosphatase 69, total bilirubin 2.2.
Albumin 4.2, amylase 69, lipase 27.
Urinalysis with large blood, 30 protein, 18 ketones, 6 to 10
red blood cells, zero to 2 white blood cells, 3 bacteria.
Abdominal CT scan demonstrated moderate to large pericardial
effusion. Pericholecystic fluid, no gallstones; renal stones
without obstruction.
EKG is sinus tachycardia at 115, low voltage, atrial
abnormality.
HOSPITAL COURSE: Mr. [**Known lastname 14779**] was admitted to the Coronary
Care Unit after successful drainage of his pericardial
effusion. He was monitored over the next 40 hours and
remained hemodynamically stable. Repeat echocardiogram
demonstrated his effusion has improved to small and he had
minimal output from his drain.
The etiology of the patient's event remained unclear. Likely
possibilities included viral illness and virus studies were
pending at time of discharge. Bacterial Gram stain was
negative and culture negative. No fungal isolates were
identified.
The patient underwent work-up for a possible malignant
etiology including chest and abdominal CT scans which were
unremarkable for mass. His PSA was within normal limits. He
has had a colonoscopy within the past two years which was
normal.
Further infectious work-ups included investigation for
tuberculosis. The patient received pre-treatment for CT scan
with Prednisone and therefore PPD placement was deferred to
an outpatient setting. The patient was instructed to follow
with Dr.[**Name (NI) 16937**] office for a PPD placement.
Further evaluation of the pericardial fluid with adenosine
viaminase studies were requested and pending at time of
discharge. HIV consent and testing were obtained with the
results pending at time of discharge.
GASTROINTESTINAL: The patient presented with left upper
quadrant pain and an isolated total bilirubin with normal
fractionation. His total bilirubin improved to normal on day
after admission.
The patient had a repeat urinalysis which demonstrated
improvement in his hematuria to only trace blood, zero to two
red blood cells. Urine cytology was pending at time of
discharge.
ENDOCRINE: The patient had persistent tachycardia and
thyroid function tests were checked and pending at time of
discharge.
DISCHARGE MEDICATIONS: Indomethacin 50 mg p.o. p.r.n.
DISCHARGE INSTRUCTIONS:
1. Follow-up appointment with Dr. [**First Name (STitle) 679**] for a PPD later this
week.
2. Dr. [**First Name (STitle) 679**] on Thursday, [**5-26**], at 09:45 a.m.
3. Cardiology follow-up with Dr. [**First Name4 (NamePattern1) 7422**] [**Doctor First Name 28796**] on
[**6-9**], at 10:30 a.m. with repeat echocardiogram to be
scheduled prior to this visit.
3. Infectious Disease Clinic with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]; the
patient to call for an appointment in two to three weeks.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES: Pericardial efffusion.
[**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 5219**]
Dictated By:[**Last Name (NamePattern1) 7485**]
MEDQUIST36
D: [**2140-5-17**] 14:58
T: [**2140-5-20**] 16:09
JOB#: [**Job Number 28797**]
|
[
"423.9",
"599.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0",
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
3009, 3189
|
8082, 8380
|
7439, 7471
|
5592, 7415
|
7495, 8027
|
4059, 5573
|
155, 182
|
212, 2440
|
2462, 2991
|
3207, 4035
|
8053, 8060
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,205
| 141,889
|
28488
|
Discharge summary
|
report
|
Admission Date: [**2133-3-6**] Discharge Date: [**2133-5-21**]
Date of Birth: [**2064-8-22**] Sex: M
Service: SURGERY
Allergies:
Novocain / Vancomycin
Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
PICC site cellulitis
Fever
Major Surgical or Invasive Procedure:
Hickman line placement
History of Present Illness:
68M discharged on [**2133-3-3**] after receiving treatment for
septicemia. A new PICC line was placed. Now returns with
cellulitis at PICC line site and fever.
Past Medical History:
Sigmoid Colon Cancer
Bowel Perforation in [**5-22**] likely secondary to diverticulitis and
onset of steroid use
Paroxsymal Atrial Fibrillation
Hypertriglyceridemia
Polyarteritis Nodosum
PSH:
Appendectomy
Tonsillectomy
Colon Resection
Percutaneous drainage of LUQ abscess
Social History:
Occassional alcohol, no tobacco, no drugs. Pt is a retired
physical education teacher. Lives with wife.
Family History:
Non-contributory
Brief Hospital Course:
[**Known firstname **] [**Known lastname **] was admitted to [**Hospital1 18**] on [**3-6**]/7 under the care of
Dr. [**Last Name (STitle) 957**]. The left arm PICC line was removed and a
peripheral IV was placed for PPN. Labs revealed WBC count at
3.2, Neut% at 72; Hct 21.6. Albumin was low at 2.5. Neupogen
and Epogen were given. Bactrim IV was continued to cover his
previous source of septicemia. Blood cultures and line tip
culture were pending. Urine was negative for infection.
Ultrasound of left upper extremity where PICC removed was read
as having retained fragment, however the PICC was verified as
being intact and there was no introducer sheath used at initial
insertion. No clots were identified. A repeat xray of the arm
was negative for foreign body.
At HD 2 WBC was increased to 23.2 and there was no change in the
Hct in response to the Epogen.
At HD 3 he continued to have fever spikes. It was decided that
Neupogen would not be continued due to its past effects on his
skin syndrome/Sweet's syndrome. Epogen was continued with no
effect. He was very weak this admission and had difficulty
eating. PPN was provided. Blood cultures and PICC line tip
culture were negative. C. difficile was negative.
At HD 4 he continued with fevers and rigors. The old PICC site
cellulitis had improved. Repeat blood cultures were sent. Chest
xray showed some consolidation at the medial right lung base.
Infectious disease and Hem/Onc were consulted. Per
recommendations Bactrim was discontinued and Cefepime was
started for empiric coverage. Flagyl was also started to combat
possible c. difficile. Irradiated PRBCs were transfused for Hct
of 20.3.
At HD 5 repeat CXR showed resolution of
consolidation/aspiration. Tests for CMV, EBV, Cryptococcal
antigen, Cryptosporidium, Giardia, Legionella, MRSA were
negative. Repeat blood cultures were negative. He continued to
have fever at 102.4. We discussed placing a nasojejunal tube
for temporary feedings, as he was not taking in adequate
calories (411 kcal and 14g protein/day) due to difficulty
swallowing. However, he decided against this option at the
time. Paxil was started for depression.
At HD 8 he had not spiked a fever within 24 hours. Hibiclens
wash was provided, and he was taken to the operating room for
Hickman placement per Dr. [**Last Name (STitle) **]. He tolerated the procedure
well and was returned to the floor. TPN was resumed after
verification of Hickman placement. WBC count was down to 2.3;
Hct was 21.0 from 24.7 post-transfusion. Red cell morphology
revealed [**Doctor Last Name 30674**] formation. Hem/Onc planned to review peripheral
smear. Hemolysis labs were WNL.
At HD 10 he continued to be afebrile on Cefepime/Flagyl. He was
weak and was unable to ingest adequate calories. Albumin was
2.4 and Transferrin was 88. TPN calories
At HD 15 CXR showed left pleural effusion. He was transfused for
a Hct of 21.2. Lasix was given with blood and he experienced
incontinence over night. A condom cath was provided. CEA was
1.1.
At HD 16 he was febrile to 101.5. Cultures were sent. Flomax
was started for urinary retention. Sputum culture was positive
for MRSA and pseudomonas. Antibiotics were changed to
Vancomycin/Meropenem. He had difficulty eating and there was
concern for aspiration. He was made NPO.
At HD 22 he continued to have episodes of fever. He was also
very weak and was incontinent of urine requiring condom
catheter. Blood/urine cultures were negative. Repeat cultures
were sent.
At HD 23 CXR showed a left pleural effusion. He developed left
eye swelling consistent with previous episodes of skin lesions.
Opthamology evaluated and treated for conjunctivitis with good
response. WBC count was 10.1; Hct 24.5. He continued to be
febrile to 102.6. Zosyn replaced Meropenem per ID
recommendation. IVIG was given.
At HD 26 Neurology was asked to see him regarding pronounced
tremors and mild confusion. Liver enzymes were elevated from
normal with T. Bili at 3.3. RUQ ultrasound showed no biliary
ductal dilatation or evidence of acute cholecystitis;polyps or
sludge balls within the gallbladder; and enlarged spleen with
unusual configuration. There was no evidence of subphrenic
abscess. Ammonia level was WNL. Urinary and serum copper levels
were sent to r/o Wilson's disease.
At HD 27 neuro recommended MRI w/ lumbar puncture to evaluate
for carcinomatous meningitis. GI medicine consulted and wanted
to treat empirically for herpetic hepatitis with Acyclovir. He
continued on Vancomycin and Zosyn. He remained afebrile. Small
bowel tissue was requested from outside pathology to evaluate
for vasculitis/amyloid but were unable to be located.
At HD 28 Bilirubin was decreased to 2.6. Sincalide was started
for cholestasis. Hct was 20.6 and 2 units PRBCs were given. HIV
test was negative.
At HD 30 serum copper was elevated at 1429. Urinary copper was
elevated at >700ml. Opthamology was consulted to evaluate for
[**Doctor Last Name 21721**]-[**Last Name (un) 23070**] rings and this was negative. Repeat urine copper
was sent. Trace elements were removed from TPN.
At HD 31 Liver consult felt that the elevated copper was related
to TPN. Ursodiol was started for cholestasis.
At HD 32 Hct was 21.3. Bilirubin was 2.2. Liver enzymes were
elevated, but trending down from initial elevation.
During hospitalization he was transferred to the ICU for
episodes of atrial fibrillation which were controlled via IV and
PO amiodarone. He continued with mild tremors, photophobia and
neck stiffness. A head/cervical MRI was completed which showed
disc protrusion and osteophytes at C3/4 resulting in compression
of the spinal cord with associated cord edema; moderate
narrowing of the left neural foramen at C7/T1; and multiple
enhancing lymph nodes in the left deep cervical chain. Neuro
was consulted and recommended soft collar which was placed when
in chair or ambulating. Dr. [**Last Name (STitle) 957**] [**Name (STitle) 69047**] a FNA of the
enlarged cervical nodes under ultrasound and this was negative
for culture/pathology.
He continued to require RBC transfusions to maintain Hct. He
became progressively debilitated with periods of confusion. He
continued with intermittent fevers. Blood Cx (-). PNA waxed and
waned as he was not mobilizing secretions. Sputum was
(+)pseudomonas, MRSA, GNR.
At HD 55 his abdomen was tender and he had watery output from
ostomy. C. diff was negative. KUB was (-) for obstruction or
pneumatosis. He was hydrated for possible ischemic colitis.
A RUQ ultrasound was reevaluated which showed gallbladder wall
edema and sludge with ? cholecystitis, and increased liver
echogenicity.
At HD 65 he had ? aspiration which required ventilatory support.
He was transferred to the unit and intubated. During his ICU
stay he was febrile. He was hypotensive and was supported with
Albumin/fluid resuscitation.
After much discussion with his wife it was decided to make the
patient CMO. On [**2133-5-21**] he died.
Medications on Admission:
Digoxin
Zyrtec
Imodium
Pantoprazole
Discharge Disposition:
Home With Service
Facility:
IVIG at [**Hospital3 **] Hospital
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2133-6-8**]
|
[
"V45.3",
"518.81",
"V15.3",
"427.31",
"682.2",
"V55.3",
"276.51",
"695.89",
"579.3",
"788.38",
"781.0",
"V09.0",
"996.62",
"576.8",
"238.75",
"600.01",
"482.1",
"V10.06",
"261",
"788.20",
"783.7",
"376.33",
"482.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.17",
"96.04",
"40.11",
"00.14",
"38.91",
"99.04",
"96.72",
"99.15",
"38.93",
"86.07"
] |
icd9pcs
|
[
[
[]
]
] |
8087, 8151
|
999, 8001
|
307, 331
|
8202, 8211
|
8267, 8304
|
958, 976
|
8172, 8181
|
8027, 8064
|
8235, 8244
|
241, 269
|
359, 522
|
544, 818
|
834, 942
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,020
| 115,829
|
6091
|
Discharge summary
|
report
|
Admission Date: [**2123-2-22**] Discharge Date: [**2123-2-28**]
Date of Birth: [**2063-12-31**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
Headache.
Major Surgical or Invasive Procedure:
Arterial line for blood pressure monitoring.
History of Present Illness:
Patient is a 59 year old right handed Chinese man with past
medical history of hypertension, asthma, eczema, allergic
rhinitis, chronic low back pain, who presented to [**Hospital1 18**] ED on
[**2123-2-22**] complaining of headache pain.
Patient was in his usual state of health until evening of
[**2123-2-21**]. At that time, he had gradual onset of headache,
described as a dull vise-like tightness, in the frontal area.
Associated with nausea, dizziness as in lightheadedness,
bilateral tingling of hands. No focal weakness, visual changes,
fevers, chills, meningismus, phonophobia, photophobia. He took
aspirin and motrin without relief. He tried a Chinese herbal tea
without relief. After headache had persisted for greater than 12
hours he called 911 and was transported to the [**Hospital1 18**] ED.
On arrival to ED, vitals temp 97.7, HT 84, BP 155/74, RR 17,
oxygen 98%/Room air. While in the ED, the numbness in his
fingers resolved. While in the ED, he received Toradol 30 mg IV,
Compazine 5 mg IV, Hydralazine 10 mg IV, and was loaded with 1
gram of Dilantin. Head CT showed a large right parietal
parasagittal hemorrhage with intraventricular hemorrhage as
well. He was seen by Neurosurgery, who deferred surgical
intervention.
Per Neurosurgery recommendations, patient underwent an MRI/MRA
while in ED. This showed ntraparenchymal hemorrhage within the
medial right occipital lobe extending into the right lateral
ventricle without underlying enhancement. Given the presence of
multiple tiny foci of abnormal signal on susceptibility imaging
within the cerebral cortex, the basal ganglia, the brainstem,
and cerebellum, this finding was felt to represent an acute
intraparenchymal hemorrhage in the setting of chronic
amyloidosis or chronic hypertensive hemorrhage.
He was admitted to the Neurology service for further work up and
management. Follow up head CT on [**2123-2-23**] showed stable
appearance of hemorrhage and no evidence of increased
intracranial pressure or hydrocephalus.
Past Medical History:
1. Hypertension
2. Asthma
3. Eczema
4. Allergic Rhinitis
5. Chronic low back pain, described as sciatica, L4/L5 level
6. Right renal cyst
7. History of renal artery stenosis
Social History:
Married. Lives with wife and son. [**Name (NI) 1403**] at [**University/College **] doing research in
an animal lab. No tobacco, alcohol, drug use.
Family History:
Father with hypertension, deceased at 89 years old from gastric
cancer. Mother died of unknown causes. No family history of
stroke, aneurysm, bleeding diathesis.
Physical Exam:
General: Well-developed, well-nourished Chinese man,
uncomfortable from headache, appears stated age, in mild
distresss.
HEENT: Normocephalic, atraumatic, oropharynx clear.
Neck: Supple, no carotid bruits.
Chest: Clear to auscultation bilaterally.
Cardiovascular: Regular rate, normal s1/s2, no murmurs, rubs,
gallops.
Extremities: No clubbing, cyanosis, edema. 2+ dorsalis pedis
pulses bilaterally.
Neurologic Exam:
Mental status: Oriented to person, place and time. Alert. Able
to say months of year backwards. Fluent speech, repetition,
naming intact. Able to read and write. Memory [**1-21**] registration,
recall [**1-21**] at 5 minutes. No apraxia. Left sided neglect.
Cranial nerves: Patient unable to cooperate with formal visual
fields but blinks to threat bilaterally. Pupils round 2 mm->
1.5mm with light. Extraocular eye movements intact without
nystagmus. Normal facial sensation and strength.
Hearing intact to finger rub. Palate rises symmetrically.
Tongue midline.
Motor: Normal tone and bulk. No tremors or fasciculations.
Pronator drift absent. Patient in fair amount of distress from
headache, so did not formally test resistance. Able to hold both
arms and legs against gravity for several seconds.
Reflexes: There are [**12-25**] reflexes in upper extremities. Right
patella 3+ with spread. No clonus. Plantar reflexes extensor
bilaterally.
Sensory: Intact to light touch.
Coordination: Intact finger to nose bilaterally.
Pertinent Results:
[**2123-2-22**] 06:35AM WBC-11.9*# RBC-5.02 HGB-15.5 HCT-45.3 MCV-90
MCH-31.0 MCHC-34.3 RDW-13.2
[**2123-2-22**] 06:35AM NEUTS-78.1* LYMPHS-18.4 MONOS-3.0 EOS-0.3
BASOS-0.2
[**2123-2-22**] 06:35AM PLT COUNT-222
[**2123-2-22**] 06:35AM PT-12.7 PTT-33.7 INR(PT)-1.0
[**2123-2-22**] 06:35AM GLUCOSE-147* UREA N-15 CREAT-1.1 SODIUM-139
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-22 ANION GAP-17
[**2123-2-22**] 06:35AM CALCIUM-9.4 PHOSPHATE-1.9* MAGNESIUM-2.0 URIC
ACID-4.7
[**2123-2-22**] 06:35AM CK(CPK)-55
[**2123-2-22**] 06:35AM CK-MB-NotDone
[**2123-2-22**] 08:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2123-2-22**] 08:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2123-2-22**] 08:00AM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0
-----
CT head without contrast: There is a nearly 24-mm area of acute
hemorrhage within the right parietal lobe in a medial
parasagittal locale. There is moderate extension of the
hemorrhage into the right lateral ventricle, with a tiny amount
of hemorrhage seen in the anterior aspect of the third ventricle
near the foramen of [**Last Name (un) 2044**]. A small quantity of blood is also
seen in the right temporal [**Doctor Last Name 534**]. There is a mild amount of edema
surrounding the right parietal hemorrhage, most notably superior
to the hemorrhage itself. Additionally, there is an 11- mm area
of hypodensity within the left frontal lobe white matter and an
approximately 5 mm solitary hypodense zone within the right
frontal white matter. There is no hydrocephalus. There is
effacement of the right cerebral hemisphere cortical sulci
superiorly, likely due to the mass effect of the hemorrhage.
There is no shift of normally midline structures. There is a
prominent degree of mucosal thickening within both ethmoid sinus
complexes, the right maxillary sinus, and in the sphenoid sinus.
There is a suggestion that some of this mucosal thickening may
be polypoid in configuration. Additional probable polyps are
seen within the nasal cavity bilaterally. No other overt
extracranial abnormalities are seen.
CONCLUSION: Large right parietal parasagittal hemorrhage with
intraventricular hemorrhage as well. In conjunction with the
hypodense areas within both frontal lobes, the most common
differential diagnostic consideration would be hemorrhage,
possibly into an underlying infarction with additional areas of
prior brain infarction. This diagnosis is favored if there is a
history of chronic hypertension. Alternatively, hemorrhage into
a preexistent tumor, with the additional hypodense foci possibly
representing other sites of neoplastic disease could be
considered. An underlying vascular malformation would be
statistically less likely.
-----
MRI head [**2123-2-22**]: A focus of acute hemorrhage is present within
the medial right occipital lobe with extension into the right
lateral ventricle. No underlying abnormal enhancement is
present. Scattered tiny foci of abnormal signal on
susceptibility imaging are present in the cerebral cortex,
thalamus, basal ganglia, pons, and cerebellum. . A chronic area
of lacunar infarction is present within the white matter of the
left frontal lobe. There is no evidence of hydrocephalus or
shift of midline structures. There is no evidence of signal
abnormalities on diffusion weighted imaging to suggest acute
infarction.
IMPRESSION:
1. Intraparenchymal hemorrhage within the medial right occipital
lobe extending into the right lateral ventricle without
underlying enhancement. Given the presence of multiple tiny foci
of abnormal signal on susceptibility imaging within the cerebral
cortex, the basal ganglia, the brainstem, and cerebellum, this
finding likely represents an acute intraparenchymal hemorrhage
in the setting of chronic amyloidosis or chronic hypertensive
hemorrhage.
2. Foci of abnormal signal within the periventricular white
matter that have an appearance suggestive of chronic
microvascular angiopathy, as well as a chronic lacunar
infarction within the centrum semiovale on the left.
-----
CT/CTA head [**2123-2-22**]: The high density material in the right
parieto-occipital region and in the right lateral ventricle is
unchanged from previous examination consistent with stable
hematoma with ventricular extension. There is no definite new
findings. Ventricular dimension is stable.
IMPRESSION: Stable appearance of right parieto-occipital
hemorrhage with intraventricular extension.
CT ANGIOGRAM: There is no evidence of aneurysm or flow
abnormality. No deficient branches noted in the right
parieto-occipital or posterior cervical regions.
IMPRESSION: Negative CT angiogram.
-----
CT head without contrast [**2123-2-25**]: This examination is unchanged
when compared to [**2123-2-23**] with a stable intraparenchymal
hemorrhage within the medial right occipital lobe extending into
the right lateral ventricle with associated surrounding
edema/mass effect. The ventricles and sulci are unchanged in
size. No new areas of hemorrhage are seen. Foci of
hypoattenuation within the centrum semiovale bilaterally are
stable. Bone windows showed continued opacification of both
sphenoid sinuses and the ethmoid air cells.
IMPRESSION: Unchanged examination when compared to [**2123-2-23**].
Brief Hospital Course:
Patient is a 59 year old Chinese man with past medical history
of hypertension who presented to the [**Hospital1 18**] ED on [**2123-2-22**] for
evaluation of 12 hours of bifrontal dull headache pain
associated with nausea, bilateral hand tingling. Neurologic exam
reveals left neglect, albeit full exam is limited by patient's
distress from headache pain. Imaging has revealed a large right
parietal parasagittal hemorrhage with intraventricular
hemorrhage as well. MRI susceptability images revealed areas of
microbleeding in the thalami bilaterally. Differential diagnosis
for etiology of bleeding includee amyloid angiopathy, cavernous
angioma, hemorrhagic stroke or hypertension.
Patient was admitted to the Neurology ICU. Blood pressure was
monitored with goal <160 systolic. Repeat CT scans showed stable
size of hemorrhage and ventricular system. On CT Angiogram,
there was no evidence of aneurysm or flow abnormality. No
deficient branches noted in the right parieto-occipital or
posterior cervical regions. MRI/MRA demonstrated
intraparenchymal hemorrhage within the medial right occipital
lobe extending into the right lateral ventricle without
underlying enhancement. Given the presence of multiple tiny foci
of abnormal signal on susceptibility imaging within the cerebral
cortex, the basal ganglia, the brainstem, and cerebellum, this
finding was felt to likely represent an acute intraparenchymal
hemorrhage in the setting of chronic amyloidosis.
On neurologic exam, he initially had a left visual neglect. Over
the course of his hospital stay, this neglect improved. Blood
pressure was well controlled on his home Diltiazem regimen.
Headache pain was initially controlled with narcotics, but
patient was later transitioned to Tylenol for pain control. An
aggressive bowel regimen was ordered to prevent straining and
subsequent increased intracranial pressure. Supportive care was
given for nausea and vomiting, including intravenous fluids and
antiemetics.
Patient was evaluated by physical therapy, who felt he could
benefit from a home safety evaluation. On day of discharge, his
headache pain was well controlled with Tylenol alone. He was
tolerating a regular diet with no nausea or vomiting.
Neurologically, he had no discernable focal deficits.
Given the microhemorrhage seen on MRI, suggestive of extensive
amyloid angiopathy, patient needs to avoid aspirin and
non-steroidal medications as these increase his risk of
subsequent bleeding. Tylenol should be utilized for pain
control.
Medications on Admission:
1. Aspirin
2. Diltiazem
3. Ibuprofen
4. Flonase
Discharge Medications:
1. Fexofenadine HCl 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
3. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
4. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
1. Right parietal intraparenchymal hemorrhage with
intraventricular extension
2. Hypertension
Discharge Condition:
Stable. Hemodynamically stable. No neurologic deficits except
for question of left visual neglect, flattening of left
nasolabial fold.
Discharge Instructions:
Please return to the hospital if you develop severe headache,
nausea/vomiting, chest pain, shortness of breath or any other
severe symptoms. Please call your doctor with any questions
about your symptoms.
Due to an increased risk of bleeding in your pain, you should
avoid use of aspirin or any non-steroidal pain medication like
Ibuprofen or Naprosyn. Use Tylenol for pain control.
Followup Instructions:
The following appointment has already been scheduled:
Provider: [**First Name8 (NamePattern2) **] [**Known lastname **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2123-3-29**] 11:40
Follow-up with Drs. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and [**Name5 (PTitle) **] [**Doctor Last Name **] in
[**Hospital 4038**] Clinic. Call [**Telephone/Fax (1) 657**] to schedule an appointment.
|
[
"276.5",
"493.90",
"401.9",
"277.3",
"431"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
12819, 12876
|
9786, 12299
|
327, 373
|
13014, 13150
|
4437, 9763
|
13582, 14074
|
2789, 2952
|
12397, 12796
|
12897, 12993
|
12325, 12374
|
13174, 13559
|
2967, 3368
|
278, 289
|
401, 2410
|
3660, 4418
|
3400, 3644
|
3385, 3385
|
2432, 2608
|
2624, 2773
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,347
| 104,003
|
45955
|
Discharge summary
|
report
|
Admission Date: [**2150-7-24**] Discharge Date: [**2150-8-4**]
Date of Birth: [**2094-12-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Right lower lobe lung nodule
Major Surgical or Invasive Procedure:
Flexible bronchoscopy, VATS right lower lobe wedge, followed by
VATS right lower lobectomy, mediastinal lymph node dissection.
History of Present Illness:
Mr. [**Known lastname 37080**] is a 55-year-old gentleman who is referred to the
Thoracic [**Hospital 32535**] Clinic by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**]. Mr.
[**Known lastname 37080**] had had a
cerebellar tumor resected in [**2140**]. The pathology on this was
adenocarcinoma, which appeared to be metastatic from an unknown
primary. During recent workup for his shoulder pain, he
underwent films which revealed a new pulmonary nodule on the
right side. This was followed with a chest CT, which confirmed
the presence of two new nodules (in comparison with CT scan done
in [**2143**]), in the right lower lobe (FDG avid) as well as a stable
nodule in the right upper lobe.
Mr. [**Known lastname 37080**] [**Last Name (Titles) **] any shortness of breath, cough, purulent
sputum production or hemoptysis. He [**Last Name (Titles) **] any recent pulmonary
infection or travel to the southwest United States. He notes
that he exercises regularly without any shortness of breath or
chest pain. He [**Last Name (Titles) **] any fevers, chills, or sweats. He [**Last Name (Titles) **]
any weight loss. He [**Last Name (Titles) **] any new body pain or neurological
symptoms.
Past Medical History:
Hypertension
Coronary artery disease s/p Myocardial infarction
CABG ([**2139**])
Heart Failure (EF 20-30%)
Hypercholexterolemia
Cerebellar tumor (adenocarcinoma) s/p resection ([**2140**])
Tremor
Anxiety
Avascular necrosis of right humerus
S/P Cholecystectomy
S/P Right shoulder surgery x 2
Hypothyroidism
Bilateral cataract surgery
Erectile dysfunction
Social History:
He is married. He has 3 children between the ages of 20-30. He
works for NSTAR and does have a history of asbestos exposure. He
smoked 2-1/2 packs per day for 20 years, but quit 10 years ago.
He does not drink alcohol.
Family History:
There is no family history of breast, ovarian, uterine, colon,
or lung cancer. His brother did have pancreatic cancer at the
age of 70. His mother died at age 83. He does not know of any
specific medical problems that she had. His father
died at age 52 of a myocardial infarction. He also had a sister
who died of an aneurysm.
Physical Exam:
VITAL SIGNS: Temperature 98.8, pulse 72, blood pressure 98/65,
respiratory rate 16, oxygen saturation 95% on room air, height
68 inches, and weight 193.8 Lbs.
GENERAL: Well-nourished, well-developed gentleman in no apparent
distress, alert and oriented x3 with an obvious tremor.
HEENT: Surgical scar on the cranium. EOMI. PERRL. Sclerae are
anicteric. Oropharynx and nasopharynx free of mucosal
abnormality. Tongue midline. Palate elevates symmetrically.
Trachea is midline.
NECK: Supple and nontender without mass. Thyroid is of normal
size.
LUNGS: Clear to auscultation and percussion. Chest excursion is
symmetric and good. There is no tactile fremitus or gapping.
There is no spine or CVA tenderness.
BACK: There is a healed median sternotomy scar.
HEART: Regular rate and rhythm without murmur, rub, or gallop.
There is no JVD, PMI is normal position.
GI: Soft, nontender, nondistended, without mass or
hepatosplenomegaly. There is a well-healed scar from his
cholecystectomy.
NEUROLOGIC: Strength is symmetric and intact. Sensation is
symmetric and intact. There is a obvious tremor. Gait is slow
but symmetric.
LYMPH NODES: No supraclavicular, cervical or axillary
lymphadenopathy.
EXTREMITIES: No clubbing, cyanosis, or edema. There is some
facial erythema.
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2150-7-30**] 10:45AM 36.1*
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2150-7-29**] 10:26AM 311
MISCELLANEOUS HEMATOLOGY ESR
[**2150-7-29**] 06:10AM 113*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2150-8-2**] 04:43AM 3.9
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2150-7-31**] 07:00AM 143*
OTHER ENZYMES & BILIRUBINS Lipase
[**2150-7-31**] 07:00AM 165*
CPK ISOENZYMES CK-MB MB Indx cTropnT
[**2150-7-24**] 10:50PM 15* 1.3 <0.011
ART
1 <0.01
CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
[**2150-7-24**] 02:40PM 5 <0.011
ADDED TNT,CK,CPIS [**2150-7-24**] 5:08PM
1 <0.01
[**Month/Day/Year 706**] Final Report
CHEST (PA & LAT) [**2150-7-31**] 10:36 AM
Reason: eval for interval change
[**Hospital 93**] MEDICAL CONDITION:
55 year old man with s/p vats RLL
REASON FOR THIS EXAMINATION:
eval for interval change
INDICATION: Evaluation for interval change.
FINDINGS: There is mild improving apical right pneumothorax.
There has been interval increase in right lower lobe
atelectasis. However, the subpulmonic effusion is stable. Left
lung is clear. Heart, mediastinum and hilar contours are normal.
The patient is status post sternotomy.
IMPRESSION: Improving small right apical pneumothorax.Worsening
right basilar atelectasis
CT HEAD W/ & W/O CONTRAST [**2150-7-28**] 10:21 AM
Reason: please eval for etiology
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
55 year old man with aggitation altern w/ episode sedation; s/p
cerebellar tumor resection '[**40**]
REASON FOR THIS EXAMINATION:
please eval for etiology
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 55-year-old man with agitation alternating with
sedation. Status post cerebellar tumor resection in [**2140**]. Please
evaluate for etiology.
TECHNIQUE: CT scan of the head prior to and following
administration of IV contrast.
COMPARISON: MR of the head with and without contrast from
[**2150-6-20**].
FINDINGS: There is no evidence of acute intracranial hemorrhage
or major vascular territorial infarcts. [**Doctor Last Name **]-white matter
differentiation is preserved. There is hypoattenuation of the
periventricular white matter consistent with chronic
microvascular disease. The ventricles are mildly enlarged and
the sulci are prominent for the patient's age, consistent with
atrophy. The fourth ventricle is enlarged from patient's
previous cerebellar resection. The superior vermis appears to be
resected.
The visualized paranasal sinuses are clear. There are no soft
tissue or bony abnormalities.
IMPRESSION:
1. No acute intracranial abnormality.
2. Evidence of prior cerebellar resection of the superior vermis
resulting in enlargement of the fourth ventricle.
3. Periventricular white matter disease.
Cardiology Report ECG Study Date of [**2150-7-28**] 8:40:14 AM
Sinus rhythm
First degree A-V delay
Left atrial abnormality
Intraventricular conduction delay
Inferior infarct, age indeterminate
Diffuse ST-T wave abnormalities - cannot exclude ischemia -
clinical
correlation is suggested
Since previous tracing of the same date, no significant change
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
69 [**Telephone/Fax (2) 97846**] 23 -7
Brief Hospital Course:
Mr. [**Known lastname 37080**] was taken to the operating room where he underwent
flexible bronchoscopy, VATS right lower lobe wedge resection,
followed by a VATS right lower lobectomy and mediastinal lymph
node dissection. He was initially extubated, however in the
PACU, he developed hypotension requiring pressors, and
progressive respiratory acidosis requiring reintubation for
airway protection and repeat flexible bronchoscopy. He was
transferred in stable condition to the thoracic intensive care
unit.
He recovered quickly with improving respiratory status and was
weaned off of pressors. He was weaned from the ventilator and
extubated without complication on the morning of post-operative
day #1 ([**2150-7-25**]). Despite being awake and alert he developed
agitation and confusion requiring a 1:1 sitter, but he continued
to improve clinically, and was transferred to the floor on
[**2150-7-27**]. His chest tubes were pulled later that afternoon
without incident.
He experienced several short burst of ventricular tachycardia on
post-operative day #4 which were asymptomatic and not
hemodynamically significant. He was evaluated by the cardiology
service for possible AICD placement, however these episodes did
not recur, and it was decided to revisit the issue once his
mental status cleared. In addition, he was evaluated by the
neurology service for his confusion and agitation. CT of the
head did not demonstrate any acute abnormality.
Mr. [**Known lastname 37080**] continued to improve both clinically and mentally.
He began to get out of bed and ambulate with the assistance of
physical therapy, and his mental status gradually cleared to the
point where he no longer required a sitter or other supervision.
He is currently doing well and ready for discharge to the
rehabilitation facility. He will require cardiac follow up for
his dysrrhytmia with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] electrophysiology at
[**Hospital1 18**].
Medications on Admission:
AMIODARONE 200 MG--One by mouth qd; brand name
ASPIRIN 81MG--One by mouth every day
ATENOLOL 25MG--Half a tablet by mouth every day
FLEXERIL 10 mg--1 tablet(s) by mouth at bedtime
GEMFIBROZIL 600 MG--One tablet by mouth twice a day
IMDUR 30MG--Every day
KLONOPIN 0.5 mg--1 tablet(s) by mouth twice a day as needed for
anxiety
LEVOXYL 75MCG--One by mouth every day
PAXIL 40MG--One by mouth qd; brand name
ZESTRIL 10MG--One by mouth every day
ZOCOR 40MG--One by mouth every day
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for headache.
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
12. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
13. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
14. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
15. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Hypertension, Coronary artery disease s/p MI & CABG '[**39**], CHF
(EF20-30%), Cerebellar tumor s/p resection '[**40**], tremor, anxiety,
^cholesterol, avascular necrosis R humerus s/p Right shoulder
surgery x2, s/p cholecystectomy.
T1/N1/Mx Lung Adenocarcinoma
Discharge Condition:
deconditioned- requires pulmonary hygeiene and physical rehab.
Discharge Instructions:
Call Dr.[**Name (NI) 2347**]/Thoracic Surgery office [**Telephone/Fax (1) 170**] for
any post- surgical issues including: fever, shortness of breath,
chest pain, productive cough.
Followup Instructions:
Please call the Thoracic Oncology Office at [**Telephone/Fax (1) 170**] to
arrange a follow-up appointment with Dr. [**Last Name (STitle) **].
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2151-4-15**]
7:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6781**], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 1844**]
Date/Time:[**2151-4-15**] 9:00
please f/u with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (cardiology) for possible
AICD placement
[**Telephone/Fax (1) 2934**]
Completed by:[**2150-8-6**]
|
[
"V45.81",
"162.5",
"196.1",
"414.00",
"428.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.21",
"33.23",
"40.3",
"32.4",
"32.29"
] |
icd9pcs
|
[
[
[]
]
] |
11212, 11282
|
7427, 9420
|
350, 479
|
11588, 11653
|
3993, 4893
|
11881, 12491
|
2351, 2680
|
9947, 11189
|
5577, 5678
|
11303, 11567
|
9446, 9924
|
11677, 11858
|
2695, 3974
|
282, 312
|
5707, 7404
|
507, 1722
|
1744, 2099
|
2115, 2335
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,157
| 128,798
|
14252
|
Discharge summary
|
report
|
Admission Date: [**2110-12-25**] Discharge Date: [**2111-1-8**]
Date of Birth: [**2049-4-13**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Azithromycin / Dapsone /
Spironolactone / tenofovir
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Bradycardia
Major Surgical or Invasive Procedure:
right internal jugular line placement
right tunneled line placement
History of Present Illness:
Mr. [**Known lastname **] is a 61yo male with a past medical history significant
for CAD s/p CABG in [**2102**], HIV, hepatitis B and C, who presented
to the ED with bradycardia to the 30s. The patient reports that
he was in his baseline state of health until about 24 hours
prior to admission, when he began to feel SOB. He also reports
that he had chest pressure for about the day prior to admission,
which was relieved with administration of oxygen in the
ambulance. The patient reports taht he has been eating a lot of
potatoe chips lately. He denies use of heroin and cocaine since
mid-[**Month (only) 359**]. Notably, the patient is somnolent and it is
difficult to obtain a throrough history although he does answer
questions appropriately. He denies cough, fevers, [**Month (only) 28877**], sore
throat, rhinorrhea, headache, ear pain, sick contacts. [**Name (NI) **] says
that he is able to walk down his hallway and is not able to walk
up stairs, limited by shortness of breath. He denies orthopnea.
He denies recent travel, no hiking and no tick bites.
In the ED, the patient was initially bradycardic to the 30s and
initially normotensive, but his pressures then dropped to
systolic 70s. Bedside ultrasound was performed which showed no
pericardial effusion and poor ventricular squeeze. Fingerstick
was 99. The patient was given atropine 1mg without change. There
was concern for beta blocker vs calcium channel blocker
overdose and the patient was given glucagon 5mg PO with zofran.
The patient vomited in response. A cordis was placed in the RIJ
and a dopamine drip was started which increased her HR to 50s
and SBP to 100. A CXR revealed bilateral pleural effusions,
unable to exclude pna. The patient was started on broad spectrum
abx for presumed pna. The patient did receive about 1L of NS.
Throughout the patient's time in the ED, he was mentating well.
Labs are notable for creatinine 4.2 (baseline 1.5), troponin
0.03, lactate 3 and potassium 6.1 repeat K is 4.2.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, cough, hemoptysis, black stools or
red stools. He denies recent fevers, [**Name (NI) 28877**] 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 paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
- Diabetes mellitus
- Dyslipidemia
- Hypertension
- Coronary artery disease s/p CABG [**2102**] with LIMA to LAD, SVG to
OM, s/p RCA stent in [**6-/2099**], re-stented in [**2-/2100**], positive
stress test in [**5-/2102**]
- CHF, LVEF 40-45% in [**2109**]
- HIV infection diagnosed in [**2084**]
- Hepatitis C, Genotype 2, not treated. Last liver biopsy in
[**2103**] showed mild portal and periportal lobular inflammation
grade 1 along with increased portal fibrosis with focal septal
and bridging fibrosis.
- Hepatitis B HBsAg-, HBsAb+, HBcAb+
- TB s/p treatment
- Anemia of chronic disease
- PVD
- History of R ocular stroke
- Status post left arm surgery for necrotizing fasciitis.
- Status post left hip surgery for abscess.
- Status post VATS [**11-1**] for pleural biopsy due to bloody
pleural effusion - cytology (-) for malignancy; c/b wound
dehiscence
- Renal insufficiency. Cr 1.2-1.5
- Hypokalemia.
- Erectile dysfunction.
- Lipodystrophy.
- Nephropathy and neuropathy, secondary to diabetes.
- Thyroid nodules.
Social History:
Mr. [**Known lastname **] is a 35 pack years smoker, stopped smoking in [**2100**]
restarted in [**3-3**]. History of alcoholism - sober since [**2100**]. No
alcohol use since then. IVDU history: Quit IV heroin and
cocaine, relapsed in [**3-3**] and is currently using. Married to a
woman who is HIV+, has one son. [**Name (NI) 1403**] two days per week at a
desk job.
Family History:
Mother died of heart disease at 32, had scarlet fever. History
of depression and alcoholism. Father died at 66 of an intestinal
gangrene after a rupture and had diabetes, alcoholism and h/o
aneurysm. There is no history of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T=95.7 BP=47 HR=103/40 RR=14O2 sat= 100% 2L NC
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa, dry mucous
membranes. No xanthalesma.
NECK: Supple with JVP of at jaw line.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. bradycardia, normal S1, S2. diastolic murmer best
appreciated at LUSB. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. decreased breath sounds
at bases.
no wheezes
ABDOMEN: Soft, NT, distended. No HSM or tenderness. Abd aorta
not enlarged by palpation. No abdominial bruits.
EXTREMITIES: No femoral bruits. Large area of scarring, well
healed on L entire left forearm including elbow. Large well
healed scar on left hip. Bilateral lower extremity edema [**2-27**]+.
SKIN: No stasis dermatitis, ulcers, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS:
[**2110-12-25**] 01:15AM [**Month/Day/Year 3143**] WBC-5.8# RBC-3.95* Hgb-11.9* Hct-37.4*
MCV-95 MCH-30.1 MCHC-31.9 RDW-15.4 Plt Ct-97*
[**2110-12-25**] 01:15AM [**Month/Day/Year 3143**] Neuts-59.2 Lymphs-29.2 Monos-7.4 Eos-3.8
Baso-0.4
[**2110-12-25**] 01:15AM [**Month/Day/Year 3143**] PT-12.9* PTT-35.8 INR(PT)-1.2*
[**2110-12-25**] 01:15AM [**Month/Day/Year 3143**] Plt Ct-97*
[**2110-12-25**] 01:15AM [**Month/Day/Year 3143**] Glucose-83 UreaN-35* Creat-4.2*# Na-134
K-6.1* Cl-104 HCO3-22 AnGap-14
[**2110-12-25**] 05:30AM [**Month/Day/Year 3143**] ALT-22 AST-39 LD(LDH)-231 CK(CPK)-97
AlkPhos-125 TotBili-1.4
[**2110-12-25**] 01:15AM [**Month/Day/Year 3143**] Calcium-8.8 Phos-3.4# Mg-2.1
[**2110-12-25**] 05:30AM [**Month/Day/Year 3143**] TSH-1.0
PERTINENT LABS:
[**2110-12-26**] 05:38AM [**Month/Day/Year 3143**] Lipase-12
[**2110-12-25**] 01:15AM [**Month/Day/Year 3143**] cTropnT-0.03*
[**2110-12-25**] 05:30AM [**Month/Day/Year 3143**] TSH-1.0
[**2110-12-26**] 10:09AM [**Month/Day/Year 3143**] RheuFac-57*
[**2110-12-25**] 05:30AM [**Month/Day/Year 3143**] ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2110-12-25**] 01:19AM [**Month/Day/Year 3143**] Lactate-3.0* K-4.2
[**2110-12-25**] 07:42PM [**Month/Day/Year 3143**] Lactate-3.3*
[**2110-12-29**] 12:05PM [**Month/Day/Year 3143**] Fibrino-297#
[**2110-12-29**] 02:00AM [**Month/Day/Year 3143**] LD(LDH)-218 TotBili-0.4
[**2110-12-29**] 02:00AM [**Month/Day/Year 3143**] Hapto-29*
[**2110-12-26**] 10:09AM [**Month/Day/Year 3143**] ANCA-NEGATIVE B
[**2110-12-26**] 10:09AM [**Month/Day/Year 3143**] [**Doctor First Name **]-NEGATIVE
[**2110-12-26**] 10:09AM [**Month/Day/Year 3143**] RheuFac-57*
HIT PF4 antibody negative
ECHO [**12-25**] The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF 65%). The right ventricular free wall
thickness is normal. The right ventricular cavity is dilated
with borderline normal free wall function. [Intrinsic right
ventricular systolic function is likely more depressed given the
severity of tricuspid regurgitation.] There is abnormal septal
motion/position. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild to moderate
([**1-26**]+) aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. Moderate to severe [3+] tricuspid
regurgitation is seen. [In the setting of at least moderate to
severe tricuspid regurgitation, the estimated pulmonary artery
systolic pressure may be underestimated due to a very high right
atrial pressure.] There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2110-5-10**], the tricuspid regurgitation appears worse, and
the right ventricle is dilated.
CXR [**12-25**] Moderate-to-large loculated right pleural effusion
appears increased in size from prior exam. Moderate left pleural
effusion is unchanged. Bibasilar opacities likely represent
atelectasis or infection in the appropriate clinical setting.
Mild pulmonary edema.
CXR [**12-25**] Comparison is made with prior study performed one hour
earlier.
Right IJ catheter sheath tip is at the distal/lower right
jugular vein.
Cardiomegaly is stable. Moderate right and small-to-moderate
left pleural
effusions with adjacent bibasilar atelectases are unchanged.
Mild pulmonary edema is unchanged. Multiple surgical clips
project over the left cardiac border. Several leads and external
monitors are noted.
KUB [**12-28**] ileus
Right UE duplex US [**12-28**] No DVT.
CXR: [**1-5**]
PA and lateral views of the chest. A right internal jugular
hemodialysis catheter ends in the low SVC. Sternotomy wires and
mediastinal clips are seen. Bilateral layering pleural effusions
are unchanged. No pneumothorax. Moderate cardiomegaly is stable.
Bibasilar atelectasis. There is decreased interstitial edema and
pulmonary vascular congestion.
IMPRESSION:
1. Stable bilateral layering pleural effusions. Decreased
pulmonary edema.
2. No evidence for pneumonia or active or nonactive
tuberculosis.
DISCHARGE LABS:
[**2111-1-7**] 06:31AM [**Month/Day/Year 3143**] WBC-5.7 RBC-2.65* Hgb-8.2* Hct-25.8*
MCV-98 MCH-31.0 MCHC-31.9 RDW-17.7* Plt Ct-130*
[**2111-1-7**] 06:31AM [**Month/Day/Year 3143**] Glucose-198* UreaN-51* Creat-6.4*# Na-136
K-3.9 Cl-100 HCO3-27 AnGap-13
Brief Hospital Course:
61yo male with past medical history of CAD s/p CABG, HTN, HLD,
diabetes, HIV, hepatitis C and B who is presented with
bradycardia, bilateral pleural effusions, concern for PNA by
chest imaging and acute on chronic renal failure.
ACUTE CARE:
# BRADYCARDIA - The patient initially presented with bradycardia
in a junctional rhythm and hypotension. With dopamine, the
patient's junctional rhythm converted to sinus bradycardia. All
home antihypertensives were discontinued, Echo showed EF of 65%
which was improved from prior. His HR and [**Month/Day/Year **] pressure
increased with dopamine, which he was eventually weaned off. The
patient's bradycardia is of unclear etiology. The most likely
etiology is the possibility of a toxin which was in the heroin
he used 2 days prior to admission. Bradycardia resolved
spontaneously and patient was able to be started on [**1-26**] dose
metoprolol.
# ELEVATED PULMONARY ARTERY PRESSURES, RIGHT VENTRICULAR
DYSFUNCTION ?????? Question of elevated PA pressures on echo but
Right heart cath did not show evidence of right heart failure or
pulm HTN. [**Doctor First Name **], ANCA were negative.
# ACUTE ON CHRONIC RENAL FAILURE - patient with chronic renal
insufficiency with baseline creatinine of 1.5 likely secondary
to poorly controlled hypertension and diabetes. Ceatinine on
presentation elevated to [**8-1**] with muddy casts on urinalysis and
no evidence of active sediment. Acute renal failure was
attributed to ATN from hypotension in the setting of poor
forward flow. Tenofovir was also discontinued given possible
cytotoxic nephrogenic effect. Medications were renally dosed.
Nephrology was consulted and although patient initially refused
HD, dialysis was eventually initiated due to metabolic
abnormalities and uremia. Although urine output slowly improved
through hospital course, patient remained with marginal GFR and
gross fluid overload. A tunneled line was placed with the plan
to continue dialysis as an outpatient. Hepatitis B surface
Antigen was negative (core antibody positive, viral load in
[**6-/2110**] was undetectable) and chest x-ray showed no evidence of
active Tuberculosis (hx of Tb s/p treatment).
# HIV: VL in [**9-/2110**] is 61 with CD4 count of 205, repeat VL
during hospitalization was 56. Due to renal function, HAART
regimen was held at time of presentation, and he was started on
a drug holiday. Management of his HAART regimen will be
difficult given his resistance and his renal failure. Atovaquone
ppx was initiated given low CD4 count. Patient will follow up
with outpatient physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 438**], to discuss possible
HAART regimens.
# Thrombocytopenia: baseline platelet count is 100, trended down
to 48 during hospitalization. Heparin was discontinued and
evaluation for TTP, DIC and HIT were negative. Acute decrease
in platelet count was felt to be secondary to acute illness.
Platelet count improved spontaneously and heparin was
reinitiated. At time of discharge, platlet count had improved
to baseline of 120s.
# Diabetes: HgA1C was 7.9% in [**2110-6-25**]. Home regimen: 70/30
40U subq qam and 30 U subq qpm. Given new onset renal failure,
insulin dose was reduced by [**1-26**] and gradually titrated to
achieve euglycemia. At time of discharge, patient was taking
70/30 30U qam and 20U qpm. If patient remains hyperglycemic, he
was instructed to increase dose by 2U and call endocrinologist
at [**Last Name (un) **].
# LOOSE STOOLS ?????? While patient was on broad spectrum abx (see
below), patient was noted to have copious loose stools. Cdiff
toxins was negative and change in bowel movements was attibuted
to antibiotic associated diarrhea. Bowel regimen was held and
patient developed relative constipation with KUB consistent with
ileus. Ileus was managed conservatively with uptitrated bowel
regimen, and by time of discharge, bowel movements had returned
to normal.
# (?) PNEUMONIA - On presentation, patient complained of dyspnea
with CXR consistent with pulmonary edema. Pneumonia could not
be excluded. Given initial presentation with hypotension,
patient was empirically covered with broad spectrum antibiotics
of vanc/ zosyn. As clinical status improved, all antibiotics
were discontinued. Respiratory status improved with initiation
of dialysis and fluid removal.
CHRONIC CARE:
# Polysubstance abuse: admitted to recent heroine use last on
[**12-22**], denies recent cocaine use. Urine tox screen positive for
opiates. Patient was seen by social work and counseled on drug
cessation
# CAD s/p CABG in [**2102**]. As above, there was no evidence of
ischemia per EKGs or repeat Echo. Patient had reportedly not
been taking his aspirin at home.
# HTN: the patient has a history of hypertension but was
hypotensive during his hospital stay. Metoprolol, felodipine,
valsartan, lisinopril, spironolactone were discontinued. [**Year (4 digits) **]
pressure stablized with SBP 110-130s and patient was able to be
re-initiated on metoprolol XL 50mg.
# Hyperlipidemia: lipids well controlled in 6/[**2110**]. Continued
pravastatin.
# Neuropathic pain: Continue amitriptyline 10mg tablet qhs prn
pain.
# Hepatitis C: chronic, stable, untreated. LFTs remained normal
throughout stay, INR is elevated and albumin is low.
ISSUES OF TRANSITIONS IN CARE:
CODE STATUS: full code (CONFIRMED)
COMM: [**Name (NI) 4134**] [**Name (NI) **] (wife) [**Telephone/Fax (1) 42348**]
PENDING STUDIES AT TIME OF DISCHARGE: none
ISSUES TO ADDRESS AT FOLLOW UP:
1. Acute on chronic Renal failure:
- continue outpatient hemodialysis
- monitor urine output and kidney function with goal to
discontinue HD once ATN has resolved
2. HIV:
- follow up with outpatient provider to discuss reinitiation of
HARRT
- cont atovaquone for ppx
3. Diabetes:
- uptitrate insulin to maintain euglycemia
4. HTN: goal BP < 140
- discontinue lisinopril, valsartan, spironolactone, felodipine
- reduce metoprolol to 50mg daily
Medications on Admission:
AMITRIPTYLINE - 10 mg Tablet - 1 (One) Tablet(s) by mouth at
bedtime as needed for neuropathy pain
DARUNAVIR [PREZISTA] - 400 mg Tablet - 2 Tablet(s) by mouth
daily
Take with ritonavir. This is in place of Atazanavir and Kaletra
EMTRICITABINE-TENOFOVIR [TRUVADA] - 200 mg-300 mg Tablet - 1
Tablet(s) by mouth daily
FELODIPINE - 2.5 mg Tablet Extended Release 24 hr - 1 Tablet(s)
by mouth daily
LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth once a day
METOPROLOL SUCCINATE - 100 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth Once daily
PRAVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day
RITONAVIR [NORVIR] - 100 mg Tablet - 1 Tablet(s) by mouth daily
SPIRONOLACTONE - 25 mg Tablet - 1 Tablet(s) by mouth once a day
-
No Substitution
TORSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth Daily
VALSARTAN [DIOVAN] - 160 mg Tablet - 1 (One) Tablet(s) by mouth
twice a day
INSULIN NPH & REGULAR HUMAN [NOVOLIN 70/30] - 100 unit/mL
(70-30)
Suspension - 40 units SQ QAM, 30 units QPM
The following medications are on the patient's medication list
but he is not taking them:
ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit Capsule - 1 Capsule(s)
by mouth every other week
ASPIRIN - 325 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth once a day
SILDENAFIL - 25 mg Tablet - 1 Tablet(s) by mouth Daily as needed
NITROGLYCERIN - 0.4 mg Tablet, Sublingual - one Tab sublingually
as needed for Chest pain, every five minutes for a total of
three
tabs. Call your doctor or go to the emergency room for severe
chest pain
POTASSIUM CHLORIDE - (Dose adjustment - no new Rx) - 20 mEq
Tablet, ER Particles/Crystals - 2 Tab(s) by mouth once a day
Discharge Medications:
1. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. amitriptyline 10 mg Tablet Sig: One (1) Tablet PO QHS PRN ()
as needed for pain.
3. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*0*
4. atovaquone 750 mg/5 mL Suspension Sig: Ten (10) mL PO DAILY
(Daily).
Disp:*1 bottle* Refills:*2*
5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. insulin NPH & regular human 100 unit/mL (70-30) Insulin Pen
Sig: see below Subcutaneous twice a day: 30 Units in the
morning; 20 Units in the evening.
Disp:*5 pens* Refills:*2*
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
acute on chronic renal failure
bradycardia
hypotension
Secondary Diagnosis:
HIV
hepatitis C
diabetes mellitus
hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to [**Hospital1 18**] for very slow heart rate and low
[**Hospital1 **] pressure. You were admitted to the ICU because you
required a medication to support your heart. Your kidneys began
to decline and you were advised to initiate dialysis. You were
not able to take your HAART medications for HIV because of your
poor renal function. You were also treated for a pneumonia. It
is unclear what caused all of these symptoms but it may be
related to your drug use. It is of the utmost importance that
you do not continue to use drugs. It is also very important that
you quit smoking cigarettes.
Unfortunately your kidney function did not recover significantly
during your hospital course to allow you to come off of
dialysis. You had to have a catheter placed to receive dialysis
as an outpatient. However, the kidney doctors think that your
kidney function may still improve over the upcoming months.
Please note the following changes to your medications:
STOP your HAART medications: darunavir, emtricitabine-
tenofovir, ritonavir
STOP lisinopril
STOP felodipine
STOP valsartan
STOP torsemide
STOP spironolactone
DECREASE your metoprolol succinate to 50mg daily
DECREASE your insulin to 30units in the morning and 20units in
the evening
DECREASE your aspirin to 81mg daily
START nephrocaps daily
START atovaquone daily
You may take senna and colace as needed for constipation
Only take the medications that are listed on your discharge
paperwork
Please be sure to follow up with your physicians.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please go to your initial dialysis session:
Friday, [**1-9**] at 5:15pm at [**Location (un) **] [**Location (un) **]
Department: [**Hospital3 249**]
When: MONDAY [**2111-1-12**] at 3:00 PM
With: [**First Name8 (NamePattern2) 488**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8033**], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] South [**Hospital **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: WEDNESDAY [**2111-1-14**] at 12:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: TUESDAY [**2111-2-10**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**Telephone/Fax (1) 127**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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7,908
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14018
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Discharge summary
|
report
|
Admission Date: [**2169-2-20**] Discharge Date: [**2169-2-24**]
Date of Birth: [**2121-7-14**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Hepatic Artery Stenosis not amenable to further angio treatment
Major Surgical or Invasive Procedure:
S/P stent placement ,s/p ex lap with tru-cut liver bx & intra op
US, lysis of adhesions [**2169-2-20**]
History of Present Illness:
Admitted with hepatic artery stenosis s/p stent placement [**2-17**]
that stenosed requiring exploratory laparotomy with extensive
lysis of adhesions, intra-op ultrasound and left lateral segment
liver biopsy with Trucut needle on [**2169-2-20**] by Drs. [**Last Name (STitle) **] and
[**Name5 (PTitle) **]. Please refer to operative note for further details.
Past Medical History:
1. HepC cirrhosis acquired by blood tx in [**2142**], Underwent
interferon therapy in [**2162**] with good response with VL to
undetectable levels with resurrgence. Pt has worseing liver
failure over [**2167**] with multiple admissions for esophageal
varices bleeds and encephalopathy
2. Liver transpalnt in [**12-16**] complicated by bile leak requiring
open repair.
3. Hepatic artery stenosis s/p stent placement in [**2-17**] and [**7-17**]
4. BPH
5. Esophageal varices Stage IV grade III
6. Acute liver rejection in [**3-17**] treated successfully with
prednisone
7. HTN
8. GERD
Social History:
Soc [**Name (NI) 41850**] Pt works as FAA mechanic is married for 25 years has 2
boys ages 23 and 17. Pt has hx of heavy EtOH use since age 14
until [**2154**]. No smoking, remote rare cocaine and marijauna use,
no IVDU.
Family History:
Fam Hx-No hx of liver disease, lung disease, CAD, stroke, CA, DM
or HTN
Physical Exam:
Gen: Pleasant, A&O, NAD
VS: 99.8, 64-16, 122/82
[**Year (4 digits) 4459**]: Perrla, EOMI, anicteric
Neck: supple, no bruits
Chest: CTA Bilaterally, No R/C/W
Heart: nl HS wit 3/5 SEM
ABD: Healed transplant incision, no guarding, no rebound, no
hernias
Ext: no C/C/E, 2+ pulses
Neuro: A&O, no asterixis, strength 5/5 symmetrically
Labs: wbc 3.3, hct 36, plt 97, sodium 146, potassium 4.1,
chloride 102, bicarb 29, bun 24, creatinine 1.1, glucose 110,
alt/ast 62/53, alk phos 202 and total bilirubin 0.9
Pertinent Results:
[**2169-2-20**] 04:05PM ALT(SGPT)-139* AST(SGOT)-117* ALK PHOS-184*
TOT BILI-1.0
[**2169-2-20**] 04:05PM GLUCOSE-126* UREA N-24* CREAT-1.4* SODIUM-139
POTASSIUM-4.9 CHLORIDE-111* TOTAL CO2-20* ANION GAP-13
[**2169-2-20**] 04:05PM WBC-5.3 RBC-3.29* HGB-10.5* HCT-30.7* MCV-93
MCH-32.0 MCHC-34.3 RDW-13.7
[**2169-2-20**] 04:05PM PLT COUNT-81*
[**2169-2-20**] 04:05PM PT-13.6 PTT-28.1 INR(PT)-1.2
[**2169-2-20**] 04:05PM FIBRINOGE-238
[**2169-2-20**] 11:45AM HGB-10.6* calcHCT-32 O2 SAT-98
Brief Hospital Course:
On post-op day one he developed a temperature of 103 orally. A
chest xray, blood, urine and sputum cultures were obtained. CXR
revealed patchy area in RLL. IV Zosyn was started with
resolution of fever on post-op day 2. Blood, urine and sputum
cultures were negative. IV Zosyn was discontinued on
[**2169-2-23**].Abdomenal incision was well approximated and without
signs of infection.
The liver biopsy revealed focal mild portal mononuclear cell
inflammation, mild steatosis, no features of rejection, no
ischemic changes, no fibrosis and moderate iron deposition in
hepatocytes. LFTs trended down to AST 35, ALT 76, Alk Phos 117,
and Total Bili 0.9 on POD 4.
On POD 4 vital signs were stable. He was afebrile, ambulatory,
tolerating regular diet, passing flatus and taking Vicodin for
incisional discomfort with relief. Incision appeared well
approximated without signs of infection.
On POD 4, he was discharged after receiving one unit of PRBC for
a hematocrit of 26.3. Of note, his WBC count was 2.7 and
cyclosporin level was 361.
He will have outpatient labs drawn on [**2169-2-27**] with results fax'd
to [**Hospital1 18**] Transplant Office.
Medications on Admission:
Neoral 150mg po bid
Cellcept 500mg po bid
Plavix 75mg po qd
[**Hospital1 **] 325mg po qd
Bactrim SS 1 tab po q mon-wed-fri
Protonix 40mg po qd
Atenolol 50mg po qd
Lantus insulin 12 units sc qam
Sliding Scale regular insulin prn qid per accuchecks
Epogen 10,000 units sc qweek
Discharge Medications:
1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO M/W/FR ().
4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
7. [**Hospital1 41851**] Modified 100 mg Capsule Sig: One (1) Capsule PO
twice a day: take with 2-25mg capsules for total of 150mg twice
a day.
8. [**Hospital1 41851**] Modified 25 mg Capsule Sig: Two (2) Capsule PO
twice a day: take with 100mg capsule for total dose of 150mg
twice a day.
9. Hydrocodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO prn q 4-6 hours: if needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
10. Insulin Glargine 100 unit/mL Solution Sig: One (1) 12
Subcutaneous every morning: continue sliding scale insulin as
before.
Discharge Disposition:
Home
Discharge Diagnosis:
47 M s/p orthotopic liver transplant for HepC cirrhosis [**12-16**]
c/w R hepatic artery stenosis. Admitted for repair of hepatic
artery stenosis, exp lap, with liver biopsy & intra op US
PMH/PSH: Hep C cirrhosis sp OLT [**12-16**],CRI, HTN, h/o cholangitis,
h/o encephelopathy/varices, h/o VRE, h/o wound dehiscence sp
repair [**2168-1-19**]
Discharge Condition:
good/stable
Discharge Instructions:
Call Transplant Office immediately at [**Telephone/Fax (1) 673**] if any feves,
chills, nausea, vomiting,lethargy or any redness/drainage from
the incision.
Have lab work done as usual q Monday with results fax'd to
transplant office
[**Month (only) 116**] shower. Wash incision with soap/water, pat dry, observe for
redness, drainage.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 5628**]
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2169-3-8**] 8:00
Please obtain blood labs starting this Mon, 2/14/5 and Thursday
[**2169-3-2**]. The patient needs the following labss: CBC, Chem 10,
AST, ALT, alk phos, albumin, T. bili, cyclosporin level at
[**Hospital1 18**]- LMOB basement located at [**Last Name (NamePattern1) 439**]. Please fax
the results to [**Telephone/Fax (1) 697**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) **]: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2169-3-1**] 10:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2169-2-24**]
|
[
"998.89",
"401.9",
"996.82",
"E878.0",
"780.6",
"530.81",
"V12.09",
"447.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"54.11",
"50.11"
] |
icd9pcs
|
[
[
[]
]
] |
5434, 5440
|
2872, 4028
|
377, 484
|
5828, 5841
|
2347, 2849
|
6225, 7089
|
1735, 1809
|
4354, 5411
|
5461, 5807
|
4054, 4331
|
5865, 6202
|
1824, 2328
|
274, 339
|
512, 874
|
896, 1481
|
1497, 1719
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,269
| 137,980
|
20958
|
Discharge summary
|
report
|
Admission Date: [**2154-7-16**] Discharge Date: [**2154-7-21**]
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base / Megace / Heparin Agents
Attending:[**First Name3 (LF) 14229**]
Chief Complaint:
Hypotension and BRBPR
Major Surgical or Invasive Procedure:
Colonoscopy [**2154-7-19**]
History of Present Illness:
[**Age over 90 **] yo man c hx of BPH requiring indwelling Foley, previous
admission for urosepsis, and hx of AAA presented to ED from
[**Hospital 100**] Rehab NH c hypotension and BRBPR. BRBPR since [**6-26**], Hct
[**7-11**] was 30 (baseline 35-36). On [**7-15**], pt had hypotensive
episode to SBP 90s. He was brought to the ER, started on IVF,
received PRBCS with SBP to 110s. Hct in ER was 32 and three hrs
later was 24. No further BRBPR in ER. Admitted to MICU for
suspected lower GI bleed. Pt refused NG tube in ER.
Past Medical History:
1. Chronic renal insuffeciency: baseline Cr~3
2. BPH with chronic indwelling foley catheter
3. Anemia secondary to CRI: baseline Hct 35-36
4. Left inguinal hernia
5. S/P pacemaker placement
6. Glaucoma
7. S/P right hip fracture
8. Aortic insuffeciency
9. Abdominal aortic aneurysm: per report
Social History:
Pt lives at [**Hospital1 100**] Senior Life. He needs assistance with
ambulation at baseline. Pt's power of attorney is his son [**Name (NI) **]
[**Known lastname **]. His phone numbers are [**Telephone/Fax (3) 55718**], and
cell [**Telephone/Fax (1) **].
Family History:
NC
Physical Exam:
PE: 96.6, 60, 90/50-101/54, 16, 100%RA
Gen: somnolent but arousable, in NAD
HEENT: NC/AT, pupils 1 mm, minimally reactive, anicteric, dry
MM, OP clear
Neck: no JVD
Lungs: CTA, fine crackles at L lung base
Heart: distant HS, RRR
Abd: soft, NT, ND; pulsatile midline mass noted
Ext: warm, well perfused, no edema, 1+ PT, 2+ fem pulses, 1 cm
anterior ankle ulcer c exudate
Pertinent Results:
[**2154-7-16**] 04:40AM BLOOD WBC-9.0 RBC-3.30* Hgb-10.3* Hct-31.8*
MCV-96 MCH-31.3 MCHC-32.5 RDW-14.5 Plt Ct-246
[**2154-7-16**] 01:24PM BLOOD Hct-29.2*
[**2154-7-16**] 04:40AM BLOOD Neuts-75.1* Lymphs-18.7 Monos-3.9 Eos-2.1
Baso-0.2
[**2154-7-16**] 04:40AM BLOOD PT-12.4 PTT-26.7 INR(PT)-1.0
[**2154-7-16**] 04:40AM BLOOD Plt Ct-246
[**2154-7-16**] 04:40AM BLOOD Glucose-122* UreaN-49* Creat-2.9* Na-132*
K-5.1 Cl-98 HCO3-26 AnGap-13
[**2154-7-16**] 04:40AM BLOOD ALT-54* AST-49* AlkPhos-84 TotBili-0.4
[**2154-7-16**] 04:40AM BLOOD Albumin-2.8*
[**2154-7-16**] 05:31PM BLOOD Calcium-10.1 Phos-2.3* Mg-1.8
[**2154-7-16**] 04:40AM BLOOD Cortsol-14.0
[**2154-7-16**] 05:31PM BLOOD Cortsol-15.9
[**2154-7-16**] 06:20PM BLOOD Cortsol-29.3*
[**2154-7-16**] 07:04PM BLOOD Cortsol-36.9*
Brief Hospital Course:
1. Hypotension - DDx includes lower GI bleed vs. urosepsis vs.
adrenal insufficiency. Likely lower GI bleed given BRBPR. GI
evaluated pt; discussed tRBC study but f/u HCT in MICU 29;
decided to defer study and proceed with colonoscopy on [**7-17**].
Urosepsis remained a possibility given dirty u/a. uctx neg
until [**7-17**] - tx c broad spec abx for 3 days. Although pt has
unclear hx of adrenal insuf., [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**]. stim test negative thus
suggesting that adrenal insuf. an unlikely cause. Pt.
maintained with 2 large bore IVs, IV ppi. Crit remained stable
between 34-36 in unit. Pt. had NG tube placed for [**Last Name (un) **] prep but
pt pulled tube within 45 minutes. Repeat tube placements
failed; pt. asked to drink prep instead. Prolonged prep with
golytely, fleet enemas, fleet phophosoda, tap water enemas. Pt.
developed elevated phos - all fleet enemas/fleet phospho soda
held, started on prep with mag citrate, golytely, and tap water
enemas, and senna. Free water given for elevated sodium likely
[**12-19**] free water loss [**12-19**] stool loss.
Colonoscopy was finally completed showing no sign of source of
bleeding. Only source seemed ot be hemorrhoidal. Pt needs
aggressive bowel regimen in future due to his large inguinal
hernia causing mechanical source of significant constipation.
.
2. CRI - [**12-19**] obstructive nephropathy. Cr at baseline
- renally dosed all meds
.
3. CV - No evidence ischemia on EKG showing dual chamber PM
- holding ASA, beta-blocker
.
4. AAA - CT scan neg for rupture; monitor exam
.
5. BPH - continue indwelling Foley/Flomax
.
6. F/E/N - bolus fluids as per clinical exam/monitoring of UOP.
NPO for now
.
7. Code - DNR/DNI
.
8. Access - 2 large bore IVs
.
9. [**Name (NI) **] - Son, [**Name (NI) **] [**Name (NI) **]
.
10. Dispo - MICU pending stable HCT/BP.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Lower Gastrointestinal Bleed
Hypotension
Anasarca
Large left inguinal hernia
Constipation
Discharge Condition:
Stable
Discharge Instructions:
Please call your primary care provider or return to the ER if
you notice blood in your stool, experience dizziness or feel
lightheaded, or have chest pain or shortness of breath.
Your daily doses of Aspirin and Lopressor were not given to you
during this hospitalization. Please restart your aspirin in 1
week at 81 mg. You should also take protonix twice per day. Your
doctor should monitor your calcium and phosphate. Restart your
fiber as indicated.
Followup Instructions:
Please follow up with your primary care physician at the [**Hospital1 10151**] Center.
|
[
"593.89",
"424.1",
"599.0",
"276.5",
"V45.01",
"585",
"578.9",
"441.4",
"458.9",
"285.1",
"211.3",
"600.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.07",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
4609, 4674
|
2703, 4586
|
288, 318
|
4808, 4817
|
1897, 2680
|
5320, 5410
|
1484, 1488
|
4695, 4787
|
4841, 5297
|
1503, 1878
|
227, 250
|
346, 876
|
898, 1193
|
1209, 1468
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,504
| 102,074
|
34941
|
Discharge summary
|
report
|
Admission Date: [**2143-8-26**] Discharge Date: [**2143-9-12**]
Date of Birth: [**2098-4-8**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Motor vehicle accident.
Major Surgical or Invasive Procedure:
- 3 Ex-Laps with Exploratory laparotomy.
Hepatorrhaphy.
Left chest tube placement.
Liver packing.
Ligation of the splenic artery and vein.
Enterorrhaphy.
Packing of the liver.
Insertion of Silastic patch closure.
Splenectomy, packing, and final closure
- Gelfoam embolization of right hepatic artery branch
- IVC filter
- Central line
- I&D closure left leg and right knee
- Initial I+D/ex fix L tibia, I&D closure left followed by
removal of ex-fix, ORIF left tibia and fibula MIPO-style
- Chest tube
History of Present Illness:
The patient was in a restrained motor vehicle accident head on
with truck at high speeds with prolonged extrication. Transfered
here on [**2143-8-26**] from outside hospital with GCS of 11 and
intubated and with obvious lower extremity injuries. Upon
arrival, the patient was noted to have blood
pressures 90's to over 50's, was saturating well. The patient
was a hemodynamic 'transient responder'. She was taken to CT
scan which revealed a grade 5 liver laceration. She was urgently
taken to the operating room. Patient was taken for exploratory
laporatory with continued care as contineud in "brief hospital
course".
Past Medical History:
Bipolar Disorder
Depression
Anxiety
Substance Abuse
Eating Disorder
Social History:
Patien is widowed with two children. Husband had successful
suicide attempt 2 years ago in patient's presence. As a result,
DSS is involved the life of her 13 yo daughter. She also has a
24 yo son. The patient's mother and sister-in-law are involved
in her life and have visited her at hospital.
Habits:
- smokes cigarettes
- substance and alcohol user (unclear to what extent)
Family History:
Family medical history: non-contributory.
Family psychiatric history:
Son and daughter with depression, son attempted suicide after
his step-father's death. Aunt with bipolar.
Physical Exam:
Physical Exam:
Vitals: T: 97.3 (max 100.9) P: 113-134 R: 20 BP: 98/60 - 102/60
SaO2: 94%2L
General: Awake, sitting in chair, cooperative, NAD. Mild
cachexia.
HEENT: NC/AT, no scleral icterus noted, dry MM, no lesions noted
in oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Bilateral rhonchi at bases.
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally. Both LEs in orthopedic devices.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 2 (states [**Month (only) **] rather than
[**Month (only) **], correctly identifies [**Hospital1 18**]). Unable to relate history
clearly. Grossly attentive, able to name [**Doctor Last Name 1841**] backward slowly
and
omitting [**Month (only) 359**], but unable to maintain thread of a moderately
long conversation. Language is sparse but fluent with intact
repetition and comprehension. There were no paraphasic errors.
Pt. was able to name both high and low frequency objects. Speech
was mildly dysarthric and hypophonic. Able to follow both
midline
and appendicular commands. Pt. was able to register 3 objects
and
recall [**1-13**] at 5 minutes, correctly selecting the third from a
list. There was no evidence of neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Diffuse atrophy, normal tone throughout. Motor exam
limited by multiple orthopedic injuries. No adventitious
movements, such as tremor, noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 4+ 5 4+ 5 5 4+ 5 5 5 5 Unable --------->
R 4+ 5 4+ 5 5 4+ 5 5 5 5 Unable --------->
-Sensory: No deficits to light touch throughout. No extinction
to
DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 3 3 3 2 -
R 3 3 3 2 -
Plantar response could not be tested due to injuries.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: Unable due to orthopedic injuries.
Pertinent Results:
[**2143-8-27**] 12:00AM TYPE-ART PO2-111* PCO2-41 PH-7.37 TOTAL
CO2-25 BASE XS--1
[**2143-8-27**] 12:00AM LACTATE-2.1*
[**2143-8-27**] 12:00AM freeCa-1.29
[**2143-8-26**] 11:56PM GLUCOSE-125* UREA N-14 CREAT-0.8 SODIUM-148*
POTASSIUM-3.4 CHLORIDE-117* TOTAL CO2-23 ANION GAP-11
[**2143-8-26**] 11:56PM ALT(SGPT)-372* AST(SGOT)-693* LD(LDH)-660*
ALK PHOS-57 TOT BILI-2.4*
[**2143-8-26**] 11:56PM LIPASE-69*
[**2143-8-26**] 11:56PM ALBUMIN-3.5 CALCIUM-9.4 PHOSPHATE-4.2
MAGNESIUM-1.8
[**2143-8-26**] 11:56PM WBC-1.8* RBC-3.61* HGB-10.3* HCT-30.2* MCV-84
MCH-28.6 MCHC-34.3 RDW-15.4
[**2143-8-26**] 11:56PM PLT COUNT-257
[**2143-8-26**] 11:56PM PT-12.5 PTT-34.5 INR(PT)-1.1
[**2143-8-26**] 11:56PM FIBRINOGE-605*
[**2143-8-26**] 09:28PM TYPE-ART PO2-96 PCO2-41 PH-7.33* TOTAL CO2-23
BASE XS--4
[**2143-8-26**] 09:28PM LACTATE-3.0*
[**2143-8-26**] 08:23PM TYPE-ART PO2-209* PCO2-56* PH-7.25* TOTAL
CO2-26 BASE XS--3
[**2143-8-26**] 08:23PM LACTATE-3.5*
[**2143-8-26**] 08:23PM freeCa-1.27
[**2143-8-26**] 08:11PM GLUCOSE-118* UREA N-13 CREAT-0.8 SODIUM-149*
POTASSIUM-3.3 CHLORIDE-116* TOTAL CO2-23 ANION GAP-13
[**2143-8-26**] 08:11PM ALT(SGPT)-271* AST(SGOT)-431* ALK PHOS-55
AMYLASE-46 TOT BILI-1.7*
[**2143-8-26**] 08:11PM LIPASE-42
[**2143-8-26**] 08:11PM ALBUMIN-3.5 CALCIUM-9.9 PHOSPHATE-4.6*
MAGNESIUM-2.1
[**2143-8-26**] 08:11PM TRIGLYCER-65
[**2143-8-26**] 08:11PM WBC-2.1* RBC-3.12*# HGB-9.0* HCT-26.8* MCV-86
MCH-28.8 MCHC-33.5 RDW-15.1
[**2143-8-26**] 08:11PM NEUTS-77.9* LYMPHS-17.3* MONOS-4.2 EOS-0.2
BASOS-0.3
[**2143-8-26**] 08:11PM PLT COUNT-252#
[**2143-8-26**] 08:11PM PT-12.6 PTT-42.1* INR(PT)-1.1
[**2143-8-26**] 08:11PM FIBRINOGE-624*#
[**2143-8-26**] 05:03PM WBC-2.1* RBC-2.44* HGB-7.5* HCT-22.1* MCV-91
MCH-30.9 MCHC-34.2 RDW-14.6
[**2143-8-26**] 05:03PM PLT COUNT-103*
[**2143-8-26**] 05:03PM PT-12.5 PTT-77.5* INR(PT)-1.1
[**2143-8-26**] 05:02PM TYPE-[**Last Name (un) **] PO2-34* PCO2-67* PH-7.07* TOTAL
CO2-21 BASE XS--12 INTUBATED-INTUBATED COMMENTS-PERIPHERAL
[**2143-8-26**] 05:02PM GLUCOSE-237* LACTATE-3.9* NA+-143 K+-5.4*
CL--116*
[**2143-8-26**] 05:02PM HGB-7.7* calcHCT-23
[**2143-8-26**] 05:02PM freeCa-0.74*
[**2143-8-26**] 04:08PM TYPE-[**Last Name (un) **] PO2-29* PCO2-69* PH-7.06* TOTAL
CO2-21 BASE XS--13 INTUBATED-INTUBATED
[**2143-8-26**] 04:08PM GLUCOSE-183* LACTATE-3.2* NA+-141 K+-4.6
CL--112
[**2143-8-26**] 04:08PM HGB-8.0* calcHCT-24
[**2143-8-26**] 04:08PM freeCa-0.63*
[**2143-8-26**] 04:08PM WBC-3.5*# RBC-2.44* HGB-7.8* HCT-22.2* MCV-91
MCH-31.8 MCHC-35.0 RDW-13.6
[**2143-8-26**] 04:08PM PLT SMR-LOW PLT COUNT-96*
[**2143-8-26**] 04:08PM PT-19.6* PTT-80.7* INR(PT)-1.8*
[**2143-8-26**] 03:11PM TYPE-[**Last Name (un) **] PO2-33* PCO2-66* PH-7.03* TOTAL
CO2-19* BASE XS--15 INTUBATED-INTUBATED
[**2143-8-26**] 03:11PM GLUCOSE-116* LACTATE-2.3* NA+-140 K+-3.2*
CL--120*
[**2143-8-26**] 03:11PM HGB-8.3* calcHCT-25
[**2143-8-26**] 03:11PM freeCa-1.03*
[**2143-8-26**] 02:46PM TYPE-[**Last Name (un) **] PO2-44* PCO2-69* PH-7.09* TOTAL
CO2-22 BASE XS--11 INTUBATED-INTUBATED
[**2143-8-26**] 03:11PM freeCa-1.03*
[**2143-8-26**] 02:46PM TYPE-[**Last Name (un) **] PO2-44* PCO2-69* PH-7.09* TOTAL
CO2-22 BASE XS--11 INTUBATED-INTUBATED
[**2143-8-26**] 02:46PM GLUCOSE-102 LACTATE-1.5 NA+-139 K+-3.5
CL--118*
[**2143-8-26**] 02:46PM HGB-6.9* calcHCT-21
[**2143-8-26**] 02:46PM freeCa-0.95*
[**2143-8-26**] 02:40PM WBC-10.0 RBC-2.18*# HGB-6.7*# HCT-20.2*#
MCV-92 MCH-30.8 MCHC-33.4 RDW-13.7
[**2143-8-26**] 02:40PM PLT COUNT-121*#
[**2143-8-26**] 02:40PM PT-23.9* PTT-103.7* INR(PT)-2.3*
[**2143-8-26**] 01:12PM GLUCOSE-158* LACTATE-2.2* NA+-139 K+-3.8
CL--105 TCO2-24
[**2143-8-26**] 01:06PM LACTATE-1.4
[**2143-8-26**] 01:06PM O2 SAT-97
[**2143-8-26**] 01:00PM UREA N-16 CREAT-1.0
[**2143-8-26**] 01:00PM estGFR-Using this
[**2143-8-26**] 01:00PM AMYLASE-110*
[**2143-8-26**] 01:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2143-8-26**] 01:00PM WBC-16.2* RBC-3.63* HGB-11.1* HCT-33.2*
MCV-91 MCH-30.6 MCHC-33.5 RDW-13.8
[**2143-8-26**] 01:00PM PLT COUNT-272
[**2143-8-26**] 01:00PM PT-15.8* PTT-38.5* INR(PT)-1.4*
[**2143-8-26**] 01:00PM FIBRINOGE-254
Brief Hospital Course:
The patient was in a restrained motor vehicle accident head on
with truck at high speeds with prolonged extrication and was
transfered here on [**2143-8-26**]. She was taken to the OR by trauma
surgery for exploratory laporatomy which was repeated twice
resulting in a liver hepatorrhaphy, chest tube placement, liver
packing, ligation of the splenic artery and vein, enterorrhaphy.
acking of the liver, insertion then removal of Silastic patch
closure, passage of long intestinal feeding tube, splenectomy,
packing, and final closure on [**2143-8-26**]. Given her
multiple lower extremity injuries, an IVC filter was placed on
[**2143-8-29**]. She was treated for a left pneumothorax which was
treated with a chest tube. She was admitted to the intensive
care unit with intubation and was later weaned and transfered to
the floor. All tubes including chest tube and JP drains have
been removed as have abdominal staples.
Consults:
Orthopedic surgery was consulted for numerous leg fractures
including Ortho Inj: Open L distal tibial pilon fx, R knee
degloving wound, R ankle fx/ talus fx
Procedures peformed and care given by orthopedics included
[**8-26**]: I+D/ex fix L tibia, washout + closure R knee wound.
[**8-27**]: I&D closure left leg and right knee. Right knee lac did
not violate the joint.
[**8-29**]: Aircast boot to R ankle fx
[**9-5**]: Removed ex-fix, ORIF left tibia and fibula MIPO-style
Neurosurgery found no urgent/emergent neurosurgical issues at
time of presentation and with ongoing assessment found evidence
of traumatic brain injury.
Psychiatry was consulted to assess mental status and manage
behavior finding that her signs and symptoms are most consistent
with a organic syndrome relating to her brain injury, with
resolving toxic-metabolic encephalopathy. While her untreated
bipolar disorder may be contributing somewhat to her mood
lability, it is unlikely to be the primary cause of her
symptoms.
Neurology was consulted to evaluate confusion and odd behavior
finding that the most likely cause of these signs and symptoms
was a toxic-metabolic encephalopathy that will simply clear with
time but additonally recommeded limiting sedating mediations.
Medications on Admission:
Alprazolam.
Discharge Medications:
1. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain for 10 days.
Disp:*30 Tablet(s)* Refills:*1*
3. Megestrol 40 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day) for 10 days.
Disp:*40 Tablet(s)* Refills:*0*
4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain or fever.
8. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Olanzapine 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
10. Thiamine HCl 100 mg/mL Solution Sig: One (1) Injection TID
(3 times a day).
11. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Liver laceration
Open L distal tibial pilon fx, R knee degloving wound, R ankle
fx/ talus fx
Bilateral Subarachnoid Hemorrhage
Left pneumothorax
Discharge Condition:
Stable vital signs. Weight bearing on right LE as tolerated.
Non-weight bearing on left LE.
Discharge Instructions:
You were in a motor vehicle accident requiring your admission
the the hospital including the intensive care unit after several
abdominal operations for injuries to your liver. Therefore it is
very important to carefully monitor your condition and return to
the Emergency Department immediately if you have any of the
warning signs listed below.
* Rest: You should restrict your activities until you are
completely better.
* Acceptable liquids include: water, tea, broth, ginger ale,
jello, diluted Gatorade, diluted apple juice or ice chips.
Avoid milk, ice cream and other dairy products.
* When your abdominal pain is gone, start a light diet in
addition to the fluids above. Good choices include: bananas,
rice, applesauce, toast, and crackers. Avoid milk products
(such as cheese) as well as spicy, fatty or fried foods.
* Do not consume alcohol or caffeine until you are completely
better.
* Continue your prescribed medications unless instructed to do
otherwise.
You had leg fractures requiring orthopedic surgery. Return to
the Emergency Department or see your own doctor right away if
any problems develop, including the following:
* Swelling, pain or redness getting worse.
* Pain not much better within 3 days.
* Fingers or toes become pale (whiter) or become dark or
blue.
* Numbness, tingling or coldness of your fingers or toes.
* Loss of movement.
* Rubbing sensation, burning or soreness of your skin,
especially under a cast.
* Chest pain, shortness of breath or trouble breathing.
* Fever or shaking chills.
* Headache, confusion or any change in alertness.
* Anything else that worries you.
<B>Warning Signs:</B>
Call your doctor or return to the Emergency Department right
away if any of the following problems develop:
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 100.4 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Given the extent of injuries and low-nutrition status, please
call back if you have any difficulty eating.
Followup Instructions:
Follow-up with the following services within the next two weeks
available at the following numbers:
- Trauma surgery: [**Telephone/Fax (1) 6429**]
- Orthopedic surgery: [**Telephone/Fax (1) 1228**]
- Neurology: [**Telephone/Fax (1) 44**]
Completed by:[**2143-9-12**]
|
[
"998.11",
"865.02",
"E812.0",
"807.09",
"305.1",
"863.39",
"349.82",
"851.80",
"958.4",
"860.0",
"864.14",
"824.9",
"296.89",
"822.1",
"286.7",
"496",
"873.20",
"891.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.59",
"79.36",
"96.6",
"84.72",
"78.17",
"46.73",
"41.5",
"38.86",
"21.81",
"50.12",
"34.04",
"50.61",
"96.72",
"38.7",
"79.46",
"54.12",
"96.04",
"78.67",
"79.66"
] |
icd9pcs
|
[
[
[]
]
] |
12384, 12464
|
9068, 11259
|
337, 843
|
12653, 12747
|
4780, 9045
|
15449, 15718
|
1993, 2171
|
11321, 12361
|
12485, 12632
|
11285, 11298
|
12771, 15426
|
3576, 4761
|
2201, 2795
|
274, 299
|
871, 1491
|
2810, 3559
|
1513, 1582
|
1598, 1977
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,974
| 103,110
|
617
|
Discharge summary
|
report
|
Admission Date: [**2111-8-4**] Discharge Date: [**2111-8-9**]
Service: SURGERY
Allergies:
Penicillins / Lyrica
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Right lower extremity rest pain with non-healing right toe ulcer
Major Surgical or Invasive Procedure:
Right femoro-peroneal bypass graft with lesser saphenous vein
graft
History of Present Illness:
This patient is an 85 year old male with a history of severe
coronary artery disease s/p myocardial infarction, congestive
heart failure, hypertension who presents with chronit
unremitting right lower extremity rest pain and a non-healing
right toe ulcer. The patient received an extensive coronary
work-up prior to presentation and was felt to be a poor
operative candidate given his other co-morbidities. This poor
candidate status was discussed at length with the patient and
his family, who remained quite insistent that, despite the high
risks, we procede with a limb-saving intervention
Past Medical History:
CAD,MI ,CHF,HTN,hypercholestremia,DUJd of rt. hip,hx TISs/p left
CEA [**2094**]'s,BPH s/p turn-now w frequency/nocturia
Social History:
Remote history of smoking, quit 40 years ago, social ETOH use.
Physical Exam:
Awake and alert, NAD
RRR w/ SEM at base
Crackles at lung bases on auscultation bilaterally
Abdomen soft, obese, non-tender
Pulse exam: DP/PT dopplerable bilaterally
Brief Hospital Course:
The patient was admitted to the hospital and started on IV
antibiotics to treat his non-healing ulcer. Cultures were taken,
and ultimately grew out gram-positive cocci and gram-negative
rods. He was taken to the operating room on [**8-6**] for a right
femoro-peroneal bypass graft with lesser saphenous vein. The
patient initially tolerated this procedure well and was taken to
the vascular surgery ICU for recovery. On the morning of
post-operative day #2, the patient began to complain of chest
pain and was found to have a systolic blood pressure of 85 with
elevated pulmonary artery pressures of 60/30. This picture was
concerning for an active coronary event. The patient was
immediately transferred to the cardiovascular surgery ICU for
further monitoring and treatment. An electrocardiogram showed
new lateral precordial ST-segment elevation. Troponins were
checked and were found to be rising to 0.67. At 2:30am on
post-operative day #3, the patient was found to be tachypnic and
tachcardic. Lasix was given emperically, however, soon after the
patient became unresponsive and asystolic. ACLS protocol was
initiated and the patient was coded for 30 minutes without
return of cardiac function. The patient was pronounced deceased
at 3:57am.
Medications on Admission:
lasix 80mgm qam,lasix 40mgm qpm,plavix 75mgm',kcl
20meq",atorvastatin 40mgm',lopressor25mgm"percoset
Discharge Disposition:
Expired
Discharge Diagnosis:
Coronary artery disease, s/p myocardial infarction
Peripheral vascular disease
Congestive heart failure
Hypercholesterolemia
Benign prostatic hyperplasia
Carotid stenosis s/p carotid endarterectomy
Discharge Condition:
Expired
|
[
"410.51",
"440.23",
"707.15",
"412",
"428.0",
"443.9",
"414.01",
"600.00",
"424.1",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"39.29"
] |
icd9pcs
|
[
[
[]
]
] |
2809, 2818
|
1409, 2658
|
290, 360
|
3060, 3071
|
2839, 3039
|
2684, 2786
|
1220, 1386
|
186, 252
|
388, 982
|
1004, 1125
|
1141, 1205
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,198
| 122,504
|
33020
|
Discharge summary
|
report
|
Admission Date: [**2199-5-13**] Discharge Date: [**2199-5-17**]
Date of Birth: [**2165-2-26**] Sex: M
Service: MEDICINE
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 2234**]
Chief Complaint:
abdominal pain, diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 34-year-old gentleman with history of Type 2
DM, Morbid Obesity, Fournier gangrene s/p diverting colostomy
who presented to the Emegrency Department with complaints of
abdominal pain and copious amounts of foul-smelling stool.
Patient reported that his symptoms began approximately 2 days
ago with crampy mid-epigastric abdominal pain associated with
increase in frequency and quantity of stool output. Described
stool output in colostomy bag as dark-green, foul-smelling, and
specifically denied black or tarry-appearing stools. No BRBPR.
Of note, patient was recently admitted to [**Hospital1 18**] [**Date range (1) 76778**] with
abdominal wall abscess treated with IV Vanc/Zosyn. Patient also
seen by Rheumatology for ankle pain thought to be secondary to
reactive arthritis, and he was started on Indomethacin with
concurrent PPI. Reported that he was taking the Indomethacin as
prescribed in conjunction with PPI, but discontinued use once
his abdominal pain began.
.
In the ED, initial VS T 99.2; HR 87; BP 155/75; RR 24; O2 94%
RA. Patient later spiked T 101.0. He was given Morhpine for
pain, Flagyl for presumed C Diff, and 1g Tylenol.
Past Medical History:
PAST MEDICAL HISTORY
1. Diabetes type 2 on insulin at home. Now followed at the
[**Last Name (un) **].
2. Fournier gangrene. Status post perineal resection and
debridement in [**2198-1-22**] at [**Hospital1 2025**] with a diverting colostomy
placed. States that he was in a medically induced coma for six
weeks. Was only discharged to [**Hospital3 **] in [**2198-4-22**].
Until recent admission in [**2198-12-22**], had been dressing
changes wet-to-dry b.i.d. at home. States that he felt out of
touch with his [**Hospital1 2025**] surgeons and has not been seeing any plastic
surgeon for routine care of his wound which was left open
intentionally.
3. Hypertension.
4. Pancreatitis. Admitted in [**2198-12-22**].
5. Hypertriglyceridemia. Noted to be elevated to 4600 in
[**2198-12-22**].
6. Morbid Obesity
7. Major depressive disorder
8. Post-traumatic stress disorder
9. Social phobia
.
PAST SURGICAL HISTORY: As stated above. Multiple perineal
surgeries and diverting colostomy in [**2198**].
Social History:
The patient was born in NH and raised in MA . The patient
completed high school and no college. The patient is unemployed
and has worked security gaurd. The patient lived alone but
became homeless after alleged electical fire had been living at
a hotel in [**Location (un) 1468**] prior to admission. Denies tobacco, alcohol,
or illicit drugs. His mother is his primary contact.
Family History:
Relatives with COPD, MS, ovarian CA, uterine CA, bladder CA,
mother and uncle with diabetes mellitus II, aunt with SLE,
mother has hidradenitis suppurativa. No known family history of
early coronary artery disease or lipid/cholesterol problems.
Physical Exam:
Upon arrival to the medical floor:
T 101.0; BP 142/82; HR 92; RR 22; O2 97% 4L NC
GEN: Morbidly obese gentleman sitting in hospital bed
HEENT: Anicteric sclerae. MM dry. OP clear
NECK: Large neck, no obvious JVD. No carotid bruits
HEART: S1S2 RRR. No M/R/G
LUNGS: CTA B/L
ABD: obese, soft, non-distended. + colostomy bag with mild
erythema around bag but not edema, calor. Mild TTP in LLQ and
mid-epigastrium, no rebound or guarding. skin breakdown. Skin
under pannus without signs of active infection.
EXT: L foot with significant asymmetric edema. TTP over left
heel. 2+ DPs.
STOOL: Guiaic positive in ED
Pertinent Results:
Admit labs:
[**2199-5-12**] 10:50PM WBC-8.0 RBC-3.56* HGB-10.2* HCT-29.3* MCV-82
MCH-28.7 MCHC-34.9 RDW-15.8*
[**2199-5-12**] 10:50PM PLT COUNT-235
[**2199-5-12**] 10:50PM NEUTS-76.3* LYMPHS-16.7* MONOS-4.4 EOS-2.3
BASOS-0.3
[**2199-5-12**] 10:50PM GLUCOSE-161* UREA N-21* CREAT-0.9 SODIUM-141
POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-21* ANION GAP-16
[**2199-5-12**] 10:50PM ALT(SGPT)-33 AST(SGOT)-28 ALK PHOS-91 TOT
BILI-0.2
[**2199-5-12**] 10:50PM LIPASE-19
========================================================
CT ABDOMEN W/O CONTRAST [**2199-5-13**] 3:03 AM
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
Reason: ABD PAIN, OSTOMY
Field of view: 50
[**Hospital 93**] MEDICAL CONDITION:
34 year old man with ostomy, N/ increased output ,abd pain.
REASON FOR THIS EXAMINATION:
eval SBO, acute process
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 34-year-old male with ostomy, now with increased
output and abdominal pain. Please evaluate for small bowel
obstruction or other acute process.
COMPARISON: [**2199-4-24**].
TECHNIQUE: MDCT acquired axial imaging of the abdomen and pelvis
was performed with oral contrast only. Intravenous contrast was
not administered secondary to the patient's history of allergy.
Multiplanar reformatted images were obtained and reviewed.
CT ABDOMEN: Visualized lung bases are clear. There is mild
pleural thickening posteriorly at the lung bases bilaterally.
Absence of intravenous contrast limits evaluation of the
abdominal parenchymal organs and vasculature. Liver is normal in
appearance. There has been prior cholecystectomy. Pancreas,
spleen, and adrenal glands are normal. Kidneys show normal
non-contrast appearance. There is no hydronephrosis. No renal
calculi are seen. Stomach and intra-abdominal loops of bowel
appear normal. There is no sign of bowel obstruction. There is
no free air, free intraperitoneal fluid, or abnormal
intra-abdominal lymphadenopathy.
CT PELVIS: Post-surgical changes within the anterior abdominal
wall are seen. Previously noted small fluid collection is no
longer apparent. Left lower quadrant ileostomy is unchanged in
appearance, with large, 4-5 cm fat- containing parastomal
hernia. Genitourinary structures appear normal. There is no free
pelvic fluid or abnormal pelvic or inguinal lymphadenopathy.
OSSEOUS STRUCTURES: No suspicious osseous lesions are seen.
Degenerative changes throughout the lumbar spine are unchanged.
IMPRESSION:
1. No evidence of bowel obstruction, or other acute process to
explain patient's pain and increased ostomy output.
2. Unchanged appearance of large fat-containing parastomal
hernia.
=============================================================
CT C-SPINE W/O CONTRAST [**2199-5-15**] 10:03 AM
CT C-SPINE W/O CONTRAST
Reason: ?evidence fracture
[**Hospital 93**] MEDICAL CONDITION:
34 year old man with fall in hospital/neck pain
REASON FOR THIS EXAMINATION:
?evidence fracture
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Fall, query fracture.
COMPARISON: None available.
TECHNIQUE: Contiguous axial non-contrast images of the cervical
spine were obtained without IV contrast. Sagittal and coronal
reconstructions were derived.
FINDINGS: The base of the skull through T1 are visualized. There
is no abnormality in alignment and no disc, vertebral or
paraspinal abnormality is seen. There is no sign of fracture. CT
is not able to provide intrathecal detail comparable to MRI. The
visualized outline of the thecal sac appears unremarkable.
IMPRESSION: Normal cervical spinal CT.
=
=
================================================================
CHEST (PA & LAT) [**2199-5-13**] 3:26 AM
CHEST (PA & LAT)
Reason: eval acute process, free air.
[**Hospital 93**] MEDICAL CONDITION:
34 year old man with sob, ostomy with increased output
REASON FOR THIS EXAMINATION:
eval acute process, free air.
INDICATION: 34-year-old male with shortness of breath, ostomy
with increased output. Please evaluate for acute process or free
air.
FINDINGS: AP upright and lateral chest radiographs are reviewed
and compared to [**2199-4-25**]. Cardiomediastinal silhouette is
unchanged. The pulmonary vascularity is normal. Lung volumes are
low, but allowing for this, the lungs are clear. There is no
pleural effusion or pneumothorax. Since previous exam, right
PICC has been removed. There is no sign of free intraperitoneal
air.
IMPRESSION: No acute cardiopulmonary process.
============================================================
Disharge labs:
Brief Hospital Course:
In brief, the patient is a 34 yo M with Type II DM, extensive
psychiatric history, recent abdominal cellulitis on IV Abx p/w
fever, diarrhea complicated by hypoxia.
.
# Diarrhea/fevers/abdominal pain: Began several days ago after
course of broad spectrum antibiotics. Patient with recent 12 day
hospitalization with 10-day antibiotic therapy raising suspicion
for C. Diff infecion. Patient also with recent initiation of
Indomethacin therapy for arhritis, and has guiaic positive stool
here, concerning for early gastritis. His hematocrit was stable
prior to discharge. Indomethacin discontinued, PPI maintained.
C. diff negative x 3 in house but B toxin pending He will
complete an empiric 2 week course of flagyl given significant
improvement as inpatient with decreased output and no further
extreme malodor. No fevers in house.
.
# Hypoxia: Patient developed acute hypoxemia in the setting of
what appears to be a severe episode of anxiety on [**5-14**]. The
patient's oxygenation did improve with ativan and morphine at
which time he was able to breath more comfortably, and
saturations improved to the high 90s on the NRB. He was
transferred to the ICU for monitoring. Chest imaging did not
show acute process. The patient was quickly weaned off oxygen
and transferred back to the floor on [**5-15**] with no further
shortness of breath, hypoxia, anxiety.
.
#Fall: Patient with unwitnessed fall on [**5-16**] AM. No apparent
injuries, complaint of neck pain but CT C-spine within normal
limits. Pain controlled with oxycodone. Unclear if actual
fall, given history of ? factitious disorder.
.
#Psycho-Social: Following transfer to the ICU the patient became
upset about the care he had received (received doses of ativan
for shortness of breath) and wanted to sign-out AMA. It was
explained to him the treatment for his shortness of breath was
to allow him to breath deeply and calmly to improve his gas
exchange. It was explained to him that the therapy had
prevented him from getting more short of breath and requiring
intubation and mechanical ventilation. It was explained to him
that our main priority was insuring his safety. From prior OMR
notes, it is difficult to define his psychiatric and personality
disorder(s) as prior physicians have noted multiple
inconsistencies in his recounting of his history.
Psychiatry consulted and familiar with patient. Multiple
inconsistencies in history offered to different providers on
past admit and this admission. Maintained on outpatient psych
regimen. Attempted to place in rehab for monitoring given
inconsistencies as to home environment and concern for possible
factitious behavior but not deemed suitable for any rehab or
long term living situation. Discharged [**Street Address(1) 21381**] INN. SW,
psych, CM very involved. Outpatient psych appointments in
place.
.
# DM2: Patient is on high doses of insulin as outpatient.
- Continued home regimen of 75/25 regimen and Humalog SS
.
# HTN: On Amlodipine, Lisinopril, Toprol XL, Valsartan as
outpatient
- Continued home regimen.
.
# Left ankle pain/Polyarticular arthritis: Patient was recently
evaluated by rheumatology on previous admission and indomethacin
was started fro reactive arthritis of left ankle. ON another
recent previous admit, had great toe swelling managed as gout.
ON admission here, still with some pain in left ankle and
patient reports indomethacin had helped but it was discontinued
with GI complaints, concern for gastritis. Rheumatology
re-consulted and performed intra articular steroid injeciton
with good effect. Oxycodone prn for breakthrough. has rheum
f/u in early [**Month (only) 116**].
.
# ColostomY/Healing wound: For fournier's ganrene, perineal
wound well healing. Patient had colostomy at [**Hospital1 2025**] and was
schedule to have reversal given that wound gangrene resolved.
Patient has not followed up as instructed. Again advised to
followup with his surgeon and instructed to follow up for wound
care.
Medications on Admission:
Amlodipine 10 mg Tablet PO qd
Valsartan 80 mg Tablet PO twice a day.
Simvastatin 40 mg Tablet PO qhs
Lisinopril 40 mg Tablet PO qd
Quetiapine 25 mg Tablet PO qhs PRN: insomnia
Toprol XL 200 mg Tablet PO qd
Escitalopram 40 mg PO qd
Aspirin 81 mg Tablet
Fenofibrate Oral
Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: One
Hundred (100) units Subcutaneous with breakfast daily.
Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: Sixty Four
(64) units Subcutaneous with dinner daily.
Humalog 100 unit/mL Solution Sig: as per sliding scale units
Subcutaneous four times daily; with meals and a bed time.
Indomethacin 50 mg Capsule PO TID x 7 d (just completed)
Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day for 14 days
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H () as
needed.
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Valsartan 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
7. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
8. Escitalopram 10 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
9. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
10. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Insulin Lispro Protam & Lispro 100 unit/mL (75-25)
Suspension Sig: One Hundred (100) units Subcutaneous qAM.
12. Insulin Lispro Protam & Lispro 100 unit/mL (75-25)
Suspension Sig: Sixty Four (64) units Subcutaneous qPM.
13. Humalog 100 unit/mL Solution Sig: 0-12 units Subcutaneous
four times a day: according to attached sliding scale.
14. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
15. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
16. Fenofibrate Oral
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Probable c. diff colitis
2. Depression
3. Fall, accidental
4. Hyperlipidemia
5. Type II Diabtes mellitus
6. Polyarticular Arthritis
7. Hypertension
Secondary:
Diabetes mellitus type 2
hypertension
PTSD
Discharge Condition:
Discharged [**Street Address(1) 21381**] INN
no fevers. ambulating unassisted. no supplemental oxygen.
diarrhea improved
Discharge Instructions:
You were admitted to the hospital with worsening abdominal pain
and stool output. These symptoms are like due to c. diff
bacterial infection. You are on the flagyl for this infection.
Take it as prescribed. YOU CANNOT DRINK ALCOHOL on this
medication as it will make you very sick.
Your ankle pain was evaluated by the joint doctor and you
received a steroid injection for it. You must follow up with
the rheumatologist for this. We are not giving you indomethacin
or NSAIDS (class of medication such as indomethacin, ibuprofen
etc.) because it caused you severe stomach upset. Use the
oxycodone for your pain until you are seen by the
rheumatologist.
You should take all medications as prescribed. The only new
medications are flagyl for your infection and oxycodone for
pain.
On last admission, your blood pressure medications were changed.
They now include amlodipine, metoprolol, lisinopril and
valsartan. Please
review these with Dr. [**Last Name (STitle) **] at your next appointment.
If you develop any new or concerning symptoms such as fever,
shortness of breath; recurrent diarrhea or any other new
concerning symptoms, seek medical attention immediately.
You should follow up with your wound care specialist and surgeon
at [**Hospital3 2576**] for your colostomy and healing ulcer. Continue
your current wound care until such time. Otherwise, follow up
as below.
Followup Instructions:
We have scheduled you an appointment with Dr. [**Last Name (STitle) **] on
Tuesday, [**6-11**] at 2:00PM. Please call [**Telephone/Fax (1) 250**] with any
questions.
.
We have scheduled you for a follow-up appointment with Dr. [**Last Name (STitle) 1667**]
from rheumatology at 2:45PM on [**2199-5-28**]. His office is
located on the [**Location (un) **] of the [**Hospital 2577**] Medical Office Building
on the [**Hospital1 18**] [**Hospital Ward Name 517**]. Please call ([**Telephone/Fax (1) 1668**] if you need
to change this.
.
Please keep your mental health appointments scheduled for you on
[**2199-5-21**] and [**2199-5-22**]. The details of these appointments have
already been provided to you.
They are:
Tuesday,[**2199-5-21**] at 11AM
Wednesday,[**5-22**] at 2:00PM
[**Location (un) 3146**] Counseling Center
[**University/College 23633**] Mental Health
[**Street Address(2) 29385**].
[**Location (un) 3146**],Ma.
[**Telephone/Fax (1) 76779**]
.
You should follow up with your wound care specialist and surgeon
at [**Hospital3 2576**] for your colostomy and healing ulcer.
|
[
"309.81",
"278.01",
"V44.2",
"401.9",
"300.00",
"008.45",
"296.20",
"272.4",
"250.02",
"716.87"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14574, 14580
|
8365, 12351
|
311, 318
|
14839, 14961
|
3835, 4504
|
16399, 17491
|
2945, 3192
|
13186, 14551
|
7585, 7640
|
14601, 14818
|
12377, 13163
|
14985, 16376
|
2446, 2531
|
3207, 3816
|
247, 273
|
7669, 8342
|
346, 1511
|
1533, 2423
|
2547, 2929
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,829
| 133,755
|
4850
|
Discharge summary
|
report
|
Admission Date: [**2175-3-7**] Discharge Date: [**2175-3-24**]
Date of Birth: [**2105-3-31**] Sex: F
Service: MEDICINE
Allergies:
Reglan / Bee Sting Kit
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Colonoscopy s/p [**Hospital1 **]-CAP Electrocautery
PICC placement
Tunneled Dialysis Catheter Replacement
Central Venous Catheter Placement - L Subclavian
Abdominal Angiography
Intubation
History of Present Illness:
69 ESRD on HD [**1-26**] presents with BRBPR starting yesterday. Had
9-10 episodes small amounts initially then up to 1 cup with
small clots yesterday evening; last episode 11:15am today. No
lightheadedness, syncope, abd pain, chest pain. Last admitted
to this hospital [**12-30**] for LGIB. Colonoscopy at that time showed
diverticulosis and hemorrhoids. EGD showed no bleed.
.
On labs, had serum K greater than 10. EKG showed PR
prolongation and widened QRS. Got kayexalate, Ca, insulin,
dextrose and EKG changes improved. K decreased to 8. Attempts
to place temp HD line failed. Plans for IR guided placement
tunneled line tomorrow AM secured by renal fellow. Over last
week she has had difficulty with HD due to a clot in her
tunneled line. Her husband notes increased lethargy and
disturbance with sleep-wake cycle. No dyspnea, orthopnea, PND,
or fevers.
.
Got levofloxacin for aymptomatic bactiuria in ESRD patient.
Past Medical History:
HTN
ESRD on HD [**1-26**] DM-2 MWF
LGIB
PVD
s/p R AKA
s/p R fem-[**Doctor Last Name **] bypass ([**2172**]), L bypass ([**2163**])
hypothyroidism
PAF
Depression
GERD
Social History:
Prior to stay at rehabiltiation center since rt. bka, the
patient lived with her husband. She is a former [**Year (4 digits) 1818**], denies
ETOH or drug use
Family History:
non-contributory
Physical Exam:
vs: bp 150/70, hr 50 NSR, rr 12, spO2 100% 2liters N/C
gen: lethargic
neuro: MAE, responds to pain, cannot arouse, gag present
lungs: crackles 25% up, occasional expiratory wheeze, good
aeration
CV: s1/s2, [**Year (4 digits) **], no m/r/g
abd: obese, soft, non-tender to palpation, no mass
ext: R AKA, Left heel ulcer, DP faint, warm and dry
Pertinent Results:
[**3-7**]: CXR: INDICATION: Multiple line attempts. There has been
interval removal of a left subclavian vascular catheter. A
preexisting right subclavian catheter is unchanged in position,
and there is no evidence of pneumothorax. A nasogastric tube is
then placed, terminating within the stomach. There is otherwise
no significant change since the recent radiograph of several
hours earlier.
.
[**3-8**]: TAgged RBC scan: No abnormal areas of tracer uptake.
.
[**3-11**]: Head CT: There is no evidence of acute intra- or
extra-axial hemorrhage. There are multiple areas of
periventricular white matter hypodensity that may represent
chronic small vessel ischemic disease. No hydrocephalus or shift
of normally midline structures. Basal cisterns appear patent.
There are air-fluid levels in the sphenoid sinus. There is
slight mucosal thickening of left maxillary sinus
.
[**2175-3-13**]: Tagged RBC scan: Got tracer, but refused imaging.
.
[**2175-3-14**]: Tagged RBC Scan: Abnormal focus of tracer activity is
present in the right upper quadrant that is felt to most likely
to localize to the hepatic flexure of the large bowel. However
relatively little distal movement of tracer limits the
confidence of this localization and a possibility that is felt
to be less likely to bleeding in the duodenum.
ADDENDUM: Additional delayed images were obtained 7 hours after
tracer
injection. Tracer is seen within the hepatic flexure and
extending antegrade into the transverse colon, and descending
colon with an appearance consistent with active bleeding at this
site.
.
EEG: [**2175-3-13**]:
BACKGROUND: In the very brief portions of the record with the
patient
awake, rare rhythms as fast as [**9-3**] Hz were seen of low to
moderate
voltage while [**7-1**] Hz rhythms predominated biposteriorly. The
anterior-posterior voltage gradient was preserved. No focal,
lateralized, or discharging abnormalities were seen.
HYPERVENTILATION: Not performed.
INTERMITTENT PHOTIC STIMULATION: No activation of the record.
SLEEP: The patient appeared to be in stages I, II, and
occasionally III
throughout the overwhelming majority of this record. Vertex
activity
was seen symmetrically in stage II.
CARDIAC MONITOR: No arrhythmias noted.
IMPRESSION: Possibly abnormal due to the excessively drowsy
record
obtained which, in the absence of medication or sleep
deprivation, might
indicate an early encephalopathy. No definitive discharging
abnormalities were seen, however.
.
[**2175-3-15**]: Angiography - Abdominal:
IMPRESSION: Nonselective aortogram, selective gastroduodenal
arteriography, selective arteriography via the third order
branches of the SMA and second order branch into the ileocolic
artery demonstrated no active bleeding. No intervention was
performed.
.
[**3-21**] Colonoscopy: Red blood was seen in most of the colon all
the way to the hepatic flexure. No blood was seen in the cecum.
An adherent clot was seen at the hepatic flexure. The clot was
washed off with active oozing seen from likely an angioectasia
or Dieulafoy's. 2 1 cc Epinephrine 1/[**Numeric Identifier 961**] injections were
applied for hemostasis with success. [**Hospital1 **]-CAP Electrocautery was
applied for hemostasis successfully. Petechial-like lesions
were noted in the cecum and hepatic flexure.
.
[**2175-3-7**] 03:35PM GLUCOSE-55* UREA N-83* CREAT-7.7* SODIUM-139
POTASSIUM->10.0 CHLORIDE-98 TOTAL CO2-26
[**2175-3-7**] 03:35PM ALT(SGPT)-45* AST(SGOT)-30 CK(CPK)-597* ALK
PHOS-185* AMYLASE-62 TOT BILI-0.2
[**2175-3-7**] 03:35PM WBC-6.7 RBC-3.62*# HGB-12.3# HCT-38.5#
MCV-106* MCH-33.9* MCHC-31.9 RDW-17.7*
[**2175-3-7**] 03:35PM NEUTS-58.8 LYMPHS-20.9 MONOS-7.5 EOS-9.7*
BASOS-3.2*
[**2175-3-7**] 03:35PM PLT COUNT-146*
[**2175-3-7**] 03:35PM ALBUMIN-4.1
[**2175-3-7**] 03:35PM CK-MB-17* MB INDX-2.8 cTropnT-0.35*
[**2175-3-7**] 04:55PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-MOD
[**2175-3-7**] 04:55PM URINE RBC-[**11-13**]* WBC->50 BACTERIA-MANY
YEAST-NONE EPI-0
Brief Hospital Course:
This is a 69 yo female with DM2 and ESRD on HD admitted with GIB
and hyperkalemia. The patient's hyperkalemia was attributed to
missed hemodialysis. She received Kayexalate, calcium, bicarb,
and insulin in the ED. EKG showed QRS complex narrowing
post-treatment. She was urgently dialyzed, but was sent to
angiography and was diagnosed with a HD catheter clot. TPA was
instilled without effect and the patient underwent dialysis
catheter change. During her hospitalization she received
dialysis per renal team.
.
The patient had a history of multiple pior admission for GI
Bleed. She began to have guaiac positive dark stool in the ICU.
She underwent tagged RBC scan from [**3-14**], which showed possible
R hepatic flexure diverticuli. Angiogram on [**3-15**] was negative.
The patient was hesistant to undergo any further procedures for
several days. General surgery was consulted and felt that the
pt was a poor surgical candidate. Finally on [**3-20**] she consented
to and underwent colonoscopy. She had cauterization and capping
of bleeding vessel. Her hematocrit was monitored Q8 hours. She
received daily blood transfusions to keep her Hct >30 (due to
NSTEMI as below). She remained hemodynamically stable. She
also received [**Hospital1 **] PPI therapy. She was kept NPO and received
nutrition by TPN. On discharge her Hct had remained stable and
she was tolerating a low-residue diet.
.
In the ICU she ruled in for an NSTEMI by elevated CK/MB and
tropT, likely [**1-26**] stress from GI bleed. No anticoagulation was
given due to GI Bleed. Serial EKG showed no changes. She was
continued on low dose [**Month/Day (2) **], lipitor, and metoprolol 25mg PO TID.
She will need to arrange outpatient cardiology follow-up.
.
She was diagnosed with an ESBL Klebsiella UTI ([**3-7**]) and
underwent 7 days treatment with meropenem. Her ICU course was
also complicated by ICU delirium with a nl EEG, TSH, B12, and
folate. She also had a seizure (episode of laterally deviated
eyes and tense muscles while returning from HD, attributed to
lowered seizure threshold with combination of meropenem and
haldol. Haldol, morphine, and benzos were held and the
patient's mental status returned to baseline by [**3-17**].
.
The patient's outpatient avandia was held for her Diabetes. She
was placed on Q6H fingersticks with humalog sliding scale.
.
She was incidentally found to have 50% stenosis of SVC. She has
no signs or symptoms at this time. She has been given the
contact information for Dr [**Last Name (STitle) 380**] in IR to disucss changing her
HD line.
.
For prophylaxis the patient received PPI, venodyne boot, and her
home synthroid and paxil. PT was consulted and worked with the
patient. SW was also consulted for coping issues.
Medications on Admission:
Paxil 20mg po qd
levothyroixine 125 mcg po qd
lipitor 20 mg qd
calcium acetate 667 mg TID
vit C 500mg [**Hospital1 **]
B-complex-vitc-folate
zinc 220 qd
neurontin 300 qd after HD
[**Hospital1 **] 81 po qd
colace 100 prn
lansoprazole 30 qd
psyllium wafer
NPH 40/10 [**Hospital1 **]; no sliding scale for meals
Discharge Medications:
1. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO once a day.
9. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily): On HD days.
11. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
12. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
unit Subcutaneous ASDIR (AS DIRECTED): per sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
1. Lower GI bleed, s/p Bicap
2. Klebsiella UTI
3. NSTEMI
4. ESRD on Hemodialysis
5. Diabetes Mellitus Type II
6. Hypertension
Discharge Condition:
Good, with stable hematocrit
Discharge Instructions:
You are discharged to [**Hospital **] Rehabilitation Facility where you
should continue your medications as prescribed.
Please tell the physicians there or contact your primary care
physician if you experience blood from your rectum, black tarry
stools, lightheadedness, dizziness, chest pain, fevers, chills,
night sweats or other concerns.
Please keep all your follow-up appointments. You should discuss
the dialysis catheter replacement and SVC stenosis with Dr
[**Last Name (STitle) 380**] at ([**Telephone/Fax (1) 20268**].
Followup Instructions:
You have a follow-up appointment with your primary care
physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 18998**] on [**Last Name (LF) 2974**], [**2180-4-6**]:45AM.
.
You should follow-up with cardiology for the heart attack that
you had. Please call [**Telephone/Fax (1) **] to make your appointment.
.
You have follow-up with Gastroenterology arranged as below:
Provider: [**First Name11 (Name Pattern1) 2671**] [**Last Name (NamePattern4) 10485**], MD Phone:[**Telephone/Fax (1) 2986**]
Date/Time:[**2175-7-4**] 10:00
|
[
"562.12",
"530.81",
"707.15",
"573.8",
"E879.1",
"440.23",
"599.0",
"459.2",
"996.74",
"410.71",
"250.00",
"428.0",
"041.3",
"511.9",
"585.6",
"E849.8",
"780.39",
"244.9",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"99.15",
"99.04",
"39.95",
"99.10",
"38.93",
"45.43",
"88.42"
] |
icd9pcs
|
[
[
[]
]
] |
10491, 10570
|
6281, 9048
|
288, 477
|
10739, 10769
|
2218, 2693
|
11349, 11890
|
1822, 1840
|
9408, 10468
|
10591, 10718
|
9074, 9385
|
10793, 11326
|
1855, 2199
|
243, 250
|
505, 1439
|
2702, 6258
|
1461, 1629
|
1645, 1806
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,343
| 192,515
|
54682+59624+59626
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2138-7-10**] Discharge Date: [**2138-7-20**]
Date of Birth: [**2083-1-28**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Hydrocodone
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 72255**] is a 55 year old woman with a history of chronic
alcohol abuse, asthma/COPD, and HTN who presented to [**Hospital 8641**]
Hospital on [**7-8**] in NH with nausea, vomiting, and abdominal pain.
She drinks >5 drinks daily, including 2 morning drinks, and has
daily nausea and abdominal pain. Her pain become more severe and
persistent in the 3 days prior to her presentation to [**Location (un) 8641**].
She had no hematemesis, melena, fever, or cough.
At [**Location (un) 8641**], a CT scan showed evidence of acute pancreatitis with
a 9.1x4.8cm fluid collection consistent with pancreatic
pseudocyst without evidence of necrosis or infection. Her
[**Last Name (un) 5063**] score was 3 (WBC 17, LDH 510, HCT 45.4 --> 34.9). An
MRCP did not show evidence of communication between the
pancreatic duct and the pseudocyst.
She was treated with LR IVF resuscitation and dilaudid IV for
pain. On [**7-9**], she had a fever to 101.1. On [**7-10**], she spiked a
fever to 103.1. Blood cultures were drawn from both episodes and
are pending. She was tachycardic to 124, with stable blood
pressure. She was given flagyl 500mg and aztreonam 1g and
transferred to [**Hospital1 18**].
Regarding her alcohol withdrawal, she was placed on standing
ativan and CIWA protocol. She had been tremulous and irritable
and had one episode of hallucination but no seizures.
On arrival to the MICU, patient's VS were 98.5, 93, 133/80, 25,
96% 2 LNC. The patient complains of fever, nausea, abdominal
pain, diarrhea, dyspnea, cough, wheezing, anxiety. Patient
denies any SI or HI.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
Denies chest pain, chest pressure, palpitations. Denies
constipation, abdominal pain, diarrhea, dark or bloody stools.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
alchol abuse--has never had withdrawal seizures
HTN
asthma
COPD
anxiety disorder
depression
s/p bilateral oophorectomy [**2135**]
Social History:
Divorced since [**2134**], currently lives alone. Currently
unemployed. Smokes 1/2ppd. Denies current illicit drug use, but
has used in the past (used crack 2 years ago for about 6
months). Never used IV drugs. Drinks >5 drinks per day (1 bottle
of wine or about 1 quart of vodka per day). Needs 2 drinks in
the morning to relieve nausea and start the day. Has been
mixing alcohol and benzodiazepines for several years.
Family History:
Father died of ESRD [**1-2**] DM, was on dialysis.
Physical Exam:
Vitals: 98.5, 93, 133/80, 25, 96% 2 LNC
General: Alert, appears uncomfortable, and diaphoretic, oriented
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: decreased breath sounds bilaterally with end expiratory
wheezing
Abdomen: distended, diffusely tender, no masses, no rebound,
+guarding, bowel sounds present
GU: no foley
Ext: Warm, clubbing of digits, well perfused, 2+ pulses, no
cyanosis or edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Pertinent Results:
RUQ U/S [**2138-7-11**]
IMPRESSION:
1. Gallbladder sludge without evidence of cholecystitis.
2. Echogenic liver consistent with fatty infiltration. Other
forms of liver
disease including more significant hepatic fibrosis or cirrhosis
or
steatohepatitis are not excluded on the basis of this
examination.
3. 7.4 x 5.6 cm fluid collection. In the setting of
pancreatitis primary
diagnostic consideration includes pseudocyst. Please compare to
the
(reportedly previously obtained) outside hospital CT.
4. Small right sided pleural effusion.
.
CT ABD & PELVIS WITH CONTRAST Study Date of [**2138-7-13**] IMPRESSION:
1. Slight interval increase in size of rim-enhancing organized
peripancreatic fluid collection. Increase in extent of
unorganized peripancreatic fluid surrounding the pancreatic
tail. Super-infection cannot be excluded by imaging.
2. Moderate left and small right pleural effusions are new
since [**7-8**].
.
CHEST PORT. LINE PLACEMENT Study Date of [**2138-7-17**]
IMPRESSION: Right-sided PICC line in place with the tip in the
lower SVC.
Otherwise unchanged chest radiograph.
.
Brief Hospital Course:
55 year old woman with a history of chronic alcohol abuse,
asthma/COPD, and HTN who transfered from [**Hospital 8641**] Hospital with
severe acute pancreatitis.
# Pancreatitis: Patient presented to OSH with n/v and abdominal
pain; CT scan performed consistent with acute pancreatitis with
9 cm pseudocyst without necrosis. Pancreatitis likely secondary
to alcohol abuse. CT did not show evidence gallstones, no
biliary duct dilatation. MRCP was performed and revealed a
unremarkable pancreatic duct. Patient was treated with IV
hydration. Patient received 1 dose of metronidazole 500mg and
aztreonam 1 g prior to transfer due to concern for sepsis (temp
to 103.1, sinus tach to 120's). Patient arrived to the ICU with
stable vital signs, afebrile. Blood cultures were sent.
Antibiotics were intially held to monitor for signs of
infection. She was started on maintenance fluids and given
dilaudid PRN for pain control. She was stable and transferred
to the floor on D3 of ICU stay. On arrival to the [**Hospital1 **], pt. had
continued fevers, abdominal pain, and evidence of significant
alcohol withdrawal syndrome including tremulousness, anxiety,
tachycardia; fevers were concerning for delerium tremens vs.
representative of possible bacterial superinfection of her known
pseudocyst. She was given valium with improvement. Antibiotics
were resumed and surgery was consulted. OSH images were loaded
to our radiology system and a repeat Abdominal CT was performed
for comparison demonstrating increased size of pseudocyst, and
ongoing significant pancreatic inflammation and peri-pancreatic
fluid including small bilateral pleural effusions. She was
managed with bowel rest and aggressive IV hydration, along with
serial abdominal examination and ongoing surgical input. She
was treated initially with Aztreonam and flagyl, and aztreonam
was later changed to Cefepime with plans for a 14-21 day course,
per Surgery recommendations. Given her ongoing abdominal pain
and distention, she was kept NPO and she was started on TPN.
She will remain on TPN while her abdominal inflammation
decreases and her abdominal exam improves. She is anticipated
to remain on TPN for approx 2 weeks before reinitiating diet.
SHe should remain on TPN and IV antibiotics until she sees Dr
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in followup. Please make an appointment for her to
see Dr [**First Name (STitle) **] within 10-14 days.
# Alcohol Withdrawal: Patient has significant history of
alcohol use (1 bottle of wine or vodka per day for several
years). Patient's last alcoholic drink sometime between Friday
[**7-4**] to Sunday [**7-7**]. She was started on thiamine,
multivitamins, electrolyte repletion, as well as CIWA protocol.
She required significant doses of valium to control symptoms,
and may have experienced some autonomic labiity possibly
consistent with delerium tremens. Suspicion is high for an
underlying cognitive impairment due to longstanding substance
abuse, possibly including the Korsokoff syndrome, as her
daughter reports that 'even on pts best days' she cannot
remember conversations from the day prior. It remains unclear
how much of this encephalopathy is due to ongoing substance use
at home vs. fixed CNS injury. Patient's mental status returned
to baseline by the time of discharge.
#Anxiety: Patient started on hydroxyzine 50 mg q 6 hours as
needed for anxiety.
#Depression
Patient has chronic benzodiazepine abuse as an outpatient in
addition to her alcohol abuse. Her alcohol withdrawal
necessitated the use of benzodiazepines in the hospital. Patient
has severe underlying anxiety s/p "nervous breakdown" several
years ago for which she has been on benzodiazepines.
Benzodiazepines doses were limited following her alcohol
withdrawl, and was eventually discontinued per Psychiatry
recommendations. She was started on Hydroxyzine, to which she
found benefit. Patient had been on Paxil at home, and our
psychiatrists recommended that her dose be increased from 30 to
40 mg daily, which was done.
# COPD: continued advair and albuterol from medications on
transfer. Added spiriva. Remained largely asymptomatic,
however, she did require occasional nebulizer treaments for mild
reactive airways disease with wheezing on occasion.
# Anemia: Macrocytic anemia HGB 11.0, MCV 104. Most likely
secondary to malnutrition with alcoholism. B12 at OSH normal.
Remained stable throughout hospitalization.
# Hyperglycemia: SHe initially had some mild hyperglycemia and
was briefly on an insulin sliding scale; this resolved and she
did not require any supplemental insulin.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from transfer record.
1. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
2. Aztreonam 1000 mg IV Q8H
3. Lorazepam 2 mg PO TID
4. Tiotropium Bromide 1 CAP IH DAILY
5. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
7. HYDROmorphone (Dilaudid) 0.25-0.5 mg IV Q4H
8. Thiamine 100 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Heparin 5000 UNIT SC TID
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
# Pancreatitis with pseudocyst with possible bacterial
superinfection
# Alcohol and benzodiazepine withdrawal syndrome including
delerium and possibly delerium tremens with autonomic
instability
# Anxiety/Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were hospitalized with severe alcoholic pancreatitis and
alcohol withdrawl. You were very sick and required ICU care
initially. Due to your pancreatitis, you should not eat or
drink, and instead you are receiving nutrition through your IV
(TPN). This will continue until the inflammation in your
abdomen improves.
It is extremely important that you do not take any alcohol or
benzodiazepines in the future, as you are addicted to these
substances, and if you continue to drink, you will likely die
from this.
You cannot eat or drink until you see Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in followup
in two weeks. IN addition, you need to continue antibiotics
until you see her in two weeks.
Followup Instructions:
PLEASE Call the office of Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 39468**] to be
seen in followup at her office in [**Location (un) 620**].
Name: [**Known lastname 18365**],[**Known firstname 1163**] L Unit No: [**Numeric Identifier 18366**]
Admission Date: [**2138-7-10**] Discharge Date: [**2138-7-20**]
Date of Birth: [**2083-1-28**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Hydrocodone
Attending:[**Doctor First Name 376**]
Addendum:
Per surgical service patient may have ice chips.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2876**] - [**Location (un) 2877**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 377**] MD [**MD Number(2) 378**]
Completed by:[**2138-7-20**] Name: [**Known lastname 18365**],[**Known firstname 1163**] L Unit No: [**Numeric Identifier 18366**]
Admission Date: [**2138-7-10**] Discharge Date: [**2138-7-20**]
Date of Birth: [**2083-1-28**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Hydrocodone
Attending:[**Doctor First Name 376**]
Addendum:
Lab tests included in addendum
Pertinent Results:
[**2138-7-20**] 04:20AM BLOOD WBC-11.5* RBC-2.89* Hgb-9.7* Hct-29.7*
MCV-103* MCH-33.5* MCHC-32.6 RDW-13.2 Plt Ct-542*
[**2138-7-20**] 04:20AM BLOOD Glucose-121* UreaN-11 Creat-0.4 Na-140
K-4.3 Cl-103 HCO3-31 AnGap-10
[**2138-7-19**] 09:14AM BLOOD VitB12-1356*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2876**] - [**Location (un) 2877**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 377**] MD [**MD Number(2) 378**]
Completed by:[**2138-7-20**]
|
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"305.1",
"303.91",
"511.9",
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"V85.24",
"493.20",
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"401.9",
"577.2",
"300.00",
"995.93",
"311",
"285.9",
"577.0",
"577.1",
"292.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
12779, 12990
|
4807, 9454
|
320, 326
|
10330, 10330
|
12494, 12756
|
11235, 11845
|
2930, 2984
|
10091, 10309
|
9480, 9973
|
10481, 11212
|
2999, 3661
|
1965, 2321
|
248, 282
|
354, 1946
|
10345, 10457
|
2343, 2475
|
2491, 2914
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,462
| 157,621
|
29850
|
Discharge summary
|
report
|
Admission Date: [**2155-12-18**] Discharge Date: [**2156-3-24**]
Date of Birth: [**2106-5-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2159**]
Chief Complaint:
AIDS; multiple ring-enhancing brain lesions
Major Surgical or Invasive Procedure:
endotracheal intubation and extubation
PICC line insertion
CT guided abscess drainage
History of Present Illness:
49 year old male with AIDS (last CD4 17 when he initially
presented), off HAART and non-compliant, being transferred from
[**Hospital 12017**] [**Hospital 71377**] Hospital for further management of
intracranial masses and seizure. Recent history includes a
duodenal perforation with resultant polymicrobial liver abscess
in [**2154-12-22**] that was treated and resolved. He presented to
[**Location (un) 12017**] Regional on [**11-19**] with progressive gait unsteadiness,
headache, and seizures; CT/MRI at the time showed multiple
subcortical ring enhancing lesions, most prominently in the
right parietal region, with some associated edema. He was
started on sulfadiazine and pyrimethamine for presumed
toxoplasmosis treatment, as well as dilantin for seizures, but
did not improve. He had an LP on [**11-21**] which showed 6 RBC, 8 WBC
(31% PMN, 48% lymphs, 21% monos), with a protein of 48 and
glucose of 57. Bacterial cultures were negative, as were other
more specific microbial studies (see below). Decadron was added.
The patient's confusion worsened, necessitating change from
sulfadiazine to clindamycin so that it could be administered IV.
Interestingly, toxoplasmosis IgG and IgM antibodies returned
negative, in addition to CSF toxo PCR. An extensive workup for
potential malignancy was undertaken, including CT torso
(negative) and colonoscopy given an elevated CEA of 14.2 (also
unrevealing).
.
The patient's right sided weakness improved, though he had
ongoing right sided incoordination. He also had a mild left 7th
cranial nerve palsy. A repeat MRI on [**12-3**] showed further
progression of the mass lesions. Neurosurgery was involved, and
ultimately proceeded to brain biopsy on [**12-7**] via left parietal
craniotomy. The aspiration revealed purulent material, however
cultures have remained negative. Cytology did not demonstrate
malignant cells. Due to concern for pyogenic abscess, meropenem
was initiated at this point ([**12-8**]). Dexamethasone was
discontinued following the surgery, and he remained seizure free
during the hospitalization.
.
He had a fever to 100 on [**12-13**] at which point metronidazole was
added. On [**12-14**] he began developing difficulty with nausea and
vomiting, and diarrhea. C. Diff assay was negative. He was more
lethargic and mildly hypoxic, in addition to increasing
confusion and hallucinations. Blood and urine cultures were
obtained on [**12-15**] when he spiked to 101.3. MRI was repeated,
demonstrating progressive enlargement of his subcortical
lesions, as well as a pontine lesion and apparent new medullary
lesion. Dexamethasone was resumed at this point (had been d/c'ed
on [**12-8**]). Clindamycin and meropenem were discontinued at this
point in favor of trimethoprim-sulfamethoxazole 5 mg/kg IV Q 12
hours for possible PCP (?). Vancomycin was added as well. A TTE
was undertaken which demonstrated calcification of the chordae
of the anterior mitral valve leaflet, without being able to
exclude a vegetation. Subsequently, both sets of blood cultures
from [**12-15**] revealed gram-positive cocci in pairs and chains. Two
sets obtained earlier on the same day remain without growth.
Blood cultures from [**11-22**] and [**11-19**] are also no growth to date.
.
Of note, he was started on HAART during this hospitalization on
[**12-10**] after CD4 count noted to be 17, and genotyping was sent
(pending at the time of dishcarge).
.
Currently, he denies pain.
Past Medical History:
1) AIDS: CD4 nadir at 45 in [**2146**], but now found to be 17 at
[**Location (un) 12017**]. Only opportunistic infection previously was thrush.
Prior to this admission was on Kaletra, tenofovir, and abacavir.
CD4 count in [**2154-5-22**] was 218, VL > 100,000 copies - was just
resuming HAART at that time after a long self-imposed drug
holiday.
2) Esophageal candidiasis
3) Alcohol abuse, history of pancreatitis and alcohol withdrawal
4) Diverticulitis, with history of diverticular abscess in
[**2154-10-22**]. Treated with percutaneous drainage and
antibiotics.
5) Duodenal perforation with E. Coli bacteremia and hepatic and
intraabdominal abscesses in [**2154-12-22**]. Hepatic abscess grew
E. coli, Klebsiella oxytoca, bacteroides [**Last Name (LF) 71378**], [**First Name3 (LF) **]
albicans, prevotella, and saccharomyces. Intraabdominal abscess
grew [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 10577**]. Treated with ertapenem and ambisome
(developed neutropenia while on caspofungin).
6) Onychomycosis
Social History:
Has not worked in eight years because of his disease. Previously
smoked 1 PPD for years until recently. As above, history of
alcohol abuse. Lives with his partner. Acquired AIDS presumably
via sexual intercourse with men. Has a pet cat at home.
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION: 98.8, 114/87, 83, 20, 90% on 2L.
GENERAL: Mildly uncomfortable appearing caucasian male.
MS: Patient knows he's in [**Location (un) 86**], not sure which hospital. The
date is "[**12-15**]."
HEENT: Moist mucous membranes. Right eye slightly ptotic.
COR: RR, normal rate, no murmurs.
LUNGS: Upper airway congestion making auscultation difficult.
ABDOMEN: Normoactive bowel sounds, distended and mildly tense
but non-tender.
EXTR: Right lower extremity with 1+ pedal edema, much cooler
than left. PT pulse palpable.
NEURO: CN VII palsy on the left, appears to be central. Pupils
equal. Slight right ptosis. Tongue midline. Strength 5/5 on the
left. [**3-25**] right upper extremity extensors but [**1-26**] biceps
flexion. [**2-23**] right lower extremity foot dorsiflexion.
Pertinent Results:
Head:
[**2155-12-16**]: MRI head: Multiple rim-enhancing lesions with slow
diffusion in the center are suggestive of infectious etiology
and favor toxoplasmosis over lymphoma. Mild surrounding edema is
seen without midline shift or hydrocephalus.
[**2156-1-20**]: MRI/A head: Interval decrease in size of multiple
cerebral and brainstem lesions consistent with abscesses.
Unchanged tiny left occipital subdural hematoma.
[**2156-3-10**]: MRI head: There has been no significant interval change
since the most recent comparison study of [**2156-2-12**]. Again
demonstrated are small ring-enhancing lesions involving the left
superior cerebellar peduncle and right corona radiata, measuring
5 mm and 10 mm respectively, not significantly changed. Two
faint foci of enhancement, one in the left frontal lobe and the
second in the right parietal lobe just superior and posterior to
the central sulcus are also unchanged. No new enhancing lesions
are appreciated. There remains a small amount of edema relating
to several of these lesions, most prominently the lesion in the
right corona radiata, also unchanged.
.
Torso:
[**2155-12-20**]: CT torso:
1. Diffuse lung abnormalities likely diffuse lung injury from
developing ARDS. Pulmonary edema is a consideration and diffuse
infectious etiology such as PCP cannot be entirely excluded.
2. High-grade small bowel obstruction with likely transition
point involving the distal jejunum in the right pelvis. No
evidence of free air, abscess, or pneumotosis.
[**2156-1-6**]: CT abd/pelvis:
1. Relatively large abscess in the lower abdomen. This abscess
cavity is located between the sigmoid colon and the bladder.
2. Diffuse thickening of the cecum and ascending colon and
sigmoid colon. This might be secondary to intraabdominal
infection. Followup of this area after resolution of infection
is recommended.
3. Unchanged appearance of diffuse ground glass opacities of
both lungs.
[**2156-2-3**]: CT abd/pelvis:
1. Extraluminal oral contrast is present surrounding the sigmoid
colon, which indicates the presence of at least another
fistulous tract in addition to the known abscess. A small linear
defect seen in the posterior aspect of the mid sigmoid may
represent the second smaller fistula.
2. Abscess collection with wide-mouth communication with
adjacent sigmoid colon.
[**2156-3-10**]: CT abd/pelvis:
1. Tiny amount of residual fluid at the site of prior pigtail
catheter. The amount of fluid is unchanged since the prior study
when the catheter was present.
2. Unchanged degree of inflammatory change about the sigmoid
colon.
.
Chest:
[**2156-1-24**]: CT chest: Small pretracheal and subcarinal nodes are
noted, however, there is no significant mediastinal or hilar
lymphadenopathy. The heart is normal in size. There is tiny
pericardial effusion, which can be physiological. There is
bilateral moderate pleural effusion, increased in its amount
since prior studies. There is bibasilar atelectasis adjacent to
the effusion. In the lung window, again note is made of
extensive peribronchial opacities and ground-glass opacities
with dilatation of the bronchi especially in upper lobes,
representing bronchiectasis, persistent, however, has worsened
since prior study, most likely representing persistent and
progressing infectious process in this patient with HIV. There
is 1 cm cavitary area in the left apex. No endobronchial lesion
is noted. Heterogeneous low density in the infracardiac IVC is
noted, probably mixing artifact given the negative cardiac echo
a day before.
[**2156-2-24**]: CT chest:
1. Continued improvement of pulmonary abnormalities including
bibasilar consolidations and diffuse centrilobular ground-glass
opacities consistent with pulmonary infection.
2. Stable bronchiectasis in the right upper lobe.
.
Endoscopy:
[**2156-1-6**]: Flex sigmoidoscopy: Normal mucosa in the sigmoid colon.
pathology: normal mucosa
[**2156-3-16**]: colonscopy: Diverticulosis of the sigmoid colon.
Normal mucosa in the rectum and sigmoid colon.
.
Bronchoscopy:
[**2156-1-15**]: BAL of lingula and transbronchial biopsy of lingula.
pathology: Alveolar tissue with scattered hemosiderin-laden
macrophages and alveolar lining hyperplasia. No viral cytopathic
changes are seen.
BAL: Negative for malignant cells. Abundant pulmonary
macrophages and rare bronchial cells. No viral cytopathic
changes or fungal forms noted.
.
Bone Marrow:
[**2156-1-22**]: Non-specific T-cell dominant reactive lymphoid profile;
no phenotypic evidence of B-cell lymphoma in specimen. B-cells
are markedly decreased in number. T-cells express mature lineage
antigens. Hypercellular myeloid dominant marrow with markedly
left shifted myelopoiesis and increased megakaryocytes.
Acid-fast and GMS stains are negative. The markedly
left-shifted myelopoiesis is consistent maturation arrest, which
may be drug-induced and/or due to HIV infection with high viral
load. The subtle dysplastic changes seen in the erythroid and
megakaryocytic lineages are compatible with HIV-associated
changes.
.
HIV monitoring:
[**2155-12-20**]: CD4 49
[**2156-1-22**]: HIV viral load >[**Numeric Identifier 4856**]
[**2156-2-10**]: CD4 230
[**2156-2-25**]: CD4 297 HIV viral load 2220
Brief Hospital Course:
In brief, the patient is a 49 year old man with HIV/AIDS who was
transferred to [**Hospital1 18**] for further management of multiple brain
lesions who course was complicated by bacteremia, an
intra-abdominal abscess secondary to small bowel obstruction,
multifocal pneumonia, hypoxic respiratory failure, CMV viremia,
pancytopenia, hypotension, malnutrition, and deconditioning.
.
#Ring Enhancing Brain Lesions: ddx at time of admission
included Toxoplasmosis, CNS lympoma, disseminated fungal
infection, or possibly bacterial abscesses. Given recent VRE
bacteremia (see below), TEE was obtained which was negative. Of
note, data from OSH showed negative Toxo Ab and negative Toxo
from CSF. EBV from brain bx fluid was positive, however rasing
the possibility of lymphoma. At [**Hospital1 18**], LP repeated. Toxo
negative, [**Male First Name (un) 2326**]/EBV/ [CMV] negative. Empirically treated for Toxo
with IV bactrim; for CNS Lymphoma with IV Decadron; and for
Bacterial abscesses with Meropenem. Underwent repeat MRI which
showed improvement of his lesions. He will thus continue on
these medications, in addition to the voriconazole that was
started primarily for the pulmonary process but could have also
led to improvement in the CNS lesions. He will need follow up
with ID, Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], for repeat imaging with brain MRI and
abdominal CT to define the course of treatment, as well as
weekly LFTs, BUN and Cr, CBC, and CPK while on meropenem and
daptomycin.
.
#VRE bacteremia/intraabd abscess: The day or two prior to
transfer to [**Hospital1 18**], the patient noted increased abdominal
swelling. At [**Hospital1 18**], KUB/CT demonstrated high grade SBO with
transition point in distal jejunum. Surgery consulted for
?biopsy (given concern for possible lymphoma/transition point)
and recommended conservative management with IVF, NPO and NGT to
suction. SBO clinically resolved and NGT d/c'd. Repeat CT
showed enlargement of the abscess, which contained air, barium,
fluid with surrounding inflamation of the sigmoid colon and fat
stranding. The findings were suggestive of a possible
fistulization between the colon and abscess. The patient was
initially treated with two week course of IV Linezolid. CT
guided aspirate culture grew vancomycin resistant enterococcus.
He was kept NPO and received his nutrition via TPN. The CT
guided drain continued to drain the collection. Given the
patient's high expected surgical morbidity and mortality, he was
managed with expectant management. Follow-up imaging over the
next 2 months revealed gradual improvement of the fluid
collection. The drain ultimately fell out with no evident of
re-expansion of the fluid collection. The follow-up imaging did
not reveal persistence of the fistulous tract from the colon to
the abscess.
.
Although the abscess is being treated with antibiotics, surgery
consult has followed periodically for possible operative
management of abscess and diverticulitis. As part of planning
any surgery that could involve removal of part of the colon,
imaging of the entire colon, ie to screen for co-incident
cancer, would be required. Because of the patient's diverticular
disease complicated by abscess, barium enema carries a risk of
re-injuring the diverticulum that was associated with the
abscess and is therefore relatively contraindicated, given the
recent occurence of the abscess. Virtual colonoscopy, which has
limited value in patients with diverticular disease, is
contraindicated for the same reason, as insufflation of air in
teh colon could perforate the recently abscessed diverticulum.
Colonoscopy was attempted, but the patient's blood pressure
response to sedation limited sedation and anesthesia and the
endoscope could not be advanced beyond the sigmoid with the
maximal level of sedation attained. He will therefore need
repeat colonoscopy when healthier over all to screen for colon
cancer, and further discussion of sigmoidectomy to prevent
future diverticulosis.
.
Similar to the brain abscess above, he will need repeat imaging
with CT of abdomen and pelvis in [**12-23**] weeks and will then visit
his ID/HIV specialist Dr [**Last Name (STitle) **] to discuss duration of antibiotic
therapy.
#HIV: as there was concern for immune reconstitution syndrome,
ID consultants recommended holding HAART. Patient is on azithro
for [**Doctor First Name **] prophylaxis and bactrim for PCP [**Name Initial (PRE) 1102**]. HAART was
restarted on [**1-21**] with Kaletra and Truvada. Once his CD4 count
has been above 200 for 3 months, azithromycin and bactrim may be
discontinued. HIV genotype was sent in [**Month (only) 958**] and is pending at
the time of discharge. [**Hospital 18**] Medical Records ([**Telephone/Fax (1) 39110**] or
[**Hospital **] Clinic/Office ([**Telephone/Fax (1) 4170**] can be contact[**Name (NI) **] for results.
#Pulmonary Infiltrates: Because of some mild hypoxia on
admission and cough, the patient had a Chest CT that
demonstrated (B) pulmonary infiltrates. The patient had 3 AFB
smears that were (-) and several PCP smears that were negative.
Repeat Chest CT demonstrated improvement on the R sided
infiltrates but new defined nodules with ground glass halos that
developed in the left upper lobe and lingula.
The patient underwent CT guided lung bx (given concern for
Aspergillis). Fungal, AFB, viral, and bacterial cultures were
all negative. Follow-up chest CT, following initiation of
voriconazole for treatment of yeast in a routine sputum showed
significant improvement. Patient completed a 21 day treatment
course for PCP and remains on voriconazole (continued for CNS
lesions) which may have led to the improvement in his pulmonary
infiltrate.
During MICU admission from [**Date range (3) 71379**], the patinet continued
to have vent requirement, initially weaning off successfully,
but then acutely w/hypoxic respiratory decompensation during
which time he had CT negative for PE but did show ARDS picture
probably [**1-23**] SIRS from abdominal abscess +/- immune
reconstitution syndrome. He was re-weaned from the ventilator
and extubated successfully. He oxygenation gradually improved
to being stable and normal on room air.
# CMV viremia: Given his extensive risk for atypical organisms
and recurrent fevers throughout his hospital course, a CMV viral
load was checked which was positive. He was treated with
ganciclovir and then valganciclovir until his CMV viral load was
undetectable. Biopsy results from flex sig and bronchoscopy did
not show viral cytopathic changes.
# Somnolence/Mental Status secondary to mutlifactorial delerium.
The patient was intermittently agitated and exhibited decreased
mental status. His neurologic exam gradually improved over the
course of his hospital stay consistent with the resolving brain
abscesses. His delirium was felt to be secondary to the
multifactorial process of his hypoxia, ongoing infections, and
sedating medications. As his overall health improved, his
mental status improved toward his baseline.
# Multi-factorial anemia and pancytopenia: This was felt to be
due to a combination of anemia of chronic disease, marrow
suppression from HIV and medication, further exacerbated by
phlebotomy. Medications that were felt to be contributing were
linezolid, and ([**Male First Name (un) **])ganciclovir. He was evaluated by the
hematology consult service and had a bone marrow biopsy
performed which was consistent with HIV and medication effects.
As his medication regimen was changed as he completed treatment
courses, his blood counts improved. He was temporarily supported
with growth factors (Epo and G-CSF). His blood counts had
stabilized in the normal level prior to discharge.
.
#HSV: Upon presentation, the patient noted pain anal
ulcerations; DAT positive for HSV2. Treated with acyclovir.
#hypotension: the patient was hypotensive with SBPs to the
70-80's and was hypotensive to the 70's. He was transferred to
the [**Hospital Unit Name 153**] were he was volume resusitated. He was continued on
broad spectrum antibiotics and stablized. He had a gradual
improvement in his blood pressures during his hospital stay. His
EF was >60%. He had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**]-stim test was revealed appropriate
response. His blood pressures stablilized by the time of
discharge.
#SIADH: The patient had a transient SIADH likely secondary to
his multiple infections (in particular the lung). As his
infectious processes were treated and improved, his serum sodium
normalized.
# MALNUTRITION: The patient had signs and symptoms of marked
malnutrition with muscle wasting, decreased strength and low
serum albumin. As he was unable to take PO nutrition for much
of his hospital stay secondary to the abdominal abscess and
fistulous connection, he received TPN (~32kcal/kg). His
nutrition labs were periodically checked showing gradual
improvement. He was eventually started on PO nutrition, since
he was taking adequate po calories as of [**3-20**].
# Dispo: Patient is to be discharged to [**Hospital **] Rehab in New
[**Location (un) **].
Medications on Admission:
Nystatin topical to groin [**Hospital1 **]
Clotrimazole topical to groin [**Hospital1 **]
Nystatin swish and spit QID
Fentanyl patch 50 mcg Q 72 hours
Fluconazole 200 mg PO DAILY
Pantoprazole 40 mg PO DIALY
Enfuviratide (Fuzeon) 90 mg SQ [**Hospital1 **]
Emtricitabine/Tenofovir (Truvada) 200/300 mg tab PO DAILY
Tipranavir (Aptivus) 500 mg PO BID
Ritonavir (Norvir) 200 mg PO BID
Abacavir (Ziagen) 300 mg PO BID
Famotidine 20 mg PO BID
Potassium 20 meq PO DAILY
Ondansetron 4 mg IV Q 12 hours
Ondansetron 4 mg IV Q 4 hours PRN
Metoclopramide 10 mg IV Q 6 hours PRN
Phenytoin 100 mg PO Q 0900, 1400
Phenytoin 200 mg PO QHS
Dexamethasone 10 mg IV Q 6 hours
Vancomycin 1.5 grams IV Q 18 hours
Sulfamethoxazole/trimethoprim 370 mg IV Q 12 hours
Albuterol INH PRN
Ipratropium INH PRN
Lorazepam 1 mg PO Q 4 hours PRN
Lorazepam 1 mg IV Q 4 hours PRN
Acetaminophen 650 mg PR Q 4 hours PRN
Saline nasal spray PRN
Morphine 2-4 mg IV Q 1-2 hours PRN
Loperamide 4 mg PO QID PRN
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
3. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
4. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
5. Lopinavir-Ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): continue as long as patient
spending more than 50% of time in bed.
8. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day): to intertrigonous areas.
10. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
11. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK
(TU): until CD4 >200 for three months.
12. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for loose stool.
13. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours).
14. Daptomycin 500 mg Recon Soln Sig: Three [**Age over 90 1230**]y (350)
mg Intravenous Q24H (every 24 hours): dose is 350mg daily.
15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehab and Living Center
Discharge Diagnosis:
Primary:
Brain Abscess NOS.
Right Hemiparesis.
Multiple Lung Abscess VRE/Stenotrophomas.
Abdominal Abscess/Phlegmon c/b Bowel Fistula.
VRE Bacteremia.
CMV Viremia.
Pancytopenia.
Hypoxemia with respiratory distress from multilobar pneumonia
HIV/AIDS.
Malnutrition - severe.
Hypotension NOS.
Relative Adrenal [**Name2 (NI) 71380**].
Discharge Condition:
Fair.
Discharge Instructions:
** please send copy of d/c summary to referring Dr. [**Last Name (STitle) **] (he is
the patient's ID doctor [**First Name (Titles) **] [**Last Name (Titles) **], but patient wishes to f/u here in
[**Location (un) 86**])
Followup Instructions:
Brain MRI and abdomen/pelvis CT in [**12-23**] weeks to eval resolution
of abscesses.
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 55052**], MD Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2156-8-6**] 1:30 [**Hospital Ward Name 23**] 5 eye clinic
|
[
"513.0",
"078.5",
"518.81",
"484.1",
"038.9",
"438.20",
"560.9",
"255.4",
"054.10",
"567.22",
"562.10",
"042",
"569.81",
"263.9",
"261",
"351.0",
"253.6",
"995.92",
"284.8",
"707.03",
"780.39",
"293.0",
"008.69",
"324.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"03.31",
"88.14",
"45.25",
"88.72",
"45.24",
"00.14",
"38.93",
"41.31",
"54.91",
"96.71",
"99.15",
"33.24",
"33.26"
] |
icd9pcs
|
[
[
[]
]
] |
22996, 23062
|
11304, 20471
|
360, 448
|
23437, 23445
|
6085, 11281
|
23714, 23994
|
5250, 5254
|
21489, 22973
|
23083, 23416
|
20497, 21466
|
23469, 23691
|
5269, 5269
|
5291, 6066
|
277, 322
|
476, 3915
|
3937, 4971
|
4987, 5234
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,827
| 115,403
|
43734
|
Discharge summary
|
report
|
Admission Date: [**2197-1-3**] Discharge Date: [**2197-1-16**]
Date of Birth: [**2117-10-12**] Sex: M
Service: NEUROSURGERY
Allergies:
Aspirin
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
Thoracic instrumented fusion with pedicle screws and iliac crest
bone graft
History of Present Illness:
HPI:This is a 79 year old patient admitted from [**Hospital **] Hospital
with recent history of a slip and fall on the ice on thursday
[**2196-12-29**] while walking his dog. He seen on [**2196-12-29**] and discharge
home that day, then readmitted Saturday was discharged and
admitted Sunday due to excessive pain and inability to care for
himself at home. On admission, his cardiac enzymes were
borderline elevated. He denies syncopy, angina, sob, excessive
exertion prior to the fall. He reports severe pain since the
fall that radiates around his truck to abdomen and down to right
hip.At the time of the fall he experienced posterior radiation
right numbness to thigh He denies LOC following the fall. He
denies numbness, tingling, radiation of pain into legs, bowel or
bladder incontinence. Patient became obtunded per family reports
in the hospital last night and transferred to the ICU at [**Hospital **]
Hospital following pain medication administration.
Past Medical History:
PMHx:HTN,dislipidemia,TIA, ankylosing spondylitis, sleep apnea,
BPH s/p prostatectomy and removal of colon polyps.
Social History:
Social Hx:lives alone in [**Hospital3 4634**]
Family History:
Family Hx: widowed with 6 children
Physical Exam:
PHYSICAL EXAM:
O: T: BP: 167/81 HR: 86 R:14 O2Sats:95% on room air
Gen: comfortable, appears to be experiencing severe pain- facial
grimacing during exam.
HEENT: Pupils: EOMs grossly intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person
Motor: patient c/o servere pain with testing of biceps and
ileopsoas
D B T grip IP Q H AT [**Last Name (un) 938**] G
R 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5
Sensation: decreased sensation over right abdomen at T10
Toes equivicol bilaterally
Rectal exam normal sphincter control
point tenderness noted T4-T10
Pertinent Results:
CT CHEST WITHOUT CONTRAST from [**Hospital **] Hospital [**2197-1-2**]:
FRACTURE THROUGH THE VERTEBRAL BODY EXTENDING INTO THE RIGHT
TRANSVERSE PROCESS AND THE RIGHT COSTOVERTEBRAL JOINT. tHERE IS
SOME RETROPULSION OF FRAGMENTS INTO THE CANAL LIKELY CAUSING
MASS EFFECT ON THE THECAL SAC. nO OBVIOUS EXTRA AXIAL BLOOD IS
SEEN.THERE IS LIKELY PARA VERTEBRAL SOFT TISSUE SWELLING.
LUMBAR SPINE W/O CONTRAST [**2197-1-2**] from [**Hospital **] Hospital
:markedly limited study due to patient motion. No evidence of
acute fracture or subluxation. Findings compatabile with known
ankylosing spondylitis. Edema along right posterior paraspinal
musculature which may represent a muscle strain versus partial
tear.
CT Abdomen [**2197-1-2**] from [**Hospital **] Hospital : consistent with T10
fracture
[**2197-1-3**] 09:57PM URINE BLOOD-LG NITRITE-POS PROTEIN-100
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG
[**2197-1-3**] 09:57PM URINE RBC-100* WBC->1000* BACTERIA-MANY
YEAST-NONE EPI-4
[**2197-1-3**] 09:57PM URINE WBCCLUMP-MANY MUCOUS-FEW
[**2197-1-3**] 07:35PM GLUCOSE-162* UREA N-29* CREAT-1.0 SODIUM-141
POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-33* ANION GAP-11
[**2197-1-3**] 07:35PM CK(CPK)-67
[**2197-1-3**] 07:35PM CK-MB-NotDone cTropnT-0.08*
[**2197-1-3**] 07:35PM CALCIUM-8.6 PHOSPHATE-2.1* MAGNESIUM-2.3
Brief Hospital Course:
Pt was admitted to the hospital and kept at bedrest. He was
seen in consultation by both medicine and cardiology for his HTN
and recent MI. He was treated for UTI. He was fit for TLSO
which he wore when HOB was elevated, he remained at bedrest. He
had full work up and treatment and was made ready for surgery.
On [**1-11**] he was brought to the OR where under general anesthesia
he underwent posterior thoracic instrumented fusion with pedicle
screws and iliac crest bone graft. He tolerated this procedure
well. Remained extubated post op due to facial/laryngeal
swelling and was transferred to the ICU where he was monitored
closely. He underwent CT showing goood hardware placement and
spinal alignment. he was extubated on [**2196-1-12**]. he was
transferred to the floor [**1-13**]. his diet and activity were
advanced. His foley was removed. he transitioned to PO pain
medication. He had full motor strength throughout, his wound was
clean and dry. Prior to discharge is INR was noted to be
elevated to 1.8 he was given vitamin K and on discharge his INR
was 1.2, if further elevation consideration of holding heparin
might be considered. He was mobilized and seen by PT and OT who
recommended disposition to a rehab facility.
Medications on Admission:
dilacor XR 300 mg, percocet,ibuprofen, lovastatin, triamterene,
ticlid, allopurinol,flonase,ambien
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
T10 fracture
anklyosing spondilitis
constipstion
NSTEM MI
respiratory distress
Discharge Condition:
neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR SPINE CASES
?????? Do not smoke
?????? Keep wound clean / No tub baths or pools until seen in
follow up/ begin daily showers
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting for two weeks.
?????? Limit your use of stairs to 2-3 times per day
?????? Have your incision checked daily for signs of infection
?????? You are required to wear back brace as instructed
?????? You may shower briefly without the back brace ??????
Take pain medication as instructed; you may find it best if
taken in the a.m. when you wake for morning stiffness and before
bed for sleeping discomfort
?????? Do not take any anti-inflammatory medications such as
Motrin, Advil, aspirin, Ibuprofen etc. for 3 months.
?????? Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by
pain medicine
?????? Any weakness, numbness, tingling in your extremities
?????? Any signs of infection at the wound site: redness,
swelling, tenderness, drainage
?????? Fever greater than or equal to 101?????? F
?????? Any change in your bowel or bladder habits
Followup Instructions:
You have thyroid nodule found on CT that should be follow up
with Ultrasound with your PCP.
Have your staples removed [**1-20**] at rehab or follow up with Dr. [**Name (NI) **] office - call for appt if needed.
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NEED XRAYS PRIOR TO YOUR APPOINMENT
Completed by:[**2197-1-16**]
|
[
"780.57",
"401.9",
"272.4",
"E885.9",
"805.2",
"293.0",
"600.00",
"599.0",
"V12.54",
"584.9",
"564.09",
"427.31",
"720.0",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.63",
"77.79",
"81.05"
] |
icd9pcs
|
[
[
[]
]
] |
5168, 5265
|
3771, 5017
|
282, 360
|
5388, 5412
|
2405, 3748
|
6793, 7204
|
1570, 1606
|
5286, 5367
|
5044, 5145
|
5436, 6770
|
1636, 1861
|
233, 244
|
388, 1353
|
1876, 2386
|
1375, 1491
|
1507, 1554
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,157
| 139,004
|
14251
|
Discharge summary
|
report
|
Admission Date: [**2102-11-15**] Discharge Date: [**2102-11-24**]
Date of Birth: [**2049-4-13**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF THE PRESENT ILLNESS: This is a 53-year-old male,
former IV drug abuser, with a history of hypertension,
hypercholesterolemia, insulin-dependent diabetes mellitus,
diagnosed with hepatitis B and C as well as HIV in the [**2089**],
who has had a history of coronary artery disease since [**2099**].
The patient underwent PTCA to his RCA in [**2099-6-25**]
following an MI and symptoms which included the inability to
catch his breath, in-stent restenosis of the RCA, presented
with the patient having similar symptoms which were relieved
by sublingual nitroglycerin. The patient reports shortness
of breath with exertion and left arm numbness and mild
diaphoresis at the time of the restenosis. He underwent a
catheterization and was restented at that time.
The patient began experiencing angina at rest, waking him
from his sleep in [**2102-4-25**] for which the patient
underwent a stress MIBI which revealed partially reversible
inferior wall defect with an EF of 385. Catheterization done
in [**2102-9-25**] revealed a 60% left main and two vessel
disease with in-stent restenosis of the RCA. The patient was
referred to CT Surgery for coronary artery bypass grafting.
At this time, the patient still complains of occasional chest
pain and shortness of breath at rest and with exertion.
Currently, he is pain-free.
PAST MEDICAL HISTORY:
1. CAD, status post RCA stent in [**2099-6-25**], [**2100-6-25**] with positive stress test in [**2102-5-25**].
2. Hypertension.
3. Hypercholesterolemia.
4. NIDDM.
5. Hepatitis B.
6. Hepatitis C.
7. HIV.
8. TB.
9. PVD.
10. Anemia.
11. GERD.
12. Right ocular stroke.
13. Status post left arm surgery for necrotizing fasciitis.
14. Status post left hip surgery for abscess.
FAMILY HISTORY: Significant in that he had a mother who
died at 32 of CAD.
SOCIAL HISTORY: He lives with his son in [**Name (NI) 5110**]. Drug
counselor in [**Location (un) 18293**]. Former IV drug abuser of
heroin. Stopped 2 1/2 years ago. Abused for 30 plus years.
Former ETOH use, stopped 2 1/2 years ago, rarely before then.
ALLERGIES: The patient states allergies to sulfa and
Zithromax.
ADMISSION MEDICATIONS:
1. Kaletra.
2. Aspirin 325 mg p.o. q.d.
3. Viread.
4. Diovan.
5. Dapsone.
6. Pletal.
7. Atenolol 100 mg q.d.
8. Lipitor 10 mg q.d.
9. Isosorbide 120 mg q.d.
10. Videx.
11. Protonix 40 mg q.d.
12. Lasix 80 mg q.d.
13. Epivir.
14. Insulin 70/30, 38 units q.a.m., 28 units q.p.m.
LABORATORY/RADIOLOGIC DATA: White count 6.2, hematocrit
30.9, platelets 151,000. PT 12.7, INR 1.1. Sodium 138,
potassium 3.2, chloride 106, C02 26, BUN 18, creatinine 1.1,
glucose 246, ALT 38, AST 30, alkaline phosphatase 76, amylase
33, total bilirubin 1.5, albumin 3.5.
Cardiac catheterization done on [**2102-10-18**] showed
left main 60% LAD with diffuse disease, left circumflex with
60-70% lesion with 90% takeoff from disease, distal left main
RCA 40% with 30% in-stent restenosis, moderate to severe left
ventricular heart failure, anomalous left main.
PHYSICAL EXAMINATION ON ADMISSION: General: The patient was
a pleasant man in no acute distress, appearing stated age,
alert and oriented times three. HEENT: The pupils were
equally round and reactive to light. The extraocular
movements were intact. Normal buccal mucosa. Neck: Supple
with no JVD, no lymphadenopathy. No thyromegaly. No carotid
bruits. Chest: Clear to auscultation bilaterally. Cardiac:
Regular rate and rhythm. S1, S2, with a II/VI systolic
ejection murmur. Abdomen: Obese, nontender, nondistended,
normoactive bowel sounds. Extremities: Warm with no edema
and no varicosities. Positive venostasis color changes
bilaterally, right thigh graft from a graft obtained for his
left arm necrotizing fasciitis surgery. Pulses: Carotids 2+
bilaterally, radial 2+ bilaterally, femoral 2+ bilaterally,
dorsalis pedis 2+ bilaterally and posterior tibial 1+
bilaterally.
HOSPITAL COURSE: The patient was a postoperative admission.
He was admitted directly to the Operating Room on [**2102-11-15**]. At that time, he underwent coronary artery bypass
grafting times two. Please see the OR report for full
details. In summary, the patient had a CABG times two with a
LIMA to the LAD and saphenous vein graft to OM. His bypass
time was 59 minutes with a cross clamp time of 35 minutes.
He tolerated the operation well and was transferred from the
Operating Room to the Cardiothoracic Intensive Care Unit.
At the time of transfer, the patient had a mean arterial
pressure of 91, CVP 17. He was in a normal sinus rhythm at
80 beats per minute. He had propofol at 10 micrograms per
kilogram in the immediate postoperative period. The patient
did well. He did have some significant drainage from his
chest tubes for that. He was transfused with 2 units of FFP
and one packed platelets. Following the resolution of his
chest tube drainage, the patient's anesthesia was reversed.
He was weaned from the ventilator and successfully extubated.
On the morning of postoperative day number one, the patient's
PA line was discontinued. He was started on Lasix and
Lopressor as well as all his antiviral medications. He was
seen by the ID Service for assistance with management of his
HIV, hepatitis B and C. He was also seen by the [**Hospital **]
Clinic for assistance with management of his diabetes.
Following these consults, the patient was transferred to [**Hospital Ward Name 121**]
II for continuing postoperative care and cardiac
rehabilitation.
The patient was noted to have a low-grade fever. He was pan
cultured and was kept on vancomycin as well as Levaquin as
per the recommendations of the Infectious Disease Department.
The low-grade fever persisted with a normal to slightly
elevated white blood cell count. A differential done at that
time showed an eosinophilia. It was, therefore, felt by the
primary team as well as that of Infectious Disease that
eosinophilia and fever were drug-induced. Therefore, the
patient's vancomycin and Levaquin were discontinued at that
time following which the patient defervesced. At the same
time, the patient was noted to have somewhat elevated
creatinine with a BUN of 28 and creatinine of 1.8 as well as
significant bilateral pedal edema.
On postoperative day number seven, the Renal Service was also
consulted to weigh in on the patient's elevated creatinine as
well as his pedal edema. Following their consultation, the
patient was sodium restricted and he was continued on his
Lasix.
On postoperative day number nine, it was felt that the
patient was stable and ready to be discharged home. At the
time of discharge, the patient's physical examination is as
follows. Vital signs: Temperature 99, heart rate 80, sinus
rhythm, blood pressure 140/70, respiratory rate 18, 02
saturation 95% on room air. Weight preoperatively 102
kilograms, at discharge 108.9 kilograms.
The laboratory data revealed a white count of 9.9, hematocrit
30.2, platelets 356,000. Sodium 136, potassium 3.8, chloride
104, C02 20, BUN 29, creatinine 1.7, glucose 114.
The patient was alert and oriented times three, moves all
extremities. The patient follows commands. Respiratory:
Clear to auscultation bilaterally. Cardiac: Regular rate
and rhythm, S1, S2. The sternum is stable. The incision
with Steri-Strips, open to air, clean and dry. Abdomen:
Soft, nontender, nondistended, normoactive bowel sounds.
Extremities: Warm and well perfused with 2-3+ edema.
DISCHARGE MEDICATIONS:
1. Aspirin 325 q.d.
2. Ritonavir three capsules b.i.d.
3. Tenofovir 300 mg q.d.
4. Prilosec 40 mg q.d.
5. Lamivudine 150 mg b.i.d.
6. .................... EL 250 mg p.o. q.d.
7. Dapsone 100 mg q.d.
8. Pletal 100 mg b.i.d.
9. Metoprolol 100 mg b.i.d.
10. Lasix 80 mg q.d. times seven days and then 40 mg q.d.
11. Potassium chloride 20 mEq q.d.
12. Insulin, resume preoperative doses.
13. Percocet 5/325 one to two tablets q. four hours p.r.n.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease, status post coronary artery
bypass grafting times two with left internal mammary artery
to left anterior descending and saphenous vein graft to
obtuse marginal.
2. Hypertension.
3. Hypercholesterolemia.
4. Insulin-dependent diabetes mellitus.
5. Hepatitis B and C.
6. HIV.
7. Tuberculosis.
8. Peripheral vascular disease.
9. Gastroesophageal reflux disease.
10. Ocular stroke.
11. Necrotizing fasciitis.
12. Left hip surgery.
DISPOSITION: The patient is to be discharged to home.
FOLLOW-UP: The patient is to have follow-up in the [**Hospital 409**]
Clinic in two weeks. The patient is to follow-up with Dr.
[**Last Name (STitle) 70**] in six weeks. The patient is to call the office
for an appointment. The patient is to follow-up with his
primary care in one to two weeks, at which time the patient
is to have his BUN, creatinine, and potassium levels checked.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2102-11-24**] 07:10
T: [**2102-11-24**] 19:41
JOB#: [**Job Number 42343**]
|
[
"998.89",
"583.81",
"584.9",
"070.30",
"250.40",
"414.01",
"288.3",
"070.51",
"780.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
1914, 1974
|
7644, 8096
|
8149, 9348
|
4094, 7621
|
2323, 3197
|
3212, 4076
|
1514, 1896
|
1991, 2300
|
8121, 8128
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,589
| 199,434
|
43075
|
Discharge summary
|
report
|
Admission Date: [**2116-10-2**] Discharge Date: [**2116-11-15**]
Date of Birth: [**2055-2-23**] Sex: F
Service: MEDICINE
Allergies:
Prochlorperazine / Sulfa (Sulfonamide Antibiotics) / Betadine
Viscous Gauze / Vancomycin / Meropenem / Zosyn / cefepime
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Admitted for Cycle 1 of MEC
Major Surgical or Invasive Procedure:
PICC line placement [**2116-10-2**]
Right IJ placement [**2116-10-16**]
History of Present Illness:
61 yo woman with history of breast CA and subsequent development
of AML s/p allo HSCT on [**2115-10-4**] who recently had episodes of
back pain X2months and MRI revealed an L2 lesion that was found
to be a chloroma, concerning for extramedullary relapse. Bone
marrow done last week on prelim read was also positive for AML.
She had been scheduled for radiation to the spine and planned
DLI. However, with positive bone marrow, she is now being
admitted for MEC. Patient with lower back pain, hip pain (R>L)
radiating down the legs. No numbness or tingling typically. Pain
is intermittent, but constant since last night. Gait feels
unsteady. Denies fevers, chills, no weight loss >2 pounds. Not
sure if having night sweats. Appetite decreased but eating
normally currently. No changes in BMs.
.
Of note, patient with tooth pain recently. 1st molar on left
painful after biting into a tums. Now right first molar also
sensitive. Pain in L>R. No HA, double vision. H/o possible TMJ.
.
.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies sinus tenderness, rhinorrhea or congestion. Denied
cough, shortness of breath. 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, rashes.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- [**2102**] TAH/BSO showed stage IIB ovarian Ca adjuvant treatment
with six cycles of carboplatin and Taxol
- [**2113-12-7**] had mammogram that showed a poorly
differentiated invasive ductal carcinoma, 8 mm in largest
diameter, without LVI. ER/PR/HER-2 negative. FNA of a palpable
right axillary lymph node was consistent with malignancy.
Imaging showed right axillary, subpectoral, and deep cervical
lymph node involvement.
- [**2114-2-4**] treated with Adriamycin and Cytoxan followed by
Taxol at the [**Company 2860**] followed by bilateral mastectomies(right
modified radical mastectomy and left simple mastectomy) at [**Hospital1 2025**].
Pathology from the right breast demonstrated LCIS, chemotherapy
changes, and no evidence of residual IDC. Zero of 24 right
axillary lymph nodes were positive for disease. There was no
evidence of cancer in the left breast.
- genetic testing negative for BRCA-1 and 2 mutations.
- [**2115-4-4**], she developed new lower back pain while undergoing
planning for bilateral breast reconstruction surgery. Initially
managed conservatively. Her pain progressed, and on [**2115-6-4**], she presented to the emergency room at [**Hospital3 **]. Blood work at the hospital demonstrated a CBC that was
notable for
white blood cell count of 19, hematocrit 23, and a platelet
count
of 12. White blood cell count differential was notable for 11%
blasts. At that time, she endorsed easy bruising, but denied
fevers, chills, night sweats, weight loss, or recurrent
infections. She was subsequently transferred to [**Hospital1 18**] where she
underwent bone marrow biopsy on [**2115-6-7**], with findings
consistent with AML with monocytic differentiation. On [**2115-6-8**], she began induction chemotherapy with 7+3. Her treatment
course was complicated by prolonged neutropenic fevers,
multifocal pneumonia requiring lung biopsy that demonstrated
evidence of BOOP. She was subsequently treated with steroids.
Bone marrow biopsy performed on day +14 and day +24 showed
residual blasts in the marrow, and she was treated with one
cycle
of HiDAC. Bone marrow biopsy on [**2115-7-16**], showed no
evidence of blasts. She was subsequently discharged, but had
several short stays in the hospital for difficulties with
infections. On [**2115-9-27**], she was admitted to [**Hospital1 18**] for
ablative allogeneic stem cell transplant from a matched
unrelated
donor. She underwent conditioning with fludarabine, busulfan,
and ATG. Her transplant was on [**2115-10-4**]. She did well
following the transplant, with no evidence of recurrent disease
or graft-versus-host disease. In [**2116-7-3**], she once again began
to develop low back pain with occasional radiation down her
legs.
An L-spine MRI on [**2116-7-31**], demonstrated a new enhancing L2
spinous process mass with associated soft tissue component and
no
spinal canal involvement. There was also new heterogeneous
marrow signal noted in the iliac bone and sacrum. Pelvis MRI on
[**2116-8-6**], once again demonstrated diffuse marrow signal
abnormality with near complete homogenous replacement of the
right posterior ilium to SI joint, and marrow replacement of the
left femur to the mid diaphysis. There were also bilateral
sacral insufficiency fractures noted. On [**2116-8-17**], she
underwent bone marrow biopsy, which demonstrated a mildly
hypocellular marrow with no evidence of AML. Flow cytometry was
negative for evidence of blasts. On [**2116-8-25**], she
underwent an FNA of this newly identified left spinous process
mass. Pathology demonstrated skeletal muscle and soft tissue
with an atypical mononuclear infiltrate consistent with myeloid
sarcoma. Immunohistochemistry staining was positive for CD4, 15,
33, 43, and 68 (similar to her previous AML). This was felt to
represent an extramedullary relapse of her AML.
-Bone marrow biopsy last week ([**9-/2116**]) was positive for AML.
-patient is being admitted for MEC chemo therapy given extent of
relapse
OTHER MEDICAL HISTORY:
relapsed AML
ovarian cancer [**2102**]
breast cancer [**2113**]
Social History:
Denies tobacco ever, EtOH (not now, was a social drinker years
back), drug use.
She lives in [**Location 3493**] ([**Hospital3 **]) w/ husband, 2 cats.
Self-employed consultant.
Family History:
Her father had a large CVA in his early 50s. MGM with ovarian
cancer. MGF with colon cancer. Sister with uterine cancer.
Maternal aunt with breast cancer. Type 2 DM in mother and
father.
Physical Exam:
Admission Exam:
VS: T 99.5, BP 110/70, HR 86, RR 18, SpO2 98%RA
Gen: Elderly female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM, OP clear. 1st
molars look intact, without erythema or fluctuance at the gums.
Teeth are not cracked, no obvious cavities.
Neck: Supple, No cervical lymphadenopathy.
CV: RRR with normal S1, S2. No M/R/G.
Chest: Respiration unlabored, no accessory muscle use. CTAB
without crackles, wheezes or rhonchi.
Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly or
masses.
Back: tender to palpation along lumbar and sacral spine.
Musculoskeletal: WWP. No C/C/E. Distal pulses intact radial 2+,
PT 2+. tender to palpation along right iliac crest and groin.
nontender along left.
Skin: No rashes, ulcers, or other lesions.
Neuro: CN II-XII grossly intact. Gait - walked with a right
limp.
Discharge Exam:
Gen: Elderly female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric, pale conjunctiva. PERRL, EOMI.
MMM, OP clear, dentition normal.
CV: RRR with normal S1, S2. No M/R/G.
Chest: CTAB without crackles, wheezes or rhonchi. No use of
accessory muscles.
Abd: normoactive bowel sounds. Soft, NT, ND. No organomegaly or
masses.
Back: nontender, full ROM.
Musculoskeletal: WWP. No C/C/E. Distal pulses intact radial 2+,
PT 2+. Nontender to palpation.
Skin: No rashes, ulcers, or other lesions.
Neuro: CN II-XII grossly intact. Gait WNL.
Pertinent Results:
Labs on admission:
[**2116-10-2**] 02:27PM BLOOD WBC-5.7 RBC-3.60* Hgb-11.2* Hct-33.5*
MCV-93 MCH-31.2 MCHC-33.6 RDW-14.6 Plt Ct-115*
[**2116-10-2**] 02:27PM BLOOD Neuts-74* Bands-1 Lymphs-8* Monos-8 Eos-4
Baso-0 Atyps-1* Metas-3* Myelos-1*
[**2116-10-2**] 02:27PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2116-10-1**] 01:07PM BLOOD PT-13.0 PTT-23.9 INR(PT)-1.1
[**2116-10-2**] 02:27PM BLOOD Glucose-96 UreaN-14 Creat-0.8 Na-141
K-3.7 Cl-103 HCO3-30 AnGap-12
[**2116-10-2**] 02:27PM BLOOD ALT-25 AST-19 LD(LDH)-[**2007**]* AlkPhos-141*
TotBili-0.2
[**2116-10-2**] 02:27PM BLOOD Calcium-9.3 Phos-3.6 Mg-2.0
Labs on discharge:
[**2116-11-15**] 07:20AM BLOOD WBC-1.3* RBC-2.93* Hgb-9.2* Hct-27.6*
MCV-94 MCH-31.3 MCHC-33.2 RDW-17.1* Plt Ct-236
[**2116-11-15**] 07:20AM BLOOD Neuts-50 Bands-1 Lymphs-20 Monos-26*
Eos-1 Baso-1 Atyps-0 Metas-0 Myelos-1* NRBC-1*
[**2116-11-15**] 07:20AM BLOOD PT-10.8 PTT-24.7 INR(PT)-0.9
[**2116-11-15**] 07:20AM BLOOD Glucose-97 UreaN-15 Creat-0.8 Na-142
K-4.4 Cl-107 HCO3-27 AnGap-12
[**2116-11-15**] 07:20AM BLOOD ALT-24 AST-18 LD(LDH)-230 AlkPhos-139*
TotBili-0.2
[**2116-11-15**] 07:20AM BLOOD Calcium-8.8 Phos-3.6 Mg-1.9
Pertint Micro Results:
URINE CULTURE (Final [**2116-10-5**]):
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML..
UNABLE TO FURTHER IDENTIFY
Blood Culture, Routine (Final [**2116-10-21**]):
THIS IS A CORRECTED REPORT 0802 [**2116-10-19**].
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (un) **] ([**Numeric Identifier **]) 0802
[**2116-10-19**].
ENTEROCOCCUS GALLINARUM.
PREVIOUSLY REPORTED AS BURKHOLDERIA (PSEUDOMONAS)
CEPACIA ON
[**2116-10-18**]. FINAL SENSITIVITIES.
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
gentamicin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details.
HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to
1000mcg/ml of
streptomycin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details..
Daptomycin = 2 MCG/ML.
Daptomycin Sensitivity testing performed by Etest.
VANCOMYCIN Sensitivity testing confirmed by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS GALLINARUM
|
AMPICILLIN------------ <=2 S
DAPTOMYCIN------------ S
LINEZOLID------------- 2 S
PENICILLIN G---------- 1 S
VANCOMYCIN------------ 8 I
.
Blood Culture, Routine (Final [**2116-10-27**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
AZTREONAM & [**Last Name (NamePattern1) 92908**] SUSCEPTIBILITIES REQUESTED BY
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**]
#[**Numeric Identifier 8022**]. RESISTANT TO AZTREONAM MIC >=32 MCG/ML.
SENSITIVE TO [**Numeric Identifier 92908**] MIC <=1 MCG/ML.
[**Numeric Identifier 92908**] MIC interpretations are based on
manufacturer's
guidelines that are FDA approved.
AZTREONAM AND [**Numeric Identifier 92908**] sensitivity testing performed
by
Microscan.
ESCHERICHIA COLI. SECOND MORPHOLOGY. FINAL
SENSITIVITIES.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
AZTREONAM & [**Last Name (NamePattern1) 92908**] SUSCEPTIBILITIES REQUESTED BY
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**]
#[**Numeric Identifier 8022**]. RESISTANT TO AZTREONAM MIC >= 32 MCG/ML.
SENSITIVE TO [**Numeric Identifier 92908**] MIC <=1 MCG/ML.
[**Numeric Identifier 92908**] MIC interpretations are based on
manufacturer's
guidelines that are FDA approved.
AZTREONAM AND [**Numeric Identifier 92908**] sensitivity testing performed
by
Microscan.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R =>32 R
AMPICILLIN/SULBACTAM-- 16 I 16 I
CEFAZOLIN------------- =>64 R =>64 R
CEFEPIME-------------- =>64 R =>64 R
CEFTAZIDIME----------- 16 R 16 R
CEFTRIAXONE----------- =>64 R =>64 R
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- S S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R 8 R
.
PATH:
.
[**2116-9-29**] Bone Marrow Biopsy: HYPERCELLULAR BONE MARROW WITH
EXTENSIVE NECROSIS AND EVIDENCE OF RELAPSED ACUTE MYELOID
LEUKEMIA. Note: There is extensive zonal confluent necrosis
alternating with sheets of blasts with abundant pink cytoplasm.
The histological and cytological features are virtually
identical to those seen at first diagnosis.
.
[**2116-11-11**]: Bone Marrow Biopsy: Mildly hypocellular for age
erythroid dominant bone marrow. No definitive morphological
evidence of acute leukemia, see note.
Note: While rare blasts and left shifted myeloids are seen
along with atypical monocytes in peripheral blood. However,
there is differentiation. Please correlate with clinical
findings and progression, flow cytometry ([**-1/4753**]) and
karyotype studies, to exclude minimal residual disease.
IMAGING:
[**2116-10-2**] Panorex: pending report
[**2116-10-2**] Echo: The left atrium and right atrium are normal in
cavity size. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF 70%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2115-8-29**], a pericardial effusion is no longer seen.
[**2116-10-3**] CXR: Left PICC line tip is at the level of mid SVC.
Heart size and mediastinum are unremarkable. Lungs are
essentially clear. No pleural effusion or pneumothorax is noted.
Right apical opacity is unchanged since the prior examination
dating back to [**2116-7-3**] and reflects a focal area of
consolidation seen back on [**2115-10-20**] radiograph and most
likely represents a residua of the cryptogenic organizing
pneumonia.
[**2116-10-16**] Limited son[**Name (NI) **] of left arm demonstrated likely
non-occlusive thrombus in the mid brachial vein. The PICC was
not placed.
[**2116-10-17**] Bone Marrow Biopsy: Hypocellular bone marrow consistent
with chemotherapeutic ablation. No diagnostic morphologic
features of acute leukemia seen.
[**2116-10-18**] CXR: IMPRESSION: No evidence of acute pneumonia.
[**2116-10-24**] CT abdomen/pelvis:
1. Within limits of a noncontrast examination, no etiology for
patient's
fever within the limitation of this unenhanced CT. No drainable
fluid
collection.
2. No retroperitoneal hematoma.
[**2116-10-26**] ECHO: IMPRESSION: Mild-moderate mitral regurgitation
without evidence of discrete vegetation. Preserved global and
regional biventricular systolic function. Compared with the
prior study (images reviewed) of [**2116-10-2**], the severity of
mitral regurgitation and estimated PA systolic pressure are
increased. If the clinical suspicion for endocarditis is
moderate or high, a TEE would be better able to define the
mitral valve morphology for possible vegetation.
[**2116-10-26**] LUE U/S: No evidence of deep venous thrombosis in the
left upper
extremity.
[**2116-11-9**] RUQ U/S:
1. Mildly coarse liver. This is a nonspecific finding but could
reflect
diffuse liver disease. Ultrasound cannot exclude [**Last Name (un) **]-occlusive
disease.
2. Small 3-mm gallbladder polyp is unchanged.
Brief Hospital Course:
61 yo F with h/o breast CA and subsequent development of AML s/p
allo HSCT (on [**2115-10-4**]) found to have a relapse of her AML with
positive BM biopsy and chloroma of the L2 spine, admitted for C1
of MEC (started [**2116-10-3**]).
.
# Relapsed AML: [**2116-9-29**] BM biopsy showed HYPERCELLULAR BONE
MARROW WITH EXTENSIVE NECROSIS AND EVIDENCE OF RELAPSED ACUTE
MYELOID LEUKEMIA. Additionally tissue sample of L2 lesion was
found to be a chloroma. Patient had been scheduled for radiation
to the spine and planned DLI. However, given her positive BM, it
was decided she should have MEC. Baseline Echo on admission WNL,
with EF>70%. MEC and allopurinol administered, patient tolerated
it well. Patient became neutropenic on D7. Acyclovir and
atovaquone were continued for prohylaxis (home regimen). She
was previously on posaconazole for fungal ppx, however this was
changed to voriconazole for a few weeks for neutropenic fevers,
but changed back to posaconazole before discharge. Patient
required several transfusions of PRBCs and platelets during
admission. CBC, Gran Count monitored closely. She experienced
prolonged pancytopenia, but her counts eventually began trending
up around day 35. She had a repeat bone marrow biopsy on
[**2116-11-11**] (day 40) which showed no evidence of her leukemia (3%
blasts). Her counts continued to trend up, and ANC was 650 on
the day of discharge (day 44 after MEC).
.
# Fever: Patient became febrile several days into MEC therapy,
prior to neutropenia. She was started on cefepime on [**10-5**], and
remained afebrile for >1week. CXR on [**10-3**] clear except for focal
area of consolidation in right apice, thought to be residua of
cryptogenic PNA from previous admission. Pt without cough,
sputum production, SOB. Urine culture negative. Blood cultures
negative from [**10-3**], [**10-5**]. PICC line was pulled for slight
erythema, nonocclusive thrombus found at that time, so PICC
could not be replaced. Instead, right IJ was placed on [**2116-10-16**].
[**10-15**] and [**10-16**] blood clutures negative. Patient again began
having fevers on [**10-17**] without localizing symptoms, with 1 out
of 2 blood cultures growing enterococcus galinerum, sensitive to
daptomycin. Cefepime was discontinued on [**2116-10-20**] for diffuse
rash. ID consulted given patient's many allergies (i.e.
meropenem and vancomycin). Treated with daptomycin, aztreonam
and ciprofloxacin. RIJ was left in place, as patient has
difficult access (cannot place line in right arm [**2-5**] lymphedema
from previous mastectomy and now with clot in left arm from
previous PICC). Daily blood cultures were negative. Patient
developed fever to 103.5F, [**10-22**] Blood culture grew E Coli while
on atreonam and ciproflozacin. She became hypotensive, minimally
responsive to fluids and was transferred to the [**Hospital Unit Name 153**]. She
stayed there for two days and was stabilized with fluids, never
requiring pressors. The E coli in her blood cultures was found
to be sensitive only to gentamicin and zosyn, so she was started
on these two antibiotics. She was stable enough to be sent back
to the floor after 2 days in the ICU. She soon developed a rash
which was consistent with a drug rash and attributed to the
zosyn (given her many penicillin-family allergies). Sensitivity
testing found the E Coli to be sensative to [**Last Name (LF) **], [**First Name3 (LF) **] she
was started on this in addition to the gentamicin. Her IJ was
pulled at this time, a new left IJ was placed. Multiple
surveillance cultures were drawn and had no growth. She
remained afebrile for the last 14+ days of her hospital stay and
did not have any more positive cultures. Her intravenous abx
were stopped a few days prior to discharge, and she remained
stable with no evidence of infection. She was sent home with
prophylactic antibiotics only-- acyclovir, posaconazole, and
atovaquone.
.
# Sepsis: Patient transferred to ICU with concern for septic
shock, with hypotension initally not responsive to IVF's.
Etiology thought to be due to E coli found on blood cx on [**10-22**]
and [**10-23**], likely from gut translocation. Patient's BP recovered
with volume expansion including 2units pRBC. Patient was never
pressor dependent. After conferring with ID, abx were narrowed
to daptomycin for previously documented VRE, and
zosyn/gentamicin for empiric GNR coverage. Patient was
maintained on voriconazole, acyclovir, and atovaquone ppx. CDiff
antigen was negative and no blood cx returned positive since
[**10-23**].
.
# L PICC line assoc blood clot: Patient found on US to have a
nonocclusive thrombus from her left PICC. Instead of replacing
PICC, IR placed a right IJ for access. No anticoagulation needed
as plts are low. LUE ultrasound was repeated 1-2 weeks later and
found that the clot had resovled.
.
# Transaminitis: LFTs rose abruptly on [**11-9**] from normal
baseline. RUQ US showed a "coarse liver", non-specific but could
signify liver disease/inflammation. Thought to be due to
voriconazole, which was DC'd [**11-9**]. Her LFTs then trended back
down to baseline/normal values. It would be reasonable to
obtain a future repeat RUQ US to assess for resolution of liver
inflammation and rule out occult, ongoing process.
.
# Rashes: Developed Started out as erythamtous, blanching
0.5-1cm papules over flank, back, inner thighs. Minimally
puritic, but worsening, becoming more diffuse over arms, chest,
abdomen, thighs, and back over 2 days. No complaints, no trouble
breathing. Pt with h/o meropenem allergy. Developed 13 days
after starting cefepime. Derm consulted and felt this was a drug
reaction to cefepime, recommended triamcinilone. ID agreed.
Cefepime discontinued 2 days after rash first developed. Got
worse for several days, and then began to to improve. While
this rash was clearing, she was started on zosyn
(pipericillin-tazobactam) and developed a new, separate rash
across her arms and some puffiness in her face. Initially
dermatology and ID felt it was possible to treat through this
reaction (given the need for zosyn for her E. coli bacteremia),
however when she developed swelling of her lips and itching of
her throat, the medication was stopped. At this point, her rash
and swelling began to subside and resolved within a week.
.
# Tooth pain: On admission, patient had been complaining of
bilateral lower 1st molar tooth pain for the past week, worse on
the left than the right. There was minimal concern for infection
on exam, and pain resolved within two days of admission. Panorex
xray of teeth was performed to evaluate for infectious process,
however report was pending at time of discharge.
.
# Back Pain: Patient presented with lower back and right hip
pain, tender to palpation and limiting the range of motion of
her back and right hip. Likely related to her chloroma at the L2
level. Patient required a lidocaine patch for pain on the first
day of her admission, however pain resolved by day 2. Patient
was also written for oxycodone prn, however she did not require
it.
.
# Transient visual changes: Patient c/o visual changes, most
notably increased floaters in right eye and 'light dimming'.
Opthomology was consulted who examined the retina, and found
only a small cotton wool spot on right macula. Unlikely to be
contributing to visual symptoms.
.
# Asthma - Stable, managed with home medications: prn albuterol,
astepro.
Medications on Admission:
acyclovir
albuterol
atovaquone
azelastine
folic acid
lidocaine patch
oxycodone
posaconazole
potassium chloride
vitamin D
colace
senna
magnesium oxide
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q8H (every 8 hours) as needed for
wheezing, SOB.
2. atovaquone 750 mg/5 mL Suspension Sig: Ten (10) ml (1500 mg)
PO DAILY (Daily).
3. Astepro 0.15 % (205.5 mcg) Spray, Non-Aerosol Sig: Two (2)
puffs Nasal [**Hospital1 **] (2 times a day) as needed.
4. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
5. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-5**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
6. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for dyspepsia.
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime)
as needed for insomnia.
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. posaconazole 200 mg/5 mL (40 mg/mL) Suspension Sig: Ten (10)
ml (200 mg) PO Q 12H (Every 12 Hours).
12. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-5**] Sprays Nasal
TID (3 times a day) as needed for nasal irritation.
13. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Relapsed acute myelogenous leukemia
Chemotherapy-induced pancytopenia
Neutropenic fever
Sepsis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname **],
It was a pleasure taking care of you in the hospital. You were
admitted for your first cycle of MEC chemotherapy, started on
[**2116-10-3**]. You became neutropenic 7 days after starting
chemotherapy. Your time in the hospital was complicated by two
bloodstream infections, both of which were treated with
antibiotics and eventually resolved. Your white blood cell
counts increased slowly but surely, and a repeat bone marrow
biopsy showed no leukemia cells.
Changes to your medication regimen:
STOP potassium chloride
STOP magnesium oxide
(you no longer need these medications)
Followup Instructions:
Please come to 7 [**Hospital Ward Name 1826**] outpatient area on Monday, [**11-16**] for
bloodwork and to make a follow up appointment with Dr. [**Last Name (STitle) **]
|
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"V58.11",
"995.92",
"205.02",
"782.1",
"785.52",
"E933.1",
"493.90",
"284.11",
"V42.82",
"V88.01",
"780.61",
"V45.71",
"999.32",
"V10.43",
"V10.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"41.31",
"99.25",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
25566, 25572
|
16557, 23923
|
409, 483
|
25711, 25711
|
7802, 7807
|
26503, 26677
|
6139, 6328
|
24167, 25543
|
25593, 25690
|
23993, 24144
|
25862, 26480
|
6343, 7207
|
23941, 23967
|
7223, 7783
|
1514, 1827
|
342, 371
|
8485, 16534
|
511, 1495
|
7821, 8466
|
25726, 25838
|
1849, 5927
|
5943, 6123
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,917
| 150,011
|
31044+57705
|
Discharge summary
|
report+addendum
|
Admission Date: [**2140-8-11**] Discharge Date: [**2140-8-20**]
Date of Birth: [**2075-11-12**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
multifocal intraductal papillary mucinous neoplasia
Major Surgical or Invasive Procedure:
Total Pancreatectomy, Splenectomy, Open Cholecystectomy, Wedge
Liver Biopsy
History of Present Illness:
This is a 64 year old female who was found to have multifocal
intraductal papillary mucinous neoplasia found incidently during
work-up for transverse colitis related to diverticulitis in
[**2140-3-10**].
In [**Month (only) 958**], she developed mid-abdominal pain. She thought it was
consistent with her previous diverticulitis. At that time, she
went to [**Hospital6 6640**] and a CT of the abdomen and
pelvis on [**2140-3-26**] showed transverse colitis. However, it also
showed diffuse cystic replacement of the
pancrease of uncertain etiology. She stayed in the hospital for
IV antibiotics and the abdominal pain abated. It was
recommended that the patient get an MRCP, however, she was
unable to get that secondary to severe claustrophobia. She had
an ERCP done on [**2140-4-19**] which showed numerous areas of
pancreatic ductal dilatation directly communicating with the
pancreatic duct. It
also showed that the pancreatic duct was enlarged and slightly
irregular in contour. At that time, the differential diagnosis
included an intraductal papillary mucinous neoplasm.
Past Medical History:
lap. tubal ligation, b/l knee replacements, carpal tunnel
release, obesity, diverticulitis, hypertension,
hypercholesterolemia.
Social History:
She is a registered nurse. She quit smoking 15 years ago and
drinks alcohol
occasionally.
Family History:
Family history is not significant for any pancreatic or biliary
disease. Her mother did have breast cancer. Her father nad
with coronary disease and an aunt had [**Name2 (NI) 499**] cancer versus a
polyp.
Physical Exam:
VS: BP 138/88 in the left arm, HR 88 and RR 12.
Gen: she looked her stated age, and was speaking in full
sentences in no apparent distress. She appeared quite
comfortable.
HEENT exam: Pupils are equal, round, and reactive to light.
Extraocular movements are intact. Sclerae anicteric.
Oropharynx is clear without any exudate.
Neck: There is no lymphadenopathy or thyroid enlargement noted.
Cardiovascular: She had a regular rate and rhythm, S1, S2. No
murmurs, rubs, or gallops.
Lungs: Clear to auscultation bilaterally with good air entry.
Abdomen: Notable for bowel sounds. It was soft, nontender,
nondistended. There was no hepatosplenomegaly appreciated and
we are unable to elicit any pain.
Pertinent Results:
[**2140-8-15**] 07:56AM BLOOD WBC-17.3* RBC-3.03* Hgb-9.0* Hct-26.9*
MCV-89 MCH-29.8 MCHC-33.6 RDW-14.1 Plt Ct-477*
[**2140-8-15**] 07:56AM BLOOD Glucose-71 UreaN-12 Creat-0.5 Na-141
K-4.1 Cl-104 HCO3-31 AnGap-10
[**2140-8-13**] 02:17AM BLOOD ALT-200* AST-91* LD(LDH)-298* AlkPhos-62
Amylase-12 TotBili-0.4
[**2140-8-13**] 02:17AM BLOOD Lipase-41
[**2140-8-13**] 02:17AM BLOOD Albumin-3.0* Calcium-8.6 Phos-2.5* Mg-2.1
.
CHEST (PORTABLE AP) [**2140-8-16**] 6:33 AM
IMPRESSION: AP chest compared to [**8-4**] through [**8-13**]:
Lung volumes remain low and atelectasis at the left base _____ a
region of scarring is the only focal pulmonary abnormality
clearly visible. Ascending thoracic aorta is dilated but mildly
tortuous. Heart size is normal. There is no pleural effusion.
In reviewing prior chest radiographs I note that the
pre-operative study on [**2140-8-4**] may show a 1-cm wide
pulmonary nodule projecting over the third left anterior
interspace. Alternatively this may be pleural thickening, more
evident in the right hemithorax. Evaluation with CT scanning
would be needed, best obtained when lung volumes have improved
and the patient has recovered from surgery. The findings were
reported to the radiology department critical results
co-ordinator for verified notification of Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**], at
the time of dictation.
Brief Hospital Course:
She went to the OR on [**2140-8-11**] for:
Total Pancreatectomy with Splenectomy; Open Cholecystectomy;
Open Liver Wedge Biopsy
Resp: She was admitted to the SICU for ventilation and
hemodynamic support and monitoring after a prolonged 10 hour
surgery. She was extubated on POD 2.
She continued to require oxygen via nasal cannula. On POD 5, she
was noted to have crackles on exam about half way up and was
given Lasix with good effect. She was seen by Physical Therapy
and she was able to come off the O2 with ambulation and IS, deep
breathing.
Pain: She was started on an Epidural and was having lots of pain
issue and so a PCA was also started. She was swithced to PO meds
once on a diet.
GI/Abd: She was NPO with a NGT. She had JP drain in place
draining serosangious fluid. The NGT was removed on POD 4. She
was started on sips on POD 5.
She was slowly advanced and was tolerating a regular, diabetic
diet at time of discharge. Her abdomen was soft, nontender. The
drain was removed on POD 8, and the staples were D/C'd with
steri strips in place.
She was seen by Dr. [**Last Name (STitle) 174**] for pancreatic insufficiency and he
recommended [**5-15**] Creon20 caps with large meals and [**3-13**] caps with
smaller meals.
Post-op Diabetes: She was started on an Insulin gtt following
surgery. She continued on this and had tight control in the low
100's. On POD 5, the Insulin gtt was stopped and she was started
on Lantus and a Humalog sliding scale. [**Last Name (un) **] was following
along and adjusted her insulin requirements.
Medications on Admission:
quinine, Synthroid 131, aspirin, lisinopril 20,
hydrochlorothiazide 25, Wellbutrin
Discharge Medications:
1. Creon 20 66,400-20,000- 75,000 unit Capsule, Delayed
Release(E.C.) Sig: Six (6) Capsule, Delayed Release(E.C.) PO
four times a day: Take [**5-15**] Caps with large meals; [**3-13**] Caps with
smaller meals.
Disp:*720 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
2. Insulin Glargine 100 unit/mL Solution Sig: Twenty Two (22)
Units Subcutaneous at bedtime.
Disp:*qs * Refills:*2*
3. Humalog 100 unit/mL Solution Sig: sliding scale Subcutaneous
three times a day: See Sliding Scale.
Disp:*qs * Refills:*2*
4. Blood Glucose Testing Strips Sig: One (1) four times a
day.
Disp:*120 * Refills:*2*
5. Lancets Misc Sig: One (1) Miscellaneous four times a
day.
Disp:*120 * Refills:*2*
6. Insulin Syringe 0.5cc/28G Syringe Sig: One (1)
Miscellaneous four times a day.
Disp:*120 * Refills:*2*
7. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 3
days.
Disp:*6 Tablet(s)* Refills:*0*
8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Bupropion 100 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO QAM (once a day (in the morning)).
13. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every six (6) hours as needed.
Disp:*35 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Multifocal Intraductal Papillary Mucinous Neoplasia
Post-op Diabetes
Discharge Condition:
Good
Blood sugars well controlled with Insulin
Pain controlled
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to monitor your blood sugars and take your insulin as
ordered.
* Continue to amubulate several times per day.
*
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 468**] in [**2-13**] weeks. Call ([**Telephone/Fax (1) 27734**] to schedule an appointment.
Please follow-up with Dr. [**Last Name (STitle) 174**] in 2 months. Call ([**Telephone/Fax (1) 22346**]
to schedule an appointment.
Completed by:[**2140-8-22**] Name: [**Known lastname **],[**Known firstname 12095**] Unit No: [**Numeric Identifier 12096**]
Admission Date: [**2140-8-11**] Discharge Date: [**2140-8-20**]
Date of Birth: [**2075-11-12**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 4987**]
Addendum:
Atelectasis: she was noted to have crackles on exam about half
way up and was given Lasix with good effect. She was seen by
Physical Therapy and she was able to come off the O2 with
ambulation and IS, deep breathing.
UTI: She was noted to have a positive UA and was placed on a 3
day course of Cipro for a UTI.
Discharge Disposition:
Home
[**Name6 (MD) 116**] [**Last Name (NamePattern4) 4988**] MD [**MD Number(1) 4989**]
Completed by:[**2140-9-16**]
|
[
"599.0",
"V43.65",
"338.18",
"230.9",
"244.9",
"518.0",
"799.02",
"571.8",
"250.00",
"577.1",
"562.10",
"V15.82",
"575.11",
"272.0",
"278.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.91",
"51.22",
"51.37",
"50.12",
"41.5",
"52.6",
"03.90"
] |
icd9pcs
|
[
[
[]
]
] |
9955, 10103
|
4148, 5698
|
323, 401
|
7740, 7805
|
2740, 4125
|
8971, 9932
|
1790, 1999
|
5831, 7598
|
7648, 7719
|
5724, 5808
|
7829, 8948
|
2014, 2721
|
232, 285
|
429, 1514
|
1536, 1666
|
1682, 1774
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,443
| 185,831
|
11029+11030
|
Discharge summary
|
report+report
|
Admission Date: [**2124-9-7**] Discharge Date: [**2124-10-7**]
Date of Birth: [**2074-4-17**] Sex: M
Service: TRAUMA SURGERY
CHIEF COMPLAINT: Motor vehicle accident.
HISTORY OF PRESENT ILLNESS: This is a 45 year old male
restrained driver in a high speed motor vehicle accident,
automobile versus tree, who sustained loss of consciousness
and was found ambulating at the scene, alert and oriented
times two. At the time, the patient was complaining of
shoulder pain and a headache only. He was Med-flighted to
the [**Hospital1 69**] with stable vital
signs, boarded and collared. At the time, he denied any
chest pain or abdominal pain.
PAST MEDICAL HISTORY: Significant for depression.
MEDICATIONS: Paxil.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: In the Emergency Department, his
physical examination was as follows: Vital signs were stable
with a blood pressure of 128/88, heart rate of 88,
respiratory rate 22, and oxygen saturation 96%. He was
boarded and collared. His GCS was 14. He was alert and
oriented times three. He had a scalp laceration with
arterial bleeding. His pupils are equal, round, and reactive
to light and accommodation. Extraocular movements are
intact. His neck examination revealed trachea midline.
Chest was clear to auscultation bilaterally. He did,
however, have left chest tenderness. He had a regular rate
and rhythm. His abdomen was soft with minimal bruising at
the left waist. His pelvis was stable and extremities were
warm with small abrasions in the legs. His rectal
examination was normal tone, prostate was normal position,
guaiac negative. He had C4 to 5 tenderness and left
posterior shoulder tenderness.
LABORATORY DATA: His white count on admission was 20.3 with
a hematocrit of 43.5. His chemistries revealed blood urea
nitrogen 20 and creatinine 0.9.
He underwent a trauma series. The lateral cervical spine
film was clear with no fracture dislocation to C6 but
inadequate. Chest x-ray demonstrated
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**Name8 (MD) 4720**]
MEDQUIST36
D: [**2124-10-7**] 12:14
T: [**2124-10-7**] 12:32
JOB#: [**Job Number 35699**]
Admission Date: [**2124-9-7**] Discharge Date: [**2124-10-7**]
Date of Birth: [**2074-4-17**] Sex: M
Service: Surgery
RADIOLOGIC DATA: The patient underwent a radiological trauma
series with a lateral cervical spine, demonstrating no
fracture dislocation from C1 through C6. The chest x-ray
showed trauma board artifact and mediastinum was widened,
with displacement of the trachea to the right. There were
irregular opacities present within the left lung field,
concerning for contusion and there was deformity of the left
upper thoracic cage, representing multiple rib fractures. No
pneumothorax was demonstrated. The pelvis demonstrated
disruption of the left pelvic rim. Assessment of the
sacroiliac joints was limited.
Given these findings, the patient was taken to the CT
scanner, where CT scans of the chest and abdomen were
performed. The CT scan of the chest demonstrated a
descending thoracic aorta strongly suggestive of aortic
transection, bilateral pleural effusions, left greater than
right, multiple rib fractures, predominantly on the left
side, with subcutaneous emphysema and underlying contusion in
the left lung. There was also an intra-articular fracture
involving the left superior pubic ramus and acetabulum,
associated with hemorrhage along the left pelvic sidewall. A
CT scan of the head demonstrated a left occipital condyle
fracture.
HOSPITAL COURSE: Cardiothoracic surgery residents were
immediately contact[**Name (NI) **] and came to evaluate the patient. The
[**Hospital 228**] hospital course is as follows.
[**Last Name (STitle) 35700**]is patient's life threatening aortic injury, he was
taken immediately to the Operating Room by Dr. [**Last Name (Prefixes) **] of
cardiothoracic surgery, where a repair of a thoracic aortic
transection was performed with a 20 mm woven interposition
gel weave graft. This required left pulmonary vein to right
common femoral artery bypass. The aorta was crossclamped
immediately proximal to the left subclavian for the repair.
The patient lost approximately five liters worth of blood
during the procedure and received 3,000 cc of cell [**Doctor Last Name 10105**],
seven liters of crystalloid, two units of fresh frozen plasma
and seven units of platelets. The crossclamp time was 33
minutes.
Postoperatively, the patient was transferred to the Surgical
Intensive Care Unit, where he was stabilized and a
neurosurgical consult was obtained for the left occipital
condyle fracture that was demonstrated on the CT scan of the
head. Neurosurgery performed a very limited examination
secondary to the fact that the patient was sedated and
intubated, but recommended continuation of the cervical
collar. There was also an orthopedic consult requested for
the left sided zone I sacral fracture and extra-articular
anterior common fracture of the acetabulum. It was
determined that it would also be managed nonoperatively.
The patient subsequently had an extended Intensive Care Unit
stay. He was in the Intensive Care Unit for 22 days. He was
moving all four extremities postoperatively and was doing
well until approximately postoperative day number five, when
he developed fevers and an elevated white blood cell count.
His Intensive Care Unit course was complicated by E. coli
pneumonia that was diagnosed by broncho-alveolar lavage. His
bronco-alveolar lavage grew out E. coli as well as Serratia,
for which the infectious disease service was consulted. The
patient was placed on vancomycin, ceftriaxone and gentamicin
initially. The gentamicin was discontinued and the patient
was placed on ciprofloxacin during his Intensive Care Unit
course. His antibiotics were subsequently changed again to
Zosyn, ceftriaxone and vancomycin. He completed a 14 day
course of Zosyn, a 22 day course of ceftriaxone and a 12 day
course of vancomycin for his hospital acquired pneumonia.
The patient required a prolonged period of intubation given
his pneumonia and his left flail chest that was demonstrated
intraoperatively. He was not extubated until Surgical
Intensive Care Unit [**Unit Number **]. During this period of intubation, he
underwent multiple bronchoscopies. He required heavy
sedation and would periodically by lightened for evaluation
of his neurological status. He was able to move all four
extremities throughout his Intensive Care Unit stay.
On [**2124-9-26**], the patient was successfully extubated
and, at this point, the slow process of rehabilitation was
begun. He did have a postpyloric feeding tube placed and he
was receiving tube feeds during his Intensive Care Unit stay.
He had also been placed on Lovenox as deep vein thrombosis
prophylaxis.
The patient was transferred to the regular floor on [**2124-9-29**], at which point an otolaryngology consult was
obtained because it was noted that, during his aortic
transection repair, the left recurrent laryngeal nerve was
removed. After evaluation by otolaryngology, they
recommended that he undergo video stroboscopy as an
outpatient. He did undergo a speech and swallow evaluation
as well, which he failed. For this reason, he underwent a
percutaneous endoscopic gastrostomy tube placement by
interventional radiology on [**2124-10-4**].
Orthopedic surgery was following the patient throughout his
course, and their final recommendations were that the patient
could touch down weightbear on the left leg and that he could
undergo full range of motion exercises.
The patient had one to two days of nausea after percutaneous
endoscopic gastrostomy tube placement, which resolved. At
that point, he was tolerating his tube feeds. His mental
status was much improved. He was alert and oriented,
conversant, moving all four extremities. He was clear to
auscultation with an irregular rhythm, tolerating his
physical therapy. Given these findings, it was felt that he
was stable for discharge.
Summary of the patient's injuries:
1. Thoracic aortic transection, status post graft
interposition repair.
2. Left occipital condyle fracture, for which patient would
remain in a cervical collar.
3. Left recurrent laryngeal nerve transection, for which he
would follow up with Dr. [**Last Name (STitle) **] as an outpatient;
telephone number [**Telephone/Fax (1) 41**].
4. Left pelvic fracture, requiring nonoperative treatment,
for which he should follow up with orthopedic surgery in two
weeks; telephone number [**Telephone/Fax (1) 2756**].
5. Multiple left rib fractures, for which he would follow up
with trauma surgery; he should call to schedule an
appointment with trauma surgery.
DISCHARGE MEDICATIONS:
Colace 100 mg pg b.i.d.
Reglan 10 mg i.v./p.o.q.6h.
Lovenox 30 mg s.c.b.i.d.
Nystatin swish and swallow.
Paxil 20 mg pg q.d.
Respalor tube feeds via PEG at 100 cc/hour.
DISCHARGE INSTRUCTIONS: The patient is to remain in his
cervical collar until further follow-up with trauma surgery
and neurosurgery. He was instructed to follow up with
neurosurgery, orthopedic surgery, otolaryngology,
cardiothoracic surgery and orthopedic surgery.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
Depression.
Status post motor vehicle accident, sustaining a thoracic
aortic injury, left occipital condyle fracture, left flail
chest, left pelvic fracture, left recurrent laryngeal nerve
transection.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 4720**]
MEDQUIST36
D: [**2124-10-7**] 12:35
T: [**2124-10-7**] 12:35
JOB#: [**Job Number 35701**]
|
[
"805.6",
"801.06",
"808.8",
"807.09",
"482.82",
"807.4",
"901.0",
"E815.0",
"997.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"99.15",
"96.72",
"38.45",
"43.11",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
9381, 9832
|
8886, 9056
|
3688, 8863
|
9081, 9336
|
800, 3670
|
9351, 9360
|
164, 189
|
218, 665
|
688, 777
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,966
| 164,951
|
15456
|
Discharge summary
|
report
|
Admission Date: [**2188-10-20**] Discharge Date: [**2188-11-3**]
Date of Birth: [**2116-3-25**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Rectal cancer.
Major Surgical or Invasive Procedure:
[**2188-10-20**] Laparoscopic converted to open proctectomy with
colostomy.
[**2188-10-22**] Exploratory laparotomy, abdominal washout, and
closure.
History of Present Illness:
The patient is a 72-year-old insulin- dependent diabetic with a
BMI of 47, who was diagnosed with rectal cancer found to be T2,
N0 by preoperative staging studies. Because of her obesity,
radiation was not a reasonable option and given her T2 status
was not recommended. We recommended primary surgery.
Anastomosis was not offered as the patient had limited mobility
and walks with the aid of a walker and had some urgency and
incontinence preoperatively. She presented to the operating room
on [**2188-10-20**] for laparoscopic converted to open proctectomy with
colostomy.
Past Medical History:
Colon adenoma, rectal adenocarcinoma, diabetes mellitus,
peripheral neuropathy, hyperlipidemia, HTN, memory loss (likely
small vessel ischemic disease), hyperparathyroidism, pulmonary
sarcoidosis, anxiety/depression, agoraphobia with panic disorder
Social History:
Patient lives with her husband in [**Name (NI) 745**], MA. She has one
daughter in [**Name (NI) 3307**] with 3 kids and a son in [**Name (NI) 21601**]. She
is able to take care of ADLs at home but her husband has been
taking on more responsibilities. She has a degree in Sociology
and worked for many years as school administrator.
Family History:
Noncontributory.
Physical Exam:
Physical Exam on Discharge:
Vitals: Temp 98, HR 51, BP 183/71, RR 18, O2 95RA
Gen: In NAD, though appears anxious
CV: No m/r/g
Resp: CTA bilaterally
Abd: 15 x 5 cm vertical midline incision with wound VAC in place
to suction. Ostomy pink, producing stool. On VAC takedown,
vertical midline wound is well granulating with fibrinous base.
Ext: 1+ bilateral pitting edema
Pertinent Results:
[**2188-10-21**] 05:40AM BLOOD WBC-11.4* RBC-3.52* Hgb-11.3* Hct-31.6*
MCV-90 MCH-32.2* MCHC-35.8*# RDW-13.1 Plt Ct-201
[**2188-10-22**] 05:15AM BLOOD WBC-18.0*# RBC-3.80* Hgb-12.1 Hct-34.1*
MCV-90 MCH-31.9 MCHC-35.6* RDW-13.0 Plt Ct-248
[**2188-10-31**] 05:05AM BLOOD WBC-12.1* RBC-3.22* Hgb-10.0* Hct-30.3*
MCV-94 MCH-31.0 MCHC-33.0 RDW-13.6 Plt Ct-357
[**2188-10-28**] 10:30AM BLOOD Neuts-82.3* Lymphs-10.2* Monos-6.6
Eos-0.6 Baso-0.2
[**2188-10-21**] 05:40AM BLOOD Glucose-155* UreaN-9 Creat-1.0 Na-138
K-4.3 Cl-102 HCO3-28 AnGap-12
[**2188-10-31**] 05:05AM BLOOD Glucose-90 UreaN-8 Creat-0.9 Na-142 K-3.7
Cl-108 HCO3-25 AnGap-13
[**2188-10-31**] 05:05AM BLOOD Calcium-7.9* Phos-2.9 Mg-2.1
.
[**2188-10-26**] 11:39 am URINE Source: Catheter.
**FINAL REPORT [**2188-10-27**]**
URINE CULTURE (Final [**2188-10-27**]):
YEAST. 10,000-100,000 ORGANISMS/ML..
.
WOUND CULTURE (Final [**2188-10-31**]):
MORGANELLA MORGANII. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
MORGANELLA MORGANII
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Final [**2188-11-2**]): NO ANAEROBES ISOLATED.
Brief Hospital Course:
The patient was admitted to the colorectal surgery service on
[**2188-10-20**] after she underwent laparoscopic converted to open
proctectomy with colostomy for rectal cancer. She tolerated the
procedure well, was extubated without difficulty, and after an
uneventful stay in the PACU was transferred to the floor.
.
CV: The patient's systollics were elevated while inpatient. She
was initially maintained on IV lopressor standing, and then
transitioned to her home atenolol, diovan, and simvastatin. On
discharge her systollics remained in the 180s, and thus
amlodipine was added to her regimen.
.
Respiratory: The patient had an elevated RR > 40 on [**2188-10-22**]. On
exam she was in no acute distress, EKG and CXR were stable and
she responded well to nebulizer treatments. On discharge she was
no longer requiring nebulizers.
.
FEN/GI: Postoperatively the patient underwent ostomy teaching
which she understood well. On POD1 she complained of nausea, and
an NGT was placed, which she self discontinued multiple times.
On discharge she was no longer nauseous. Her diet was gradually
advanced post operatively, and on discharge she was tolerating a
regular diet. She was taken back to the OR on [**2188-10-22**] for
fascial dehiscence. Her wound was opened, washed out, the fascia
was closed, and skin reapproximated. However, following this
procedure she continued to have purulent drainage from her
wound. As a result, her wound was partially opened superiorly
and inferiorly and a VAC was placed on [**2188-10-29**] with a skin
bridge (with underlying white foam sponge). The VAC should be
changed every 3 days (and was last changed on [**2188-11-1**]). On
discharge her wound was noted to be granulating well with a
fibrinous base.
.
GU: Postoperatively on [**10-28**] her foley cathether was
discontinued, however she failed a voiding trial, and therefore
her foley was replaced. Her foley insertion was extremely
difficult, and thus she will likely require the foley to remain
in place for the next few days, after which another voiding
trial may be attempted.
.
Heme: She remained stable from a hematology standpoint.
.
ID: The patient had a progressively upward trending WBC count
postoperatively. Given an equivocal urinalysis and yeast on
urine culture, she was started on fluconazole, which was
discontinued prior to discharge. While inpatient she also
received nystatin cream for a vaginal infection, which improved
and was also discontinued prior to discharge. She did have
purulent exudate from her vertical midline incision, and wound
culture showed MORGANELLA MORGANII. She was treated with unasyn,
transitioned to augmentin, of which she will complete an
additional 5 day course on discharge. Her WBC count was
downtrending on discharge and she remained afebrile on
discharge.
.
Endocrine: Her finger stick glucoses remained elevated during
admission, and she was evaluated by the [**Last Name (un) **] diabetes service
who helped adjust her sliding scale. On discharge she should
continue her sliding scale, and follow up with [**Last Name (un) **] as an
outpatient.
.
Psych/Neuro: The patient was transferred to the SICU on [**2188-10-22**]
for altered mental status. After IV hydration and close
monitoring she was transferred back to the floor the following
day. She was evaluated by the psychiatry service given her low
desire to walk and participate in her care. The service
evaluated her and felt she has agoraphobia with panic disorder,
and recommended her home citalopram be increased from 20 mg
daily to 30 mg daily. On discharge her affect was bright, and
she was walking in the hallways. She was evaluated by physical
therapy prior to discharge who felt she would benefit from
rehab.
.
On discharge the patient was instructed to follow up with Dr.
[**Last Name (STitle) 1120**] in 2 weeks.
Medications on Admission:
Atenolol 50', bupropion 100'', citalopram 20'qd, gabapentin 600
qid, Lantus 80qam, novolog, lorazepam 1'prn, simvastatin 40' qd,
trazodone 75'qhs, Diovan 80 mg-12.5'
Discharge Medications:
1. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. bupropion HCl 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
4. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO QID (4
times a day).
5. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Diovan 80 mg Tablet Sig: One (1) Tablet PO once a day.
8. trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: One (1)
Subcutaneous once a day: Per sliding scale.
Disp:*50 * Refills:*2*
10. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO four
times a day for 1 months.
Disp:*120 Tablet(s)* Refills:*0*
11. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day for
1 months.
Disp:*30 Tablet(s)* Refills:*2*
12. citalopram 20 mg Tablet Sig: 1.5 Tablets PO once a day for 1
months.
Disp:*45 Tablet(s)* Refills:*2*
13. amoxicillin-pot clavulanate 250-62.5 mg/5 mL Suspension for
Reconstitution Sig: One (1) PO Q12H (every 12 hours) for 5
days.
Disp:*10 * Refills:*0*
14. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain for 3 weeks.
Disp:*60 Tablet(s)* Refills:*0*
15. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) for 2 weeks.
Disp:*40 * Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital 745**] Health Care Center
Discharge Diagnosis:
T2, N0 rectal cancer
Morbid obesity. BMI of 47.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital after a open proctectomy for
surgical management of your rectal cancer. You have recovered
from this procedure well and you are now ready to return home.
Samples from your colon were taken and this tissue has been sent
to the pathology department for analysis. You will receive these
pathology results at your follow-up appointment. If there is an
urgent need for the surgeon to contact you [**Name2 (NI) 19605**] these
results they will contact you before this time. You have
tolerated a regular diet, passing gas and your pain is
controlled with pain medications by mouth. You may return home
to finish your recovery.
.
Please monitor your bowel function closely. You may or may not
have had a bowel movement prior to your discharge which is
acceptable, however it is important that you have a bowel
movement in the next 3-4 days. After anesthesia it is not
uncommon for patient??????s to have some decrease in bowel function
but your should not have prolonged constipation. Some loose
stool and passing of small amounts of dark, old appearing blood
are explected however, if you notice that you are passing bright
red blood with bowel movments or having loose stool without
improvement please call the office or go to the emergency room
if the symptoms are severe. If you are taking narcotic pain
medications there is a risk that you will have some
constipation. Please take an over the counter stool softener
such as Colace, and if the symptoms does not improve call the
office. If you have any of the following symptoms please call
the office for advice or go to the emergency room if severe:
increasing abdominal distension, increasing abdominal pain,
nausea, vomiting, inability to tolerate food or liquids,
prolonges loose stool, or constipation.
.
You have a long vertical incision on your abdomen that is closed
with a VAC dressing. The dressing should be changed every 3 days
while you are at rehab. Please monitor the incision for signs
and symptoms of infection including: increasing redness at the
incision, opening of the incision, increased pain at the
incision line, draining of white/green/yellow/foul smelling
drainage, or if you develop a fever. Please call the office if
you develop these symptoms or go to the emergency room if the
symptoms are severe. You may shower, let the warm water run
over the incision line and pat the area dry with a towel, do not
rub.
.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. [**Last Name (STitle) 1120**] or Dr. [**Last Name (STitle) **]. You may
gradually increase your activity as tolerated .
.
You will be prescribed a small amount of the pain medication.
Please take this medication exactly as prescribed. You may take
Tylenol as recommended for pain. Please do not take more than
4000mg of Tylenol daily. Do not drink alcohol while taking
narcotic pain medication or Tylenol. Please do not drive a car
while taking narcotic pain medication.
.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
.
You have a new colostomy. It is important to monitor the output
from this stoma. It is expected that the stool from this ostomy
will be solid and formed like regular stool. You should have [**2-3**]
bowel movements daily. If you notice that you have not had any
stool from your stoma in [**2-3**] days, please call the office. You
may take an over the counter stool softener such as colace if
you find that you are becoming constipated from narcotic pain
medications. Please watch the appearance of the stoma, it should
be beefy red/pink, if you notice that the stoma is turning
darker blue or purple, or dark red please call the office for
advice. The stoma (intestine that protrudes outside of your
abdomen) should be beefy red or pink, it may ooze small amounts
of blood at times when touched and this should subside with
time. The skin around the ostomy site should be kept clean and
intact. Monitor the skin around the stoma for buldging or signs
of infection listed above. Please care for the ostomy as you
have been instructed by the wound/ostomy nurses. At rehab nurses
will help you care for your ostomy.
Followup Instructions:
Please call Dr.[**Name (NI) 3377**] office at ([**Telephone/Fax (1) 3378**] to schedule a
follow up appointment within the next 2 weeks.
.
Please follow up with [**Last Name (un) **] for further management of your
diabetes. Call [**Telephone/Fax (1) 2384**] to schedule an appointment within
1-2 weeks.
Completed by:[**2188-11-3**]
|
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icd9cm
|
[
[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,705
| 199,958
|
43445
|
Discharge summary
|
report
|
Admission Date: [**2178-9-2**] Discharge Date: [**2178-9-8**]
Date of Birth: [**2133-6-10**] Sex: M
Service: MEDICINE
Allergies:
Fish Product Derivatives / Shellfish Derived / Peanut / Grass
Pollen-Bermuda, Standard / Mold Extracts / Cat Hair Std Extract
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
45 year old male with history of severe asthma requiring
numerous hospitalizations and intubations in the past, now
re-presenting with recurrent dyspnea and cough for 2 days. His
productive cough started about 2 days ago, in the absence of any
other URI symptoms. His shortness of breath began yesterday,
for which he usually tries his nebulizer and a Z-pack. His
nebulizer machine was not working overnight, he actually went to
work the next day and he called [**Company 191**] in the morning to try to get
another script to replace it. When this did not work, he drove
himself from work to the pharmacy to pick one up and then gave
himself a treatment on the way home. Before he got a chance to
take his high-dose prednisone, he decided to come to the ED. He
has been taking 50mg prednisone in a slow taper, but the goal
dose was 30mg every other day until he was able to get off
steroids entirely.
.
He was previously discharged from [**Hospital1 18**] after a similar
presentation and ICU admission, felt to be consistent with a
combination of asthma and COPD exacerbations. He received
albuterol/ipratropium nebs q6h with clinical improvement in
wheezing, azithromycin for antibiotic coverage, and was
discharged on a prednisone taper to be determined by his
outpatient pulmonologist, Dr. [**Known firstname **] [**Last Name (NamePattern1) **]. Prior peak flows
were 350 on [**8-24**] and 300 on [**8-25**]. Prior admissions this year
have followed a similar pattern, none of which have required
intubations and have lasted 1-2 days.
.
In the ED, initial vitals were: 101.4, 137, 148/127, 92% on 4L
O2. He received solumedrol 125mg IV, Magnesium 2g IV, Cefepime
1g IV, Levofloxacin 750mg IV, Combivent + albuterol nebs, and 1g
tylenol for fever. Given his continued tachypnea and
tachycardia as well as his prior history of severe asthma, the
decision was made to admit him to the ICU for further
monitoring. On transfer to the MICU, vitals were: Sats 91% RA,
RR 28, HR 120, BP 121/102 (151/96 prior).
.
On arrival to the MICU, he is still very wheezy, but comfortable
on RA.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
- Severe asthma
--- [**2177**]: 6 hospitalizations since beginning of the year, all
lasting 1-2 days
--- More than 100 lifetime hospitalizations with multiple
intubations (17)
--- Most recent prolonged admission was in [**2169**], which was
complicated by MRSA and xanthomonas bronchitis
- OSA on CPAP at night
- GERD
- Avascular necrosis of the hip s/p left TKR [**6-/2175**] and shoulder
repair from prolonged steroid use
- L Achilles tendon rupture s/p repair
Social History:
Smokes five cigarettes a day, ~30 pack-year history. Drinks ~1
bottle of wine per week. Occasionally uses marijuana. He is
currently living with his wife and young daughter in his
mother's house in [**Location (un) 583**], previously in [**Location (un) 5503**]. Currently
has a lot of social stressors; his house in [**Location (un) 5503**] is being
foreclosed. He lost his job as a Volkswagen car mechanic due to
his asthma and has been a bus driver since then. He is married,
has three children
Family History:
Maternal history of cancer and asthma.
Physical Exam:
Admission Physical Exam:
Vitals: T: BP: 138/77 P: 93 R: 24 O2: 95% on RA
General: Alert, oriented, mild respiratory distress
HEENT: Sclera anicteric, MMM, oropharynx clear but mildly
difficult to visualize, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: diffuse inspiratory and expiratory wheezing with
prolonged expiratory phase. No crackles or rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: nonfocal exam with CNII-XII grossly intact and full
strength and sensation bilaterally
Discharge Physical Exam:
VS - 97, 131/88 (to to 160s systolic), 87 (up to 130s), 22, 96RA
GENERAL - sleeping with CPAP
HEENT - EOMI, sclerae anicteric, MMM, OP clear
HEART - RR, nl S1-S2, no MRG
LUNGS - Diffuse inspiratory and expiratory wheezes with
prolonged I/E ratio, improved from yesterday. no rales. Speaking
in full sentences. No accessory muscle use.
ABDOMEN - NABS, soft and adipose/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
MSK - Full ROM throughout.
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle and
sensation grossly intact throughout
Pertinent Results:
ADMISSION LABS:
[**2178-9-2**] 11:20PM GLUCOSE-185* UREA N-11 CREAT-0.8 SODIUM-140
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-23 ANION GAP-16
[**2178-9-2**] 11:20PM CK(CPK)-166
[**2178-9-2**] 11:20PM CK-MB-4 cTropnT-<0.01
[**2178-9-2**] 11:20PM CALCIUM-8.5 PHOSPHATE-2.5* MAGNESIUM-2.4
[**2178-9-2**] 11:20PM WBC-15.5* RBC-5.09 HGB-15.3 HCT-46.1 MCV-91
MCH-30.1 MCHC-33.2 RDW-13.1
[**2178-9-2**] 11:20PM NEUTS-94.0* LYMPHS-3.9* MONOS-1.2* EOS-0.8
BASOS-0.2
[**2178-9-2**] 11:20PM PLT COUNT-282
[**2178-9-2**] 11:20PM PT-12.8* PTT-32.4 INR(PT)-1.2*
[**2178-9-2**] 06:54PM LACTATE-1.4
[**2178-9-2**] 06:40PM GLUCOSE-102* UREA N-12 CREAT-0.9 SODIUM-141
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-27 ANION GAP-13
[**2178-9-2**] 06:40PM estGFR-Using this
[**2178-9-2**] 06:40PM WBC-13.2* RBC-5.43 HGB-16.5 HCT-48.9 MCV-90
MCH-30.5 MCHC-33.8 RDW-13.0
[**2178-9-2**] 06:40PM NEUTS-73.3* LYMPHS-11.8* MONOS-10.0 EOS-4.4*
BASOS-0.5
[**2178-9-2**] 06:40PM PLT COUNT-329
CBC
[**2178-9-2**] 11:20PM BLOOD WBC-15.5* RBC-5.09 Hgb-15.3 Hct-46.1
MCV-91 MCH-30.1 MCHC-33.2 RDW-13.1 Plt Ct-282
[**2178-9-4**] 06:40AM BLOOD WBC-21.6* RBC-4.51* Hgb-13.5* Hct-41.4
MCV-92 MCH-30.1 MCHC-32.7 RDW-13.2 Plt Ct-265
[**2178-9-5**] 07:50AM BLOOD WBC-13.6* RBC-4.44* Hgb-13.5* Hct-41.0
MCV-92 MCH-30.5 MCHC-33.0 RDW-13.3 Plt Ct-267
[**2178-9-6**] 08:21AM BLOOD WBC-17.4* RBC-4.68 Hgb-14.6 Hct-42.4
MCV-91 MCH-31.2 MCHC-34.4 RDW-13.4 Plt Ct-283
[**2178-9-7**] 07:05AM BLOOD WBC-16.9* RBC-4.45* Hgb-13.7* Hct-40.1
MCV-90 MCH-30.8 MCHC-34.2 RDW-13.4 Plt Ct-264
[**2178-9-2**] 11:20PM BLOOD Neuts-94.0* Lymphs-3.9* Monos-1.2*
Eos-0.8 Baso-0.2
CHEMISTRY:
[**2178-9-2**] 11:20PM BLOOD Glucose-185* UreaN-11 Creat-0.8 Na-140
K-4.3 Cl-105 HCO3-23 AnGap-16
[**2178-9-4**] 06:40AM BLOOD Glucose-102* UreaN-18 Creat-0.8 Na-142
K-3.9 Cl-110* HCO3-26 AnGap-10
[**2178-9-5**] 07:50AM BLOOD Glucose-131* UreaN-15 Creat-0.8 Na-146*
K-3.4 Cl-112* HCO3-26 AnGap-11
[**2178-9-6**] 08:21AM BLOOD Glucose-81 UreaN-14 Creat-0.8 Na-145
K-3.5 Cl-108 HCO3-27 AnGap-14
[**2178-9-7**] 07:05AM BLOOD Glucose-81 UreaN-19 Creat-0.8 Na-146*
K-3.4 Cl-107 HCO3-29 AnGap-13
[**2178-9-4**] 06:40AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.2
[**2178-9-5**] 07:50AM BLOOD Calcium-8.6 Phos-3.5 Mg-1.9
[**2178-9-6**] 08:21AM BLOOD Calcium-9.1 Phos-3.6 Mg-1.9
[**2178-9-7**] 07:05AM BLOOD Calcium-9.0 Phos-4.9* Mg-2.0
OTHER LABS:
[**2178-9-2**] 11:20PM BLOOD CK-MB-4 cTropnT-<0.01
[**2178-9-2**] 11:20PM BLOOD CK(CPK)-166
[**2178-9-2**] 11:20PM BLOOD PT-12.8* PTT-32.4 INR(PT)-1.2*
MICRO:
Blood cultures [**2178-9-8**]: no growth
IMAGING:
CXR [**2178-9-2**]: IMPRESSION: No acute cardiopulmonary pathology.
ECHO [**2178-9-3**]: The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Left ventricular systolic function is
hyperdynamic (EF 75%). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
Brief Hospital Course:
CHIEF COMPLAINT: SOB
REASON FOR ADMISSION: 45 year old male with multiple prior
hospitalizations requiring intubation for asthma exacerbation
and ?additional pulmonary disease, re-presenting with acute
onset dyspnea consistent with an asthma exacerbation after a
recent discharge for the same.
# Asthma exacerbation: Exacerbating factors for this
presentation include broken nebulizer machine, life stressors,
smoking, weather, and URI. Outpatient management of this
patient's asthma has been extremely difficult, as he has
required 6 hospitalizations this year despite back-up plans of
high-dose prednisone as needed and very high doses of inhaled
glucocorticoids and controller meds. During his ICU course he
received standing albuterol and ipratropium q2h nebs, prednisone
60mg, azithromycin and continued his home regimen of
flovent,singulair and salmeterol. On the medicine floor, he
completed a 5 day azithromycin course. His PCP prophylaxis with
bactrim was continued, and calcium/vitamin D given chronic
intermittent high dose steroid use. Outpatient consideration for
thermoplasty and consideration of therapy with zolair was
discussed in emails with outpatient providers. After spacing of
his nebulizers, he was discharged on a prednisone taper starting
at 60mg daily x7 days, then to 40mg until followup with his PCP.
[**Name10 (NameIs) **] has an appointment with his pulmonologist Dr. [**Last Name (STitle) **] in
[**Month (only) 1096**], but he was encouraged to make an earlier appointment
if possible.
# Anxiety: Patient cited multiple life stressors, including
marital discord, which are likely contributing to his frequent
asthma exacerbations. Was seen by social work who recommended
outpatient resources. He was given ativan 1mg prn to help with
anxiety, which he will continue on discharge.
# Smoking cessation: Patient reports interest in smoking
cessation. He used nicotine lozenges during admission and also
expressed interest in discussing Chantix with his PCP.
# OSA on CPAP: Patient was on home CPAP at night, with the
exception of the night spent in the ICU for more frequent
nebulizer therapy.
# GERD: Likely secondary to chronic steroid use, continued his
home dose PPI.
TRANSITIONAL ISSUES:
Asthma exacerbation - He is on a steroid taper with close
outpatient followup
Life stressors - He was given a list of outpatient resources by
SW
Smoking cessation - He was given lozenges, and expressed
interest in discussing Chantix with outpatient providers.
MEDICATION CHANGES:
START nicotine lozenges
START calcium and vitamin D
START prednisone taper at 60mg daily x7days, then to 40mg daily
until following up with PCP
START lorazepam for anxiety
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Fluticasone Propionate NASAL 2 SPRY NU DAILY
2. Montelukast Sodium 10 mg PO DAILY
3. Omeprazole 20 mg PO BID
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
6. Loratadine *NF* 10 mg Oral daily allergies
7. Tiotropium Bromide 1 CAP IH DAILY
8. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
9. Fluticasone Propionate 110mcg 12 PUFF IH [**Hospital1 **]
home dose of 220mcg, 6 puffs [**Hospital1 **]
10. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg
base)/3 mL Inhalation q4h SOB
11. Magnesium Oxide 400 mg PO DAILY
12. Guaifenesin ER 1200 mg PO Q12H
13. PredniSONE 50 mg PO DAILY
for the last 3 days. Goal dose 30mg every other day for now,
until able to taper.
Discharge Medications:
1. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit [**Unit Number **] tablet(s) by mouth
twice daily Disp #*120 Tablet Refills:*0
2. Nicotine Lozenge 4 mg PO Q2H:PRN desire to smoke
RX *nicotine (polacrilex) 4 mg 1 lozenge every two hours as
needed Disp #*60 Lozenge Refills:*0
3. Calcium Carbonate 500 mg PO BID
RX *calcium carbonate [Calcium 600] 600 mg (1,500 mg) 1
tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*0
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. fluticasone *NF* 220 mcg/actuation INHALATION 12 PUFFS [**Hospital1 **]
7. Magnesium Oxide 400 mg PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg
base)/3 mL Inhalation q4h SOB
10. Guaifenesin ER 1200 mg PO Q12H
11. Loratadine *NF* 10 mg Oral daily allergies
12. Montelukast Sodium 10 mg PO DAILY
13. Omeprazole 20 mg PO BID
14. PredniSONE 60 mg PO DAILY Duration: 7 Days
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*21 Tablet
Refills:*0
15. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
16. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
17. Lorazepam 1 mg PO BID:PRN anxiety
RX *lorazepam 1 mg 1 tablet by mouth twice daily Disp #*14
Tablet Refills:*0
18. PredniSONE 40 mg PO DAILY
Start taking after finishing 7 days of prednisone 60mg.
Continue this dose until otherwise directed by your doctor.
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Asthma exacerbation
Tachycardia
Anxiety
Tobacco use
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure to be a part of your care at [**Hospital1 18**]. You were
admitted for increasing shortness of breath. Your symptoms were
consistent with an asthma exacerbation. You were treated with
nebulizers, systemic and inhaled steroids, and your home
medications. You will be on a prednisone taper for several
weeks. Given the side effects of steroids, you were given
calcium and vitamin D in the hospital, which you should continue
at home.
Your heart rate was very fast during hospitalization. Causes of
your elevated heart rate include some of the medications that
you were on, as well as anxiety. You were given low dose
benzodiazepines to help with anxiety and were seen by the
hospital social worker to discuss coping mechanisms and
outpatient therapy resources. It is strongly suggested that you
pursue out patient counseling as well as psychiatry to help
address your anxiety which is likely contributing to your asthma
exacerbations. You can continue to take the low dose
anti-anxiolytic as an outpatient, but must not drink or operate
machinery on the medication.
You were counseled on smoking cessation during your stay. You
were given nicotine lozenges to help with cravings during
hospitalization. We strongly encourage continued smoking
cessation in the outpatient setting, as smoking is contributing
to your frequent asthma exacerbations. You are being sent home
with lozenges and should talk to your primary care doctor about
a prescription medicine called Chantix.
Followup Instructions:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2178-9-16**] at 11:10 AM
With: [**Company 191**] POST [**Hospital 894**] CLINIC [**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: [**Hospital3 1935**] CENTER
When: WEDNESDAY [**2178-9-16**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14290**], OD [**Telephone/Fax (1) 253**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2178-9-16**] at 3:00 PM
With: BONE DENSITY TESTING [**Telephone/Fax (1) 4586**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
** Pulmonary follow up**
Your next appointment with Dr. [**Last Name (STitle) **] is scheduled for [**2178-12-16**]
at 8:30 AM. Please call his office at ([**Telephone/Fax (1) 513**] to try to
have an earlier appointment scheduled.
It is strongly suggested that you pursue out patient counseling
as well as psychiatry to help address your anxiety which is
likely contributing to your asthma exacerbations. Below are a
list of agencies you can contact:
[**Location (un) 577**]-[**Location (un) 583**] Mental Health
[**First Name8 (NamePattern2) **]
[**Location (un) 583**], [**Numeric Identifier 994**]
[**0-0-**]
[**Hospital **] [**Hospital 4189**] Health Center
[**Street Address(2) 93488**]
[**Location (un) **], [**Numeric Identifier 822**]
[**Telephone/Fax (1) 93489**]
If you need assistance with this upon discharge, please contact
the social worker you saw while you were here, [**Name (NI) 636**] [**Last Name (NamePattern1) 12471**], at
[**Telephone/Fax (1) 57081**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
|
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] |
icd9cm
|
[
[
[]
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[] |
icd9pcs
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[
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[]
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] |
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|
8650, 8650
|
404, 410
|
13834, 13834
|
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4730, 5363
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,378
| 106,361
|
48993
|
Discharge summary
|
report
|
Admission Date: [**2165-8-9**] Discharge Date: [**2165-9-3**]
Date of Birth: [**2095-10-11**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cipro Cystitis / Aspirin / Nsaids / Dicloxacillin
/ Aldomet / Motrin / Lisinopril / Vioxx
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
hallucinations
Major Surgical or Invasive Procedure:
none
History of Present Illness:
CC:[**CC Contact Info 102866**]
HPI: (per patient, who is a poor historian given her altered
mental status) Pt is a 69 yo F with PMH schizoaffective
disorder, DM2, CAD, dCHF, HTN, restrictive lung disease, discoid
lupus, and vascular dementia who presented to [**Hospital1 18**] from her
[**Hospital3 **] facility for altered mental status and
hallucinations of 3 day duration. Pt states the hallucinations
began around the same time that developed sores in her mouth
that made it painful/hard for her to eat. Visual hallucinations
consist of animals and people. The animals are "sometimes
scary." Also admits to auditory hallucinations in which she
hears voices. She cannot recall the specific things the voices
tell her, but says they are sometimes bad and sometimes good.
She knows the hallucinations are not real. She denies suicidal
or homicidal ideation. She also c/o fatigue and weakness for
past three days, and reports insomnia and racing thoughts over
that time as well. She c/o pain in her left leg and has a
history of falls, but denies recent fall (confirmed by [**Hospital 4382**] facility).
ROS per HPI plus:
(+) headache "like my head is going to bust open," feeling cold,
shortness of breath, cough productive of yellow sputum,
rhinorrhea, urinary incontinence (at baseline), abdominal pain,
constipation, left shoulder pain, and left knee pain.
(-) She denies chest pain, nausea, vomiting, dysuria.
In ED VS were T 98.6 F, HR 110, BP 148/100, RR 20, O2 sat 98% on
room air.
ED course: Chest x-ray, and head CT without contrast were
obtained. No neurologic symptoms were noted. UA was negative.
Lactate and CPK were found to be elevated. Final ED Diagnosis:
Hallucinations
Past Medical History:
#. DM2 - oral meds.
#. CAD s/p MI '[**46**]
- does not tolerate aspirin or ACE -> on Plavix
#. diastolic CHF, EF > 55% 7/08
#. HTN
#. Restrictive lung disease - not on home O2. FEV/FVC 108%, FVC
45%, FEV1 48% 6/07.
#. h/o R LE DVT, many years ago per pt
#. discoid lupus erythematosus
#. h/o CVA - MRI in [**2156**] w/ moderate microvascular changes in
the cerebral white matter
#. h/o of SVT
#. schizo-affective disorder
#. dementia
#. GERD c/b short segment [**Last Name (un) 865**] and hiatal hernia
#. h/o cellulitis
#. h/o seizures, per pt many years ago, not on medications
#. s/p total abdominal hysterectomy
#. small bowel obstruction s/p ex lap w/ lysis of adhesions and
partial small bowel resection ([**2162-7-30**])
#. OSA, does not use CPAP
#. OA
#. osteopenia
Social History:
Resides in [**Last Name (un) 4367**] [**Hospital3 400**] Facility where she has meals
prepared. She dresses and bathes herself. She is able to see her
family members frequently. She smoked 2ppd for 20 yrs, but quit
in [**2162-6-29**]. Denies current alcohol. She uses a walker for
ambulation.
Family History:
Father: Died of MI at less than 50 years of age.
Mother: History of breast CA.
Physical Exam:
ADMISSION EXAM:
Physical Exam:
VS: 99.4 F, BP 155/98, HR 106, RR 18, 96% on 2L
GA: AOx3, NAD
HEENT: head normocephalic, atraumatic. moist mucous membranes.
EOM intact. visual field exam limited by pt's limited attention.
Cards: RRR S1/S2 heard. no murmurs/gallops/rubs.
Pulm: crackles heard at lung bases bilaterally, diminished lung
sounds.
Abd: soft, obese, NT, +BS. no g/rt. HSM difficult to assess due
to body habitus. neg [**Doctor Last Name 515**] sign.
Extremities: no edema. DPs, PTs 2+.
Skin: hyperpigmented macule present on forehead, hypopigmented
patch of skin on left shin, erythema on left foot, midfoot,
medial maleolus, 1st MTP joint.
Neuro/Psych: CNs III-XII intact. visual acuity not assessed. [**5-2**]
strength in U/L extremities, however, pt. is slow to lift her
left arm, and strength testing is also limited by pain in knees.
DTRs 2+ BL (biceps, brachioradialis). sensation intact to LT.
cerebellar fxn (FTN, HTS) and gait not assessed.
MSE findings: flat affect. tangential thought process and
content, with perseveration on the topic of her marriage at the
age of 17. poor attention (cannot state days of the week in
reverse order; gets only from Sat. to Wed.)
.
Discharge PE:
Physical Exam:
VS: 98.6 130/72 87 22 98 on RA
GEN: AAO x2 (not oriented to date), pleasant and conversational,
NAD, breating comfortably
CVS: RRR, no m/r/g, normal S1, S2
PULM: lungs clear to auscultation b/l
ABD: soft, obese, NT, ND, +BS
EXT: slight LE edema b/l. No TTP, 2+ DP pulses
neuro: AAOx2, CN 2-12 grossly intact, [**5-2**] UE/LE strength
Pertinent Results:
[**2165-8-9**] 12:21PM BLOOD WBC-12.8* RBC-5.07 Hgb-13.3 Hct-41.5
MCV-82 MCH-26.3* MCHC-32.1 RDW-16.7* Plt Ct-350
[**2165-8-9**] 12:21PM BLOOD Neuts-74.1* Lymphs-19.9 Monos-3.1 Eos-1.8
Baso-1.0
[**2165-8-9**] 12:21PM BLOOD PT-12.8 PTT-26.0 INR(PT)-1.1
[**2165-8-10**] 07:30AM BLOOD ESR-52*
[**2165-8-11**] 07:35AM BLOOD ACA IgG-2.2 ACA IgM-3.2
[**2165-8-11**] 07:35AM BLOOD Lupus-NEG
[**2165-8-9**] 12:21PM BLOOD Glucose-373* UreaN-28* Creat-1.3* Na-133
K-4.7 Cl-95* HCO3-25 AnGap-18
[**2165-8-9**] 12:21PM BLOOD ALT-31 AST-46* AlkPhos-119* TotBili-0.6
[**2165-8-9**] 04:50PM BLOOD proBNP-248
[**2165-8-10**] 07:30AM BLOOD CK-MB-3 cTropnT-<0.01
[**2165-8-9**] 12:21PM BLOOD Calcium-10.2 Phos-4.7*# Mg-2.0
[**2165-8-12**] 11:40AM BLOOD TotProt-7.1 Albumin-3.7 Globuln-3.4
[**2165-8-11**] 07:35AM BLOOD %HbA1c-9.7* eAG-232*
[**2165-8-13**] 09:05AM BLOOD VitB12-621 Folate-13.9
[**2165-8-11**] 07:35AM BLOOD TSH-2.6
[**2165-8-19**] 08:00AM BLOOD Ammonia-18
[**2165-8-10**] 07:30AM BLOOD CRP-119.2*
[**2165-8-10**] 07:30AM BLOOD [**Doctor First Name **]-NEGATIVE dsDNA-NEGATIVE
[**2165-8-11**] 07:35AM BLOOD b2micro-3.4*
[**2165-8-12**] 11:40AM BLOOD PEP-NO SPECIFI
[**2165-8-9**] 12:29PM BLOOD Lactate-2.7*
[**2165-8-20**] 03:28PM BLOOD freeCa-1.23
Images:
[**2165-8-9**] CXR: Mild interstitial edema and cardiomegaly.
[**2165-8-9**] CT HEAD: No acute intracranial process.
[**2165-8-10**] LLE DOPPLER:No left lower extremity deep vein
thrombosis.
[**2165-8-12**] CALF MRI:1. No signs of muscle edema or myonecrosis in
the left calf.2. Subcutaneous soft tissue edema of the left calf
may reflect third spacing of fluid and edematous changes or
cellulitis in the proper clinical setting. 3. Probable small
bone infarcts involving the posterolateral distal tibia and
lateral aspect of the talus correlated with [**2165-8-9**] left
ankle radiographs 4. Mild thickening of the Achilles tendon at
attachment site with associated enthesopathy at the posterior
calcaneus.
[**2165-8-15**] CTA CHEST: No evidence of PE. Moderate cardiomegaly with
moderate coronary calcifications. Small hiatal hernia. No
evidence of aortic pathology.
[**2165-8-16**] MRI HEAD NON CON:1. No evidence of acute infarct,
intracranial hemorrhage, or mass lesion. 2. Changes of chronic
small vessel ischemic disease. 3. Generalized cerebral atrophy.
4. Focus of old hemorrhage in right frontal lobe which is
unchanged.
Brief Hospital Course:
69 yo F with PMH schizoaffective disorder, CAD, HTN, DM,
restrictive lung disease, discoid lupus, and h/o CVA, who p/w 3d
h/o audio and visual hallucinations, leg pain, and SOB with
altered mental status.
ACTIVE ISSUES:
#Alered Mental Status/Hallucinations: Given pt's history of
schizoaffective disorder and vascular dementia, initial
presentation was thought to be related to delirium vs.
progressive dementia or primary psychiatric condition. Initial
work-up for infectious and neurologic causes of delirium were
unrevealing. Urine analysis was unremarkable, chest xray showed
no infiltrate, blood cultures showed no growth. A head CT was
negative for an acute intracranial process. A head MRI was also
obtained to further evaluate for neurologic causes,and showed
only chronic changes and no new areas of ischemia. An EEG was
obtained and was negative for epileptiform activity. Over the
course of the work up described above, the pt slowly became more
withdrawn, which was different from her initial presentation in
which she was talkative and quite labile with religious ideosity
and frequent outburts of "hallelujah" and "praise [**Doctor Last Name **]." She
began to answer fewer questions, and began to appear somewhat
paranoid. Psychiatry saw pt and recommended increasing
antipsychotic dosage from short acting seroquel 250mg po qhs, to
long-acting seroquel 300mg po qHS and adding on haldol 1mg po
BID. This was done, and the next morning ([**2165-8-16**]) the patient
seemed withdrawn and stuporous. She was awake but not
responsive to questions verbally, answering only with mild head
nodding. At this time, she was found to have a urinary tract
infection (see below), seroquel and haldol were discontinued and
the urinary tract infection was treated and her mental status
improved the following day, returning to a level similar to at
the time of admission.
On [**2165-8-20**], she appeared ill and was again withdrawn. She was
febrile and diaphoretic. Antibiotic coverage was broadened to
vanc/cefepime/flagyl. Pt then developed recurrent SVT to the
220s, relieved with carotid massage. She appeared rigid and
diaphoretic. She was transferred to the ICU for further
management. In the unit psychiatry was consulted and atypical
presentation for neuroleptic malignant syndrome was considered.
She was treated with 2mg cogentin and ativan with mild
improvement in her mental status. She was transferred back to
the general medicine floor, where her mental status continued to
wax and wane but never returned to her initial level of
interactiveness on admission. She was responsive to some
questions, but refusing to answer others. She did not
participate in physical exam commands. She remained stable at
this point for several days. Given the extensive negative work
up for delirium, this was considered to be her new baseline and
placement was found for skilled nursing facility for discharge
with permission from her health care proxy. At time of
discharge, the patient remains AAO x2 (unchanged from before);
she is alert and talkative; still having delusions that her
family is outside waiting for her; gets agitated about wanting
to leave hospital and often refuses to sit or stay in bed.
Throughout hospitalization the patient was convinced that her
hallucinations and delusions were real.
.
# Urinary tract infection: [**2165-8-18**] patient was febrile and urine
analysis suggested urinary tract infection. She was treated with
ceftriaxone. Urine culture revealed
grew out presumptive Strep Bovis and E.coli grow out in her
urine.
.
# Supraventricular Tachycardia: Patient has a remote hx SVT, on
metoprolol for rate control. On [**2165-8-19**] she developed SVT to the
220s, which resolved spontaneously. Over the course of the
following day, she had 4 more episodes of SVT which responded to
carotid massage, she was never hypotensive. SHe was transferred
to the MICU for closer monitoring. Cardiology was consulted who
identified the rhythm as atrial tachycardia vs. AVNRT. The
patient has been stable on Metoprolol 200 mg [**Hospital1 **].
# Hypoxia: On admission, patient was hypoxic with 2LNC O2
requirement. There was no evidence of pulmomary edema or
consolidation. She was quickly weaned to room air. As part of a
work up, an ABG was performed which showed pO2 of 58, this
corrected to 92 with 2LNC. Patient was maintained on
supplemental oxygen without improvement in mental status. Given
significant a-A gradient, and persistent tachycardia, CTA was
performed and showed no evidence of pulmonary embolism. Patient
has a 20 pack year history and likely has baseline hypoxia with
sufficient compensation to maintain peripheral O2 saturation
>92%. At time of discharge, the patient no longer has an oxygen
requirement, and is satting mid to high 90s on RA.
# Ankle pain: Initial laboratory analysis was remarkable for CK
in the 800s and an elevated ESR and CRP. Given her complaints of
left leg and ankle pain, orthopedic and rheumatologic causes
were considered, as well as PE. Plain films of the left ankle
and hip were negative for fracture, but did show an area of
possible bone infarct in the distal tibia of unclear
significance. Rheumatology was consulted who did not believe
the presentation was consistent with SLE, or gout. Amyloidosis
was also considered however SPEP and UPEP, total protein and
globulin levels were unremarkable. Statin-induced myopathy was
considered, and statin was held however CK had already begun to
trend down when the statin was stopped, making statin induced
myopathy unlikely. A LE doppler was negative for DVT. MRI of
the leg MRI was done to evaluate for myositis, skeletal
vasculitis or other inflammatory myopathy, and diabetic
myonecrosis. It was negative for any muscle inflammation or
necrosis, and showed only edema in the subcutaneous tissues,
which had been noted on physical exam. Within the first few days
of her admission, ankle pain and erythemia resolved, etiology
remains unclear.
.
#Cog-wheel rigidity/masked facies/resting tremor - On admission
to the MICU, the patient developed acute presentation of
symptoms concerning for extrapyrimidal symptoms related to
antipsychotics. Patient had received PRN doses of haldol, home
seroquel 250 mg. However, all antipsychotics had been D/C'd 2
days prior to symptom onset. Antipsychotics were held. The
patient was given 1 mg cogentin x 2. Psych was consulted, who
felt that her symptoms were consistent with EPS. The patient
was started on Ativan 1mg q6 hrs PRN agitation. Upon transfer
back to the general medicine floor, her rigidity had improved
and she continued to be treated with prn ativan for agitation,
though this made pt quite somnolent. On [**2165-8-25**] she was
restarted on seroquel 50mg po BID prn agitation in an effort to
avoid sedation associated with benzos. Then as per Psych
recommendation, the patient was restarted on low dose, 25 mg,
seroquel [**Hospital1 **]. All other PRN doses of seroquel and Ativan were
held. The patient seems to be responding well to this regimen.
.
# Hypertension - pt had very difficult BP management while in
house. She was still measuring in SBP 170s on several occasions
despite being on max dose of numerous BP meds, including
metoprolol, losartan, furosemide, and clonidine patch. While in
house, hydralazine 10mg po TID was added to pt's regimen, and
metoprolol was further increased to 200mg po BID for management
of SVT. On this regimen, her pressures ranged from SBP 140s -
150s, occassionally in the 170s.
# hypercholesterol: Because of elevated CKs (peaked at 819),
the patient's Simvastatin was discontinued. CK normalized to 92
by time of discharge. She should have her CK rechecked as
outpatient and consider restarting simvastatin as outpatient.
INACTIVE ISSUES:
# CAD - Chronic. Clopidogrel was continued on admission but
simvastatin was discontinued shortly after admission secondary
to elevated CK levels.
# restrictive lung disease: Chronic. Patient was continued on
albuterol, ipratropium, tiotropium. Symbicort was replaced with
advair during admission due to formulary. Pt is likely
compensated at a lower pO2 secondary to her lung disease. She
was repeatedly hypoxic during admission without complaints of
shortness of breath. Of note, pulse oximetry measured O2 sats
in mid-90s on several occasions in which ABG drawn at same time
showed hypoxia, so pulse ox is not reliable measure of oxygen
status in this patient.
# DM - held glyburide, gave SSI while in house
# h/o candidal rash: miconazole powder
TRANSITIONAL ISSUES:
# schizoaffective disorder: The patient was admitted on Seroquel
250 qhs and because of the possibility of NMS, the patient is
being discharged on Seroquel 50 mg [**Hospital1 **]. Her lorazepam was held
throughout hospital admission.
# please check the patient's CK as an outpatient, as she had
elevated CK levels as outpatient.
Medications on Admission:
- AMLODIPINE 10mg daily
- CLOPIDOGREL [PLAVIX] - 75 mg daily
- FUROSEMIDE - 40 mg daily
- GLYBURIDE - 5 mg daily
- IPRATROPIUM-ALBUTEROL [COMBIVENT] - 2.5-0.5/3mL one vial neb
q6H prn
- LORAZEPAM - 0.5mg qHS
- LOSARTAN [COZAAR] - 100 mg daily
- METOPROLOL ER - 200 mg daily
- PANTOPRAZOLE - 40 mg [**Hospital1 **]
- QUETIAPINE [SEROQUEL] - 250 mg qHS
- SIMVASTATIN - 20 mg daily
- CALCIUM CARBONATE - 500 mg (1,250 mg) TID with meals
- ERGOCALCIFEROL (VITAMIN D2) - 1000 unit daily
- FERROUS SULFATE - 325 mg (65 mg Iron) daily
- MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth daily
- SENNA - 8.6 mg two tabs daily prn constipation
- CLONIDINE patch 0.3mg apply every wednesday
- saline nasal spray 1 spray each nostril [**Hospital1 **]
- spiriva 18mcg cap 1 puff daily
- symbicort 160/4.5 mcg HFA two puffs [**Hospital1 **]
- ibuprofen 400mg po TID prn
- nystatin 100,000U powder apply to affected area TID prn
- proair HFA inh 90mcg 1-2 puffs q4-6h prn
- acetaminophen 650mg po TID
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
4. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) INH
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
5. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. senna 8.6 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) as
needed for constipation.
9. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
10. Saline Nasal 0.65 % Aerosol, Spray Sig: One (1) spray Nasal
twice a day.
11. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
12. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) puffs Inhalation twice a day.
13. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
14. nystatin 100,000 unit/g Powder Sig: One (1) APPL Topical
three times a day as needed: to affected area.
15. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**12-30**]
puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
16. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for fever or pain.
17. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO TID with meals.
19. ergocalciferol (vitamin D2) 400 unit Tablet Sig: 2.5 Tablets
PO once a day.
20. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
21. metoprolol tartrate 100 mg Tablet Sig: Two (2) Tablet PO
twice a day.
22. hydralazine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
23. Outpatient Lab Work
Please check CK on [**2165-9-9**] and fax results to Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1266**]
at [**Telephone/Fax (1) 23926**]
24. Seroquel 50 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Center - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
altered mental status, NOS
extra-pyramidal adverse effect, anti-pyschotics
hypertension
supraventricular tachycardia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Thank you for letting us take part in your care at [**Hospital1 771**]. You came to the hospital because you
were having hallucinations, altered mental status, and shortness
of breath. You were given a diuretic that removed fluid from
your lungs and your breathing improved. You had an extensive
work up to identify the cause of your altered mental status and
no cause could be found.
While you were in the hospital, you developed muscular side
effects from your anti-psychotic medications. These were
stopped temporarily and your symptoms improved. We restarted
you at low doses of your anti-psychotic medications now that
your symptoms have been improving.
Your blood pressure and heart rate were elevated during your
admission. You were started on two new medications to manage
this.
The following changes were made to your medications:
STARTED:
hydralazine 10mg by mouth three times a day
CHANGED:
metoprolol 200mg by mouth twice a day
seroquel 50 mg by mouth twice a day
STOPPED:
lorazepam
simvastatin
Thank you for letting us take part in your care at [**Hospital1 771**]. You came to the hospital because you
were having hallucinations, altered mental status, and shortness
of breath. You were given a diuretic that removed fluid from
your lungs and your breathing improved. You had an extensive
work up to identify the cause of your altered mental status and
no cause could be found.
While you were in the hospital, you developed muscular side
effects from your anti-psychotic medications. These were
stopped temporarily and your symptoms improved. We restarted
you at low doses of your anti-psychotic medications now that
your symptoms have been improving.
Your blood pressure and heart rate were elevated during your
admission. You were started on two new medications to manage
this.
The following changes were made to your medications:
STARTED:
hydralazine 10mg by mouth three times a day
CHANGED:
metoprolol 200mg by mouth twice a day
seroquel 25 mg by mouth twice a day
STOPPED:
lorazepam
simvastatin: please discuss with your primary care doctor when
you can restart simvastatin
Thank you for letting us take part in your care at [**Hospital1 771**]. You came to the hospital because you
were having hallucinations, altered mental status, and shortness
of breath. You were given a diuretic that removed fluid from
your lungs and your breathing improved. You had an extensive
work up to identify the cause of your altered mental status and
no cause could be found.
While you were in the hospital, you developed muscular side
effects from your anti-psychotic medications. These were
stopped temporarily and your symptoms improved. We restarted
you at low doses of your anti-psychotic medications now that
your symptoms have been improving.
Your blood pressure and heart rate were elevated during your
admission. You were started on two new medications to manage
this.
The following changes were made to your medications:
STARTED:
hydralazine 10mg by mouth three times a day
CHANGED:
metoprolol tartrate 200mg by mouth twice a day
seroquel 50 mg by mouth twice a day
STOPPED:
lorazepam
simvastatin: please discuss with your primary care doctor when
you can restart simvastatin
Followup Instructions:
Your doctor, Dr. [**Last Name (STitle) 1266**], [**First Name3 (LF) **] see you at [**Location (un) 583**] House.
Below is his contact information.
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Location: [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **]
Address: 545A CENTRE ST, [**Location (un) **],[**Numeric Identifier 6809**]
Phone: [**Telephone/Fax (1) 608**]
Department: [**Hospital3 1935**] CENTER
When: TUESDAY [**2165-9-24**] at 10:15 AM
With: [**Location (un) 394**]/[**Name8 (MD) **] MD [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2165-9-4**]
|
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"295.70",
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"729.5",
"782.3",
"041.4",
"427.89",
"428.0",
"695.4",
"348.30",
"333.90",
"437.0",
"276.0",
"428.32",
"788.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
19495, 19583
|
7316, 7522
|
377, 383
|
19763, 19763
|
4906, 6238
|
23186, 23911
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|
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7538, 15105
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411, 2112
|
6247, 7293
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15123, 15882
|
19623, 19742
|
19778, 19914
|
2134, 2910
|
2926, 3221
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,116
| 131,400
|
9955+56086
|
Discharge summary
|
report+addendum
|
Admission Date: [**2112-6-8**] Discharge Date: [**2112-6-27**]
Date of Birth: [**2030-9-30**] Sex: M
Service: MEDICINE
Allergies:
Salsalate / Ace Inhibitors
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
melena, hct drop
Major Surgical or Invasive Procedure:
Endoscopy with push enteroscopy
History of Present Illness:
Mr. [**Name14 (STitle) 33347**] an 81 M with history of AF on coumadin until recent
UGIB (gastritis) in the setting of INR 22, prior history of PE,
MR/TR, recurrent pleural effusion who was transferred back to
[**Hospital1 18**] from [**Hospital3 **] with persistently dropping hct and
melena. At last admission, he presented with a HCT of 12.5 and
confusion in the setting of INR 22. His INR was reversed with
vitamin K and 4 units of FFP. He received a total of 10 units of
PRBC during that admission. On prior admission, an EGD was
performed which showed only mild gastritis and no active
bleeding. A colonoscopy showed moderate diverticulosis but also
no signs of active bleeding. A benign appearing polyp was also
removed. He was discharged after several days of stable
hematocrits. His hospital course was complicated by subacute L
superior cerebellar stroke, and he was placed back on lovenox
and coumadin.
.
Since his discharge, the patient is complaining of dyspnea with
exertion over last 2 days but no rest dyspnea. Denies abd pain,
n/v, hematemasis, BRBPR, melena, chest pain, LH, orthopnea, PND,
weight gain. Pt is not sure about melena as he doesn't check his
stools. INR 1.4 at OS lab.
.
In ED, + melenic stools with positive guaiac. Pt did not
tolerated NG lavage due to deviated septum with obstructed L
nare. Pt was given iv protonix and 1 unit of PRBC for hct 25
(prior to d/c on [**5-20**] hct 30). There was a question of ST
depression laterally and 1st cardiac enzymes were negative.
.
In the ED patient got 1 unit of PRBC. He remained
hemodynamically stable. Small bowel enteroscopy and EGD which
showed gastritis and a small angioectasia in the proximal ileum
which was treated with thermal therapy. GI is recommending Q8H
Hct checks. Per GI, it is okay to resume heparin. Most recent
Hct 27.6 (up from 23.6).
.
Currently, pt has no complaints. He is resting comfortable after
EGD/enteroscopy.
Past Medical History:
1. Paroxysmal atrial fibrillation
2. Dementia: hallucinates at night
3. Dilated cardiomyopathy with EF 55%
4. Hypertension
5. Ventricular fibrillation w/ AICD
6. Psoriasis
7. Diabetes, diet controlled
8. Macular degeneration
9. Basal cell carcinoma
10. Valvular heart disease (severe MR [**First Name (Titles) **] [**Last Name (Titles) **])
11. Osteoarthritis w/ decreased mobility from pain
12. Varicose vein
13. PE - [**12-7**] RLL segmental
14. Recent UGIB [**2-5**] gastritis
15. Recurrent pleural effusion- unclear etiology, cytology
negative in the past.
16. Asbestosis exposure.
Social History:
Denies tobacco, EtOH, illicits. Recently at [**Hospital3 **], but
previously living with wife on [**Name (NI) 3146**] [**Name (NI) **]. Retired teacher and
coach.
Family History:
Notable for a father who had macular degeneration. His mother
lived to be 90 and was reported to be healthy. He has one
younger sister who died from cancer. There is no family history
of any memory disorders.
Physical Exam:
T 96.5 HR 66 BP 97/51 RR 14 O2Sat 97% on RA.
Gen: pleasant male in NAD
Heent: OP clear, + conjunctival pallor,
Lungs: Decreased BS at left base with crackles [**1-7**] way up,
decreased breath sound at R base, otherwise clear.
Cardiac: irregularly irregular S1/S2, [**3-8**] holosystolic murmur
radiating to axilla
Abdomen: obese, soft NT NABS
Ext: nonpitting edema of LE b/l, + venous stasis changes
Neuro: Awake, alert, oriented to place, MS R>L [**5-6**]+ UE. [**5-7**] LE,
CN II-XII intact. FTN intact.
Skin: pale
Pertinent Results:
ECG: AF at 64, LAD, IVCD, no acute ST/ t wave changes compared
to [**2112-5-6**] ECg.
.
Echo [**5-9**]:
The left atrium is markedly dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). The right atrium is markedly dilated. The
left ventricle is normal in wall thickness, caviity size and
systolic function (LVEF>55%). Regional left ventricular wall
motion is normal. The right ventricular cavity is moderately
dilated with free wall hypokinesis. The aortic root is mildly
dilated at the sinus level. The ascending aorta is
mildly dilated. The aortic valve leaflets are moderately
thickened. There is a minimally increased gradient consistent
with minimal aortic valve stenosis. Trace aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**1-5**]+) mitral regurgitation is seen. Moderate
[2+]tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is a small
inferolateralpericardial effusion.
Compared with the prior study (images reviewed) of [**2111-9-21**],
minimal aortic stenosis is now suggested and a very small
inferolateral pericardial effusion is now identified.
.
[**2112-5-11**] Colonoscopy:
Findings:
Protruding Lesions A single sessile 6 mm polyp of benign
appearance was found in the proximal rectum at 14cm. A
piece-meal polypectomy was performed using a cold forceps. The
polyp was completely removed. Grade 1 internal hemorrhoids were
noted.
Excavated Lesions Multiple diverticula with medium openings
were seen in the proximal sigmoid colon and mid-sigmoid
colon.Diverticulosis appeared to be of moderate severity.
Impression: Grade 1 internal hemorrhoids
Polyp at 14cm in the proximal rectum (polypectomy)
Diverticulosis of the proximal sigmoid colon and mid-sigmoid
colon
Otherwise normal colonoscopy to cecum
.
EGD:
Brief Hospital Course:
8A/P: 81yo M with recurrent left-sided pleural effusion of
unclear etiology, afib on anticoagulation, recent embolic stroke
(while off anti-coagulation), admitted with recurrent GI bleed,
transferred to ICU with acute respiratory failure.
.
# Respiratory failure (hypoxic and hypercarbic): The patient
with history of chronic left sided pleural effusion s/p several
taps in the last year. The source is unknown but concerning for
malignant process given history of asbestos exposure, but
cytology has been negative. The acute respiratory event is most
likely secondary to left sided pleural effusion reaccumulation
vs. hemothorax in the setting of anticoagulation. Bedside
thoracentesis was attempted but aborted due to difficulties with
aspiration. Other possible explanations for decompensation
include PE (less likely as no significant tachycardia and the
patient has been anticoagulated), mucous plugging, CHF, flash
pulmonary edema.
On [**2112-6-15**], pt intubated for increasing hypercarbia & work of
breathing. A left sided thoracentesis was performed by IP with
drainage of 600cc of bloody fluid. A chest tube was then placed.
CT chest showed trapped L lung w/ incompletely drained L
effusion. Large right sided effusion w/ associated atelectasis
+/- consolidation.
Pt's acute respiratory failure thought to be due to worsening
left hemothorax, which may have worsened spontaneously with
bleeding on anti-coagulation vs pleural bleeding after
unsuccessful thoracentesis on [**2112-6-15**] vs malignancy. Other
contributors to pt's respiratory failure include possible
hospital acquired PNA, ? COPD, and possibly CHF. Pt treated for
all of the above. Respiratory failure resolving as of [**2112-6-22**].
His chest tube removed. Pt extubated on [**2112-6-20**].
- treated for COPD exacerbation with nebs standing, steroids and
Vanc & Zosyn
- Pt diuresed w/ lasix
- BiPAP if necessary
- strict ins/outs
- patient was seen by Dr. [**Last Name (STitle) 33348**] and offered surgical options, but
pt and family declined and wanted pursue thoracenteses for
right-sided effustion.
- Antibiotics discontinued on [**2112-6-22**] after 8day course w/
vanc/zosyn for possible PNA
.
# AF: Currently HD stable.
- Continue beta blocker if BPs tolerates.
- No anti-coagulation given recurrent GI bleed as well as recent
hemothorax.
.
# Cardiomyopathy: EF stable at 55%.
- Giving lasix to diurese ORN
- strict ins/outs
- beta blocker
- patient elected not tu turn on his ICD. He was aware of risks.
.
# GIB: AVM seen on enteroscopy which has been treated with
thermal therapy. Also has gastritis. Status post multiple units
of PRBCs on this admission (last [**2112-6-22**])
- transfusion for Hct ~21
- maintain active T&S with 2 peripheral IVs
- continue to monitor on tele
- Continue IV ppi [**Hospital1 **]
- On iron therapy
.
# Renal. Pre-renal in setting of hypovolemia & hypotension. Now
resolving s/p IVF.
- renally dose meds
.
# DM: previously diet controlled, has had elevated sugars during
hospital stay
- HISS, started glargine on [**2112-6-22**]
.
# H/O of PE - Patient with history of PE in [**12-7**] however CTA
[**9-8**] did not show any PE. Holding anticoagulation.
.
# FEN: Pureed, thin liquids, cleared by s+s, asp precautions.
Patient had NG tube placed before discharge for tubefeedings.
.
# PPX: PPI, on coumadin/heparin
.
# Comm: Wife is health care proxy. [**Name (NI) **] contact is Daughter
[**Name (NI) 2048**] cell - [**Telephone/Fax (1) 33345**]
.
# DNR but intubation OK
.
# ACCESS: 2 PIV
.
# DISPO: ICU care
Medications on Admission:
1. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Feosol 325 (65) mg Tablet Sig: One (1) Tablet PO twice a day.
4. Lasix 20 mg Tablet Sig: Three (3) Tablet PO once a day.
5. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
6. Aricept 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Enoxaparin 120 mg/0.8 mL Syringe Sig: One Hundred-Ten (110)
units Subcutaneous Q12H (every 12 hours): Needs to be continued
until INR therapeutic for two days. .
9. Humalog 100 unit/mL Solution Sig: per sliding scale. per
sliding scale Subcutaneous QACHS: Patient has very little
insulin requirement. Please use standard sliding scale.
.
From rehab:
ASA 81 mg daily
protonix 40 mg [**Hospital1 **]
docusate 100 mg [**Hospital1 **] prn
mag gluconate [**2105**] TID
KcL 60 mEq [**Hospital1 **]
regular insulin
mupirocin ointment
zinc oxide paste
nystatin powder
donepezil 5 mg daily
metoprolol 50 mg daily
lasix 60 mg daily
ferrous sulfate 325 TID
warfarin per protocol
mag hydroxide
tylenol prn
bisacodyl supp prn
mag hydroxide 30 mL daily
psyllium 3.7 gm
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
10. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours).
11. Insulin Regular Human 100 unit/mL Cartridge Sig: per sliding
scale Injection four times a day.
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Morphine Sulfate 1 mg IV Q2H:PRN dyspnea
Hold for oversedation or RR <15
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
respiratory distress
Discharge Condition:
extubated, NG tube in place
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
please take all your meds as prescribed.
Followup Instructions:
with PCP Dr [**Last Name (STitle) **]
Completed by:[**2112-6-24**] Name: [**Known lastname 5830**],[**Known firstname 63**] W Unit No: [**Numeric Identifier 5831**]
Admission Date: [**2112-6-8**] Discharge Date: [**2112-6-27**]
Date of Birth: [**2030-9-30**] Sex: M
Service: MEDICINE
Allergies:
Salsalate / Ace Inhibitors
Attending:[**First Name3 (LF) 5448**]
Addendum:
Patient transferred from ICU to floor [**6-24**]. Initially had
Dobhoff feeding tube which was placed at radiology. However
patient pulled this out during night. Otherwise has been stable
on nasal canula. Patient required electrolyte repletion.
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
intubation
thoracentesis
History of Present Illness:
Mr. [**Name14 (STitle) 5832**] an 81 M with history of AF on coumadin until recent
UGIB (gastritis) in the setting of INR 22, prior history of PE,
MR/TR, recurrent pleural effusion who was transferred back to
[**Hospital1 8**] from [**Hospital3 **] with persistently dropping hct and
melena. At last admission, he presented with a HCT of 12.5 and
confusion in the setting of INR 22. His INR was reversed with
vitamin K and 4 units of FFP. He received a total of 10 units of
PRBC during that admission. On prior admission, an EGD was
performed which showed only mild gastritis and no active
bleeding. A colonoscopy showed moderate diverticulosis but also
no signs of active bleeding. A benign appearing polyp was also
removed. He was discharged after several days of stable
hematocrits. His hospital course was complicated by subacute L
superior cerebellar stroke, and he was placed back on lovenox
and coumadin.
.
Since his discharge, the patient is complaining of dyspnea with
exertion over last 2 days but no rest dyspnea. Denies abd pain,
n/v, hematemasis, BRBPR, melena, chest pain, LH, orthopnea, PND,
weight gain. Pt is not sure about melena as he doesn't check his
stools. INR 1.4 at OS lab.
.
In ED, + melenic stools with positive guaiac. Pt did not
tolerated NG lavage due to deviated septum with obstructed L
nare. Pt was given iv protonix and 1 unit of PRBC for hct 25
(prior to d/c on [**5-20**] hct 30). There was a question of ST
depression laterally and 1st cardiac enzymes were negative.
.
In the ED patient got 1 unit of PRBC. He remained
hemodynamically stable. Small bowel enteroscopy and EGD which
showed gastritis and a small angioectasia in the proximal ileum
which was treated with thermal therapy. GI is recommending Q8H
Hct checks. Per GI, it is okay to resume heparin. Most recent
Hct 27.6 (up from 23.6).
.
On arrival, pt has no complaints. He is resting comfortable
after
EGD/enteroscopy.
Past Medical History:
1. Paroxysmal atrial fibrillation
2. Dementia: hallucinates at night
3. Dilated cardiomyopathy with EF 55%
4. Hypertension
5. Ventricular fibrillation w/ AICD
6. Psoriasis
7. Diabetes, diet controlled
8. Macular degeneration
9. Basal cell carcinoma
10. Valvular heart disease (severe MR [**First Name (Titles) **] [**Last Name (Titles) **])
11. Osteoarthritis w/ decreased mobility from pain
12. Varicose vein
13. PE - [**12-7**] RLL segmental
14. Recent UGIB [**2-5**] gastritis
15. Recurrent pleural effusion- unclear etiology, cytology
negative in the past.
16. Asbestosis exposure.
Social History:
Denies tobacco, EtOH, illicits. Recently at [**Hospital3 **], but
previously living with wife on [**Name (NI) 3744**] [**Name (NI) 5833**]. Retired teacher and
coach.
Family History:
Notable for a father who had macular degeneration. His mother
lived to be 90 and was reported to be healthy. He has one
younger sister who died from cancer. There is no family history
of any memory disorders.
Physical Exam:
T 96.5 HR 66 BP 97/51 RR 14 O2Sat 97% on RA.
Gen: pleasant male in NAD
Heent: OP clear, + conjunctival pallor,
Lungs: Decreased BS at left base with crackles [**1-7**] way up,
decreased breath sound at R base, otherwise clear.
Cardiac: irregularly irregular S1/S2, [**3-8**] holosystolic murmur
radiating to axilla
Abdomen: obese, soft NT NABS
Ext: nonpitting edema of LE b/l, + venous stasis changes
Neuro: Awake, alert, oriented to place, MS R>L [**5-6**]+ UE. [**5-7**] LE,
CN II-XII intact. FTN intact.
Skin: pale
Pertinent Results:
[**2112-6-8**] 09:01PM COMMENTS-GREEN TOP
[**2112-6-8**] 09:01PM HGB-8.6* calcHCT-26
[**2112-6-8**] 06:59PM COMMENTS-GREEN TOP
[**2112-6-8**] 06:59PM GLUCOSE-132*
[**2112-6-8**] 06:59PM HGB-8.6* calcHCT-26
[**2112-6-8**] 06:49PM GLUCOSE-139* UREA N-32* CREAT-1.2 SODIUM-138
POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-32 ANION GAP-10
[**2112-6-8**] 06:49PM estGFR-Using this
[**2112-6-8**] 06:49PM cTropnT-0.01
[**2112-6-8**] 06:49PM CALCIUM-8.6 PHOSPHATE-3.3 MAGNESIUM-2.5
[**2112-6-8**] 06:49PM WBC-3.5* RBC-2.86* HGB-8.5* HCT-25.8* MCV-90
MCH-29.6 MCHC-32.8 RDW-20.1*
[**2112-6-8**] 06:49PM NEUTS-56.0 LYMPHS-33.5 MONOS-6.0 EOS-3.3
BASOS-1.2
[**2112-6-8**] 06:49PM PLT COUNT-145*
[**2112-6-8**] 06:49PM PT-15.0* PTT-28.1 INR(PT)-1.3*
ECG: AF at 64, LAD, IVCD, no acute ST/ t wave changes compared
to [**2112-5-6**] ECg.
.
Echo [**5-9**]:
The left atrium is markedly dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). The right atrium is markedly dilated. The
left ventricle is normal in wall thickness, caviity size and
systolic function (LVEF>55%). Regional left ventricular wall
motion is normal. The right ventricular cavity is moderately
dilated with free wall hypokinesis. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets are moderately thickened.
There is a minimally increased gradient consistent with minimal
aortic valve stenosis. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild to moderate
([**1-5**]+) mitral regurgitation is seen. Moderate [2+]tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a small inferolateralpericardial
effusion.
Compared with the prior study (images reviewed) of [**2111-9-21**],
minimal aortic stenosis is now suggested and a very small
inferolateral pericardial effusion is now identified.
[**2112-5-11**] Colonoscopy:
Protruding Lesions A single sessile 6 mm polyp of benign
appearance was found in the proximal rectum at 14cm. A
piece-meal polypectomy was performed using a cold forceps. The
polyp was completely removed. Grade 1 internal hemorrhoids were
noted. Excavated Lesions Multiple diverticula with medium
openings were seen in the proximal sigmoid colon and mid-sigmoid
colon. Diverticulosis appeared to be of moderate severity.
Impression: Grade 1 internal hemorrhoids
Polyp at 14cm in the proximal rectum (polypectomy)
Diverticulosis of the proximal sigmoid colon and mid-sigmoid
colon Otherwise normal colonoscopy to cecum
.
[**2112-5-7**] EGD:
Erythema in the fundus compatible with mild gastritis
.
[**2112-6-9**] Small Capsule Endoscopy
Erythema and congestion in the antrum compatible with mild
gastritis
Angioectasia in the proximal ileum (thermal therapy)
Otherwise normal small bowel enteroscopy to proximal jejunum
Brief Hospital Course:
8A/P: 81yo M with recurrent left-sided pleural effusion of
unclear etiology, afib on anticoagulation, recent embolic stroke
(while off anti-coagulation), admitted with recurrent GI bleed,
transferred to ICU with acute respiratory failure.
.
# Respiratory failure (hypoxic and hypercarbic): The patient
with history of chronic left sided pleural effusion s/p several
taps in the last year. The source is unknown but concerning for
malignant process given history of asbestos exposure, but
cytology has been negative. The acute respiratory event is most
likely secondary to left sided pleural effusion reaccumulation
vs. hemothorax in the setting of anticoagulation. Bedside
thoracentesis was attempted but aborted due to difficulties with
aspiration. On [**2112-6-15**], pt intubated for increasing hypercarbia
& work of
breathing. A left sided thoracentesis was performed by IP with
drainage of 600cc of bloody fluid. A chest tube was then placed.
CT chest showed trapped L lung w/ incompletely drained L
effusion. Large right sided effusion w/ associated atelectasis
+/- consolidation.
Pt's acute respiratory failure thought to be due to worsening
left hemothorax, which may have worsened spontaneously with
bleeding on anti-coagulation vs pleural bleeding after
unsuccessful thoracentesis on [**2112-6-15**] vs malignancy. Other
contributors to pt's respiratory failure include possible
hospital acquired PNA, ? COPD, and possibly CHF. Pt treated for
all of the above with nebs standing, steroids and Vanc & Zosyn.
Patient was offered surgical options, but
pt and family declined and wanted pursue thoracenteses for
right-sided effustion.
Antibiotics discontinued on [**2112-6-22**] after 8day course w/
vanc/zosyn for possible PNA
Patient discharged on 3L nasal canula.
.
# AF: Currently stable.
- Continued on beta blocker.
- No anti-coagulation given recurrent GI bleed as well as recent
hemothorax.
- After discussion of risk/benefits with the family the ICD was
turned off.
.
# Cardiomyopathy: EF stable at 55%.
- Contunued lasix, strict ins/outs, beta blocker.
- patient elected not to turn on his ICD. He was aware of
risks.
.
# GIB: AVM seen on enteroscopy which has been treated with
thermal therapy. Also has gastritis. Status post multiple units
of PRBCs on this admission (last [**2112-6-22**]). Patient has had
stable hct. Patient now on protonix [**Hospital1 **].
.
# Renal. Pre-renal in setting of hypovolemia & hypotension.
Resolved by discharge
.
# DM: previously diet controlled. Sent out on lantus and
humalog sliding scale.
.
# H/O of PE - Patient with history of PE in [**12-7**] however CTA
[**9-8**] did not show any PE. Holding anticoagulation [**2-5**] bleeding
risks.
.
# FEN: Pureed, thin liquids, cleared by s+s, asp precautions.
Patient had NG tube placed before discharge for tubefeedings,
however he pulled this out on [**6-25**].
.
# PPX: PPI, heparin sc
.
# Comm: Wife is health care proxy.
.
# DNR but intubation OK
Medications on Admission:
ASA 81 mg daily
protonix 40 mg [**Hospital1 **]
docusate 100 mg [**Hospital1 **] prn
mag gluconate [**2105**] TID
KcL 60 mEq [**Hospital1 **]
regular insulin
mupirocin ointment
zinc oxide paste
nystatin powder
donepezil 5 mg daily
metoprolol 50 mg daily
lasix 60 mg daily
ferrous sulfate 325 TID
warfarin per protocol
mag hydroxide
tylenol prn
bisacodyl supp prn
mag hydroxide 30 mL daily
psyllium 3.7 gm
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
10. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours.
Disp:*60 Tablet(s)* Refills:*2*
14. Insulin Glargine 100 unit/mL Cartridge Sig: Ten (10) units
Subcutaneous at bedtime.
Disp:*qs * Refills:*2*
15. Humalog 100 unit/mL Solution Sig: sliding scale units
Subcutaneous four times a day: Humalog Sliding Scale.
16. Potassium Chloride 20 mEq Packet Sig: Two (2) packets PO
once a day.
17. Magnesium Gluconate 500 mg Tablet Sig: Two (2) Tablet PO
three times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
Discharge Diagnosis:
Respiratory Failure
Atrial Fibrillation
Hemothorax
Cardiomyopathy
AVM leading to GI bleed
Diabetes Type II
h/o Pulmonary Embolism
Discharge Condition:
Stable breathing on nasal canula
Discharge Instructions:
Please take all medications as listed in the discharge
paperwork. Please make all appointments as listed in the
discharge paperwork.
Weigh yourself every morning, [**Name8 (MD) 233**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
Please [**Name6 (MD) 233**] your MD or go to the emergency room for fevers,
chills, chest pain, shortness of breath, abdominal pain, nausea,
vomitting, diarrhea, or any other concerning symptoms.
Patient has needed electrolyte repletion. Please follow K, Mg,
and Phos closely and replete.
Followup Instructions:
Please follow up in [**1-5**] weeks with your primary care provider
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 1813**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5451**] MD [**MD Number(2) 5452**]
Completed by:[**2112-6-27**]
|
[
"518.81",
"584.9",
"427.31",
"287.5",
"438.9",
"486",
"724.5",
"285.1",
"V45.02",
"428.0",
"V12.72",
"535.50",
"511.8",
"569.85",
"934.1",
"V15.84",
"458.9",
"496",
"263.9",
"V10.83",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"99.04",
"96.72",
"34.91",
"96.05",
"45.34",
"38.93",
"33.22",
"96.04",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
24545, 24626
|
19558, 22521
|
13070, 13097
|
24800, 24835
|
16625, 19535
|
25411, 25702
|
15860, 16071
|
22977, 24522
|
24647, 24779
|
22547, 22954
|
24859, 25388
|
16086, 16606
|
13022, 13032
|
13125, 15047
|
15069, 15657
|
15673, 15844
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,574
| 109,633
|
25649
|
Discharge summary
|
report
|
Admission Date: [**2187-8-15**] Discharge Date: [**2187-8-22**]
Date of Birth: [**2143-11-3**] Sex: F
Service: EMERGENCY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
1-2days jaudice, nausea and mild RUQ on palpation on [**2187-8-15**]
Major Surgical or Invasive Procedure:
ERCP with stent placement was performed on [**2187-8-16**]
History of Present Illness:
This a 43 year old female with metastatic breast cancer, to
liver, lung, brain, and bone who presented with 1-2days jaudice,
nausea and mild RUQ on palpation on [**2187-8-15**]. In the ED, a RUQ U/S
was unable to identify the CBD but it did show dilatation of the
pancreatic duct which was suspcious for CBD stone. ERCP with
stent placement was performed on [**2187-8-16**]. Patient was treated
with IV Ciprofloxacin and stable on the OMED service until the
early am of [**2187-8-19**] when patient was found to be hypotensive to
SBP 70s, hypothermic to 95, with a rising lactate of 4.2.
Patient received 3L IVF boluses and blood pressure remained
fluid responsive.
.
Patient reported feeling the worst of her stay this am but
denies localizing symptoms. She denies RUQ pain, fevers, chills,
nausea, vomiting, cough, urinary urgency or frequency, dysuria,
or SOB. No HA or confusion. Of note, she has chronic back pain
that is unchanged from baseline.
.
Onc History:
Recurrent breast CA dx'd [**2181**] tx'd w/ lumpectomy/XRT/ CA.
[**7-17**]: XRT for osseous disease. She then rec'd wkly taxol/[**Doctor Last Name **]/
herceptin until markers went down to normal range. She was on
q3w Herceptin from [**12/2184**] - [**4-/2186**], when she developed brain
mets and consented to trial 06-356 combining Lapatinib 1000mg QD
with whole brain radiation then Lapatinib with weekly Herceptin.
She progressed and was changed to Xeloda- Lapatanib
w/progression. After cyberknife she was tx'd w/
Herceptin/Navelbine for 4 doses. Recent Brain MRI shows 2 small
new lesions for which she had Cyberknife tx.
In [**Month (only) 116**] she Avastin/ Gemzar therapy but developed thigh pain and
impending femur fx was discovered requiring surgery and XRT to
right leg. Recent MRI with 3 new small brain lesions, s/p
cyberknife to brain [**6-19**]. Known L4 compression fracture, being
evaluated for XRT.
Past Medical History:
Breast cancer - as above
S/p cholecystectomy
Chronic Back Pain L4 compression fracture
Social History:
She lives with her husband and two children.
Previously worked as a hostess. Tob: 20 pack-yr, quit 10 yrs ago
Family History:
PGM had breast cancer in her 70s
Mother and Father have hyperlipidemia
Physical Exam:
Vitals: T: 97.3 BP:138/49 HR:112 RR:26 O2Sat: 98% on 4L
GEN: Chronically ill appearing female, hirsuit, obese
HEENT: EOMI, PERRL, + sclera icterous, no epistaxis or
rhinorrhea, DMM
NECK: unable to assess JVD [**1-13**] neck girth, carotid pulses brisk,
no bruits, no cervical lymphadenopathy, trachea midline
COR: Tachy, regular, HS distant no M/G/R, normal S1 S2, radial
pulses +1
PULM: Expiratory wheezes, BS distant, decreased BS at right base
ABD: Soft, +RUQ TTP, ND, +BS, no rebound or guarding
EXT: 2+ pitting edema to sacrum. No C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. Attention
intact - spells world backwards. CN II ?????? XII grossly intact.
Moves all 4 extremities. Generalized weakness but strength 4+/5
in upper and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. Unable to assess gait.
SKIN: + jaundice, no cyanosis, or gross dermatitis. +
ecchymoses.
Pertinent Results:
On Admission:
[**2187-8-15**] 03:05PM WBC-2.6* RBC-2.92* HGB-9.2* HCT-27.6* MCV-95#
MCH-31.7 MCHC-33.4 RDW-20.8*
[**2187-8-15**] 03:05PM NEUTS-47* BANDS-21* LYMPHS-10* MONOS-16*
EOS-4 BASOS-0 ATYPS-0 METAS-1* MYELOS-1* NUC RBCS-1*
[**2187-8-15**] 03:05PM PLT SMR-VERY LOW PLT COUNT-71*
[**2187-8-15**] 03:05PM GLUCOSE-63* UREA N-11 CREAT-0.3* SODIUM-136
POTASSIUM-3.0* CHLORIDE-93* TOTAL CO2-31 ANION GAP-15
[**2187-8-15**] 03:05PM ALT(SGPT)-49* AST(SGOT)-101* ALK PHOS-747*
TOT BILI-15.8* DIR BILI-12.2* INDIR BIL-3.6
[**2187-8-15**] 03:05PM ALBUMIN-2.7* CALCIUM-8.3* PHOSPHATE-3.6
MAGNESIUM-1.8
[**2187-8-15**] 03:05PM LIPASE-145*
[**2187-8-15**] 03:15PM LACTATE-2.3*
RUQ ultrasound - Limited examination, but no evidence of biliary
ductal
dilatation.
Brief Hospital Course:
On transfer to the [**Hospital Unit Name 153**]
# Hypotension - Patient met SIRS criteria with T < 96 and SBP<70
on the floor prior to transfer which resolved with 3L IVF bolus
and broadening of antibitoics to include vancomycin and zosyn.
Likely source is biliary duct obstruction but also has
long-standin effusion and line as possible sources. Patient with
right porta-cath as only access. No central venous line placed
as patient's goal of care were clarified. Initially on pressors
and IV fluid boluses to maintain adequate MAP and urine output.
decision to d/c once clear that patient was CMO given widely
metastatic breast CA. Patient was started on IV morphine drip.
Antibiotics were continued for comfort. Other unnecessary
medications/diagnostic studies were discontinued. family was all
around and present and patient passed away [**2187-8-21**].
Medications on Admission:
Oxycontin 10mg [**Hospital1 **]
Oxycodone 5mg PRN
.
Meds on transfer:
Ciprofloxacin 400mg IV Q12H
Albuterol nebs Q6H prn
Chlorhexidine oral rinse [**Hospital1 **]
Colace 100mg [**Hospital1 **]
Heparin SC TID
Hydrocortisone 100mg IV Q8H
Ipratropium Neb Q6H prn
Magnesium sliding scale
Oxycontin 10mg [**Hospital1 **]
Oxycodone 5mg Q4H prn
Pantoprazole 40mg po Q24H
Zosyn 4.5mg IV Q8H day#1 [**8-19**]
Potassium sliding scale
Prochlorperazine 10mg Q6H prn
Senna 1 tab po BID
Vancomycin 1000 mg IV Q 12H D#1 [**8-19**]
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
metastatic breast cancer
Discharge Condition:
death
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2187-8-22**]
|
[
"284.89",
"995.92",
"785.52",
"338.3",
"038.9",
"198.5",
"518.81",
"198.3",
"197.0",
"733.13",
"E933.1",
"V10.3",
"570",
"197.7",
"576.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.87",
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
5893, 5902
|
4438, 5298
|
385, 445
|
5970, 5977
|
3641, 3641
|
6028, 6061
|
2617, 2689
|
5866, 5870
|
5923, 5949
|
5324, 5376
|
6001, 6005
|
2704, 3622
|
277, 347
|
473, 2363
|
3656, 4415
|
2385, 2473
|
2489, 2601
|
5394, 5843
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,976
| 139,823
|
50647
|
Discharge summary
|
report
|
Admission Date: [**2115-1-31**] Discharge Date: [**2115-2-12**]
Date of Birth: [**2034-6-29**] Sex: M
Service: MEDICINE
Allergies:
Cozaar / Ace Inhibitors / Morphine
Attending:[**Last Name (NamePattern1) 1572**]
Chief Complaint:
scrotal swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 80 yo M with h/o DM, CAD (s/p CABG in [**2083**], [**2088**]), infarct
related cardiomyopathy (EF 20-25%), s/p biv ICD, prostate cancer
s/p b/l orchiectomy and TURP, [**Last Name (un) 938**] of bladder stones and
radiotherapy [**2110**], who p/w gradually increasing scrotal pain and
swelling as well as decreased UOP. He states that this urinary
stream gradually became weaker in the last 3 days and then
nothing came out yesterday. His scrotum also became acutely
enlarged to the point where he could not walk. He also noticed
increased bilateral leg swelling, and that his "whole body is
leaking fluid". He has gained 12 pounds in the last 2 days. He
admits to eating TV dinners every 2-3 days for years, but
noticed a decreased appetite when his edema started. He states
he has been taking all his meds faithfully. Last night, he felt
SOB at rest and required his home O2 which he hasn't needed in a
while. He also had concomitant chest pressure that was relieved
with 3 tabs of nitro (typically happens 3x/month). Denies
f/c/n/v, cough, orthopnea, palpitations, syncope, h/a,
dizziness.
.
Of note, pt was admitted in [**2-/2114**] for scrotal swelling and
renal failure [**12-27**] CHF exacerbation that responded to PO
torsemide but not IV lasix.
.
In ED, initial VS 97.4 80 101/60 20 98%. Because scrotal exam
was concerning for necrotizing fasciits, pt received
vanc/clinda. Scrotal US was obtained and Urology c/s felt no
contributing gaseous process. CXR showed cardiomegaly without
pulmonary edema or pleural effusions. Foley was also placed and
pt then admitted to Cardiology for management of likely CHF
exacerbation.
.
On arrival to the floor, VS 97.3 67 98/67 18 99%RA. Pt feels
well without CP or SOB. Foley put out 350cc.
Past Medical History:
CARDIAC HISTORY: Hyperlipidemia, Hypertension, Diabetes mellitus
* CABG: [**2083**] (SVG-distal LAD, distal LCx, distal RCA), re-do in
[**2088**]
* PERCUTANEOUS CORONARY INTERVENTIONS: None
* PACING/ICD: [**Company 1543**] biventricular ICD (placed in [**2104**])
.
PAST MEDICAL & SURGICAL HISTORY
1. Paroxysmal atrial fibrillation
2. Infarct-related cardiomyopathy with significant coronary
disease, (EF 20-25%, left ventricular systolic dysfunction with
akinesis of the inferior septum, inferior wall, and
inferolateral wall)
3. Coronary artery disease
4. Ventricular tachycardia storm status-post biventricular ICD
placement in [**2104**] ([**Company 1543**] [**First Name9 (NamePattern2) **] [**Last Name (un) 24119**] generator replacement
in [**3-/2108**])s/p VT ablation [**14**]/[**2114**]. Atrial tachycardia
status-post ablation ([**2104**], [**2105**]), atrial flutter status-post
ablation, and AVNRT status-post slow pathway modification
6. Prior history of stroke post-CABG in [**2088**]; another stroke
([**2108**]) - mild residual visual disturbance and unsteady gait
7. Prostate cancer s/p TURP
8. Diet-controlled diabetes mellitus
9. Chronic renal insufficiency (baseline 2.0-2.3)
10. h/o nephrolithiasis
11. Intermittent vertigo history
12. Mild insomnia (sleeps 2-3 hours nightly)
13. s/p Tonsillectomy (at age 40 years)
14. s/p Mastoidectomy
Social History:
Patient lives at home alone in [**Hospital1 3494**], MA. Patient is
independent in his ADLs. Has a cane for walking but only uses it
occasionally. Retired nurse. [**First Name (Titles) 4084**] [**Last Name (Titles) 18038**] or used illicits.
Usually has 1 glass of wine with dinner but none in past 8
months.
Family History:
Patient is adopted. Unaware of biological family history.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 97.3 67 98/67 18 99%RA UOP 350cc
GENERAL: A&Ox3, lying in bed, appears deconditioned, NAD
HEENT: NC/AT. Sclera anicteric, EOMI. Dry, cracked lips.
Neck: Supple with JVP of 8 cm. No carotid bruits appreciated.
CV: RRR, nl S1, S2, no S3, III/VI systolic murmur @LLSB without
radiation to axilla
Pulm: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
GU: Scrotum markedly erythematous and edematous (2+). No TTP.
B/l inguinal folds with fine scales and well-demarcated bright
red patches.
Extr: 2+ b/l LE edema to the knees. Overlying skin is
hyperkeratotic, scaly with red-purple-brown hyperpigmentation.
Neuro: A&Ox3, mild dysarthria.
.
DISCHARGE PHYSICAL EXAMINATION:
VS: 98.5 98.1 130/89 69 20 199% RA FBS 136
Wt: 81.6kg, from 82.2kg
I/O 24H: 1000/1700
GENERAL: A&Ox3, lying in bed, appears deconditioned, NAD
HEENT: Sclera anicteric. MM dry
Neck: JVP at ~6cm on right
CV: RRR, nl S1, S2, no S3, II/VI systolic murmur @LLSB without
radiation to axilla
Pulm: Resp were unlabored, no accessory muscle use. inspiratory
crackles at bases b/l. Some mild wheezes as well in bases.
Coughing.
Abd: Soft, NT, ND, +BS. No HSM or TTP. Ecchymosis on mid abdomen
GU: Scrotal skin much less taut, rugae more visibly defined.
Size much decreased. Penis no longer buried. No TTP. B/l
inguinal folds much less red and scaly.
Extr: trace b/l LE edema, much improved since admission.
Overlying skin is hyperkeratotic, scaly with red-purple-brown
hyperpigmentation
Pertinent Results:
CBC:
[**2115-1-31**] WBC-7.8# RBC-4.04* Hgb-11.4* Hct-33.3* MCV-83 MCH-28.2
MCHC-34.1 RDW-16.0* Plt Ct-100*
[**2115-1-31**] Neuts-73.5* Lymphs-19.8 Monos-5.6 Eos-0.7 Baso-0.4
[**2115-2-12**] 04:08AM BLOOD WBC-6.3 RBC-3.59* Hgb-9.9* Hct-30.4*
MCV-85 MCH-27.6 MCHC-32.6 RDW-16.9* Plt Ct-137*
.
CHEMISTRY:
[**2115-1-31**] Glucose-136* UreaN-95* Creat-4.7*# Na-133 K-4.4 Cl-93*
HCO3-27
[**2115-2-12**] 04:08AM BLOOD Glucose-134* UreaN-96* Creat-3.1* Na-135
K-3.5 Cl-89* HCO3-34* AnGap-16
[**2115-2-12**] 04:08AM BLOOD Calcium-9.1 Phos-4.0 Mg-2.3
.
CARDIAC ENZYMES:
[**2115-1-31**] 12:40PM CK-MB-7 cTropT-0.09* proBNP-[**Numeric Identifier 105384**]*
[**2115-1-31**] 07:00PM CK-MB-7 cTropT-0.09*
[**2115-2-1**] 05:55AM CK-MB-6 cTropT-0.08*
.
LIVER TESTS:
[**2115-1-31**] ALT-34 AST-43* CK(CPK)-239 AlkPhos-96 TotBili-0.5
[**2115-1-31**] Lipase-22
[**2115-1-31**] Albumin-3.2*
.
OTHER:
[**2115-1-31**] Lactate-1.8
[**2115-2-1**] %HbA1c-7.7*
[**2115-1-31**] CK(CPK)-214
[**2115-2-1**] 05:55AM BLOOD Triglyc-69 HDL-40 CHOL/HD-2.7 LDLcalc-54
LDLmeas-54
.
SCROTAL US [**2115-1-31**]
FINDINGS: The patient is status post bilateral orchiectomies.
There is
marked enlargement of the scrotum with striking widespread edema
including
areas of ill-defined fluid, although there is no dominant or
discrete fluid collection. No definite foci of gas are
visualized.
IMPRESSION: Marked edema and ill-defined fluid, which could be
of infectious etiology or due to a form of third spacing in the
appropriate setting, without definite foci of gas or discrete
collection.
.
CXR [**2115-1-31**]
FINDINGS: The patient is status post coronary artery bypass
graft surgery. A BiV pacemaker/ICD device with three leads
appears unchanged. The heart is moderately enlarged. The
cardiac, mediastinal and hilar contours appear unchanged. The
lungs appear clear. There are no pleural effusions or
pneumothorax. Mild degenerative changes are similar along the
thoracic spine.
IMPRESSION: No evidence of acute disease.
.
RENAL US [**2115-1-31**]
FINDINGS: The kidneys are normal in size with the right kidney
measuring 10.0 cm and the left kidney measuring 9.1 cm. Within
the left interpolar region, there is a 9 mm simple cyst. No
suspicious renal mass is seen. There is no hydronephrosis or
evidence of renal calculi. The bladder is collapsed and
suboptimally evaluated.
IMPRESSION: Small left renal simple cyst. Otherwise,
unremarkable renal
ultrasound with no hydronephrosis. No son[**Name (NI) 493**] evidence of
renal stone,
although CT is more sensitive.
.
TTE [**2115-1-31**]
The left atrium is elongated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
The estimated right atrial pressure is at least 15 mmHg. There
is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is severely depressed (LVEF= 25 %) with
akinesis to dyskinesis of the inferior and infero-lateral
segments (basal infero-lateral aneurysm) and hypokinesis of the
remaining segments (the lateral wall contracts best). LV
dysynchrony is present). No masses or thrombi are seen in the
left ventricle. There is no ventricular septal defect. The right
ventricular cavity is moderately dilated with moderate global
free wall hypokinesis. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild to moderate ([**11-26**]+) mitral regurgitation
is seen. The tricuspid valve leaflets are mildly thickened.
Moderate [2+] tricuspid regurgitation is seen. There is mild
pulmonary artery systolic hypertension. Significant pulmonic
regurgitation is seen. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2113-4-18**], no
change.
.
[**2115-2-7**] RUQ U/S: The liver shows no focal or textual
abnormalities. Portal vein is patent showing hepatopetal flow. A
gallstone is seen in a collapsed gallbladder, grossly unchanged
from prior CT examination. There is no intra-or extra-hepatic
biliary duct dilatation. The CBD measures 0.3 cm. Trace amount
of fluid is seen around the liver. The pancreas is unremarkable,
note is made that the pancreas tail is obscured
by bowel gas. The spleen measures 12.7 cm and is unremarkable.
No fluid is seen in the right and left lower abdominal quadrant.
IMPRESSION:
1. Trace amount of fluid around the liver.
2. Cholelithiasis in a collapsed gallbladder.
3. Normal echotexture of the liver with no intra- or
extra-hepatic biliary
duct dilatation.
[**2-10**] CXR: As compared to the previous radiograph, there is
unchanged evidence of a perihilar increase in density of the
lung parenchyma, right more than left. The distribution of these
changes, notably combine to the cardiomegaly of the patient, are
more consistent with pulmonary edema than with pneumonia. There
is no evidence of pleural effusions. Normal appearance of the
hilar and mediastinal contours. Right central venous access line
and left Port-A-Cath in situ.
Brief Hospital Course:
A/P: 80 yo M with h/o DM, CAD s/p CABG in [**2083**], [**2088**]), CHF with
EF 20-25% s/p biv ICD, h/o prostate cancer and nephrolithiasis,
who p/w scrotal and LE edema suggestive of CHF exacerbation.
.
# CHF exacerbation: Likely precipitated primarily by BiV pacing
being shut off, and also by dietary indiscretion. In [**10/2114**],
his LV lead was turned off as it was thought to be abutting a
scar, and he was in VT storm at that time. He now presents with
evidence of significant right-sided heart failure on admission
with scrotal and LE edema, but clear lungs and high O2 sats.
Given his borderline hypotension, lasix gtt was started and
uptitrated to 20 mg/hr. However, the rate of diuresis continued
to be suboptimal at -700cc/day. He was then transferred to CCU
to initiate milrinone gtt. He tolerated this well, and with a
combination of lasix 30mg/hr and milrinone, was making
~1000-1500cc/day, though given intakes was not really diuresing.
Renal decided that he would benefit from dialysis. A temporary
HD line was placed, and he received 2 ultrafiltration sessions,
with about 3L fluid removed per session. He then appeared to be
euvolemic to slightly volume up. It was decided that his goal
was slightly volume up, given pre-load [**Last Name (LF) 105385**], [**First Name3 (LF) **]
lasix/milrinone and ultrafiltration sessions were stopped on
[**2-8**]. Given he is now on anti-arrythmics (mexilitine and
quinidine), his LV lead was restarted. Previously, he has had
great benefit from receiving BiV pacing, so did not want to give
up on this therapy for him per attending. He continued to make
1100-1700cc/day urine, and his creatinine continued to trend
down. He developed a cough and CXR showed slightly worsening
pulmonary edema, so his home dose of torsemide was restarted on
[**2-10**], and he tolerated this well.
.
# oliguric acute on chronic kidney failure: He presented close
to anuric, though to be pre-renal etiology from CHF causing
decreased RBF. Cr was markedly elevated from baseline of 1.7-2.0
in [**10/2114**], to 4.9 on admission. Therapy for CHF (above)
resulted in continual improvement in renal function. He received
2 sessions of ultrafiltration, but did not get HD, given renal
did not think he needed it and they didn't want to cloud the
picture in terms of his diuresis. By discharge, he was making
1700cc urine per day, and creatinine was down to 3.0
.
# Urinary retention: foley was placed via cystoscopy on
admission, difficult in part [**12-27**] buried penis. Removed on [**2-11**]
as thought to be unnecessary. On [**2-12**] he had urinary retention,
with 750cc residual after a small urination. His bladder was
distended and painful. Urology replaced the foley, and he should
f/u with Urology (Dr [**Last Name (STitle) **]) in 2 weeks (appnt made for him)
.
# Hypokalemia: pt has had issues with hypokalemia, K+ 3.1
lowest. Worse when he was receiving active diuresis. He has
required near daily K+ repletion. At rehab, his K+ should be
checked regularly, so that he gets appropriate repletion. Also,
he has a metabolic alkalosis frmo diuresis. As this resolves, K+
will shift out of his cells and potentially create hyperkalemia,
so that should be watched as well.
.
# scrotal swelling: Fluid retention [**12-27**] CHF exacerbation.
Urology evaluated scrotum in the ED and felt there was no
infectious etiology. he received a scrotal U/S (per report
section), which was reassuring that infection was unlikely.
Edema improved dramatically during admission, as was back to
baseline upon discharge
.
# CAD s/p CABG: EKG showed no new ischemic changes, and cardiac
enzymes normal. He was ruled out for MI. Home aspirin 81 mg,
isordil, metoprolol and atorvastatin were continued.
.
# RHYTHM/?afib: Pt is A/V paced, has BiV pacemaker for chronic
dCHF, not on coumadin at home. Anticoagulated with ASA325 daily.
Maintained on home mexilitine, quinidine, and metoprolol. His
BiV was reactivated, per above.
.
# Cough: developed non-productive cough, no fever or
leukocytosis. CXR from [**2-10**] (PA/LA) suggests pulmonary edema
more than pneumonia. He is not on an ACEi. Minimal relief with
saline nebs, ipratropium nebs, and tessalon pearls. Cough may be
[**12-27**] pulm edema and perhaps will improve when that is cleared.
Started on guaifenesin w/ codeine as well, which is providing
symptomatic relief.
.
# DM: A1C 7.7%. Sugars well controlled with home Lantus and
sliding scale.
.
# HLD: Good lipid profile, continued atorvastatin.
.
# intertrigo: Had a groin rash [**12-27**] scrotal edema. Successfully
treated with topical miconozole powder.
.
# anemia: Has baseline anemia with Hct in low-mid 30s, worsening
during this admission, labs suggestive anemia of chronic disease
and likely contribution from CKD.
.
# Coagulopathy/thrombocytopenia: INR 1.2-1.5, albumin 3.2
suggests diminished synthetic function of liver. LFTs normal on
admission. RUQ U/S w/o liver abnormalities. Hepatitis
serologies also negative. Labs do not suggest consumptive
process. Likely [**12-27**] congestive hepatopathy.
.
# IJ clot: Discovered upon placing HD line. Not be good
candidate for anti-coagulation beyond what he is already on, so
no changes made.
.
# HypoNa: Na+ ranging 131-135. Likely hypervolemic hyponatremia
from CHF exacerbation. Expected to improve with ongoing
diuresis. Pt is asymptomatic
.
# Goals of care: Palliative Care saw pt, who has been aware of
his declining functional status. He lives independently and is
not interested in health aids. he is DNI, but OK to resuscitate.
========================
TRANSITIONAL ISSUES
# Potassium should be checked and repleted regularly at rehab
# f/u with Urology in 2 weeks to f/u urinary retention
# Please contact [**First Name8 (NamePattern2) **] [**Name (NI) **] (patient's primary cardiologist) as
soon as possible after arrival as he would like to remain
informed of Mr. [**Known lastname **] progress. He can be reached at
[**Telephone/Fax (1) 6937**]
Medications on Admission:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) PO QD
2. atorvastatin 20 mg PO QD
3. metoprolol succinate XR 100 mg Tablet PO QD
4. isosorbide dinitrate 20 mg PO TID
5. torsemide 60 mg Tablet PO QD
6. metolazone 2.5 mg PO on Sundays
8. quinidine gluconate XR 324 mg PO TID
9. mexiletine 150 mg PO Q8H
10. insulin glargine 100 unit/mL Soln 14 Units SC qHS
11. miconazole nitrate 2% Powder TOP [**Hospital1 **] prn rash
12. cholecalciferol (vitamin D3) 2,000 unit PO QD
13. folic acid 0.5 mg PO QD
14. ascorbic acid 1,000 mg PO QD
15. senna 8.6 mg PO BID
16. docusate sodium 100 mg PO BID
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day. Tablet
Extended Release 24 hr(s)
4. isosorbide dinitrate 20 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours).
5. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. quinidine gluconate 324 mg Tablet Extended Release Sig: One
(1) Tablet Extended Release PO Q12H (every 12 hours).
7. mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
8. insulin glargine 100 unit/mL Solution Sig: Fourteen (14)
units Subcutaneous at bedtime.
9. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
10. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
11. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. ascorbic acid 1,000 mg Tablet Sig: One (1) Tablet PO once a
day.
13. senna 8.6 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily) as
needed for constipation.
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain or fever.
15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
17. Tessalon Perles 100 mg Capsule Sig: One (1) Capsule PO three
times a day as needed for cough.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary: Congestive heart failure, acute on chronic kidney
failure, hyponatremia
Secondary: coronary artery disease, anemia, hypertension,
hyperlidpidema
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 **],
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
because you stopped urinating and had scrotal edema. This was
found to be secondary to heart and kidney failure. You were
treated with medications, and your heart and kidneys are making
a recovery, though are still sick.
Weigh yourself every morning, and call your doctor if weight
goes up more than 3 lbs.
The following changes have been made to your medications:
** DECREASE metoprolol succinate to 50mg once daily [heart rate
control]
** DECREASE torsemide to 40mg once daily [water pill]
** CHANGE quinidine to TWICE daily (instead of 3x daily), while
your kidney function recovers
** START nephrocaps [kidney health]
** START Tessalon Pearls for cough supression
Followup Instructions:
Name: [**Last Name (LF) **], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD
Address: [**Hospital1 **], [**Location (un) **],[**Numeric Identifier 6425**]
Phone: [**Telephone/Fax (1) 6937**]
*Please call your cardiologist to book a follow up appointment
for your hospitalization. You need to book an appointment within
2-3 weeks of discharge. If you have any questions or concerns
please call the office.
We are working on a follow up appointment in Nephrology with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7473**] for your hospitalization within 2-3 weeks of
discharge. The office will contact you at the facility with the
appointment information. If you have not heard within 2 business
days please contact the office at [**Telephone/Fax (1) 63790**].
Department: SURGICAL SPECIALTIES
When: TUESDAY [**2115-2-26**] at 9:30 AM
With: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2115-2-25**] at 2:00 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2115-5-7**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 3217**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"V45.81",
"V45.11",
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"585.6",
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"403.91",
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"428.23",
"276.1",
"584.9",
"V45.02",
"428.0",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.95"
] |
icd9pcs
|
[
[
[]
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|
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|
320, 326
|
19082, 19082
|
5558, 6102
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264, 282
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354, 2102
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3503, 3814
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,176
| 151,348
|
7031
|
Discharge summary
|
report
|
Admission Date: [**2121-5-26**] Discharge Date: [**2121-6-8**]
Date of Birth: [**2052-9-4**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
left upper lobe squamous cell
carcinoma, either metastatic versus a new primary
Major Surgical or Invasive Procedure:
L thoracotomy with LULobectomy [**2121-5-26**]
History of Present Illness:
Patient is a delightful woman who
has been diagnosed and treated for laryngeal carcinoma. This
included surgery as well as radiotherapy. She also
subsequently developed a left upper lobe squamous cell
carcinoma, either metastatic versus a new primary and
underwent a left thoracotomy with wedge excision in [**2116**] by
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 175**]. Recently, she has been found to have a
recurrent mass in the left upper lobe, suspicious for either
recurrent squamous cell or a new primary within the lung.
Obviously, it is difficult to determine whether this is a
metastatic lesion or primary lung cancer; however, it is her
only site of recurrence on extensive metastatic workup. We
therefore took her forward for completion left upper
lobectomy.
Past Medical History:
Obstructive sleep apnea, left lung sqaumous ca, laryngeal ca s/p
laryngectomy, tracheostomy and chemo/XRT, UE DVT on coumadin,
Asthma, low back pain, hypothroidism, obesity, GERD.
Social History:
lives alone in [**Hospital3 **] setting
tobacco free x 12 months. No ETOH use
Family History:
on contibutory
Physical Exam:
general: well appering female in NAD.
resp: rhonchi through out
COR: RRR S1, S2
ADB; protruberant, ND, NT, +BS, no masses.
Extrem: no C/C/E
neuro: no focal neuro deficits.
Pertinent Results:
PA AND LATERAL CHEST ON [**2121-6-8**] AT 07:41.
INDICATION: LUL lobectomy - followup film after chest tube
removal.
COMPARISON: [**2121-6-7**] at 16:56.
FINDINGS: Compared to the prior study, there is no significant
interval change with a persistent small left apical pneumothorax
and increased density projecting over the left lower lung field.
Right lung remains clear. Pulmonary vascular markings are
normal.
IMPRESSION: Persistent left apical PTX and no interval change
versus prior.
[**2121-5-26**] 03:16PM UREA N-22* CREAT-0.9 SODIUM-138 CHLORIDE-106
TOTAL CO2-23
[**2121-5-26**] 03:16PM WBC-6.2# RBC-4.11* HGB-12.8 HCT-37.4 MCV-91
MCH-31.3 MCHC-34.3 RDW-14.6
Brief Hospital Course:
Pt was admitted and taken to the OR on [**2121-5-26**] for a left upper
lobectomy via left thoracotomy complicated by an avulsion of the
PA branch which was repaired. Trach was also changed
intraoperatively. An epidural was placed for pain control.
Pt was admitted to the ICU post-operatively d/t hypotension
requiring neo gtt and IVF boluses. Cardiac enzymes were neg.
Two left pleural chest tubes were to sxn and draining mod amt
serosang fluid.
POD#1 extubated and [**Last Name (un) 1815**] trach mask. hemodynamically stable off
neo. chest tubes cont'd to sxn w/ persistant air leak.
POD# 3 failed bedisde swallow exam -kept NPO. Persistant air
leak. Epidural removed on PCA
POD#4 chest tubes to water seal.
POD#5 Chest tubes clamped.
POD#6 purulent sputum on po levo. Breathing comfortably but did
not [**Last Name (un) 1815**] clamping trial- back to water seal w/ perisistant air
leak.
POD# 7, 8 kept on water seal. progressing w/ post [**Doctor First Name **] recovery.
ambulating. [**Last Name (un) 1815**] reg diet and po pain med. one chest tube
d/c'd. remaining chest tube w/ residual air leak.
POD# [**10-6**] persistant air leak on water seal. progressing w/post
[**Doctor First Name **] recovery.
POD#12 chest tube clamping trial- tolerated trial and chset tube
removed. post pull CXR unremarkable.
POD#13 d/c'd to home .
Medications on Admission:
Coumadin, Levoxyl, Protonix, Tramadol, norflex, quinnine
Discharge Medications:
1. Levothyroxine 100 mcg 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. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*200 ML(s)* Refills:*0*
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
while taking narcotics, to prevent constipation.
Disp:*45 Capsule(s)* Refills:*2*
7. Norflex 100 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO at bedtime.
8. Quinine Sulfate 260 mg Tablet Sig: One (1) Tablet PO once a
day: continue at prior dosage/frequency.
9. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
10. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) puffs Inhalation every six (6) hours.
Disp:*1 inhaler* Refills:*2*
11. Coumadin 3 mg Tablet Sig: One (1) Tablet PO at bedtime: 3mg
every Tuesday and Thursday.
Disp:*30 Tablet(s)* Refills:*2*
12. Coumadin 4 mg Tablet Sig: One (1) Tablet PO at bedtime: 4mg
every Monday, Wednesday, [**Doctor First Name 2974**], Saturday, Sunday.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Allcare VNA Greater [**Location (un) **]
Discharge Diagnosis:
recurrent squamous cell lung cancer, LUL
persistent air leak
OSA
h/o tracheostomy
h/o DVT
asthma
hypothyroid
GERD
chronic back pain
Discharge Condition:
stable
Discharge Instructions:
[**Name8 (MD) **] MD [**First Name (Titles) **] [**Last Name (Titles) **] or chills; shortness of breath or difficulty
breathing; worsening chest pain or pain no longer controlled by
your pills; nausea, vomiting, diarrhea, or inability to tolerate
diet; sputum or phlegm that is yellow or green or brown- or
red-tinged; if incision develops redness, swelling, or drainage;
or any other symptom that concerns you.
Usual home medications. The antibiotic course completed on the
day of your discharge. Do resume coumadin at your prior regular
doses. Please have the visiting nurse check your INR level
accordingly.
[**Month (only) 116**] take Percocet for pain. Do not drive or drink alcohol while
taking narcotic pain medicine such as Percocet. For milder
pain, may take tylenol instead; but do not take tylenol with
percocet because percocet already contains tylenol. [**Month (only) 116**] use a
stool softener such as colace to prevent constipation from the
narcotic pain medicine.
[**Month (only) 116**] shower tomorrow. Do not bathe or swim for 4 weeks. No
heavy lifting or straining for 4 weeks. The dressing over your
chest tube site should be removed tomorrow afternoon and may
then be covered with a plain gauze and tape if needed.
Followup Instructions:
Follow-up with Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**] (Thoracic Surgery) in [**1-27**] weeks.
Call the office [**Telephone/Fax (1) 170**] early this week for an appointment
date/time.
Completed by:[**2121-6-11**]
|
[
"162.3",
"493.20",
"125.1",
"530.81",
"244.9",
"512.1",
"998.2",
"327.23",
"V10.21",
"V64.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.31",
"40.3",
"33.22",
"32.4"
] |
icd9pcs
|
[
[
[]
]
] |
5396, 5467
|
2515, 3855
|
407, 456
|
5643, 5652
|
1819, 2492
|
6952, 7205
|
1596, 1612
|
3962, 5373
|
5488, 5622
|
3881, 3939
|
5676, 6929
|
1627, 1800
|
288, 369
|
484, 1282
|
1304, 1485
|
1501, 1580
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,914
| 192,646
|
49286
|
Discharge summary
|
report
|
Admission Date: [**2152-7-14**] Discharge Date: [**2152-7-16**]
Date of Birth: [**2074-11-7**] Sex: M
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old
male with a history of coronary artery disease, endstage
renal disease on hemodialysis who presented with a thrombosed
right upper extremity AV graft. On the day of admission he
was taken to the operating room for revision of his AV graft.
His hospital course will follow.
PAST MEDICAL HISTORY:
1. Significant for end stage renal disease, on hemodialysis.
2. Hypertension.
3. Coronary artery disease status post myocardial infarction
in [**2144**].
4. EF of 55%.
5. Peptic ulcer disease.
6. Peripheral neuropathy.
PAST SURGICAL HISTORY:
1. Coronary artery bypass graft x 5 in [**2144**].
2. Status post abdominal aortic aneurysm repair in [**2126**].
3. Status post cholecystectomy.
4. Status post appendectomy.
5. Status post right upper extremity AV graft.
MEDICATIONS ON ADMISSION:
1. Atenolol 25 mg PO once daily.
2. Lisinopril 5 mg PO once daily.
3. Simvastatin 10 mg PO once daily
4. Protonix 40 mg PO once daily
5. Allopurinol 200 mg PO once daily.
6. Renagel 800 mg PO t.i.d.
7. Cinacalcet 30 mg PO once daily
8. Neurontin 200 mg PO tid
9. Oxycodone PRN.
10. Lidoderm patch.
ALLERGIES: Ampicillin, penicillin and Norvasc.
PHYSICAL EXAMINATION: The patient prior to the surgery had a
no thrill palpable in his right upper extremity. The graft
otherwise was unremarkable.
LABORATORY DATA: Lab studies upon admission were
unremarkable. EKG demonstrated first degree AV block, right
bundle branch block, and sinus rhythm.
HOSPITAL COURSE: The patient was taken to the operating room
on the day of admission where he underwent a right upper
extremity AV graft, thrombectomy and revision. This case is
fully detailed in Dr.[**Name (NI) 1381**] operative note and also in this
gentleman's chart. Of note, the anesthesia record
demonstrated the patient was hypotensive for a portion of the
case requiring Neo-Synephrine. The case was difficult due to
the stenosis which was found and required revision.
Postoperatively, the patient was taken to the post anesthesia
care unit. Significant events included bradycardia which was
treated with atropine and intravenous fluids. Cardiology
service evaluated the patient and felt that this most likely
represented a reflex of bradycardia secondary to Neo-
Synephrine use. After his treatment with Atropine, his
rhythm stabilized but he remained hypotensive and Levophed
was used for pressor support. He was ruled out for myocardial
infarction as EKGs remained unchanged. He was brought to the
intensive care unit for closer monitoring and slow wean of
the Levophed. He is currently postoperative day 2. He is
weaned off the Levophed and he has been hemodynamically
stable. All of his laboratory values are unremarkable at this
point and he is stable for discharge to home from the
intensive care unit.
DISCHARGE DIAGNOSIS:
1. Thrombosed right upper extremity AV graft.
2. Hypotension.
3. Bradycardia.
4. Endstage renal disease on hemodialysis.
5. Coronary artery disease.
6. Peptic ulcer disease.
7. Hypertension.
MEDICATIONS ON DISCHARGE:
1. Atenolol 25 mg PO once daily.
2. Lisinopril 5 mg PO once daily.
3. Simvastatin 10 mg PO once daily.
4. Protonix 40 mg PO once daily.
5. Allopurinol 200 mg PO once daily.
6. Renagel 800 mg PO t.i.d.
7. Cinacalcet 30 mg PO once daily.
8. Neurontin 200 mg PO t.i.d.
9. Oxycodone PRN.
10. Lidoderm patch.
11. TUMS.
DISPOSITION: The patient is scheduled to go home to follow
up with Dr. [**Last Name (STitle) 816**] in 2 weeks and to follow up with his
nephrologist as directed.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**], M.D. [**MD Number(2) 6727**]
Dictated By:[**Last Name (NamePattern1) 8958**]
MEDQUIST36
D: [**2152-7-16**] 13:32:01
T: [**2152-7-16**] 15:08:02
Job#: [**Job Number 103297**]
|
[
"444.89",
"458.29",
"533.90",
"E879.9",
"414.00",
"272.0",
"403.91",
"427.89",
"996.73",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"39.42"
] |
icd9pcs
|
[
[
[]
]
] |
3004, 3197
|
3223, 3988
|
1005, 1359
|
1677, 2983
|
755, 979
|
1382, 1659
|
183, 486
|
508, 732
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,212
| 154,617
|
40127
|
Discharge summary
|
report
|
Admission Date: [**2132-11-3**] Discharge Date: [**2132-11-10**]
Date of Birth: [**2077-6-23**] Sex: F
Service: SURGERY
Allergies:
Demerol / band aid adhesive
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Morbid obesity
Major Surgical or Invasive Procedure:
[**2132-11-3**]: Laparascopic Roux-en-Y gastric bypass
History of Present Illness:
[**Known firstname 1154**] has class III morbid obesity with weight of 243.5 pounds
as a [**2132-6-30**] (her initial screen weight on [**2132-6-23**] was 244
pounds), height of 61 inches and BMI of 46. Her previous weight
loss efforts have included Weight Watchers, Nutrisystem, RD
visits, over-the-counter ephedra-containing Metabolife,
over-the-counter dietary supplement Dexatrim and prescription
weight loss medication Redux now off the market for one month
with no weight loss. Her weight at age 21 was 140 pounds her
lowest adult weight with her initial screen weight of 244 pounds
being her highest weight. She weighed 230 pounds one year ago.
She states she has been struggling with weight since her late
teens/early 20s and cites as factors contributing to her excess
weight large portions, inconsistent meal pattern on weekends,
too many carbohydrates and lack of exercise. Her current
activity is walking 15 minutes twice per day 5 days per week.
She denied history of eating disorders and does have depression
that is reactive but has not seen a therapist or been
hospitalized for mental health issues and she is on psychotropic
medication (Celexa).
Past Medical History:
PAST MEDICAL HISTORY: Notable for gastroesophageal reflux, type
2 diabetes, obstructive sleep apnea, hypothyroidism,
fibromyalgia, atrial fibrillation, and depression, now well
controlled.
PAST SURGICAL HISTORY: Notable for right knee replacement,
laparoscopic cholecystectomy, laparoscopic oophorectomy, vaginal
hysterectomy, appendectomy, tonsils, and bladder sling
Social History:
She denied tobacco or recreational drug usage, has wine on rare
occasions and does consume caffeinated beverages. She works as
an administrative assistant at [**Hospital1 18**], she is married living with
her husband a 61 and they have 3 grown children.
Family History:
Her family history is noted for both parents living father age
78 with hyperlipidemia; mother age 78 with history of stroke and
arthritis; brother living age 56 with diabetes
Physical Exam:
Vital signs: T 97.5, HR 83, BP 121/44, RR 18, O2 97%RA
Constitutional: NAD, pleasant
Neuro: Alert and oriented to person, place and time
Cardiac: RRR, No MRG, NL S1,S2
Lungs: CTA B
Abdomen: Soft, non-tender, non-distended, no rebound tenderness/
guarding
Wounds: Abd incision open to air with staples, no periwound
erythema or drainage; JP w/ serosanguinous drainage; Gtube
clamped
Ext: No edema
Pertinent Results:
[**2132-11-10**]:
BAS/UGI AIR/SBFT:
IMPRESSION: No evidence of leaks or holdup at the gastrojejunal
anastomosis
Brief Hospital Course:
The patient presented to pre-op on [**2132-11-3**]. Pt was
evaluated by anaesthesia and taken to the operating room for
laparoscopic Roux-en-Y gastric bypass. There were no adverse
events in the operating room; please see the operative note for
details. Pt was extubated, taken to the PACU where she was noted
to have bloody NGT output, hematemesis and a decreased
hematocrit level consistent with acute blood loss anemia. The
patient received 2 units of PRBCs and was taken back to the
operating room where she underwent an exploratory laparatomy,
oversew of staple lines, placement of a gastrostomy tube and
repeat upper endoscopy by GI; see operative report for details.
The patient remained intubated and was transferred to the SICU
for further management.
Neuro: Post-operatively, the patient was sedated with propofol
which was discontinued upon extubation. On POD 2, the patient
became delerious requiring discontinuation of both lorazepam and
dilaudid PCA; pain was subsequently managed with intravenous
fentanyl while in the ICU. Her mental status grandually
improved to baseline and she remained alert and oriented
throughout the remainder her hospitalization; once on the floor
and tolerating a stage 2 diet pain was managed with oral Roxicet
and then oral acetaminophen.
CV: The patient remained stable from a cardiovascular
standpoint. Of note she complained of palpitations on POD7; an
EKG showed normal sinus rhythm and cardiac enzymes were
negative; intravenous metoprolol was initiated on POD1 and
transitioned to the patient's home atenolol dose on POD6. Upon
discussion with the patient's PCP, [**Name10 (NameIs) **] patient may discontinue
atenolol altogether.
Pulmonary: The patient was extubated on POD1 without incident.
She subsequently remained stable from a pulmonary standpoint;
vital signs were routinely monitored. Good pulmonary toilet,
early ambulation and incentive spirometry were encouraged
throughout hospitalization.
GI/GU/FEN: She was initially kept NPO with intravenous Protonix.
An NGT, maintained to low intermittent suction, was
discontinued on POD1. Her g-tube remained to low intermittent
suction. Her diet was advanced to a bariatric stage 1 diet,
which was advanced sequentially to stage 3, and well tolerated.
Patient's intake and output were closely monitored. An upper GI
study was performed on post-operative day 7 and was negative for
a leak.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's received a total of 4 units PRBCs on POD0
due to acute blood loss anemia as described above. On POD 2,
her hematocrit trended downward, however, she remained
clinically stable. Her hematocrit levels were closely monitored
and remained stable throughout the remainder of her
hospitalization and remained stable.
Prophylaxis: Subcutaneous heparin was held due to concerns for
bleeding; [**Last Name (un) **] dyne boots were used during this stay; she was
encouraged to get up and ambulate as early as possible.
Rehab: Pt was seen by both PT and OT who felt the patient was
independent with mobility and ADLs without needs for home
services.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a stage 3
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:
Atenolol 25 mg daily
Celexa 10 mg daily
Esomeprazole 40 mg daily
Levothyroxine 125 mcg daily
Pravastatin 20 mg daily
Tramadol 25 mg daily
Trazadone 100 mg q HS
Reclast once annually
Discharge Medications:
1. acetaminophen 325 mg/10.15 mL Solution Sig: Twenty (20) ml PO
every six (6) hours as needed for pain: Do not exceed 3000 mg
per 24 hour period.
Disp:*300 ml* Refills:*0*
2. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day: Open capsule,
sprinkle contents onto applesauce, swallow whole.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
3. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a
day as needed for constipation.
Disp:*300 ml* Refills:*0*
4. multivitamin with minerals Tablet Sig: One (1) Tablet PO
once a day: Chewable/ crushable.
5. pravastatin 20 mg Tablet Sig: One (1) Tablet PO once a day:
Please crush.
6. tramadol 50 mg Tablet Sig: One (1) Tablet PO once a day:
Please crush.
7. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO once a
day: Please crush.
8. zoledronic acid-mannitol&water Intravenous
9. Celexa 10 mg Tablet Sig: One (1) Tablet PO once a day: Please
crush.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Obesity, body mass index of 45..
2. Type 2 diabetes.
3. Reflux.
4. Sleep apnea.
5. Acute blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions: Please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.
Diet: Stay on Stage III diet until your follow up appointment.
Do not self advance diet, do not drink out of a straw or chew
gum.
Medication Instructions:
Resume your home medications, CRUSH ALL PILLS.
You will be starting some new medications:
1. You are being discharged on medications to treat the pain
from your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
2. You should begin taking a chewable complete multivitamin with
minerals. No gummy vitamins.
3. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
4. You must not use NSAIDS (non-steroidal anti-inflammatory
drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and
Naproxen. These agents will cause bleeding and ulcers in your
digestive system.
Activity:
No heavy lifting of items [**9-20**] pounds for 6 weeks. You may
resume moderate exercise at your discretion, no abdominal
exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain. Call
the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
Department: BARIATRIC SURGERY
When: FRIDAY [**2132-11-14**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Doctor Last Name **], RD,LDN [**Telephone/Fax (1) 305**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: BARIATRIC SURGERY
When: FRIDAY [**2132-11-14**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD [**Telephone/Fax (1) 305**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: BARIATRIC SURGERY
When: WEDNESDAY [**2132-12-24**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RD [**Telephone/Fax (1) 305**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2132-11-13**]
|
[
"250.00",
"578.0",
"278.01",
"785.1",
"571.8",
"998.11",
"E878.2",
"327.23",
"V43.65",
"V64.41",
"427.31",
"V85.42",
"293.0",
"285.1",
"998.2",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.5",
"46.73",
"44.43",
"43.11",
"44.38"
] |
icd9pcs
|
[
[
[]
]
] |
7720, 7726
|
2984, 6489
|
302, 359
|
7880, 7880
|
2847, 2961
|
11422, 12410
|
2239, 2415
|
6721, 7697
|
7747, 7859
|
6515, 6698
|
8055, 8621
|
1793, 1950
|
2430, 2828
|
248, 264
|
9584, 11399
|
387, 1556
|
8646, 9572
|
7895, 8007
|
1601, 1769
|
1966, 2223
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,042
| 184,232
|
10441
|
Discharge summary
|
report
|
Admission Date: [**2129-8-18**] Discharge Date: [**2129-8-27**]
Service: [**Hospital Unit Name 196**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
transient arm/leg weakness
Major Surgical or Invasive Procedure:
1. carotid stenting
2. femoral artery clot removal
History of Present Illness:
The patient is an 80 year old male with a history of afib on
warfarin, cad s/p 3 MI's, PVD, and carotid stenosis s/p right
carotid stenting now presenting with transient right arm and leg
weakness. As per the patient, he was walking in the lobby of
his
wife's PCP when his right leg suddenly "gave-out" and he fell to
the ground hitting the knee against a chair on the way down. He
did not lose consciousness or experience any head ache or visual
disturbance prior to or during the event. Moreover, the patient
states he's had episodes over the last 3-4 months were the right
side of his body has felt weaker and has nearly fallen in the
past. The last such episode occurred a few days prior to
admission.
When the patient told his wife's PCP, [**Name10 (NameIs) **] referred him to an OSH
ER, from there they transferred him to [**Hospital1 **] for further
management.
Past Medical History:
-htn
-CAD, with 2 CABG's in 85 and 97, 3 MI's
-afib on coumadin with pacemaker
-IDDM with CRI
-CHF with documented ef=25%
-PVD s/p bypass grafts
-AAA
-?COPD
-carotid stenosis with stent placed in R carotid in [**2107**], and
"bad blockage " of left carotid, with no prior operation.
Social History:
Retired wholesale distributor, lives at home with wife, 35
pack year hx smoking, quit 35 yrs ago. No Etoh, drug use
Family History:
Non-contributory
Physical Exam:
Vitals: T=98.4 BP=120/84 P=72 R=18
General: Well nourished, in no acute distress
Neck: supple, bilateral carotid bruits
Lungs: soft crackles on the right
CV: RR; [**2-15**] sysytolic murmur at apex
Abdomen: non-tender, non-distended, bowel sounds present
Ext: warm, no edema; faint dp pulses
Neurologic Examination:
Mental Status: Awake and alert, cooperative with exam, normal
affect
Oriented to person, place, month and president
Attention: Can say months of year backward in 30 with 2 errors
Language: Fluent, no dysarthria, no paraphasic errors, naming
intact
Fund of knowledge normal
Registration: [**4-13**] items, only able to recall [**2-12**] with prompting
at 15 minutes
No apraxia, No neglect
[**Location (un) **] and writing intact
Cranial Nerves: Visual fields are full to confrontation. Pupils
equally round and reactive to light, 3 to 2 mm bilaterally.
Extraocular movements intact, no nystagmus. Facial sensation
equal bilaterally; mild lessening of right nlf, but good
excursion . Hearing intact to finger rub bilaterally. Tongue
midline, no fasciculations. Sternocleidomastoid and trapezius
normal bilaterally.
Motor:
Normal bulk and slight increased tone bilaterally
slight right tremor
D T B WF WE FiF [**Last Name (un) **] IP Gl Q H AF AE TF TE
Right 4 4 4 5 5 4 4 4 4 4 4 4 4 4 4
Left 4+4+4+5 5 4+ 4+ 4+ 4+ 4+4+4+ 4+ 4+ 4+
No pronator drift
Sensation: intact to light touch, pin-prick on all four
extremities; extinction to dss on right
Reflexes: B T Br Pa Pl
Right 2 2 2 2+ 2
Left 2 2 2 2+ 2
Grasp reflex absent
Toes were equivical
Coordination is slowed on finger-nose-finger on right, rapid
alternating slowed on right
Gait was wider based, short steps, slow speed, unsteady
Pertinent Results:
Cbc: 5.1/32.7/106
Chem: 139/3.5 99/23 124/3.4 119
C/M/P: 8.7/2.9/6.3
Coags: 22.3/41.8/3.3
Head CT:
areas of hypoattenuation in the left frontal lobe consistent
with old infarct; periventricular white matter changes
consistent with small vessel disease
Carotid US:
Findings of left internal carotid artery occlusion. Of note, no
prior studies available for comparison. Ultrasound can not 100%
accurate in differentiating between a 99% stenosis and an
occlusion. Clinical followup is warranted. On the right there is
significant plaque with a 60-69% stenosis.
Echo:
The left atrium is mildly dilated. The right atrium is
moderately dilated. The
left ventricular cavity is mildly dilated. Overall left
ventricular systolic
function is severely depressed (ejection fraction 20%). The
septum is
akinetic. The inferior wall is severely hypokinetic. The
remaining walls are
hypokinetic. There is no thrombus seen in the left ventricle.
Right
ventricular systolic function appears depressed. The number of
aortic valve
leaflets cannot be determined. The aortic valve leaflets are
mildly thickened.
There is mild aortic valve stenosis. No aortic regurgitation is
seen. The
mitral valve leaflets are moderately thickened. Moderate to
severe (3+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened.
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary
artery systolic hypertension. There is no pericardial effusion.
Brief Hospital Course:
The patient was admitted to the neurology service for management
of a presumed TIA episode. He underwent a stenting procedure on
the right carotid artery several days into his admission which
was performed successfully. He subsequently developed loss of
his distal pulse in the right lower extremity and had to undergo
an emergent surgical clot removal to restore pefusion and it was
done successfully. Over the remainder of the patient's
admission on the Neurology service his neurologic deficits
improved to where he was less weak and more alert. He was
discharged in stable condition.
Medications on Admission:
-coumadin
-procrit
-hydralazine
-zocor 40
-flomax
-lasix 80 qd
-isosrbide 10 qd
-neurontin 300 qd
-metoprolol 50 [**Hospital1 **]
-lantus
-glipizide
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day) for 300 days.
Disp:*30 Tablet(s)* Refills:*10*
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
5. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*14 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Community VNA
Discharge Diagnosis:
1. stroke
2. chf
3. htn
Discharge Condition:
stable, talking without difficulty, walking with assistance.
Discharge Instructions:
Please return to nearest ER if symptoms of weakness, dizziness,
or difficulty speaking occur. Please take medications as
prescribed. You will need to have your INR followed closely
while you are on the warfarin.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY Where: [**Last Name (NamePattern4) **]
SURGERY Date/Time:[**2129-9-1**] 10:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 8506**] An appointment has
been made for you on [**8-31**] at 1pm.
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 4267**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 34520**] Call to schedule
appointment
BP check with Dr. [**First Name (STitle) **] on Monday [**2129-8-29**]
Completed by:[**2129-10-6**]
|
[
"433.30",
"447.0",
"496",
"444.22",
"414.00",
"441.4",
"427.31",
"V45.81",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6298, 6342
|
5016, 5609
|
309, 361
|
6410, 6472
|
3527, 3622
|
6734, 7381
|
1723, 1741
|
5809, 6275
|
6363, 6389
|
5635, 5786
|
6496, 6711
|
1756, 2054
|
243, 271
|
389, 1266
|
2523, 3508
|
3631, 4993
|
2093, 2507
|
2078, 2078
|
1288, 1573
|
1589, 1707
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,579
| 172,052
|
37639
|
Discharge summary
|
report
|
Admission Date: [**2121-9-4**] Discharge Date: [**2121-9-16**]
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins
Attending:[**First Name3 (LF) 18794**]
Chief Complaint:
Acute blood loss anemia, hypoxia, lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is an 85 yo W with PMH of HTN, COPD and recent hip fracture
s/p R hip pinning here with anemia and worsening lethargy. Has
been in USOH at rehab until Since that time has not had a BM.
Her son noted a significant decline in overall status with
worsening lethargy and disorientation in last 4 days. Denied CP,
fevers, chills, cough. Does note some urinary frequency but no
dysuria or hematuria. At rehab she was found to be acutely SOB
and hypoxic. She was sent to [**Location (un) 620**] ED for further evaluation.
Of note, she was started on lovenox 3 weeks prior in setting of
hip surgery.
At [**Location (un) 620**], VS 100.5 HR75 BP 119/63 RR21 100NRB. PT was found to
have HCT of 17. Plts of 1035. CXR showed airspace opacities with
mild evidence of CHF. BNP was [**Numeric Identifier **]. She received lasix 20mg IV
for presumed pulmonary edema. She had a +UA and received
levaquin 750mg IV x1. Rectal exam with heme positive black
stool. NG lavage at OSH was negative for blood. Also noted to
have TN T 0.133 with negative CK and no EKG changes. She was
transferred to [**Hospital1 18**] [**Location (un) 86**] for further management.
In the ED, VS: T98 BP123/51 HR 87 16 99% on 1L. Repeat labs
revealed HCT 20, Plts 1163. UA + with 21-50 WBCs. Tn 0.17. 2
large bore IVs were placed and she was type and crossmatched.
She was started on 1st unit of blood. Bcx and urine cx were sent
in ED. She was transferred to the MICU for further management.
On arrival to the MICU, pt is stable, accompanied by Son, HCP.
She denies CP, SOB, abdominal pain/n/v/d. Does report decreased
appetite and recent poor PO intake.
Past Medical History:
HTN
COPD
PVD
Blood dx NOS (thrombocytosis)
glaucoma
[**Doctor Last Name 933**] disease
Hx of C diff
R hip fracture s/p pinning [**8-3**]
s/p LLE ?angioplasty
Social History:
HX: Currently at rehab. Recently quit smoking at time of hip
fracture. Has 6 children involved in care. No ETOH.
Family History:
Non contributory
Physical Exam:
VS: T99.3 BP123/53 HR 80 95% on 2L
GEN: Elderly female lying in bed in NAD, appears chronically ill
HEENT: EOMI, PERRL, anicteric, Dry MM
NECK: Supple, no JVD
CHEST: Crackles at bases bilaterally
CV: RRR, S1S2, no m/r/g; distant heart sounds
ABD: Soft/NT; firm mass, likely stool in [**Doctor Last Name **]/LLQ; +BS
EXT: no c/c/e
SKIN: excoriations and ecchymoses on bilateral LEs
NEURO: AAOx2, answering questions appropriately; CN ii-xii
intact; no focal deficits
Pertinent Results:
ADMISSION LABS:
[**2121-9-4**] 12:41AM WBC-8.7 RBC-1.70* HGB-5.9* HCT-20.3* MCV-120*
MCH-34.7* MCHC-28.9* RDW-24.5*
[**2121-9-4**] 12:41AM PLT SMR-VERY HIGH PLT COUNT-1163*
[**2121-9-4**] 12:41AM GLUCOSE-124* UREA N-28* CREAT-0.6 SODIUM-147*
POTASSIUM-4.0 CHLORIDE-109* TOTAL CO2-28 ANION GAP-14
[**2121-9-4**] 12:41AM CK(CPK)-51
[**2121-9-4**] 12:41AM cTropnT-0.17*
[**2121-9-4**] 12:41AM VIT B12-1444* FOLATE-11.0
[**2121-9-4**] 10:29AM TRIGLYCER-101 HDL CHOL-31 CHOL/HDL-4.2
LDL(CALC)-80
EKG: NSR 86, nl axis, RBBB, TWI in V1-V5, no ST elevations
(repeat on arrival unchanged)
.
IMAGING: CXR (OSH) cephalization; blunting of left costophrenic
angle; no clear inflitrates
CT Abdomen/Pelvis:
1. Bibasilar areas of consolidation are concerning for
superimposed
infection.
2. A non-relaxed gallbladder containing stones, however, there
is no
pericholecystic fluid or peri-gallbladder fat stranding,
however, in the
appropriate clinical setting cholecystitis may be present.
3. Complex appearing right adnexal mass for which a pelvic
ultrasound on a
non-emergent basis is recommended.
4. Hypodensity in the spleen, which may represent a hemangioma,
abscess or
metastasis but is not fully assessed. Would recommend further
evaluation with contrast-enhanced CT or abdominal ultrasound.
5. Extensive atherosclerotic vascular calcifications with a
femoral-femoral bypass graft.
6. No retroperitoneal hemorrhage or other hematoma
Video Swallow Study:
Aspiration on nectar consistency, penetration with honey-thick
consistencies.
CT Head w/o contrast:
1. No definite evidence of acute major vascular territorial
infarction.
Please note that MRI is more sensitive given the extensive white
matter
changes and lack of priors which limits assessment for small
acute infarcts.
2. Extensive chronic small vessel ischemic changes and global
volume loss.
MRI/MRA head:
1. Left vertebral artery aneursym, largely thrombosed, with a
small central patent component. There is extensive edema within
the medulla some flow anteriorly. The findings suggest a large
partially thrombosed left vertebral artery aneurysm which has
invaginated into the medulla.
2. Punctate embolic infarcts, predominantly within the posterior
circulation distribution.
3. A 2 mm anterior communicating artery aneurysm.
CTA head/neck:
1. Large aneurysm arising from the left vertebral artery, either
at the
origin of the left PICA or just superior to the origin of the
left PICA.
2. A 2-mm ACOM and right A1/A2 junction aneurysm.
3. Chronic small vessel ischemic changes.
4. Lung nodules measuring greater than 1 cm in diameter,
concerning for
neoplastic process. Small left pleural effusion. Dedicated chest
CT is
recommended to further evaluate the above findings.
5. Multiple pathologically enlarged mediastinal lymph nodes.
6. Multiple hypodense and partially calcified nodules in thyroid
gland.
7. Emphysematous changes.
Pelvic ultrasound:
Complex cystic mass lesion in the right adnexa, containing
internal septations and a mural nodule, concerning for a cystic
neoplasm. Further evaluation of this lesion would require
surgery.
CXR: Bilateral lower lobe collapse, left greater than right with
left
pleural effusion.
Brief Hospital Course:
85 year old female with history of recent hip fracture, HTN,
COPD, thrombocytosis who presented with SOB, fever, UTI and
anemia. She was originally admitted to the MICU and then
transferred to the floor with a diagnosis of anemia, pneumonia,
and UTI. She was later found to have a large vertebral artery
aneurysm, an ovarian mass, and multiple lung nodules concerning
for metastatic cancer.
#. Ovarian mass and lung nodules: Upon admission to the
hospital, she had a CT abdomen/pelvis which showed an adnexal
mass which was not well characterized. She had a follow-up
pelvic ultrasound which demonstrated a large cystic adnexal mass
concerning for cystic neoplasm. Gynecology-oncology was
consulted who was concerned that this was ovarian cancer. The
next step in diagnosis would be exploratory laparotomy.
However, given the patient's poor respiratory and functional
status, surgery was not recommended. She was also found to have
multiple lung nodules concerning for metastatic disease, as well
as a pleural effusion and pathologically enlarged mediastinal
lymph nodes. It is unclear whether the lung nodules are related
to a primary ovarian, lung, or other type of cancer, or whether
these are related to her ovarian mass. Given these findings,
multiple family meetings were held, and per the patient's and
family's wishes, palliative care was chosen as the best option.
She was discharged on hospice with focus on comfort measures.
#. Dysphagia: Throughout her hospitalization, she had difficulty
swallowing. This progressed to the point where she couldn't eat
or drink anything without aspirating and going into respiratory
distress with hypoxia requiring a face mask. She had a video
swallow study which showed that she aspirated both liquids and
solids. She was then kept NPO and was evaluated for causes of
dysphagia. During this workup, she was found to have the above
adnexal mass and lung nodules concerning for metastatic disease.
Given her prognosis, the family and patient decided not to
pursue other means of nutrition such as a PEG tube or TPN. At
discharge, the patient denies feeling hungry or thirsty and is
taking no oral intake.
#. Vertebral artery aneurysm: A brain MRI showed a medullary
mass which was later characterized as a large vertebral artery
aneurysm. Neurosurgery was consulted who offered possible
treatments, but given the patient's overall medical condition,
recommended no intervention. Neurosurgery did not feel as
though this was likely contributing to her dysphagia.
#. Anemia: She had guaiac positive stools on admission with a
negative NG lavage. Her hematocrit was 20 on admission and she
was given 4 units of blood and her hematocrit increased and
remained stable during her stay. She had a CT scan which showed
an enlarged gall bladder, stool, an adnexal mass and pneumonia.
The gastroenterology team evaluated the patient and recommended
an EGD/colonoscopy under anesthesia to evalute anemia in this
patient. It was felt that her use of lovenox as an outpatient
likely contributed to a slow GI bleed. Cardiology was consulted
to assess the risk of EGD under general anesthesia as she had a
troponin of 0.17 on admission with an echo that showed subtle
hypokinesis of mid-inferolateral wall but no significant wall
motion abnormality. Cardiology initially felt that she could
complete EGD/colonoscopy without further cardiology testing and
should start a beta blocker for BP control. As her respiratory
status and functional status were poor, the patient and her
family elected to defer further workup due to multiple
comorbidities. When her goals of care transitioned to comfort
measures only, her beta blocker was stopped.
#. Pneumonia: On admission, she had an oxygen requirement and
shortness of breath. Chest xray showed new infiltrate in the
left lower lobe. She was treated with Vancomycin and Cefepime
for an 8 day total course ending on [**2121-9-12**]. Her blood cultures
were negative. She used incentive spirometry and continued to
have a productive cough.
#. UTI: She had two positive urinalyses with urine cultures that
grew E. Coli. The E. coli was sensitive to cefepime and she was
treated with an 8-day course. Her final urine culture had not
grown any bacteria at the time of discharge, although did grow
yeast.
#. Thrombocytosis: She has known thrombocytosis and had elevated
platelets on admission. Her hydroxyurea was initially held but
was restarted during hospitalization. Her platelets remained
elevated at the time of discharge, and her hydroxyurea was
stopped when her goals of care became comfort measures only.
#. Coronary artery disease: She had positive troponin to 0.17
and T wave inversions in precordial leads. She remained without
chest pain and the ECG changes were not dynamic. She may have
had a prior event in setting of her hip procedure or blood loss.
An echo was completed with subtle hypokinesis of mid
inferolateral wall but no significant wall motion abnormality.
She was on aspirin 81mg po daily and she was started on
metoprolol and simvastatin, which were subsequently stopped when
she began comfort measures only.
#. Hip fracture: She had a hip fracture prior to admission and
was admitted from rehab. She worked with physical therapy while
in the hospital but was significantly deconditioned. Lovenox
was stopped due to concern for bleeding. She complained of
occasional hip pain which was initially managed with tramadol
and later with morphine.
#. Hypernatremia: She had transient hypernatremia which was
corrected with free water.
#. Constipation: She had episodes of constipation after
admission and was maintained on an aggressive bowel regimen with
docusate, senna, and miralax.
#. COPD: Atrovent was continued and she was started on standing
nebulizer treatments to improve her breathing. These were
continued at discharge as she states they help her breathing.
#. Glaucoma: Travaprost for glaucoma treatment.
#. Code Status: She was DNR/DNI during this hospitalization,
confirmed with the patient and family. She is being discharged
on hospice as comfort measures only.
Medications on Admission:
ASA 325mg PO daily
Verapamil 120 TID
Lovenox 40mg/0.4mL daily
hydroxyurea 1000mg DAILY (T, TH, [**Last Name (LF) **], [**First Name3 (LF) **]
Tylenol 500mg TID prn
VitD 50,000unit weekly
Advair Diskus 250-50mcg 1 puf [**Hospital1 **]
Niferex 100mg/5mL 7.5mL DAILY (150mg)
Travatan 0.004% drops OU HS
Vicodin 5/500mg TID prn
MVI
Milk of Mag
Discharge Medications:
1. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day): Hold for diarrhea.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Hospital1 **]:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
4. Travoprost 0.004 % Drops [**Hospital1 **]: One (1) drop Ophthalmic HS (at
bedtime).
5. Guaifenesin 100 mg/5 mL Syrup [**Hospital1 **]: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
6. Colace 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO twice a day.
7. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) nebulization
Inhalation Q6H (every 6 hours).
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) nebulization Inhalation Q6H (every 6
hours).
9. Tylenol 325 mg Tablet [**Hospital1 **]: Three (3) Tablet PO every six (6)
hours.
10. Sodium Chloride 0.65 % Aerosol, Spray [**Hospital1 **]: [**12-27**] Sprays Nasal
QID (4 times a day) as needed for for congestion.
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
12. Roxanol Concentrate 20 mg/mL Solution [**Last Name (STitle) **]: 5-20 mg PO
Q1-3h:PRN as needed for pain.
Disp:*45 ml* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) **]
Discharge Diagnosis:
Primary Diagnosis:
Pneumonia
Anemia
Vertebral artery aneurysm
Ovarian mass
Secondary Diagnoses:
Chronic Obstructive Pulmonary Disease
Multiple lung nodules
Discharge Condition:
Fair, vital signs stable
Discharge Instructions:
You were admitted to the hospital with anemia and pneumonia. In
addition, you were found to have a urinary tract infection. You
were treated with IV antibiotics called Vancomycin and Cefepime.
You also have been using oxygen to help you breathe. You had
multiple tests while you were in the hospital, and were found to
have an aneurysm in your brain and a mass on your ovary, as well
as multiple nodules in your lungs. You, your family, and your
medical team have decided that you would be most comfortable
being discharged to a facility that specializes in palliative
and comfort care.
Changes to your medications:
STOPPED aspirin
STOPPED Lovenox
STOPPED verapamil
STOPPED hydroxyurea
STOPPED vitamin D
STOPPED vicodin
ADDED albuterol nebulizer every 4 hours
ADDED ipratropium nebulizer every 4 hours
ADDED senna, colace, and bisacodyl for constipation
ADDED guaifenesin for cough
ADDED roxanol for pain and breathing
ADDED lansoprazole
Followup Instructions:
None
|
[
"496",
"486",
"285.1",
"197.0",
"564.00",
"276.0",
"238.71",
"196.2",
"437.3",
"599.0",
"787.20",
"401.9",
"198.6",
"041.4",
"578.9",
"199.1",
"365.9",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13957, 14005
|
6012, 12138
|
280, 287
|
14206, 14233
|
2786, 2786
|
15225, 15233
|
2267, 2285
|
12528, 13934
|
14026, 14026
|
12164, 12505
|
14257, 14850
|
2300, 2767
|
14123, 14185
|
14879, 15202
|
197, 242
|
315, 1940
|
2802, 5989
|
14045, 14102
|
1962, 2121
|
2137, 2251
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,060
| 156,606
|
54200
|
Discharge summary
|
report
|
Admission Date: [**2150-5-18**] Discharge Date: [**2150-5-23**]
Date of Birth: [**2111-12-26**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Percocet / Augmentin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest/neck pain
Major Surgical or Invasive Procedure:
thoracentesis
History of Present Illness:
38 yo f with PMH of ASD and pulmonary vein anolmous circulation
(LL pulm vein drained into coronary sinus) s/p repair in [**2146**]
(coronary sinus into LA), asthma, migraines presents with dry
cough and chest pain/ neck pain exacerbated by deep breathing.
Initially, PCP felt pain was musculoskelatal and was given
flexeril, ibuprofen w/ little relief. She also reports N/V x2
days. CXR shows a left pleural effusion with associated opacity
and a small right pleural effusion. WBC elevated to 17. She was
initially hemodynamicallyt stable but then pressure dropped to
70's/50. She was started on dopamine. Echo showed large
circumferential pericardial effusion with stranding and clotted
appearance. She was given 4L of fluid in ED with little UO,
morphine 4mg, ketorolac, ASA, tylenol, levetiracetam, dopamine,
promethazine, zofran.
.
Upon arrival to CCU she was afebrile, BP 90/60 on dopamine 5, RR
14, HR 100. Cardiac and thoracic surgery saw her in CCU and plan
was for thoracentesis and probable surgery tomorrow.
REVIEW OF SYSTEMS:
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.
Denies recent fevers, chills or rigors. Denies exertional
buttock or calf pain. All of the other review of systems were
negative.
Cardiac review of systems is notable for chest pain, dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations,
presyncope. She denies syncope or lower extremity edema.
Past Medical History:
ASD, Migraines, asthma, endometriosis
Past surgical hx:
ASD repair in [**2146**] (repair of an ASD and baffle of ananomalous
pulmonary vein using the pericardium - so that coronary sinus
drains in left atrium), lipoma resection from lower back, cystic
ovary s/p resection, tubal ligation.
Social History:
Significant for the absence of tobacco use. No history of
alcohol abuse or drug abuse.
Family History:
Father died of MI at 72 years. No history of sudden death.
Physical Exam:
.
PHYSICAL EXAMINATION:
VS: T 96.8 BP 90/60 HR 100 RR 16 O2 97% 3L NC, pulses 5
Gen: well appearing, oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: no elevation of JVP appreciated.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, slightly distant 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. +wheezes on R
scattered, +bronchial breath sounds on L side up to half way.
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 ulcers
.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
Pertinent Results:
2D-ECHOCARDIOGRAM performed on [**2150-5-18**] demonstrated:
LA is mildly dilated. A relatively immobile outpocketing is
along
the mid-interatrial septum (coronary sinus baffle) with both
systolic an diastolic flow. No intracardiac flow is identified
with saline injection at rest or with maneuvers. Estimated RA
pressure is 11-15mmHg. Mild symmetric LVH with normal cavity
size and systolic function (LVEF>55%). Regional systolic
function is normal. Abnormal septal motion/position (?post op
vs. constriction - less likely).
RV chamber size is normal. RV systolic function appears
depressed. AV leaflets appear structurally normal with good
leaflet excursion. No AR. MV structurally normal with trivial
MR. Moderate [2+] TR. Mild PA systolic hypertension. Moderate
sized (~1.5cm) circumferential, echo-filled pericardial effusion
with some stranding c/w organization. Tamponade physiology is
not suggested on transmitral Doppler, but this can be absent
with pulmonary artery systolic hypertension.
.
ETT performed on [**2150-5-18**] normal perfusion
CARDIAC CATH performed on [**2146**] showed moderate left to right
intracardiac shunt, Secundum-type atrial septal defect,
Anomalous pulmonary vein to coronary sinus drainage.
ECHO Study Date of [**2150-5-19**]
*** Report not finalized ***
PRELIMINARY REPORT
PATIENT/TEST INFORMATION:
Indication: Intraop pericardial fluid drainage and
pericadiectomy
Height: (in) 62
Weight (lb): 121
BSA (m2): 1.55 m2
BP (mm Hg): 120/50
HR (bpm): 105
Status: Inpatient
Date/Time: [**2150-5-19**] at 16:29
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW1-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **]
DR. [**First Name (STitle) 1532**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1533**]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.6 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 3.9 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.8 cm (nl <= 5.0 cm)
Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: *6.0 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 4.4 cm
Left Ventricle - Fractional Shortening: *0.27 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 55% to 65% (nl >=55%)
Left Ventricle - Peak Resting LVOT gradient: 1 mm Hg (nl <= 10
mm Hg)
Aorta - Valve Level: 2.7 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.5 cm (nl <= 3.4 cm)
Aorta - Arch: 1.9 cm (nl <= 3.0 cm)
Aorta - Descending Thoracic: 1.5 cm (nl <= 2.5 cm)
Aortic Valve - Peak Velocity: 0.9 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 3 mm Hg
Aortic Valve - Mean Gradient: 1 mm Hg
Aortic Valve - LVOT Peak Vel: 0.67 m/sec
Aortic Valve - LVOT VTI: 10
Aortic Valve - LVOT Diam: 2.3 cm
Aortic Valve - Valve Area: 3.3 cm2 (nl >= 3.0 cm2)
Mitral Valve - Peak Velocity: 0.7 m/sec
Mitral Valve - Mean Gradient: 1 mm Hg
Mitral Valve - Pressure Half Time: 80 ms
Mitral Valve - MVA (P [**1-6**] T): 4.2 cm2
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.4 m/sec
Mitral Valve - E/A Ratio: 1.75
Mitral Valve - E Wave Deceleration Time: 140 msec
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No ASD by 2D
or color
Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV
cavity.
LV WALL MOTION: basal anterior - normal; mid anterior - normal;
basal
anteroseptal - normal; mid anteroseptal - normal; basal
inferoseptal - normal;
mid inferoseptal - normal; basal inferior - normal; mid inferior
- normal;
basal inferolateral - normal; mid inferolateral - normal; basal
anterolateral
- normal; mid anterolateral - normal; anterior apex - normal;
septal apex -
normal; inferior apex - normal; lateral apex - normal; apex -
normal;
RIGHT VENTRICLE: Mild global RV free wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta
diameter. Normal aortic arch diameter. Normal descending aorta
diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+]
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic
(normal) PR.
PERICARDIUM: Large pericardial effusion. Effusion
circumferential. Effusion
echo dense, c/w blood, inflammation or other cellular elements.
Effusion is
loculated. Stranding is visualized within the pericardial space
c/w
organization.
Conclusions:
Pre pericardial drainage: The left atrium is mildly dilated. A
promient/enlarged coronary sinus is seen with a baffle joining.
Flow in the
baffle is consistent with pulmonary venous flow (this most
likely represents
the previous correction of partial anamolus pulmonary venous
return). The
atrial septum is bowed toward the right atrial side No atrial
septal defect is
seen by 2D or color Doppler. 2 distinct right sided pulmonary
veins are seen
with normal flow profiles. Only one left sided pulmonary vein
can be clearly
seen. Left ventricular wall thicknesses are normal. The left
ventricular
cavity is moderately dilated. There is mild global right
ventricular free wall
hypokinesis. 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. Moderate
[2+] tricuspid
regurgitation is seen. There is a large pericardial effusion and
an echogenic
pericardium.. The effusion appears circumferential, but is
loculated and
focused mainly posteriorly toward the apex. It is 2.8 cm in
diameter at
largest. The effusion is echo dense, consistent with blood,
inflammation or
other cellular elements. Stranding is visualized within the
pericardial space
c/w organization.
Post drainage and pericardial stripping: The pericardial
effusion is now
absent/trace. There is still some thickened/bright pericardium
seen posterior
to the heart, but the remaining pericardium is no longer seen.
RV function
appears somewhat improved (borderline normal). Tricuspid
regurgitation is now
mild. The remaining exam is unchanged. All findings discussed
with surgeons at
the time of the exam.
RADIOLOGY Preliminary Report
CHEST (PORTABLE AP) [**2150-5-22**] 4:02 PM
CHEST (PORTABLE AP)
Reason: evaluate for pneumo s/p chest tube removal
[**Hospital 93**] MEDICAL CONDITION:
38 year old woman with ASD, chest pain, pericardial effusion and
pneumonia/pleural effusion s/p Pericardiectomy
REASON FOR THIS EXAMINATION:
evaluate for pneumo s/p chest tube removal
CLINICAL HISTORY: ASD, chest pain, pericardial effusion.
CHEST
Since the prior chest x-ray of [**5-20**], the right chest tube has
been removed. There is no pneumothorax on this side and only a
small area of basilar atelectasis is now present.
The left chest tube is still present. No pneumothorax is
present. Some atelectasis is seen on this side but no
infiltrates are present.
No failure is present.
IMPRESSION: Right chest tube removed. No pneumothorax. No
failure or pneumonia seen.
DR. [**First Name11 (Name Pattern1) 3347**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5034**]
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2150-5-23**] 07:10AM 8.3 3.99* 9.7* 29.7* 75* 24.3* 32.7 18.2*
545*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2150-5-23**] 07:10AM 90 8 0.6 140 4.5 103 29 13
Brief Hospital Course:
This is a 38 yo F with h.o ASD and anolmous pulmonary vein to
coronary sinus s/p repair in [**2146**], she presented with chest
pain, neck pain, worse with deep breathing. She was found to
have a organized pericardial effusion and pleural effusion and
pneumonia. Thoracic was consulted as was Dr. [**Last Name (STitle) 914**] from
cardiac surgery. She had a thoracentesis in the ED and 550 cc
was obtained. She had a CT scan which revealed enhancement of
the pericardium and was concerning for infection. On [**5-19**] she
underwent redo sternotomy and drainage of pericardial and L
pleural effusion. She tolerated the procedure well and was
transferred to the CSRU in stable condition. She was extubated
on the post op night and was transferred to the floor on POD#1.
She was treated with Vanco and Cipro until all of the cultures
came back and upon dishcarge they were all negative. On POD#3,
the chest tubes were d/c'd and she was discharged on POD#4 in
stable condition.
Medications on Admission:
Flovent
Albuterol
ASA 325 mg daily
Discharge Medications:
1. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 6 weeks.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
2 months.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Flovent HFA 110 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
Disp:*1 * Refills:*2*
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Atenolol 25 mg PO daily.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
s/p redo sternotomy, draiage of pericardial and left pleural
effusion [**5-19**]
PMH: ASD s/p repair '[**46**], Migranes, Asthma, Endometriosis, lypoma
resection, cystic ovary resection, tubal ligation
Discharge Condition:
good
Discharge Instructions:
Keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever>100.5, and for redness or drainage from wound
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks.
Dr [**Last Name (STitle) 914**] in 4 weeks
Dr [**Last Name (STitle) **] in [**3-8**] weeks
Completed by:[**2150-5-25**]
|
[
"250.00",
"V45.89",
"V13.69",
"493.90",
"511.9",
"423.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.31",
"88.72",
"37.12",
"34.04",
"34.91",
"34.09"
] |
icd9pcs
|
[
[
[]
]
] |
12520, 12578
|
10926, 11909
|
303, 318
|
12824, 12831
|
3303, 4621
|
13045, 13205
|
2327, 2388
|
11994, 12497
|
9835, 9947
|
12599, 12803
|
11935, 11971
|
12855, 13022
|
4647, 9798
|
2403, 2405
|
2427, 3284
|
1387, 1893
|
248, 265
|
9976, 10903
|
346, 1368
|
1915, 2206
|
2222, 2311
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,480
| 165,898
|
11002
|
Discharge summary
|
report
|
Admission Date: [**2131-3-6**] Discharge Date: [**2131-3-20**]
Date of Birth: [**2070-7-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Procaine
Attending:[**First Name3 (LF) 14964**]
Chief Complaint:
Chest tightness, fatigue, and leg tightness with exertion for
several months.
Major Surgical or Invasive Procedure:
Coronary artery bypass graft x 3 [**2131-3-7**].
Sternal wound debridement [**2131-3-15**].
History of Present Illness:
This is a 60 year old male with history of right sided heart
failure and mitral regurguitation. A stress test on [**3-2**]/T waves changes with a ficed anterior defect amd
a mild lateral fixed defect. He was referred for cath [**2131-3-6**]
showing EF 50%, 1+ MR, LM 20%, LAD 70-80%, D1 60-80%, OM 100%,
RCA 90%, PDA 90%, and RPL 40%. He was therefore referred for
CABG.
Past Medical History:
Diabetes.
Hyperlipidimia.
Hypertension.
Cardiomyopathy.
Mitral regurgitation.
Right heart failure.
Left fem-[**Doctor Last Name **] bypass [**5-16**].
Social History:
Lives in [**Location 17927**] with wife. Retired from printing business.
Drives. Uses cane with ambulation. Denies ETOH use. Reports
60 pack year smoking history quit 4 years ago.
Family History:
Father deceased at age 57.
Pertinent Results:
[**2131-3-19**] 05:35AM BLOOD WBC-12.7* RBC-3.67* Hgb-10.6* Hct-31.4*
MCV-86 MCH-29.0 MCHC-33.9 RDW-14.0 Plt Ct-479*
[**2131-3-20**] 05:45AM BLOOD PT-18.5* PTT-34.9 INR(PT)-2.2
[**2131-3-19**] 05:35AM BLOOD Plt Ct-479*
[**2131-3-19**] 05:35AM BLOOD Glucose-111* UreaN-24* Creat-1.5* Na-135
K-4.9 Cl-98 HCO3-28 AnGap-14
[**2131-3-6**] 11:50AM BLOOD ALT-22 AST-14 AlkPhos-49 TotBili-0.4
[**2131-3-19**] 05:35AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.3
Brief Hospital Course:
Mr. [**Known lastname **] was admitted [**2131-3-6**] for an elective cardiac cath
showing 3 VD. He was referred for CABG. On [**3-7**] he proceeded
to the OR for a CABG x 3 with LIMA to the LAD, SVG to the RCA,
and SVG to the OM1. Please see OP note for full details. He
was successfully weened and extubated in his operative evening.
On POD one his BUN and creatinine elevated (creat 1.7 from 1.4)
and a renal consult was obtained. The elevated creatinine was
attributed to an early underlying diabetic nephropathy or ATN --
with full recover expected.
On POD three he was transferred to the inpatient/telemetry floor
for ongoing management.
On POD four he sustained rapid bursts of atrial fibrillation
treated with IV lopressor and amiodarone. He continued with
bursts of afib throughout that day and the next and was started
on IV heparin and PO coumadin on POD 5.
On POD five he was also noted to have a small amount of drainage
from the lower most pole of his sternal incision.
On POD 6 his lopressor was further increased with ongoing atrial
fibrillation. His blood glucoses were elevated to the mid-200s
and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was obtained for better management of
diabetes.
On POD eight, his sternal drainage was thought to have increased
in volume with small amount of purulent drainage and he
proceeded to the OR for exploration (INR 1.2). Sternal wound
debridement in the OR revealed small amount of pus in the
subcutaneous tissue at the top portion of the incision;
debrided; closed with interrupted sutures.
On PODs [**8-16**] he converted from afib to a NSR. He was also
continued on vancomycin (started post-debridement) with qid
dressing changes. He continued to be followed by physical
therapy with increasing activity level and was continued on his
coumadin.
On POD [**9-16**], his vancomycin was discontinued and he was started
on PO keflex. His INR elevated to 1.9.
On PODs 13/5 it was decided that he was safe for discharge home
with sternum stable without further drainage, NSR, appropriate
activity level per physical therapy.
It was decided that he would go home with PO amiodarone but no
coumadin since he had remained in a NSR without any atrial
fibrillation for 4 days.
Medications on Admission:
Aspirin 162 daily.
HCTZ 25 daily.
Lipitor 40 daily.
Avandia 4 daily.
Imdur 30 daily.
Glucotrol 20 [**Hospital1 **].
Potassium chloride 20 daily.
Lantus insulin 58 units qhs.
Atenolol 25 mdaily.
Lisinopril 40 daily.
Lasix 40 daily.
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO every [**3-21**]
hours as needed.
Disp:*40 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*0*
5. Rosiglitazone Maleate 4 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Glipizide 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*0*
7. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO once a
day for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
8. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO once a
day: To start after 400 mg daily dose complete.
Disp:*30 Tablet(s)* Refills:*0*
9. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 2 weeks.
Disp:*56 Capsule(s)* Refills:*0*
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days.
Disp:*20 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10
days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Coronary artery disease.
DM 2.
Hypertension.
Hyperlipidemia.
S/P coronary artery bypass graft x 3 and sternal debridement.
Discharge Condition:
Stable.
Discharge Instructions:
Shower daily and wash incisions with soap and water. Rinse
well. Do not apply any creasm, lotions, powders, or ointments.
No lifting greater than 10 pounds.
No driving.
Schedule follow-up appointments as directed.
Followup Instructions:
[**Last Name (LF) **],[**First Name3 (LF) **] R. [**Telephone/Fax (1) 170**] Call to schedule appointment
[**Last Name (LF) **],[**First Name3 (LF) 177**] A. [**Telephone/Fax (1) 5315**] Call to schedule
appointment
[**Last Name (un) **],RAFIK [**Telephone/Fax (1) 35661**] Call to schedule appointment
Completed by:[**2131-3-20**]
|
[
"250.40",
"E878.2",
"583.81",
"998.59",
"425.4",
"401.9",
"427.31",
"440.21",
"424.0",
"428.0",
"V70.7",
"998.11",
"458.29",
"285.1",
"584.9",
"V58.67",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.22",
"88.53",
"88.72",
"99.04",
"37.23",
"88.56",
"37.11",
"39.61",
"36.12",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
5702, 5753
|
1755, 4017
|
353, 447
|
5920, 5929
|
1288, 1732
|
6193, 6537
|
1241, 1269
|
4298, 5679
|
5774, 5899
|
4043, 4275
|
5953, 6170
|
236, 315
|
475, 850
|
872, 1024
|
1040, 1225
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
88
| 123,010
|
15162
|
Discharge summary
|
report
|
Admission Date: [**2111-8-29**] Discharge Date: [**2111-9-3**]
Date of Birth: [**2087-12-1**] Sex: M
Service: TRAUMA SX
HISTORY OF PRESENT ILLNESS: Patient is a 23-year-old
gentleman who was in his usual state of health when in the
early on the day of admission was reportedly stabbed in the
chest. It is unknown the actual sequence of events. It is
reported that the patient had been stabbed, entered his
vehicle, began to drive and subsequently crashed into some
parked cars. Patient was taken from his car and brought to
the [**Hospital1 69**] with initial heart
rate in the 90s, blood pressure in the 90s and saturation of
98%.
The patient, upon entering the Trauma Room, had a heart rate
of 78, blood pressure of 98/66, respiratory rate of 24 and
saturating at 100% on room air. The patient underwent a DPO
which was negative and VATS exam which showed a pericardial
effusion. He was resuscitated with four liters of lactated
ringers and a unit of blood in the Trauma Room. The patient
was then moved to the Operating Room for emergent exploration
of the wound.
PAST MEDICAL HISTORY: None.
PAST SURGICAL HISTORY: None.
MEDICATIONS ON ADMISSION: None.
ALLERGIES: None.
SOCIAL HISTORY: Patient is an information technology worker
at a computer firm at [**Hospital1 8**].
PHYSICAL EXAMINATION: Head and neck are within normal
limits. Chest had bilateral breath sounds. Abdomen soft,
nontender, nondistended. He had positive extremity pulses.
Patient had a 3 cm stab wound of the fifth intercostal space
on the left.
LABORATORY: On admission white count was 9.8, hematocrit
36.6, platelets 161,000. PT was 14.5, PTT 28.5, INR 1.5.
Urinalysis was negative. Sodium 145, potassium 3.6, chloride
112, bicarbonate 19, BUN 10, creatinine 0.9. Glucose 151.
Amylase 54, calcium 7.4, magnesium 1.5, phosphorus 2.4.
ETOH was 245. Other tox screen was negative.
Arterial blood gas drawn once he was intubated initially was
7.33, 37, 205, 20.
Chest x-ray showed an enlarged cardiac silhouette and slight
widening of mediastinum. A subsequent head CT Scan was
negative. Subsequent C spine CT Scan was negative for
injury. CT Scan of the abdomen was also negative. AP pelvis
was negative.
HOSPITAL COURSE: Upon being transferred to the Operating
Room for emergent exploration, the patient lost blood
pressure and in the Operating Room underwent an emergent
thoracotomy and exploration. Injury to the right ventricle
was found and repaired. The patient was resuscitated
successfully and was transferred to the Intensive Care Unit
in stable conditions on no pressors. Patient's postoperative
course is as follows.
In the Intensive Care Unit the patient was weaned and
extubated on postoperative day #1 without any incident. The
patient had a postoperative echo which was within normal
limits. Postoperative day #2, the patient was transferred to
the floor for the remainder of his recovery. The patient had
a right chest tube discontinued and his diet was advanced.
He was evaluated by Physical Therapy and began to ambulate.
On postoperative day #3 the patient had a temperature spike
to 102.7 F. Blood cultures were sent which have only been
only significant for one bottle out of four with staph
coagulase negative. He was started on Vancomycin. He
subsequently defervesced. His white count went to a high of
10.6 and more recently is 7.7. The left chest tubes were
discontinued without incident. The wound was examined. It
has been clean, dry and intact. The patient had a second
echo was [**2111-9-1**] for evaluation of the valves which showed
no vegetations.
On postoperative #5 his antibiotics were discontinued. The
patient was ambulating, tolerating diet and is now stable and
ready to go home.
DISCHARGE DIAGNOSES:
1. Stab wound to the right ventricle status post emergent
thoracotomy and surgical repair.
DISCHARGE MEDICATIONS:
1. Percocet one to two p.o. q. four hours p.r.n.
2. Colace 100 mg p.o. b.i.d.
CONDITION ON DISCHARGE: Stable.
DISCHARGE INSTRUCTIONS: Patient will follow up in Trauma
Clinic in one week to have staples removed.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36
D: [**2111-9-3**] 09:52
T: [**2111-9-8**] 11:05
JOB#: [**Job Number 44168**]
|
[
"E966",
"423.9",
"511.9",
"861.13"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.4",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
3785, 3878
|
3901, 3982
|
1180, 1206
|
2247, 3764
|
4041, 4393
|
1146, 1153
|
1332, 2229
|
166, 1092
|
1115, 1122
|
1223, 1309
|
4007, 4016
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,878
| 198,803
|
50382
|
Discharge summary
|
report
|
Admission Date: [**2162-12-7**] Discharge Date: [**2162-12-20**]
Date of Birth: [**2113-11-22**] Sex: F
Service: MEDICINE
Allergies:
Flagyl / Sulfa (Sulfonamide Antibiotics) / Penicillins /
Dilaudid
Attending:[**First Name3 (LF) 2108**]
Chief Complaint:
sob/abdominal pain/black stool
Major Surgical or Invasive Procedure:
None
History of Present Illness:
EAST HOSPITAL MEDICINE ATTENDING ADMISSION NOTE
Date: [**2162-12-7**]
Time: 22:25
PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **]: [**Telephone/Fax (1) 94697**]
The patient is a 49F with PMH including morbid obesity,
psychiatric / developmental problems, hyperlipidemia, HTN,
lymphedema, depression, chronic shortness of breath/asthma on
home 02 3-4 liters, panic attacks, abdominal pain (EGD in [**2157**]
revealed gastritis) and hypothyroidism, who was recently
admitted [**Date range (3) 105001**] where she presented with n/v,
abdominal pain, which was thought to be due to a viral
gastroenteritis.
She presents today with SOB, abdominal pain, and fever up to 103
for past 2 days. Her home health care noticed a one day h/o
right leg redness. Also, had a temp 101 this am and black stool
today but on pepto bismol. Also, had a recent GI bug. Also
reported diffuse abdominal pain.
In ER:
VS: 8 99.9 100 130/60 20 100%; Exam notable for significant
cellulitis in right lower extremity, cool/dusky toes
bilaterally. Impossible to do a guiac exam due to morbid
obesity.
Studies: LENIs negative B, u/s abdomen showed possible
gallstones.
Fluids given: none
Meds given: Levofloxacin 750mg IV x 2, Vancomycin 1g IV x 1
Consults called: none
VS prior to transfer to the floor: 99.4 104 143/70 28 97% (4L
NC)
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies visual changes, headache, sinus tenderness,
rhinorrhea, congestion or sore throat. Denies chest pain or
tightness, palpitations, orthopnea, dyspnea on exertion. Denies
cough, shortness of breath, wheezes or pleuritic pain. Denies
nausea, vomiting, diarrhea, constipation, BRBPR, melena, or
abdominal pain. No dysuria, urinary frequency. Denies
arthralgias or myalgias. Denies rashes. No numbness/tingling or
muscle weakness in extremities. No feelings of depression or
anxiety. All other review of systems negative.
Past Medical History:
-Morbid obesity
-DM
-Hypertension
-Hyperlipidemia
-Hypothyroidism
-Gastroesophageal reflux disease (GERD)
-Asthma
-Depression/Anxiety
-Possible sleep apnea (has declined sleep studies)
-chronic low back pain
Social History:
Lives alone, with home health aide. She endorses only rare
social alcohol intake and she smokes [**12-19**] cigarettes daily. At
baseline, she is wheelchair bound. Home health aide helps her
with her errands and ADLs. Patient has a long psychiatric
history including counselling since childhood, learning
disabilities, she has left the hospital AMA on multiple
occasions, she has had Code Purples called for aggressive
behavior, she has been accused of calling EMS inappropriately
(several times per month at one point) for factitious
complaints, and she has reported history of sexual assault.
There have been SW involved to try to have this patient live in
rehab or another situation to better care for herself but these
attempts have all failed.
Family History:
father w/CA of "belly", Mother alive & healthy, 2 grandparents
w/DM. Brother died of illicit drug related causes.
Physical Exam:
VS: 98.5 124/79 103 24 97% 4L
GEN: Alert and oriented to person, place and situation; no
apperent distress
HEENT: no trauma, pupils round and reactive to light and
accomodation, no LAD, oropharynx clear, no exudates
CV: regular rate and rhythm, no murmurs/gallops/rubs
PULM: clear to auscultation bilaterally, no
rales/crackles/rhonchi
GI: soft, mild tenderness to palpation diffusely, obese; no
guarding/rebound
EXT: right leg with erythema 7x7" and warmth above the knee, no
clubbing / cyanosis; toes [**2-19**] cold bilaterally with no pain;
peripheral IV present
NEURO: CN II-XII intact, [**4-21**] motor function globally
DERM: 1 x 0.5 cm skin break-down underneath right breast
Pertinent Results:
[**2162-12-7**] 03:54PM LACTATE-1.0
[**2162-12-7**] 03:48PM GLUCOSE-185* UREA N-10 CREAT-0.7 SODIUM-140
POTASSIUM-4.4 CHLORIDE-96 TOTAL CO2-30 ANION GAP-18
[**2162-12-7**] 03:48PM ALT(SGPT)-40 AST(SGOT)-32 TOT BILI-0.7
[**2162-12-7**] 03:48PM LIPASE-31
[**2162-12-7**] 03:48PM WBC-14.4* RBC-3.81* HGB-11.6* HCT-35.5*
MCV-93 MCH-30.5 MCHC-32.8 RDW-14.5
[**2162-12-7**] 03:48PM NEUTS-80.2* LYMPHS-14.8* MONOS-3.4 EOS-0.8
BASOS-0.8
[**2162-12-7**] 03:48PM PLT COUNT-295
[**2162-12-7**] 03:48PM PT-14.1* PTT-28.3 INR(PT)-1.2*
[**2162-12-12**] 05:32AM BLOOD WBC-10.0 RBC-3.49* Hgb-10.2* Hct-33.9*
MCV-97 MCH-29.3 MCHC-30.2* RDW-13.9 Plt Ct-384
[**2162-12-13**] 06:01AM BLOOD Glucose-237* UreaN-6 Creat-0.5 Na-141
K-4.1 Cl-95* HCO3-41* AnGap-9
[**2162-12-13**] 08:46PM BLOOD Vanco-29.0*
[**2162-12-15**] 05:13AM BLOOD Vanco-11.3
[**2162-12-7**]:
Sinus tachycardia. S1-Q3 pattern. RSR' pattern in leads V1-V2.
Low T wave
amplitude. Findings are non-specific and tracing may be within
normal limits. Clinical correlation is suggested. Since the
previous tracing of [**2162-11-30**] no significant change.
[**2162-12-7**] Abdominal U/S:
Extremely limited study. Echogenic liver.
GPossible gall stones within a non-distended gall bladder.
[**2162-12-7**] B LENIs:
Due to patient body habitus, the study could not be performed.
[**2162-12-7**] pCXR:
Poor film due to body habitus
RUE ultrasound [**12-15**]:
No fluid collection or abscess identified.
CXR AP [**12-15**]:
Right entering PIC line can be traced as far as the low SVC, but
the tip is indistinct. Conventional radiographs might be able to
provide a more reliable localization. Right lung and left upper
lung are clear. Left lower lung is obscured by the heart shadow
which is normal size. No pneumothorax. No appreciable pleural
effusion.
ULTRASOUND RIGHT LEG [**2162-12-13**]:
No fluid collection or abscess identified.
[**2162-12-7**] BLOOD CULTURE X 2 NO GROWTH
[**2162-12-9**] BLOOD CULTURE X 2 NO GROWTH
Brief Hospital Course:
49F with multuiple PMH including GERD, chronic SOB/asthma
requiring 3-4 L home oxygen, GERD, hypertension, morbid obesity,
anxiety and developmental disorder, who presents with SOB,
abdominal pain, and fever up to 103 for past 2 days. Exam
notable for cellulitis in right lower extremity, cool/dusky toes
bilaterally.
Right leg cellulitis: She was treated with Vanc and
ciprofloxacin as well as miconazole powder. Vancomycin was used
for a 14 day course. She did not have a DVT, she improved and
an ultrasound confirmed no abscess.
Hypercarbic respiratory failure: She developed hypercarbic
respiratory failure from untreated obesity hypoventilation
syndrome in the setting of narcotics (previously noted to be
sedated on narcotics). She was started on biPAP. She was
continued on bronchodilator nebulizers and Advair. She underwent
an inpatient sleep study which revealed severe sleep apnea and
was sent home to use home BiPAP, set up with. She will follow
up in sleep clinic.
Type 2 DM, uncontrolled, without complications: Her insulin was
uptitrated to 40 units of lantus [**Hospital1 **], continued home humalog
sliding scle.
Hypothyroidism: Her TSH was elevated at 12 during her prior
admission, and levothyroxine dose was increased from 88mcg to
100mcg. She will need outpatient follow up.
OBESITY: gastric bypass would be an option, so the bariatric
surgery team was consulted inpt and provided her with
information, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] suggested that the patient would
likely need to lose 100 pounds prior to surgery. (Currently
weighs, 600 pounds)
Medications on Admission:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Puff Inhalation Q4H (every 4 hours) as needed for
shortness of breath.
2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed for insomnia.
5. insulin glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous twice a day.
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
8. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. albuterol sulfate 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) nebulizer Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
10. Humalog 100 unit/mL Solution Sig: as directed units
Subcutaneous three times a day.
11. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed) as needed for skin rash.
12. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
6. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every six (6) hours as
needed for SOB or wheeze.
8. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
9. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
10. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Rolling walker
Bariatric Rolling Walker to capacity up to 600 lbs
12. [**Hospital **] MEDICAL EQUIPMENT
BIPAP. Settings [**11-24**] with supplemental oxygen (4L).
Mask type: [**Doctor Last Name **] and Paykel - size small
13. Humalog Pen 100 unit/mL Insulin Pen Sig: per sliding scale
units Subcutaneous four times a day.
Disp:*1 pen* Refills:*2*
14. Lantus Solostar 100 unit/mL (3 mL) Insulin Pen Sig: Forty
(40) units Subcutaneous twice a day.
Disp:*1 pen* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Nizhoni VNA
Discharge Diagnosis:
Cellulitis
Hypercarbic respiratory failure
Diabetes mellitus
Hypothyroidism
Morbid obesity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted with cellulitis of your leg. During your
admission, you developed respiratory failure. You were started
on BIPAP mask overnight to help your breathing. You MUST
continue to wear this mask at night.
Please STOP taking TRAZODONE.
Your INSULIN dose was increased, take GLARGINE (LANTUS) 40 units
twice a day.
Start taking CIPROFLOXACIN (orally) for 2 days.
Followup Instructions:
Department: MEDICAL SPECIALTIES-Sleep Medicine
When: THURSDAY [**2162-12-23**] at 1 PM
With: DR. [**First Name (STitle) **] & DR. [**First Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) 1877**],[**First Name3 (LF) **] A.
Address: [**Street Address(2) 12840**],[**Apartment Address(1) 40744**], [**Location (un) 6017**],[**Numeric Identifier 12842**]
Phone: [**Telephone/Fax (1) 40745**]
Appt: Dr [**Last Name (STitle) 105002**] office will call you at home to coordinate a
follow up appt with your from your hospital stay. If you dont
hear from them by Thursday, please call them directly
|
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icd9cm
|
[
[
[]
]
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[
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] |
icd9pcs
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[
[
[]
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359, 366
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,662
| 130,358
|
37094
|
Discharge summary
|
report
|
Admission Date: [**2198-11-28**] Discharge Date: [**2198-12-11**]
Date of Birth: [**2137-11-10**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
near falling
Major Surgical or Invasive Procedure:
Endotracheal intubation, tracheostomy, PEG tube
History of Present Illness:
Per admitting resident:
Patient is a 61 yo man with hx of occasionally elevated BP
but not on any anti-hypertensive who presented to [**Hospital3 **] around midnight after a near-fall at home. Per
patient's girlfriend/HCP, she came home late after school and
found him watching television. While she went to wash up
upstairs, he reportedly went to the bathroom to urinate then she
heard a "thud, thud" and found him leaning next to a fall but
awake and conversant although appeared confused. She laid him
down on the floor and put a pillow under his head then proceeded
to call 911. Then she came back with 2 ASA with water, he
coughed a bit but was able to swallow the pills. She called 911
again and the EMS arrived and took him to [**Hospital3 **].
Per report, he was quite hypertensive initially (213/133) with L
sided weakness and slurring of speech but answering questions
appropriately. Head CT revealed large R BG hemorrhage (3X7cm)
with some midline shift to the left. Patient developed
nausea/vomiting hence was intubated for airway protection prior
to being med-flighted here for further care.
NSURG reviewed the films and given no signs of hydrocephalus,
did
not intervene. Patient remains intubated and sedated with
Propofol.
Past Medical History:
HTN
Social History:
Lives with girlfriend (home [**Telephone/Fax (1) 83593**], cell [**Telephone/Fax (1) 83594**])
[**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) **] who is also HCP/POA. Retired VP of a tech company.
Very remote smoking hx - quit over 35 yrs ago and drinks 1 glass
of wine nightly. Walks about 3~4 miles daily. Full code but
would not want prolonged care if in persistent
Family History:
Unknown
Physical Exam:
Exam on admission:
T BP 140/95 HR 57 RR 18 O2Sat 100% vented.
Gen: Lying in bed, sedated and intubated.
HEENT: hard-cervical collar in place.
CV: RRR, no murmurs/gallops/rubs
Lung: Clear anteriorly.
Abd: +BS, soft.
Ext: No edema - some cuts/blood in toes.
Neurologic examination:
MSE: Sedated and intubated but examined off Propofol for 5
minutes. Keeps eyes closed and not responsive to verbal or
noxious stimuli but has some spontaneous, anti-gravity movements
in RUE and both legs.
Cranial Nerves:
Pupils small but reactive (1.5 ->1mm) and midline. No Doll's
eyes and no blinking to visual threats. Positive corneal's on R
only. +Cough when suctioning. Face appears symmetric.
Motor:
Normal bulk and tone bilaterally. Spontaneous, anti-gravity
movements in both legs and RUE. Withdraws to noxious stim in
both legs and RUE but extensor posturing for LUE.
Sensation: Intact to noxious stim in all extremities.
Reflexes:
2s for biceps and 2 for R patellar but none for L. Toes upgoing
bilaterally.
Exam at time of discharge:
Pertinent Results:
[**2198-11-28**] 01:30AM BLOOD WBC-6.1 RBC-4.22* Hgb-13.9* Hct-41.6
MCV-99* MCH-33.0* MCHC-33.5 RDW-13.7 Plt Ct-202
[**2198-11-29**] 02:01AM BLOOD WBC-15.3*# RBC-4.80 Hgb-15.5 Hct-47.2
MCV-99* MCH-32.4* MCHC-32.9 RDW-13.9 Plt Ct-236
[**2198-12-2**] 02:18AM BLOOD WBC-11.3* RBC-3.70* Hgb-12.2* Hct-36.3*
MCV-98 MCH-33.0* MCHC-33.7 RDW-13.4 Plt Ct-272
[**2198-11-28**] 01:30AM BLOOD Neuts-80.7* Lymphs-12.7* Monos-5.0
Eos-1.2 Baso-0.4
[**2198-11-28**] 01:30AM BLOOD Glucose-156* UreaN-20 Creat-0.8 Na-142
K-3.3 Cl-104 HCO3-28 AnGap-13
[**2198-12-2**] 02:18AM BLOOD Glucose-142* UreaN-36* Creat-1.0 Na-144
K-3.9 Cl-115* HCO3-22 AnGap-11
[**2198-11-28**] 01:30AM BLOOD cTropnT-<0.01
[**2198-11-28**] 01:30AM BLOOD CK(CPK)-122
[**2198-11-28**] 03:53AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.2 Cholest-196
[**2198-11-28**] 03:53AM BLOOD %HbA1c-5.8
[**2198-11-28**] 03:53AM BLOOD Triglyc-138 HDL-47 CHOL/HD-4.2
LDLcalc-121
[**2198-11-28**] 01:30AM URINE RBC-[**2-22**]* WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0
[**2198-11-28**] 01:30AM URINE Blood-MOD Nitrite-NEG Protein-75
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2198-11-28**] 01:30AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2198-12-11**] 05:45AM 10.3 3.54* 11.1* 33.7* 95 31.3 32.9 12.9
506*
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2198-12-11**] 05:45AM 83.9* 9.8* 4.8 1.2 0.3
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2198-12-11**] 05:45AM 506*
[**2198-12-11**] 05:45AM 13.7* 34.5 1.2*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2198-12-11**] 05:45AM 135* 25* 0.8 141 4.1 104 27 14
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2198-12-10**] 06:40AM 56* 35
CPK ISOENZYMES CK-MB cTropnT
[**2198-11-28**] 01:30AM <0.011
[**2198-11-28**] 01:30AM 4
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
Cholest
[**2198-12-11**] 05:45AM 8.6 3.7 2.3
DIABETES MONITORING %HbA1c
[**2198-11-28**] 03:53AM 5.81
LIPID/CHOLESTEROL Cholest Triglyc HDL CHOL/HD LDLcalc
[**2198-11-28**] 03:53AM 196 138 47 4.2 121
PITUITARY TSH
[**2198-12-10**] 06:40AM 1.3
THYROID Free T4
[**2198-12-10**] 06:40AM 1.0
Blood Gas
BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calTCO2 Base XS AADO2 REQ O2 Intubat
[**2198-12-8**] 04:20AM ART 127* 36 7.48* 28 4
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Lactate Na K Cl
[**2198-12-1**] 09:59AM 127* 1.1 143 3.8 110
HEMOGLOBLIN FRACTIONS ( COOXIMETRY) Hgb calcHCT O2 Sat
[**2198-12-1**] 09:59AM 13.9* 42 99
CALCIUM freeCa
[**2198-12-4**] 01:45AM 1.14
Microbiology:
[**2198-11-30**] 8:56 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2198-11-30**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN CLUSTERS.
1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Preliminary):
Further incubation required to determine the presence or
absence of
commensal respiratory flora.
STAPH AUREUS COAG +. MODERATE GROWTH.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
[**2198-12-5**] 12:37 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2198-12-8**]**
GRAM STAIN (Final [**2198-12-5**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2198-12-8**]):
Commensal Respiratory Flora Absent.
KLEBSIELLA OXYTOCA. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA OXYTOCA
|
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- 8 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2198-12-10**] 9:30 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2198-12-10**]**
GRAM STAIN (Final [**2198-12-10**]):
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final [**2198-12-10**]):
TEST CANCELLED, PATIENT CREDITED.
BCx [**11-30**] - No Growth, [**12-5**]- No growth
UCx [**11-30**] - no growth
Imaging:
CT C-spine - IMPRESSION:
1. No fracture or malalignment of the cervical spine.
2. Degenerative changes result in mild-moderate canal narrowing
at C6-7,
deforming the ventral thecal sac. If there are neurologic
symptoms referable
to this level (e.g. new myelopathy), MRI can be obtained to
evaluate the
thecal sac and its contents.
3. Multilevel neural foraminal narrowing, most severe at C6-7.
CT head:
[**11-28**] -
IMPRESSION:
1. Interval increase in size of right basal ganglia hemorrhage,
now measuring
approximately 7.5 x 3.2 cm, with new intraventricular extension
and new
leftward subfalcine herniation.
2. Stable asymmetry of the ambient cisterns, concerning for
impending
downward transtentorial herniation.
3. No new foci of bleeding.
4. No fracture.
[**11-20**] pm:
IMPRESSION:
1. Large right basal ganglia hemorrhage with intraventricular
extension,
subfalcine herniation, sulcal effacement, and effacement of the
ambient
cisterns concerning for impending transtentorial herniation.
2. No new site of hemorrhage, and no interval development of
hydrocephalus.
[**11-30**]
IMPRESSION:
1. Large right basal ganglia hemorrhage with intraventricular
extension,
shift of midline structures towards the left, sulcal effacement,
which appears
unchanged in size and appearance from [**2198-11-28**].
2. No new site of hemorrhage.
[**12-2**]
IMPRESSION: 1. No significant change in large right basal
ganglia hemorrhage
with intraventricular extension. Persistent shift of normally
midline
structures towards the left, not significantly changed.
[**11-30**] CTA chest
IMPRESSION:
1. Right middle lobe segmental and bilateral lower lobe
subsegmental
pulmonary artery filling defects compatible with acute pulmonary
embolism.
2. Right hilar prominent 7-mm lymph node and a few subcentimeter
mediastinal
lymph nodes.
3. 4-mm lingular nodule. Followup CT in 12 months is
recommended.
4. Distended esophagus containing fluid-secretions; NG tube at
the GE
junction. Repositioning is recommended.
5. Right lower lobe pneumonia
[**11-30**] LENIs - no DVT b/l
CXR [**11-28**]:
IMPRESSION:
1. Nasogastric tube terminating within the stomach, with the tip
oriented
cephalad.
2. Interval removal of the endotracheal tube.
3. Small left pleural effusion and adjacent atalectasis.
CXR [**12-10**]
FINDINGS: As compared to the previous examination, there is no
relevant
change. Tracheostomy tube is in unchanged position. The
retrocardiac lung
areas have increased in transparency, no evidence of newly
occurred focal
parenchymal opacity suggesting pneumonia. No pleural effusions.
Unchanged
size of the cardiac silhouette.
USG kidneys [**12-10**]
IMPRESSION:
1. No son[**Name (NI) 493**] evidence for renal artery stenosis.
2. Normal grayscale appearance of the kidneys bilaterally.
Brief Hospital Course:
61 yo man with likely HTN not on medications who had a near fall
at home and found to have L sided weakness by EMS, was
hypertensive (213/133) with a head CT revealing a large R
Putamenal/IPH, at which time was transferred to [**Hospital1 18**]. He was
admitted to NeuroICU for further treatment and monitoring.
NEURO. On initial examination he was unable to open eyes, but
grunted to verbal stimuli. He had roving eye movements with
rightward gaze deviation as well as spontaneous R sided
movements and L sided hemiplegia. Initial repeat CT showed some
progression of ICH (likely putamenal w/ extension along white
matter tracts), with new IVH, worsening midline shift and
subfalcine herniation, however the following CT in PM on day of
admission was unchanged. Patients' BP was maintained at < 160,
HOB > 30 and a negative fluid balance was achieved. By HD2, he
was able to follow appendicular commands, was able to answer
yes/no questions and his gaze deviation improved. He had full
strength on R side and began to move L side. He was extubated
and transferred to floor.
However developed tachypnea and fever and respiratory distress,
along with decreased responsiveness and inability to move L
sides w/ R withdrawal to noxious as flexor while on the floor.
He was transferred back to ICU on HD#3. Repeat CT head was
unchanged. He was diagnosed with a PNA (likely VAP) and a
Pulmonary embolism (see below)
An IVC filter was placed on [**2198-12-1**]. He continued to have mild
improvement in awareness but was not able to be wened of the
ventilator. After a long discussion with his girlfreind and
health care proxy the decision was made to go ahead with a
tracheostomy and PEG feeding tube. These were both placed on
[**2198-12-6**]. The patient continued to do well and was transferred
to the floor on [**2198-12-8**]. He was able to come of the ventilator
but is trach dependant. After coming back to floor, he was
maintaing a good saturation on tracheostomy. His physical exam
at the time of discharge is significant for left sided
hemiparesis and inattention towards left, minimal response to
verbal commands. He has hypotonia on left side and his plantar
is upgoing on the left side.
CV. Hypertensive to SBP max of 180 intermittently, however
maintained < 160 for majority of HD 1 - 3. He was treated with
nicardipine gtt for one day and transition to PO medications
including hydralazine, captopril and amlodipine, also on
clonidine patch and HCTZ. he had renal doppler for evaluation of
renal artery stenosis which did not show evidence of renal
artery stenosis. His blood pressure medicines need to be
adjusted at rehab hospital depending upon his blood pressure.
His blood pressures at the time of discharge were
110-120/70-80s.
PULM/ID. Extubated on [**11-28**] as above but reintubated on [**11-30**].
Diagnosed with VAP on HD#2 and treated with Vancomycin and Zosyn
(day 1 = [**11-30**]). Also found to have right segmental and
subsegmental PE. He is on tracheostromy and needs usual
trachostormy care.
HEME. Pt. was on pneumoboots x 48 hrs after admission due to
ICH. On HD#2, was noted to have tachypnea to 50s. CTA revealed
R segmental and subsegmental PEs. He underwent IVC filter
placement on [**2198-12-1**] as anticoagulation was contraindicated in
setting of a large intracranial hemorrhage. LENIs were negative
b/l on [**2198-11-30**]., given his intracranial bleed, long term
anticoagulation was not favoured.
ID- He was started on zosyn in ICU based on tracheal asp which
showed Klebsiella (scanty) , after coming to floor he did not
spike fever, his chest Xray, UA was repeated and which did not
show evidence of infection. His antibiotics (zosyn and
vancomycin) were stopped at the time of discharge.
Medications on Admission:
Occasionally ASA
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: 1-2 MLs Mucous
membrane [**Hospital1 **] (2 times a day).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
8. Clonidine 0.3 mg/24 hr Patch Weekly Sig: Two (2) Patch Weekly
Transdermal every twenty-four(24) hours.
9. Captopril 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a
day).
10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. Metoprolol Tartrate 25 mg Tablet Sig: Five (5) Tablet PO TID
(3 times a day).
12. Hydralazine 50 mg Tablet Sig: 1.5 Tablets PO Q4H (every 4
hours): hold if sbp less than 100.
13. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily): hold if sbp less than 100.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Right basal ganglia /intraparenchymal bleed
Discharge Condition:
Mental Status:Confused - always
Level of Consciousness:Lethargic but arousable
Activity Status:Bedbound
Discharge Instructions:
You were admitted for evaluation and management of stroke.
Please take your medicines as prescribed and call 911 or your
doctor if you have any concerns.
Followup Instructions:
Please follow up with neurology clinic as
Scheduled Appointments :
Provider [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2199-1-9**] 4:00
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"431",
"E928.9",
"415.19",
"693.0",
"348.4",
"401.9",
"E849.7",
"518.81",
"893.0",
"584.9",
"E930.0",
"342.92",
"276.0",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"31.1",
"96.6",
"96.72",
"96.71",
"38.7",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
15991, 16061
|
10953, 14714
|
331, 381
|
16149, 16149
|
3199, 6376
|
16457, 16804
|
2112, 2122
|
14782, 15968
|
16082, 16128
|
14740, 14759
|
16279, 16434
|
2137, 2142
|
6417, 8530
|
279, 293
|
409, 1661
|
2643, 3180
|
8540, 10930
|
2157, 2396
|
16163, 16255
|
2420, 2627
|
1683, 1689
|
1705, 2096
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,990
| 179,653
|
53447+59525
|
Discharge summary
|
report+addendum
|
Admission Date: [**2153-6-23**] Discharge Date: [**2153-6-29**]
Date of Birth: [**2101-2-9**] Sex: M
Service: MED
CHIEF COMPLAINT: Abdominal pain.
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old
male with multiple medical problems, status post recent
discharge from the [**Hospital1 69**] for
hypoxia who presents now with one to two days of abdominal
pain, fever with a temperature of 102.6, and leukocytosis. A
chest x-ray at [**Hospital3 7**] demonstrated new right lower
lobe pneumonia and the patient was started on vancomycin and
ceftazidime. On the day of admission, the patient had
worsening symptoms and there was concern over his rigid
abdomen so the patient was transferred to the [**Hospital1 346**] for further evaluation. The patient
denied any rigors, nausea, vomiting, diarrhea, but did
complain of a significant amount of right upper quadrant
abdominal pain.
PAST MEDICAL HISTORY: Status post mitral valve replacement
times two in [**2142**] and 1984 with a St. Jude's valve.
Status post Staphylococcal endocarditis after his first
mitral valve replacement.
Congestive heart failure with an ejection fraction of [**11-9**]
percent.
Status post brain abscess and septic emboli from the
staphylococcal endocarditis.
Atrial fibrillation.
Diabetes mellitus type 2.
End-stage renal disease, on hemodialysis.
History of upper GI bleeding from duodenal ulcers.
Restrictive interstitial lung disease felt to be secondary to
ankylosing spondylitis.
Gout.
Respiratory failure requiring tracheostomy and ventilatory
support in [**2153-3-26**].
PEG tube placement in [**2153-3-26**] that was complicated by
abdominal wall hematoma.
Nonsustained ventricular tachycardia.
Anemia.
Sacral decubitus ulcers.
Coronary artery disease, status post CABG with a LIMA to LAD.
Status post right lower extremity cellulitis.
Depression.
ALLERGIES: The patient has no known drug allergies
MEDICATIONS ON ADMISSION:
1. Aspirin 81 mg daily.
2. Reglan 5 mg q.h.s.
3. Lansoprazole.
4. Ascorbic acid.
5. Zinc.
6. Epogen 5,000 units t.i. week.
7. Tylenol p.r.n.
8. Percocet p.r.n.
9. Atrovent.
10. Albuterol.
11. Ambien.
12. Senna.
13. Colace.
14. Celexa.
15. Carvedilol 3.125 mg b.i.d.
16. Bactrim double-strength times ten days.
17. Glargine 15 units q.h.s.
18. Coumadin 5 mg q.h.s.
FAMILY HISTORY: Positive for coronary artery disease and
valvular disease.
SOCIAL HISTORY: Remote tobacco use, quit 20 years ago. The
patient does not drink alcohol.
PHYSICAL EXAMINATION: Vital signs: On admission,
temperature 100.6, heart rate 112, blood pressure 97/59,
oxygen saturation 100 percent on ventilator support.
General: The patient was a chronically ill-appearing male.
HEENT: Dry mucosal membranes. The pupils were equal, round,
and reactive to light. The extraocular muscles were intact.
Heart: Irregularly/irregular with a II/VI systolic ejection
murmur at the left lower sternal border at the apex. Lungs:
Coarse breath sounds bilaterally. There was scattered
rhonchi at the bases. Abdomen: Tense, tender, positive
bowel sounds with guarding, mainly in the right upper
quadrant. Extremities: There was no clubbing, cyanosis, or
edema. Chronic venostasis changes with mottling in the lower
extremities bilaterally.
LABORATORY DATA: White blood cell count 30.5, 98 percent
polys, 5 percent lymphs, hematocrit 32, platelets 230,000.
Sodium 148, potassium 3.9, BUN 52, creatinine 3.7. PTT 43.6,
INR 3.6. The U/A was negative for infection.
The abdominal CT showed right lower lobe consolidation
consistent with pneumonia, multiple intra-abdominal loculated
fluid collections with peripheral enhancement concerning for
infected fluid and a distended gallbladder.
HOSPITAL COURSE:
1. SEPSIS: In the Emergency Department, the patient was
febrile to 100.6 with a blood pressure of 90/60 and
tachycardia. He was enrolled in the MUST protocol for
sepsis. His lactate was 1.8. He had a right IJ triple
lumen catheter placed. He was given IV fluids, was
continued on vancomycin and ceftazidime. His abdominal CT
revealed a right lower lobe pneumonia and several
abdominal wall fluid collections with a faint peripheral-
enhancing ring. The patient was seen and evaluated by the
surgical team as there was concern for acalculous
cholecystitis and/or abdominal wall abscesses. At this
time, it was felt that the patient was a poor surgical
candidate and that the best option would be to undergo an
ultrasound-guided drainage of these abdominal wall fluid
collections by Interventional Radiology.
The patient underwent this procedure and the abdominal
ultrasound revealed a large left lower quadrant fluid
collection and a simple right upper quadrant fluid collection
with a few thin septations. The gallbladder was distended
and full of sludge. There was gallbladder wall edema and
irregularities along the mucosal surface and the nondependent
portion. There was no common bile duct dilatation and there
were no stones identified. The two abdominal wall fluid
collections were drained and a #8 French pigtail catheter was
left in the right upper quadrant fluid collection. Over the
next several days, the right upper quadrant fluid collection
contained dark material with a total bilirubin of 2.2 and an
LDH of 923. Initially, the right upper quadrant fluid
collection was felt to potentially be a biloma; however, upon
further discussion with the Surgery Team, it was felt that
this low-level bilirubin was more consistent with an
abdominal wall hematoma and breakdown of red blood cells.
The patient was continued on a seven day course of vancomycin
and Zosyn, renally dosed, and defervesced within 48 hours.
He continued to do well and have improvement in his abdominal
pain. However, on the day of discharge, the patient had mild
to moderate tenderness and tenseness in his right upper
quadrant. He was seen by his surgeon, Dr. [**Last Name (STitle) **] who felt
that his abdominal examination was consistent with his
baseline abdominal examination preadmission.
RIGHT LOWER LOBE PNEUMONIA: On admission, the patient had a
chest x-ray from [**Hospital3 7**] which showed a right lower
lobe consolidation. In addition, his admission CAT scan at
the [**Hospital1 69**] showed a right lower
lobe consolidation. The patient was continued on a seven day
course of vancomycin and Zosyn for his sepsis and on the day
of discharge the patient had no further evidence of ongoing
pneumonia.
RESTRICTIVE LUNG DISEASE AND RESPIRATORY FAILURE: The
patient has a history of restrictive lung disease and was
recently intubated and had a tracheostomy performed in [**2153-3-26**] for progressive respiratory failure. His respiratory
disease is felt to be due to restriction secondary to his
ankylosing spondylitis. During this admission, the patient
was maintained on his usual ventilator settings of AC with a
tidal volume of 400, rate of 12, PEEP 5, and an FI02 of 40
percent. The patient underwent several two to three hour
periods where he was off ventilatory support. Upon
discharge, the patient should continue at Pulmonary
Rehabilitation and should have his ventilator weaned with a
goal of having him eventually off the ventilator during the
day and resting on the ventilator with AC overnight. The
patient's pulmonary rehabilitation and ventilator weanings
should include several short one to three hour periodic
breaks off the ventilator as bursts of respiratory muscle
exercise are better than long-term trials over several days
that could exhaust the patient.
CONGESTIVE HEART FAILURE: The patient was with congestive
heart failure with an ejection fraction of [**11-9**] percent.
His volume was maintained with hemodialysis three times a
week. The patient has ischemic cardiomyopathy with an
ejection fraction less than 35 percent and has NSVT with
short runs of up to 25-30 beats seen on telemetry. He should
be continued on his heart failure beta blocker and if he
continues to do well at the rehabilitation facility an
outpatient EP consult should be considered for possible ICD
placement.
END-STAGE RENAL DISEASE: On hemodialysis. The patient has
been in renal failure since [**2153-3-26**]. His end-stage
renal disease was felt to be multifactorial. The etiology is
unclear. The patient has hemodialysis on Monday, Wednesday,
and Friday.
MITRAL VALVE REPLACEMENT: The patient has had two mitral
valve replacements and the first mitral valve replacement was
complicated by staphylococcal endocarditis with septic emboli
and a brain abscess. The patient was taken off of his
Coumadin for his interventional procedure and was placed on a
heparin drip using a weight-based protocol. Upon discharge,
the patient had been restarted on Coumadin but did not have a
therapeutic INR. His heparin drip should be continued until
his Coumadin INR is within his goal range of 2.5 to 3.5. In
addition, once his heparin drip has been stopped, he should
be restarted on a baby aspirin daily.
ANEMIA: The patient has anemia of chronic disease and anemia
secondary to renal disease. He receives occasional
transfusions at hemodialysis as needed. His goal hematocrit
is 28. He is on Epogen 5,000 units subcutaneously three
times a week on Monday, Wednesday, and Friday.
DIABETES MELLITUS TYPE 2: The patient was initially on an
insulin drip during this hospitalization; however, he was
converted over to regular insulin sliding scale. The patient
had been admitted on Glargine and this should be restarted at
his rehabilitation facility. His dose of Glargine can be
titrated up to achieve optimal blood glucose control.
CORONARY ARTERY DISEASE: The patient has documented coronary
artery disease, status post coronary artery bypass graft,
LIMA to LAD in [**2142**]. He should be continued on his low-dose
beta blocker and should be restarted on a baby aspirin once
his heparin drip is stopped.
SACRAL DECUBITUS ULCERS: The patient is with a history of
sacral decubitus ulcers. He should be rotated frequently, be
encouraged to get up out of bed to chair and should be
ambulating if possible with physical therapy. The sacrum
should be monitored for decubitus ulcers and wound should be
checked as appropriate.
PAIN: The patient's pain was initially treated with a
Fentanyl drip; however, this was weaned after several days.
Once his infection had improved, he was transitioned to IV
morphine p.r.n. and Percocet per PEG tube p.r.n.
NUTRITION: The patient had a PEG tube placed for aspiration
several months prior to this admission. The patient has tube
feeds with full strength Nepro with 45 grams of ProMod daily.
The patient's goal rate is 35 cc per hour on nonhemodialysis
days and 40 cc per hour for 20 hours on hemodialysis days
with 20 hour cycles in order to allow him to have a four hour
tube feed-free window during hemodialysis. His PEG tube
should be flushed with 30 milliliters of free water every
eight hours. If the patient continues to improve at the
rehabilitation facility, his swallowing mechanism should be
reevaluated.
ACCESS: The patient has a semi-permanent right antecubital
PICC line with two parts and a left chest Hickman catheter
with two parts.
The remainder of the discharge summary will be dictated on
the day of discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 18138**]
Dictated By:[**Last Name (NamePattern1) 18139**]
MEDQUIST36
D: [**2153-6-28**] 17:18:50
T: [**2153-6-28**] 20:09:34
Job#: [**Job Number **]
Name: [**Known lastname 18020**], [**Known firstname 126**] Unit No: [**Numeric Identifier 18021**]
Admission Date: [**2153-6-23**] Discharge Date: [**2153-7-2**]
Date of Birth: [**2101-2-9**] Sex: M
Service: MED
ADDENDUM:
HOSPITAL COURSE: The patient remained in the hospital for
three additional days as he developed increased congestion,
cough and a low grade fever after stopping the Zosyn and
vancomycin. A repeat chest x-ray did not reveal any new
infiltrate and showed only resolving right lower lobe patchy
infiltrate. His sputum gram stain on the [**5-31**] revealed
4+ gram negative rods and 1+ gram positive cocci in pairs.
Given his worsening clinical signs and symptoms and his
history of Pseudomonas colonization, this 4+ gram negative
rods in the sputum was felt to be a recurrence of his
Pseudomonas pneumonia. His previous Pseudomonal infections
grew Pseudomonas that was resistant to ciprofloxacin,
gentamicin and tobramycin and was sensitive to cefepime,
ceftazidime, piperacillin, Zosyn and meropenem. It was felt
that the patient was likely developing a recurrence of his
Pseudomonas pneumonia and he was restarted on his Zosyn along
with meropenem for double Pseudomonal coverage. He will be
discharged on both of these antibiotics which should be
continued for one week. The Zosyn is renally dosed at 2.25 gm
IV q8h and the meropenem is renally dosed at 500 mg IV q24h.
His doses of meropenem should be given after hemodialysis on
hemodialysis days.
In addition, the patient has a history of atrial fibrillation
which is his current rhythm and a prosthetic mitral valve.
The patient will need to be on Coumadin with a goal INR of
2.5-3.5. However, on the day of discharge, his INR was 1.6.
He will be discharged on a heparin drip which should be
continued until his INR is at least 2.5. At that time, his
heparin drip should be discontinued. He should be started on
a baby aspirin at 81 mg a day and have his INRs monitored
serially as his dose of Coumadin may need to be adjusted.
Respiratory failure/respiratory status: The patient has
restrictive lung disease felt to be secondary to ankylosing
spondylitis. He has been trached for several months. During
his stay here in the Intensive Care Unit, he has had several
breaks from the ventilator where he was up out of bed and off
of ventilatory support completely. This should be continued
at Rehab with a goal of short one to two hour bursts of being
off of the vent. This will help to strengthen his respiratory
muscles. He should be rested at night back on the ventilator
at his setting which currently are assist-control with a rate
of 12, volume of 400, PEEP of 10 and an FIO2 of 40 percent.
The patient should be continued on his diabetic regimen of
Regular insulin sliding scale and Glargine 15 units qhs. His
dose of Glargine may need to be increased and he should have
fingersticks checked before each meal and before bedtime.
The patient has had his abdominal wall hematomas drained.
These were initially felt to be either infected or possibly
containing bile. However, the fluid cultures from these
hematomas never grew any organisms. The gram stains were
negative and the total bilirubin was not consistent with a
biloma and was more consistent with old collections of blood.
CONDITION ON DISCHARGE: Medically stable on ventilatory
support throughout the night and through most of the day.
DISCHARGE STATUS: To [**Hospital **] Rehab Facility.
DISCHARGE DIAGNOSES: Congestive heart failure with an
ejection fraction of [**11-9**] percent, acalculous cholecystitis,
abdominal wall hematoma status post ultrasound-guided
drainage, status post mitral valve placement, restrictive
lung disease secondary to ankylosing spondylitis on a
ventilator with a chronic trach, coronary artery disease
status post CABG in [**2132**] with a LIMA to LAD, end-stage renal
disease on hemodialysis, Pseudomonas pneumonia, atrial
fibrillation, status post PEG tube placement on tube feeds,
gout, diabetes mellitus, nonsustained ventricular
tachycardia, ankylosing spondylitis, sacral decubitus ulcer,
sepsis, history of staphylococcus endocarditis.
FOLLOW UP: Please follow-up with the primary care physician
within one to two weeks and please follow-up with the
cardiologist in three to four weeks.
DISCHARGE MEDICATIONS: Reglan 5 mg in solution per NG tube
qhs, Colace one tablet per PEG tube [**Hospital1 **], Ambien 5 mg per PEG
tube qhs, carvedilol 3.125 mg per PEG tube [**Hospital1 **], Atrovent two
puffs qid, lansoprazole 30 mg per PEG tube qd, zinc sulfate
220 mg capsule per PEG tube qd, albuterol one to two puffs
q6h, prn, Percocet one to two tablets per PEG q4-6h, prn,
Coumadin 5 mg per PEG tube qhs, Senna one tablet [**Hospital1 **],
citalopram 20 mg qd, ascorbic acid 500 mg qd, lorazepam 0.5
mg IV prn, qhs for insomnia, Regular insulin sliding scale,
morphine 1-4 mg IV q4h, prn for pain, heparin flushes for
PICC line and Hickman care daily as needed, heparin drip
currently running at 1250 units an hour. PTT should be
checked every six hours and dose adjusted via a weight-based
sliding scale until his dose has been stable for two
successive checks. His goal is a PTT of 60-100. The heparin
drip can be stopped once his INR is between 2.5 and 3.5.
Aspirin 81 mg daily is to be started once the heparin is
discontinued. He is on Glargine 15 units subcu qhs, meropenem
500 mg IV q24h for seven days (please give his dose after
hemodialysis on the days when he has hemodialysis) and Zosyn
2.25 gm IV q8h for seven days.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2393**], [**MD Number(1) 2394**]
Dictated By:[**Last Name (NamePattern1) 18027**]
MEDQUIST36
D: [**2153-7-2**] 12:37:54
T: [**2153-7-2**] 13:47:51
Job#: [**Job Number 18028**]
|
[
"584.9",
"038.9",
"403.91",
"707.0",
"518.84",
"428.0",
"427.31",
"482.1",
"427.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.93",
"54.91",
"99.04",
"39.95",
"96.6",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
2391, 2451
|
15118, 15783
|
15960, 17450
|
1963, 2374
|
11897, 14925
|
15795, 15936
|
2568, 3775
|
153, 170
|
199, 913
|
936, 1937
|
2468, 2545
|
14950, 15096
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,630
| 186,078
|
47113
|
Discharge summary
|
report
|
Admission Date: [**2166-3-3**] Discharge Date: [**2166-3-7**]
Date of Birth: [**2096-1-17**] 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:
Intubation with mechanical ventilation [**2166-3-3**] - [**2166-3-4**]
History of Present Illness:
70 year-old woman with severe kyphoscoliosis and chronic
restrictive lung disease/hypoventilation with some obstructive
component and sleep disordered components as well, on home O2;
presenting to ED with shortness of breath. EMS was called to
her home today for worsening respiratory distress. Reportedly
had sats in the 40% range and placed on a non-rebreather mask.
Nebs given en route. Noted to become very lethargic with EMS.
In the ED, initial vs were: T96.8 112 160/78 30 97% on NRB.
Oriented x2 and noted to be lethargic. Poor air movement and
intubated. Patient was given solumedrol 125 mg IV, zosyn,
vancomycin, and started on propofol gtt. High pressures
following intubation. Was reparalyzed with vecuronium 10 mg x1.
Changed to PCV, last setting FiO2 0.7, PEEP 6, peak pressures
40 with ABG 7.37/77/184.
In the [**Hospital Unit Name 153**], patient denies shortness of breath, chest pain,
headache, abdominal pain, leg pain. When questioned does
endorse feeling unwell in days prior to ED presention - endorses
cough and diarrhea, no fevers. Does not answer when asked if
wearing bipap at nighttime, but endorses wearing oxygen.
She was recently admitted from [**Date range (1) 99865**] for altered mental
status. She was found to have acute on chronic hypercarbic
respiratory failure but was able to be managed on NIPPV alone.
Past Medical History:
- Severe kyphoscoliosis s/p operative repair in [**2140**]. Last
spirometry [**8-/2165**] FVC 30% pred (490cc), FEV1 27% pred (300cc),
ratio 0.62, DLCO 17% pred
- Severe sleep disordered breathing
- Hypoventilation syndrome due to severe restrictive lung
disease
- Asthma
- Chronic hypercapneic, hypoxic respiratory failure- resting ABG
pH of 7.40 and PCO2 of 85 on continuous home oxygen
- Chronic diastolic heart failure
- Pulmonary hypertension - TTE [**1-/2166**] with TR gradient 60-70,
RVH and mild RV dilation in setting of elevated PCWP.
- Large hiatal hernia
- GERD
- Hypertension
- h/o severe skin burns as child
- Osteoporosis
- h/o hip and back pain
Social History:
Prior smoke (X 11 years) but quit in [**2138**]. No alcohol. Lives
with daughter and performs own ADLs (bathing, dressing,
cooking). Previously worked as a home health aide. Widowed.
Family History:
Father died of liver cancer. Daughter with breast cancer at 45.
Also history of colon cancer. No history of pulmonary disease.
Physical Exam:
Exam in the ICU:
General: Alert, intubated, no distress.
HEENT: Sclera anicteric, PERRL, MMM, visible oropharynx is clear
Neck: supple, JVD appears ~4 cm ASA, no LAD.
Lungs: Clear to auscultation bilaterally, diffuse end expiratory
wheezing with prolonged expiratory phase.
CV: Regular rate and rhythm, S1 + S2, [**2-15**] SM best at LUSB, loud
P2. Prominent impulse at left sternal border.
Abdomen: Markedly and tightly scarred from abdomen into pelvis
and upper thighs. Denies tenderness to palpation.
Ext: cool, 2+ pulses, no clubbing, no edema.
Neuro: alert with mild sedation. Follows complex commands.
Strength 5/5 in both UE and LE distal motor groups.
Exam on the floor:
VS: 99.6 134/82 93 18 100% on 2L
GEN: NAD, Kyphotic
HEENT: EOMI, MMM, no oral lesions
NECK: Supple, JVP flat
CHEST: CTAB, small lung volume
CV: RRR, normal s1 and s2
ABD: Soft, nontender, nondistended, bowel sounds present
EXT: No BLE edema
NEURO: Alert, fully oriented, CN 2-12 intact, sensory intact,
strength 5/5 BUE/BLE, fluent speech
PSYCH: Calm, appropriate
Pertinent Results:
Admission labs [**2166-3-3**]:
PT-10.9 PTT-26.7 INR(PT)-0.9
NEUTS-79.1* LYMPHS-14.0* MONOS-5.4 EOS-1.1 BASOS-0.3
WBC-5.8# RBC-3.71* HGB-10.5* HCT-36.9 MCV-100* PLT-132
ALBUMIN-3.9 CALCIUM-9.8 PHOSPHATE-4.2 MAGNESIUM-2.2
CK-MB-5 cTropnT-0.01 proBNP-1843*
ALT(SGPT)-10 AST(SGOT)-18 LD(LDH)-246 CK(CPK)-92 ALK PHOS-86 TOT
BILI-0.2
GLU-118* UREA N-24* CR-1.1 [**Month/Day/Year 11516**]-147* POTASSIUM-5.6*
CHLORIDE-96 CO2-46*
ABG: TEMP-36.9 RATES-20/ TIDAL VOL-290 PEEP-5 O2-50 PO2-99
PCO2-51* PH-7.57* TOTAL CO2-48* BASE XS-21 -ASSIST/CON
INTUBATED-INTUBATED
URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010 BLOOD-NEG
NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILI-NEG
UROBILNGN-NEG PH-8.5* LEUK-TR RBC-6* WBC-4 BACTERIA-NONE
YEAST-NONE EPI-0 MUCOUS-RARE
Stool C-diff: negative
Urine Culture: negative
Urine legionella: negative
Sputum culture: negative
MRSA screen: negative
Blood Cultures: No growth to date
CXR [**3-3**]:
1. Endotracheal tube approximately 3 cm above the carina.
2. Large hiatla hernia.
3. Probable bibasilar atelectasis.
4. Stable cardiomegaly.
CXR [**3-5**]:
Given patient position, the radiograph is limited and difficult
to evaluate for interval changes. The endotracheal tube has been
removed in the interval. The patient position is grossly
unchanged.
There is no evidence of pneumothorax, areas of basilar
atelectasis cannot be excluded. There is no overt pulmonary
edema, but crowding of the vessels and minimally increased
vessel diameter could suggest increased pulmonary blood volume.
No evidence of interval recurrence of focal parenchymal
opacities suggesting pneumonia.
Brief Hospital Course:
70 year-old woman with severe kyphoscoliosis and chronic
restrictive lung disease/hypoventilation, presenting with
hypercarbic respiratory failure. The patient was intubated in
the ED and admitted to the ICU. Acute decompensation was likely
multifactorial: CPAP noncompliance, CHF exacerbation (elevated
BNP, and overloaded on admission), COPD exacerbation, severe
systolic pulmonary HTN. ECG at baseline and w/o rising CE
making ischemic event less likely. She was treated with lasix
for CHF, steroids and nebs for COPD, and antibiotics for concern
for hospital aquired pneumonia with atypical coverage. Patient
was extubated successfully without any complications and
maintained on nasal cannula and nasal BIPAP overnight.
# COPD Exacerbation: Treated w/short course of steroids,
nebulizers, and antibiotics. Will complete a 10-day course of
antibiotics with Levofloxacin.
# Acute on Chronic diastolic CHF (LVEF>75% [**1-/2166**]): Initially
volume overloaded. Diuresed with IV lasix with improvement in
respiratory status. Subsequently restarted on her home dose
lasix and maintained on her home dose ace-inhibitor.
# Acute on Stage 3 CKD: [**Month (only) 116**] be [**2-11**] poor forward flow from Acute
on chronic diastolic heart failure (LVEF>75%). Euvolemic at
discharge.
# Anemia. She was noted to have macrocytosis w/ boarderline B12
levels. F/u as outpatient.
# Fever: Fever with Temp 101 on [**3-4**], but afebrile throughout
rest of admission. Sputum, Urine, Stool cultures negative.
Blood culture no growth to date. HAP antibiotics started.
Antibiotics narrowed to Levofloxacin to complete a 10-day
course.
# Patient will go home with home VNA nursing services
Medications on Admission:
- Albuterol Solution for Nebulization q4-6H prn wheeze or
dyspnea.
- Albuterol 90 mcg/Actuation, Two Q6H prn wheeze/dyspnea.
- Fosamax 70 mg Tablet once a week
- Fexofenadine 180 mg DAILY
- Fluocinonide 0.05 % Cream Topical as directed.
- Fluticasone [**1-11**] sprays Nasal daily.
- Flovent HFA 220 mcg inhaled twice a day.
- Lasix 80 mg daily.
- Reglan 10 mg before meals and hs for reflux esophagitis.
- Lisinopril 40 mg once a day.
- Naproxen 250 mg 1-2 tabs twice a day as needed for pain
- Protonix 40 mg once a day.
- Salmeterol 50 mcg/Dose One (1) puff Inhalation at bedtime.
- Docusate [**Month/Day (2) **] 100 mg once a day.
- Calcium Carbonate 500 mg TID
- Cholecalciferol 800 unit DAILY
- Polyethylene Glycol 17 gram/dose DAILY
- Multivitamin DAILY
- Home Oxygen
Medications on transfer from ICU:
Heparin 5000 UNIT SC TID
Vancomycin 1000 mg IV Q 24H
Piperacillin-Tazobactam 2.25 g IV Q6H
Pantoprazole 40 mg IV Q24H
Multivitamins 1 TAB PO/NG DAILY
Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation
Azithromycin 250 mg PO/NG Q24H Start: In am
Cyanocobalamin 1000 mcg PO/NG DAILY
Lisinopril 40 mg PO/NG DAILY
PredniSONE 20 mg PO/NG ONCE Duration: 1 Doses Start: [**2166-3-6**]
PredniSONE 10 mg PO/NG ONCE Duration: 1 Doses Start: [**2166-3-7**]
Acetaminophen 650 mg PO/PR Q6H:PRN fever, pain
Docusate [**Month/Day/Year **] 100 mg PO BID
Albuterol 0.083% Neb Soln 1 NEB IH Q4H
Ipratropium Bromide Neb 1 NEB IH Q6H
Furosemide 80 mg PO/NG DAILY
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) unit Inhalation every 4-6 hours as
needed for shortness of breath or wheezing.
2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation four times a day as needed for
shortness of breath or wheezing.
3. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
4. [**Doctor First Name **] 180 mg Tablet Sig: One (1) Tablet PO once a day.
5. Fluocinonide 0.05 % Cream Sig: One (1) application Topical
once a day: apply to affected areas.
6. Fluticasone 220 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation twice a day.
7. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO once a day.
8. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. Reglan 10 mg Tablet Sig: One (1) Tablet PO QAC and QHS: 30
mins before meals and before sleep for reflux esophagitis.
10. Naproxen 250 mg Tablet Sig: 1-2 Tablets PO twice a day: Use
only a max of 3 days per week.
11. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
12. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) puff
Inhalation at bedtime.
13. Calcium Carbonate 300 mg (750 mg) Tablet, Chewable Sig: Two
(2) Tablet, Chewable PO twice a day.
14. Coenzyme Q10 50 mg Capsule Sig: One (1) Capsule PO once a
day.
15. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day.
16. Ergocalciferol (Vitamin D2) Oral
17. Multivitamin with Iron-Mineral Tablet Sig: One (1)
Tablet PO once a day.
18. Omega-3 Fatty Acids-Fish Oil 360-1,200 mg Capsule Sig: One
(1) Capsule PO once a day.
19. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once
a day.
20. Levofloxacin 750 mg Tablet Sig: Four (4) Tablet PO Q48H
(every 48 hours) for 4 doses: Take one tablet [**3-7**], [**3-9**], [**3-11**],
and [**3-13**].
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnoses:
1. Acute respiratory failure with intubation
2. Acute exacerbation of chronic obstructive pulmonary disease
3. Acute exacerbation of chronic diastolic heart failure
(LVEF>75%)
Secondary Diagnoses:
1. Severe kyphoscoliosis with operative repair in [**2140**]. Last
spirometry [**8-/2165**] FVC 30% pred (490cc), FEV1 27% pred (300cc),
ratio 0.62, DLCO 17% pred
2. Severe sleep disordered breathing
3. Hypoventilation syndrome due to severe restrictive lung
disease
4. Asthma
5. Chronic hypercapneic, hypoxic respiratory failure- resting
ABG
pH of 7.40 and PCO2 of 85 on continuous home oxygen
6. Pulmonary hypertension - TTE [**1-/2166**] with TR gradient 60-70,
RVH and mild RV dilation in setting of elevated PCWP.
7. Large hiatal hernia
8. Gastroesophageal reflux disease
9. Hypertension
10.Osteoporosis
11.History of hip and back pain
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 came to the hospital with shortness of breath so severe that
you required intubation and mechanical ventilation. Your
shortness of breath was likely caused by a combination of
exacerbation of COPD and your heart failure. You responded well
to diuresis, antibiotics, nebulizer treatment, and prednisone.
You were only on mechanical ventilation for 2 days. You are now
back to your baseline.
MEDICATION CHANGES:
START: Levofloxacin through [**3-13**] to complete a 10-day total
antibiotic course.
OTHER INSTRUCTIONS:
Please check your weight daily to monitor for fluid retention.
If you find that you gain more than [**2-13**] pounds above your
regular weight, please contact your primary care clinic to help
manage your congestive heart failure.
Followup Instructions:
It is very important for you to follow up with your primary care
physician and pulmonologist given you had such severe
respiratory problems this hospital admission.
Appointment #1: Pulmonary
Department: PULMONARY FUNCTION LAB
When: MONDAY [**2166-3-10**] at 2:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: MONDAY [**2166-3-10**] at 2:30 PM
With: DR. [**First Name8 (NamePattern2) 3688**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Appointment #2: Primary Care
Department: [**Hospital3 249**]
When: WEDNESDAY [**2166-3-26**] at 4:15 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4131**], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
[
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10644, 10702
|
5555, 7246
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333, 405
|
11604, 11604
|
3904, 5532
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2692, 2821
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433, 1789
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11619, 11759
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2492, 2676
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,270
| 192,345
|
48387+59084
|
Discharge summary
|
report+addendum
|
Admission Date: [**2190-6-9**] Discharge Date: [**2190-6-25**]
Service: GENERAL SURGERY PURPLE TEAM
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old
female with a history of colon cancer status post colectomy
with colostomy who presented with weakness and unsteady gait
and some abdominal pain. The patient was unable to climb
upstairs. No chest pain, shortness of breath. She had
nausea, no vomiting. She had ostomy output which was normal,
three recent admissions for dehydration. The patient
presented with a large peristomal hernia which has been there
for, as patient states, years.
PAST MEDICAL HISTORY:
1. Congestive heart failure, ejection fraction of 30%
2. Colon cancer as stated above
3. Hypertension
4. Chronic back pain
5. Renal insufficiency, baseline of 1.3
6. AICD
7. Osteoporosis
8. Degenerative joint disease
9. Hypothyroidism
HOME MEDICATIONS:
1. Protonix 40 mg qd
2. Atenolol 100 mg qd
3. Flexeril 10 mg qd
4. Neurontin 400 mg qid
5. Paxil 20 mg qd
6. Tobradex 1 drop both eyes tid
7. Norvasc 5
8. Duragesic patch 25 mg q 72 hours
9. Zyprexa 2.5 mg qd
10. Thyroxine 0.1 mg po qd
11. Iron sulfate 325 mg po tid
12. Albuterol
13. Aspirin
PHYSICAL EXAM:
VITAL SIGNS: Her vital signs were stable, afebrile.
GENERAL: She was sleepy, confused.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft. The peristoma hernia was the size of a
grapefruit. She was tender. The ostomy site was fine. She
has a well healed midline scar. The hernia was also warm.
Bowel sounds were present. It was non reducible and she was
guaiac positive. She had no guarding, no rebound and no
tenderness on percussion.
LABS: White blood cells 18.3, 8 bands, 76 neutrophils, 39
hematocrit. Urinalysis was negative. Chem-7 was normal.
Amylase 114, lipase 61, ALT 28, AST 15. Head CT was negative
for bleed, no shift. Chest x-ray was negative, normal. CT
scan showed large left sided hernia sac 4.3 cm defect in the
abdominal wall at site of colostomy. Large bowel present in
hernia, no dilated loops of small bowel. Area of loop of
bowel is compressed against the abdominal wall.
HOSPITAL COURSE: The patient was taken to the Operating Room
on [**6-10**] for a strangulated peristomal hernia. She had
undergone total abdominal colectomy and ileostomy repair of
the hernia using S/S. Please see operative note for further
details. Findings were ischemic colon within peristomal
hernia, diffusely dilated large bowel. Postoperatively, the
patient was admitted to the Intensive Care Unit for prolonged
ventilation. The patient did not have any complications.
The patient required nitroprusside drip while in the
Intensive Care Unit. Central venous line was placed for
adequate monitoring. The patient was on ceftriaxone,
ampicillin and Flagyl. Postoperatively, the patient was
placed on tube feeds, Ultracal at a rate of 60.
She was transferred to the floor on [**2190-6-20**]. While
she was on the floor, the patient had postoperatively three
JPs. Each JP successfully decreased in output. JPs were
removed. Her ostomy started putting out stool. The patient
had multiple CT scans for lethargy and confusion while in the
Intensive Care Unit which were negative for stroke or bleed.
Multiple cultures were taken, all of which came back
negative. However, JP site cultures were positive for yeast.
However, they were removed. The patient's left arm was
swollen with tenderness on her shoulder. Ultrasound Doppler
studies were done and showed no deep venous thromboses on the
left upper extremity. Shoulder films were done and showed no
fracture. However, she does have degenerative joint disease.
She also has a pacemaker.. Multiple
chest x-rays were done, the
latest of which demonstrates a left lower lobe consolidation
consistent with atelectasis. Her exam improved. She became
more alert and oriented. Swallowing evaluation was done
which was successful. She did not aspirate liquids or pureed
food. However, her cognition was slow during the process and
she had to be reminded multiple times to chew. Please see
the speech and swallow recommendations. She can tolerate of
thin liquids and pureed foods, supervise feedings to remind
her how to swallow. She is to feed upright at 90??????. She
needs to take small bites and sips, two swallows per bite or
sip alternating between pureed bite and liquid sip, crush
medications and given mustard. Caloric counts should be done
to maintain nutrition with po's. She is being discharged to
rehabilitation on medications.
DISCHARGE MEDICATIONS:
1. Captopril 75 mg po nasogastric tid crushed
2. Levothyroxine 100 mcg po qd crushed
3. Heparin 5000 units subcutaneous [**Hospital1 **]
4. Lopressor 100 mg po tid, hold if pulse is less than 60
and systolic blood pressure less than 110.
5. Hydralazine 20 mg po q4h, hold if systolic blood pressure
is less than 110
6. Protonix 40 mg po qd crushed
7. Tylenol 325 to 650 mg po q 4 to 6 prn
8. Tube feed Ultracal full strength at the rate of 60, slush
with 150 cc of free water q8h. Check residuals q4h, hold if
tube feed greater than 100.
DIET: She is on full liquids currently. However, she can be
advanced as per stated recommendations above when tolerating
full liquids. Please see swallowing instructions. She is
sent for physical therapy, nutritional monitoring and ostomy
care.
FOLLOW UP: She has follow up with Dr. [**Last Name (STitle) **] in two to four
weeks.
She is discharged to rehabilitation on postoperative day 16
and will be followed by Dr. [**Last Name (STitle) **] from [**Hospital6 649**].
[**Name6 (MD) 843**] [**Name8 (MD) 844**], M.D. [**MD Number(1) 845**]
Dictated By:[**Name8 (MD) 6908**]
MEDQUIST36
D: [**2190-6-25**] 07:31
T: [**2190-6-25**] 08:44
JOB#: [**Job Number 88055**]
Name: [**Known lastname **], [**Known firstname 3344**] Unit No: [**Numeric Identifier 16412**]
Admission Date: [**2190-6-9**] Discharge Date: [**2190-6-25**]
Date of Birth: [**2112-4-22**] Sex: F
Service: GENERAL [**Doctor First Name **]
HISTORY OF THE PRESENT ILLNESS: This is a 78-year-old woman
born on [**2112-4-22**], admitted to the General Surgery
Service Purple Team on [**2190-6-9**] and discharged on [**2190-5-30**].
ADDENDUM TO DISCHARGE SUMMARY: The [**Hospital 1325**] hospital course
was extended from [**6-25**] to [**6-30**], as the patient was
waiting for a rehabilitation facility with the appropriate
services to manage her tube feeds via the Dobbhoff tube. Her
tubes feeds have increased to 90 cc per hour. During this
time calorie counts were continued, which indicated that the
patient was still unable to maintain sufficient caloric
intake by mouth. There has been no other acute change in the
patient's condition, and she is being discharged to
rehabilitation in stable condition on all of the
previously-listed medications.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 3676**]
Dictated By:[**Last Name (NamePattern1) 2751**]
MEDQUIST36
D: [**2190-6-30**] 11:57
T: [**2190-6-30**] 10:56
JOB#: [**Job Number 14786**]
|
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icd9cm
|
[
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637, 882
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,368
| 147,016
|
24865+57418
|
Discharge summary
|
report+addendum
|
Admission Date: [**2172-11-23**] Discharge Date: [**2173-1-6**]
Date of Birth: [**2094-1-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
AML,Shortness of breath, hematuria
Major Surgical or Invasive Procedure:
Whole Brain Radiation Therapy
Placement of a PICC line
Placement of a central venous line
History of Present Illness:
78 year old woman who was in in her usual state of excellent
health unti she was admitted to [**Location (un) 62562**] Hospital with
substernal chest pain, shortness of breath and upper mid back
pain on [**2172-11-18**]. She was also noted to have gross hematuria.
*
Her WBC was about 18 and rose to 28 over the following two days.
On admission: fibrinogen was decreased on admission to 30 and
she was maintained >100 with cyroprecipitate transfusions. Her
fibrin split products was >40. PTT normal at 29.8 and PT was
elevated at 18.6. On peripheral smear [**11-19**] she was noted to
have early forms, including [**Last Name (un) **], myelos and myeloblasts. Her
LDH was 1,500. Her creatinine rose from 1.1 to 2.5 during her
admission (nephrotoxic drugs included vanco and CT contrast dye.
Uric acid was normal Electrolytes were normal and w/o evidence
of tumor lysis. On admission her plts were 87 and her hct=44.
Today ([**11-23**]) her hct=24, plts=55 and wbc=21. Over her hospital
course, she recieved plts x 7, FFP x 4 and cryo x 3 and one unit
of PRBC.
*
Her temperature was 38.2 max at the OSH. On [**11-18**] CXR w/
increase vasc congestion and small left effusion and ill-defined
desity at right lung base ? RLLL infiltrate. She was treated
with vancomycin and zosyn (both started [**11-18**]). Blood cultures
x 4 are negative to date by report. Ucrine culture grew several
mixed organisms. CT [**11-17**] showed diverticulosis and precarinal
LAD w/ likely RUL opacity c/w scar. Also showed left adnexal
cystic structure.
*
She was given vitamin K 20mg IV once for PT of 17.8, which
responded by declining to 12.4 on [**11-23**]. PTT was normal
throughout her stay. haptoglobin-127
*
Total bilirubin elevated up to 2.3, but declined to 1.9 the
following day ([**11-20**])
*
Bone marrow aspirate by Dr. [**First Name (STitle) **] and on her review, she had
increased luekemic blasts, without obvious auer rods. She did
not note schistocytes.
*
On ER presentation [**11-18**] her BP was elevated to 204/92 and she
complained of urine discoloration since starting nitrofurantoin
for urinary frequency x 1 week. A bone marrow biopsy revealed
acute myeloid leukemia best classified as monoblastic M5a (FAB
classification) with >90% cells in her bone marrow being blasts.
.
REVIEW OF SYSTEMS: No weight loss, fever or lymphadenopathy. No
other bleeding other than hematuria. No nausea, vomitting. chest
and back pain now resolved. no diarrhea. No shortness of breath
Past Medical History:
PAST MEDICAL HISTORY:
1) Kidney stone 3 years ago
2) GERD
3) MIBI/stress test [**6-26**] -- reportedly unremarkable w/o
reversible ischemic changes.
4) Diverticulosis
5) ?tonsillectomy as a child
Social History:
SOCIAL HISTORY: No smoking. 1 cocktail every night. Lives in
[**Location **] with her sister who is 83. Never married.
Family History:
FAMILY HISTORY: + CAD. NO cancers or blood disorders.
Brief Hospital Course:
AML M5a: She was admitted and started on a low dose Ara C +
hydrea protocol + GM-CSF x 14 days for her AML. She had a slow
decline in respiratory function in the setting of DIC and
initiation of chemotherapy, and was transferred to the ICU for
noninvasive ventilation and diuresis. This resolved and she was
transferred back to the floor where her course was complicated
by mucositis as she became neutropenic and her counts declined.
Her hct and platelets were supplemented as needed with
transfusions to keep her hct > 25 and platelets > 10. The
mucositis was treated with gelclear, viscous lidocaine and
eventually liquid roxicet, and she was placed on TPN. She also
suffered hearing loss, which was initially thought to be
secondary to vancomycin. However, this was followed by delirium
and mental status changes. Benadryl, oxycodone, ativan and
other psychoactive drugs were initially discontinued, but her
mental status continued to vacillate. A head CT was negative,
but a head MRI ordered [**12-22**] showed a possible infiltration in
the right and left frontal lobes and left cerebellum as well as
a small CVA in the left frontal lobe. She had small vessel
disease. Radiation oncology was consulted and she was started
on dexamethasone and a 10-course treatment of whole brain
radiation. Her mental status improved soon after the radiation
was started. Her counts began to return on [**12-24**] and normalized,
requiring no further transfusions. Her last CBC showed WBC 13.6
(elevation thought to be due to steroids), Hct 33.1 and
Platelets differential showed Her mucositis resolved, and her
TPN was weaned off and eventually d/c'ed.
*
Respiratory Distress: Patient was admitted with respiratory
distress that was likely multifactorial. The inciting processes
likely include pulmonary edema (diastolic dysfunction, as echo
[**11-25**] with EF 60-70%, [**1-26**]+ MR) and pneumonia. After starting her
chemo, her respiratory status further declined and she was
transferred to the MICU. There, she was treated for her
pneumonia with vancomycin, flagyl and levofloxacin, placed on
noninvasive ventilation to decrease her afterload and preload,
and she was diuresed gently given her ARF with lasix. She was
initially tried on a CCB for afterload reduction, but was
eventually switched over to atenolol 25 mg PO QD. She was ruled
out for an MI with cardiac enzymes x 5 with a baseline troponin
of 0.05. On transfer to the floor, she finished her course of
antibiotics. The vancomycin was d/c'ed early because of
concerns that it was worsening her hearing. She was sat'ing
97-98%, but still fluid overloaded with LE edema. Due to her
bad mucositis, she was placed on TPN and her medications were
made IV. The increased fluid worsened her volume status and her
respiratory status declined with sats at 93%. As her RF
resolved, she was aggressively diuresed with 20 mg IV lasix QD.
Her respiratory status improved with sats at 99% RA with
resolution of her LE edema at time of discharge. Her baseline
weight at discharge was 134 lbs. Over the course of her
admission, she did have a PICC line attempt on her left arm
which resulted in an UE DVT. This was not treated as her
platelets were <50 at the time. She then developed a second UE
DVT due to a PICC line in her right arm, which was also not
treated due to low platelets. As her platelets improved, the
decision was made not to treat her DVTs given resolution of her
erythema, tenderness and edema in her upper extremities and the
risk of bleeding from her leukemic infiltrates. She had no
evidence of pulmonary embolus secondary to these DVTs during her
admission.
*
Renal Failure: On admission, she was found to be in ARF with a
Cr 2.6 after a contrast-enhanced CT at the OSH. She had a low
FENA, no glomerular hematuria on sediment, just red cells and
very rare muddy browns (3 total). Etiology of arf was thought to
initially be due to contrast-induced nephropathy. Her Cr
eventually came down and stabilized at 0.9-1.0 which was
reportedly her baseline. After aggressive diuresis for her CHF,
her Cr increased back up to 1.2, but resolved with some fluids
and the discontinuation of her diuretics.
*
DIC: Likely [**2-26**] AML. She was given cyroprecipitate to increase
her fibrinogen to 100 and FFP for procedures. Her DIC resolved
after her treatment with AraC and hydrea.
.
Hepatitis with Hyperbilirubinemia: Her bilirubin was 2 on
admission and trended up to a peak of 5.9. Fractionation
revealed roughly half direct and half indirect. A RUQ U/S on
[**11-30**] was normal. Her bilirubin began to elevate again and a
follow-up RUQ U/S [**12-24**] showed sludge in gallbladder with no
evidence of acute cholecystitis or gallstones seen or biliary
ductal dilatation. She also developed a mild transaminitis at
this point. Her fluconazole was discontinued and her liver
enzymes have continued to normalize.
.
Coagulase negative staph line infection - She developed an
infection of her PICC line during her hospital course. As she
had hearing loss with vancomycin previously, she was treated
with daptomycin. The line was d/c'ed and she has finished a 10
day course of daptomycin since rebound of her ANC to > 500, as
recommended by ID. Surveillance cultures show NGTD. Central
line d/c'ed - tip culture showed NGTD at time of discharge. She
has remained afebrile.
.
Hypertension - currently on atenolol. Her BP has normalized as
her dexamethasone has been weaned. HCTZ d/c'ed today due to
overdiuresis and normalized BP.
.
Bowel and bladder incontinence - During her hospital course, she
developed bowel and bladder incontinence. The initial concern
was that patient may have leukemic infiltration in cauda equina
as well. She stated that she could not tell when she needed to
have a BM or to urinate. A foley was placed, and later d/c'ed
as her strength recovered. At time of discharge, she was able
to alert staff when she needed assistance to her bedside
commode, with few accidents. She will need assistance to the
commode. If she continues to have incontinence, a barrier cream
should be applied to her perineal area to avoid infection.
.
Nutrition - Due to bad mucositis, she was placed on TPN during
her admission. As her mucositis resolved, she was restarted on
a regular diet.
.
Dispo - Patient will be discharged to rehab in [**Location (un) **], New
[**Location (un) **]. Greater than 30 minutes was spent in the
coordination of her care.
Medications on Admission:
MEDICATIONS AT HOME:
fosamax, mvi, zantac, asa daily, nitrofurantoin
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
treatment Inhalation Q6H (every 6 hours) as needed.
2. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
3. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
Units Injection TID (3 times a day): Subcutaneous.
7. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic QID
(4 times a day).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day).
Discharge Disposition:
Extended Care
Facility:
St. [**Hospital **] Healthcare Center
Discharge Diagnosis:
Acute Myelogenous Leukemia
Discharge Condition:
fair
Discharge Instructions:
1. Please take all medications as prescribed.
2. Please keep your follow-up appointment with Dr. [**First Name (STitle) 1169**]
([**Telephone/Fax (1) 60008**]) and Dr. [**First Name (STitle) **] . Please make a follow-up
appointment with Dr. [**Last Name (STitle) 62563**] ([**Telephone/Fax (1) 19102**]) or Dr. [**First Name8 (NamePattern2) 2048**]
[**Last Name (NamePattern1) **] (whomever you prefer) within the next 2 weeks.
3. Please seek medical attention if you develop fevers, chills,
nausea, vomiting, shortness of breath, chest pain or any other
concerning symptoms.
Followup Instructions:
A follow-up appointment has been made for you with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1169**] ([**Telephone/Fax (1) 60008**]) on [**1-21**] at 2 PM, and Dr. [**First Name (STitle) **]
([**Telephone/Fax (1) 3237**]) on [**2-9**] at 2 PM. Please also make a
follow-up appointment with either Dr. [**First Name (STitle) **] or Dr. [**Last Name (STitle) 62563**]
([**Telephone/Fax (1) 19102**]) within the next 2 weeks, whomever you prefer.
Dr. [**First Name (STitle) 1557**] will give Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 138**] and Dr. [**First Name (STitle) **] will give Dr.
[**Last Name (STitle) 62563**] a call.
.
CC:[**Last Name (NamePattern1) 62564**]
Completed by:[**2173-1-6**] Name: [**Known lastname 11211**],[**Known firstname **] P Unit No: [**Numeric Identifier 11212**]
Admission Date: [**2172-11-23**] Discharge Date: [**2173-1-6**]
Date of Birth: [**2094-1-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6199**]
Addendum:
Acyclovir was discontinued on [**1-6**], day of discharge, as
patient's mucositis had resolved.
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
treatment Inhalation Q6H (every 6 hours) as needed.
2. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic QID
(4 times a day).
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day).
7. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QHS
(once a day (at bedtime)): Please apply to left eyelid until
erythema resolves.
8. Dexamethasone 1 mg Tablet Sig: One (1) Tablet PO once a day
for 1 days: one more day ([**1-7**]), then stop.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
St. [**Hospital **] Healthcare Center
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6201**] MD [**MD Number(2) 6202**]
Completed by:[**2173-1-6**]
|
[
"996.74",
"486",
"573.3",
"518.81",
"389.9",
"205.00",
"599.7",
"401.9",
"286.6",
"E930.8",
"584.9",
"562.10",
"528.0",
"453.8",
"434.91",
"996.62",
"293.0",
"428.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.06",
"99.04",
"93.90",
"99.25",
"99.07",
"92.29",
"57.32",
"38.93",
"99.05",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
13696, 13916
|
3403, 9869
|
350, 442
|
10868, 10875
|
11501, 12767
|
3341, 3380
|
12790, 13673
|
10818, 10847
|
9895, 9895
|
10899, 11478
|
9916, 9965
|
2778, 2953
|
276, 312
|
470, 803
|
817, 2759
|
2997, 3173
|
3205, 3309
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,385
| 193,295
|
34310
|
Discharge summary
|
report
|
Admission Date: [**2114-6-30**] [**Month/Day/Year **] Date: [**2114-7-11**]
Date of Birth: [**2044-3-25**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Abdominal and back pain
Major Surgical or Invasive Procedure:
[**2114-6-29**] Scrotal debridment
[**2114-7-10**] Scrotal flap
History of Present Illness:
70 yo male who initially presented to [**Hospital 1474**] Hospital with
lower
abdominal pain on [**2114-6-23**] but left hospital against medical
advice, then re-presented again at the same hospital with
similar symptoms, including back pain, fatigue, acute renal
failure, and testicular swelling on [**2114-6-25**]. He is s/p operative
scrotal debridement by urology [**2114-6-29**]. He was transferred to
[**Hospital1 18**] for further management.
Past Medical History:
HTN
Type II DM
Family History:
Noncontributory
Physical Exam:
Upon admission:
Vitals- T 101, HR 67, BP 150/81, RR 33, O2sat 99% 2L
Gen- moderate distress, alert
Head and neck- AT, NC, soft, supple, no masses
Heart- RRR, no murmurs
Lungs- CTAB, no rhonchi, no crackles
Abd- soft, NT, ND, decreased BS
Perineum- extensive skin and subQ tissue debridement of entire
scrotum and perineal region, left testicle pallorous, no
obviously necrotic tissue, no emphysematous or erythema of
surround skin, exquisitely tender
Ext- warm, well-perfused, no edema
Pertinent Results:
[**2114-7-11**] 06:00AM BLOOD WBC-13.3* RBC-3.17* Hgb-8.5* Hct-26.2*
MCV-83 MCH-26.8* MCHC-32.5 RDW-14.9 Plt Ct-409
[**2114-7-10**] 06:15AM BLOOD WBC-13.5* RBC-3.28* Hgb-8.7* Hct-27.0*
MCV-82 MCH-26.6* MCHC-32.4 RDW-15.2 Plt Ct-528*
[**2114-7-9**] 05:40AM BLOOD WBC-11.3* RBC-3.67* Hgb-9.8* Hct-30.4*
MCV-83 MCH-26.7* MCHC-32.2 RDW-14.8 Plt Ct-510*
[**2114-7-4**] 8:53 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT [**2114-7-5**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2114-7-5**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
Radiology Report DUPLEX DOP ABD/PEL LIMITED Study Date of
[**2114-7-1**] 2:26 AM
SCROTAL ULTRASOUND: The right testicle measures 2.7 x 2.8 x 3.8
cm. The left
testicle measures 3.2 x 2.5 x 2.6 cm.
There is no subcutaneous gas. Within the tissues superior to the
testicles
bilaterally, heterogeneously echogenic, irregular soft tissue
swelling is
present. This is distinct from the testicles. The epididymis is
unremarkable
bilaterally.
Color and Doppler examination of the testicles reveal normal
arterial and
venous waveforms in the right testicle. However, the left
testicle shows an
overall relative decrease in blood flow, and no arterial
waveforms are
identified. Venous flow is present.
IMPRESSION:
1. No ischemic changes in the left testicle, but no arterial
flow is
visualized, though strangely venous flow is. This raises concern
for
developing ischemia of the left testicle. Normal arterial and
venous waveforms
in the right testicle.
2. Massive subcutaneous swelling superficial to the testes. No
subcutaneous
air.
Findings discussed with Dr. [**Last Name (STitle) 6955**] at 10:15 a.m.
Radiology Report SCROTAL U.S. Study Date of [**2114-7-10**] 4:06 PM
FINDINGS: Each testicle has been repositioned superiorly into
the inguinal
region of the ipsilateral side. The right testicle measures 3.1
x 2.0 x 2.7
cm. The left measures 3.3 x 1.7 x 2.8 cm. The right testicle
again shows
normal color Doppler flow, as well as spectral arterial and
venous waveforms.
Compared to the right, the left again shows less overall
vascularity than the
right on color Doppler imaging. Doppler waveforms can be
obtained in the left
testicle which shows venous flow as well as greater pulsatile
activity
suggestive of low-level arterial flow. Except for the appearance
of greater
pulsatility suggestive of arterial flow, there has been no
significant
change.
IMPRESSION: Similar appearance of reduced vascularity of the
left testicle
compared to the right, although there is greater pulsatility in
the Doppler
waveforms of the left testicle suggestive of low-level arterial
flow.
Brief Hospital Course:
He was admitted to the Surgical Service under the care of Dr.
[**Last Name (STitle) **]. He was initially taken to the Surgical ICU where he
remained for several days. Infectious Disease was consulted and
his antibiotics were changed to Vancomycin, Levofloxacin and
Flagyl. He did have blood cultures drawn on [**7-1**] and they were
negative; a stool for C-Diff was sent and was also negative.
Twice daily Dakin's dressing changes were continued. Urology was
consulted and he underwent scrotal ultrasound to assess for
residual infection and for flow. He was transferred to the
regular nursing unit. He continued to have ongoing pain control
issues; requiring IV narcotics initially, and this was changed
to PCA.
Plastic Surgery was then consulted for possible flap; he was
taken to the operating room on [**7-9**] for open wound extensive
debridement of skin, subcutaneous tissue and bilateral local
advancement flap elevation with baring of the scrotum in the
abdominal and a suprapubic cavity. His antibiotics, Levofloxacin
and Flagyl were continued and will need to continue for another
week following the surgery. His Foley catheter was removed;
there was a fecal incontinence pouch system previously in place
to keep open wound clean; this was also removed. His pain was
much less postoperatively, he no longer required IV narcotics
and was changed to an oral pain regimen using long and short
acting narcotics.
He was evaluated by Physical therapy and they have recommended
rehab after acute hospital stay.
Medications on Admission:
lisinopril 40', metformin 500", glyburide 5", humulin
insulin 20 qhs, diltiazem xr 240', HCTZ 25', atenolol 50'
[**Month/Day (4) **] Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
2. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
hold for SBP>110.
5. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day): hold for SBP<110; HR<60.
7. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
8. Oxycodone 5 mg Tablet Sig: 2-3 Tablets PO Q3H (every 3 hours)
as needed for breakthrough pain.
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours).
10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
11. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily): hold for SBP<110.
13. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
14. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
15. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Forty
(40) Units Subcutaneous QAM @ breakfast.
16. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
(20) Units Subcutaneous HS.
17. Regular Insulin Sliding Scale Sig: One (1) Dose
Subcutaneous four times a day as needed for per sliding scale:
See attached sliding scale.
[**Month/Day (4) **] Disposition:
Extended Care
Facility:
[**Hospital 2971**] Rehabilitation and Nursing Center - [**Hospital1 1474**]
[**Hospital1 **] Diagnosis:
Fournier's gangrene
[**Hospital1 **] Condition:
Hemodynamically stable, tolerating an oral diet, pain being
adequately controlled
[**Hospital1 **] Instructions:
AVOID any extremes of adduction/abduction of hips in order to
prevent placing pressure on the scrotum and operative site.
Followup Instructions:
Follow up this Friday [**7-13**] at 1:30 p.m. in Plastic's clinic with
Dr. [**First Name (STitle) **]. Location: [**Location (un) **], [**Hospital Ward Name 23**] Bldg, [**Location (un) 470**]
Surgical Specialities call [**Telephone/Fax (1) 4652**] if the appointment needs
to be changed.
Follow up in [**Hospital 159**] clinic in [**1-3**] weeks, call [**Telephone/Fax (1) 164**] for
an appointment.
Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from
rehab.
Completed by:[**2114-7-20**]
|
[
"782.1",
"608.83",
"603.8",
"250.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"61.49",
"63.1",
"62.2",
"62.69"
] |
icd9pcs
|
[
[
[]
]
] |
4234, 5753
|
349, 415
|
1487, 4211
|
7996, 8535
|
948, 965
|
5779, 7658
|
980, 982
|
286, 311
|
443, 894
|
996, 1468
|
7686, 7819
|
916, 932
|
7850, 7973
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,591
| 144,402
|
18162+56951
|
Discharge summary
|
report+addendum
|
Admission Date: [**2150-11-23**] Discharge Date: [**2150-11-28**]
Date of Birth: [**2113-3-29**] Sex: M
Service: NEUROLOGY
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 50220**] is a 37-year-old
male with no past medical history who developed a sudden
onset of right face, arm, and leg weakness on [**2150-11-23**] associated with some sensation of confusion, speech
difficulties, as well as right sided numbness. This lasted about
30 minutes and resolved. He had an identical five minute episode
in [**Month (only) 216**] with right-sided hemiplegia, numbness and speech
difficulties which resolved spontaneously, but he did not seek
medical attention at the time. He saw his primary care physician
after the second episode who sent him for an MRI and he was
referred to the Emergency Room at [**Hospital6 649**]. The MRI was read as "total occlusion of left
MCA." The patient denied any loss of consciousness, nausea,
vomiting, or recurrence of episode after [**2150-11-23**].
The patient also denied any constitutional symptoms over the
last five or six months.
Patient was on no medications with no known drug allergies when
he presented to the Emergency Room.
He denies history of trauma, headaches or neck pain.
FAMILY HISTORY: No history of cerebral vascular
disease or myocardial infarctions in his family and no
recurrent history of thrombosis or miscarriages in his
family.
SOCIAL HISTORY: The patient did smoke heavily one to two
packs per day for several years and continually smokes. The
patient is also a moderate alcohol user. He drinks six beers
per day. He denies intravenous drug use and last used
cocaine greater than ten years ago. He works as a furniture
ispector for [**Hospital1 **] Furniture Company. His work requires
lifting heavy furniture.
PHYSICAL EXAMINATION: Vital signs were as follows: Blood
pressure 130/60. Pulse 70. Respiratory rate: 16, afebrile.
Pertinent positives on physical examination: The patient
had no carotid bruits, had normal heart sound, S1, S2 with a
regular rate and rhythm. Chest was clear to auscultation.
Patient had excellent dorsalis pedis pulses with no evidence
of any cyanosis, clubbing or edema in extremities. On
neurological examination, the patient's mental status was
oriented to person, place and time with fluent speech,
comprehension, naming and repetition was intact. Patient had
no neglect, agnosia, apraxia and was able to register and
recall [**6-8**] properly. Patient had normal thought content and
affect. Pertinent positives on neurological examination is
as follows: Patient's cranial nerves were intact. Tone was
normal with no pronator drift or adventitious movement.
Patient had [**6-8**] throughout on power testing. Deep tendon
reflexes were 2+/4 throughout. Plantar reflexes were
downgoing. On coordination exam, patient had no dysmetria or
ataxia. Patient's gait was narrowed based and stable, and he
was able to perform Romberg exam without difficulty. Sensory
exam was intact to light touch, pinprick, vibration, joint
position sense and temperature throughout.
PERTINENT LABORATORIES, X-RAYS, ELECTROCARDIOGRAMS AND OTHER
TEST FINDINGS AS FOLLOWS: Patient was admitted and had
elevated cholesterol at 301 with elevated triglycerides at
616 on admission. MRI/MRA from outside hospital shows tiny
linear foci of diffusion weighted imaging along left deep
periventricular white matter in a watershed distribution.
There is also an area of diffusion weighted abnormality in
the left insular cortex. MRA at the outside hospital showed
occlusion of left MCA main stem with no flow signal
throughout the entire left MCA and its distal branches.
Normal flow is seen in both ACA arteries, throughout the
posterior circulation and carotid system.
HOSPITAL COURSE: The patient was started on IV heparin
and admitted to the Neuro Intensive Care Unit at [**Hospital3 **]
[**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] for close neurological checks and for
angiogram. A conventional angiogram revealed complete occlusion
of the left middle cerebral artery with some degree of retrograde
collateral flow through the ACA and posterior circulation. The
patient had a transesophageal echocardiogram attempted in the
Intensive Care Unit which he did not tolerate, therefore, a
transthoracic echocardiogram was performed the following day,
which showed a negative bubble study times three for patent
foramen ovale investigation, as well as normal right
ventricular and left ventricular function. The transthoracic
echocardiogram also showed no pericardial effusions.
During the Intensive Care Unit stay, toxicology screen was
negative, blood cultures were taken, which were negative, and
a hypercoagulable work-up was sent. Fibrinogen, ESR, antithrombin
III and protein C & S all returned within normal limits. ANCA
level was negative and [**Doctor First Name **] was negative. Prothrombin mutation was
pending at the time of discharge. Factor V Leiden mutation was
also pending. Angiotensin-converting enzyme levels were high at
198 with normal range being 9 to 67.
It was felt that the patient's MCA occlusive disease was likely
due to intracranial atherosclerosis. However, the possibility
of an obstructive clot could not be entirely excluded. The
patient was then transferred to the floor with goal of therapy
being heparinization while patient was being given Coumadin for
anticoagulation. The intention was to continue anticoagulation
for a few months and to reassess 1) the status of his
intracranial circulation and collateral flow; 2) TEE; and 3) his
neurological status to determine if life-long anticoagulation vs.
antiplatelet therapy is indicated.
However, the patient's INR remained persistently low despite
higher doses of coumadin for 5 days. The patient's insurance
refused to cover bridging therapy with Lovenox on an
outpatient basis, and the patient was maintained on IV
heparin. Dr. [**Last Name (STitle) 50221**], who subsequently covered the stroke
service, felt that it is unsafe for the patient to be discharged
on coumadin given concerns about his job duties and future
compliance. The patient was started on antiplatelets instead.
The patient was also started on a nicotine patch and a statin
for his elevated cholesterol profile during his inpatient
stay. He was advised multiple times by all members of the
health care team to stop smoking and to minimize his alcohol
consumption as these are significant risk factors leading to
his entire left MCA occlusion. The patient was also informed
to be in compliant with his medication and to follow-up with
his primary care physician and stroke neurologist as written
in discharge paperwork. He was asymptomatic throughout his
hospitalization.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Improved and stable.
DISCHARGE DIAGNOSIS:
1. S/P transient left hemispheric ischemia.
2. Hypelipidemia
3. Left MCA occlusion
DISCHARGE MEDICATIONS:
1. Atorvastatin 10 mg po q.d.
2. Plavix 75 mg qd
3. Aspirin 325 mg qd
4. Nicotine 21 mg patch for smoking cessation.
FOLLOW-UP PLANS: The patient will follow-up with primary
care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in
clinic on [**1-12**]. Patient will also be scheduled for an
outpatient TEE and will be contact[**Name (NI) **] with its exact timing.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**], M.D. [**MD Number(1) 4269**]
Dictated By:[**First Name3 (LF) 50222**]
MEDQUIST36
D: [**2150-11-27**] 02:13
T: [**2150-11-25**] 16:32
JOB#: [**Job Number 50223**]
Name: [**Known lastname 9429**], [**Known firstname 9430**] Unit No: [**Numeric Identifier 9431**]
Admission Date: [**2150-11-23**] Discharge Date: [**2150-11-28**]
Date of Birth: [**2113-3-29**] Sex: M
Service: NEUROLOGY
ADDENDUM: Patient was discharged on Saturday, [**2150-11-28**],
after discussion with Dr. [**Last Name (STitle) **].
DISCHARGE MEDICATIONS:
1. Aspirin.
2. Plavix. (No Coumadin.)
DISCHARGE INSTRUCTIONS: Patient will follow up in [**Hospital 2996**]
Clinic on [**2151-1-12**] at 3 p.m.
Patient's INR remained subtherapeutic on day of discharge.
[**Name6 (MD) **] [**Name8 (MD) **], M.D.
Dictated By:[**Dictator Info 9432**]
MEDQUIST36
D: [**2150-11-28**] 19:32
T: [**2150-11-28**] 22:07
JOB#: [**Job Number 9433**]
|
[
"272.0",
"435.9",
"790.29",
"437.0",
"305.1",
"272.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
1269, 1420
|
8159, 8201
|
6888, 6972
|
3809, 6792
|
8226, 8578
|
1979, 3791
|
7135, 8136
|
173, 1252
|
1437, 1811
|
6817, 6867
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,690
| 123,674
|
43662
|
Discharge summary
|
report
|
Admission Date: [**2200-6-25**] Discharge Date: [**2200-6-29**]
Date of Birth: [**2143-3-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Recurrent chest pain
Major Surgical or Invasive Procedure:
Coronary artery bypass graft x4:
1. Left internal mammary artery to the lateral branch of
the left anterior descending artery.
2. Bypass from ascending aorta to the medial branch of the
left anterior descending artery using reversed
autologous saphenous vein graft.
3. Bypass from the ascending aorta sequential to the
posterior descending artery branch of right coronary
artery and then through the CA lateral branch of the
right coronary artery.
History of Present Illness:
The patient is a 57-year-old male with past medical history
significant for coronary artery disease status post inferior
STEMI and bare metal stent to
the right coronary artery in [**2198-12-25**] complicated by
ventricular fibrillation. The patient received an ICD in [**Month (only) **]
[**2198**]. The patient now presents for recurrent chest pain.
Stress test was abnormal in [**Month (only) **]. The patient underwent
ultimately left heart cath and coronary angiogram
which showed that he had 3-vessel disease. Decision was made to
take the patient to the operating room for revascularization.
The decision with its risks, benefits and alternatives were
discussed with the patient and the patient
agreed to proceed. A consent was signed and included in the
chart.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia
2. CARDIAC HISTORY:
- CAD: s/p STEMI [**2199-1-8**]- on cath table had pulseless VF and was
defribrillated x3. Cath showed 100% RCA stented with BMS, 60%
diag, 60% OM. Uneventful post procedure & d/c'd to cardiac rehab
- CHF: EF 45% - recent TTE with posterior wall hypokinesia, inf
wall akinesis
3. OTHER PAST MEDICAL HISTORY:
renal cell carcinoma s/p partial nephrectomy [**2196**]
AAA (measured 4.8 cm recently per the pt)
Social History:
Works as a police office in [**Location (un) 3320**]. Married with 3 children.
Stopped smoking in [**2188**]. Denies alcohol or illicit drug use.
Family History:
Both parents were heavy smokers and had COPD. Father with CAD
and CABG in his 70s.
Physical Exam:
Exam
Pulse: 48SR Resp: 20 O2 sat: 96%RA
B/P Right: Left: 114/77
Height: 6'0" Weight: 195lb
General: NAD, WGWN, appears stated age
Skin: Dry [x] intact [x] sun-tanned
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [] diminished throughout
Heart: RRR [x] Irregular [] Murmur [] grade ______
well healed left anterior chest ICD pocket
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x], well healed right lateral incision s/p partial
nephrectomy
Extremities: Warm [x], well-perfused [x] Edema [] _none_
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: 2+ Left:cath site
Carotid Bruit Right: Left:
no bruits
Discharge Exam:
VS: T: 99.9 HR: 60-80 SR BP: 114-130/70 Sats: 93% RA
Weight: 86.5 kg
General: 57 year-old man in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Cardiac: RRR normal S1,S2 no murmur
Resp: decreased breath sounds throughout no crackles or wheezes
GI: benign
Extr: warm no edema
Incision: sternal and left lower extremity clean dry intact no
erythema or click
Neuro: awake, alert oriented
Pertinent Results:
TEE [**2200-6-25**]
Prebypass:
The left atrium is moderately enlarged. No mass/thrombus is seen
in the left atrium or left atrial appendage.
Left ventricular wall thicknesses are normal with thinning of
the inferior and inferolateral walls to 0.5 cm. The thinned wall
segments are also more brightly echogenic, consistent with scar
tissue. The left ventricular cavity is moderately dilated.
Estimated EF 40-45%. Right ventricular chamber size and free
wall motion are normal.
The ascending, transverse and descending thoracic aorta are
mildly dilated in diameter with simple atherosclerotic plaque..
The ascending aorta is mildly dilated. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion.
Trace aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no pericardial effusion.
Postbypass:
Left ventricular function remains unchanged from prebypass,
estimated EF= 40-45%. Inferior and inferolateral all hypokinesis
appears unchanged. No apparent new wall motion abnormalities.
Mitral regurgitation remains trace. Other valvular function
remains unchanged. No evidence of aortic dissection.
Chest X-Ray [**2200-6-28**]
The lungs are hyperinflated and the diaphragms are flattened,
consistent with COPD. The patient is status post sternotomy
with mediastinal clips.
Left-sided pacemaker is present, with lead tip over the right
ventricle.
There is mild cardiomegaly and slight prominence of the
cardiomediastinal
silhouette, similar to [**2200-2-24**]. No CHF. There are small
bilateral effusions, with underlying atelectasis, slighlty
larger. Some pleural thickening at the left lung apex laterally
is unchanged. The lungs are otherwise grossly clear.
[**2200-6-28**] WBC-12.1* RBC-3.65* Hgb-11.0* Hct-33.5 Plt Ct-133*
[**2200-6-25**] WBC-9.9 RBC-3.64* Hgb-11.2* Hct-33.3 Plt Ct-97*
[**2200-6-28**] Glucose-122* UreaN-16 Creat-1.0 Na-136 K-4.5 Cl-100
HCO3-30
[**2200-6-26**] Glucose-95 UreaN-17 Creat-0.9 Na-139 K-4.0 Cl-104
HCO3-29
[**2200-6-28**] Calcium-8.1* Phos-2.4* Mg-1.9
[**2200-6-25**] MRSA SCREEN (Final [**2200-6-27**]): No MRSA isolated.
Brief Hospital Course:
The patient was admitted to the hospital after cardiac cath. She
was brought to the operating room on [**2200-6-25**] where the patient
underwent Left internal mammary artery to the lateral branch of
the left anterior descending artery. Bypass from ascending aorta
to the medial branch of the left anterior descending artery
using reversed autologous saphenous vein graft. Bypass from the
ascending aorta sequential to the
posterior descending artery branch of right coronary artery and
then through the CA lateral branch of the right coronary artery.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. First night
post-op he was hypotensive with marginal urine output, he
required a-pacing and Lopressor and Lasix were delayed 24hrs.
Chest tubes were removed without incident. He was transferred to
the floor in POD#1. His ICD was interrogated by
electrophysiology no arrhythmia were found. His beta-blockers
were restarted. He was gently diuresed toward his preop weight.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD4 the patient was ambulating freely, the wound was healing
and pain was controlled with oral analgesics. The patient was
discharged home with [**Hospital1 1474**] VNA [**Telephone/Fax (1) 18681**] in good condition
with appropriate follow up instructions.
Medications on Admission:
Lisinopril 40mg daily
Lorazepam 1mg [**Hospital1 **]
Metoprolol Succinate 50mg daily
NTG prn
Protonix 40mg daily
Prasugrel 10mg daily
Simvastatin 40mg hs
Aspirin 81mg daily
Allergies: NKDA
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Lorazepam 1 mg PO BID
3. Pantoprazole 40 mg PO Q24H
4. Simvastatin 40 mg PO DAILY
5. Acetaminophen 650 mg PO/PR Q4H:PRN temperature >38.0
6. Docusate Sodium 100 mg PO BID
7. HYDROmorphone (Dilaudid) 2-4 mg PO Q3H:PRN pain
RX *Dilaudid 2 mg [**11-25**] tablet(s) by mouth every six (6) hours
Disp #*50 Tablet Refills:*0
8. Ibuprofen 400 mg PO Q8H:PRN pain give with food and water
9. Metoprolol Succinate XL 50 mg PO DAILY
10. Nitroglycerin SL 0.3 mg SL PRN chest pain
11. Furosemide 20 mg PO DAILY Duration: 3 Days
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Coronary artery disease. (BMS to RCA [**2199-1-5**])
STEMI, Ventricular Tachycardia s/p ablation [**2199-1-22**], Ischemic
cardiomyopathy, LVEF 30-35% by echo, s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 86**] Sci ICD [**4-/2199**],
PSVT
Hyperlipidemia
Hypertension
Diabetes Mellitus Type 2
Anxiety
Gastric ulcer (spring [**2199**]- resolved)
Hiatal hernia
PSH:
[**2196**] renal cell carcinoma s/p right partial nephrectomy,
AAA (Patient reports it was noted at 4.1cm by ultrasound at
[**Hospital3 **], results of most recent U/S few mos ago not
available), followed by Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg, Left - healing well, no erythema or drainage.
Edema: none
Discharge Instructions:
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
NO lotions, cream, powder, or ointments to incisions
Daily weights: keep alog.
No driving for approximately one month and while taking
narcotics.
No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Please call for a follow-up appointment with Dr. [**Last Name (STitle) **] and the
wound clinic [**Telephone/Fax (1) 170**]
Surgeon: Dr. [**Last Name (STitle) 93879**] [**Name (STitle) **]
Cardiologist: Please call for a follow-up appointment with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3321**] within the next 2 weeks.
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 30224**] [**Name (STitle) **], Raafati [**Telephone/Fax (1) 81193**] in [**2-27**] 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:[**2200-6-29**]
|
[
"300.00",
"272.4",
"414.01",
"412",
"V45.82",
"250.00",
"401.9",
"441.4",
"414.8",
"458.29",
"428.0",
"V10.52",
"V53.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.13",
"89.49"
] |
icd9pcs
|
[
[
[]
]
] |
8233, 8294
|
5865, 7343
|
330, 804
|
8998, 9211
|
3682, 5842
|
9777, 10496
|
2276, 2361
|
7584, 8210
|
8315, 8977
|
7369, 7561
|
9235, 9754
|
2376, 3207
|
1688, 1965
|
3223, 3663
|
270, 292
|
832, 1608
|
1996, 2095
|
1630, 1668
|
2111, 2260
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,952
| 182,681
|
18786
|
Discharge summary
|
report
|
Admission Date: [**2151-2-14**] Discharge Date: [**2151-3-4**]
Date of Birth: [**2116-2-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Suicidal ideation, mental status changes (acute mania), Acute
Renal Failure
Major Surgical or Invasive Procedure:
Lumbar puncture
Thoracentesis
History of Present Illness:
HPI: The patient is a 35 year old female who has recently been
undergoing evaluation with Dr. [**First Name4 (NamePattern1) **] [**Doctor Last Name 51447**] from the
division of Rheumatology for complaints of joint pains,
psoriasis and chemosis with highly positive [**Doctor First Name **]. The patient was
seen [**2151-2-3**] for evaluation of pain in her PIP joints with
associated swelling (patient noted to take Ibuprofen
intermittently). The patient was noted to have been suffering a
dry cough with associated low-grade temperatures and general
fatigue since [**Month (only) **] with reported "normal" renal function at
that time (creatinine not documented). The patient was noted to
have no Raynaud's, weight loss, oral/genital ulcers, chest pain,
photosensitivity, alopecia, headache or dysuria. At this office
visit a unifying diagnosis was not immediately made but further
evaluation for underlying CVD was undetaken with consideration
of skin biopsy to confirm psoriasis vs. other, CPK levels, UA,
C3/C4, Hep serologies and plain films. Ibuprofen was also
increased this visit to 800mg twice daily. Labs at this visit
were revealing for [**Doctor First Name **]+, 1:640 with low C3/C4 (17/4), urine with
proteinurea and trace blood.
On [**2150-2-13**] the on-call attending rheumatologist received a
call for concern for evolving symptoms. The patient was recently
diagnosed with peri-orbital inflammation for which an MRI Head
had been performed revealing a mastoid opacity for which the
patient was started on antibiotics although no clinical evidence
of sinusitis. The patient was noted to have Glaucoma with
intraocular pressures of 40mm thought secondary to periorbital
inflammation with drop in visual acuity from 20/20 to 20/40. The
patient's ophthamologist subsequently prescribed 80mg daily
Prednisone given the orbital inflammation but the patient wanted
to discuss this further with her Rheumatologist before starting.
The patient was noted by covering attending to be confused and
reported passive suicidal ideation. The patient was discussed
with the patient's parents and sibling (ED physician) as well as
outpatient ophthalmologist with recommendation that patient be
admitted given she was having neurologic problems, orbital
inflammation and labs now consistent with active SLE with active
urine sediment.
ED Course: Vitals 97.1, 154/86, 103, 18, 96% RA. In the ED
the patient had labs performed revealing for sodium 127, Bicarb
16, Cr 2.4, lactate 2.2. The patient was discussed with
psychiatry but official consult was post-poned until after
medical evaluation and stabilization per discussion between
Emergency Department and Psychiatry. The patient received 1L NS,
is now transferred to medicine for ongoing care.
On arrival to the floor the patient is noted to talk
continuously. She reports she is "the female version of house",
"I am insane" with multiple allusions of grandeur: "I am
untouchable", "I am smarter than all of you", "I have magical
powers". The patient reports suicidal ideation and when asked
about a plan reports "I will cut myself with a razor blade." The
patient is not easily redirected on questioning, majority of H+P
received from external sources as above.
Past Medical History:
Past Medical History: (Existing data reviewed in OMR)
#. Recent diagnosis of SLE
#. OSA
#. Psoriasis
#. Hypertension
#. anxiety disorder- followed by a therapist for five years, on
no medications
Social History:
The patient was previously a Medicine resident at [**Location (un) 51448**] but was released from the program, subsequently
transferred to a Rehab/physiatry program at [**Hospital1 3278**]. The patient
has since been involved in research at the VA [**Location 1268**] in
the Spinal Cord Injury Division. The patient is single and has
never been pregnant, no current sexual partners. Attempts to
contact patient's family are unsuccessful.
Tobacco: None
ETOH: None
Illicits: None
Family History:
Notable for coronary artery disease, stroke, hypertension,
leukemia, and atopic dermatitis as well as diabetes mellitus.
No history of any rheumatological disorders.
Physical Exam:
Physical Examination:
Vitals: 130/103, 118, 18, 96% RA
General: Patient is a young female, sitting upright in bed,
holding a large [**Male First Name (un) **] bear. Patient is talking continuously on a
variety of subjects. She answers some questions, mostly
inappropriately and changes the conversation frequently.
HEENT: Patient with prominent periorbital edema with massive
lower conjunctival swelling and secondary extrusion over the
lower lid. Lids able to be separated manually, EOMI bilaterally,
pupils 4 -> 3 mm with light bilaterally. Patient able to
identify flashlight color as red
OP: MMM, no oral ulcers or lesions
Neck: Supple, no LAD, no meningismus
Chest: Difficult to appreciate as patient will not stop talking
for examination. Generally clear to auscultation
Cor: Tachycardic, regular, no M/R/G
Abdomen: Obese, mildly distended. SOft, non-tender, normal bowel
sounds
Ext: no cyanosis, clubbing, edema
Skin/Nails: Patient with fine erythematous papular rash over
trunk and extremities, more prominent over LE bilaterally
Neuro:
Orientation: "[**Female First Name (un) 51449**]", "The [**Hospital Ward Name **]", "Zero"
General: As above
Motor: Patient does not participate with exam, will not move
limbs to command but seen to move all spontaneously during exam
Sensation: Intact to noxious stimuli (end of reflex hammer) over
trunk, extremities
Reflexes: 2+ at patella, biceps, BR bilaterally
Pertinent Results:
[**2151-2-14**] 10:32PM URINE HOURS-RANDOM CREAT-176 SODIUM-17 TOT
PROT-165 PROT/CREA-0.9*
[**2151-2-14**] 10:32PM URINE OSMOLAL-480
[**2151-2-14**] 10:32PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2151-2-14**] 10:32PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2151-2-14**] 10:32PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2151-2-14**] 10:32PM URINE RBC-2 WBC-11* BACTERIA-FEW YEAST-NONE
EPI-<1
[**2151-2-14**] 10:32PM URINE GRANULAR-4* HYALINE-18*
[**2151-2-14**] 10:32PM URINE MUCOUS-RARE
[**2151-2-14**] 06:53PM LACTATE-2.2*
[**2151-2-14**] 06:40PM GLUCOSE-89 UREA N-54* CREAT-2.4*# SODIUM-127*
POTASSIUM-4.9 CHLORIDE-98 TOTAL CO2-16* ANION GAP-18
[**2151-2-14**] 06:40PM estGFR-Using this
[**2151-2-14**] 06:40PM ALT(SGPT)-33 AST(SGOT)-46* LD(LDH)-254* ALK
PHOS-111 TOT BILI-0.3
[**2151-2-14**] 06:40PM calTIBC-170* FERRITIN-1634* TRF-131*
[**2151-2-14**] 06:40PM OSMOLAL-284
[**2151-2-14**] 06:40PM OSMOLAL-284
[**2151-2-14**] 06:40PM WBC-7.0 RBC-5.32 HGB-12.0 HCT-35.0* MCV-66*
MCH-22.6* MCHC-34.3 RDW-16.6*
[**2151-2-14**] 06:40PM NEUTS-81* BANDS-1 LYMPHS-15* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2151-2-14**] 06:40PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-OCCASIONAL
TEARDROP-OCCASIONAL ELLIPTOCY-OCCASIONAL
[**2151-2-14**] 06:40PM RET AUT-1.8
[**2151-2-14**] 06:40PM RET AUT-1.8
.
TTE ([**2-24**])
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 0-10mmHg. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). Right ventricular chamber size
and free wall motion are normal. There is a very small
circumferential pericardial effusion without echocardiographic
evidence for tamponade physiology.
Compared with the prior study (images reviewed) of [**2151-2-22**],
the findings are similar.
.
ON REPEAT
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is unusually small (underfilling?). Left
ventricular systolic function is hyperdynamic (EF>75%). There is
a small pericardial effusion. The effusion appears
circumferential. There are no echocardiographic signs of
tamponade.
Compared with the prior study (images reviewed) of [**2151-2-24**],
there is no change.
Brief Hospital Course:
.
# Altered Mental Status with manic features: On admission, the
patient appeared to have some elements of mania with continuous
speech, flight of ideas, and statements of grandeur. She had
suicidal ideation and reports she would use a razor blade
although she is noted to make many fleeting comments. Patient
was given 1:1 sitter. Psych was consulted who agreed with likely
lupus cerebritis and recommended treating underlying lupus.
Antipsychotics were not recommended. Patient had MRI which was
unremarkable. LP did not show any infection. Rheumatology was
consulted. She was given high dose (1000mg) steroids daily for
three days before swithing to po prednisone. Rheumatology
suggested starting cytoxan to which the patient agreed.
Gynecology service was consulted to give advice on future
fertility given that cytoxan would cause ovarian failure,
however would have required approx 3 weeks of lupron prior to
cytoxan, and patient declined. Finally, decision to start
cellcept was made. Psychiatry followed Ms. [**Known lastname 10940**] throughout her
admission and felt outpatient follow-up was appropriate. She was
treated with ativan prn for anxiety and has scheduled follow-up
with her therapist.
.
# Sinus tachycardia: The patient was tachycardic during the
beginning of her hospitalization. She was initially treated with
IV fluids but quickly became volume overloaded and began third
spacing. TSH was normal. She had intermittent complaints of
dyspnea, and on imaging was found to have a large pleural
effusion and small pericardial effusion. Heart rate improved
initially after thoracentesis, however the procedure was stopped
early due to negative pressures after less than 1L of fluid was
removed. The patient was transferred to the CCU due to
persistent tachycardia. A repeat thoracentesis removed more
fluid which improved her symptoms. Upon acheiving a stable
rhythm she was transferred to the medical floor. She remained in
normal sinus rhythm for the remainder of her admission.
.
# Pericardial effusion: Thought to be secondary to SLE. During
her admission, two transthoracic echos were performed to follow
the effusion. Both showed no signs of expansion or tamponade.
She was continually monitored for hemodynamic instability
indicating signs of tamponade or decompensation but remained
stable.
.
# Acute pleural effusion: the patient developed an acute pleural
effusion during her hospital stay. As above, thoracentesis was
done on [**2-18**] and pleural fluid studies were consistent with a
transudate. Cultures were negative for infection. Repeat
thoracentesis on [**2-24**] removed another 1L of fluid which
significantly improved her dyspnea. On CXR her bilateral pleural
effusions remained stable for the remainder of her stay, without
any worsening shortness of breath. Prior to discharge her O2
saturation was 98-100% on room air with activity.
.
# Hypertension: Patient normotensive on admission on ACEi, which
was held in setting of acute renal failure. It is likely her
pressure worsened given her extended steroid course. On transfer
to CCU, patient concerned about ACE and CCB causing exacerbation
of lupus/psoriasis. Labetalol and lisinopril were initiated,
however Ms.[**Known lastname 10940**] preferred not to take ACE inhibitors given their
effect on lupus. On transfer to the medicine service, she was
started on lasix and labetalol. Valsartan was added and, over
the course of [**3-31**] days her blood pressure improved to SBP 140s.
Her pressures remained labile, with an average of 140-150s
during the day, 120-130s overnight. VNA would be available
post-discharge for frequent blood pressure checks, and the
patient was scheduled for her first PCP [**Name9 (PRE) 702**] within 2 weeks
of discharge for further [**Name9 (PRE) **] of her hypertension.
.
# Acute Renal Failure: Patient last noted to have "normal"
creatinine with GFR > 60 in [**Month (only) **] although no actual
creatinine/GFR was available for review. The patient had
potential etiologies including active lupus nephritis, NSAID
toxicity, and pre-renal etiologies. Renal was consulted. NSAIDs
and her ACE-I held. Patient's creatinine continued to improve
with IV fluids. The renal team considered a biopsy at first but
later deferred the biopsy as it was not going to affect
[**Month (only) **] at that time. She was started on Bactrim prophylaxis
for cytoxan treatment (MWF). She will be followed as an
outpatient by the renal service for further evaluation and
[**Month (only) **].
.
# Positive blood cultures: On admission 2 of 4 blood cultures
grew coag negative staph. It was unclear at the time whether
this was real infection or contaminant, however given her acute
illness on presentation vancomycin was administered for
approximately 10 days. A leukocytosis was also present however
it was unclear whether this was secondary to her steroid course.
The remaining cultures drawn during her admission were negative.
.
# Periorbital edema/Chemosis: Ophthalmology was consulted to
evaluate her edema and marked chemosis. Per ophthalmology there
were no changes consistent with vasculitis in the eye.
Prednisolone and bacitracin ointment were recommended, plus
artificial tears while her edema resolved. Over the course of
her admission, during her resolving renal failure and active
diuresis, her periorbital edema slowly improved. Her vision
remained intact. She will be seen in ophthalmology clinic as an
outpatient.
.
# Follow-up: The patient has a new primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 18**]
who she will see within two weeks of discharge. She has
follow-up appointments with ophthalmology, renal, and
rheumatology. She will also continue to see her therapist as an
outpatient.
Medications on Admission:
Clobetasol 0.05% cream [**Hospital1 **] up to 2 weeks per month
Fluocinonide .05% to scalp [**Hospital1 **] x 2weeks/month
Fluticasone .05% cream up to 2 weeks/month
Pred Forte eye gtts, dose unknown
Lisinopril 40mg daily
Ibuprofen 800mg twice daily
Calcium-Cholecalciferol
Discharge Medications:
1. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic QID (4 times a day).
Disp:*1 * Refills:*3*
2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-29**]
Drops Ophthalmic TID (3 times a day).
Disp:*1 * Refills:*2*
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Bacitracin 500 unit/g Ointment Sig: One (1) Appl Ophthalmic
Q2 HOURS ().
Disp:*1 * Refills:*2*
5. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal PRN (as needed).
Disp:*1 * Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
Disp:*30 Tablet(s)* Refills:*1*
8. 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*
9. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*3*
10. Hydroxychloroquine 200 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO BID (2 times a day).
Disp:*120 Tablet, Chewable(s)* Refills:*2*
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
13. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
Disp:*1 bottle* Refills:*1*
14. Mycophenolate Mofetil 500 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
15. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
Disp:*20 Tablet(s)* Refills:*2*
16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
17. Labetalol 100 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
18. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
19. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
20. Amlodipine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Systemic Lupus Erythematosus
probable lupus cerebritis
Acute Renal Failure
Pleural effusion
Pericardial effusion
hypertension
Discharge Condition:
The patient was hemodynamically stable, afebrile and without
pain at the time of discharge.
Discharge Instructions:
You were admitted to the hospital for treatment of Lupus.
During this hospitalization, you were found to have active signs
of systemic lupus, including kindey failure, pleural effusion
and pericardial effusion. You were followed by the renal service
and your BUN/Creatinine levels were trended for resolution of
your renal failure. Your pericardiac effusion was followed by
echo and was found to be unchanged and not causing concerning
symptoms. You had two thoracenteses to remove fluid from the
lungs. The rheumatology service was also consulted and
recommended treating with steroids (prednisone) and cell cept.
You were also found to be hypertensive. This was treated with
amlodipine, labetalol, and valsartan. Your medications will need
to be adjusted as your elevalted blood pressure changes with
your steroid medications. It is important to follow up with your
primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] of these medications.
You were also seen in ophthalmology clinic for ocular
involvement of your lupus. You should follow up with an
ophthalmologist after your discharge (see appointment below).
You have been started on several medications for the treatment
of your Lupus:
Cellcept
Prednisone
Bactrim
Vitamin D
Calcium
Labetalol
valsartan
amlodipine
Please take all medications as directed by your physician.
Please call your doctor if you develop chest pain, shortness of
breath, fevers, chills, increasing joint aches, swelling,nausea,
vomiting, diarrhea or any other symptom of concern.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2151-3-18**] 2:30
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2151-3-18**]
3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4853**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2151-3-24**] 10:15
You are also scheduled for an appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 51450**]
(psychiatric therapist) on [**2151-3-8**] at 10 am at Bayview Associates
[**0-0-**].
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
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54,254
| 118,324
|
35710
|
Discharge summary
|
report
|
Admission Date: [**2130-12-25**] Discharge Date: [**2130-12-27**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Intracranian hemorrhage
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms [**Known lastname 6955**] is a 86 yo RIGHT-handed woman with a PMH remarkable
for valvular heart disease (rheumatic disease), AF on AC, HLD,
HTN a question of a stroke 3 years ago (unknown deficits) and
colon cancer s/p surgery who p/w CNS bleed with an INR of 3.6.
She was having dinner with her family when she suddenly
syncopized while sitting at the table (son's version). Another
version of the events (husband) states that she went to bed
after dinner and at 11:00 pm she complained of a sudden
throbbing frontal headache and started vomiting.
She was taken to [**Hospital 487**] Hospital: Her BP was 220/ 80, 66 bpm,
18 RR 100% SO2 in RA. Her GSC was initially 12 and complained of
a right - sided droop and right hand weakness. Eventually, her
GCS worsened (<8) and hence she was ETT'd to protect her airway.
She received ativan 8 mg and given her INR 3.6, vitamin K 10 mg
iv. A Ct scan with Bleed left frontal plus LEFT lateral
ventricle bleed and LEFT hemocontussion. She was transferred by
helicopter to [**Hospital1 18**].
Once at the ED: SBP 183, she received labetalol 10 mg iv. Her
SBP remained > 180, so a labetalol drip was started. However,
her HR decreased from 80 bpm to 50 bpm and the ED team stopped
it and started NTG drip.
She was afebrile 98.7F, connected to a ventilator in CMV mode. I
recommended the ED team to start profilnine, FFP and
hyperventilate the patient. In addition, she was loaded on PHT
20 mg/ kg. Once her CT scan was done, I also started a mannitol
load with 1.5 g/ kg.
I discussed the prognosis with the family according to the ICH
scale. They initially wanted all the measures to be pursued.
However, once informed that she would need surgery, they decided
to make her DNR.
Baseline: IADLs. Walked without a cane.
Past Medical History:
Valvular heart disease (rheumatic disease),
AF on AC,
HLD,
HTN.
Colon Ca s/p surgery
Social History:
As per husband, [**Name (NI) **]: ETOH, Drugs, Tobacco. Lives with her
husband.
Services: None
Family History:
NC
Physical Exam:
Gen: Lying in bed, unresponsive. Intubated.
HEENT: NC/AT, moist oral mucosa
Neck: supple, no carotid or vertebral bruit
Back: No point tenderness or erythema
CV: Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Abd: Soft, nontender, non-distended. No masses or megalies.
Percussion within normal limits. +BS.
Ext: no edema, no DVT data. Pulses ++ and symmetric.
Neurologic examination:
No meningismus. No photophobia.
MS:
Non-responsive to noxious stimuli.
CN: Brain stem reflexes :
Corneals - bl. Pupils 2 to 1 bl and symmetrically. Dolls eyes
-No gaze deviation. No bobbing or Robbing. No nystagmus. Gag +.
Difficult to assess facial weakness with the ETT.
Motor: does withdraw to pain in both legs, not in the arms.
Tone: Normal.
DTR: 1+ throughout. Toes downgoing.
Pertinent Results:
[**2130-12-25**] 02:32AM BLOOD WBC-10.2 RBC-4.23 Hgb-11.7* Hct-35.3*
MCV-83 MCH-27.6 MCHC-33.1 RDW-16.8* Plt Ct-277
[**2130-12-25**] 02:32AM BLOOD PT-26.8* PTT-28.8 INR(PT)-2.7*
[**2130-12-25**] 11:40AM BLOOD Fibrino-351
[**2130-12-25**] 02:32AM BLOOD Glucose-153* UreaN-32* Creat-0.9 Na-135
K-3.9 Cl-101 HCO3-25 AnGap-13
[**2130-12-25**] 06:27AM BLOOD CK-MB-6 cTropnT-0.30*
[**2130-12-25**] 11:24AM BLOOD CK-MB-6 cTropnT-0.28*
[**2130-12-25**] 09:03PM BLOOD CK-MB-6 cTropnT-0.21*
[**2130-12-25**] 06:27AM BLOOD ALT-72* AST-99* LD(LDH)-293* CK(CPK)-145*
AlkPhos-109 TotBili-0.5
[**2130-12-25**] 06:27AM BLOOD Triglyc-82 HDL-58 CHOL/HD-2.8 LDLcalc-88
[**2130-12-26**] 02:18AM BLOOD Phenyto-19.1
CT HEAD: Multifocal acute parenchymal hemorrhage with
intraventricular
extension of blood and associated obstructive hydrocephalus.
Associated
vasogenic edema and mass effect result in effacement of
overlying gyri and mm rightward shift of normally midline
structures.
Brief Hospital Course:
Ms. [**Known lastname 6955**] is a 86 yo RIGHT-handed woman with a PMH remarkable
for valvular heart disease (rheumatic disease), AF on AC, HLD,
HTN, question of a stroke 3 years ago (unknown deficits) and
colon ca s/p surgery who p/w CNS bleed in the context of an INR
of 3.6.
Her exam is remarkable for no corneal reflex, pupils 2 to 1 bl
and symmetrically. She was not withdrawing to pain in both legs
nor in the arms.
The most likely cause of her bleed is HTN in the context of her
elevated INR. There may be a component of AA. In addition there
seems to be a traumatic component in the LEFT frontal lobe
(minor bleed and edema). She has an ICH score of 4 which makes
her
prognosis extremely poor. In addition, she is developing
hydrocephalus per imaging.
Patient's situation and prognosis was discussed per admitting
resident with the family including husband who initially decided
on DNR code status and upon further discussion with family,
decided on comfort measures only. She was started on morphine
drip and ativan as needed to maximize comfort. She was
initially admitted to the ICU but once family decided on
maximizing comfort, was transferred to the floor where she
expired on [**2130-12-27**].
Family decline autopsy and it was also decline per medical
examiner as well.
Medications on Admission:
Amiodarone 200 qd.
Pravastatin 20 qhs.
Coumadin.
Discharge Medications:
Morphine drip
Ativan as needed
Discharge Disposition:
Expired
Discharge Diagnosis:
Intracerebral hemorrhage with obstructive hydrocephalus
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2131-1-6**]
|
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17,617
| 151,985
|
28340
|
Discharge summary
|
report
|
Admission Date: [**2195-5-2**] Discharge Date: [**2195-5-14**]
Date of Birth: [**2116-1-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
Push enteroscopy with electrocautery of gastric angioectasia
History of Present Illness:
(history mostly obtained from patient's PCP) 79 yo M with
dilated non-ischemic cardiomyopathy (EF 20%), mechanical AVR,
cirrhosis thought to be secondary to right heart failure, h/o
recurrent GIB mostly secondary to angioectasias of the
stomach/UGI tract, who presents with persistent anemia and
melena. The pt was initially admitted on [**2-1**] at [**Hospital1 18**] for CHF
exacerbation and PNA. During that admission his hematocrit
dropped to 26 from 31, so he received 2 units of PRBC. After
discharge, he was diagnosed with recurrent PNA and was admitted
to [**Hospital3 2568**] in [**3-4**]. The pt was subsequently placed on
antibiotics, resulting in an elevation in INR to approx 10 and
GI bleeding requiring transfusions. His coumadin was stopped due
to his GIB, in light of his chronic afib and AVR. He was
discharged home from [**Hospital3 **] with a hct of 31, but subequent
hct one week later was 24. Again, he was admitted to [**Hospital3 **]
from [**Date range (1) 1919**] in the ICU receiving PRBC transfusions, and was
discharged home with a hct of 31. Again, 1 week later (today)
his hct is 26. At his PCP's office his VS were: 90/60 (may be
baseline), HR 64, some basilar rales. Of note, his baseline wt
is 165 lbs, and at his PCPs office it was up to 172 lbs. His
lasix had been increased for several days from 40 mg [**Hospital1 **] to 60
mg [**Hospital1 **], with his weight decreaseing to 165 lbs, but it is now
back to 172 lbs. Apparently pt had black stool 2 days ago, but
it is now brown.
.
In the ED: pt vitals were Tm 97.2 HR 74 BP 94/49 HR 16-18 Sat
99-100%. NGL negative. Guaiac positive. His hct was 26.
Past Medical History:
- AF on coumadin
- Mechanical AVR (bileaflet aortic valve prosthesis) [**2182**]
- h/o GIB secondary to AVM s/p thermal therapy [**2194-10-24**] (first
GIB in [**Hospital1 46**] 6 months ago)
- Ascites (first noted 4 months ago)
- CKD (baseline in recent months 2.2-2.6)
- CHF (EF 25%)
- Cirrhosis
- ?clean cath prior to AVR
Social History:
From [**Last Name (un) 26580**], Arabic speaking only. Former farmer. Quit smoking
30years ago (1ppd x 24 years). [**Last Name (un) 4273**] any ETOH or other drug use
hx.
Family History:
-M: Stomach CA
-F:?
-No known liver disease in the family
Physical Exam:
T 97.2 P 77 Resp 26 BP 96/49 Sat 99% 2LNC
Gen: elderly male sitting up in bed, NAD
HEENT: L eye surgical, R pupil reactive, MMM
Neck: +JVD to jawline, +HJR, no LAD
CV: irregular, bradycardic, grade [**3-29**] HSM at LUSB and at apex
radiating to axilla
Lungs: mild expiratory wheezes b/l
Abd: +bs, +fluid wave, distended but soft and non-tender
Ext: 2+ pitting edema of LE, pulses full BL
Pertinent Results:
Admission labs:
[**2195-5-2**] 12:15PM BLOOD WBC-4.4 RBC-2.72*# Hgb-8.8*# Hct-26.0*#
MCV-96# MCH-32.3* MCHC-33.8 RDW-16.3* Plt Ct-133*
[**2195-5-2**] 12:15PM BLOOD Neuts-68.9 Lymphs-20.2 Monos-7.6 Eos-2.9
Baso-0.4
[**2195-5-2**] 12:15PM BLOOD PT-16.8* PTT-47.2* INR(PT)-1.5*
[**2195-5-2**] 12:15PM BLOOD Glucose-115* UreaN-38* Creat-2.0* Na-137
K-3.7 Cl-100 HCO3-30 AnGap-11
[**2195-5-2**] 12:15PM BLOOD ALT-5 AST-13 CK(CPK)-46 AlkPhos-261*
Amylase-58 TotBili-0.7
[**2195-5-2**] 12:15PM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2195-5-2**] 12:15PM BLOOD Lipase-40
[**2195-5-3**] 02:57AM BLOOD Calcium-8.4 Phos-4.3 Mg-2.4
[**2195-5-3**] 02:57AM BLOOD Digoxin-0.8*
.
Discharge labs:
[**2195-5-14**] 09:40AM BLOOD WBC-3.3* RBC-2.90* Hgb-9.0* Hct-27.6*
MCV-95 MCH-31.0 MCHC-32.6 RDW-15.8* Plt Ct-124*
[**2195-5-14**] 09:40AM BLOOD PT-25.0* PTT-53.7* INR(PT)-2.5*
[**2195-5-14**] 09:40AM BLOOD Glucose-158* UreaN-45* Creat-2.4* Na-137
K-3.7 Cl-101 HCO3-27 AnGap-13
[**2195-5-14**] 09:40AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.2
.
Studies:
[**2195-5-2**] ECG: Atrial fibrillation with a slow ventricular response
and occasional ventricular premature beats. Delayed R wave
transition. Low limb lead voltage. Non-specific ST-T wave
abnormalities. Compared to the previous tracing of [**2195-2-22**] the
ventricular ectopic activity is new. Otherwise, no change.
.
[**2195-5-2**] CXR: Cardiomegaly with prior cardiac surgery. Small
right pleural effusion. No consolidation.
Brief Hospital Course:
79 yo M with dilated non-ischemic cardiomyopathy (EF 20%),
mechanical AVR, cirrhosis thought to be secondary to right heart
failure, h/o recurrent GIB mostly secondary to angioectasias of
the stomach/UGI tract, who presents with persistent anemia and
melena. The following issues were investigated during this
hospitalization:
.
# GI bleed: Likely secondary to known angioectasias of the upper
GI tract. Pt. was started on PPI [**Hospital1 **] and transfused 2 units of
PRBCs. GI was consulted and performed push enteroscopy on [**5-5**]
with cauterization of a gastric angioectasia. No other source of
bleeding was identified and the GI team was able to visualize to
the proximal jejunum. Colonoscopy was not performed as he has
had a reported negative study one year prior, but can be
readdressed as an outpatient pending review of his OSH report if
able to be obtained. His hematocrit remained stable after
transfusion and he was likewise hemodynamically stable. He was
restarted on a heparin gtt and coumadinized to therapeutic
(2.5-3.0 goal) prior to discharge.
.
#Anemia: Likely secondary to slow GIB as well as chronic renal
insuffiency. Patient's hematocrit stabilized as mentioned above,
s/p transfusion. He was maintained on iron supplements.
.
# Dilated Cardiomyopathy: Known EF of 20-25% and currently is
chornically volume overloaded with ascites and LE edema
(right-sided failure). His SaO2 remained in the high 90's on
room air at rest and with ambulation. The patient was continued
on his outpatient regimen of 40mg lasix po BID for most of the
hospitalization, however was decreased the day prior to
discharge to 20mg po BID given a slight rise in serum
creatinine. Per prior cardiology notes, toprol XL was held given
tachy/brady syndrome and lisinopril was held given renal
insufficiency and hypotension. However, given significant NSVT
(see below) EP was consulted and toprol XL 25mg was restarted
which he tolerated well without bradycardia.
.
# Chronic Afib: Per cardiology, pt needs to be anticoagulated
given high stroke risk. Coumadin and heparin gtt were given as
per above. Continued digoxin.
.
# AVR: Pt at high risk for stroke off anticoagulation given AVR,
dilated CM, and afib. Coumadin and heparin gtt were given as per
above.
.
# CRI: Cr ranged 2.0-2.4, with BL of 2.6-3. Medications were
renally dosed.
.
# Ventricular ectopy: Pt has frequent PVCs and NSVT (up to 40
beats) on tele. This has been documented in prior d/c summaries.
ICD discussed extensively with patient, family, and EP service
during prior admissions and as an outpatient. This was
re-addressed during this admission with the patient and EP was
reconsulted. Given significant comorbidities and high risk of
peri-procedure mortality, the EP service stated that an ICD is
contraindicated. After detailed discussion, the patient stated
his wish to remain FULL CODE and desires to pursue ICD
placement. Toprol XL restarted per above. K+ and Mg+ were
continually repleted to above 4.0 and 2.0, respectively.
Medications on Admission:
Medications at home:
Digoxin .0625 mcg daily
Prilosec 2 tabs [**Hospital1 **]
Furosemide 40mg [**Hospital1 **]
Coumadin 4 mg daily
.
Medications on transfer from MICU:
Albuterol Nebs
Digoxin 0.0625 daily
Colace 100mg [**Hospital1 **]
Heparin gtt
Ipratroprium nebs
Iron complex
Pantoprazole 40mg IV
Discharge Medications:
1. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
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 BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
4. Warfarin 6 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. 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*
6. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. UGIB: Intestinal Angioectasia.
2. Blood Loss Anemia.
3. Systolic Heart Failure.
4. Non-sustained Ventricular Tachycardia.
Secondary:
1. Atrial fibrillation.
2. Bicuspid aortic valve status post Mechanical AVR.
3. Non-coronary Systolic Cardiomyopathy.
4. Class IV Heart Failure.
5. Severe MR [**First Name (Titles) **] [**Last Name (Titles) **].
6. Non-Sustained Ventricular Tachycardia.
7. Chronic Kidney Disease Stage III/IV
8. Cirrhosis NOS - Portal HTN and Ascites.
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for GI bleeding. Your blood count stabilized
with blood transfusions and an enteroscopy was performed with
cauterization of an area in the stomach that may have been
responsible for the bleeding. You were restarted on coumadin and
will need to continue to have your INR level checked at your
outpatient laboratory.
It is very important that you have your coumadin level (INR)
checked on Saturday, [**2195-5-16**], at your outpatient laboratory. You
will need to have this checked every 2-3 days until it is stable
at the appropriate level (2.5-3.0) in order to eliminate risk
for further bleeding.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500ml
Please take all medications as prescribed.
New medications: nifirex, toprol XL
Changed medications: coumadin, lasix
Call your doctor or return to the ED immediately if you
experience worsening chest pain, shortness of breath, nausea,
vomiting, sweating, fevers, chills, bleeding, or other
concerning symptoms.
Followup Instructions:
You are scheduled for the following appointments. Please contact
the [**Name2 (NI) 11686**] provider with any questions or if you need to
reschedule.
Primary care physician: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1726**], MD Date/Time: [**2195-5-21**] at
4:30PM. Phone: [**Telephone/Fax (1) 68797**]. It is very important that you
attend this appointment.
|
[
"280.0",
"537.83",
"424.0",
"572.3",
"427.1",
"V43.3",
"428.30",
"428.0",
"585.4",
"425.4",
"571.5",
"427.31",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.14",
"44.43",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
8608, 8614
|
4566, 7572
|
319, 382
|
9140, 9148
|
3084, 3084
|
10252, 10634
|
2600, 2659
|
7920, 8585
|
8635, 9119
|
7598, 7598
|
9172, 10229
|
3761, 4543
|
7619, 7897
|
2674, 3065
|
273, 281
|
410, 2047
|
3100, 3745
|
2069, 2395
|
2411, 2584
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,973
| 134,815
|
31245
|
Discharge summary
|
report
|
Admission Date: [**2158-11-7**] Discharge Date: [**2158-11-12**]
Date of Birth: [**2095-1-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Tetracycline
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
s/p ASD closure/R CFA repair [**11-7**]
History of Present Illness:
63 yo F with recent echo with secundum ASD and left to right
shunt.
Past Medical History:
ASD now s/p closure
COPD, ^lipids, HTN, s/p meningitis, s/p T+A, s/p appy, s/p wrist
surgery
Social History:
retired
45 pack year smoking history, wuit [**2158-10-30**].
no etoh
Family History:
NC
Physical Exam:
HR 76 RR 18 BP 134/70
NAD
Lungs CTAB
Heart RRR
Abdomen soft/NT/ND
No varicosities
Neuro Grossly intact
Extrem warm, no edema, 2+dp/pt pulses
Bilat carotid bruits
Pertinent Results:
[**2158-11-10**] 06:45AM BLOOD WBC-10.5 RBC-3.36* Hgb-10.9* Hct-32.4*
MCV-96 MCH-32.4* MCHC-33.6 RDW-14.2 Plt Ct-253
[**2158-11-10**] 06:45AM BLOOD Plt Ct-253
[**2158-11-9**] 03:22AM BLOOD PT-12.2 PTT-27.1 INR(PT)-1.0
[**2158-11-10**] 06:45AM BLOOD Glucose-119* UreaN-12 Creat-0.5 Na-139
K-4.2 Cl-100 HCO3-34* AnGap-9
CHEST (PORTABLE AP) [**2158-11-8**] 6:47 PM
CHEST (PORTABLE AP)
Reason: s/p ct d/c
[**Hospital 93**] MEDICAL CONDITION:
63 year old woman s/p ASD repair
REASON FOR THIS EXAMINATION:
s/p ct d/c
AP CHEST, 6:57 P.M., [**11-8**]
HISTORY: ASD repair. Chest tube discontinued.
IMPRESSION: AP chest compared to [**11-7**]:
Patient has been extubated, and midline drain has been removed.
Small bilateral pleural effusions are larger on the right,
stable on the left. There is no pneumothorax or appreciable
mediastinal widening. Pneumomediastinum is no longer visible.
Left jugular line has been removed, and there is no nasogastric
tube in place.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 73733**], [**Known firstname 3679**] [**Hospital1 18**] [**Numeric Identifier 73734**] (Complete)
Done [**2158-11-7**] at 9:24:38 AM 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: [**2095-1-27**]
Age (years): 63 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intraoperative TEE for closure of ASD
ICD-9 Codes: 745.5, 440.0, 424.0, 424.2
Test Information
Date/Time: [**2158-11-7**] at 09:24 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW1-: Machine: [**Pager number **]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.7 cm <= 4.0 cm
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.5 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Ascending: 2.6 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.1 cm <= 2.5 cm
Pulmonary Artery Main Diameter: *3.4 cm < 3.0 cm
Findings
LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo
contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. All four
pulmonary veins identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. Left-to-right shunt
across the interatrial septum at rest. Large secundum ASD.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness, cavity size,
and systolic function (LVEF>55%).
RIGHT VENTRICLE: Dilated RV cavity. Borderline normal RV
systolic function.
AORTA: Normal ascending aorta diameter. Focal calcifications in
ascending aorta. Simple atheroma in aortic arch. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild MVP.
Mild mitral annular calcification. Eccentric MR jet. Mild to
moderate ([**1-3**]+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
to moderate [[**1-3**]+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR. Dilated branch PA.
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 patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
PRE CPB The left atrium is moderately dilated. No spontaneous
echo contrast or thrombus is seen in the body of the left atrium
or left atrial appendage. The right atrium is dilated. A
left-to-right shunt across the interatrial septum is seen at
rest. A large secundum atrial septal defect is present (2 cm in
length). Left ventricular wall thickness, cavity size, and
systolic function are normal (LVEF>55%). The right ventricular
cavity is significantly dilated. Right ventricular systolic
function is borderline normal. There are simple atheroma in the
aortic arch. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is mild anterior mitral valve leaflet prolapse.
An eccentric, posteriorly directed jet of at least miild to
moderate ([**1-3**]+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is mild to moderate
tricuspid regurgitation. The right main branch pulmonary artery
is significantly dilated.
POST CPB The right ventricle displays mild global hypokinesis.
Left ventricular systolic function is normal. The interatrial
septum is s/p repair with a patch. No discreet jets are seen
crossing the interatrial septum. There are some small pinholes
of left to right flow seen at the edge of the patch which
disappeared after protamine reversal. Initially after separation
from bypass, inferior EKG changes felt to be secondary to right
coronary air embolus were seen. At that time, the mitral
regurgitation was significantly worse than seen during the
pre-CPB period. After resolution of the EKG changes, the mitral
regirgitation was similar as to that seen pre-CPB. The tricuspid
regurgitation is now mild. The thoracic aorta appears intact.
Brief Hospital Course:
She was taken to the operating room on [**2158-11-7**] where she
underwent an ASD clsure via mini-sterntomy after a minimally
invasive approach was aborted secondary to pleural adhesions.
She also sustained an injury to her right common femoral artery
which was repaired. She was transferred to the ICU in critical
but stable condition. SHe was extubated later that same day. She
was ready for transfer to the flor on POD #1, however was
transferred on day 2. She had atrial fibrillation for which her
beta blocker was increased and she was started on amiodarone, pt
converted with amiodarone to NSR. She is on a amiodarone taper.
She will have this followed up by her cardiologist. POD# 2 chest
tubes removed. Reapeat x-ray no sequele. POD # 3 PW removed. PT
consult obtained. Pt clear for home with VNA. Pt in NSR for 48
hrs post conversion.
Medications on Admission:
Dig 0.125", Lipitor 10', ASA 81', Lopressor 25", Albuterol,
Chantix
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Atorvastatin 10 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:*50 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400 mg [**Hospital1 **] x 5 days then 400 mg daily x 1 weeks then 200
mg daily ongoing until dc'd by cardiologist.
Disp:*120 Tablet(s)* Refills:*0*
8. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
once a day: prn.
9. Chantix 0.5 mg Tablet Sig: One (1) Tablet PO five times a
day: prn.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
ASD now s/p closure
intraop R CFA injury s/p repair
COPD, ^lipids, HTN, s/p meningitis, s/p T+A, s/p appy, s/p wrist
surgery
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (STitle) 6402**] 2 weeks
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**Last Name (Prefixes) **] 4 weeks
Completed by:[**2158-11-12**]
|
[
"401.9",
"427.31",
"492.8",
"511.0",
"998.2",
"E878.4",
"272.4",
"745.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.31",
"39.61",
"35.51"
] |
icd9pcs
|
[
[
[]
]
] |
8916, 8971
|
6825, 7670
|
284, 326
|
9140, 9148
|
842, 1248
|
641, 645
|
7788, 8893
|
1285, 1318
|
8992, 9119
|
7696, 7765
|
9172, 9424
|
9475, 9627
|
660, 823
|
241, 246
|
1347, 6802
|
354, 423
|
445, 539
|
555, 625
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,284
| 156,856
|
31960
|
Discharge summary
|
report
|
Admission Date: [**2129-1-22**] Discharge Date: [**2129-1-28**]
Service: SURGERY
Allergies:
Amoxicillin / Percocet
Attending:[**First Name3 (LF) 3200**]
Chief Complaint:
transferred with hypoxia and leukocytosis
Major Surgical or Invasive Procedure:
[**2129-1-23**]
Left PICC line placement
[**2129-1-24**]
Right pleural pigtail catheter placement
History of Present Illness:
[**Age over 90 **]F with CAD/CHF/A.fib s/p Exploratory laparotomy,
colocutaneous fistula takedown, extended right colectomy, lysis
of adhesions, ileocolostomy, percutaneous gastrostomy tube,
extensive soft tissue and skin debridement, and primary ventral
hernia repair on [**2128-12-26**] with Dr.[**First Name (STitle) 2819**] now presents as transfer to
[**Hospital1 18**] ED with hypotension and hypoxia. Pt transferred from OSH
for ? infection/sepsis. Pt received Vancomycin and Flagyl en
route and was given ciprofloxacin in ED at [**Hospital1 18**]. Upon arrival,
pt had an O2 Saturation of 71% and was placed on 100% NRB to
which her O2 Sat came to 100%. She was temporarily hypotensive
to
89/56, HR 102 and was fluid responsive to a bolus of NS which
brought her BP to 110/46 with a HR of 76.
.
Past Medical History:
A. fib, vertigo, CAD, CHF
PSH: hysterectomy, incisional hernia repair ~ 30 years ago c/b
colocutaneous fistula, s/p resection of infected mesh and
closure
of colocutaneous fistula [**2125-12-14**]
Social History:
No EtOH and tobacco. Lived with her son and was
independent (per her daughter)prior to last hospitalization.
Has been in rehab since.
Family History:
Noncontributory
Physical Exam:
Temp 96.7, HR 76 (A-flutter), BP 110/46, RR 19, O2 100% on NRB
Gen: Pleasant, Confused, Oriented x1 to self
CV: Irreg/Irreg, No R/G/M
RESP: Decreased at bases, clear anteriorally b/l
Chest: Right subclavian triple lumen CVL with dressing dated
[**2129-1-19**], antibiotic gel/pad in place with no obvious line site
infection
ABD: Gastrostomy tube in place and capped. Would vac not to
suction in place with DuoDerm at perimeter of extremely large
abdominal surgical wound approx 20x30cm. Vac removed. Fascia
closed with no sign of dehiscence, no purulence, no sign of
feculent drainage, two small 2-3cm areas of fat necrosis in
inferior wound debrided at bedside, otherwise good granulation
tissue throughout wound which does track on right lateral aspect
approx 5-7cm. Abdomen soft otherwise. Diffuse mild tenderness.
Soft palpation non-tender of flanks.
Ext: [**12-26**]+ upper extremity edema, trace lower extremity edema.
Feet warm.
Foley catheter in place.
.
Pertinent Results:
[**2129-1-21**] 06:56PM WBC-16.8* RBC-3.16* HGB-9.2* HCT-29.6* MCV-94
MCH-29.1 MCHC-31.1 RDW-15.3
[**2129-1-21**] 06:56PM NEUTS-94.8* LYMPHS-3.4* MONOS-1.4* EOS-0.2
BASOS-0.2
[**2129-1-21**] 06:56PM PLT COUNT-267#
[**2129-1-21**] 06:56PM PT-13.7* PTT-26.7 INR(PT)-1.2*
[**2129-1-21**] 06:56PM GLUCOSE-123* UREA N-34* CREAT-0.9 SODIUM-135
POTASSIUM-5.4* CHLORIDE-96 TOTAL CO2-34* ANION GAP-10
[**2129-1-22**] 04:30AM ALT(SGPT)-10 AST(SGOT)-22 CK(CPK)-26* ALK
PHOS-88 TOT BILI-0.3
[**2129-1-21**] CT Abd/pelvis :
1. Right colectomy and end-to-side ileocolostomy, with free
fluid and
surrounding inflammatory changes, the latter of which may be
post-surgical. Foci of extraluminal air extending anteriorly
from colonic pouch to fascial flap are noted, and a repeat CT
study with oral gastrografin contrast can be performed to assess
for residual fistula formation or leak.
2. Moderate bilateral pleural effusions and bibasilar
atelectasis.
3. Renal atrophy
[**2129-1-22**] CT Abd/pelvis :
1. No extraluminal oral contrast identified though majority of
contrast is
still within small bowel and has not passed the anastomosis. If
indicated,
delayed examination may be performed to allow time for contrast
to reach the large bowel. Locules of air in the anterior abdomen
with surrounding
inflammatory stranding and fluid could indicate residual
postoperative changes and inflammation.
2. Bilateral pleural effusions and compressive atelectasis as
previously
seen.
[**2129-1-23**] CXR :
The wire in the left PICC ends in the mid SVC. Moderate
bilateral pleural effusions have increased and there is still
pulmonary edema, difficult to assess given the obscuration by
pleural fluid, but not likely to have improved. Severe
cardiomegaly is chronic. No pneumothorax
[**2129-1-24**] Cardiac echo :
Rigth ventricular cavity enlargement with preserved free wall
motion. Pulmonary artery systolic hypertension. Mild-moderate
mitral regurgitation. Mild aortic regurgitation. Normal left
ventricular cavtiy size and regional/global systolic function.
Biatrial enlargement.
Brief Hospital Course:
Mrs. [**Known lastname **] was evaluated by the Acute Care service in the
Emergency Room and was found to be hypotensive and hypoxic. She
was admitted to the ICU for further management with a working
idagnosis of possible sepsis. Her O2 sats improved with a non
rebreather and her blood pressure responded to volume. She was
cultured and placed on broad spectrum antibiotics and her
central line was removed as possibly a source of sepsis.
Her oxygenation improved and she was weaned quickly to a nasal
cannula at 2L, although she had bilateral pleural effusions on
her chest xray, right > left. On [**2129-1-25**] she underwent placement
of a pigtail catheter in the right chest which drained one
liter. Her blood pressure remained stable and her rhythme was
atrial fibrillation rate 70-100. All cultures were negative
except for yeast in her urine.
Due to problems with access a PICC line was placed in the left
arm on [**2129-1-23**].
Following transfer to the Surgical floor she continued to
improve. Her tube feedings were resumed and well tolerated and
she underwent a Swallow test and was cleared for ground solids
and thin liquids. She remained afebrile and her antibiotics
were discontinued. Her abdominal wound is healing well with the
VAC dressing and it was last changed on [**2129-1-27**]. Her pigtail
catheter was removed on [**2129-1-28**]. She remained hemodynamically
stable. Her follow up chest x ray four hours later did not show
a pneumothorax.
After slow improvement she is being transferred back to rehab
for further Physical Therapy, wound care and nutrition. She had
a picc line for access and a foley in place. The patient was
cared for by the rotating attending services of the Acute Care
Surgical Service.
Medications on Admission:
levothyroxine 50 mcg DAILY, digoxin 125 mcg QOD, atenolol 25
DAILY, pantoprazole 40 Q24H, Colace 100 [**Hospital1 **], Dulcolax PRN, MOM
PRN
.
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution [**Hospital1 **]: 5000 (5000)
units Injection TID (3 times a day).
2. levothyroxine 50 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
3. digoxin 125 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
4. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. atenolol 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
6. miconazole nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical TID
(3 times a day) as needed for rash.
7. Colace 60 mg/15 mL Syrup [**Last Name (STitle) **]: Twenty Five (25) ml PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **]
Discharge Diagnosis:
right pleural effusion
leukocytosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
* You were admitted to the hospital with an infection possibly
from the central line that was in place. You also had an
accumulation of fluid on your lung and had a small tube placed
for drainage.
* Your infection appears to have resolved and you are breathing
much better.
* The Speech and Swallow therapist evaluated your ability to
swallow food and you did well with ground solids. Your dentures
are loose and at some point should be refitted.
* You will still need to have feedings thru your stomach tube
while you heal your abdominal wound and your appetite improves.
* You are being transferred back to rehab for further physical
therapy and medical care.
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in [**1-27**] weeks.
|
[
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"428.0",
"995.92",
"785.52",
"999.31",
"682.2",
"799.02",
"511.9",
"038.9",
"707.22",
"112.2",
"244.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"96.6"
] |
icd9pcs
|
[
[
[]
]
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7394, 7437
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4713, 6457
|
271, 372
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7517, 7517
|
2613, 4690
|
8381, 8491
|
1596, 1613
|
6651, 7371
|
7458, 7496
|
6483, 6628
|
7693, 8358
|
1628, 2594
|
190, 233
|
400, 1205
|
7532, 7669
|
1227, 1427
|
1443, 1580
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,577
| 191,080
|
55070
|
Discharge summary
|
report
|
Admission Date: [**2126-8-12**] Discharge Date: [**2126-8-13**]
Date of Birth: [**2042-10-12**] Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Unwitnessed fall
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
83 y/o spanish speaking man with PMHx dementia, ICH, CHF,
depression and HTN presenting s/p unwhitnessed fall. Pt is
minimally communicative at baseline [**2-14**] dementia, lives at a
nursing home and is dependent of all ADLs (at the [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 6930**] nursing home vitals were 97.3 HR 79 BP 130/74 RR 20).
His nursing home was [**Name (NI) 653**], nurses heard a bang and he was
found lying with head against side table, sheets wrapped around
legs, not incontinent, no loss of bowel/bladder (baseline
incontinent of urine), no tongue biting, agitated but alert
right after event/ uses walker for ambulation, often
non-compliant; baseline oriented to person; usual place of care
is [**Hospital1 2177**].
He was transferred to the [**Hospital1 18**] ED, where CXR was notable for
widened mediastinum on CXR. CTA of the chest was performed to
r/o aortic dissection, and was notable for a thoracoabdominal
aneurysm involving the ascending, descending, thoracic and
abdominal aorta. Vascular surgey was consulted and recommended
permissive hypotension with goal SBP 110s and ICU admission.
There were no EKG changes and no evidence of coronary arterial
involvement. He is not a surgical candidate per vascular
evaluation.
.
His initial vitals in the ED were T 98.2 BP 170/86 HR 60 RR 16
Sat 100%RA. He received lorazepam IV 2 mg x2, labetgalol 100mg
IV x1, lasix 100 mg x1, esmolol and nitroprusside drip were
initiated. Vitals on transfer to MICU were 97.6, 79, 121/81, 19,
98%RA.
On arrival to the MICU, patient's VS were T 97.3, BP 92/70, HR
84, RR 10, Sat 100%RA.
Review of systems:
Denied fever, chills. Denies headache, Denies shortness of
breath, cough. Denies chest pain. Denies abdominal pain.
Past Medical History:
HTN
ICH
Dementia
CHF
Social History:
lives at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6930**] nursing home. used to smoke and be
heavy drinker per daughter
Family History:
deferred
Physical Exam:
Vitals: T 97.3, BP 92/70, HR 84, RR 10, Sat 100%RA.
General: Alert, interactive no acute distress, trying to pull
the foley
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI. forehead
abrasion
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: expiratory rhonchi bilaterally on anterior exam. faint
insp crackles bibasally at the axillae.
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: on foley
Ext: Warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema. unhealthy looking toe nails bilaterally. equal pulses
bilaterally.
Neuro: CNII-XII grossly intact, moving all extremities. on upper
extremity restraints. gait deferred.
Physical exam on discharge unchanged. Foley is out.
Vital signs are: Afebrile, HR 70-80's, SBP 100-120's
Pertinent Results:
[**2126-8-12**] 01:00AM BLOOD WBC-7.4 RBC-5.13 Hgb-14.6 Hct-43.5 MCV-85
MCH-28.5 MCHC-33.6 RDW-13.8 Plt Ct-260
[**2126-8-13**] 05:11AM BLOOD WBC-7.3 RBC-4.39* Hgb-12.4* Hct-36.5*
MCV-83 MCH-28.3 MCHC-34.0 RDW-13.8 Plt Ct-228
[**2126-8-12**] 01:00AM BLOOD Glucose-124* UreaN-22* Creat-1.6* Na-142
K-4.6 Cl-103 HCO3-31 AnGap-13
[**2126-8-13**] 05:11AM BLOOD Glucose-161* UreaN-18 Creat-1.6* Na-139
K-3.9 Cl-103 HCO3-30 AnGap-10
[**2126-8-13**] 05:11AM BLOOD Calcium-8.5 Phos-3.1 Mg-1.8
[**2126-8-12**] 06:00AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2126-8-12**] 06:00AM URINE RBC-<1 WBC-0 Bacteri-NONE Yeast-NONE
Epi-0
Imaging:
CT C spine without contrast:
------------
FINDINGS: There no evidence of fracture or malalignment.
Severe cervical
spine degenerative changes are present, with moderate loss of
disc space,
anterior and posterior osteophyte formation, and subchondral
cysts at all
levels. There is minimal anterolisthesis of C3-C4 and C4-C5.
Ventral thecal sac is indented by osteophytes at several levels.
Marked uncovertebral and facet joint hypertrophy results in
mild-to-moderate foraminal stenoses.
Visualized brain is significant for global atrophy. There are
trace layering aerosolized secretions in the right maxillary
sinus. The middle ear cavities are clear. There is cerumen in
the bilateral external auditory canals. There are prominent
lingual and palatine tonsils, and several right palatine
tonsilloliths are present. A non-specific density is noted in
the right vallecula, which may represent secretions or retention
cyst.
There are no pathologically enlarged cervical lymph nodes.
Coarse
calcifications of the bilateral carotid bifurcation, right
greater than left. The thyroid gland appears heterogeneous,
without discrete nodularity.
Imaged lung apices demonstrate a rounded density lesion at the
left lung apex. This is aortic and better demonstrated on the
chest CTA of the same date. There is diffuse emphysema and
pleuroparenchymal scarring. Incidental note is made of an
azygos lobe.
IMPRESSION:
1. No evidence of fracture of significant malalignment.
Multilevel severe degenerative cervical spine changes.
2. Partially imaged aortic abnormality. Please refer to
subsequent CTA.
CT head without contrast:
--------
FINDINGS: There is no hemorrhage, edema, mass effect, or recent
infarction. Ventricles and sulci are diffusely enlarged,
compatible with age-related involutional changes. A remote
right MCA infarct is present, with encephalomalacia in the right
parietal lobe. There is relative sparing of the peripheral
cortical layers, compatible with laminar necrosis.
Corresponding ex vacuo dilation of the right occipital [**Doctor Last Name 534**].
Diffuse, partially confluent periventricular and subcortical
white matter hypodensities compatible with small vessel ischemic
disease. Chronic lacunes are noted in the bilateral caudate
heads, caudolenticular junction, and insula. There are no acute
fractures. Note is made of a remote nasal fracture. Mild
mucosal thickening at the frontal ethmoid junction and right
maxillary sinus. The mastoid air cells and middle ear cavities
are clear. There is cerumen in the bilateral external auditory
canals. Orbits and intraconal structures are symmetric.
IMPRESSION:
1. No evidence fractures, hemorrhage or recent infarction.
2. Global atrophy, old right MCA infarct, and microvascular
disease.
pelvis XRAY AP:
-----
no fracture
CXR AP:
----
IMPRESSION: Severe mediastinal widening, concerning for aortic
aneurysm.
Please refer to subsequent CT for further details
CT chest/abdomen/pelvis with and without contrast
-------------
CHEST: There is an 8-mm hypodense nodule in the right thyroid
lobe.
Moderate, apical-predominant centrilobular emphysema and pleural
parenchymal scarring are noted. At the lung bases, there is
early fibrosis with subpleural reticulations, architectural
distortion, and traction bronchiolectasis. Incidental note is
made of an azygos lobe. The trachea demonstrates a lunate
morphology, which can be associated with tracheomalacia in the
correct clinical setting. Scattered retained secretions are
noted throughout the airways. No pleural effusions.
The heart is normal in size, with a small amount of physiologic
pericardial fluid. Dense calcifications are noted in the aortic
valve. The central pulmonary arteries are unremarkable.
Multiple prominent mediastinal and hilar lymph nodes are
present, but not pathologically enlarged by size criteria.
Note is made of a small sliding hiatal hernia.
ABDOMEN: The liver, gallbladder, and pancreas are unremarkable.
There is no intra- or extra-hepatic biliary ductal dilation.
The spleen is normal in size.
The adrenals are normal. The kidneys are atrophic, but enhance
symmetrically without masses or hydronephrosis.
The stomach and small bowel are normal.
PELVIS: The appendix is normal. Scattered pancolonic
diverticula,
particularly in the descending and sigmoid colon, without acute
inflammation. Foley catheter is present in a collapsed bladder.
The prostate is slightly enlarged and heterogeneous.
There is no free intraperitoneal fluid or air. No
pathologically enlarged
retroperitoneal or mesenteric lymph nodes.
CT ANGIOGRAM: There is a [**Doctor Last Name **] type 1 thoracoabdominal
aortic aneurysm, which measures 4.4 x 3.4 cm at the root, 3.4 x
2.9 cm in the proximal ascending aorta, 4.0 x 3.8 cm in the
distal descending aorta, 3.5 x 3.3 cm proximal to the right
brachiocephalic origin, 3.8 x 3 cm between the right
brachiocephalic and left common carotid origins, 3.1 x 2.6 cm
between the left common carotid and left subclavian origins, 4.2
x 2.7 cm distal to the left subclavian origin, 4 x 3.6 cm in the
proximal descending aorta, 27 x 2.2 cm in the distal descending
aorta, 4.6 x 4.3 cm at the aortic hiatus, 4.3 x 3.1 cm superior
to the celiac artery takeoff, and 2.4 x 2.4 cm in the infrarenal
region. There are also bilateral common iliac artery aneurysms
measuring 1.7 cm, and diffuse ectasia throughout the iliac and
femoral arterial systems.
Two saccular areas of outpouching are noted along the aortic
arch (300BK:36). Throughout the aorta are extensive mural
thrombus, intimal calcification, and ulcerated plaques.
Findings are most severe involving the distal arch and
descending thoracoabdominal aorta, but also involve the root of
the left subclavian artery and mesenteric/renal branch vessels
with mild luminal stenosis. No evidence of intimal flap or
delayed contrast pooling to suggest dissection or
pseudoaneurysm.
There are multilevel degenerative changes in the thoracolumbar
spine, with
right lateral bridging osteophytes.
IMPRESSION:
1. [**Doctor Last Name **] type 1 thoracoabdominal aneurysm with extensive
sacculation,
mural thrombus, and ulcerated plaques.
2. Emphysema and early pulmonary fibrosis.
3. Renal atrophy.
4. Colonic diverticulosis.
Brief Hospital Course:
Primary Reason for Hospitalization: 83 y/o man with poor
functional status presenting s/p fall and was found to have
large aortic aneurysm.
ACTIVE ISSUES
.
# s/p fall: Pt underwent extensive trauma workup in the ED,
including CT-head, C-spine, X-ray pelvis, CXR negative for
fractures. Physical exam also did not reveal evidence of
trauma. The nature of the fall was felt to be mechanical based
on history. He was monitored on telemetry closely without
events. Further cardiac/neurological workup was differed.
.
# Aortic Aneurysms: Because of the findings of widened
mediastinum, pt underwent CTA chest/abdomen/pelvis in the ED,
which revealed [**Doctor Last Name **] type 1 thoracoabdominal aneurysm with
extensive sacculation, mural thrombus, and ulcerated plaques.
There was no evidence of dissection. Vascular surgery was
consulted and felt that pt is not a candidate for surgery. He
was initially started on esmolol and nitroprusside gtt to
maintain a SBP < 120. His blood pressure medication were
switched back to clonidine patch and metoprolol. We increased
his metoprolol to 50 mg tid. His blood pressure was well
controlled with SBP < 130. Per Vascular Surgery, his systolic BP
should be strictly maintained below 120.
# [**Last Name (un) **]: Baseline Cr unclear. CTA did not show dissection of the
renal arteries but dilatations include renal arteries. Given the
contrast exposure, will recommend followup on renal function
closely for contrast induced nephropathy.
TRANSITIONAL ISSUES
# CODE STATUS: full code, pending further family dicussion (to
be followed)
# PENDING STUDIES: none
# MEDICATION CHANGES:
- INCREASE metoprolol to 50 mg tid
# FOLLOWUP PLAN:
- Judicious blood pressure control with goal SBP < 120
- Per Vascular surgery, no surgical intervention recommended
for aneurysm.
- Should continue routine follow up with PCP
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Nursing Home.
1. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QTHUR
2. Furosemide 20 mg PO DAILY
3. Mirtazapine 7.5 mg PO HS
4. Simvastatin 40 mg PO DAILY
5. Acetaminophen 325 mg PO Q6H:PRN pain
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
7. Metoprolol tartrate 25 mg three time daily
8. Aspirin 81 mg daily
Discharge Medications:
1. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QMON
2. Acetaminophen 325 mg PO Q6H:PRN pain
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
4. Mirtazapine 7.5 mg PO HS
5. Furosemide 20 mg PO DAILY
6. Simvastatin 40 mg PO DAILY
7. Metoprolol Tartrate 50 mg PO TID
please hold for SBP < 100 or HR < 60
RX *Lopressor 50 mg 1 tablet(s) by mouth three times daily Disp
#*90 Tablet Refills:*3
8. Aspirin 81 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnoses:
1. [**Doctor Last Name **] type 1 thoracoabdominal aneurysm with extensive
sacculation, mural thrombus, and ulcerated plaques.
2. Emphysema and early pulmonary fibrosis.
3. Renal atrophy.
4. Colonic diverticulosis.
Secondary diagnoses:
1. Dementia
2. Hypertension
3. Chronic CHF
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Clear, oriented to self.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a great pleasure taking care of Mr [**Known lastname 92093**] at [**Hospital1 1535**].
He presented to us after having a fall that seemed mechanical
per history by the nursing home. Upon arrival, his imaging
studies have shown extensive dilatations in his aorta which is
the large vessel that goes out from the heart to provide blood
to the body. The dilation is extensive starting from the root of
the vessel all the way down to his vessels in his pelvis.
Vascular surgery evaluated him and did not find him a surgical
candidate given the extensiveness of the disease and high risk
procedure.
Blood pressure control will be very essential to reduce the
chances of these dilatations to burst. The goal for the systolic
blood pressure is less than 120.
We made the following changes in his medication list
- Please INCREASE metoprolol from 25 mg three times daily to 50
mg three times daily
Please continue the rest of his home medications the way he was
taking them at home prior to admission.
Please follow with his physician at the nursing home for blood
pressure control with the goal as mentioned above.
Followup Instructions:
Nursing home physician
|
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icd9cm
|
[
[
[]
]
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[
"38.93"
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icd9pcs
|
[
[
[]
]
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1979, 2097
|
11879, 12113
|
248, 266
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340, 1960
|
13479, 13581
|
2119, 2141
|
2157, 2299
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,814
| 193,834
|
47124
|
Discharge summary
|
report
|
Admission Date: [**2167-6-21**] Discharge Date: [**2167-7-9**]
Date of Birth: [**2098-6-5**] Sex: F
Service: NEUROLOGY
Allergies:
Bactrim / Hydrochlorothiazide / lisinopril
Attending:[**First Name3 (LF) 20506**]
Chief Complaint:
left-sided sensory changes
Major Surgical or Invasive Procedure:
PEG/GT Placement
History of Present Illness:
[**Known firstname **] [**Known lastname **] is a 69 year-old right handed woman who presented to
the ED after having 10 days of left sided numbness followed by
gait difficulties over the past 3 days and then waking with
incontinence this morning as well as weakness of the left side.
She states that around 10 days ago she had gotten into the
shower
and then noticed a num tingling and squeezing sensation that
wrapped around her left chest from the scapula to the lower part
of the ribcage. This was then followed by left thigh numbness
and
left foot numbness. She did not initially note any problems with
her gait as she walks for exercise. She did start to feel some
incoordination while walking then over the past 1 week. She had
no trips or falls and no difficulty manipulating objects with
her
left hand. She awoke on Sunday morning and says that her left
arm
felt weak and that she had urinary incontinence whenver she
stood
up. She has had no recent neck trauma, and no slips or falls. No
motor vehicle accidents.
She did describe some nausea and emesis over the past 2 days and
a headache this morning that she described as squeezing in
nature. She has ahistory of migraines that caused her to lose
vision, but states this did not feel like one of her migraine
headaches that have mostly resolved since menopause.
She has a recent history of a squamous cell carcinoma of the
tongua and is s/p resection at [**Hospital 13128**] and s/p local
radiation therapy as well. She has been dysarthric since the
surgery and also thinks she has lost ~10 lbs due to difficulty
eating following the surgery.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, lightheadedness, vertigo, tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech.
On general review of systems, the pt denies recent fever or
chills. No night sweats. Denies cough, shortness of breath.
Denies chest pain or tightness, palpitations. Denies diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Denies rash.
Past Medical History:
Stage II squamous cell carcinoma of the tongue s/p resection and
radiation therapy
Migraine headache
Hypertension - no longer requiring medication
Basal cell carcinom of skin
Melanoma
Social History:
lives in [**Hospital1 8**]. Was a homemaker. Non-smoker. Minimal EtOH
Family History:
Father - colon cancer, [**Name (NI) 2481**]
Mother - liver cancer, dementia NOS
brother - healthy
Physical Exam:
ADMISSION EXAM
Vitals: 97.1 57 107/43 16 100%
General: Awake, cooperative, NAD, mild cachexia
HEENT: NC/AT
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: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall [**3-28**] at 5 minutes. The pt. had
good
knowledge of current events. There was no evidence of apraxia
or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, paratonia in LE. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**]
L 5 4 4 4 5 4 4 5 4 4 5 4
R 5 5 5 5 5 5 4+ 5 5 5 5 5
-Sensory: deficits to pinprick on left arm in hand and along the
medial aspect of forearm, absent proprioception in toes b/l
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 3 3 3 3 2
R 3 3 3 3 2
crossed adductors
Plantar response was extensor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: significant sway on romberg, wide gait, unsteady good arm
swing.
Pertinent Results:
[**2167-6-21**] 12:30PM BLOOD WBC-4.9 RBC-4.38 Hgb-12.7 Hct-38.9 MCV-89
MCH-29.0 MCHC-32.6 RDW-13.3 Plt Ct-273
[**2167-6-21**] 12:30PM BLOOD PT-11.1 PTT-25.2 INR(PT)-1.0
[**2167-6-21**] 12:30PM BLOOD Plt Ct-273
[**2167-6-21**] 12:30PM BLOOD Glucose-109* UreaN-13 Creat-0.7 Na-139
K-3.8 Cl-102 HCO3-25 AnGap-16
[**2167-6-21**] 12:30PM BLOOD ALT-40 AST-26 AlkPhos-56 TotBili-0.4
[**2167-6-24**] 01:10AM BLOOD CK(CPK)-43
[**2167-6-21**] 12:30PM BLOOD Lipase-32
[**2167-6-21**] 12:30PM BLOOD cTropnT-<0.01
[**2167-6-23**] 12:34PM BLOOD CK-MB-2 cTropnT-<0.01
[**2167-6-23**] 10:00PM BLOOD CK-MB-4 cTropnT-<0.01
[**2167-6-21**] 12:30PM BLOOD Albumin-4.5 Calcium-9.8 Phos-3.5 Mg-2.0
[**2167-6-21**] 01:14PM BLOOD Lactate-1.2
[**2167-6-23**] 04:09AM BLOOD NEUROMYELITIS OPTICA (NMO) EVALUATION
WITH REFLEX-Test Name negative
[**2167-6-19**] MRI Head and C-Spine c/s contrast
IMPRESSION:
1. Signal abnormality in the upper cervical spinal cord and the
lower
medulla, with abnormal diffusion in the medulla (no
diffusion-weighted images
through the cord are available), and with partial contrast
enhancement. These
findings suggest transverse myelitis and subacute infarction.
Diagnostic
considerations include sequela of recent radiation therapy
and/or vasculitis.
Acute demyelinating disease may also be considered. Neoplastic
disease may be
considered, but less likely. These findings were discussed by
Dr. [**Last Name (STitle) 1603**]
with Dr. [**First Name (STitle) **] from neurology by telephone at 11:19 a.m. on [**6-22**], [**2167**].
2. Unchanged multilevel degenerative disease with slight
deformation of the
ventral spinal cord at the C5-6 level, but no evidence of spinal
cord
compression.
[**2167-6-21**] MRI T/L Spine c/s contrast
IMPRESSION:
1. No evidence of neoplastic disease in the thoracic or lumbar
spine.
2. No evidence of abnormalities in the thoracic spinal cord or
conus
medullaris.
3. Degenerative disease in the lumbar spine, with prominent
fluid in some of
the facet joints as detailed above. No evidence of nerve root
impingement in
supine position.
[**2167-6-23**] ECG
Sinus bradycardia with an atrial premature beat. Q-T interval
prolonged for
rate. Precordial T wave inversions of uncertain significance.
Prominent
QRS voltage but probably does not meet criteria for left
ventricular
hypertrophy. Clinical correlation is suggested. No previous
tracing available
for comparison.
[**2167-6-30**] MRI Head NC, MRA Head NC, MRA Neck with contrast
IMPRESSION:
1. Unchanged appearance of signal abnormality in the lower
brainstem and
visualized upper cervical cord similar to that seen on the
previous study.
The differential diagnoses are the same as mentioned on the
prior study, and
include but are not limited to subacute infarcts, demyelinating
disease,
reaction to radiation therapy, vasculitis.
2. Unremarkable MRA of the head and neck.
3. Bilateral periventricular, subcortical, and deep white
matter signal
changes which are nonspecific and may represent small vessel
ischemic disease.
[**2167-7-9**] 10:45AM BLOOD WBC-11.7* RBC-3.00* Hgb-8.7* Hct-27.5*
MCV-92 MCH-29.0 MCHC-31.6 RDW-14.9 Plt Ct-367
[**2167-7-9**] 10:45AM BLOOD Plt Ct-367
[**2167-7-7**] 05:15AM BLOOD PT-12.0 PTT-47.6* INR(PT)-1.1
[**2167-7-9**] 10:45AM BLOOD Glucose-172* UreaN-16 Creat-0.5 Na-140
K-3.8 Cl-105 HCO3-29 AnGap-10
[**2167-7-9**] 10:45AM BLOOD Calcium-8.3* Phos-1.6* Mg-1.8
Brief Hospital Course:
On Admission:
69 year-old right handed woman who presented to the ED after
having 10 days of left sided numbness followed by gait
difficulties over 3 days and then incontinence this morning as
well as weakness of the left side. She had history of a squamous
cell carcinoma of the tongue and was s/p resection at [**Hospital 87678**] and s/p local radiation therapy as well. She has been
dysarthric since the surgery. She had an MRI of brain and
c-spine on admission show a retrolisthesis at C5-7 with
impingement on the cord which led to a question of cervical
myelopathy. She was seen by ortho spine who did not feel that
cord impingment was causing her symptoms and defered surgical
management.
She was placed in a c-collar and started on steroids and
admitted to neurology floor for observation. However, overnight
she was reported to be more somnolent and having difficulty
managing secretions with possible worsening of her L sided
weakness. She was transfered to the ICU for closer observation
and possible airway management.
Differential at that time included radiation-induced myelopathy
vs. infectious/inflammatory myelitis.
ICU course ([**2167-6-22**])
# Neuro:
Mrs. [**Known lastname **] was maintained on close observation and required
frequent suctioning of her airways given her oropharyngeal
weakness. She was maintained on decadron 10mg q6h for 3 days
which was increased to 1g Solumedrol daily. After 24 hrs,
although her L sided plegia had not improved, she was noted to
have increased strength in her neck flexors.
Neuro-oncology was contact[**Name (NI) **] and recommended higher dose
steroids and LP to help rule out infectious/inflammatory
myelitis. the LP was bloody and revealed only 5 WBC, viral
cultures were sent as well. They also recommended possible
Avastin for radiation-induced necrosis.
Her radiation-oncologist was contact[**Name (NI) **] and documents regarding
her radiation doses were sent to our hospital.
# Pulm:
Although she demonstrated initial improvment on day1, she
continued to have significant difficulties with her airway and
was noted to have frequent desats with blood gases showing
worsening hypercarbia. her NIFs/VCs were markedly low (-11/0.66)
but this was thought to be somewhat erroneously low given her
poor motivation/participation. Frequent suctioning and
acapella/theravest device helped clear her airway and she
avoided intubation.
NEUROLOGY FLOOR COURSE:
69yoW h/o SCC of the tongue and migraine headaches p/w left
hemisensory changes, urinary incontinence, dysarthria, and gait
changes with subsequent progression to left hemiplegia,
secondary to brainstem and upper cervical cord lesion which may
represent radiation-induced demyelination. Besides her left
hemiplegia, her other concerning impairment is her respiratory
capacity which has been compromised with hypercapnea and excess
secretions but currently is stable. High dose corticosteroid
therapy was continued with IV Methylprednisolone for 5 days, and
then she was transition to Prednisone 80 mg daily for one week.
Radition Oncology was consulted to comment on the possibility of
radiation necrosis which they felt was less likely given the
low-dose and the localization to the cervical cord only (below
the level of the medullary lesion), but this does not exclude
more acute forms of radiation-induced cord damage. Based on the
appearance and clinical picture, radiation-induced demyelination
was thought to be the most likely explanation. She continued to
have marked dysphagia on repeat Speech evaluations, so ACS was
consulted for GT/PEG placement. A PEG was placed
withoutcomplications. She was transitioned to Prednisone 60 mg
daily which she will continue for at least one month before a
subsequent downtitration.
.
PENDING STUDIES: None
.
TRANSITIONAL CARE ISSUES:
[ ] Neurology - Please followup her neurologic examination for
improvement of her left hemiplegia. Titrate down her prednisone
slowly (continue at 60mg for at least one month).
[ ] PT/OT - Please continue therapy for her left hemiplegia and
right sided milder hemiparesis for maximal functional recovery.
[ ] Rehab - Please continue her Prednisone therapy and
supportive medications including a PPI, insulin slide scale,
etc.
[ ] Phosphorous - Please replenish her phosphorous and monitor
her Chem-10. She has only recently been restarted on tube feeds
and may have a small component of refeeding syndrome.
[ ] Followup appointments - Please schedule a PCP followup for
her 1-3 weeks after her discharge from rehab.
Medications on Admission:
Vitamin D
Valium PRN anxiety
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever, headache
2. Calcium Carbonate 1000 mg PO DAILY
3. Docusate Sodium 200 mg PO BID
4. Senna 1 TAB PO BID:PRN constipation
5. traZODONE 25 mg PO HS:PRN insomnia
6. PredniSONE 60 mg PO DAILY
7. Polyethylene Glycol 17 g PO DAILY
8. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
9. Heparin 5000 UNIT SC TID
10. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
11. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
12. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
13. Vitamin D 400 UNIT PO DAILY
14. Neutra-Phos 2 PKT PO TID Duration: 2 Days
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS: Radiation-induced demyelination/myelitis
SECONDARY DIAGNOSIS: Hemiparesis/hemiplegia of nondominant side
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Neurologic: Mild left nasolabial flattening, mild dysarthria,
left hemiplegia (arm and leg).
Discharge Instructions:
Dear Mrs. [**Known lastname **],
You were hospitalized due to symptoms of NAUSEA/VOMITING, GAIT
DISTURBANCE, and LEFT-SIDED WEAKNESS and SENSORY DISTURBANCES
resulting from injury to the medulla (part of the brainstem) and
upper cervical cord (the spinal cord in the neck). We suspect
that this is an early reaction to the recent radiation therapy
you received for treatment of your tongue cancer. To treat this,
we started corticosteroid therapy.
We are changing your medications as follows:
1. Please continue to take PREDNISONE 60 MG daily for recovery
of your spinal cord injury.
2. Please take your other supportive medications as prescribed.
Some of these will be changed your rehab facility.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek medical
attention.
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
Please followup with DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the General [**Hospital 878**]
clinic at [**Hospital1 69**] ([**Hospital Ward Name 516**],
[**Hospital Ward Name 23**] [**Location (un) 858**], [**Location (un) 830**], [**Location (un) 86**], MA) The contact
number for the office is ([**Telephone/Fax (1) 3345**]. DATE/TIME: [**2167-8-5**] at 9:30AM
Please followup with your Primary Care Physician:
[**Name Initial (NameIs) 7274**]: [**Last Name (LF) 8682**], [**Name8 (MD) **] MD
Location: [**Hospital1 **] HEALTHCARE - [**Hospital **] MEDICAL
GROUP
Address: [**Street Address(2) 2687**],8TH FL, [**Location (un) **],[**Numeric Identifier 822**]
Phone: [**Telephone/Fax (1) 133**]
Fax: [**Telephone/Fax (1) 445**]
|
[
"V10.82",
"V10.83",
"346.90",
"V10.01",
"788.30",
"E947.8",
"787.20",
"342.92",
"263.9",
"341.9",
"599.0",
"323.72",
"336.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"03.31",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
13915, 13985
|
8653, 8653
|
330, 349
|
14153, 14153
|
5226, 8630
|
15336, 16101
|
2805, 2905
|
13255, 13892
|
14006, 14006
|
13201, 13232
|
14381, 15313
|
3891, 5207
|
2920, 3259
|
264, 292
|
12458, 13175
|
377, 2493
|
14087, 14132
|
14025, 14066
|
8668, 12432
|
14168, 14357
|
2515, 2701
|
2717, 2789
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,702
| 157,222
|
31297
|
Discharge summary
|
report
|
Admission Date: [**2160-7-30**] Discharge Date: [**2160-9-6**]
Date of Birth: [**2107-7-7**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Shellfish
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
[**2160-7-31**]: Subtotal colectomy with end ileostomy and G-tube
placement
[**2160-8-25**]: Tracheostomy
History of Present Illness:
Mrs. [**Known lastname 73818**] is a 53 year old woman who was transferred from
[**Hospital 1474**] Hospital after undergoing a right total knee
replacement on [**2160-7-21**], which was complicated by oversedation,
when she was found to be in renal failure, febrile with
leukocytosis. Per records, she received a dose of Vancomycin
and Cefazolin peri-operatively. She was admitted to [**Hospital1 1474**]
ICU. She subsequently developed ARDS, requiring steroid tx and
pressors. She was started on Imipenem and Vancomycin
empirically. Cultures have remained negative. Within a day or
two, she was weaned off pressors and her white count had
improved. She continued to have low grade fevers, until [**7-26**]
when her fever curve started to climb. Her WBC rose to 32 on
[**2160-7-28**], 3-4 days prior to transfer she developed increased
diarrhea, and stool came back positive for C diff toxin ([**7-28**]).
ID was consulted. She was started on Flagyl and Vancomycin, but
later became hypotensive, requiring Levophed; steroids were
restarted. IVIG (one dose) was given per ID recommendations. CT
abdomen revealed some colonic thickening, but the study was
limited due to lack of IV contrast. Surgery evaluated the
patient and recommended medical management. Catheter tip on [**7-27**] grew Coagulase negative staphylococcus. Due to concern for
C diff toxic megacolon and sepsis, pt was transferred to [**Hospital1 18**]
MICU for management. All blood cultures were negative at time of
transfer.
Past Medical History:
Dyslipidemia, hypothyroidism, depression, bladder repair
Social History:
The patient lives with her husband and two daughters. [**Name (NI) 4084**]
smoked, no EtOH, no drug use. Traveled to [**Country 149**] and [**Country 7936**] in
[**2160-6-10**] when she developed vaginal yeast infection and UTI.
Recently went camping in NH.
Family History:
Non-contributory
Physical Exam:
VS: T 98.9; BP 126/45; HR 93; RR 17; O2sat 100% on a vent
VENT: AC 400x15(1); FiO2 0.6; PEEP 8; min vent 9.1
ABG: pH 7.15; pCO2 80; pO2 119
GENERAL: intubated, sedated, does not open eyes to voice, does
not follow up commands
NECK: JVP not elevated
HEENT: NC, AT, PERRL, no scleral icterus
CV: regular, hyperdynamic precordium, nl S1S2, no M/R/G
PULM: CTA
ABD:+ BS, soft, NT, ND
EXTR: 2+ ankle edema; R knee slightly swollen, surgical incision
c/d/i, toes dusky, DP and TP pulses are palpable bilaterally,
NEURO: intubated and sedated
SKIN: macerated in groin/inner thighs
Right subclavian (placed [**2160-7-27**] @OSH) site w/o signs of
symptoms of infection
Pertinent Results:
Radiology:
[**7-30**] CT Chest/Abdomen/Pelvis
1. Diffuse colonic wall thickening, consistent with history of
C. difficile colitis. The maximal dimension of large bowel is
approximately 6.4 cm in diameter, upper limits of normal.
2. No evidence of perforation.
3. Multifocal pneumonia
[**7-30**] Right Knee X-ray: Status post placement of a
tricompartmental right total knee replacement without evidence
of hardware-related complication.
[**7-31**] Head CT: No hemorrhage, mass effect, hydrocephalus, or
shift of normally midline structures is identified. The
[**Doctor Last Name 352**]-white matter differentiation is preserved. The visualized
paranasal sinuses and mastoid air cells remain normally aerated.
Old right basal ganglia is identified. Atherosclerotic
calcification is noted within the basilar artery.
[**7-31**] Echo: The left atrium is normal in size. Left ventricular
wall thicknesses and cavity size are 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 number of aortic valve leaflets
cannot be determined. No masses or vegetations are seen on the
aortic valve. 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 mass or vegetation is seen on
the mitral valve. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
[**8-7**] CT Abdomen/Pelvis:
1. Severe colitis of distal remnant colon.
2. No radiographic evidence for pancreatitis.
3. Fluid along the subcutaneous fat at the incision site. Cannot
exclude early infection and clinical correlation is recommended.
[**8-7**] CT Head:
1. No evidence of hemorrhage or mass effect. If high clinical
suspicion for infarct, MRI would be a more sensitive evaluation.
2. Interval worsening of bilateral mastoid air cells
opacification. Please correlate clinically for signs of acute
mastoiditis.
[**8-17**]: No DVT Right leg. Exam of left leg suspended due to
cardiac arrest.
[**8-17**] CTA Chest/Abdomen/Pelvis:
1. Diffuse wall thickening with surrounding fat-stranding and
edema involving the Hartmann's pouch with slight interval
improvement.
2. No evidence of central or segmental PE.
3. Multifocal air-space opacities as seen on the previous CT
from [**2160-7-31**] likely representing active or resolving pneumonia.
4. Focal small bowel intussception in the left upper quadrant
without evidence of obstruction which may be transient -
clinical correlation recommended.
[**8-18**] CT Head: There is no intracranial hemorrhage, shift of
normally midline structures, hydrocephalus, or evidence of acute
major vascular territorial infarction. A mucus retention cyst is
noted within the sphenoid sinus. The mastoid air cells appear
well aerated. Surrounding osseous structures are otherwise
unremarkable.
[**8-18**] 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.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
[**8-19**] CT Head: There is no intracranial hemorrhage, shift of
normally midline structures, hydrocephalus, or evidence of acute
major vascular territorial infarct. [**Doctor Last Name **]-white matter
differentiation appears preserved. An approximately 4-mm right
sublenticular hypodensity may represent a sublenticular cyst or
prominent Virchow [**Doctor First Name **] space. Opacification of multiple ethmoid
air cells is noted with a moderate-sized polyp within the
sphenoid sinus. Opacification of multiple bilateral mastoid air
cells is observed. The sinus changes are likely inflammatory in
origin.
[**8-19**] EEG: Abnormal EEG due to diffusely low and slow rhythms
overall.
This suggests a moderate degree of diffuse encephalopathy
[**8-20**] MR [**Name13 (STitle) 430**]: The evaluation of the lower brain is limited due
to large amount of artifact caused by dental hardware. The
artifact is specially limiting on the GRE, DWI, and FLAIR
images.
There are no definite areas of abnormal enhancement or masses.
There are no intracranial hemorrhages. The [**Doctor Last Name 352**]/white matter is
differentiation is maintained with no areas of slow diffusion
given the limitations described above.
There are scattered small subcortical, deep, and periventricular
white matter T2 hyperintensities which likely represent small
vessel ischemic changes. The ventricles and extraaxial CSF
spaces are within normal limits. There is asymmetry in the sizes
of the temporal horns with the left greater than right but the
hippocampi appear to be within the normal limits.
There is increased T2 signal within the mastoid air cells as
well as fluid layering within the nasopharynx. Some kind of
tubing is seen within the mouth.
There is mild mucosal thickening involving the left frontal,
ethmoid, and sphenoid sinuses with mucous retention cyst within
the sphenoid sinus.
The visualized orbits are grossly normal. No suspicious bony
abnormalities are seen.
[**8-22**] EEG: This telemetry captured no well-recorded or reliable
pushbutton activations. The two recorded were probably
artifactual.
Routine sampling and automated detection showed a very
encephalopathic
slow background. There was an occasional sharp wave discharge
but no
electrographic seizures, and most sharp features were
artifactual.
[**8-26**] Echo (TTE): The left atrium is mildly dilated. The
estimated right atrial pressure is 0-5mmHg. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF 70%) Tissue Doppler imaging suggests a
normal left ventricular filling pressure (PCWP<12mmHg).
Transmitral Doppler and tissue velocity imaging are consistent
with normal LV diastolic function. 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. No vegetation/mass is seen on the pulmonic valve.
There is no pericardial effusion.
[**8-28**] Echo TEE: No mass/thrombus is seen in the left atrium or
left atrial appendage. No atrial septal defect is seen by 2D or
color Doppler. Overall left ventricular systolic function is
normal (LVEF>55%). Right ventricular systolic function is
normal. The ascending, transverse and descending thoracic aorta
are normal in diameter and free of atherosclerotic plaque. The
aortic valve leaflets (3) are mildly thickened. No masses or
vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve. No
mitral regurgitation is seen. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion.
Brief Hospital Course:
Neurological: The patient had a high fever spike and went into
asystolic arrest while awaiting ultrasound. A neurology consult
was obtained. She was started on the appropriate antibiotic and
antiviral regimen. A CNS infection was ruled out. Head CT and
MRI revealed no anatomical or structural abnormality. EEG's
obtained showed no seizure activity. Her mental status has
improved dramatically. She is now alert and oriented and able
to converse freely. She understands her situation and wants to
improve her health.
Cardiovascular: Upon arrival, the patient was supported with
pressors, which were weaned off. She required additional
pressor support after her asystolic event of [**2160-8-18**]. She
underwent multiple echocardiograms demonstrating no vegetations,
and normal function. When her cardiovascuilar status had
stabilized, and she was no longer requiring pressors, she was
placed on metoprolol, which she has continued.
Pulmonary: She was transferred intubated, improving from her
pneumonia, likely due to aspiration at [**Hospital 1474**] Hospital. She
had continued to show marked improvement until the time of her
asystolic event. She was then intubated, and after 7 days, she
underwent a bedside tracheotomy for inability to wean from the
ventilator. After the tracheostomy, she rapidloy progressed to
tolerating trach mask for a substatial portion of the day.
GI: After initial NPO status, she was supported with TPN. She
was then transitioned to tube feedings on POD 13, and these were
advanced to goal. Her feedings were held in the time around her
asystolic event, and then advanced to goal. She remains on
Replete with Fiber, full strength at her goal rate of 50
cc/hour. As she has a non-fenestrated tracheostomy in place at
this time, and she has tolerated these tube feeds, a second
swallowing evaluation has not been performed. This should be
obtained prior to initiating oral feeding.
GU: She had a candidal and lactobacillus UTI, which have been
adequately treated. She currently has an indwelling foley
catheter with a daily urine output of approximately 2500cc.
Heme: She did require a blood transfusion on [**8-18**]. Her
hematocrit at that time was 18.3. After transfusions her
hematocrit rose to 25.7. Her hematocrit is now stable and has
steadily risen to 34.9 on the day of discharge.
ID: Her C. diff has resolved and the last stool specimen sent on
[**7-31**] was negative. Her urine cultures on [**2160-8-17**] revealed a
candidal and lactobacillus UTI. Blood cultures obtained on the
same day revealed candidemia and lactobacillus bacteremia. She
was started on the appropriate antibiotics and surveillance
blood cultures drawn on [**2160-8-24**] are negative. She has been
instructed by ID to stop the Linezolid on [**9-5**], stop the
Caspofungin on [**9-6**], and stop the PO Vancomycin on [**9-12**].
Medications on Admission:
Florinef
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: Five (5)
ML PO Q4H (every 4 hours) as needed: Via G-tube.
2. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Via G-tube.
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Via G-tube.
4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 6-8 Puffs
Inhalation Q4H (every 4 hours) as needed for when on vent: When
on ventilator.
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): Via G-tube
Hold for SBP <100, HR <60.
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
7. Albuterol 90 mcg/Actuation Aerosol Sig: 6-8 Puffs Inhalation
Q4H (every 4 hours) as needed for when on vent: When on
ventilator.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Sepsis
Clostridium difficile colitis/Toxic megacolon
Asystolic arrest
Respiratory failure
Discharge Condition:
Stable
Discharge Instructions:
Return to the Emergency room or call the office if you
experience:
** Fever above 101.5 F
** Inability to tolerate nutrition by mouth or G-tube
** Chest pain
** Shortness of breath
** Difficulties with your tracheostomy
** Any other concerns
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in [**3-16**] weeks. You may call his
office at ([**Telephone/Fax (1) 2047**] to make an appointment when you are
stable enough to be seen in clinic.
|
[
"112.5",
"789.5",
"507.0",
"038.3",
"427.5",
"707.05",
"518.81",
"401.9",
"998.59",
"008.45",
"599.0",
"244.9",
"V43.65",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.17",
"00.14",
"96.04",
"99.15",
"88.72",
"38.93",
"96.6",
"93.59",
"86.04",
"31.1",
"43.19",
"96.72",
"03.31",
"99.04",
"99.60",
"46.23",
"45.8"
] |
icd9pcs
|
[
[
[]
]
] |
14349, 14421
|
10623, 13503
|
288, 396
|
14555, 14564
|
3005, 3455
|
14854, 15053
|
2291, 2309
|
13562, 14326
|
14442, 14534
|
13529, 13539
|
14588, 14831
|
2324, 2986
|
242, 250
|
424, 1920
|
6637, 10600
|
3464, 4864
|
1942, 2000
|
2016, 2275
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,081
| 148,585
|
49850
|
Discharge summary
|
report
|
Admission Date: [**2126-10-22**] Discharge Date: [**2126-10-29**]
Date of Birth: [**2052-9-15**] Sex: M
Service: MEDICINE
Allergies:
Sporanox / Ace Inhibitors / Penicillins / Lisinopril
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Right upper extremity swelling, shortness of breath.
Major Surgical or Invasive Procedure:
Hemodialysis
CVL
History of Present Illness:
In brief, the patient is a 74 y.o. HD-dependent Male w/ multiple
medical problems including ESRD [**2-12**] FSGS (focal segmental
glomerular sclerosis), s/p DDRT (deceased donor renal
transplant) in [**2121**], failed graft function [**2-12**] chronic rejection
on Mycophenylate (MMF), CAD s/p CABG, HTN, HL, s/p recent RUE AV
graft on [**10-18**].
.
Four days after placement of the AV graft he was admitted to the
transplant surgery team w/ edema, parasthesias, and SOB. Pt went
to dialysis 3 days post-procedure and was diuresed "close to dry
weight", then had sudden onset SOB on the following day after
exertion. In the ED, there was concern for fluid overload; also
CTA was performed to rule out a PE. In addition, there was
concern for infection versus dvt in the right arm [**2-12**] forearm
swelling and tenderness but this was was ruled out with U/S.
.
On [**10-22**], he continued to have SOB on exam and developed new
oxygen requirement. Chest CT and chest xray were concerning for
evolving pulmonary edema. He was dialyzed 2.3L on [**10-22**] and 1L
on [**10-23**] during hemodialysis for concern CHF exacerbation- got a
dose of Vanc at HD empirically. On [**10-23**], he developed ST
segment depressions in the V3-V5 with elevated enzymes (trop T
0.45, CKMB 7) without any chest pain. Echocardiogram showed no
new wall motion abnormalities and stable ejection fraction 40%.
Cardiology was consulted and suggested that the patient had had
ACS event on day prior to admission when he had developed acute
SOB vs enzyme bump in the setting of CHF. Patient was thought to
be euvolemic by cardiology consult at that time. Enzymes
continued to rise (0.08->0.45->0.55->0.70.) Heparin gtt was
started. Patient was transferred to [**Hospital1 1516**] [**10-24**]. HD on [**10-24**] with
removal 1L.
.
Pt was not urgently sent to cath despite elevated enzymes and
EKG changes, as renal had goal to salvage remaining kidney and
did not want to subject patient to dye load. Patient went for
pMIBI [**10-25**] to look for reversible defect; early in stress test,
patient developed deep ST depressions and was sent emergently to
cath.
.
On cath, SVG to RCA was found to be occluded and SVG to D1 was
successfully stented with DES. Also noted was severe L
subclavian stenosis, patent LIMA. Plan was for ASA 325 mg daily
indefinitely and Plavix 75 mg daily for one year.
.
At the end of the procedure, the patient developed respiratory
difficulty with sats in the mid 80s. He received narcan, at
which point he became more alert but the team noticed that he
was not moving his L side. The patient was transported
immediately to the CCU, where he was evaluted by Neurology. He
was initially sat-ing 97% on RA but was gasping and using all
accessory muscles. He proceeded to desat to 70s; ABG on 100%
non-rebreather was pH 7.35/pO2 47/pCO2 49/HCO3 28. He was
transported to CT scan which showed perfusioin abnormality of
right MCA M1 segment.
Past Medical History:
ESRD [**2-12**] FSGS s/p CRT [**4-15**] c/b chronic rejection
CAD s/p 3V CABG [**5-13**] (SVG to OM, SVG to PDA, LIMA to LAD)
Chronic diastolic CHF
Mild MR
COPD
E. coli pelvic abscess
HTN
Hyperlipidemia
Angiodysplasias in stomach, duodenum and colon
VZV c/b PHN
Gout
BCC
Umbilical hernia repair
BPH
Social History:
Retired HMS physiologist. He has been living at rehab since
recent discharge. Quit smoking in [**1-19**]. Former heavy ETOH use,
now rare use.
Family History:
Father had CAD and died of a CVA. Mother died of an unknown
cancer that had metastasized to the liver. One brother has CAD.
Physical Exam:
EXAM UPON ARRIVAL TO CCU
GENERAL: WDWN elderly male with slurred speech, able to state
name, answer basic questions.
HEENT: Pale pallor, dry mucous membranes, minimal reaction to
threatening his eyes. Full ROM in EOM.
CARDIAC: Nl S1, S2 with no murmurs but difficult to auscultate
given breath sounds.
LUNGS: Patient using all accessory muscles and abdominal muscles
for breathing; appears to be gasping. Rhonchi throughout lung
field bilaterally anteriorly.
ABDOMEN: Soft, distended, using abdominal muscles for breathing.
EXTREMITIES: No lower extremity edema.
PULSES: Pedal pulses not palpable but marked by doppler.
Pertinent Results:
[**2126-10-22**] 11:00AM PT-13.2 PTT-29.2 INR(PT)-1.1
[**2126-10-22**] 11:00AM PLT COUNT-204
[**2126-10-22**] 11:00AM WBC-9.9 RBC-2.87* HGB-8.7* HCT-27.3* MCV-95
MCH-30.3 MCHC-31.8 RDW-15.9*
[**2126-10-22**] 11:00AM GLUCOSE-104* UREA N-53* CREAT-7.8* SODIUM-138
POTASSIUM-5.0 CHLORIDE-96 TOTAL CO2-27 ANION GAP-20
[**2126-10-22**] 11:00AM CALCIUM-9.2 PHOSPHATE-8.1*# MAGNESIUM-2.4
[**2126-10-22**] 11:00AM cTropnT-0.08*
[**2126-10-23**] 06:35AM BLOOD WBC-9.9 RBC-3.06* Hgb-9.1* Hct-28.9*
MCV-95 MCH-29.6 MCHC-31.3 RDW-16.3* Plt Ct-204
[**2126-10-23**] 06:35AM BLOOD Glucose-92 UreaN-30* Creat-6.0*# Na-138
K-4.2 Cl-93* HCO3-35* AnGap-14
[**2126-10-23**] 06:35AM BLOOD Calcium-9.4 Phos-5.6*# Mg-2.1
Peritent Imaging:
[**10-25**] Head CT
1. Head CT demonstrates loss of [**Doctor Last Name 352**]-white matter
differentiation and right MCA distribution suggestive of an
early infarct.
2. CT perfusion demonstrates large area of middle cerebral
artery territorial ischemia with a small evolving infarct.
3. CT angiography of the head demonstrates occlusion of the
right M1 segment secondary to a clot. Diminished numbers of
distal vascular structures are seen in the sylvian region.
4. CT angiography of the head demonstrates moderate left carotid
stenosis
with exuberant calcification and nonvisualization of the origin
of the left vertebral artery with diffuse atherosclerotic
disease in the aortic arch and proximal vessels as described
above.
5. The images through the lung demonstrate dependent atelectatic
changes and pleural effusion and signs indicative of cardiac
decompensation.
[**2126-10-25**] Cath
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease of the RCA and LAD.
2. Patent LIMA-LAD.
3. Occluded SVG-RCA.
4. Proximal 80% stenosis of SVG-D1, occluded D1-OM.
5. 70% left subclavian stenosis.
[**2126-10-27**] RUQ US with dopplers
IMPRESSION: Diminutive but patent portal vein. Please note that
this exam is limited due to patient's clinical status and the
proximal portion of the portal vein was not imaged.
Labs Priot to VT/PEA arrest:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2126-10-29**] 17:28 24.4*1 3.36* 10.3* 31.3* 93 30.7 32.9 17.9*
212
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2126-10-29**] 21:23 122*1 43* 5.5* 140 4.5 96 27 22*
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2126-10-28**] 04:46 1727* 1438* 1262*1 89 90 1.3
BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calTCO2 Base XS Intubat
[**2126-10-29**] 21:38 ART 75* 37 7.48* 28 3
Brief Hospital Course:
74 y.o. HD-dependent Male w/ MMP including ESRD [**2-12**] FSGS, s/p
DDRT in [**2121**], failed graft function [**2-12**] chronic rejection on
MMF, CAD s/p CABG for 3VD, HTN, HL, initially hospitalized for
concern of infection in recent RUE AV graft who was then worked
up for CHF decompensation.
In the interim he developed a NSTEMI and had markedly positive
adenosine MIBI study. Cardiac catheterization noted ulcerated
lesion of SVG to D1. This was stented successfuly but his
catheterization complicated by acute stroke. He was emergently
taken to interventionial neuroradiology. The filling defect in
the RMCA territory could not be removed, and he subsequently had
L sided paralysis. He was admitted to the CCU where his
hospital course was complicated by a LGIB, lactic acidosis, a
profound transaminitis, and persistent fevers without culture
evidence of infection. Serial head CT's did not show any
interval change in the area of his stroke. He also had unstable
VT and was amio loaded with resolution of the VT. Further
testing demonstrated encephalopathic changes on EEG and he was
started on lactulose. On the day the patient expired, he
received dialysis prior to developing unstable VT and PEA arrest
with an interval of Torsades. The patient did not receive chest
compressions per the family's request.
The patient expire on [**2126-10-29**] at 11:12 pm after undergoing
resuscitation with DC cardioversion and medications for greater
than 20 minutes.
Medications on Admission:
Medications - Prescription
ALLOPURINOL - 100 mg Tablet - 2 Tablet(s) by mouth once a day
AMLODIPINE - (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth once a day
B COMPLEX-VITAMIN C-FOLIC ACID [RENAL CAPS] - (Prescribed by
Other Provider) - 1 mg Capsule - 1 Capsule(s) by mouth once a
day
COLCHICINE - (Prescribed by Other Provider; Dose adjustment -
no
new Rx) - 0.6 mg Tablet - 1 Tablet(s) by mouth twice a week
FENTANYL - (Prescribed by Other Provider; Dose adjustment - no
new Rx) - 75 mcg/hour Patch 72 hr - q 48 hours
FUROSEMIDE - (Prescribed by Other Provider) - 80 mg Tablet -
Tablet(s) by mouth q d
ISOSORBIDE MONONITRATE - (Prescribed by Other Provider) - 60 mg
Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth once a day
METOPROLOL TARTRATE - (Prescribed by Other Provider) - 25 mg
Tablet - 1 Tablet(s) by mouth twice a day
MYCOPHENOLATE MOFETIL [CELLCEPT] - 250 mg Capsule - 1 Capsule(s)
by mouth twice a day
OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - [**1-12**] Tablet(s) by
mouth every 4 hours as needed for pain
PANTOPRAZOLE [PROTONIX] - (Prescribed by Other Provider) - 40
mg
Tablet, Delayed Release (E.C.) - Tablet(s) by mouth q d
PREGABALIN [LYRICA] - (Prescribed by Other Provider) - 200 mg
Capsule - 1 Capsule(s) by mouth once a day
SEVELAMER HCL [RENAGEL] - (Prescribed by Other Provider; Dose
adjustment - no new Rx) - 800 mg Tablet - 3 Tablet(s) by mouth
three times a day
SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth qe
SULFAMETHOXAZOLE-TRIMETHOPRIM - (Prescribed by Other Provider)
-
400 mg-80 mg Tablet - 1 Tablet(s) by mouth
TACROLIMUS [PROGRAF] - (Prescribed by Other Provider) - 0.5 mg
Capsule - 1 Capsule(s) by mouth twice a day
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Chewable - 1 Tablet(s) by mouth once a day
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Patient expired from VT/PEA arrest
Discharge Condition:
Patient Expired
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2126-10-30**]
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82,381
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45721
|
Discharge summary
|
report
|
Admission Date: [**2175-6-19**] Discharge Date: [**2175-7-3**]
Date of Birth: [**2097-3-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Shortness of breath and chest discomfort
Major Surgical or Invasive Procedure:
[**2175-6-19**] Cardiac Catherization
[**2175-6-26**] Three Vessel Coronary Artery Bypass Grafting(left
internal mammary to left anterior descending artery with
saphenous vein grafts to diagonal and PDA).
History of Present Illness:
Mr. [**Known lastname 86418**] is a 78 year-old man with a history of inferior MI,
hypertension, hypercholesterolemia and claudication who was
admitted to the CCU following emergent cardiac catheterization
after presenting with acute onset shortness of breath and chest
discomfort. He is a vague historian although does feel that he
has been more fatigued in general over the last 2-3 weeks with
shortness of breath noticed when it was hot and humid. He
noticed he has felt more short of breath since the evening prior
to admission ([**6-18**]) and first noticed this when he was tryng to
go to sleep. He was restless and felt that his breathing was
labored at rest. He also notes epigastric/lower chest discomfort
which was continuous since the evening of [**6-18**] and was a dull
pain which had no particular radiation and was assocated with
some chest heaviness. He denied significant nausea, no vomiting
although he was diaphoretic.
.
His symptoms were considerably worse by the morning of [**6-19**] and
he called EMS and was admitted to the outside hospital ([**Hospital1 **]) ED and ECG at the time showed a LBBB and inferior Q
waves and CXR showed pulmonary edema and cardiac enzymes were
mildly elevated with Trop 0.12, BNP 3490. Baseline labs at
[**Hospital3 **] showed BUN 41 Cr 1.4.
.
In the [**Hospital 97437**] Hospital ED, he was loaded with clopidogrel 600mg
and 4x81mg aspirin and integrilin infusion at 14ml/hour and a
nitroglycerin 50mcg/min infusion. On arrival at [**Hospital3 **] ED
he received furosemide 40mg IV and taken to cardiac
catheterization. Cardiac cath demonstrated diffuse 3-vessel
disease not amenable to PCI.
.
On review of systems, he denied any recent fever, chills, change
in weight, change to bowel or bladder habbits, arthalgia,
myaglia, dizziness, numbness or weakness. Cardiac review of
systems is notable for absence of typical chest pain, although
he was dyspneic at rest, had no paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope. He
noted bilateral claudication at 200yrds with no rest pain. Of
note he had dark/black stools for three days and settled two
days ago. He has chronic problems with increased urinary
frequency/urgency.
Past Medical History:
- History of Inferior MI [**89**] years ago
- Hypertension
- Hypercholesterolemia.
- Previous gastric/DU 10 years ago and had a GI bleed requiring
hospital admission.
- Mild Osteoarthritis
- GERD
- s/p left knee surgeries
- s/p hemorrhoidectomy
Social History:
Retired [**Doctor Last Name **] at Stop and Shop and limousine driver.
-Tobacco history: 5 cigars/day since teens
-ETOH: 0-2 units per week. Denies prev alcohol excess.
-Illicit drugs: denies
Normally walks unaided and has ET 1 mile on the flat.
Family History:
Mother had MI and pancreatic ca
Father - asthma
Sibs - No cardiac disease. 2 sisters otherwise well
Physical Exam:
Admission Exam
Gen: Well appearing main with some SOB.
HEENT: PERRL, EOMI. MMM. OP clear. Conjunctiva well pigmented.
Neck: Supple, without adenopathy. Some JVD and JVP elevated at
7-8cm above sternal angle.
Chest: Decreased breath sounds bilaterally to midzones and
crackles to midzones bilaterally worse on the left. Dullness at
bases.
Cor: HS SI+ soft SII + ESM with no radiation. RRR. No deviated
apex.
Abdomen: Obese Soft, non-tender.. +BS, no HSM. R groin cath site
no hematoma no bruit.
Extremity: Femorals 2+ b/l Popliteals 2+ on L 1+ on R, DP
present barely on teh left and absent on the right. PT absent
bilaterally. All foot pulses present on doppler with monophasic
waveforms. No peripheral edema. No clinical evidence of DVT.
Neuro: Alert and oriented. CN 2-12 intact. Motor strength intact
in all extremities. Sensation intact grossly.
Pertinent Results:
[**2175-6-19**] WBC-12.4* RBC-4.46* Hgb-12.0* Hct-36.6* Plt Ct-296
[**2175-6-19**] PT-12.7 PTT-23.6 INR(PT)-1.1
[**2175-6-19**] Glucose-140* UreaN-44* Creat-1.7* Na-142 K-4.5 Cl-107
HCO3-20*
[**2175-6-19**] ALT-8 AST-14 LD(LDH)-177 CK(CPK)-25* AlkPhos-126
TotBili-0.6
[**2175-6-19**] CK-MB-2 cTropnT-0.16*
[**2175-6-20**] CK-MB-4 cTropnT-0.17*
[**2175-6-20**] CK-MB-3 cTropnT-0.14*
[**2175-6-21**] CK-MB-2 cTropnT-0.13*
[**2175-6-19**] Albumin-4.0 Calcium-9.5 Phos-5.0* Mg-2.3 Cholest-209*
[**2175-6-19**] %HbA1c-5.9 eAG-123
[**2175-6-19**] Triglyc-167* HDL-30 CHOL/HD-7.0 LDLcalc-146*
[**2175-6-19**] Cardiac Cath:
1. Selective coronary angiography of this right dominant system
revealed two vessel coronary artery disease. The LMCA had mild
diffuse disease.
The LAD had serial 90% stenoses, including near the ostium. The
Lcx had
moderate diffuse disease. The RCA (engaged with AL1) was totally
occluded and filled distally via left to right collaterals.
2. Resting hemodyanmics revealed severely elevated filling
pressures
with RVEDP of 23 and LVEDP of 39 mmHg. There was severe
pulmonary
hypertension with PASP of 50/31 mmHg. There was preserved
cardiac index
of 2.7 L/min/m2. There was a 20mmHg gradient across the aortic
valve,
which was confirmed on LV pullback, consistent with aortic
stenosis.
[**2175-6-19**] Echocardiogram:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is severely
depressed (LVEF= 25-30 %) with global hypokinesis and regional
inferior, lateral and apical near akinesis. There is no
ventricular septal defect. with borderline normal free wall
function. The aortic root is mildly dilated at the sinus level.
The aortic valve leaflets are moderately thickened. There is
probably moderate to severe aortic valve stenosis (valve area
0.8-1.0cm2) (low output AS). Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Trivial mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
[**2175-6-20**] Carotid Ultrasound:
Right ICA stenosis 60-69%. Left ICA stenosis <40%.
[**2175-6-26**] Intraop Echocardiogram:
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity is severely dilated. There is severe regional
left ventricular systolic dysfunction with thinning and akinesis
of the inferior, inferoseptal walls. There is hypokinesis of the
inferolateral wall.. Right ventricular chamber size and free
wall motion are normal. The aortic root is mildly dilated at the
sinus level. There are complex (mobile) atheroma in the
ascending aorta as demonstrated by an epiaortic scan. There are
complex (mobile) atheroma in the aortic arch. There are multiple
complex (>4mm) atheroma in the descending thoracic aorta. The
aortic valve leaflets are moderately thickened with decreased
mobility of the left and non coronary cusps.. There is severe
aortic valve stenosis (valve area 0.8- 0.9 cm2). Peak/mean
gradient is 25/15 mm Hg. Given the patients low CI of 1.5, this
may represent pseudo-aortic stenosis. Dobuatmine testing of this
hypothesis was not performed. Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**12-3**]+) mitral regurgitation is seen. Dr. [**Last Name (STitle) **].
POSTBYPASS
The patient is receiving dobutamine 5 ucg/kg/min
LV systolic function appears slightly improved in the setting of
inotropes. There is slight improvement of the anterior and
lateral walls. The AV gradient peak/mean gradient is now 35/20
and the [**Location (un) 109**] is 1.0-1.1 cm2. The MR is now trace/mild. RV
systolic function remains normal
WBC Hgb Hct Plt Ct
[**2175-7-3**] 12.2* 10.8* 32.9 317
[**2175-7-2**] 12.6* 11.8* 36.0 289
[**2175-7-1**] 11.8* 10.4* 31.7 229
[**2175-6-30**] 13.7* 10.1* 30.6 220
UreaN Creat Na K Cl HCO3
[**2175-7-3**] 34* 1.7* 136 4.2 102
[**2175-7-2**] 35* 1.7* 142 3.7 106 24
[**2175-7-1**] 39* 1.8* 140 3.7 104 25
[**2175-6-30**] 39* 1.8* 141 3.7 104 26
Brief Hospital Course:
While in the CCU, patient had a pre surgical work up which
included echocardiogram and carotid ultrasound. Given that the
patient was stable on medical therapy, surgery was delayed for
Plavix washout. Echocardiogram was notable for moderate aortic
stenosis and severely depressed LV function (EF 25%-30%).
Carotid ultrasound showed moderate disease of the right internal
carotid artery. See result section for further details. Given
potential for valve replacement, patient underwent several teeth
extractions prior to surgery. On admission, creatinine was
elevated at 1.7. Renal function remained stable prior to
surgery.
On [**6-26**], Dr. [**Last Name (STitle) **] performed coronary artery bypass grafting
surgery. Given intraoperative findings, aortic valve replacement
was not performed. See operative note for further details.
Following the operation, he was brought to the CVICU for
invasive monitoring. Within 24 hours, he awoke neurologically
intact and was extubated. He maintained stable hemodynamics and
weaned from inotropic support. On postoperative day two, he
transferred to the SDU. He experienced some confusion which
improved with the discontinuation of narcotics. His chest tubes
and pacing wires were removed without complication. Heart
failure regimen was resumed postoperatively except for the ACE
inhibitor given his chronic renal insuffiency. Single 7 beat run
of NSVT was noted but otherwise he remained in a normal sinus
rhythm with further atrial or ventricular arrhythmias. Over
several days, he continued to make clinical improvements with
diuresis and was eventually cleared for the [**Hospital **] Rehab in
[**Location (un) 686**] on post-operative day seven.
Of note, he had several days of diarrhea prior to discharge
which was D. difficile negative. Despite negative EIA for C.
diff toxin, he will empirically be treated with Flagyl for seven
days. With the negative EIA, antidiarrheals were given.
Medications on Admission:
Propranolol 80mg qd
Gemfibrozil 600mg [**Hospital1 **]
Hydroxyzine 50mg tid
Nitroglycerin patch 0.2mcg/hr applied daily
Multivitamin 1 tab qd
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. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 7 days: Please stop after one week.
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day: please
hold if K > 4.5 - dose may need to be titrated accordingly.
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day:
Please titrate accordingly.
10. Outpatient Lab Work
Please monitor weekly CBC, lytes, BUN/Cr while at rehab and fax
results to cardiac surgery office @ [**Telephone/Fax (1) 5793**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 6560**] Care & Rehab Center - [**Location (un) 86**]
Discharge Diagnosis:
Coronary Artery Disease, s/p CABG
Ischemic Cardiomyopathy
Postop Non Sustained Ventricular Tachycardia
Aortic Stenosis
Chronic Systolic Congestive Heart Failure
Non ST Elevation Myocardial Infarction
Hypertension
Dyslipidemia
Chronic Renal Insufficiency
Carotid Disease
Postop Diarrhea(C. difficile negative)
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. 1+ Edema
bilaterally
PAGE 1 ?????? for VNA and Rehabs
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 until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**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:
Dr. [**Last Name (STitle) **] on [**2175-7-26**] 1PM, call office with any questions
[**Telephone/Fax (1) 170**]
PCP/Cardiologist, Dr. [**Last Name (STitle) **] - call office for appt
Completed by:[**2175-7-3**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,579
| 127,074
|
29166
|
Discharge summary
|
report
|
Admission Date: [**2100-12-23**] Discharge Date: [**2100-12-27**]
Date of Birth: [**2035-3-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4028**]
Chief Complaint:
Nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
This is a 65-year-old female with a long history of interstitial
cystitis status post cystectomy and ileal neo-bladder
complicated by recurrent urinary tract infections who presented
to an outside hospital on the day prior to admission here with
three days of nausea, vomiting, and abdominal pain. This pain
was in the lower abdomen and radiating to the back; she
described it as [**10-8**] severity. The patient also mentioned
having had one night of diarrhea. She had a CT abdomen at the
outside hospital, which was read as appendicitis with question
of perforation or abcess. At that time she was seen by surgery
but requested transfer to [**Hospital1 18**]. She also had a blood culture
that was preliminarily positive for gram negative rods and thus
received pipercillin/tazobactam and levofloxacin prior to
transfer here.
In the ED, initial VS were T 99.4,(Tm 101.4), P74, BP 90/48 (her
lowest recorded blood pressure was 85/41) with O2 saturation of
97% on RA. The OSH CT scan was reviewed by a [**Hospital1 18**] radiology
attending who thought there was no evidence of appendicitis
(consistent with patient's previous appendectomy) but did agree
with the outside read of a L hydoureter (though this is a common
finding with neobladder. The patient received 4L IVF given that
she was hypotensive. she was given levofloxacin and
pipercillin/tazobactam in the outside hospital ED and received
vancomycin soon after her arrival here.
On arrival to the ICU, the pain was [**4-8**]. she was mildly
nauseous. she denied any chills but was feeling thirsty. She
denied chest pain, dyspnea, presyncope, or palpitations.
Past Medical History:
-Interstitial cystitis refractory to medical therapy leading to
cystectomy and replacement with ileal neobladder in [**12/2098**]
-Recurrent UTI after neobladder construction most recently on
TMP/Sulfa suppression
-Cholecystectomy
-Appendectomy
-Anxiety
Social History:
She is a lifelong non-smoker. She uses alcohol occasionally but
denies illicit drug use. She lives with her husband.
Family History:
Non-contributory
Physical Exam:
On Presentation
----------------
Vitals: T: 101.9, BP 110/52, HR 69, RR 20, O2 Sat 93% on 2L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Crackles bilaterally [**12-31**] of the way up
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, moderate tenderness to palpation, worse at RUQ,
CVA tenderness +, non-distended, bowel sounds present, no
rebound.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
On Discharge:
VS: T 99.6 (afebrile >24 hours), BP 120/60, HR 54, RR 20, O2 Sat
942% (94-96% w ambulation)
Exam notable for scattered crackles at lung bases on
auscultation without other signs of respiratory distress.
Abdomen no longer tender to palpation and without CVA
tenderness. Otherwise exam unchanged from presentation and was
benign.
Pertinent Results:
==================
LABORATORY RESULTS
==================
On Admission ([**2100-12-23**])
WBC-11.9*# RBC-3.45* Hgb-11.0* Hct-32.1* MCV-93# RDW-12.6 Plt
Ct-214
--Neuts-90.5* Lymphs-5.1* Monos-3.7 Eos-0.3 Baso-0.5
Glucose-110* UreaN-12 Creat-0.8 Na-138 K-3.8 Cl-107 HCO3-23
AnGap-12
ALT-43* AST-70* CK(CPK)-148* AlkPhos-73 TotBili-0.6
Lipase-21 Albumin-3.4
Urinalysis: Color-Straw Appear-Cloudy Sp [**Last Name (un) **]-1.05* Blood-MOD
Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG
Urobiln-NEG pH-6.5 Leuks-MOD
[**2100-12-23**] 06:35PM URINE RBC-[**6-8**]* WBC->50 Bacteri-MANY Yeast-NONE
Epi-0-2
On Discharge ([**2100-12-27**])
WBC-6.4 RBC-3.27* Hgb-10.2* Hct-29.4* MCV-90 RDW-13.1 Plt Ct-250
Glucose-173* UreaN-9 Creat-0.7 Na-141 K-3.7 Cl-106 HCO3-26
AnGap-13
ALT-62* AST-76* AlkPhos-118* TotBili-0.2
=============
MICROBIOLOGY
=============
-Final Urine Cx from Outside Hospital revealed E Coli sensitive
to all agents tested except TMP/Sulfa.
-Final Blood Culture at Outside Hospital was negative for growth
per report.
-In House Urine Cx on [**12-23**] and [**12-24**] failed to grow any
organism
-In House Blood Cx taken on [**12-23**] were negative for growth
-In House Blood Cx from [**12-24**] and [**12-25**] were pending at the time
of discharge
-C difficile Toxin A and B were checked on a stool sample on
[**12-26**] and these toxins were not detected
================
RADIOLOGY
================
CXR on [**2100-12-23**] (at presentation)
FINDINGS: The cardiomediastinal silhouette is stable. Previously
seen right pleural effusion has resolved. There is no focal
consolidation, pleural effusion or pneumothorax. Pulmonary
vascularity is increased, there is mild interstitial edema.
-
IMPRESSION: Mild interstitial edema, no radiographic evidence of
Pneumonia.
RIGHT UPPER QUADRANT ULTRASOUND ([**2100-12-24**])
FINDINGS: A well-defined 1.9 x 2.3 x 2.4 cm simple-appearing
cyst is seen in the inferomedial aspect of the right hepatic
lobe, corresponding to the cystic lesion seen on CT. No
significant internal echoes are identified within this lesion.
No other focal hepatic lesion is identified. There is no
intrahepatic biliary ductal dilatation. The gallbladder is
surgically absent and the common bile duct measures 9 mm. The
main portal vein demonstrates normal hepatopetal flow. A trace
amount of free fluid is identified perihepatically. A small
right pleural effusion is partially imaged. The head and body of
the pancreas appear unremarkable, but the tail is poorly
evaluated.
-
IMPRESSION:
1. Simple-appearing cyst in the inferior aspect of the right
hepatic lobe.
Trace perihepatic free fluid without focal fluid collection
identified.
2. Right pleural effusion partially imaged.
CT ABDOMEN AND PELVIS W/ AND W/O CONTRAST ([**2100-12-24**])
FINDINGS: There are small bilateral
pleural effusions, which are simple in attenuation. There are
associated
bibasilar opacities, which may represent atelectasis,
consolidation, or
accommodation of these. In segment V of the liver, there is a
rounded
hypodense lesion measuring 24 Hounsfield units and 2.5 cm in
diameter, which is not fully characterized. This structure could
represent a cyst or other fluid-containing structure. Mild
relative hypodensity of the liver parenchyma adjacent to the
falciform ligament is compatible with focal fatty infiltration.
There is slight hypodensity along the portal structures,
possibly related to fluid resuscitation. Per report, the patient
is post- cholecystectomy. The common bile duct is generous,
measuring nearly 11 mm in the porta hepatis, tapering to 7 mm in
the pancreatic head and then tapering at the ampulla. There is
no intrahepatic biliary ductal dilation. The pancreas is
unremarkable in appearance, without pancreatic ductal dilation.
There is a moderate amount of ascites fluid, which
predominates in the right upper quadrant, which does not appear
to be particularly dependent in this prone patient. Fluid
surrounds the portal structures in the second portion of the
duodenum, which is distended to mildly dilated.
The spleen, splenule, and adrenal glands are normal. There is
no
hydronephrosis of the kidneys. Enhancement and excretion is
relatively
symmetric, with mild vague hypodensity seen in the upper pole of
the left
kidney. There are no clearly wedge-shaped areas of hypodensity,
however. A
rounded hypodensity of the lower pole of the left kidney
measures 6 mm and is too small to characterize, but likely
represents a cyst. Aside from duodenal findings already
discussed, small bowel loops are notable for post-surgical
changes related to ileal neobladder formation. There is no free
air in the abdomen. The abdominal aorta is normal in caliber. No
mesenteric or retroperitoneal nodes meet CT size criteria for
pathologic enlargement.
The ureters are opacified from the kidneys down to the ileal
neobladder, without abnormalities demonstrated. The neobladder
contains urine and some air (3:79). The uterus is unremarkable.
There is oral contrast in the distal colon and rectum, possibly
from a study performed at an outside institution. Please
correlate. No definite colonic abnormalities are seen. Fluid
surrounds an epiploic appendage in the right abdomen (3:50). The
terminal ileum is unremarkable in appearance. The appendix
cannot be clearly identified. There are small amounts of free
pelvic fluid. No pathologically enlarged pelvic or inguinal
nodes.
BONE WINDOWS: There are no suspicious osteolytic or sclerotic
lesions.
-
IMPRESSION:
1. The ileal neobladder contains urine and air. Air could be
related to
infection or instrumentation. Please correlate clinically. The
ureters are
visualized throughout their course, unremarkable. There is no
hydronephrosis of the kidneys. There is slight
heterogeneity/hypodensity in the upper pole of the left kidney,
where pyelonephritis cannot be excluded. There are no clear
wedge-shaped defects to confirm this diagnosis by CT. Please
correlate.
2. There is a moderate amount of free fluid in the abdomen,
particularly in the right upper quadrant, in the periportal
region and adjacent to the second portion of duodenum, which
appears distended. There is no free air. The etiology of this
fluid is unclear, and GI inflammation cannot be entirely
excluded. The appendix is not visualized. While bladder
perforation cannot be excluded on this study, there is
relatively little free-fluid in the pelvis compared to that seen
in the right upper quadrant. If indicated, a cystogram could be
performed to evaluate the bladder integrity.
3. Rounded hypodensity of segment V of the liver, possibly
representing a
cyst, but not fully characterized on this study. If indicated,
this lesion
could be further evaluated with ultrasound to assess the
internal composition.
4. Small bilateral pleural effusions and bibasilar
Consolidations/ atelectasis. Infection cannot be excluded.
DEDICATED CT PELVIS W/ AND W/O CONTRAST ([**2100-12-25**])
FINDINGS: Neobladder is present in the pelvis. There is no
evidence of leak
of contrast from the neobladder. Mildly distended bowel is seen
in the upper pelvis with sutures, probably due to previous
resection of small bowel for creation of patient's neobladder.
There is trace amount of free fluid in the pelvis.
Minimal nodularity and gas in the anterior abdominal wall,
probably due to
subcutaneous injections. Mild subcutaneous edema. Scarring in
the midline
anterior abdomen. Colonic diverticulosis. Tiny bone island in
the right
femoral head.
-
IMPRESSION: No evidence of contrast leak from the neobladder.
DOUBLE CONTRAST UPPER GI STUDY ([**2100-12-25**])
FINDINGS: Single- and double-contrast images of the duodenum
were obtained
following administration of effervescent granules and thick
barium. These
demonstrate no filling defect and no mucosal abnormality. There
is no
extraluminal contrast to indicate perforation.
-
IMPRESSION: No perforation. No evidence of duodenal ulcer.
RIGHT UPPER QUADRANT ULTRASOUND ([**2100-12-24**])
FINDINGS: A well-defined 1.9 x 2.3 x 2.4 cm simple-appearing
cyst is seen in the inferomedial aspect of the right hepatic
lobe, corresponding to the cystic lesion seen on CT. No
significant internal echoes are identified within this lesion.
No other focal hepatic lesion is identified. There is no
intrahepatic biliary ductal dilatation. The gallbladder is
surgically absent and the common bile duct measures 9 mm. The
main portal vein demonstrates normal hepatopetal flow. A trace
amount of free fluid is identified perihepatically. A small
right pleural effusion is partially imaged. The head and body of
the pancreas appear unremarkable, but the tail is poorly
evaluated.
-
IMPRESSION:
1. Simple-appearing cyst in the inferior aspect of the right
hepatic lobe.
Trace perihepatic free fluid without focal fluid collection
identified.
2. Right pleural effusion partially imaged.
Brief Hospital Course:
65 year-old Woman with a long history of interstitial cystitis
s/p cyctectomy and ileal neo-bladder, presenting with abdominal
pain, nausea, and vomiting and transferred with presumptive
diagnosis of gram negative bacteremia/urosepsis.
1) Urinary Tract Infection/Concern for Urosepsis: The final
culture results from the outside hosptial suggested that the
patient had urinary tract infection caused by E coli. sensitive
to all agents tested except E. coli. Despite the presumptive
positive blood cultures final results would suggest the patient
did not have a true bacteremia. All cultures taken at our
institution were negative for growth at the time of discharge.
At [**Hospital1 18**] the patient initially received a dose of vancomycin
then was continued on pipercillin-tazobactam from [**Date range (1) 70177**]
when final culture and sensitivity results from the urinary
pathogen were obtained from the outside hospital and showed
sensitivity to quinolones. Thus, patient was transitioned to
oral ciprofloxacin therapy. She remained afebrile on this
regimen and was discharged on day five of appropriate therapy to
complete a nine additional days of antibiotic therapy for a
total course of 14 days Regarding management of her neobladder
the patient had a foley placed on presentation. Once
perforation was essential ruled out by the CT cystogram urology
approved her to return to her home schedule of clean
intermittent cathterization and she was discharged to continue
this.
2)Abdominal Fluid/Hepatic Process?: Initially some of the
patient's symptoms were localizing to her right upper quadrant
and she did have LFT elevations. Therefore, a right upper
quadrant ultrasound was obtained that showed trace perihepatic
fluid. Further imaging with CT abdomen and pelvis also showed
variable amounts of fluid in the abdomen. This raised concern
for a perforation or abccess though there was never air or an
actual abscess visualized on scans. Per recommendations of
urology and general surgery a dedicated CT cystogram and double
contrast upper GI radiograph were obtained. These showed no
bladder or bowel perforation and the cause of these processes
were never fully explained. This fluid was never present in a
large enough collection to allow safe paracentesis for testing.
As the patient's abdominal exam had resolved and she did not
appear toxic at that time neither urology nor surgery believed
this required re-imaging or further inpatient work-up. It is
unclear if these processes contributed to her nausea/vomiting or
abdominal symptoms or if these were simply due to her UTI but
her abdominal pain had resolved by [**12-26**] and by [**12-27**] she was no
longer nauseous and eating well. The patient persisted in
having elevated liver enzymes as reported above. The multiple
differential diagnostic possibilities of the patient's elevated
liver enzymes and free abdominal/pelvic fluid were discussed and
mentioned to her including malignancy and inflammation. The
importance of following up with a primary care physician to
recheck her LFT's and follow up of the ascites was repeatedly
emphasized to her and she has promised to do this.
3) Abdominal Pain/Nausea/Vomiting: The patient presented
primarily with upper GI pathology and intially required morphine
to control her abdominal pain. This resolved as she received
antibiotics and was treated in the hospital and by [**10-26**] her
abdominal pain had basically disappeared. The patient has a
history of pain very similar to this with previous UTI's per her
report. She had some intermittent vomiting and nausea that also
improved over her hospitalization. She received anti-emetics
for symptomatic improvement and was issued some of these for use
at home as she completes her recovery. She had not vomited for
two days as of the time of discharge and was eating and drinking
without complaint.
4) Hypotension: The patient's baseline SBP's have run in the
90's per report but she was slightly lower than her baseline at
presentation though minimally symptomatic with this. This could
have been a result of a low grade bacteremia, though this is
made less likely by the negative cultures. More likely this
could have simply been a result of dehydration due to nausea and
vomiting. The patient received 5 L of fluid on the day of her
presentation for volume reexpansion and she remained
hemodynamically stable with SBP's in the 100's therafter.
5)Hypoxia: The patient intermittently had mild hypoxia requiring
2 L of O2 by nasal cannula to maintain O2 Sats greater than 92.
She was never frankly dyspneic and always corrected quickly on
supplementary O2. CXR revealed no signs of pulmonary infection
or acute cardiopulmonary process, and early in her
hospitalization this was considered most likely due to her
vigorous volume reexpansion and some degree of fluid
overload/pulmonary edema. Her oxygen requirement had resolved
but then worsened a bit again with saturations in the low 90's
noted on room air. Nevertheless, the patients O2 saturations
went up to 94-95% on ambulation on room air and she was not
dyspneic suggesting this was primarily due to
immobility/compression atelectasis in the hospital. At
discharge she was maintaining saturations in the mid 90's on
room air and as she didn't desaturate on ambulation her treating
team believed she was safe to be discharged. Her oxygen
saturations should be rechecked as an outpatient.
6)Diarrhea: The patient presented with some loose stools and
these continued to be a problem throughout her hospitalization.
There was never any blood and this was more of a nuisance per
her description than a major concern. C difficile toxin testing
was negative times one and this was thought to be associated
with the patient's underlying illness or perhaps a concurrent
viral infection. Antibiotic associated diarrhea would be
another possibility as the patient had been on chronic
antibiotics at home and was on antibiotic throughout her course.
7)Anxiety: The patient has a history of anxiety, which was well
controlled with lorazepam PRN in the hospital.
The patient was administered subcutaneous heparin for DVT
prophylaxis. She was fed a full diet. She was full code.
TESTS/STUDIES PENDING AT DISCHARGE:
Blood Cultures from [**2100-12-24**] and [**2100-12-25**]
RECOMMENDED FOLLOW UP:
The patient should schedule up an appointment with urology in
one to two weeks to discuss her chronic antibiotic suppression
and this hospitalization.
The patient was instructed to make an appointment with her PCP
and make an appointment in approximately two weeks. Major
issues to address at this appointment would include checking
that the patient's diarrhea has resolved as well as checking
that her LFT's have normalized and her hypoxia is not
persistent. The treating team feels strongly the patient should
have repeat imaging of her abdomen such as abdominal ultrasound
in approximately one month to assure her ascitic fluid has
resolved. If she continues to have further fluid in the abdomen
or pelvis this would suggest a need for a more comprehensive
malignancy/inflammatory/infectious work-up.
The CT scan at the outside institution noted a small
retrocardiac nodule and suggested a repeat scan to follow-up.
There was no clear timetable suggested for this and this was not
noted on our imaging studies.
Medications on Admission:
trimethoprim 100 qd
Discharge Medications:
1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 9 days: Please take one dose on the evening
after your discharge and then take twice a day for nine
additional days. .
Disp:*19 Tablet(s)* Refills:*0*
2. Compazine 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for nausea for 2 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Complicated Urinary Tract Infection
Hypotension
Status post cystectomy with neobladder
Discharge Condition:
Afebrile, tolerating PO's, comfortable
Discharge Instructions:
You were admitted from the outside hospital because there was
concern you had a bloodstream infection. After getting final
results from the outside hospital it does not look like this was
the case. Most likely you had a urinary tract infection and
your blood pressure was low because you were nauseous, vomiting,
and became dehydrated. We observed you and made sure you were
not getting sicker and you received fluids to help your
dehydration. You improved dramatically on these therapies and
antibiotics. We are sending you home to complete a course of
treatment for your infection.
Your medications have been changed. You will be on antibiotics
for a total course of 14 days. The antibiotic you will be
taking at home is called CIPROFLOXACIN. We also gave you
medications for your nausea to take as needed.
In the hospital we found you had slightly elevated liver enzymes
and fluid in your abdomen and pelvis around your organs. We
worked this up and found no immediately dangerous issues, but it
is possible these could be the early signs of a serious problem.
It will be important that you follow up with your primary care
doctor to re-evaluate this.
Please call your doctor or report to the emergency room if you
have chest pain, shortness of breath, fever >101 F,
lightheadedness or fainting, or any other concerning changes in
your health.
Followup Instructions:
You should schedule a follow-up with Dr [**Last Name (STitle) 365**] in urology in [**12-30**]
weeks to discuss further management of your urology issues.
You need to schedule a follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 9449**], in
[**12-30**] weeks to discuss this admission. The most important issues
Dr. [**Last Name (STitle) 9449**] needs to check on are to make sure your liver
enzymes are improving (she should have the values from this
hospitalization by that time)and to schedule an abdominal
ultrasound to see if the abdominal fluid has resolved (this
would probably best be obtained around the end of [**Month (only) 404**], four
weeks after your discharge). Dr.[**Name (NI) 70178**] office can be
reached at [**Telephone/Fax (1) 70179**].
|
[
"458.9",
"599.0",
"790.6",
"511.9",
"789.59",
"300.00",
"V45.74",
"799.02",
"V03.82",
"041.4",
"593.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.55"
] |
icd9pcs
|
[
[
[]
]
] |
20091, 20097
|
12270, 18522
|
350, 356
|
20247, 20288
|
3389, 12247
|
21696, 22491
|
2442, 2460
|
19708, 20068
|
20118, 20118
|
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|
20312, 21673
|
2475, 3025
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18618, 19638
|
18536, 18607
|
3039, 3370
|
278, 312
|
384, 2013
|
20137, 20226
|
2035, 2290
|
2306, 2426
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,697
| 151,196
|
7457
|
Discharge summary
|
report
|
Admission Date: [**2168-1-7**] Discharge Date: [**2168-1-8**]
Service: MEDICINE
Allergies:
Codeine / Digoxin / amiodarone / Bactrim / lisinopril
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo F with sCHF EF 25% (Echo [**2167-12-26**]), NIDDM, HTN, HLD,
history of AF/AVNRT, CVA, and other medical issues, recently
admitted to [**Hospital1 18**] [**2167-12-25**] for CHF exacerbation with
hypotension and UTI treated with cipro, now presents to the ED
with AMS.
.
Per ED report, patient came from home with AMS since about 6AM.
The daughter says patient asked for water and crackers at 3AM
but then between 6:30-7AM appeared disoriented, unable to tell
where she was and did not recognize her daughter. The daughter
was unclear if it was potassium, BP, or glucose problem, so
called EMS. When EMS found her, her BS was in the 50s. Her
mental status improved with 1 amp of D50, and BS improved to
160. Per report, she did not have any SOB, chest pain,
abdominal pain, or N/V/D but has chronic LE edema and cold LE.
In the ED, initial vitals were 97F, HR 80, BP 85/45, RR 16,
difficult to interpret O2Sat. LE pulses were dopplarable. Labs
were significant for BNP up to [**Numeric Identifier 27326**] (highest value compared to
the past), creatinine up to 2.4 from baseline 1.0-1.1, troponin
of 0.1, and lactate of 3.4. EKG, per report, showed sinus
bradycardia at 58, c/w prior but has prolonged QTc at 495, TWI
in lateral leads, Q in III/aVF, no STEMI. Bedside ultrasound
apparently showed poor squeeze. CXR, per report, showed
bilateral pleural effusion at baseline. Patient was confirmed
to be DNR/DNI. Family declined central line despite SBP 85->
70s. Per report baseline MS [**First Name (Titles) **] [**Last Name (Titles) 3584**] and oriented x 2, not to
time. She received 250 cc NS bolus and 325 mg ASA. Because O2
Sat was difficult to interpret, she was placed on 10L NRB at
93%. Foley catheter was placed.
Of note, patient is on glipizide at home for DM. Baseline
weight was 125 lb (56.7 kg) per the patient and discharge weight
was 64.7 kg on [**2167-12-30**]. Of note, she was discharged with
reduction of metoprolol from 100 mg to 50 mg, increased
torsemide from 25 mg to 100 mg, initiation of spironolactone 25
mg and losartan 12.5 mg daily. She was treated with
ciprofloxacin for UTI. She is unable to give the list of her
medications as her daughter handles her medical care. She does
not use O2 at home. Per the daughter, her baseline SBP usually
90-100. However, since discharge, SBP goes to the 70s-80s/50s
intermittently. She spoke with her cardiology and the plan was
to go down to torsemide 100 mg and 50 mg on alternating days and
to stop losartan starting on [**2168-1-7**]. Of note, she only
takes amiodarone twice a week. She states the patient has been
eating well without fever or SOB, but patient always feels cold.
On arrival to the MICU, VS were T 33.1 (rectal), HR 58, BP
118/11, O2Sat 94-100% on [**6-19**] L. Denies pain. States a mild
cough since she got to the ED but not productive.
Past Medical History:
- Severe coronary artery disease (s/p STEMI [**2157**] with
anterolateral wall involvement, s/p LAD stenting - s/p NSTEMI
[**6-/2167**] with BMS placed in LAD)
- Systolic dysfunction (EF 25%), congestive heart failure
- NIDDM
- HTN
- HLD
- afib/AVNRT
- PVD
- CVA/stroke (small vessel stroke in R MCA territory [**7-/2165**],
with no residual effects)
- Osteoporosis
- h/o + MRSA screen [**2167-12-25**]
- b/l rotator cuff injuries
- s/p hysterectomy 20 years ago
- s/p L posterior tibiliais injury (L leg brace)
- s/p R bilateral malleolar fracture
- aspiration PNA in [**4-/2166**]
- s/p cataract surgeries
Social History:
Patient previously worked as a billing administrator for VW.
Patient lives at home with daughter. [**Name (NI) **] [**Name2 (NI) 269**]. Uses a wheelchair
and has orthotics for her legs.
Tobacco: never smoker
EtOH: rare
Illicits: none
Family History:
Denies family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory. Son s/p
CABG. Mother with congestive heart failure.
Physical Exam:
1. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day. Disp:*30
Tablet Extended Release 24 hr(s)* Refills:*0*
2. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. amiodarone 200 mg Tablet Sig: One (1) Tablet PO 2X/WEEK
([**Doctor First Name **],WE).
6. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual ASDIR as needed for chest pain: [**Month (only) 116**] repeat x 3 [**Month (only) 4319**]
Call your doctor if you are using.
7. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
8. glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
(for a couple of years)
9. alprazolam 0.25 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for insomnia. (only as needed got
10. senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day as needed
for constipation.
11. psyllium 1.7 g Wafer Sig: One (1) Wafer PO DAILY (Daily).
12. omega-3 fatty acids Capsule Sig: One (1) Capsule PO
DAILY (Daily).
13. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain, fever.
14. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. losartan 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*0*
16. torsemide 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
17. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
18. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days. Disp:*8 Tablet(s)* Refills:*0*
Pertinent Results:
ECHO [**2168-1-8**]:
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is severely depressed (LVEF=
25 %) secondary to severe global hypokinesis with focal inferior
and posterior akinesis. Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). The
right ventricular free wall thickness is normal. The right
ventricular cavity is dilated with severe global free wall
hypokinesis. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Severe (4+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. Significant
pulmonic regurgitation is seen. The main pulmonary artery is
dilated. The branch pulmonary arteries are dilated. There is no
pericardial effusion.
Brief Hospital Course:
Primary Reason for Hospitalization:
[**Age over 90 **] yo F with sCHF EF 25% (Echo [**2167-12-26**]), h/o CAD s/p stent,
HTN, HLD, NIDDM, h/o AF/AVNRT, h/o CVA, recent hospitalization
with CHF exacerbation/hypotention and UTI admitted to the ICU
for hypotension and hypoxia.
# Brief Hospital Course: Patient was admitted with hypotension
and hypoxia, felt most likely to be [**3-18**] acute on chronic sCHF
given physical exam findings and data. ACS considered given
elevated troponins, however CK-MB was wnl and EKG was unchanged.
Sepsis also considered given 1/2 blood cx growing GPC and she
was empirically started on IV vancomycin, however this was
thought more likely to be contaminant as she was afebrile with
nl WBC and had no focal s/sx of infection. Pt's clinical status
continued to deteriorate with increased O2 and pressors
requirement. A family meeting was held, and it was decided to
change goals of care to comfort-measures only. At 7:45PM on
HD#2, Ms. [**Known lastname 27320**] passed away. Family was present, PCP
[**Name Initial (PRE) 13109**]. Family declined autopsy.
Medications on Admission:
1. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day. Disp:*30
Tablet Extended Release 24 hr(s)* Refills:*0*
2. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. amiodarone 200 mg Tablet Sig: One (1) Tablet PO 2X/WEEK
([**Doctor First Name **],WE).
6. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual ASDIR as needed for chest pain: [**Month (only) 116**] repeat x 3 [**Month (only) 4319**]
Call your doctor if you are using.
7. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
8. glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
(for a couple of years)
9. alprazolam 0.25 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for insomnia. (only as needed got
10. senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day as needed
for constipation.
11. psyllium 1.7 g Wafer Sig: One (1) Wafer PO DAILY (Daily).
12. omega-3 fatty acids Capsule Sig: One (1) Capsule PO
DAILY (Daily).
13. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain, fever.
14. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. losartan 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*0*
16. torsemide 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
17. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
18. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days. Disp:*8 Tablet(s)* Refills:*0*
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
Acute on chronic systolic heart failure
Secondary:
Acute renal failure
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
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icd9cm
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[
[
[]
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[] |
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[
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[]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,155
| 111,083
|
48870
|
Discharge summary
|
report
|
Admission Date: [**2149-9-22**] Discharge Date: [**2149-10-3**]
Date of Birth: [**2080-8-7**] Sex: M
Service: SURGERY
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 158**]
Chief Complaint:
Unresectable Colonic Polyp.
Major Surgical or Invasive Procedure:
#1 Laparoscopic Right Colectomy
#2 Exploratory laparoscopy and flexible sigmoidoscopy for
suspected post-procedure bleeding.
History of Present Illness:
The patient is a 69-year-old male who was on a routine screening
found to have a large polyp at the hepatic flexure which was
unamenable to endoscopic removal; it was entered by biopsy. The
patient also has 2 mechanical valves
and he is on Coumadin. The risks and benefits of surgery
including but not limited to infection, bleeding, leak, need for
reoperation, need for further procedures, bowel injury, need for
drain or tubes was discussed. The patient agreed. He has
stopped his Coumadin a week ago and was changed to Lovenox, and
he stopped his Lovenox 2 days prior to presenting.
Past Medical History:
Past Medical History:
sCHF EF 30%
Colonic adenomas
Rheumatic heart disease s/p mechanical AVR/MVR in [**2137**]
Hypertension
Atrial fibrillation
?Osteoporosis
BPH
.
Past Surgical History:
b/l shoulder arthroplasties
Ankle surgery
surgery for gynecomastia
Social History:
Supportive wife and daughter.
Physical Exam:
General: NAD, A&OX3, Appears well, ambulating the floor
independantly, no pain, passing bowel movements, +flatus per
rectum.
VS: 99.4, 75, 117/51, RR18, RR 18, 99 RA
Cardiac: no MRG, Audbile click of valves, irregular rythm
Lungs: CTA, no distress
Abd: NBS, soft, nontender, no rebound/no gaurding
Wounds: Laparoscopic sites intact, open to air, umbilical site
intact
Pertinent Results:
[**2149-9-23**] 08:54AM BLOOD Hct-25.9*
[**2149-9-22**] 06:35PM BLOOD WBC-6.1 RBC-3.04*# Hgb-10.3*# Hct-29.9*
MCV-98 MCH-33.8* MCHC-34.3 RDW-12.7 Plt Ct-110*#
[**2149-9-22**] 10:53AM BLOOD Hct-37.1*
[**2149-9-22**] 06:35PM BLOOD Plt Ct-110*#
[**2149-9-22**] 08:50AM BLOOD PT-13.7* PTT-30.7 INR(PT)-1.2*
[**2149-9-23**] 08:50AM BLOOD Glucose-111* UreaN-19 Creat-0.9 Na-135
K-4.3 Cl-103 HCO3-29 AnGap-7*
[**2149-9-22**] 06:35PM BLOOD Glucose-98 UreaN-17 Creat-0.7 Na-136
K-4.1 Cl-103 HCO3-31 AnGap-6*
[**2149-9-22**] 10:53AM BLOOD Na-135 K-4.4 Cl-102
[**2149-9-23**] 08:50AM BLOOD Calcium-7.5* Phos-2.5* Mg-1.9
[**2149-9-22**] 06:35PM BLOOD Calcium-7.6* Phos-2.2* Mg-2.0
[**2149-9-22**] 10:53AM BLOOD Mg-2.2
[**2149-9-23**] 01:49PM BLOOD WBC-5.0 RBC-2.89* Hgb-9.7* Hct-28.2*
MCV-98 MCH-33.6* MCHC-34.5 RDW-13.6 Plt Ct-128*
[**2149-9-23**] 08:20PM BLOOD WBC-4.4 RBC-3.22* Hgb-10.3* Hct-30.8*
MCV-96 MCH-31.9 MCHC-33.4 RDW-14.7 Plt Ct-117*
[**2149-9-24**] 01:07AM BLOOD Hct-28.7*
[**2149-9-24**] 03:57AM BLOOD WBC-2.8* RBC-2.94* Hgb-9.6* Hct-27.6*
MCV-94 MCH-32.7* MCHC-34.8 RDW-14.7 Plt Ct-94*
[**2149-9-24**] 12:11PM BLOOD Hct-28.7*
[**2149-9-24**] 05:36PM BLOOD WBC-2.4* RBC-3.18* Hgb-10.2* Hct-29.4*
MCV-92 MCH-32.2* MCHC-34.8 RDW-15.7* Plt Ct-100*
[**2149-9-24**] 11:27PM BLOOD Hct-27.7*
[**2149-9-25**] 05:30AM BLOOD WBC-2.9* RBC-3.14* Hgb-10.3* Hct-29.1*
MCV-93 MCH-32.7* MCHC-35.3* RDW-16.1* Plt Ct-110*
[**2149-9-25**] 05:00PM BLOOD WBC-2.9* RBC-3.35* Hgb-11.0* Hct-31.2*
MCV-93 MCH-32.7* MCHC-35.1* RDW-16.1* Plt Ct-137*
[**2149-9-26**] 04:40AM BLOOD WBC-2.8* RBC-3.12* Hgb-10.2* Hct-29.3*
MCV-94 MCH-32.6* MCHC-34.7 RDW-15.8* Plt Ct-141*
[**2149-9-26**] 12:01PM BLOOD WBC-2.6* RBC-3.23* Hgb-10.4* Hct-30.2*
MCV-94 MCH-32.3* MCHC-34.5 RDW-15.7* Plt Ct-146*
[**2149-9-27**] 04:16AM BLOOD WBC-3.4* RBC-3.11* Hgb-9.9* Hct-28.7*
MCV-92 MCH-31.7 MCHC-34.5 RDW-15.7* Plt Ct-172
[**2149-9-27**] 12:25AM BLOOD Hct-29.1*
[**2149-9-26**] 07:33PM BLOOD Hct-30.3*
[**2149-9-27**] 04:28PM BLOOD Hct-28.2*
[**2149-9-28**] 09:46PM BLOOD WBC-5.1 RBC-3.20* Hgb-10.2* Hct-29.6*
MCV-92 MCH-31.9 MCHC-34.6 RDW-15.5 Plt Ct-192
[**2149-9-29**] 06:50AM BLOOD WBC-4.6 RBC-3.44* Hgb-10.9* Hct-32.0*
MCV-93 MCH-31.8 MCHC-34.1 RDW-15.3 Plt Ct-221
[**2149-9-30**] 07:13AM BLOOD WBC-4.6 RBC-3.23* Hgb-10.4* Hct-30.4*
MCV-94 MCH-32.2* MCHC-34.3 RDW-15.8* Plt Ct-252
[**2149-9-22**] 08:50AM BLOOD PT-13.7* PTT-30.7 INR(PT)-1.2*
[**2149-9-22**] 06:35PM BLOOD Plt Ct-110*#
[**2149-9-23**] 01:49PM BLOOD PT-12.8 PTT-28.0 INR(PT)-1.1
[**2149-9-23**] 01:49PM BLOOD Plt Ct-128*
[**2149-9-23**] 08:20PM BLOOD PT-12.3 PTT-28.6 INR(PT)-1.0
[**2149-9-23**] 08:20PM BLOOD Plt Ct-117*
[**2149-9-24**] 03:57AM BLOOD PT-12.7 PTT-28.7 INR(PT)-1.1
[**2149-9-24**] 03:57AM BLOOD Plt Smr-LOW Plt Ct-94*
[**2149-9-24**] 05:36PM BLOOD PT-12.7 PTT-29.8 INR(PT)-1.1
[**2149-9-25**] 05:00PM BLOOD Plt Smr-LOW Plt Ct-137*
[**2149-9-25**] 10:01PM BLOOD PTT-28.9
[**2149-9-26**] 04:40AM BLOOD PT-12.6 PTT-29.3 INR(PT)-1.1
[**2149-9-26**] 04:40AM BLOOD Plt Ct-141*
[**2149-9-26**] 12:01PM BLOOD Plt Ct-146*
[**2149-9-26**] 05:13PM BLOOD PTT-28.2
[**2149-9-26**] 05:13PM BLOOD PTT-28.2
[**2149-9-27**] 12:25AM BLOOD PT-12.8 PTT-31.7 INR(PT)-1.1
[**2149-9-27**] 04:16AM BLOOD PT-12.4 PTT-38.0* INR(PT)-1.0
[**2149-9-27**] 04:16AM BLOOD Plt Ct-172
[**2149-9-27**] 08:06AM BLOOD PTT-37.5*
[**2149-9-27**] 04:28PM BLOOD PT-13.0 PTT-39.5* INR(PT)-1.1
[**2149-9-27**] 09:47PM BLOOD PT-12.9 PTT-40.6* INR(PT)-1.1
[**2149-9-28**] 04:25AM BLOOD PT-13.6* PTT-54.5* INR(PT)-1.2*
[**2149-9-28**] 01:53PM BLOOD PTT-52.3*
[**2149-9-28**] 09:46PM BLOOD Plt Ct-192
[**2149-9-28**] 10:45PM BLOOD PTT-53.2*
[**2149-9-29**] 06:50AM BLOOD PT-15.0* PTT-55.1* INR(PT)-1.3*
[**2149-9-29**] 06:50AM BLOOD Plt Ct-221
[**2149-9-30**] 07:13AM BLOOD PT-18.7* PTT-64.4* INR(PT)-1.7*
[**2149-9-30**] 07:13AM BLOOD Plt Ct-252
[**2149-10-1**] 06:10AM BLOOD PT-18.9* PTT-65.1* INR(PT)-1.7*
[**2149-10-2**] 06:15AM BLOOD PT-21.9* PTT-77.6* INR(PT)-2.0*
[**2149-10-3**] 06:25 PT 24.4* PTT 87.5* INR 2.3*
[**2149-9-24**] Chest Xray
FINDINGS: In comparison with study of [**2142-9-1**], there are
continued low lung volumes that may account for some of the
prominence of transverse diameter of the heart. There is
indistinctness of engorged pulmonary vessels, consistent with
the clinical impression of some volume overload. Intact midline
sternal wires and prosthetic valve is in place.
CT Abdomen [**2149-9-26**]
1. Unremarkable-appearing ileocolonic anastomotic site with no
peri-anastomotic fluid collection or significant inflammation.
Minimal
peritoneal fluid and mesenteric stranding as expected.
2. Small bowel ileus.
3. Pockets of hematoma within the abdomen and lower pelvis left
rectus sheath likely at prior port site as detailed above.
Expected mild-to-moderate amount of residual postoperative
pneumoperitoneum.
4. Mild perihepatic ascites.
Brief Hospital Course:
The patient was admitted to the inpatient unit after a
laparoscopic right colectomy for removal of an colonic adenoma.
Pre-operatively the patient was found to have hematocrit of
37.1. Post-operatively a complete blood count was sent and the
hematocrit was 29.9. The patient complained of pain overnight
despite management with Hydromorphone PCA. The patient was seen
on morning rounds by the surgical team and appeared well with
only the complaint of pain. On the morning of post-operative day
one, the patient was found to have management reduced urine
output of 10-12cc/hr and hypotension to 78/42. The patient was
triggered for hypotension, repeat laboratory values were sent
and the patient's hematocrit was 25.9. The patient was given a
bolus of 500 cc normal saline with little response, the patient
was ordered to receive two units of packed red blood cells. An
EKG and showed atrial fibrillation with a rate of 88 which was
his baseline rhythm. Because of persistent hypotension, the
patient was transferred to the [**Hospital Unit Name 153**] for closer monitoring. In
the [**Hospital Unit Name 153**], the patient continued to have borderline blood
pressure readings. The patient received 2 unites of packed red
blood cells and the hematocrit was Serial hematocrit levels were
drawn and was 28.2. Because of recent anticoagulation, the
appearance of the patients tissue during the case, a moderate
amount of ecchymosis around the port sites of the original
laparoscopic procedure and persistent hypotension the patient
was taken back to the operating room on [**2149-9-23**] for exploratory
laparoscopy and flexible sigmoidoscopy to view the anastomosis
and lumen of the colon. During this case, little blood was
visualized at the anastomosis however site, however a large
amount of blood and clot was seen on flexible sigmoidoscopy
which was washed out. It was determined that this was not an
anastomotic bleed, just oozing of blood at the staple line. The
patient received 2 units of packed red blood cells during the
case. The patient returned to the FI CU for further monitoring.
Serial hematocrits were drawn and remained stable with the goal
to transfuse the patient if his hematocrit was below 25.
Throughout this time, the patient was not anticoagulated for his
prosthetic heart valves. The patient was kept in the [**Hospital Unit Name 153**] for
close monitoring while initiating intravenous heparin at 500u/hr
with a goal PTT 50-70 on [**2149-9-25**]. At this time the patient was
distended but denied nausea and it was thought that the patient
most likely had a post-operative ileus, he tolerated sips of
clears. Because of pancytopenia with a notable monocytosis
oncology was consulted to comment on abnormal lab values and
determined that the patient's anemia was most likely related to
acute blood loss, thrombocytopenia related to possibly a stress
reaction from acute illness, and leukopenia with monocytosis
also likely a stress reaction. The patients platelet level
slowly improved over time. An abdominal CT scan was obtained
[**2149-9-26**] which showed: Unremarkable-appearing ileocolonic
anastomotic site with no
peri-anastomotic fluid collection or significant inflammation,
Small bowel ileus with no transition point to suggest
obstruction, pockets of hematoma within the abdomen and lower
pelvis as well as within the lower left rectus sheath likely at
port site as delineated above, expected mild-to-moderate amount
of residual postoperative pneumoperitoneum, with Mild amount of
perihepatic ascites. The patient transferred to the inpatient
floor in stable condition on [**2149-9-27**]. On the inpatient [**Hospital1 **] the
patient did well, slowly progressed his diet and level of
activity tolerated. The patient began passing gas and had
multiple post-operative bowel movements. He remained on the
intravenous heparin awaiting elevation of his INR to above 2.5
for Aortic/Mitral prosthetic valves. The patients INR progressed
to 2.3 on the day of discharge. The patient's cardiologist Dr.
[**Last Name (STitle) **] was aware for three days prior to the patients discharge of
his INR level. Because of insurance issues, the patient was
unable to be discharged with a Lovenox bridge. On [**2149-10-3**], the
INR level reached 2.3, Dr. [**Last Name (STitle) **] was contact[**Name (NI) **] by [**Name (NI) 636**] [**Last Name (NamePattern1) 28528**],
NP and consulted. Dr.[**Last Name (STitle) **] was satisfied with this result and
requested that the patient be discharged on 7mg of Coumadin
daily until [**2149-9-26**] when he would monitor his INR level at home
(the patient tests his INR at home) and call his office for
advice. The patient was given these instructions in detail and
returned home post-operative day 10. The patient had been taking
Diovan however this was held at discharge because of stable
blood pressure and the patient was asked to follow-up with is
outpatient cardiologist.
Medications on Admission:
Alendronate
Carvedilol PO 6.25mg [**Hospital1 **]
Eplerenone PO 50mg qd
Flomax PO 0.4mg qd
Diovan PO 320mg qd,
Warfarin PO 61/2mg and 7mg every other day,
Calcium
Magnesium.
Discharge Medications:
1. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Eplerenone 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day:
Please take 7mg of Coumadin daily until Monday [**2149-10-6**] when you
should call Dr. [**Last Name (STitle) **] for any needed dose adjustment. .
4. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day:
Please take 7mg of Coumadin daily until Monday [**2149-10-6**] when you
should check your INR and call Dr.[**Name (NI) 29343**] office for any dose
adjustment needed. .
5. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO at bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
Unresectable Colonic Polyp and Anastomotic bleed.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for surgical managment of the
polyp in your colon that was not removed during you colonoscopy.
After the procedure, you developed low blood pressure and were
found to have some bleeding in your abdomen where the procedure
was done. The surgical team beleives that this was related to
the coumadin that you take at home to prevent dangerous clots
from your heart valves. This bleeding caused you to need
transfer to the intensive care unit and ultimately being
transfered to the operating room to look inside of your abdomen.
Your abdomen was washed out and the anastomosis looked great.
You were recovered in the intesive care until until your blood
level returned to [**Location 213**] and anticoagulation was initiated and
you were transferred to the inpatient unit. We monitored you
vital signs, lab values, and restarted your coumadin. You are
ready to be discharged home, you are tolerating a regular diet,
your pain is controlled and you will return home on your usual
coumadin regimen. We have kept you in the hospital on a heparin
drip while your INR returned to goal with coumadin therapy. Your
INR is now 2.3 which is close to your goal and you are now able
to return home. It is very important that you continue to manage
your INR as you were doing previously to prevent any chance of
the formation blood clots from your heart valves. You should see
Dr. [**Last Name (STitle) **] in follow up in 7 days, please call his office to make
an appointment. Please check your INR at home on Monday and call
his office for any dose adjustment needed, your INR should be
between 2.5-3.5. Please check your INR level tomorrow at home
and be sure your INR has not decreased. Dr. [**Last Name (STitle) **] would like you
to take 7mg of Coumadin daily until Monday [**2149-10-6**] when you will
call his office for advice. You have reported that you have 2mg
and 5mg tablets of Coumadin at home. Please take one 2mg tablet
and one 5mg tablet for a total of 7mg daily until Monday
[**2149-10-6**]. We have stopped your Diovan which is a medication for
your blood pressure because your blood pressure has been under
good control to slightly low during your hospitalization. You
should continue to take your other medications on your discharge
medication list. The night before your discharge your blood
pressure was 117/31. Please monitor your blood pressure at home
it the top number should be above 100 but not higher than
120-130. Check your blood pressure everyday and adress this with
your with Dr. [**Last Name (STitle) **] when you see him at his clinic and he can
adjust your blood pressure medications.
Please monitor your bowel function closely. If you develop:
nausea, vomiting, increasing abdominal pain, loose/bloody
stools, abdominal distension, or inability to tolerate food or
liquid, please call the office or if your symptoms are severe
return to the emergency room. You may take a stool softener,
colcace, while you are taking pain medications as the pain
medications will constipate you.
Please monitor your surgical incision. Currently the
laparoscopic sites are closed with skin glue and steri-strips.
These may be left open to air, you may shower, please pat the
area dry and do not rub. Watch for signs and symptoms of
infection including: increased redness, drainage
(white/green/yellow) drainage, foul smelling odor, increased
pain at the site, or if you develop a fever please call the
office or go to the emergency room if your symptoms are severe.
Avoid lifting greater than 6 pounds for 6 weeks after your
surgery unless told otherwise by Dr. [**Last Name (STitle) **]. You may shower
however no swimmingor taking baths for 6 weeks after surgery.
You have not needed pain medication for a number of days. Please
call the office if you develop pain. It is important to report
this symptom if it occurs.
Followup Instructions:
Please make an appointment to see Dr. [**Last Name (STitle) **] in 1 week. Call
[**Telephone/Fax (1) 7728**] to make an appointment. Please check your INR on
Monday [**2149-10-6**] and call Dr.[**Name (NI) 29343**] office to report your INR and
any recieve any needed dose adjustment.
Please make an appointment to see Dr. [**Last Name (STitle) **] in follow up in [**3-12**]
weeks. Call ([**Telephone/Fax (1) 3378**] to make an appointment.
Completed by:[**2149-10-3**]
|
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icd9cm
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[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,353
| 145,039
|
52579
|
Discharge summary
|
report
|
Admission Date: [**2166-3-31**] Discharge Date: [**2166-4-6**]
Date of Birth: [**2101-6-19**] Sex: M
Service: MEDICINE
Allergies:
Benadryl / Morphine / Ativan / Compazine
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
intubated for fever, hypercarbic resp failure
Major Surgical or Invasive Procedure:
Intubation
Insertion of left internal jugular central venous line.
History of Present Illness:
Pt is a 64 y/o M hx CAD, DM, HTN, ESRD on HD and MMP who
presents with fever and dyspnea. Per OMR records and his wife,
pt had been feeling his usul self until last dialysis on Friday
after which he had a temperature 101, new SOB, drowsiness. He
also has a cough which is new. Pt sig SOB walking up 1
flight--usual not difficult for him; and difficult
talking--usually not difficult for him. Otherwise, he denied any
chest pain, abd pain, no N/V/F/C.
.
In the ED, 100.2, 77, 101/77, 13 , 88% RA -> 100% NRB. He was
complaining of bilateral leg pain and given dilaudid 1mg IV.
Shortly afterwards, he became increasingly somnolent. An ABG was
7.29/71/67 and as he became less arousable, he was intubated for
hypercarbic respiratory failure and transferred to MICU. He also
received Ceftriaxone 1gm IV, Azithryomycin 500 mg PO.
.
On the floor, he is intubated and minimally responsive.
Past Medical History:
1. Coronary artery disease: Myocardial infarction in [**2155**],
MQWMI in [**2160**]. Most recent cath, [**2163-10-18**]: LCx stenting; previous
RCA stent patent at that time.
2. Nonischemic dilated cardiomyopathy; EF [**12-6**] 33%. EF [**2164-1-11**]
to 25%
3. Diabetes greater than 20 years; with triopathy.
4. Hypertension.
5. End stage renal disease on hemodialysis, q. Monday,
Wednesday and Friday via right arteriovenous fistula.
6. Hypothyroidism.
7. Chronic obstructive pulmonary disease.
8. Hepatitis C.
9. Chronic pancreatitis.
10. Peptic ulcer disease.
11. Right perinephric hematoma; status post embolization.
12. Obstructive sleep apnea on CPAP.
13. Ruptured right groin abscess; recurrent right groin
abscess in [**2162-12-4**].
14. Peripheral [**Year (4 digits) 1106**] disease.
15. Status post R PFA to BK [**Doctor Last Name **] bypasss graft with vein
16. Status post 2nd and 3rd toe amps
17. Status post left CFA to AK [**Doctor Last Name **] with PTFE
18. Status post L inguinal hernia repair
19. Status post umbilical hernia repair
20. Ischemic left foot
21. A - Fib
Social History:
Social: Lives in [**Location 686**] with wife, has older children
tobacco: 1 ppd x 60 yrs. quit 3 months ago, no EtOH
Family History:
Non contributory
Physical Exam:
MICU admission
PE: 97.9 91/54 68 16 100% O2 Sats
GEN - intubated, sedated, minimally responsive
HEENT- atraumatic, anicteric, pupils 1 mm and minimally reactive
CV - RRR, S1, S2 , 2/6 systolic ejection murmur LUSB and apex,
Lungs - coarse breath sounds throughout
ABD - soft, obese, NT/ND, no masses
EXT - trace pitting edema; Right 1 st toe amp site clean,
intact, Left foot wound - healing, granulation tissue, no
discharge or surrounding erythema
PULSES: dopplerable bilaterally
Pertinent Results:
ECHO on [**2166-4-2**]:
Conclusions:
The left atrium is dilated. The right atrium is moderately
dilated. The left ventricular cavity is moderately dilated.
Overall left ventricular systolic function is severely
depressed. The right ventricular cavity is dilated. Right
ventricular systolic function appears depressed. [Intrinsic
right ventricular systolic function is likely more depressed
given the severity of tricuspid regurgitation.] The aortic root
is moderately dilated athe sinus level. The aortic valve
leaflets are moderately thickened. There is no aortic valve
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. Mild to moderate ([**2-4**]+)
mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2166-2-7**],
mitral
regurgitation is now slightly more prominent. Ventricular
function appears similar.
CXR on [**2166-3-31**]
IMPRESSION:
1. Left IJ line, with tip projecting over the junction of
brachiocephalic and subclavian veins. No pneumothorax.
2. Unchanged appearance of cardiomegaly and mild CHF.
3. Apparent overinflation of the endotracheal tube cuff, as on
the earlier
study.
CXR on [**2166-3-30**]:
IMPRESSION:
1. Dilated pulmonary arteries consistent with pulmonary
hypertension.
2. Moderate cardiomegaly, unchanged. Mild [**Date Range 1106**]
engorgement, perhaps
indicating early CHF.
[**2166-3-31**] 02:59AM BLOOD Type-ART pO2-67* pCO2-71* pH-7.29*
calTCO2-36* Base XS-4 Intubat-NOT INTUBA
[**2166-4-1**] 11:05AM BLOOD Type-ART pO2-128* pCO2-49* pH-7.40
calTCO2-31* Base XS-4
Brief Hospital Course:
64 M with CAD, DM, HTN, ESRD on HD, admitted for community
acquired pna and intubated for hypercarbic respiratory failure
due to dilaudid-induced somnolence, now extubated, with
persistent somnolence initially on floor, now improved
postdialysis.
.
# Hypercarbic respiratory failure: Patient came to the ED for
sx of fever and productive cough, however, in the ED received IV
dilaudid for chronic leg pain. In the ED he became somnolent
with decreased respiratory drive and blood gas revealed
hypercarbia with pCO2 of 71. He was intubated and admitted to
the MICU on [**3-31**] and was extubated [**4-1**]. Although he remained
somnolent following extubation and transfer to the floor, his
blood gas was improved althoug pCO2 elevated to low 50s (Patient
does have a h/o COPD and in review of his labs, his unintubated
pCO2 fluctuates from normal to low 50s). He also has been
diagnosed with OSA and used CPAP while here (despite not using
it at home) so as not to worsen his hypercarbia.
.
# Community-acquired pneumonia: Although there was noo clear
infiltrate on CXR, he presented with increased productive cough
and fever. He was started on ceftriaxone, azithromycin and
vancomycin. During his stay on the floor, he remained afebrile
and without elevated WBC count. His cough improved. He
received one week of vancomycin, completed his course of
azithromycin and was discharged to complete a 10 day course of
cefpodoxime.
.
# Somnolence: Despite holding all narcotics upon transfer to
the floor, he had been receiving prn IV dilaudid in the MICU.
He remained somnolent, falling asleep during his exam. ABG
revealed elevated pCO2, but had been awake with the same pCO2
just the day prior so it seemed less likely [**3-7**] to his
hypercarbia. However, CPAP was initiated at night, given his
h/o OSA so as not to precipitate worsening hypercarbia. All
narcotics were held for concern of his clearance. His BUN was
in the mid 20s and he had been getting regularly dialyzed so it
also did not appear to be uremia. Given his h/o hepatitis C,
LFTs were obtained which were normal with the exception of alk
phos which appears chronically elevated upon review of old labs.
Given his cleared mental status as below, ammonia was not sent.
He was also on neurontin which can be sedating, but he had been
on this stable dose for an extended period of time despite his
ESRD (because on HD) and had not had problems previously.
Interestingly, however, his mental status cleared following
hemodialysis so perhaps medications lingering were causing
somnolence and were cleared with dialysis. He will not be
discharged home on narcotics nor neurontin so his lower
extremity pain control will have to be addressed upon follow up.
.
# Hypotensive episodes: He had episodes of hypotension in the
MICU. Etiology appeared multifactorial, related to receiving
dilaudid IV in ED, partly related to hypovolemia associated with
HD, as well as likely autonomic dysfunction associated with DM2.
He was started on midodrine to which his BP responded well.
Midodrine was discontinued on the floor and his BPs remained
stable.
.
# Cardiac:
Pump: EF 20% in TTE [**2166-4-1**], has been chronically 20-30% for the
past year. Also has 3+TR, [**2-4**]+MR, trace AR. No signs or
symptoms of CHF during this stay.
.
Rhythm: He remained in atrial fibrillation well rate controlled.
He was continued on his home dose amiodarone.
.
Ischemia: Cardiac enzymes were cycledd and troponin 0.2 at max,
CK and MB were flat and his troponin elevation was likely
secondary to his ESRD. EKG showed no new ischemic changes and he
had no chest pain. He was continued on [**Month/Day (2) **], [**Month/Day (2) 4532**], lipitor,
and lisinopril.
.
# ESRD: He was continued on sevelamer, cinacalcet, and phosLo
and his regular dialysis schedule was followed (qMWF).
.
# Anemia: Iron studies were consistent with anemia of chronic
disease. His baseline hct fluctuates but appears largely 27-29
where he remained during his hospital stay.
.
# Diabetes mellitus, type II: His blood sugar remained well
controlled on HISS. Hemoglobin A1C was found to be 5.7. He was
discharged on his his home insulin SS regimen.
.
# B/L midfoot amputations: His right foot wound was dressed
with wet to dry dressings [**Hospital1 **]. He will follow up with Dr.
[**Last Name (STitle) **] upon discharge.
.
# Hypertension: Following his episodes of hypotension in the
ICU, his blood pressure returned to baseline, midodrine was
discontinued and lisinopril was restarted when his BP returned
to baseline with good control of his blood pressure.
.
# Hypothyroidism: Continued on home dose levothyroxine.
.
# COPD/OSA: Although he denies using CPAP at home, CPAP was used
while inpatient given his hypercarbia. This should be followed
up as an outpatient to ensure CPAP continuation in the
outpatient setting.
.
# Hepatitis C: Most recent viral load ([**1-3**]) was 623,000 IU/mL.
LFTs were normal with exception of chronically elevated alk
phos.
.
# Chronic pancreatitis: No active issues.
Medications on Admission:
1. Aspirin 81 mg daily
2. Clopidogrel 75 mg daily
3. Atorvastatin 10 mg daily
4. Lisinopril 2.5 mg daily
5. Amiodarone 200 mg daily
6. Sevelamer 800 mg TID
7. Cinacalcet 30 mg daily
8. B Complex-Vitamin C-Folic Acid 1 mg daily
9. Gabapentin 100 mg [**Hospital1 **]
10. Insulin sliding scale
11. Metoclopramide 5 mg QIDACHS
12. Levothyroxine 50 mcg daily
13. Citalopram 20 mg daily
14. Pantoprazole 40 mg daily
15. Zinc Sulfate 220 mg daily
16. Oxycodone-Acetaminophen 5-325 mg [**2-4**] Q4-6H PRN
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
11. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
12. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
13. Becaplermin 0.01 % Gel Sig: One (1) Appl Topical DAILY
(Daily).
14. Insulin Lispro (Human) 100 unit/mL Solution Sig: As directed
unit Subcutaneous ASDIR (AS DIRECTED).
15. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 4 days.
[**Month/Day (2) **]:*8 Tablet(s)* Refills:*0*
16. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain: Do not exceed max 200mg/day.
[**Month/Day (2) **]:*40 Tablet(s)* Refills:*0*
17. Becaplermin 0.01 % Gel Sig: One (1) application Topical once
a day: To be applied to wound on right foot by visiting nurse.
[**Last Name (Titles) **]:*1 bottle* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
PRIMARY:
1) Hypercarbic respiratory failure requiring intubation
2) Somnolence
3) End stage renal disease on hemodialysis
4) Pneumonia
SECONDARY:
1) Peripheral [**Location (un) 1106**] disease
2) Diabetes mellitus, type II
3) Hypertension
4) Coronary artery disease
5) Obstructive sleep apnea
6) Nonischemic cardiomyopathy
7) Chronic obstructive pulmonary disease
8) Hypothyroidism
Discharge Condition:
Stable, mental status at baseline.
Discharge Instructions:
Please call your doctor or return to the emergency room if you
develop fevers, chills, chest pain, shortness of breath or any
trouble breathing, excessive sleepiness, unremitting lower
extremity pain or any other symptoms that concern you.
.
Your breathing was affected requiring intubation because your
pain medications made you excessively sleepy. Thus, you should
avoid narcotics previously prescribed to you, and should not
take any narcotic pain medications until you follow up with Dr.
[**First Name (STitle) **]. Your neurontin was also stopped, and you not continue
taking neurontin at home until you discuss this with Dr. [**First Name (STitle) **].
.
You have been diagnosed with obstructive sleep apnea previously,
but do not use CPAP at home. You should use your CPAP at home
and should be fitted for a mask if you do not already have one
at home. Your primary care doctor can help you with this.
Followup Instructions:
Please call Dr.[**Name (NI) 14065**] office [**Telephone/Fax (1) 250**] in order to
schedule a follow up appointment within one week of your
discharge. It will be important at that time to address other
options of pain management than your regimen prior to this
admission. You should also address your obstructive sleep apnea
and need for CPAP.
.
You will also need to follow up with Dr. [**Last Name (STitle) **] of [**Last Name (STitle) 1106**]
surgery so please call her office at [**Telephone/Fax (1) 1237**] in order to
schedule an appointment.
.
Appointments scheduled prior to admission:
.
Provider: [**Name10 (NameIs) 6122**] WEST INPATIENT RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2166-4-21**] 3:00
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
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1,088
| 172,055
|
272
|
Discharge summary
|
report
|
Admission Date: [**2170-3-22**] Discharge Date: [**2170-4-8**]
Date of Birth: [**2102-3-5**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
SOB, hypercapnea
Major Surgical or Invasive Procedure:
endotracheal intubation
History of Present Illness:
68M with history of COPD (on 2-3L O2 at home) with history of
multiple intubations, CAD with ischemic cardiomyopathy (EF
20-25%) who was transferred to [**Hospital1 18**] from an outside hospital on
[**2170-3-22**] with SOB. Pt initially noted fever to 102, 4 days prior
to admission. However patient was without respiratory
complaints or cough. Pt was started on course of Azithromycin
as an outpatient for suspected bronchitis and reports some
improvement in pulm Sx. The evening prior to admisssion, the
patient became progressively dyspnic with a minimally-productive
cough.
Pt presented to an outside hospital where he was found to have
HR 150 that was believed to be possible Aflutter but, per
report, was found to be sinus tachcardia. CXR, per report, was
consistent with mild CHF and possible RML PNA. ABG on 100% NRB
was 7.25/61/77. Further treamtent at outside hospital included
ASA 325, NTG SL times 2, Alb/Atr nebs, Lasix 60 mg IV,
Sloumedrol 125mg IV, Ceftriaxone and Moxifloxacin. Pt was
subsequently transferred to [**Hospital1 18**] for further management.
On arrival to MICU [**2170-3-22**] pt felt "much better" and was
without chest pain, palpitations, N/V, abd pain,
dysuria/frequency. He was transferred to the floor, however he
subequently developed SOB and diaphoresis. He developed
increased respiratory distress, ABG's revealed (pH 7.33/44/70
lactate 4.9->7.22/66/130 @ 11am->7.3/59/145. Pt was again
brought to the MICU and intubated for this resp distress.
Past Medical History:
COPD (2-3L home O2, intubated 3 times for exacerbations)
CAD s/p MI [**2165**] and stent (unclear anatomy/location of stent)
Cardiomyopathy, ischemic (EF 20-25%)
Hypercholesterolemia
HTN
Chronic kidney disease baseline cr 1.8
Periph vascular disease
CVA, multiple with residual R>L weakness, aphasia
Parox atrial fibrillation
Peripheral neuropathy
Social History:
h/o heavy tob use quit [**2159**] as well as prior EtOH abuse, no
illicit drug use. Pt lives with his wife and is able to
ambulate with walker at baseline.
Family History:
NC
Physical Exam:
1) on presentation ([**2170-3-22**]):
VS- 98.4, HR 111, BP 110/59, RR 24, 96% 50% face mask
7.41/42/103
gen- elderly man, mild exp aphasia, mod resp distress while
speaking in short sentences
heent-PERRL, EOMI, OP wnl, dry MM
neck-supple, JVP at ~10cm, no LAD
cvs-tachy with RR, no M/R/G
pulm-tachypneic, decreased BS thru/o, bibasilar rales at bases
incompletely cleared with cough, no audible wheezes
abd-soft, NT, ND, NABS
ext-no C/E, left shin abrasion, 1+ DP b/l
neuro-A&O3, 4/5 weakness thr/o, 3+ DTR [**Name (NI) **], 2+ DTR [**Name (NI) 2642**]
2) on transfer to MICU:
VS- 98.9, HR 102 (90-110), BP 124/62 (90-120/50-60), RR 24, 95%
4LNC
gen- elderly man, comfortable, no resp distress
heent-PERRL, EOMI, OP wnl, dry MM
neck-supple, JVP at ~8-10cm
cvs-distant HS, tachy but RR, s1/s2, no M/R/G
pulm-tachypneic, decreased BS, bibasilar rales at bases, mild
exp. wheeze at upperlung fields b/l, no rhonchi. speaks in short
sentences
abd-soft, RUQ tenderness, +/- [**Doctor Last Name **], ND, NABS
ext-no C/C/E, left shin abrasion, 1+ DP b/l
neuro-A&O3, answers questions, follows commands
Pertinent Results:
1. CXR at admission: Emphysema. Right lower lobe patchy opacity
concerning for pneumonia. Left basilar patchy opacity may
represent atelectasis or infection as well.
2. CXR ([**3-23**]): worsening pneumonia w/underlying emphysema
3. CXR ([**3-31**]): bilat pleural effusions, improved RLL opacity,
probable mild CHF.
4. ECHO ([**3-23**]): Overall left ventricular systolic function is
severely depressed. Resting regional wall motion abnormalities
include inferior, inferoseptal and inferolateral and apical
akinesis with a small apical aneurysm present. Right ventricular
chamber size is normal. Right ventricular systolic function
appears depressed. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are structurally
normal. Moderate (2+) mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
5. Lab data:
- Microbiology: blood and urine Cx with no growth. Sputum with
no microorg seen. Influenza DFA negative.
- proBNP ([**4-1**]): 12,009 (range 0-229, levels >1000 have 78% PPD)
- peak CK 390 on [**3-23**]
- TropT 2.86 ([**4-2**])
- creatinine 1.3 (at admission) -> 1.6 ([**3-25**]) -> 0.9-1.0
Brief Hospital Course:
68 yo man with h/o COPD, CAD, cardiomyopathy with depressed EF
who presented with SOB and hypercapnia in setting of COPD
exacerbation s/p intubation and MICU for resp failure c/b NSVT.
ICU course significant for:
1) Pulm: Resp Failure [**2-7**] COPD exacerbation. Self-extubated ICU
D#2, reintubated ICU D#3 for resp failure. COPD treated with
slow steroid taper, nebs. Extubated again ICU D#5 complicated by
resp. distress requiring NRB -> BiPAP and received Lasix 40mg
IV.
2) CVS: During initial ICU presentation, was hypotensive
requiring pressor support (weaned off over first 2 days).
During MICU course, suffering from runs of NSVT. With
tachycardia, evidence of demand ischemia by CE's and ECG.
Tachycardia with ectopy, likely secondary to respiratory
distress; responded to B-B. Cardiology felt likely has new
coronary lesion and recommended cath given h/o 3VD. Pt was
initially to be transferred to [**Hospital1 2025**] for cath (Accepting
physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2643**] ([**Telephone/Fax (1) 2644**]) or Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 2645**],
interventionalist), however, he decided he did not want an
intervention and was d/c'ed home. Heparin not initiated. Medical
management was maximized.
3) ID: RLL PNA treated with 10 day course of CTX (finished
[**2170-4-2**]).
4) Hypotension: BP dropped after intubation. Best guess of
sequence of events is mucous plug leading to hypoxemia that
caused inadequate oxygen supply to the myocardium causing
transient myocardial ischemic; CK, CK-MB, and troponin rising on
transfer to MICU. This may have led to transient cardiac failure
(quasi-cardiogenic shock). BP initially maintained on Levophed
Hospital course by problems:
1) COPD exacerbation in setting of PNA. Pt with acute
respiratory decompensation requiring intubation on [**3-23**] thought
to be secondary to mucous plug. Respiratory status returned to
baseline prior to discharge.
- He was treated with a slow steroid taper, tiotropium, Advair,
Singulair, and Alb prn
2) CHF: Pt with h/o Cardiomyopathy and EF 30%. He was euvolemic
without evidence of decompensated CHF at time of discharge. I/O
goal of even to slightly negative was maintained on Lasix 40 mg
[**Hospital1 **] (home regimen 80 [**Hospital1 **]). He was continued on an ACEi for
afterload reduction. His heart rate was well controlled on Metop
25 [**Hospital1 **].
3) CAD: 3VD s/p MI [**2165**] and stent. Elevated Trop-t likely [**2-7**]
demand ischemia in setting of tachycardia (sinus tach with
ectopy thought to be [**2-7**] to resp distress). ECG with ST
depression lat. Cardiac enzymes trending down at time of
discharge. Cardiology feels there may be a new lesion and given
h/o 3VD and would prefer cath, however pt declines. He
understands risks and benefits He was continued on ASA, Lipitor
(80mg), B-B, ACEi (lisinopril 5 mg). He had no subsequent events
on tele.
4) NSVT: Pt with intermittent runs of NSVT during MICU stay
likely secondary to demand ischemia and lung disease. [**Month (only) 116**]
benefit from ICD placement. Will defer to pt's outpt
cardiologist. Rate well controlled on Metop 25 [**Hospital1 **].
5) RLL PNA. Received 10 day course of CTX (ended on [**2170-4-2**]).
6) CRF. Baseline Cr thought to be 1.8, however Creat improved to
0.9 at time of discharge.
7) FEN: He was tolerating a Low sodium/Cardiac diet at time of
discharge. Checking QID finger sticks with RISS while on
steroids.
8) PPx: PP1, HepSC/Pneumoboots. Started on Ca/Vit D supplements
given prolonged course of steroids.
9) Access: L subclavian line placed [**3-23**]. Arterial line placed
on [**3-23**] while in ICU.
10) Full Code
11) Dispo: D/c'ed home with services.
Medications on Admission:
ASA, lipitor, lasix 80 [**Hospital1 **], singulair, flomax, advair, albuterol
prn, spiriva, neurontin, potassium
Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
inj Injection TID (3 times a day): discontinue once ambulating
regularly.
2. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.
3. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4-6H (every 4 to 6 hours) as needed.
5. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO HS (at bedtime).
6. Prednisone 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily):
plan slow taper.
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
12. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Insulin Regular Human 100 unit/mL Solution Sig: as directed
units Injection four times a day: sliding scale for FS glucose
>121 while on prednisone.
15. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) inhalation Inhalation once a day: (use ipratropium MDI
qid if this is not available).
16. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
17. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
18. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) 2646**]
Discharge Diagnosis:
chronic obstructive pulmonary disease exacerbation
bacterial pneumonia, right lower lobe
congestive heart failure
non-ST-elevation myocardial infarction
Discharge Condition:
stable, tolerating POs
Discharge Instructions:
Please call your primary care physician or return to the
hospital if you experience chest pain, shortness of breath,
fever >100.4, or have any other concerns.
Please weigh yourself daily. If your weight increases by 3 lbs
call Dr. [**First Name (STitle) 2643**]. Please do not drink more than 1.5 liters per
day. Please adhere to a low Na diet.
Followup Instructions:
follow-up with primary care physician/cardiologist within [**2-9**]
weeks
|
[
"482.9",
"518.81",
"E932.0",
"438.11",
"491.21",
"427.89",
"251.8",
"458.29",
"933.1",
"410.71",
"E912",
"414.8",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.71",
"38.91",
"96.6",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10561, 10617
|
4819, 8599
|
287, 313
|
10814, 10838
|
3532, 4796
|
11232, 11309
|
2395, 2399
|
8762, 10538
|
10638, 10793
|
8625, 8739
|
10862, 11209
|
2414, 3513
|
231, 249
|
341, 1834
|
1856, 2205
|
2221, 2379
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,543
| 161,694
|
16051
|
Discharge summary
|
report
|
Admission Date: [**2116-1-8**] Discharge Date: [**2116-2-5**]
Date of Birth: [**2051-10-11**] Sex: F
Service: [**Company 191**]
HISTORY OF PRESENT ILLNESS: This 65-year-old woman was
transferred from [**Hospital3 417**] Hospital for further
management of spontaneous bleeding into her left thigh. She
has a history of rheumatoid arthritis, and a recent diagnosis
of acquired Factor VIII inhibitor. She also has a past
history of serum positive for anticardiolipin antibody. The
patient underwent a left colectomy for diverticular disease
in [**2115-9-27**]. She had some bleeding after this
surgery and was also noted to have an isolated elevated APTT.
The bleeding spontaneously resolved and she did not have
further symptoms until her current problems began.
In [**Month (only) 404**], the patient presented to primary care physician
with left hip pain. She was diagnosed with trochanteric
bursitis, and received a corticosteroid injection into the
left hip. Several days after this injection, the patient
noted the development of a hematoma at the injection site.
Her coagulation studies again reveals an isolated elevated
APTT.
Laboratories sent to the [**Hospital3 14659**] revealed the presence of
markedly diminished Factor VIII activity (less than 1) as
well as the presence of a Factor VIII inhibitor. Patient's
primary care physician at that time increased her prednisone
from her longstanding dose of 10 mg q day to 20 mg [**Hospital1 **].
About one week later the patient was turning in her kitchen
and noted a popping sound coming from her left thigh.
Thereafter, she developed excruciating pain and presented to
[**Hospital3 417**] Hospital for further evaluation. She was
noted to have a drop in her hematocrit, as well as a physical
examination suspicious for a hemorrhage into the left thigh.
She was transferred to [**Hospital1 69**]
for further management.
PAST MEDICAL HISTORY:
1. Rheumatoid arthritis, status post synovectomy of the right
elbow and right fifth finger.
2. Acquired Factor VII inhibitor.
3. Anticardiolipin antibody.
4. Dyslipidemia.
5. Hypertension.
6. Recurrent diverticulitis, status post left colectomy.
7. Lacunar infarct.
8. Osteoporosis.
9. Resting tremor.
MEDICATIONS ON TRANSFER:
1. Prednisone 20 mg po tid.
2. Calcium 600 mg [**Hospital1 **].
3. Propanolol 40 mg tid.
4. Iron 325 mg po bid.
5. Atorvastatin 10 mg q hs.
6. Multivitamin one tablet q day.
7. Methotrexate 10 mg subcutaneous q weekly.
PHYSICAL EXAMINATION ON ADMISSION: Was significant for
marked swelling over the left lateral thigh with exquisite
tenderness to palpation. Her sensation and pulses were
intact distally to the swelling.
LABORATORIES ON ADMISSION: Significant for a white blood
cell count of 14.2 with 85% neutrophils, 3% bands, hematocrit
27.9, platelet count 201, INR 1.2, PTT 49.1. Factor VIII
assay of 6 (normal range 50-150). Sodium 133, potassium 3.6,
chloride 105, total CO2 23, BUN 22, creatinine 0.7, glucose
94. CK of 26. Total bilirubin of 2.5. Haptoglobin of 107.
Anticardiolipin IgG of 4.8 with normal range between 0 and
15.
Plain films of the left hip and femur were negative for
evidence of fracture.
HOSPITAL COURSE BY SYSTEM:
1. Orthopedic: The patient's physical examination and
history were both suggestive of spontaneous bleeding into her
left thigh. She was evaluated by the Orthopedic service, who
performed measurements of the patient's compartment pressures
in her left thigh. She had three measurements that were over
40, consistent with a diagnosis of compartment syndrome. She
subsequently went to the operating room, and received a
fasciotomy that went without complication. This procedure
successfully alleviated the patient's pain, and she had no
compromise of any of the structures of her leg
postoperatively.
2. Heme/Rheumatology: The patient was evaluated by the
Hematology Service upon admission. They started her on
Factor VII A transfusions for treatment of the Factor VIII
inhibitor. Initially, she received these transfusions every
two hours. They were tapered to q4h, q8h, q12h, and finally
off as of [**1-20**] when the patient did not have
evidence of further bleeding. She was also continued on her
admission dose of 60 mg of prednisone q day.
After the initial Factor VII A taper, developed bleeding at
several sites including her nose, her left shoulder, and
oozing around her peripheral IV sites. When her epistaxis
proved refractory to silver nitrate cauterization, the ENT
service was consulted, and they packed her nose. At this
time, her Factor VII A transfusions were restarted at a
frequency of every four hours. She was transferred to the
[**Hospital Unit Name 153**] on [**1-27**] for discontinuation of her nasal packing
and increasing the frequency of her Factor VII A transfusions
to every two hours for 24 hours. Prior to transfer to the
[**Hospital Unit Name 153**], the patient had also been started on cyclophosphamide
for augmentation of her regimen against the Factor VIII
inhibitor.
When she returned to the floor, her Factor VII A transfusions
were again tapered and were eventually discontinued on [**2-3**]. The patient was stable without any evidence of further
bleeding from any site after her transfer back to the floor
from the [**Hospital Unit Name 153**]. The patient received multiple units of packed
red cells throughout her admission for anemia related to
blood loss. Her hematocrit remained stable over 30 after her
final blood transfusion on the [**1-27**]. Her Factor VIII
inhibitor level assays in Bethesda units were as follows:
3.4 on [**2035-1-7**].4 on [**1-14**], 7.2 on [**2028-1-22**].2 on [**1-30**], and 14.5 on [**2-4**].
3. Cardiovascular: The patient had an episode chest pressure
without electrocardiogram changes and with negative cardiac
enzymes early on during her admission. She had sudden onset
of dyspnea and tachypnea without hypoxemia on [**1-20**].
A CT angiogram was performed and was negative for pulmonary
embolism. She was continued on atorvastatin for her
dyslipidemia. A lipid profile checked during admission
revealed elevated triglycerides and low HDL.
4. Infectious Disease: The patient received oxacillin for
prophylaxis after her fasciotomy for compartment syndrome.
This was continued until the nasal packing was removed after
her epistaxis. She had persistent fevers from [**1-23**]
through [**1-27**]. All blood and urine cultures drawn over
this time were negative. For a brief period of time,
ceftriaxone was added to her medical regimen, but this was
discontinued as well after her nasal packing was
discontinued. At this time and for the remainder of her
admission, the patient remained afebrile. Bactrim DS one
tablet 3x a week was reintroduced to the patient's regimen
for PCP prophylaxis on [**2-1**]. The patient tolerated this
medication without fever and without neutropenia.
DISCHARGE DIAGNOSES:
1. Acquired Factor VIII inhibitor.
2. Rheumatoid arthritis.
3. Status post compartment syndrome and fasciotomy.
4. Osteoporosis.
5. Dyslipidemia.
6. Hypertension.
DISCHARGE CONDITION: Fair.
DISCHARGE STATUS: Home with followup with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2805**] of
Hematology on Friday, [**2116-2-7**] at 9 am. The patient
was instructed to return to the Emergency Department for
further bleeding of any kind as well as onset of new pain.
DISCHARGE MEDICATIONS:
1. Bactrim DS one tablet q Monday, Wednesday, Friday.
2. Prednisone 60 mg q day.
3. Calcium carbonate 500 mg 3x a day.
4. Atorvastatin 10 mg q day.
5. Colace 100 mg [**Hospital1 **].
6. Alendronate 5 mg q day.
7. Propanolol 40 mg tid.
8. Senna one tablet q hs.
9. Folic acid 1 mg q day.
10. Iron 325 mg [**Hospital1 **].
11. Pantoprazole 40 mg q day.
12. Cyclophosphamide 50 mg q am.
[**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1775**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1776**]
Dictated By:[**Last Name (NamePattern1) 5596**]
MEDQUIST36
D: [**2116-2-10**] 15:58
T: [**2116-2-11**] 07:17
JOB#: [**Job Number 45933**]
|
[
"788.20",
"401.9",
"784.7",
"285.1",
"286.0",
"459.0",
"578.9",
"733.00",
"958.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.14",
"21.03"
] |
icd9pcs
|
[
[
[]
]
] |
7111, 7414
|
6925, 7089
|
7437, 8132
|
3211, 6904
|
174, 1905
|
2708, 3184
|
2255, 2496
|
1927, 2230
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,415
| 110,961
|
1007
|
Discharge summary
|
report
|
Admission Date: [**2133-8-17**] Discharge Date: [**2133-8-21**]
Date of Birth: [**2059-5-6**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 74 year old man
with metastatic adenocarcinoma of unclear primary, presumably
lung. This was diagnosed in [**2124**], after biopsy of
supraclavicular lymph node. He was treated with XRT and
surgery and did quite well subsequently. Recently, he was
diagnosed with microscopic hematuria.
Urologic evaluation revealed a duplicated right ureter with
filling defect and wall thickening in the duplicated ureter
at the level of the iliac crest with right hydronephrosis.
A right ureteronephrectomy was planned with suspicion for a
transitional cell carcinoma. On laparoscopy, studding of the
liver with presumed metastases was noted. The procedure was
aborted after multiple liver biopsies. The patient was
extubated post surgery but subsequently developed respiratory
distress and wheezing. Chest x-ray was done and was
suggestive of pulmonary edema. The patient was hypoxic on
100% oxygen and was reintubated. He was then sent to the
Medical Intensive Care Unit for 24 hours and then diuresed.
He was able to come off ventilator and was sent to ALCOVE.
PAST MEDICAL HISTORY: The patient has a past medical history
of adenocarcinoma, metastatic to the right supraclavicular
node, unclear primary, diagnosed in [**2124**]; status post XRT.
Chronic obstructive pulmonary disease, secondary to
emphysema. Congestive heart failure with an ejection
fraction of 40% in [**2130**]. Hypertension.
MEDICATIONS ON ADMISSION: Zantac; Lipitor; Valsartan;
Hydrochlorothiazide.
PHYSICAL EXAMINATION: On admission to ALCOVE, temperature
was 99.8; blood pressure 170/72; pulse 88, irregular;
respiratory rate 20; 99% on five liters. In no apparent
distress. Alert, oriented, somewhat forgetful of recent
medical events. Cardiovascular: Regular rhythm, no murmurs,
no rubs. Respiratory: Poor expansion; few lung crackles;
few wheezes. Abdomen: Tender from incision, which is non
weeping, non erythematous and central. Bowel sounds
positive. No distention, no masses. Neurologic: A bit
forgetful, otherwise intact; possible element of denial.
ENT: Extraocular movements intact. NC/AT. Skin: No skin
rashes, no edema.
LABORATORY DATA: White blood cell count of 12.2; hematocrit
of 31.5; PLT 309; NA 137; K 4.0; CL 99; C02 26; BUN 21; CR
1.3; glucose 130. CK triple was 83, 70 and 60, ruled out for
myocardial infarction. Magnesium 2.0.
Chest x-ray on [**8-17**] revealed significant pulmonary edema;
left retrocardiac opacity. [**8-18**] revealed substantial
clearing of pulmonary edema.
HOSPITAL COURSE: 1.) Cardiovascular: On telemetry, the
patient was noted to have multiple premature ventricular
contractions. These were asymptomatic and not treated. Due
to the sudden episodes of pulmonary edema, we decided to send
him for repeat echo which showed him to have an ejection
fraction of 20%, half of what it was two years ago. This is
felt to be due to just progressive left ventricular
dysfunction, in the setting of hypertension and most likely
the primary cause for the pulmonary edema.
He was placed on Digoxin 0.125 mg and started on Coumadin as
well as put on Lasix 40 mg twice a day, in order to prevent
further episodes of pulmonary edema.
2.) Respiratory: The patient was brought to the floor on
five liters of oxygen saturating at about 90%. He was stable
on that until the night when he decompensated and we needed
to put him on non rebreathing mask, when he desaturated to
the mid 80's on nasal prongs. They also gave him 20 mg of
Lasix intravenous. By morning, he was back on oxygen. Over
the course of the admission, he did not have any further
episodes of pulmonary edema. He was able to be weaned off of
treatment by the last 24 hours of hospitalization and was
saturating between 89 and 92% on room air, ambulating freely.
There was no evidence of any pneumonia or infectious
pulmonary process throughout the course of dissection.
Additionally, the patient had three unwitnessed episodes of
hemoptysis, in which he coughed up small amount of clear
mucus laced with red blood. This was thought to be secondary
to trauma on intubation which bled slightly on the starting
of heparin for anticoagulation. There is no evidence that
this is a more malignant pathology behind this at this time.
3.) Neurologic: Prior to starting anticoagulation, it was
thought prudent to assess for risk of intracranial metastases
which would be an absolute contraindication for any sort of
anticoagulation. The patient underwent head CT. He
tolerated the procedure well. No abnormalities were found on
the study.
4.) Renal: The patient remained stable throughout the course
of admission. His creatinine was 1.3 at the upper level of
normal. He was given Mucomyst and hydration prior to CT of
the head with contrast to lessen the chances of any
nephrotoxicity. He tolerated the procedure without
complications.
5.) Gastrointestinal: The system was inactive during the
time of admission. Diet as tolerated.
DISPOSITION: The patient was discharged home in stable
condition to the care of his family. He will be followed up
by his primary care physician and by his oncologist, Dr.
[**Last Name (STitle) **] in the near future for possible treatment and
evaluation of his cancer and other health problems.
MEDICATIONS: Coumadin 5 mg p.o. q. day. Toprol XL 100 mg
p.o. q. day. Lasix 40 mg p.o. twice a day. Digoxin 0.125 mg
p.o. q. day. Diovan 160 mg p.o. q. day. Zantac 150 mg p.o.
twice a day.
DISCHARGE DIAGNOSES:
Pulmonary edema.
Congestive heart failure.
Metastatic carcinoma.
Hypertension.
Chronic obstructive pulmonary disease.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Last Name (NamePattern4) 6627**]
MEDQUIST36
D: [**2133-8-21**] 17:28
T: [**2133-8-27**] 20:01
JOB#: [**Job Number 6628**]
|
[
"V10.11",
"197.0",
"401.9",
"518.81",
"285.9",
"428.0",
"496",
"189.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.21",
"46.73",
"96.71",
"50.11",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
5635, 6000
|
1598, 1648
|
2695, 5614
|
1671, 2677
|
154, 1232
|
1255, 1571
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,669
| 140,088
|
10736
|
Discharge summary
|
report
|
Admission Date: [**2105-5-11**] Discharge Date: [**2105-5-16**]
Date of Birth: [**2058-6-14**] Sex: M
Service: CARDIOTHORACIC
CHIEF COMPLAINT: Mr. [**Known lastname 35123**] is a direct admission to the
operating room for coronary artery bypass grafting and
preadmission testing done [**2105-5-1**]. The patient's
chief complaint was dyspnea on exertion, shortness of breath,
and chest pain x 2 weeks.
HISTORY OF PRESENT ILLNESS: The patient is status post
cardiac cath done for a complaint of increasing shortness of
breath and chest pain with known CAD, status post PTCA of the
circumflex and OM1, as well as RCA and LAD in [**2102**].
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Hypothyroidism.
4. Insulin dependent diabetes mellitus.
5. Coronary artery disease.
6. Status post right shoulder surgery.
ALLERGIES: No known drug allergies.
MEDS:
1. Insulin 70/30, 28 U q am and 20 U q pm.
2. NPH sliding scale.
3. Toprol 50 mg q am and 25 mg q pm.
4. Synthroid 300 mcg qd.
5. Aspirin 81 mg qd.
6. Zocor 40 mg qd.
7. Diovan 80 mg qd.
CARDIAC CATHETERIZATION: Showed left main with mild disease.
LAD with diffuse disease with focal 70% lesion in the
midstent. The circumflex was totally occluded proximally
with diffuse in-stent restenosis and left-to-left
collaterals. RCA with diffuse occlusive in-stent restenosis
with left-to-right collaterals. No ventriculogram was done
at that time.
LABS AT TIME OF CATHETERIZATION: White count 5.7, hematocrit
39.6, platelets 296, sodium 136, potassium 4.6, chloride 101,
CO2 27, BUN 19, creatinine 1.0, glucose 288, PT 13, INR 1.3,
PTT 90 on heparin, AST 27, ALT pending, alk phos 72, total
bili 0.5. UA was negative.
PHYSICAL EXAM: Temperature 97.8, heart rate 64/sinus rhythm,
blood pressure 124/64, respiratory rate 16, O2 sat 98% on
room air.
NEUROLOGICALLY: Awake, alert and oriented x 3. Pupils
equally round and reactive to light. Extraocular movements
intact. Strength was equal in the upper and lower
extremities bilaterally.
CARDIOVASCULAR: Regular rate and rhythm with no rubs or
murmurs.
RESPIRATORY: Clear to auscultation bilaterally.
ABDOMEN: Flat, nontender, nondistended with positive bowel
sounds.
EXTREMITIES: No edema. No varicosities.
PULSES: Femoral 2+ with no bruit bilaterally. Popliteal 1+
bilaterally. Dorsalis pedis and posterior tibial 2+
bilaterally. Radial 2+ bilaterally. Carotids without
bruits, and no stenosis by ultrasound.
HOSPITAL COURSE: The patient was discharged to home
following his cardiac catheterization and, as stated
previously, a direct admission to [**Hospital Ward Name 26168**] [**First Name (Titles) **] [**Last Name (Titles) **]
on the [**5-11**] for coronary artery bypass grafting. In
summary, the patient had a CABG x 4 with a LIMA to the LAD,
saphenous vein graft to diag, saphenous vein graft to OM, and
saphenous vein graft to the PDA. His bypass time was 97
minutes with a crossclamp time of 55 minutes. Please see the
OR report for full details. The patient tolerated the
operation well and was transferred from the operating room to
the cardiothoracic intensive care unit. At the time of
transfer, the patient was in a sinus rhythm at 80 beats per
minute with a mean arterial pressure of 70, and a CVP of 7.
He had propofol at 20 mcg/kg/min, insulin at 1 unit/h, and
phenylephrine at 0.5 mcg/kg/min. The patient did well in the
immediate postoperative period. His anesthesia was reversed.
He was weaned from the ventilator and successfully extubated.
He had no other events on the day of his surgery. However,
he was able to wean off of his Neo-Synephrine drip.
On postoperative day #1, the patient remained hemodynamically
stable. His Swan-Ganz catheter was removed. He was begun on
diuretics, as well as low dose beta blockers, and transferred
to the floor for continued postoperative care and cardiac
rehabilitation. Additionally, on postop day #1, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
consult was requested to help control his diabetes mellitus.
On postoperative day #2, the patient continued to progress
well. He remained hemodynamically stable. His chest tubes
were discontinued. His beta blockade was increased. With
the assistance of the nursing staff and physical therapist,
his activity level was also advanced over the next several
days. The patient had an uneventful hospital course, with
the exception of a persistent low-grade temperature between
99 and 101.
He had several x-rays which showed bibasilar atelectasis and
small pleural effusions. He had 2 urinalysis that were both
negative. His wounds were clean, dry and open to air without
erythema. He had a normal white blood cell count.
On postoperative day #5, it was decided that the patient
would be stable and ready to be discharged to home. At the
time of this dictation, the patient's physical exam is as
follows:
PHYSICAL EXAM - VITAL SIGNS: Temperature 100, heart rate
96/sinus rhythm, blood pressure 140/50, respiratory rate 20,
O2 sat 96% on room air. Weight preoperatively was 82 kg and
at discharge is 84.2 kg.
NEURO: Alert and oriented x 3. Moves all extremities.
Follows commands.
RESPIRATORY: Clear to auscultation bilaterally.
CARDIAC: Regular rate and rhythm. S1, S2 with no murmurs.
STERNUM: Stable. Incision with Steri-Strips, open to air,
clean and dry.
ABDOMEN: Soft, nontender, nondistended with active bowel
sounds.
EXTREMITIES: Warm and well-perfused with no edema. Right
saphenous vein graft harvest site with Steri-Strips, open to
air, clean and dry.
LAB DATA: White count 7.5, hematocrit 26.6, platelets 279,
potassium 5.0, BUN 19, creatinine 1.4, glucose 130.
DISCHARGE MEDICATIONS:
1. Enteric-coated aspirin 325 qd.
2. Synthroid 300 mcg qd.
3. Zocor 40 mg qd.
4. Metoprolol 50 mg [**Hospital1 **].
5. Lasix 20 mg qd x 2 weeks.
6. Potassium chloride 20 mEq qd x 2 weeks.
7. Niferex 150 mg qd x 30 days.
8. Vitamin C 500 mg [**Hospital1 **] x 30 days.
9. Insulin 70/30, 28 U q am, 20 U q pm.
10.Regular insulin sliding scale.
11.Colace 100 mg [**Hospital1 **].
12.Dilaudid 2-4 mg q 4-6 h prn.
DISCHARGE CONDITION: Good.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post coronary artery
bypass grafting x four with left internal mammary artery to
left anterior descending, saphenous vein graft to diagonal,
saphenous vein graft to obtuse marginal, saphenous vein graft
to posterior descending artery.
2. Hypothyroidism.
3. Insulin dependent diabetes mellitus.
4. Right shoulder surgery.
5. Hypertension.
6. Hypercholesterolemia.
DISCHARGE DISPOSITION: He is to be discharged to home with
visiting nurses.
FOLLOW-UP:
1. He is to have follow-up in the [**Hospital 409**] Clinic in 2 weeks.
2. Follow-up with Dr. [**First Name (STitle) **], the primary care physician, [**Last Name (NamePattern4) **]
3 weeks.
3. Follow-up with Dr. [**Last Name (STitle) 70**] in 6 weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2105-5-15**] 15:37
T: [**2105-5-15**] 16:21
JOB#: [**Job Number 35124**]
|
[
"780.6",
"414.01",
"998.89",
"250.01",
"401.9",
"272.0",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6608, 7216
|
6157, 6164
|
6185, 6584
|
5725, 6135
|
2494, 5702
|
1736, 2476
|
165, 426
|
455, 664
|
686, 1720
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,559
| 145,304
|
16313
|
Discharge summary
|
report
|
Admission Date: [**2153-4-24**] Discharge Date: [**2153-5-8**]
Date of Birth: [**2090-1-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
abdominal pain, constipation
Major Surgical or Invasive Procedure:
Right IJ central line placement
PICC placement
Transfusion of [**First Name3 (LF) **] products
History of Present Illness:
63-yo M with history of AS s/p AVR, PAF, [**Hospital **] transferred from
OSH with Hct drop, esophageal mass. He initially presented to
his PCP with constipation [**Name Initial (PRE) **] 3 weeks, with mild abd distention
and diffuse abd pain. Poor PO intake due to fear of abd pain.
Lost a few pounds x past few weeks. No n/v. About 1 week PTA, he
had abd and chest CT that showed retroperitoneal and
retro-mediastinal LAD. Was seen by GI, who found him to have
positive guaiac on exam and referred to [**Hospital3 **] ED,
where repeat abd CT again showed LAD with ?colonic obstruction,
which prompted a barium enema study that was negative for bowel
obstruction. Since the enema, he has had dark-colored diarrhea.
He also reports malaise x past few weeks.
.
He was admitted to [**Hospital3 **]. Labs were notable for WBC
25, Hct 22 (42 one week prior), plts 122. INR 3.0, Cr 1. For his
Hct drop, he received 4 units of pRBCs alogn with 2 units of
FFP. Hct increased to 26. He underwent an EGD which revealed a
lower esophageal mass which was oozing [**Hospital3 **]. Bx and brushings
were taken. Per GI, the patient was also having some hemoptysis,
raising suspicion for tracheoesophageal fistula. He was
hemodynamically stable, mentating well without any hematemesis,
hemoptysis, or rectal bleeding. He was transferred to [**Hospital1 18**] for
further management.
On arrival, he was stable, alert, awake.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denied cough, shortness of
breath. Denied chest pain or tightness, palpitations. Denied
nausea, vomiting. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
AS s/p AVR (Booing valve)
PAF not on warfarin
hemachromatosis with regular phlebotomies; normal liver bx a few
months ago
Social History:
Works as a dye maker. No smoking. Social drinking.
Family History:
Mother had gastric ca and died of emphysema
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, 3/6 systolic murmur
best heard at RUSB
Abdomen: soft, non-tender, moderately distended, slightly tense,
bowel sounds present, no rebound tenderness or guarding
Rectal: guaiac positive
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs
[**2153-4-24**] 07:50PM [**Year/Month/Day 3143**] WBC-24.0*# RBC-3.22* Hgb-9.9* Hct-28.0*
MCV-87# MCH-30.8 MCHC-35.5* RDW-17.4* Plt Ct-110*#
[**2153-4-24**] 07:50PM [**Year/Month/Day 3143**] Neuts-57 Bands-14* Lymphs-8* Monos-2
Eos-2 Baso-1 Atyps-0 Metas-8* Myelos-8* NRBC-7*
[**2153-4-24**] 07:50PM [**Year/Month/Day 3143**] PT-17.7* PTT-34.9 INR(PT)-1.6*
[**2153-4-24**] 07:50PM [**Year/Month/Day 3143**] Fibrino-75*
[**2153-4-24**] 08:20PM [**Year/Month/Day 3143**] FDP-320-640*
[**2153-4-25**] 09:39AM [**Month/Day/Year 3143**] Ret Aut-4.3*
[**2153-4-24**] 07:50PM [**Year/Month/Day 3143**] Glucose-141* UreaN-43* Creat-0.8 Na-139
K-4.6 Cl-103 HCO3-25 AnGap-16
[**2153-4-24**] 07:50PM [**Year/Month/Day 3143**] ALT-31 AST-78* LD(LDH)-1665* AlkPhos-193*
TotBili-1.5
[**2153-4-24**] 07:50PM [**Year/Month/Day 3143**] Calcium-8.8 Phos-4.1# Mg-2.8*
UricAcd-7.4*
Interim/Discharge Labs
[**2153-5-4**] 02:29PM [**Month/Day/Year 3143**] CEA-5432*
[**2153-4-25**] 12:32AM [**Month/Day/Year 3143**] Lactate-1.7
[**2153-5-2**] 03:15AM [**Month/Day/Year 3143**] Albumin-2.0* Calcium-7.7* Phos-2.7 Mg-2.0
[**2153-5-6**] 12:00AM [**Month/Day/Year 3143**] Albumin-2.5* Calcium-7.7* Phos-3.6 Mg-2.1
[**2153-5-6**] 12:00AM [**Month/Day/Year 3143**] ALT-44* AST-33 LD(LDH)-621* AlkPhos-148*
TotBili-0.7
[**2153-4-29**] 06:32AM [**Month/Day/Year 3143**] Glucose-192* UreaN-47* Creat-0.8 Na-147*
K-4.0 Cl-115* HCO3-25 AnGap-11
[**2153-5-7**] 11:50PM [**Month/Day/Year 3143**] Glucose-115* UreaN-12 Creat-0.6 Na-138
K-3.9 Cl-105 HCO3-26 AnGap-11
[**2153-4-26**] 05:15AM [**Month/Day/Year 3143**] FDP-[**Telephone/Fax (1) 14007**]*
[**2153-5-2**] 07:31PM [**Month/Day/Year 3143**] Fibrino-367
[**2153-5-7**] 01:00AM [**Month/Day/Year 3143**] Fibrino-326
[**2153-4-26**] 02:45PM [**Month/Day/Year 3143**] Plt Smr-VERY LOW Plt Ct-53* LPlt-2+
[**2153-4-26**] 05:47PM [**Month/Day/Year 3143**] PT-16.6* PTT-36.5* INR(PT)-1.5*
[**2153-4-30**] 07:51PM [**Month/Day/Year 3143**] PT-15.3* PTT-29.1 INR(PT)-1.4*
[**2153-5-7**] 01:00AM [**Month/Day/Year 3143**] PT-13.9* PTT-21.5* INR(PT)-1.2*
[**2153-5-7**] 11:50PM [**Month/Day/Year 3143**] Plt Ct-120*
[**2153-5-6**] 12:00AM [**Month/Day/Year 3143**] Neuts-72* Bands-4 Lymphs-9* Monos-6 Eos-1
Baso-1 Atyps-0 Metas-7* Myelos-0
[**2153-4-26**] 05:47PM [**Month/Day/Year 3143**] WBC-18.8* RBC-3.02* Hgb-9.1* Hct-25.2*
MCV-83 MCH-30.0 MCHC-36.1* RDW-18.0* Plt Ct-56*
[**2153-4-29**] 02:44AM [**Month/Day/Year 3143**] WBC-9.8 RBC-3.49* Hgb-10.5* Hct-30.4*#
MCV-87 MCH-30.0 MCHC-34.4 RDW-18.3* Plt Ct-83*
[**2153-4-30**] 05:08AM [**Month/Day/Year 3143**] WBC-6.3 RBC-2.85* Hgb-8.6* Hct-25.0*
MCV-88 MCH-30.3 MCHC-34.5 RDW-17.6* Plt Ct-58*
[**2153-5-2**] 07:31PM [**Month/Day/Year 3143**] WBC-4.4 RBC-3.13* Hgb-9.1* Hct-26.5*
MCV-85 MCH-29.1 MCHC-34.4 RDW-16.2* Plt Ct-68*
[**2153-5-7**] 11:50PM [**Month/Day/Year 3143**] WBC-3.3* RBC-3.16* Hgb-9.8* Hct-29.0*
MCV-92 MCH-31.0 MCHC-33.8 RDW-19.2* Plt Ct-120*
Micro Data
[**Month/Day/Year **] cx no growth
IMAGING
[**2153-4-25**] CXRIMPRESSION: AP chest compared to [**2147-2-4**]:
Diaphragm is elevated, lowering the lung volumes. Examination is
marked as an
upright view, this may not be the case. Nevertheless, no free
subdiaphragmatic gas is demonstrated. Colon and stomach are
distended with
gas. Lungs are grossly clear aside from mild left basal
atelectasis.
Moderate cardiomegaly is longstanding. No pneumothorax or
pleural effusion.\
[**2153-4-25**] KUB IMPRESSION: No definite evidence of obstruction. No
evidence of free air on
limited supine view.
[**4-28**] Abdomen: Contrast material is again present throughout the
colon. There is distention
of the transverse colon measuring about 10 cm, compared to 8.4
cm previously.
Contrast is seen distally within the rectosigmoid region and in
the descending
colon, both of which appear nondistended. Mildly prominent air-
filled loops
of small bowel are also present.
[**2153-5-5**] Abdomen: Portable AP radiograph of the abdomen was
compared to [**2153-4-29**].
On the current study, no evidence of large bowel dilatation has
been
demonstrated, but note is made that the upper abdomen was not
included in the
field of view. The currently imaged pattern of the bowel gas
distribution is
nonspecific and does not demonstrate any apparent abnormality.
Brief Hospital Course:
63 year old gentleman with newly diagnosed esophageal
adenocarcinoma and upper GI bleed.
1) GI Bleed/[**Year (4 digits) **] loss anemia: Patient developed GI bleed and
[**Year (4 digits) **] loss anemia due to bleeding from esophageal mass which was
complicated by thrombocytopenia and DIC as below. The patient
was admitted to the ICU from [**Hospital3 4107**] with a hematocrit
in the 20s requiring 23 unit [**Hospital3 **] transfusions while in the
ICU. Surgery, GI & Radiation/Oncology were consulted and the
patient underwent XRT which alleviated his bleeding. He did not
require tranfusions of [**Hospital3 **] for ~36 hours and was called out to
the Oncology floor. On the floor, he was transfused 2 unit PRBCs
intitially [**5-4**] then did not require any further transfusions.
His platelets also remained stable and DIC resolved. He was
started on PPI [**Hospital1 **] and continued on this at discharge.
2) DIC: The patient presented with an INR of 3, fibrinogen near
100 and platelets in the 50s. The etiology of his DIC was felt
to be due to underlying tumor burden. He was transfused
multiple units of platelets, FFP and cryoprecipitate. As his
bleeding subsided with XRT, his DIC resolved as well.
3) Esophageal Adenocarcinoma: The patient was diagnosed with
stage IV adenocarcinoma. Oncology was consulted and they
initiated 5FU/Oxalyplatin therapy in conjunction with XRT. He
will have an outpatient PET which was scheduled prior to
discharge and will follow up with Dr. [**Last Name (STitle) 3274**].
4) Afib: Pt had episodes of afib with RVR in the [**Hospital Unit Name 153**] responding
to diltizem but remained rate controlled on the floor in the
80s. He was continued on his previous metoprolol dosing at
discharge.
5) Foot ulcerations: Pt developed maceration and erythema of his
feet bilaterally with lower extremity edema. Podiatry was unable
to see him prior to discharge in house but an appointment was
made with his outpatient podiatrist the following day after
discharge.
6) Low grade fever: Pt had a low grade fever 2 days prior to
discharge but had no signs or symptoms of infection other than
possibly feet as above. He was afebrile 24 hours prior to
discharge off antibiotics and cx were negative and f/u arranged
with podiatry as above.
Medications on Admission:
metoprolol 25 mg PO bid
atorvastatin 40 mg qhs
acetaminophen
flexeril prn
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
2. 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*
3. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
Disp:*1 tube* Refills:*2*
4. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)) as needed for nausea.
Disp:*100 Tablet(s)* Refills:*0*
5. Outpatient Lab Work
Please check CBC on Thursday [**2153-5-10**] and fax to Dr. [**Last Name (STitle) 3274**] at
[**Telephone/Fax (1) 22294**]
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Primary Diagnosis
Esophageal Adenocarcinoma
Acute [**Hospital3 **] loss anemia secondary to Esophageal cancer
Disseminated intravascular coagulation
Secondary Diagnosis:
Paroxysmal atrial fibrillation
Discharge Condition:
Hemodynamically stable, HR 80s and regular,stable [**Hospital3 **] counts,
last transfused [**2153-5-4**], afebrile with low grade fever 100.8 on
[**2153-5-7**]
Discharge Instructions:
You were admitted to the the hospital with bleeding and problems
with [**Name2 (NI) **] clotting likely related to cancer in your esophagus.
You received [**Name2 (NI) **] and platelet transfusions in the intensive
care unit. You were then transferred to the regular oncology
floor and you did well with no further bleeding. You were seen
by physical therapy who recommended you have more physical
therapy at home.
We made the following changes to your medications
We added Bacitracin
We added Pantoprazole 40mg PO BID
We added reglan as needed for nausea
Please return to the ER or call your primary oncologist if you
develop chest pain, palpitations, shortness of breath, abdominal
pain, nausea, vomiting, [**Name2 (NI) **] in the stool or dark stools, or
any other concerning symptoms.
Followup Instructions:
Dr. [**Name (STitle) 3548**] [**Doctor Last Name 776**], [**2153-6-6**], 11 AM, [**Hospital Ward Name 332**] Basement
(Radiation Oncology)
Please follow up with Drs. [**Last Name (STitle) 3274**] and [**Name5 (PTitle) 1852**] [**0-0-**].
You have an appointment on Tuesday [**5-15**] at 2pm, on [**Hospital Ward Name 23**] [**Location (un) 8939**].
Please follow up with the Podiatrist, Dr. [**Last Name (STitle) **] (who works
with Dr. [**Last Name (STitle) **] tomorrow [**2153-5-9**] at noon. Call [**0-0-**] if
you have any questions.
You also have a PET scan scheduled for Friday [**5-11**]. You were
given information regarding this over the telephone
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,706
| 184,765
|
38991
|
Discharge summary
|
report
|
Admission Date: [**2111-3-1**] Discharge Date: [**2111-3-24**]
Date of Birth: [**2078-3-4**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
s/p ATV crash
Major Surgical or Invasive Procedure:
[**2111-3-1**]
Closed treatment right femoral shaft fracture with traction and
placement of traction pin
[**2111-3-4**]
IM nail right femur
History of Present Illness:
32M + EtOH s/p high speed ATV collision this. Friends report
found patient beside a tree, disoriented and unconscious. Upon
EMS arrival he was intubated at scene and evaluated at [**Hospital3 **]
hospital. CT head showing frontal and temporal IPH; he was
transferred to [**Hospital1 18**] for further care.
Past Medical History:
ADHD per family report (not treated with medication)
Social History:
+EtOH
Family History:
Noncontributory
Physical Exam:
Upon presentation to [**Hospital1 18**]:
O: T:98.5 BP: 133/ 72 HR: 68 R:20 O2Sats
99%ventilated Cpap
Gen:intubated off propofol for exam
HEENT: Pupils: 3.5-3mm EOMs;pt does not comply
Neck: hard cervical collar in place
Extrem:left lower leg in traction
Neuro:
Mental status: intubated, no eye opening to noxious stimuli, but
facial grimaces, pt does not follow commands
Orientation:not opening eye or verbal
Recall,Language:pt unable to perform at this time
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3.5 to 3
mm bilaterally. Visual fields unable to test
III, IV, VI: Extraocular movements unable to test
V, VII: Facial strength grossly symmetric.
VIII: Hearing-unable to test
IX, X: Palatal elevation unable to test
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius unable to test
XII: Tongue midline unable to test
Motor: patient briskly localizes to painful stimuli with
bilateral upper extremities. Left leg moves up off bed to pain,
right lower leg appears in traction and right foot flexes and
withdraws to pain. Patient does not follow commands
Sensation: unable to test
Toes downgoing bilaterally
Coordination: unable to test
Pertinent Results:
[**2111-3-1**] 11:19AM GLUCOSE-142* UREA N-18 CREAT-0.7 SODIUM-141
POTASSIUM-4.5 CHLORIDE-108 TOTAL CO2-25 ANION GAP-13
[**2111-3-1**] 11:19AM ALT(SGPT)-61* AST(SGOT)-128* CK(CPK)-4588*
AMYLASE-109*
[**2111-3-1**] 11:19AM WBC-14.2* RBC-3.75* HGB-12.3* HCT-36.2*
MCV-96 MCH-32.8* MCHC-34.0 RDW-12.7
[**2111-3-1**] 11:19AM PLT COUNT-324
[**2111-3-1**] 08:35AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2111-3-16**] ECG QTC 386
[**2111-3-11**] ECG QTC 390
[**2111-3-10**] ECG QTC 405
[**2111-3-7**] LENIS No evidence of DVT
[**2111-3-5**] miniBAL no PMNs, no orgs, NG
[**2111-3-5**] CATH tip NG
[**2111-3-5**] CXR unchanged b/l LL opacities, atelectasis R>L, no new
opacities
[**2111-3-4**] BCx neg
[**2111-3-4**] UCX neg
[**2111-3-4**] CT chest bibasilar consolidation new/unchanged, ? pna
vs. aspiration
[**2111-3-4**] CT head stable hemorrh foci, no acute hemorrhage, bolt
in R front lobe
[**2111-3-4**] LENIS No evidence of DVT in bilateral lower
extremities.
[**2111-3-3**] CXR Improving R middle and LL atelectasis,
consolidation LLL
[**2111-3-3**] CT head No evidence of infarction or significant mass
effect, no herniation
[**2111-3-3**] BCX neg
[**2111-3-3**] MRSA neg
[**2111-3-2**] CT head Unchanged bilateral scattered punctate
hemorrhagic foci
[**2111-3-2**] CXR New right lower and middle lobe collapse, likely
bronchus plug
[**2111-3-2**] BCX NGTD
[**2111-3-2**] UCX NG
[**2111-3-2**] miniBAL 4+ PMNs, 4+ GPdiplos, MORAXELLA CATARRHALIS
>100,000 orgs
[**2111-3-1**] CT head b/l temporal petechial hemorrhage
[**2111-3-1**] CT spine C6/C7 transverse processes frx
[**2111-3-1**] CT torso R distal clavicle fx, b/l 1st rib fxs, pulm
contusions
[**2111-3-1**] CXR Comminuted fracture of right clavicle
[**2111-3-1**] CT head [**Hospital1 **] punctate foci of hemorrhage ? diffuse axonal
injury
[**2111-3-1**] R shoulder right clavicular fracture
[**2111-3-1**] R femur No acute pelvic frx, frx R femoral diaphysis
[**2111-3-1**] pelvis XR No acute pelvic frx, frx R femoral diaphysis
[**2111-3-1**] R knee No acute pelvic frx, frx R femoral diaphysis
Brief Hospital Course:
He was admitted to the trauma service and transferred to the
Trauma ICU where he remained sedated and vented. Neurosurgery
was consulted; his head CT scan revealed multiple bilateral
scattered punctate hemorrhagic foci with pattern compatible with
diffuse axonal injury. Serial exams and head CT scans were
followed closely, his head CT scans remained stable with no new
areas of bleeding. His sedation was eventually weaned and he was
extubated. His mental status was intermittently agitated and
disoriented. He required antipsychotic to manage his behaviors.
He was taken to the operating room by Orthopedics for closed
treatment right femoral shaft fracture with traction and
placement of traction pin and again taken back on [**3-4**] for
intramedullary nail of the right femur.
Psychiatry and Cognitive Neurology were consulted once patient
was transferred to the regular nursing unit. Adjustments to his
antipsychotic were made; he was also started on Depakote as a
mood stabilizer.
He was followed by Physical and Occupational therapy who worked
closely with him given that he was not able to go to a rehab
facility due to lack of insurance. The Masshealth application
process was initiated.
At time of discharge his mental status had improved
significantly although he did continued short term memory
problems. [**Name (NI) **] will follow up with Cognitive Neurology as an
outpatient.
Medications on Admission:
Denies
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
2. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO once a day.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*2*
3. Olanzapine 15 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO at bedtime.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*2*
4. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO HS (at bedtime).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
Disp:*60 Tablet(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
7. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's
PO twice a day as needed for constipation.
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**2-24**]
hours as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
s/p ATV crash vs. tree
C6, C7 transverse process fracture
Bifrontal diffuse axonal injury
Right clavicle fracture
Right distal femur fracture
Bilateral 1st rib fracture
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were hospitalized following a trauamtic event where you
sustained a brain injury, right femur fracture, right clavicle
fracture and rib fractures. Your femur fracture was repaired in
the operating room; your staples have been removed. It is common
to have pain from time to time from your injuries. You have been
prescribed a pain medication called Dilaudid which you should
take only as needed.
Your brain injury has left you with some memory deficits and at
times you act impulsively. It is important that you listen to
your care providers and take your medications as prescribed.
Followup Instructions:
Follow up in 2 weeks with Dr. [**Last Name (STitle) 86496**] [**Name (STitle) **], Cognitive
Neurology for ongoing evaluation of your traumatic brain injury;
call [**Telephone/Fax (1) 6335**] for an appointment.
Follow up in 4 weeks with CT of brain with Dr. [**First Name (STitle) **],
Neurosurgery; call [**Telephone/Fax (1) 1669**] for an appointment.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2111-4-15**]
|
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"810.00",
"821.20",
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icd9cm
|
[
[
[]
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[
"96.6",
"01.10",
"01.24",
"79.15",
"33.24",
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icd9pcs
|
[
[
[]
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] |
6754, 6760
|
4269, 5670
|
282, 425
|
6974, 6974
|
2137, 4246
|
7738, 8232
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876, 893
|
5727, 6731
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6781, 6953
|
5696, 5704
|
7126, 7715
|
908, 1188
|
229, 244
|
453, 761
|
1403, 2118
|
6989, 7102
|
783, 837
|
853, 860
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,050
| 114,358
|
37911
|
Discharge summary
|
report
|
Admission Date: [**2197-10-31**] Discharge Date: [**2197-11-11**]
Date of Birth: [**2125-8-28**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
gastric adenocarcinoma
Major Surgical or Invasive Procedure:
s/p subtotal gastrectomy, D2 lymphadenectomy, CBD exploration,
and choledochojejunostomy
History of Present Illness:
The patient is a 72 yo M, who initially presented w/ obstructing
choledocholithiasis [**8-30**] (CBD 2.0 cm), s/p ERCP + stent on
[**2197-9-11**] performed by [**Doctor First Name **] [**Doctor Last Name **]. During the procedure, the
patient was incidentally found to have a large antral ulcerated
tumor on ERCP. Biopsy was consistent with gastric (antral)
adenocarinoma. He is now presenting to [**Hospital Unit Name 153**] for post-operative
monitoring and management after undergoing subtotal gastrectomy,
D2 lymphadenectomy, CBD exploration, and choledochojejunostomy.
Found densely adherent abdomen with difficult lysis of
adhesions. Gastric adenocardinoma in antrum, distal margin
negative on frozen section. Distal stomach, gallbladder, CBD
stones sent to pathology. The case ~12 hours. EBL 2700. Received
6000 Crystalloid, 1000 Albumin, 3 units pRBCs. UOP 500. Abx
Cefazolin 2g x4?, Flagyl. Initially got Metoprolol, later
required Neo briefly.
.
On arrival to [**Name (NI) 153**], pt. on AC 600/14/5/40%, satting 93%.
Sedation with Fentanyl 75, Midaz 2. No pressor requirement. Pt.
was agitated, Fentanyl increased to 100.
Past Medical History:
choledocholithiasis s/p ERCP + stent [**2197-9-11**], COPD, varicose
veins, ventral hernia repair in [**2191**]
Social History:
Born in [**Country 6257**]. Worked as a cleaning person in a factory, but
who is now retired. Long smoking history, 1 ppd recently. He
apparently is a former alcoholic, but after counseling 10 years
ago, his alcohol intake is much reduced. Current EtOH
consumptions unclear. 3 children who are all well.
Family History:
"stomach cancer" in his mother who died at age [**Age over 90 **]. His father
had laryngeal cancer
Physical Exam:
GENERAL: intubated sedated
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP= 8cm
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM, several incisions with
clean dressings, one JP drain
EXTREMITIES: No edema, 2+ dorsalis pedis/ posterior tibial
pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: occ opens eyes and follows commands
Pertinent Results:
[**2197-10-31**] 07:27PM TYPE-ART RATES-/11 TIDAL VOL-640 O2-50
PO2-225* PCO2-46* PH-7.41 TOTAL CO2-30 BASE XS-4
INTUBATED-INTUBATED VENT-CONTROLLED
[**2197-10-31**] 07:27PM GLUCOSE-143* LACTATE-1.6 NA+-136 K+-4.4
CL--101
CXR [**2197-11-2**]: As compared to the previous examination, the
patient has been extubated. The nasogastric tube is in unchanged
position. The lung volumes have slightly decreased. The
pre-existing bilateral pleural effusions are slightly more
extensive than on the previous examination. Also slightly more
extensive are the pre-existing bilateral areas of atelectasis.
Unchanged evidence of mild pulmonary edema. No newly occurred
focal parenchymal opacities suggesting pneumonia. Unchanged
moderate cardiomegaly.
Brief Hospital Course:
72 year old male with s/p subtotal gastrectomy, D2
lymphadenectomy, CBD exploration, and choledochojejunostomy for
gastric antral CA.
[**11-1**] pt admitted to the [**Hospital Ward Name **] ICU post op. He was kept
intubated, NPO/ IVF, PPI [**Hospital1 **], EBL was 2700 intraop given 3 untis
of pRBC, 1 L of albumin. Epidural in place for pain control.
[**11-2**] Extubated , good urine ouput. Hct stable 28.9. Slight
hyppotension to 80s systolic wiht response to decresing the
epidural and 2 L of IVF bolus.
[**11-3**] Trophic tube feeds started. Jp drain removed. Transferred
out of the [**Hospital Unit Name 153**].
[**11-4**] Started on [**Last Name (LF) 84754**], [**First Name3 (LF) **] with norm gas pattern. Epidural
dcd. Cefoxitan started for ? PNA on CXR.
[**11-5**] High NGT output 1600 cc - TF at 30 cc / hr. PCa for pain
control.
[**11-6**] Febrile to 102.5 - pancultured. Nutrition consult.
[**11-7**] Tf at 60cc , sterted on cefoxitan. Dulcolax given.
Physical therapy consulted.
[**11-8**] NGT removed. Diarrhea. C diff checked. Foley removed. Tf
decreased to [**2-22**] stregth with improvement in diarrhea. UGIB
with low gastric emptying.
[**Date range (1) 84755**] Fluids dcd. started on sips to clears.
[**11-11**]: Advanced to regular diet, pain well controlled,
ambulating. Dcd home with VNA, HHA and PT.
Medications on Admission:
Protonix 40 mg [**Hospital1 **]
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing.
Disp:*qs 1* Refills:*0*
2. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 6138**] Home Care Services
Discharge Diagnosis:
1. Gastric adenocarcinoma.
2. Common bile duct obstruction with cholelithiasis and
choledocholithiasis
Discharge Condition:
VSS, toleratins a regular diet with supplements, pain well
controlled with po pain medications, ambulating without
assistance
Discharge Instructions:
General:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Please call ([**Telephone/Fax (1) 5323**] to schedule follow up with Dr. [**Last Name (STitle) 519**]
for early next week - please call monday [**2197-11-13**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2197-11-11**]
|
[
"E849.7",
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
[]
]
] |
5294, 5368
|
3527, 4868
|
339, 429
|
5519, 5647
|
2757, 3503
|
7191, 7511
|
2064, 2164
|
4950, 5271
|
5389, 5498
|
4894, 4927
|
5671, 6830
|
6845, 7168
|
2179, 2738
|
277, 301
|
457, 1592
|
1614, 1727
|
1743, 2048
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,446
| 193,414
|
50715
|
Discharge summary
|
report
|
Admission Date: [**2114-6-13**] Discharge Date: [**2114-7-26**]
Date of Birth: [**2045-2-17**] Sex: F
Service: SURGERY
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
abdominal aortic aneurysm
Major Surgical or Invasive Procedure:
[**2114-6-13**] open retroperitoneal AAA repair
[**2114-6-13**] exploratory laparotomy, splenectomy
[**2114-6-29**] retroperitoneal exploration, evacuation of hematoma,
bronchoscopy
[**2114-7-17**] tunneled hemodialysis catheter placement
[**2114-7-21**] PEG tube placement
History of Present Illness:
[**Known firstname **] [**Known lastname 41841**] is a 69-year-old patient of Dr. [**Last Name (STitle) 2903**] who presents
for evaluation of an aortic aneurysm recently discovered. She
has a twin sister with both cerebral and abdominal aortic
aneurysm and had treatments. She also has other sisters and
family members with aneurysms. No early ruptures that I was
aware of. Over the last few months, she describes as a beating
sensation in her abdomen. Dr. [**Last Name (STitle) 2903**] examined her and ordered a
CT scan and identified the aneurysm. In addition, she has had
some weight loss about 18 lbs over the last year. It is not
clear why. She has no food fear. She has no pain when she
eats. She does have some depression and thinks as a part of it.
Past Medical History:
PMH: Hypertension, COPD, depression/anxiety, high cholesterol,
chronic renal insufficiency.
PSH: TAH.
Social History:
Alcohol, occasionally. Tobacco, stopped a week ago, smoked a
pack a day for 50 years. She is retired waitress. G2, P2.
Widowed with 2 adult children, grandchildren,
great-grandchildren.
Family History:
unknown
Physical Exam:
She is a thin female in no acute distress. Carotids are 2+
without bruit. Lungs are clear. Heart is regular rate and
rhythm. Neck is supple. Thyroid is without
masses. Neuro is grossly intact.
Peripheral vascular exam: Palpable femoral, popliteal and
dorsalis pedis pulses bilaterally. Palpable radial and brachial
pulses bilaterally.
Pertinent Results:
Hematocrit drop following AAA repair, secondary to splenic lac.
[**2114-6-13**] 08:07PM BLOOD Hct-25.7*
[**2114-6-13**] 08:32PM BLOOD Hct-18.6*#
Rising WBC:
[**2114-6-19**] 02:24AM BLOOD WBC-10.5 RBC-3.69* Hgb-11.0* Hct-32.8*
MCV-89 MCH-29.7 MCHC-33.5 RDW-18.1* Plt Ct-169
[**2114-6-20**] 02:05AM BLOOD WBC-12.0* RBC-3.74* Hgb-11.3* Hct-33.0*
MCV-88 MCH-30.1 MCHC-34.1 RDW-17.8* Plt Ct-209
[**2114-6-21**] 03:00AM BLOOD WBC-14.7* RBC-3.58* Hgb-10.6* Hct-32.3*
MCV-90 MCH-29.5 MCHC-32.7 RDW-17.7* Plt Ct-262
[**2114-6-22**] 02:42AM BLOOD WBC-18.3* RBC-3.62* Hgb-10.6* Hct-32.2*
MCV-89 MCH-29.2 MCHC-32.8 RDW-17.8* Plt Ct-371
[**2114-6-22**] 11:36AM BLOOD WBC-17.7* RBC-3.58* Hgb-10.4* Hct-32.5*
MCV-91 MCH-29.1 MCHC-32.1 RDW-17.7* Plt Ct-371
[**2114-6-23**] 02:56AM BLOOD WBC-21.1* RBC-3.34* Hgb-9.8* Hct-30.2*
MCV-90 MCH-29.4 MCHC-32.6 RDW-17.9* Plt Ct-439
[**2114-6-19**] 2:47 am SPUTUM CULTURE Source: Endotracheal.
**FINAL REPORT [**2114-6-22**]**
GRAM STAIN (Final [**2114-6-19**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2114-6-22**]):
OROPHARYNGEAL FLORA ABSENT.
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH.
PSEUDOMONAS SPECIES. SPARSE GROWTH. PSEUDOMONAS
ORYZIHABITANS.
sensitivity testing performed by Microscan.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| PSEUDOMONAS SPECIES
| |
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S S
CEFTAZIDIME----------- <=1 S <=2 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S <=0.5 S
GENTAMICIN------------ <=1 S <=1 S
IMIPENEM-------------- <=1 S <=1 S
MEROPENEM-------------<=0.25 S S
PIPERACILLIN---------- <=8 S
PIPERACILLIN/TAZO----- <=4 S <=8 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2114-6-27**] 11:46 am URINE CULTURE Source: Catheter.
**FINAL REPORT [**2114-6-28**]**
URINE CULTURE (Final [**2114-6-28**]):
YEAST. >100,000 ORGANISMS/ML..
Hematocrit drop secondary to retroperitoneal hematoma.
[**2114-6-28**] 12:16PM BLOOD Hct-28.2*
[**2114-6-29**] 12:22AM BLOOD Hct-16.7*
Rising creatinine secondary to ARF.
[**2114-6-13**] 03:08PM BLOOD Glucose-86 UreaN-17 Creat-1.3* Na-138
K-4.5 Cl-114* HCO3-21* AnGap-8
[**2114-6-14**] 03:52PM BLOOD Glucose-84 UreaN-19 Creat-1.6* Na-142
K-4.4 Cl-118* HCO3-21* AnGap-7*
[**2114-6-15**] 03:26AM BLOOD Glucose-124* UreaN-21* Creat-1.7* Na-146*
K-4.0 Cl-116* HCO3-23 AnGap-11
[**2114-6-15**] 09:32PM BLOOD Glucose-100 UreaN-25* Creat-2.1* Na-143
K-4.1 Cl-111* HCO3-24 AnGap-12
[**2114-6-16**] 04:18AM BLOOD Glucose-94 UreaN-28* Creat-2.2* Na-142
K-3.9 Cl-111* HCO3-23 AnGap-12
[**2114-6-17**] 07:51PM BLOOD Glucose-113* UreaN-39* Creat-2.4* Na-141
K-3.9 Cl-112* HCO3-22 AnGap-11
[**2114-6-20**] 02:05AM BLOOD Glucose-120* UreaN-50* Creat-2.6* Na-138
K-4.2 Cl-107 HCO3-22 AnGap-13
[**2114-7-1**] 02:59AM BLOOD Glucose-145* UreaN-101* Creat-2.8* Na-144
Cl-109* HCO3-25
[**2114-7-2**] 03:07AM BLOOD Glucose-97 UreaN-112* Creat-3.0* Na-146*
K-4.0 Cl-110* HCO3-24 AnGap-16
[**2114-7-2**] 05:56PM BLOOD UreaN-118* Creat-3.2* K-4.6
[**2114-7-3**] 01:59AM BLOOD Glucose-140* UreaN-123* Creat-3.3* Na-142
K-4.5 Cl-107 HCO3-22 AnGap-18
[**2114-7-3**] 03:08PM BLOOD UreaN-130* Creat-3.5* K-4.7
[**2114-7-4**] 02:56AM BLOOD Glucose-126* UreaN-137* Creat-3.7* Na-140
K-4.4 Cl-105 HCO3-22 AnGap-17
[**2114-7-5**] 03:14AM BLOOD Glucose-95 UreaN-148* Creat-4.1* Na-138
K-4.4 Cl-103 HCO3-22 AnGap-17
[**2114-7-6**] 04:28AM BLOOD Glucose-96 UreaN-146* Creat-4.3* Na-136
K-4.5 Cl-100 HCO3-21* AnGap-20
[**2114-7-7**] 03:07AM BLOOD Glucose-105 UreaN-149* Creat-4.6* Na-137
K-4.4 Cl-100 HCO3-19* AnGap-22*
[**2114-7-8**] 03:59AM BLOOD Glucose-121* UreaN-151* Creat-5.0* Na-137
K-4.1 Cl-99 HCO3-18* AnGap-24
[**2114-7-8**] 02:33PM BLOOD Glucose-107* UreaN-154* Creat-5.2* Na-135
K-4.3 Cl-97 HCO3-20* AnGap-22
Brief Hospital Course:
On [**6-13**], patient underwent open abdominal aortic aneurysm repair
with Dacron
graft via a retroperitoneal approach. During the procedure, she
had mobilization of her left kidney and spleen over the aorta
and retracted to allow access to the
supraceliac aorta. The case proceeded very smoothly and the
patient was taken to the recovery room and kept intubated.
Initially the patient appeared to be hypovolemic and was given a
combination of fluid and blood and stabilized. She was not on
pressors at the time. Later in the evening, a hematocrit came
back at 25. She was given 2 units of blood and was still very
stable, making urine with no acidosis. However, she became more
distended and the decision was made to return her to the
operating room for exploratory laparotomy. The spleen was found
to have a significant laceration and was thus removed. She had
Cell [**Doctor Last Name **] and multiple transfusions intraoperatively. She was
taken to the ICU afterwards.
On [**6-15**], she began to have bursts of afib with rate up to 140s.
IV heparin, lopressor, and amiodarone were started as per
Cardiology recs. These episodes continued throughout her
hospitalization despite treatment.
Vanco was started on [**6-16**] for wound leakage. Cefepime was added
on [**6-21**] when her WBC rose to 18.3 from 14.7. WBC further
increased to 21 on [**6-23**]. A CT chest/abdomen was performed to
look for a source of infection; none was found. Sputum cultures
drawn [**6-19**] grew Pseudomonas & Klebsiella. Cipro was added on
[**6-25**]. Urine cultures from [**6-27**] grew yeast, and caspofungin was
added.
She was extubated on [**6-26**].
On [**6-27**], the [**Doctor Last Name 406**] drain was removed.
On [**6-29**], patient's Hct dropped from 28.2 to 16.7. She was not
hemodynamically unstable. She underwent a non-contrast CT scan
which revealed a large retroperitoneal hematoma with abdominal
fluid. IV heparin was stopped and she was taken to the
operating room on [**6-30**] for exploration and evacuation of the
hematoma. She also underwent bronchoscopy. Mucous plugging was
noted and lavage was performed. She was then taken to the CSRU.
On [**7-1**], she was extubated and reintubated for CO2 retention.
Caspo was d/c'd on [**7-2**].
On [**7-3**], she underwent ultrasound guided thoracentesis of right
pleural effusion. Cultures were negative.
Nephrology was consulted on [**7-2**] for ARF. A duplex renal
ultrasound showed lack of diastolic flow. Medical diuresis
failed, and she was started on CVVH on [**7-8**].
On [**7-4**], BRBPR was noted. On [**7-5**], her NGT output was
bloody/coffee grounds emesis. GI was consulted. She underwent
EGD on [**7-5**], which showed ulcers in the lower third of the
esophagus and in the fundus, as well as erosion in the stomach.
A PPI was started. Colonoscopy showed an ulcer in the rectum,
and an otherwise normal colon up to the sigmoid. There was poor
visualization of the sigmoid colon.
She was extubated on [**7-6**]. Vanco was d/c'd.
Speech & swallow could not rule out aspiration on [**7-12**]. Dr. [**Name (NI) 45689**] service was consulted to place a PEG, but deferred
until her WBC decreased. Dobhoff tube was placed on [**7-14**].
On [**7-15**] she was transferred to the VICU. Antibiotics were d/c'd
on [**7-16**].
A tunneled cath was placed by IR on [**7-17**] for hemodialysis.
On [**7-19**], she returned to the CSRU for respiratory distress
requiring BiPAP.
PEG was placed on [**7-21**].
She was transferred back to the VICU on [**7-23**].
Cardiology was consulted on [**7-23**] re: anticoagulation for Afib in
the face of recent GI bleed. ASA 325 was recommended.
On [**7-24**], she underwent a repeat bedside swallowing evaluation,
and she was cleared for a thin liquids/pureed solids diet with
continued PEG tube feeds for nutrition.
On [**7-26**], patient was deemed stable for discharge to rehab. Her
Foley was d/c'd. She has minimal urine output. She has
received her post-splenectomy vaccinations. She will continue
on her current medications and hemodialysis. She will
eventually need a colonoscopy, which can be performed an an
outpatient basis.
Medications on Admission:
Zoloft 75', Xanax 0.5''', Toprol XL 50', lisinopril 10',
simvastatin 20'
Discharge Medications:
1. Simvastatin 10 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO DAILY
(Daily).
2. Sertraline 50 mg Tablet [**Month/Year (2) **]: 1.5 Tablets PO DAILY (Daily).
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [**Month/Year (2) **]: [**3-2**]
Puffs Inhalation QID (4 times a day).
4. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (3) **]: One (1) ml
Injection [**Hospital1 **] (2 times a day).
5. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: Four (4) ml PO Q6H
(every 6 hours) as needed.
6. Acetylcysteine 10 % (100 mg/mL) Solution [**Hospital1 **]: 1-10 MLs
Miscellaneous Q6H (every 6 hours) as needed.
7. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical PRN
(as needed).
8. Sodium Chloride 0.65 % Aerosol, Spray [**Hospital1 **]: [**11-28**] Sprays Nasal
DAILY (Daily) as needed.
9. Metoprolol Tartrate 25 mg Tablet [**Month/Day (2) **]: 1.5 Tablets PO TID (3
times a day).
10. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Month/Day (2) **]: One (1)
neb Inhalation Q6H (every 6 hours).
11. Ipratropium Bromide 0.02 % Solution [**Month/Day (2) **]: One (1) neb
Inhalation Q6H (every 6 hours).
12. Morphine 2 mg/mL Syringe [**Month/Day (2) **]: 0.5 ml Injection Q4H (every 4
hours) as needed.
13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
14. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO QID
(4 times a day).
15. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 MLs
PO Q4H (every 4 hours) as needed.
16. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
17. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
18. Olanzapine 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
19. Calcium Carbonate 500 mg Tablet, Chewable [**Last Name (STitle) **]: One (1)
Tablet, Chewable PO TID (3 times a day).
20. Ativan 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO three times a
day as needed.
21. Ondansetron HCl (PF) 4 mg/2 mL Solution [**Last Name (STitle) **]: Two (2) ml
Injection Q8H (every 8 hours) as needed for nausea.
22. regular insulin sliding scale
fingersticks qAC & qHS
Glucose: Regular Insulin
0-50 mg/dL [**11-28**] amp D50
51-120 mg/dL 0 Units
121-160 mg/dL 2 Units
161-200 mg/dL 4 Units
201-240 mg/dL 6 Units
241-280 mg/dL 8 Units
281-320 mg/dL 10 Units
> 320 mg/dL Notify M.D.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Hospital @ [**Doctor Last Name 1263**]
Discharge Diagnosis:
AAA s/p repair, splenic laceration s/p splenectomy,
retroperitoneal hematoma s/p evacuation, dysphagia s/p PEG tube,
HTN, COPD, depression, hypercholesterolemia, renal failure on
hemodialysis
Discharge Condition:
fair
Discharge Instructions:
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**5-4**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**12-30**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over incision, rinse
and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2114-8-28**] 10:45
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 1241**] Follow-up appointment
should be in 2 weeks
Completed by:[**2114-7-26**]
|
[
"E878.2",
"585.9",
"584.9",
"427.31",
"530.21",
"934.9",
"998.11",
"263.9",
"272.0",
"998.12",
"300.4",
"441.4",
"569.41",
"403.90",
"285.1",
"493.20",
"998.2",
"276.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"96.6",
"96.72",
"99.04",
"41.5",
"96.05",
"34.91",
"39.95",
"33.22",
"38.44",
"38.95",
"45.13",
"99.15",
"43.11",
"54.12"
] |
icd9pcs
|
[
[
[]
]
] |
13309, 13406
|
6426, 10607
|
297, 573
|
13642, 13649
|
2101, 6403
|
16278, 16622
|
1718, 1727
|
10730, 13286
|
13427, 13621
|
10633, 10707
|
13673, 15826
|
15852, 16255
|
1742, 2082
|
232, 259
|
601, 1371
|
1393, 1496
|
1512, 1702
|
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