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47,620
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|
40229
|
Discharge summary
|
report
|
Admission Date: [**2143-11-25**] Discharge Date: [**2143-12-3**]
Date of Birth: [**2063-11-6**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Iodine-Iodine Containing / Polyethylene Glycol
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Known Aortic stenoss now with increasing dyspnea
on exertion
Major Surgical or Invasive Procedure:
[**2143-11-25**] Aortic Valve Replacement(21mm porcine)with pericardial
patch of ascending aorta
[**2143-11-25**] Re-exploration for bleeding
History of Present Illness:
80-year-old woman with known history of aortic stenosis, has
increasing dyspnea on exertion, and shortness of breath. She
has been followed with serial echocardiograms and most recent
echocardiogram shows an aortic valve area of 0.7 cm2. The
cardiac catheterization from [**2143-10-30**] shows diffuse
mild
coronary artery disease.
Past Medical History:
Past Medical History:
Hypertension
Bell's palsy
T-cell lymphoma (remission)
Diverticulosis
Diarrhea
Migranes
Lyme disease
Social History:
Race: Caucasian
Last Dental Exam: 4 months ago will get clearance faxed to
office
Lives with: grandson. Daughter- [**Name2 (NI) 553**]-cell [**Telephone/Fax (1) 88314**](physical
therapist)
Tobacco: current 1/2PPD x3yrs, had quit x5 years until granson
moved in. Previously 1PPD x50yrs
Family History:
non contributory
Physical Exam:
Pulse: 61 Resp: 18 O2 sat:
B/P Right: 121/60 Left:
Height: 5'1" Weight: 115 lbs
General: NAD-quite anxious
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally []-scattered rhonchi
Heart: RRR [x] Murmur: 4/6 SEM
Abdomen: Soft[x] non-distended[x] non-tender[x] + bowel
sounds[x]
Extremities: Warm [x], well-perfused [] Edema: none
Varicosities: mild
Neuro: A&Ox3, MAE-follows commands. Nonfocal exam
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: - Left: -
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: cath Left: 2+
Carotid Bruit: transmitted murmur
Pertinent Results:
Radiology Report CHEST (PA & LAT) Study Date of [**2143-11-30**] 5:22 PM
[**Hospital 93**] MEDICAL CONDITION: 80 year old woman with AV repair
Final Report: As compared to the previous radiograph, the right
central venous access line has been removed. Mild bilateral
areas of atelectasis. No pneumonia. No pulmonary edema. Presence
of small bilateral pleural effusions cannot be excluded.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.3 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.8 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Aorta - Annulus: 2.2 cm <= 3.0 cm
Aorta - Sinus Level: 2.9 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.2 cm <= 3.0 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Findings
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV.
LEFT VENTRICLE: Mild symmetric LVH. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Bioprosthetic aortic
valve prosthesis (AVR). AVR leaflets move normally. Severe AS
(area 0.8-1.0cm2). No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Moderate mitral annular calcification. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to
moderate [[**12-22**]+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
No PR.
Conclusions PRE-CPB:
The left atrium is elongated.
There is mild symmetric left ventricular hypertrophy. Overall
left ventricular systolic function is normal (LVEF>55%).
There are grade 3 atheroma in the descending thoracic aorta.
There are three aortic valve leaflets. The aortic valve leaflets
are severely thickened. There is severe aortic valve stenosis.
No aortic regurgitation is seen.
There is moderate posterior mitral annular calcification. Mild
(1+) mitral regurgitation is seen.
POST-CPB:
There is a bioprosthetic valve in the aortic position. The peak
gradient across the valve is 15mmHg, the mean gradient is 6mmHg.
The valve is well seated with normally mobile leaflets. There
does not appear to be a paravalvular leak.
There is concentric LVH with normal systolic function.
There is no evidence of dissection.
[**2143-12-2**] 06:25AM BLOOD WBC-7.9 RBC-3.53* Hgb-11.0* Hct-32.3*
MCV-92 MCH-31.2 MCHC-34.0 RDW-15.3 Plt Ct-207
[**2143-12-3**] 04:30AM BLOOD PT-12.1 INR(PT)-1.0
[**2143-12-2**] 06:25AM BLOOD Glucose-94 UreaN-27* Creat-0.6 Na-141
K-3.8 Cl-105 HCO3-29 AnGap-11
[**2143-12-3**] 04:30AM BLOOD TotBili-4.7*
Brief Hospital Course:
Admitted [**11-25**] and underwent surgery with Dr. [**Last Name (STitle) **].
Transferred to the CVICU in stable condition, but then returned
to the OR for bleeding re-exploration. Transferred back to the
CVICU in stable condition on titrated phenylephrine and propofol
drips. Went into A Fib and treated with amiodarone. Extubated on
POD #2. Inotropic support was weaned and she was transferred to
the floor on POD #4 to begin increasing his activity level.
Chest tubes and pacing wires removed per protocol. Beta blockade
titrated and gently diuresed toward her preop weight. Went into
A fib on POD #7 and amiodarone and coumadin started.Chest tubes
and pacing wires removed per protocol. Continued to make good
progress and was cleared for discharge to home with VNA on POD
#8. First blood draw tomorrow with results to [**Hospital1 **] coumadin
clinic. target INR 2.0-2.5. All f/u appts were advised.
Medications on Admission:
Immodium-prn
Atenolol 100 daily
Lisinopril 10 daily
Alendronate 70 Qwk
Calcium daily
Alprazolam 0.25/prn
Fioricet 1-2tabs Q6hrs/prn
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
4. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 6 days: 400 mg [**Hospital1 **] through [**12-9**]; then 200 mg [**Hospital1 **]
[**Date range (1) 88315**]; then 200 mg daily ongoing as directed by Dr. [**First Name (STitle) 1075**].
Disp:*100 Tablet(s)* Refills:*0*
5. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*1*
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
7. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 10 days.
Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
8. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
9. warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day for
1 doses: 3 mg today [**12-3**]; then all further daily dosing per
coumadin clinic at [**Hospital1 **]; target INR 2.0-2.5.
Disp:*100 Tablet(s)* Refills:*0*
10. Outpatient Lab Work
first INR check Wed [**12-4**]; then please check daily until
therapeutic; target INR 2.0-2.5; results to [**Hospital1 **] coumadin
clinic [**Telephone/Fax (1) 6256**]
Discharge Disposition:
Home With Service
Facility:
tba
Discharge Diagnosis:
s/p AVR (21mm porcine) pericardial patch ascending aorta [**11-25**]
reop for bleeding
postop A Fib
PMH: HTN, Bell's palsy, T-cell lymphoma (remission),
Diverticulosis,
Diarrhea, Migranes, Lyme disease
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:BLE 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
Surgeon: Dr. [**Last Name (STitle) **] at [**Hospital1 **] Thursday [**1-2**] @ 9AM
Cardiologist: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] [**1-7**] at 10 AM
Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) **],[**First Name3 (LF) 488**] J [**Telephone/Fax (1) 8036**] in [**3-25**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication A Fib
Goal INR 2.0-2.5
First draw Wed [**2143-12-4**]; daily draws until therapeutic
Results to [**Hospital1 **] coumadin clinic [**Telephone/Fax (1) 6256**]
Completed by:[**2143-12-3**]
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,380
| 106,102
|
41534
|
Discharge summary
|
report
|
Admission Date: [**2145-6-11**] Discharge Date: [**2145-6-29**]
Date of Birth: [**2072-5-17**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 158**]
Chief Complaint:
R colon cancer
Major Surgical or Invasive Procedure:
Colonoscopy [**2145-6-15**]
Right Colectomy [**2145-6-18**]
History of Present Illness:
73 year old male with PMHx of EtOH abuse, hyperlipoproteinemia,
CVA with residual RLE weakness, suspected embolic strokes from
PFO who is being transferred to the ICU for altered mental
status. The patient was admitted to the Neurology service on
[**2145-6-11**] for concern of repeat stroke. The plan was to start
aspirin 325mg daily, however this was delayed because he was
noted to be anemic. GI was consulted and a colonoscopy was done
which showed a hepatic flexure mass, which on biopsy showed high
grade dysplasia concerning for colon cancer. Colorectal surgery
was consulted and took the patient to the OR for a right
colectomy. The patient tolerated the procedure well, with EBL
of 100cc. Had epidural catheter placed for anesthesia, received
2 units of PRBC during procedure to ensure adequate perfusion.
He received ciprofloxacin/flagyl intraop. The patient was
extubated and taken to the PACU. In the PACU, he was noted to
be tachycardic, hypertensive, and tremulous. EKG, CEs checked
and normal. Because of concern of EtOH withdrawal, he was given
a total of ativan 1.5mg IV x1. After he received the ativan, he
had acute worsening of his mental status becoming lethargic and
a Code Stroke was called. He had a stat CT and CTA of his head
and neck which showed no evidence of acute stroke per the Stroke
fellow. The patient was then admitted to the ICU for further
monitoring.
Past Medical History:
- Prior CVAs thought to be embolic from PFO (Multifocal stroke
involving left Occipital, left Thalamic/IC [**1-/2145**])
- Hyperlipoproteinemia
- EtOH abuse
Social History:
Mr [**Known lastname 14738**] lives with his mother. [**Name (NI) **] was previously in the
military and retired from being a bus driver.
A friend reports he has abused ETOH for the last 5 years and
drinks [**11-29**] liter vodka daily. He denies ever smoking.
Family History:
His mother has had 3 MIs. His father died from complications of
alcoholism. He has a sister who died from renal failure
secondary to a kidney stone. He reports no history of strokes of
blood disorders in his family.
Physical Exam:
VS: T:97.4; HR: 77; BP: 155/103; RR: 16; Sat: 99% RA
Gen: WD/WN M in NAD
CV: RRR, no m,r,g
Chest: CTA
Abd: Soft, nontender, nondistended, dermabonded midline surgical
wound
Ext: no c/c/e
Pertinent Results:
[**2145-6-22**] 06:00AM BLOOD WBC-4.2 RBC-4.03* Hgb-9.0* Hct-30.6*
MCV-76* MCH-22.4* MCHC-29.5* RDW-21.9* Plt Ct-470*
[**2145-6-22**] 06:00AM BLOOD Glucose-122* UreaN-7 Creat-0.9 Na-139
K-3.6 Cl-106 HCO3-26 AnGap-11
[**2145-6-22**] 06:00AM BLOOD Calcium-8.8 Phos-2.4* Mg-2.0
CTA Head/Neck [**6-18**]:
1. Little overall interval change from the complete CTA,
performed only a
week ago; specifically, the known predominantly left frontal
deep "watershed"
infarcts are not well-seen, with no evidence of acute vascular
territorial
infarction (though no dedicated CT-perfusion study was requested
or
performed).
2. No acute intracranial hemorrhage.
3. Unchanged appearance of high-grade stenosis of the proximal
P2 segment of
the left PCA, with preserved distal flow.
4. Diffuse atherosclerotic disease of the intracranial vessels,
most markedly
involving the superior division of the left MCA, as well as the
hypoplastic A1
segment of the right ACA, with no new flow-limiting stenosis.
5. Unremarkable cervical vessels, with no flow-limiting
stenosis.
6. Patchy airspace opacities involving the posteromedial lung
apices,
apparently new, which should be closely correlated clinically
and with chest
radiography.
7. 3-mm sialolith in the proximal left submandibular duct.
ABDOMEN (SUPINE & ERECT) Study Date of [**2145-6-25**] 10:52 AM
IMPRESSION: Continued dilation of small bowel loops and
air-fluid levels.
Dilation is worsened since film from [**2145-6-24**] at 8:35 a.m.
CT ABD & PELVIS WITH CONTRAST Study Date of [**2145-6-25**] 3:40 PM
IMPRESSION:
1. Dilated small bowel to level of the anastomosis. No evidence
of leakage
or infection at anastomotic site. Dilated colon distal to
anastomosis with a second focal area of narrowing in the
transverse colon. Distal to the second narrowing, there again is
dilated large bowel through to the rectum. Findings
are consistent with ileus or partial small bowel obstruction.
2. Multiple unchanged hepatic cysts.
3. Free fluid in the pelvis and minimal perihepatic fluid.
CHEST PORT. LINE PLACEMENT Study Date of [**2145-6-25**] 10:05 PM
IMPRESSION:
1. Interval placement of a right PICC catheter with the tip in
the proximal right atrium. Re-positioning would be advised.
Overall cardiac and mediastinal contours are stable given
differences in positioning. Lung
volumes are low but no focal airspace consolidation, pleural
effusions, or
pneumothoraces are seen. Epidural catheter is no longer seen. A
left
perihilar opacity is less apparent on the current examination
possibly related to differences in positioning or interval
improvement. Continued close followup imaging would be advised.
CHEST (PORTABLE AP) Study Date of [**2145-6-26**] 10:04 AM
IMPRESSION: Normally positioned left-sided PICC. No
pneumothorax.
ABDOMEN (SUPINE & ERECT) Study Date of [**2145-6-27**] 12:12 PM
IMPRESSION:
1. Lung bases appear clear. There is gas scattered throughout
small and
large bowel with some air-fluid levels on the upright study.
Overall, the
bowel loops appear slightly more distended although given the
degree of gas in both the small and large bowel, this would
still favor a postoperative ileus. However, given worsening
distention, early small bowel obstruction can not be entirely
ruled out. Clinical correlation is advised. No free air.
Multiple calcifications in the pelvis are consistent with
phleboliths. Radiopaque material in the left lateral mid abdomen
likely represents retained contrast in diverticula. Chain
sutures are seen in the mid abdomen likely at the anastomosis
site.
ABDOMEN (SUPINE & ERECT) Study Date of [**2145-6-29**] 9:33 AM
Continued ileus per surgical team.
Brief Hospital Course:
Mr. [**Known lastname 14738**] was initially admitted to neurology on [**6-11**] for
weakness and found to have an acute L cortical ischemic stroke.
Please see the neurology admission note for more detail. He was
not a candidate for tPA. He was found to be anemic with
Hemoccult positive stool. On [**6-15**] EGD and colonoscopy were
performed. EGD was normal but on colonoscopy a 2-3 cm
ulcerated, malignant appearing lesion in the hepatic flexure was
seen. The lesion was partly obstructing and the scope could not
be passed beyond this point. The patient was taken to the
operating room on [**2145-6-18**] for a R colectomy. Please see the
operative report for more detail. His postoperative course was
complicated by an acute mental status change in the PACU for
which he was transferred to the ICU. A stroke consult was
obtained, CT and CTA imaging was obtained, neurology felt this
to be likely of toxic/metabolic origin from anesthesia. His
epidural was removed and his mental status returned to baseline.
He was observed in the ICU and transferred to the floor on
POD2. His course was further complicated by bilious emesis on
POD2, an NGT was placed. It was removed on POD4, when he was
passing flatus and having bowel movements. By the day of
discharge he was tolerating a normal diet. After restarting a
regular diet, the patient's abdomen again became distended and
he vomited. On [**2145-6-24**] a repeat KUB showed air fluid levels and
the patient was backed down to sips. On [**2145-6-25**] a PICC line was
placed. Also on [**2145-6-25**] as well as [**2145-6-26**] the patient was noted
to have several runs of nonsustained Vtach, a cardiology consult
was called and the patient's electrolytes were repleated and his
Lopressor doses were titrated. In addition he was noted to have
hypertension post operatively for which he was started on
Lopressor and Lisinopril 5 mg daily. The Lopressor was titrated
up by discharge to 37.5 mg PO BID. The patients blood pressure
was stable. The patient continued to have bowel movements and
pass flatus despite being medically stable and have evidence of
ileus on KUB. The patient was started on TPN and followed
closely by nutrition On [**2145-6-29**] an additional KUB was obtained
which showed continued ileus. The patient remained without an NG
tube, stable. The patient was assessed by the surgical team and
it was thought that perhaps, the patient had an overgrowth of
bacteria causing this ileus. Treatment of bacterial overgrowth
was started with Rifamixin 200mg TID for 10 days. The patient is
to be discharged to rehabilitation hospital on sips of clear
liquids and ensure 30cc/hr until follow-up with Dr. [**Last Name (STitle) **] in 2
weeks when he will have a repeat KUB to access the ileus. TPN
will continue throughout this time period.
Medications on Admission:
Patient endorses taking no meds.
Per prvious d/c [**1-/2145**]:
1. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours).
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Reglan 10 mg Tablet Sig: One (1) Tablet PO Three Times Daily
Before Meals and At Bedtime.
9. rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) for 10 days. Tablet(s)
10. 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.
11. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO twice a
day: hold for SBP<100 or HR<60.
12. insulin regular human 100 unit/mL Solution Sig: per sliding
scale Injection ASDIR (AS DIRECTED): Please see sliding scale,
use while patient recieving TPN.
13. Regular Insulin Sliding Scale
Q6H
Regular
Glucose Insulin Dose
0-70mg/dL Proceed with hypoglycemia protocol
71-159mg/dL 0 Units
160-199mg/dL 2 Units
200-239mg/dL 4 Units
240-279mg/dL 6 Units
280-319mg/dL 8 Units
320-359mg/dL 10 Units
360-399mg/dL 12 Units
> 400mg/dL Notify M.D.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Acute Ischemic Stroke
Right Sided Colon Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital after a Right Sided Colectomy
for surgical management of your near-obstructing right sided
colon 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. Your pathology results were communicated to you by
Dr. [**Last Name (STitle) **], if you have any questions regarding these results,
please call the office. You have tolerated a regular diet,
passing gas and having bowel movements 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 have had a
slowing of your intestine called an ileus for the past weeks or
so. You have had multiple Xrays of your abdomen which showed
this slowing as well as a CT scan which showed no [**Last Name 16423**] problem
from the surgery. It is believed that this slowing is related to
am overgrowth of bacteria in your bowels and this will be
treated with an antibiotic called Rifamixin which you will take
for the next 10 days. You will continue to take reglan by mouth
during this time. You will continue to recieve TPN through the
PICC line in your arm until your follow-up appointment. You
cannot take more by mouth than sips of clears and sips of
ensure, which is 30cc of fluid an hour until you are cleared by
Dr. [**Last Name (STitle) **]. You will have an abdominal xray prior to your
follow-up appointment with Dr. [**Last Name (STitle) **]. 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, prolonged loose stool, or
constipation.
You have a long vertical incision on your abdomen that is closed
with sutures underneath the skin and dermabond glue. This
incision can be left open to air or covered with a dry sterile
gauze dressing if the staples become irritated from clothing.
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 but clear heavy
exercise.
You will be prescribed a small amount of 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.
You will continue your physical therapy as recommended to you at
the rehabiliation facility.
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!
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in [**12-31**] weeks, call for an appointment,
[**Telephone/Fax (1) 160**]
Department: NEUROLOGY
When: TUESDAY [**2145-8-3**] at 11:30 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2145-6-29**]
|
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"V15.81",
"518.4",
"599.0",
"573.8",
"745.5",
"427.1",
"211.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.25",
"45.42",
"45.13",
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] |
icd9pcs
|
[
[
[]
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11237, 11307
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11397, 11397
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2517, 2705
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263, 279
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407, 1811
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11412, 11556
|
1833, 1991
|
2007, 2269
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,426
| 110,202
|
18720
|
Discharge summary
|
report
|
Admission Date: [**2110-3-4**] Discharge Date: [**2110-3-12**]
Date of Birth: [**2034-8-22**] Sex: F
Service: MEDICINE
Allergies:
vancomycin / Sulfamethizole
Attending:[**Doctor First Name 3298**]
Chief Complaint:
s/p ERCP for gallstones
Major Surgical or Invasive Procedure:
[**2110-3-4**] ERCP with sphincterotomy, stent removal and stone
extraction
History of Present Illness:
75 yo F with afib/TIA on coumadin, systolic heart failure
(unknown EF), COPD on 3L NC, DM2, gastroparesis and gastritis
who was admitted in [**2109-9-26**] with cholangitis from stones
in CBD s/p stent placement only due to anticoagulation presents
from rehab for repeat ERCP for stent removal and sphincterotomy.
Patient has been off anticoagulation x 5 days. Sphincterotomy
performed today with removal of old stent. A large 14 mm stone
and large amount of sludge were extracted. The CBD was free or
stone or debris at the end of the procedure. Patient tolerated
the procedure well.
Currently patient complains of severe [**9-5**] lower back pain. She
denies any radiation, states it is similar to her usual coccyx
pain however "more extreme". Denies any abdominal pain or
bowel/bladder incontinence. No nausea or vomiting. No cp or
sob. Patient a poor historian and unable to provide further
history due to severity of pain.
ROS as per HPI, 10 pt ROS otherwise negative
Past Medical History:
Diabetes-II with complications
Atrial fibrillation
Systolic heart failure
Asthma/ COPD on 2 L O2
OSA
Arthritis, currently wheelchair bound
Gastritis
Gastroparesis
Hypertension
GIB
Chronic kidney disease, baseline creatinine is 1.0
Constipation
Morbid Obesity
Anxiety state
Peripheral vascular disease
CHF, unknown EF
H/o TIA without residual deficit
Social History:
Currently resides at [**Hospital 9188**] Rehab Center. Wheelchair bound.
Quit tobacco 25 years ago, 60 pack year history. No etoh or
illicits.
Family History:
mother and father with DM
Physical Exam:
On Admission:
VS: 97.1 128/78 98P 18 97%2LNC
Appearance: aaox3, in moderate distress due to pain
Eyes: eomi, perrl, icteric
ENT: OP clear s lesions, mm very dry, no JVD, neck supple
CV: irreg irreg, bilateral arm edema, [**1-27**]+ LE edema with chronic
venous stasis changes, feet are mildly cool to touch but with 1+
pulses bilateral feet
Pulm: clear bilaterally although difficult exam due to patient
distress
Abd: soft, mild RUQ ttp, no distension, no rebound/guarding, +bs
Msk: 5/5 strength upper extremities, moving lower extremities
with 5/5 plantar flexion/extension but 3/5 strength hip
flexors/extensors (unchanged from [**2109-9-26**] exam)
Neuro: cn 2-12 grossly intact, no focal deficits
Skin: chronic venous stasis change of legs, + palpable ? port
left chest, non-tender
Psych: appropriate
Heme: no cervical [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **]: ++ tenderness of coccyx, no other spinal ttp, no
ecchymoses
On Discharge:
VS: T 96.1 (afebrile >72 hrs), BP 134/81, P 60, RR 20, O2 100%
on 2L
Gen: Obese woman in NAD sitting in chair
HEENT: OP clear, mucous membranes moist
CV: Slow, irregular, no murmurs/rubs/gallops; port a cath in
left upper chest without any erythema, purulence, or fluctuance
appreciated
Pulm: Clear to auscultation bilaterally without wheezes,
rhonchi, or rales
Abd: Obese, soft, nontender, nondistended, bowel sounds positive
Extrem: 1+ edema to knees bilaterally with changes of chronic
venostasis, dark brown/black discoloration of anterior shins
bilaterally
Neuro: Alert, responsive, appropriate, speech is fluent
GU: foley in place
Pertinent Results:
===================
LABORATORY RESULTS
===================
On Admission:
WBC-5.2 RBC-2.67* Hgb-9.3* Hct-27.3* MCV-102* RDW-13.5 Plt
Ct-163
--Neuts-75* Bands-18* Lymphs-0 Monos-4 Baso-3* Atyps-0 Metas-0
Myelos-0
PT-17.0* PTT-44.1* INR(PT)-1.6*
UreaN-25* Creat-0.9 Na-140 K-3.8 Cl-98 HCO3-38*
ALT-26 AST-42* AlkPhos-287* Amylase-14 TBili-1.7* DBili-1.2*
IndBili-0.5
Lipase-9
Calcium-7.8* Phos-3.1 Mg-1.1*
On Discharge:
WBC-4.3 RBC-3.00* Hgb-9.4* Hct-29.3* MCV-98 RDW-14.9 Plt Ct-115*
PT-12.1 PTT-36.8* INR(PT)-1.1
Glucose-79 UreaN-12 Creat-0.7 Na-139 K-4.0 Cl-104 HCO3-32
AnGap-7*
==============
MICROBIOLOGY
==============
Blood Culture 4/4 bottles [**2110-3-5**] at 3:20
lood Culture, Routine (Final [**2110-3-9**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Trimethoprim/Sulfa sensitivity testing performed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]
sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
ESCHERICHIA COLI. SECOND MORPHOLOGY. FINAL
SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R =>32 R
AMPICILLIN/SULBACTAM-- 16 I 16 I
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
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 =>16 R
Anaerobic Bottle Gram Stain (Final [**2110-3-5**]): GRAM
NEGATIVE ROD(S).
Anaerobic Bottle Gram Stain (Final [**2110-3-6**]): GRAM
NEGATIVE ROD(S).
Blood Culture [**2110-3-5**] at 12:26 and blood culture from [**2110-3-6**]:
NGTD
Urine Culture [**1-27**] [**2110-3-5**]:
URINE CULTURE (Final [**2110-3-6**]):
ESCHERICHIA COLI. ~7000/ML. PRESUMPTIVE
IDENTIFICATION.
==============
OTHER STUDIES
==============
TTE [**2110-3-5**]:
IMPRESSION: Preserved regional and global left ventricular
function. Mild right ventricular dilatation with mild global
hypokinesis. Moderate pulmonary systolic hypertension.
[**2110-3-4**] ercp:
The ampulla was bulging and fleshy. (biopsy)
The old stent was removed with a snare.
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique. Contrast medium was
injected resulting in complete opacification. A straight tip
.035in guidewire was placed. At least one large, 14 mm, stone
and large amount of sludge were seen in CBD. CBD measured 18 mm.
A sphincterotomy was performed in the 12 o'clock position
using a sphincterotome over an existing guidewire. Given the
large size of stone, sphincteroplasty was performed with a 12 mm
balloon. A large 14 mm stone and large amount of sludge were
extracted successfully using a 15 mm balloon. At the end of
procedure CBD was free of stone or debris. Otherwise normal
ercp to third part of the duodenum.
Chest Radiograph [**2110-3-5**]:
IMPRESSION: AP chest compared to [**10-1**]:
Severe cardiomegaly has worsened and there is mild interstitial
edema, but
most significant change is new moderate right pleural effusion.
Infusion port catheter ends in the right atrium. No
pneumothorax.
CT Abdomen and Pelvis w/o Contrast [**2110-3-7**]:
IMPRESSION:
1. Bilateral nonhemorrhagic pleural effusions, moderate on the
right and
small on the left.
2. Unchanged moderate cardiomegaly with a catheter terminating
in the right
atrium.
3. Moderate intra- and extra-hepatic pneumobilia, findings
consistent with
recent ERCP and sphincterotomy.
4. Vascular calcifications with moderate plaque seen at the
origins of the
celiac axis and right renal artery.
5. No free fluid within the peritoneal cavity or retroperitoneum
to suggest
hematoma.
6. Stable small uncomplicated ventral hernia.
7. Unchanged hepatic steatosis.
Brief Hospital Course:
75 yo F with afib/TIA on coumadin, systolic heart failure
(unknown EF), COPD on 3L NC, DM2, gastroparesis and gastritis
who was for planned biliary stent removal with course
complicated by cholangitis/sepsis.
1) Cholangitis/E coli sepsis: The patient was admitted for
scheduled stent removal and had stent and stone removal with
sphincterotomy prior to being admitted to the medical floor.
Soon after presenation to the medical procedure post procedure
developed hypotension requiring pressor support and was
transferred to the MICU. Presumed source of sepsis was her
biliary tree given interventions so she was empirically covered
with IV piperacillin-tazobactam. She improved with antibiotic
therapy and was weaned off pressors to be transferred back to
the medical floor on [**2110-3-7**]. When final blood cultures grew
two species of E coli both sensitive to ceftriaxone she was
transitioned to this [**Doctor Last Name 360**] as well as metronidazole to cover any
occult anerobes given source. She should continue her
antibiotics until [**2110-3-20**]. ID was consulted and agreed with
this duration of therapy. Discussion regarding removing her
port-a-cath was carried out between IV team, ID, and medicine
and given that this was not likely the source of her transient
bacteremia and gram negatives less likely to seed port immediate
removal was not pursued. ULTIMATELY HER PORT DOES SERVE AS A
POTENTIAL PORTAL OF INFECTION HOWEVER AND REMOVAL SHOULD BE
CONSIDERED ELECTIVELY AFTER SHE COMPLETES HER CURRENT COURSE OF
THERAPY.
2) Acute blood loss anemia: Patient had gastrointestinal blood
loss in the context of sphinctertomy and received three units of
pRBC's in the MICU with improvement of her hematocrit, which was
stable thereafter. Given no obvious large volume bleed CT scan
of abdomen was performed to rule out RP bleed and this was
negative.
3) Bacteriuria: Though initial urine culture was negative repeat
culture with small organism burden of E coli. ID and team felt
possibly due to hematogenous spread from bacteremia. Patient
does have an indwelling foley for chronic incontinence and
habitus, which could serve as a portal for infection. Risks and
benefits of indwelling foley should be continued with the
patient and her caretakers.
4) Dysphagia: Pt reported dysphagia in the AM notable of
accumulation of a "ball of spit" in the throat. Pt had ERCP and
passage of large scope for this procedure essentially rules out
significant peptic stricture (and none was seen). Video swallow
study showed no clear dysphagia and patient had no choking,
coughing, or worsened hypoxemia so no suggestion of aspiration.
Given this was mild and only occurred with breakfast further
work up was deferred. Pt was instructed to eat upright and to
sip - bite-sip. If this continues to be an issue barium swallow
should be considered.
5) OSA: Patient with known OSA and echo with pulmonary
hypertension. She has refused CPAP in past due to intolerance.
She offered to attempt to use again but was unable to tolerate
this in house and asked for it to be removed. She understands
this poses a risk of long term damage to her heart. This should
continue to be addressed with the patient.
6) Atrial fibrillation: She remained in slow afib throughout her
hospitalization. Coumadin and aspirin were held for 7 days post
sphincterotomy and should both be restarted on [**3-12**]. Her
digoxin was continued as was atenolol.
7) COPD, without exacerbation: Patient without signs of
worsening of baseline COPD, she was kept on her normal 2L O2 by
nasal cannula. She was continued on tiotroprium and
bronchodilators.
8 )Chronic diastolic CHF: Patient with EF of 55 but given
pulmonary hypertension high suspicion of some degree of
diastolic CHF. She was continued on atenolol and digoxin. Her
lasix was held in house but should be restarted at discharge.
She was not on ACEi but starting this was deferred given
complicated medical situation and lack of acute issues with her
dCHF.
9) Hypertension: Remained well controlled. She was continued on
amlodipine and atenolol.
10) Neuropathy/ Chronic lower extremity pain: She was continued
on her gabapentin and oxycodone.
11) Depression: She was continued on venlafaxine.
12) Gastritis/ GERD: She was continued on her home [**Hospital1 **]
pantoprazole
Code status was full throughout hospitalization. Her HCP is
[**Name (NI) **] [**Name (NI) 51307**] (sister) [**Telephone/Fax (1) 51308**].
Transitional Issues:
-She should have further conversations about risk and benefits
of removal of chronic foley and port a cath as these both
increase risks of infection.
-She should have PT to work on increasing functionality and
ability to ambulate independently
-She should complete here course of antibiotics for cholangitis.
Medications on Admission:
Albuterol inh prn
Amlodipine 2.5mg daily
Ascorbic acid 500mg daily
Atenolol 25mg daily
Digoxin 0.125mg daily
Duoneb qid prn
Lasix 60mg daily
Loperamide prn
Loratadine 10mg daily
MVI
Neurontin 100mg [**Hospital1 **]
Omeprazole 20mg [**Hospital1 **]
Oxybutynin ER 15mg daily
Phenazopyridine 200mg [**Hospital1 **]
Tiotropium daily
Coumadin 4mg daily
Venlafaxine 37.5mg daily
Colace 100mg [**Hospital1 **]
Mag oxide 400mg daily
Miralax 17gm daily
Senna q2 sYA
Tylenol 650mg q6h prn
Oxycodone 5mg q4h prn
Oxycodone 10mg qhs
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
wheeze.
3. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
4. gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
5. venlafaxine 37.5 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
6. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain: hold for sedation.
8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
13. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
14. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
15. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, flush with 10 mL Normal Saline followed by
Heparin as above per lumen.
16. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
17. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
18. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
19. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 8 days: Last day of therapy [**2110-3-20**]
.
20. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig:
Two (2) gm Intravenous Q24H (every 24 hours) for 8 days: Last
day of tehrapy is [**3-20**]
.
21. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
22. furosemide 20 mg Tablet Sig: Three (3) Tablet PO once a day.
23. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
24. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO once a
day.
25. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
26. multivitamin Tablet Sig: One (1) Tablet PO once a day.
27. oxybutynin chloride 15 mg Tablet Extended Rel 24 hr Sig: One
(1) Tablet Extended Rel 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 9188**] Care and Rehab
Discharge Diagnosis:
Gram negative bacteremia and septic shock from cholangitis
Chronic Obstructive Pulmonary Disease
Obesity
Chronic Systolic Heart Failure
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted for a severe infection related to an
obstruction of your biliary tree. You had a stone removed and a
stent replaced and improved. You are being discharged to
complete a course of antibiotics and your recovery.
Your medications have been changed. You have been started on
ceftriaxone and metronidazole to treat the bloodstream
infection. You will complete your course of these antibiotics
on [**3-20**].
Please take all other medications as prescribed.
Followup Instructions:
You should be scheduled to resume care with your usual providers
as an outpatient.
|
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,736
| 186,206
|
50406
|
Discharge summary
|
report
|
Admission Date: [**2172-1-28**] Discharge Date: [**2172-2-5**]
Date of Birth: [**2117-5-26**] Sex: M
Service: MEDICINE
Allergies:
Formaldehyde
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Vomiting blood
Major Surgical or Invasive Procedure:
Posterior [**Last Name (un) **]/oropharynx imaging by ENT
EGD
History of Present Illness:
54 y/o M PMH SCC of the tongue, PE on lovenox who presents with
hematemesis. Patient describes significant heartburn for the
past 2 days. Yesterday he began to vomit (6x total) described as
bilious with bright red blood streaks (no coffee grinds).
Patient finds it difficult to quantify - approximately tablesoon
per episode. Denies blood in the stool, black stool or diarrhea.
He denies associated chest pain, shortness of breath, abdominal
pain. Patient reports prior history of black stool and multiple
EGDs.
.
In the ED, initial vs were: T 98.8 P 102 BP 114/79 R 18 O2 sat.
98% RA. Vitals ranged BP 106-120/52-86, HR 90, RR18, 96% RA.
Patient given zofran, dilaudid, ativan, reglan.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills. Denies headache, sinus tenderness,
rhinorrhea or congestion. Denies cough, shortness of breath, or
wheezing. Denies chest pain, chest pressure, palpitations, or
weakness. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
SCC of tongue - recent CT chest/abd/pelvis was negative for
metastatic disease
- Weekly paclitaxel (30mg/m2), carboplatin (1.5 AUC) on
11.18-12.23.
- XRT: treated with radical chemoradiation, 6750 cGy, completed
on [**2171-11-17**]
.
Other Past Medical History:
PE admission [**Date range (1) 25865**]: large PE in LLL territory
GERD (proceeding SCC)
hiatal hernia
MI [**2165**] s/p 2 stents
atrial fibrillation
"vasculitis"
partial testicular removal (benign)
leg fracture
migraines
Guillain-[**Location (un) **] syndrome
Social History:
History of PVC glue inhalation in work requiring a prolonged
hospitalization and increased mucous secretions since.
- Tobacco: smoked 1PPD from [**2138**]-[**2146**]
- etOH: hx of etoh use, more recently [**1-8**] drinks 0-1x/week
Family History:
Father deceased of MI at age 68
Mother deceased of CHF at age 88, also had skin cancer unsure of
type
Maternal grandmother had liver cancer
Maternal grandfather had skin cancer, unsure of type
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: pale conjunctiva, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Micro: Blood culture sent
.
Images: CXR admission clear.
.
EKG: Normal axis. HR 94. No ST elevation or depression.
.
Peritent prior imaging:
PEG [**2171-10-16**]:
Normal esophagus.
Stomach: Normal stomach.
Duodenum: Normal duodenum.
.
CT head/neck with and without contrast & recon:
1. Submucosal hypervascularity and enhancement extending from
the base of the tongue to the supraglottic larynx is likely a
sequela of radiation therapy; however, no definite actively
bleeding arterial lesion is seen.
2. Concentric soft tissue thickening and narrowing of the
supraglottic larynx is likely also a radiation effect though
direct inspection can help confirm this. Limited evaluation of
the base of the tongue secondary to streak artifacts related to
dental hardware.
3. Unchanged left thyroid nodule.
.
Bilateral LENI: Negative for DVT
.
Chem 10
140 102 8 93 AGap=12
3.6 30 0.6
Ca: 9.4 Mg: 1.8 P: 3.9
.
CBC
3.7 > 12.0 < 192
34.9
N:79.8 L:12.1 M:6.0 E:1.8 Bas:0.3
.
[**Name (NI) 2591**]
PT: 13.1 PTT: 40.4 INR: 1.1
.
Labs on discharge:
[**2172-2-5**] 06:39AM BLOOD WBC-3.6* RBC-3.78* Hgb-11.8* Hct-34.2*
MCV-91 MCH-31.3 MCHC-34.6 RDW-13.3 Plt Ct-215
[**2172-2-5**] 06:39AM BLOOD Plt Ct-215
[**2172-2-5**] 12:27PM BLOOD PT-14.1* PTT-37.4* INR(PT)-1.2*
[**2172-2-5**] 06:39AM BLOOD Glucose-82 UreaN-9 Creat-0.7 Na-139 K-3.7
Cl-101 HCO3-30 AnGap-12
[**2172-2-5**] 06:39AM BLOOD Calcium-9.4 Phos-3.9 Mg-1.8
.
KUB [**1-30**]: IMPRESSION:
1. Appropriately positioned GJ tube.
2. Normal passage of contrast into the distal duodenum and
jejunum, which
appear normal.
3. Normal bowel gas pattern. No evidence of obstruction
4. Large amount of stool within the colon. Dense inferior loops
of small
bowel are likely old tube feedings.
.
CT abdomen/pelvis [**2172-2-1**]:
1. G-J tube in expected location with the tip at the
duodenojejunal junction. Oral contrast seen in the colon without
evidence of bowel obstruction or stricture. SMall bowel is
decompressed and without abnormality evident. If clinical
suspicion remains high for small bowel pathology, outpatient MR
enterography can be performed.
2. Simple renal cysts.
3. Unchanged small bladder diverticulum.
.
Video swallow eval:
Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple
consistencies of barium were administered. Barium passes freely
through the oropharynx and esophagus without evidence of
obstruction.
Mild to moderate oropharyngeal dysphagia is noted with reduced
tongue
movement, epiglottic deflection, pharyngeal contraction, and
narrow upper
esophageal sphincter relaxation. There is evidence of valleculae
residue often spilling to the poorly defined pyriform sinuses
resulting in penetration of thick liquids and aspiration of thin
liquids after the swallow and during follow-up swallows.
There was clearing of penetration and intermittently effective
in clearing aspiration after cough-swallow.
Brief Hospital Course:
54 y/o M PMH SCC of the tongue, PE on lovenox who presents with
hematemesis. Issues during this hospitalization divided by
problem below:
.
# Hematemesis: Concern for upper GI bleed versus oropharyngeal
bleed from squamous cancer. Patient remained hemodynamically
stable. Two large bore IVs were maintained, hematocrits were
checked every 6 hours, IV PPI and H2 blocker continued. Patient
underwent EGD with GI which showed: Some contact induced
bleeding was noted in the pharynx. The mucosa in the upper third
of esophagus was very friable with some amount of diffuse oozing
compatible with radiation-induced esophagitis. There was no
exudates suggestive of [**Female First Name (un) **]. Abnormal mucosa in the stomach.
ENT visualized patient's posterior [**Last Name (un) **]/oropharynx, however, and
initially found friable area near the vallecula. Upon
re-scoping, the area was improved and it was felt that the
mucosa friability was not consistent with radiation damage.
(Area may have been irritated by severe GERD --> emesis). It was
recommended by the ENT attending that patient be further
[**Last Name (un) 6349**] by GI for reflux control and other etiology for his
bleed. In the interim, neuro-IR had recommended a CTA for
possible embolization. CTA showed hypervascular region near
vallecula but no active bleed to intervene upon. Throughout
[**Hospital 228**] hospital course, his primary oncologist, Dr. [**Last Name (STitle) 2036**]
(and later, Dr. [**First Name (STitle) **], as per Dr.[**Name (NI) 13339**] secretary he went
on medical leave), and ENT physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 105042**] (who
was consulted and saw patient in-house) were updated. Patient
endorsed improved GERD control with IV PPI twice daily staggered
with IV H2 blocker. He was transferred to the floor on these
medications and had no further issues with vomiting. He was
discharged on lansoprazole (dissolving tab) and famotidine.
.
# Nausea and inability to tolerate TPN or PEG feedings: The
patient was continued on TPN in the MICU, and a PICC was placed
for better access, but upon arriving on the medical floor, had
constant complaints of a chemical taste in his mouth as well as
a strong burning sensation in his throat, which he said began
when TPN was initiated and only would stop when it was turned
off. Per discussions with Nutrition, the chemical/metallic taste
was possibly related to TPN, but they said it was extremely
unlikely that the burning sensation was related to TPN. Patient
was insistent that TPN was stopped, and refused it for >24
hours. Patient also endorsing history of fullness after
tubefeeds or getting meds via PEG tube. Given suspicion that PEG
(per reports, tip in jejunum) might have migrated leading to
feeds ending in stomach, a PEG/GJ study was done at the bedside
with gastrograffin contrast. This demonstrated the PEG to
terminate in the jejunum. After discussion with Dr. [**First Name (STitle) **],
Mr. [**Known lastname **] was started on very low-rate elemental formula
(Vivonex). GI was re-consulted and suggested contrast CT to
evaluate for obstruction. The patient was able to tolerate the
contrast per PEG and had the CT [**2-1**] am. This demonstrated no
obstruction. He was then started on Vivonex TEN tube feeds at 10
cc/hr. He was advanced to 35 by [**2-3**]. He tolerated this very
well, and his antiemetics were increased. He was seen by speech
and swallow, and they recommended a video swallow eval. This was
done on [**2-4**]. Mr. [**Known lastname **] was cleared at this time for
nectar-thickened liquids and pureed solids. ENT recommended that
he not take whole pills PO given the friable area, but did say
that liquids, soft foods such as purees, and crushed pills would
be safe for the patient. His medications were switched to PO or
dissolving tablet per availability and he was re-started on many
of his home meds on [**2-4**]. He was able to tolerate these and was
discharged home on this regimen with TF at 65/hr.
.
# PE: Initially lovenox was held for concern of acute bleed.
After discussion among services, the Lovenox was restarted at 80
mg [**Hospital1 **] per pharmacy recs. LENIs of his lower extremities were
negative for DVT.
.
# Squamous cell carcinoma of the tongue: Patient received IV
narcotics until [**2-4**], when he was re-started on his home narcotic
regimen.
.
# Atrial fibrillation: Regular rate on EKG on admission.
Remained in sinus rhythm during this hospitalization. Metoprolol
was held in the MICU given the recent bleed, but was re-started
after he was noted to be hemodynamically stable with no evidence
of further bleeding on the floor.
.
Medications on Admission:
Per recent discharge summary
1. TPN
cycle over 16 hours on [**1-12**] and 12 hours thereafter.
volume: 2400 ml/d; Amino Acid: 130 g/d; Branched chain AA: 0
Dextrose: 435 g/d; Fat: 50 g/d; trace elements added daily
standard adult MVI; NaCl: 180; NaAc: 0; MgSO4: 10; CaGluc: 9
2. 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.
3. Enoxaparin 100 mg/mL Syringe [**Month/Day (4) **]: Ninety (90) mg Subcutaneous
Q12H (every 12 hours).
4. Metoclopramide 10 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO QID (4
times a day) as needed for nausea.
5. Lorazepam 1 mg Tablet [**Month/Day (4) **]: 1-2 Tablets PO Q4H (every 4 hours)
as needed for nausea/anxiety.
6. Methadone 5 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO TID (3 times a
day) for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
7. Methadone 5 mg/5 mL Solution [**Month/Day (4) **]: Five (5) mL PO three times
a day for 30 days: do NOT release to patient before [**2172-1-16**].
Disp:*450 mL* Refills:*0*
8. Hydromorphone 4 mg Tablet [**Month/Day/Year **]: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain for 5 days.
Disp:*60 Tablet(s)* Refills:*0*
9. Dilaudid-5 1 mg/mL Liquid [**Month/Day/Year **]: [**3-12**] mL PO every four (4) hours
as needed for pain for 30 days: do NOT release to patient before
[**2172-1-16**].
Disp:*1440 mL* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*5*
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] twice a day.
12. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet,
Rapid Dissolve PO three times a day as needed for nausea.
Disp:*90 Tablet, Rapid Dissolve(s)* Refills:*5*
.
Allergies: Formaldehyde
Discharge Medications:
1. Enoxaparin 80 mg/0.8 mL Syringe [**Last Name (STitle) **]: One (1) injection
Subcutaneous Q12H (every 12 hours).
2. Famotidine 20 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
Disp:*60 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
4. Lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety, nausea.
Disp:*120 Tablet(s)* Refills:*1*
5. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Metoclopramide 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*120 Tablet(s)* Refills:*2*
7. Prochlorperazine Maleate 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO
Q6H (every 6 hours) as needed for nausea.
Disp:*150 Tablet(s)* Refills:*1*
8. Zolpidem 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
9. Hydromorphone 4 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
10. Ondansetron 4 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: [**12-7**] Tablet,
Rapid Dissolves PO every four (4) hours as needed for nausea.
11. Bisacodyl 5 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO once a day as
needed for constipation.
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 5065**] Healthcare
Discharge Diagnosis:
Gastric Reflux
Mucositis
Nausea
Vomiting
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were admitted for blood in your vomit. You had an area in
your mouth that was found to be a possible souce of bleeding.
You had an upper GI endoscopy with the gastroenterologists that
showed irritation of your stomach and esophagus but no ulcers.
They recommended using two different medications to decrease
acid production in your stomach. The ENT doctors [**Name5 (PTitle) 6349**] [**Name5 (PTitle) **]
and [**Name5 (PTitle) **] this irritated area at the back of your tongue that
was most likely the source of bleeding, probably caused by
continued irritation from vomiting that you had been having at
home as well as reflux of acid from your stomach.
.
You had significant problems with TPN while in the hospital.
First we made sure your PEG tube was in the right place and
working. We then did a CT scan that showed that you had no
obstruction in your bowels. We worked with nutrition to find a
tube feed that you could tolerate. This was started and you were
able to get to 65 cc/hr by the time of discharge. We gave you a
maximum amount of medications to help with nausea. You were
eventually able to tolerate these either by mouth as crushed
pills or dissolving pills or via your PEG. It is very important
to take your anti-nausea medications around the clock to prevent
nausea so that you can get the maximum dose of tube feeds.
.
We tried to keep as many of your home medications as possible.
We ADDED:
Lansoprazole (for stomach acid)
Famotidine (for stomach acid)
Bisacodyl (for constipation)
Ambien (Zolpidem), a medication for sleep
We CHANGED:
Decreased Lovenox dose to 80 mg twice daily.
Increased amount of Zofran
Stopped Methadone
.
You should continue to take your other medications as
prescribed.
.
You will need to establish care with a primary care doctor
(PCP). This person can help you coordinate some of your
complicated medical problems. Please consider asking your PCP
about repeating your cholesterol level check and if these are
high, starting medication to decrease your cholesterol levels.
Also consider asking your PCP or Dr. [**First Name (STitle) **] about perhaps
using a medication called Coumadin for long-term therapy for
your pulmonary embolism.
Followup Instructions:
We have arranged appointments with the nutritionists; please
call their office for further instructions regarding location.
DIETITIAN PROVIDER [**Name Initial (PRE) **]:[**Telephone/Fax (1) 3681**] Date/Time:[**2172-2-6**] 1:00
DIETITIAN PROVIDER [**Name Initial (PRE) **]:[**Telephone/Fax (1) 3681**] Date/Time:[**2172-3-5**] 2:00
.
You have an appointment with Dr. [**Last Name (STitle) **]:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], M.D. Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2172-2-26**] 1:00
.
You have an appointment with Dr. [**Last Name (STitle) 2036**] at [**Hospital3 **] on [**3-5**]
at 3:30 pm. If you end up needing to cancel this appointment,
please call the office at [**Telephone/Fax (1) 58714**].
.
Dr. [**First Name (STitle) **] will be able to see you within two weeks. You
should contact his office about setting up this appointment.
.
Unfortunately your primary care doctor has moved away; you will
need to establish a new primary care provider.
.
We were unable to reach Dr.[**Name (NI) 20390**] office to arrange
outpatient follow-up for you. His office phone number is
[**Telephone/Fax (1) 41**]; please call to arrange an appointment in [**1-8**] weeks
for hospital follow-up.
Completed by:[**2172-2-6**]
|
[
"V10.01",
"528.09",
"414.01",
"553.3",
"V45.82",
"V58.61",
"412",
"787.01",
"427.31",
"530.82",
"V12.51",
"V44.1",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"99.15",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
14112, 14173
|
5870, 10530
|
287, 350
|
14258, 14258
|
2903, 3932
|
16619, 17889
|
2213, 2407
|
12506, 14089
|
14194, 14237
|
10556, 12483
|
14406, 16596
|
2422, 2884
|
1086, 1399
|
233, 249
|
3951, 5847
|
378, 1067
|
14273, 14382
|
1683, 1946
|
1962, 2197
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,612
| 187,257
|
7683
|
Discharge summary
|
report
|
Admission Date: [**2164-7-11**] Discharge Date: [**2164-7-17**]
Date of Birth: [**2099-1-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
[**2164-7-11**] Mini-Maze/Pulmonary Vein Isolation with Ligation of Left
Atrial Appendage via bilateral Mini Thoracotomies.
History of Present Illness:
Mr. [**Known lastname 27941**] is a 65 year old male with paroxsymal atrial
fibrillation since [**2158**]. His current symptoms include
palpitations and slight dizziness. After extensive preoperative
evaluation, he was admitted for Mini Maze procedure.
Past Medical History:
Paroxysmal Atrial Fibrillation
Coronary Artery Disease, prior PCI/stenting [**2153**], [**2154**]
Elevated Triglycerides
Hyperhomocystenemia
Macular Degeneration
Left Knee Arthroscopy
Social History:
Retired. Quit tobacco in [**2139**]. Admits to social ETOH. Married.
Family History:
Father diagnosed with coronary disease at age 51.
Physical Exam:
Admission
Vitals: 105/63, 56, 97% room air
General: WDWN male in no acute distress
HEENT: Oropharynx benign, EOMI
Neck: Supple, no JVD. Carotids 2+ without bruits.
Lungs: CTA bilaterally
Heart: Regular rate and rhythm, normal s1s2, no murmur
Abdomen: Soft, nontender with normoactive bowel sounds
Ext: Warm, no edema
Pulses: 2+ distally
Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal
deficits noted
Discharge
VS T97 HR61 BP107/59 RR20 O2sat100%RA
Gen NAD
Neuro A&Ox3, nonfocal exam
CV RRR no murmur
Pulm CTA-bilat
Abdm soft, NT/ND/+BS
Ext warm, trace pedal edema bilat
Incision Bilat thoracotomy-CDI
Pertinent Results:
[**2164-7-11**] Intraop TEE: The left atrium is mildly dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium or left atrial appendage. No spontaneous echo
contrast is seen in the body of the right atrium or right atrial
appendage. No atrial septal defect or patent foramen ovale is
seen by 2D, color Doppler or saline contrast with maneuvers.
Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is low normal (LVEF
50-55%). The right ventricular cavity is mildly dilated with
normal free wall contractility. There are simple atheroma in the
descending thoracic aorta. There are three aortic valve
leaflets. The aortic valve leaflets are mildly thickened. There
is no aortic valve stenosis. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
[**2164-7-11**] 02:43PM GLUCOSE-96 LACTATE-0.9 NA+-138 K+-4.2 CL--103
[**2164-7-11**] 02:48PM PT-14.9* PTT-27.6 INR(PT)-1.3*
[**2164-7-11**] 02:48PM PLT COUNT-241
[**2164-7-11**] 02:48PM WBC-6.5 RBC-4.11* HGB-13.2* HCT-38.6* MCV-94
MCH-32.2* MCHC-34.2 RDW-13.8
[**2164-7-15**] 07:35AM BLOOD WBC-5.5 RBC-3.41* Hgb-11.5* Hct-31.1*
MCV-91 MCH-33.6* MCHC-36.8* RDW-14.2 Plt Ct-188
[**2164-7-16**] 05:44AM BLOOD PT-18.1* INR(PT)-1.7*
[**2164-7-17**] 05:10AM BLOOD Na-130* K-3.8
[**Known lastname **],[**Known firstname 7167**] [**Medical Record Number 27942**] M 65 [**2099-1-26**]
Radiology Report CHEST (PA & LAT) Study Date of [**2164-7-16**] 7:54 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2164-7-16**] SCHED
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 27943**]
Reason: f/u pneumothoraces
[**Hospital 93**] MEDICAL CONDITION:
65 year old man with s/p mini maze
REASON FOR THIS EXAMINATION: f/u pneumothoraces
Wet Read: ARHb MON [**2164-7-16**] 9:50 PM
Persistent tiny biapical pneumothoraces. Small right effusion.
Bibasilar
atelectasis, improved .
Preliminary Report !! WET READ !!
Persistent tiny biapical pneumothoraces. Small right effusion.
Bibasilar
atelectasis, improved .
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3904**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Wet read entered: MON [**2164-7-16**] 9:50 PM
Brief Hospital Course:
Mr. [**Known lastname 27941**] was admitted and underwent Mini-maze procedure by Dr.
[**Last Name (STitle) 914**]. For surgical details, please see seperate dictated
operative note. Following the operation, he was brought to the
CVICU for invasive monitoring. Within 24 hours, he awoke
neurologically intact and was extubated without incident. Beta
blockade, Amiodarone and Warfarin were resumed. He maintained
stable hemodynamics and transferred to the SDU on postoperative
day two. He was empirically started on a course of Indocin and
Colchicine to prevent percarditis. He remained in a normal sinus
rhythm for his entire postoperative course. Serial chest x-rays
were notable for tiny bilateral pneumothoraces. A repeat chest
Xray reveasled no change. He was also noted to be hyponatremic,
at that time he was started on a fluid restriction and his
sodium replaced. the hyponatremia resolved and he will have his
electrolytes checked by the visiting nurses on discharge. On
POD6 the patient was discharged home
.
Medications on Admission:
Warfarin, Aspirin 81 qd, Folate 2 qd, Niaspan ER [**2155**] qd,
Metoprolol 50 qd, Amiodarone 200 qd, B12, B6, Metamucil
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
3. Niacin 500 mg Capsule, Sustained Release Sig: Four (4)
Capsule, Sustained Release PO daily ().
Disp:*120 Capsule, Sustained Release(s)* Refills:*2*
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
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:*0*
6. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO every
twenty-four(24) hours: sun, mon, wed, thurs, fri, sat.
Disp:*60 Tablet(s)* Refills:*2*
7. Warfarin 2 mg Tablet Sig: Three (3) Tablet PO every tuesday.
Disp:*15 Tablet(s)* Refills:*2*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*1*
10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Folic Acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
12. Sodium Chloride 1 gram Tablet Sig: Two (2) Tablet PO TID (3
times a day) for 2 days.
Disp:*12 Tablet(s)* Refills:*0*
13. Indomethacin 50 mg Capsule Sig: One (1) Capsule PO three
times a day for 1 months.
Disp:*90 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 27944**] Health Care
Discharge Diagnosis:
Paroxysmal Atrial Fibrillation - s/p Mini Maze
Postoperative Pneumothoraces
Coronary Artery Disease
Elevated Triglycerides
Hyperhomocystenemia
Discharge Condition:
Good
Discharge Instructions:
1)Shower daily. Wash incisions with soap and water only. Please
avoid lotions, creams and ointments to incisions.
2)Please call if there is concern for wound infection. Office
can be reached at [**Telephone/Fax (1) 170**].
Followup Instructions:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**] in 2 weeks, call for appt
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 23097**] in [**12-25**] weeks, call for appt
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27945**] in [**12-25**] weeks, call for appt
Completed by:[**2164-7-17**]
|
[
"270.4",
"272.1",
"427.31",
"512.1",
"V45.82",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"37.26",
"37.33"
] |
icd9pcs
|
[
[
[]
]
] |
7075, 7138
|
4168, 5186
|
290, 416
|
7325, 7332
|
1710, 3516
|
7603, 7955
|
1007, 1058
|
5356, 7052
|
3556, 3591
|
7159, 7304
|
5212, 5333
|
7356, 7580
|
1073, 1691
|
238, 252
|
3623, 4145
|
444, 698
|
720, 905
|
921, 991
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,431
| 158,398
|
17298
|
Discharge summary
|
report
|
Admission Date: [**2143-12-4**] Discharge Date: [**2143-12-5**]
Service: CCU
HISTORY OF PRESENT ILLNESS: Patient is an 84-year-old female
with a history of coronary artery disease, referred by her
primary care physician for cardiac catheterization due to a
positive stress test obtained on [**2143-11-13**].
The patient had been admitted under CMI service and had
tolerated the cardiac catheterization well, however,
following cardiac catheterization, she developed hypotension
at which time, she was transferred to the CCU.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Congestive heart failure with an ejection fraction of 45%
on an echocardiogram from [**2143-11-6**].
3. Chronic obstructive pulmonary disease.
4. Arthritis.
5. History of cerebrovascular accident according to her
hospital record, but the patient denies any history of CVA.
6. GERD.
7. History of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear 10 cm in [**2143-5-2**]
requiring multiple transfusions.
8. Status post partial hysterectomy.
ALLERGIES:
1. Valium.
2. Ativan.
3. Protonix.
4. IV dye.
MEDICATIONS ON ADMISSION:
1. Lopressor.
2. Norvasc.
3. Furosemide.
4. Quinine.
5. Lipitor.
6. Lisinopril.
7. Amitriptyline.
8. Prevacid.
9. Aspirin.
10. Albuterol inhaler.
11. Nitro-Dur patch.
12. Plavix.
13. Vioxx.
14. Insulin.
SOCIAL HISTORY: Patient lives alone. The patient received
premedications for her dye allergy including Zantac,
prednisone, and Benadryl.
PHYSICAL EXAMINATION ON ADMISSION TO THE CCU: Notable for a
temperature of 95.5, heart rate of 80 on pacemaker, and a
blood pressure of 100/40 on dopamine drip. The patient is
confused and agitated. Her abdomen is distended and tender.
She has good lower extremity pulses bilaterally.
LABORATORIES: Notable for a creatinine of 0.3 and a
hematocrit of 28. INR is 2.6. PTT is 150.
HOSPITAL COURSE: The patient on admission underwent cardiac
catheterization. She was found to have a right coronary
artery, which was diffusely diseased. Her LAD showed 95%
stenosis which was stented. Her left circumflex did not
require stenting. Following cardiac catheterization, the
patient developed an episode of hypotension with a blood
pressure down to the 70s. Her heart rate did not change due
to the pacemaker. The patient received 1.5 mg of atropine,
which increased her blood pressure.
Her femoral sheath was pulled later in the day. She again
became hypotensive and there was high suspicion for
retroperitoneal bleed. A bedside echocardiogram was obtained
to rule out cardiac tamponade. There was no evidence of
pericardial effusion on bedside echocardiogram. Patient was
aggressively fluid resuscitated and was started on dopamine
drip for blood pressure support. At that time the patient
was agitated and somewhat confused.
The CCU team was called to admit her. The patient was taken
to CT for evaluation of a possible retroperitoneal bleed. CT
scan of the abdomen and pelvis showed a large retroperitoneal
bleed. The patient was transferred to the Trauma SICU to be
followed by the CCU team. The patient received multiple
blood products including 6 units of packed red blood cells, 6
units of FFP, and two apheresis units of platelets over the
next three hours.
A Vascular Surgery consult was obtained to evaluate for
possible surgical intervention. At that time, she had
palpable femoral pulses bilaterally as well as dorsalis pedis
and posterior tibial pulses. It was felt that the limbs were
not acutely threatened, and they recommended continued
medical management by quickly correcting her coagulopathy as
well as resuscitating with blood. Patient was able to be
briefly weaned off dopamine.
At 1:30 in the morning, however, the patient complained of
shortness of breath. She then began to vomit. At that time,
heart rate and blood pressure were stable, but then she
became unresponsive to verbal or noxious stimuli. Anesthesia
was called to intubated for respiratory distress. She soon
lost palpable pulses and a code was called. The patient was
coded for approximately 30 minutes before she was finally
pronounced at 1:59 a.m. in the morning.
The family was notified of the patient's death. Hematocrit
taken shortly before the code was 24 despite having received
6 units of packed red blood cells. Her abdomen over the
course of the night had greatly increased in size. It is
highly suspected that patient most likely went into cardiac
arrest due to continued massive retroperitoneal bleed.
DISCHARGE DIAGNOSIS: Cardiac arrest due to large
retroperitoneal bleed.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**Name8 (MD) 4993**]
MEDQUIST36
D: [**2143-12-5**] 02:40
T: [**2143-12-5**] 08:53
JOB#: [**Job Number 48427**]
|
[
"518.5",
"250.00",
"507.0",
"428.0",
"414.01",
"286.9",
"998.12",
"458.29",
"998.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"99.05",
"99.07",
"36.01",
"36.07",
"99.04",
"88.56",
"37.22",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
4558, 4842
|
1158, 1362
|
1907, 4536
|
116, 538
|
560, 1132
|
1379, 1889
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,606
| 125,237
|
18113
|
Discharge summary
|
report
|
Admission Date: [**2116-10-1**] Discharge Date: [**2116-10-9**]
Date of Birth: [**2069-2-26**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**Last Name (NamePattern1) 15344**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Bone Marrow biopsy
History of Present Illness:
47 F with multiple medical problems presented to [**Name (NI) **]
with RUQ abdominal pain, diarrhea x5 days. Pt had nausea and
vomitng 10 days ago. She presented with hypotension, fever and
bandemia. Admitted to ICU, IVF, [**Last Name (LF) **], [**First Name3 (LF) **] c/s. Due to multiple
medical problems and lack of U/S pt transferred to [**Hospital1 18**]
Past Medical History:
IDDM
Acute and Chronic renal failure
Polymyositis
Alopecia
GERD
Neuropathy w/ dysphagia
h/o B LE DVT
Hyperlipidemia
Depression
Chronic Diarrhea
Social History:
Quit smoking 13 years ago
Denies EtOH
Family History:
non contributory
Physical Exam:
On admission:
98.9 80 140/75 16 98% 2L NC
NAD, A&O
NC/AT, EOMI, PERRL, O/P clear
supple no LAD, no JVD
CTAB, w/o w/r/r
RRR w/o m/r/g
obese, ND, soft, minimally tender RUQ, neg murphys, no rebound
No CCE, 2+DP pulses
strength 5/5, sensation intact throughout
Pertinent Results:
[**2116-10-8**] 08:05AM BLOOD WBC-2.9* RBC-2.71* Hgb-8.7* Hct-25.7*
MCV-95 MCH-32.0 MCHC-33.7 RDW-19.4* Plt Ct-92*
[**2116-10-1**] 02:52AM BLOOD WBC-3.8* RBC-2.41*# Hgb-7.6*# Hct-23.1*#
MCV-96 MCH-31.7 MCHC-33.0 RDW-19.0* Plt Ct-112*
[**2116-10-7**] 03:41PM BLOOD Neuts-89* Bands-0 Lymphs-7* Monos-2 Eos-2
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2116-10-1**] 06:02PM BLOOD Neuts-76* Bands-15* Lymphs-6* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2116-10-7**] 03:41PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-1+ Tear Dr[**Last Name (STitle) **]1+
[**2116-10-8**] 08:05AM BLOOD Plt Smr-LOW Plt Ct-92*
[**2116-10-1**] 02:52AM BLOOD PT-41.6* PTT-57.1* INR(PT)-13.6
[**2116-10-7**] 03:41PM BLOOD Ret Aut-1.0*
[**2116-10-8**] 08:05AM BLOOD Glucose-174* UreaN-24* Creat-1.6* Na-138
K-4.3 Cl-109* HCO3-21* AnGap-12
[**2116-10-1**] 06:10AM BLOOD Glucose-130* UreaN-54* Creat-3.6* Na-134
K-5.2* Cl-103 HCO3-18* AnGap-18
[**2116-10-1**] 06:10AM BLOOD ALT-29 AST-85* AlkPhos-26* Amylase-32
TotBili-0.5
[**2116-10-1**] 02:52AM BLOOD ALT-31 AST-90* AlkPhos-27* Amylase-36
TotBili-0.6
[**2116-10-1**] 06:10AM BLOOD Lipase-22
[**2116-10-1**] 02:52AM BLOOD Lipase-24
[**2116-10-8**] 08:05AM BLOOD Calcium-8.0* Phos-2.3* Mg-1.7
[**2116-10-1**] 02:52AM BLOOD Calcium-6.9* Phos-4.3 Mg-1.9
MRI Abdomen ([**2116-10-4**]):
1. Widely patent celiac axis, SMA and [**Female First Name (un) 899**]. Patent SMV.
2. Limited evaluation of the colon shows wall thickening within
the cecum and ascending colon. Prior CT scan from [**Hospital 4068**]
Hospital shows evidence for pneumatosis in the ascending colon.
As discussed with Dr. [**Last Name (STitle) **], a CT scan will be evaluated to
further evaluate this finding.
3. Free fluid in the perihepatic space and pericolic gutters.
Ct Abd ([**2116-10-5**]):
1. Interval decrease in cecum and ascending colon wall
thickening.
2. Mesenteric soft tissue mass along the transverse colon.
3. Right pleural effusion.
4. Important ascites.
Brief Hospital Course:
Pt transferred to [**Hospital1 18**] on [**2116-10-1**] to SICU. NPO, IVF,
Levoflox, Vanc, Flagyl. INR found to be 15, pt was given Vit K
and one unit pRBC, next INR 8.4. Diarrhea and abdominal pain
resolved, hemodynamically stable. Stool O&P and c. diff
negative. Blood Cx on [**10-1**] negative. HD2 INR- 2.0. GI
consulted for acute colitis on chronic lymphocytic colitis.
Recs: labs, CT, hold on scoping [**1-15**] inflammation. Pt noted to
have decreasing WBC (2.8 on [**10-3**]). Hem/Onc consulted labs sent
and bone marrow biopsy taken [**10-8**]. Thought to be due to
methotrexate. Pt to follow up with Hematologist at [**Location (un) 620**].
HD5 pt transferred to surgical floor, Restarted on coumadin 2.5
QD. INR 2.0. On HD7 pt to have Hct of 21 and was transfused on
e unit pRBC. Pt's diet was advanced to regular and tolerated
well. Pt started on lasix 20mg PO QD for temporary diuresis
after discharge Pt discharged home in good condition with
extesive follow up for chronic medical problems.
Medications on Admission:
Lipitor 10 QD
Humalog mix 75/25- sliding scale QD
Humalog pen- Sliding scale [**Hospital1 **]
Epogen [**Numeric Identifier **] Qweek
Diphenoxylate 3-6 tabs per day
Zoloft 25 QD
Hydroxychloroquine 200 [**Hospital1 **]
Protonix 40 [**Hospital1 **]
Prednisone 8 QD
Methotrexate 7.5 q Monday, 5 q Thursday
Folic Acid 3 QD
Fosamax 70 qweek
Magnesium 400 QD
Tums 2 QD
Advair [**Hospital1 **]
Flonase QD
Discharge Medications:
1. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days.
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
3. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Lipitor 10 QD
Humalog mix 75/25- sliding scale QD
Humalog pen- Sliding scale [**Hospital1 **]
Epogen [**Numeric Identifier **] Qweek
Diphenoxylate 3-6 tabs per day
Zoloft 25 QD
Hydroxychloroquine 200 [**Hospital1 **]
Protonix 40 [**Hospital1 **]
Prednisone 8 QD
Folic Acid 3 QD
Fosamax 70 qweek
Magnesium 400 QD
Tums 2 QD
Advair [**Hospital1 **]
Flonase QD
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Inflammatory colitis
Pancytopenia
Acute renal failure
Discharge Condition:
Good
Discharge Instructions:
You may resume your regular activities and diet. Please resume
taking all home medications, except Methotrexate, and take all
new medications as directed.
You may take a shower, but do not take a bath for one week.
Please call your doctor go to the ER if you experience: fever
(>101.5), increasing abdominal pain, diarrhea, inability to eat,
or other symptoms concerning to you.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] within one week. Call
[**Telephone/Fax (1) 19980**] to make an appointment.
You are scheduled for a CT scan of your abdomen on Monday
[**10-27**] at 12:00. You are not to eat or drink for 3 hours
before the scan.
Follow up with Dr. [**Last Name (STitle) **] on Tuesday [**10-27**] at 2:15.
Please follow up with the Hematologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2539**].
Please call [**Telephone/Fax (1) 49151**] to make an appointment.
Please make an appointment with your Gastroenterologist to have
a colonoscopy as soon as possible.
|
[
"V58.65",
"250.41",
"V12.51",
"584.9",
"V58.67",
"585.3",
"710.4",
"276.51",
"369.4",
"284.8",
"790.92",
"558.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.07",
"41.31"
] |
icd9pcs
|
[
[
[]
]
] |
5372, 5430
|
3286, 4309
|
295, 316
|
5528, 5535
|
1267, 3263
|
5965, 6596
|
948, 966
|
4757, 5349
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5451, 5507
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4335, 4734
|
5559, 5942
|
981, 981
|
241, 257
|
344, 709
|
995, 1248
|
731, 876
|
892, 932
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,594
| 190,672
|
37111
|
Discharge summary
|
report
|
Admission Date: [**2190-12-12**] Discharge Date: [**2190-12-14**]
Date of Birth: [**2139-5-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
STEMI
Major Surgical or Invasive Procedure:
cardiac catheterization with drug eluting stent to left
circumflex artery
History of Present Illness:
This is a 51 yom with history of htn, hep C who presented today
with sudden onset of L chest pain associated with sob, sweating,
and radiation to the left neck and LUE.
This pain has been progressively becoming worse over the last 2
weeks. Initially it was exertional in nature but this afternoon
he noticed pain that occurred at rest. The pain is located in
his left side and radiated to his left arm/jaw. Pain was
constant for 2 hours prior to presentation, reported to be
[**2191-6-2**]. Ibuprofen did not relieve CP. Denies any recent injury,
or changes in vision, or change in gait, no n/v/f/c. He denies
palpitations, LH or changes in vision. Denies recent bleeding.
He intially presented to [**Hospital3 3583**] ED where initial vitals
were 98.2 77 20 187/104 100% on 2L. He received 2 peripheral
IVs, IVF bolus of 1L NS, morphine 8mg then 6mg x2, ASA 325,
nitro 0.4mg x3, ativan 0.5mg, nitropaste 1", heparin 4500 units
bolus, heparin gtt 1400u/hr, plavix 600mg PO, integrilin bolus
and gtt. Laboratory work up there showed: WBC of 11.6, Hct of
47.9, plt of 252, Na 137, k 3.9, co2 28, crt 1.0, CK 162, and
trop 1. Associated EKG showed NSR, no ectopy, STE in II, III,
AVF, V5, V6, STD and TWI AVR, AVL, V1, V2, no Q waves.
He was transfered at [**Hospital1 18**] where he underwent a uncomplicated
cardiac catheterization showing occlusion in circumflex with DES
placed. Post cath he is on ASA, clopidrogel and eptifibatide. He
is curretnly symptom free.
.
On review of systems, he denies chest pain, paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope or
presyncope any prior history of stroke, TIA, deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. He denies recent fevers, chills or rigors. S/he denies
exertional buttock or calf pain. All of the other review of
systems were negative.
Past Medical History:
HTN
hepatitis C
chronic pain in right knee
Social History:
-Tobacco history: quit smoking 2 yrs ago. MJ use.
-ETOH: denies
-Illicit drugs: MJ use on the day of presentation. No cocaine.
Family History:
Father with early onset CVD and CABG
Physical Exam:
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple without JVD.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. No groin strikethrough
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2190-12-12**] 11:43PM BLOOD CK-MB-330* MB Indx-12.3* cTropnT-11.67*
[**2190-12-13**] 05:16AM BLOOD CK-MB-226* MB Indx-11.7* cTropnT-7.07*
[**2190-12-14**] 07:15AM BLOOD CK-MB-24* MB Indx-4.8 cTropnT-2.96*
[**2190-12-13**] 05:16AM BLOOD Triglyc-152* HDL-25 CHOL/HD-6.8
LDLcalc-115
[**2190-12-12**] 11:43PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG
[**2190-12-12**] 11:43PM BLOOD %HbA1c-5.7
[**2190-12-12**] 11:43PM BLOOD TotProt-6.3* Albumin-4.1 Globuln-2.2
Calcium-8.5 Phos-4.3 Mg-2.0
[**2190-12-12**] 11:43PM BLOOD Glucose-101 UreaN-14 Creat-1.0 Na-139
K-4.3 Cl-105 HCO3-27 AnGap-11
[**2190-12-13**] 05:16AM BLOOD Glucose-109* UreaN-14 Creat-0.9 Na-137
K-4.3 Cl-103 HCO3-28 AnGap-10
[**2190-12-14**] 07:15AM BLOOD Glucose-95 UreaN-19 Creat-1.0 Na-138
K-4.2 Cl-101 HCO3-24 AnGap-17
[**2190-12-12**] 11:43PM BLOOD WBC-12.1* RBC-4.09* Hgb-12.6* Hct-35.7*
MCV-87 MCH-30.8 MCHC-35.3* RDW-13.8 Plt Ct-229
[**2190-12-13**] 05:16AM BLOOD WBC-14.8* RBC-4.42* Hgb-13.7* Hct-38.8*
MCV-88 MCH-30.9 MCHC-35.2* RDW-13.4 Plt Ct-239
[**2190-12-14**] 07:15AM BLOOD WBC-12.5* RBC-5.13 Hgb-15.6 Hct-44.7
MCV-87 MCH-30.4 MCHC-34.9 RDW-13.2 Plt Ct-268
Cardiac Cath Study Date of [**2190-12-12**]
1. Coronary angiography in this right dominant system revealed
single
vessel coronary artery disease. The LMCA had minor
irregularities. The
LAD had minor irregularities. The LCX had a thrombus, with
total
occlusion, in the distal portion just after the origin of the
OM1
branch. There was a 30-40% stenosis in the origin of the OM1
branch.
The RCA had a 50-60% stenosis in the proximal portion, and did
not
supply a large distribution of the myocardium.
2. Resting hemodynamics revealed normal blood pressure of
130/88.
3. Left ventriculography revealed very mild hypokinesis of the
posterior
segment of the heart, with a normal LVEF estimated at 55%.
There was no
evidence of mitral regurgitation.
4. Successful PTCA, manual aspiration thrombectomy, and
placement of a
3.5x18mm Endeavor stent were performed. Final angiography
showed normal
flow, no apparent dissection, and no residual stenosis. (See
PTCA
comments.)
5. The right common femoral arteriotomy was successfully closed
using a
6 Fr Angioseal STS device.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Normal ventricular function.
3. Placement of a drug-eluting stent in the distal LCX.
Portable TTE (Complete) Done [**2190-12-13**]
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. There is mild regional left ventricular systolic
dysfunction with inferior and lateral hypokinesis (LVEF= 45 %).
The remaining segments are dynamic. No masses or thrombi are
seen in the left ventricle. There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The ascending aorta is mildly dilated. The aortic arch
is mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
([**1-29**]+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
ECG Study Date of [**2190-12-13**]
Sinus rhythm. Low limb lead QRS voltage is non-specific. ST-T
wave changes raise the consideration of possible ischemia/injury
or possible early repolarization pattern. Clinical correlation
is suggested. Since the previous tracing of [**2190-12-12**] further
ST-T wave changes are present.
Brief Hospital Course:
In brief this is a 51 year old man with history of HTN, Hep C
low grade cirrhosis and chronic leg pain on ibuprofen who
presents with unstable angina over the last two weeks and found
to have STEMI in the circumflex territory with DES placed during
uncomplicated c. catheterization.
# STEMI: Patient first arrived to OSH with angina and was found
to have STEMI, he was transferred to [**Hospital1 18**] for emergent PCI with
revascularization using DES to his left circumflex. His cardiac
enzymes were falling after revascularization. He Has had some
mile chest soreness since cath, waxing and [**Doctor Last Name 688**] mostly. On
the day of discharge, he was chest pain free on ASA,
clopidrogel, BB, and ACE. HgA1C was wnl and lipid panel with
inc TG. Heart rate increased to ambulation and caffeine, which
resolved prior to his discharge.
.
# HTN: Controlled. goal BP<130, increased BB on the day of
discharge. He will followup with outpatient cardiologist for
his care.
.
# Hep C cirrhosis: Compensated clinically. He should not take
more than 2 grams of Tylenol in 24 hours. He was instructed to
follow up outpatient.
.
# Chronic leg pain: He was told to avoid NSAIDs while on
concurrent ASA for secondary prevention. He will start Tylenol
on an as needed bases and was told to not take more than 2 grams
of Tylenol in 24 hours. He was instructed to follow up with his
PCP.
Medications on Admission:
motrin 600mg [**Hospital1 **] (held)
omerprazole 40mg QD
mvi 1 tab QD
was on HCTZ till 2 monthes ago (stopped by PCP)
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
3. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest
pain/tightness: take 5 mintues apart for a total of 3 tablets,
if you still have chest pain, call 911.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day): Do not take more than twice daily.
7. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. Centrum Silver Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
ST Elevation Myocardial Infarction
Hypertention
Hepatitis C
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You had a heart attack and one stent was placed in your left
circumflex artery to fix a blockage. You will need to take new
medicines to keep the stent open and prevent another heart
attack.
You will need to avoid strenuous activity until after you see
your new cardiologist. A physical therapist has reviewed these
restrictions with you. The most important medicine you take is
the Plavix or clopodigrel. You must take this every day for at
least one year, do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking Plavix
unless Dr. [**Last Name (STitle) 3321**] tells you to. If you stop taking this, you
run the risk of the stent clotting off and having another heart
attack.
New Medicines:
1. Aspirin: take 325mg every day to prevent blood clots
2. Metoprolol: a beta blocker to slow your heart rate and help
your heart recover
3. Lisinopril: a medicine to lower your blood pressure
4. Simvastatin: a medicine to lower your cholesterol and help
your heart recover
5. Clopodigrel: a medicine to keep the stent open.
6. Stop taking Ibuprofen, this can harm your heart. You can take
1000mg of Tylenol twice daily for your knee pain. Do not take
more than twice daily because of your hepatitis.
7. Nitroglycerin: to take if you have chest pain again. Take 1
tablet under your tongue 5 minutes apart for a total of 3 [**Last Name (STitle) 4319**].
If you still have chest pain call 911. Please call your
cardiologist if you have any reoccurance of chest pain.
.
You have been set up with 2 new doctors, please keep all appts.
Followup Instructions:
Cardiology:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3321**], MD
[**Last Name (un) 34851**]
[**Location (un) 3320**], [**Numeric Identifier 34852**] Phone: ([**Telephone/Fax (1) 73315**] Ext.3822 Date/Time:
Tues [**1-4**] at 11:20am.
.
Primary Care:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3322**], MD
[**Doctor Last Name 83623**]
Suite # 102
[**Location (un) 3320**], [**Numeric Identifier 34852**] Phone: ([**Telephone/Fax (1) 45282**] Date/Time: office
will call you at home with an appt.
|
[
"305.20",
"V17.3",
"719.46",
"070.70",
"414.01",
"410.41",
"427.1",
"V15.82",
"571.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"88.53",
"00.40",
"00.66",
"99.20",
"00.45",
"88.56",
"36.07"
] |
icd9pcs
|
[
[
[]
]
] |
9882, 9888
|
7166, 8558
|
324, 400
|
9992, 9992
|
3470, 5684
|
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|
2582, 2620
|
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|
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|
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|
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|
10137, 11692
|
2635, 3451
|
278, 286
|
428, 2356
|
10006, 10113
|
2378, 2422
|
2438, 2566
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,807
| 198,511
|
44723
|
Discharge summary
|
report
|
Admission Date: [**2177-5-31**] Discharge Date: [**2177-7-9**]
Service: MEDICINE
Allergies:
Plavix
Attending:[**First Name3 (LF) 317**]
Chief Complaint:
Mental Status Changes
Major Surgical or Invasive Procedure:
Upper Endoscopy, Colonoscopy
History of Present Illness:
The pt is a 81M w/ h/o CAD s/p 3V CABG, multiple PCI to bypass
grafts, AS, CHF w/ EF 35%, AICD, Afib s/p ablation, CRI recently
discharged from [**Hospital1 18**] for CHF exacerbation who presented to an
OSH for mental status changes. Per his wife, since his discharge
he has been extremely weak, to the point where he has fallen to
the floor and required assistance to get back up. Twice the fire
department had to come to help with this. She has since hired a
male nursing aide to watch him while she is at work. He has been
intermittently irritable at home and more tired than usual,
having trouble sometimes staying awake during conversations. The
evening before admission he was agitated, repeatedly demanding
his wife get him scissors to cut off his pants that he felt were
constricting him. She took off his pants and tried to calm him
down enough to go to bed. She was awakened by police officers in
her house, as her husband had apparently called 911 saying
someone was trying to kill him. He was found with a large amount
of blood on the floor, apparently from a laceration on his left
foot. His wife later found an [**Name (NI) 95689**] knife by the bed. He was
brought to [**Hospital 5871**] Hospital where he denied CP and SOB. He was
subsequently transferred to [**Hospital1 18**] where he has gotten much of
his medical care.
Past Medical History:
- CAD: CABGx3 [**2156**] (SVG-OM, SVG-PDA, LIMA-LAD), last cath [**3-20**]
(LMCA 50% stenosis, LCX 80% stenosis, LAD total occlusion, RCA
occluded, SVG-PDA c patent stent, SVG-OM c two stents and 90%
occlusion in distal stent); had [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**]/balloon dilation
of SVG-OM lesion.
- Aortic stenosis: last ECHO [**3-20**] showing valve area 0.8 cm2,
mean gradient 26 mmHg s/p valvuloplasty x 2 (last [**3-20**])
- CHF EF 35% (ECHO [**3-20**]), cardiac index 1.8 by Fick
- Chronic MV pseudomonal endocarditis/abscess dx [**2174**] on chronic
cipro (ECHO [**3-20**] described mildly thickened MV leaflets,
moderate thickening of MV chordae and [**12-16**] + MR)
- s/p AICD placement [**2171**]
- Chronic renal insufficiency (~2.0)
- h/o a-fib was on coumadin, s/p ablation
- h/o thyroid CA s/p thyroidectomy & parathyroidectomy resulting
in post-op hypothyroidism & hypoparathyroidism
- Diabetes mellitus, type II
- h/o aspiration pneumonia
- h/o delirium
- Anemia on iron, neg colonoscopy [**10-16**]
- h/o diverticulosis h/o LGIB
- h/o TIA [**2156**]
- OA of spine s/p laminectomy [**2170**]
- basal cell CA of nose
- C.diff [**4-18**]
- h/o recurrent epistaxis
- overflow incontinence/BPH
Social History:
Extensive TOB hx, started smoking as a child and quit 25 yrs
ago. Denies ETOH, OTC drugs.
Family History:
No early history of MI.
Physical Exam:
VS: 96.5, 122/74, 60, 18, 100% 2L
Gen: awake, responsive to verbal commands, elderly man lying
comfortably in bed in NAD
HEENT: left lower lid droop, anicteric, EOMI, MM dry, OP clear
Lungs: diffuse crackles bilaterally ~[**12-16**]-way up
CV: RRR, nl S1S2, III/VI HSM at RUSB
ABD - +BS, S/NT, distended
EXT - 1+ pitting [**Location (un) **] b/l, no c/c
NEURO - AAO to self, place
Pertinent Results:
CXR [**5-31**] in ED: Mild congestive heart failure with unchanged
size of left pleural effusion. Left lower lobe opacity may
represent atelectasis versus consolidation, but is unchanged
since the prior exam
.
EKG: AV paced, no change from prior.
.
PERTINENT ADMIT LABS (SEE OMR FOR FULL LIST)
[**2177-5-31**] 07:50AM BLOOD WBC-6.0 RBC-2.89* Hgb-9.0* Hct-27.1*
MCV-94 MCH-31.1 MCHC-33.2 RDW-18.1* Plt Ct-195
[**2177-5-31**] 07:50AM BLOOD Neuts-79.7* Lymphs-11.1* Monos-4.9
Eos-3.9 Baso-0.4
[**2177-5-31**] 07:50AM BLOOD Anisocy-1+ Macrocy-1+
[**2177-5-31**] 07:50AM BLOOD Plt Ct-195
[**2177-5-31**] 07:50AM BLOOD Glucose-100 UreaN-42* Creat-2.7* Na-145
K-4.3 Cl-103 HCO3-34* AnGap-12
[**2177-5-31**] 07:50AM BLOOD CK(CPK)-107
.
THYROID STUDIES
[**2177-7-2**] 06:30AM BLOOD TSH-21*
[**2177-7-2**] 06:30AM BLOOD T4-4.7 Free T4-0.8*
[**2177-5-31**] 02:47PM BLOOD TSH-45*
[**2177-5-31**] 02:47PM BLOOD Free T4-0.5*
.
VANCO LEVEL
[**2177-7-8**] 07:56PM BLOOD Vanco-22.8*
[**2177-7-8**] 05:06AM BLOOD Vanco-25.7*
.
DISCHARGE LABS
[**2177-7-9**] 05:08AM BLOOD WBC-8.0 RBC-3.68* Hgb-11.2* Hct-33.4*
MCV-91 MCH-30.3 MCHC-33.4 RDW-16.3* Plt Ct-347
[**2177-7-9**] 05:08AM BLOOD Plt Ct-347
[**2177-7-7**] 11:52AM BLOOD PT-14.8* PTT-35.7* INR(PT)-1.3*
[**2177-7-9**] 05:08AM BLOOD Glucose-116* UreaN-43* Creat-2.3* Na-140
K-3.6 Cl-103 HCO3-26 AnGap-15
[**2177-7-9**] 05:08AM BLOOD Calcium-7.0* Phos-4.1 Mg-2.2
.
COLONOSCOPY - Internal hemorrhoids, non bleeding diverticuli.
EGD - gastritis, erosions in duodenum
.
[**7-3**] echo - [**Location (un) 109**] 0.6 peak gradient 60, mean gradient 38
.
MICRO -
BCTX [**7-1**] [**7-22**] ctx + MRSA, cath tip ctx + MRSA.
BCTX [**7-4**] pending
Brief Hospital Course:
81M w/ h/o CAD, AS, CHF w/ EF 35%, AICD, Afib s/p ablation, CRI
recently discharged from [**Hospital1 18**] for CHF exacerbation who presents
with mental status changes
* Mental Status changes - the differential diagnosis of this
included hypothyroidism, medications (rozerem, seroquel
possible), infection, worsening aortic stenosis, baseline
dementia. Endocrine consulted and felt that coadministration of
thyroid hormone with iron/calcium replacement likely limiting
absorption; switched timing of med administration and increased
dose of thyroxine as per endocrine recs. Indeed, TSH was as
elevated as 52. Pt required two days of 300mcg levothyroxine
challenge as there initially seemed to be no change in FT4 or
Total T4 levels.
However, pt was ultimately noted to have steadily increasing
total T4 levels and was changed to a high dose of levothyroxine
175mcg. Target levels are T4 >6 and FT>1.0
In addition, mental status altering meds were also discontinued.
Pt mental status improved and had fewer episodes of
sun-downing. Culture data unrevealing for infection. Checked
B12, folate, RPR - all unrevealing for reversible causes.
In summary, given chronic nature of poor mental status and
difficulty with memory, it was felt that pt likely had chronic
progressive dementia with an element of psychosis further
exacerbated by delirium in the setting of hypothyroidism as well
as sundowning.
On discharge, his mental status was much improved and he was
significantly less delirious in the evenings.
* CHF - Initially treated with home PO lasix dose and
intermittent IV doses; pt. did well with weight at 81 kg. On
presentation had no orthopnea but had low O2 requirement (2 L).
Ultimately was transitioned to a daily dose of PO Bumetanide
with good effect. Per attending, pt was intermittently
transfused with packed red cells and required 40mg IV lasix to
remain euvolemic.
It should be noted, however, that pt did have fairly severe
abdominal distention which was thought to be due to ascites and
bowel edema as a result of right sided failure. This was felt
in part to be worsened by hypothyroidism.
He was discharged on his home dose of 40 lasix PO bid; this
regimen should be addressed with him as an outpatient.
* Inguinal Hernia - Midway into the [**Hospital 228**] hospital course,
he was noted to have a large right inguinal hernia as well as a
scrotal hematoma. As this was exquisitely tender, a stat u/s
was performed which revealed herniation of bowel, ascitic fluid,
but no torsion or limitation of vascular flow. General surgery
consultants recommended no reduction at this time as 1) pt was
poor sgy candidate and 2) it was unclear how long the hernia had
been in place although it did not appear incarcerated as the pt
had no obstructive symptoms. It was felt that the hernia could
probably be safely reduced once ascitic fluid pressure and edema
improved with resolving heart failure. Lactic acid was not
elevated.
* Severe aortic stenosis - Pt has undergone multiple
valvuloplasties in the past, however, while this may have
contributed to mild CHF on presentation, the issue was fairly
stable during this admission and did not require intervention.
Repeat echocardiogram revealed an aortic valve area of 0.6cm2.
* CAD - continued [**Hospital **], [**Hospital 8213**], BB, statin; forms faxed to
[**State **] for approval to use covered stent for
pseudoaneurysm (SVG-OM between two stents) noted on cath earlier
this month. No response has been received.
* MRSA Bacteremia: pt found to have infected R. subclavian line
with 4/4 blood cultures (+) for MRSA. He was transferred to the
CCU and treated under the sepsis protocol (he did not require
intubation). He was started on Vancomycin & also received 1
dose of gentamycin as well as piperacillin tazobactam. He
showed significant improvement after initiation of anti-biotics.
Echo did not reveal any evidence of endo-carditis. He was
transferred back to floor after two days with plan for 6wk
course of vanco via a PICC placed after clear blood cultures
>48hours. He needs to be on vanco for 5 more weeks.
* GIB - pt experienced a HCT drop on transfer out of the CCU.
This was accompanied by melena. EGD showed gastritis and non
bleeding duodenal ulcers. He underwent a difficult colonoscopy
prep and colonoscopy showing diverticuli and internal
hemorrhoids. Received several units pRBC but bleeding stopped
spontaneously and on d/c pt c stable HCT, stable hemodynamics.
* Goals of care - This was discussed with the patient's wife,
his health care proxy, who felt that patient should not be
resuscitated or intubated, however, attending discussed with
patient who wished to be full code. Goals of care should be
further discussed with patient and patient's wife given improved
mental status.
Medications on Admission:
1. Quetiapine 25 mg [**State 8426**] Sig: One (1) [**State 8426**] PO QHS (once a
day (at bedtime))
2. Ticlopidine 250 mg [**State 8426**] Sig: One (1) [**State 8426**] PO BID (2 times
a day).
3. Atorvastatin 10 mg [**State 8426**] Sig: One (1) [**State 8426**] PO DAILY
(Daily).
4. Aspirin 325 mg [**State 8426**], Delayed Release (E.C.) Sig: One (1)
[**State 8426**], Delayed Release (E.C.) PO DAILY (Daily).
5. Folic Acid 1 mg [**State 8426**] Sig: One (1) [**State 8426**] PO DAILY (Daily).
6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
7. Pantoprazole 40 mg [**State 8426**], Delayed Release (E.C.) Sig: One
(1) [**State 8426**], Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
9. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Pyridoxine 50 mg [**State 8426**] Sig: One (1) [**State 8426**] PO DAILY
(Daily).
11. Cyanocobalamin 1,000 mcg [**State 8426**] Sig: One (1) [**State 8426**] PO once
a day.
12. Calcium Carbonate 500 mg [**State 8426**], Chewable Sig: One (1)
[**State 8426**], Chewable PO TID (3 times a day).
13. Ferrous Sulfate 325 (65) mg [**State 8426**] Sig: One (1) [**State 8426**] PO
DAILY (Daily).
14. Ciprofloxacin 250 mg [**State 8426**] Sig: One (1) [**State 8426**] PO Q12H
(every 12 hours).
15. Rozerem 8 mg [**State 8426**] Sig: One (1) [**State 8426**] PO qhs ().
16. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO daily ().
17. Lisinopril 5 mg [**State 8426**] Sig: One (1) [**State 8426**] PO DAILY (Daily).
18. Metoprolol Tartrate 25 mg [**State 8426**] Sig: 0.5 [**State 8426**] PO TID (3
times a day).
Disp:*90 [**State 8426**](s)* Refills:*2*
19. Levothyroxine 100 mcg [**State 8426**] Sig: One (1) [**State 8426**] PO DAILY
(Daily).
Disp:*30 [**State 8426**](s)* Refills:*2*
20. Furosemide 40 mg [**State 8426**] Sig: One (1) [**State 8426**] PO BID (2 times
a day).
Disp:*80 [**State 8426**](s)* Refills:*2*
Discharge Medications:
1. Vancomycin 1,000 mg Recon Soln Sig: One (1) g Intravenous
once a day for 5 weeks.
Disp:*35 vials* Refills:*0*
2. PICC line
PICC line care as per usual protocol
3. Outpatient Lab Work
Check vancomycin level qMonday * 5 weeks and fax results to
[**First Name8 (NamePattern2) **] [**Doctor Last Name **] office
phone number: ([**Telephone/Fax (1) 11230**]
4. Compazine 5 mg [**Telephone/Fax (1) 8426**] Sig: One (1) [**Telephone/Fax (1) 8426**] PO every six (6)
hours as needed for nausea.
Disp:*30 [**Telephone/Fax (1) 8426**](s)* Refills:*0*
5. Atorvastatin 10 mg [**Telephone/Fax (1) 8426**] Sig: One (1) [**Telephone/Fax (1) 8426**] PO DAILY
(Daily).
Disp:*30 [**Telephone/Fax (1) 8426**](s)* Refills:*0*
6. Ciprofloxacin 250 mg [**Telephone/Fax (1) 8426**] Sig: One (1) [**Telephone/Fax (1) 8426**] PO Q12H
(every 12 hours).
Disp:*60 [**Telephone/Fax (1) 8426**](s)* Refills:*0*
7. Cyanocobalamin 500 mcg [**Telephone/Fax (1) 8426**] Sig: Two (2) [**Telephone/Fax (1) 8426**] PO DAILY
(Daily).
Disp:*60 [**Telephone/Fax (1) 8426**](s)* Refills:*0*
8. Ferrous Sulfate 325 (65) mg [**Telephone/Fax (1) 8426**] Sig: One (1) [**Telephone/Fax (1) 8426**] PO
DAILY (Daily).
Disp:*30 [**Telephone/Fax (1) 8426**](s)* Refills:*0*
9. Folic Acid 1 mg [**Telephone/Fax (1) 8426**] Sig: One (1) [**Telephone/Fax (1) 8426**] PO DAILY (Daily).
Disp:*30 [**Telephone/Fax (1) 8426**](s)* Refills:*0*
10. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
11. Pyridoxine 50 mg [**Telephone/Fax (1) 8426**] Sig: Two (2) [**Telephone/Fax (1) 8426**] PO DAILY
(Daily).
Disp:*60 [**Telephone/Fax (1) 8426**](s)* Refills:*0*
12. Acetaminophen 325 mg [**Telephone/Fax (1) 8426**] Sig: One (1) [**Telephone/Fax (1) 8426**] PO Q4-6H
(every 4 to 6 hours) as needed.
13. Ticlopidine 250 mg [**Telephone/Fax (1) 8426**] Sig: One (1) [**Telephone/Fax (1) 8426**] PO BID (2
times a day).
Disp:*60 [**Telephone/Fax (1) 8426**](s)* Refills:*0*
14. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
15. Aspirin 325 mg [**Telephone/Fax (1) 8426**], Delayed Release (E.C.) Sig: One (1)
[**Telephone/Fax (1) 8426**], Delayed Release (E.C.) PO DAILY (Daily).
16. Trazodone 50 mg [**Telephone/Fax (1) 8426**] Sig: One (1) [**Telephone/Fax (1) 8426**] PO HS (at
bedtime).
Disp:*30 [**Telephone/Fax (1) 8426**](s)* Refills:*0*
17. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO daily ().
18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
19. Senna 8.6 mg [**Telephone/Fax (1) 8426**] Sig: One (1) [**Telephone/Fax (1) 8426**] PO BID (2 times a
day) as needed.
20. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
21. Levothyroxine 175 mcg [**Telephone/Fax (1) 8426**] Sig: One (1) [**Telephone/Fax (1) 8426**] PO DAILY
(Daily): give in morning and separate from other medications.
Disp:*30 [**Telephone/Fax (1) 8426**](s)* Refills:*0*
22. Calcium Carbonate 500 mg [**Telephone/Fax (1) 8426**], Chewable Sig: Two (2)
[**Telephone/Fax (1) 8426**], Chewable PO QAM (once a day (in the morning)).
Disp:*100 [**Telephone/Fax (1) 8426**], Chewable(s)* Refills:*0*
23. Calcium Carbonate 500 mg [**Telephone/Fax (1) 8426**], Chewable Sig: Two (2)
[**Telephone/Fax (1) 8426**], Chewable PO LUNCH (Lunch).
24. Calcium Carbonate 500 mg [**Telephone/Fax (1) 8426**], Chewable Sig: One (1)
[**Telephone/Fax (1) 8426**], Chewable PO DINNER (Dinner).
25. Sucralfate 1 g [**Telephone/Fax (1) 8426**] Sig: One (1) [**Telephone/Fax (1) 8426**] PO QID (4 times a
day): do not give two hours within levothyroxine.
Disp:*120 [**Telephone/Fax (1) 8426**](s)* Refills:*0*
26. Metoprolol Tartrate 25 mg [**Telephone/Fax (1) 8426**] Sig: 0.5 [**Telephone/Fax (1) 8426**] PO BID (2
times a day).
Disp:*30 [**Telephone/Fax (1) 8426**](s)* Refills:*0*
27. Pantoprazole 40 mg [**Telephone/Fax (1) 8426**], Delayed Release (E.C.) Sig: One
(1) [**Telephone/Fax (1) 8426**], Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 [**Telephone/Fax (1) 8426**], Delayed Release (E.C.)(s)* Refills:*0*
28. Outpatient Lab Work
please check free t4 and tsh 1 week following discharge and fax
results to pt's endocrinologist; number is on page 1
29. Lasix 40 mg [**Telephone/Fax (1) 8426**] Sig: One (1) [**Telephone/Fax (1) 8426**] PO twice a day:
discuss dose with PCP in follow up.
Disp:*60 [**Telephone/Fax (1) 8426**](s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Company **]
Discharge Diagnosis:
Congestive Heart Failure
Hypothyroidism
Severe Aortic Stenosis
Coronary artery disease
Chronic renal insufficiency
Dementia
Delirium
Discharge Condition:
Fair - renal failure, severe aortic stenosis and stable
congestive heart failure
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5L
Continue to take your medications as directed.
.
You should take all your medications as directed. You should
call Dr.[**Name (NI) 9920**] office to arrange follow up in a week. If you
have worsening chest pain, shortness of breath, nausea,
vomiting, dizziness, light headedness, or other concerning
symptom, call Dr. [**Last Name (STitle) **] or your PCP [**Name Initial (PRE) **]/or come to the ER.
Followup Instructions:
Please check free T4, Total T4, TSH one month following
discharge with your PCP or Dr. [**Last Name (STitle) **].
.
Call Dr. [**Last Name (STitle) **] tomorrow to arrange appropriate follow up.
|
[
"294.8",
"585.9",
"041.7",
"V45.81",
"V58.61",
"584.9",
"V45.82",
"280.0",
"535.50",
"789.5",
"293.0",
"V10.87",
"550.90",
"427.31",
"424.1",
"562.10",
"421.0",
"038.11",
"250.00",
"244.1",
"428.0",
"531.90",
"996.62",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"45.13",
"99.04",
"45.23",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
16428, 16473
|
5158, 9969
|
234, 264
|
16650, 16733
|
3461, 5135
|
17309, 17506
|
3020, 3045
|
11984, 16405
|
16494, 16629
|
9995, 11961
|
16757, 17286
|
3060, 3442
|
173, 196
|
292, 1634
|
1657, 2896
|
2912, 3004
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,599
| 118,961
|
2458
|
Discharge summary
|
report
|
Admission Date: [**2155-8-29**] Discharge Date: [**2155-9-17**]
Date of Birth: [**2108-9-6**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Methadone / Codeine / Demerol / Oxycontin / Fentanyl / Dilaudid
/ Darvocet-N 100 / Oxycodone
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest heaviness; transfer from OSH for cath
Major Surgical or Invasive Procedure:
[**9-6**] PICC placement
[**9-11**] CABGx1 (SVG-RCA)
History of Present Illness:
46yo F with h/o atypical CP, and chest heaviness, COPD and
recent diagnosis of "anomalous coronary artery" transferred from
OSH for further evaluation and management of her chest pain in
the setting of this anomalous vessel. She reports that over the
past 1-2 months, she has developed progressively worsening chest
pressure (not described as pain, but rather describes as
sensation of "someone sitting on chest" and "suffocating") to
the point that it is constantly present. She notes worsening of
the pressure intermittently (every few days) at which time she
develops chest pain that radiates to her left arm. She does not
note that this happens at any particular time and reports it
seems "random" and can occur both at rest or with exertion. She
does, however, notice it more at night when she is lying flat.
She states that the exacerbations (when heaviness becomes pain)
are freq. associated with shortness of breath, nausea and
diaphoresis. The chest pain episodes are often self limited,
but she reports that she developed anterior, substernal chest
pressure today with pain in the left shoulder assoc. w/ the
above symptoms today while at rest. The symptoms did not
resolve on their own and, thus, she presented to [**Hospital3 **] ED.
.
Of note, she was cathed recently at [**Hospital3 **] that did not
show flow-limiting coronary artery disease but did reveal
anomalous takeoff of one of the coronaries (? RCA). A CTA
performed in NH reportedly confirms this). She was supposed to
have been cathed by Dr. [**Last Name (STitle) 11255**] on Tuesday, but this did not
happen for unclear reason.
.
In the ED at [**Hospital3 **], initial vitals revealed T 97.6 BP
115/72 P 90 R 18 O2sat 98%RA. EKG revealed NSR at rate of [**Street Address(2) 12592**] depression in V3-V6 as well as II, III, and aVF
(reportedly during CP). She received IV morphine 4mg x2, NTP
which improved her CP to her baseline "heaviness", and later
reglan for "indigestion". CXR was performed which was normal
per OSH report. BNP was sent which was 33 where normal range is
5-100. CEs were reportedly negative, but I do not see the
actual results in her tx paperwork.
Past Medical History:
# Atypical chest pain/heaviness
# Shingles; reportedly anterior chest (crossed midline), b/l
upper extremities and upper back for which she was treated w/
valtrex in [**6-5**]
# COPD (appears to be clinical diagnosis per pt, no PFTs in our
system)
# Migraines
# Low vit. D
# Benign tumor compressing right carotid s/p removal in [**2152**]
# s/p C-spine fusion?
# s/p inguinal hernia repair
# s/p TAH/BSO for abnormal vaginal bleeding
# Thyroid nodule s/p surgical removal not on supplementation
Social History:
Lives alone at home. Has 7 children, all live locally. Recent
"messy" divorce in [**2155-5-30**]. +tobacco 0.5-1ppd x31yrs, had
cut down to 1/2 ppd last month, but has increased smoking w/
increased stress over past month. No EtOH nor other illicits,
no h/o IVDU.
Family History:
Father died at 77 of lymphoma, did have h/o CAD (unsure when
diagnosed), Mother with h/o "angina" and is still living, "most
family" including both parents and siblings w/ HTN, no DM in
parents nor siblings.
Physical Exam:
PE: 98.7 70 14 96%RA 94/64 (pt. reports BL BP is "very low")
Gen: NAD, pleasant, thin female, speaking full sentences,
comfortable
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, dry MM
Neck: No JVD apprec., supple
CV: RRR, no mrg apprec.
Resp: Diffuse expiratory wheezes, no rhonchi, fine crackles at
left lung base
Abd: +BS, vertical incision inferior to umbilicus w/ small soft
tissue prominence just left lateral of incision (? weakening of
abdominal wall although no distinct hernia), mildly TTP over
this.
Ext: Strong DP and PT pulses b/l, no edema, feet warm and well
perfused
Neuro: Alert and oriented x3, appropriate
Skin: No rashes. Well healed right groin incision from [**Month (only) 205**]
cath.
Pertinent Results:
[**2155-9-17**] 09:00AM BLOOD WBC-6.3 RBC-3.59* Hgb-11.0* Hct-32.5*
MCV-91 MCH-30.7 MCHC-33.9 RDW-17.2* Plt Ct-458*
[**2155-9-16**] 02:14AM BLOOD WBC-6.6 Hct-27.0*
[**2155-9-17**] 09:00AM BLOOD Plt Ct-458*
[**2155-9-17**] 09:00AM BLOOD Glucose-144* UreaN-4* Creat-0.7 Na-141
K-3.5 Cl-100 HCO3-33* AnGap-12
CHEST (PA & LAT) [**2155-9-15**] 4:06 PM
Cardiomediastinal contours are stable in the postoperative
period but cardiac contour has widened since preoperative CXR.
Bibasilar opacities show interval improvement. Small pleural
effusions, left greater than right, appear unchanged. Left PICC
line remains in standard position.
IMPRESSION:
1. Improving bibasilar opacities, likely atelectasis. Persistent
small pleural effusions, left greater than right.
2. Postoperative enlargement of cardiac silhouette, likely due
to pericardial effusion given change in size and contour since
the preoperative radiograph.
Brief Hospital Course:
Per report confirmed with Dr. [**Last Name (STitle) **] who reviewed her scans,
the patient had clean coronaries on a [**2155-6-29**] catheterization
but was found to have an anomalous right coronary artery that
courses between the aorta and pulmonary artery, which could
contribute to her chest pain syndrome. She had a set of negative
cardiac enzymes here. Imdur was continued. She was started on
low-dose metoprolol, and measures were taken to limit extra
oxygen demand, including controlling her chronic pain and
advising her to limit her physical activity. Her anomalous RCA
was confirmed by MRI. CT surgery was consulted.
On the night of [**9-2**] her R antecubital IV was found to be
erythematous and painful, with a palpable cord noted.
Superficial thrombophlebitis was confirmed via ultrasound.
Shortly thereafter she spiked a fever to 104. In this context
she was mildly delirious. She was initially given acyclovir,
vanco, and cetriaxone. However, once her fever resolved her
mentation returned to baseline. However, her blood cultures
grew [**4-2**] MSSA. Her vanco was switched to nafcillin. She
defervesced and remained stable thereafter. TTE demonstrated
normal wall motion and no vegetations. A right PICC was placed
on [**9-6**]. Follow up cultures were negative.
She was taken to the operating room on [**9-11**] where she underwent
a CABG x 1 with Dr. [**Last Name (STitle) **]. She was transferred to the ICU in
critical but stable condition on propofol and phenylephrine
drips.Extubated that evening and transferred to the floor on POD
#1. Hct decreased to 19 on POD #2 and abd CT negative for bleed.
As she was hypotensive, she was transferred back to the CVICU
for closer monitoring. Transferred back to the floor on POD #4
and chest tubes and pacing wires removed without incident.Social
work and chronic pain services were consulted. Pancultured for
fever on POD #5 and PICC removed on POD #6. Made good progress
and cleared for discharge to home with services on POD #6. Pt.
is to make all followup appts. as per discharge instructions.
Medications on Admission:
Soma 350mg q4h prn
Xanax 1 mg qid prn (just changed to ativan 1mg qhs prn 2 days
ago)
Fiorcet 1-2 tabs q4-6h prn migraine
Imdur 30mg PO daily
Combivent inhaler
Advair 1 puff [**Hospital1 **]
Ambien prn for sleep (pt. reports doesn't work so she's not
taking)
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*30 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
6. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): 300 mg [**Hospital1 **] for 3-5 days, then increase to TID if
tolerating(watch for lethargy).
Disp:*60 Capsule(s)* Refills:*0*
8. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for back spasms .
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Primary: anomalous right coronary artery
Secondary: chronic back pain, migraines, anxiety,COPD,vit. D
deficiency,shingles [**6-5**]
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.
Followup Instructions:
Dr. [**Last Name (STitle) 12593**] 2 weeks
Dr. [**Last Name (STitle) **] 1 month
Dr. [**Last Name (STitle) 5017**] 2 weeks
Completed by:[**2155-9-30**]
|
[
"746.85",
"918.1",
"346.90",
"305.1",
"451.82",
"411.1",
"300.00",
"496",
"284.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.60",
"38.93",
"36.11",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8854, 8937
|
5396, 7472
|
402, 457
|
9113, 9121
|
4458, 5373
|
9420, 9574
|
3469, 3679
|
7782, 8831
|
8958, 9092
|
7498, 7759
|
9145, 9397
|
3694, 4439
|
319, 364
|
485, 2646
|
2668, 3166
|
3183, 3453
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,585
| 181,079
|
12057
|
Discharge summary
|
report
|
Admission Date: [**2175-3-1**] Discharge Date:
Date of Birth: [**2111-5-21**] Sex: M
Service:
CHIEF COMPLAINT: Change in mental status.
HISTORY OF THE PRESENT ILLNESS: This is a 63-year-old male
with a history of renal cell carcinoma, status post
nephrectomy, alcoholic cirrhosis, right MCA cerebrovascular
accident with dense left hemiplegia. The patient is a
nursing home resident who presents with change in mental
status and fevers to the [**Hospital1 69**]
Emergency Room. The patient was noted to have a change in
mental status at the nursing home and they brought him into
the emergency room. In the emergency room, the patient
received Narcan with good effect, but the patient remained
somnolent with withdrawal to painful stimuli on the right
side. Subsequently, the patient had a witnessed seizure in
the emergency room. Dilantin level was found to be low and
the patient was reloaded with Dilantin. CT of the chest was
obtained, which was consistent with bilateral bibasilar
infiltrates, possible aspiration pneumonia. The patient was
started on Levofloxacin, Flagyl, and Vancomycin. The patient
also had a head CT, which was negative for any evidence of
bleed or any pathology.
The patient was initially admitted to the ICU, where abnormal
labs were significant for an alkaline phosphatase of 1.043,
GET of 951, calcium 12.6 and albumin of 2.3. The patient was
treated with IV fluids and Lasix and the calcium subsequently
decreased into the low 10s. Abdominal CT was obtained, which
showed evidence of a new liver mass likely to be
hepatocellular carcinoma. There was also evidence of
ascites, which was tapped in the ICU and negative for SBP
with SSG gradient of 0.8. There was a question for portal
hypertension on abdominal CT, so ultrasound was obtained,
which was negative for any evidence of Chiari. The patient's
newly diagnosed possible hepatocellular carcinoma, as well as
his poor neurological function, was discussed with the family
and secondary to the poor prognosis, the family is in
agreement that the patient should be DNR/DNI with no
aggressive procedures or interventions. They would like pain
release as primary goal, but would favor treatment of his
infections and treatments of abnormal electrolytes.
PAST MEDICAL HISTORY:
1. Insulin dependent diabetes mellitus.
2. Hypertension.
3. Chronic obstructive pulmonary disease.
4. Alcohol abuse.
5. History of cerebrovascular accident with left
hemiparesis.
6. History of seizure disorder.
7. Renal cell carcinoma status post nephrectomy.
8. Cirrhosis.
9. Esophageal varices.
10. History of depression.
11. Status post right hip arthroplasty.
12. Peripheral vascular disease.
13. Gastroesophageal reflux disease.
14. Glaucoma.
15. Macular degeneration.
16. Multinodular goiter.
17. Hypercholesterolemia.
18. Aortic stenosis.
19. Status post retinal artery occlusion.
20. Nursing home resident.
21. Pneumonia.
MEDICATIONS ON ADMISSION:
1. Insulin 5 units subcutaneously q.a.m. and regular insulin
sliding scale.
2. NPH 30 units q.a.m. and q.p.m.
3. Dilantin 200 mg b.i.d.
4. Neurontin 200 mg t.i.d.
5. Zantac 150 mg q.d.
6. Levofloxacin 500 mg q.d.
7. Thiamine 100 mg q.d.
8. Folate 1 mg q.d.
9. Duragesic patch 15 mcg q.72 hours.
10. Hydrochlorothiazide 25 mg q.d.
11. Zinc sulfate 220 mg q.d.
12. Vitamin C.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient is a nursing home resident with
a physician contact, Dr. [**Last Name (STitle) 37823**]. Phone #: [**Telephone/Fax (1) 37824**].
The patient has an extensive family with nine children, who
are not that familial with the patient. The patient's
sister, [**Name (NI) **], is his proxy and she has had discussion with
the family. As stated in the history of present illness, the
patient was made DNR/DNI this admission.
PHYSICAL EXAMINATION: Examination revealed the following:
VITAL SIGNS: Temperature 98.8, pulse 106, blood pressure
110/85, respirations 28, oxygen saturation 98% on four
liters. GENERAL: The patient is lethargic, opens eyes to
voice, but does not respond to commands. HEENT: Pupils
equal, round, and reactive to light; evidence of cataracts
bilaterally. Normocephalic, atraumatic, extraocular muscles
are intact, oropharynx dry. Neck is without any evidence of
JVD. CHEST: Rhonchi at the bases, right greater than left.
HEART: Decreased heart sounds, no murmurs, rubs, or gallops.
ABDOMEN: Distended, tympanitic, decreased bowel sounds.
There is now tenderness diffusely. EXTREMITIES: Without any
clubbing, cyanosis or edema. NEUROLOGICAL: The patient's
eyes were closed, some brief spontaneous eye opening, no eye
opening to name or sternal rub. No commands when the eyes
passively open, roving eye movements, doll's eyes
horizontally. Intermittent blink to threat. Pupils
3-mm x 2-mm bilaterally. Bilateral cataracts. Occasional
eye deviation to the left for a few second, but not sustained
or jerking. Left face decreased excursion with grimace to
pain. Spontaneous movements of right arm and leg. Right
deltoid gives some resistance, biceps and triceps able to
lift right leg up for a few seconds. No movement of the left
arm or leg. The patient grimaces to nail bed pressure in all
extremities. Tone decreased in the left arm. However,
reflexes slightly more brisk at the left bicep. Knee jerks
normal and symmetrical, no ankle jerks. Plantar extensors
are upgoing bilaterally.
LABORATORY DATA: Labs on admission revealed the following:
white count 8.4, sodium 145, potassium 3.3, chloride 110,
bicarbonate 22, BUN 0.6, glucose 170, calcium 12.6, Dilantin
level initially 1.0, ammonia level 32.
HOSPITAL COURSE: This is a 63-year-old man with a history of
renal-cell carcinoma, alcoholic cirrhosis, status post right
MCA, cerebrovascular accident with dense left hemiparesis,
nursing home resident, who presents with change in mental
status, fevers, and recently transferred from the Intensive
Care Unit with workup, which likely revealed hepatocellular
carcinoma, probable portal vein thrombosis and hypercalcemia.
As described in the history of present illness, the chest CT
showed evidence of a bilateral bibasilar pneumonia, which is
likely to be aspiration pneumonia. The patient was treated
initially with Floxin, Flagyl, and Vancomycin. Sputum was
obtained and revealed gram-positive rods, 3+ gram positive
cocci, and 3+ yeast. Cultures are pending at the time of
this dictation and antibiotics will be further titrated as
the cultures return. The patient will likely need a full
14-day course for his aspiration pneumonia.
The finding of his liver mass was suspicious for horizontal
cleavage component. There is a question of a portal vein
thrombosis on the abdominal CT. A right upper quadrant
ultrasound was obtained to rule out portal vein thrombosis
and there was no evidence of Budd-Chiari syndrome. An AST
was obtained, which was significant for gross elevation at
5,259. Liver service consultation was obtained and they
agreed that the description on the CT, as well as the
elevated AST was consistent with the hepatocellular carcinoma
and the patient would likely not benefit from a biopsy at the
time. This information was presented to the family and the
family was very realistic and understood the poor prognosis
of this patient.
As described in the history of present illness, the patient
and the patient's family has agreed to make the patient a
DNR/DNI with pain management their primary concern. The
patient's hypercalcemia was thought to be likely secondary to
a perineoplastic syndrome in the setting of multiple
carcinomas. The patient was treated with IV fluids, Lasix,
and the patient's calcium decreased to the low 10s. The
patient continued to receive IV fluids and Lasix as needed to
bring down the calcium to within normal limits.
The patient's anemia was also worked up with iron studies,
which were significant for TIBC of 138. No evidence of B12
or folate deficiency. Reticulocyte count was 3.4. The
patient's labs were consistent with anemia of chronic
disease. The patient had no evidence of blood loss during
this hospital stay.
It is felt that the patient's change of mental status was
likely secondary to multiple factors including hypercalcemia,
seizure disorder, increased narcotics, infection including
pneumonia. The patient was treatment with Lactulose p.r.n.
The patient was reloaded on Dilantin as his initial level was
low. The patient had a head CT, as stated above, which
showed no evidence of an acute bleed. The [**Hospital 228**] medical
status actually improved dramatically as the calcium began to
decrease back to normal, as well as after a few days of
antibiotic therapy. It is unclear whether it was the
Dilantin, antibiotics, or the decrease in calcium, which
contributed to the improvement in mental status, but it is
likely a combination of all of the above.
At the time of this dictation, the patient is being screened
for a place to go for acute nursing facility. The patient
will likely return to his previous nursing facility. As
noted above the patient is DNR/DNI, and this has been
discussed with the family.
CONDITION ON DISCHARGE: Guarded.
DISCHARGE STATUS: The patient will be discharged back to
rehabilitation when his calcium has returned back to normal
limits, when the mental status continued to improve, and
speciation of his sputum culture has been obtained
subsequently allowing us to further tailor his antibiotics.
DISCHARGE DIAGNOSIS:
1. Change in mental status, etiology of which is likely
multifactorial.
2. Bilateral bibasilar pneumonia, likely aspiration.
3. Seizure disorder.
4. Hypercalcemia.
5. Likely newly diagnosed hepatocellular carcinoma.
6. History of renal cell carcinoma.
7. Alcoholic cirrhosis.
8. Status post right CVA with dense left hemiplegia.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] [**First Name8 (NamePattern2) **] [**Doctor First Name **] 12-735
Dictated By:[**Name8 (MD) 2402**]
MEDQUIST36
D: [**2175-3-1**]
T: [**2175-3-3**] 11:18
JOB#: [**Job Number 37825**]
|
[
"507.0",
"275.42",
"780.39",
"438.20",
"250.00",
"456.21",
"780.9",
"155.0",
"571.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9537, 10147
|
2961, 3399
|
5700, 9193
|
3872, 5682
|
131, 2273
|
2295, 2935
|
3416, 3849
|
9219, 9516
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,184
| 104,042
|
49338+59174
|
Discharge summary
|
report+addendum
|
Admission Date: [**2107-6-17**] Discharge Date: [**2107-6-26**]
Service: CME
CHIEF COMPLAINT: The patient was admitted with a chief
complaint of hypotension and bradycardia.
HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old
gentleman with a past medical history significant for
hypertrophic obstructive cardiomyopathy (HOCM), type 2
diabetes mellitus, hypertension, polymyalgia rheumatica, and
osteoporosis who presents with fatigue and nausea after
taking an accidental extra dose of 240 mg of sustain release
verapamil and his first ever dose of atenolol (12.5 mg).
The patient was home alone and confused about whether he had
taken his medications. He took atenolol and began to feel
fatigued and nauseated with substernal chest pain. The
patient also has been complaining of increased palpations and
vision dimming lately which precipitated the addition of
atenolol in the setting of the patient's history of
hypertrophic obstructive cardiomyopathy. The patient denies
any recent fevers, chills, sweats, shortness of breath, or
dyspnea on exertion.
After the patient began to experience these symptoms, he
phoned [**Pager number **]. On arrival of Emergency Medical Service arrival,
he was found to be hypotensive with a blood pressure of
80/60. The patient was also found to be bradycardic with a
rate of 45.
In the Emergency Department, the patient was found to have
severe sinus bradycardia versus sinus arrest and junctional
escape. He was then given calcium, insulin, glucose, 7
liters of normal saline, Glucagon, and dopamine. The patient
was subsequently intubated for airway protection. He also
had a transcutaneous temporary wire placed and was then in a
normal sinus/an accelerated junctional rhythm.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Verapamil sustain release 240 mg by mouth once per day (as
noted, the patient took and extra dose on the morning of
admission).
2. Atenolol 12.5 mg by mouth once per day (which the patient
started today).
3. Glucovance 5/500 mg by mouth in the morning and 2.5/500 mg
by mouth in the evening.
4. Hydrochlorothiazide 12.5 mg by mouth once per day.
5. Prednisone 5 mg by mouth once per day.
6. Prilosec.
7. Aspirin 81 mg by mouth once per day.
8. Novolog 6 units in the morning and 4 units in the evening.
SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] denies
any drugs or a history of digoxin use.
FAMILY HISTORY: Family history was not able to be obtained.
PHYSICAL EXAMINATION ON PRESENTATION: The patient was
afebrile, his pulse was 80 (which was paced), his blood
pressure was 40 to 113/19 to 70, and he was on 100 percent
FiO2 and intubated with a respiratory rate of 12, tidal
volume was 600, and positive end-expiratory pressure of 5.
The patient was intubated and agitated. He had pessary
muscle contractions consistent with transcutaneous pacing.
The lungs were clear. He had a 2/6 systolic ejection murmur.
The abdomen was soft and distended. There were positive
bowel sounds. There was no hepatosplenomegaly. The rest of
his examination was not pertinent.
LABORATORY VALUES ON PRESENTATION: Initial laboratory data
revealed his white blood cell count was 17.1, his hematocrit
was 36.7, and his platelets were 243. Chemistry-7 revealed
his sodium was 138, potassium was 5.8, chloride was 102,
bicarbonate was 22, blood urea nitrogen was 31, creatinine
was 1.3, and his blood glucose was 234. A creatine kinase
was obtained which was 86. A troponin was negative.
Coagulations were unrevealing.
PERTINENT RADIOLOGY-IMAGING: An electrocardiogram revealed a
likely high junctional escape rhythm at 40 with sinus node
activity. QRS of 118, and no ST-T wave changes.
A chest x-ray showed pulmonary edema and endotracheal tube in
good position. The pacing wire was also well positioned.
Of note, the patient had a recent echocardiogram in
[**2106-10-4**] which showed an ejection fraction of 55
percent to 60 percent and symmetric left ventricular
hypertrophy, a severe resting outflow tract obstruction of
the left ventricle, as well as 3 plus mitral regurgitation, 1
plus tricuspid regurgitation, and moderate pulmonary
hypertension. The findings were consistent with hypertrophic
obstructive cardiomyopathy.
SUMMARY OF HOSPITAL COURSE BY ISSUES-SYSTEMS:
1. HYPERTENSION AND BRADYCARDIA ISSUES: It was felt by the
Coronary Care Unit team that the most likely explanation
of his hypertension and bradycardia was from the extra
dose of verapamil he took on the day of admission. The
patient was admitted to the Coronary Care Unit intubated
with a temporary pacing wire. The patient was initially
started on dopamine and then transitioned to phenylephrine
for blood pressure support. His nodal blocking agents
were subsequently held.
Given the high white blood cell count and hypotension, there
was also some concern for sepsis. The patient had an
infections workup which included blood and urine cultures
which were all negative. The patient was initially
maintained on broad spectrum antibiotics to cover for
possible infection.
He was also initially given stress-dose steroids as there was
concern that he may have possible adrenal insufficiency given
he is on chronic steroids. Furthermore, he had a set of
cardiac enzymes which were obtained which were negative.
The patient also had a subsequent echocardiogram done while
in house which showed severe concentric left ventricular
hypertrophy, an ejection fraction of 60 percent, and left
ventricular outflow tract obstruction. Additionally, there
was mild-to-moderate mitral regurgitation seen.
Eventually, the patient's blood pressure began to recover as
the nodal agents worked off and his pacemaker was
functioning. He was initially started on a labetalol drip as
well as hydralazine for blood pressure control. It was felt
that after a few days that his nodal blocking agents had
eventually worn off. Therefore, he was started on metoprolol
and verapamil for blood pressure control and heart rate
control. The Coronary Care Unit team felt that it was
extremely important he be on nodal blocking agents in the
future, as this is the treatment for hypertrophic obstructive
cardiomyopathy. The patient was eventually continued on
verapamil 40 mg by mouth q.8h. and was then switched from
metoprolol to labetalol for further blood pressure control;
however, the patient stated that he felt extremely dizzy, and
the team attributed this to his beta blocker dose.
Therefore, he was continued on just verapamil 40 mg by mouth
q.8h., and his blood pressures subsequently returned to
[**Location 213**].
On [**2107-6-24**], the patient had a dual-chamber pacemaker
inserted. The patient tolerated the procedure well and did
not have any evidence of hematoma around the pacemaker
pocket.
1. OTHER ISSUES: As noted, the patient was initially
intubated for airway protection in the setting of
receiving 7 liters of fluid. The patient was eventually
weaned from intubation and was extubated without incident.
He was given Lasix as needed as he was clearly volume
overloaded from having received large volume
resuscitation.
As mentioned previously, none of the numerous blood cultures
that were obtained were revealing for any type of infection.
The patient was continued on an insulin sliding scale for his
type 2 diabetes mellitus.
DISCHARGE DIAGNOSES:
1. Hypertrophic obstructive cardiomyopathy.
2. Calcium channel overdose with resultant intubation and
large volume resuscitation.
3. Pacemaker insertion.
4. Type 2 diabetes mellitus.
5. Polymyalgia rheumatica.
6. Hypertension.
DISCHARGE INSTRUCTIONS-FOLLOWUP: The patient was instructed
to contact his primary care physician should he develop any
chest pain, shortness of breath, nausea, vomiting, dizziness,
or lightheadedness, as well as any other serious complaints.
MAJOR SURGICAL-INVASIVE PROCEDURES PERFORMED:
1. Intubation.
2. Pacemaker insertion.
3. Temporary pacemaker wire placement.
CONDITION ON DISCHARGE: Stable.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg by mouth once per day.
2. Several eyedrops which the patient takes at home.
3. Prednisone 5 mg by mouth once per day.
4. Protonix 40 mg by mouth once per day.
5. Metformin 1000 mg by mouth in the morning.
6. Pravastatin 40 mg by mouth once per day.
The exact verapamil dose that he will be taking will be
dictated as an Addendum as well as the remainder of his
endocrine medications.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 13600**]
Dictated By:[**Doctor Last Name 10457**]
MEDQUIST36
D: [**2107-6-25**] 17:43:03
T: [**2107-6-25**] 19:51:29
Job#: [**Job Number 103355**]
Name: [**Known lastname 16743**], [**Known firstname 77**] S Unit No: [**Numeric Identifier 16744**]
Admission Date: [**2107-6-17**] Discharge Date: [**2107-6-27**]
Date of Birth: [**2024-4-24**] Sex: M
Service: CME
ADDENDUM: This is an Addendum to a previously dictated
Discharge Summary. Please change the date of discharge to
[**2107-6-27**].
MEDICATIONS ON DISCHARGE: (The following is a list of the
patient's discharge medications)
1. Aspirin 325 mg by mouth once per day.
2. Brimonidine eyedrops 1 drop q.8h.
3. Latanoprost eyedrops 1 drop at hour of sleep.
4. Dorzolamide-Timolol eyedrops 1 drop twice per day.
5. Prednisone 5 mg by mouth once per day.
6. Protonix 40 mg by mouth once per day.
7. Pravastatin 40 mg by mouth once per day.
8. Glipizide 5 mg by mouth twice per day.
9. Lasix 40 mg by mouth once per day.
10. Potassium chloride 20 mEq by mouth every day.
11. Verapamil sustained-release 360 mg by mouth once per
day.
12. Tylenol as needed.
13. Colace 100 mg by mouth twice per day.
14. Sliding scale insulin.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 16745**]
Dictated By:[**Doctor Last Name 14574**]
MEDQUIST36
D: [**2107-8-14**] 14:34:37
T: [**2107-8-14**] 14:55:17
Job#: [**Job Number 16746**]
|
[
"416.8",
"425.1",
"397.0",
"458.29",
"427.89",
"972.4",
"428.0",
"E858.3",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"37.83",
"37.72",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
2483, 7437
|
7458, 8061
|
9199, 10148
|
1831, 2351
|
107, 188
|
217, 1805
|
2368, 2466
|
8086, 8095
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,488
| 137,459
|
18979
|
Discharge summary
|
report
|
Admission Date: [**2199-9-30**] Discharge Date: [**2199-10-15**]
Date of Birth: [**2122-12-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy (showing esophageal varices)
History of Present Illness:
76 yo M with CHF, CAD, AF on coumadin presented to OSH with DOE
x few days, chest pain a few days ago, diarrhea yesterday, today
became very weak. Pt c/o increasing edema R>L, +orthopnea,
denied bloody/black stools, but dark urine, feeling very weak
with standing, "near syncope" at home. At OSH appeared cyanotic,
o2 sats in 80s on RA. 1st CXR with cardiomegaly, early chf.
Per OSH notes, "exam worrisome for PE given large swollen leg,
but already anticoagulated with INR 3.2". During ED eval,
became suddenly very hypoxic to 50s, bradycardic to 40s-50s.
Got atropine 1mg x 2. Intubated easily but never able to get
O2sats up above 90%, easy to vent. ? PE, but already
anticoagulated and unable to get cta (creat 1.9). Received blood
for hct 27 and melena on exam (OGT negative for blood). ABG with
pO2 466 -- so o2sat not realiable. ETT advanced 2cm after post
tube CXR. Pt transferred to [**Hospital1 18**] ED for further evaluation and
management.
.
[**Hospital1 18**] ED COURSE: Initial VS T97.6 HR 70 BP 185/102, Placed on
propofol for sedation BP dropped to 93/42-->88/50, HR 65.
Propofol off, BP increased to 113/56, 1U PRBC and 2UFFP given,
unclear why Atropine 0.5mg x1 given. Also received Factor IX for
unclear reasons, no frank BRBPR or signs of sanguination. Pt
received Protonix 40mg x1, GI made aware, IVF bolus 500cc x1,
sent pt to MICU for further management and evaluation.
Past Medical History:
-CHF, ?EF
-HTN
-Afib on coumadin
-hypercholesterolemia
-wrist arthritis
.
Social History:
-lives alone
-Worked as [**Doctor Last Name 3456**]
-smoked several years ago, unclear pack hx, no significant ETOH
use per daughter
Family History:
-heart dz, no hx of stroke or neurological dz
Physical Exam:
VS: 96.1 HR 64 BP 74/55 RR 23 AC 700X16 FiO2 1.0 PEEP 0
GEN: Intubated, sedated
HEENT: ETT in place with cyanotic lips, dry MM
RESP: CTABL Ant'ly
CV: Reg Nml S1, S2, no M/R/G
ABD: Soft, distended, NT, diminished BS
EXT: Diffuse 3+pitting edema up to thighs, dependent edema,
significant erythema throughout shins R>L extends up to thighs
with some erythema on abdomen and scrotum, cyanotic fingernails
NEURO: unable to assess accurately, moves extremeties with light
sedation, withdraws to pain
Pertinent Results:
[**2199-9-30**] 08:45PM WBC-5.6 RBC-3.14* HGB-8.7* HCT-27.1* MCV-86
MCH-27.8 MCHC-32.2 RDW-16.5*
[**2199-9-30**] 08:45PM NEUTS-79.9* LYMPHS-12.2* MONOS-5.6 EOS-2.1
BASOS-0.2
[**2199-9-30**] 08:45PM PLT COUNT-259
[**2199-9-30**] 08:45PM PT-37.0* PTT-39.0* INR(PT)-4.1*
.
.
[**2199-9-30**] 08:45PM GLUCOSE-105 UREA N-51* CREAT-1.7* SODIUM-137
POTASSIUM-4.9 CHLORIDE-105 TOTAL CO2-22 ANION GAP-15
[**2199-9-30**] 08:45PM ALT(SGPT)-11 AST(SGOT)-31 LD(LDH)-238
CK(CPK)-88 ALK PHOS-49 AMYLASE-49 TOT BILI-0.8
[**2199-9-30**] 08:45PM LIPASE-23
[**2199-9-30**] 08:45PM cTropnT-0.03*
[**2199-9-30**] 08:45PM CK-MB-NotDone
[**2199-9-30**] 08:45PM ALBUMIN-3.0* CALCIUM-8.1* PHOSPHATE-4.3
MAGNESIUM-2.9*
[**2199-9-30**] 08:45PM TSH-3.7
.
.
[**2199-9-30**] 10:55PM URINE HOURS-RANDOM UREA N-515 CREAT-145
SODIUM-19 POTASSIUM-47 TOT PROT-96 PROT/CREA-0.7*
[**2199-9-30**] 10:55PM URINE OSMOLAL-359
[**2199-9-30**] 10:55PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.014
[**2199-9-30**] 10:55PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2199-9-30**] 10:55PM URINE RBC->50 WBC-[**4-1**] BACTERIA-OCC YEAST-NONE
EPI-[**4-1**]
[**2199-9-30**] 10:55PM URINE HYALINE-0-2
[**2199-9-30**] 10:55PM URINE MUCOUS-FEW
[**2199-9-30**] 09:27PM URINE COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.013
[**2199-9-30**] 09:27PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-TR
[**2199-9-30**] 09:27PM URINE RBC->50 WBC-[**7-7**]* BACTERIA-FEW
YEAST-NONE EPI-0-2 TRANS EPI-[**4-1**]
.
.
[**2199-9-30**] 08:57PM PO2-21* PCO2-49* PH-7.33* TOTAL CO2-27 BASE
XS--1
[**2199-9-30**] 08:57PM HGB-8.8* calcHCT-26
[**2199-9-30**] 09:11PM LACTATE-2.1*
.
[**2199-9-30**] 11:40PM TYPE-ART PO2-370* PCO2-30* PH-7.42 TOTAL
CO2-20* BASE XS--3
[**2199-9-30**] 11:40PM LACTATE-1.3
[**2199-9-30**] 11:40PM freeCa-0.99*
Brief Hospital Course:
AP: 76 yo M with HTN, hyperlipidemia, AF on coumadin, CHF EF
presents with hypoxia, pulm edema, ARF, GIB with
supratherapeutic INR.
.
#. Hypoxia: Pt initially felt to be a vasculopath with poor
pleth and inaccurate peripheral O2 sat [**Location (un) 1131**] resulting in
likely premature intubation. CXR c/w pulm edema which may have
improved with BiPAP. However, pt was already intubated. No signs
of PNA on CXR. PE less likely with INR>4 on coumadin, PaO2>400
which also suggests otherwise. On HD#2 pt with increased sputum
production, with sputum cx positive for GNR. He was continued
on vanco/ctx empirically for ?sepsis as below, however CTA was
negative for consolidation or PE. He was transitioned to PS on
HD#2.
.
Sputum cultures speciated enterbacter with intermediate
sensitivity to ceftriaxone on [**10-4**], so pt switched to cefepime.
2nd GNR isolate speciated to citrobacter, both were sensitive to
[**Last Name (LF) 9847**], [**First Name3 (LF) **] pt was started on [**First Name3 (LF) 9847**] on [**10-7**], with plan for 14d
course (day 1 [**10-7**]). Pt extubated [**10-5**], without difficulty,
though had been some concern regarding periods of sinus pauses
(up to 10 seconds) with coughing on the vent, felt [**3-1**] increased
vagal tone. EP consult obtained, as below, felt pauses were [**3-1**]
pulmonary disease and vagal tone, without intrinsic conduction
disease. On [**10-10**] pt stable on 2L NC x 2d. He was treated with
albuterol/atrovent nebs prn.
.
Pt weaned off O2 gradually (goal O2 sat > 90%), with plan to
complete 14 d course [**Month/Year (2) 9847**]. Still with O2 by NC requirement, has
been satting in mid-90s with 2-3L NC stably. Given emphysema
seen on CXR may continue to need O2 chronically but should
reassess as edema/CHF continues to improve.
.
#. GIB: pt with melena per OSH records in setting of
supratherapeutic INR, unclear hx of GIB or colonoscopy done. Pt
received factor IX in ED for unclear reasons, and was given 2U
PRBC without bump in HCT (27->28). ASA and coumadin where held,
PPI IV BID started, GI consult obtained, however EGD deferred
given ongoing hypotension. Serial HCT were stable 27-28
throughout MICU stay, no recurrence of melena. Per GI, plan was
to obtain re-consult once pt stable and on floor for
EGD/colonoscopy. On [**10-9**], pt underwent EGD [**10-10**] (no colonoscopy
[**3-1**] unable to complete prep [**3-1**] n/v and MS changes). EGD showed
?varices, though not clearly varices. GI deferred inpatient
repeat EGD and colonoscopy, but hope to do this later within the
next month, as his health status continues to improve, and
perhaps after variceal banding.
.
We continued to hold coumadin and anticoagulation as risk of
variceal bleed remains considerable, balance is of risk from GIB
versus several week risk of stroke from atrial fibrillation; GIB
risk appears at this point to be more severe and immediately
worrying.
.
For follow up on GI bleeding and arranging for possible
procedures, an appointment was made with Dr [**Last Name (STitle) 1407**], of the
gastoenterology department, who had seen pt while he was inpt.
.
.
#. Hypotension: admit SBP 74/55, etiology unclear, ddx sepsis vs
volume loss [**3-1**] GIB vs some component of pump failure (RV vs
LV). pt initially covered with vanco/clind for concern for
cellulitis. clinda d/c'd on HD#1 in favor of CTX for broader
coverage. he was started on dopamine gtt HD#1, switched to
levophed given excess tachycardia on dopa gtt. TTE revealed
severe RV dysfunction raising concern for PE, however LENI's and
CTA were unremarkable. pt febrile to 100.9 on HD#2. cardiac
enzymes flat (trop 0.03->0.02). on HD#2, pt initially doing
well after ~1L diuresis overnight (pt felt to be in RV failure,
significantly volume overloaded, and with poor starling
physiology). pt afebrile, hct stable. Some concern for
transient hypoxic vasoconstriction [**3-1**] intracardiac shunting
resulting in transient exacerbation of RV failure. Pt continued
to get diuresed, tolerating this well, with stable SBPs, thus
levo gtt was weaned off after ~24-36hrs. Pt did not require
pressors after HD#3.
.
For much of the admission he was on diltiazem for rate control,
an inheritance of the diltiazem drip which he had required for
rate control in the MICU. A day prior to admission we changed
this to metoprolol which he tolerated well, with the reasoning
that this would likely be more appropriate for both his
cardiovascular issues and his varices. We started him on less
than his prior home dose (100 mg daily), at 37.5 [**Hospital1 **]; rate and
pressures remained within good control without hypotension or
bradycardia. This will need to be followed.
.
.
#. CV: ?Syncope episode in setting of GIB prior to admission. Pt
with elevated dig level on admission (2.1).
.
**PUMP- baseline EF, however moderate pulm edema on CXR. TTE
obtained which showed EF 40-50%, no new [**Male First Name (un) 4746**], 1+MR, and severe RV
dysfunction concerning for PE. CTA negative for PE, but showed
severe COPD, which is likely chronic cause of RV strain. pt
diuresed aggressively, with 1-3L removed daily (grossly total
body up, likely 10-15L) with lasix gtt + prn lasix, with
improvement in O2 sats and creatinine, and transitioned to prn
80mg iv lasix q8h on [**10-7**].
.
**RHYTHM- h/o AF on anticoagulation, initially in NSR, found to
have supratherapeutic dig level (2.1), dig was held. over
coarse of HD#[**1-31**] of MICU stay pt with frequent episodes of
bradycardia, initially attributed to vagal effects from coughing
while on mechanical ventilation. on HD#2, pt brady to 20s,
inciting event unclear, received 0.5 mg atropine x 2 with rapid
and appropriate HR response to 160s, SBPs dropping slightly
during event from 100s to 80-90s. EKG shows afib, with IVCD,
but otherwise no evidence of dig toxicity. Pt seen by EP, who
felt sinus arrest / asystole was [**3-1**] pulmonary disease only, and
no intrinsic cardiac conduction disease was present. Pt was
placed on extrinsic cardiac pacing pads, with intermittent
episodes of bradycardia with coughing requiring pacing. Some
concern about bradycardia with extubation, however pt extubated
without complication on [**10-5**].
.
His episodes of bradycardia resolved after extubation, rather pt
had persistent episodes of his chronic afib (rates 130s-140s);
per EP consult, there were no plans for pacemaker presently.
Rather the pt was started on diltiazem gtt and transitioned to
PO diltiazem for rate control. His coumadin was held pending
EGD/colonscopy to evaluate for melena, planned for [**10-10**]; and
given varices, this was held until discharge and beyond (see
above re GI bleed). See notes re diltiazem to metoprolol switch
above; discharged on metoprolol. Note that given this recent
medication change, periodic monitoring for changes in rate or
rhythm will be particularly important for the first several days
of his rehabilitation facility stay.
.
** ISCHEMIA - unclear h/o CAD s/p MI, EKG without evidence of
active ischemia, low voltage, cardiac enzymes unremarkable (peak
trop 0.03), TTE without focal WMA. ASA held [**3-1**] GIB, BB held
[**3-1**] hypotension initially. Changed back to metoprolol for
discharge, as described above.
.
.
#. ARF: Unclear Cr baseline, initially elevated most likely [**3-1**]
poor forward flow [**3-1**] total body volume overload, no obvious
recent contrast loads or other periods of hypotension though
although ?recent episode of syncope. Pt initially hydrated
(~500cc) + mucomyst for CTA, then diuresed aggressively as above
(-7-8L), with improvement in cre 1.5->1.1. Cr = 1.1 on
discharge.
.
.
#. Cellulitis: pt initially with diffuse erythema, warmth and
edema of LE R>L, not diabetic but extremeties appear to have
chronic venous stasis changes with LE ulcers, dopplerable pulses
b/l. [Per daughter pt recently on [**Name (NI) **] at home with VNA services
at home to change dressings daily, unclear [**Name (NI) **] use prior to this
admission]. Per pt's pcp felt to have bilateral le cellulitis,
and was initially started on vanco/clinda, broadened to
vanco/CTX to give additional empiric pneumonia coverage, however
later felt cellulitis unlikely, perhaps more likely to be
chronic edema changes, and d/c'd vanco after 5d course. Erythema
improved with brief [**Name (NI) 621**] course, wrapping LE, elevation, and
diuresis as above; this care should continue in his next
placement.
.
# FEN: pt given TF while intubated, then seen by speech &
swallow [**10-8**], and advanced to regular diet 9/12 per S&S recs.
.
# ACCESS: L IJ TLC placed on admission [**9-30**], d/c'd on [**10-9**] after
pt found to have superficial cephalic vein clot (no need for
anticoagulation). PIV's in place.
.
# PROPH: PPI, heparin SC, bowel regimen prn.
.
# CODE: FULL
Medications on Admission:
-Digoxin 0.25mg qd
-Metoprolol 100mg daily
-Coumadin 2.5mg qhs but varies
-lisinopril 10mg qd
-furosemide 20mg [**Hospital1 **]
-lipitor 20mg qd
-Ferrous sulfate 1 tab qd
-Naprosyn 500mg [**Hospital1 **] (stopped taking)
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
neb Inhalation Q4H (every 4 hours) as needed.
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
9. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 8 days: 14 day course day 1=[**10-7**].
11. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
Primary diagnoses:
Heart failure
Esophageal varices
.
Respiratory failure, resolved
Hypotension, resolved
.
Secondary diagnoses:
atrial fibrillation
Discharge Condition:
Good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
You should not have more than 1.5 liters (1500 mL) of fluid each
day.
.
Make sure to take your medicines regularly. If you are having
symptoms of chest pain, chest tightness or chest pressure; if
you are feeling your heart "fluttering" in your chest; or if you
are feeling faint or light-headed or dizzy, please tell a doctor
or nurse right away.
Followup Instructions:
Rehabilitation facility
.
Follow up with gastrointestinal doctor, Dr [**Last Name (STitle) 1407**], [**Hospital Unit Name **],
[**Hospital1 18**], [**Location (un) 453**]. Appt as follows:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 21795**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2199-10-22**] 1:00
|
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"428.0",
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"707.03",
"427.81",
"482.83",
"790.92",
"682.6",
"453.8",
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icd9cm
|
[
[
[]
]
] |
[
"99.07",
"96.6",
"96.72",
"99.04",
"45.16"
] |
icd9pcs
|
[
[
[]
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14827, 14910
|
4629, 13436
|
319, 377
|
15103, 15110
|
2644, 4606
|
15606, 15941
|
2067, 2114
|
13707, 14804
|
14931, 15039
|
13462, 13684
|
15134, 15583
|
2129, 2625
|
15060, 15082
|
276, 281
|
405, 1804
|
1826, 1901
|
1917, 2051
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,161
| 168,634
|
17795
|
Discharge summary
|
report
|
Admission Date: [**2138-7-18**] Discharge Date: [**2138-7-27**]
Date of Birth: [**2055-3-1**] Sex: M
Service: MEDICINE
Allergies:
Phenylephrine
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
83 yo Russian speaking male with a history of CAD and a recent
NSTEMI reportedly complicated by cardiogenic shock (hospitalized
at [**Hospital3 **] and discharged to rehab yesterday) presents
from rehab after experiencing CP and subsequent hypotension
following NTG adminstration. At [**Hospital3 **] apparently
underwent cath which demonstrated anatomy not ammendable to
stenting. At rehab today, experienced chest pain and was given
ASA and NTG. He subsequently became hypotensive with SBPs
reportedly in the 80s. Per wife for many years pt had chest
discomfort lasting about 5-10 minutes about once a month at home
that usually resolves with NTG. however for the past 5-6 days he
has had it everyday and at times more than once a day at rest.
this morning he was in bed when chest pain began. after he took
ntg he began to feel unwell and bp was noted to be in the 80s.
he apparently also has been having blood streak in the stool and
urine since admitted at [**Hospital3 **] but was evaluated there.
she also states he has exertional dyspnea on going up the stairs
but denies syncope. pt apparent has not had any fever, chill,
rigor. he however does have a cough with minimal sputum
production.
.
In the [**Hospital1 18**] ED, the pt's initial vitals were stable. He denied
any further chest pain. A chest x-ray was concering for possible
pneumonia and the patient was treated with antibiotics. However
he's afebrile and has a normal wcc. He was also evaluated in the
ED by cardiology who advised against emperic anticoagulation.
The pt is now admitted to the CCU for close monitoring. His most
recent vitals prior to transfer were: HR 60, RR 23, 110/47, 97%
4L
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS: Hypertension
2. CARDIAC HISTORY:
-PERCUTANEOUS CORONARY INTERVENTIONS:
3. OTHER PAST MEDICAL HISTORY:
.
MR
AS, severe
CHF, systolic and diastolic dysfunction,
Recurrent MI with cardiogenic shock [**2133-8-7**].
Multiple PCI procedures
PAD with IC
Right foot plantar ulcer
CRI.
Bronchiectasis/emphysema/recurrent bronchitis
Diabetic neuropathy, possible early diabetic nephropathy
Chronic recurrent left ear infection
Social History:
Lives at home with wife.
-Tobacco history: Denies.
-ETOH: Rare social EtOH.
-Illicit drugs:
Family History:
Noncontributory
Physical Exam:
Temp 37.3, hr 70/min, bp 107/70, rr 16/min, sats 96% on ra
GENERAL: appears in no apparent distress. Mood, affect
appropriate.
[**Month/Day/Year 4459**]: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, jvp mildly elevated in a 30% angle
CARDIAC: rrr, nl s1, faint s2, [**5-12**] ejection systolic murmur in
right second intercostal space with radiation to neck.
LUNGS: reduce air entry bilaterally with expiratory wheeze.
ABDOMEN: soft, non tender, nl bs
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: 1+ dp and pt pulses
Pertinent Results:
ADMISSION LABS:
CBC:
[**2138-7-18**] 01:39PM BLOOD WBC-5.0 RBC-3.18*# Hgb-9.6*# Hct-28.9*#
MCV-91 MCH-30.1 MCHC-33.1 RDW-16.2* Plt Ct-340#
[**2138-7-18**] 01:39PM BLOOD Neuts-78.4* Lymphs-14.4* Monos-4.0
Eos-2.7 Baso-0.5
[**2138-7-27**] BLOOD WBC-8.7 Hgb-8.1*# Hct-24.6*# Plt Ct-191#
COAGS:
[**2138-7-18**] 01:39PM BLOOD PT-13.8* PTT-24.3 INR(PT)-1.2*
CHEMISTRIES:
[**2138-7-18**] 01:39PM BLOOD Glucose-289* UreaN-32* Creat-1.6* Na-135
K-4.9 Cl-98 HCO3-28 AnGap-14
[**2138-7-27**] BLOOD Glucose-83* UreaN-35* Creat-1.6* Na-139 K-4.0
Cl-103 HCO3-26
LFTS:
[**2138-7-19**] 06:00AM BLOOD ALT-27 AST-22 LD(LDH)-213 CK(CPK)-61
AlkPhos-85 TotBili-0.6
CEs:
[**2138-7-18**] 01:39PM BLOOD cTropnT-0.05*
[**2138-7-18**] 01:39PM BLOOD CK-MB-NotDone
[**2138-7-18**] 07:08PM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2138-7-19**] 06:00AM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2138-7-22**] 05:15AM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2138-7-18**] 01:39PM BLOOD CK(CPK)-71
[**2138-7-18**] 07:08PM BLOOD CK(CPK)-64
[**2138-7-18**] 07:08PM BLOOD Calcium-8.2* Phos-2.8 Mg-2.1
IRON STUDIES:
[**2138-7-19**] 06:00AM BLOOD calTIBC-247* VitB12-918* Folate-11.9
Ferritn-240 TRF-190*
URINE STUDIES:
[**2138-7-22**] 06:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009
[**2138-7-22**] 06:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
=
=
=
=
=
=
=
=
================================================================
MICRO:
[**2138-7-25**] Urine Cx:
URINE CULTURE (Final [**2138-7-27**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**7-25**], [**7-26**] Blood Cx: Pending
=
=
=
=
=
=
=
=
================================================================
[**7-18**] TTE
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. LV systolic function appears depressed
(ejection fraction 30 percent) secondary to akinesis of the
posterior wall and anterior septum, and hypokinesis of the rest
of the left ventricle. Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. The supporting
structures of the tricuspid valve are thickened/fibrotic. There
is borderline pulmonary artery systolic hypertension. There is
no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2138-2-21**], the left ventricular ejection fraction is
further reduced.
CXR [**7-19**]
The current study demonstrates left basilar opacity which is new
since [**2138-4-17**], and although appears to be smaller than on
[**2138-7-18**], is consistent with a new left lower lobe
infiltrate that might be worrisome for infectious process. No
short interval change in the cardiomediastinal silhouette is
demonstrated. There is no evidence of failure, pleural effusion,
or pneumothorax.
CXR [**7-25**]
FINDINGS: In comparison with study of [**7-19**], there is increased
opacification
at the right base medially with silhouetting of the heart
border. Although
some of this may merely represent atelectasis, the appearance is
worrisome for
developing middle lobe pneumonia. Unfortunately, the lateral
view is somewhat
limited and does not adequately show this region.
No evidence of vascular congestion.
Video Swallow:
Gross aspiration of nectar thick liquids which the patient was
sensate.
Brief Hospital Course:
83 year old man with complex medical issues including Diasolic
and systolic CHF, severe AS, CKD, COPD and DM-2, PVD and chronic
ulcers presents from nursing facility after taking NTG for his
chest pain that resulted in hypotension that subsequently
resolved spontanously. Pt also has new AF at [**Hospital3 5097**], started on
amiodarone, persistant hematuria and anemia.
.
# CAD: Patient with recent NSTEMI reportedly complicated by
cardiogenic shock (hospitalized at [**Hospital3 **] and
discharged to rehab one day prior to admission). He reportly
had CP at rehab and was given SLN with subsequent hypotension.
At [**Hospital3 **] the patient underwent cath that demonstrated
clean LM, LAD total occulsion, LCx 50%, RCA 60%, LAD collaterals
being filled by RCA and anatomy was not ammendable to stenting.
On arrival he was chest pain free. The patient was medically
managed with high dose statin, BB and ASA. His cath films were
reviewed by both cardiac surgery and interventional cardiology.
The plan is to continue medical mangement given his lesions are
not amenable to either PCI or CABG. He had 2 episodes of chest
pain during his hospital course associated with no ECG changes
or cardiac enzyme elevation. The pain was relieved with IV
morphine.
.
#. Severe Aortic Stenosis: ECHO revealed a valve area of
0.8-1.0cm2 with a mean gradient of 23. He was evaluated by
Cardiac Surgery who as noted above did not recommend CABG/AVR.
Notably, the patient's severe AS makes treating his chest pain
difficult since he is pre-load dependent and medications such as
sub-lingial nitroglycerin can result in hypotension. Thus, this
medication should be avoided.
# Atrial Fibrillation: His AF was noted during his admission to
[**Hospital3 5097**] in mid [**Month (only) 116**]. He was started on an amiodorone gtt at OSH
and discharged to rehab on 200mg [**Hospital1 **]. His dose was further
reduced to 200 mg daily during this hospitalization. He was also
continued on metoprolol.
# Chronic Systolic Congestive Heart Failure: The patient
underwent ECHO that showed and EF of 30%. There was no evidence
of overload clinically. He was continued on lasix,
spironolactone, lisinopril and metoprolol.
# Urinary Tract Infection: Patient found to have asymptomatic
UTI. Gram neg rods in urine. He was started on cipro on [**7-26**],
but cx grew E. Coli resistant to cipro. He was changed to
Bactrim DS 1tab [**Hospital1 **] on [**7-27**] and should complete a total 7 day
course.
# Left lower lob infiltrate: This was felt to be secondary to
aspiration pneumonitis since the patient was shown to aspirate
during speech and swallow evaluation. Given he remained afebrile
without leukocytosis he was not treated with ABX for this
condition. Patient was started on a diet of pureed solids and
honey thickened liquids to prevent further aspiration events.
# Aspiration: Patient underwent video swallow that demonstrated
aspiration. Speech and swallow had the following recs:
1. PO diet: pureed solids, honey thick liquids
2. PO meds: crushed in puree
3. Q4 oral care
4. 1:1 assist with meals to maintain aspiration precautions
They also recommend f/u by swallow therapy in rehab setting and
will require videoswallow study in [**2-7**] weeks to consider diet
upgrade.
# Iron deficiency Anemia: The patient's Hct in [**3-17**] 40, but on
admission Hct was 28 and has remained stable. Notably, he has
had multiple guiac positive stool and plan is for him to undergo
outpatient EGD and colonoscopy on [**2138-7-28**]. However, the patient
and family would like to postpone the GI workup until after
rehab. They were given the phone number for [**Hospital **] clinic to
reschedule if they would like to. The patient was continued on
PPI and Iron.
#) Hematuria: On admission the patient had hematuria that had
started during his prior admission to [**Hospital3 **]. On [**7-20**]
he was seen by urology and removed a large amount of old clot
from his foley. There was no active bleeding. His foley was
changed to a larger diameter foley. A repeat UA [**7-22**] was
negative for blood.
Patient should follow up as an outpatient with Dr. [**Last Name (STitle) 27027**]. The
Urology contact number is [**Telephone/Fax (1) 164**].
#) Acute on Chronic Kidney Disease: The patient's creatinine
was 1.6 on admission and has remained stable. He is at his
baseline.
#) DM: The patient's insulin was increased to his home dose of
50U lantus with improved glucose control. His home glyburide and
precose were held during his admission and was covered with an
ISS.
Medications on Admission:
simvastatsin 80mg daily
aspirin 325 mg daily
Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q12H
amiodarone 200mg [**Hospital1 **]
allopurinol 150mg daily
lasix 40mg daily
lisinopril 5mg daily
metoprolol 50mg [**Hospital1 **]
spironolactone 12.5mg daily
lantus 40units daily and sliding scale
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
3. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Outpatient Speech/Swallowing Therapy
Please reassess swallowing on [**2138-7-30**] thanks
14. Lantus 100 unit/mL Solution Sig: Fifty (50) U Subcutaneous
at bedtime.
15. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day: please follow attached sliding
scale.
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
17. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
18. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO BID
(2 times a day) as needed for constipation.
19. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
20. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a
day for 7 days: day1: [**7-27**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] rehab
Discharge Diagnosis:
Primary:
-Coronary Artery Disease
-Aortic Stenosis
-Hematuria
-Acute on chronic Renal Failure
-Urinary Tract Infection
Secondary:
Chronic systolic heart failure
Diabetes Mellitus Type 2
Discharge Condition:
stable
Discharge Instructions:
You had chest pain and was transferred from [**Hospital3 580**] for evaluation. You were evaluated by cardiac surgery
for a possible bypass and aortic valve replacement. At this
time, it is not recommended that you get this surgery. We do not
think your chest pain is related to your heart. Please take
tylenol if you develop the pain. You will need to see Dr. [**First Name (STitle) 572**]
for evaluation of blood in your stools and a urologist for blood
in your urine.
A colonoscopy and endoscopy was scheduled for [**7-28**] to
evaluate bleeding and pain. However, you requested to postpone
the procedure for a few weeks while you are at rehab. Please
call GI: ([**Telephone/Fax (1) 2233**] to reschedule.
You were seen by a speech therapist who felt that you were
aspirating food into your lungs. You were started on a honey
thick liquids and pureed food diet. Intravenous fluids were
started to prevent dehydration. You will need to be re evaluated
in about a week to determine if you are still aspirating.
You also had a UTI and was started on bactrim DS 1 tab twice a
day which you should continue for 7 days.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day
or 6 pounds in 3 days.
Adhere to 2 gm sodium diet
Followup Instructions:
Cardiology:
[**First Name8 (NamePattern2) 1026**] [**Doctor Last Name 1016**] Phone: [**Telephone/Fax (1) 62**] Date/Time: [**8-28**] at 1:20pm.
Urology:
Dr. [**Last Name (STitle) 770**] Phone: [**Telephone/Fax (1) 164**] Please make f/u as outpt to
evaluate hematuria. [**9-22**] at 1:10pm. [**Hospital Ward Name 23**] Clinical
Center, [**Location (un) 470**].
Gastroenterology:
Colonoscopy and EGD: Monday [**7-28**] at 11:30am. [**Hospital Ward Name 1950**] 3 on
[**Hospital Ward Name 516**]. Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 452**] will do procedure.
However, you requested to have it postponed for a few weeks
while you recover at rehab. Please call GI: ([**Telephone/Fax (1) 2233**] to
reschedule your appointment.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2138-7-31**] 3:00
Podiatry:
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2138-8-20**] 1:30
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2138-8-21**] 10:10
Completed by:[**2138-7-27**]
|
[
"428.0",
"599.70",
"E928.9",
"285.1",
"443.81",
"507.0",
"410.72",
"280.9",
"357.2",
"414.01",
"440.23",
"V58.67",
"041.4",
"494.0",
"250.60",
"427.31",
"250.40",
"585.9",
"564.09",
"599.0",
"411.1",
"867.0",
"396.2",
"414.2",
"428.42",
"584.9",
"578.1",
"403.90",
"250.70"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14640, 14688
|
7935, 12495
|
284, 291
|
14918, 14927
|
3656, 3656
|
16228, 17478
|
2936, 2953
|
12842, 14617
|
14709, 14897
|
12521, 12819
|
14951, 16205
|
2968, 3637
|
2424, 2462
|
234, 246
|
319, 2344
|
3673, 7912
|
2493, 2810
|
2366, 2404
|
2826, 2920
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,054
| 180,067
|
46867
|
Discharge summary
|
report
|
Admission Date: [**2188-12-17**] Discharge Date: [**2188-12-22**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Witnessed fall with striking leg
Major Surgical or Invasive Procedure:
Central line placement
History of Present Illness:
This is an 88 yo F with a past medical history of afib and
frequent falls, recently admitted in [**10-16**] after a mechanical
fall, who was brought to the ED by EMS after a witnessed fall at
home. Her husband said he saw her fall, noting that she only hit
her leg, no head trauma, no LOC, no loss of bowel/bladder
function. When she was picked up by EMS to be brought to [**Hospital1 18**],
she was thought to have an altered mental status and to be
slightly tachypneic, which resolved en route. In the ED, she was
found to have a temp of 101.2. She received 1L IVF and her SBP's
dropped from 100's to 70's. An EJ was placed for another liter
of IVF, and her pressure came up to the 90's. At that point a
RIJ was placed, she was given a dose of vanco, levofloxacin and
flagyl, blood cultures and ua/urine cultures were sent. Her UA
came back with moderate leuks, neg nitrates, large blood and >50
WBC's. She was admitted to the MICU for further management of
urosepsis in the setting of a leukocytosis to 20,000, persistent
fevers to 102.3, lactate of 2 and hypotension.
Of note, on last admission she was found to have a dirty UA and
was treated for 3 days on ciprofloxacin. Urine culture grew out
E. coli.
On ROS, the patient denies chest or abdominal pain, shortness of
breath, n/v/d. Admits to leg pain, but this is chronic. Denies
dysuria, but admits to 24 hours of polyuria prior to
presentation.
Past Medical History:
Past Medical History:
frequent falls
CAD - s/p MI [**00**] years ago
CHF - ? last ECHO [**7-12**] EF 70%
Atrial fibrillation, no longer on antiarrhythmic or
anticoagulation
Chronic venous stasis with b/l lower extremity edema
constipation
hernia repair
s/p appy
Social History:
Lives at home with husband (married last year). Previous husband
died 10 [**Name2 (NI) 1686**] ago. Has two children, both of whom live in [**Location (un) 5426**], and three grandchildren. She used to smoke a PPD for 40
[**Location (un) 1686**] stopped roughly 20 [**Location (un) 1686**] ago after her MI. Drinks a glass of
wine a week. No other drugs.
Family History:
NC
Physical Exam:
Temp: 98.8 (r) BP: 108/58 HR: 68 RR: 25 O2sat 92% RA, CVP 16
GEN: pleasant, comfortable, NAD (able to lay flat with no
respiratory distress)
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, poor
dentition
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules.
RESP: CTA b/l with good air movement throughout, some dependent
dry crackles
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: chronic venous stasis changes in bilateral lower
extremities, 1+ pitting edema to knees, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. 2+DTR's-patellar
and biceps
Pertinent Results:
URINE CULTURE (Final [**2188-12-18**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 16 I
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
88 yo female with h/o afib, frequent falls, admitted with
urosepsis.
# Sepsis [**1-10**] UTI: Initially presumed to be secondary to UTI
given UA results. Was, however, also evaluated for pneumonia,
community acquired or aspiration, but chest film was negative
for infiltrate or consolidation. Upon admission was hypotension
but responded to fluid [**Last Name (LF) 1868**], [**First Name3 (LF) **] patient was not in shock.
APACHE II score was 14 which estimated mortality risk of almost
17%. She improved rapidly with fluid resuscitation and never
required pressors while in the ICU. Antibiotic coverage was
started empirically for gram negative rods and gram positive
cocci with cipro and vanco. Was briefly changed to levofloxacin
for improved pulmonary coverage when she developed a cough for
one day. This was changed to ceftriaxone given her confusion,
but was ultimately returned to ciprofloxacin. E.coli was
ciprofloxacin sensitive.
Was discharged with continued antibiotics for 10 day total
course.
# Afib with RVR: Was in normal sinus rhythm upon admission but
the evening of [**2188-12-17**] developed Afib with RVR. Broken with
diltiazam boluses, then diltiazem gtt, with no response to
metoprolol IV (although had been on metoprolol XL 25mg daily at
home). Was transition to diltiazam boluses, then to a diltiazam
oral equivalent prior to discharge.
# Altered Mental Status: Initially likely secondary to
sundowning versus infection with plan to treat underlying causes
and monitor. On [**2188-12-17**] did recieve lorazepam 0.5mg IV and
olanzapine 5mg PO/SL x2 with increased delirium [**12-18**] AM. These
medications were not used further. Much improved with
conservative treatment. Continued to keep windows open and
re-orient frequently. Avoided sedating meds and physical
restraint when possible. Oral medications were briefly held for
her altered mental status as there was concern for aspiration.
Speech/swallow evaluation was obtained and her diet was adjusted
appropriately. Upon discharge, had minimal aspiration risk, but
patient consistently tries to eat/drink while lying down. She
will need to be continually sat up for all oral intake at rehab.
Will need PT/OT at rehabilitation for further treatment.
# Respiratory distress: SOB initially developed while receiving
fluid resuscitation. Initial considerations included
bronchospasm [**1-10**] volume overload v. aspiration pneumonitis v.
penumonia. CXR was unrevealing for these processes beyond mild
fluid overload. Initially responded to diuresis, but wheezing
recurred intermittently. Albuterol & ipratroprium nebs were
used as needed and she did experience mild relief. Aspiration
assessed with speech & swallow and diet adjusted accordingly.
# CAD: STABLE. CAD s/p MI [**00**] years ago. Continued Atorvastatin.
BB initially held given hypotension, then restarted for Afib
rate control. Ultimately was not useful, and was transitioned
to diltiazam.
# Hyperlipidemia: STABLE. Continued Atorvastatin.
# HTN: Normotensive since admission, and home regimen of
metoprolol XL 25mg daily held. Started on diltiazam prior to
discharge given atrial fibrillation with RVR. Discharged on
this medication.
.
# Falls: PT/OT evaluation recommended upon discharge. Social
work consult was obtained for placement. Should be monitored
for orthostatic hypotension given prolonged duration in bed
while inpatient.
Medications on Admission:
1. Atorvastatin 40 mg Tablet [**Year (2 digits) **]: One (1) Tablet PO DAILY
(Daily).
2. Docusate Sodium 100 mg Capsule [**Year (2 digits) **]: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet [**Year (2 digits) **]: One (1) Tablet PO BID (2 times a
day) as needed.
4. Folic Acid 1 mg Tablet [**Year (2 digits) **]: One (1) Tablet PO DAILY (Daily).
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Propoxyphene N-Acetaminophen 100-650 mg Tablet [**Last Name (STitle) **]: One
(1)Tablet PO Q6H (every 6 hours) as needed: Please hold for
RR<10, SBP<95.
7. Magnesium Hydroxide 1,200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
once a day as needed for low magnesium: Please resume at home
dose.
8. Quinidine Sulfate 300 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a
day as needed for for pain: Please resume at home regimen.
9. Ambien 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime as
needed for insomnia: as needed for insomina, resume at home
dosing.
10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
[**Last Name (STitle) **]: One (1) Tablet Sustained Release 24 hr PO once a day:
Please hold for HR<55.
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2
times a day).
3. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1) mL
Injection Q8H (every 8 hours): [**Month (only) 116**] discontinue as patient
becomes more active. Should not go home from rehab on this
medication if mobile.
4. Folic Acid 1 mg Tablet [**Month (only) **]: One (1) Tablet PO DAILY (Daily).
5. Hexavitamin Tablet [**Month (only) **]: One (1) Cap PO DAILY (Daily).
6. Atorvastatin 40 mg Tablet [**Month (only) **]: One (1) Tablet PO DAILY
(Daily).
7. Acetaminophen 325 mg Tablet [**Month (only) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
8. Ipratropium Bromide 0.02 % Solution [**Month (only) **]: One (1) NEB
Inhalation Q6H (every 6 hours) as needed for Wheeze.
9. Diltiazem HCl 30 mg Tablet [**Month (only) **]: One (1) Tablet PO QID (4
times a day): hold for heart rate less than 55, blood pressure
less than 95 .
10. Ciprofloxacin 500 mg Tablet [**Month (only) **]: One (1) Tablet PO Q12H
(every 12 hours) for 4 days: Total course of antibiotics 10
days.
11. Aspirin 81 mg Tablet, Chewable [**Month (only) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Outpatient Occupational Therapy
Please evaluate and treat while in rehab.
13. Outpatient Physical Therapy
Please evaluate and treat while in rehab.
14. Outpatient Speech/Swallowing Therapy
Please reassess in 1 week to establish if current diet
modifcations are still appropriate
Discharge Disposition:
Extended Care
Facility:
HEALTH BRIDGE
Discharge Diagnosis:
Primary: Urosepsis
Secondary: Atrial fibrillation with rapid ventricular response,
delirium, respiratory distress, coronary artery disease,
hyperlipidemia, hypertension
Discharge Condition:
Hemodynamically stable and afebrile
Discharge Instructions:
You were admitted for urinary tract infection that effected your
whole body, causing you to have low blood pressure. You were
treated with antibiotics. You should continue the course of
treatment as prescribed for a full 10 day course
.
Your medications have been changed while in the hospital to
control your heart rate and blood pressure. Take all
medications as prescribed, your rehab facility has been provided
with a new list which you should take.
.
Please return to the hospital or seek medical care if you notice
new fevers, pain with urination, back pain, chills or new
worsening fatigue, as these can be signs of infection. Or, for
any other symptom for which you are concerned.
Followup Instructions:
Provider: [**Name10 (NameIs) **] RM 5 [**Name10 (NameIs) **]-PREADMISSION TESTING Date/Time:[**2188-12-24**]
1:30
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2189-2-5**] 10:20
|
[
"427.31",
"401.9",
"518.82",
"414.01",
"428.0",
"272.4",
"428.32",
"038.42",
"995.92",
"785.52",
"293.0",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10496, 10536
|
4062, 5446
|
297, 322
|
10749, 10787
|
3238, 4039
|
11525, 11792
|
2431, 2435
|
8811, 10473
|
10557, 10728
|
7504, 8788
|
10811, 11502
|
2450, 3219
|
225, 259
|
350, 1758
|
5461, 7478
|
1802, 2043
|
2059, 2415
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,734
| 151,732
|
26214
|
Discharge summary
|
report
|
Admission Date: [**2199-8-15**] Discharge Date: [**2199-8-18**]
Date of Birth: [**2142-2-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Right lower lobe nodule.
Major Surgical or Invasive Procedure:
Flexible Bronchoscopy, cervical mediastinoscopy, VATS right
lower lobe wedge, VATS right lower lobe lobectomy, mediastinal
lymph node dissection
History of Present Illness:
Ms. [**Known lastname 59366**] is a 57-year-old woman who underwent a trauma and
sustained a distal radius fracture of the left. She underwent a
CT scan, which incidentally noted a 2.4 cm mass at the right
lung base.
Past Medical History:
Right lower lobe nodule
Hypothyroidism
Hemorrhoids
Lower GI bleed with a colonscopy
Unilateral oophorectomy and partial contraleral oophorectomy
[**2162**]
Vaginal polypectomy [**2198**]
Social History:
She lives with her partner. [**Name (NI) 1139**]: 30-pack-year smoker,
stopped [**2176**].
ETOH: drinks wine on weekends. Occupation: works in the human
resources.
Exposure: worked at ground zero for 4 days.
Family History:
Mother had [**Name2 (NI) 64962**] cancer
Father coronary artery disease
Brother has diabetes and sister endometriosis
Physical Exam:
General: Well-nourished, well-developed women in no apparent
distress
HEENT: EOM's full, PERRL, Sclerae anicteric, mucus membranes
moist
Neck: supple, non-tender without [**Hospital 64963**]: clear to auscultation
Cardiac: regular, rate & rhythm
GI: abdomen soft, nontender, nondistended without mass or
hematosplenomegly
Skin: no rashes or lestions noted
Neurologic: unremarkable
Brief Hospital Course:
The patient was admitted on the day of surgery and underwent an
uneventful R VATS lower lobectomy for adenocarcinoma of the
lung. Please refer to the operative note of [**2199-8-15**] for further
details of the procedure. Her [**Doctor Last Name 406**] thoracostomy tubes were
placed to water seal in the PACU, and post-operative chest X-ray
showed no pneumothorax or evidence of air leak. On POD#1,
however, she had an air leak and her [**Doctor Last Name 406**] drains were left in
until the leak resolved. On POD#2, the Blakes were put to bulb
suction and were discontinued on POD#3. By POD#4, she was tube-
and line-free, was tolerating a regular diet and oral pain
medication, and was able to care for herself with no difficulty.
She was discharged with instructions to follow up with Dr.
[**Last Name (STitle) **] in clinic in about 2 weeks.
Medications on Admission:
1. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q3-4H (Every 3 to 4 Hours) as needed for pain.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Right lower lobe lung cancer
Hypothyroidism
Hemorrhoids
Lower GI bleed with colonscopy [**2198**]
Vaginal polypectomy [**2198**]
Unilateral oophorectomy and partial contralateral oophorectomy
[**2162**]'s
Discharge Condition:
Good
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office ([**Telephone/Fax (1) 170**]) if you experience
any of the following symptoms:
* Fever (>101 F) or chills
* new and continuing nausea or vomiting
* Abdominal or chest pain
* Shortness of breath
* Redness or drainage, swelling, warmth, or pus production
around wound site
* Any other concerns
You may remove your dressings XXXX and shower.
If you experience clear drainage from your wounds, cover them
with a
clean dressing and stop showering until the drainage subsides
for at
least 2 days.
No driving while taking pain medications.
Narcotics can cause constipation. Please take an over the
counter stool softener such as Colace or a gentle laxative such
as Milk of Magnesia if you experience constipation.
You may resume your regular diet as tolerated.
Walk at least 4-5 times per day for 10-15 minutes at a time with
rest periods as needed. please gradually activity level as
tolerated
Followup Instructions:
Follow-up with Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**]
Completed by:[**2199-8-18**]
|
[
"244.9",
"162.5",
"455.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.22",
"32.4",
"34.21",
"40.3"
] |
icd9pcs
|
[
[
[]
]
] |
2895, 2901
|
1691, 2540
|
304, 451
|
3150, 3157
|
4132, 4237
|
1152, 1271
|
2659, 2872
|
2922, 3129
|
2566, 2636
|
3181, 4109
|
1286, 1668
|
239, 266
|
479, 699
|
721, 909
|
925, 1136
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,481
| 180,195
|
29732
|
Discharge summary
|
report
|
Admission Date: [**2109-5-16**] Discharge Date: [**2109-5-23**]
Date of Birth: [**2041-10-30**] Sex: M
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Mental status change
Major Surgical or Invasive Procedure:
Ligation of VP shunt
History of Present Illness:
The patient is a 67 year old man with a history of head trauma
from MVA 2.5 months ago during which he sustained subdural,
subarachnoid, and epidural bleeds. He subsequently [**First Name3 (LF) 1834**] a
right sided hemi-craniectomy for hematoma evacuation. About one
month later, he developed significant hydrocephalus and a VP
shunt was placed from the left on [**4-25**].
Was recently admitted to [**Hospital1 18**] [**2109-5-6**] for leukocytosis of
unknown
origin. Shunt was not tapped and source of leukocytosis was not
found, but did find DVT.
Was at [**Hospital1 **] where someone noted that he was less verbal
than
usual. Usually mumbles but had been noted to stop. There fore
had CT which showed right hemispheric bleed he was then
transferred here
Past Medical History:
# Right hemicraniectomy in [**3-6**] - struck as a pedestrian and
sustained a closed head injury resulting in SAH, SDH, epidural
hemorrhage, sagittal sinus laceration and fractures requiring
right-sided hemicraniectomy, evacuation of hematoma, and dural
repair of the superior sagittal sinus by Dr. [**Last Name (STitle) **]. Resides at
[**Hospital3 **] where is baseline function is awake
occassionally, interactive, plegic on left and withdraws on the
right.
# Superior saggital thrombosis
# From hospital admission in [**2109-2-28**]
1) Fevers likely secondary to:
2) drug hypersensitivity with Dilantin
3) Chemical pancreatitis (likely secondary to #2)
4) Transaminitis/hepatitis (likely secondary to #2)
5) Thrombocytosis - likely secondary to #2 + s/p CNS
injury/surgery
6) Moderate malnutrition
7) Anemia of inflammation, no evidence for hemolysis, with some
mild blood loss - trace occult blood positive stools
8) Hypertension
9) Elevation of alpha-1-antitrypsin - query significance -
would repeat when acute inflammatory state subsides
# IVC filter place [**3-19**]
# S/P PEG
# S/P VP shunt on [**2109-4-25**] for hyrdrocephalus
# Central apnea - uses BIPAP
Social History:
Married with involved family, patient now resides at [**Hospital1 **].
Family History:
Noncontributory
Physical Exam:
Vitals: 97.8 97 140/77 18
General: well nourished, in no acute distress, evidence of right
crani.
Neck: supple
Lungs: clear to auscultation
CV: regular rate and rhythm
Abdomen: non-tender, non-distended, bowel sounds present, GT
intact.
Ext: warm, trace pedal edema
Neurologic Examination:
eyes closed, not talking, not following commands, pupils
equal and reactive, eyes at mid-position, face
symmetric, paratonia in arms, withdraws to pain on right
vigorously, slight extenor posturing on left with noxious stim
and and withdraws in left leg. reflexes 2+ throughout, toe up on
left, down right.
Pertinent Results:
[**2109-5-16**] 04:30PM PT-12.8 PTT-26.9 INR(PT)-1.1
[**2109-5-16**] 04:30PM PLT COUNT-468*
[**2109-5-16**] 04:30PM ANISOCYT-1+
[**2109-5-16**] 04:30PM NEUTS-79.5* LYMPHS-13.3* MONOS-3.9 EOS-2.6
BASOS-0.8
[**2109-5-16**] 04:30PM WBC-15.5* RBC-4.12* HGB-12.1* HCT-36.2*
MCV-88 MCH-29.5 MCHC-33.5 RDW-16.7*
[**2109-5-16**] 04:30PM estGFR-Using this
[**2109-5-16**] 04:30PM GLUCOSE-106* UREA N-18 CREAT-0.5 SODIUM-141
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-29 ANION GAP-14
[**2109-5-16**] 07:45PM URINE AMORPH-FEW
[**2109-5-16**] 07:45PM URINE RBC->50 WBC-0 BACTERIA-MOD YEAST-NONE
EPI-0
[**2109-5-16**] 07:45PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2109-5-16**] 11:30PM CEREBROSPINAL FLUID (CSF) PROTEIN-143*
GLUCOSE-82
[**2109-5-16**] 11:30PM CEREBROSPINAL FLUID (CSF) WBC-6 RBC-3175*
POLYS-55 LYMPHS-27 MONOS-11 EOS-4 MESOTHELI-1 MACROPHAG-2
[**2109-5-16**] 07:50PM TYPE-ART PO2-89 PCO2-41 PH-7.47* TOTAL
CO2-31* BASE XS-5
[**2109-5-16**] 07:45PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.017
[**2109-5-16**] 07:45PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
Brief Hospital Course:
The patient is a 67-year-old male after a severe motor vehicle
accident. A craniectomy was performed in the past and then a VP
shunt from the left side. However, the shunt has been over
shunting and the patient presented with
progressive decline in mental status with a CAT scan showing
severe midline shift towards the left side and intracranial
hemorrhage. Based on that, we decided that the patient was over
shunted and that was creating negative pressure which
has as a result the midline shift and the pressure and the
hemorrhage in the patient's brain. Extensive discussion was
carried out with the family especially the guarded prognosis and
it was decided to take the patient to the OR to reverse
the shunt by tying down and revising the proximal part. The
risks and benefits were discussed. In the OR CSF was sent for
culture which was negative.
He was monitored in the ICU for 4 days with a poor exam, he
developed a right non reactive pupil on POD#1 and his exam was
consistent with posturing. His CT did show some improvement in
midline shift for 48 hours but then later worsened on post op
day 3 The degree of inward deformation of the right
frontal-temporal convexity cortex is unaltered. No apparent
extension of the hemorrhage seen along the posterior margin of
the craniectomy defect is apparent.
Given the overall poor prognosis, the family decided to make Mr
[**Known lastname 3315**] CMO. He was placed on a Morphine drip, given a
scopolamine patch and pallative care was consulted.
Patient passed away [**2109-4-22**] at 2315. Wife [**Name (NI) 12056**] [**Name (NI) 3315**] was
called. Deferred autopsy. Medical examiner called and case
accepted.
Medications on Admission:
Methylphenydate 15 [**Hospital1 **]
Modafinil 200mg daily
SRH miracle cream
Chlorhexadine Glucon rinse [**Hospital1 **]
Biscodul supp 10 daily
Dalteparin Sodium 7500 units [**Hospital1 **]
Lopressor 50 [**Hospital1 **]
Albuterol QID
Amantadine 100 [**Hospital1 **]
Thiamine 100 QHS
MVI
Tylenol
MOM
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
head trauma s/p MVA
Discharge Condition:
NA
Discharge Instructions:
NA
Followup Instructions:
NA
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
|
[
"263.9",
"453.41",
"E878.1",
"V66.7",
"432.9",
"996.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"54.95"
] |
icd9pcs
|
[
[
[]
]
] |
6384, 6393
|
4325, 6006
|
307, 329
|
6457, 6462
|
3069, 4302
|
6513, 6614
|
2416, 2433
|
6355, 6361
|
6414, 6436
|
6032, 6332
|
6486, 6490
|
2448, 2716
|
247, 269
|
357, 1118
|
2740, 3050
|
1140, 2311
|
2327, 2400
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,182
| 169,146
|
25379
|
Discharge summary
|
report
|
Admission Date: [**2145-3-28**] Discharge Date: [**2145-4-5**]
Date of Birth: [**2071-1-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
left heart catheterization, coronary angiogram, left
ventriculogram
Coronary Artery Bypass Graftingx5(left internal mammary artery
to left anterior descending, with saphenous vein grafts to
diagonal, first obtuse marginal, second obtuse marginal, and
posterior descending artery
History of Present Illness:
Mr. [**Known lastname 4541**] is a 70 year old male who presented to another
institution with right sided chest pain and ruled in for NSTEMI
with a troponin of 1.0. He was transferred to [**Hospital1 18**] for
catheterization.
He reported right sided, parasternal pain intermittently for 2
weeks. No pain prior to this. This was descibed as squeezing
and dull, lasting 10-15 minutes, both at rest and with
exertion, but mostly in exertion. It radiated to the right
shoulder and down to his arm. On [**3-27**] after a large meal, he had
a recurrence, with nausea and diaphoresis. He was taken to the
ED at [**Location (un) **] where he had Sinus bradycardia, AV block (old),
TwI V1, V2 biphasic Tw, I Twf, aVL TwI. He was free of angina
upon arrival to ED. He ruled in based on a Troponin of 1.05. he
was loaded with Plavix 300mg, given ASA, beta blocker, and a
Heparin infusion was begun. Heparin infusion was discontinued at
transfer.
Past Medical History:
Coronary Artery Disease
Prior PCI/stenting(drug-eluting) to LAD and RCA in [**2140**]
hyperlipidemia
Hypertension
Type 2 Diabetes Mellitus
s/p AAA repair [**10-6**]
Renal tumor - stable per patient
Social History:
Civil engineer, still works, married.
.
-Tobacco history: Quit [**2118**], 4ppd x 30 years
-ETOH: Denies
-Illicit drugs: Denies
Family History:
(+) FHx CAD: Father died of an MI at age 74
No family history of arrhythmia, cardiomyopathies; otherwise
non-contributory.
Physical Exam:
Admission
VS: 96.5F 109/59 60 18 97% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 5 cm.
CARDIAC: PMI could not assess. RR, Low S1, nl S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Obese, Soft, NTND. No abdominial bruits.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+
Left: Carotid 2+ Femoral 2+ DP 2+
Pertinent Results:
[**2145-3-29**] Echocardiogram: The left atrium is dilated. Left
ventricular wall thicknesses and cavity size are normal. There
is mild regional left ventricular systolic dysfunction with mild
hypokinesis of the mid to distal anterior wall, anterior septum
and apex and moderate hypokinesis of the anterolateral wall..
Diastolic function could not be assessed. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic root is moderately
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
[**2145-3-30**] Carotid Ultrasound:
Right ICA stenosis <40%. Left ICA stenosis <40%.
.
[**2145-3-30**] Chest CT Scan:
No pneumonia, no lung masses, no pleural effusions.
Calcifications of the coronary arteries, the aorta and the
supraaortic branches. Slightly increased number of mediastinal
lymph nodes, but no mediastinal lymphadenopathy. Large hepatic
cyst.
.
[**2145-4-1**] Intraop TEE:
PRE BYPASS The left atrium is markedly dilated. The left atrium
is elongated. No spontaneous echo contrast or thrombus is seen
in the body of the left atrium or left atrial appendage. No
atrial septal defect is seen by 2D or color Doppler. The left
ventricular cavity size is normal. There is mild global left
ventricular hypokinesis (LVEF = 40-45 %). In addition, the
anterior, anterolateral, anteroseptal and apical walls have
slightly more hypokinesis then the rest of the other myocardial
segments. Right ventricular chamber size and free wall motion
are normal. The ascending aorta is mildly dilated. There are
simple atheroma in the aortic arch. There are complex (mobile)
atheroma in the descending 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. Physiologic mitral regurgitation is seen
(within normal limits). Dr. [**Last Name (STitle) 914**] was notified in person of
the results in the operating room at the time of the study.
POST BYPASS The patient is being AV paced. There is normal right
ventricular systolic function. The left ventricle displays
slightly improved global function with continued mild
hypokinesis of the anterior, anteroseptal, anterolateral, and
apical segments. Overall ejection fraction is about 45%. The
mitral regurgitation is slightly worse, now mild. The thoracic
aorta appears intact.
[**2145-4-5**] 05:40AM BLOOD WBC-8.0 RBC-2.98* Hgb-9.2* Hct-26.4*
MCV-89 MCH-31.0 MCHC-35.0 RDW-13.1 Plt Ct-177
[**2145-4-5**] 05:40AM BLOOD Glucose-129* UreaN-18 Creat-0.9 Na-131*
K-4.3 Cl-97 HCO3-24 AnGap-14
Brief Hospital Course:
Mr. [**Known lastname 4541**] was admitted to cardiology with a non ST elevation
myocardial infarction. He remained pain free on intravenous
Heparin and medical therapy. The following day, he underwent
cardiac catheterization which revealed severe three vessel
coronary artery disease. Based upon the findings, cardiac
surgery was consulted and further preoperative evaluation was
performed. In anticipation of surgery, Plavix was discontinued.
Carotid ultrasound found only minimal disease of the internal
carotid arteries. To further evaluate his ascending aorta, chest
CT scan was obtained which showed that the ascending aorta had a
maximal diameter of only four centimeters. The remainder of his
preoperative course was uneventful. He remained pain free and
was eventually cleared for surgery.
On [**4-1**], Dr. [**Last Name (STitle) 914**] performed coronary artery bypass
grafting surgery. For surgical details, please see operative
note. Given his inpatient stay was greater than 24 hours prior
to surgery, he was given Vancomycin for perioperative antibiotic
coverage. Following surgery, he was brought to the CVICU for
invasive monitoring. Within 24 hours, he awoke neurologically
intact and was extubated without incident. The patient was
transferred to the telemetry floor on POD 1. Chest tubes and
pacing wires were discontinued without incident according to
protocol. The physical therapy service was consulted for
assistance with post-operative strength and mobility.
He did have multifocal atrial tachycardia for which EP was
consulted. Low dose beta blockers were recommended and begun.
He remained stable and was ready for discharge. Dr. [**Last Name (STitle) **] will
follow him after discharge for cardiology and is aware of the
dyrhythmia.
Discharge medications, restrictions and followup were discussed
with the patient prior to going home.
Medications on Admission:
Medications at home: MEDS ON TRANSFER:
AMLODIPINE 5MG DAILY ASA 325MG DAILY
ATENOLOL 50MG DAILY PLAVIX 75 MG DAILY
ASA 325MG DAILY METOPROLOL 12.5MG [**Hospital1 **]
ZOCOR 40MG DAILY OMEPRAZOLE 40MG DAILY
LATANOPROST QHS SIMVASTATIN 80MG DAILY
Metformin GLARGINE 10UNITS QHS
INSULIN HSS
LATANOPROST 1GTT EACH EYE
HEPARIN
Discharge Medications:
1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain .
7. Oxycodone-Acetaminophen 5-500 mg Capsule Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain for 2 weeks.
Disp:*50 Tablet(s)* Refills:*0*
8. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary Artery Disease,
s/p coronary artery bypass grafts
s/p Non ST Elevation Myocardial Infarction
Type II Diabetes
s/p coronary artery stenting
s/p Abdominal Aortic Aneurysm Repair
Renal Tumor
hyperlipidemia
Discharge Condition:
good
Discharge Instructions:
No lotions, creams or powders on any incision.
Shower daily and pat incision dry. No baths or swimming.
No driving for one month and taking narcotics.
No lifting greater than 10 pounds for 10 weeks.
Call for fever greater than 100.5.
Call for redness of, or drainage from incisions.
Call for weight gain greater than 2 pounds a day or 5 pounds in
a week
take all medications as directed.
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 47998**] in [**1-5**] weeks ([**Telephone/Fax (1) 3070**])
Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **] in [**1-5**] weeks, call for appt
[**Hospital Ward Name 121**] 6 wound clinic in 2 weeks
please call for appointments
Completed by:[**2145-4-5**]
|
[
"427.89",
"426.13",
"239.5",
"401.9",
"410.71",
"416.8",
"250.00",
"V45.82",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"36.15",
"88.56",
"39.61",
"36.14"
] |
icd9pcs
|
[
[
[]
]
] |
9322, 9381
|
5763, 7635
|
330, 611
|
9637, 9644
|
2820, 5740
|
10081, 10501
|
1968, 2093
|
8236, 9299
|
9402, 9616
|
7661, 7661
|
9669, 10058
|
7696, 7696
|
2108, 2801
|
280, 292
|
639, 1583
|
1605, 1806
|
1822, 1952
|
7714, 8213
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,559
| 146,108
|
1151
|
Discharge summary
|
report
|
Admission Date: [**2154-9-16**] Discharge Date: [**2154-9-24**]
Date of Birth: [**2085-11-19**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Ace Inhibitors
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Found unresponsive
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Patient is a 68 yo woman with PMH of MI, HTN, Breast CA s/p
treatment without recurrence, Bipolar, right lung nodule. She
is
primarily Russian speaking but understands some English. She
lives alone in an appartement and was last hear from yesterday
at
1800 when she spoke with her sister. She was well at that time
and had no complaints. This morning, the patient did not show
up
for her adult daycare program. The daughter was notified of
this
and called 911 around 1000 to have them go check on her mother.
EMS arrived at 1030 and found her on the floor, unresponsive
with
GCS 3. Their notes are minimal, but report stable vital signs
including sats of 96% on o2 and BS 198. They reported no facia
droop. They witnessed a generalized seizure lasting unknown
period of time which was treated with Ativan 2mg. Arrived to ED
unresponsive except for sternal rub. Per ED, she was noted to
move both sides but R>L with sternal rub. She was not following
any commands and was not moving sponatneously. She had a second
witnessed GTC seizure lasting 1 minute in the ED which was
treated with 2mg Ativan IV.
The patient's daughter [**Name (NI) 391**] says that the patient has been
going to adult day care for "depression and living alone", but
says the patient has no diagnosis of dementia. Reports that the
patient does live alone (was erroneously reported earlier that
pt
may live in nursing home). Was last heard from yesterday at
1800. Was not depressed at that time, but has been noted to be
extremely Manic the last 2 weeks. The patient has h/o bipolar
but has not had a manic episode for weeks now. Reports that her
mother some times enjoys being manic, but is also sometimes
exhausted and tormented by this state. Has had suicide attempt
by overdose in the past, about 5 yrs ago and more recently has
had mild unintentional overdoses when trying to self medicate
for
insomnia. The daughter reports that in addition to the mania,
her memory has been poor these last 2 weeks. She recently
started seeing a new Psychiatrist who started her on lithium.
Past Medical History:
PMH: per daughter, has no h/o stroke or seizures.
Per Notes:
1. Her past medical history is significant for coronary artery
disease, status post myocardial infarction and she has been
followed by you for this.
2. Hypertension.
3. Dyslipidemia.
4. Bilateral breast cancer, status post treatment without
recurrence.
5. Osteoarthritis, particularly affecting both knees but she
states that the osteoarthritic knee pain is different than her
claudication symptoms.
6. Depression, status post ECT and being followed actively by a
psychiatrist.
7. History of tubulovillous adenoma.
8. Right lung nodule followed by serial CAT scans without
progression.
Social History:
Smokes. There is no history of drug or alcohol abuse. She is a
retired
engineer. She lives in [**Location 86**] in an appartment. There was
report from EMS and ED that patient was coming from some type of
elderly living situation, however daughter says that this is
just
an appartment complex with security and that there is no nursing
care or other there. The patient goes to adult day care during
the day time.
Family History:
There is no family history for premature coronary artery disease
or sudden cardiac death.
Physical Exam:
T- 99.2 R BP- 123/53 HR- 110 RR- vented O2Sat 100 VEnt
Gen: Lying in bed, getting bagged pre-intubation. Sedated with
ativan. Not yet paralyzed but soon.
HEENT: NC/AT, moist oral mucosa
Neck: hard collar
Back: No erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft
ext: no edema
Neurologic examination:
Mental status: Getting bagged pre-intubation and now s/p 4mg
Ativan. Eyes closed and does not respond to sternal rub or
other
noxious stim x 4. Does not follow commands. No spontaneous
movement.
Cranial Nerves:
Pupils 2mm and only minimally reactive bilaterally. No Doll's
reflex. No deviation. No blink to threat. No corneals. No
gag. Tongue midline. Face difficult to assess.
Motor:
Normal bulk bilaterally. Tone flaccid throughout. No observed
myoclonus or tremor
Does not withdraw to noxious stim x 4 and no spontaneous. Noted
by ED to move with sternal rub Right greater than left.
Sensation: no withdrawl or grimace x 4.
Reflexes:
Trace at Biceps, otherwise absent.
Toes mute bilaterally
Coordination: NA.
Gait: NA.
Romberg: NA
Pertinent Results:
[**2154-9-16**] 10:58PM CK(CPK)-979*
[**2154-9-16**] 10:58PM CK-MB-17* MB INDX-1.7 cTropnT-0.02*
[**2154-9-16**] 05:59PM TYPE-ART PO2-124* PCO2-46* PH-7.41 TOTAL
CO2-30 BASE XS-4
[**2154-9-16**] 05:59PM LACTATE-1.3
[**2154-9-16**] 05:45PM GLUCOSE-129* UREA N-16 CREAT-1.1 SODIUM-135
POTASSIUM-2.8* CHLORIDE-99 TOTAL CO2-26 ANION GAP-13
[**2154-9-16**] 05:45PM CK(CPK)-784*
[**2154-9-16**] 05:45PM CK-MB-18* MB INDX-2.3 cTropnT-0.01
[**2154-9-16**] 05:45PM CALCIUM-9.0 PHOSPHATE-3.0# MAGNESIUM-1.7
[**2154-9-16**] 05:45PM PHENYTOIN-11.2 LITHIUM-2.0*
[**2154-9-16**] 01:15PM CEREBROSPINAL FLUID (CSF) PROTEIN-41
GLUCOSE-103
[**2154-9-16**] 01:15PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 POLYS-0
LYMPHS-40 MONOS-60
[**2154-9-16**] 12:35PM WBC-14.7*# RBC-4.40# HGB-13.4# HCT-39.0#
MCV-89# MCH-30.3 MCHC-34.3# RDW-14.9
[**2154-9-16**] 12:35PM NEUTS-94.6* BANDS-0 LYMPHS-3.0* MONOS-2.2
EOS-0.2 BASOS-0
[**2154-9-16**] 12:35PM NEUTS-94.6* BANDS-0 LYMPHS-3.0* MONOS-2.2
EOS-0.2 BASOS-0
[**2154-9-16**] 12:35PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2154-9-16**] 12:35PM PLT SMR-NORMAL PLT COUNT-236#
[**2154-9-16**] 11:55AM URINE HOURS-RANDOM
[**2154-9-16**] 11:55AM URINE HOURS-RANDOM
[**2154-9-16**] 11:55AM URINE GR HOLD-HOLD
[**2154-9-16**] 11:55AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2154-9-16**] 11:55AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2154-9-16**] 11:55AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2154-9-16**] 11:55AM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2154-9-16**] 11:25AM GLUCOSE-126* NA+-139 K+-3.4* CL--99* TCO2-14*
[**2154-9-16**] 11:10AM ALT(SGPT)-31 AST(SGOT)-40 CK(CPK)-349* ALK
PHOS-106 AMYLASE-88 TOT BILI-0.3
[**2154-9-16**] 11:10AM LIPASE-100*
[**2154-9-16**] 11:10AM CK-MB-12* MB INDX-3.4
[**2154-9-16**] 11:10AM cTropnT-0.02*
[**2154-9-16**] 11:10AM ALBUMIN-4.4 CALCIUM-9.8 PHOSPHATE-6.7*
MAGNESIUM-2.2
[**2154-9-16**] 11:10AM LITHIUM-2.4*#
[**2154-9-16**] 11:10AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2154-9-16**] 11:10AM PT-13.4* PTT-25.4 INR(PT)-1.2*
[**2154-9-16**] 11:08AM COMMENTS-GREEN TOP
[**2154-9-16**] 11:08AM GLUCOSE-66* LACTATE-7.8* NA+-142 K+-1.9*
CL--127* TCO2-6*
[**2154-9-16**] 11:00AM UREA N-8 CREAT-0.5
[**2154-9-16**] 11:00AM estGFR-Using this
[**2154-9-16**] 11:00AM AMYLASE-26
[**2154-9-16**] 11:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2154-9-16**] 11:00AM WBC-5.5 RBC-2.36* HGB-7.0* HCT-23.4* MCV-99*
MCH-29.8 MCHC-30.0* RDW-14.8
[**2154-9-16**] 11:00AM PLT COUNT-146*
EEG [**2154-9-16**]: This is a likely normal portable EEG. No focal,
lateralized, or epileptiform discharges were noted. No seizure
activity
was noted. If clinically warranted, the study could be repeated
during
the more waking state so that transitions in state could be
evaluated.
CXR [**2154-9-16**]: An endotracheal tube terminates with its tip 3
cm above the carina in satisfactory position. The
cardiomediastinal contour is normal. Allowing for technique,
the heart is not definitely enlarged. There is a linear
retrocardiac density and blunting of the left costophrenic angle
likely due to left lower lobe atelectasis. The right lung is
clear. The bony thorax is normal.
NCHCT [**2154-9-16**]:
1. No evidence of intracranial hemorrhage or other acute
process. An MRI is recommended if there is concern for acute
stroke.
2. Cerebellar lacunes, mild small vessel ischemia changes.
C-spine CT [**2154-9-16**]:
1) No evidence of fracture or dislocation.
2) Mild degenerative changes.
3) Heterogeneous thyroid with suggestion of a left lobe nodule.
Correlation with clinical evaluation is recommendend.
4) Emphysema.
MRI/A head [**2154-9-17**]:
Small right frontal subcortical acute infarction, otherwise
unremarkable
study.
Sequela of small vessel ischemia and old bilateral cerebellar
infarcts.
EEG [**2154-9-19**]:
Abnormal EEG due to the mildly slow and very disorganized
background with bursts of generalized slowing. These findings
indicate
a widespread encephalopathy affecting both cortical and
subcortical
structures. Medications, metabolic disturbances, and infection
are
among the most common causes. There were no areas of prominent
focal
slowing, and there were no epileptiform features.
Carotid U/S [**2154-9-19**]:
Duplex and color Doppler demonstrate normal carotid systems
bilaterally. There is also normal antegrade flow involving both
vertebral
arteries.
ECHO [**2154-9-19**]:
The left atrium is mildly elongated. The estimated right atrial
pressure is 0-5mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and systolic function
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets appear structurally normal with good leaflet excursion.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. No
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is an anterior space
which most likely represents a fat pad.
Mild symmetric left ventricular hypertrophy with preserved
global and regional biventricular systolic function. Moderate
mitral annular calcification. No definite structural cardiac
source of embolism identified.
Brief Hospital Course:
The patient was initially admitted to the neurology ICU with
diagnosis of seizures. Initial psychiatric medications were
held, and she was intubated for decreased mental status. She
was loaded with dilantin. Her lithium level was found to be
elevated to 2.4; she was seen by toxicology, who felt that
dialysis was not indicated at this point. Her lithium level
trended down in the blood, though psychiatry pointed out that
CNS levels remain quite high for a lengthier period of time, and
that she may prove to be slow to return to baseline. The
seizures were felt to be related to the lithium toxicity, thus
dilantin was discontinued. Her EEG showed no epileptiform
activity. She was extubated within 24 hours. Incidentally, she
was found to have a punctate infarct on MRI in the right frontal
lobe (MRI performed as part of workup for seizure). She was
transferred to the floor, where LFTs were found to be elevated,
and gradually trended down once she was taken off statin
therapy. Her second EEG showed mild encephalopathy with a
background of 7.5 Hz and periodic generalized slowing. Her
renal function also worsened slightly during the hospital stay,
after reinitiation of HCTZ, Lasix and an ace-I for blood
pressure control. This improved with IV fluid and elimination
of her renally cleared medications. Intermittently, she had
some urinary retention, thought due to dehydration from not
eating or drinking enough; both her BUN/Creatinine and urinary
output improved with some IV fluid boluses, and at the time of
discharge, she was urinating without a foley catheter and eating
and drinking. HCTZ and Lisinopril were reinitiated with no
change in her BUN/Creatinine. Peak transaminases were: AST 150,
ALT 106, LDH 450; at discharge, AST 59, ALT 85, Alk phos 85,
tBili 0.4, LDH 323.
Her mental status after extubation was consistent with
inattention, suggestive of encephalopathy. She also had
auditory hallucinations, and became mute (without neurological
cause) on one day. She required a sitter for her active
hallucinations and agitation at times. This was felt to be
related to toxic-metabolic disturbances above (transaminitis,
elevated BUN/Creatinine (creat to 1.4 peak), and residual
effects from the lithium). Psychiatry followed her throughout
the admission and she was noted to have some improvement of the
encephalopathy; as this cleared she was noted to be more manic
on exam, with pressured speech and inappropriate laughter. She
had been placed on Zyprexa with doses titrated up to 5mg [**Hospital1 **]
plus 10mg qhs at the time of discharge, to treat both the
delirium and the mania.
She had a rash at discharge that was felt to be consistent with
Zoster; she was started on Valtrex at the time of discharge.
She had guaiac positive stools at one point (no frank blood),
and as her hematocrit was stable (minus dilutional effects from
IV fluid boluses), she was instructed to follow up with GI as an
outpatient.
Regarding workup of the incidental stroke, her echo and carotids
were normal, revealing no source of embolus. Her a1c was 5.7,
suggesting no diabetes, and as her cholesterol panel was checked
(HDL 54, LDL 81, Tchol 169, trig 172) and was near goal for this
patient with CAD history and stroke, and due to her
transaminitis, statin therapy was not continued. She was
continued on aspirin and plavix for stroke prevention, and
ultimately the stroke was felt to be related to an accumulation
of vascular risk factors with no obvious embolic source.
Medications on Admission:
Cymbalta 40 [**Hospital1 **]
Clonipin 1 [**Hospital1 **]
Lasix 20 daily
Pepcid 20
Topamax 25 [**Hospital1 **] - NOT TAKING, per family
Loperamide 2
Colace
Seroquel 200 QHS
Prednisone (has bottle, but old Rx and doubt taking)
Lisinopril/HCTZ 20/25 daily
Benadryl 50 daily
Trazadone 150 daily
Vytorin 10/40
Plavix 75 daily
Lopressor 50 [**Hospital1 **]
Lacmital 50 [**Hospital1 **] - NOT TAKING, per family
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: [**11-27**] puff
Inhalation Q4H (every 4 hours) as needed for wheezing.
7. Ipratropium Bromide 0.02 % Solution Sig: 1-2 puffs Inhalation
Q8H (every 8 hours) as needed for wheezing.
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. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day).
11. Olanzapine 10 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)).
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] elizabeths
Discharge Diagnosis:
Seizures due to lithium toxicity
Right frontal stroke
Discharge Condition:
Stable. The patient was awake, alert, laughing frequently. She
was able to do the days of the week forward only and could
identify objects on her meal [**Doctor Last Name **]. She had diffuse motor
impersistence on exam.
Discharge Instructions:
Please take your medications as prescribed and follow up with
appointments as scheduled.
Followup Instructions:
Please call your primary care physician, [**Name10 (NameIs) **] [**Name11 (NameIs) 5102**] at ([**Telephone/Fax (1) 7393**] to schedule follow up in [**12-30**] weeks.
Please call Neurology [**Hospital 4038**] Clinic to set up follow up with
either Dr. [**First Name (STitle) **] [**Name (STitle) **] [([**Telephone/Fax (1) 7394**]] or Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
in [**12-30**] weeks.
There was evidence of microscopic blood in your stool. Please
call ([**Telephone/Fax (1) 2233**] to set up an outpatient follow up.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
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"414.01",
"780.09",
"434.91",
"305.1",
"296.40",
"780.39",
"E849.0",
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icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.93",
"96.04"
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icd9pcs
|
[
[
[]
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15416, 15477
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10469, 13976
|
309, 321
|
15575, 15801
|
4807, 10446
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14432, 15393
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251, 271
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349, 2425
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4249, 4788
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4049, 4233
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4034, 4034
|
2447, 3104
|
3120, 3540
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,865
| 165,493
|
40008
|
Discharge summary
|
report
|
Admission Date: [**2162-11-28**] Discharge Date: [**2162-12-3**]
Date of Birth: [**2078-7-13**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
left rib fractures, left clavicle fracture
Major Surgical or Invasive Procedure:
Placement of epidural catheter [**11-29**], d/c [**12-1**]
History of Present Illness:
This patient is a 84 year old male who complains of MVC.
Patient crashed his moped. He was helmeted, there was no
loss of consciousness. He was initially taken to an outside
hospital where he was found to have fractures of ribs 2
through 5. Shortly thereafter, the patient became
hypotensive and a repeat chest x-ray demonstrated a wide
mediastinum. At this point to transfer was arranged here.
In the interim, the patient has had a CT scan of the torso.
This reveals no aortic injury. The patient's blood pressure
stabilized with fluids, and he is remained stable for the
past hour.
Timing: Sudden Onset
Severity: Moderate
Duration: Minutes to Hours
Past Medical History:
PMH: HTN
Social History:
nc
Family History:
son and daughter live with patient
Physical Exam:
[**2162-11-28**]:
PHYSICAL EXAMINATION
HR:80s BP:130/p Resp:16 O(2)Sat:98 normal
Constitutional: Boarded/collared
HEENT: Normocephalic, atraumatic
Chest: Clear to auscultation, tender chest wall upper left
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
Extr/Back: Extremities atraumatic
Skin: Warm and dry
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2162-12-3**] 05:30 9.2 4.38* 12.5* 37.2* 85 28.6 33.7 15.9* 221
[**2162-12-1**] 06:30AM BLOOD WBC-7.7 RBC-3.99* Hgb-11.6* Hct-33.7*
MCV-84 MCH-29.0 MCHC-34.3 RDW-15.6* Plt Ct-154
[**2162-11-30**] 12:26AM BLOOD WBC-8.3 RBC-3.80* Hgb-11.0* Hct-32.1*
MCV-84 MCH-28.9 MCHC-34.2 RDW-15.7* Plt Ct-137*
[**2162-11-29**] 06:12AM BLOOD WBC-9.8 RBC-4.01* Hgb-11.7* Hct-34.1*
MCV-85 MCH-29.2 MCHC-34.3 RDW-15.8* Plt Ct-156
[**2162-11-28**] 06:50PM BLOOD WBC-14.4* RBC-4.57* Hgb-13.2* Hct-39.2*
MCV-86 MCH-28.9 MCHC-33.7 RDW-15.6* Plt Ct-176
[**2162-12-1**] 06:30AM BLOOD Plt Ct-154
[**2162-11-30**] 12:26AM BLOOD Plt Ct-137*
[**2162-11-29**] 06:12AM BLOOD Plt Ct-156
[**2162-11-28**] 06:50PM BLOOD Fibrino-538*
[**2162-11-30**] 12:26AM BLOOD Glucose-102* UreaN-14 Creat-0.8 Na-138
K-4.3 Cl-106 HCO3-26 AnGap-10
[**2162-11-29**] 06:12AM BLOOD Glucose-99 UreaN-15 Creat-0.8 Na-139
K-4.3 Cl-109* HCO3-25 AnGap-9
[**2162-11-28**] 06:50PM BLOOD UreaN-21* Creat-1.2
[**2162-12-1**] 06:30AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.2
[**2162-11-30**] 12:26AM BLOOD Calcium-8.4 Phos-2.3* Mg-2.2
[**2162-11-28**] 11:08PM BLOOD Lactate-1.1
[**2162-11-28**]: EKG:
Normal sinus rhythm. Borderline first degree A-V block. Right
bundle-branch block. Compared to tracing #1 there is no
diagnostic interim change
[**2162-11-28**]:
IMPRESSION:
1. Left clavicle and left rib fractures, better assessed on OSH
CT.
2. Irregular, bubbly appearance of the right humeral head.
Dedicated right
shoulder radiographs are recommended
[**2162-11-28**]: cat scan of pelvis:
IMPRESSION:
1. Left posterior rib fractures (3-8th). Left mid clavicle
fracture.
2. Mildly thickened esophagus. Please correlate clinically and
with EGD is
indicated.
3. Lucent lesion in the right humeral head which is incompletely
imaged,
dedicated radiograph of the right humerus is recommended for
further workup.
4. Sclerotic lesion at the right medial pubic ramus, DDx
includes
post-radiation, bony metastasis (h/o prostate ca?) or
degenerative
[**2162-11-28**]: Chest x-ray:
Mild interstitial pulmonary edema has worsened. Heart is
borderline enlarged.
Mediastinal and pulmonary vascularity is engorged. Small right
pleural
effusion is new. No pneumothorax
[**2162-11-29**]: echo:
The left atrium and right atrium are normal in cavity size. The
right atrial pressure is indeterminate. There is mild symmetric
left ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The ascending aorta and aortic arch are mildly
dilated. The aortic valve leaflets are moderately thickened.
There is moderate aortic valve stenosis (valve area 1.0-1.2cm2).
No aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
estimated pulmonary artery systolic pressure is high normal.
There is no pericardial effusion.
IMPRESSION: Moderate to severe aortic valve stenosis. Mild
symmetric left ventricular hypertrophy with preserved global
biventricular systolic function. Dilated thoracic aorta
[**2162-11-30**]: chest x-ray:
FINDINGS: In comparison with the study of [**11-29**], there is
continued pulmonary vascular congestion. Some increased
opacification at the left base raises the possibility of
developing consolidation
[**2162-12-2**]: right elbow x-ray:
FINDINGS: Again demonstrated is an extensive permeative and
lytic process
involving the right proximal humerus and humeral head,
concerning for
infiltrative neoplastic process. There is no evidence of
cortical
breakthrough, pathologic fracture, periosteal reaction or
definite associated
soft tissue mass.
IMPRESSION: Permeative lesion involving proximal right humerus
and head of
humerus, concerning for neoplastic infiltration
Brief Hospital Course:
84 year old gentleman admitted to the Acute Care Service after
a fall off his moped. Initially admitted to an outside hospital
where on x-ray reported to have left sided fractured ribs,
fractured left clavicle and a widened mediastinum. He was
hypotensive and was transferred here.
Upon admission to the trauma intensive care unit, he was made
NPO and given intravenous fluids. He had a cat scan of his chest
which did not show a widened mediastinum. It did show that he
sustained left rib fractures and a fractured left clavicle. He
also had a cardiac echo done with an EF >55%. He had a thoracic
epidural catheter placed for management of his rib pain with
hypotension upon placment. His rib pain was well managed with
the epidural. Since removal of his epidural catheter his rib
pain has been managed with oral agents. He had an isolated
episode yesterday of hypotension yesterday which was managed
with increased oral fluids with no further recurrence.
He is tolerating a regular diet. Voiding without difficulty.
He has been seen by physical therapy and is cleared for
discharge with the recommendation of outside physical therapy.
His vital signs are stable. He will follow-up with the Acute
Care Service in 2 weeks and with his primary care provider [**Last Name (NamePattern4) **] 1
week.
Medications on Admission:
[**Last Name (un) 1724**]: lisinopril 10', simvastatin 20', vit D 1000mcg', mag?
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**5-11**]
hours: as needed for pain.
3. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
Disp:*20 Tablet(s)* Refills:*1*
4. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime):
hold for diarrhea.
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation: hold for
diarrhea.
6. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO every 4-6 hours as
needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
left clavicular fracture
left [**4-15**] posterior rib fractures, [**6-11**] displaced
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance related to
left sided rib fractures
Discharge Instructions:
You were admitted to the hospital with left fracture ribs, left
clavicular fracture. You are being discharged with the
following instructions:
Your injury caused left posterior rib fractures [**4-15**], displaced
[**6-11**], which can cause severe pain and subsequently cause you to
take shallow breaths because of the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non steroidal antiinflammatory drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
Followup Instructions:
Please follow up with the with Acute Care Service in 2 weeks.
You can schedule this appointment by callling #[**Telephone/Fax (1) 600**].
Please follow up with your PCP [**Last Name (NamePattern4) **] 1 week.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2162-12-3**]
|
[
"810.02",
"401.9",
"E816.2",
"V10.46",
"458.29",
"276.69",
"807.08",
"272.4",
"338.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.90"
] |
icd9pcs
|
[
[
[]
]
] |
7815, 7877
|
5729, 7038
|
357, 418
|
8008, 8008
|
1745, 5704
|
9830, 10177
|
1233, 1269
|
7170, 7792
|
7898, 7987
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446, 1165
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1187, 1197
|
1213, 1217
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,157
| 129,039
|
11400+56302
|
Discharge summary
|
report+addendum
|
Admission Date: [**2195-10-31**] Discharge Date: [**2195-11-5**]
Date of Birth: [**2122-7-19**] Sex: M
Service: CCU
CHIEF COMPLAINT:
Status post transfer from [**Hospital3 1280**] for possible cardiac
catheterization.
HISTORY OF PRESENT ILLNESS: The patient is a 73 year old
white male with a past medical history significant for
previous myocardial infarction and coronary artery bypass
grafting in [**2182**], who awoke on the day of admission with
chest pressure and shortness of breath at 4:30 a.m., which
was better with sitting up.
Review of systems at that time was negative for nausea,
vomiting and positive for lightheadedness and palpitations
which had been present at baseline. Symptoms improved with
getting up but returned after the patient went back to bed.
At that time, 911 was activated and the patient was taken to
[**Hospital3 1280**] Hospital for further evaluation. At that time,
arterial blood gases showed a pH of 7.15, pCO2 68, pO2 68
with a CPK of 45 and troponin less than 0.3.
At that time, the patient's blood pressure was noted to be
209/129. He was acutely dyspneic and thus intubated, given
nitroglycerin paste, intravenous Lasix 200 mg, intravenous
morphine 2 mg and Versed. Post intubated arterial blood
gases showed a pH of 7.31, pCO2 45 and pO2 106. At that
point, he developed a mottled allergic rash and hypotension
to 57/36. It was thought to be an allergic reaction to
morphine. He was started on a Dopamine for maintenance of
his blood pressure. The maximum Dopamine dose was 4
mcg/kg/minute and he was weaned off gradually. Prior to
transfer, the patient experienced a one time ICD shock,
presumably because of atrial fibrillation.
Of note, urine output was 1,300 cc from the intravenous
Lasix. The patient was started on intravenous nitroglycerin
and transferred to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for
further evaluation. Ventilator settings on transfer were an
assist control of 700 by 14 with a PEEP of 5. Outside
laboratory data were significant for an AST of 39, ALT 53,
alkaline phosphatase 217, total bilirubin 0.9, white blood
cell count 11.1, hematocrit 45, platelet count 283,000,
sodium 146, potassium 3.6, bicarbonate 23, chloride 105, BUN
24, creatinine 1.7 and blood sugar 251.
In the [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] Emergency Room,
nitroglycerin was continued. The patient was awake and
alert, and was gradually extubated. His Emergency Room stay
was notable for a urine output of 800 cc.
PAST MEDICAL HISTORY: 1. History of coronary artery
disease, status post myocardial infarction at age 50, again
in [**2195-5-22**], status post coronary artery bypass grafting in
[**2182**] with left internal mammary artery to left anterior
descending artery, saphenous vein graft to obtuse marginal
one, saphenous vein graft to right coronary artery; most
recent cardiac catheterization in [**2195-5-22**] showed 100%
proximal left anterior descending artery lesion, 50% mid-
left anterior descending artery lesion, 70% first marginal
lesion, 100% proximal right coronary artery lesion with
collaterals coming from the circumflex to the right coronary
artery, left ventricular ejection fraction 25% with mild
mitral regurgitation; right heart catheterization showed
elevated right sided pressures including a right atrial
pressure of 24, right ventricular pressure 50, pulmonary
artery pressure 52/20 and wedge of 33, cardiac output 6.05
and cardiac index 2.79. 2. Hypertension. 3. Dyslipidemia.
4. Peripheral vascular disease, status post left femoral to
anterior tibial bypass in [**2194-2-19**] with jump graft in [**2195-5-22**] and status post TPA several months later. 5. Deep vein
thrombosis. 6. Status post AICD placement on [**2195-5-27**];
patient had been transferred from [**Hospital3 1280**] to [**Hospital6 8866**] after developing chest pain and shortness of
breath; he was found hypotensive and in respiratory failure,
requiring intubation; he became tachycardiac and went into
pulseless ventricular tachycardia and required shock; he
ruled in at [**Hospital3 1280**] with a high CK and, at [**Hospital6 8866**] workup included cardiac catheterization,
echocardiogram and exercise tolerance test; ICD placement was
also at that time; the device is known to be a Guident
device, the details of which will be included in a discharge
addendum.
ALLERGIES: Morphine.
SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] quit
tobacco approximately 30 years ago. He has one to two drinks
per day.
FAMILY HISTORY: Noncontributory.
MEDICATIONS ON ADMISSION: Aspirin 325 mg p.o.q.d., Lasix 40
mg p.o.q.d., Zestril 20 mg p.o.q.d., Norvasc 5 mg p.o.q.d.,
Lipitor 20 mg p.o.q.d., Coumadin 5 mg p.o.q.d., atenolol 50
mg p.o.q.d.
PHYSICAL EXAMINATION: On physical examination on admission,
the patient had a pulse of 75, blood pressure 133/87,
respiratory rate 13 and oxygen saturation 93% on two liters
oxygen and 88% in room air. General: Intubated, awake, nods
to questions, resting right hand tremor and head bobbing.
Head, eyes, ears, nose and throat: Pupils equal, round, and
reactive to light and accommodation, oropharynx unable to be
examined secondary to intubation, extraocular movements
intact. Neck: No bruits, 10 cm jugular venous distention.
Chest: Midline coronary artery bypass grafting scar,
otherwise clear to auscultation bilaterally. Cardiovascular:
Regular rate and rhythm, no murmur, rub or gallop. Abdomen:
Soft, nontender, nondistended, positive bowel sounds.
Extremities: Clean, dry and intact, good dorsalis pedis and
posterior tibialis pulses, trace edema in bilateral lower
extremities.
LABORATORY DATA: White blood cell count was 12.3 with a
differential of 85.7% neutrophils, 8.7% lymphocytes, 4%
monocytes, 1.3% eosinophils and 0.3% basophils, hematocrit
36.6, platelet count 202,000, prothrombin time 19.7, partial
thromboplastin time 31.3, INR 2.7, sodium 141, potassium 5.7,
chloride 103, bicarbonate 27, BUN 24, creatinine 1.4, blood
sugar 96, and first CK with a troponin of 1.6. Urinalysis
showed large blood, 1,120 red blood cells, 6 to 10 white
blood cells, occasional bacterial and 0 to 2 epithelial
cells.
Electrocardiogram from [**2195-5-22**] showed atrial
fibrillation with a heart rate between 100 to 120, ST
elevations and inverted T waves and Q waves present in leads
II and AVF, ST depressions and inversions of T wave present
in leads V4 through V6, inverted T wave also present in V1;
this was compared with the most recent electrocardiogram from
[**2195-10-31**], showing sinus rhythm with minimal ST
elevations and inverted T waves in leads III and AVF, Q waves
still present in leads II, III and AVF, right sided leads
showed no ST elevation in lead V4R, there were occasional Q
waves in leads V4 through V6.
Chest x-ray showed improvement in congestive heart failure.
Echocardiogram from outside hospital showed severely reduced
left ventricular systolic function with a ejection fraction
of 25% to 30%, akinesis of the posterior wall, basal and
mid-portions of the septum and inferior wall, hypokinesis in
the rest of the ventricles, 2+ mitral regurgitation, 1+
tricuspid regurgitation, enlarged left atrium. Adenosine
Cestimibi in [**2195-5-22**] showed a fixed inferolateral defect
with a systolic ejection fraction of 26%.
HOSPITAL COURSE: Mr. [**Known lastname **] was admitted to the Coronary
Care Unit for further evaluation and observation. He had
been previously extubated in the Emergency Room and was
stable upon entry to the Coronary Care Unit. The rest of the
hospital course will be broken down in systems.
1. Cardiovascular/coronary artery disease: Mr. [**Known lastname **] was
continued on aspirin, nitroglycerin drip and heparin as per
myocardial infarction protocol. Three serial CKs were done
showing values of 83 with troponin of 1.6, 244 with troponin
of 1.5, and 336. The troponin-I levels were not suggestive
of an acute myocardial infarction per laboratory standards.
Thus, it was considered that the patient had ruled out for a
myocardial infarction and heparin was discontinued.
Repeat cardiac catheterization was considered but, in light
of Mr. [**Known lastname 5024**] recent catheterization and flat CKs, he
instead underwent an exercise treadmill test on Tuesday,
[**2195-11-3**]. This showed a severe fixed perfusion
defect of the inferior wall and left ventricular ejection
fraction of 30% with global hypokinesis. This was after 5.25
minutes of exercise time. No electrocardiographic changes or
anginal type symptoms were evident.
Mr. [**Known lastname **] was restarted on beta blockage, in particular,
Lopressor 50 mg twice a day which was gradually increased to
100 mg twice a day. He was also started on Imdur for
anti-anginal effects.
As stated above, the patient's left ventricular ejection
fraction was noted to be 25% from the outside hospital.
However, the stress test showed a left ventricular ejection
fraction of 37%. He was continued on Zestril after the day
of admission, with good blood pressure effects.
Rhythm: Mr. [**Known lastname **] was in normal sinus rhythm throughout his
stay. He was continued on telemetry. On the night of
admission, his ICD was interrogated, which showed atrial
fibrillation. In the intervening days, he had several
episodes of fast ventricular pacing at 100 beats per minute
for various lengths of time, including anywhere from as few
as five beats to as many as 25 beats. He was asymptomatic
throughout and his blood pressure was well maintained. Mr.
[**Known lastname **] was thought to be going into atrial
fibrillation/atrial flutter during these times, which induced
the ventricular pacing.
The patient underwent electrophysiology studies on [**2195-11-4**], which discovered multiple foci of atrial flutter,
some of which were ablated. His symptoms will be continued
on high dose Lopressor and amiodarone. At this time, his ICD
was re-programmed for the shocking of atrial fibrillation.
2. Vascular/hypertension: Mr. [**Known lastname **] was restarted on
Norvasc 5 mg per day without event.
3. Renal: Mr. [**Known lastname 5024**] creatinine on admission was 1.7. In
the intervening days, creatinine returned to his baseline of
1. He had good urine output throughout.
4. Hematology: Mr. [**Known lastname **] had a hematocrit of 45 at the
outside hospital. His hematocrit at this facility was 36.6
on admission. However, it remained stable throughout the
length of his stay and no further transfusions were needed.
His INR was also monitored. Coumadin was held secondary to
possible invasive intervention such as cardiac
catheterization, which would require an INR of less than 1.5.
On [**2195-11-3**], his INR was noted to be below 2 and a
heparin drip was restarted. Coumadin will be restarted on
[**2195-11-4**].
5. Lines; Mr. [**Known lastname **] had peripheral lines only. A central
line was deemed not to be necessary at the time of admission.
6. Prophylaxis: Mr. [**Known lastname **] was started on gastrointestinal
prophylaxis with Protonix and deep vein thrombosis
prophylaxis with heparin.
7. Disposition: Mr. [**Known lastname **] was a full code. He was seen by
both physical therapy and occupational therapy, who deemed
that he had no outpatient needs. At the appropriate time, he
will be discharged home without further services.
FOLLOW-UP: Mr. [**Known lastname **] will follow up with his outside
cardiologist in two weeks.
DISCHARGE MEDICATIONS:
Aspirin 325 mg p.o.q.d.
Lasix 40 mg p.o.q.d.
Zestril 20 mg p.o.q.d.
Norvasc 5 mg p.o.q.d.
Lipitor 20 mg p.o.q.d.
Coumadin 5 mg p.o.q.d.
Lopressor 100 mg p.o.b.i.d.
Amiodarone 200 mg p.o.t.i.d. for one week then 200 mg
p.o.q.d.
Imdur 30 mg p.o.q.d.
DISCHARGE STATUS: Stable.
DISCHARGE DIAGNOSES:
Congestive heart failure exacerbation possibly secondary to
arrhythmia.
Coronary artery disease.
Status post coronary artery bypass grafting.
Hypertension.
Dyslipidemia.
Peripheral vascular disease.
Deep vein thrombosis.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2057**]
Dictated By:[**Name8 (MD) 8073**]
MEDQUIST36
D: [**2195-11-4**] 14:14
T: [**2195-11-5**] 16:26
JOB#: [**Job Number **]
Name: [**Known lastname 1985**], [**Known firstname **] Unit No: [**Numeric Identifier 6761**]
Admission Date: [**2195-10-31**] Discharge Date: [**2195-11-5**]
Date of Birth: [**2122-7-19**] Sex: M
Service: CCU
ADDENDUM: The ICD pacemaker placement from [**2195-5-27**] was the
following: Guidant device, product is automatic implantable
cardioverter - defibrillator with model #1861, serial
#[**Serial Number 6762**]. There is also Guidant leads, model #4054, serial
#[**Serial Number 6763**]. And finally a [**Company 1331**] lead, model #6943. The
doctor who placed the ICD was Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6764**] with phone
number [**Telephone/Fax (1) 6765**].
Electrophysiology study notable for ablation around the node
which has caused prolonged conduction at the node, as well as
an intraventricular conduction delay. Post-procedure, Mr.
[**Known lastname **] had a baseline right bundle branch block. In the
intervening time, he has had ventricular pacing with rates
between 60 and 140. Electrophysiology was made aware of
this. They will see him prior to discharge.
DISCHARGE MEDICATIONS: Include all of the following, plus
nitroglycerin 0.5 mg sublingual q five minutes prn chest pain
up to three times before calling M.D..
[**First Name8 (NamePattern2) 77**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 715**]
Dictated By:[**Name8 (MD) 1037**]
MEDQUIST36
D: [**2195-11-5**] 12:02
T: [**2195-11-5**] 12:15
JOB#: [**Job Number 6766**]
|
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"412",
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"458.9",
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"V45.81",
"414.01",
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icd9cm
|
[
[
[]
]
] |
[
"37.34",
"37.26",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
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] |
4721, 4739
|
11981, 13623
|
13647, 14041
|
4766, 4933
|
7520, 11660
|
4956, 7502
|
150, 236
|
265, 2665
|
2688, 4559
|
4576, 4704
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,263
| 130,897
|
34473
|
Discharge summary
|
report
|
Admission Date: [**2198-7-30**] Discharge Date: [**2198-8-2**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Transferred from OSH with hypotension and elevated troponin.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is an 80 year old female with h/o type II DM, HTN,
hyperlipidemia, and recent diagnosis of pancreatic cancer
([**6-/2198**]) awaiting Whipple procedure, who presented to [**Hospital1 3325**] on the day of admission after a mechanical fall. EMS
VS en route to [**Hospital3 3583**] were BP 142/74, HR 90, RR 20,
100% 2L.
.
Per patient, she was sitting on the toilet having a BM when she
slipped off the toilet seat onto the floor. Says that she did
not experience any lightheadedness, dizziness, palps, or chest
pain prior to the episode. There was no LOC. She recalls the
entire event. A friend found her on the floor and helped her
onto her feet and called an ambulance.
.
At OSH ([**Hospital3 3583**]) her vital signs were 97.4, HR 68, RR
20, BP 78/56, 99% 2L. Subsequently she was noted to be
hypotensive to SBP 60s, she was given 1.5 liters IVF with SBP to
80s and started on dopamine gtt. She was noted to have STE in
leads I and aVL and also a troponin I of 3.67 with flat CKs.
She was started on a heparin gtt with bolus. A head CT at OSH
showed no evidence of intracranial hemorrhage.
.
At baseline, patient says she lives independently and is able to
carry out ADLs and most IADLs. She denies exertional angina
although to be fair, does not regularly walk up stairs or
long-distances. ROS positive for one loose bowel movement on
morning of admission, no blood and no mucous. No abdominal
cramping or pain. She denies fevers, chills, N/V, or decreased
PO intake in days leading up to admission. She denies dysuria,
cough or URI symptoms. ROS positive for malaise during the last
several months and weight loss of twenty pounds which is
attributed to her recent diagnosis of pancreatic cancer
([**Date range (1) 9184**]) made by ERCP at [**Hospital1 18**].
.
Of note, patient was recently treated for UTI with 7-day course
of ciprofloxacin.
Past Medical History:
PAST MEDICAL HISTORY:
#. TYPE II DM x35 years without end-organ damage
#. HYPERTENSION
#. HYPERLIPIDEMIA
#. SVT: Noted to be in an unspecified SVT when she presented
with painless jaundice at [**Hospital3 3583**] on [**6-26**]. Found to have
a troponin leak thought to be rate related. She was seen by
cardiology at [**Hospital1 46**], and BB recommended.
#. PANCREATIC MASS WITH OBSTRUCTIVE JAUNDICE: Presented with sxs
of malaise and jaundice to [**Hospital3 **] on [**6-26**], transferred
to [**Hospital1 18**] for further work up. Work up during [**Hospital1 18**] admission
([**Date range (1) 18128**]) included following:
* [**2198-6-28**] - ERCP: attempted but failed to cannulate the CBD,
cannulated the pancreatic duct and placed a proximal stent. No
distal pancreatic duct obstruction (ductal width not specified)
* [**2198-6-29**] - repeat ERCP: CBD cannulated - very tight 3cm distal
CBD stricture, brushing cyology suspicious for carcinoma. Stent
placed.
* CTA pancreas [**2198-6-29**] - 1.6 x 1.9 pancreatic head mass
consistent
with adenocarcinoma of uncinate process without CT evidence
vascular invasion or significant adenopathy
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. There is no family
history of premature coronary artery disease or sudden death.
Lives in [**Location 3320**], is widowed with 3 children who live near by.
Retired and lives independently.
Family History:
Non-contributory
Physical Exam:
On Admission:
VS: T 100.6, BP 96/57 (manual 110/70-->no pulsus), HR 81, RR,
100% 2L
Gen: Elderly female in NAD, respiratory or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with no JVD.
CV: RRR, distant S1/S2. No obvious m/r/g.
CHEST: Mild kyphosis. No focal changes in breath sounds. No
wheezes. No crackles.
[**Last Name (un) **]: Obese, soft, NTND. No [**Doctor Last Name 515**] sign on right or left
side. Normal to slightly hyperactive bowel sounds.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Dopplerable triphasic DP pulses bilaterally
.
.
On Discharge:
VS: Tm 99.1, BP 104/60, HR 98, RR 20, O2 Sat 99% on RA. Exam
otherwise not notably changed and benign.
Pertinent Results:
<B><U>LABORATORY RESULTS<U><B>
On Admission:
WBC-16.0* RBC-3.20* Hgb-9.7* Hct-29.8* MCV-93 Plt Ct-551*
Glucose-88 UreaN-28* Creat-1.3* Na-141 K-3.9 Cl-111* HCO3-18*
AnGap-16
PT-14.5* PTT-150* INR(PT)-1.3*
ALT-17 AST-31 LD(LDH)-276* CK(CPK)-127 AlkPhos-193* Amylase-48
TotBili-1.3
Lipase-34
Albumin-2.9* Calcium-8.8 Phos-2.7 Mg-2.0
.
On Discharge:
WBC-10.2 RBC-2.71* Hgb-8.4* Hct-26.0* MCV-96 Plt Ct-435
Glucose-135* UreaN-15 Creat-0.8 Na-138 K-4.3 Cl-108 HCO3-17*
AnGap-17
PT-17.1* PTT-53.4* INR(PT)-1.5*
Calcium-8.8 Phos-2.7 Mg-1.6
.
Cardiac Enzymes
----------------
CK: 127- 131- 91
CK-MB-12*-13*-NotDone
MB Indx-9.4*-9.9*
cTropnT-0.50*-0.42*-0.30*
.
Urinalysis:
Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
RBC-<1 WBC-3 Bacteri-NONE Yeast-NONE Epi-2
.
<b><u>IMAGING/RADIOLOGY<B><U>
EKG on [**2198-7-30**]: Normal sinus rhythm with indeterminate axis. Low
QRS voltage throughout, most pronunced in the limb leads.
Anterior myocardial infarction of indeterminate age. ST-T wave
changes are suggestive of ischemia in the anteroapical region.
Compared to the previous tracing of [**2198-7-13**] QRS voltage is lower
throughout. Anterior Q waves are more pronounced and anterior ST
segment changes are new.
(When compared to previous EKG's from OSH from as long a [**8-3**]
mos ago no significant changes)
.
TRANSTHORACIC ECHO ([**2198-7-30**]):
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. There
is moderate regional left ventricular systolic dysfunction with
near akinesis of the distal half of the septum and anterior
walls, distal inferior and lateral walls, and apex. The apex is
aneurysmal with a 2.3cm mural thrombus. The remaining segments
contract normally (LVEF = 30-35 %). The estimated cardiac index
is normal (>=2.5L/min/m2). Right ventricular chamber size is
normal. with focal hypokinesis of the apical free wall. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Extensive regional left ventricular systolic
dysfunction c/w CAD (mid-LAD distribution and extending to
apical right ventricle). Apical left ventricular aneurysm/large
mural thrombus. Mild mitral regurgitation. Mild pulmonary artery
systolic hypertension.
.
VENOUS LOWER EXTREMITY DOPPLERS ([**2198-7-30**]):
No DVT seen in either leg.
.
Persantine Stress Test [**2198-8-1**]:
IMPRESSION: No anginal symptoms or ST segment changes in
response to
dipyridamole infusion. Nuclear report sent separately.
IMPRESSION:
1. Fixed distal anterior and inferior as well as apical defects
along the
distal anterior and inferior walls as well as apex consistent
with known
anterior wall MI with apical aneurysm.
2. Images at the apex are limited but there is likely
paradoxical motion of the known left apical ventricular
aneurysm.
Brief Hospital Course:
This is an 80-year old female with h/o type II diabetes
mellitus, hypertension, hyperlipidemia, and recent diagnosis of
pancreatic cancer who presents from OSH s/p mechanical fall with
hypotension and elevated cardiac markers.
# PUMP/HYPOTENSION: Per OSH records, she had hypotension to SBP
70 and subsequently received a 700 cc bolus of NS with bump in
SBP to 100 at time of transfer. Upon arrival, she received an
additional 2L of NS by repeated 500 cc boluses and her SBP came
up to 110-120. Differential diagnosis on admission for her
hypotension included cardiogenic causes (principally acute MI,
pericardial tamponade, or pulmonary embolism) versus
distributive causes (sepsis) versus hypovolemia from decreased
PO intake and recent diarrhea. A TTE on night of admission
showed LVEF 30-35% and regional systolic dysfunction in the
distribution of the mid-LAD. There was an apical left
ventricular aneurysm and mural thrombus. There was no
significant pericardial effusion. LE dopplers were negative for
DVT. Cardiac enzymes, as below, were down-trending. She was
started empirically on IV flagyl for C dif colitis. Her blood
pressure increase in response to fluid boluses suggested that
the main cause for her hypotension was hypovolemia in the
context of generally well compensated systolic heart failure.
This was supported by her bump in creatinine at presentation,
which resolved with IVF. Ultimately, we were able to obtain
outside EKGs, which showed Q waves suggesting her MI had
occurred greater than six months ago and that her decreased EF
and systolic heart failure had been well compensated to this
point with minimal symptomatology especially given her sedentary
lifestyle. Initially, she had been started on heparin and then
coumadin for anticoagulation of the LV thrombus, but after
concluding that her LV dysfunction and aneurysm had been present
for several months we discontinued this anticoagulation given
the generally stable nature of long-standing clots and minimal
risk of embolization. She was also restarted on ACEI and
restarted on a BB when her blood pressure recovered for her
hypovolemia as part of a good CHF regimen. She never had signs
of fluid overload or decompensated heart failure while in the
hospital.
# CAD/ISCHEMIA: At time of presentation, she had no known
history of coronary artery disease. As above, her
echocardiogram was strongly suggestive of apical ischemia and
showed Q waves suggestive of old MI. Large wall motion
abnormality and aneurysmal dilation of LV was consistent with
this. Initially, there was some concern she was having and ACS
but CKs were relatively low and stable and troponin elevations
were not impressive. Her treating team believed this was most
consistent with demand ischemia in the context of hypotension as
opposed to ACS. She had previously been on a statin for known
hyperlipidemia but this had been discontinued due her
transaminitis (in the setting of biliary obstruction from
pancreatic CA) in [**2198-6-22**]. We restarted her statin as
her transaminases had since returned to [**Location 213**]. We continued
her outpatient aspirin in the hospital. A persantine stress
test was performed prior to hospitalization and showed no
reversible ischemia.
# RHYTHM: She was monitored on telemetry throughout
hospitalization. She had several bouts of atrial tachycardia
that were managed by up-titrating her beta blocker dose. She
was asymptomatic and remained hemodynamically stable during
these events.
# DIARRHEA: Initially, given her previous course of
ciprofloxacin and diarrhea with hypotension on presentation she
was started on IV metronidazole for empiric therapy of C. diff.
Given her abdominal exam remained benign and the quick
resolution of her hypotension we became less concerned for C
diff and/or toxic megacolon. After one negative C diff toxin
assay we discontinued her IV metronidazole and she remained
afebrile. Prior to discharge she had a second negative toxin
assay. Most likely this was simply antibiotic associated
diarrhea vs a viral enteritis.
# POSITIVE BLOOD CULTURE: On admission she had blood cultures
drawn as part of a general hypotension work up. On hospital day
two one out of two of these cultures turned positive for gram
positive cocci. Thus, given the etiology of hypotension was
still unclear and we were unsure of the organism, vancomycin was
started empirically. This was discontinued when the culture was
speciated as coagulase negative staph as this organism in [**11-22**]
blood cultures is likely to represent a contaminant.
.
# HTN: When her blood pressure permitted, we restarted her
outpatient BB and started her on an ACEI for its
cardioprotective effect. Hydrochlorthiazide was held and not
restarted so as to give her the most room for increased ACEI and
BB.
.
# DM: She was initially started on her outpatient insulin
regimen, 70/30, 20 units twice daily. On HD 1, she was
hypoglycemic to 40s overnight. We decided to stop her standing
insulin and treat her only with sliding scale. On discharge,
assuming she would eat better at home we restarted her on a much
smaller dose of 70/30 of 2 units [**Hospital1 **] with instructions to
titrate up with her PCP and following her blood glucose values.
.
Ms. [**Known lastname **] was fed a cardiac/heart healthy and diabetic diet.
She was treated with subcutaneous heparin for DVT prophylaxis
(when she wasn't on IV heparin). She was full code.
Medications on Admission:
HCTZ 25 daily
Avapro 300 qam
Atenolol 25 daily
Novolog 70/30 20 units [**Hospital1 **]
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Novolog 100 unit/mL Solution Sig: Two (2) units Subcutaneous
twice a day.
6. Toprol XL 100 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*
Discharge Disposition:
Home With Service
Facility:
Partners
Discharge Diagnosis:
Coronary heart Disease
Hypotension with Troponin Leak
Diabetes type 2
Pancreatic Cancer
Discharge Condition:
Vital signs stable. Afebrile.
Discharge Instructions:
You were admitted to the hospital because your blood pressure
was low and some of the enzymes in your blood were elevated
indicating that you may have suffered a heart attack. With
further testing we do not believe you had an acute blockage in a
vessel in your heart. Your EKG showed an old heart attack so
your couamdin (warfarin) was discontinued. Your stress test did
not show any evidence that your heart is not getting enough
blood flow at present.
.
Please weigh yourself every day, let Dr. [**First Name (STitle) 27598**] know if you gain
more than 3 pounds in 1 day of 6 pounds in 3 days.
.
You did not need a lot of insulin in the hospital. We decreased
the Novolog to [**12-23**] to take after discharge. Please continue to
check your fingersticks at home, you may need to increase the
Novolog.
Followup Instructions:
PCP:
[**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone: [**Telephone/Fax (1) 27599**] Date/time: Thursday
[**2198-8-9**] at 3pm.
.
Surgery:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone: ([**Telephone/Fax (1) 2363**] Date/Time:
His office will call you with an appt.
Completed by:[**2198-8-3**]
|
[
"250.80",
"272.4",
"787.91",
"429.89",
"428.0",
"157.0",
"412",
"401.9",
"428.20",
"414.01",
"276.52",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14095, 14134
|
7925, 13391
|
374, 380
|
14266, 14299
|
4618, 4649
|
15154, 15566
|
3801, 3819
|
13528, 14072
|
14155, 14245
|
13417, 13505
|
14323, 15131
|
3834, 3834
|
4965, 7902
|
274, 336
|
408, 2298
|
4663, 4951
|
2342, 3471
|
3487, 3785
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,440
| 179,766
|
32838
|
Discharge summary
|
report
|
Admission Date: [**2106-1-23**] Discharge Date: [**2106-2-3**]
Date of Birth: [**2026-9-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 922**]
Chief Complaint:
s/p arrest
Major Surgical or Invasive Procedure:
[**1-29**] CABG x 2/MAZE procedure
History of Present Illness:
79 M w/ PMH of afib on coumadin, HTN, hyperlipidemia, angina,
s/p Vfib arrest with immed bystander [**Month/Year (2) **] X 20 minutes. Family
found pt unresponsive w/ max 2 minutes of unobserved time. s/p
7 shocks in the field by EMS (12:38 pm) and intubated w/ vec
given. + intentional movements by report. Given epi and
atropine X 1. Converted to Narrow-complex tachycardia after
shocks HR 124, BP 172/117. Given amio X 1 300 mg IV. At OSH,
was PEA on arrival so [**Month/Year (2) **] started and given epi/atropine.
Hypotensive since arrest, arrived at [**Hospital1 18**] on levo and dopa
ggts. CT heat at OSH w/o bleed. Guiac neg at OSH. Cooling
initiated at OSH. Also given versed at OSH (13:05).
.
In the ED, received amio load and was continued on dopa and levo
ggts and taken to the cath lab. Cath showed chronic occlusion
of LAD with mod diffuse disease of LCX and RCA. An IABP was
placed for cardiogenic shock.
.
Per family, had been feeling unwell for the past few days. He
apparently suffers from chronic stable angina but had complained
of increased chest pain when shoveling this am. He called his
daughter before driving to his family's [**Holiday 944**] gathering. He
asked them to come get him if he wasn't there in one hour. He
also brought his medical record to the gathering. He arrived
and helped to bring in packages. When seated with his family,
he was noted to fall asleep which is not unusual for him. His
son then noted that he looked cyanotic. His daughter, who is a
nurse, along with his granddaughter who is also a nurse [**First Name (Titles) **] [**Last Name (Titles) **]
for at least 10 minutes before EMT arrived (he was pulseless
prior to [**Last Name (Titles) **]). His daughter thinks he may have been "asleep"
for up to 10 minutes before [**Last Name (Titles) **] was started.
Past Medical History:
PAST MEDICAL HISTORY:
Afib
CAD w/ stent and ? Angina
Hyperlipidemia
HTN
S/p Appy
Social History:
former smoker but not for years
no etoh
Family History:
NC
Physical Exam:
VS: T 34.7 C, BP 88/40, HR 63, 100% on AC 100% FIO2 10 PEEP
Gen: WDWN middle aged male intubated and sedated.
HEENT: NCAT. Sclera anicteric. Pupils 1.5 mm bilaterally and
minimally reactive, Conjunctiva were pink.
Neck: R IJ in place.
CV: irreg irreg, distant heart sounds, no murmurs noted.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Hypoactive bowel sounds, Soft, NTND, No HSM or tenderness.
No abdominial bruits.
Ext: Trace bilateral LE edema to knees.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ w/ IABP sheath in
place; dopplerable pt, no dp
Left: Carotid 2+ without bruit; Femoral 2+ without bruit;
dopplerable pt, no dp
Pertinent Results:
[**2106-2-2**] 06:15AM BLOOD WBC-11.0 RBC-3.57* Hgb-11.1* Hct-31.4*
MCV-88 MCH-31.2 MCHC-35.4* RDW-15.0 Plt Ct-290
[**2106-2-3**] 09:10AM BLOOD PT-16.2* INR(PT)-1.5*
[**2106-2-2**] 06:15AM BLOOD PT-16.1* PTT-32.4 INR(PT)-1.4*
[**2106-2-1**] 04:33AM BLOOD PT-15.4* INR(PT)-1.4*
[**2106-1-30**] 04:42AM BLOOD PT-15.8* PTT-34.0 INR(PT)-1.4*
[**2106-2-3**] 09:10AM BLOOD Glucose-161* UreaN-25* Creat-1.5* Na-137
K-3.6 Cl-96 HCO3-32 AnGap-13
[**2106-2-2**] 06:15AM BLOOD Glucose-100 UreaN-27* Creat-1.4* Na-138
K-3.2* Cl-99 HCO3-30 AnGap-12
[**2106-2-1**] 04:33AM BLOOD Glucose-106* UreaN-25* Creat-1.4* Na-137
K-3.8 Cl-98 HCO3-29 AnGap-14
CHEST (PORTABLE AP) [**2106-2-1**] 9:52 AM
CHEST (PORTABLE AP)
Reason: s/p Chest tube removal
[**Hospital 93**] MEDICAL CONDITION:
79 year old man with
REASON FOR THIS EXAMINATION:
s/p Chest tube removal
REASON FOR EXAMINATION: Follow up of a patient after CABG after
removal of the chest tube and mediastinal drains.
Portable AP chest radiograph compared to [**2106-1-30**] and
to pre- operative radiograph from [**2106-1-23**].
The patient was extubated in the meantime interval with removal
of mediastinal drains, NG tube and chest tube. The heart size is
moderately enlarged but stable. The post-sternotomy wires are
unremarkable. The mediastinal contours are within normal limits.
Bibasal opacities including discoid atelectasis in the left base
most likely represent post-surgery atelectasis. Small right
pleural effusion is noted. There is no pneumothorax. There is no
evidence of congestive heart failure.
IMPRESSION:
1. Bibasal atelectasis, postsurgical.
2. No pneumothorax. Small left upper chest subcutaneous
emphysema.
3. No evidence of congestive heart failure.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 177**] [**Hospital1 18**] [**Numeric Identifier 76455**] (Complete)
Done [**2106-1-29**] at 7:42:59 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**Known firstname 177**]
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2026-9-18**]
Age (years): 79 M Hgt (in): 76
BP (mm Hg): 115/57 Wgt (lb): 186
HR (bpm): 80 BSA (m2): 2.15 m2
Indication: Limited TEE - pt to OR for cardiac tamponade and
bleeding s/p chest opened in ICU
ICD-9 Codes: 799.02, 423.3, 424.0
Test Information
Date/Time: [**2106-1-29**] at 19:42 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1510**], MD
Doppler: Limited Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Suboptimal
Tape #: 2007AW2-: Machine: [**Pager number 5741**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 30% >= 55%
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: Bidirectional shunt across the
interatrial septum at rest. Small secundum ASD.
LEFT VENTRICLE: Severely depressed LVEF.
RIGHT VENTRICLE: Markedly dilated RV cavity. Moderate global RV
free wall hypokinesis.
MITRAL VALVE: Mild to moderate ([**2-10**]+) MR.
PERICARDIUM: No pericardial effusion. No echocardiographic signs
of tamponade.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The rhythm appears
to be A-V paced. Emergency study. Results were personally
Conclusions
Limited examination in the OR
1. Overall left ventricular systolic function is severely
depressed (LVEF= 25 %).
2.The right ventricular cavity is markedly dilated. There is
moderate global right ventricular free wall hypokinesis.
3.There is no pericardial effusion. There are no
echocardiographic signs of tamponade.
Brief Hospital Course:
He remained intubated with IABP and was diuresed. He was seen by
cardiac surgery. He awaited normal INR. His IABP was dc'd and he
was extubated on [**1-26**]. He developed a fever and was cultured
and started on empiric antibiotics. He was taken to the
operating room on [**1-29**] where he underwent a CABG x 2 and MAZE
procedure. He was transferred to the ICU. He was given 48 hours
of perioperative vancomycin since he was in the hospital
preoperatively. He became unstable and was reopened at the
bedside, and was taken back to the OR for hematoma evacuation
and oversew of the area of bleeding in the left upper lobe
parenchyma. He was transferred back the ICU. He was extubated on
POD #1. His vasoactive drips were weaned and He was transferred
to the floor on POD #3. He was started on coumadin and
amiodarone for atrial fibrillation. He was ready for discharge
to rehab on POD # 5.
Medications on Admission:
Diltiazem 240', Coumadin 3.75-5mgs daily, Lovastatin 20',
Atenolol 25', ASA 81', HCTZ 25-50'
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Warfarin 1 mg Tablet Sig: Five (5) Tablet PO ONCE (Once) for
2 days: check INR 12/.
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 10 days: then reassess need for diuresis.
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO BID (2 times a
day) for 10 days: while on lasix.
Discharge Disposition:
Extended Care
Facility:
Woodbriar of [**Location (un) 4444**]
Discharge Diagnosis:
CAD now s/p CABG
cardiogenic shock
s/p VF arrest
HTN, Afib, ^chol., s/p appy, angina
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.
Followup Instructions:
Dr. [**First Name (STitle) 1022**] & Cardiologist 2 weeks
Dr. [**Last Name (STitle) 914**] 4 weeks
Completed by:[**2106-2-3**]
|
[
"403.90",
"414.01",
"785.51",
"428.0",
"998.12",
"427.31",
"807.2",
"E876.8",
"585.9",
"584.9",
"423.3",
"410.11",
"416.0",
"428.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.01",
"37.23",
"88.56",
"36.15",
"36.11",
"78.41",
"37.33",
"37.61",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
9246, 9310
|
7184, 8076
|
329, 366
|
9439, 9447
|
3234, 3968
|
9746, 9875
|
2407, 2411
|
8219, 9223
|
4005, 4026
|
9331, 9418
|
8102, 8196
|
9471, 9723
|
2426, 3215
|
279, 291
|
4055, 7161
|
394, 2230
|
2274, 2334
|
2350, 2391
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,535
| 194,346
|
46285
|
Discharge summary
|
report
|
Admission Date: [**2172-7-21**] Discharge Date: [**2172-7-30**]
Date of Birth: [**2119-6-11**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Penicillins / Ivp Dye, Iodine Containing
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Endotracheal intubation
Hemodialysis
History of Present Illness:
53 year old woman with PMH of ESRD on HD (last dialysis Friday
[**7-21**]), hyperkalemia, CHF with severely depressed EF, DMII, HTN
who was in interventional radiology for a AV fistulogram. She
had received 20 cc of IV contrast and intrafistula TPA with
angioplastic dilation of some stenosis sites. After about 30
minutes later she became dyspnic. She was found to have an O2
sat of 88% on room air and appeared short of breath. A code was
called and the cardiac arrest team was notified. Vitals revealed
tachycardia to the 130's, SBP of 230's. She received 80 mg IV
lasix, 2 amps sodium bicarb, 1 amp D50, 10 units insulin, 1 amp
calcium chloride, and 4 inches nitropaste. She was intubated and
the tube had frothy sputum on ventilation. ABG 5 mins post
ventilation was 7.17/57/454/22 with lactate of 2.9 and K of 3.8.
Her O2 sat improved to 100% and she was transported to the MICU
Past Medical History:
ESRD on HD-has fistula
CHF with 3+MR
T2DM
Hypertension
Paranoid schizophrenia
?Dementia
Social History:
Pt lives in [**Location 86**] with husband and son. [**Name (NI) **] prior notes,
denies tobacco or etoh history.
Family History:
None per previous notes
Physical Exam:
t 97.9, bp 165/72, hr 104, rr 20, spo2 100%
vent a/c vt 500/peep 8/rr 14/fio2 100%
gen- intubated, sedated female, chronic ill appearance,
diaphoretic
heent- irregular pupils with surgical appearance
cv- tachy but regular, no m/r/g
pul- moves air well, diffuse harsh anterior rhonchi, decr bs
posteriorly at bases with occ bibasilar rales
abd- soft, nt, nabs
extrm- no cyanosis/edema, warm/dry
nails- no clubbing, no pitting/color changes/indentations
neuro- Unresponsive to deep pain, pupils with surgical
appearance
Pertinent Results:
[**2172-7-28**] 06:15AM BLOOD WBC-11.2* RBC-3.96* Hgb-12.3 Hct-38.1
MCV-96 MCH-31.0 MCHC-32.2 RDW-15.2 Plt Ct-202
[**2172-7-27**] 07:52AM BLOOD WBC-10.4 RBC-3.66* Hgb-11.5* Hct-34.3*
MCV-94 MCH-31.5 MCHC-33.6 RDW-15.1 Plt Ct-190
[**2172-7-26**] 06:42AM BLOOD WBC-17.1* RBC-3.70* Hgb-11.9* Hct-35.6*
MCV-96 MCH-32.2* MCHC-33.3 RDW-16.2* Plt Ct-199
[**2172-7-25**] 04:00AM BLOOD WBC-22.4* RBC-3.95*# Hgb-13.0# Hct-37.1#
MCV-94 MCH-32.9* MCHC-35.0 RDW-17.3* Plt Ct-191
[**2172-7-24**] 03:36AM BLOOD WBC-21.3* RBC-2.86* Hgb-9.3* Hct-27.6*
MCV-97 MCH-32.6* MCHC-33.7 RDW-15.9* Plt Ct-219
[**2172-7-23**] 05:08AM BLOOD WBC-20.8* RBC-3.18*# Hgb-9.9*# Hct-30.7*#
MCV-97 MCH-31.2 MCHC-32.4 RDW-16.1* Plt Ct-227
[**2172-7-22**] 05:16AM BLOOD WBC-14.0* RBC-2.49* Hgb-7.7* Hct-24.0*#
MCV-97 MCH-31.0 MCHC-32.2 RDW-16.1* Plt Ct-247
[**2172-7-21**] 02:35PM BLOOD WBC-20.0*# RBC-3.25* Hgb-10.2* Hct-32.4*
MCV-100* MCH-31.4 MCHC-31.5 RDW-15.5 Plt Ct-332
[**2172-7-21**] 10:30AM BLOOD WBC-12.9* RBC-2.70* Hgb-8.7*# Hct-26.2*
MCV-97 MCH-32.2* MCHC-33.2 RDW-15.9* Plt Ct-253#
[**2172-7-27**] 07:52AM BLOOD Neuts-73.5* Lymphs-13.2* Monos-7.4
Eos-5.1* Baso-0.7
[**2172-7-28**] 06:15AM BLOOD Plt Ct-202 LPlt-1+
[**2172-7-27**] 07:52AM BLOOD Plt Ct-190
[**2172-7-26**] 06:42AM BLOOD Plt Smr-NORMAL Plt Ct-199
[**2172-7-25**] 04:00AM BLOOD Plt Ct-191
[**2172-7-24**] 03:36AM BLOOD Plt Ct-219
[**2172-7-24**] 03:36AM BLOOD PT-14.9* PTT-30.7 INR(PT)-1.5
[**2172-7-23**] 05:08AM BLOOD Plt Ct-227
[**2172-7-22**] 05:16AM BLOOD Plt Ct-247
[**2172-7-22**] 05:16AM BLOOD PT-14.8* PTT-28.8 INR(PT)-1.5
[**2172-7-21**] 02:35PM BLOOD Plt Ct-332
[**2172-7-21**] 02:35PM BLOOD PT-13.6* PTT-23.8 INR(PT)-1.2
[**2172-7-21**] 10:30AM BLOOD Plt Ct-253#
[**2172-7-21**] 10:30AM BLOOD PT-13.8* INR(PT)-1.3
[**2172-7-28**] 06:15AM BLOOD Glucose-166* UreaN-45* Creat-9.4*# Na-137
K-3.6 Cl-96 HCO3-24 AnGap-21*
[**2172-7-27**] 07:52AM BLOOD Glucose-280* UreaN-68* Creat-12.2* Na-134
K-4.1 Cl-92* HCO3-24 AnGap-22
[**2172-7-26**] 04:55PM BLOOD Glucose-255* UreaN-67* Creat-11.8* Na-134
K-4.3 Cl-92* HCO3-24 AnGap-22*
[**2172-7-26**] 06:42AM BLOOD Glucose-238* UreaN-60* Creat-11.0*#
Na-135 K-5.0 Cl-92* HCO3-19* AnGap-29*
[**2172-7-25**] 04:00AM BLOOD Glucose-165* UreaN-33* Creat-7.9*# Na-142
K-3.7 Cl-98 HCO3-30 AnGap-18
[**2172-7-24**] 03:36AM BLOOD Glucose-131* UreaN-45* Creat-10.1*#
Na-138 K-3.4 Cl-93* HCO3-27 AnGap-21*
[**2172-7-23**] 05:08AM BLOOD Glucose-107* UreaN-102* Creat-17.6*#
Na-139 K-4.0 Cl-94* HCO3-18* AnGap-31*
[**2172-7-22**] 06:04PM BLOOD K-4.0
[**2172-7-22**] 11:58AM BLOOD Glucose-59* UreaN-150* Creat-23.5* Na-137
K-5.7* Cl-96 HCO3-17* AnGap-30*
[**2172-7-22**] 05:16AM BLOOD Glucose-75 UreaN-149* Creat-22.9* Na-137
K-6.1* Cl-97 HCO3-18* AnGap-28*
[**2172-7-21**] 06:12PM BLOOD Glucose-163* UreaN-141* Creat-22.5*
Na-137 K-5.1 Cl-96 HCO3-17* AnGap-29*
[**2172-7-21**] 02:35PM BLOOD Glucose-299* UreaN-142* Creat-21.9*#
Na-138 K-4.3 Cl-96 HCO3-19* AnGap-27*
[**2172-7-23**] 05:08AM BLOOD ALT-22 AST-25 LD(LDH)-368* AlkPhos-64
Amylase-111* TotBili-0.5
[**2172-7-22**] 05:16AM BLOOD CK(CPK)-88
[**2172-7-21**] 06:12PM BLOOD CK(CPK)-105
[**2172-7-21**] 02:35PM BLOOD ALT-23 AST-22 LD(LDH)-315* CK(CPK)-127
AlkPhos-69 TotBili-0.4
[**2172-7-23**] 02:43PM BLOOD CK-MB-6 cTropnT-0.87*
[**2172-7-22**] 05:16AM BLOOD CK-MB-NotDone cTropnT-0.70*
[**2172-7-21**] 06:12PM BLOOD CK-MB-12* MB Indx-11.4* cTropnT-0.57*
proBNP-[**Numeric Identifier 98424**]*
[**2172-7-21**] 02:35PM BLOOD CK-MB-13* MB Indx-10.2* cTropnT-0.48*
[**2172-7-28**] 06:15AM BLOOD Calcium-9.3 Phos-5.6* Mg-1.9
[**2172-7-27**] 07:52AM BLOOD Calcium-8.8 Phos-6.4* Mg-2.0
[**2172-7-26**] 04:55PM BLOOD Mg-2.1
[**2172-7-26**] 06:42AM BLOOD Calcium-8.6 Phos-6.7* Mg-2.1
[**2172-7-25**] 04:00AM BLOOD Calcium-8.9 Phos-5.5* Mg-2.0
[**2172-7-24**] 03:36AM BLOOD Calcium-8.2* Phos-7.0*# Mg-1.5*
[**2172-7-23**] 05:08AM BLOOD Albumin-3.4 Calcium-9.1 Phos-8.7* Mg-1.8
[**2172-7-22**] 11:58AM BLOOD Calcium-10.3* Phos-9.9* Mg-2.3
[**2172-7-22**] 05:16AM BLOOD Calcium-10.3* Phos-10.7* Mg-2.3
[**2172-7-21**] 06:12PM BLOOD Calcium-10.7* Phos-10.3* Mg-2.3
[**2172-7-21**] 02:35PM BLOOD Albumin-3.6 Calcium-15.7* Phos-10.1*#
Mg-2.5
[**2172-7-26**] 04:55PM BLOOD Acetone-NEG
[**2172-7-28**] 06:15AM BLOOD Vanco-19.8*
[**2172-7-27**] 07:52AM BLOOD Vanco-22.8*
[**2172-7-26**] 04:50PM BLOOD Type-ART Temp-36.3 pO2-83* pCO2-48*
pH-7.38 calHCO3-29 Base XS-1 Intubat-NOT INTUBA
[**2172-7-21**] 09:03PM BLOOD Type-ART Temp-36.7 Rates-/14 PEEP-5
pO2-143* pCO2-38 pH-7.32* calHCO3-20* Base XS--5
Intubat-INTUBATED Vent-CONTROLLED
[**2172-7-21**] 02:16PM BLOOD Type-ART pO2-454* pCO2-57* pH-7.17*
calHCO3-22 Base XS--8
[**2172-7-26**] 04:50PM BLOOD Lactate-1.6
[**2172-7-22**] 01:21PM BLOOD Lactate-1.8
[**2172-7-21**] 09:03PM BLOOD Glucose-76 Na-136 K-5.1 Cl-98*
[**2172-7-21**] 02:16PM BLOOD Glucose-437* Lactate-2.9* Na-134* K-3.8
[**2172-7-21**] 02:16PM BLOOD Hgb-9.3* calcHCT-28 O2 Sat-98
[**2172-7-21**] 09:03PM BLOOD freeCa-1.36*
[**2172-7-21**] 02:16PM BLOOD freeCa-1.19
Brief Hospital Course:
1) Respiratory distress:
In MICU, she was initially thought to be in flash pulmonary
edema in the setting of missed dialysis and significant HTN,
tachycardia. She was extubated on [**7-23**] without complication, and
was quickly weaned off O2. For the duration of her stay on the
floor, her SaO2 was excellent on room air.
2) Cards:
Ischemia: Patient was found to have elevated troponin after
arrest. This was thought to be [**12-18**] demand ischemia in context of
respiratory arrest. She also has a hx of chronic troponin leak
in the setting of ESRD (see lab records) Cardiology was
consulted but no immediate intervention was thought to be
needed. An attempt was made to do a persantine MIBI stress test;
however, on the day of scheduled testing, Ms. [**Known lastname 11461**] stated
she did not wish to have the test. In our records, she has never
had a stress test, and should have one arranged as an
outpatient.
Pump: BNP was found to be significantly elevated. Echo from [**6-17**]
suggested severely decreased LV function. Echo was repeated [**7-23**],
which showed EF>65%, severe symmetric LVH, 3+ MR, moderate PA
systolic HTN. Pt likely has diastolic dysfunction
3) ESRD: Fistula was clotted such the HD was not able to be
performed initially. Attempts at TPA for fistula was successful
such that dialysis could resume. She was initilaly scheduled
for fistula revision on [**7-24**], but she developed a fever. As the
procedure was delayed pending infection w/u and treatment,
dialysis continued to be done through original fistula with no
difficulties. Transplant surgery decided that fistula revision
no longer necessary due to what appears to be patent fistula.
4) The MICU team suspected UTI vs PNA and started treatment her
with ceftazadime and vancomycin. Once transferred to floor, pt
continued to be afebrile with wbc that normalized from 20 to 10
after two days. [**2172-7-24**] Urine Cx grew pansensitive
enterobacteriaciae. [**2172-7-24**] sputum Cx grew pan-sensitive
Klebsiella. CXR originally showed left perihilar patchy
opacities, c/w aspiration or developing pneumonia. Subsequent PA
and lateral CXR showed resolution of these opacities. [**2172-7-24**] BCx
positive for Corynebacteria diphtheriae in [**11-19**] bottles. Follow
up cultures were negative, and corynebacteria thought to be
contaminant. Ceftazadime continued for three days, then switched
to levofloxacin 250mg PO q48, p HD after speciation and
sensitivities had returned. Vancomycin was d/c'ed after two
days, though levels were still therapeutic three days later.
Transplant surgery requested dentistry consult for evaluation of
"rotten tooth" prior to anticipated AV fistula revision. Panorex
taken, and dentist examined films and pt, finding no infection
or abscess, but recommended extraction of 2 teeth (#21 and 30)
prior to any surgery [**12-18**] caries involving pulp. Since procedure
was cancelled, pt should have these teeth extracted as an
outpatient.
5) HTN: Blood pressure was initially controlled with nitro drip
and was transferred out of the MICU on metroprolol PO, clonidine
TD, and hydralazine IV. ACEI were not given per renal
recommendations due to h/o hyperkalemia. Her hydralazine and
clonidine were weaned off, and nifedipine CR was started at 30mg
PO qD, with good results.
6) T2DM: Mrs. [**Known lastname 11461**] was transferred from MICU on NPH insulin
8U qAM and 2U qHS and RISS. Her FS were consistently elevated,
from 200s-400s. Her NPH was increased to 16U qAM and 6U qHS and
RISS, with some improvement, but still quite elevated FS in
200s. Her regimen was switched to glargine 25U qHS with humalog
RISS. This yielded improved results, with BS typically between
100-200. She was eventually d/c'ed on this regimen.
7) Mental Status: Mrs. [**Known lastname 11461**] has h/o delusional disorder. Per
husband, she was at her baseline mental status at d/c.
Medications on Admission:
ASA 81mg daily
Amlodipine 10mg daily
Clonidine 2 patches weekly
Atenolol 50mg daily
Hydralazine 10 q4 hours
Risperidone 3 mg qHS
Insulin NPH (17am/5pm) and RISS
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
[**Known lastname **]:*30 Cap(s)* Refills:*2*
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Known lastname **]:*30 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
[**Known lastname **]:*60 Capsule(s)* Refills:*2*
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
[**Known lastname **]:*60 Tablet(s)* Refills:*2*
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Known lastname **]:*30 Tablet(s)* Refills:*2*
6. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
[**Known lastname **]:*30 Tablet Sustained Release(s)* Refills:*2*
7. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours) for 7 days: Take on [**8-18**], [**8-5**], [**8-7**]. On
dialysis days, take pill after dialysis.
[**Month/Year (2) **]:*4 Tablet(s)* Refills:*0*
8. Insulin Glargine 100 unit/mL Solution Sig: One (1) 25 Units
Subcutaneous at bedtime.
[**Month/Year (2) **]:*1 month supply* Refills:*2*
9. Insulin Syringe Syringe Sig: One (1) syringe Miscell.
qid prn.
[**Month/Year (2) **]:*120 syringes* Refills:*2*
10. Humalog 100 unit/mL Solution Sig: One (1) per sliding scale
Subcutaneous qid prn: Glucose 0-50: 4oz juice and call doctor
Glucose 51-150: Nothing
Glucose 151-200: 2 units
Glucose 201-250: 4 units
Glucose 251-300: 6 units
Glucose 301-350: 8 units
Glucose more than 350: 10 units and call doctor.
[**Last Name (Titles) **]:*1 month supply* Refills:*2*
11. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: Three
(3) Tablet Sustained Release 24HR PO once a day.
[**Last Name (Titles) **]:*90 Tablet Sustained Release 24HR(s)* Refills:*2*
12. Risperidone 1 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
[**Last Name (Titles) **]:*45 Tablet(s)* Refills:*2*
13. PhosLo 667 mg Tablet Sig: Two (2) Tablet PO four times a
day.
[**Last Name (Titles) **]:*240 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Respiratory arrest, pneumonia, urinary tract infection
Discharge Condition:
Good
Discharge Instructions:
You have been diagnosed with a urinary tract infection and a
pneumonia. You should return to the ED with shortness of breath,
fever, abdominal pain, confusion, dizziness, or any other
problems that concern you.
Followup Instructions:
You should follow up with your nephrologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 60**] within the next 2 weeks.
You should follow up with your psychiatrist, Dr. [**First Name8 (NamePattern2) 915**] [**Last Name (NamePattern1) **]
at ([**Telephone/Fax (1) 98425**] as needed.
You should follow up with your primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) **], in the next 1-2 weeks.
You should continue to get dialysis at [**Hospital1 1426**] on MWF.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
|
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1425, 1542
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
947
| 122,379
|
2433
|
Discharge summary
|
report
|
Admission Date: [**2189-12-26**] Discharge Date: [**2189-12-30**]
Date of Birth: [**2125-1-8**] Sex: F
Service: MEDICINE
Allergies:
Crestor
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
64F hx CAD s/p MI in [**2181**] with 2 DES placed to the pLAD, iCMY EF
45-50%, HTN, HLP who presented to the ED with chest burning. At
4am she awoke with substernal chest burning radiating to the
back associated with nausea, no vomiting or dyspnea.
.
In the ED, she was found to have EKG changes with ST elevations
in V1-V2. She was given heparin, plavix loaded, full strength
aspirin and morphine/SLNTG for pain. Catheterization
demonstrated total occlusion of the LAD in the proximal portion
of her previous stent. Thrombectomy was performed and another
DES was placed. She was transferred to the CCU for further
management.
.
Upon arrival to the CCU, she was chest pain free and felt
comfortable. She was on a nitroglycerin drip and was
hemodynamically stable.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY: anterior STEMI in [**2181**] with 2 DES in LAD
3. OTHER PAST MEDICAL HISTORY:
- PAD
- ischemic CM with EF 45%
- HTN
- HLP
Social History:
SOCIAL HISTORY
- Tobacco history: never smoked
- ETOH: does not drink
- Illicit drugs: no drugs
Family History:
FAMILY HISTORY:
- strong family history of cardiac disease in her first and
second degree relatives
Physical Exam:
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
NECK: Supple, unable to appreciate JVD due to position.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Mild bibasilar rales.
ABDOMEN: Soft, NTND, obese. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
[**2189-12-30**] 06:30AM BLOOD WBC-5.1 RBC-3.96* Hgb-10.5* Hct-32.6*
MCV-82 MCH-26.4* MCHC-32.1 RDW-13.4 Plt Ct-208
[**2189-12-29**] 05:30AM BLOOD WBC-5.3 RBC-3.96* Hgb-10.5* Hct-32.6*
MCV-82 MCH-26.6* MCHC-32.2 RDW-13.3 Plt Ct-198
[**2189-12-28**] 01:27AM BLOOD WBC-5.0 RBC-4.04* Hgb-10.8* Hct-33.3*
MCV-83 MCH-26.6* MCHC-32.3 RDW-13.4 Plt Ct-208
[**2189-12-27**] 05:12AM BLOOD WBC-5.4 RBC-4.08* Hgb-10.9* Hct-33.7*
MCV-83 MCH-26.7* MCHC-32.3 RDW-13.3 Plt Ct-210
[**2189-12-26**] 06:55AM BLOOD WBC-8.7 RBC-4.57 Hgb-12.3# Hct-38.4#
MCV-84 MCH-26.9* MCHC-32.0 RDW-13.4 Plt Ct-281
[**2189-12-29**] 05:30AM BLOOD Neuts-60.5 Lymphs-31.7 Monos-5.5 Eos-1.8
Baso-0.4
[**2189-12-30**] 06:30AM BLOOD Plt Ct-208
[**2189-12-30**] 06:30AM BLOOD PT-12.1 PTT-29.1 INR(PT)-1.1
[**2189-12-30**] 06:30AM BLOOD Glucose-121* UreaN-12 Creat-0.7 Na-141
K-4.6 Cl-107 HCO3-28 AnGap-11
[**2189-12-26**] 06:55AM BLOOD Glucose-179* UreaN-18 Creat-0.8 Na-137
K-7.9* Cl-102 HCO3-25 AnGap-18
[**2189-12-30**] 06:30AM BLOOD ALT-27 AST-37 LD(LDH)-486* AlkPhos-41
TotBili-0.5
[**2189-12-29**] 05:30AM BLOOD ALT-30 AST-46* LD(LDH)-605* AlkPhos-46
TotBili-0.5
[**2189-12-26**] 08:58PM BLOOD CK(CPK)-4058*
[**2189-12-26**] 01:01PM BLOOD ALT-56* AST-346* LD(LDH)-657*
CK(CPK)-3786* AlkPhos-50 TotBili-0.3
[**2189-12-26**] 01:01PM BLOOD Lipase-19
[**2189-12-27**] 05:12AM BLOOD CK-MB-133* MB Indx-5.1 cTropnT-3.84*
[**2189-12-26**] 08:58PM BLOOD CK-MB-423* MB Indx-10.4* cTropnT-6.69*
[**2189-12-26**] 06:55AM BLOOD cTropnT-<0.01
[**2189-12-30**] 06:30AM BLOOD Albumin-3.8 Calcium-9.1 Phos-3.5 Mg-2.0
[**2189-12-26**] 01:01PM BLOOD Mg-2.0 Cholest-204*
[**2189-12-30**] 06:30AM BLOOD %HbA1c-6.6* eAG-143*
[**2189-12-29**] 05:30AM BLOOD %HbA1c-6.5* eAG-140*
[**2189-12-26**] 01:01PM BLOOD Triglyc-47 HDL-64 CHOL/HD-3.2
LDLcalc-131*
[**Last Name (un) 12504**],[**Known firstname 12505**] [**Medical Record Number 12506**] F 64 [**2125-1-8**]
Cardiovascular Report Cardiac Cath Study Date of [**2189-12-26**]
*** Not Signed Out ***
BRIEF HISTORY: This is a 65 year-old woman with hypertension,
dyslipidemia, and coronary artery disease who presented with
refractory
chest pain despite aggressive early medical management. Her
coronary
history is notable for an anterior ST-elevation myocardial
infarction on
[**2182-3-28**], at which time Culotte stenting of the proximal LAD and
D1/S1
branches. A 2.75x16mm Taxus stent was used in the septal-LAD and
a
3.0x12mm Taxus stent was used in the diagonal-LAD. RCA stenosis
(80-90%)
was not intervened upon at that time.
INDICATIONS FOR CATHETERIZATION:
Coronary artery disease, Canadian Heart Class IV, unstable.
Prior q
wave anterior MI, [**2182-3-28**]. Prior PTCA [**2182-3-28**].
PROCEDURE:
Coronary angiography via percutaneous entry of the right common
femoral
artery with a 6F sheath. 4Fr JL4 catheter was used to engage the
left
coronary artery. 4Fr AL2 catheter was used to sub-selectively
engage the
right coronary artery.
Percutaneous coronary revascularization was performed using
placement of
drug-eluting stent(s).
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.69 m2
HEMOGLOBIN: 12.3 gms %
FICK
**PRESSURES
LEFT VENTRICLE {s/ed} -/28
AORTA {s/d/m} 157/86/115
**CARDIAC OUTPUT
HEART RATE {beats/min} 83
RHYTHM SINUS
O2 CONS. IND {ml/min/m2} 125
OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed.
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA DISCRETE 80
2) MID RCA DISCRETE 80
2A) ACUTE MARGINAL NORMAL
3) DISTAL RCA NORMAL
4) R-PDA NORMAL
4A) R-POST-LAT NORMAL
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN NORMAL
6) PROXIMAL LAD DISCRETE 100
12) PROXIMAL CX NORMAL
13) MID CX NORMAL
13A) DISTAL CX NORMAL
14) OBTUSE MARGINAL-1 NORMAL
15) OBTUSE MARGINAL-2 NORMAL
16) OBTUSE MARGINAL-3 NORMAL
**PTCA RESULTS
LAD
PTCA COMMENTS:
A 6fr XBLAD 3.5 guiding catheter was engaged into the LMCA and a
Choice
PT ES guidewire was used to cross the lesion. An OTW balloon was
used to
ensure intralumenal postion and following that an Export
catheter was
used for manual thrombectomy for 8 passes. Following
thombectomy,
angiography revealed a significant proximal LAD stenosis. A
2.5x20mm
Apex balloon was used to predilate the lesion and a 2.75x28mm
Promus DES
was placed at the lesion in the proximal LAD to 12atm. A
3.25x15mm NC
Quantum Apex balloon was used to post-dilate the stent to 22
atm. TIMI 0
flow was present prior to the intervention and TIMI III flow at
the end.
No complications. A 6fr AngioSeal device was deployed
successfully in
the right CFA with excellent hemostasis.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 1 hour 12 minutes.
Arterial time = 1 hour 10 minutes.
Fluoro time = 31.7 minutes.
IRP dose = 2719 mGy.
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol 280 ml
Premedications:
Midazolam 0.5 mg IV
Fentanyl 75 mcg IV
ASA 325 mg P.O.
Clopidogrel 600mg
Nitroglycerine gtt
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Heparin 3000 units IV
Other medication:
Eptifibatide 13.6ml (2mg/ml) IVB f/b 11.5ml/hr
(75mg/100ml)
Cardiac Cath Supplies Used:
- [**Company **], CHOICE PT EXTRA SUPPORT 300CM
2.0MM [**Company **], APEX RX 20
2.5MM [**Company **], APEX RX 20
2.0MM [**Company **], QUANTUM MAVERICK 12MM
3.25MM [**Company **], QUANTUM MAVERICK 15MM
6FR CORDIS, [**Doctor Last Name **] .75
6FR CORDIS, XBLAD 3.5
6FR [**First Name8 (NamePattern2) **] [**Male First Name (un) **], ANGIOSEAL VIP
2.75MM [**Company **], PROMUS RX 28MM
6FR [**Company **], EXPORT ASPIRATION CATHETER
- ALLEGIANCE, CUSTOM STERILE PACK
- MERIT, LEFT HEART KIT
- [**Doctor Last Name **], PRIORITY PACK 20/30
COMMENTS:
1. Selective coronary angiography of this right-dominant system
demonstrated severe 2 vessel CAD. The LMCA was normal. The LAD
was
totally occluded at the proximal segment of the prior stent. The
LCX was
normal with a large OM branch. The dominant RCA, which had an
anomolous
origin in the left coronary cusp, was only sub-selectively
engaged, and
had 80% stenoses in the proximal and mid-vessel segments, which
were not
significantly different from images during her [**2181**]
catheterization.
2. Limited resting hemodynamics revealed elevated left-sided
filling
pressures with a measured LVEDP of approximately 28mmHg.
Systemic
arterial pressure was elevated with a measured central aortic
pressure
of 157/86/115.
3. Left ventriculography was deferred.
4. Successful thrombectomy and PCI to the pLAD with a 2.75x28mm
Promus
DES.
5. AngioSeal to the Right CFA site.
6. No complications.
FINAL DIAGNOSIS:
1. Severe 2 vessel CAD.
2. Elevated left-sided filling pressures.
3. Continue ASA and clopidogrel indefinitely.
4. Continue integrillin for 18hr post-PCI.
5. Repeat echocardiography and consider elective
revascularization of
RCA disease.
6. Successful PCI to the pLAD with Promus DES.
7. AngioSeal to the right CFA.
8. No complications
[**2189-12-26**] TTE
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is severe regional
left ventricular systolic dysfunction with akinesis of the
anterior wall, septum and apex. The remaining segments contract
normally (LVEF = 25%). No masses or thrombi are seen in the left
ventricle. There is a distal septal post infarction ventricular
septal rupture (VSR). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Severe regional left ventricular systolic
dysfunction, c/w extensive anterior infarction. Post-infarction
distal ventricular septal rupture.
Compared with the prior study (images reviewed) of [**2185-3-30**],
regional wall motion abnormalities are significantly more
extensive and the ventricular septal rupture is new. Findings
discussed with the CCU team including Dr. [**First Name (STitle) 437**].
[**2189-12-28**] TTE
The left atrium is normal in size. A patent foramen ovale is
present with premature appearance of saline contrast in the left
atrium after intravenous injection. Left ventricular wall
thicknesses and cavity size are normal. There is moderate
regional left ventricular systolic dysfunction visualized on the
limited views with septal and apical near akinesis. No definite
ventricular septal defect is identified, though a small systolic
color flow Doppler jet is seen near the apex of the right
ventricle (clip #[**Clip Number (Radiology) **]) . Right ventricular chamber size and free
wall motion are normal. The mitral valve leaflets are mildly
thickened. The pulmonary artery systolic pressure could not be
determined. There is an anterior space which most likely
represents a prominent fat pad.
IMPRESSION: Patent foramen ovale. No definite ventricular septal
defect identified Normal left ventricular cavity size with
regional systolic dysfunction.
Compared with the prior study (images reviewed of [**2189-12-26**]), no
definite color flow signal of a VSD is seen and a PFO is now
identified.
[**2189-12-26**] CXR
No acute cardiopulmonary pathology
Brief Hospital Course:
64 year old female with hypertension, hyperlipidemia, coronary
artery disease, infarct-related cardiomyopathy with an EF 45%,
CAD s/p pLAD stent [**2182**] after STEMI, HLP, HTN who presents with
chest pain found to have ST elevations on EKG with total
occlusion of the LAD on cath.
.
# STEMI/CAD: On cardiac catheterization, Ms. [**Name13 (STitle) **] was found
to have total occlusion of the LAD in the proximal area of her
previous stent, thrombectomy and drug eluting stent placement
were performed. She remained hemodynamically stable after the
procedure for the remainder of her hospital course and was free
of chest pain, dyspnea or palpitations. Cardiac enzymes peaked
and declined appropriately. She received integrillin post-cath
per protocol. She was initially on a nitroglycerin drip, which
was weaned shortly after arrival to the CCU. Once heart rate
improved to 70s-80s, her metoprolol was restarted. Aspirin
325mg, plavix 75mg were started. She was started on crestor 40
for acute MI in spite of having a past history of myalgias with
statin use; throughout her hospitalization she refused her
statin intermittently. CT surgery was consulted and they wil
see her as an outpatient to discuss the possibility of CABG in
the future.
.
# Concern for VSD, now resolved: She had a post-catheterization
echocardiogram, which was significant for color-flow imaging
suspicious for VSD. however, the patient had no murmur, was
entirely hemodynamically stable, and repeat echo with bubble
study performed on [**2189-12-28**] clarified that there was no VSD.
The patient was found to have a Patent Foramen Ovale with
valsalva. Echo also demonstrated a small right ventricle which
likely contributed to the colour flow imaging appearance of
abnormal flow.
.
# sCHF: hx of iCMY with EF 45-50% with 2+ TR. LVEDP at end of
case 28 suggesting fluid overload, with likely worsening EF.
Echocardiogram on [**2189-12-26**] shwoed a worse EF of 25%, but repeat
echo on [**2189-12-28**] showed improvement of EF with improvement in
septal wall motion. Her oxygen saturations remained good
throughout her hosptalisation, and she did not have any other
evidence of fluid overload. Her Beta [**Date Range 7005**] and ACE inhibitor
were restarted once blood pressures improved, and will require
continued titration as an outpatient as we were unable to
uptitrate her ACE due to blood pressure concerns.
.
# Hyperlipidemia: She as difficulty with crestor and lipitor
with myalgias, appears to have been on/off statins recently.
Last LDL [**6-16**] was 299. She was restarted on her home dose of
crestor 20mg three times per week and will follow up with lipid
clinic for further management of her hypercholesterolemia.
.
# Hypertension: Low-normal BP during this admission. As blood
pressure improved, we restarted her on metoprolol and
lisinopril, which will need further uptitration as an
outpatient.
.
TRANSITIONAL ISSUES:
- She will followup with Dr. [**Last Name (STitle) 911**] in clinic and will need
uptitration of her antihypertensive medication as tolerated.
- Given her history of myalgias with statin therapy, her home
dose statin (crestor 20mg 3 days per week) and will need to
followup in lipids clinic for optimisation of her medical
management.
- She will followup with cardiothoracic surgery regarding the
possibility of future CABG.
Medications on Admission:
IBUPROFEN - 600 mg Tablet - 1 Tablet(s) by mouth three times a
day as needed for pain
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day for
blood pressure
METOPROLOL SUCCINATE - 100 mg Tablet Extended Release 24 hr -
One
tablet once a day
NIFEDIPINE - 30 mg Tablet Extended Release - 1 Tablet(s) by
mouth
once a day
ROSUVASTATIN [CRESTOR] - 20 mg Tablet - 1 Tablet(s) by mouth
daily
ACETAMINOPHEN - 500 mg Tablet - 2 Tablet(s) by mouth three times
a day as needed for pain also called TYLENOL
ASPIRIN [ENTERIC COATED ASPIRIN] - 81 mg Tablet, Delayed Release
(E.C.) - 2 Tablet(s) by mouth once a day
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. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Toprol XL 100 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
5. Crestor 20 mg Tablet Sig: One (1) Tablet PO 3 days/ week.
6. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary artery disease
Ischemic cardiomyopathy (weak heart muscle, EF 45%)
Hypertension
Dyslipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**].
You were admitted for a heart attack, which was treated with a
drug-eluting stent. Ultrasound imaging of the heart showed some
reduction in function due to the heart attack.
Medication changes:
INCREASE Aspirin 325mg daily indefinitely
START Plavix 75mg daily for minimum of one year
DECREASE Lisinopril to 10mg daily
STOP Nifedipine
*otherwise, continue your medications as usual*
Your cholesterol has been an issue, the numbers are very high
but you are unable to tolerate many of the cholesterol
medications. We scheduled you an appointment in the lipid clinc,
this is to help find a medication(s) you can tolerate which will
help to lower your cholesterol. *follow a low cholesterol, low
fat diet
If you have chest pain at home you can take Nitroglycerin under
your tongue as directed. If the pain does not go away, call 911.
If you have pain in your right groin, fevers, chills or
shortness of breath, call Dr. [**Last Name (STitle) 911**].
For your heart failure diagnosis: weigh yourself daily, [**Name8 (MD) 138**] MD
if weight goes up more than 2 lbs in 2 days or 5 lbs in 3 days,
follow a low salt diet, restrict your fluid intake to 1500 ml/
day.
Followup Instructions:
Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: THURSDAY [**2190-1-7**] at 3:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: CARDIAC SURGERY
When: TUESDAY [**2190-1-12**] at 1:30 PM
With: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 170**]
Building: LM [**Hospital Unit Name **] [**Location (un) 551**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2190-1-20**] at 3:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Dr. [**Last Name (STitle) 12507**] ([**Telephone/Fax (1) 62**]) Fri [**2-12**] 8:30 am
lipid clinic
[**Hospital Ward Name **] [**Location (un) 453**]
|
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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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|
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1384, 1482
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,224
| 117,806
|
2
|
Discharge summary
|
report
|
Admission Date: [**2154-4-30**] Discharge Date: [**2154-5-3**]
Date of Birth: [**2092-11-28**] Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 12**]
Chief Complaint:
fever, chills, rigors
Major Surgical or Invasive Procedure:
Arterial line placement
History of Present Illness:
61F w/ sign PMH for UC s/p colectomy, Stage II breast cancer
presented on day 13 of second cycle of chemotherapy with fever
to 100.6 at home w/ severe rigors. She took two Ibuprofen at
home and then went to onc clinic today where she was then
referred to the ED for admission. She stated that for the past
two days she has noticed an increasing amount of stool output in
her ostomy bag but denies abdominal discomfort or blood in her
stool. She has had nausea but similar to how she has felt in the
past with chemo. She also mentioned that she recently cut her
finger in the garden on Sunday which is now red and slightly
tender to the touch. She otherwise denies any vomiting, rash,
rhinorrhea, dysuria, cough, SOB or abdominal discomfort. She
denies any recent travel or sick contacts as well.
.
In the ED inital vitals were, Temp: 101 ??????F (38.3 ??????C), Pulse: 93,
RR: 16, BP: 77/38, O2Sat: 94, O2Flow: RA. Her labs were notable
for WBC of 0.7 and PMN count of 21. Her U/A was bland and two
blood cultures were obtained and are pending. His CXR did not
show definitive source of infection either. She was started on
Cefepime for neutropenic fever. While in the ED she developed
hypotension not responding to IVF boluses, the pt denied CVL
placement and required the initiation of phenylepherine
peripherially in order to maintain SBPs in the 90s-100s. She did
not have a change in her mentation during these episodes of
hypotension.
.
On arrival to the ICU, she was mentating normally and answering
questions appropriately. She was in NAD.
.
Review of systems:
(+) Per HPI
(-) Denies current chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath, or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies vomiting, constipation,
abdominal pain. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes.
Past Medical History:
Ulcerative colitis s/p Total colectomy with hartmanns pouch in
[**2147-11-26**]
Ileostomy revision for ileocutaneous fistula.
Chronic back pain
Right leg pain for which she underwent exploration for a
possible reflex sympathetic dystrophy at [**Hospital 13**] Hospital.
basal cell carcinoma of her right shoulder
Left Colles fracture
Depression
Breast Cancer Diagnosed in [**1-31**] w/ biopsy currently in cycle 2
of Docetaxel (Taxotere) + Cyclophosphomide, completed cycle 1 in
[**4-1**]
Social History:
Lives alone, works for non-profit.
- Tobacco:denies
- Alcohol: denies
- Illicits: denies
No tob, Etoh. Patient lives alone in a 2 family home w/ a
friend. She is an administrative assistant
Family History:
Mother had breast cancer in 70s.
brother w/ ulcerative proctitis, mother w/ severe arthritis,
father w/ h/o colon polyps and GERD
Physical Exam:
ADMISSION EXAM:
Vitals: T:99.2 BP:78/34 P:71 R: 13 O2:94% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear no tonsilar
exudate
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, ileostomy in place in RLQ no
erythema or tenderness to palpation on exam
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, left fourth finger has erythematous area of skin
measuring approx 2cm in diameter surrounding an scabbed over
skin lesion, no swelling or purulent drainage noted
DISCHARGE EXAM:
Physical Exam:
Vitals: 97.9 106/60 78 20 97%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear no tonsilar
exudate
Neck: supple, JVP 6-8, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, ileostomy in place in RLQ no
erythema or tenderness to palpation on exam
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, left fourth finger has erythematous area of skin
measuring approx 1cm in diameter surrounding an scabbed over
skin lesion, no swelling or purulent drainage noted
Pertinent Results:
[**2154-4-30**] 10:45AM BLOOD WBC-0.7*# RBC-3.19* Hgb-9.7* Hct-28.8*
MCV-90 MCH-30.3 MCHC-33.5 RDW-13.1 Plt Ct-233
[**2154-4-30**] 11:43AM BLOOD WBC-1.0* RBC-3.10* Hgb-9.1* Hct-27.5*
MCV-89 MCH-29.5 MCHC-33.2 RDW-12.9 Plt Ct-209
[**2154-5-1**] 04:12AM BLOOD WBC-2.3*# RBC-2.59* Hgb-7.8* Hct-23.8*
MCV-92 MCH-30.0 MCHC-32.7 RDW-13.2 Plt Ct-165
[**2154-5-1**] 05:36PM BLOOD WBC-4.2# RBC-2.70* Hgb-8.5* Hct-24.4*
MCV-90 MCH-31.3 MCHC-34.7 RDW-13.6 Plt Ct-178
[**2154-5-2**] 03:49AM BLOOD WBC-5.6 RBC-2.77* Hgb-8.7* Hct-25.1*
MCV-91 MCH-31.4 MCHC-34.6 RDW-13.2 Plt Ct-177
[**2154-5-3**] 09:00AM BLOOD WBC-4.9 RBC-3.02* Hgb-8.9* Hct-27.3*
MCV-90 MCH-29.3 MCHC-32.5 RDW-13.6 Plt Ct-221
[**2154-4-30**] 10:45AM BLOOD Neuts-3* Bands-0 Lymphs-27 Monos-69*
Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0
[**2154-4-30**] 11:43AM BLOOD Neuts-7* Bands-1 Lymphs-53* Monos-32*
Eos-1 Baso-0 Atyps-6* Metas-0 Myelos-0
[**2154-5-1**] 04:12AM BLOOD Neuts-16* Bands-7* Lymphs-38 Monos-37*
Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0
[**2154-5-2**] 03:49AM BLOOD Neuts-67 Bands-0 Lymphs-22 Monos-11 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2154-5-3**] 09:00AM BLOOD Neuts-77* Bands-0 Lymphs-14* Monos-7
Eos-1 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2154-4-30**] 11:43AM BLOOD Glucose-112* UreaN-18 Creat-1.1 Na-137
K-4.5 Cl-105 HCO3-23 AnGap-14
[**2154-5-1**] 04:12AM BLOOD Glucose-106* UreaN-12 Creat-0.9 Na-142
K-3.6 Cl-115* HCO3-20* AnGap-11
[**2154-5-2**] 03:49AM BLOOD Glucose-97 UreaN-13 Creat-0.9 Na-140
K-3.9 Cl-114* HCO3-21* AnGap-9
[**2154-5-3**] 09:00AM BLOOD Glucose-92 UreaN-10 Creat-0.9 Na-143
K-4.0 Cl-115* HCO3-22 AnGap-10
Galactomannan - negative
B-d-glucan - negative
Cdiff - negative
BCX - pending
Brief Hospital Course:
Ms. [**Known lastname 14**] is a 61 yo w/ Stage II breast cancer who was
admitted on day 13 or cycle 2 of Docetaxel (Taxotere) +
Cyclophosphomide who developed fever to 100.6 at home with
associated rigors in the setting of neutropenia.
.
#Neutropenic Fever- On presentation the pt's PMN count was 21
most likely from her most recent chemotherapy cycle and lack of
Neulasta use. Two possible sources of infection existed
including pulmonary or from a laceration on her finger suffered
while gardening. She was broadly covered with Vancomycin and
cefepime to cover both possible sources, as well as flagyl to
cover for cdiff as the patient mentioned that she had increased
ostomy output. When cdiff returned negative, flagyl was
discontinued. Blood cultures were sent and a U/A was not
concerning for infection. We also sent off galactomannan antigen
and beta-D-glucan labs initially as part of her neutropenic
fever workup which were negative. The following day after
admission her WBC rose significantly and she no longer was
neutropenic. As her WBC rose she started to develope a cough and
he CXR became concerning for an infiltrate. She was continued on
Vanc/Cefepime until afebrile and with ANC>1000 for greater than
48 hours, after which she was switched to PO levofloxacin to
complete an 8 day total course for community acquired pneumonia.
.
# Hypotension- In the [**Name (NI) **] pt's SBP dropped to 70s, not responding
to IVF boluses. She refused central line placement in the ED and
peripheral pressors were initiated. This is most likely related
to her underlying infectious process. She was not administered
any medications recently that could be accounting for her
hypotension. Looking through OMR her baseline blood pressures
are sbp of 90s-100s. An a-line was obtained which showed higher
BP than what was being recorded by the blood pressure cuff. She
was given several liters of IV fluid boluses and weaned off
pressors the night of admission to the ICU. Her cuff and a-line
pressures correlated after fluid resuscitation and the a-line
was discontinued.
.
# Breast Cancer- currently in cycle 2 of Docetaxel (Taxotere) +
Cyclophosphomide. Most likely this current episode of
neutropenia is due to the fact that Neulasta was not given
during this cycle of chemo per pt's request, however due to the
rapid rise in her WBC count myelosuppression from sepsis was
also a possibility.
.
# Depression / Anxiety- Continue Duloxetine and clonazepam at
home doses.
.
# Nausea- Continued compazine and PO zofran prn.
Medications on Admission:
CLONAZEPAM - 1 mg Tablet - 1 (One) Tablet(s) by mouth once a day
anxiety
DULOXETINE [CYMBALTA] - 20 mg Capsule, Delayed Release(E.C.) - 2
Capsule(s) by mouth daily
LORAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth twice a day as
needed for nausea or insomnia
METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg
Tablet - 1 (One) Tablet(s) by mouth twice a day as needed
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth
twice a day as needed for nausea
ZOLPIDEM - (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth at bedtime as needed for insomnia
Medications - OTC
CALCIUM [CALCIO [**Doctor First Name 15**] [**Month (only) 16**]] - (Prescribed by Other Provider) - 500
mg Tablet - Tablet(s) by mouth Total daily dose 1200 mg
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - (Prescribed by
Other
Provider) - Dosage uncertain
MULTIVITAMIN - (Prescribed by Other Provider) - Dosage
uncertain
OMEPRAZOLE - (OTC) - 20 mg Capsule, Delayed Release(E.C.) - 1
Capsule(s) by mouth once a day
Discharge Medications:
1. clonazepam 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*4 Tablet(s)* Refills:*0*
5. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for insomnia.
6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
7. zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
8. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1)
Tablet PO once a day.
9. Vitamin-D + Omega-3 350 mg- 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
10. multivitamin Tablet Sig: One (1) Tablet PO once a day.
11. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
1) Neutropenic fever
2) Community acquired pneumonia
3) Severe sepsis
4) Anemia
5) Stage II breast cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear [**Known firstname 17**],
It was a pleasure to take care of you here at [**Hospital1 18**]. You were
admitted for low white cell (neutrophil count), fever, and
pneumonia. You required monitoring with blood pressure
supporting medications and IV antibiotics in the intensive care
unit. Fortunately, your counts improved and you responded nicely
to the antibiotics. Please continue to take levofloxacin to
treat your pneumonia for a total of 8 days (last dose on
[**2154-5-7**]). As we discussed if you notice fever, worsening
breathing problems, or any other concerning symptoms to return
to the emergency room immediately.
We have made the following changes to your medications:
START levofloxacin 750mg by mouth daily for 4 more days
([**2154-5-7**])
You should discuss with Dr. [**Last Name (STitle) 19**] the possibility of restarting
neulasta with your next chemotherapy cycle.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2154-5-9**] at 10:30 AM
With: [**First Name11 (Name Pattern1) 20**] [**Last Name (NamePattern1) 21**], M.D. [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2154-5-9**] at 10:30 AM
With: [**First Name8 (NamePattern2) 25**] [**First Name4 (NamePattern1) 26**] [**Last Name (NamePattern1) 27**], NP [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2154-5-9**] at 12:00 PM
With: [**Name6 (MD) 26**] [**Name8 (MD) 28**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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icd9cm
|
[
[
[]
]
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[
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icd9pcs
|
[
[
[]
]
] |
10974, 10980
|
6409, 8934
|
289, 314
|
11130, 11130
|
4705, 6386
|
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|
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|
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1911, 2269
|
228, 251
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342, 1892
|
11145, 11257
|
2291, 2782
|
2798, 2992
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,786
| 111,372
|
46143
|
Discharge summary
|
report
|
Admission Date: [**2119-8-14**] Discharge Date: [**2119-8-23**]
Service: CARDIOTHORACIC
Allergies:
Morphine / Percocet / Codeine
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Shoulder pain
Major Surgical or Invasive Procedure:
PICC placement [**2119-8-15**]; Surgery for hiatal hernia
[**2119-8-16**] 1. Laparoscopic reduction of giant paraesophageal
hernia.
Primary repair of diaphragm. Laparoscopic G tube. Endoscopy.
History of Present Illness:
[**Age over 90 **] year-old female with CAD, thoracic aortic aneurysm, large
hiatal hernia, and gastritis admitted with shoulder pain. Pain
began approximately 3PM on day prior to admission. Described as
'ache', not associated with movement, chest pain, palpitations,
shortness of breath, or palpitations. Patient also with nausea.
Reports she has had previous pain in the past, but not to this
severity or duration. Per discussion with patient's daughter
([**Name (NI) **]) and review of [**Name (NI) **], pain previously attributed in part
to uncontrolled GERD. Following onset of pain, patient took 2
[**Name (NI) 9181**] without relief. Given persistence of pain, she called EMS.
Unclear if this is her anginal equivalent. Per discussion with
patient's daughter, daughter-in-law, often has 'attacks' of
gassy pain with radiation to left shoulder, at times associated
with nausea. Episodes often precipitated by eatting out. This
episode different due to severity/persistence of pain.
.
In the ED, 98 68 106/63 16 100%RA. Left shoulder pain initially
thought to be cardiac equivalent. BP came down to 90/50s soon
after admission, attributed to [**Name (NI) 9181**]. Blood pressure improved
with fluid bolus. First set cardiac biomarkers within normal
limits. EKG showed atrial fibrillation (known), without acute
ischemic changes. CTA showed stable thoracic aortic aneurysm.
Patient subsequently developed abdominal pain, nausea. Lipase
mildly elevated at 65; LFTs within normal limits. CT
abdomen/pelvis noncontrast showed large hiatal hernia and many
renal cysts, no acute change from prior imaging studies. She
received antiemetics (Zofran, Ativan, compazine, phenergan),
acetaminophen, IVF NS 2-3L. On transfer, 98.6, 95 (afib),
106/52, 16, 97%RA. HR occasionally to 120s, hemodynamic
stability.
.
On the floor, patient is drowsy and unable to provide history.
She reports left shoulder pain, nausea. She denies chest pain,
shortness of breath, abdominal pain.
.
Review of sytems: (limited because patient is drowsy)
(+) Per HPI. Reports intermittent constipation, last BM
yesterday morning.
(-) Denies fever, chills. Denies sinus tenderness, rhinorrhea.
Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. No recent change in bowel or bladder
habits. No dysuria.
Past Medical History:
Atrial fibrillation on coumadin
- Hypertension
- Hyperlipidemia
- Esophageal varices, grade I-II
- CAD s/p inferior MI ([**2108**])
- Gastritis
- Large hiatal hernia s/p UGI with barium in [**2113**] with normal
motility
- Multiple pulmonary nodules (non-calcified granulomas on CT
[**2111**])
- h/o left nephrolithiasis (uric acid stones)
- Chronic heart failure, systolic (EF 35%)
- Osteoporosis s/p multiple fractures
- Hypothyroidism
- Gout
- Ascending aortic aneurysm (4.5 cm on [**2115**] MRA)
- Chronic renal insufficiency
Social History:
(from [**10-29**] discharge summary)
"Pt lives alone, has home health aide 4x/week and a VNA 1x/wk.
Can perform ADLS and is fairly independent. Quit tobacco 30yrs
ago. Denies alcohol, illicit drug use."
Family History:
(from [**10-29**] discharge summary)
"Her mother died of a heart attack at age 59."
Physical Exam:
On admission [**2119-8-14**]:
96.7, 97, 137/67, 14, 98% 4L NC
LUE 128/71; RUE 110/64
General: Sedated; AOx3; comfortable
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
Neck: Supple, JVP not elevated
Lungs: Limited by anterior auscultation; no wheezes, rales,
ronchi
CV: Irregularly irregular; normal S1/S2; no murmurs
Abdomen: Hypoactive bowel sounds; soft, nontender, not
distended
Ext: Warm, well-perfused; no lower extremity edema.
.
On Discharge
97.7 80 afib 110/70 18 96% 2L NC
General: Pleasant, conversational, comfortable
HEENT: Sclera anicteric, dry mucous membranes
Neck: Supple
Lungs: bilateral crackles L>R
CV: Irregularly irregular; normal S1/S2; no murmurs
Abdomen: Hypoactive bowel sounds; soft, nontender, not
distended
Ext: Warm, well-perfused; [**12-23**]+ lower extremity edema
Neuro: awake, alert and oriented
Pertinent Results:
[**2119-8-22**] WBC-9.3 RBC-2.82* Hgb-9.0* Hct-27.4 Plt Ct-131*
[**2119-8-21**] WBC-9.5 RBC-2.76* Hgb-8.8* Hct-27.5 Plt Ct-111*
[**2119-8-16**] WBC-12.3* RBC-3.03* Hgb-9.5* Hct-29.3 Plt Ct-153
[**2119-8-14**] WBC-6.6 RBC-3.55* Hgb-11.4* Hct-34.0* Plt Ct-211
[**2119-8-22**] Glucose-165* UreaN-33* Creat-0.9 Na-142 K-4.0 Cl-105
HCO3-30
[**2119-8-21**] Glucose-243* UreaN-39* Creat-0.9 Na-144 K-3.6 Cl-111*
HCO3-26
[**2119-8-14**] Glucose-149* UreaN-37* Creat-1.7* Na-145 K-3.9 Cl-107
HCO3-24
[**2119-8-22**] Calcium-8.5 Phos-3.3 Mg-1.8
[**2119-8-21**] calTIBC-192* Ferritn-136 TRF-148
CXR: [**2119-8-22**] FINDINGS: Since the previous study, the left
paraesophageal thoracic hernia is unchanged which is distended
with air and contains barium. This is associated with a large
left pleural effusion with atelectasis and displacement of the
mediastinum to the right.
There is also a moderate right pleural effusion with fluid in
the horizontal fissure.
Esphogus: [**2119-8-19**] FINDINGS: With the patient at approximately
45-degree incline, thin barium was orally administered which
transited through the esophagus, passed the GE junction and into
the proximal stomach. There was approximately one hour delay of
transit of contrast from the proximal stomach, which was now
supradiaphragmatic, into the more distal stomach, which was
subdiaphragmatic. The more subdiaphragmatic portion of the
stomach is approximately one-third of the total volume of the
stomach and contains a PEG tube. Residual contrast from prior
examinations is present in the colon. Marked bibasilar
atelectasis is present. On the initial fluoroscopic image, no
contrast was present in the intrathoracic stomach from the prior
examination one day ago.
CCT/Pelvic [**2119-8-18**]: IMPRESSION:
1. No evidence of bowel obstruction, or herniation of bowel
loops through the hiatal defect. Fluid density structure at the
right lower mediastinum appears to represent fluid filling the
previous intrathoracic hernia sac, or possibly postsurgical
change secondary to mobilization of omentum.
2. Complex air and oral contrast-filled structure in the left
lower chest
could represent re-herniated stomach, with areas of redundant
folds collapsed on itself. However, gastric perforation/leak
cannot be excluded, and contrast-swallow evaluation is
recommended for further evaluation.
3. Stable appearance of ascending aortic dilatation, better
characterized on recent contrast-enhanced CTA of the chest.
CCT/Pelvic:[**2119-8-14**] Minimal interval enlargement of the
ascending thoracic aortic aneurysm, now measuring 4.9 x 4.4 cm.
There is no evidence of dissection or pulmonary embolism.
2. Interval enlargement and a large hiatal hernia
PICC line [**2119-8-15**]: Left PICC line passes deep into the right
atrium, at least 8 cm beyond the superior cavoatrial junction. N
Brief Hospital Course:
[**Age over 90 **]F with CAD, thoracic aortic aneurysm, gastritis, GERD admitted
with left shoulder pain, nausea with transient relative
hypotension in context of [**Name (NI) 9181**]. Pt c/o abdominal pain during ED
course and CT imaging obtained with results above.
.
# Respiratory: she was extubated on [**2119-8-16**] for the operating
room and extubated on [**2119-8-17**]. Her improved over the course of
her hospitalization with nebs and pulmonary toileting. Her
oxygen saturations were 93% in 3L upon discharge.
# Hiatal hernia: Pt with large hiatal hernia. On [**2119-8-16**] she
was taken to the operating room for Laparoscopic reduction of
giant paraesophageal hernia. Primary repair of diaphragm.
Laparoscopic G tube. Endoscopy.
# Nutrition: She was maintained on TPN until she could tolerate
PO's. On [**2119-8-21**] she was started on clears and advanced to
puree with thin liquids. She tolerated small amounts. She did
not tolerate Tube feeds secondary to shortness of breath. They
were discontinued.
#. Atrial fibrillation: Dilated left atrial noted on TTE [**4-24**].
s/p cardioversion x3, most recent [**4-28**]. rate controlled with
metoprolol.
Coumadin restarted [**2119-8-23**] 0.5 mg.
.
#. CAD s/p inferior MI ([**2108**]): Cardiac catheterization [**12-27**]
with diffuse atherosclerosis. Pt on beta-blocker IV. Aspirin and
statin held as pt not taking PO meds. Careful use of [**Month/Year (2) 9181**] for
chest pain given relative hypotension after doses (2) prior to
admission.
#. Chronic heart failure, systolic (EF 35%): Appears euvolemic,
although pulmonary exam was limited by poor inspiratory effort.
Patient does have oxygen requirement at this time. Beta blocker
continued. Lasix restarted.
.
#. Ascending aortic aneurysm: Based on imaging in ED, slightly
enlarged in size. No evidence of dissection.
.
#. Chronic renal insufficiency: Stable. Current 0.9. Baseline
1.5-1.6.
.
#. Anemia: Borderline macrocytic. Baseline 28-32. Currently
27.0. Known esophageal varices from EGD [**2119-6-13**]. Colonoscopy at
same time with hyperplastic polyp, diverticuli. Iron studies
normal in [**2115**]. B12, folate not checked in our system.
Hct was trended.
.
#. Hypertension: Pt had relative hypotension in [**Name (NI) **] following
[**Name (NI) 9181**], improved on admission. Amlodipine held for SBP 100-116.
.
#. Hyperlipidemia: statin restarted
.
#. Gastritis/GERD: large hiatal hernia. PPI [**Hospital1 **].
.
#. Osteoporosis: Unclear why patient is not taking vitamin D or
calcium supplement.
.
#. Hypothyroidism: Continued Levothyroxine
.
#. Gout: allopruinol restarted
#. PICC line was placed Left [**2119-8-15**] chest film revealed
placement at the cavo-atrial junction and was pulled back 8 cm
per radiology recommendations.
.
Code status: FULL CODE
.
Communication: [**Doctor First Name **] (daughter), ([**Telephone/Fax (1) 98148**]; [**Name (NI) **]
(daughter-in-law), ([**Telephone/Fax (1) 98149**]
.
Disposition: She was seen by physical therapy who recommended
rehab.
Medications on Admission:
(confirmed with patient's daughter)
- Vitamin C
- Aspirin, coated
- MVI
- Norvasc 2.5mg PO daily
- Allopurinol 100mg PO daily
- Lipitor 40mg PO QHS
- Toprol 12.5mg PO daily
- Esomeprazole 40mg PO BID - **she's not taking the evening dose
- Zantac 150mg PO BID - **may not be taking at night
- Klorcon 10meq PO BID
- Levoxyl 75mcg PO daily
- Coumadin 1-2mg PO daily
- Lasix 20mg PO daily
- [**Telephone/Fax (1) 9181**]
- Miralax
Discharge Medications:
1. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
QID (4 times a day): oral thrush.
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: Five (5)
ML PO Q4H (every 4 hours) as needed for pain.
3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet
Sig: One (1) packet PO DAILY (Daily): hold for loose stool.
10. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Ascorbic Acid 250 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO BID (2 times a day).
12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO DAILY (Daily).
13. Regular Insulin Sliding Scale
Glucose Insulin Dose
0-70 mg/dL 4 oz. Juice
71-150 mg/dL 0 Units
151-200 mg/dL 4 Units
201-250 mg/dL 9 Units
251-300 mg/dL 14 Units
301-350 mg/dL 19 Units
14. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4H (every 4 hours) as needed for wheezing.
15. Warfarin 1 mg Tablet Sig: 0.5-1 Tablet PO Once Daily at 4
PM: to maintain INR 2.0-2.5 for Afib.
16. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
17. Hep Flush-10 10 unit/mL Solution Sig: Two (2) mL Intravenous
as needed as needed for PICC line: Flush with 10 cc normal sale
following heparin.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Giant paraesophageal hernia.
Atrial fibrillation: rate control
Hypertension/Hyperlipidemia
Esophageal Varices
CAD s/p inferior MI [**2108**]
Systolic Heart Failure: EF 35%
Gastritis
Hypothyroidism
Gout
Osteoporosis
Chronic renal failure
Ascending Aorta Aneurysm (4.5 cm on [**2114**] MRA)
Discharge Condition:
deconditioned
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if experience:Fevers > 101
or chills, Increased painful or difficulty swallowing.
Followup Instructions:
Follow-up with Dr. [**First Name8 (NamePattern2) **] [**9-7**] at 10:00am on the [**Hospital Ward Name 516**]
[**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**].
Report to the [**Location (un) 861**] Radiology Department for a chest x-ray
45 minutes before your appointment
Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1728**] for coumadin follow-up after
discharge from rehab
Completed by:[**2119-8-24**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
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[]
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3675, 4542
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204, 219
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2469, 2783
|
480, 2450
|
2805, 3336
|
3352, 3557
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,828
| 118,452
|
23763
|
Discharge summary
|
report
|
Admission Date: [**2130-11-16**] Discharge Date: [**2130-11-24**]
Date of Birth: [**2061-8-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Fever, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 12130**] is a 69 year-old male with a history of prostate
cancer, RA on prednisone, AAA, HTN frequent admits for LE
ulcers, who has been admitted twice recently for fevers of
unclear source. On his admission in early [**Month (only) **], he was
treated for presumed cellutitis with 2 weeks of Nafcillin. On
his last admission in mid-[**Month (only) **], he received 1 dose of vanco
for fever in ED but afebrile thereafter and not c/w with RA,
pneumonia, cellulitis, osteomyelitis by Xray. He presents from
[**Hospital 38**] Rehab this time with intermittent fevers fever for one
week, and fever to to 102.5 s/p right LE angiography yesterday.
Patient reports that he was felt well after the procedure but
was a little depressed because he was admitted for RLE angiogram
for RLE ischemia and gangrene and no intervention was performed.
Angiogram had demonstrated severely diseased right superficial
femoral artery and occluded posterior tibial artery requiring a
femoral to below-knee popliteal bypass graft in order to heal
his RLE gangrene. However, he woke this morning feeling
generally unwell, reporting nausea. He went to physical therapy
but went back to his room shortly after as felt fatigued, had 4
bouts of emesis prior to falling asleep. He woke up with fevers
and chills and was noted by Rehab to have had a rectal temp of
101.3, vomited once, and had drop in BP from 160/50 to 116/70 as
well as desatted to 80% on RA, improved to 98% on 4LNC.
.
In the [**Name (NI) **], pt was awake but delirious with temp to 100.1. He was
hypotensive to SBP high 70s which increased to 100-105 with 3L
IVF. Lactate nl. He was hypoxic to 92% on RA, 98% on 2L.
Pancultured and started on CTX, vanco, and azithromycin for
concern for pneumonia (CXR read as no consolidation), and
transferred to ICU. Of note, he had a systolic ejection murmur
which had not been documented in prior notes.
.
ROS: No headaches recently, vision changes, jaw claudication.
Poor dentition, no recent visit to dentist, no tooth pain.
Intentional weight loss. Pt reports having had alternating
diarrhea and constipation over the past several days, not bloody
or black at that time. He last received antibiotics (1 day on
vanco) during his last admission in mid-[**Month (only) **]. On his
admission prior to that in early [**Month (only) **], he had been treated
with 2 weeks of Nafcillin. Last colonoscopy 1 year ago with
benign polyp per report. Reports clear rhinorrhea x 1 week; no
h/o allergies, no shortness of breath, cough, or sinusitis. No
dysuria. Lower extremity ulcers stable per pt. Chronic back
pain. Of note, he has been on Solumedrol 8 mg daily x few years
for RA, increased to 10 mg three weeks ago for RA flare. Upper
extremity weakness 2/2 RA flare and still unable to flex fingers
fully but improved.
Past Medical History:
- S/p left AT and left popliteal angioplasty [**2130-10-2**]
- S/p debridement of left lateral malleolus ulcer [**2130-10-16**]
- S/p split-thickness skin graft to left lateral malleolar ulcer
([**2130-10-20**])
- Hypertension
- Hyperlipidemia
- Atrial fibrillation: S/p DC cardioversion, no recurrence.
- Rheumatoid arthritis: As above
- Prostate cancer: S/p chemotx and radiation tx (completed 40
tx)
- Neuropathy
- Lumbar spinal stenosis
- Abdominal aortic aneurysm (4.7cm): being monitored
- Rosacea
- Ocular migraines
Social History:
Currently coming from [**Hospital 38**] Rehab, lives alone at home.
Retired security guard. H/o tobacco use 2 ppd x 40 years, quit
18 years ago. H/o heavy EtOH use (beer) for many years, stopped
few months ago. Denies illicit drug use. Able to drive on his
own, buys his own groceries. Has son and sister who are his
support structure.
Family History:
Parents both smokers and died of lung cancer, father at 57 [**Name2 (NI) **]
and mother at [**Age over 90 **] [**Name2 (NI) **].
Physical Exam:
Vitals: T: 97.7 BP: 98/78 HR: 81 RR: 17 O2Sat:100% RA
GEN: Well-appearing, well-nourished, no acute distress, pale.
HEENT: NCAT, no temporal tenderness, EOMI, PERRL, no
conjunctival icterus or pallor, no epistaxis or rhinorrhea, poor
dentition.
NECK: No JVD, carotid pulses brisk, no bruits, no cervical or
supraclavicular lymphadenopathy, trachea midline.
BACK: No focal spine or CVA tenderness.
COR: RRR, S1-S2+, 1/6 SEM loudest at USB, no r/g.
PULM: Lungs CTAB, no W/R/R.
ABD: Soft, NT, ND, +BS, no HSM, no masses, no CVA tenderness.
EXT: Warm, no inguinal lymphadenopathy, no LE edema, no calf
tenderness or palpable cords, DP pulses difficult to palpate, no
palpable PT, no acute synovitis.
RECTAL: Rectal tone intact, tender circumferentially on exam
with bright red blood but no masses palpated.
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Decreased hand grip
limited by RA. Patellar DTR +1. Plantar reflex downgoing. No
gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. Left thigh and
lateral malleolus skin graft sites and right 1st toe and right
heel dark, necrotic ulcers not infected-appearing, no skin
breaks. No [**Doctor Last Name **] spots. No [**Last Name (un) 1003**] lesions.
Pertinent Results:
Admission labs
[**2130-11-15**] 06:10AM
HCT-25.4*
UREA N-16 CREAT-0.8 POTASSIUM-3.8
PLT COUNT-138*
NEUTS-88.9* LYMPHS-7.4* MONOS-2.3 EOS-1.2 BASOS-0.1
WBC-6.4 RBC-3.01* HGB-9.0* HCT-27.3* MCV-91 MCH-29.8 MCHC-32.9
RDW-16.6*
GLUCOSE-115* UREA N-16 CREAT-0.8 SODIUM-135 POTASSIUM-4.3
CHLORIDE-101 TOTAL CO2-26 ANION GAP-12
LACTATE-1.4
.
[**2130-11-16**] 05:55PM URINE
RBC-0-2 WBC-[**2-15**] BACTERIA-FEW YEAST-NONE EPI-0-2
COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.021
HOURS-RANDOM CREAT-206 TOT PROT-25 PROT/CREA-0.1
.
Time Taken Not Noted Log-In Date/Time: [**2130-11-16**] 10:30 pm
URINE CULTURE (Final [**2130-11-18**]): NO GROWTH.
.
[**2130-11-16**] 5:00 pm BLOOD CULTURE
Blood Culture, Routine (Final [**2130-11-22**]): NO GROWTH.
.
[**2130-11-17**] 6:54 am BLOOD CULTURE
Blood Culture, Routine (Final [**2130-11-23**]): NO GROWTH.
.
[**2130-11-17**] 10:44 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT [**2130-11-19**]**
FECAL CULTURE (Final [**2130-11-19**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2130-11-19**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2130-11-18**]):
REPORTED BY PHONE TO [**Doctor First Name **] PFEIFFER @ 0541 ON [**2130-11-18**].
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
A positive result in a recently treated patient is of
uncertain
significance unless the patient is currently
symptomatic
(relapse).
.
Discharge Labs:
[**2130-11-24**] 07:30AM WBC 5.0, Hb 8.3, Hct 25.6, Plt 139
[**2130-11-24**] 07:30AM Gluc 86, BUN 13, Cr 0.7, Na 142, K 3.8, Cl
109, CO2 27
.
ECG: Sinus rhythm at 86 bpm, nl axis, nl intervals no ST or
T-wave changes.
.
Venous Dupplex [**11-15**] IMPRESSION: 1. Patent left and right great
saphenous veins.
.
CHEST (PORTABLE AP) Study Date of [**2130-11-16**] 6:37 PM: FINDINGS:
The lungs are clear without consolidation or edema. There is
minimal tortuosity of the atherosclerotic aorta. The cardiac
silhouette is within normal limits for size. No effusion or
pneumothorax is seen. Bridging osteophytes are noted throughout
the thoracic spine. IMPRESSION: No acute pulmonary process.
.
CHEST (PA & LAT) [**2130-11-17**]: FINDINGS: In comparison with the
earlier study of this date, the patient has taken a somewhat
better inspiration. Again there is no change in appearance of
the heart and lungs. Specifically, no evidence of acute
pneumonia.
.
Portable TTE (Complete) Done [**2130-11-17**] at 11:19:51 AM. The left
atrium is elongated. There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size and free wall motion are normal. The number of
aortic valve leaflets cannot be determined. The aortic valve
leaflets are mildly thickened. No masses or vegetations are seen
on the aortic valve, but cannot be fully excluded due to
suboptimal image quality. Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Trivial mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. No obvious valvular
vegetations, but limited views of the aortic and tricuspid
valves. If clinically indicated, a TEE may better assess for
endocarditis. Preserved global biventricular systolic function.
Trivial aortic regurgitation.
.
ABDOMEN (SUPINE & ERECT) Study Date of [**2130-11-18**] 1:41 PM.
FINDINGS: The patient is status post vertebroplasty at L2. There
are multiple gas-filled loops of small and large bowel without
any air-fluid levels and no free air. IMPRESSION: No
obstruction.
.
ANKLE XRAY [**2130-11-20**]: There is patchy demineralization about the
ankle. No fracture is identified. The mortise is preserved on
this non-stressed view. The talar dome is intact. Small plantar
calcaneal spur is again identified. Vascular calcifications are
noted. No soft tissue gas or radiopaque foreign body is
identified. IMPRESSION: Osteopenia. No acute injury identified.
.
BONE SCAN [**2130-11-21**]: INTERPRETATION:
A three phase bone scan was performed, with blood flow and blood
pool images performed over the lower extremities. Whole body
delayed images in anterior and posterior projections were also
acquired. Blood flow images demonstrate asymmetric increased
flow over the left lateral malleolus. The blood pool phase also
demonstrates asymmetric increased uptake over the left lateral
malleolus. This asymmetry remains on whole body delayed images.
This uptake was not present on the prior bone scan from
[**2129-7-1**]. No abnormal right lower extremity uptake is
identified on blood flow, blood pool, or delayed images.
The previously identified linear uptake involving the L2
vertebral body is somewhat less conspicuous but again consistent
with prior compression
deformity. Uptake involving the cervical spine and at L5/S1 is
again consistent with degenerative changes. While the two
previously described foci of right rib uptake have diminished,
an adjacent focus of rib uptake is more prominent, but likely
also consistent with traumatic changes. No foci of uptake
worrisome for metastatic disease are identified.
The kidneys and urinary bladder are visualized, the normal route
of tracer
excretion.
IMPRESSION: 1. Uptake over the left lateral malleolus on all
three bone scan phases may be consistent with osteomyelitis,
however correlation with a white blood cell scan is recommended
for further characterization. 2. Focal uptake involving a lower
right rib is adjacent to prior rib uptake and likely traumatic
in origin. No uptake worrisome for metastasis identified.
.
CTA Chest [**2130-10-29**]:
1. Somewhat limited assessment of the pulmonary arterial
vasculature. No definite central or segmental pulmonary embolism
or evidence of aortic dissection.
2. Extensive coronary artery calcific disease.
3. Focal area of plaque at origin of the left subclavian artery
takeoff from the aorta.
4. Right lower lobe mass slightly smaller when compared to the
CT of [**2128**]. No associated pleural effusion. This may also
represent a focus of round atelectasis.
5. Left pulmonary nodule seen on previous exam is not visualized
on the current study and may be related to slice selection
and/or motion
degradation.
6. Several hyperenhancing lesions of the liver, incompletely
characterized but unchanged compared to the CT of [**2128**].
.
Tagged WBC Scan [**2130-11-23**]:
INTERPRETATION: Following the injection of autologous white
blood cells labeled with In-111, images of the whole body with
dedicated views of the feet and ankles were obtained at 24
hours. These images show very mild nonfocal uptake involving the
left lower extremity in comparison to the right. No focal uptake
to suggest osteomyelitis is observed. Decreased WBC uptake in
the bone marrow at L2 corresponds to the known site of
compression deformity. IMPRESSION: No definite evidence of
osteomyelitis.
Brief Hospital Course:
69 year-old male with a history of Prostate cancer, RA, CAD,
AAA, s/p RLE angiography yesterday who presents with recurrent
fevers.
.
# Fevers of unknown origin: Patient received CTX, Vanco,
Azithromycin in the ED and continued on Vanco and Zosyn in MICU
given hypotension. In the ICU, continued on Vanco and started on
Zosyn given hypotension. TTE done with no evidence of
vegetation. As patient with diarrhea, stool studies including C.
diff were sent. These as well as blood and urine cultures are
pending to date. He was transferred to the floor in stable
condition. C. diff studies returned positive, and pt was started
on Flagyl. Vanco and Zosyn were stopped after cultures were
negative x 72 hours. Although pt remained afebrile and without
leukocytosis, it was not clear that C. diff was the etiology for
his recurrent fever over the past month, and there was concern
for an underlying infection not fully treated. In terms of
infection, no evidence of upper respiratory tract, urinary
infection, cellulitis, endocarditis, prostatis (low PSA and s/p
chemo/XRT, rectal not specific), bacterial gastroenteritis. No
osteomyelitis of spine. In terms of inflammation, not consistent
with acute RA flare, temporal arteritis. In terms of malignancy,
[**10-29**] CTA not very concerning for lung or liver malignancy
(Compared to [**2128**] CT, RLL mass slightly smaller without
associated pleural effusion; hyperenhancing liver lesions); no
lung nodules on CXR or recent CTA chest; last colonoscopy 1 year
ago w/ benign polyp; completed treatment for prostate CA; no
evidence of bone marrow suppression or multiple myeloma (bone
pain but no reported lytic lesions, renal failure, or
hypercalcemia, SPEP neg). As pt later complained of left lateral
malleolus, XR was done which was significant only for
osteopenia. Bone scan was pursued, and there was a question of
possible osteomyelitis at that site. Tagged WBC scan to further
evaluate was (on prelim read) significant for some abnormal
uptake but no definite evidence of osteomyelitis. As patient
remained afebrile and hemodynamically stable without
leukocytosis off vanco and zosyn, he was discharged back to
Rehab to complete treatment for C. diff (14 days total after the
cessation of Vanco and Zosyn). If he spikes again, would
consider checking MRI of left foot to evaluate for osteomyelitis
but no further work-up indicated at this time.
.
# Altered mental status: Resolved in the ICU after receiving
antibiotics and IV fluids. Consistent with delirium, likely in
setting of fever.
.
# Hypotension: Differential dx includes dehydration versus
infection (pre-sepsis), hemodynamically stable after receiving
IVF and antibiotics in the ICU. BP meds held initially in
setting of hypotension but restarted gradually as pt remained
hemodynamically stable even off antibiotics.
.
# Anemia: Hct stable in mid-20s over past month (baseline in 30s
as recently as [**9-20**]). Last colonoscopy 1 year ago with benign
polyp per pt. Rectal exam positive for small amount of bright
red blood, likely secondary to inflammatory changes s/p
radiation for prostate cancer, stools not grossly blood and Hct
stable. Iron studies c/w anemia of chronic disease. No further
work-up pursued as inpatient given stable Hct, but pt should
have further work-up by PCP as outpatient.
.
# Peripheral vascular disease: Pt evaluated by Vascular Surgery
and determined to have no evidence of cellulitis or
osteomyelitis related to ulcer or graft sites. Continued on home
dose of oxycodone prn pain. Pt is to see PCP [**Last Name (NamePattern4) **] [**2130-11-28**] for
pre-op evaluation and to f/u with Dr. [**Last Name (STitle) **] of Vascular
Surgery on [**2130-12-13**].
.
# RA: Pt still with upper extremity weakness but improved since
flare. Continued on methylprednisolone.
.
# CAD/Dyslipidemia: Stable, continued on simvastatin and
aspirin.
Medications on Admission:
- ASA 81 mg daily
- Toprol 100 mg daily
- Lisinopril 40 mg daily
- Simvastatin 10 mg daily
- Methylprenisolone 10 mg daily
- Pantoprazole 40 mg daily
- Colace 100 mg [**Hospital1 **]
- Oxycodone 5-10 mg q4h prn pain
- Multivitamin
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Methylprednisolone 2 mg Tablet Sig: Five (5) Tablet PO DAILY
(Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Flagyl 500 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours for 9 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Primary
- C. diff infection
Secondary
- Peripheral vascular disease
- Anemia
- Prostate cancer s/p chemo/XRT
- Hypertension
- Hyperlipidemia
- Rheumatoid arthritis
Discharge Condition:
Stable, afebrile.
Discharge Instructions:
You were admitted for recurrent fever. You were started
empirically on IV antibiotics in the setting of low blood
pressure, which may have been secondary to infection or
dehydration. As your blood and urine cultures were negative,
your IV antibiotics were stopped. You were found to have
diarrhea secondary to a bacteria called C. diff, for which you
were treated. There was a question of possible left ankle
osteomyelitis on your bone scan, but Vascular Surgery did not
think this was likely on exam, and your tagged white blood scan
was not suggestive of this. You remained afebrile and
hemodynamically stable during your hospitalization, and you will
be discharged back to Rehab to complete treatment of your C.
diff.
You were started on the following new medication:
- Flagyl for C. diff.
Please continue to take all other medications as prescribed.
Please call your PCP or come to the ED if you have another fever
>100.3, infected-appearing ulcers or graft site, persistent
abdominal pain, inability to keep food down, intractable
diarrhea, or any other concerning symptoms.
Followup Instructions:
You are scheduled to see your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 1968**], on
Tuesday, [**2130-11-28**] at 2pm for follow-up as well as pre-op
clearance for R leg bypass. The office number is [**Telephone/Fax (1) 3329**].
You are scheduled to see Dr. [**Last Name (STitle) **] on [**2130-12-13**] at 9:30 am
for Vascular Surgery follow-up. The office number is
[**Telephone/Fax (1) 2625**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
|
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2,479
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48348
|
Discharge summary
|
report
|
Admission Date: [**2118-6-7**] Discharge Date: [**2118-6-9**]
Date of Birth: [**2054-1-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cozaar / Ace Inhibitors / Lipitor
Attending:[**First Name3 (LF) 20146**]
Chief Complaint:
Hypertensive emergency
Major Surgical or Invasive Procedure:
none
History of Present Illness:
64F with longstanding history of poorly controlled HTN and s/p
hemorrhagic stroke presumably from HTN emergency at [**Hospital1 2177**], CAD s/p
MI, CHF witH EF 35%, DM A1c 7.3%, who was seen at PCP's office
with chest pain and intermittent 'gasping' over the last few
days. Notes has had chest and back pain (cardiac equivalent in
her) on and off for several days, as well as "gasping"
particularly bothersome at night. Stable 2 pillow orthopnea.
Shortness of breath and headache progressed over the past day,
prompting her to keep a scheduled appt with her PCP. [**Name10 (NameIs) **] her
visit earlier today, SBP found to be 220-235 and she was sent to
the ED for further management.
.
In the ED, initial VS: 96 97 189/62 18 100% RA. CXR showed mild
volume overload. She was given po hydral and metoprolol with no
effect and started on a nitro gtt. She also received lasix 40mg
iv once without much UOP. Her pressure came down to the 150's on
the nitro gtt and it was decreased as goal bp 160-170. Her labs
were remarkable for trop<0.01 and negative CK with creatinine at
baseline. EKG showed sinus rhythm with TWI in the precordial
leads. She denied any chest pain while in the ED and refused
ASA. CT head wet read showed no evidence of any acute
intracranial pathology but showed a large region of
encephalomalcia in the right hemisphere suggestive of old right
MCA infarction.
.
CXR final read showed engorged pulmonary hilar vasculature, with
diffuse pulmonary vascular congestestion, no effusion.
.
On evaulation on the floor patient reports CP and SOB have
resolved, HA present, but improved. She notes she has not been
taking her diovan as prescribed, but maintains compliance with
her other medications, including her beta blocker, hydralazine,
coumadin, and CCB.
.
On review of systems, she notes some back pain and left-sided
pruritis. Reports recent hospitalization at [**Hospital1 2177**] for "dizziness,
feeling like she was going to black out." Denies any prior
history pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, diarrhea black stools
or red stools. She denies recent fevers, chills or rigors. All
of the other review of systems were negative.
.
Cardiac review of systems is notable for positive features as
above. Denies any current chest pain, ankle edema, palpitations,
or syncope.
Past Medical History:
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS:
Cath [**1-23**]: 100% pLCx. STEMI
Cath [**7-24**]: 20% LM, 30% D1, 100% in-stent pLCx, 50% mRCA.
Cath [**8-27**]: chronic 30% LMCA, 50% LAD, 100% in stent LCx, 50%
RCA.
Cath [**5-1**]: LCx 100% (chronic), D1 50%, 30% prox 50% mid RCA,
PTCA to mid RCA
-PACING/ICD: none
.
3. OTHER PAST MEDICAL HISTORY:
Poorly controlled HTN
Diabetes on insulin
sCHF EF 45% (ischemic)
H/O hemorrahgic CVA [**12/2117**] at [**Hospital1 2177**]
Hypothyroid
CKD baseline 1.2-1.3
Severe pulm HTN by R heart cath [**8-/2113**]
? H/o anoxic brain injury after prolonged ICU stay
Anxiety
Social History:
SOCIAL HISTORY: Lives with her son and future daughter in law
since her stroke in [**12-31**].
Tob: 2.5 pack year history; quit
EtOH: Used to drink on the weekends. Quit.
Drugs: Denies
Family History:
Father with CAD, siblings with 'heart problems'. Grandfather
died of MI.
Physical Exam:
PHYSICAL EXAMINATION:
VS: BP= 186/86 HR= 71 RR= 23 O2 sat= 96% on RA
GENERAL: obese AA woman slumped in stretcher. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, JVD difficult to appreciate [**2-23**] habitus.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: Distant breast sounds, no obvious crackles or rhonchi
appreciated. ? faint expiratory wheezing.
ABDOMEN: Soft, obse NTND.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Right: DP 2+ PT 2+; Left: DP 2+ PT 2+
Neuro: alert and oriented x3; Left sided facial droop, otherwise
cranial nerves II-XII intact. Left upper extremity hemiplegia.
Decreased light touch sensation of left lower extremity. [**5-26**]
motor in RLE, 5-/5 in LLE; [**5-26**] in RUE. brisk biceps reflex on
L>R, unable to elicit b/l patellar reflexes
Pertinent Results:
ADMISSION LABS:
[**2118-6-7**] 01:39PM GLUCOSE-154* UREA N-12 CREAT-1.3* SODIUM-140
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-25 ANION GAP-15
[**2118-6-7**] 01:39PM WBC-6.5 RBC-4.33 HGB-12.5 HCT-38.4 MCV-89
MCH-28.8 MCHC-32.4 RDW-14.8
[**2118-6-7**] 01:39PM cTropnT-<0.01
LABS/STUDIES
[**6-7**] EKG: Sinus at 66 bpm. TW normalization in leads I, II, AVF,
V4-6 compared to prior in [**5-1**].
.
[**6-7**] CT HEAD: Encephalomalacia in the region of the right middle
cerebral artery territory compatible with the sequela of old
infarct. No evidence of any acute intracranial pathology.
.
2D-ECHOCARDIOGRAM: [**4-/2117**]
The left atrium is elongated. The right atrium is moderately
dilated. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is mildly depressed (LVEF= 45 %) secondary to
hypokinesis of the inferior septum, inferior free wall, and
posterior wall. The right ventricular cavity is dilated with
depressed free wall contractility. There are focal
calcifications in the aortic arch. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
ETT: [**4-/2117**]
This was a 63 year old DM woman with a known history of CAD/CHF
(MI's, stents '[**13**]/'[**16**]) who was referred to the lab from the ED
after negative serial cardiac enzymes for an evaluation of
increasing
shortness of breath and chest discomfort with exertion. She
exercised for only 3.5 minutes of a Modified [**Doctor Last Name 4001**] protocol
(~1.7 METs) and had to stop due to fatigue and shortness of
breath. This represents a limited functional capacity. She
denied any chest, arm, neck or back
discomfort throughout the study. In the setting of diffuse T
wave
inversion on baseline ECG, there was T wave normalization noted
during exercise, which returned to baseline morphology by 7
minutes of recovery. The rhythm was sinus with rare APB's and
one PVC during
exercise. There was hypertension noted at rest with an
appropriate blood pressure response to the level of exercise
performed. Hear rate response was blunted due to the patients
limited functional capacity.
.
IMPRESSION: Non-specific T wave changes noted in the presence of
uninterpretable baseline ECG abnormalities. No anginal type
symptoms
reported. Limited functional capacity demonstrated. Resting
hypertension.
Brief Hospital Course:
64 yo F with poorly controlled HTN, ischemic sCHF, DM, CAD s/p
MI admitted to MICU with hypertensive emergency with SBP >220,
chest pain, and mild pulmonary edema.
.
# Hypertensive Emergency: SBP >220 with report of chest pain and
CXR with acute pulmonary edema. On review of CXR, appears
similar to prior, without significant worsening. Per patient,
has not been taking meds as prescribed ("diovan leaves a bad
taste in my mouth"). SBP down to 150s on nitro gtt. Once
transitioned to PO meds her blood pressures stabilized in the
150s-160s systolic. In an effort to simplify her regimen and
provide control with agents she would take, we adjusted her
outpatient medication regimen to - Carvedilol 12.5 mg [**Hospital1 **],
Losartan 100 mg daily, Lasix 20 mg [**Hospital1 **], Isosorbide Mononitrate
ER 90 mg daily, and Spironolactone 25 mg once daily. She met
with Social Work to discuss barriers to complaince and was
discharged home with services to help with medication
administration and vitals monitoring.
.
# Chest Pain: CP likely in setting of HTN emergency, less likely
ACS. Cardiac enzymes were cycled and were negative. No evidence
of acute ischemia on EKG.
.
# Acute on Chronic Systolic Congestove Heart Failure: Known
systolic dysfunction 45% on last echo. Acutely worsened with HTN
emergency and improved with control of blood pressure. Lasix was
restarted at home dose and the patient was breathing comfortably
on room air. Continued on ASA 81 mg daily, [**Last Name (un) **], Beta-blocker,
and Spironolactone.
.
# Chronic Renal Insufficiency: Baseline creatinine as of [**5-1**]
appears to be between 1.2 and 1.4. Creatinine remained around
baseline at 1.3.
.
# Prior CVA: Ischemic. Treated at [**Hospital1 2177**] 12/[**2117**]. CT head on
admission with no acute bleed. She was continued on Coumadin 5
mg daily. She was also give a script for outpatient Occupational
Therapy to improve function of her left arm, which has residual
weakness.
.
# DM: Continued home lantus and SSI, last A1c 7.3%.
.
# HLD: Continued home Simvastatin 20 mg daily.
.
# Hypothyroidism: Continued home Levothyroxine 50 mcg daily.
.
# GERD: Reported history of, not taking PPI or H2 blocker
currently.
.
# ACCESS: PIV's
.
# PROPHYLAXIS:
-DVT ppx with coumadin
-Pain management with tylenol
-Bowel regimen with colace, senna
.
# CODE: Full
.
# COMM: [**Name (NI) **]
Medications on Admission:
albuterol inh prn
furosemide 20 mg [**Hospital1 **]
hydralazine 30 mg tid
glargine 55 units QAM
lispro SSI
isosorbide mononitrate ER 90 mg qd
levothyroxine 50 mcg qd
metoprolol tartrate 25 mg [**Hospital1 **]
omeprazole 20 mg qd ? not taking
simvastatin 20 mg qhs
spironolactone 25 mg qd
valsartan 320 mg qd ? not taking
warfarin 5 mg qd
aspirin 81 mg Tablet
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. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day). Tablet(s)
3. insulin glargine 100 unit/mL Solution Sig: Fifty Five (55)
units Subcutaneous at bedtime.
4. insulin lispro 100 unit/mL Solution Sig: as directed by
sliding scale Subcutaneous four times a day.
5. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: Three (3) Tablet Extended Release 24 hr PO once a day: for
a total of 90 mg daily.
7. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: please continue to have your INR monitored for Coumadin dose
adjustments as needed.
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
12. losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
13. Outpatient Occupational Therapy
please perform occupation therapy for left arm
Discharge Disposition:
Home With Service
Facility:
At home VNA
Discharge Diagnosis:
Hypertensive Emergency
Coronary Artery Disease
Acute on Chronic Systolic Congestive Heart Failure
Chronic Kidney Injury
Diabetes Mellitus
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 13014**],
You were admitted to the Intensive Care Unit for treatment of
dangerously high blood pressures. We provided you with
medications and you improved. You were then transferred to the
Medicine floor. You were seen by Social Work and will be having
a Visiting Nurse Assistant come to help you with your
medications and blood pressure monitoring at home. It is very
important that you take your prescribed medications as directed
and follow up with your Primary Care Physician for further
evaluation.
.
The following changes were made to your current medication
regimen:
-Please STOP taking Hydralazine
-Please STOP taking Metoprolol
-Please STOP taking Diovan (Valsartan)
-Please START Carvedilol 12.5 mg by mouth TWICE daily
-Please START Cozaar (Losartan) 100 mg by mouth ONCE daily
-Please CONTINUE Lasix (Furosemide) 20 mg TWICE daily,
Isosorbide Mononitrate (Extended Release) 90 mg ONCE daily, and
Spironolactone 25 mg ONCE daily
.
Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up
more than 3 lbs.
Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2118-6-16**] at 1:30 PM
With: [**First Name4 (NamePattern1) 2184**] [**Last Name (NamePattern1) 2185**], MD. [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
*This appointment is with a hospital-based doctor as part of
your transition from the hospital back to your primary care
provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up.
Department: [**Hospital3 249**]
When: WEDNESDAY [**2118-7-13**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16163**], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
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11702, 11814
|
3114, 3377
|
2742, 2742
|
3409, 3580
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,308
| 120,420
|
20631
|
Discharge summary
|
report
|
Admission Date: [**2157-9-29**] Discharge Date: [**2157-10-4**]
Date of Birth: [**2078-2-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
COPD exacerbation transfer from OSH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
79-year-old man w/ COPD on home O2 was transferred from OSH
yesterday w/ COPD flair. He initially presented to OSH ED w/
dyspnea for 20 minutes. He was tachypnic, O2 sat 95% NRB, and
ABG 7.19/82/211. He was treated w/ Combivent nebs, IV
enalapril, solumedrol 125 mg IV and levofloxacin 500 mg IV.
Placed on BiPaP resulting in improved ABG to 7.27/67/125. He
was then transferred to [**Hospital1 18**] [**Hospital Unit Name 153**] for ongoing care.
In the [**Name (NI) 153**], pt had good O2 sat on 2L/m NC. He was ruled out
for MI by CEs x 3, and was transitioned to prednisone 60mg,
combivent nebs, and azithromycin. His resp status remained
stable throughout the day. Currently, he denies any fever,
chills, chest pain, palpitations, abd pain, nausea, melena, and
hematochezia. He does have cough occasionally productive of
scant white sputum. He is now transferred to the Medicine team
for ongoing care.
Past Medical History:
1. Hypertension
2. COPD: Per OSH note, FEV1 0.77 (30%), FVC 1.55 (39%), now on
home O2 2L/m at night, pulmonologist at [**Hospital1 2177**] is Dr [**Last Name (STitle) **] (tel:
[**Telephone/Fax (1) 55132**])
3. Hypercholesterolemia
4. Gout
5. Chronic renal insufficiency: baseline creat unknown
6. Myelodysplastic anemia: baseline HCT unknown
7. h/o CVA
8. h/o cold agglutinin dz
Social History:
lives on [**Hospital3 4298**] with his wife; retired from the
tobacco industry; smoked 60 pack years; occasional alcohol use;
no intravenous drug use.
Family History:
non-contributory
Physical Exam:
Gen: chronically ill appearing elderly man sitting up in a
chair, speaking in full sentences, NAD
HEENT: anicteric, EOMI, PERRL, OP clear w/ MMM, no JVD
CV: barely audible s1/s2, no s3/s4/m/r
Pulm: good air movement, diffuse expiratory wheezing w/
prolonged exp phase throughout, no crackles
Abd: scaphoid, +BS, soft, NT, ND
Ext: warm, 2+ DP B, no edema
Pertinent Results:
CXR: Stable appearance of bilateral emphysema with patchy
atelectasis in bilateral bases. No evidence of pneumonia.
Trachea and mediastinum normal.
[**2157-9-29**] 08:04PM BLOOD WBC-12.2* RBC-3.47* Hgb-11.0* Hct-33.5*
MCV-97 MCH-31.7 MCHC-32.8 RDW-11.7 Plt Ct-242
[**2157-9-30**] 04:00AM BLOOD WBC-14.6* RBC-3.17* Hgb-10.3* Hct-30.7*
MCV-97 MCH-32.7* MCHC-33.7 RDW-11.7 Plt Ct-240
[**2157-10-1**] 06:40AM BLOOD WBC-11.1* RBC-3.30* Hgb-10.7* Hct-33.1*
MCV-100* MCH-32.4* MCHC-32.3 RDW-12.0 Plt Ct-249
[**2157-10-2**] 06:25AM BLOOD WBC-11.8* RBC-3.67* Hgb-11.8* Hct-36.7*
MCV-100* MCH-32.3* MCHC-32.2 RDW-11.9 Plt Ct-253
[**2157-9-29**] 08:04PM BLOOD Plt Ct-242
[**2157-10-2**] 06:25AM BLOOD Plt Ct-253
[**2157-9-29**] 08:04PM BLOOD Glucose-119* UreaN-33* Creat-1.8* Na-142
K-4.6 Cl-106 HCO3-26 AnGap-15
[**2157-10-2**] 06:25AM BLOOD Glucose-82 UreaN-36* Creat-1.5* Na-144
K-3.8 Cl-105 HCO3-29 AnGap-14
[**2157-9-29**] 08:04PM BLOOD CK(CPK)-148
[**2157-9-30**] 04:00AM BLOOD CK(CPK)-201*
[**2157-9-30**] 03:35PM BLOOD CK(CPK)-161
[**2157-9-29**] 08:04PM BLOOD CK-MB-9 cTropnT-0.02*
[**2157-9-30**] 04:00AM BLOOD CK-MB-9 cTropnT-0.01
[**2157-9-30**] 03:35PM BLOOD CK-MB-7
[**2157-9-29**] 08:04PM BLOOD Calcium-9.2 Phos-3.1 Mg-1.9
[**2157-10-2**] 06:25AM BLOOD Mg-2.1
[**2157-9-29**] 06:02PM BLOOD Type-ART Temp-37.1 O2 Flow-2 pO2-94
pCO2-46* pH-7.38 calHCO3-28 Base XS-0 Intubat-NOT INTUBA
Comment-NASAL [**Last Name (un) 154**]
Brief Hospital Course:
79-year-old man with COPD, HTN, hyperlipidemia, CRI, anemia
transferred from the [**Hospital Unit Name 153**] to the Medicine team for ongoing care
of COPD exacerbation.
.
1. COPD exacerbation: On admission to the [**Hospital Unit Name 153**] the patient was
on 2L NC with fairly normal ABG with minimal CO2 retention. He
was ruled out for MI and was feeling much better by the time he
arrived to the [**Hospital Unit Name 153**]. He was started on azithromycin,
albuterol/Atrovent nebs and prednisone 60 mg po qd. His
respiratory status continued to improve and he was transferred
to the floor the next day for further monitoring. His WBC
trended down, repeat PA/lateral CXR was unremarkable other than
for stable emphysema. He was weaned down to RA by the second
hospital day and was satting 94% on RA at rest. On ambulation he
desatted to 85 % but was satting well on 2 L nasal cannula on
ambulation (95%). At discharge he had no oxygen requirement at
rest, wheezing resolved, but was discharged with home oxygen for
ambulation, albuterol/Atrovent nebs, Advair INH, and a
prednisone to complete a 1 week taper. By discharge he felt that
he was at about his baseline respiratory status. He will follow
up with his PCP [**Last Name (NamePattern4) **] [**6-26**] days. We would also recommend that he
follow up with an allergist as an outpatient for further
evaluation of what may be prompting his frequent exacerbations.
.
2. HTN: Patient was hypertensive on transfer to the medicine
floor to 190's but stabilized to the 160's without intervention
and was asymptomatic throughout this time. He was started on
metoprolol in the [**Hospital Unit Name 153**], but this was discontinued given his COPD
especially in the setting of an acute exacerbation. He was
restarted on his home regimen of Avapro 300 mg po qd, lisinopril
40 mg po qd and nifedipine 90 mg po qd and his BPs stabilized to
the 130's/70's-80's. His SBPs remained in the high 130's. He was
continued on the regimen at discharge but may consider
increasing his nifedipine as an outpatient.
.
3. Anemia: Patient has known history of anemia secondary to
MDS. His hematocrit remained in the low 30's throughout
admission and stable.
.
4. Chronic Renal Insufficiency: This is likely due to HTN
nephropathy. His baseline creatinine was unknown. He appeared
euvolemic throughout admission and creatinine remained stable at
1.4-1.8. His medications were renally dosed and his creatinine
and volume status closely monitored His creatinine was 1.4 at
discharge.
5. Hyperlipidemia: Continued on Lipitor.
Medications on Admission:
Advair
Duoneb
[**Doctor First Name **]
Avapro 300 qd
Procardia XL 90 qd
Lipitor 20 qd
Lisinopril 40 qd
ASA 81mg daily
Theophylline 200mg D/C 7 d ago
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Irbesartan 150 mg Tablet Sig: Two (2) Tablet PO Qday ().
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed.
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
8. Nifedipine 10 mg Capsule Sig: Three (3) Capsule PO Q8H (every
8 hours).
9. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day for
2 days: Start on [**10-5**].
Disp:*4 Tablet(s)* Refills:*0*
10. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day
for 2 days: Take after you finish your 40 mg doses.
Disp:*6 Tablet(s)* Refills:*0*
11. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days: start after you finich your 30mg doses.
Disp:*2 Tablet(s)* Refills:*0*
12. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days: Take after you finish your 20 mg doses then stop.
Disp:*2 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. COPD exacerbation
2. Hypertension
Secondary:
1. Hypercholesterolemia
2. Chronic renal insufficiency
3. MDS
Discharge Condition:
No shortness of breath, O2 sats stable, afebrile
Discharge Instructions:
If you have any increasing shortness of breath, chest pain,
fevers, chills or any other concerning symptoms, call your
doctor or come to the emergency room.
.
1. Take all of your medications as directed.
2. You are on a prednisone taper that you should complete
3. Keep all of your follow up appointments
4. You should use your oxygen when you are walking or exerting
yourself
Followup Instructions:
You should make a follow up appointment with your primary doctor
Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 55133**] in [**6-26**] days.
|
[
"491.21",
"401.9",
"272.4",
"274.9",
"272.0",
"238.7",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7812, 7818
|
3761, 6326
|
350, 356
|
7981, 8032
|
2310, 3738
|
8457, 8605
|
1896, 1914
|
6525, 7789
|
7839, 7960
|
6352, 6502
|
8056, 8434
|
1929, 2291
|
275, 312
|
384, 1305
|
1327, 1712
|
1728, 1880
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,046
| 143,595
|
35675+58023
|
Discharge summary
|
report+addendum
|
Admission Date: [**2186-4-11**] Discharge Date: [**2186-4-19**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
PICC line placement and removal
History of Present Illness:
Mrs [**Known lastname 81165**] is a 86 yo f with h/o HTN, CHF, COPD, Afib, and
aortic stenosis who presents for evaluation for possible AVR.
Patient presented to the hospital in [**3-13**] with shortness of
breath, fluid overload, and hypotension. She was found to have
critical aortic stenosis. She underwent valvuloplasty with
suboptimal results. Patient was discharged to rehab with
moderate improvement of her symptoms. After discharge patient
reevaluated her options and decided she was not content with her
quality of life. Her edematous legs and pulmonary edema has made
it impossible for her to be independently mobile. She requires
assistance for nearly all ADLs. She decided she was willing to
undergo surgical repair of her aortic valve in attempt to
improve her symptoms. She was seen by her physician who
recommended hospital admission for aggressive diuresis and a
complete preop evaluation.
.
On arrival to the floor, patient states she is comfortable and
without any pain. She thinks her shortness of breath has been
stable since her recent discharge but is unsure because she has
not been as mobile. She admits to significant increase in
bilateral lower extremity edema. She denies chest pain, nausea,
lightheadedness or diaphoresis. She denies any recent illness
with the exception of 1 day of diarrhea last week. She admits to
no other changes in her medical history since her last
admission. The patient denies palpitations or syncope,
claudication-type symptoms, melena, rectal bleeding, or
transient neurologic deficits. No change in weight or urinary
symptoms. No cough, fever, night sweats, arthralgias, myalgias,
headache or rash. All other review of systems negative.
.
Past Medical History:
# HTN
# CHF
# COPD: recently diagnosed by Dr. [**Last Name (STitle) 656**] at [**Last Name (un) 4199**]
# stable goiter
# afib on coumadin
# ? aortic stenosis
# GERD
# osteoporosis
# basal cell under left eye
# s/p resection of childhood tumor "behind heart"
Social History:
Lives at [**Hospital3 **]. Smoking: quit 40 years ago, but had 10
pack year priot to that
Family History:
NC
Physical Exam:
VS: T 96.9 BP 104/66 HR 104 RR 24 SpO2 95% 4L
Gen: NAD, comfortable
HEENT: PERRL, EOMI, NCAT, mmm
NECK: large nontender goiter on R, no JVD visible
CV: holosystolic murmur with loss of S2 consistent
with severe AS, no delayed upstrokes
LUNGS: bibasilar crackles, good air movement
ABD: + bs, Soft, NTND
EXT: BLE 3+ pitting edema
Skin: warm, dry, weeping edematous BLE
Neurologic: no focal deficits, CN 2-12 grossly intact
Pertinent Results:
[**2186-4-11**]
Na 138 / K 3.5 / Cl 89 / CO2 42 / BUN 35 / Cr 1.2 / BG 118
ALT 13 / AST 27 / LDH 269 / Alk Phos 74 / TB 1.8
Alb 3.5 / Ca [**87**].2 / Mg 2.1 / Phos 2.8
WBC 7.9 / Hct 30.8 / Plt 222
INR 5.7
[**2186-4-13**] CXR - Marked widening of right superior mediastinal
contour is consistent with intrathoracic extension of a goiter
as reported on recent CT. Heart remains enlarged. Mild pulmonary
vascular engorgement and new perihilar haziness are likely due
to congestive heart failure. Multifocal patchy and linear
opacities in the left mid and both lower lungs favor
atelectasis. Small pleural effusions are present bilaterally.
[**2186-4-14**] Echo
The left atrium is moderately dilated. The right atrium is
markedly dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Overall left ventricular
systolic function is moderately depressed (LVEF= 35-40%). The
right ventricular cavity is moderately dilated with mild global
free wall hypokinesis. There is abnormal systolic septal
motion/position consistent with right ventricular pressure
overload. The ascending aorta is moderately dilated. The aortic
valve leaflets (3) are severely thickened/deformed. There is
severe aortic valve stenosis (area <0.8cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. The mitral valve shows characteristic rheumatic
deformity. There is mild valvular mitral stenosis (area
1.5-2.0cm2). Severe (4+) mitral regurgitation is seen. Moderate
[2+] tricuspid regurgitation is seen. There is severe pulmonary
artery systolic hypertension. The end-diastolic pulmonic
regurgitation velocity is increased suggesting pulmonary artery
diastolic hypertension. There is no pericardial effusion.
.
IMPRESSION: Mild LVH with moderate global systolic dysfunction.
Mild right ventricular systolic dysfunction. Severe aortic
stenosis. Mild aortic regurgitation. Mild valvular mitral
stenosis. Severe mitral regurgitation. Moderate tricuspid
regurgitation. Severe pulmonary hypertension.
Brief Hospital Course:
86 year old female with a history of HTN, CHF, COPD, Afib, and
aortic stenosis s/p valvuloplasty was admitted for evaluation of
aortic valve replacement.
.
1. Aortic Stenosis:
She was diagnosed with critical stenosis during a prior
admission. At that time, she was not interested in surgical
aortic valve repair but did agree to a cardiac catheterization
with valvuloplasty. She had minimal improvement in her aortic
valve after valvuloplasty. She tolerated the procedure well and
was discharged to rehab. Given her persistent symptoms, she did
ultimatly agree to surgery. Unfortunately she was thought to be
a very high risk for surgery due to likelihood of a difficult
extubation and prolonged ventilator wean, and she was no longer
a candidate for surgical aortic valve repair. Given her limited
other medical options, she was not interested in additional
therapy. She was made DNR/DNI/ Do not rehospitalize and was
discharged to rehab with plans to transition to hospice.
.
2. Congestive Heart Failure:
Ms. [**Known lastname 81165**] was in acute on chronic systolic heart failure upon
arrival to [**Hospital1 18**] likely worsened related to her severe aortic
stenosis. She was diuresed aggressively with a lasix drip and
then transitioned to oral lasix prior to discharge. She was
initially on 4L upon admission, required BiPap briefly, and was
back to 3-5L upon discharge. Her furosemide was transitioned
from a lasix drip to 120mg oral furosemide.
.
3. Hypoxia
Her hypoxia was likely multifactorial and related to her
congestive heart failure, valvular disease, kyphosis, and her
thyroid enlargement.
.
4. Atrial fibrillation
She has chronic atrial fibrillation and was maintained on a beta
blocker for rate control with coumadin for anticoagulation. She
was continued on her beta blocker and warfarin for symptomatic
control of her symptoms secondary to atrial fibrillation.
.
5. Goals of Care
Patient was initially full code upon admission to [**Hospital1 18**] in
anticipation of an aortic valve repair; however, when surgical
aortic valve repair was no longer an option, Ms. [**Known lastname 81165**] was
clear that she would not like any further interventions. She is
interested primarily in symptom control. She now has a do not
resuscitate, do not intubate, and do not rehospitalize order.
Her health care proxy, [**Name (NI) 3608**] [**Name (NI) 81166**], is aware of these wishes
and in full agreement. Palliative care was very helpful in
assisting with these discussions.
# CONTACT: [**Name (NI) 3608**] (daughter) (h) [**Telephone/Fax (1) 81167**] (c) [**Telephone/Fax (1) 81168**]
Medications on Admission:
1. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO daily ().
2. Lovastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
3. Calcium 600 + D(3) 600 mg(1,500mg) -200 unit Tablet Sig: One
(1) Tablet PO twice a day.
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO four times a
day as needed for fever or pain.
6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Every
day except Sunday.
7. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day: Take
Sunday only.
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
10. Furosemide 20 mg Tablet Sig: One (3) Tablet PO DAILY
(Daily).
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-3**] Sprays Nasal
QID (4 times a day) as needed.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO Q6H
(every 6 hours).
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed.
6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
7. Furosemide 80 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
8. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
9. Morphine 10 mg/5 mL Solution Sig: 2.5-5 mg PO Q2H (every 2
hours) as needed for shortness of breath or wheezing.
10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 1848**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Congestive Heart Failure
2. Aortic Stenosis s/p valvuloplasty
3. Atrial Fibrillation
Discharge Condition:
Stable. Patient is tolerating 3-5L of oxygen with adequate
saturations. She is alert and can speak clearly intermittently
throughout the day
Discharge Instructions:
You were admitted to the hospital with shortness of breath. This
was thought likely related to your heart failure and severe
valvular disease. Unfortunately you are not a candidate to have
surgical repair of your valve. Given that your symptoms will
likely not improve significantly without surgery, you were not
interested in further treatment of your medical problems in a
hospital setting. We fully support you in these brave and
difficult decisions and wish you the best of luck.
.
We have made several changes to your medications to align with
your current goals of care.
- raloxifene, lovastatin, calcium, aspirin - we have
discontinued these medications as they do not seem to be
treating your current symptoms.
- morphine - this is a medication you can use as you need for
pain control or shortness of breath.
- seroquel - this is a medication to help you sleep at night.
Followup Instructions:
Good luck to you in your future care.
Name: [**Known lastname 13018**],[**Known firstname 4497**] Unit No: [**Numeric Identifier 13019**]
Admission Date: [**2186-4-11**] Discharge Date: [**2186-4-19**]
Date of Birth: [**2099-7-14**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3780**]
Addendum:
Patient should be referred to Hospice of the [**Location (un) 95**] /
Palliative Care.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 13020**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3782**] MD [**MD Number(2) 3783**]
Completed by:[**2186-4-19**]
|
[
"401.9",
"240.9",
"V58.61",
"V15.82",
"427.31",
"496",
"799.02",
"733.00",
"737.10",
"424.1",
"173.1",
"530.81",
"428.23",
"428.0",
"V66.7",
"276.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11182, 11392
|
4976, 7581
|
283, 317
|
9567, 9710
|
2915, 4953
|
10639, 11159
|
2453, 2457
|
8408, 9341
|
9437, 9437
|
7607, 8385
|
9734, 10616
|
2472, 2896
|
223, 244
|
345, 2047
|
9456, 9546
|
2069, 2329
|
2345, 2437
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,777
| 185,810
|
47999
|
Discharge summary
|
report
|
Admission Date: [**2182-8-9**] Discharge Date: [**2182-8-17**]
Date of Birth: [**2141-6-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
None
Major Surgical or Invasive Procedure:
[**2182-8-9**] - Coronary artery bypass grafting x4 with left internal
mammary artery to left anterior descending coronary artery;
reverse saphenous vein single graft from the aorta to first
obtuse marginal coronary artery; reverse saphenous vein single
graft from the aorta to the first diagonal coronary artery;
reverse saphenous vein single graft from the aorta to the
posterior descending coronary artery.
History of Present Illness:
41 year old gentleman undergoing evaluation for renal [**Month/Day/Year **]
who had an abnormal ETT. He was subsequently referred for a
cardiac catheterization which three vessel disease. He is now
being admitted for surgical revascularization.
Past Medical History:
# Stage V CKD d/t diabetic nephropathy, followed by Dr.
[**Last Name (STitle) 4883**], last seen [**2182-2-6**].
# Congestive heart failure with an ejection fraction of 60-70%
in [**10-31**], mod LVH, diastolic dysfunction.
# Moderate pulmonary hypertension with significant pulmonic
regurgitation and markedly dilated right atrium on [**10-31**]
# Diabetes mellitus, type 2, insulin dependent, diagnosed [**2171**]
complicated by diabetic neuropathy, retinopathy, nephropathy and
vascular insufficiency, s/p toe amputation.
# Hypertension.
# Obesity.
# Hypercholesterolemia.
# History of sickle trait.
# Acid reflux.
# Secondary hyperparathyroidism
# s/p L vitrectomy
Social History:
The patient lives with wife and two children. He is a chef. No
tobacco or alcohol use. Cat, fish and parrot at home.
Family History:
Mother with diabetes
Physical Exam:
64 sr 20 159/85 right Left AV fistula
GEN: NAD
SKIN: Unremarkable
NECK: Supple, FROM, No JVD
LUNGS: CTA. Permacath in right upper chest
HEART: RRR, Nl S1-S2
ABD: S/NT/ND/NABS
EXT: Warm, well perfused. Maturing AV fistula. Will be ready for
use [**2182-7-30**]. No varicosities, 2+ pulses
NEURO: Nonfocal
Pertinent Results:
[**2182-8-9**] ECHO
PRE-BYPASS:
The left atrium is 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 or patent foramen ovale is
seen by 2D, color Doppler or saline contrast with maneuvers.
There is severe symmetric left ventricular hypertrophy. 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 mildly dilated. There are simple atheroma in the aortic
arch. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. Mild
(1+) aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no pericardial effusion.
POST_BYPASS:
Preserved biventricular systolic function. LVEF 55%.
There is a mild AI and Mild TR.
Thoracic aortic contour is intact.
[**2182-8-14**] CXR
Improved aeration with improvement in volume status. Small
persistent bilateral pleural effusions. Left internal jugular
approach central line exchange apparently without complication.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2182-8-9**] for surgical
management of his coronary artery disease. He was taken to the
operating room where he underwent coronary artery bypass
grafting to four vessels. Postoperatively he was taken to the
intensive care unit for monitoring. The renal service followed
him given his history of end stage renal failure on
hemodialysis. CVVH was started for hyperkalemia and acidosis. On
postoperative day one, Mr. [**Known lastname **] [**Last Name (Titles) 5058**] neurologically intact
and was extubated. Packed red blood cells were transfused for
postoperative anemia. He was pancultured for a fever and was
started on levofloxacin and vancomycin empirically. Results of
his cultues were negative. Mr. [**Known lastname **] developed atrial flutter
and his beta blockade was increased. Amiodarone was not used
given his baseline elevated hepatic function enzymes. The
cardiology service was consulted who recommended cardioversion.
On [**2182-8-13**], Mr. [**Known lastname **] was taken to the operating room where he
underwent a successful cardioversion. On postoperative day five,
Mr. [**Known lastname **] was transferred to the step down unit for further
recovery. He continued his routine hemodialysis. The physical
therapy service was consulted for assistance with his
postoperative strength and mobility. Pt stable for home with VNA
Medications on Admission:
Coreg 25mg TID
Renagel 800mg
Aspirin 325mg QD
Insulin
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*2*
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
Disp:*30 Suppository(s)* Refills:*0*
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Insulin
Insulin SC Fixed Dose Orders
Breakfast
70 / 30 10 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular
Glucose Insulin Dose
0-60 mg/dL 4 oz. Juice
61-120 mg/dL 0 Units 0 Units 0 Units 0 Units
121-160 mg/dL 2 Units 2 Units 2 Units 0 Units
161-200 mg/dL 4 Units 4 Units 4 Units 2 Units
201-240 mg/dL 6 Units 6 Units 6 Units 4 Units
241-280 mg/dL 8 Units 8 Units 8 Units 6 Units
281-320 mg/dL 10 Units 10 Units 10 Units 8 Units
321-360 mg/dL 12 Units 12 Units 12 Units 10 Units
> 360 mg/dL Notify M.D.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
CAD s/p CABG
ESRD on HD
Hyperlipidemia
HTN
IDDM
Cardiomyopathy/CHF
Pulmonary HTN
Obesity
Hyperparathyroidism
Sickle cell trait
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 914**] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with cardiologist Dr. [**Last Name (STitle) **] in 2 weeks. [**Telephone/Fax (1) 2386**]
Follow-up with pcp [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**12-29**] weeks. [**Telephone/Fax (1) 3581**]
Currently Scheduled Appointments:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER - NON BILLING
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2182-9-9**] 2:30
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2182-9-9**] 3:30
Provider: [**Name10 (NameIs) **] IMAGING Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2182-9-25**] 9:30
Completed by:[**2182-8-17**]
|
[
"440.23",
"707.15",
"357.2",
"250.62",
"428.0",
"250.42",
"416.8",
"285.1",
"272.0",
"403.91",
"427.32",
"530.81",
"282.5",
"414.01",
"362.01",
"583.81",
"250.52",
"428.30",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"99.04",
"99.61",
"36.13",
"39.61",
"36.15",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6602, 6657
|
3567, 4983
|
324, 737
|
6828, 6837
|
2221, 3544
|
7580, 8415
|
1858, 1880
|
5087, 6579
|
6678, 6807
|
5009, 5064
|
6861, 7557
|
1895, 2202
|
280, 286
|
765, 1011
|
1033, 1705
|
1721, 1842
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,264
| 137,846
|
32605
|
Discharge summary
|
report
|
Admission Date: [**2187-12-5**] Discharge Date: [**2187-12-13**]
Date of Birth: [**2108-2-23**] Sex: M
Service: SURGERY
Allergies:
Ancef
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
ascending weakness and numbness of bilateral lower extremities
(L > R).
Major Surgical or Invasive Procedure:
Left open aortofemoral limb thrombectomy with
abdominal aortogram, left lower extremity four compartment
fasciotomies, bilateral aortoiliac Endograft, left
superficial femoral artery thrombectomy.
History of Present Illness:
The patient is a 79-year-old male who presented
acutely to [**Hospital6 3105**] with sudden onset of
back pain after bending over associated with intense
weakness, numbness and pain of the left lower extremity. Non-
contrast CT at [**Hospital6 3105**] demonstrated an
aortic dilatation at the infrarenal aorta. The patient is
status post an open aneurysm repair with a bifurcated aortic
graft in [**2167**] as well as an open colectomy, gastrectomy and a
left nephrectomy. Upon presentation to [**Hospital1 18**] the patient was
found to have an acutely threatened left leg, reason for
which he underwent a CTA of the abdomen and pelvis and lower
extremities which demonstrated presence of an occluded
aortofemoral limb on the left side as well as a
pseudoaneurysm of the infrarenal aorta. Because of the
ongoing worsening acutely threatening ischemia, the patient
was brought to the operating room for an open thrombectomy
and possible stent grafting for restoration of flow of the
left leg.
Past Medical History:
PMH: AAA, colon CA, HTN, hypercholesterolemia, esophagitis, ? L
renal atrophy, ? arrythmia
PSH: open AAA repair [**2167**], colectomy (side unknown), ?
gastrectomy, ? partial L nephrectomy, ? LLE bypass surgery,
pacemaker
Social History:
pos smoker
pos drinker
Family History:
n/c
Physical Exam:
Vitals: T 97.9, P 61, BP 182/81, RR 18, O2sat 98% 2L NC
Gen: NAD, alert
Neck: no bruits
Chest: RRR, no murmur, CTAB, L upper chest scar
Abd: soft, NT, ND, + BS, large midline scar
Rectal: guiac neg
Ext:
Pulse: fem [**Doctor Last Name **] PT DP
R dopp - palp palp
L dopp - dopp dopp
Pertinent Results:
[**2187-12-11**] 04:53AM BLOOD
WBC-6.4 RBC-3.26* Hgb-9.3* Hct-28.6* MCV-88 MCH-28.4 MCHC-32.4
RDW-14.8 Plt Ct-222
[**2187-12-10**] 11:31PM BLOOD
PT-13.0 PTT-74.7* INR(PT)-1.1
[**2187-12-11**] 04:53AM BLOOD
Glucose-104 UreaN-18 Creat-1.4* Na-139 K-4.2 Cl-105 HCO3-25
AnGap-13
[**2187-12-11**] 04:53AM BLOOD
Calcium-8.9 Phos-3.4 Mg-2.4
[**2187-12-6**] 08:23AM
URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.036*
URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
URINE RBC-21-50* WBC-[**4-9**] Bacteri-RARE Yeast-NONE Epi-0
Time Taken Not Noted Log-In Date/Time: [**2187-12-6**] 5:05 am
URINE Site: CATHETER Y.
URINE CULTURE (Final [**2187-12-7**]): NO GROWTH.
RADIOLOGY Final Report
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2187-12-11**] 4:49 PM
CT CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST:
There are several scattered subcentimeter pulmonary nodules in
both lungs, with the largest measuring 8.5 x 6.3 mm at the right
lung base (image 99, series 3). There is a dual-lumen pacemaker
with the tip in the right atrium and right ventricle
respectively. There is no pericardial or pleural effusion. There
is no significant intrathoracic lymphadenopathy.
There is a 12 x 11 mm low-attenuation focus in the left lobe of
the thyroid gland, a dedicated thyroid ultrasound for this would
be helpful.
CT ABDOMEN WITH AND WITHOUT INTRAVENOUS CONTRAST:
There are calculi in an otherwise unremarkable gallbladder.
There is bilateral adrenal gland thickening. The left kidney is
atrophic and calcified in keeping with chronically infarcted
left kidney. The right kidney has multiple exophytic and
intraparenchymal low attenuation foci likely representing cysts.
The liver and spleen appear unremarkable. There is no
significant upper abdominal lymphadenopathy.
CT PELVIS WITH AND WITHOUT INTRAVENOUS CONTRAST:
There are multiple ventral abdominal hernias in the anterior
abdominal wall. There is no bowel obstruction. There are
surgical clips present in the sigmoid colon suggestive of a
prior dissection. The prostate gland measures 45 x 43 mm and
contains multiple calcific foci within it.
MUSCULOSKELETAL:
There are multilevel degenerative changes present in the spine.
There is some erosion of the body of L3 anteriorly, most likely
by pulsations/pressure of the abdominal aortic aneurysm.
There is a 21 x 15 mm fat-containing subcutaneous focus over the
right posterior lower neck, likely a sebaceous cyst. There are
bilateral inguinal hematomas in keeping with recent
angiography/intervention.
There is mild-to-moderate narrowing of the spinal canal at the
L3-L4 level and L4-L5 level secondary to thickening of the
ligamentum flavum and disc disease.
CT ANGIOGRAM:
There is extensive atherosclerosis present in the coronary
arteries, thoracic and abdominal aorta as well as the iliac
arteries. There is extensive ulcerated plaque present in the
aortic arch, descending thoracic aorta and the abdominal aorta.
The ascending aorta at the level of the right main pulmonary
artery measures 35 x 34 mm. The descending thoracic aorta is
ectatic and measures 40 x 35 mm in its course in mid thorax.
The celiac artery, superior mesenteric artery and right renal
artery are patent. There is an occluded small left renal artery.
The inferior mesenteric artery fills in retrogradely.
There are stents present in the abdominal iliac grafts. There is
contrast extravasation in the hematoma surrounding the
infrarenal abdominal aorta/ endoleak which measures 46 x 40 mm,
previously 37 x 34 mm. The right limb of the aortoiliac graft is
patent and the right internal and external iliac arteries also
show good contrast opacification.
The left limb of the aortoiliac graft is patent and the contrast
is also retrogradely refilling the native left external iliac
artery which is chronically occluded at its origin. The left
internal iliac artery shows good contrast opacification. The
left common femoral artery is aneurysmal at the site of the
insertion of the graft with a soft tissue rind surrounding it
and altogether measures 40 x 36 mm.
CONCLUSION:
1. Aortoiliac endovascular graft post-surgical revision of the
left iliac occlusion. The aortoiliac graft is patent with
filling of the native left common iliac artery via collaterals.
2. Type 1 endoleak with infrarenal abdominal aorta measuring 46
x 39 mm, previously 37 x 34 mm as described above.
3. Multiple pulmonary nodules with the largest measuring 8.5 x
6.3 mm. These nodules may represent metastases if there is a
known history of malignancy, particularly since the patient has
had a prior sigmoid colon resection. Standard followup is three
months for known malignancy or six-month otherwise.
4. Atrophic left kidney with multiple hypodensities in the right
kidney likely represent cysts, however, a dedicated renal
ultrasound would help characterize further.
4. Bilateral adrenal gland thickening likely represent ademonas.
5. A 11 x 12 mm cystic focus in the left lobe of the thyroid
gland should be assessed further with a thyroid ultrasound.
Brief Hospital Course:
Mr. [**Known lastname 75999**],[**Known firstname 1569**] E. [**Numeric Identifier 76000**] was admitted on [**2187-12-5**] with Acute
left lower extremity ischemia with occluded aortofemoral graft
limb.
He agreed to have an elective surgery. Pre-operatively, he was
consented. Emergently taken to the OR.
He underwent a Left open aortofemoral limb thrombectomy with
abdominal aortogram, left lower extremity four compartment
fasciotomies, bilateral aortoiliac Endograft, left superficial
femoral artery thrombectomy.
.
He was prepped, and brought down to the operating room for
surgery. Intra-operatively, he was closely monitored and
remained hemodynamically stable. He tolerated the procedure well
without any difficulty or complication.
Post-operatively, he was transfered to the CVICU. There he was
weaned from pressure support, extubated and transferred to the
VICU for further stabilization and monitoring.
While in the VICU he recieved monitered care. When stable he was
delined. His diet was advanced. A PT consult was obtained. When
he was stabalized from the acute setting of post operative care,
he was transfered to floor status.
On the floor, he remained hemodynamically stable with his pain
controlled. He progressed with physical therapy to improve her
strength and mobility. He continues to make steady progress
without any incidents. He was discharged home with VNA
To note pt did have some oozing from his fasciotomy site.
Staples were removed. Had a large extravagation of clot. Wet to
dry dressing were placed.
Pt also has residual psuedoanuerysm. CT scan is being sent to
MMS for imaging. Pt will probably have endovascular repair in
the future if amendable. he will need to recover from the the
aforementioned hospital course.
Medications on Admission:
[**Last Name (un) 1724**]: atenolol 50", simvastatin 20', norvasc 5', ferrous sulfate
TID, protonix 40', isosorbide mononitrate 30', nitro SL prn
Discharge Medications:
1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Isosorbide Dinitrate 5 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual PRN (as needed) as needed for CP.
6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for CP.
7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
10. [**Last Name (un) 1724**]
atenolol 50", simvastatin 20', norvasc 5', ferrous sulfate
TID, protonix 40', isosorbide mononitrate 30', nitro SL prn
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Acute left lower extremity ischemia
with occluded aortofemoral graft limb.
Discharge Condition:
stable
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Angioplasty/Stent Discharge Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? If instructed, take Plavix (Clopidogrel) 75mg once daily
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**3-10**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
?????? It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**4-8**] weeks for
post procedure check and ultrasound
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.
In addition, you should monitor your leg wounds daily. VNA will
be helping you with dressing changes daily. If you notice any
new bleeding, swelling, loss of sensation in your foot, then you
should call the clinic or the ER immediately.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2187-12-26**] 9:30
Completed by:[**2187-12-13**]
|
[
"414.01",
"E878.2",
"V45.01",
"441.4",
"272.0",
"401.9",
"V10.05",
"996.74"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.50",
"99.04",
"88.42",
"39.49",
"83.14",
"00.40",
"39.71"
] |
icd9pcs
|
[
[
[]
]
] |
10335, 10418
|
7340, 9098
|
339, 538
|
10537, 10546
|
2206, 7317
|
13396, 13581
|
1863, 1868
|
9296, 10312
|
10439, 10516
|
9124, 9273
|
10570, 12559
|
12585, 13373
|
1883, 2187
|
227, 301
|
566, 1561
|
1583, 1807
|
1823, 1847
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,300
| 125,148
|
2186
|
Discharge summary
|
report
|
Admission Date: [**2126-3-2**] Discharge Date: [**2126-3-6**]
Date of Birth: [**2061-11-8**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 9824**]
Chief Complaint:
N/V, Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt. is a 64 y/o F with a PMH of ESRD on HD, DM, and HTN
presenting after dialysis with hypotension, nausea, vomiting and
abdominal pain. The patient reports six episodes of emesis since
HD with mild epigastric pain. Per report temp to 100.5 at HD
with complaint of aches and chills. 4L fluid taken off at HD,
pre-treatment BP 96/58, post-treatment 169/92. T 97.8.
.
In the ED, initial vs were: T 102.9 BP 146/65, HR 110, RR 20 O2
92% RA. FS 215. Blood Cx sent. Emesis X1. Patient was given
Vancomycin 1gm IV, Levofloxacin 500mg IV, Flagyl 500mg IV,
Morphine 2mg IV. Her BP fell to 94/43 and she was given 1 L NS.
WBC 11.2, lactate 3.2. CXR demonstrated no evidence of
infiltrate. CT Abd/Pelvis showed no evidence of colitis. Per ED
report, beside US showed limited views but a normal caliber
aorta.
.
On arrival to the ICU, the patient was resting comfortably. She
denies lightheadedness. C/o b/l knee pain and low back pain
unchanged from her baseline. The pt. reports increased fatigue X
1 week, she has had decreased mobility since her knee surgery in
[**12-31**]. She reports that typically post-HD she has increased
enerygy, however she noted no improvement this week. Denies
fever, had chills last evening but temp was 97.8 at home. She
c/o abd pain, similar to her chronic symptoms, mostly epigastric
but burning symptoms occur in various locations with no clear
pattern or relation to meals. Denies cough, rhinorrhea. +Frontal
and occipital HA last pm. + chronic constipation, no diarrhea.
Her appetite is normal.
Past Medical History:
End stage renal disease on hemodialysis (TuThSa) - LSC HD
catheter changed [**2125-3-8**]
Hx of Back Abscess - [**2123**] treated with I&D, Vanc X 14 days
Diabetes mellitus type II
Hypertension
Hypercholesterolemia
Coronary artery disease (nonobstructive on cath in [**2119**], normal
stress in [**2124-6-23**])
Constipation
Status post total abdominal hysterectomy
Status post C-section
H. Pylori s/p treatment in [**2124-3-23**]
Gastritis
Right knee subtotal medial meniscectomy and subtotal lateral
meniscectomy with medial femoral chondroplasty [**2126-1-8**]
Social History:
Married and lives with husband, 2 children who live nearby,
former home health aid. Smokes <[**1-25**] ppd x 40 years, quit in [**3-3**]
after being hospitalized for influenza. no ETOH, no
drugs. Received the influenza and pneumococcal vaccines
Family History:
+ Premature CAD in brothers and mother. Daughter with kidney
disease. Siblings with DM, CAD, HTN, CVA, no cancer.
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,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild TTP epigastrium, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no edema
Skin: multiple scars from prev fistula attempts on both
forearms, scar, scar - midback from prev. incision site, L SC
site no erythema surrounding catheter + skin breakdown around
adhesive dressing, no fluctuance, no drainage
Pertinent Results:
[**2126-3-2**] 01:15PM WBC-11.2*# RBC-3.97* HGB-12.7 HCT-37.9 MCV-95
MCH-32.0 MCHC-33.5 RDW-15.1
[**2126-3-2**] 01:15PM NEUTS-90.2* LYMPHS-4.6* MONOS-4.1 EOS-0.8
BASOS-0.2
[**2126-3-2**] 01:15PM PLT COUNT-203
[**2126-3-2**] 01:15PM GLUCOSE-197* UREA N-9 CREAT-2.9*# SODIUM-144
POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-29 ANION GAP-22*
[**2126-3-2**] 01:15PM ALT(SGPT)-34 AST(SGOT)-31 CK(CPK)-69 ALK
PHOS-193* TOT BILI-0.5
[**2126-3-2**] 01:21PM LACTATE-3.1*
[**2126-3-2**] 04:16PM LACTATE-2.3*
[**2126-3-6**] 04:35AM BLOOD WBC-6.5 RBC-3.03* Hgb-9.3* Hct-28.8*
MCV-95 MCH-30.7 MCHC-32.3 RDW-15.5 Plt Ct-207
[**2126-3-6**] 04:35AM BLOOD Glucose-98 UreaN-16 Creat-4.6*# Na-137
K-4.2 Cl-98 HCO3-28 AnGap-15
[**2126-3-4**] 05:30AM BLOOD ALT-20 AST-15 LD(LDH)-151 AlkPhos-143*
TotBili-0.3
[**2126-3-3**] 01:35AM BLOOD Lipase-36
[**2126-3-2**] 01:15PM BLOOD CK-MB-3 cTropnT-0.05*
[**2126-3-6**] 04:35AM BLOOD Calcium-10.3* Phos-4.7*# Mg-1.8
[**2126-3-6**] 04:35AM BLOOD PTH-1368*
[**2126-3-5**] 06:35AM BLOOD Vanco-9.8*
[**2126-3-3**] 06:04PM BLOOD Vanco-12.4
[**2126-3-4**] 05:55AM BLOOD Lactate-1.2
[**2126-3-2**] 1:00 pm BLOOD CULTURE
**FINAL REPORT [**2126-3-9**]**
Blood Culture, Routine (Final [**2126-3-8**]):
PRESUMPTIVE PEPTOSTREPTOCOCCUS SPECIES.
ISOLATED FROM ONE SET ONLY.
BACILLUS SPECIES; NOT ANTHRACIS.
Sensitivity testing performed by Sensititre.
GENTAMICIN = SENSITIVE ( <=2 MCG/ML ).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
BACILLUS SPECIES; NOT ANTHRACIS
|
CLINDAMYCIN----------- 0.5 S
GENTAMICIN------------ S
LEVOFLOXACIN----------<=0.25 S
VANCOMYCIN------------ <=1 S
[**2126-3-2**] 1:15 pm BLOOD CULTURE
**FINAL REPORT [**2126-3-8**]**
Blood Culture, Routine (Final [**2126-3-8**]):
BACILLUS SPECIES; NOT ANTHRACIS.
SENSITIVITIES PERFORMED ON CULTURE # 266-9949D [**2126-3-2**].
Anaerobic Bottle Gram Stain (Final [**2126-3-5**]):
GRAM POSITIVE ROD(S).
REPORTED BY PHONE TO [**Doctor First Name **] [**Doctor Last Name **]-[**Doctor Last Name **] #[**Numeric Identifier 11629**] [**2126-3-4**]
2:30PM.
CONSISTENT WITH CLOSTRIDIUM AND
BACILLUS SPECIES.
Blood Cx: [**3-2**], [**3-4**], [**3-4**], [**3-5**]: No growth
Cardiology Report ECG Study Date of [**2126-3-2**] 2:04:54 PM
Sinus rhythm. Modest inferolateral T wave changes which are
non-specific.
Compared to the previous tracing of [**2125-12-26**] there is no
significant diagnostic
change.
CXR: [**3-2**]
IMPRESSION: No significant change when compared to prior exam.
CT- abd/pelvis: [**3-2**]
IMPRESSION:
1. No evidence of colitis.
2. Unchanged angiomylipoma of right kidney. Multiple tiny
hypodensities in
the kidneys too small to accurately characterize.
3. Several small nodules in the left adrenal gland likely not
changed from
[**2122**] but incompletely characterized on the current study.
4. Atherosclerotic disease.
RUQ U/S [**3-3**]
IMPRESSION:
Unchanged cholelithiasis with no secondary findings to suggest
acute
cholecystitis.
TTE [**3-6**]
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild regional left ventricular systolic
dysfunction with probable mild hypokinesis of the basal to mid
inferolateral and lateral segments (suboptimal image quality
limits interpretation). Right ventricular chamber size and free
wall motion are normal. The number of aortic valve leaflets
cannot be determined. The aortic valve leaflets are moderately
thickened. No masses or vegetations are seen on the aortic
valve, but cannot be fully excluded due to suboptimal image
quality. There is mild aortic valve stenosis (area 1.2-1.9cm2).
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No masses or vegetations are seen
on the mitral valve, but cannot be fully excluded due to
suboptimal image quality. Trivial mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] No masses or vegetations
are seen on the tricuspid valve, but cannot be fully excluded
due to suboptimal image quality. Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality limits interpretation.
There is no evidence of endocarditis or abscess. Calcification
of the aortic valve and mitral annulus. Mild aortic stenosis and
trace aortic regurgitation. Probable inferolateral and lateral
hypokinesis.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
Compared with the prior study (images reviewed) of [**2122-11-6**],
the aortic valve is more calcified and there is now aortic
stenosis and trace aortic regurgitation. The degree of tricuspid
regurgitation has increased. The lateral/inferolateral
hypokinesis was similar in appearance on the prior echo.
Brief Hospital Course:
Assessment and Plan: The pt. is a 64 y/o F with a PMH of ESRD on
HD, DM, and HTN presenting after dialysis with hypotension,
nausea, vomiting and abdominal pain.
.
#. Bacteremia - The patient presented with associated symptoms
of N/V, but patient has hadh chronic abd pain and was not
clearly changed from prior. A CT A/P showed no acute process.
Her LFTs were wnl, with her alk ph mildly elevated.
Additionally, RUQ U/S did was unremarkable. Her CXR showed no
clear infiltrate. The patient was initially treated with
Vancomycin 1gm IV, Levofloxacin 500mg IV, Flagyl 500mg IV and
transferred to the ICU. The patient symptomatically improved
and her antibiotics were tailored to Vancomycin and Cipro and
transferred to the floor. The patient's blood cultures did grow
peptostreptococcus from one set and bacillus (non-anthracis)
from another set. The patient did not have evidence of dental
abcsess on exam. The patient remained afebrile and clinically
stable. She underwent TTE that did not show evidence of
endocarditis. She will continue a 2 week course of Vancomycin at
HD. The patient remained stable and no further blood cultures
were positive.
.
#. Hypotension - The pt briefly dropped BP to 90s systolic in
the ED. On review of HD flow sheets, the pt commonly has BP in
this range post-HD. She had 4L taken off at dialysis the day of
admission. The patient was given IVF and her pressures
responded. Her BP med were intially held. After transfer to the
floor she was restarted on clonidine, lisinopril, while her
diltiazem was held. She will follow-up with her PCP regarding
restarting her diltiazem.
.
#. Abd pain: The patient has a history of gastritis on EGD,
treated previously for H.pylori with f/u negative breath
testing. She was continued on her PPI [**Hospital1 **]. She continued to
have chronic abdominal pain, but it was not changed from her
baseline. CT A/P showed no acute process.
.
#. End stage renal disease on hemodialysis - The patient with
LSC HD catheter [**2125-3-8**]. She was continued on HD as scheduled
T/Th/Sa.
.
#. Diabetes mellitus type II - She was initially continued on
her home lantus 8U Qam, 26U Qpm. The patient's glucose were low
during her hospitalization and her PM lantus dose was titrated
down. This is likely due to adhereing to a diabetic diet while
in the hospital. She was discharged on 8U qAm and 24U qPM with
follow-up with her PCP.
.
#. Hypercholesterolemia - continue statin
.
#. Constipation - continue bowel regimen
.
#. Gastritis - continue PPI
.
#. FEN: diabetic diet
.
# Prophylaxis: Subcutaneous heparin
.
# Access: L SC HD, peripheral X2
.
# Code: Full
Medications on Admission:
Active Medication list as of [**2126-2-7**]:
CITALOPRAM [CELEXA] - 20 mg Tablet - 1 Tablet(s) by mouth once a
day; take half a tablet daily for the first week
CLONAZEPAM [KLONOPIN] - 0.5 mg Tablet - half Tablet(s) by mouth
twice a day as needed for anxiety
CLONIDINE - 0.2 mg Tablet - 1 Tablet(s) by mouth twice a day
DILTIAZEM HCL [DILACOR XR] - 240 mg Capsule,Degradable Cnt
Release - 1 (One) Capsule,Degradable Cnt Release(s) by mouth
every day in the afternoon
FLONASE - 50MCG Spray, Suspension - 2 SPRAYS IN EACH NOSTRIL
EVERY DAY
KETOCONAZOLE [NIZORAL] - 2 % Shampoo - appy daily
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day
NORVASC - 10MG Tablet - ONE BY MOUTH EVERY DAY
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 (One)
Capsule(s) by mouth twice a day
OXYCODONE-ACETAMINOPHEN [PERCOCET] - 5 mg-325 mg Tablet - [**1-25**]
Tablet(s) by mouth every 4 hours as needed for pain. Do not
drink, drive or operate heavy machinery while taking this
medication.
SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth once a day
Medications - OTC
ACETAMINOPHEN [TYLENOL 8 HOUR] - 650 mg Tablet Sustained Release
- 2 Tablet(s) by mouth three times a day
CLOTRIMAZOLE [CLOTRIMAZOLE-7] - 1 % Cream - 1 applicator full
applied at bedtime
INSULIN NPH HUMAN RECOMB [HUMULIN N] - 100 unit/mL Suspension -
8
units subcutaneous every morning and 26 units subcutaneous every
evening
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Klonopin 0.25 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO twice a day as needed.
3. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
5. Ketoconazole 2 % Shampoo Sig: One (1) Topical once a day.
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Tylenol 325 mg Tablet Sig: 1300 (1300) mg PO three times a
day.
12. Clotrimazole 1 % Cream Sig: One (1) Topical at bedtime.
13. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen Sig: as
directed Subcutaneous twice a day: 8U qAM/ 26U qPM.
14. Vancomycin 1,000 mg Recon Soln Sig: at HD Intravenous at HD
for 2 weeks: 2 week course
Last day: [**2126-3-15**].
15. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO once a day as
needed for pain.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Bacteremia
ESRD on HD
Secondary:
Diabetes mellitus type II
Hypertension
Hypercholesterolemia v
Coronary artery disease
Constipation
Gastritis
Discharge Condition:
stable, afebrile, normotensive, ambulating
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital. You were admitted to [**Hospital1 18**] because of an infection in
his blood. You were treated with antibiotics and improved. You
also had an ultrasound of your heart that did not show any
infection. You will continue Vancomycin at dialysis for 2 weeks.
Please follow the medications prescribed below.
1) Please stop taking your diltiazem for now given your low
blood pressure
2) Your night-time insulin was decreased to 24U. Please continue
your AM dose as usual.
3) Please take percocet prior to your PT sessions
Please follow up with the appointments below.
Please call your PCP or go to the ED if you experience chest
pain, palpitations, shortness of breath, nausea, vomiting,
fevers, chills, or other concerning symptoms.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2126-3-20**] 9:40
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2126-3-25**] 2:20
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2126-3-25**]
3:30
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2126-4-23**] 2:30
Completed by:[**2126-3-11**]
|
[
"V88.01",
"564.09",
"272.0",
"535.50",
"285.21",
"V58.67",
"250.00",
"V45.11",
"V17.3",
"585.6",
"995.92",
"785.52",
"E878.1",
"996.62",
"403.91",
"414.01",
"038.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
14196, 14202
|
8771, 11404
|
287, 293
|
14398, 14443
|
3535, 8748
|
15294, 15867
|
2715, 2831
|
12878, 14173
|
14223, 14377
|
11430, 12855
|
14467, 15271
|
2846, 3516
|
231, 249
|
321, 1849
|
1871, 2437
|
2453, 2699
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,450
| 190,818
|
9084
|
Discharge summary
|
report
|
Admission Date: [**2108-5-12**] Discharge Date: [**2108-5-17**]
Date of Birth: [**2030-11-10**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Wound erythema, new atrial fibrillation
Major Surgical or Invasive Procedure:
Intubation, mechanical ventilation
History of Present Illness:
The patient is a 77 year old man with a history of ischemic R
foot pain s/p recent R fem-AT popliteal bypass with cephalic
vein [**2108-4-27**] who presents to the ED with drainage from his RLE
incision and rapid AF without hypotension, with subsequent
respiratory code in the [**Hospital1 18**] ED.
.
The patient was admitted in early [**Month (only) **] for RLE rest pain and
underwent an angiogram which demonstrated R SFA disease, and
subsequently underwent R fem-AT popliteal bypass with
non-reversed cephalic vein on [**2108-4-27**]. His post-operative course
was slightly protracted and complicated by acute on chronic
renal failure (creatinine at the time of discharge was 3.9) and
a reactive leukocytosis with WBC of ~30 during admission. He
was seen and followed by both the hematology and the nephrology
services during his hospitalization. He ultimately did well,
however, and was discharged to rehab on [**2108-5-10**].
.
He was doing well at rehab until today by report: he has been
ambulating, moving his bowels, and eating and drinking normally.
This morning, however, he noted some drainage from the dorsal
aspect of his R foot with some wound breakdown which prompted
his presentation to the [**Hospital 8125**] Hospital ED. He has not had
fevers/chills, chest pain, shortness of breath, or dizziness.
Also of note, he has never had rapid atrial fibrillation before.
.
At the Tody ED he had a leukocytosis (WBC 57- baseline is 20-30)
and a HR of 140 with rapid AF without hypotension. He was
transferred to [**Hospital1 18**] for further management. At the time of
evaluation in the [**Hospital1 18**]
ED, he reports mild pain in his R foot but denies other
complaints including chest pain, shortness of breath, and
dizziness.
.
In the ED, initial vs were: T 97.2 P 106 BP 102/75 R 14 O2 sat
99% on NC. He was stable and mentating well for ~45 minutes, and
then had an acute respiratory decompensation with neck/chest
pain requiring emergent intubation. He was talking with his
nurse when he stopped breathing, grabbed his neck, and became
unresponsive. He was intubated emergently. He maintained his
pulse throughout the event, and his HR remained tachycardic at
~140 with a SBP>100. Empiric IV heparin (bolus and gtt) was
begun immediately thereafter. He was not started on any
sedation. He was given IV fluids (with bicarb) and transferred
to the floor.
.
On the floor, patient was comfortable. Intubate but not
sedated. Denied any active complaints at that time.
Past Medical History:
Diabetes Mellitus Type Two
- Hypertension
- Hyperlipidemia
- Thrombocythemia
- History shingles
- Myeloproliferative disorder
- Status-post appendectomy, left elbow ulnar nerve repair,
carpal tunnel repair, right inguinal hernia repair
Social History:
Posting 1PPD tobacco hx quit 40 year ago, EtOH 1 vodka/day, no
ilicit drugs. Married with 5 children, retired registrar at
[**University/College 31355**]now is a golf coach.
- Tobacco: 1 PPD x40
- Alcohol: 1 vodka/day
- Illicits: None
Physical Exam:
Physical Exam:
Vitals: T: BP: P: R: 18 O2:
General: Intubated. Alert, arousable. No acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation anterolaterally, 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, 1+ pulses in b/l LE, 1+ edema in b/l LE, no clubbing,
cyanosis. Multiple steri-strips in place in right leg. No
active bleed noted.
Pertinent Results:
CXR- Retrocardiac opacity, tubes in place
.
CT chest-
1. Left lower lobe pneumonia with bilateral pleural effusions,
left greater than right.
.
2. Small volume abdominal ascites.
.
3. Extensive atherosclerotic disease including CAD.
.
4. NG tube and ET tube appropriately positioned.
.
5. No hydronephrosis. Nonspecific bilateral perinephric
stranding. Left upper pole renal hypodensity could represent a
small cyst, too small to characterize.
.
6. Prostatic enlargement. Please correlate with PSA.
.
CT Head- 1. No acute intracranial pathology.
2. Marked periventricular white matter hypodensity, compatible
with small vessel microvascular infarcts. With these findings
the sensitivity for subtle infarcts is diminished, an MRI could
be performed if there is persisting concern for acute infarct.
.
3. Sinus opacification.
Brief Hospital Course:
Respiratory arrest: The pt's initial respiratory arrest was of
unclear etiology. ABG on arrival to the floor- 7.39/43/105/27 on
[**3-28**]. Primary possibilities investigated were pna, flash
pulmonary edema vs PE after his recent surgery. Broad spectrum
antibiotics were initiated, vancomycin, ciprofloxacin and
metronidazole to cover for nosocomial pneumonia. The pt was
extubated on [**5-14**]. On [**5-16**] the pt became hypoxemic and CXR
demonstrated evidence of RUQ pneumonia and possible pulmonary
edema. The patient had been diuresed overnight and aztreonam was
added to his antibiotic coverage. On the evening of [**5-16**] the
patient became hypoxemic to the mid 80s after eating. Repeat
CXR on demonstrated radiographic evidence of increasing
consolidation of the RUQ pneumonia with evidence of a new right
lower lobe process perhaps secondary to an aspiration event.
Broad antibiotic coverage was continued. The family was
involved in discussions regarding the patients disposition.
With worsening of his respiratory distress, the family decided
to make the patient DNR/DNI and finally comfort care. The
patient expired surrounded by his family at 17:31pm.
.
Atrial fibrillation: New onset afib at time of admission,
CHADS2 score was 5. The patient was placed on a diltiazam gtt
for rate control. Metoprolol was added on the second day of
admission for better rate control. On [**5-16**] the patient
developed tachycardia despite diltiazam drip and metoprolol.
His metoprolol was increased to 75mg tid and an amiodarone gtt
was initiated on [**5-17**] for better rate control.
.
Wound infection: The pt's initial reason for ED visit was for
concern for recent surgical procedure. He was continued on
broad spectrum antibiotics. Vascular and Wound Consult were
consulted and recommendations regarding care were followed.
.
Leukocytosis: The patient presented with underlying
leukocytosis thought to be reactive from prior work up revealing
no evidence of CLL/CML. Heme onc briefly consulted the team and
suggested restarting the patients home dose hydroxyurea which
had recently been decreased in dose.
.
GI Bleed: The patient had an EGD [**5-15**] which demonstrated 2
nonbleeding cords of grade II varices which were cauterized. The
patient tolerated heparin challenges and drip with no further
bleeds.
.
The patient's statin were held during the admission and he was
placed on his home insulin regiment and BPH medications.
Medications on Admission:
- Aspirin 325 mg po qd
- Plavix 75 mg po qd
- Insulin NPH 25 UQAM, 20U QPM
- Insulin humalog 5 units QAM, 5 units QPM
- pravastatin 20 mg po qd
- pioglitazone 30 mg po qd
- colace, senna, dulcolax
- lasix 80 mg po qd
- flomax 0.4 mg po qd
- pantoprazole 40 mg po q12hrs
- dilaudid prn pain
- prazosin 5 mg po bid
- hydroxyurea 500 mg 2x/week
- reglan 10 mg po tid
- ciprofloxacin 500 mg po qd x 7 days
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Respiratory arrest
2. Atrial fibrillation
3. Hospital Acquired Pneumonia
4. Aspiration Pneumonia
5. Wound Infection
Discharge Condition:
patient expired
Discharge Instructions:
patient expired
Followup Instructions:
patient expired
|
[
"427.31",
"272.4",
"E878.2",
"276.0",
"507.0",
"682.6",
"537.83",
"584.9",
"428.33",
"401.9",
"518.81",
"998.59",
"707.14",
"238.79",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43",
"96.04",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7787, 7796
|
4882, 7335
|
312, 348
|
7958, 7975
|
4032, 4859
|
8039, 8057
|
7817, 7937
|
7361, 7764
|
7999, 8016
|
3423, 4013
|
232, 274
|
376, 2879
|
2901, 3139
|
3155, 3393
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,446
| 150,404
|
6925
|
Discharge summary
|
report
|
Admission Date: [**2185-7-12**] Discharge Date: [**2185-7-27**]
Date of Birth: [**2130-12-10**] Sex: F
Service: GYN/ONCOLOGY
HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old
female with history of metastatic breast cancer since [**2178**]
who was admitted on [**2185-7-12**] for resection of a pelvic mass
and ureterolysis. The patient is status post diagnosis in
[**2182**] of bony metastases and status post STAMP in [**2183-7-17**]
via an allodonor. She is in the midst of chemotherapy with
weekly Navelbine.
In [**2185-5-17**], the patient was found to have bilateral
hydronephrosis. This was discovered incidentally during a CT
for her breast cancer followup and restaging. A subsequent
MRI demonstrated bilateral large adnexal masses (most likely
Krukenberg tumors-metastases from breast) causing
hydronephrosis. The patient was referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5166**]
for removal of her bilateral adnexal masses for the purposes
of diagnosis as well as relief of her bilateral
hydronephrosis.
PHYSICAL EXAMINATION: The patient is an obese white female
in no apparent distress. Her weight was 265 pounds, height 5
feet 6 inches tall. O2 saturation was 93% on room air,
temperature 98.6, pulse 79, blood pressure 135/79. The lungs
were clear to auscultation bilaterally. HEENT examination
revealed anicteric, normocephalic, atraumatic. Cardiac
examination was remarkable for a regular rate and rhythm,
normal S1 and S2, and no murmurs, rubs, or gallops. The
abdomen was soft, obese, and nontender with no palpable
masses. Extremity examination revealed left lower extremity
edema, upper and lower extremity. Lymph node survey was
negative. Pelvic examination was as follows: Adnexal masses
were not appreciated secondary to the patient's body habitus.
The cervix was firm.
HOSPITAL COURSE: The patient was taken to the Operating Room
on [**2185-7-12**] where an exploratory laparotomy, radical
hysterectomy with bilateral salpingo-oophorectomy, and
ureterolysis on the right side were performed.
Intraoperatively, she did receive 5 units of packed red blood
cells. Her estimated blood loss was 1200 cc. Surgery was
uncomplicated.
The patient was then taken to the Post Anesthesia Care Unit
where she was unable to be extubated secondary to
laryngospasm, therefore she was transferred to the Surgical
Intensive Care Unit for care overnight. In the morning she
was extubated without difficulty.
Immediately postoperative, her course was complicated by
anuria. She was therefore taken to the urology suite where
cystoscopy and fluoroscopy were done. This demonstrated that
both ureters were patent. Her bilateral hydronephrosis was
noted, right greater than left. She did have a stent placed
in the left ureter. She was noted at this time to be making
small amounts of urine.
Overnight in the Surgical Intensive Care Unit, the patient
had better urine output and did well after extubation. She
was transferred to the floor.
Upon reaching the floor, the patient did continue to have
adequate urine output initially. However her creatinine was
noted to be rising. Ultrasound showed continued
hydronephrosis. Her creatinine reached a level of 3.3 and
the decision was made to place a percutaneous nephrostomy
tube on the right side. This was done without complication
on Sunday, [**2185-7-17**]. The patient also required two
additional units of blood. Of note, she was marrow
suppressed secondary to her chemotherapy.
After nephrostomy placement, the patient's creatinine
eventually dropped to 0.9. She did have a copious post
obstructive diuresis of approximately 11 liters per day for
several days. As of today, her urine output is approximately
3000 cc. The patient did occasionally need electrolyte
repletement which was achieved without difficulty.
The patient's postoperative course was also remarkable for a
temperature spike to 101.6 on [**2185-7-20**]. Blood and urine
cultures subsequently grew out Escherichia coli and
Klebsiella. She was started on Ampicillin, Gentamicin, and
Flagyl initially and switched over eventually to p.o.
Levofloxacin 500 mg q. day which she is still on. This
produced a good result and she defervesced well. Her
postobstructive diuresis continued and her urine output was
very copious, thus diabetes insipidus workup was initiated.
Those results are still pending.
It was noted as well that the patient had a fair amount of
leaking from her nephrostomy site. Interventional Radiology
came and evaluated and decided that the patient's nephrostomy
did not need to be replaced. After some manipulation and
dressing changes, the leaking was prevented. There was a
small amount of skin breakdown which was improved
dramatically with Desitin and dressing changes.
At this point in time, the patient is doing very well, taking
a regular diet, and ambulating with the help of physical
therapy and assistance. She is afebrile. Her electrolytes
have normalized. She has no active issues at this point. Of
note, the patient did get two additional units of packed red
blood cells on [**2185-7-22**]. She was seen by hematology
oncology and given Epogen 40,000 units subcutaneously the day
before her discharge.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: The patient will be sent to rehabilitation
initially and then eventually the plan is for her to go home.
She will have physical therapy at rehabilitation. She will
follow up with Interventional Radiology in two weeks and with
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5166**] in two weeks. She will also follow up with
hematology oncology in approximately two weeks.
MEDICATIONS ON DISCHARGE: Epogen 40,000 units subq. q. week
(last dose [**2185-7-26**]), Tylenol 650 mg p.o. q. 6 hours p.r.n.
pain, Levofloxacin 500 mg p.o. q.d., Zoloft 100 mg p.o. q.d.,
Ativan 1 mg p.o. q. 4 hours p.r.n., Dilaudid 2-4 mg p.o. q. 4
hours p.r.n. pain, Valium 5 mg p.o. b.i.d. p.r.n., Fentanyl
100 mcg patch one to skin q. 3 days, K-Dur 40 mEq p.o. q.d.,
Compazine 10 mg q. 8 hours p.r.n. given p.o., Lopressor 12.5
mg p.o. b.i.d., Desitin apply to affected area around
nephrostomy site as needed, Xylocaine to affected area as
needed.
SPECIFIC NURSING NEEDS: Change port-A-Cath dressing q. week,
change nephrostomy dressing with normal saline wash and dry
sterile dressings q. day, wound surveillance with dressing
change q. day.
PATHOLOGY: The pathology returned as metastatic breast
cancer for all specimens from the surgery.
DISCHARGE DIAGNOSES: Metastatic breast cancer; hypertension;
question diabetes insipidus (workup in progress); Escherichia
coli and Klebsiella bacteremia; bilateral hydronephrosis.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 26060**]
Dictated By:[**Last Name (NamePattern1) 26061**]
MEDQUIST36
D: [**2185-7-26**] 15:14
T: [**2185-7-26**] 17:57
JOB#: [**Job Number 26062**]
|
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56,269
| 190,943
|
35813
|
Discharge summary
|
report
|
Admission Date: [**2108-5-17**] Discharge Date: [**2108-5-20**]
Date of Birth: [**2036-5-12**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Pericardiocentesis
History of Present Illness:
72 yo M with HTN, HLD, and DMII presenting with worsening
exertional dyspnea and chest pain for the past three days. He
and his family report that he had been in his usual state of
health, but began to notice that he would have to rest after
walking up stairs and later after walking on flat ground. He
denies symptoms at rest, no orthopnea, no PND, no change in
chronic LE edema, no increased salt intake, but does report a
chronic noctural nonproductive cough. He denies sharp chest
pains and his symptoms were not positional.
.
Wednesday evening, he reported having such difficulty breathing
walking to his car that he could barely walk more than a few
steps, prompting a family friend to drive him to the emergency
room. He denies recent viral illness, but does report having
multiple "colds" this year. No fevers or chills, occasional
"sweats" that he attributes to his blood sugar being low, but no
over night sweats. He has lost 10 lbs in the last 2 months, but
has intentionally been trying to eat less.
.
He is originally from Somolia and [**Last Name (un) **] to [**Country 16465**] in [**2087**]. He
later moved to [**Location (un) 86**] in [**2092**]. He is not currently working, but
previously worked as a tractor operator. He denies known TB
exposure and is unsure of his PPD status (of note, according to
our medical records, it appears he may have had a positive
[**Location (un) 1131**] in the past). No history of chest trauma or
intrathoracic surgeries.
.
In the ED, his initial vitals were 98.3, 75, 150/70, 17, 100%
2-4L NC. A EKG revealed NSR at 80 bpm with evidence of
electrical alternans. His labs were significant for a K of 8.4,
a hct of 26.8, a bicarb 16, and Cr of 2.4. Pt underwent a
bedside echo which revealed a large pericardial effusion with
evidence of tamponade physiology. He was given 40 mg of lasix IV
and remained hemodynamically stable. He was then taken to the
cath lab for pericardiocentesis and then transferred to the CCU
for further management.
Upon arrival to the floor, the patient reported feeling much
better. His breathing as significantly improved, although he
reports having some pain at the incision site that is worse with
sitting forward. He is not having other chest pain, no numbness
or tingling or palpitations.
.
REVIEW OF SYSTEMS
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
All of the other review of systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
-HTN
-DMII, on insulin
-HLD
-?Positive PPD
Social History:
He is originally from Somolia and fled to [**Country 16465**] in [**2087**]. He
later moved to [**Location (un) 86**] in [**2092**]. He is not currently working, but
previously worked as a tractor operator. Stopped smoking
cigarettes approximately 11 years prior, no EtOH or recreational
drugs.
Family History:
DMII, remainder unknown.
Physical Exam:
Admission-
VS: T 98.7 BP 175/59 HR 82 RR 22 O2 sat 95% on 4L NC
GENERAL: Well appearing man in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: [**Name (NI) 15262**], pt is lying flat.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. Possible faint rub.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, scattered
bibasilar crackles, no wheezes or rhonchi.
ABDOMEN: Firm, NTND. No HSM or tenderness. NABS.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Right: DP 1+ PT 1+ Left: DP 1+ PT 1+
Discharge-
VS- 97.3, 159/68 (SBP 144-183), 89 (64-89), 24, 100% on 2L
i/o [**Telephone/Fax (1) 81453**]; wt 90.6
GENERAL: Well appearing man in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: [**Name (NI) 15262**], pt is lying flat.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB. no wheezes,
rales, or rhonchi.
ABDOMEN: Firm, NTND. No HSM or tenderness. NABS.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Right: DP 1+ PT 1+ Left: DP 1+ PT 1+
Pertinent Results:
Admission-
[**2108-5-17**] 09:20PM BLOOD WBC-10.1 RBC-2.80* Hgb-8.0* Hct-26.8*
MCV-96 MCH-28.5 MCHC-29.7* RDW-16.0* Plt Ct-464*#
[**2108-5-17**] 09:20PM BLOOD Neuts-74.0* Lymphs-14.5* Monos-7.3
Eos-3.7 Baso-0.5
[**2108-5-17**] 09:20PM BLOOD PT-11.9 PTT-30.5 INR(PT)-1.1
[**2108-5-17**] 09:20PM BLOOD Glucose-213* UreaN-48* Creat-2.4* Na-134
K-8.4* Cl-108 HCO3-16* AnGap-18
[**2108-5-17**] 09:20PM BLOOD Calcium-7.7* Phos-5.9* Mg-3.1*
[**2108-5-18**] 12:45AM BLOOD Type-ART O2 Flow-3 pO2-74* pCO2-38
pH-7.36 calTCO2-22 Base XS--3 Intubat-NOT INTUBA
[**2108-5-18**] 03:12AM BLOOD CRP-117.8*
[**2108-5-18**] 03:12AM BLOOD ESR-114*
[**2108-5-18**] 03:12AM BLOOD Hapto-350*
[**2108-5-18**] 08:01AM BLOOD [**Doctor First Name **]-PND
[**2108-5-17**] 09:33PM BLOOD Lactate-1.5
[**2108-5-17**] 09:20PM BLOOD proBNP-458*
[**2108-5-17**] 09:20PM BLOOD cTropnT-<0.01
[**2108-5-18**] 03:12AM BLOOD ALT-102* AST-58* LD(LDH)-267*
AlkPhos-184* TotBili-0.2
[**2108-5-18**] 01:21AM URINE Hours-RANDOM UreaN-133 Creat-15 Na-90
K-17 Cl-93 TotProt-49 Prot/Cr-3.3*
[**2108-5-17**] 10:30PM URINE Hours-RANDOM
Discharge-
[**2108-5-20**] 06:18AM BLOOD WBC-9.9 RBC-2.96* Hgb-8.2* Hct-26.3*
MCV-89 MCH-27.5 MCHC-31.0 RDW-15.2 Plt Ct-549*
[**2108-5-18**] 03:12AM BLOOD Neuts-71.2* Lymphs-17.2* Monos-7.2
Eos-4.0 Baso-0.6
[**2108-5-20**] 06:18AM BLOOD PT-12.1 PTT-29.1 INR(PT)-1.1
[**2108-5-20**] 06:18AM BLOOD Glucose-65* UreaN-42* Creat-1.8* Na-138
K-4.5 Cl-106 HCO3-25 AnGap-12
[**2108-5-20**] 06:18AM BLOOD Calcium-7.2* Phos-4.7* Mg-2.5
Pericardial fluid-
[**2108-5-18**] 12:15AM OTHER BODY FLUID WBC-[**Numeric Identifier 961**]* Hct,Fl-15.0*
Polys-27* Lymphs-45* Monos-19* Eos-5* Macro-4*
[**2108-5-18**] 12:15AM OTHER BODY FLUID TotProt-4.4 Glucose-156
LD(LDH)-[**2068**] Amylase-36 Albumin-2.3
Microbiology-
[**2108-5-18**] 12:15 am FLUID,OTHER; PERICARDIAL FLUID.
GRAM STAIN (Final [**2108-5-18**]): 2+ (1-5 per 1000X FIELD):
POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary):
ACID FAST CULTURE (Pending):
ACID FAST SMEAR (Final [**2108-5-19**]): NO ACID FAST BACILLI SEEN ON
DIRECT SMEAR.
[**2108-5-18**] 12:15 am FLUID RECEIVED IN BLOOD CULTURE BOTTLES.
PERICARDIAL FLUID. Fluid Culture in Bottles (Preliminary): NO
GROWTH.
[**2108-5-17**] Cytology PERICARDIAL FLUID [**2108-5-18**] [**Last Name (LF) **],[**First Name7 (NamePattern1) **]
[**Initial (NamePattern1) **] [**Last Name (NamePattern4) 63632**]
Transthoracic Echos
TTE ([**2108-5-17**] at 11:11:46 PM)
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There is a moderate to large sized pericardial effusion. There
is sustained right atrial collapse, consistent with low filling
pressures or early tamponade. There is significant, accentuated
respiratory variation in mitral/tricuspid valve inflows,
consistent with impaired ventricular filling.
IMPRESSION: Moderate to large pericardial effusion with evidence
of early tamponade physiology.
TTE ([**2108-5-18**] at 1:09:06 AM)
There is a very small pericardial effusion. There are no
echocardiographic signs of tamponade. Compared with the
findings of the prior study (images reviewed) of [**2108-5-17**], the
pericardial effusion has been successully drained.
TTE ([**2108-5-18**] at 3:40:36 PM)
There is a trivial/physiologic pericardial effusion. There are
no echocardiographic signs of tamponade. The echo findings are
suggestive of constrictive physiology.
IMPRESSION: No significant residual pericardial fluid seen.
There is now evidence of constrictive physiology with
echocardiographic equivalent of Kussmaul's sign.
pCXR ([**2108-5-17**])
FINDINGS: Single AP upright portable view of the chest was
obtained. Since the prior study, there has been significant
interval enlargement of now globular cardiac silhouette, raising
concern for underlying pericardial effusion. There may be mild
pulmonary vascular congestion without overt pulmonary edema. No
definite focal consolidation is seen. The left costophrenic
angle is not well seen, which may be due to overlying soft
tissue, although a small pleural effusion is not excluded. No
neumothorax.
IMPRESSION: Significant interval increase in size of cardiac
silhouette which is globular in configuration, concerning for
underlying pericardial effusion. Possible minimal-to-mild
pulmonary vascular congestion without overt pulmonary edema.
Slight blunting of the left costophrenic angle is most likely
due to overlying soft tissue, although a trace pleural effusion
is not excluded.
CT CHEST, ABD & PELVIS W/O CONTRAST ([**2108-5-18**]) - Prelim
PRELIM IMPRESSION:
1. Moderate pericardial effusion.
2. Small left loculated pleural effusion.
3. No abdominal or pelvic adenopathy or other evidence of occult
malignancy.
4. Severe multilevel thoracolumbar degenerative disease.
Brief Hospital Course:
72 yo M with h/o HTN, HLD and DMII presenting with shortness of
breath and chest pressure x3 days. Noted to have pericardial
effusion with concern for tamponade physiology. S/p
pericardiocentesis and drain placement on [**2108-5-18**].
.
# Pericardial effusion
S/p pericardiocentesis (~720 cc) and tube placement upon
admission. It was felt that this represented a subacute fluid
accumulation given hemodynamic stability and symptomatology
course. The etiology of his effusion remains unclear. Although
concerning for malignancy (lymphoma/breast/lung/melanoma), the
prelim cytology and CT Torso did not reveal overt evidence of a
malignant process. Cultures remain negative to date, and his
AFB smear was negative. [**Doctor First Name **] was also pending upon discharge.
Subsequent TTE revealed resolution of the effusion. He is to
follow up with cardiology in [**2-13**] weeks.
.
# Hypertension:
The patient has a history of hypertension on an outpatient
regimen consisting of HCTZ, amlodipine, Toprol, lisinopril, and
clonidine. His acute hypertension was felt to likely be
secondary to not taking his home medications and rebound
hypertension from unopposed alpha agonism given stopping
clonidine. He was started on carvedilol in place of metoprolol
and restarted his clonidine patch (with po clonidine doses to
bridge). He was the restarted on amlodipine. Both lisinopril
and HCTZ were held and not restarted upon discharge given [**Last Name (un) **].
.
# Acute systolic heart failure
The patient presented with evidence of clinical volume overload.
Felt to be secondary to the effusion and early tamponade
physiology seen on admission echo. The patient was diuresed
with lasix boluses and appeared euvolemic upon discharge.
Repeat TTE revealed a preserved LVEF of 55%.
.
# Acute on chronic kidney injury,
As per report from his PCP, [**Name10 (NameIs) **] patient's baseline Cr was 2.0.
Upon admission, his Cr had increased to 2.4. Felt to be
secondary at least in part to poor forward flow. The etiology
of his chronic kidney disease is unknown, but felt to be
secondary to hypertension vs. diabetic nephropathy. His Cr
improved throughout his admission and was 1.8 at discharge.
.
# Hyperkalemia
The patient's admission K was noted to be 8.9 in the ED. His
PCP's office reported a baseline of 6.0. The acute increase was
felt to be secondary to AOCKD. The patient did not have
electrocardiographic evidence of hyperkalemia. He had no
evidence of increased potassium intake or intracellular shift.
His potassium level trended down during his hospital stay but
should continue to be monitored.
.
# Arrythmia
Noted to have pauses (longest 2.9 seconds) on telemetry,
asymptomatic and sleeping. The patient should consider a
referral to sleep medicine for concern for possible OSA.
.
# Normocytic Anemia
Baseline unknown, pericardial fluid was hemorrhagic, but
unlikely to lead to his extent of anemia. He did not have
evidence of hemolysis, DIC, or other bleeding. This should
continue to be monitored as an outpatient.
.
# Diabetes
Pt reports being on insulin at home and was maintained on his
home NPH regimen with a humalog sliding scale.
.
=========================================
TRANSITIONS OF CARE
=========================================
1. Pericardial effusion: Etiology unclear
Studies pending upon discharge - Final read of CT Torso, Final
fluid culture date, Final fluid anaerobic culture, Final fluid
Acid fast culture, Final fluid cytology
report.
2. History of positive PPD: Pt should have a quantiferon gold
study sent as an outpatient.
3. Changes to antihypertensive regimen: Started carvedilol,
continued amlodipine, continued clonidine patch, stopped
lisinopril, stopped hydrochlorothiazide
4. Normocytic anemia: Baseline and etiology unclear, no evidence
of hemolysis or DIC. Pt would likely benefit from outpatient
work up.
5. Arrythmia: Pt noted to have symptomatic pauses on telemetry,
would likely benefit from outpatient sleep medicine referral.
Medications on Admission:
NPH 40u QAM, 35 QPM
Norvasc 10mg daily
Toprol XL 100mg daily
Lisinopril 40mg daily
Clonidine patch 0.1mg Qweek
HCTZ 25mg daily
Simvastatin 20mg daily
ASA 81mg daily
Ultram 50mg TID
Tylenol 500mg QID:PRN
Doxepin 25mg QHS
Calcium, Vit D 500/200 daily
Naprosyn 50mg [**Hospital1 **]:PRN
Discharge Medications:
1. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: As directed units Subcutaneous twice a day: Please take 40
units in the morning and 35 units in the evening.
2. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) patch
Transdermal qsat.
4. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
6. Ultram 50 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for pain.
7. doxepin 25 mg Capsule Sig: One (1) Capsule PO at bedtime.
8. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO DAILY (Daily).
9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO four
times a day as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
-Pericardial effusion
Secondary:
-Acute on chronic kidney insufficiency
-Hyperkalemia
-Hypertension
-Acute systolic heart failure
-Insulin dependant diabetes mellitus, type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 81454**],
It was a pleasure taking part in your care during this
hospitalization. You were admitted because fluid had collected
around your heart and you were having difficulty breathing. The
fluid was drained and we gave you medication to help reduce
fluid that had built up in your lungs. We are not exactly sure
what caused this fluid to build up. It is very important that
you continue to follow up with your new cardiologist.
You also were found to have some kidney injury. We think that
this is a long [**Last Name **] problem that had been made worse by the
fluid around your heart. This has begun to improve.
We hope you continue to feel well. Please make the following
changes to your medications:
-START: Carvedilol 12.5 mg twice daily (this is for your blood
pressure)
-STOP: Metoprolol (Toprol)
-STOP: Lisinopril
-STOP: Hydrochlorothiazide
-STOP: Naprosyn (naproxen) as this medication can be bad for
your kidneys
Your cardiologist and PCP may restart some of these medications
in the future if you continue to improve.
You had a number of studies and labs that were not back at the
time of discharge. Be sure to ask about these when you see your
PCP and cardiologist.
Followup Instructions:
Please call ([**Telephone/Fax (1) 2037**] on Monday to schedule an appointment
with your new cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8271**] in [**2-13**] weeks. It is
VERY important you make and keep this appointment.
Please also call your primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
([**Telephone/Fax (1) 14918**]) to schedule an appointment this coming week. Be
sure to tell him you were recently hospitalized for fluid around
your heart.
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14056, 14342
|
15798, 16513
|
3589, 5045
|
3071, 3144
|
7143, 7143
|
16543, 17020
|
7172, 10004
|
264, 273
|
359, 2958
|
7102, 7113
|
15662, 15774
|
3175, 3219
|
2980, 3051
|
3235, 3532
|
7058, 7069
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,640
| 140,722
|
47382
|
Discharge summary
|
report
|
Admission Date: [**2133-10-9**] Discharge Date: [**2133-10-11**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Dyspnea, respiratory distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] y/o with severe AS, CHF with preseved EF, h/o DVT, phemigus
vulgaris presents from [**Hospital **] rehab. Pt had wt gain over week
prior to admission up to 153.8lb. On [**10-7**] lasix 80mg daily was
started with improvement to 149 lb on [**10-9**] (goal wt 140).
During this time pt had progressive fatigue. Yesterday (per
family) he had a coughing spell after eating yesterday. [**10-8**] he
developed phlegm production, cough, and left pleuritic chest
pain and was started on Levofloxicin for new lung (LUL)
infiltrates. This am he developed a low grade temp. Flagyl was
added for aspiration PNA. Nebs and roxanal was also added.
Diuresis was continues. This afternoon dested to 90% on 3L and T
99. Transfered to [**Hospital1 18**] for further evaluation.
.
Review of systems: Denies F/C, no SOB. No CP. NO abd pain or
diarrhea. No dysuria. Chronic skin break down.
.
In the [**Hospital1 18**] emergency department initial VS T99.2, HR 90, BP
125/52, R 26, P02 low 80s RA. Improved to mid 90s on NRB. BP
quickly droped to SBP 60s. Given IVF (1L), RIJ was placed and
the pt was started on Levophed at 0.4. CXR concerning for LUL
infiltrate. Given vanco. zosyn ordered but not given. Was
oxygenating well on NRB, however because of worsening fatigue
switched to BiPAP FiO2 40%, Peep 5, TV 445, R 22. Vital prior to
transfer 82, 19, 125/52, 100% on BiPAP
Past Medical History:
pemphigus vulgaris s/p PO steriods and IVIG
Severe AS with [**Location (un) 109**] 0.7 cm2
CHF
R femoral haed avascular necrosis
c diff colitis with severe infection [**2-13**], on longstanding
vancomycin
pAF
HTN
osteoporosis
hx of prostate ca s/p XRT, lupron
hx of colon ca s/p resection 23 years ago
hx of RLE DVT [**2129**], s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] IVC filter in place
VRE colonization
MSSA bacteremia [**9-17**] at [**Hospital1 112**]
Social History:
Longterm resident of [**Hospital **] rehab for 1 year. baseline
independent in feeding but needs assistance in other ADLs.
Baseline is oriented and able to hold conversations. Quit
tobacco > 50 years ago. No recent ETOH. Son is a neurologist at
[**Hospital1 112**].
Family History:
NC
Physical Exam:
Physical Exam on Admission:
General Appearance: Well nourished, No(t) Overweight / Obese,
mild resp distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, thrush
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),
late peaking systolic ejection murmur loudest at LUSB
Peripheral Vascular: (Right radial pulse: Diminished), (Left
radial pulse: Diminished), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Diminished: LUL)
Abdominal: Soft, Non-tender, Bowel sounds present, tympanic to
percussion
Extremities: Right lower extremity edema: 2+, Left lower
extremity edema: 2+, edema to mid shin BL. no calf pain
Musculoskeletal: Unable to stand
Skin: Cool, Rash: multiple crusted / scabed lesions in varied
stages of healing. No pus or erythema. thin skin
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): person, Movement: Purposeful,
Tone: Normal
Pertinent Results:
Labs on Admission:
[**2133-10-9**] 05:15PM BLOOD WBC-9.1 RBC-4.40* Hgb-12.4* Hct-38.7*
MCV-88 MCH-28.2 MCHC-32.0 RDW-17.4* Plt Ct-154
[**2133-10-9**] 05:15PM BLOOD Neuts-69 Bands-16* Lymphs-4* Monos-3
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-5* Promyel-1* Other-1*
[**2133-10-9**] 04:15PM BLOOD PT-12.7 PTT-27.4 INR(PT)-1.1
[**2133-10-9**] 04:15PM BLOOD Glucose-183* UreaN-49* Creat-1.4* Na-141
K-4.7 Cl-104 HCO3-24 AnGap-18
[**2133-10-9**] 04:15PM BLOOD ALT-29 AST-25 CK(CPK)-11* AlkPhos-85
TotBili-0.3
[**2133-10-9**] 04:15PM BLOOD Lipase-8
[**2133-10-10**] 03:53AM BLOOD Calcium-8.1* Phos-4.1 Mg-1.8
[**2133-10-9**] 04:28PM BLOOD Type-ART pO2-99 pCO2-48* pH-7.33*
calTCO2-26 Base XS--1 Intubat-NOT INTUBA
[**2133-10-9**] 04:28PM BLOOD Glucose-179* Lactate-2.9* Na-139 K-4.8
Cl-101
Cardiac Enzymes:
[**2133-10-9**] 04:15PM BLOOD CK-MB-NotDone cTropnT-0.11*
[**2133-10-9**] 05:15PM BLOOD cTropnT-0.12*
[**2133-10-10**] 03:53AM BLOOD CK-MB-4 cTropnT-0.08*
CXR ([**2133-10-9**])
FINDINGS: Single AP upright portable chest radiograph is
obtained. Low lung volumes limit evaluation. There is extensive
upper lobe and lower lobe opacity involving the left lung
concerning for pneumonia. There is likely underlying effusion.
Right lung is grossly clear. Cardiomediastinal
silhouette is difficult to assess with atherosclerotic
calcifications noted at the aortic knob. Bony structures are
grossly intact.
IMPRESSION:
Left-sided multifocal pneumonia.
Brief Hospital Course:
[**Age over 90 **] y/o with Severe AS, CHF, h/o c diff, pemphigus vulgaris with
hypotension, fever with LUL infiltrate and sepsis.
The patient's symptoms were secondary to LUL PNA given cough,
fatigue, new onset infiltrate suggestive of aspiration PNA.
However, given the possibility of other sources of infection
(skin, urine, GI/ C.diff etc) pt. was pan-cultured. There was
also significant degree of bandemia on CBC. Given nursing home
resident the patient was started on broad spectrum Abx coverage
for HAP with vanco, zosyn, Cipro. He was also started on Flagyl
for empiric coverage of C. diff. The patient was also started
on stress dose steriods given chronic use of Prednisone in this
patient. Standing nebs were ordered. Per discussion with HCP and
family on admission, the patient was confirmed to be DNR/DNI,
but pressor use was allowed. Influenza DFA came back negative.
Urine Legionella negative as well. Urine cultures and blood
cultures were pending. Sputum grew normal oropharyngeal flora.
The patient was noted to have mildly elevated but stable
Troponins likely secondary to demand ischemia in the setting of
hypotension/sepsis and CHF. He also had evevated Lactate levels
secondary to sepsis.
Due to worsening hypotension, aggressive resusitation with IVF
was started, while watching closely for signs of pulmonary edema
given severe AS and CHF. CVP remained 0-1 cm H2O despite
agressive fluid resuscitation, suggesting a profound vascular
leak. Over the next day, the patient became progressively more
hypotensive and required increased doses of Levophed, which was
titrated to maintain MAP>65. He was also becoming more
hypoxemic, requiring initiation of NIPPV. Despite aggressive
treatment with antibiotics, fluid resuscitation and use of
pressors, the patient was becoming progressively hypoxemic,
hypotensive and oliguric. A discussion was held with the family
to update them on prognosis, during which the decision was made
to make him comfort care only. The NIPPV was discontinued and
the patient was switched to nasal canula for dyspnea. He was
given Morphine as needed for comfort. Pressors were withdrawn.
The patient went into asystole and passed away with his family
at the bedside.
Medications on Admission:
Amoxicillin 2gm PO prn dental procedure
levofloxacin 250mg daily [**10-9**] to [**10-14**]
flagyl 500mg TID [**10-9**] - [**10-14**]
morphine oral soln 20mg/ml 4mg SL hourly prn
amiodarone 200mg PO daily
famotidine 20mg daily
mirtazapine 15mg qhs PO
prednisone 3mg PO daily
timolol 0.25% 1 drop daily to both eyes
vancomycin 125mg PO BID
gabapentin 100mg qhs
clobetasol propionate daily 1 application
eucerin crm [**Hospital1 **]
acetaminopehn 650mg PO q6h prn
guaifenesin 100mg PO q6h prn
aluminum acetate 1 apply daily
furosemide 80mg PO daily start [**10-7**]
albuterol neb q4h prn
ipratropium q4h prn
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory Failure
Discharge Condition:
Expired
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2133-10-14**]
|
[
"486",
"112.0",
"507.0",
"V10.46",
"276.2",
"428.0",
"518.81",
"424.1",
"V10.05",
"995.91",
"038.9",
"733.00",
"427.31",
"799.02",
"694.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
7902, 7911
|
5016, 7246
|
293, 299
|
7974, 8139
|
3545, 3550
|
2508, 2512
|
7932, 7953
|
7272, 7879
|
2527, 2541
|
1126, 1703
|
4345, 4993
|
224, 255
|
327, 1107
|
3565, 4327
|
1725, 2209
|
2225, 2492
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,123
| 167,747
|
39746
|
Discharge summary
|
report
|
Admission Date: [**2167-9-3**] Discharge Date: [**2167-9-11**]
Date of Birth: [**2084-5-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
OSH transfer concern for STEMI
Major Surgical or Invasive Procedure:
intubation
IJ central line
History of Present Illness:
Patient is an 83 y/o female with PMHx DM, HTN, prior CVA, L
carotid stenosis who presents from OSH with elevated troponins
and EKG changes (STE, LBBB) concerning for STEMI. Patient
presented to OSH with hypoxia to 85%, a right infiltrate, and
WBC to 15,000. While at [**Hospital1 **], she had a troponin return at
6.33. She denied chest pain, but admitted to nausea and
vomiting. She received ceftriaxone and zosyn prior to her
transfer for concern of pneumonia. She was transferred to [**Hospital1 18**]
for further management.
In the ED, she arrived with O2 sat of 68% on RA that increased
to 91% with 100% NRB. She was intubated, started on a heparin
gtt, dopamine, levophed, got one dose of levaquin, and admitted
to the CCU for further management. A bedside echo showed a
severely depressed LVEF (15-20%) with global HK/AK. She had a
troponin of 1.5 while in the ED, lactate of 2.8. Her potassium
returned 9.6 but was thought to be hemolyzed due to her value of
3.9 at OSH.
In the CCU, she arrived intubated and on dopamine of 2.5 and
phenylephrine of . A right IJ was placed.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY: Unknown
3. OTHER PAST MEDICAL HISTORY:
CVA, depression, renal insufficiency
Social History:
The patient has been living at a skilled nursing facility in
[**Hospital1 **], MA for the past 5 years. She is wheelchair bound at
baseline and is unable to perform ADLs independently. She has
been able to participate in activities such as dining out and
bingo. She has many friends at this facility, however her family
is unhappy with the care she is receiving. They would like to
look into other possible facilities to receive hospice care. Her
health care proxy is her sister [**First Name5 (NamePattern1) **] [**Name (NI) 87547**]), [**Telephone/Fax (1) 87548**] and
her nephew is [**Name (NI) **] [**Name (NI) 87547**], [**Telephone/Fax (1) 87549**].
Family History:
unable to obtain
Physical Exam:
GENERAL: elderly female, awake, responsive, oriented, aphasic
HEENT: Sclera anicteric. Right pupil larger than left
NECK: Supple
CARDIAC: RRR
LUNGS: diffuse rhonchi on anterior exam
ABDOMEN: Soft, NTND. +bowel sounds, No HSM or tenderness.
EXTREMITIES: Cold hands and feet, 1+ DP/PT pulses. Palpable
radial pulses. No edema appreciated in lower extremities.
Pertinent Results:
[**2167-9-3**] 10:01PM LACTATE-2.8* K+-9.6*
[**2167-9-3**] 09:50PM cTropnT-1.40*
[**2167-9-3**] 09:50PM WBC-20.5* RBC-3.24* HGB-9.5* HCT-28.5* MCV-88
MCH-29.4 MCHC-33.4 RDW-13.7
[**2167-9-3**] 09:50PM NEUTS-86.6* LYMPHS-10.0* MONOS-3.0 EOS-0.1
BASOS-0.4
[**2167-9-3**] 09:50PM PLT COUNT-355
[**2167-9-3**] 09:50PM PT-14.8* PTT-144.9* INR(PT)-1.3*
Brief Hospital Course:
83 y/o female with PMHx DM, HTN, prior CVA, L carotid stenosis
who presents from OSH with elevated troponins and EKG changes
concerning for STEMI. Extubated [**9-7**] and off pressors. Pt's
family made her DNR/DNI and [**Month/Year (2) 3225**] [**9-9**].
.
# Cardiogenic Shock: Most likely acute on chronic systolic heart
failure. Patient was hypotensive requiring 2 pressors which
were weaned. Right IJ triple lumen placed in ED was removed.
Patient was extubated. She was kept on medications for comfort
only. Palliative care was consulted. Speech and Swallow saw
patient and kept her NPO with extremely high aspiration risk;
family/health care proxy expressed understanding regarding
aspiration risk but requested that patient have some food by
mouth so she was given honey thickened, pureed solids.
.
# Coronaries - Patient with elevated troponin to 6 at OSH and
1.3 at [**Hospital1 **]. No interventions indicated.
.
# Respiratory status - Extubated [**9-7**]. Comfortable and sat'ing
95-100% on RA.
.
# Chronic renal failure - Likely element of acute on chronic
renal failure as Cr at OSH was 1.7. BUN/Cr ratio of about 20:1,
with low urine output, probably poor forward flow from low
cardiac output.
.
# Leukocytosis - Patient with supposed right infiltrate at OSH.
Has leukocytosis to 20. Likely reactive secondary to large MI.
Could be [**2-24**] infectious as well. C diff negative. Given
tylenol for pain/fever. Since [**Month/Day (2) 3225**], no labs indicated.
.
# Anemia - normocytic. Likely anemia of chronic disease. Since
[**Month/Day (2) 3225**], no labs were pursued.
.
# Diabetes mellitus - Per OSH records, patient with IDDM. Had
elevated blood sugar to 258 on admission to CCU. Initially
managed with ISS which was discontinued when patient was made
[**Month/Day (2) 3225**].
.
# RHYTHM: incomplete LBBB on EKG, unknown if old or new. No
tele, pt [**Name (NI) 3225**].
Medications on Admission:
1. Simvastatin 80mg daily
2. Zofran 4mg PRN
3. Olopatadine Hcl 1 OP [**Hospital1 **]
4. Cefuroxime 250mg daily
5. Furosemide 20mg daily
6. Duoneb 1 inh PRN
7. Escitalopram 5mg daily
8. Amlodipine 10mg daily
9. Aspirin 81mg daily
10. Metoprolol succinate 50mg daily
11. Protonix 40mg daily
12. Losartan 50mg daily
13. Hydralazine 25mg daily
14. Colace 100mg [**Hospital1 **]
15. Humulin ISS
16. Carboxymethylcellulose sodium 1% OU [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
2. Refer to hospice care for pain/comfort medications.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4542**] Rehabilitation and Nursing of [**Location (un) 38**]
Discharge Diagnosis:
Primary Diagnosis:
cardiogenic shock
Secondary diagnosis:
chronic renal failure
anemia
diabetes
Discharge Condition:
Activity Status: Bedbound.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent. Aphasic - occasionally has 1
word, articulated with difficulty
Discharge Instructions:
You were admitted for concern for a heart attack. You were
intubated to help you breathe. You were given pressors to help
maintain circulation. The pressors were weaned and your
breathing tube was taken out on [**9-7**]. You did very well
breathing on room air.
You had a swallowing evaluation which showed a great difficulty
swallowing therefore increasing your risk of choking and
inhaling food into your lungs. Your healthcare proxies decided
to decline placement of a feeding tube through your nose or
through your belly. Your code status was changed to DNR/DNI and
you were made comfort measures only. All medications were
stopped except for pain medications and oxygen if you felt short
of breath.
Please make the following changes to your medications:
You may STOP all Home medications
You can CONTINUE Colace 100 mg [**Hospital1 **] for constipation
You may choose to START pain medications at your hospice
facility
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Follow up with your primary care physician as needed at your
wishes.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
[
"785.51",
"428.23",
"428.0",
"V58.67",
"403.90",
"V66.7",
"276.51",
"585.9",
"250.00",
"787.22",
"410.11",
"518.81",
"438.83",
"285.29",
"426.3",
"584.9",
"311",
"438.82",
"272.4",
"433.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"99.20",
"38.91",
"38.93",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5720, 5819
|
3164, 5073
|
346, 375
|
5960, 6034
|
2781, 3141
|
7201, 7402
|
2370, 2388
|
5570, 5697
|
5840, 5840
|
5099, 5547
|
6158, 6893
|
2403, 2762
|
1604, 1612
|
6922, 7178
|
275, 308
|
403, 1500
|
5899, 5939
|
5859, 5878
|
6049, 6134
|
1643, 1681
|
1522, 1584
|
1697, 2354
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,468
| 139,522
|
25307
|
Discharge summary
|
report
|
Admission Date: [**2155-7-17**] Discharge Date: [**2155-7-22**]
Date of Birth: [**2077-9-25**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This 77-year-old gentleman well
known to our service with inferior myocardial infarction at
an outside hospital in early [**Month (only) **] transferred to [**Doctor First Name **]-
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for cardiac catheterization..
This revealed 3-vessel disease with preserved ejection
fraction. He now returns on [**7-17**] for surgery the
following day.
PAST MEDICAL HISTORY:
1. Insulin dependent diabetes mellitus.
2. Hypertension.
3. Hypercholesterolemia.
4. Peripheral vascular disease.
5. Glaucoma.
6. Benign prostatic hypertrophy.
7. Chronic obstructive pulmonary disease.
8. Coronary artery disease.
9. Atrial fibrillation.
10. Chronic renal insufficiency with baseline creatinine of
1.5 to 1.9.
PAST SURGICAL HISTORY:
1. Right carotid endarterectomy in [**2153**] with known occluded
left internal carotid.
2. Cataract surgery.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Cosopt for his glaucoma.
2. Alphagan for glaucoma.
3. Lisinopril 20 mg PO once daily.
4. Insulin NPH 45 units q a.m., Insulin NPH 16 units q p.m.
5. Rosiglitazone 4 mg PO once a day.
6. Glucophage 1000 mg PO twice a day.
7. Digoxin 0.25 mg PO once a day.
8. Hydrochlorothiazide 25 mg PO once a day.
9. Aspirin 81 mg PO once a day.
10. Zocor 20 mg PO once a day.
11. Plavix 75 mg PO once a day which was discontinued at
admission on [**7-17**].
12. Isordil 10 mg 3 times a day.
13. Sublingual nitroglycerine as needed.
14. Gemfibrozil 600 mg PO once a day.
15. Finasteride 5 mg PO once a day.
Cardiac catheterization revealed 90% LAD lesion, 80% diagonal
1 lesion, 90% circumflex lesion at the OM1 take off and a
totally occluded RCA of EDP 31, wedge 33.
PREOPERATIVE LABORATORY DATA: White blood cell count 7.3,
hematocrit 32.7, platelet count 192,000, PT 14.0, PTT 29.1,
INR 1.3. Sodium 140, K 4.9, chloride 103, bicarb 29, BUN 28,
creatinine 1.6, blood sugar of 102. Magnesium 2.1.
Preoperative chest x-ray as follows: No acute cardiopulmonary
process identified preoperatively.
Preoperative EKG showed sinus bradycardia of 51 with diffuse
ST-T wave changes that were nonspecific. Please refer to the
official report dated [**2155-7-17**].
Preoperative echocardiogram showed a ejection fraction of 45
to 50% with 1+ MR and mild left ventricular hypertrophy.
Preoperative carotid ultrasound showed totally occluded left
internal carotid and no plaque in his right internal carotid
artery with antegrade vertebral flow bilaterally.
Renal ultrasound showed no hydronephrosis.
PHYSICAL EXAMINATION: His temperature was 98, heart rate 56,
with blood pressure of 180/80, respiratory rate 20, oxygen
saturations 96% on room air. He was sitting in his chair
eating his dinner. He was alert and oriented x 3, moving all
extremities, following commands, with a nonfocal neurologic
examination. His pupils were equal, round and reactive to
light with extraocular muscles intact. He was anicteric with
normal buccal mucosa. Neck was supple with no lymphadenopathy
or thyromegaly. No jugular venous distention. Bruits on the
right carotid and no bruit appreciated on the left. His lungs
were clear bilaterally. His heart had regular rate and rhythm
with no murmurs. Abdomen was soft and nontender,
nondistended. Normal bowel sounds. Extremities warm and well
perfused with no varicosities.
He was referred to Dr. [**Last Name (STitle) **] for coronary artery bypass
grafting. On [**7-18**], the following day, he underwent
coronary artery bypass grafting x 4 with left internal
mammary artery to the LAD, vein graft to the patent ductus
arteriosus and a vein graft to the OM and a vein graft to the
LAD. He was transferred to cardiothoracic ICU in stable
condition.
On postoperative day 1, he had been extubated overnight, was
in sinus rhythm maintaining a good blood pressure.
POSTOPERATIVE LABORATORY DATA: White blood cell count 9.2,
hematocrit 35, K 5.0, BUN 17, creatinine 1.3, INR 1.4. He
was saturating 100% on 4 liters via nasal cannula.
He was alert and oriented. His examination was unremarkable.
Incisions were clean, dry and intact. He began Lasix diuresis
and Lopressor beta blockade. His Swan was discontinued and he
was transferred up to floor 4. On the floor he was encouraged
to work with the nurses and physical therapist for increasing
his activity level which he did as well as his exercise
tolerance. He appeared to be fairly motivated. He was alert
and oriented but occasionally had some confusion regarding
person and place. His lungs were clear bilaterally on
postoperative day 2. His blood pressure was up slightly at
264/73. Lopressor was increased to 37.5 twice a day. His
chest tubes were removed. Repeat chest x-ray was performed.
His examination was otherwise unremarkable. He was re-started
on his Plavix and continued with Lasix diuresis as well as
completing his perioperative antibiotics.
On postoperative day 3, he discontinued his Foley himself. It
was reinserted for resulting hematuria. His examination was
otherwise unremarkable. His Foley did remain in place. He was
encouraged to increase his physical therapy as well as his
pulmonary toilet and his Lasix dosing was decreased. His
epicardial pacing wires were removed without incident. He
continued to increase his activity level. He was very anxious
to get home. He appeared to be very motivated and on [**7-22**], postoperative day 4, he was discharged to home with
visiting nurses with the following discharge diagnoses.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass grafting x 4.
2. Insulin dependent diabetes mellitus.
3. Hypertension.
4. Hypercholesterolemia.
5. Peripheral vascular disease with known carotid artery
disease and status post right CEA.
6. Glaucoma.
7. Benign prostatic hyperplasia.
8. Chronic obstructive pulmonary disease.
9. Coronary artery disease.
10. Atrial fibrillation.
11. Chronic renal insufficiency.
He was instructed to follow up with Dr. [**Last Name (STitle) **] at 4 weeks
post discharge for his postoperative surgical visit, and to
see his cardiologist and primary care physicians also at 2
weeks post discharge.
DISCHARGE MEDICATIONS:
1. Colace 100 mg PO twice a day.
2. Enteric coated aspirin 81 mg PO once a day.
3. Plavix 75 mg PO once a day.
4. Zocor 20 mg PO q h.s
5. Tylenol 650 mg PO p.r.n. q 4 hours for pain.
6. Lisinopril 5 mg PO once daily.
7. Lasix 40 mg PO once a day.
8. Finasteride 5 mg PO once a day.
9. Metoprolol 37.5 mg PO twice a day.
10. Protonix 40 mg PO once a day.
11. His home dosing of Recombinant Human Insulin NPH.
12. Cosopt 2-0.5% ophthalmic drops.
13. Preoperative dose of Alphagan ophthalmic drops.
14. Gemfibrozil 600 mg PO once a day.
The patient was discharged home with VNA services in stable
condition on [**2155-7-22**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2155-8-1**] 14:52:52
T: [**2155-8-2**] 01:25:15
Job#: [**Job Number 63321**]
|
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"600.00",
"401.9",
"414.01",
"365.9",
"443.9",
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icd9cm
|
[
[
[]
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[
"36.13",
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icd9pcs
|
[
[
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5748, 6381
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6404, 7273
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1188, 2788
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1007, 1162
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2811, 5727
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165, 622
|
644, 984
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,555
| 147,778
|
7640
|
Discharge summary
|
report
|
Admission Date: [**2154-4-8**] Discharge Date: [**2154-4-25**]
Date of Birth: [**2086-11-22**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name8 (NamePattern2) 1103**]
Chief Complaint:
MVC
Major Surgical or Invasive Procedure:
[**4-11**]:
1. Open reduction and internal fixation of right
supracondylar humerus fracture.
2. Closed reduction and casting of posterior dislocation,
unstable left elbow
History of Present Illness:
67 y/o female, unrestrained passenger in MVC with airbag
deployment. ?LOC. Initially taken from the scene to [**Hospital 487**]
hospital. GCS 11 at [**Hospital1 487**]. Reportedly, CT
head/c-spine/chest/ab/pelvis neg by noted to have fractures of R
distal radius and left elbow. Transferred to [**Hospital1 18**] for further
care. Here, head CT read as L occipital contusion and C2
fracture
Past Medical History:
diverticulitis
hypothyroidism
HTN
Cardiac hx: PTCA of LCx [**2138**], [**2141**], [**2147**] (w/ stent)
Cath [**2148**] showing LAD 60% prox stenosis, LCx stent patent
LVEF 30%
Social History:
lives with husband, large support network with children and
grandchildren, son is nurse [**First Name (Titles) **] [**Name (NI) 121**] 6
no EtOH, no tobacco
Family History:
non-contributory
Physical Exam:
on arrival in the trauma bay
Vitals: Temp 97.8 HR 76 BP 162/76 RR 18 sats 100% on 4L
GEN: elderly female, NAD, GCS 15
HEENT: +abrasions across forehead, +ecchymosis and swelling
periorbitally
PERRL 3-->2mm bilaterally and reactive, EOMI, TM clear, trachea
midline, OP clear, dentition intact
NECK: c-collar in place
CHEST: no crepitus
PULM: CTA bilaterally
CV: RRR
ABD: SNTND, FAST negative
RECTAL: normal tone, guiac negative
PELVIS: stable to AP/Lateral compression
EXT: Bilaterally UE, in splints, ecchymosis, defusely tender, no
obvious deformity, radial pulses 2+ bilaterally, cap refill<2
sec, bilateral LE NTTP, no deformity palpable DP/PT pulses 2+
and symmetric
BACK: no stepoffs, NTTP
NEURO: CN II-XII intact, no focal motor or sensory deficits
Pertinent Results:
labs on admission:
[**2154-4-8**] 09:40PM BLOOD WBC-21.8*# RBC-3.49* Hgb-10.7* Hct-32.0*
MCV-92 MCH-30.7 MCHC-33.5 RDW-12.4 Plt Ct-202
[**2154-4-8**] 09:40PM BLOOD PT-13.3 PTT-37.6* INR(PT)-1.2
[**2154-4-9**] 01:57AM BLOOD Glucose-145* UreaN-21* Creat-0.7 Na-141
K-4.6 Cl-107 HCO3-22 AnGap-17
[**2154-4-9**] 01:57AM BLOOD CK(CPK)-793*
[**2154-4-9**] 01:57AM BLOOD CK-MB-22* MB Indx-2.8 cTropnT-<0.01
[**2154-4-9**] 09:23AM BLOOD CK(CPK)-777*
[**2154-4-9**] 09:23AM BLOOD CK-MB-17* MB Indx-2.2 cTropnT-<0.01
REPORTS:
CTA Neck [**2154-4-9**] IMPRESSION: No evidence of vascular injury.
Small areas of intimal damage cannot be excluded.
CT Cspine [**2154-4-9**] IMPRESSION: Fracture through the left C2
pedicle in the region of the superior articular facet, extending
through the foramen transversarium.
CT Head [**2154-4-9**] IMPRESSION: Small left occipital hematoma or
hemorrhagic contusion. Right maxillary sinus disease as
described.
REPEAT CT HEAD IMPRESSION: Focal hyperdensity within the left
occipital lobe, likely representing intraparenchymal hemorrhage
from contusion. Additionally, there is a small focus of likely
subarachnoid hemorrhage adjacent to the right occipital lobe.
These appear unchanged from the prior study from 24 hours prior.
x-ray Right arm [**2154-4-9**] IMPRESSION: Supracondylar humerus
fracture with significant displacement.
x-ray left arm [**2154-4-10**] IMPRESSION: Subluxation/distraction,
radiocapitellar joint with associated tiny cortical avulsion.
T/L spine [**2154-4-9**] IMPRESSION: no evidence of fx
Brief Hospital Course:
TSICU [**2154-4-8**] to
After initial stabilization and evaluation in the trauma bay,
diagnostic imaging studies including a Head, C-spine, and CTA of
the neck were repeated because of the question of injury on
prior scans read as normal at [**Hospital1 487**]. Again the patient was
noted to have a left C2 pedicle fracture, a left occipital lobe
intraparenchymal hemorrhage and small right occipital lobe SAH.
transferred to the ICU for close monitoring.
On [**4-11**] the patient was taken to the OR for:
1. Open reduction and internal fixation of right
supracondylar humerus fracture.
2. Closed reduction and casting of posterior dislocation,
unstable left elbow.
POD 3 ([**4-14**]):MR taken of the left elbow which
POD 5 ([**4-16**]): Patient taken back to OR for ORIF of left elbow
and revision of ORIF right elbow.
Pt was transferred to the floor post-operatively, where she
remained clinically. It was noted, however, that she displayed
left radial nerve dysfunction, which manifested as wrist drop
and poor flexion of the left mcp joints. However, the radial
nerve was fully visualized during the operation and known to not
be injured by the fixation device, or surgical technique. The
nerve likely is irritated by the device and its dysfunction will
resolve with time. Ms. [**Known lastname 27835**] [**Last Name (Titles) 27836**] nicely working with
physical therapy. Her wounds continued to appear well-healing.
She will remain in C-collar for 8 weeks. She was discharged to
rehab in good condition on [**2154-4-25**].
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Quinapril HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
7. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
11. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
12. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q4-6H (every 4 to 6 hours) as needed.
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed.
14. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
15. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
16. Morphine Sulfate 1 mg/mL Solution Sig: q4-6 hrs prn for
breakthrough or while on CPM machine Injection every 4-6 hours:
For breakthrough, or while on CPM machine.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
right distal humerous fracture
left nondisplaced intraarticular distal radius fracture
unstable left elbow
left C2 pedicle fracture
a left occipital lobe intraparenchymal hemorrhage
small right occipital lobe SAH
Discharge Condition:
Good
Discharge Instructions:
1. Please monitor for the following: fever, chills, nausea,
vomiting, inability to tolerate food/drink, increased pain in
upper extremities, increased numbness, or decreased ability to
move upper extremetiis. If any of these occur, please contact
your physician [**Name Initial (PRE) 2227**].
Physical Therapy:
full wt on bilateral lower extremities
Continue w/ external fixation and left splint and immobilizer on
right upper extremity
Continue C-Collar for 8 weeks.
Will need assistance getting OOB and toileting
Continuous passive motion machine (CPM) for 1-2 hrs [**Hospital1 **]
Treatments Frequency:
Continue to perform wound care to fixation pin sites twice daily
1/2 strength peroxide.
Sutures will be removed outpatient by Dr. [**First Name (STitle) **].
Followup Instructions:
Please call Dr. [**Last Name (STitle) 10538**] office for follow up in 2weeks.([**Telephone/Fax (1) 15940**]
Completed by:[**2154-4-25**]
|
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[
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[]
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[
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icd9pcs
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[
[
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6842, 6912
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3698, 5245
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333, 506
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7169, 7175
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2128, 2133
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290, 295
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534, 926
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2147, 3675
|
948, 1127
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1143, 1303
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,582
| 157,255
|
44496
|
Discharge summary
|
report
|
Admission Date: [**2168-11-15**] Discharge Date: [**2168-11-30**]
Date of Birth: [**2102-1-19**] Sex: M
Service: MEDICINE
Allergies:
Tagamet / Ditropan / Penicillins / Lisinopril
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
Intubation, right subclavian central line, PICC line placement
History of Present Illness:
66 yo M with PMH of DM2, CRI, recent subdural hematomas and
bacteremia who presents from rehab with altered mental status.
Per the report from the rehab, at baseline he desats with
activity, requiring 3-6L O2 to maintain O2 sats 88-92% and is a
chronic CO2 retainer. He was given IV Lasix and was refusing
bipap. Given he was more disoriented he was brought to the ED.
Of note, his wife says that he received a blood transfusion on
[**2168-11-12**] and has been more confused since that time.
.
In addition, in [**8-12**] he was hospitalized for a fall and
subsequent right subdural hematoma. This was complicated by a
strep bovis endocarditis which was treated with 6 week of
ceftriaxone. Shortly after stopping the antibiotics he developed
line sepsis from the PICC which grew out MRSA and enteroccus.
The tip was removed and he was treated with vancomycin given his
penicillin allergy from [**2168-11-3**] until [**2168-11-14**].
.
In the ED, his initial vital signs were T 98.1 HR 92 BP 118/78
RR28 94% 2L NC. Temp rose to 101.8. He was oriented x1 or 2 and
complained of abdominal pain intermittently. Was given combivent
neb and became more lethargic. Surgery was consulted for ?
ischemic bowel given is abdominal tenderness. Lactate was normal
though and CT scan was ordered. His blood pressure then dropped
to systolic 64/48s and he was given 3L IVF, CVL was placed and
levophed was started. He was intubated for airway protection
given his altered mental status, but per report was not in any
respiratory distress. He was given etomodate and succ, ativan.
He had a CT torso looking for a source of infection. The only
acute finding was a right pericardial effusion and right pleural
effusion. He was given vancomycin and zosyn for empiric
coverage.
Past Medical History:
-Morbid obesity
-DM type 2 poorly controlled with complications
-Chronic renal insufficiency
-HTN
-reactive airways disease
-asbestosis
-GERD
-Parkinson's disease
-detrusor instability
-gout
-hypothyroidism
-aortic stenosis, valve area 0.9cm2, peak gradient 24, median
gradient 48
-Anemia
-h/o nephrolithiasis
-fall [**8-12**] w/ R subdural hematoma, s/p strep bovis bacteremia
and 6 wks Ceftriaxone, developed bacteria after completion of tx
with MRSA and enterococcus. line removed, tx with Vanco then
d/c'd. Neg cx 3 consecutive days. [**11-4**] - febrile, blood cxs +
enterococcus, [**Last Name (un) 36**] to PCN and Vanc. got Vancomycin due to PCN
allergy.
Social History:
no alcohol or tobacco use, currently resides at [**Hospital **] [**Hospital **]
Rehabilitation Center, formerly owned pizzaria restuarants
Family History:
non-contributory
Physical Exam:
vitals: afebrile BP 140/69, HR 83, 100% o2 sat. CVP 15, AC
650/18 peep 5, FIO2 0.5, FS 132
General: morbidly obese, intubated and sedated. Opens eyes to
voice but does not follow commands
HEENT: anicteric sclera, non-injected conjunctiva, pupils about
3mm and symmetric but sluggish, dry MM
CV: RRR 3/6 SEM heard best at the USB
Lungs: expiratory wheeze bilaterally, course breath sounds. mild
crackles
Abdomen: obese, umbilical hernia reducible. +BS, soft, seems
non-tender
Ext: trace bilateral edema, DP and PT pulses are strong and
symmetric, bilateral upper extremity tremor with cogwheel
rigidity
Neuro: opens eyes to voice. not following commands. moving all
extremities. toes are down going bilaterally
Pertinent Results:
Admission Labs:
WBC-10.9# RBC-3.14*# Hgb-8.2*# Hct-26.1*# MCV-83 MCH-26.0*
MCHC-31.2 RDW-15.1 Plt Ct-313#
Neuts-87.8* Lymphs-8.1* Monos-3.4 Eos-0.6 Baso-0.1
PT-17.0* PTT-35.8* INR(PT)-1.5*
Glucose-68* UreaN-40* Creat-2.3* Na-140 K-3.7 Cl-96 HCO3-35*
ALT-17 AST-64* CK(CPK)-32* AlkPhos-105 TotBili-0.6 Albumin-3.1*
-ART Rates-/22 Tidal V-650 PEEP-5 FiO2-100 pO2-382* pCO2-44
pH-7.49* calTCO2-34* Base XS-10 AADO2-311 REQ O2-56 -ASSIST/CON
Intubat-INTUBATED
Lactate-0.8
.
Additional Labs:
[**2168-11-19**] 01:23AM BLOOD %HbA1c-6.5*
[**2168-11-19**] 01:23AM BLOOD Triglyc-169* HDL-15 CHOL/HD-7.1
LDLcalc-58
[**2168-11-18**] 09:11PM BLOOD TSH-9.2*
[**2168-11-18**] 11:12PM BLOOD Cortsol-29.1*
[**2168-11-18**] 09:11PM BLOOD Cortsol-13.6
[**2168-11-18**] 12:22PM BLOOD Lipase-13
.
Studies:
[**2168-11-15**] EKG: Sinus rhythm. Non-specific intraventricular
conduction delay. Non-specific ST-T wave abnormalities. Compared
to the previous tracing of [**2163-6-6**] no change in comparable leads.
.
[**2168-11-15**] CXR - IMPRESSION: Limited exam due to low inspiratory
effort. Evaluation for new focal consolidation is limited, and a
dedicated PA and lateral view of the chest is recommended.
Alternatively, CT can be performed for further evaluation.
Asbestos-related pleural disease.
.
[**2168-11-15**] CT Head without contrast - IMPRESSION:
1. No hemorrhage or edema.
2. Chronic small vessel ischemic disease.
3. Age-related involutional change.
.
[**2168-11-15**] Central Line Placement - IMPRESSION: Relatively stable
x-ray examination with possibility of added volume imbalance and
overload. The central line has been introduced with no
pneumothorax. Distal tip at adequate position. Support tubes as
above.
.
[**2168-11-15**] CT abdomen & pelvis without contrast - IMPRESSION:
1. New right pleural effusion and pericardial effusion.
2. Possible cholelithiasis, but no evidence of cholecystitis.
3. Bilateral atrophic kidneys.
4. No evidence of diverticulitis.
.
[**2168-11-16**] Pleural fluid cytology:
NEGATIVE FOR MALIGNANT CELLS.
Scattered mesothelial cells present singly and abundant
lymphocytes.
.
[**2168-11-17**] TEE - No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is normal.
There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets are severely thickened/deformed. There is a
moderate-sized (1.1 x 0.9 cm) nonmobile density on the right
cusp of the aortic valve associated with partial cusp prolapse.
The bulk of the echodensity is likely an old/healed vegetation,
although a more acute superimposed valvular infection cannot be
excluded on the basis of echocardiography alone. There is an
associated eccentric, anteriorly-directed jet of moderate (2+)
aortic regurgitation. There is mild aortic valve stenosis, with
a valve area by planimetry of 1.6cm2. The mitral valve leaflets
are structurally normal. No mass or vegetation is seen on the
mitral valve. Mild (1+) mitral regurgitation is seen. No masses
or vegetations are seen on the tricuspid valve, but cannot be
fully excluded due to suboptimal image quality. The estimated
pulmonary artery systolic pressure is normal. No vegetation/mass
is seen on the pulmonic valve. There is no pericardial effusion.
IMPRESSION: Likely aortic valve endocarditis, without evidence
of an abscess or involvement of other valves. Moderate aortic
regurgitation. Mild aortic stenosis.
.
[**2168-11-17**] Bilateral upper extremity veins - IMPRESSION: No
evidence of DVT in either the right or left upper extremity.
.
[**2168-11-17**] MR [**Name13 (STitle) 430**], MRA Brain without contrast - IMPRESSION:
1. Focal area of slow diffusion in the left frontal lobe
consistent with an area of acute infarction secondary to
proximal emboli.
2. Chronic small vessel ischemic disease.
.
[**2168-11-17**] MR C, T, & L spine - IMPRESSION:
1. No evidence for abscess, spinal cord compression, or other
spinal cord
abnormality.
2. Multilevel degenerative joint disease. Disc protrusion at the
level of
T8-T9, and disc bulges at the level of L3-L4, and L4-L5.
.
[**2168-11-18**] Bilateral Lower Extremity Veins - IMPRESSION: No lower
extremity DVT.
.
[**2168-11-21**] Carotid Ultrasound - IMPRESSION:
1. Normal right carotid ultrasound with 0% stenosis.
2. Minimal echogenic plaque within the left proximal internal
carotid artery with normal peak systolic velocities consistent
with less than 40% stenosis.
[**2168-11-27**] CXR - IMPRESSION: PICC line at SVC-RA junction,
decreasing effusions.
[**2168-11-28**] TTE ECHO - The left atrium is mildly dilated. There is
mild symmetric left ventricular hypertrophy with normal cavity
size. There is mild regional left ventricular systolic
dysfunction with focal hypokinesis of the distal half of the
septum. The remaining segments contract normally (LVEF = 50
%).Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets are moderately thickened. A
vegetation is suggested but cannot be confirmed due to
suboptimal image quality. There is moderate to severe aortic
valve stenosis. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
Significant pulmonic regurgitation is seen. There is a
trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2166-5-28**], the
septal wall motion abnormality is new, the aortic valve
morphology is more deformed, and the severity of both aortic
stenosis and aortic regurgitation has increased.
[**2168-11-29**] CXR - Since yesterday, the patient was extubated and
the nasogastric tube is removed. Left PICC still ends in
unchanged position.
Interstitial edema decreased. Heterogeneous opacities on the
right slightly decreased, back to baseline from [**2168-11-27**]. Small bilateral pleural effusions are unchanged. Moderate
cardiomegaly and vascular engorgement are stable. Bilateral
calcified plaques are also unchanged.
Brief Hospital Course:
66 yo M with PMH of DM2, CRI, recent subdural hematomas and
bacteremia who presents from rehab with altered mental status
and fevers.
# Pneumonia/Failure to Wean: The patient was initially intubated
for airway protection but his course was complicated by
acineobater pneumonia and pulmonary edema secondary to volume
overload required for fluid resuscitation in the setting of
sepsis. The patient may also have some muscular weakness due to
his prolonged illness. Weaning from the ventillator was also
complicated by copious secretions. The infectious disease
service was consulted and recommended that for his acinobacter
pneumonia he should be treated with Tobramcyin and Unasyn for a
14 day course to end [**2168-12-1**]. His tobramycin dose was
gradually increased based on checking trobra serum levels. He
was also given lasix boluses to help diurese some of the extra
fluid and was on a lasix gtt for the last several days of his
ICU stay. He has been d/c'd on 40mg [**Hospital1 **] of Lasix which is new
for him, so his BP and Cr should be followed closely; lasix dose
- Continue standing atrovent with prn albuterol.
# Endocarditis with AR: The ID service was consulted and
recommended that the patient receive a 6 week course of
vancomycin (to end [**2168-12-21**]) based on a positive blood culture
for Vancomycin sensitive Enterococcus from [**11-4**] at an OSH
(first negative blood culture on [**2168-11-9**]). CT surgery was
consulted during the middle of his ICU stay and felt that aortic
valve replacement was not indicated at this time. Given the
increased severity of aortic regurgitation noted on his [**11-28**]
ECHO, he will likely need to be reconsidered for aortic valve
replacement when his condition has improved. Patient should
have colonoscopy to r/o underlying colon CA in the setting of
strep bovis endocarditis.
- He is to follow up with CT Surgery, Dr. [**Last Name (STitle) 914**], on [**12-27**].
# Echo with focal wall motion abnormalities ([**11-28**]): These are
new from prior echo (TEE on [**2168-11-17**]) although per cardiology
the former was a poor study. These findings are likely ischemic
in origin but it is unknown exactly when this change occurred.
The patient was already on aspirin. He was started on a low
dose statin and beta-blocker for CAD after a likely NSTEMI based
on these findings but we held [**Last Name (un) **] until we see how his blood
pressure does with the B-blocker. He had a fasting cholesterol
panel earlier during his hospitalization with an LDL of 58.
- [**Last Name (un) **] can be added as indicated at rehab facility per discretion
of rehab MD based on creatinine and blood pressure.
# CVA: likely embolic stroke on MRI, either from endocarditis,
or atheroembolic. U/S of carotids was negative. The patient was
evaluated by neurology while he was still intubated and
recommended treating with aspirin but not otherwise
anticoagulating. They did not feel that the stroke would
contribute to mental status while he was intubated but have not
otherwise weighed in since he had been extubated. He does not
have any focal motor deficits.
# altered mental status: Likely secondary to infection and
sedation while on the ventillator. Head CT and MRI do not
explain AMS per neurology. His mental status slowly improved
during his ICU stay, however, he continued to be somewhat
confused and disoriented on discharge.
# acute on chronic renal insufficiency stage 4: On admission the
patient's creatinine was elevated to 2.3. His baseline was
1.3-1.4 earlier this year. His creatinine improved to a new
baseline of 1.5 - 1.6 during his admission. He was continued on
calcitriol and medications, including antibiotics, were renally
dosed. For the 2 days before extubation and 2 days
post-extubation Mr [**Known lastname **] was getting Lasix boluses and then a
lasix drip. He was started on 40 mg Lasix PO BID at discharge
and should have his Cr followed closely; as above, lasix can be
- We continued his calcitriol 0.25 mcg daily.
# Hypertension: Losartan and metoprolol were initially held due
to sepsis and hypotension. Metoprolol was restarted at a lower
dose for CAD. Losartan was held due to continued low blood
pressures while the patient was being diuresed. Consider
re-initiation of [**Last Name (un) **] once BP stabilized on beta blocker.
# Type 2 diabetes mellitus: The patient was placed on an insulin
sliding scale with regular insulin and Q6H finger sticks while
he was on tube feeds.
# Hypothyroidism: The patient's was continued on levothyroxine
per his home dose.
# Hypotension: The patient had an episode of hypotension w/SBPs
down to 70??????s in the morning of [**11-18**]. Pressures improved with
NS and 2U of PRBCs. The patient was started on Levophed but
developed a run of ventricular tachycardia. Levophed was
changed to neosynephrine, which patient tolerated much better.
The most likely etiology was septic shock. Cardiac enzymes were
negative. CXR was without pneumothorax. CTA was not performed
to r/o PE, but was felt to be unlikely given the patient's
improvement. Pressors were stopped later in the evening of
[**11-18**] and his blood pressure returned to [**Location 213**].
# Parkinsons Disease: Carbidopa/levodopa and requip were
continued per the patient's home regimen.
# Anemia: The patient has a history of chronic anemia for the
last few months since his illness began. His anemia is likely
related to chronic illness and iron deficiency (one report of
colonic polyps removed). His hematocrit had returned to
baseline following a transfusion a few days prior to admission.
* Prophylaxis: Patient discharged on SC heparin and PPI. Bowel
meds prn.
Medications on Admission:
Actos 15 mg daily
calcitriol 0.25 mcg daily
carbidopa-levodopa 50-200 5X/day
cyanocobalamin [**2160**] mcg daily
glipizide 5 mg qday
prilosec 40 mg daily
requip 3 mg qid
synthroid 87.5 mcg daily
Heparin SC TID
Levofloxacin 250mg qday
Arinesp 0.1 mg qTuesday
Singular 10mg qday
Zinc Sulfate 250mg PO qday
Simethecone PRN
Metoprolol 25mg PO BID
Losartan 100mg PO qday
KCL 20 meq qday
Aspirin 325mg PO qday
Iron 300mg PO BID
Colace 100mg PO BID
Senna 2 tabs daily
Bisacodyl PRN
Combivent MDI PRN
Fluticasone 1 puff [**Hospital1 **]
Duoneb PRN
Tylenol PRN
Regular insulin 151-200 give 2U, every 50 of blood sugar
increase 2 U
Miconazole powder daily
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
3. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
4. Carbidopa-Levodopa 25-100 mg Tablet [**Hospital1 **]: Two (2) Tablet PO
5X/DAY (5 Times a Day).
5. Cyanocobalamin 500 mcg Tablet [**Hospital1 **]: Four (4) Tablet PO DAILY
(Daily).
6. Ropinirole 1 mg Tablet [**Hospital1 **]: Three (3) Tablet PO QID (4 times
a day).
7. Levothyroxine 25 mcg Tablet [**Hospital1 **]: 3.5 Tablets PO DAILY
(Daily).
8. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily).
10. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: Four (4) Puff
Inhalation Q4H (every 4 hours) as needed for wheezing.
11. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Four (4)
Puff Inhalation QID (4 times a day).
12. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever.
13. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical QID
(4 times a day) as needed.
14. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment [**Hospital1 **]: One (1)
Appl Rectal [**Hospital1 **] (2 times a day) as needed for hemorrhoids.
15. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID
(2 times a day): hold for sbp <100, hr < 50.
16. Atorvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
17. Vancomycin 1000 mg IV Q 24H
for 6 week course, last date [**12-21**]
18. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
19. Insulin Regular Human 100 unit/mL Solution [**Month/Year (2) **]: As directed
Injection QACHS.
20. Multivitamins with Minerals Capsule [**Month/Year (2) **]: One (1) Tablet
PO DAILY (Daily).
21. Docusate Sodium 100 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO BID
(2 times a day).
22. Tobramycin Sulfate 60 mg/6 mL Solution [**Month/Year (2) **]: Three Hundred
(300) mg Intravenous Q48h: last dose 11/27.
23. Unasyn 3 gram Piggyback [**Month/Year (2) **]: Three (3) g Intravenous every
six (6) hours: Last day [**12-1**].
24. Lasix 40 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO twice a day.
Tablet(s)
25. Outpatient Lab Work
Please draw liver function tests, BUN, creatinine, vancomycin
trough weekly and fax results to ID physician [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 432**].
26. Calcitriol 0.25 mcg Capsule [**Telephone/Fax (1) **]: One (1) Capsule PO once a
day.
27. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
28. Neutra-Phos [**Last Name (STitle) **]: One (1) Packet three times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnoses:
1. Acinobacter pneumonia
2. Endocarditis with aortic regurgitation
3. Embolic cerebrovascular accident (CVA)
4. Acute on chronic renal insufficiency
5. Altered mental status
Secondary Diagnoses:
1. Diabetes mellitus, type 2
2. Hypothyroidism
3. Parkinson's Disease
4. Hypertension
5. Coronary artery disease
Discharge Condition:
Stable, afebrile, satting well on a 40% face tent, SBP 100s-180s
Discharge Instructions:
You were admitted to the hospital because of altered mental
status and a decrease in your oxygen level. You were found to
have a pneumonia and were treated with antibiotics. You were
placed on a ventillator to help support your breathing as a
result of the pneumonia and the IV fluids that you received to
support your blood pressure. You also have an infection on your
heart valves which is being treated with antibiotics.
Please call your doctor or return to the emergency room should
you develop any of the following symptoms: chest pain, fevers,
difficulty breathing, altered mental status, or any other
concerns.
Followup Instructions:
You should follow-up with your primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) **], within two weeks of discharge from rehab. Call
[**Telephone/Fax (1) 250**] to make this appointment. Please discuss colorectal
cancer screening with Dr. [**Last Name (STitle) **].
Please come to [**Hospital **] Clinic to see Dr. [**First Name (STitle) **] on Friday, [**2169-1-6**].
Call his clinic at ([**Telephone/Fax (1) 4170**] to confirm the time of this
appointment.
Please keep this other already-scheduled appointment.
Provider: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2168-12-27**] 1:30
|
[
"458.29",
"250.00",
"278.01",
"332.0",
"V02.54",
"427.1",
"421.0",
"995.92",
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"434.11",
"574.20",
"584.5",
"424.1",
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"997.31",
"285.29",
"482.83",
"276.3",
"V58.67",
"553.1",
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"428.0",
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icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"34.91",
"96.72",
"96.04",
"88.72",
"99.04"
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icd9pcs
|
[
[
[]
]
] |
19303, 19369
|
9894, 13031
|
328, 392
|
19741, 19808
|
3804, 3804
|
20477, 21173
|
3040, 3058
|
16291, 19280
|
19390, 19584
|
15620, 16268
|
19832, 20454
|
3073, 3785
|
19605, 19720
|
267, 290
|
420, 2181
|
3820, 9871
|
13046, 15594
|
2203, 2867
|
2883, 3024
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,980
| 136,521
|
7841+55855
|
Discharge summary
|
report+addendum
|
Admission Date: [**2191-11-15**] Discharge Date: [**2191-11-20**]
Date of Birth: [**2144-1-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 25342**]
Chief Complaint:
s/p podiatry surgery and need for insulin drip
Major Surgical or Invasive Procedure:
[**11-15**]: right charcot reconstruction
History of Present Illness:
47 M c poorly controlled type II DM on insulin and complicated
by peripheral neuropathy who presented for R charcot joint
reconstruction. Had approx. 400 cc EBL during surgery. Intraop
had blood sugars in 300 range. Postop had blood sugars > 400 and
required insulin drip. Transferred to [**Hospital Unit Name 153**] for management of
insulin drip. In [**Hospital Unit Name 153**] initially had blood sugar greater than
could be picked up by monitor. Bolused 10 u regular insulin and
continued on regular insulin drip at 10u/hr.
Past Medical History:
DM2 - last HgbA1C 12 in [**8-3**]. Complicated by peripheral
neuropathy. No hx retinopathy or nephropathy (Cr 1.1-1.6 range,
nl alb/cre urine ratio [**9-2**])
HTN
PVD - ? normal arterial hemodynamics [**11/2184**]
Hep B - hep B surface AB + [**2188**]
Genital Herpes
Social History:
SH: lives c wife & 8 kids, works at [**Hospital1 18**] housekeeping, smokes
pipe
4xd, etoh 4-5 drinks weekend, 1-2 drinks each weekday
Family History:
Mother c DM
Physical Exam:
VS- 95.9, 67-80, 95-122/61-75, 15-18, 100%RA
HEENT- OP clear, MMM
LUNGS- CTA
HEART- S1, S2, no murmurs
ABD- soft, ND, NT, BS+
EXT- R foot c large metallic brace; can move R toes, states that
he can feel light touch over R foot, capillary refill somewhat
delayed over R foot. 2+ popliteal pulses b/l.
Pertinent Results:
[**2191-11-15**] 04:12PM HGB-13.7* calcHCT-41
[**2191-11-15**] 04:12PM GLUCOSE-297* LACTATE-2.6* NA+-135 K+-4.8
CL--103
[**2191-11-15**] 08:06PM freeCa-1.17
[**2191-11-15**] 08:06PM HGB-13.3* calcHCT-40
[**2191-11-15**] 08:06PM GLUCOSE-416*
[**2191-11-15**] 08:06PM TYPE-[**Last Name (un) **] PH-7.38 INTUBATED-INTUBATED
[**2191-11-15**] 08:22PM freeCa-1.14
[**2191-11-15**] 08:22PM HGB-13.1* calcHCT-39
[**2191-11-15**] 08:22PM TYPE-ART TEMP-37 RATES-/8 TIDAL VOL-800
O2-50 PO2-133* PCO2-41 PH-7.38 TOTAL CO2-25 BASE XS-0
INTUBATED-INTUBATED VENT-CONTROLLED
[**2191-11-15**] 09:15PM PLT COUNT-193
[**2191-11-15**] 09:15PM WBC-8.5 RBC-4.22* HGB-11.6* HCT-33.4* MCV-79*
MCH-27.6 MCHC-34.8 RDW-14.2
[**2191-11-15**] 09:15PM CALCIUM-8.1* MAGNESIUM-1.7
[**2191-11-15**] 09:19PM freeCa-1.11*
[**2191-11-15**] 09:19PM HGB-11.3* calcHCT-34
[**2191-11-15**] 09:19PM GLUCOSE-358* LACTATE-4.4* NA+-135 K+-3.9
CL--109
[**2191-11-15**] 09:19PM TYPE-ART TEMP-37 PO2-154* PCO2-37 PH-7.35
TOTAL CO2-21 BASE XS--4 INTUBATED-NOT INTUBA
[**2191-11-15**] 11:57PM PLT COUNT-171
[**2191-11-15**] 11:57PM WBC-12.4* RBC-4.03* HGB-10.9* HCT-30.9*
MCV-77* MCH-27.1 MCHC-35.4* RDW-13.6
[**2191-11-15**] 11:57PM CALCIUM-8.1* PHOSPHATE-3.4# MAGNESIUM-1.7
[**2191-11-15**] 11:57PM GLUCOSE-404* UREA N-23* CREAT-1.3* SODIUM-138
POTASSIUM-4.5 CHLORIDE-107 TOTAL CO2-19* ANION GAP-17
Brief Hospital Course:
[**Hospital Unit Name 13533**]:
The patient was admitted to the [**Hospital Unit Name 153**] s/p podiatric surgery with
hyperglycemia. He was placed on an insulin drip, and his blood
sugars became well controlled. He required as much as 30 Units
of insulin/hour. He was seen by [**Last Name (un) **], who recommended starting
Glargine and an insulin sliding scale. The first glargine dose
tried was 20 Units. This resulted in poorly controlled sugars,
and so his dose was increased to 50 Units. 50 Units of Glargine
and a RISS worked well to control his blood sugars as well 1000
metformin [**Hospital1 **]. The patient reports that his home insulin dose
was 5 NPH [**Hospital1 **]. It is felt on his transfer that this is
inadequate, given his documented AiC of 12 and hyperglecmia seen
as an inpatient. He was transfered to the floor with stable
vital signs and podiatry following.
A/P: 47 M c uncontrolled type II DM on insulin presents for
hyperglycemia requiring insulin drip postoperatively.
.
1. Hyperglycemia: Pt was transitioned to Glargine 50U at
breakfast w/ISS, metformin 1gm [**Hospital1 **]. He tolerated POs well with
FS range 150-190s. Given recent stress response to surgery
sugars may be better controlled once he recovers from procedure.
.
2. Charcot Joint: Pt was placed in a frame and dressing changes
done per podiatry. He was started on Cefazolin and transitioned
to Keflex PO. He will complete a two week course of Keflex. Pain
was well controlled w/Percocet prn. Pt was cleared by podiatry
on day of discharge and provided with crutches. Pt was
instructed to follow up w/podiatry within 5 days of discharge
for close wound monitoring. No signs of infection throughout his
course. He had a low grade temp 100.3 on [**11-18**] post op but
remained afebrile for 48hours prior to discharge. Pt was sent
home w/good bowel regimen given narcotics for pain control. Pt
was also started on ASA for ppx given recent surgery and
somewhat limited mobility.
.
3. Hypertension: Pt was re-started on Lisinopril and continued
on norvasc.
.
#. Code: Full
.
Medications on Admission:
Androgel 1% qd to shoulder
ASA 81 qd
Atorvastatin 10 qd
Caverject 20 mcg qd PRN
Humalog 6 u tid
Lantus 35 u q PM
Lisinopril 40 qd
Metoprolol Succ 100 qd
Norvasc 10 qd
Spironolactone 50 mg qd
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for 2 weeks.
Disp:*60 Tablet(s)* Refills:*0*
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 2 weeks.
Disp:*30 Capsule(s)* Refills:*0*
4. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 12 days.
Disp:*48 Capsule(s)* Refills:*0*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) for 2 weeks.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Insulin Glargine 100 unit/mL Solution Sig: One (1)
Subcutaneous qAM: Please take 50U Glargine at breakfast-daily.
Disp:*1 vial* Refills:*2*
12. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous three times a day: please use per scale.
Disp:*1 vial* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetes
Charcot Joint s/p Intra-op repair
Hyperglycemia
Hypertension
Discharge Condition:
Stable
Discharge Instructions:
Continue to take all your medications as directed.
.
You need to continue Keflex, antibiotic for two weeks and see
podiatry in clinic next week.
.
If you notice fevers, increasing pain not relieved by your pain
medication, or significant bleeding please call your
podiatrist/surgeon or go to the emergency room.
.
You may do touch-down weight bearing of your Right foot.
Followup Instructions:
Please call [**Telephone/Fax (1) 543**] [**Hospital **] clinic on Tuesday for a follow
up appointment next week.
.
Please call your Primary Care Physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 4223**] at
[**Telephone/Fax (1) 7976**] for a follow up appointment in [**12-31**] weeks.
Completed by:[**2191-11-20**] Name: [**Known lastname 4815**],[**Known firstname 4816**] M. Unit No: [**Numeric Identifier 4817**]
Admission Date: [**2191-11-15**] Discharge Date: [**2191-11-20**]
Date of Birth: [**2144-1-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4818**]
Addendum:
Pt also noted to be anemic, had 1200cc Blood loss intra-op and
received IUPRBC transfusion w/improvement in HCT. His initial
HCT was 33 down to 23. Pt's HCT stabilized. Was unable to do
full anemia w/u in house givne blood transfusion. Pt's PCP was
notified of anemia and will pursue anemia w/u as outpatient. His
HCT was stable at 25 for 3 days prior to discharge. He remained
HD stable.
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4819**] MD [**MD Number(2) 4820**]
Completed by:[**2191-11-20**]
|
[
"070.32",
"250.62",
"357.2",
"401.9",
"713.5",
"443.9",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.72",
"78.37",
"78.17",
"83.85",
"81.17",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8619, 8783
|
3192, 5262
|
365, 408
|
7012, 7021
|
1775, 3169
|
7440, 8596
|
1426, 1439
|
5503, 6869
|
6919, 6991
|
5288, 5480
|
7045, 7417
|
1454, 1756
|
279, 327
|
436, 966
|
988, 1257
|
1273, 1410
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,088
| 169,938
|
47161
|
Discharge summary
|
report
|
Admission Date: [**2107-1-4**] Discharge Date: [**2107-1-11**]
Date of Birth: [**2029-7-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Central venous line placement
Arterial line placement
Endotracheal intubation
History of Present Illness:
HPI: 77 yo man nursing home resident with Parkinsons Disease,
dementia, found to be acutely SOB, per transfer notes: patient
was 87% RA, with rales, increased with supplemental O2 and was
transferred to OSH for managment. In outside ED, patient was
tx'd intially for CHF with lasix 80, nitro, tried on bipap but
failed and intubated (recieved succ/vec/etom/vers/fentanyl),
also noted to have BRBPR, and was transferred to [**Hospital1 18**] for
further managment.
Upon arrival: T 98.8 HR 120 BP 104/50 RR 14 O2 100% on AC
500/14/.40/5
WBC 13 w/10% bands, CXR unchanged from prior (hx of LLL
resection), + UTI, CKMB flat, Trop 0.16, HCT [**Month (only) **] from 35->30
with IVF, NGL clear, brown stool, scant BRBPR. Intitial lactate
was 1.4.
Past Medical History:
CAD: S/p 3V CABG '[**96**], PCI to RCA '[**02**], PCA instent stenois seen
on cath [**8-8**], patent grafts
HTN
Hyperlipidemia
CHF EF 40%, [**2-5**]+ MR [**First Name (Titles) **] [**Last Name (Titles) 113**] [**8-8**]
PVD: S/p L aorto-fem bypass
Hx of TB with LLL resection in [**2062**]
Lymphoma s/p XRT
Parkinsons Disease
Vascular Dementia
Depression
Diverticulosis
BPH
Social History:
SH: [**Location (un) 1036**] NH resident. Divorced, estranged from children,
sister is contact person. [**Name2 (NI) **] was wearing comfort care
bracelet, but per attg conversation with sister patient was full
code.
Family History:
NC
Physical Exam:
Tm 99.4 Tc 98.8 HR 124 BP 132/45 R 14 O2 100%
Gen: Elderly, non-responsive, paralyzed
HEENT: NCAT, ETT, OGT, Pupils - pinpoint non responsive
NECK: Supple, No bruits, JVP 8cm
CVS: Tachy, Reg rythym, no murmur
PUL: Diminished BS on left, + bl rhonchi
ABD: Soft, + BS, Non-distended
EXT: 2+ DPP bl, no edema
NEURO: Non responsive, paralyzed
Pertinent Results:
[**2107-1-4**] 10:53PM LACTATE-1.4
[**2107-1-4**] 10:53PM HGB-10.0* calcHCT-30
[**2107-1-4**] 10:51PM TYPE-ART TEMP-37.1 RATES-/14 TIDAL VOL-500
PEEP-5 O2-100 PO2-442* PCO2-55* PH-7.23* TOTAL CO2-24 BASE XS--5
AADO2-226 REQ O2-45 -ASSIST/CON INTUBATED-INTUBATED
[**2107-1-4**] 10:38PM GLUCOSE-195* UREA N-32* CREAT-1.3*
SODIUM-147* POTASSIUM-4.0 CHLORIDE-115* TOTAL CO2-23 ANION
GAP-13
[**2107-1-4**] 10:38PM ALT(SGPT)-1 AST(SGOT)-16 CK(CPK)-112
AMYLASE-164* TOT BILI-0.2
[**2107-1-4**] 10:38PM LIPASE-72*
[**2107-1-4**] 10:38PM CK-MB-6 cTropnT-0.16*
[**2107-1-4**] 10:38PM CALCIUM-7.9* PHOSPHATE-4.6* MAGNESIUM-1.7
[**2107-1-4**] 10:38PM WBC-13.8* RBC-3.19* HGB-9.5* HCT-28.8* MCV-90
MCH-29.7 MCHC-32.8 RDW-14.9
[**2107-1-4**] 10:38PM NEUTS-77* BANDS-10* LYMPHS-6* MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 HYPERSEG-1*
Brief Hospital Course:
ASSESS: 77 yo man with Parkinsons disease, dementia and CAD,
presents with acute respiratory distress, due to sepsis/CHF.
Patient was initially intubated for respiratory failure and
concern for GIB. Subsequently developed hypotension with
sedation, with persistent tachycardia, elevated lactate, stable
hct.
1. Sepsis/Hypotension: Cause strongly suspected to be urosepsis,
outside urine culture from [**Hospital1 18**] [**Location (un) 620**] grew E. Coli sensitive
to Ceftriaxone. The patient initially received Ceftriaxone at
[**Location (un) 620**] and a dose of Vanc, Levo, and Flagyl here. After HD #1
only Vanc and Ceftriaxone were continued. The patient was
agressively fluid recussitated, initially requiring Levophed for
BP support. By AM of HD#1, this was able to be d/c. BP was
further supported with fluid boluses titrated to keep UOP
>30CC/hr. Steroid therapy was started empirically for suspected
sepsis. This was continued only transiently. Initially Hct fell
to <25, the patient had presented to [**Location (un) 620**] with hx of BRBPR.
His HCT appropriately responded to transfusion. He was intubated
initially for support and was successfully extubated on [**1-8**].
He was given a 5-day course of vancomycin (for gpc in sputum)
and 14-day course of ceftriaxone (for E. coli in urine). His
WBC continued to trend down, he remained afebrile, and was
clinically improved at time of discharge. All cultures remained
negative (only positive culture was from [**Hospital1 18**] [**Location (un) 620**]; E. coli
[**Last Name (un) 36**] to ceftriaxone, resistant to quinolones). He received a
PICC prior to discharge for completion of his IV antibiotic
course. He remained hemodynamically stable, and his BP meds
were restarted. He was additionally diuresed with lasix (for CHF
and s/p fluids given in unit for sepsis). He was stable at time
of discharge).
2. Demand Ischemia: MB flat, Trop +, likely demand. He was
managed medically on ASA, metoprolol (which was titrated up with
good success), Plavix, Zocor, and lisinopril. He was discharged
on this medical regimen. He had no events on tele while
in-house, and his EKG remained stable.
3. CHF: Pt with an EF=40%. He was given large volume fluid
resuscitation on presentation for sepsis and became quite volume
overloaded. When he was stable hemodynamically, he was diuresed
with lasix with good success. He was discharged on a standing
dose of lasix (40 mg PO) to maintain clinical euvolemia by
ins/outs.
4. GIB: HCT decrease to 28. Baseline: 32-34. He was initially
transfused and had a stable hct since that time. As per GI, he
will have outpatient GI follow up and will likely need an
outpatient colonoscopy. After the initial episode of BRBPR, he
was guaiac negative subsequently.
5. AMS: Likely sedation for intubation, lingering effect given
poor baseline with dementia and Parkinson's. Head CT was
without any acute event/mass. HE was at his baseline (according
to family) at time of discharge). His donepezil and Sinemet
were continued throughout hospitalization.
6. ACCESS: R femerol groin line, R Subclavian sepsis line
placed. These were d/ced and he had a right PICC placed on
discharge for completion of his antibiotic course.
7. CODE: Full per OSH ED attg's discussion with family.
8. PROPH: SQ heparin, IV PPI were continued in-house
9. Dispo: pt to return to [**Hospital **] nursing home, to complete
14-day course of antibiotics (ceftriaxone). He was stable at
time of discharge. He was cleared by speech and swallow for
PO's (thin liquids/ground solids). He will need assistance with
feedings, hob elevated during and post meals. Pills can be
crushed if necessary or taken whole with liquids.
Medications on Admission:
Metoprolol 25mg po bid
Asa 81mg po qd
Plavix 75mg po qd
Lisinopril 5mg po qd
Lasix 20mg po qd
Imdur 30mg po qd
Lipitor 80mg po qhs
Sinemet 25-250 TID
Aricept 10mg po qhs
Megace 200mg po bid
Protonix 40mg po qd
Flomax 0.4mg po qhs
Artificial tears
Erythromycin opth ointment qhs
Neomycin/Poly/Dex 0/1% eye solution qhs
Zithromax [**11-28**] - [**11-30**]
Albuterol prn (since starting z-pack)
Calcium w/Vit D500mg po qd
Flonase [**Hospital1 **]
MVI, Colace, Senna,
Discharge Medications:
1. Carbidopa-Levodopa 25-250 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
2. Donepezil Hydrochloride 10 mg Tablet Sig: One (1) Tablet PO
HS (at bedtime).
3. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
4. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
5. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID PRN as needed.
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
9. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
10. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Insulin Regular Human 100 unit/mL Solution Sig: as directed
Injection ASDIR (AS DIRECTED): For BS 150-200, give 2 U, for BS
201-250, give 4 U, for BS 251-300, give 6U, for BS 301-350, give
8 U, for BS 351-400, give 10 U.
13. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
15. Erythromycin 5 mg/g Ointment Sig: [**2-5**] Ophthalmic QID (4
times a day) for 12 days: until [**1-24**].
16. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
17. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
18. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
19. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
20. Ceftriaxone 1 gm IV Q24H
21. Ceftriaxone Sodium 1 g Piggyback Sig: One (1) Intravenous
once a day for 7 days: Until [**1-18**].
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
Primary diagnosis:
Urosepsis
Secondary:
Hematochezia
CAD
Parkinson's Disease
Discharge Condition:
Stable
Discharge Instructions:
1. Please take all medications as outlined in the discharge
instructions. You will need to complete a 14-day course of
ceftriaxone for your urosepsis (continue until [**1-18**]). We added
standing lasix to your medication regimen. This might need to
be titrated based on your In's/Out's status. Your Ins/Outs
should be well recorded. Goal for 1 week should be 1L negative.
Goal should then be decreased to 500 cc negative, and then
euvolemia when your peripheral edema is resolved. We also
increased the dose of your metoprolol for better management of
your CAD
2. You should follow up with GI; you had some GI bleeding in
the hospital, but your hematocrit remained stable after that
isolated event. You will need a colonoscopy as an outpatient.
3. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5 L/day
4. Call your PCP/let MD's at NH know if you are experiencing
chest pain, shortness of breath, fever/chills, or with any
other concerns
Followup Instructions:
1. Follow up with the MD's at your nursing home. Your lasix
dosage should be titrated as described above.
2. Please follow up with [**Hospital **] clinic (appt scheduled)
|
[
"V45.81",
"995.92",
"V12.01",
"038.9",
"578.1",
"785.52",
"428.0",
"V45.82",
"311",
"401.9",
"285.9",
"443.9",
"518.81",
"041.4",
"414.00",
"599.0",
"276.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.71",
"38.93",
"96.6",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
9299, 9376
|
3082, 6795
|
333, 413
|
9498, 9506
|
2213, 3059
|
10582, 10760
|
1832, 1836
|
7310, 9276
|
9397, 9397
|
6821, 7287
|
9530, 10559
|
1851, 2194
|
274, 295
|
441, 1186
|
9416, 9477
|
1208, 1582
|
1598, 1816
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,328
| 163,260
|
54560
|
Discharge summary
|
report
|
Admission Date: [**2173-2-10**] Discharge Date: [**2173-2-15**]
Service: MEDICINE
Allergies:
Ceftriaxone / Bactrim DS
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
transfer to MICU for tachypnea, respiratory distress
Major Surgical or Invasive Procedure:
Intubated ([**2173-2-11**])
A-line ([**2173-2-11**])
History of Present Illness:
Pt is a [**Age over 90 **] year old male with two vessel CAD, COPD, CVA and
hypertension who was presented to [**Hospital1 18**] Ed with worsening
dyspnea over the previous few days.
.
Per the patient's fiance, Mr. [**Known lastname **] has difficulty breathing at
baseline. He was previously weaned off of supplemental 02 while
in rehab and is not on O2 at home. His breathing markedly
worsened 3-4 days prior to admission. He did not experience any
symptoms of cold; denies cough, fever, chills, sputum
production, nausea, and vomitting. He was very constipated and
took miralax this morning following which he had "incredible
diarrhea."
.
On day of admission, patient was noted by VNA to be short of
breath while standing and talking, with wheezes and rales on
pulmonary exam. [**Hospital3 **] was contact[**Name (NI) **] and the
patient presented to [**Hospital1 18**] ED. Of note, his weight had been
stable at home, oxygenating 93% on RA when seen by VNA.
.
Initial vitals in the ED were as follows: Temp:97.8 HR:84
BP:147/84 Resp:18 O(2)Sat:99. Subsequently he desated to mid-80%
and triggered. Patient received azithromycin, solumederol, and
combivent x3 in the ED (last doses at ~1pm). A CXR and CT Chest
demonstrated no acute intrathoracic process and unchanged
emphysematous changes particularly in the right lung; there were
no signs of PE. An EKG was concerning for new TWI in V2-V4 and
Troponin was elevated to 0.08. Cardiology was not consulted. Mr.
[**Known lastname **] stabilized with on O2 sat of 97% on 4L NC and was
transfered to the medical floor.
.
Upon arrival to the floor, Mr. [**Known lastname **] was 93% on 4L with marked
tachynpea (~60 breaths/min) with a nine beat Vtach run. He was
tachycardic to 130-140s and hypertensive to SBP170-180s. The
patient received Lasix 40mg IV, combivent neb X2, morphine 1 mg
IV. A Foley was placed with good urine output. EKG demonstrated
no changes when compared to those from the ED. ABG showed pH
7.33; pC02 38; p02 83, HCO3 21. Repeat ABG at 1 hr showed pH
7.37; pCO2 35, pO2 79, HCO3 21. Mr. [**Known lastname **] was transferred to the
MICU for further care.
.
In the MICU, he reports slight improvement in his breathing. He
was alert and oriented to person, place and time. He did not
report chest pain, dizziness but does report shortness of
breath.
Past Medical History:
Cerebrovascular accident
CAD
Hypertension
Anemia
Chronic obstructive pulmonary disease
NPH-[**2162-6-22**] pt underwent right frontal ventricular peritoneal
shunt
placement
BPH
Pernicious anemia- monthly B12 shots
GERD
Dyslipidemia
Social History:
Quit smoking 35 yrs ago, heavy smoker prior, no ETOH use, lives
by himself, is engaged to his girlfriend who lives in the same
building. He has a son [**Name (NI) **] who is very involved. He is
independent in ADLS. He is independent of cooking. His fiance
and son do the shopping. His fiance does the bills. He walks
with a walker or a cane but he states that he walks best with a
walker. No recent falls. he does not use his glasses. No hearing
aides. + dentures. Fiance does his medications. He has a HHA who
comes 3x per week to shower him. He has a HHA who comes 2/month
to clean the appt.
[**Name (NI) **] - son cell: 1 ([**Telephone/Fax (1) 111589**]
Family History:
He cannot remember what his father dies of. He remembers that
his mother was obese but he cannot remember what she died of. He
has two children who are healthy.
Physical Exam:
Vitals: T:98.8 BP:183/103 P:124 R:24 O2:100% 100%NRB
General: Alert, oriented x 3 in moderate distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Use of accessory muscle and abdominal breathing. Moving
air. Clear to auscultation bilaterally with no crackles or
wheezing appreciate.
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: Foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2173-2-10**] 12:43PM BLOOD WBC-10.3 RBC-4.54* Hgb-13.4* Hct-39.0*
MCV-86 MCH-29.6 MCHC-34.5 RDW-15.1 Plt Ct-268
[**2173-2-10**] 12:43PM BLOOD Neuts-86.2* Lymphs-9.4* Monos-3.8 Eos-0.3
Baso-0.4
[**2173-2-10**] 12:43PM BLOOD Glucose-122* UreaN-18 Creat-1.2 Na-138
K-4.3 Cl-103 HCO3-24 AnGap-15
CXR ([**2173-2-11**]): The patient was intubated in the interim with
the ET tube being approximately 6 cm above the carina. In
addition to the known lucency of the left upper lung, there is
interval development of left pneumothorax, moderate with the
presence of deep sulcus sign. The right lung is unchanged and
the cardiomediastinal silhouette is unchanged, although slight
additional shift to the right is noted, most likely due to
pneumothorax.
CT Chest ([**2173-2-11**]): Large left pneumothorax persists. Large
left apical component causes resulting LUL atelectasis, with
second left chest tube now terminating in pleural air
collection. Left basilar catheter extending along fissure,
terminates above basal component of PTX. Increased left basilar
atelectasis compared to chest CTA the prior day. Expiratory scan
demonstrates
tracheobronchomalacia, with focal left lobwer lobe complete
bronchial
collapse.
CT Head ([**2173-2-11**]):
1. No evidence of acute intracranial process.
2. VP shunt in unchanged position
3. Left subdural collection is unchanged in size.
Brief Hospital Course:
[**Age over 90 **] year old male two vessel CAD, COPD, CVA and hypertension who
was presented to [**Hospital1 18**] Ed with worsening dyspnea over the
previous few days.
.
# Acute respiratory distress: Initilaly thought to be flash
pulmonary edema in the setting of hypertensive emergency due to
ACS on the floor. His anginal equivalent for his two disease CAD
seems to be shortness of breath but no chest pain and V4-V6 as
noted by his stress test in [**2150**]. CTA negative for PE. CXR not
consistent with pneumonia. ABG and clinical presentation not
consistent with COPD exacerbation. Improved with nitroglycerin
gtt. On [**2173-2-10**] around midnight, he was noted to be acutely
hypoxic and satting in 50%. Anesthesia was called to intubate.
He was requiring 100% FiO2 and 10 cm PEEP with peak pressures
extremely elevated around 50 but pO2 only in 60s. He was noted
to have left tension pneumothorax. IP placed two chest tubes
with one tube showing persistent air leak. There was concern
for bronchopulmonary fistula especially on [**2173-2-13**] when he was
noted to have worsening of his subcutaenous empysema tracking
down to his scrotum and up to his eyes. IP placed a 14 french
pig tail catheter. He was weaned down to 50% FiO2 and 5 cm PEEP
by [**2173-2-14**]. However he required increased FiO2 back to 70% on
[**2173-2-15**]. He continued to have significant air leak and
worsening subcutaneous emphysema. Family meeting was held with
son [**Name (NI) **] [**Name (NI) **] on [**2173-2-15**], and decision was made to make patient
CMO. ET tube removed at 4:30pm, and patient expired at 6:15pm.
.
# Two vessel CAD/Systolic heart failure: EF of 35-45% on TTE in
10/[**2172**]. Continued on asprin, metoprolol and high dose statin.
.
# COPD: CTA consistent with severe COPD. Continued combivent,
spiriva and albuterol nebs prn
.
# Hypothyroidism: Continued levothyroxine 25 mcg po qdaily
.
# BPH: Continued finasteride 5 mg po qhs
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - [**2-7**] sprays by
mouth up to qid as needed for rescue symptoms
ASPIRIN - 81 mg Tablet - 1 Tablet(s) by mouth once a day
ATENOLOL - 25 mg Tablet - One half Tablet(s) by mouth at bedtime
ATORVASTATIN [LIPITOR] - 10 mg Tablet - 1 (One) Tablet(s) by
mouth once a day
CYANOCOBALAMIN (VITAMIN B-12) - 1,000 mcg/mL Solution - inject
IM
1000 mcg monthly [**Hospital3 **] VNA to inject starting [**2171-9-9**] once
a
month
FINASTERIDE - 5 mg Tablet - 1 Tablet(s) by mouth daily
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs
by mouth twice a day
IPRATROPIUM-ALBUTEROL [COMBIVENT] - 18 mcg-103 mcg (90
mcg)/Actuation Aerosol - 2 puffs twice a day
KETOCONAZOLE [NIZORAL] - 2 % Shampoo - wash scalp, ears,
eyebrows
3 times per week
LEVOTHYROXINE [LEVOXYL] - 25 mcg Tablet - 1 (One) Tablet(s) by
mouth once a day
NITROGLYCERIN - 0.3 mg Tablet, Sublingual - 1 (One) Tablet(s)
sublingually every 5 minutes x 3 for chest pain then call 911 if
pain continues
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth once a day
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - inhale contents of one capsule once a day
TRAZODONE - 50 mg Tablet - 0.5 (One half) Tablet(s) by mouth
prior to going to sleep as needed for insomnia
BISACODYL - 5 mg Tablet, Delayed Release (E.C.) - 1 to 2
Tablet(s) by mouth once a day as needed
DOCUSATE SODIUM - 100 mg Capsule - 1 (One) Capsule(s) by mouth
twice a day as needed
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 400 unit Capsule - 2
Capsule(s) by mouth once a day
POLYETHYLENE GLYCOL 3350 [MIRALAX]
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
pt passed away
Discharge Condition:
pt passed away
Discharge Instructions:
pt passed away
Followup Instructions:
pt passed away
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2173-2-15**]
|
[
"493.20",
"518.0",
"600.00",
"530.81",
"414.8",
"518.81",
"276.52",
"410.71",
"428.22",
"348.1",
"244.9",
"414.01",
"512.1",
"427.1",
"518.1",
"V12.54",
"276.2",
"272.4",
"E879.8",
"V45.89",
"281.0",
"584.9",
"V15.82",
"428.0",
"402.91",
"997.31",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"96.6",
"34.04",
"38.91",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
9515, 9524
|
5833, 7790
|
285, 340
|
9582, 9598
|
4441, 5810
|
9661, 9832
|
3639, 3801
|
9488, 9492
|
9545, 9561
|
7816, 9465
|
9622, 9638
|
3816, 4422
|
193, 247
|
368, 2691
|
2713, 2947
|
2963, 3623
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
946
| 149,258
|
26866
|
Discharge summary
|
report
|
Admission Date: [**2120-5-29**] Discharge Date: [**2120-5-31**]
Date of Birth: [**2040-3-16**] Sex: M
Service: SURGERY
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
need for feeding tube
Major Surgical or Invasive Procedure:
PEG
History of Present Illness:
Patient with prolonged history with repiratory failure
transferred here for PEG placement.
Past Medical History:
-s/p appendectomy
-h/o polio as a child; wife tells me he was diagnosed in the
[**2064**]'s during the polio epidemic; had a headache at the time; no
weakness or diarrhea
-recent new atrial fibrillation
-h/o recent pneumonia
-dvt lower extremity [**4-25**]
Physical Exam:
neuro-alert, disoriented
cor-irregularly irregular
lungs-cta b/l
abd-doft nt/nd
ext-no edema
Pertinent Results:
[**2120-5-29**] 07:48PM GLUCOSE-98 UREA N-27* CREAT-0.7 SODIUM-138
POTASSIUM-4.9 CHLORIDE-101 TOTAL CO2-30 ANION GAP-12
[**2120-5-29**] 07:48PM ALT(SGPT)-23 AST(SGOT)-17 ALK PHOS-125*
AMYLASE-44 TOT BILI-0.6
[**2120-5-29**] 07:48PM LIPASE-27
[**2120-5-29**] 07:48PM ALBUMIN-3.1* CALCIUM-8.8 PHOSPHATE-4.6*
MAGNESIUM-2.1
[**2120-5-29**] 07:48PM WBC-9.6 RBC-3.63* HGB-10.2* HCT-30.5* MCV-84
MCH-28.2 MCHC-33.6 RDW-17.0*
[**2120-5-29**] 07:48PM PLT COUNT-222
[**2120-5-29**] 07:48PM PT-13.7* PTT-26.4 INR(PT)-1.2*
Brief Hospital Course:
Patient had a PEG placed on [**5-29**] with no complications. Tube
feeds were restarted. Lovenox (therapeutic dose) was started as
a bridge to coumadin. Patient briefly went into rapid afib
which was controlled with B-blockade and calcium channel
blockers. A chest CT to follow up his pulmonary disease was
also done. This showed improvement of ground glass opacities and
pleual effusions with slightly worsening fibrosis.
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
2. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale
Injection ASDIR (AS DIRECTED).
3. Enoxaparin 80 mg/0.8 mL Syringe Sig: 70 mg Subcutaneous Q12H
(every 12 hours).
4. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for agitation.
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for agitation.
6. Warfarin 1 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1
doses.
7. Metoprolol Tartrate 5 mg/5 mL Solution Sig: One (1)
Intravenous Q6H (every 6 hours).
8. Lansoprazole 15 mg Susp,Delayed Release for Recon Sig: One
(1) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 23973**] [**Hospital1 **]
Discharge Diagnosis:
s/p PEG
afib
dvt
ards
pneumonia
s/p jejunal resection
[**Doctor First Name 329**] [**Doctor Last Name **] tear
Discharge Condition:
stable
Discharge Instructions:
daily INR until [**2-23**]. Continue lovenox until then. Secure G-tube
at all times. Chem 10 to assess electrolytes in 2 days. Free
water boluses through tube may need to be adjusted. Thank you.
Followup Instructions:
as needed
|
[
"427.31",
"453.40",
"530.7",
"428.0",
"V55.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
2573, 2638
|
1391, 1819
|
307, 312
|
2792, 2800
|
842, 1368
|
3047, 3059
|
1842, 2550
|
2659, 2771
|
2824, 3024
|
729, 823
|
246, 269
|
340, 432
|
454, 714
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,945
| 116,984
|
43958
|
Discharge summary
|
report
|
Admission Date: [**2123-7-11**] Discharge Date: [**2123-7-11**]
Date of Birth: [**2057-2-15**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5608**]
Chief Complaint:
hypoxemia, unresponsiveness
Major Surgical or Invasive Procedure:
Mechanical ventilation
History of Present Illness:
66F with nasopharyngeal CA s/p radiation, cerbrovascular disease
who presents after being found unresponsive this morning. Pt has
had poor nutritional status and declining functional status over
the past months living at home with care from her husband. She
was having frequent falls over the past couple of days although
was otherwise in her USOH until she fell last night and the
husband helped her into bed. This morning he found her sleepy,
poorly responsive, and with labored breathing. He called EMS
In the ED, she was noted to be hypoxemic, hypotensive and had a
dilated R pupil and she was emergency intubated and given
Mannitol for concern for brain edema. Head CT however showed no
evidence of hemorrhage or obvious mass lesion. CXR showed
evidence of ARDS. Femoral central line was placed and the
patient was started on levophed and neosynephrine. She received
1L NS. Ceftriaxone and flagyl were administered to treat a
suspected aspiration PNA.
Past Medical History:
- Nasopharyngeal CA, diagnosed in [**2093**] and treated with
radiation
- R ICA occlusion, thought to be [**3-20**] radiation vasculopathy
- L ICA stenosis, s/p L common carotid to L ICA bypass in [**2115**]
at
[**Hospital3 **]
- Vertebral Artery angioplasty (mentioned in [**Hospital3 **] Op Note
from [**2115**])
- ? TIA, episodes of leg weakness
- hypothyroidism
Social History:
Taught computer science at [**University/College **], lives with husband, no tobacco,
very occ EtOH
Family History:
no FH of stroke
Physical Exam:
T: 100.8 BP 70/49 HR 92 RR 28 O2Sat: 83%
Gen: intubated
HEENT: JVP flat
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: bilateral rhonchi
Abd: +BS soft, nontender
ext: groin central line in place, c/d/i no edema
Pertinent Results:
Admission labs:
[**2123-7-11**] 12:15PM WBC-5.1 RBC-3.53* HGB-9.3* HCT-30.0* MCV-85
MCH-26.4* MCHC-31.1 RDW-13.5
[**2123-7-11**] 12:15PM NEUTS-13* BANDS-20* LYMPHS-22 MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-34* MYELOS-8* NUC RBCS-1*
[**2123-7-11**] 12:15PM PLT COUNT-369
[**2123-7-11**] 12:15PM PT-13.9* PTT-43.4* INR(PT)-1.2*
[**2123-7-11**] 12:15PM GLUCOSE-140* UREA N-23* CREAT-1.2*
SODIUM-127* POTASSIUM-4.0 CHLORIDE-92* TOTAL CO2-20* ANION
GAP-19
[**2123-7-11**] 12:15PM ALBUMIN-2.4* CALCIUM-8.2* PHOSPHATE-4.9*
MAGNESIUM-1.9
[**2123-7-11**] 12:15PM ALT(SGPT)-11 AST(SGOT)-17 CK(CPK)-64 ALK
PHOS-59 TOT BILI-0.5
[**2123-7-11**] 01:12PM LACTATE-9.5*
Brief Hospital Course:
A/P: 66F with nasopharyngeal CA s/p radiation, cerbrovascular
disease who presented after being found unresponsive morning on
admission.
.
The patient presented to the ICU on norepinephrine and
phenylephrine drips. She had remained severely hypoxemic in the
ED with pO2 in the 40s for two hours despite mechanical
ventilation with FiO2 100%. The husband had been updated by the
medical team in the ED and understood that the prognosis was
very poor. The son who is an anesthesiologist was updated on
arrival of the patient to the ICU. The plan discussed with the
son and husband was to preserve life if possible until the son
and daughter to arrived to [**Name (NI) 86**] to be with the mother. After
arrival to ICU, she required dopamine gtt and vasopressin gtt as
well. She was administered 13L of IVF, including IVFs with
bicarbonate to correct her acidemia. After the family arrived a
meeting was held with the family and the attending physician.
[**Name10 (NameIs) **] patient was made CMO. Morphine gtt was started and pressors
were discontinued. The pt passed away soon afterward.
Medications on Admission:
Propranolol
Levoxyl
Aspirin
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Anoxic brain injury
Hypoxic respiratory failure
Shock
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"507.0",
"E849.0",
"348.1",
"518.5",
"995.92",
"038.9",
"244.9",
"389.8",
"V10.02",
"276.2",
"785.52",
"E888.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
4039, 4048
|
2839, 3932
|
343, 367
|
4145, 4154
|
2149, 2149
|
4206, 4212
|
1879, 1896
|
4011, 4016
|
4069, 4124
|
3958, 3988
|
4178, 4183
|
1911, 2130
|
276, 305
|
395, 1354
|
2165, 2816
|
1376, 1745
|
1761, 1863
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,035
| 174,791
|
47016
|
Discharge summary
|
report
|
Admission Date: [**2190-11-21**] Discharge Date: [**2190-11-27**]
Date of Birth: [**2120-2-8**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Abdomenal pain
Major Surgical or Invasive Procedure:
1. Laparoscopy.
2. Open cholecystectomy.
History of Present Illness:
This was a 70 year-old woman who
entered the hospital 36 hours earlier with abdominal
discomfort and mild emesis. Her preoperative liver function
tests were normal. An ultrasound of the gallbladder
demonstrated thickening of the wall with some inflammatory
changes and a normal common bile duct. A CT scan also
demonstrated edema of the gallbladder wall. She appeared to
potentially have a stone impacted in the neck. She had a
prior history of type II diabetes mellitus. She was placed on
broad-spectrum antibiotics and plans were made for removal of
the gallbladder.
Past Medical History:
s/p CVA
HTN
DM
A fib
Neurogenic bladder
Obesity
Physical Exam:
At presentation, the patient was in no acute distress. Hear was
regular rate rhythm. Lungs were clear to ascultation. Her
abdomen was soft, with RUQ tenderness, without rebound or
guardin.
Brief Hospital Course:
Upon admission, the patient was made NPO, given IVF, as well as
broad sprecturm antibiotics. She was given IV pain medication
for comfort. She was taken to the operating room the next day
to have an open (converted from laprascopic) cholecystectomy.
She tolerated the procedure well. Post-operatively, she had
bouts of afib, but eventually stabilized on a beta-blocker and a
calcium-[**Last Name (un) 21766**] blocker. She also had poor PO intake. However,
she has increased her intake to an acceptable level over the
last 2 days. She now also reports of being hunger. Since the
operation, she has been afrible with stable vital, with the
exception of several bouts of Afib. She has been tolerating a
regular diet. She will be discharged to day back to her
previous rehab in fair/stable condition.
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Albuterol Sulfate 0.083 % Solution Sig: [**12-27**] Inhalation Q6H
(every 6 hours) as needed.
4. Ipratropium Bromide 0.02 % Solution Sig: [**12-27**] Inhalation Q6H
(every 6 hours).
5. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
6. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
7. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] (2
times a day).
8. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day. Tablet, Delayed
Release (E.C.)(s)
9. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed.
10. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day:
**Please check INR** medication restarted [**2190-11-27**].
11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day.
12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed. Capsule(s)
13. Compazine 10 mg Tablet Sig: One (1) Tablet PO every [**3-31**]
hours as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Cholecystitis
Discharge Condition:
Fair/Stable
Discharge Instructions:
Please take medications as prescribed and read warning labels
carefully. If previous symtoms recur, such as fever/chills,
nausea/vomiting, please go to the emergency room immediately.
If signs of infections such as purulent discharge from wound,
increase pain and redness at wound, please call or go to the
emergency room. Remember to call for a follow up appointment
(bellow). Light activities until seen in clinic. [**Month (only) 116**] eat
regular food. [**Month (only) 116**] shower but no baths. Pat incision wounds
dry, do not scrub wound when showering. Absolutely no smoking.
Followup Instructions:
Please call Dr.[**Name (NI) 1745**]([**Telephone/Fax (1) 5323**] office to be seen in [**12-27**]
weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2190-11-27**]
|
[
"574.00",
"574.10",
"V64.41",
"250.00",
"401.9",
"692.9",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.22"
] |
icd9pcs
|
[
[
[]
]
] |
3321, 3391
|
1275, 2084
|
330, 373
|
3449, 3462
|
4102, 4367
|
2107, 3298
|
3412, 3428
|
3486, 4079
|
1059, 1252
|
276, 292
|
401, 972
|
994, 1044
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,781
| 106,507
|
35956+58049
|
Discharge summary
|
report+addendum
|
Admission Date: [**2146-11-24**] Discharge Date: [**2147-1-12**]
Date of Birth: [**2081-2-8**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
Headache, LOC
Major Surgical or Invasive Procedure:
[**11-24**]: Left Burr Hole and placement of External Ventricular
Drain(EVD)
[**12-1**]: Removal of EVD, Cyst Aspiration, [**Last Name (un) **] catheter
placement.
[**12-14**]: scalp wound revision
History of Present Illness:
65M presented to OSH this am after complaining of headache on
[**11-24**]. Per reports from ED records, and parents(with whom he
resides), he then went upstairs to the bathroom when a "thump"
was heard. His mother went upstairs into the bathroom and found
him on the floor, incontinent of urine and unresponsive. She
then called 911, and was taken to OSH. Upon presentation to
OSH, he was found to be hypertensive to 230/150, started on
Nipride. His head was scanned and revealed a "Massive Head
Bleed, without midline shift". He was then subsequently
transferred to [**Hospital1 18**] for definitive care and Neurosurgical
evaluation. In the duration of transfer, per EMS noted, started
decorticate posturing and they began infusion of 25 gm Mannitol
IV.
Past Medical History:
None; per mother
Social History:
Resides at home with parents
Family History:
Non-contributory
Physical Exam:
On Admission:
BP:143/68(off Nipride) HR:79 RR:25 O2 Sats: 100% CMV
Gen: WD/WN,indigent appearing gentleman.
HEENT:normocephalic, atraumatic.
Pupils: Symmetric EOMs: Unable to assess
Neuro:
+Corneals, +Swallowing, intubated at OSH. Spontaneous movement
of
left side observed, ?purposeful. No observed mvmt of the right
side. Pupils: Lt 3mm, minimally reactive, Rt 3mm non-reactive.
On Discharge:
AOx3, moving all extremities, ambulating in [**Doctor Last Name **] with assistance
Pertinent Results:
Labs on Admission([**11-24**]):
138 101 15 184
-------------/
3.5 22 0.9
estGFR: >75 (click for details)
CK: 175 MB: Pnd
Ca: 8.4 Mg: 2.1 P: 3.1
ALT: 14 AP: 62 Tbili: 0.7 Alb: 4.6
AST: 28 LDH: Dbili: TProt:
[**Doctor First Name **]: Lip: 26
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc:
Urine Benzos: Pos
Urine Barbs, Opiates, Cocaine, Amphet, Mthdne: Negative
WBC:20.6 Hgb:12.9 Plt:242 Hct:35.9
N:92.2 L:3.5 M:4.0 E:0.2 Bas:0.1
PT: 14.5 PTT: 23.0 INR: 1.3
Imaging:
NON-CONTRAST HEAD CT [**11-24**]: There is a large amount of acute
hemorrhage centered at the level of the mid brain with blood
filling the lateral, third, and fourth ventricles. Dilatation of
the ventricles and transependymal migration of CSF is consistent
with obstructive hydrocephalus. There is 8 mm rightward shift of
normally midline structures. Grey-white matter differentiation
remains preserved. Secretions in the nasopharynx may be related
to NG tube. Ethmoidal, maxillary, and sphenoidal mucosal
thickening is mild. The mastoid air cells remain normally
aerated. The surrounding osseous structures are unremarkable.
Note is made of prominent CSF space in the suprasellar
cistern,which can be seen with marked obstructive hydrocephalus,
but a suprasellar arachnoid cyst can have a similar appearance.
CXR [**11-24**]:
FINDINGS: There is an endotracheal tube whose tip is
approximately 2.4 cm
above the level of the carina. There is a nasogastric tube that
courses below the diaphragm and lies within the stomach. The
stomach, however, remains moderately distended with gas. The
lungs are clear. There is no evidence of congestive heart
failure or pneumonia. There is no evidence of pleural effusions
or pneumothorax. The cardiac and mediastinal contours are normal
in appearance. The visualized osseous structures are
unremarkable.
MRI Head +/- [**11-25**]:
IMPRESSION:
1. Extensive intraventricular hemorrhage involving all the
ventricles as
described above, predominantly in the acute stage with a small
subacute
component.
2. Obstructive hydrocephalus, with dilatation of the left
lateral ventricle
and moderate on the right.
3. While there is no obvious abnormal enhancement noted within
the area of
hemorrhage, small neoplastic or vascular causes within the
ventricles cannot be excluded. Repeat evaluation can be
considered after evacuation or
resolution of the hematoma.
4. Subarachnoid hemorrhage, in both cerebral hemispheres.
Given the presence of intraventricular and subarachnoid
hemorrhage, patient
needs further evaluation to exclude a vascular cause like an
aneurysm by CT
angiogram. The intracranial arteries are not adequately assessed
on the
present study. Displacement of the right internal carotid artery
termination and the anterior cerebral arteries on both sides
related to the enlarged ventricles is noted.
CTA Head [**11-25**]:
IMPRESSION:
1. No evidence of aneurysm, arteriovenous malformation or other
vascular
abnormality as source of massive intraventricular hemorrhage.
There is also no focal contrast extravasation to suggest a
bleeding source or risk of continued hemorrhage.
2. Only scant subarachnoid hemorrhage, unchanged, with no
evidence of
cerebral vasospasm.
3. Extensive intraventricular hemorrhage, with severe
obstructive
hydrocephalus, unchanged.
4. Persistent dilatation of the left lateral ventricle, despite
the
ventriculostomy catheter, whose tip may abut or even transgress
the lateral
ventricular wall.
5. Persistent disproportionate and cystic-appearing dilatation
of the 3rd
ventricle (despite presence of lateral ventriculostomy) which
may,
effectively, be "trapped."
CT Sinus [**11-27**]:
IMPRESSION: Panmucosal thickening within the paranasal sinuses,
increased
compared to the CT of [**2146-11-24**]. Obstruction of the ostiomeatal
units
bilaterally. Extensive nasal secretions. Left frontal
ventricular catheter
appears to terminate in brain parenchyma as discussed on
concurrent head CT.
Head CT [**11-27**]:
FINDINGS: A ventricular catheter entering from a left frontal
approach appears to terminate within the left frontal lobe
(2:13). The left lateral ventricle remains extremely dilated but
not significantly changed compared to the examination two days
prior. Large amount of blood within the lateral
ventricles and the third ventricle is essentially unchanged.
Scattered foci
of subarachnoid hemorrhage throughout both cerebral hemispheres
are unchanged. Thickening of the ethmoid, sphenoid, and
maxillary sinuses of the mucosal surface is stable compared to
the most recent exam.
MRI [**12-1**]:
FINDINGS: There has been a reduction in the volume of hemorrhage
present
within the bodies of the lateral ventricles. The large
suprasellar cyst,
previously identified, has enlarged dramatically in this
interval. A left
frontal ventricular catheter is again identified. No
pre-contrast imaging was performed. It is unclear whether
hyperintensity of the lateral ventricular margins represent
enhancement or subacute hemorrhage.
HeadCT IMPRESSION [**12-1**]:
1. Status post drain placement in the previously noted large
suprasellar/prepontine cyst, change in the shape of the cyst,
and possible
mild or no significant change in the overall size. Close f/u.
2. Extensive intraventricular, some amount of subarachnoid and
subdural
hemorrhage partially imaged and not significantly changed.
Head CT [**12-4**]:IMPRESSION:
1. No change in position of left frontal approach catheter
terminating within
a large cyst centered in the suprasellar/pre-pontine cistern.
2. No definite change in size of cyst.
3. Similar extensive hemorrhage within the lateral ventricles,
and smaller
subarachnoid hemorrhage in bilateral sylvian fissures.
4. Slight decrease in degree of hemorrhage within the cyst or
third
ventricle.
Brief Hospital Course:
The patient arrived to [**Hospital1 18**] as transfer from OSH for a
significantly sized intracerebral hemorrhage. On initial exam,
he was following some commands after receiving 20gm Mannitol en
route to hospital. He was emergently take to the OR for EVD
placement after CT findings. His exam post drain did improve and
MRI showed no obvious mass. CT showed with decrease in size of
IVH and stable ICPs. CTA of head was done showed no AVM, however
bleeding was likely due to arachnoid cyst. On [**12-1**], he was
again taken to the OR for endoscopic cyst aspiration and Rickham
catheter placement. Post-operatively he continue to improved
markedly. On his examination on [**12-6**], he was found to have
gross visual field deficits and ophthalmology was consulted. He
was found to be blind with some light awareness bilaterally.
This was thought to be secondary to vitreous hemorrhage of
unclear origin. He was also able to see shadows towards the end
of his hospital course. Ophthamology would like to see him on
follow up.
The patient was able to be extubated and was breathing well on
his own and his diet was advanced to regular. He was eating and
drinking without difficulty. He did have hyponatremia for
several days for which he was placed on salt tablets and kept on
a fluid restriction. On [**12-22**] his sodium was improving and the
salt tabs were decreased. They were decreased again on [**12-23**] and
his fluid restriction was liberalized. Since that time his
sodium has normalized, without any recurrance of issue.
Guardianship was pursued. The patient continued to have daily PT
while waiting for guardianship. The papers were drawn up by the
legal department, signed by Dr. [**Last Name (STitle) **], and given to the family
on [**2147-1-7**].
Throughout the duration of his hospital stay, Mr [**Known lastname **] worked
daily with PT and was determined to be an appropriate rehab
candidate. He was discharged to an appropriate facility on
[**2147-1-12**].
Medications on Admission:
None
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-16**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
5. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/headache.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 38076**] House - [**Location (un) 47**]
Discharge Diagnosis:
Massive Central Intraparenchymal Hemorrhage
Arachnoid Cyst
Acute Sinusitis
Right sided weakness
Acute blindness / bilaterally
Bilateral foot drop
Discharge Condition:
Neurologically Significantly improved
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
??????You haven been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
??????Make sure to continue to use your incentive spirometer while at
home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 3 months.
??????You will need an MRI scan of the brain with/without contrast.
- You need to be seen in the [**Hospital 40791**] Clinic by Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 7572**]. Please hit option #1 and then option #3 to get to
[**Hospital 40791**] clinic
Completed by:[**2147-1-12**] Name: [**Known lastname **],[**Known firstname 33**] Unit No: [**Numeric Identifier 13093**]
Admission Date: [**2146-11-24**] Discharge Date: [**2147-1-12**]
Date of Birth: [**2081-2-8**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3656**]
Addendum:
After Mr. [**Known lastname **] [**Last Name (Titles) 13094**] appt, he was determined to need
surgery with the following instructions included in the
discharge order:
**YOU WILL BE HAVING EYE SURGERY(LEFT VITRECTOMY AND PHACO IOL,
LEFT) ON MONDAY [**1-16**] AT 7:30AM. YOU MUST REPORT TO THE
[**Location (un) **] OF THE [**Hospital Ward Name **] BUILDING([**Hospital1 8**] [**Hospital Ward Name **]) AT
6:30AM. YOU CANNOT HAVE ANYTHING TO EAT OR DRINK(EXCEPT
MEDICATIONS) AFTER MIDNIGHT. YOU CANNOT TAKE ANY ASPIRIN FROM
NOW UNTIL YOUR SURGERY. PLEASE CALL [**Telephone/Fax (1) 13095**] IF YOU HAVE ANY
ADDITIONAL QUESTION OR CONCERNS.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 13096**] House - [**Location (un) 4887**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3657**] MD [**MD Number(2) 3658**]
Completed by:[**2147-1-12**]
|
[
"379.23",
"401.9",
"369.00",
"461.9",
"E878.8",
"736.79",
"430",
"348.0",
"431",
"299.80",
"997.09",
"307.9",
"V85.1",
"331.4",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"86.59",
"38.93",
"02.12",
"96.6",
"02.39",
"02.2"
] |
icd9pcs
|
[
[
[]
]
] |
13923, 14165
|
7767, 9752
|
333, 533
|
11260, 11300
|
1969, 7744
|
12404, 13900
|
1422, 1440
|
9807, 10964
|
11091, 11239
|
9778, 9784
|
11324, 12381
|
1455, 1455
|
1865, 1950
|
280, 295
|
561, 1320
|
1469, 1851
|
1342, 1360
|
1376, 1406
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,813
| 175,044
|
7270
|
Discharge summary
|
report
|
Admission Date: [**2116-1-15**] Discharge Date: [**2116-1-19**]
Date of Birth: [**2036-3-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
1. Cardiac Catheterization with stent placement and angioplasty
History of Present Illness:
79 year old female with ANCA + vasculitis came into the ED after
experiencing a dull, non radiating SSCP at 9am this morning. The
patient thought that she strained a muscle while reaching for
something. Since the pain was persistent, she decided to call
her nephrologist who sent her to the [**Hospital1 18**] ED where she was
noted to have STE V2-V6, Q waves in V2-3, I and AVL. She was
started on ASA, Lopressor, heparin, integrilin, NTG and sent to
Cath lab. Denied SOB, diaphoresis, orthopnea, PND, LE edema.
Noted an episode of nausea.
On admission to ED, VS: 95.6; HR: 126; BP: 162/97; RR:16; 100%
on RA
Past Medical History:
ANCA + GN - Wegener's
HTN
Physical Exam:
PE on discharge:
Gen: AAO x 3; thin female in NAD
HEENT: (-) JVD
Heart: +s1+s2 Reg rhythm and rate
Lungs: CTA B/L No crackles or wheezing
Abd: +BS Soft NT ND
Ext: No pretibial edema. Extremities warm and well perfused x
4. No mottling. Good distal pulses.
Pertinent Results:
Cath [**1-15**]
- 2VD - 100% mid-LAD - > Cypher DES, 70% ostial stenosis of 1st
diagonal branch-> got PTCA
- LCx - diffuse disease with as much as 40% stenosis
- RCA - 40% prox, 80% mid
- R heart cath revealed elevated L sided filling P ,
- PCWP: 20mmHg, CO: 2.72L/min, CI: 1.72 L/min/m2
- RA: 4mmHg, PA: 33/16 (PA mean 24)
- RV: 43/5
.
ECHO: [**1-16**]:
The left atrium is normal in size. 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 moderately depressed (ejection fraction
30-40 percent) secondary to akinesis of the apex, and severe
hypokinesis of the anterior free wall and anterior septum; the
basal segments are hyperdynamic. Right ventricular chamber size
is normal. There is focal hypokinesis of the apical free wall of
the right ventricle. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
([**2-3**]+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior report (images
unavailable for review) of [**2114-2-8**], left ventricular
contractile function is significantly reduced.
Brief Hospital Course:
#Cardiac:
79 yar old female with AMI s/p DES for 70% mid LAD occlusion and
PTCA for stent obstruction of "jailed" diagonal. The
cathterization demonstrated elevated PCWP and RV pressure. Post
procedure ECHO showed an EF of 30-40% with 1-2+ MR, akinesis of
the apex, and severe hypokinesis of the anterior free wall and
anterior septum; the basal segments were hyperdynamic.
.
Patient tolerated the catheterization well. She did not
experience any subsequent episodes of chest pain while in house.
She was cleared by PT for return home.
.
- cont ASA as outpatient
- start plavix as outpatient for the newly placed stent
- started on toprol XL low dose and titrated up to 25mg daily on
discharge
- Losartan for remodeling and afterload reduction (was on [**Last Name (un) **] as
outpatient)
- discharged with statin
- was heparinized in anticipation for coumadin anticoagulation
as outpatient -> patient was started on warfarin as inpatient
and discharged home with 5mg daily of warfarin. Arrangements
were made to have patient's blood drawn by VNA and faxed to Dr. [**Name (NI) 26892**] office with subsequent monitoring/adjustment. Dr. [**Last Name (STitle) **]
was also contact[**Name (NI) **] with this information.
- Patient had a 3 point HCT drop in house, and was transfused
without any further Hct drops. This was likely related to blood
loss during cath. There was no change in stool color, no new
back pain or flank ecchymosis. No hypotension or tachycardia
accompanyied this event.
.
# CRI
- Patient's baseline Cr is 1.7-1.9. Hence meds were renally
dosed.
- She received mucormyst and bicarbonate after catheterization
.
# Low grade fever
- No clear evidence of infection or accompanying leukocytosis.
Cultures were negative. This may have been due to post MI
inflammation.
.
# FEN
- Patient was maintained on a heart healthy diet
.
# Dispo: PAtient was discharged home with VRN services. Her INR
would be monitored as above. She was instructed to make an
appointment with Dr.[**Name (NI) 26893**] office over the next 7-10 days in
order for Dr. [**Last Name (STitle) 26894**] to assess her new status post-MI and to help
her to manage her coumadin levels. In addition, she was given
the office number for Dr. [**Last Name (STitle) **] and instructed to make a follow
up appointment in the next 4 weeks for a follow up. She was
stressed the importance of only undertaking low stress
activities over the next few days post discharge.
Medications on Admission:
Cozaar 25mg daily
Imuran 25mg QOD
Fosamax 35mg weekly
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: [**2-3**] Tablet,
Sublinguals Sublingual PRN (as needed) as needed for chest pain.
Disp:*20 Tablet, Sublingual(s)* Refills:*0*
5. Azathioprine 50 mg Tablet Sig: 0.5 Tablet PO Q48H (every 48
hours).
Disp:*20 Tablet(s)* Refills:*2*
6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
7. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
9. FOSAMAX 35 mg Tablet Sig: One (1) Tablet PO once a week:
Resume taking this on your regularly scheduled day.
Disp:*4 Tablet(s)* Refills:*2*
10. Zantac 150 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary ARtery Disease
Discharge Condition:
AAOx3
Ambulating
Chest pain free
Breathing comfortably on room air.
Discharge Instructions:
Please call Dr. [**Last Name (STitle) 26895**] office, Dr.[**Name (NI) 26896**] office or come to
the emergency room if you develop chest pain, shortness of
breath, fast heart rates or any other concerning symptoms.
.
Weigh yourself every morning, call Dr. [**Last Name (STitle) 26894**] if weight > 3 lbs.
Adhere to 2 gm sodium diet
.
Please take the medications listed on this discharge paperwork.
Followup Instructions:
You have had a major heart attack. As such, you need to be
closely monitored and followed up in the next few weeks.
.
You need to follow up with Dr. [**Last Name (STitle) **] - the cardiologist who saw
you in the hospital - within the next month. Please call his
office at [**Telephone/Fax (1) 4022**] to arrange an appointment at your
convenience in approximately 3-4 weeks.
.
Please call Dr. [**Last Name (STitle) 26895**] office at [**Telephone/Fax (1) 3329**] to set up an
appointment over the [**Last Name (un) 10128**] of the next 7-10 days. I have called
her office and am also going to email her regarding your
hospitalization and follow up.
.
You have the following pre-scheduled appointment for your kidney
disease:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D., PH.D. Date/Time:[**2116-4-2**] 1:00
Completed by:[**2116-1-22**]
|
[
"401.9",
"410.71",
"593.9",
"414.01",
"285.9",
"446.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"00.66",
"99.04",
"00.45",
"36.07",
"00.41",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
6726, 6784
|
2920, 5364
|
326, 392
|
6852, 6922
|
1372, 2897
|
7370, 8265
|
5468, 6703
|
6805, 6831
|
5390, 5445
|
6946, 7347
|
1095, 1098
|
1112, 1353
|
276, 288
|
420, 1031
|
1053, 1080
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,308
| 113,465
|
49098
|
Discharge summary
|
report
|
Admission Date: [**2158-4-28**] Discharge Date: [**2158-5-2**]
Date of Birth: [**2091-3-11**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Fenofibrate / STEROIDS / Wellbutrin / lobsters /
crabs
Attending:[**First Name3 (LF) 4611**]
Chief Complaint:
confusion, altered mental status
Major Surgical or Invasive Procedure:
none this hospitalization
History of Present Illness:
67 yo M with widely metastatic lung cancer since [**6-/2157**]
including brain mets found [**2158-4-8**] presents today with increased
confusion x 1 day. Patient was scheduled to receive final
fraction of course of Whole Brain Radiation Therapy today. On
Monday [**2158-4-24**] was started on a steroid taper-dose was decreased
from Dexamethasone 4 MG PO twice a day down to once a day.
Yesterday received first cycle of Pemetrexed. Wife states as
part of chemo regimen on day before chemo (Wed); day of (Thurs)
and plan is for today (Fri) was to take 4 MG PO Dexamethasone PO
twice each day. States was instructed to resume Dexamethasone
4MG PO once a day tomorrow. Was noted in pre-treatment labs to
have a lower Na level of 121 with Cl of 86 and decreased the
amount of iv fluids that he received with chemo and advised
fluid restriction to [**Telephone/Fax (1) 20571**] ml per day. He and his wife report
that the headaches are improving, and that his gait originally
improved, but is now worse again since yesterday. Wife reports
that he was repeating routines and forgetful of habitual
activities last night such as [**Location (un) 1131**] the psalm and seen trying
to take his medications twice. She performed a minimental at
home yesterday and he scored very poorly but now he is improved.
They phoned his outpt provider who recommended [**Name9 (PRE) **] evaluation. Of
note, pt has hx of hyponatremia attributed to SIADH from [**7-/2157**]
resulting in discontinuation of diuretics.
.
ED course: initial vitals 98.8 71 164/85 14 100%. No fluids
given in ED. Initial labs showed WBC 7.7, Hct 37.4, plt 149,
coag wnl, Na 119, lactate 0.7. Blood cultures sent. Neuro exam
felt to be non-focal. Pt admitted to [**Hospital Unit Name 153**] for management of
hyponatremia. Outpt oncologist/[**Doctor Last Name 3274**] was emailed.
.
On arrival to the ICU pt is [**Name (NI) **]3 and feels well. He denies
nausea/vomiting, anorexia, fever/chills or urinary complaints.
Had headache and visual changes for the last few weeks with
intermittent confusion per wife. Confusion was worse over last
couple days. Pt reduced fluid consumption after chemo appt
yesterday. Currently wife and pt feel he is at baseline.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Stage IV Adenocarcinoma lung (KRAS wild-type;EGFR negative; ALK
rearrangement unknown)
Oncologic history:
- [**6-/2157**] - Imaging of the back for severe back pain revealed
metastatic vertebral lesions
- [**7-/2157**] - Biopsy of L2 lesion consistent with metastatic
carcinoma positive for CK7 and TTF-1.
- Staging scans revealed primary lesion in the right lower lobe
and right hilum with mediastinal lymphadenopathy, lung lesion in
the left lower lobe, liver lesion, left adrenal lesion, and
multiple bone lesions. No brain lesions.
- [**2157-8-11**] - Carboplatin (6 AUC)/Paclitaxel (200
mg/m2)/Bevacizumab (15 mg/kg) initiated (C1D1)
- [**2157-9-1**] - C2D1 [**Doctor Last Name **]/Taxol/Bevacizumab
- [**2157-9-16**] - Palliative radiotherapy to lumbosacral vertebrae.
- [**2157-9-22**] - C3D1 [**Doctor Last Name **]/Taxol (Bevacizumab held as patient
receiving radiation treatment)
- [**2157-10-13**] - C4D1 [**Doctor Last Name **]/Taxol/Bevacizumab
- [**2157-11-3**] - C5D1 [**Doctor Last Name **]/Taxol/Bevacizumab
- [**2157-11-24**] - [**2158-3-9**] C1-6 Maintenance Bevacizumab (15 mg/kg)
- [**4-/2158**] - MRI brain revealed metastatic lesions to the brain.
Presented with gait changes and headaches.
- [**2158-4-13**] - whole brain radiation, completed 10 cycles. Also with
dexamethasone PO
.
Other medical history:
1) Hypertension
2) Hyperlipidemia
3) Vitamin D deficiency
4) Bronchial asthma
5) Allergic rhinitis/sinusitis
6) Monoclonal gammopathy
Social History:
Social History: He has a 15 pack year smoking history and
currently smokes 6 cig/day. He usually drinks [**2-13**] glasses of
wine with dinner. He has 2 grown sons who live in [**Name (NI) 583**]. He
is widowed and remarried 3 years ago. He works as a plasma
physicist.
Family History:
Family History: His mother died at the age of eight nine of
unknown causes. His father died at the age of 81 of emphysema.
He has a sister who is 57 years old and is well.
Physical Exam:
Admission Physical Exam:
.
Vitals 97.1 138/86 73 13 98/RA
General: Alert, oriented, elderly male in no acute distress
HEENT: PERRL, EOMI, Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AOx3, strength intact b/l, reflexes 2+ b/l upper/lower
ext, downgoing plantar reflexes, gait deferred, CN II-XII
grossly intact, finger to nose intact
.
Discharge Exam:
Vitals: T 96.7 BP 110s-130s/60s-80s HR 60s-80s RR 18 O2 sat 97%
RA
General: Alert, oriented, elderly male in no acute distress
HEENT: Sclera anicteric, EOMI, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AOx3 CN II-XII intact, 5/5 strength, intact finger to
nose, gait deferred
Pertinent Results:
ADMISSION LABS:
.
[**2158-4-27**] 08:50AM BLOOD WBC-10.3 RBC-4.13* Hgb-13.3* Hct-39.7*
MCV-96 MCH-32.2* MCHC-33.5 RDW-13.5 Plt Ct-183
[**2158-4-27**] 08:50AM BLOOD Neuts-84.3* Lymphs-8.5* Monos-6.2 Eos-0.7
Baso-0.2
[**2158-4-28**] 11:00AM BLOOD PT-9.7 PTT-27.7 INR(PT)-0.9
[**2158-4-27**] 08:50AM BLOOD UreaN-13 Creat-0.6 Na-121* K-4.3 Cl-86*
HCO3-29 AnGap-10
[**2158-4-27**] 08:50AM BLOOD ALT-36 AST-26 AlkPhos-49 TotBili-0.5
[**2158-4-27**] 08:50AM BLOOD TotProt-6.4 Albumin-4.3 Globuln-2.1
Calcium-9.1 Phos-2.8 Mg-2.1
[**2158-4-28**] 11:00AM BLOOD Osmolal-249*
[**2158-4-28**] 03:21PM BLOOD TSH-0.67
[**2158-4-27**] 08:50AM BLOOD CEA-3.2
[**2158-4-28**] 11:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-7*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2158-4-28**] 11:12AM BLOOD Lactate-0.7
.
DISCHARGE LABS:
[**2158-5-2**] 06:25AM BLOOD Glucose-102* UreaN-16 Creat-0.6 Na-130*
K-4.8 Cl-97 HCO3-27 AnGap-11
[**2158-5-2**] 06:25AM BLOOD WBC-7.3 RBC-4.00* Hgb-12.4* Hct-38.3*
MCV-96 MCH-30.9 MCHC-32.4 RDW-13.5 Plt Ct-140*
.
MICROBIOLOGIC DATA:
.
[**2158-4-27**] Monospot testing - negative
[**2158-4-28**] MRSA screen - pending
[**2158-4-28**] Blood culture - pending
[**2158-4-28**] Urine legionella - negative
[**2158-4-28**] Influenza culture - pending
[**2158-4-28**] Respiratory viral culture - pending
[**2158-4-28**] Sputum culture - contaminated; PCP immunostain [**Name Initial (PRE) **] pending
[**2158-4-28**] Urine culture - negative
[**2158-4-29**] HIV viral load PCR - pending
.
[**2158-4-28**] 2D-ECHO - The left atrium is normal in size. No atrial
septal defect is seen by 2D or color Doppler. The estimated
right atrial pressure is 0-5 mmHg. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The estimated pulmonary artery systolic pressure is normal. The
main pulmonary artery is dilated. There is no pericardial
effusion.
.
[**2158-4-28**] CHEST (PORTABLE AP) - As compared to the previous
radiograph, there is no relevant change. No evidence of
pneumonia. No pulmonary edema. No pleural effusions. Normal size
of the cardiac silhouette.
CT HEAD W/O CONTRAST Study Date of [**2158-4-28**] 11:41 AM
IMPRESSION: Extensive metastatic disease without evidence of
acute
hemorrhage, edema, or mass effect.
Brief Hospital Course:
67y M w h/o metastatic lung ca s/p 9/10 sessions total brain
irradiation presenting with acute confusion/MS changes and
hyponatremia.
.
# Hyponatremia: Given acute MS changes would presume acute Na
decrease from baseline however on arrival to ICU pt and wife
confirmed return to baseline wo intervention. He had started
fluid restricting the day prior after his clinic appt. Serum Osm
249. Likely SIADH related to brain mets given hyponatremia and
hypochloremia but differential would include hypervolemic and
hypovolemic states but exam is not clinically consistent with
either. Low suspicion for adrenal insufficiency given normal
adrenal findings 1 year ago on CT and normotensive. FeNA 1.7%.
TSH was wnl. He was monitored overnight in the ICU and remained
clinically stable. Serial Na levels showed improvement with
fluid restriction to 1000cc daily and the addition of salt tabs
twice per day. At time of discharge his sodium level was 130.
.
# Mental status changes: He presented with 2 days of
waxing/[**Doctor Last Name 688**] quality of mental status. CT head negative for
findings to explain MS changes. Chest xray and cultures were
NGTD as part of infectious etiology for confusion. Neurology
exams remained nonfocal. His mental status improved as his
sodium levels improved as well.
.
# Brain metastases: Has been on outpt course of TBI for recently
diagnosed mets 02/[**2158**]. CT head on presentation negative for
edema or midline shifts. He was continued on dexamethasone 4mg
daily per outpt plan. He completed his last dose of whole brain
radiation during this hospitalization.
.
# Lung ca: Dx'd [**6-/2157**] s/p most recent chemo treatment with
Pemetrexed on [**2158-4-27**]. He follows up with Dr. [**Last Name (STitle) 3274**] as an out
patient.
.
# HTN: continued home dose amlodipine and ASA.
# HL: continued home dose rosuvastatin
.
TRANSITION OF CARE ISSUES:
1. Pt has a follow up appointment with Dr. [**Last Name (STitle) 3274**] two days
post discharge. His sodium level should be repeated at that
time. The pt should also be given further guidance about whether
to continue the salt tabs at that time as well.
Medications on Admission:
AMLODIPINE 5 mg daily
CLONAZEPAM 1-2 mg qhs
DEXAMETHASONE 4 mg [**Hospital1 **] (will change to daily [**2158-4-24**])
FLUTICASONE nasal spray [**Hospital1 **]
HYDROMORPHONE 2 mg po q4h prn
IPRATROPIUM-ALBUTEROL nebs prn
OMEPRAZOLE 20 mg daily
PROCHLORPERAZINE 190 mg q6h
ROSUVASTATIN 40 mg qhs
SILDENAFIL prn
ACETAMINOPHEN prn
ASCORBIC ACID 500 mg [**Hospital1 **]
ASPIRIN 81 mg daily
CHOLECALCIFEROL 8000 u daily
loratidine
NICOTINE patch
OMEGA-3
miralax prn
SENNOSIDES 1-2 tabs qhs
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. clonazepam 1 mg Tablet Sig: 1-2 Tablets PO QHS (once a day
(at bedtime)) as needed for anxiety.
3. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
5. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
6. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution
for Nebulization Sig: One (1) nebulizer Inhalation every [**5-19**]
hours as needed for shortness of breath or wheezing.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
9. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
10. sildenafil 50 mg Tablet Sig: One (1) Tablet PO as needed :
take 1 hr before sexual activity.
11. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
12. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: Two (2)
Tablet PO four times a day.
15. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
16. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
17. Omega 3 350-400 mg Capsule Sig: One (1) Capsule PO once a
day.
18. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
19. senna 8.6 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed
for Constipation.
20. sodium chloride 1 gram Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Hyponatremia
Stage IV Adenocarcinoma lung
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 103023**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital with low blood
sodium levels. We restricted your fluid intake and supplemented
your diet with salt. These treatments have caused your sodium
level to rise. It is important that you continue to restrict
your fluid intake to no more than 1.5L per day until instructed
by your doctor not to do so.
The following changes have been made to your medications:
START:
Sodium Chloride Tabs twice per day until instructed by a
physician to stop
Please see below for follow up appointments that have been made
for you.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2158-5-4**] at 10:00 AM
With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2158-5-4**] at 10:00 AM
With: DR. [**Last Name (STitle) **] [**Name (STitle) **] [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2158-5-18**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 21833**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"197.7",
"162.5",
"493.00",
"198.5",
"272.4",
"198.3",
"V15.3",
"273.1",
"564.00",
"268.9",
"198.7",
"401.9",
"305.1",
"V87.41",
"253.6",
"196.1",
"293.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13771, 13777
|
9177, 11318
|
361, 388
|
13862, 13862
|
6460, 6460
|
14674, 15583
|
4908, 5067
|
11854, 13748
|
13798, 13841
|
11344, 11831
|
14012, 14651
|
7258, 9154
|
5107, 5800
|
5816, 6441
|
2649, 3097
|
289, 323
|
416, 2630
|
6476, 7242
|
13877, 13988
|
3119, 4585
|
4617, 4876
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,801
| 128,536
|
7747
|
Discharge summary
|
report
|
Admission Date: [**2180-5-24**] Discharge Date: [**2180-5-28**]
Date of Birth: [**2112-12-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac catheterization ([**2180-5-25**])
History of Present Illness:
This is a very pleasant 67-year-old blind and deaf male with
past history of HTN, dilated cardiomyopathy, h/o NSTEMI's,
Systolic failure (EF = 35%)CAD s/p 1) Left Anterior Descending
stent in [**2169**] (at the [**Hospital1 18**]), 2) ?Angioplasty in [**2171**] and 3)
balloon angioplasty with Cordis Cypher stent placement in the
3rd marginal as well as balloon angioplasty of the distal circ
on [**2177-4-29**] (at the [**Hospital1 2025**]). He is transferred here from [**Hospital 6451**] in the setting of recurrent chest pain for cardiac
catheterization.
.
The patient's broader cardiac past medical history begins in
[**2156**], at which time he was diagnosed with hypertension. In
[**2170-7-29**], he began experiencing chest pain while walking
and lifting heavy objects, prompting him to present to [**Hospital 6451**] Hospital. At that time, he characterized his pain as
chest tightening and burning, with associated radiation to his
neck, jaw and arms. ECHO during that admission showed concentric
LVH with an ejection fraction of 55-60%, mild AI, and no
regional wall motion abnormalities. A stress test performed
during that hospitalization revealed exercise to 90% of his
age-predicted maximum, limited by chest discomfort with
radiation to both arms as well as shortness of breath, with new
ST depressions in II, III and V6. In light of these results and
his recurrent pain c/w unstable angina, the patient was then
transferred to [**Hospital1 18**] for cardiac catheterization.
.
At the [**Hospital1 18**] on [**2170-8-13**], the patient underwent cardiac
catheterization that revealed severe focal stenosis in the
proximal LAD. Dilation was successfully opened and stented with
minimal residual stenosis. Some moderate focal disease in the
proximal diagonal branch of the LAD was noted.
.
He subsequently underwent Angioplasty in [**2171**] (details are not
clear in the available records) and then balloon angioplasty
with Cordis Cypher stent placement in the 3rd marginal as well
as balloon angioplasty of the distal circ on [**2177-4-29**] (at the
[**Hospital1 2025**]).
.
Fast-forwarding to the present: the patient presented to his [**Hospital **]
clinic on [**2180-5-16**] and was told that he was not supposed to
recieve HD on that day. He refused to leave, complaining of
abdominal pain. While there, his pressure was noted to be in the
systolic 60s and 70's and he was said to be "somewhat confused".
.
The patient was therefore bolused and taken by ambulance to the
[**Hospital3 417**] ED, where he then complained of chest pain. Per
OSH records, troponins were slightly elevated, peak 6.89 -->
2.52. MB rose to around 37. ECG showed left bundle branch block
but no ST elevations. He was givin ASA, Morphine and Pepcid and
then started on a Nitro drip. The OSH notes state that the nitro
drip relieved the pain for a short time only, and in the context
of his presenting low BP's, presumed unstable CP as well as a
reported leukocytosis to 16.2, he was transferred from the ED to
the ICU to rule-out for MI as well as, per report, sepsis.
.
In the ICU, he ruled-out for STEMI. Heparin was NOT started in
the ICU because of a reportedly supratherapeutic INR (the value
is not stated in the OSH notes) reportedly without any history
of Coumadin use, although this seems peculiar given his reported
history of AFib. He received Vitamin K. He was transfused for
HCT = 25% --> 2 units --> 34% attributed to chronic blood loss
anemia with external hemorrhoids noted on exam. Although he had
a low-grade fever while there, cultures at the OSH showed no
growth times three. MRSA negative. No urine culture was taken
given anuria. The patient was started on Augmentin after dental
consultation for dental carries. He reportedly complained
throughout the hospitalization of heart-burn like symptoms. Dr.
[**Last Name (STitle) **] at [**Hospital3 417**] arranged for cardiac catheterization
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**], which is to take place tomorrow.
.
On arrival to the floor, VS: HR 74, SBP 105/59, RR 18, 95%RA.
The patient complained of continuing stomach burning and chest
pain, which he had great difficulty describing. He was able to
say that it was worse when he lied back, requiring him to sleep
with pillows on the couch at home. He admits to associated cough
and nausea. He states that there is a "funny" taste in his mouth
during these times. There does not seem to be a clear
correlation with meals. He noted that PO sucralfate makes his
discomfort much better, and repeatedly asked for this medication
during the interview. He admitted to non-specific arm pain in
both arms, but no back or jaw pain. ROS was otherwise negative
in detail.
.
.
.
Past Medical History:
As above, and:
1) Hypertension.
2) Speech and hearing deficit.
3) Peptic ulcer disease, dyspepsia
4) Gout
5) Osteoarthritis.
6) Chronic renal insufficiency, thought [**1-31**] nephrosclerosis
7) Retinitis pigmentosa
8) A fib on Amio
9) h/o NSTEMI
Social History:
He denies tobacco or alcohol use. He is currently unemployed on
disability and lives with girlfriend.
Family History:
Mother died of MI after age 80. Father died at 20's of an
unspecified brain "problem". Other family history is not known
by patient.
Physical Exam:
VS: HR 74, SBP 105/59, RR 18, 95%%A.
GEN: NAD, Supine in bed, smiling.
HEENT: NC/AT. MMM. Oropharynx clear. No oral abscess identified.
Poor dentition.
PULM: Right sided crackles limited to lower field. No wheezing
or rhonchi. No A/E changes.
CV: Systolic murmur, decrescedo, BH@ RUSB.
ABD: S/NT/ND. NA BS
EXT: WWP Rust pulses, strength and reflexes BL. Trace BL pitting
edema.
Pertinent Results:
EKG ([**2180-5-24**]): Sinus rhythm. Left atrial abnormality.
Borderline P-R interval prolongation. Intraventricular
conduction delay of left bundle-branch block type. ST-T wave
abnormalities. No previous tracing available for comparison.
Clinical correlation is suggested.
Cardiac catheterization ([**2180-5-25**]):
1. Selective coronary angiography of this right dominant system
demonstrated two vessel CAD. The LMCA was non-obstructed. The
mid LAD had moderate in-stent restenosis. The LCX had widely
patent stents. The RCA had a recanalized chronic total occlusion
in the mid vessel with severe diffuse ahd heavily calcified
disease in the mid to distal vessel.
2. Limited resting hemodynamics demonstrated normal systemic
arterial pressures.
3. Unsuccessful PTCA of the RCA chronic total occlusion.
4. Right femoral arteriotomy site was closed with a 6 French
ANgioseal device.
EKG ([**2180-5-25**]): Baseline artifact. Probable sinus rhythm. Since
the previous tracing limb lead voltage has diminished.
Otherwise, no change.
CXR 2V ([**2180-5-25**]): Large dialysis catheter in place, cardiac
enlargement and evidence of moderate degree of pulmonary
vascular congestion with small amounts of pleural effusions.
Retrocardiac left lower lobe atelectasis. Followup examination
recommended to monitor improvement.
TTE ([**2180-5-26**]): No atrial septal defect is seen by 2D or color
Doppler. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. No
masses or thrombi are seen in the left ventricle. Overall left
ventricular systolic function is moderately depressed (LVEF=
35%) with global hypokinesis and inferior/infero-lateral
thinning/akinesis. There is no ventricular septal defect. with
mild global free wall hypokinesis. The aortic root is moderately
dilated at the sinus level. The ascending aorta is moderately
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**12-31**]+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. The end-diastolic pulmonic
regurgitation velocity is increased suggesting pulmonary artery
diastolic hypertension. There is no pericardial effusion.
Compared to the report from [**2170-8-14**], decreased biventricular
systolic function is new.
On admission ([**2180-5-24**]):
WBC-8.8 Hgb-10.7* Hct-33.6* MCV-87# Plt Ct-215
Neuts-86.1* Lymphs-7.6* Monos-4.5 Eos-1.6 Baso-0.2
Glucose-159* UreaN-31* Creat-5.2*# Na-140 K-4.6 Cl-102 HCO3-24
Calcium-8.5 Phos-2.6* Mg-3.2*
PT-14.2* PTT-22.0 INR(PT)-1.2*
CK(CPK)-24 > 21*
cTropnT-2.22* > 2.36*
On discharge ([**2180-5-28**]):
WBC-8.5 Hgb-9.2* Hct-29.9* MCV-89 Plt Ct-239
Glucose-72 UreaN-58* Creat-7.5*# Na-137 K-4.7 Cl-98 HCO3-24
Calcium-8.1* Phos-3.0 Mg-2.9*
Brief Hospital Course:
67 year-old blind and deaf male with CAD with prior NSTEMI and
prior stent placements, hypertension, dilated cardiomyopathy
admitted [**2180-5-24**] with recurrent chest pain. Hospital course was
as follows.
1. Coronary artery disease: Patient has significant CAD history
with prior stent to LAD in [**2169**] and Cordis Cypher stent
placement in 3rd marginal as well as balloon angioplasty of the
distal circ in 5/[**2176**]. On admission, etiology of chest pain was
unclear - differential included ACS vs. GERD. On admission, CK
flat, troponin not surprisingly elevated given ESRD. Cardiac
catheterization revealed RCA lesion with collaterals,
unsuccessful PTCA of RCA, moderate instent restenosis of LAD,
patent left circumflex stents. Patient was evaluated by CT
surgery for surgery and felt not be a good surgical candidate
given diffuse disease. Medication managment was maximized,
including starting Plavix and Imdur. Patient was continued on
aspirin, metoprolol, and statin.
2. GERD: Also on the differential for this patient's burning
chest pain. Chest pain was initially relieved with Maalox,
sucralafate. Given the possibility of aluminum toxicity in ESRD
patients, these medications were discontinued and patient was
started on calcium carbonate and viscous lidocaine as needed. In
addition, he was continued on a PPI and H2-blocker per his home
regimen.
3. Anemia: Hematocrit was stable around 30. Baseline unknown.
Patient underwent evaluation by hematology service at [**Hospital 6451**] Hospital; anemia was thought to be multifactorial and
secondary to external hemorrhoids, ESRD, iron deficiency.
Patient was continued on Procrit with hemodialysis. As an
outpatient, he is recommended to have a colonoscopy for further
evaluation.
4. Atrial fibrillation: Patient was continued on amiodarone,
metoprolol. Coumadin therapy was discussed via email with
patient's PCP; given concern for compliance with INR checks and
appropriate daily dosing, risk was thought to outweigh benefit
that coumadin therapy would provide.
5. Systolic dysfunction, chronic: LVEF= 35%. Global hypokinesis
and inferior/infero-lateral thinning/akinesis. Patient appeared
euvolemic on admission. He was continued on metoprolol and
started on lisinopril, as above.
6. Dental abscess/caries: Patient was started on Augmentin for
2 week course for dental infection while at [**Hospital3 417**]
Hospital. This was continued throughout hospital course. Given
diarrhea without fever, leukocytosis, or abdominal pain, Imodium
was started. Patient was asked to call his doctor or return to
the emergency department if he developed any of the above.
7. Hypertension: Blood pressure remained in good control with
beta-blocker, ACE inhibitor, and Imdur.
8. ESRD: MWF HD regimen. As above, Maalox and sucralafate were
discontinued given concern for aluminium buildup/toxicity.
Medications on Admission:
Allopurinol 100mg PO QD
Amiodarone HCl 200mg PO QD
ASA 325mg PO QD
Simvastatin 40mg PO QD
Vitamin B Complex
Folic Acid
Vitamin C
Vitamin E 400 units PO QD
Iron 325mg PO BID
Sevelamer HCl 1600mg PO W, M
Amoxicillin/Clavulanate Potassium 500mg PO q12hrs
Metoprolol Tartrate 50mg PO BID at 1000hrs and 2000hrs
Omeprazole 40mg PO BIDAC
Lactobacillus PO BID
Famotidine 20mg PO Q2days at 8AM
Sucralfate 1000mg PO ACHS
NaCl 10Ml IV TID
Hydrocortisone one topical application QHS
Nitroglycerin Paste 1 inch q 8 hours
Epo Alfa [**Numeric Identifier 24587**]/[**Numeric Identifier 961**]/9000 IV at HD
Heparin Line Washes at HD
Acetaminophen 650mg PO Q4H PRN
Aluminum Hydroxide/Mg Hydroxide/Simethicone 15mL PO Q6Hrs PRN
Docusate 200mg PO BID PRN
Oxycodone/Acetaminophen 1-2 tabs q6Hrs PRN
Nitroglycerin .4mg SL PRN
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for consitpation.
8. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: [**1-1**] Tablet,
Sublinguals Sublingual PRN (as needed) as needed for chest pain:
Take every 5 minutes for total of 3 doses.
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for
Indigestion.
12. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
14. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
15. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
16. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Every other
day.
17. Imdur 30 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*
18. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 9 days.
Disp:*18 Tablet(s)* Refills:*0*
19. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for Diarrhea.
20. Lidocaine HCl 2 % Solution Sig: Twenty (20) ML Mucous
membrane TID (3 times a day) as needed for indigestion, reflux.
Disp:*1 week supply* Refills:*0*
**Per discussion with pharmacist at [**Company **] on [**2180-5-28**], dosing
was changed to 10ml PO TID prn GERD, dispense 150ml total
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary artery disease
Hypertension
Dilated cardiomyopathy
GERD
Discharge Condition:
Ambulatory; chest pain-free; hemodynamically stable.
Discharge Instructions:
You were transferred to [**Hospital1 18**] on [**2180-5-24**] with recurrent chest
pain after sustaining a heart attack recently. You were taken
for cardiac catheterization, which showed some blockages in your
arteries that, after discussion with our surgeons, we determined
would best be managed with medications rather than surgery. We
started you on a medication, Imdur, which should help to control
the frequency of your chest pain.
New medicines:
1. Plavix
2. Imdur
3. Viscous lidocaine (as needed for reflux)
4. Tums (as needed for reflux)
5. Lisinopril
6. Augmentin (continue for 9 days)
7. Imodium (as needed for diarrhea)
Stop taking:
1. Sucralafate (this medication can cause aluminum buildup in
patients with kidney disease)
2. Maalox (this medication can also cause aluminum buildup in
patients with kidney disease)
Please take all of your medications as prescribed. Please note
that you cannot take Sucralfate or Maalox. You must stop these
medications. You must stop these medications because they
contain Aluminum, a toxic metal that will accumulate in your
body because your kidneys do not work well enough to clear this
substance. Of note, hemodialysis is likewise unable to filter
aluminum. In short, you must not take Sucralfate or Maalox.
Please follow-up with your physicians as suggested below.
Please call Dr. [**Last Name (STitle) **] if you have any trouble breathing,
weakness, increasing chest pain, vomiting, dark stools,
abdominal pain, blood in your stools, confusion (a symptom of
aluminum toxicity), dizziness, fever, chills, night sweats or
any other symptom that concerns you.
Followup Instructions:
Please follow-up within Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 28095**]). We phoned
his office on [**2180-5-25**] and requested that his secretary phone you
on Monday to set-up an appointment to occur within two weeks of
discharge.
.
Cardiology:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] Phone:([**Telephone/Fax (1) 28096**] 15 [**Name (NI) **] Brothers [**Name (NI) **], [**Location 28097**] MA Date/time: [**6-20**] at 3:20pm.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2180-5-31**]
|
[
"428.0",
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"455.5",
"414.01",
"427.31",
"425.4",
"389.9",
"428.22",
"369.4",
"522.5",
"403.91",
"362.74"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"37.22",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
14937, 14992
|
9040, 11910
|
327, 370
|
15101, 15156
|
6080, 9017
|
16821, 17491
|
5533, 5667
|
12766, 14914
|
15013, 15080
|
11936, 12743
|
15180, 16798
|
5682, 6061
|
277, 289
|
398, 5127
|
5149, 5398
|
5414, 5517
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,059
| 125,889
|
48136
|
Discharge summary
|
report
|
Admission Date: [**2122-5-11**] Discharge Date: [**2122-5-18**]
Date of Birth: [**2065-11-22**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Clindamycin / Celery / Bee Sting Kit
Attending:[**Doctor First Name 7227**]
Chief Complaint:
cough, increasing SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
56yo woman with hx of pulmonary HTN, OSA, COPD, obesity
hypoventilation syndrome on home BiPAP and home O2 (3L) who
presents with three days of a cough. She has had productive
sputum. She ran out of her revatio one week ago and has noted
increasing SOB and leg edema. Her cough is productive of thick
mucous but no blood. She has no chest pain or dyspnea on
exertion. She also denies any worsening orthopnea. No recent
f/c/ns or weight changes. Other than the revatio, she has been
compliant with her medications.
.
In the ED: VS: 98.0 92 128/72 28 93% on 3L. Received combivent
nebs with improvement in O2, levaquin 750 for possible pna, and
lasix 40mg IV x1 for possible CHF exacerbation. CXR showed known
cardiomegaly, pulm HTN but minimal evidence of CHF and no
infiltrate. EKG showed NSR, borderline RAD, nl intervals, TWI
III, II, aVF. TW flattening V4-V6
.
Currently, she reports that she feels well. She has a persistent
cough but otherwise no SOB, chest pain, abd pain, worsening leg
edema, f/c/ns
Past Medical History:
- morbid obesity s/p hernia repair [**6-1**],
- OSA on nocturnal BIPAP (18/15) and 3-5L home O2,
- obesity hypoventilation syndrome,
- COPD,
- pul HTN (PAP 54)
- SLE
- documented right heart failure
- chronic anemia (bl 32), iron def anemia
- asthma
- restrictive lung dz
- HTN
- OA
- Hay fever
Social History:
The patient lives with her family. She denies any ciggs or etoh
use.
Family History:
mother also uses BiPAP, and had breast ca
Physical Exam:
VS: 98.2 98/68 70 22 91% 4L
GEN: obese. NAD. able to speak in full sentences very
comfortably.
HEENT: MMM, OP clear, JVD not elevated.
HEART: RRR, nl S1S2, no MGR. no heave. laterally displaced PMI.
Lungs: diffuse rhonchi and wheeze. no crackles. no decreased bs
Abd: multiple scars which are old and without erythema.
Ext: 2+ periph edema. chronic venous stasis changes. pulses
palpable.
Neuro: AAOx3, CNII-XII intact. strength bilat [**5-2**]
Pertinent Results:
Admission Labs:
144 98 22
-------------< 114
3.8 44 1.0
.
CK 50, Trop <0.01
proBNP: 4999
Lactate: 1.4
WBC 8.6, Hct 42, Plt 255
.
CXR: cardiomegaly, no evidence of infiltrate or CHF. PA
prominence c/w known pulm HTN.
.
EKG: NSR, borderline RAD, nl intervals, TWI III, II, aVF. TW
flattening V4-V6
.
old images:
CTA [**1-19**]: limited, but no PE
Echo [**1-4**]: EF 60-65%, nl LV function. minimal AS, mod TR, mod
pulm HTN
[**3-3**]: c cath: no disease.
.
Trends:
WBC 8.8, 8.8
diff: 8% bands on [**5-15**], resolved by [**5-16**]
HCO3: 44, 47, 49, 50, 48
ABGs: pH 7.27 - 7.20
ABDs: CO2 113, 91, 117
Lactate 1.1
.
Radio:
[**5-13**] CXR: Moderate cardiomegaly and pulmonary vascular
congestion are both worsened since [**5-11**], which may indicate a
component of left-sided heart failure in addition to
longstanding pulmonary hypertension responsible for pulmonary
artery and hilar enlargement and possible right ventricular
failure with elevation of central venous pressure reflecting
distension of the azygous vein. No focal pulmonary abnormality
or pleural effusion is seen.
.
[**5-14**] CXR: The heart size is markedly enlarged but unchanged as
well as pulmonary vascular congestion and perihilar haziness,
demonstrating pulmonary edema. There is worsening of left
retrocardiac consolidation which might be either due to
pneumonia or to developmenting atelectasis due to heart failure.
There is no sizeable pleural effusion.
.
[**5-15**] CXR: Mild pulmonary edema has improved since [**5-14**] and has
been substantial decrease in mediastinal vascular engorgement.
Mild cardiomegaly and particular pulmonary artery dilatation are
longstanding. There is no pleural effusion
Brief Hospital Course:
56 year old female with obesity hypoventilation syndrome,
obstructive sleep apnea, and pulmonary hypertension on
sildenafil, who presented with increased dyspnea and cough in
the setting of missing a week of sildenafil. Hospital course by
problem:
.
# SOB: multifactorial. Thought to be related to COPD, asthma,
CHF, pulmonary hypertension, possible PNA, obesity
hypoventilation syndrome. See below for details.
.
# Hypoxia: patient transiently became hypoxic while on the
BiPAP. This occurred in the setting of hypercarbic respiratory
failure and delta ms [**First Name (Titles) 6643**] [**Last Name (Titles) 59337**] a transfer to the ICU
briefly. The etiology was uncertain but thought likely related
to mobilization of fluid now that sildenafil is restarted giving
LV a higher work load. Patient's relative hypoxia is also a
chronic problem for her and resuming her home therapy would be
the most therapeutic. She was started on levofloxacin as below
with regard to the bandemia and retrocardiac opacity as
described below.
.
# Hypercarbic respiratory failure: This is likely secondary to
obesity hypoventilation and pulmonary hypertension with reduced
DLCO. She also was markedly wheezy on exam at times,
particularly on transfer to the ICU. She was started on
solumedrol high dose for several days. She continued on nebs
but at a higher frequency. We transitioned her to oral steroids
and recommend a 14 day total dose/taper. We asked patient to
bring in her own BiPAP machine which helped her mental status,
oxygenation, and we believe ventilation. *** if readmitted, get
home BiPAP machine in-house asap ***
.
# Asthma: She has COPD written in her records, however PFTs have
been consistent with a restrictive picture, and she has a
minimal smoking history. Nevertheless, she does have wheezes on
exam, and in the setting of hypercarbic/hypoxic respiratory
failure, we treated with IV steroids, as well as standing
nebulizer treatments as above.
.
# CHF, right sided, preserved EF: Patient with lower extremity
edema which is old per patient report and OMR. We initially
diuresed her with 1-2L negative per day. Her dry weight is
reportedly 263 pounds. She was 281 pounds on admission and
improved to 264 on discharge. She was discharged on lasix 80
[**Hospital1 **].
.
# Hypotension: The patient had transient episodes of hypotension
in the ICU that were attributed to the re-introduction of the
sildenafil. Small amounts of IVF were given as boluses to
support the transient decrements. She remained asymptomatic with
each episode.
.
# Cards vascular: CE neg x3. Not thought to be related to
ischemia
.
# ID: as above. Additionally, there was concern for a UTI and
possibly a PNA. She received levoflox for a 7 day course. She
had a bandemia (although no elevated WBC) which improved on
therapy. Her cultures were negative.
.
# Code: Full. this was discussed on admission and on transfer
to unit. The patient has difficulty making this decision. She
would like transient intubation but was hesitant to receiving a
trach. The ICU team explained to her that she would likely
require a trach if she is ever intubated. The patient remained
full code but with plans to further discuss this with her
mother.
Medications on Admission:
1. Advair 50/250 [**Hospital1 **]
2. Albuterol daily
3. Asa 325 daily
4. Atrovent prn
5. Dulcolax q24h
6. Flonase [**Hospital1 **]
7. Lasix 80mg [**Hospital1 **]/tid
8. Lisinopril 5mg daily
9. Revatio 20mg tid
10. Rhinocort [**Hospital1 **]
11. Senna
12. Toprol XL 50 q24h
Discharge Medications:
1. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Revatio 20 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
9. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day as needed for shortness of [**Hospital1 1440**] or
wheezing.
10. Atrovent 0.02 % Solution Sig: Two (2) puffs Inhalation four
times a day as needed for shortness of [**Hospital1 1440**] or wheezing.
11. Rhinocort Aqua 32 mcg/Actuation Spray, Non-Aerosol Sig: Two
(2) sprays Nasal once a day.
12. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
14. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day for 1 months.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
15. Prednisone 20 mg Tablet Sig: variable Tablet PO DAILY
(Daily) for 9 days: take 60mg x3 days, then 40mg x3 days, then
20mg x3 days.
Disp:*18 Tablet(s)* Refills:*0*
16. Outpatient Lab Work
basic chemistry panel on [**5-21**] at [**Company 191**]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
- COPD exacerbation
- Pulmonary hypertension
- asthma
- pneumonia
- right sided heart failure
- obesity hypoventilation syndrome and OSA
.
Secondary:
- SLE
- chronic anemia or iron deficiency
- restrictive lung disease
- HTN
- OA
- hay fever
Discharge Condition:
fair
Discharge Instructions:
You came in with shortness of [**Location (un) 1440**] and a cough. Your symptoms
were likely from a combination of your obesity hypoventilation
syndrome, pulmonary hypertension, COPD, asthma, CHF, and
possibly a pneumonia. You briefly required an ICU stay to help
with your breathing. Your symptoms improved.
.
Please take all of your medications as instructed. We made the
following adjustments:
1. Revatio 20mg tid was approved by your insurance
2. Levaquin (antibiotic): take for two more days
3. Prednisone taper: take as instructed for 9 days.
4. Omeprazole: Take once daily while on the prednisone
.
Please contact your physician if you experience worsening cough,
shortness of [**Last Name (LF) 1440**], [**First Name3 (LF) 691**] chest pain, or worsening fatigue.
.
It is important for you to followup with your PCP's office by
[**First Name3 (LF) 16337**] or Friday of this week. Have lab work done beforehand
as instructed.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: [**2114**] ml per day
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) 279**], [**Name12 (NameIs) 280**] Date/Time:[**2122-7-7**] 10:40
Provider: [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. Date/Time:[**2122-10-6**] 10:40
.
Please see your PCP or nurse practitioner [**First Name (Titles) **] [**Last Name (Titles) 16337**] or Friday
of this week and have lab work performed.
|
[
"278.01",
"416.8",
"710.0",
"428.33",
"428.0",
"518.81",
"486",
"493.22",
"276.3",
"401.9",
"786.05",
"327.23",
"280.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9345, 9402
|
4028, 7267
|
336, 343
|
9697, 9704
|
2330, 2330
|
10839, 11285
|
1803, 1847
|
7591, 9322
|
9423, 9676
|
7293, 7568
|
9728, 10816
|
1862, 2311
|
274, 298
|
371, 1380
|
2346, 4005
|
1402, 1699
|
1715, 1787
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,866
| 194,188
|
48696
|
Discharge summary
|
report
|
Admission Date: [**2134-10-4**] Discharge Date: [**2134-10-8**]
Date of Birth: [**2084-5-28**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Enalapril
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Lethargy
Major Surgical or Invasive Procedure:
Central line placement (L IJ) - now removed
R femoral tunnelled line insertion
History of Present Illness:
50M with DM (diet controlled), ESRD on HD after failed LRRT,
HCV, PAF on coumadin, HTN, h/o pulm aspergillosis and
sarcoidosis and recent vertebral abscess with MRSA was admitted
to [**Hospital1 18**] after girlfriend noticed that he was more lethargic
than usual and 'acting funny'. He was feeling ill over last few
days with decreased PO intake. Girlfriend called EMS that found
FS to be 59. Oral glucose was given and patient was brought to
ED.
In the ED VS 101.1, HR 115, BP 89/58, RR 22-26, O2 Sat 93%. FS
26, D50 was given with 2L open fluid. His BPs remained low and
he was started on levophed after a L IJ was placed. ABG/VBG
confirmed venous access, but CXR showed likely placement in
branch of IJ. He was started on levophed and covered with broad
abx (vanco/levo/flagyl). He was also given 1U FFP for INR 5.4.
His labs were notable for WBC of 16K, lactate 2.2, Na 130
(baseline mid-130s), Crea 6.4, TnT 0.12(baseline 0.08-0.12),
CK14. ABG 7.35/48/236.
.
ROS: Denies N/V/CP/SOB/Abd pain/diarrhea/rash
Past Medical History:
ESRD secondary to amyloidosis -failed LRRT in [**7-4**] now on HD- R
groin line
IVC stent
Sarcoidosis
Pulmonary aspergillosis
DM (diet controlled)
Chronic HCV
Hypertension
Sinusitis,
Paroxysmal atrial fibrillation,
C. difficile [**3-8**]
MRSA line sepsis
Renal osteodystrophy
Adrenal insufficiency
Upper extremity DVT ([**2132**])
Pancreatitis
Bilateral BKA
Right index and fifth finger amputations
Social History:
Patient currently living home. Discharged from rehab 1-2 months
ago. Smoked 1 ppd X 30 years but quit one year ago. No alcohol.
Previous drug use (IVDU). Girlfriend is involved in his care.
Family History:
Mother, brother with diabetes.
Physical Exam:
VS T 100.2, HR 93, BP 119/72 (on 0.341 Levophed), HR 84, O2 sat
100% on 100% Non-Reb, CVP 19
Gen: looks fatigued, awake, responsive
HEENT: injected conjunctiva R>L, mask on face, anicteric, JVD, L
IJ in place
Chest: Bibasal crackles on anterior exam, no wheezing, no rales
CV: RRR, no r/m/g
Abd: hyperactive BS, S/NT/ND
Ext: s/p BKA b/l, R groin line in place
Neuro: AOx3, knows president
Skin: dry, no visible rashes or petechiae
Pertinent Results:
[**2134-10-3**]
WBC-10.0 HGB-12.2*# HCT-42.8# MCV-80*# RDW-19.9* PLT-344
NEUTS-71.9* LYMPHS-15.4* MONOS-7.2 EOS-4.1* BASOS-1.5
PT-46.3* PTT-50.7* INR(PT)-5.4*
GLUCOSE-419* UREA N-20 CREAT-6.4* SODIUM-130* POTASSIUM-3.5
CHLORIDE-92*
TOTAL CO2-25 ANION GAP-17
ALBUMIN-2.9* CALCIUM-9.4 PHOSPHATE-3.5 MAGNESIUM-1.6
ALT-15 AST-30 CK(CPK)-14* ALK PHOS-226* AMYLASE-37 TOT BILI-1.0
LIPASE-15
ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
LACTATE-2.9*
cTropnT-0.12* (c/w baseline)
.
ECG: sinus tachy, otherwise no change to prior
.
CXR: Cardiac and mediastinal contours are within normal limits.
Evaluation of the lung is limited due to positioning, however,
again note is made of biapical pleural thickening with faint
opacities in the upper lobes with volume loss as noted
previously, representing sarcoidosis, as noted on the prior CT
scan. No evidence of pneumothorax is noted.
Left internal jugular vein terminating in the left upper chest,
of unknown location. Possibilities include insertion to the
mediastinal venous branches such as thymic or internal mammary
vein,extravascular location in the mediastinum, or arterial
insertion. Please correlate linically by drawing blood from the
line (blood confirmed venous).
Brief Hospital Course:
A/P 50M with DM, ESRD on HD after failed LRRT, HCV, PAF on
coumadin, PVD, HTN, h/o pulm aspergillosis and sarcoidosis and
recent vertebral abscess with MRSA a/w fever, hypotension.
.
#) MRSA Septicemia: Source of infection initially unclear.
However, 4/4 bottles from day of admission turned positive for
MRSA. Likely line infectionOther infectious workup included CXR
(w/o PNA); no urine for U/A. On PE no other focal source.
Previous vertebral abscess appeared unchanged on neck CT and
previous mitral valve vegetation/endocarditis also appeared
similar. Vancomycin was started with gentamicin for synergy for
the first two weeks of treatment (given history of
endocarditis). His R femoral dialysis catheter was also pulled.
Attempts to place an HD line in his L groin were unsuccessful,
so another R tunnelled HD catheter was placed. Hypotension
associated with his sepsis managed as below. He will receive a
total of 6 weeks vancomycin plus 2 weeks gentamicin with
hemodialysis.
.
#) Hypotension. In setting of MRSA septicemia. As per HPI,
initally required Levophed in the MICU. He also received 2 L NS
in the ED. His infection was managed as above. He is also on
chronic steroids. He had a very poor response to [**Last Name (un) 104**] stim
testing and was given stress dose steroids. Pt also on stress
dose steroids for poor response to [**Last Name (un) 104**] stim. He was weaned off
pressors and transferred to the floor with stable BP and
resumption of his anti-hypertensive meds began.
.
#) Hypoglycemia/Diabetes: Had low glucose at home prior to
presentation; likely in setting of sepsis. Patient denies
taking insulin at home. Was later hyperglycemic after receiving
exogenous glucose. Has h/o DM, but most recent A1c in [**3-10**] was
5.1. He denies use of insulin or oral hypoglycemic agents at
home. He should continue diet control at home.
.
# ESRD: Due to amyloidosis. He is status post failed renal
transplant. He is maintained on chronic HD on a Tues-Thurs-Sat
schedule. Dr [**Last Name (STitle) 1366**] is nephrologist. He was dialyzed daily and
then per usual Tu/Th/Sa schedule. New HD line as above. He
continued his nephrocaps, lanthanum, sevelamer, cinacalcet.
.
# H/o asperg infxn: Itraconazole was continued; no active
issues.
.
# H/o adrenal insufficiency: related to chronic steroid use (for
renal transplant and/or amyloid). Failed [**Last Name (un) **] stim as above and
given stress dose steroids.
.
# Afib: currently in NSR. coumadin initially held [**3-5**] INR 5.4,
then restarted. Beta blocker was also initially held then
restarted.
.
#) Access: difficult access given multiple scars from prior
dialysis lines. Had R groin tunneled line (from [**2134-7-5**]). HD
line replacement as above. Has chronic femoral line [**3-5**]
inability to maintain UE line. .
.
# Code: Full
Medications on Admission:
Meds (partially per last D/C summary with adjustment per patient
report)
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Itraconazole 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
5. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
10. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
12. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
13. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
14. Prednisone 5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
15. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
17. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
20. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime:
Please check INR, goal [**3-6**].
Discharge Medications:
1. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg
Intravenous at every hemodialysis for 6 weeks.
Disp:*18 grams* Refills:*0*
2. Gentamicin in Normal Saline 80 mg/100 mL Piggyback Sig:
Eighty (80) mg Intravenous with every hemodialysis for 4 doses.
Disp:*320 mg* Refills:*0*
3. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
4. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
5. Itraconazole 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
7. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO every other
day.
8. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
12. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed for constipation.
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
16. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
17. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**5-7**]
hours as needed for pain.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
MRSA septicemia
Hypotension
End stage renal disease
Hypertension
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with an infection in your blood. We had to
remove your dialysis catheter and replace it with a new one.
This new catheter is working well. We treated you with
antibiotics and you will continue to get antibiotics at dialysis
for 6 weeks. You briefly required treatment with medications to
support your blood pressure because of this infection.
.
Please keep all of your appointments with your doctors and take
[**Name5 (PTitle) **] of your medications as prescribed. We have made the
following changes in your medications: You will receive two
antibiotics (gentamicin and vancomycin) at hemodialysis. We
have made no changes to your home medications.
.
Please return to the hospital if you are having recurrence of
fever, pain at your dialysis catheter site, shortness of breath,
or any new symptoms that you are concerned about.
Followup Instructions:
You have the following upcoming appointments:
.
-[**Known firstname **] [**Last Name (NamePattern1) 7212**], MD (primary care) Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2134-10-19**] 2:00
-[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5866**], MD (infectious disease) Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2134-10-20**] 8:30
.
Please go to dialysis as usual tomorrow, [**10-9**].
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"585.6",
"V45.1",
"V58.61",
"403.91",
"070.54",
"135",
"427.31",
"255.4",
"458.9",
"785.52",
"250.00",
"995.92",
"038.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.95",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9594, 9651
|
3844, 6678
|
288, 369
|
9759, 9767
|
2556, 3821
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|
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6704, 8008
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9791, 10644
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2105, 2537
|
240, 250
|
397, 1410
|
1432, 1832
|
1848, 2041
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,624
| 139,415
|
3562
|
Discharge summary
|
report
|
Admission Date: [**2185-1-25**] Discharge Date: [**2185-2-1**]
Date of Birth: [**2145-1-19**] Sex: F
Service: MEDICINE
Allergies:
azithromycin
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
[**2185-1-28**] - EGD and colonoscopy (upper and lower endoscopy)
History of Present Illness:
40F with a newly diagnosed adenocarcinoma of unknown primary who
presents with gradually increasing weakness and dyspnea over the
past 3 weeks, but especially prominent over the past 2-3 days.
.
Patient was scheduled for head and torso CT tomorrow, as well as
initial appointments with Dr. [**Last Name (STitle) **] on Wednesday [**12/2101**] and Dr.
[**Last Name (STitle) 1852**], oncology, this Friday, [**1-28**], however, her degree of
dyspnea and weakness at home worsened to the point where she did
not feel safe and was unable to stay hydrated. She has been
eating very little, but drinking very large quantities of water
every day for several weeks. She also c/o nausea and liquid
stools.
.
In the [**Name (NI) **] pt was tachycardic to 124, which improved after a one
liter bolus. Labs were notable for a sodium of 120, WBC of 22.
A CT head and CT torso were ordered and were negative for any
acute intracranial process or pulmonary embolism, respectively.
Because the pt was breathing in 30s, uncomfortable with HR in
120s, it was decided that the pt should be admitted to the MICU.
.
Vitals prior to transfer were Pulse: 110, RR: 30, BP: 143/104,
O2Sat: 99.
.
On arrival to the MICU, pt is fairly comfortable, comlaining of
shortness of breath and abdominal pain.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath, or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes.
Past Medical History:
Polycystic ovarian syndrome
Social History:
- Tobacco: none
- Alcohol: none
- Illicits: none
Family History:
No family h/o malignancy.
Physical Exam:
ADMISSION EXAM:
.
Vitals: Afebrile BP:117/110 P: 118 R: 22 O2:98% on ra
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear,
EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: distended, tenderness to palpation throughout the
entire abdomen, hepatomegaly with liver tip felt 2 cm below the
sternal border
GU: no foley
Ext: warm, well perfused, 2+ pulses, 1+ pitting edema to the
level of the ankle
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation.
.
DISCHARGE EXAM: Deceased. No spontaneous heart sounds or
respirations. Pupils non-reactive and without noxious
withdrawal.
Pertinent Results:
ADMISSION LABS:
.
[**2185-1-25**] 06:45PM BLOOD WBC-22.6*# RBC-4.20 Hgb-12.3 Hct-35.7*
MCV-85 MCH-29.3 MCHC-34.4 RDW-14.5 Plt Ct-559*
[**2185-1-25**] 06:45PM BLOOD Neuts-86.7* Lymphs-8.0* Monos-4.3 Eos-0.3
Baso-0.8
[**2185-1-26**] 05:06AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-1+ Spheroc-1+ Ovalocy-1+
Schisto-OCCASIONAL
[**2185-1-25**] 06:45PM BLOOD PT-19.9* PTT-28.7 INR(PT)-1.9*
[**2185-1-26**] 05:06AM BLOOD Fibrino-431*
[**2185-1-25**] 06:45PM BLOOD Glucose-89 UreaN-11 Creat-0.8 Na-120*
K-3.9 Cl-82* HCO3-21* AnGap-21*
[**2185-1-25**] 06:45PM BLOOD Albumin-3.4* Calcium-9.3 Phos-4.3 Mg-1.7
[**2185-1-25**] 06:45PM BLOOD ALT-54* AST-156* AlkPhos-212* TotBili-1.5
[**2185-1-25**] 06:45PM BLOOD Lipase-18
[**2185-1-25**] 06:50PM BLOOD Lactate-3.2*
.
DISCHARGE LABS: Not applicable
.
MICROBIOLOGIC DATA:
[**2185-1-25**] Blood culture - negative
[**2185-1-26**] MRSA screen - negative
[**2185-1-26**] C.diff toxin - negative
[**2185-1-29**] Blood cultures (x 2) - pending
[**2185-1-30**] MRSA screen - pending
.
IMAGING STUDIES:
[**2185-1-25**] CT CHEST, ABD & PELVIS WITH CO - Massive hepatomegaly
with extensive hepatic metastasis, upper abdominal
lymphadenopathy, moderate ascites. Primary tumor not identified.
Bilateral small lung nodules, concerning for metastasis. Mildly
enlarged nodes in the chest. No pulmonary embolism.
.
[**2185-1-31**] 2D-ECHO - The left atrium is normal in size. There is
right atrial compression from massive hepatomegaly and liver
mets, likely resulting in low volume/flow to right side of heart
(decrease in preload). 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/hyperdynamic. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
a trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade. Suboptimal image quality.
Hyperdynamic left ventricular systolic function. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Normal right ventricular size with
normal/hyperdynamic function. No significant valvular disease.
Compression of the right atrium (from massive hepatomegaly and
liver mets), likely resulting in low volume/flow to right side
of heart (decrease preload).
Brief Hospital Course:
Following admission, Ms. [**Known lastname 16266**] clinical status rapidly
deteriorated. She presented with a relatively new diagnosis of
metastatic adenocarcinoma of undetermined primary. She was
transferred to the ICU given worsening anuric renal failure,
metabolic acidosis and uremia in the setting of a respiratory
compensation. An urgent femoral dialysis catheter was placed and
she received hemodialysis. However, given her clinical status
and her extremely poor prognosis she was made comfort measures
only after a long family discussion involving her outpatient
Oncologist. She expired on [**2185-2-1**] at 4:30 AM.
Medications on Admission:
None
Discharge Medications:
Not applicable
Discharge Disposition:
Expired
Discharge Diagnosis:
IMMEDIATE: Uremia, anuric renal failure
ANTECEDENT: Acute liver failure, encephalopathy
CHIEF CAUSE OF DEATH: Adenocarcinoma of unknown primary
Discharge Condition:
Not applicable
Discharge Instructions:
Not applicable
Followup Instructions:
Not applicable
|
[
"584.5",
"256.4",
"277.88",
"197.7",
"276.7",
"197.0",
"786.06",
"276.4",
"789.59",
"112.84",
"286.9",
"348.30",
"785.0",
"V66.7",
"787.91",
"276.1",
"789.00",
"537.3",
"199.1",
"570"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"38.95",
"39.95",
"88.74",
"45.25"
] |
icd9pcs
|
[
[
[]
]
] |
6403, 6412
|
5682, 6309
|
292, 360
|
6600, 6617
|
3035, 3035
|
6680, 6698
|
2170, 2197
|
6364, 6380
|
6433, 6579
|
6335, 6341
|
6641, 6657
|
3838, 4082
|
2212, 2892
|
2908, 3016
|
1686, 2037
|
233, 254
|
388, 1667
|
3051, 3822
|
2059, 2088
|
2104, 2154
|
4099, 5659
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,558
| 104,521
|
39907
|
Discharge summary
|
report
|
Admission Date: [**2188-11-16**] Discharge Date: [**2189-1-12**]
Date of Birth: [**2121-1-11**] Sex: F
Service: SURGERY
Allergies:
Meropenem
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
abdominal pain, hypotension, sepsis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
67F w/ who initially presented to an OSH in [**Month (only) 359**] with acute
onset of abdominal pain. She was diagnosed with biliary
pancreatitis. She was transferred to [**Hospital1 18**] for an [**Hospital1 **] on [**10-9**],
but she could not undergo sphincterotomy because of ampullary
and duodenal wall edema. A biliary stent was inserted and she
was transferred back to the OSH. Over the following days, the
patient developed respiratory distress and renal failure and was
intubated and transferred back to [**Hospital1 18**] for further management.
Given ongoing
leukocytosis, a C. diff toxin was checked and was positive, and
she was started on p.o. metronidazole. She was extubated [**10-21**].
On [**11-4**] she had abrupt onset of pain with an increase in her
WBC
to 43.8. A repeat CT at the time demonstrated worsening areas of
pancreatic necrosis and increased mesenteric omental phlegmon,
but no evidence of colitis. She had a colonoscopy demonstrating
no colitis, and was treated conservatively with meropenem and
oral C. diff therapy starting the evening of [**11-4**]. Micafungin
was added on [**11-6**] thereafter as empiric therapy. She slowly
improved, with WBC trending downward to 30-40K. All antibiotics
were stopped on [**11-12**], and she was discharged to rehab off
antibiotics on [**11-14**]. WBC at that time was 30K.
She was readmitted with abdominal pain and hypotension (BP
60/40)
on [**11-16**]
Past Medical History:
obesity, seasonal allergies
tonsillectomy, cesarean section, appendectomy
Social History:
no tobacco, rare EtOH
Family History:
neg for pancreatic or liver diseases
Physical Exam:
Patient expired
Pertinent Results:
imaging:
[**11-16**] CT ABD/PELVIS: 1. Severe, necrotizing pancreatitis with
large areas of pancreatic necrosis, in addition to
retroperitoneal inflammatory change and multiloculated
peritoneal fluid (particualrly pelvic and peri-hepatic) which
have increased in volume. 2. Bilateral pleural effusions and
basal atelectasis. 3. Calcified cholelithiasis.
[**11-16**] CT-guided drainage of abdominal fluid collection: 8Fr
catheter placed w/ drainage of 600cc grey-brown fluid
[**11-20**] ABD U/S: 1. Cholelithiasis. 2. No extra- or intra-hepatic
biliary duct dilatation. 3. Small amount of perihepatic free
fluid.
4. Small bilateral pleural effusions
[**11-23**] CXR: Large bilateral pleural effusions, increased in the
interim. Pulmonary edema +
[**11-24**]: CXR:Consolidation persisting at the left lung base could
be atelectasis or
pneumonia. On the right is a new large relatively round
radiopacity in the suprahilar right lung; bilateral pleural
effisuons.
[**11-27**]: Extubated (intubated [**11-24**] with PEA)
[**11-27**]: Pulled LEFT pigtail catheter. RIGHT pleural effusion -
thoracentesis 1.1L. Repeat CXR with improved effusion on RIGHT
after thoracentesis 1.1L but reaccumulation on LEFT.
[**11-29**]: CXR: In comparison with the study of [**11-28**], the right
pneumothorax is not definitely appreciated on this limited study
that is degraded by patient motion. Continued enlargement of the
cardiac silhouette with bilateral pleural effusions and volume
loss involving both lower lungs. Monitoring and support devices
remain in place. The engorgement of pulmonary vessels is less
prominent on the current study.
[**12-2**] RUQ U/S: Complex multiseptated collection centered over L
hepatic lobe not present on prior u/s ([**10-31**]). Sm simple fluid
collection ant to the R hepatic lobe. No biliary dilatation.
Patent portal vein. Cholelithiasis w/no sign of cholecystitis.
[**12-3**] [**Month/Day (4) **]: small stones and slugde in CBD. Replaced stent.
[**12-3**] CT Abd/Pelvis - (wetread): interval decr size of
multilobulated a/p fluid collections being drained by two
pigtail catherers--residual fluid remains present; new 15x8cm L
subdiaprhagmatic fluid collection; overall stable apperarance to
extensive fatty pancreatic necrosis, no vessel compromise; L
gallstone in gallbladder, lg b/l pleural effusion w/atlectesis.
[**12-8**]: CT Abd/Pelvis: Improved bilateral pleural effusions.
Severe necrotizing pancreatitis with minimal residual normal
appearing
pancreatic tissue. Multiple intra-abdominal fluid collections
with three drains in situ. Interval decrease in fluid
collections containing drains. Other fluid collections are
stable. Large calcified gallstone. Biliary stent in place. No
evidence of cholecystitis or biliary tree dilatation.
[**12-16**] CXR: No significant change with redistribution of
bilateral pleural effusions.
[**12-17**] CT chest: (wet read) RLL, RML and LLL bronchi are
occluded, probably with secretions. bilateral lower lobe
collapse, RML collapse. Only the upper lobes are aerated, with
focal atelectasis of medial RUL. RUL with nonspecific ground
glass opacities, nonspecific (could be
infection/aspiration/hemorrhage). Small right pneumothorax.
Chest tube in right pleural space. Small bilateral pleural
effusions.
[**2189-1-11**] U/S -
1. Abdominal fluid collection measuring up to 10.4 cm and
appears to
communicate with previously placed abdominal drain.
2. No intrahepatic biliary dilation. CBD measures 8 mm with
stent in place.
3. Small amount of perihepatic free fluid.
MICRO:
[**11-26**] BAL: GS: budding yeast, GNR, STENOTROPHOMONAS
[**12-14**]: urine - enterococcus (>100,000), sensitive to vancomycin
[**12-14**]: BAL - stenotrophomonas maltophilia, sensitive to bactrim
[**12-17**]: BAL - 3+ PMNs, 4+ GNRs, 2+ GPCs
[**2188-12-27**]: Left pleural fluid - enterococcus+, stenotrophomonas
[**2189-1-4**]: urine - ENTEROBACTER CLOACAE
[**2189-1-10**]: HD line - GNRs
Brief Hospital Course:
The patient was readmitted with abdominal pain and hypotension
(BP 60/40) on [**11-16**]. WBC ranged 48-72K on the day of admission,
and CT scan showed increased, loculated intraabdominal fluid
collections and retroperitoneal inflammatory changes. She was
admitted to the SICU and started on norepinephrine, and
CT-guided drainage of one
of her fluid collections was done, yielding 600 cc of cloudy,
grey-brown fluid. Pressors were weaned off [**11-17**] pm. She has
been afebrile, but was hypotensive [**11-16**] to 94.1. On the morning
of [**11-23**], the patient had a witnessed aspiration event and
immediately had sustained desaturations to the 60s. She was
emergently intubated but developed PEA arrest. She recovered
after just one round of epi and was transferred to the TSICU for
further management.
[**11-23**]: witnessed aspiration event w/ subsequent resp distress
and desat to 60s, PEA arrest. rhythm restored after 1 round of
epinephrine. tx'd to TSICU. bedside echo performed. pt initially
unresponsive but later awake and appropriate, following
commands. renal consult obtained. free water increased per their
recs. family updated. hypotensive requiring neo.
[**11-24**]: Diuresis. L CT guided thoracentesis. Bronch.
[**11-25**]: Continued to wean her from the vent; pigtail clamped at 6
pm; CXR at 6 am; free water flushes-100cc q6h
[**11-26**]: Pt. was bronched after L pleural tube clamped. She was put
on a SBT, but gas still showed PCO2 > 60, Bicarb 41. In
consultation with primary team we DC'd lasix drip and switched
to diamox due to concern for contraction alkalosis.
[**11-27**]: Extubated / OOB to chair
[**11-27**]: Removed Left pleural pigtail catheter. Later w/ acute SOB
found to have RIGHT pleural effusion on CXR. Thoracentesis for
1.1L with brief hypotension - given 25g Albumin.
[**11-28**]: Persistant and worsening respiratory distress -->
thoracentesis 1.1L on RIGHT and reintubated, grade 2 view. post
intubation CXR showed b/l pleural effusion; USG chest done- no
fluid on the left and minimal fluid on the right; Dophoff
advanced to post pyloric position under IR; tube feeds started;
Lasix 40 mg IV given; Bed changed.
[**11-29**]: had difficulty diuresing patient and remained alkalotic
with elevated bicarb. Diamox was increased to 500 and she was
started on a lasix drip once more. After the lasix drip was
started, she did start to diurese although overall she remained
positive.
[**11-30**]: persistent metabolic alkalosis with respiratory
compensation
[**12-1**]: diuresis not successful, but improved hypernatremia,
worsening metabolic alkalosis and respiratory acidosis, somewhat
increased lethargy, all antibiotics stopped
[**12-2**]: Added spironolactone for hypokalemia and had decreased
free water flushes, but then increased them due to worsening
hypernatremia back to 400 cc q4h. RUQ U/S showed new loculated
fluid collection.
[**12-3**]: [**Month/Day (4) **] - small stones and slugde in CBD. Replaced stent by
GI.
[**12-4**]: To IR for CT-guided placement L pigtail and hepatic
collection drain
[**12-5**]: Trach and R sided CT placed at bedside. Pt. transfused 2
units PRBCs and given albumin for low BPs.
[**12-8**]: CT showed improvement of abdominal fluid collections.
[**12-9**]: R SC CVL placed (removed and cultured L IJ); Bumex gtt
increased 0.5->0.75
[**12-10**]: continued diuresis, transitioned to trach mask,
electrolytes normalized
[**12-12**]: placed PICC, d/c'ed R subclavian CVL, Passy-muir valve
trial - not phonating, voicing only
[**12-14**]: RIGHT CT to suction (new leukocytosis, worsening CXR);
bronched
[**12-15**]: Became hypotensive 80's/40's on the way to IR for G-tube
-aborted - pneumosepsis ([**12-14**] GNRs) vs urosepsis ([**12-14**]
Enterococcus). s/p 1L LR and 2U pRBCs, Vanc/Zosyn, low dose Levo
gtt; bedside echo low filling with good contraction
[**12-15**]: Bilious liquid in mouth. ? ileus in setting of sepsis.
Abdomen soft. NGT placed and 350ml bilious fluid return
initially - 700cc overnight. KUB showed dobhoff no longer
post-pyloric.
[**12-18**]: Worsening ARF, CRT 1.6. Rising bilirubin, ASL, ALT
stable. Rising INR.
[**12-19**]: transfused 2u pRBC for low Hct
[**2188-12-30**]: R chest tube was placed by IP for worsening effusions on
CXR
[**2188-12-31**] - [**2189-1-12**]: The patient remained on low dose levophed
requirement to keep BP elevated. Intermittent CVVH was performed
as her kidney function had completely deteriorated. She became
more septic as her PNA continued despite several different
antibiotic regimens per infectious disease and multiple chest
tubes in place. Her liver function began to decrease as the
patient became more sick. Her liver enzymes were trending
upward, and she became more jaudinced. Due to persistent PNA,
patient was unable to be weaned off the ventilator. Her
pancreatic collections appeared to improve during this time, and
her abdominal drains were putting out decreasing amounts of
fluid. Her HD line and central lines were pulled as potential
sources of infections and grew out GNRs. Ultimately the patient
had enterococcus in her blood, urine, and chest along with
stenotrophomas in her chest as well. The patient's nutritional
status was maintained via tube feeds, but patient had become
very weak and deconditioned. Per renal, the patient would
require life-long dialysis for her damaged kidneys. Due to the
extent of her multi-organ failure it was felt that patient was
unlikely to recover from her current state of health. A family
meeting was held on [**1-10**] and [**1-11**] to discuss goals of care for
the patient. The family ultimately decided to make the patient
CMO. On [**2189-1-12**] all medications were discontinued including
pressors. The vent was also stopped, and the patient expired two
hours later. Ultimately the patient succumbed to overwhelming
sepsis and multi-system failure.
Medications on Admission:
1. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
2. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation QID (4 times a day).
3. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
4. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheeze.
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.
8. insulin regular human 100 unit/mL Cartridge Sig: insulin
sliding scale Injection qid.
9. TPN, TPN via PICC
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Death due to sepsis, multi-organ failure
Discharge Condition:
expired
Completed by:[**2189-1-12**]
|
[
"577.0",
"785.52",
"707.22",
"293.0",
"574.51",
"584.5",
"427.5",
"038.40",
"278.00",
"287.5",
"008.45",
"427.31",
"276.0",
"997.31",
"276.4",
"995.92",
"707.25",
"560.1",
"693.0",
"E930.8",
"E930.9",
"707.03",
"E930.5",
"493.20",
"457.8",
"518.81",
"707.09",
"585.6",
"511.9",
"599.0",
"276.8",
"567.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"43.11",
"33.23",
"31.1",
"96.6",
"54.91",
"34.91",
"99.15",
"96.72",
"38.95",
"39.95",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
12744, 12753
|
5980, 11838
|
306, 312
|
12837, 12875
|
2017, 5957
|
1927, 1966
|
12715, 12721
|
12774, 12816
|
11864, 12692
|
1981, 1998
|
230, 268
|
340, 1774
|
1796, 1871
|
1887, 1911
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,112
| 129,596
|
17701+56882
|
Discharge summary
|
report+addendum
|
Admission Date: [**2159-5-10**] Discharge Date: [**2159-6-1**]
Date of Birth: [**2084-3-4**] Sex: M
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old man
admitted from an outside hospital with chest pain and
positive cardiac enzymes. He has had a three week history of
chest pressure and shortness of breath without radiation,
relieved by Nitroglycerin, made worse with exertion. The
night prior to admission, he had chest pain, [**8-26**], at 3:00 am
while asleep; it woke him up. He took some Nitro and then
went to the Emergency Room. He was pain-free on arrival to
the Emergency Room at [**Hospital3 23439**] Hospital in [**Location (un) 8973**]. He
was started on heparin and Integrelin, and transferred to
[**Hospital Ward Name 26168**] [**First Name (Titles) **] [**Last Name (Titles) **] for cardiac catheterization.
Troponin at [**Hospital3 23439**] was 13.6 with a CK of 243, MB 18.8,
and ST-T wave changes in the inferolateral leads.
PAST MEDICAL HISTORY: 1) Diabetes mellitus, 2) Status post
cerebrovascular accident in [**2154**], with left leg and hand
weakness, 3) Hypertension, 4) Hypercholesterolemia, 5)
Hypothyroidism, 6) Dementia, 7) Status post appendectomy, and
8) Hearing loss.
ALLERGIES: No known drug allergies.
MEDS: 1) paxil 20 mg qd, 2) Lipitor 40 mg qd, 3) atenolol
100 mg qd, 4) vasotec 10 mg [**Hospital1 **], 5) digoxin 0.125 mg qd, 6)
Synthroid 50 mcg qd, 7) Isordil 20 mg tid, 8) Coumadin 2.5 mg
alternating with 5 mg, 9) insulin 25 U q am, 20 U q pm.
SOCIAL HISTORY: Lives with his wife. [**Name (NI) **] is dependent.
Remote tobacco use, quit five years ago. Rare alcohol use.
PHYSICAL EXAM AT ADMISSION: Temperature 97.2, heart rate 50,
blood pressure 120/80, respiratory rate 20, O2 sat 99% on
room air. General - no acute distress, alert and oriented x
1. HEENT - OP clear, mucous membranes moist, pupils equally
round and reactive to light, extraocular movements intact.
Neck was supple, JVD to 8 cm. Cardiovascular - regular rate
and rhythm, soft systolic ejection murmur at the left sternal
border. Pulmonary - bibasilar crackles and no wheezes.
Abdomen soft, nontender, nondistended with positive bowel
sounds. Extremities - no edema, 2+ pulses bilaterally.
Neuro - cranial nerves II through XII intact. Muscle
strength - [**5-21**] of the left lower and upper extremities, and
[**4-21**] of the left wrist.
LAB DATA: White count 14.3, hematocrit 36.4, platelets 220,
PT 20, PTT 76, INR 2.6, sodium 140, potassium 3.7, chloride
102, CO2 24, BUN 17, creatinine 1.2, glucose 132. Chest
x-ray - mild CHF with no infiltrates. EKG - sinus brady at
54, flipped T waves in lead I, V4-5-6.
HOSPITAL COURSE: The patient was admitted to the medicine
service, and the cardiology service was consulted. On [**5-11**], he was brought to the Cardiac Catheterization Lab.
Please see the cath report for full details. In summary, the
cath showed an EF of 45%, left main was normal, LAD with
60-80% lesion, 90% diagonal-2 lesion, left circumflex with
99% ostial lesion, and RCA 100% lesion filled with
left-to-right collaterals. Following that, cardiothoracic
surgery was consulted.
The patient was seen by cardiac surgery and initially refused
to have surgery. The following day, cardiac surgery was
reconsulted because the patient had agreed to undergo
surgery. At that time, it was decided that the patient
should have carotid Dopplers which showed no significant
stenoses in the right or left carotid arteries, and to be
seen by the neurology service who felt that the patient had
moderate dementia that may or may not become more profound
with coronary artery bypass surgery.
The patient and his family continued to agree to surgery, and
on [**5-17**], he was brought to the operating room. Please see
the OR report for full details. In summary, the patient had
coronary artery bypass grafting x 3 with a LIMA to the LAD,
saphenous vein graft to the PDA, saphenous vein graft to the
OM. His bypass time was 77 minutes with a crossclamp time of
47 minutes. Following the operation, he was transferred to
the Cardiothoracic Intensive Care Unit. At the time of
transfer, he had epinephrine at 0.3 mcg/kg/min, Nitroglycerin
at 3 mcg/kg/min, propofol at 20 mcg/kg/min, and insulin at 2
U/h. The patient did well in the immediate postoperative
period. His anesthesia was reversed; however, he remained
too sedated to successfully wean from the ventilator.
On postoperative day #1, the patient was weaned from his
epinephrine drip and was successfully extubated; however, he
remained in the Cardiothoracic Intensive Care Unit due to
tenuous pulmonary status. Over the next two days, the
patient was receiving vigorous chest PT with good results.
He was also started on Levofloxacin for fever and large
sputum production. He was cultured at that time.
On postoperative day #4, the patient's central venous lines,
as well as his pacing wires and chest tubes were
discontinued, and he was transferred to the floor for
continued postoperative care and cardiac rehabilitation. On
the floor, the patient remained somewhat demented consistent
with his preoperative dementia; however, he also had episodes
of agitation. His activity level was increased with the
assistance of the Physical Therapy Department and the nursing
staff, and a sitter was placed for patient protection.
On postoperative day #8, the geriatric service was asked to
consult on the patient, given his preoperative dementia and
postoperative agitation. Following their recommendations,
risperidone was started initially with too much of a sedative
affect; therefore, the dose was tapered. On postoperative
day #13, it was felt that the patient would be stable and
ready to be discharged to home within the next day or two.
CURRENT PHYSICAL EXAM AS FOLLOWS: Temperature 98.6, heart
rate 80--sinus, blood pressure 107/64, respiratory rate 18,
O2 sat 99% on room air. Awake, alert, oriented x 1, dementia
consistent with baseline, followed simple commands.
Respiratory - clear to auscultation bilaterally. Cardiac -
regular rate and rhythm. Sternum was stable. Incision clean
and dry, open to air, no erythema or purulence. Abdomen
soft, nontender, nondistended, positive bowel sounds.
Extremities were warm and well-perfused with no clubbing,
cyanosis or edema.
LAB DATA: White count 14.3, hematocrit 30.1, platelets 414,
PT 19.1, PTT 42, INR 2.4. Chemistries - sodium 139,
potassium 4.5, chloride 103, CO2 26, BUN 26, creatinine 1.3,
magnesium 1.8.
DISCHARGE MEDICATIONS: 1) colace 100 mg [**Hospital1 **], 2) NPH Insulin
20 in the morning and 20 in the evening, 3) regular Insulin
sliding scale, 4) paroxetine 20 mg q hs, 5) levothyroxine 50
mcg qd, 6) Lipitor 40 mg qd, 7) atenolol 50 mg qd, 8)
Risperdal 25 mg in the am and 5 mg in the evening, 9)
Coumadin 3 mg qd--goal INR is to be 2-2.5.
DISCHARGE CONDITION: Good.
DISCHARGE DIAGNOSES: 1) Coronary artery disease, status post
coronary artery bypass grafting x 3 with left internal
mammary artery to left anterior descending, saphenous vein
graft to the posterior descending artery, and saphenous vein
graft to obtuse marginal. 2) Diabetes mellitus. 3) Status
post cerebrovascular accident. 4) Hypertension. 5)
Hypercholesterolemia. 6) Hypothyroidism. 7) Dementia. 8)
Status post appendectomy.
FOLLOW-UP: 1) He is to have follow-up with his primary care
provider [**Last Name (NamePattern4) **] [**1-18**] weeks. 2) Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**]
in 6 weeks. 3) Follow-up for his Coumadin administration and
INR checks in 2 days.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2159-5-31**] 10:28
T: [**2159-5-31**] 09:32
JOB#: [**Job Number 49239**]
Name: [**Known lastname 5887**], [**Known firstname 651**] Unit No: [**Numeric Identifier 9130**]
Admission Date: [**2159-5-10**] Discharge Date: [**2159-6-1**]
Date of Birth: [**2084-3-4**] Sex: M
Service:
DISCHARGE INSTRUCTIONS: The patient is to have his Coumadin
dosage monitored by his primary care provider, [**Last Name (NamePattern4) **]. [**First Name (STitle) 9131**]
[**Name (STitle) 9132**], on an ongoing basis. The patient has been advised to
have biweekly blood draws to measure his PT and INR for the
two weeks following discharge and to call his results to Dr.
[**Last Name (STitle) 9132**] for adjustment of his Coumadin dosage. Subsequent
testing of the patient's PT and INR is at the discretion of
his primary care provider. [**Name10 (NameIs) 1672**] plan was discussed with the
patient's primary care provider, [**Name10 (NameIs) 3308**] agreed to the
above-stated plan.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 681**]
Dictated By:[**Last Name (NamePattern1) 9133**]
MEDQUIST36
D: [**2159-6-1**] 12:58
T: [**2159-6-1**] 13:27
JOB#: [**Job Number 9134**]
|
[
"410.71",
"290.0",
"250.01",
"401.9",
"272.0",
"311",
"438.89",
"293.0",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.12",
"37.22",
"39.61",
"99.20",
"88.56",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
6920, 6927
|
6949, 8195
|
6575, 6898
|
2724, 6551
|
8220, 9140
|
174, 1004
|
1027, 1551
|
1568, 2706
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,491
| 110,178
|
52050
|
Discharge summary
|
report
|
Admission Date: [**2163-1-1**] Discharge Date: [**2163-1-8**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 13386**]
Chief Complaint:
fever and respiratory distress
Major Surgical or Invasive Procedure:
Intubation
PICC line removal
History of Present Illness:
Mr. [**Known lastname 107750**] is a 86M with dementia, afib, and prior strokes
who presents from his nursing home with fever and respiratory
distress. Per records, patient had decreased PO over last 3
days, was started on ceftriaxone and flagyl [**12-31**] pm for
?aspiration pna. Was febrile to 103 overnight, evaluated at
[**Hospital1 882**]. There given 30mg diltiazem for afib with RVR, given 4L
of IVF. [**Hospital **] transferred to [**Hospital1 18**] for ICU eval.
.
In the ED, vitals were 99.4 149 92/48 13 92% on 50% venti mask.
He was started on a diltiazem drip for rapid atrial fibrillation
but BP decreased to 70's. ABG was 7.28/41/54 on ?NRB and he was
subsequently intubated. He was started on neosynephrine, and was
also given vancomycin 1g. Per cardiology recommendations he was
bolused with amiodarone and started on an amiodarone drip; he
subsequently converted to sinus rhythm. Received addl ~6L of
saline in [**Hospital1 **] ER.
Past Medical History:
afib
R MCA embolic stroke [**8-23**]
cerebellar hemorrhage s/p craniotomy [**2126**]
alzheimers
colon CA stage III s/p resection
CAD
HTN
ASD
MR
LVH
cervical radiculopathy/myelopathy
t12 compression fracture
gerd
liver hemangioma
CRI
renal cyst
bph s/p turp
h/o bowel obstruction
glaucoma, cataracts
multiple falls
h/o ETOH abuse
h/o pulmonary TB [**2110**]
Social History:
Relationships: [**Name (NI) **] (brother)- Cell: [**Telephone/Fax (1) 107744**], Home:
[**Telephone/Fax (1) 107745**]; [**Doctor First Name **] (neice, [**Name (NI) 2979**] daughter) - Cell:
[**Telephone/Fax (1) 107746**]; [**First Name5 (NamePattern1) 440**] [**Last Name (NamePattern1) 107747**] (neice, and [**Name8 (MD) **] MD [**First Name (Titles) **] [**Last Name (Titles) **]), Cell:
([**Telephone/Fax (1) 107748**]; Friend [**Name (NI) 751**]
Social:
Immigrated from [**Country 532**] in [**2134**], at baseline speaks & understands
limited English - translator needed. Positive h/o alcohol abuse,
but per PCP note stopped drinking ~1 year ago. He does not
smoke. Previously employed as a photographer. Brother states
patient is a Holocaust survivor.
Assistive Devices:
Glasses at baseline, upper & lower dentures; no hearing aides,
did not use walker or cane prior to admission.
Functional Status:
Was living independantly in senior housing: elevator & no steps
into building. Had HHA/HM (?) for personal care & cleaning,
three meals delivered to him every day. Supportive brother lives
nearby & does shopping. Out-patient Neurological evaluation ([**Year (4 digits) **]
[**2162-8-12**]) notes abnormal mental status screen, h/o disinhibition
and frontal dysfunction, positive visuospatial signs that may
suggest Alzheimer's Disease. PCP had recently filled out forms
for adult daycare.
Values/Belief: [**Hospital1 **]
Family History:
Both parents died in [**2095**] in the [**Location (un) 25508**] ghetto.
Physical Exam:
ON DISCHARGE:
T 97.1( afebrile) BP146/68 HR 72 RR 18 O2sat 94/RA
WT 61 kg BMI 26.4
incont of urine, BM x1 yesterday
GENERAL: Thin elderly man in NAD, sitting up in bed
HEENT: Anicteric sclerae, OP clear, poor dentition, dry tongue
NECK: No LAD/TM, JVP 7,L IJ in place
RESP: Decreased BS at bases, R>L; improved rhonchi
CV: RRR, normal S1/S2, no m/r/g
ABD: +BS, S, NT/ND, no HSM
EXT: 1+ DP LLE, trace DP RLE, WWP
GU: Condom catheter in place
SKIN: In waffle boots, red-purple blister R heel, 3X3;
fluid-filled blister L heel; stage I coccyx (the latter [**Name8 (MD) **] RN
notes)
NEURO:progressively more alert and interactive, shaking hands
ON ADMISSION
Vitals 97.1 75 111/77 21 91% on AC 500x14 5 0.5
General Chronically ill appearing man, intubated and sedated
HEENT Sclera anicteric, PEARL. occasional twitching of tongue.
Neck IJ in place
Pulm Lungs with few rales left base
CV Regular S1 S2 no m/r/g
Abd Flat +bowel sounds nontender
Extrem No edema, toes and fingers with cyanosis, cool palpable
pulses
Derm No rash or peripheral stigmata of endocarditis
Lines/tubes/drains Right PICC, LIJ, foley with small amount
yellow urine
Pertinent Results:
GRAM STAIN (Final [**2163-1-1**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
URINE CULTURE (Final [**2163-1-3**]):
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ <=1 S
[**1-1**] Renal U/S:
IMPRESSION: No hydronephrosis.
.
[**2163-1-1**] 12:39 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2163-1-8**]**
GRAM STAIN (Final [**2163-1-1**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2163-1-6**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
MORGANELLA MORGANII. SPARSE GROWTH.
WORKUP FOR IDENTIFICATION AND SENSITIVITIES REQUESTED
BY DR.
[**Last Name (STitle) **] (PAGER [**Numeric Identifier 32140**]) ON [**2163-1-3**].
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
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
An 86 year old (per brothers report, conflicts with [**Name (NI) **])
gentleman with CAD, dementia, atrial fibrillation, and prior
strokes presented with hypotension and respiratory distress from
[**Hospital 882**] hospital.
.
1. Sepsis: The patient was transferred to the MICU hypotensive
and septic from a likely respiratory source based on preliminary
culture data. The patient was intubated for airway protection,
given fluid resuscitation started on levophed for pressor
support and Vancomycin, Zosyn and Ciprofloxacin were started for
hospital acquired pneumonia. The patient's blood pressures
remained labile hypo- and hyper-tensive often associated with
bouts of atrial fibrillation to the 120s. Prior to transfer to
the medical floor the patient was stabily extubated and off
pressures & fluid resuscitation. His sputum culture showed
pan-sensitive Morganella. He was initieally covered with
Vancomycin, Zosyn, and Ciprofloxaxin from [**12-31**]. Vanc was stopped
on [**1-4**] and Zosyn stopped [**1-6**]. On the floor, he remained
afebrile with normal white count and satting well on room air.
He completed an eight day course on [**1-8**].
.
2. Likely aspiration event: Per speech and swallow, patient is
very unlikely to safely tolerate anything PO. He previously had
a G-tube which the patient pulled out. This was replaced on
[**2163-1-6**].
- He should remain NPO per speech and swallow recommendations.
He is at high risk for aspiration.
- Recommend Altzheimer's clothing to prevent undressing to
prevent this tube from being removed again.
.
3. Acute renal failure: The patient was admitted with pre-renal
acute on chronic renal failure due to significantly poor PO
intake. Urine lytes were c/w ATN.
He was fluid resuscitated and his creatinine and urine output
improved while in the ICU. Nephrology was consulted and did not
see renal replacement as indicated. ACE inhibitor held and all
medications were renally dosed. UOP and creatinine have
continued to improve. His baseline Cr is 1.1-1.3 and he was 1.3
on discharge.
.
4. Hypernatremia: The patient was admitted with an inital Na of
170. Through free water tube feed bolus & high free water iv
fluids the patient's sodium was safely and slowly lowered. On
transfer to the floor, he had a free water deficit around 2 L.
This resolved with aggressive free water repletion in tube
feeds. Free water boluses were reduced in rate as Na improved
to reduce aspiration risk.
.
5. Atrial fibrillation with RVR: The patient intermittently
developed atrial fibrillation with rates to 120s-130s. He was
loaded with Amiodarone IV and converted to Amiodarone 200mg PO.
He remained primarily in sinus rhythm once on PO medication.
Metoprolol was used intermittently (when the patient was not on
pressor support) but was ineffective at rate control and
compromised his blood pressure. On the floor, he remained in
SR. His Afib with RVR was likely provoked by catecholaminergic
state of sepsis. He was continued on Amiodarone 200 mg [**Hospital1 **]. He
is not on anticoagulation, although this has been discussed with
the patient's family. They are currently holding off given his
fall risk.
- can recheck TSH when over illness
.
6. Coagulopathy: The patient was found to have an INR of 1.8
without clear explanation and no history of anticoagulation.
His DIC work up was unrevealing and this was attributed to his
nutritional state. He was treated with 2.5 mg Vitamin K on
[**2162-1-5**] and had FFP prior to G-tube placement
.
7. CAD: The patient's admission EKG indicated ST depressions
with T wave inversions in the setting of a rapid rate.
Troponins were mildly elevated as the patient was in renal
failure, but no clear evidence of infarction was discovered. He
was maintained on aspirin, except for 3 days prior to G-tube
placement. No beta-blocker as above.
.
8. Anemia: The patient experienced a hematocrit drop from 37 to
33 after significant fluid hydration. No evidence of bleeding
was found and he was not transfused.
.
9. Tongue twitching: The patient was found to have a twitching
tongue on admission that was attributed to either old stroke or
hypernatremia. He was loaded with Keppra but the tremor ceased.
He had no further seizure activty off Keppra.
.
10. Depression: His remeron was stopped in setting of altered
mental status. This could be restarted as needed pending
further evaluation.
.
11. Glaucoma: Continued home eye drops
Medications on Admission:
tums 650 [**Hospital1 **]
vitamind 1000 daily
alphagan 0.2% 1 drop ou [**Hospital1 **]
xalatan 0.005% 1 drop ou qhs
senna [**Hospital1 **], mvt daily
remeron 30 qhs
sorbitol 70% 30ml daily
saliva substitute tid
ceftriaxone 1g daily - given [**12-31**] at 1900
flagyl 500mg [**12-31**] at 2200 and at 0400
zestril 10 daily -- last dose 1/12
metoprolol 12.5 [**Hospital1 **] -- last dose 1/14
prn tylenol, dulcolax, sl morphine, levsin
NOT on anticoag for afib
Discharge Medications:
1. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
2. Brimonidine 0.15 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
3. Latanoprost 0.005 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic HS (at
bedtime).
4. Calcitrate-Vitamin D 315-200 mg-unit Tablet [**Hospital1 **]: One (1)
Tablet PO twice a day.
5. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
6. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Ten (10) mL PO BID (2
times a day) as needed for constipation.
7. Amiodarone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day:
in the morning.
8. Amiodarone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day
for 10 days: in the evening.
9. Omeprazole 20 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
10. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: [**10-4**] mL PO Q6H
(every 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
HYPOXIC RESPIRATORY FAILURE
ASPIRATION PNEUMONIA
ACUTE ON CHRONIC RENAL FAILURE
HYPERNATREMIA
ATRIAL FIBRILLAITON WITH RAPID VENTRICULA RESPONSE
COAGULOPATHY
CORONARY ARTERY DISEASE
ANEMIA
DEMENTIA
POSSIBLE SEIZURE ACTIVITY
DEPRESSION
GLAUCOMA
Discharge Condition:
Stable, normal vital signs and on room air
Discharge Instructions:
You were admitted for an aspiration pneumonia. You had food go
into your lungs that then became infected. You were inturbated,
given broad-spectrum antibiotics and treated with medications to
support your blood pressure. Your infection has since improved
and you have completed your course of antibiotics.
Followup Instructions:
Please follow up with your primary care doctor. You have an
appointment scheduled for [**2163-7-26**] at 1:40PM, but should call
[**Telephone/Fax (1) 250**] to get this scheduled for earlier. As it is the
weekend, we were unable to reschedule this for you.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2163-4-15**]
9:30
Completed by:[**2163-1-10**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
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12236, 12301
|
6264, 10705
|
292, 322
|
12589, 12634
|
4393, 6241
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|
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|
222, 254
|
350, 1302
|
1324, 1683
|
1699, 3133
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,270
| 138,355
|
34304
|
Discharge summary
|
report
|
Admission Date: [**2187-7-24**] Discharge Date: [**2187-8-1**]
Date of Birth: [**2135-7-8**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Altermed mental status
Major Surgical or Invasive Procedure:
Placement of temporary HD catheter, [**2187-7-26**]
History of Present Illness:
Ms [**Known lastname 4587**] is a 52 year-old female with history of DM2, HTN,
morbidly obese, who is brought in by her son due to altered
mental status. The patient receives all of her care at [**Hospital1 112**] and
was unable to answer questions on admission. Per the family,
patient was having diarrhea, nausea and vomit over the prior
week, but improved back to normal. Then she started feeling
fatigued and weak 2 days prior admission, then she was not
making sense, was having difficulty breathing and was not moving
at all, with very poor concentration and perseveration,
intermittently following commands so her two sons brought her to
the [**Hospital1 1388**] ER. Per EMS report she was lethargic and with a
non-focal neurologic deficit. Pt and family deny fevers, chills,
neck stiffness, photophobia or blurred vision. There is no
history of trauma. Patient has standing narcotis regimen, for
unclear reasons.
.
Past Medical History:
- CAD
- DM
- CRI, baseline Cr around [**2-6**]
- Pyoderma gangrenosum
- HTN
- CVA
- GERD
Social History:
Patient does clerical work. Lives alone. Does not smoke or drink
significant EtOH. Patient has not traveled outside MA in the
last 6 months.
Family History:
Parents with DM2; negative for CVD and Ca.
Physical Exam:
Vital Signs: T 98.7 BP 154/64 P 72 RR 96 % RA
.
GENERAL: Morbidly obese African-American female, walking in the
[**Hospital1 **].
HEENT: PEERLA, no jaundice, no uremic fetor
NECK: Supple, no LAD, no appreciable JVD, huge thick neck
CV: RRR, normal S1S2, no murmurs, rubs or gallops. Sounds are
low volume due to obsesity.
PULM: CTAB, no w/r/r, good air movement bilaterally
ABD: Obese Soft, NTND, normoactive bowel sounds, no
organomegaly, no abdominal bruit appreciated
EXT: Warm and well perfused, full and symmetric distal pulses,
no pedal edema. Legs bandaged with ulcers compatible with
pyoderma gangrenosum.
NEURO: A&Ox3, craneal nerves [**1-16**] intact, strength 5/5 all
extremities, normal ROTs, patient with normal gait.
Pertinent Results:
On Admission:
[**2187-7-24**] 06:35PM WBC-8.7 RBC-3.57* HGB-10.5* HCT-33.3* MCV-93
MCH-29.6 MCHC-31.7 RDW-14.7
[**2187-7-24**] 06:35PM NEUTS-73.3* LYMPHS-18.9 MONOS-5.0 EOS-2.6
BASOS-0.2
[**2187-7-24**] 06:35PM PLT COUNT-338
[**2187-7-24**] 06:35PM GLUCOSE-83 UREA N-89* CREAT-10.6* SODIUM-136
POTASSIUM-7.8* CHLORIDE-105 TOTAL CO2-15* ANION GAP-24*
[**2187-7-24**] 06:35PM PT-13.4 PTT-25.7 INR(PT)-1.2*
[**2187-7-24**] 06:35PM CALCIUM-8.6 PHOSPHATE-9.2* MAGNESIUM-2.4
[**2187-7-24**] 06:35PM CK-MB-6
[**2187-7-24**] 06:35PM cTropnT-0.07*
[**2187-7-24**] 06:35PM CK(CPK)-138
[**2187-7-24**] 06:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2187-7-24**] 07:50PM URINE CA OXAL-RARE
[**2187-7-24**] 07:50PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0
[**2187-7-24**] 07:50PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2187-7-24**] 07:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2187-7-24**] 07:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2187-7-24**] 10:00PM AMMONIA-21
[**2187-7-24**] 10:00PM LIPASE-45
[**2187-7-24**] 10:00PM ALT(SGPT)-14 AST(SGOT)-13 CK(CPK)-78 ALK
PHOS-89 TOT BILI-0.2
.
ECG: Physiologic left axis, normal sinus at 70bpm, Poor R wave
progression across precordium, TWI in aVL and flattening in I.
.
Non-contrast head CT: No acute intracranial process.
.
CXR: Supraclavicular right-sided central line tip is in the
cavoatrial junction. No pneumothorax or pleural effusion.
Cardiomegaly is stable. The lungs are clear.
Brief Hospital Course:
Patient arrived to the ER with T [**Age over 90 **] F, HR 66 BP 167/97 RR 18
SpO2 96%; EKG had NSR @68 bmp, axis -30, no abnormalities. She
was given IVF and IV morphine for pain control. A CT scan of the
head did not show any abnormalities. Lab values were remarkable
for a creatinine of 10.6 from a baseline of ~3.8 at [**Hospital1 112**] (from
outside records). A CT of the abdomen showed atherosclerosis.
Patient was admitted to the medicine floor and then triggered
for nursing concern, difficulty breathing and AMS and was
transfered to the MICU.
.
In the MICU all sedating medicines were held, pt had a CXR with
cardiomegaly without any other acute process. She was hydrated.
In the MICU patient required CPAP for ventilatory support.
Nephrology was consulted for the need of hemodialysis. Patient
had a right hemodialysis catheter put in place, but was never
used. The AMS was most likely due to uremia and acute pre-renal
renal failure, that improved with medical management with
hydration. There was no evidence for infection or toxic process.
Patient became acidotic, but improved as the creatinine trended
down. 5 days after MICU admission the patient was transfered to
the medicine floor.
.
In the medical floor, patient was encouraged to have liquids PO
and diet was advanced slowly. Creatinine was followd and trend
dow up to 5.0 upon discharge. HD line was removed. PT was
consulted and cleared her to go home.
.
Medications on Admission:
Nifedipine ER 30 mg daily
Niacin 100 mg Tab Oral
Acetaminophen-Codeine -- Unknown Strength
Meclizine 12.5 mg TID
Oxybutynin -- Unknown Strength
Protonix 40 mg Tab daily
Atenolol 100 mg daily
Folic Acid 1 mg Tab daily.
Topamax 25 mg Tab
Minocycline 50 mg Cap [**Hospital1 **]
Oxycodone 5 mg q4-6 hours PRN
Discharge Medications:
1. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*2*
2. Labetalol 300 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lovastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Tablet(s)* Refills:*2*
7. Insulin Glargine 100 unit/mL Solution Sig: Fifty (50) units
Subcutaneous at bedtime: Take insulin as directed by your
[**Hospital1 756**] doctors.
8. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO MWF
(Monday-Wednesday-Friday).
Disp:*12 Capsule(s)* Refills:*2*
9. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
10. Fluoxetine 10 mg Tablet Sig: One (1) Tablet PO once a day.
11. Niacinamide 100 mg Tablet Sig: One (1) Tablet PO three times
a day.
12. Topamax 25 mg Tablet Sig: One (1) Tablet PO at bedtime.
13. Tylenol-Codeine #3 300-30 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for pain.
14. Neurontin 100 mg Capsule Sig: One (1) Capsule PO at bedtime.
Disp:*30 Capsule(s)* Refills:*0*
15. ACCUZYME Topical
16. Protopic Topical
17. Regranex Topical
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary
1. Acute on chronic renal failure
2. Hypertension
3. Diabetes mellitus
4. Coronary artery disease
5. Pyoderma gangrenosum
Discharge Condition:
Good, ambulatory, confusion resolved, creatinine improved
Discharge Instructions:
You came into the hospital because of confusion. You were found
to have worsening of your kidney disease.
You were seen by the kidney specialists in the hospital. You had
a dialysis catheter placed, but fortunately you did not require
dialysis during this admission. Your kidney function improved
after you received intravenous fluids. Your kidney tests were
improving at the time of discharge from the hospital.
.
It is VERY important that you follow up with the [**Hospital1 **] kidney disease (nephrology) clinic for ongoing
treatment.
.
Please do NOT use any medications such as ibuprofen (motrin) or
naproxen ("NSAID" medications) without talking with your kidney
doctor.
.
Please take your medications as directed and keep your followup
appointments. We adjusted your medications in the hospital.
Please see the medication list.
-- We stopped your Toprol XL (metoprolol) and Procardia
(Nifedipine)
-- Instead you should take labetalol and hydralazine for blood
pressure
-- We also recommend that you take a lower dose of neurontin at
home for your leg pains. Dr. [**First Name (STitle) 123**] will adjust the dose of your
pain medications as needed.
-- Please continue your leg ointments and dressings as
recommended by your [**Hospital1 756**] physicians
.
Call Dr. [**First Name (STitle) 123**] [**Telephone/Fax (1) 40827**] and seek medical attention if you
develop:
*** Increased trouble breathing, chest pains, nausea and
vomiting, confusion, or if you have any other symptoms that
worry you
Followup Instructions:
Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and Dr. [**Last Name (STitle) **] at
[**Hospital6 **] Nephrology (kidney disease) clinic [**8-8**] 2:30 [**Telephone/Fax (1) 78950**] [**Last Name (NamePattern1) **] [**Location (un) **].
.
Please followup with your primary care [**First Name8 (NamePattern2) **] [**Last Name (Titles) **],[**First Name3 (LF) **]
[**Telephone/Fax (1) 40827**] on [**8-9**] at 1pm.
|
[
"414.01",
"530.81",
"585.4",
"285.21",
"278.01",
"250.40",
"424.1",
"276.7",
"327.23",
"584.9",
"403.90",
"686.01",
"276.2",
"008.8",
"293.0",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
7324, 7381
|
4115, 5545
|
336, 389
|
7555, 7615
|
2438, 2438
|
9166, 9625
|
1628, 1672
|
5900, 7301
|
7402, 7534
|
5571, 5877
|
7639, 9143
|
1687, 2419
|
274, 298
|
417, 1341
|
3894, 4092
|
2452, 3885
|
1364, 1454
|
1470, 1612
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
394
| 159,229
|
9776
|
Discharge summary
|
report
|
Admission Date: [**2179-5-21**] Discharge Date: [**2179-6-7**]
Date of Birth: [**2101-9-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
s/p Aortic Valve Replacement w/19mm CE perimount Magna, Mitral
Valve Replacement w/ 25mm [**Company **] mosaic, Endarterectomy of
Left main and Aorta
History of Present Illness:
Patient is a 77 y/o Russian speaking female with a history of
critical AS, chronic pleural effusions, RBBB, who presented to
hospital with increasing SOB over the past 2 days. Pt. also
admits to decreased exercise tolerance over the past two months.
Past Medical History:
Critical AS
Hypertension
^Chol
Hypothyroidism
Chronic pleural effusions
Right BRCA s/p masectomy XRT [**2167**]
Lymphedema in right arm
Post herpetic neuralgia L thorax
Social History:
She lives with [**First Name9 (NamePattern2) 32939**] [**Name (NI) 583**].
Family History:
Mother died of unknown cancer in her 40's, father with DM died
at 74, sister with ? heart disease
Physical Exam:
PEx: T 98.1 Hr 94 BP 99/63 RR 18 O2SAT 96 2l NC Ht 5'6" Wt 129
Gen: Lying in bed in NAD
Skin: W/D, -lesions
HEENT: PerrlA, EOMI, NC/AT
Neck: Supple no LAD
Lungs: Decreased breath sounds at the bases bilaterally, no
crackles or wheeze
Heart: RR Rapid +S1S2, 4/6 SEM w/ radiation to carotids
Abd: Soft, NT/ND +BS
Ext: 1+ edema, scattered varicosities, swollen R arm
Neuro: CN 2-12 intact, non-focal
Pertinent Results:
CXR [**2179-5-21**]-Worsening bilateral pleural effusions and lower lung
zone
atelectasis, left greater than right.
CXR [**2179-5-30**]-No evidence of a pneumothorax following chest tube
removal
EKG [**2179-5-21**]-Sinus tachycardia. Right bundle-branch block.
Cath 4/12/05-1. Two vessel coronary artery disease. 2.
Severe/critical rheumatic and calcific aortic stenosis 3. Mitral
stenosis could not be confirmed or excluded. At least mild
mitral regurgitation seen. 4. Normal LV systolic function.
Moderate-severe LV diastolic dysfunction. 5. No hemodynamic
evidence of hypertrophic cardiomyopathy. 6. Mild-moderate
pulmonary hypertension.
[**2179-5-21**] 08:20AM BLOOD WBC-7.3 RBC-3.48* Hgb-11.0* Hct-32.4*
MCV-93 MCH-31.6 MCHC-33.9 RDW-13.7 Plt Ct-189
[**2179-5-28**] 12:36PM BLOOD WBC-8.8 RBC-3.11* Hgb-9.5* Hct-26.9*
MCV-87 MCH-30.6 MCHC-35.3* RDW-15.0 Plt Ct-58*#
[**2179-5-28**] 03:40PM BLOOD Hct-35.4*# Plt Ct-106*#
[**2179-6-3**] 10:13AM BLOOD WBC-6.1 RBC-3.62* Hgb-10.3* Hct-31.1*
MCV-86 MCH-28.3 MCHC-33.0 RDW-15.9* Plt Ct-150#
[**2179-5-21**] 08:20AM BLOOD PT-12.4 PTT-24.9 INR(PT)-1.0
[**2179-6-3**] 10:13AM BLOOD PT-12.7 PTT-26.4 INR(PT)-1.0
[**2179-5-21**] 08:20AM BLOOD Glucose-169* UreaN-15 Creat-0.8 Na-140
K-4.1 Cl-105 HCO3-29 AnGap-10
[**2179-5-27**] 06:48AM BLOOD Glucose-101 UreaN-16 Creat-0.7 Na-140
K-4.4 Cl-106 HCO3-27 AnGap-11
[**2179-6-4**] 08:00AM BLOOD UreaN-21* Creat-0.8 K-4.7
[**2179-5-21**] 08:20AM BLOOD Calcium-9.4 Phos-3.6 Mg-1.9
[**2179-5-21**] 08:20AM BLOOD ALT-28 AST-28 CK(CPK)-67 AlkPhos-76
Amylase-64 TotBili-0.5
[**2179-5-26**] 06:15AM BLOOD %HbA1c-5.0 [Hgb]-DONE [A1c]-DONE
[**2179-5-22**] 08:05AM BLOOD TSH-10*
[**2179-5-26**] 02:20AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.045*
[**2179-5-26**] 02:20AM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2179-5-26**] 02:20AM URINE RBC-[**4-17**]* WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0-2
[**2179-5-31**] 07:22AM BLOOD HEPARIN DEPENDENT ANTIBODIES-Negative
Brief Hospital Course:
Pt was initially diuresed in ED. Admitted and medically managed
for several days. Cardiac surgery was then consulted to see this
pt. Pt. was initially seen before cardiac cath and then again
following cath on [**2179-5-25**]. Pt. first needed carotid U/S and
dental consult/Panorex before surgery. Following dental
clearance and carotid u/s(- stenosis), pt. was brought to the
operating room on [**2179-5-28**] and underwent an
AVR/MVR/Endarterectomy of LM & Aorta. Please see op note for
full surgical details. Pt. tolerated the procedure well with a
total bypass time of 188 minutes and x-clamp time of 162
minutes. Pt. was transferred to the CSRU on Vasopressin,
Levophed, and propofol with a MAP of 68, CVP 5, PAD 12, [**Doctor First Name 1052**] 17,
and HR of 80 AV paced.
Pt. remained on ventilator overnight and on POD #1 pt was weaned
from propofol and mech vent and extubated. Pt. was awake, alert,
oriented and following commands.
POD #2/HD 9, pt. remained on Neo for BP support. Chest tubes and
Swan-ganz cathetor were removed. Lasix and Lopressor were
started.
POD #3/HD 10 pt remained in the CSRU due pt. cont. to need Neo
for BP support. Lasix was stopped today for increase BUN/Cr.
Nutrion consult for poor appetite. HIT panel done for decreased
platelets.
POD #4/HD 11 Neo was weaned off. Pt. transferred to telemetry
floor. HIT panel Negative.
POD #5/HD 12 Pt. progressing well. Hemodynamically stable. PE
unremarkable. Foley D/C'd today. Lasic restarted.
POD #6/HD 13 No events overnight. Central line d/c'd. PIV
placed. Pt. cont. to receive PT/OT.
POD #7/HD 14 Pt. appears to be doing well. Level 5 today. Pacing
wires removed. PE unremarkable.
By POD#10, patient was cleared by PT to d/c home with home PT,
and patient was discharged
Medications on Admission:
1. Levoxyl 50 mcg QD
2. Lasix 20 mg QD
3. Lipitor 40 mq QD
4. ASA 325 mg QD
5. Doxepin 5%TP
Discharge Medications:
1. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
7. Tylenol-Codeine #3 300-30 mg Tablet Sig: One (1) Tablet PO
every 4-6 hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Aortic Stenosis, Mitral Stenosis, s/p Aortic Valve Replacement
w/19mm CE perimount Magna, Mitral Valve Replacement w/ 25mm
[**Company **] mosaic, Endarterectomy of Left main and Aorta
CHF
Hypertension
Hypercholesterolemia
Hypothyroidism
RBBB
Right BRCA s/p masectomy XRT [**2167**]
Lymphedema in right arm
Post herpetic neuralgia L thorax
Discharge Condition:
Stable
Discharge Instructions:
Do not take bath. Can take shower and wash incision with warm
water and gentle soap.
Do not apply lotions, creams, ointments, powders to incision.
Do not life more than 10 pounds for 2 months.
Do not drive for 1 month.
Keep all follow-up appointments.
[**Last Name (NamePattern4) 2138**]p Instructions:
Follow-up at [**Hospital 409**] Clinic in [**Hospital Ward Name 121**] 2 in 2 weeks
Follow-up with PCP in Dr. [**Last Name (STitle) 3357**] 1-2 weeks
Follow-up with Dr. [**Last Name (Prefixes) **] in 4 weeks
Completed by:[**2179-6-7**]
|
[
"396.0",
"401.9",
"285.9",
"414.01",
"272.0",
"V10.3",
"458.29",
"426.4",
"398.91",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.23",
"35.23",
"88.53",
"39.61",
"38.14",
"35.21",
"36.03",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
6610, 6671
|
3595, 5351
|
281, 433
|
7053, 7061
|
1546, 3572
|
1013, 1113
|
5494, 6587
|
6692, 7032
|
5377, 5471
|
7085, 7339
|
7390, 7627
|
1128, 1527
|
238, 243
|
461, 713
|
735, 905
|
921, 997
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,273
| 155,942
|
28312
|
Discharge summary
|
report
|
Admission Date: [**2176-9-24**] Discharge Date: [**2176-10-17**]
Date of Birth: [**2111-5-10**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Histamine / Ranitidine / Nafcillin
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
Difficulty to arouse and respiratory distress
Major Surgical or Invasive Procedure:
Intracerebral Drain
VP shunt
PEG placement
PICC placement
History of Present Illness:
65 yo male with past medical history of schizophrenia,
depression, pituatary adenoma s/p resection [**2166**] transferred
from OSH with head CT showing intracranial hemorrhage without
shift. Pt recently admitted to OSH ([**9-22**]) presents with
difficulty to arouse and respiratory distress (negative chest CT
and labs). Pt subsequently discharged back to long term care
facility. Symptoms persisted so he was brought to another OSH
for further evaluation where a head CT was performed and bleed
was appreciated. Vital signs T 101.7 (tylenol given), BP 151/90,
HR 83 sinus, RR 22, O2 sat 98. At the OSH, pt was placed on
levofloxacin 250 mg iv q8 hrs ([**9-25**]), metronidazole 500 mg IV q6
hrs, salumetrol 60 mg IV q 24 hrs, albuterol 2.5 mg + atrovent
0.5 mg nebulizer q6 hrs. Pt was then transferred to [**Hospital1 18**] for
further evaluation/treatment.
Baseline evaluation per long term care facility- ambulates with
assist; alert and oriented x 3, knows mother's name and staff
names.
ROS: Unable.
Past Medical History:
adrenal insufficiency, GERD, degenerative joint disease,
hypopituatary, chronic paranoid schizophrenia, depression,
?dementia, chronic back pain
PSH: pituatary adenoma resection ([**2166**])
Social History:
Pt lives in a long term care facility called [**Hospital3 13990**]
Healthcare in [**Location (un) 5110**], MA. Phone [**Telephone/Fax (1) 68734**].
Patient has a guardian [**Telephone/Fax (1) 46208**], cell [**Telephone/Fax (1) 68735**] ([**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) **]).
Family History:
Unknown
Physical Exam:
T-99.5 BP-79/52 HR-82 RR-14 O2Sat 98 ICP 4
Vent: CMV Vt 0.650, Rate 14, 100% FiO2, PEEP 5
Gen: Intubated, not sedated, won't open eyes to rub or voice,
eyes closed, in 2 pt restraints, R ventricular drain in place
HEENT: NC/AT
CV: RRR, Nl S1 and S2 distant, no murmurs/gallops/rubs
Lung: bilateral rhonchi
aBd: +BS soft, not distended
ext: no edema
Neurologic examination:
Mental status: unresponsive, some spontaneous movement to
noxious
stimuli
Cranial Nerves: pupils 3 to 2.5 mm bilaterally, blinks to threat
bilaterally, +corneal reflex, no gag reflex, no grimace to nasal
tickle. Rhythmic tongue movements noted.
Motor: Normal bulk and decreased tone, no clonus, legs
externally
everted, withdraws to noxious stimuli in lower extremities
(R>L),
localizes on R upper extremity to noxious stimuli. Left upper
extremity demonstrated spontaneous movement.
Sensation: responds to noxious stimuli in all extremities as
above.
Reflexes: +1 and symmetric throughout, Toes upgoing bilaterally,
?grasp reflex
OSH Labs:
WBC 12.0* Hgb 13.9 Hct 42.4 Plt 337
Na 140 K 3.2* Cl 101 CO2 25 BUN 27* Cr 1.4* Glc 138*
Ca 8.4 Mg 2.0 Alb 2.8* TSH 1.11
ALT 54* AST 111* AP 111 TB 0.38* Amyl 63 Lip 238
CK 728 CK-MB 0.5 TropI 0.04
Theophylline 9.4*
UA neg
ABG 7.47/28/89.6/97.4
Labs [**Hospital1 18**]:
Na 140, K 4.2 Cl 103, CO2 21, BUN 23, Cr 1.1, Gluc 235
CK 639, MB 5, trop <0.01
Ca 8.9, MG 2.0, Phos 2.2
WBC 12.7, Hct 43.6, plts 332, N 97.0 bands 0, lymph 2.4, mono
0.5, eos 0.1, baso 0
PTT 22.4, INR 1.0
Pertinent Results:
[**2176-9-24**] 09:56PM TYPE-ART TEMP-37.7 RATES-14/14 TIDAL VOL-650
PEEP-5 O2-100 PO2-195* PCO2-22* PH-7.44 TOTAL CO2-15* BASE XS--6
AADO2-512 REQ O2-84 INTUBATED-INTUBATED VENT-CONTROLLED
[**2176-9-24**] 05:20PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2176-9-24**] 05:20PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2176-9-24**] 05:20PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2176-9-24**] 05:20PM URINE RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2176-9-24**] 05:15PM GLUCOSE-235* UREA N-23* CREAT-1.1 SODIUM-140
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-21* ANION GAP-20
[**2176-9-24**] 05:15PM CK(CPK)-639*
[**2176-9-24**] 05:15PM cTropnT-<0.01
[**2176-9-24**] 05:15PM CK-MB-5
[**2176-9-24**] 05:15PM CALCIUM-8.9 PHOSPHATE-2.2* MAGNESIUM-2.0
[**2176-9-24**] 05:15PM WBC-12.7* RBC-5.00 HGB-15.0 HCT-43.6 MCV-87
MCH-30.1 MCHC-34.5 RDW-17.7*
[**2176-9-24**] 05:15PM NEUTS-97.0* BANDS-0 LYMPHS-2.4* MONOS-0.5*
EOS-0.1 BASOS-0
[**2176-9-24**] 05:15PM NEUTS-97.0* BANDS-0 LYMPHS-2.4* MONOS-0.5*
EOS-0.1 BASOS-0
[**2176-9-24**] 05:15PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL
[**2176-9-24**] 05:15PM PLT SMR-NORMAL PLT COUNT-332
[**2176-9-24**] 05:15PM PT-11.7 PTT-22.4 INR(PT)-1.0
[**2176-9-24**] NON-CONTRAST HEAD CT:
There is increased density in the lateral ventricles especially
on the left as well as the third ventricle and probably the
interpeduncular cistern and/or the region of the lamina
terminalis. There is a small amount of increased density in the
acqueduct and fourth ventricle. There is a small amount of
increased density peripherally in the posterior frontal on the
right and parietal region on the left consistent with a
subarachnoid hemorrhage. Ventricles and sulci are mildly
prominent. There is low density in the periventricular white
matter. The appearance of the sella is abnormal. There is a
history on subsequent examinations (this examination is being
interpreted on [**2176-9-30**]) of a transsphenoidal resection of a
pituitary tumor and the appearance of the sella is consistent
with.
IMPRESSION: Intracranial hemorrhage is noted. This is largely
intraventricular but some of this is subarachnoid.
CT ANGIOGRAM: There is no definite evidence of aneurysm or flow
abnormality. There is no evidence of vascular malformation.
There is no evidence of irregularity of the arteries in the
region of the skull base. There is mild calcification of the
cavernous carotid arteries.
IMPRESSION: No evidence of aneurysm or apparent cause for the
intracranial hemorrhage.
[**2176-9-25**] NON-CONTRAST HEAD CT:
INDICATIONS: 65-year-old man status post ventricular catheter
replacement.
COMPARISONS: Prior evening.
TECHNIQUE: Non-contrast head CT.
FINDINGS: There is a new ventricular catheter, extending from a
right frontal approach, and terminating in the right lateral
ventricle. There is a small amount of nondependent air in the
right lateral ventricle, and pneumocephalus, presumed related to
recent surgery. There is a similar degree of intraventricular
hemorrhage occupying much of the left lateral and the entire
third ventricle. There is also similar hemorrhage within the
right anterior [**Doctor Last Name 534**], layering in the right occipital [**Doctor Last Name 534**]. The
degree of ventricular dilatation is similar, and primarily
involves the supratentorial ventricles, and again noted is a
subependymal edema, which may overlap somewhat with diffuse
white matter hypodensity suggestive of chronic small vessel
ischemic disease. There is opacification of the sphenoid sinus
and some of the posterior ethmoid cells, which is often seen in
intubation. Mastoid air cells are clear. Osseous structures are
unremarkable.
IMPRESSION:
1. Similar appearance of extensive intraventricular hemorrhage
with
hydrocephalus of the supratentorial ventricles.
2. Status post ventricular catheter placement with appropriate
positioning.
NOTE ADDED AT ATTENDING REVIEW: There is irregularity at the
margins of the sphenoid sinus, with areas of demineralization.
There may not be integrity of the sinus walls and a direct
coronal sinus CT could provide a better evaluation of this area.
In addition, there is asymmetric soft tissue at the right side
of the sella, and a sella mass cannot be excluded. A sella MRI
with gadolinium should be obtained for further evaluation. Dr.
[**Last Name (STitle) 11315**] was contact[**Name (NI) **] with these findings on [**2176-9-25**].
[**2176-9-25**] POST-TPA NON-CONTRAST HEAD CT:
FINDINGS: Again seen is a ventriculostomy catheter traversing
the right
frontal lobe, terminating in the right lateral ventricle. There
has been
interval decrease in the amount of pneumocephalus. A small
focus of
intraventricular air remains stable in size and appearance.
There has been an interval decrease in the amount of
intraventricular hemorrhage within the right and left lateral
ventricles, although the amount of hemorrhage layering within
the occipital horns is similar. There is a similar amount of
hemorrhage within the third ventricle. The degree of
ventricular dilatation has not significantly changed. Again
seen is diffuse hypodensity within the periventricular white
matter which has previously been suggested to represent
subependymal edema Vs. chronic small vessel ischemic changes.
The surrounding osseous and soft tissue structures are
unremarkable. The visualized paranasal sinuses again show
opacification of the sphenoid sinuses with irregularity of the
bony margins and demineralization. The remaining visualized
paranasal
sinuses are well aerated.
IMPRESSION:
1. Slight interval decrease in amount of intraventricular
hemorrhage with
unchanged hydrocephalus.
2. Irregularity within the sphenoid sinuses with areas of
demineralization.
The integrity of the sinuses cannot be determined on this head
CT and a
coronal sinus CT should be obtained for evaluation of this
region.
3. Unchanged position of right transfrontal ventriculostomy
catheter with
interval decrease in pneumocephalus.
.
[**9-27**] CT head without contrast
FINDINGS: There is a right frontal ventriculostomy catheter with
the tip in the frontal [**Doctor Last Name 534**] of the right lateral ventricle. As
before, there is layering blood within the occipital horns of
the lateral ventricles. The blood clot near the left foramen of
[**Last Name (un) 2044**] is no longer present. There is some subarachnoid blood
bilaterally as before. There is no midline shift, mass effect.
The size and configuration of the lateral ventricles is
unchanged from before. A tiny amount of pneumocephalus is
present within the frontal [**Doctor Last Name 534**] of the right lateral ventricle.
The degree of subependymal edema is unchanged.
Unchanged amount of subarachnoid blood in the right
parietotemporal region. Unchanged amount of blood within the
region of the left parietotemporal lobe. Unchanged amount of
intraventricular hemorrhage. No change in size and configuration
of lateral ventricles.
.
[**10-4**] ECG
Sinus rhythm. Left anterior fascicular block. Delayed
transition. Compared to the previous tracing no significant
change.
.
[**10-8**] CT head without contrast
FINDINGS: As before, there is a right frontal ventriculostomy
catheter with the tip in the frontal [**Doctor Last Name 534**] of the right lateral
ventricle. There is a small amount of intraventricular blood as
before. There has been continued evolution in the attenuation
pattern of the blood. The size and shape of the lateral
ventricles is unchanged. A small amount of hyperdensity along
the falx, within one of the posterior frontal lobe gyri appears
stable.
IMPRESSION: Stable intraventricular and subarachnoid hemorrhages
previously described. Ventriculostomy catheter is unchanged in
position. No new hemorrhage.
.
[**10-9**] ECHO
Conclusions:
1. A 3 X 2 cm mass is seen in the right atrium. This mass is
partially mobile but seems to be attached to the wall of the
right atrium. Consider atrial myxoma, fibrionous material or a
thrombus.
2. Left ventricular wall thicknesses are normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%).
3.The aortic root is moderately dilated.
4.The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. There is no aortic valve stenosis. No
aortic regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen.
6.There is no pericardial effusion.
Impression: 3x 3 right atrial mass that is partially mobile but
seems to be attached to the wall of the right atrium. Consider
atrial myxoma, fibrionous material or a thrombus.
.
[**10-11**] CXR
Portable AP view of the chest dated [**2176-7-11**] compared with the
prior from [**2176-10-17**] at 17:59. There has been interval retraction
of the Dobhoff tube, which now terminates in the region of the
gastric antrum. A right PICC line terminates in the SVC. A
ventricular drain catheter courses down the right neck, and
traverses the abdomen to terminate probably within the right mid
abdomen, however, the tip of the catheter is off the area
imaged. A PEG tube is seen within the stomach. The
cardiomediastinal and hilar contours are unchanged. The heart
size is normal given the technique and patient positioning.
There is no pulmonary vascular congestion. There is no airspace
opacity to suggest consolidation. There is no pleural effusion
or pneumothorax.
IMPRESSION: Lines and tubes as described above. Interval
placement of PEG tube within the stomach. No evidence for
airspace opacification to suggest consolidation.
.
[**10-11**] CT Abd/Pelvis
TECHNIQUE: Non-contrast MDCT axial images of the abdomen and
pelvis were acquired. Coronal and sagittal reformats were then
also acquired.
CT OF THE ABDOMEN WITHOUT CONTRAST: There is no evidence of
acute bleeding in the abdomen. Note is made of a VP shunt in the
anterior aspect on the right side of the abdomen. There is a PEG
tube placed with bumper abutting the anterior gastric wall.
There is some high attenuation density around the area of the
bumper which could represent hematoma. However, this area is
very insignificant in size. There is a NG tube noted within the
stomach. The patient incidentally has a hiatal hernia.
Non-contrast images of the liver, pancreas, spleen, adrenal
glands, kidneys, abdominal portions of the small and large bowel
are unremarkable. There does not appear to be significant
pathologic mesenteric or retroperitoneal lymphadenopathy. There
is no evidence of free air or free fluid in the abdomen.
CT OF THE PELVIS WITHOUT CONTRAST: The rectum, sigmoid, bladder
are unremarkable. There is no evidence of significant pathologic
inguinal or pelvic lymphadenopathy. There is a very small amount
of simple peritoneal fluid located within the pelvis.
IMPRESSION:
1. No evidence of acute bleeding.
2. Normal-appearing PEG placement in the anterior wall of the
stomach.
3. Note made of NG tube as well as VP shunt.
4. Minimal amount of free fluid noted in the pelvis.
.
labs on d/c
06:24a
Na 135 Cl 99 BUN 17 Gluc 81 AGap=12
K 3.7 HCO3 28 Cr 0.6
Ca: 7.9 Mg: 2.3 P: 3.8
MCV 89
WBC 10.3 Hgb 9.6 Plt 421
Hct 28.3
PT: 11.7 PTT: 22.3 INR: 1.0
Dilantin level: 13.2 on [**10-15**]
Alb: 2.9 on [**10-8**]
Brief Hospital Course:
Hospital Course: 65 y.o. M recently admitted to OSH ([**9-22**])
presents to OSH with difficulty to arouse and respiratory
distress (negative chest CT and labs). Pt subsequently
discharged back to long term care facility. Symptoms persisted
so he was brought to another OSH for further evaluation where a
head CT was performed and an interventricular bleed was noted.
He was transferred to [**Hospital1 18**] on [**9-24**], where he was admitted to
the neurosurgical intensive care unit, was intubated, an an
intracerebral drain was placed, followed by a VP shunt for
persistent hydrocephalus. He was then transfered to the general
medical service for further management. Problems were as follows
while on medicine:
# Hypotension: He was found to be hypotensive to SBP in 90s the
day after his PEG placement. Thought to be [**2-1**] periprocedure
adrenal insuffiency as he was afebile, blood, urine cx neg, CXR
neg and CT abdomen not concerning for bleed or free air in
abdomen. He responded nicely to hydrocortisone 50 mg IV tid and
has been hemodynamically stable now for several days with SBP
from 110 - 130.
# L calf ulcer: He is now s/p a 7- day course of Vanc for
possible skin infection on L calf which is now resolving.
# ICH: s/p VP shunt (sutures removed [**10-15**]). The patient had
possible seizure activity [**10-8**] in the setting of a
subtherapeutic dulantin level, for which he underwent a dilantin
load. He had no further evidence of seizure activity and, at the
time of discharge, his dilantin level was therapeutic.
# Hyponatremia: He had a period of hyponatremia thought to be
[**2-1**] volume depletion in the context of his pulling out his NGT
and the fact that we had trouble replacing it. Urine osm was
high in context of low serum osms.
# Hypopituitary: started levothyroxine [**10-8**] for his
panhypopituitarism
# Atrial flutter: had 2-3 episodes on [**10-8**] but none since then.
No h/o atrial tachycardia but has had surgery recently so is at
increased risk. He was started on low dose metoprolol. TTE
showed a right atrial mass, which most likely represents an
atrial myxoma, although clot remains on the differential
diagnosis. He is a poor
anticoagulation candidate, given his recent intraventricular
hemorrhage and fall risk, and, therefore, anticoagulation was
not initiated.
# Adrenal insufficiency: changed [**10-17**] from hydrocortisone 50 mg
IV tid to prednisone 10 mg po qam and 5 mg po qpm.
# H/o hypoxia: He was found to be hypoxic for a short period
after extubation. This is now resolved. Satting 94% on RA.
Prior hypoxia was likely [**2-1**] fluid overload. Now appears
euvolemic. No infiltrate on [**10-10**] CXR. Has not needed any
furosemide since transfer to medicine
# Hematuria: He had several episodes of hematuria during his
hospital course but this was thought to be [**2-1**] bladder/urethra
trauma from the foley. Foley cath d/c'd on [**10-16**] and he was
switched to a condom cath. If hematuria persists as an
outpatient, urology follow-up may be considered at the
discretion of his PCP.
# Gerd: continue Lansoprazole
# Anemia: He was not anemic on admission but became anemic
during his hospital coure. There was no clear source of active
bleeding. On CT abdomen, there may be a small hematoma
peri-PEG-site. Likely also [**2-1**] intracranial bleed and serial
phlebotomy. Iron studies consistent with ACD. Hct 28 on
discharge
# Schizophrenia: continue olanzapine, benztropine for prevention
of EPS? (was taking on admission)
# FEN: continue TF with PEG, replete lytes prn, failed speech
and swallow eval
- speech and swallow video eval should be repeated in one month
to see if he could begin to tolerate po
- s/p PEG placement [**10-10**]
# Contact: third party guardian [**Name (NI) **] [**Name (NI) 68736**]
[**Telephone/Fax (1) 46208**], cell [**Telephone/Fax (1) 68735**] (best number). PCP [**Name9 (PRE) **] [**Name9 (PRE) **]
[**Telephone/Fax (1) 6019**]
[**Hospital3 **] Health Care [**Telephone/Fax (1) **]
# Code: Full (discussion with HCP on [**10-11**])
# Dispo: to Cedarhill with physical and occupational therapy.
HCP and Dr. [**Last Name (STitle) **] were contact[**Name (NI) **] on day of discharge.
Medications on Admission:
Meds: Prior to Admission:
MEDS:
-zyprexa 2.5 mg qid pm
-potassium chloride 2 capsules (20 meq) am
-protonix 40 mg qid am
-vit C 500 mg qid am
-benztropine 0.5 mg (one half tab [**Hospital1 **])
-chlorhexidine 15 ml [**Hospital1 **] after meals
-cortisone 2 tabs (50 mg) qid am
-cortisone 1 tablet (25 mg) qid pm
-docusate sodium 100 mg [**Hospital1 **]
-acetominophen 2 tabs (650 mg) tid
-diphenhydramine 2 capsules (50 mg) prn for itch
-duoneb (ipratroprium/albuterol) one unit dose tid prn
-guaifenesin 100 mg/5ml 15 ml prn
-kaopectate 525 mg/15 ml prn
-prochlorperazine 25 mg supp. rect prn for nausea
-maalox 225/200 prn
-milk of magnesia 30 ml prn
.
Meds on transfer to [**Hospital1 18**]:
Acetaminophen 325-650 mg PO Q4-6H:PRN
Bisacodyl 10 mg PR HS:PRN
Insulin Sliding scale
Vancomycin HCl 1000 mg IV Q 12H (day #5 is [**10-1**])
Hydrocortisone Na Succ. 50 mg IV QAM
Hydrocortisone Na Succ. 25 mg IV QPM
Olanzapine 2.5 mg PO HS [**9-27**] @ 0628
Benztropine Mesylate 0.5 mg PO BID
Levofloxacin 500 mg PO Q24H (day #4 is [**10-1**])
Ipratropium Bromide Neb 1 NEB IH Q6H
Albuterol 0.083% Neb Soln 1 NEB IH Q6H
Guaifenesin 10 ml PO TID
Phenytoin (Suspension) 100 mg PO Q8H
Lansoprazole Oral Suspension 30 mg NG DAILY
Discharge Medications:
1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
2. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Benztropine 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. Phenytoin 100 mg/4 mL Suspension Sig: Two Hundred (200) mg PO
Q8H (every 8 hours).
7. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
9. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO q pm.
11. 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.
12. DuoNeb 2.5-0.5 mg/3 mL Solution Sig: One (1) Inhalation
three times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 13990**]
Discharge Diagnosis:
Adrenal insufficency
ICH
Hypopituitary
MRSA PNA
Paranoid Schizophrenia
Gastritis
R atrial mass
Discharge Condition:
Hemodynamically stable.
Discharge Instructions:
Please take all medications as instructed. There were several
changes made to your current medications regimen.
If you experience any fever, nausea, vomiting, lightheadedness,
chest pain, shortness of breath, or any other concerning
symptoms please seek medical attention immediately.
Followup Instructions:
Please make a follow-up appointment with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].
within the next 2 weeks. Tel ([**Telephone/Fax (1) 68737**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
|
[
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"276.1",
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"787.2",
"996.1",
"428.0",
"285.29",
"431",
"331.4",
"780.39",
"295.32",
"276.52",
"458.9",
"253.7",
"496",
"682.6",
"V09.0",
"599.7",
"427.32",
"212.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.34",
"96.6",
"96.71",
"02.39",
"99.10",
"38.93",
"96.04",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
21669, 21717
|
15102, 15102
|
357, 417
|
21856, 21882
|
3555, 4983
|
22218, 22515
|
2012, 2021
|
20582, 21646
|
21738, 21835
|
19337, 20559
|
15119, 19311
|
21906, 22195
|
2036, 2386
|
271, 319
|
445, 1456
|
2500, 3536
|
8236, 15079
|
2425, 2484
|
2410, 2410
|
1478, 1671
|
1687, 1996
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,935
| 149,261
|
48414
|
Discharge summary
|
report
|
Admission Date: [**2150-3-22**] Discharge Date: [**2150-3-27**]
Service: MEDICINE
Allergies:
Sulfonamides / Dicloxacillin
Attending:[**First Name3 (LF) 1865**]
Chief Complaint:
BRBPR and epistaxis
Major Surgical or Invasive Procedure:
Biopsy of R leg lesion
History of Present Illness:
Patient is an 86 yo female with PMH afib/aflutter on coumadin,
SSS, VT on last admission s/p pacer, CHF, HCM w/dynamic LVOT
with recent admission from [**Date range (1) 101938**] during which she had an
elevated INR 8.4 an epistaxis presenting with 1 day of BRBPR and
epistaxis. On morning of admission, she had an episode of BRBPR
and epitaxis which stopped after 1 episode. She noticed that she
felt some dripping in her nose and out some tissues in her nose
and when she took then out she ntoced they were bloody. Of note,
she says that she often picks at her nose, which results in nose
bleed. Also, she was straining to have a bowel movement. She has
had problems with constipation in the past which result in
BRBPR. She had only 1 episode of hard brown stool with BRB on
paper and in the toilet. She denies black stools, hematemesis,
N/V, dizziness, lightheadedness, hematuria. Her last colonoscopy
was on [**11-19**] and revealed rectal ulcers and a bowel regimen and
high fiber diet were recommended.
.
In the ED, BP 110/84 HR 64 RR 14 O2 sats 98% on RA. She was
typed and screened, 2 18 gauge PIVs were placed, she as given 1
liter NS and protonix 40 mg IV x1 and GI was consulted with plan
to see the patient in the AM.
.
On arrival to the ICU she denies CP, SOB, N/V, dizziness. She
does have some pain over her pace maker site as well as in her
abdomen where they have been giving her SC heparin injections.
.
She is now transferred to the floor as her hct stabilized. Gi
felt that her bleeding is most likely due to hemorrhoids or her
rectal ulcers in the setting of anticoagulation and
anti-platelet therapy, and would consider flex sig if she cont
to have bleed tomorrow. She was given 1 u pRBC this today for
hct 24.2-> 27.9
Past Medical History:
-Atrial fibrillation: on coumadin
-Sick sinus syndrome: temporary pacer placed during [**11-19**]
admission, was to return for permanent pacemaker placement,
which was again deferred during [**1-21**] admission secondary to
medical
illness and was placed during admission from [**Date range (1) 101939**]
-HOCM -> echo [**8-20**] showing LVOT obstruction (16 mm Hg) w/
increased gradient on Valsalva (63 mm Hg)
.
-CAD s/p NSTEMI s/p cath on [**2150-3-13**] which revealed three vessel
coronary artery disease. The LMCA had minimal ostial disease.
The LAD was a highly calcifed vessel with a 99% stenosis at the
take off of the diagonal. The diagonal branch had a 70%
stenosis. There was an 805 stenosis in the apical LAD. The LCx
was widely patent and highly calcified. The RCA was totally
occluded at the ostium and
filled via collaterals from the conus medullaris. There was
sustained ventricular tachycardia with hemodynamic collapse upon
injection of the LMCA follow by sucessful defibrillation with
200 Joules.
No stents were placed
-HTN
-Hyperlipidemia
-Chronic venous stasis
-Squamous cell carcinoma: right medial calf, s/p excision
[**11-19**], positive margins on 1st and 2nd excision attempts, needs
XRT to area 6 weeks after the wound heals.
-h/o UTI: last culture w/ enterobacter resistant to all but
bactrim and meropenem
-rectal ulcers: possibly from constipation and straining as
above
-History of C diff colitis
-Anemia: from blood loss after GI bleed, last HCT 25-30 in
[**11-19**], HCT 29.3 on discharge [**3-19**]
-NSTEMI [**1-21**], [**2-18**]
-Urge incontinence
-Schizoaffective disorder
-Depression
-Colon adenoma in [**2141**]: last colonoscopy in [**2143**], no polyps
-s/p hysterectomy
Social History:
Husband recently died from terminal liver disease. Lived in
[**Hospital3 **] facility in [**Location (un) **] but now at [**Hospital 100**] Rehab.
No TOB, EtOH, or other drugs. Has a nephew and nieces but no
family in the area. Walks with a walker.
Family History:
Non-contributory
Physical Exam:
VS: T 96.7 BP 119/58 HR 70 RR 20 O2 sats 97% on 2 L NC
GEN: elderly female; NAD. A&Ox3. Cooperative and interactive.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. OP clear, MMM.tongue
appears smooth, dried blood in right nare
Neck: Supple.
CV: RR, normal S1/S2. III/VI systolic murmur loudest at
LLSB. No rub. No S3 or S4.
CHEST: pacer in place in left upper chest. tender to palpation
with steri strips in place. No drainage. some residual hematoma.
Per patient is unchanged.
Lungs: few crackles at the bases b/l
ABD: Soft, ND. NABS. large hematomas and echymoses in areas in
which she was given SC heparin. These areas or TTP. No HSM.
EXT: chronic venous stasis changes. RLE chronic wound above
ankle and s/p skin graft from thigh. dry and intact. 1+ Dp
pulses.
NEURO: CN2-12 intact, strength 5/5 in UE/LE bilat,
sensation grossly intact bilat
Pertinent Results:
[**2150-3-22**] 09:05PM BLOOD WBC-8.6 RBC-3.22* Hgb-9.3* Hct-28.4*
MCV-88 MCH-28.9 MCHC-32.9 RDW-15.9* Plt Ct-261
[**2150-3-27**] 06:15AM BLOOD WBC-7.2 RBC-3.78* Hgb-11.1* Hct-32.2*
MCV-85 MCH-29.3 MCHC-34.3 RDW-16.8* Plt Ct-287
[**2150-3-22**] 09:05PM BLOOD Neuts-62.9 Lymphs-26.5 Monos-6.6 Eos-3.2
Baso-0.8
[**2150-3-22**] 10:30PM BLOOD PT-23.6* PTT-36.0* INR(PT)-2.3*
[**2150-3-25**] 05:55AM BLOOD PT-17.7* PTT-27.7 INR(PT)-1.6*
[**2150-3-22**] 09:05PM BLOOD Glucose-106* UreaN-24* Creat-0.9 Na-133
K-5.4* Cl-102 HCO3-21* AnGap-15
[**2150-3-27**] 06:15AM BLOOD Glucose-87 UreaN-25* Creat-1.1 Na-135
K-3.7 Cl-99 HCO3-26 AnGap-14
[**2150-3-24**] 09:50PM BLOOD CK(CPK)-31
[**2150-3-25**] 05:55AM BLOOD CK(CPK)-31
[**2150-3-24**] 09:50PM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2150-3-25**] 05:55AM BLOOD CK-MB-NotDone cTropnT-0.04* proBNP-3100*
[**2150-3-23**] 04:33AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.3
[**2150-3-27**] 06:15AM BLOOD Calcium-9.6 Phos-3.6 Mg-2.1
[**2150-3-24**] 03:57AM BLOOD Type-ART pO2-71* pCO2-36 pH-7.41
calTCO2-24 Base XS-0 Intubat-NOT INTUBA
.
[**3-24**] CXR
Small right pleural effusion, borderline interstitial edema and
subsegmental atelectasis at the left base are new. Moderate
cardiomegaly with particular left atrial enlargement is chronic.
Transvenous right atrial and right ventricular pacer leads
present since [**3-17**] are unchanged in their respective
positions. The right ventricular lead does not extend as far as
the apex of the right ventricle. Heavy mitral annular
calcification and marked left atrial enlargement are noted.
.
[**3-25**] EKG
A-V sequential pacing at 70 beats per minute. No change compared
to the
previous tracing of [**2150-3-23**].
.
[**3-28**] Biopsy of R LE lesion pathology pending
Brief Hospital Course:
86 year old female with a history of coronary artery disease s/p
recent non-ST elevation myocardial infarction in [**1-/2150**], atrial
fibrillation on coumadin, SSS, and HOCM with recent admission
significant for VT s/p pacer on [**3-16**], CHF, presenting with
epistaxis and BRBPR, episode of flash pulm edema now resolved.
Hospital course complicated by:
.
# ACUTE DYSPNEA/CHF: Had an episode of likely flash pulmonary
edema in setting transfusion. CE neg X 2. Now resolved and
satting in high 90s on RA. BNP elevated.
- diuresed over 2 days with furosmide 40 mg po each day with
good effect
- volume restrict to 1.5L daily
- will not add daily furosemide for now but may need this on an
ongoing basis
.
# BRBPR: Now resolved. Guiac negative. Most likely due to
hemorrhoids or her rectal ulcers in the setting of
anticoagulation and constipation with straining during BMs. Post
1u pRBC transfusion on [**3-23**] with appropriate increase in Hct and
hemodynamically stable. Spoke with EP regarding peri-procedure
prophylactic antibiotics and they generally do not recommend abx
for such procedures post-ICD placement. HOWEVER, flex sig was
cancelled finally as she is now guiac negative. Her hct was
stable X > 48 hrs
- cont to hold coumadin but re-started ASA 81 mg, Per Dr. [**Last Name (STitle) **],
will likely restart coumadin in a month or so once stable
- po PPI
- cont bowel regimen
.
# EPISTAXIS: Currently resolved. Required nasal packing on last
admission. Currently no further bleeding. Dr. [**Last Name (STitle) **] to determine
if pt ever been evaluated by ENT in past as no mention in OMR.
- consider ENT consult for caudery if recurrent bleeding
- afrin nasal spray prn for nosebleeds but many not need this
now as no longer on coumadin
.
# CAD: Underwent cardiac catheterization on [**2150-3-13**] which
revealed a totally occluded right coronary artery, 99% LAD which
was ballooned, no stents were placed only baloon angioplasty. No
EKG changes in setting of acute SOB 2. CE neg x2
- toprol xl 50mg qd
- continue asa
- continue statin
.
# ATRIAL FIBRILLATION: s/p VT and pacer placement on amiodarone
coumadin and metoprolol. Currently A-V paced. Wound site without
evidence of infection. Pt with multiple episodes of
supratherapeutic INR. In previous DC summaries, no mention of
outpatient INR level checks and followup instructions regarding
coumadin dosing.
- continue amiodarone, metoprolol, will hold coumadin for now
given bleeding risk but continue ASA
.
# SQUAMOUS CELL CARCINOMA: Plastic surgery thinks new growth c/w
keratocanthoma. Derm refused inpatient consult. Now s/p biopsy
of lesion. Dr. [**Last Name (STitle) **] will follow-up pathology results.
- continue topical antibiotic ointment to biopsy site
withdressing changes daily
.
# DEPRESSION:
- continue citalopram
.
# COMMUNICATIONS: With patient. Also has social worker /case
manager [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 33578**] [**Telephone/Fax (1) 101940**]. Did not want for us to
call her niece or nephew
.
# CODE: DNR/DNI
.
# DISPO: to rehab
.
Medications on Admission:
Acetaminophen 325 mg PO Q4-6H as needed for pain, fever.
Aspirin 81 mg Tablet PO DAILY
Atorvastatin 80 mg PO DAILY
Citalopram 60 mg PO DAILY
Docusate Sodium 100 mg PO BID
Bisacodyl 10 mg PO DAILY as needed for constipation.
Hexavitamin 1 Cap PO DAILY
Fluticasone-Salmeterol 250-50 mcg [**Hospital1 **]
Albuterol Sulfate One (1) neb Q4H PRN
Ipratropium Bromide Q6H as needed.
Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
Metoprolol Tartrate 50 mg PO BID
Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
Clopidogrel 75 mg PO DAILY
Warfarin 5 mg PO HS
Amiodarone 200 mg PO BID
Amiodarone 200 mg PO once a day:
START ON [**2150-3-22**] AFTER AMIODARONE LOAD WITH 400MG [**Hospital1 **] IS
COMPLETED.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
2. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Puff Inhalation [**Hospital1 **] (2 times a day).
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) NEB
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain: please try tylenol first, hold for
sedation
.
9. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO DAILY (Daily).
13. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
14. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
15. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID
(3 times a day) as needed for thrush for 5 days.
16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
17. Oxymetazoline 0.05 % Aerosol, Spray Sig: One (1) Spray Nasal
[**Hospital1 **] (2 times a day) as needed for for nose bleed.
18. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
Lower GI bleed
Pulmonary Edema
Epistaxis
Squamous Cell Carcinoma
.
Atrial Fibrillation (npw not on coumadin)
CAD
Depression
Discharge Condition:
Hemodynamically stable. Ambulatory with a walker.
Discharge Instructions:
You were admitted with a gastrointestinal bleed thought to be
related to coumadin use and hemorroidal and ulcer bleeding of
your rectum. Please seek medical attention immediately if you
have more rectal bleeding. We have stopped your warfarin for
now but Dr. [**Last Name (STitle) **] may re-start this in about a month.
.
You also had a biopsy of your old skin cancer site. Dr. [**Last Name (STitle) **]
will follow-up the biopsy results.
.
Please seek medical attention immediately if you have and
additional rectal bleeding, chest pain, fever, shortness of
breath or any other concerning symptoms.
Followup Instructions:
Please make a follow-up appointment with Dr. [**Last Name (STitle) **] within a week
of discharge from [**Hospital 1319**] Rehab. Tel ([**Telephone/Fax (1) 1300**].
.
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2150-4-7**] 9:00
Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING
Date/Time:[**2150-4-7**] 9:00
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 902**]
Date/Time:[**2150-4-15**] 10:20
|
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"428.0",
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"311",
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"414.01",
"112.0",
"280.0",
"272.4",
"564.00",
"V58.61",
"425.1",
"238.2",
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"428.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"86.11"
] |
icd9pcs
|
[
[
[]
]
] |
12563, 12629
|
6733, 9813
|
256, 280
|
12806, 12858
|
4967, 6710
|
13510, 14067
|
4069, 4087
|
10651, 12540
|
12650, 12785
|
9839, 10628
|
12882, 13487
|
4102, 4948
|
197, 218
|
308, 2051
|
2073, 3786
|
3802, 4053
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,332
| 107,180
|
32154
|
Discharge summary
|
report
|
Admission Date: [**2193-12-13**] Discharge Date: [**2193-12-18**]
Date of Birth: [**2133-1-31**] Sex: F
Service: SURGERY
Allergies:
Demerol / Morphine / Adhesive Tape
Attending:[**First Name3 (LF) 5547**]
Chief Complaint:
Large and symptomatic parastomal hernia in the left mid-abdomen.
Major Surgical or Invasive Procedure:
Parastomal hernia repair
Bleeding diathesis
Post-op Delerium
History of Present Illness:
This is a 60-year-old female who underwent an abdominoperineal
resection in [**2189-3-7**] for the management of multiple rectal
villous adenomas which were not amenable to local excision. In
[**Month (only) 205**], she was struck by a car and developed a fairly large and
symptomatic parastomal hernia in the left mid-abdomen. She
develops intermittent bowel obstructions that require admission
to the hospital as well as frequent incarcerations of this
parastomal hernia that require manual reduction. As such, this
parastomal hernia has a significant impact on her quality of
life and she desired repair. In addition, it was evident that
she had a small midline ventral hernia just medial to her
parastomal hernia as well. She does have a long history of a
significant bleeding diathesis of unclear nature and has had
fairly significant bleeding after all of her
surgical procedures. As such, she was evaluated by Dr. [**Last Name (STitle) 2805**] of
the hematology service who advised the administration of DDAVP
and Amicar perioperatively.
Past Medical History:
Past Medical History:
1. Bleeding diathesis of unclear nature. She does give a
history of profuse bleeding after any surgical procedure
including her prior total abdominal hysterectomy, bilateral
inguinal hernia repairs and multiple breast biopsies. She
admits
to easy bruising and has had one significant episode of
epistaxis
that required prolonged nasal packing and transfusions. She has
never been given a firm diagnosis as to the origin of the
bleeding problems and apparently all of her clotting factor
levels and bleeding times have been normal.
2. Hypertension.
3. Elevated lipids.
4. Anxiety disorder.
5. Depression.
6. Meniere's disease
Past Surgical History:
1. Status post total abdominal hysterectomy and bilateral
salpingo-oophorectomy.
2. Status post bilateral inguinal hernia repairs.
3. Status post multiple previous benign breast biopsies.
4. Status post bladder suspension for urinary incontinence.
5. Status post abdominoperineal resection for villous adenomas
of the low rectum.
6. Status post laparoscopic cholecystectomy as management for
acute cholecystitis.
7. Status post previous small-bowel obstruction in [**4-/2192**],
which resolved with bowel rest and NG tube suction
Social History:
She lives in [**Location 1468**] and has two children. She
is currently on disability but worked as a phlebotomist in the
past. She has never smoked and does not drink alcohol.
Family History:
Family History: Her mom died of breast cancer. She has a
maternal grandfather who died of rectal cancer after an [**Month (only) **] her
brother has kidney cancer and Waldenstrom macroglobulinemia.
Her
father died of an MI and her son has had a previous deep venous
thrombosis.
Physical Exam:
Gen: pleasant and well-appearing.
HEENT: Sclerae are anicteric. Neck and supraclavicular fossa is
supple without
lymphadenopathy.
Chest: Lungs are clear to auscultation bilaterally.
Heart: regular rate and rhythm.
Abdomen: well-healed midline incision without hernia. There is
a pink rosebud stoma in the left lower quadrant of the abdomen.
There is an easily
reducible and somewhat tender large peristomal hernia containing
loops of small bowel. Her abdomen is otherwise soft and
nontender.
Extremities: show no edema and are warm.
[**2193-5-17**] CT scan of the abdomen and pelvis. There are several
loops of small bowel in a hernia adjacent to the left mid
abdominal stoma without evidence of
bowel obstruction, free air or free fluid.
Pertinent Results:
[**2193-12-13**] 01:43PM BLOOD Hct-30.4*
[**2193-12-15**] 03:44AM BLOOD WBC-13.3* RBC-3.05* Hgb-9.6* Hct-27.9*
MCV-92 MCH-31.6 MCHC-34.5 RDW-12.9 Plt Ct-349
[**2193-12-17**] 06:40AM BLOOD WBC-13.5* RBC-3.19* Hgb-10.0* Hct-29.2*
MCV-92 MCH-31.3 MCHC-34.1 RDW-12.9 Plt Ct-440
[**2193-12-14**] 05:20AM BLOOD Plt Ct-392
[**2193-12-17**] 06:40AM BLOOD Plt Ct-440
[**2193-12-14**] 07:10PM BLOOD Glucose-131* UreaN-11 Creat-0.8 Na-137
K-4.5 Cl-106 HCO3-23 AnGap-13
[**2193-12-17**] 06:40AM BLOOD Glucose-105 UreaN-12 Creat-0.6 Na-142
K-4.2 Cl-107 HCO3-27 AnGap-12
[**2193-12-17**] 06:40AM BLOOD Calcium-9.0 Phos-2.9 Mg-2.1
.
CHEST (PORTABLE AP) [**2193-12-15**] 7:26 AM
IMPRESSION: No pneumothorax after removal of the gastric tube.
Brief Hospital Course:
This is a 60 year old female with a parastomal hernia in the
left mid-abdomen. She developed intermittent bowel obstructions
and incarcerations necessitating manual reduction. She has a
history of a bleeding diathesis of unclear nature. The
hematology service advised the administration of DDAVP and
Amicar perioperatively.
She went to the OR on [**12-13**] for:
1. Exploratory laparotomy.
2. Extensive lysis of adhesions.
3. Repair of parastomal and ventral hernias with underlay
placement of [**Doctor Last Name 4726**]-Tex DualMesh.
She did well post-op and was followed by the hematology group
their recommendations were as follows:
DDAVP at 0.3 mcg/kg IV given q day for 3 days. The basis for
DDAVP action for treating bleeding associated with platelet
abnormalities is unknown, but it usually is effective.
Amicar, 1 g Amicar q 4 hrs iv or po for 3 days, then q 6 hrs PO
for another 3-4 days. This assumes surgery is uncomplicated and
wound healing is normal.
.
Due to the complexity of these meds and frequent monitoring, she
was in the ICU for 2 days. Her HCT remained stable
post-operatively at ~28, she had no signs or symptoms of
bleeding.
Pain: She had a PCA for pain control and did well. She had some
transient post-op delirium, likely due to the PCA, but this
resolved on its own. Once tolerating clear liquids, she was
switched to PO narcotics.
GI/ABD: She was NPO with IVF. She was started on clears on POD 4
and tolerating these. Her ostomy had +gas on POD 4. Her abdomen
was round, and slightly distended. We were able to advance her
diet as she had return of bowel function.
Her incision was C/D/I with staples in place. She wore an
abdominal binder with ambulation.
Medications on Admission:
Atenolol 25", Buspar 10", HCTZ 25', Protonix 40', Simvastatin
80', Xanax 1''', Buproprion 100", Meclizine 25''', Fiorocet 1prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
3. BuSpar 10 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
7. Xanax 1 mg Tablet Sig: One (1) Tablet PO three times a day.
8. Bupropion 100 mg Tablet Sig: One (1) Tablet PO twice a day.
9. Meclizine 25 mg Tablet Sig: One (1) Tablet PO three times a
day.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
11. AMICAR 1,000 mg Tablet Sig: One (1) Tablet PO every six (6)
hours for 2 doses.
Disp:*2 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Parastomal hernia
Discharge Condition:
Good
Tolerating diet
Pain well 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 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 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 take any new meds as ordered.
* Continue to ambulate several times per day. Please wear
abdominal binder when out of bed and ambulating.
* No heavy lifting >10 lbs for 6 weeks.
* Continue with ostomy care.
* Continue to eat several, small meals throughout the day.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1924**] in 2 weeks. Call [**Telephone/Fax (1) 7508**]
to schedule an appointment
Completed by:[**2193-12-18**]
|
[
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"569.69",
"568.0",
"287.9",
"E935.8",
"300.4",
"401.9",
"292.81",
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] |
icd9cm
|
[
[
[]
]
] |
[
"54.59",
"46.42",
"53.61"
] |
icd9pcs
|
[
[
[]
]
] |
7555, 7561
|
4764, 6463
|
361, 423
|
7623, 7667
|
4012, 4741
|
8905, 9066
|
2968, 3233
|
6641, 7532
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7582, 7602
|
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7691, 8882
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3248, 3993
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257, 323
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451, 1497
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1541, 2176
|
2754, 2935
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,690
| 166,559
|
48362
|
Discharge summary
|
report
|
Admission Date: [**2203-10-22**] Discharge Date: [**2203-10-27**]
Date of Birth: [**2134-12-21**] Sex: F
Service: MEDICINE
Allergies:
Lipitor / Lisinopril / Iodine / Paper Tape
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Dypsnea
Major Surgical or Invasive Procedure:
right IJ Central Line
History of Present Illness:
68 yo female with a history of HTN, CAD s/p CABG, CRI, DM, CHF
EF 20% now presents with dypsnea and weakness. She was admitted
[**Date range (1) 34969**] for a CHF exacerbation, was diuresed 5L and
discharged with many adjustments to her medications including
changing Lasix to Torsemide and adding Imdur. She left the
hospital without reviewing the medication list with the RN and
without prescriptions. Many attempts were made to contact the
patient since discharge but were unsuccessful. Over the past few
days she was noted by her husband to be have profound fatigue
and moderately worse dyspnea.
.
Her husband called EMS and she was brought to [**Hospital3 4107**],
SBP 102/52, HR 56, 98%2L. Her labs were notable for BNP 3270,
Trop 0.48, Cr 4.4, Hct 26.5. She was given 40mg IV Lasix and
reported minimal urine output. Transferred here. In ED SBP 70s,
HR 50s, 97%2L. A RIJ placed, dopamine @ 5 started in ED. Given
dose of aspirin. No additional Lasix given. EKG without changes
from prior. CXR showed no pulmonary edema but did show small
ptx.
.
Labs notable for new ARF 4.2 (from 2.0), Na 129, Trop 1.09,
Lactate 3.4, mildly positive U/A for which she received 1 dose
of Ceftriaxone.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She reports nausea in ED. Does report loose stools x1
day. Denies abdominal pain.
.
Cardiac review of systems is notable for absence of chest pain.
Does report dypsnea on exertion, denies paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope or
presyncope.
Past Medical History:
1. CAD s/p 4v CABG in [**1-14**] with LIMA-LAD, SVG-Diag (known
occluded), SVG-OM1, and SVG-RCA; non-sustained VT on tele s/p
CABG, had intervention to the LIMA-LAD anastamosis in [**7-20**] with
Cypher stent at the anastomosis; cath'd most recently in [**6-20**]
with instent restenosis of LIMA-LAD prior Cypher stent that was
successfully treated with Taxus stent.
2. DM2 since [**2189**]
3. Hypercholesterolemia
4. Osteoarthritis: b/l shoulder, knee arthritis with
intermittent effusions, RF +; also DJD of both knees and L
thumb, s/p TKR of L knee [**10-15**]
5. Dyspnea on exertion x years, followed by cardiology and
pulmonology, thought to be most likely related to ischemic
cardiomyopathy and CAD
6. CHF (EF 20-30%) [**2202-6-13**]. 1+ MR, 1+TR. Small atrial secundum
defect
7. Hypertension
8. Asthma
9. Uterine fibroids, has had peri-menopausal spotting, received
HRT
10. History of occult blood positive stool
11. Myelodysplastic syndrome- WBC 2.0
12. Cataracts
13. ICD
Social History:
Social history is significant for the absence of current tobacco
use. She previously smoked ~1 ppd but quit 10 years ago. Denies
current ETOH use. She lives with her husband. They previously
owned a restaurant called Pit Stop BBQ. She has four children,
one of whom is deceased.
Family History:
Mother had DM and CAD, but died at 79 from lung CA. Father died
of an accidental death, but had a h/o CAD.
Physical Exam:
VS: T=97.3 BP 97/54 HR 72 RR 18 99%2L
CVP 23
GENERAL: Middle aged AA female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. .
NECK: Supple, JVP difficult to assess [**1-15**] RIJ
CARDIAC: normal S1, S2. Mild holosystolic murmur heard best at
apex
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 1+ edema to ankles bilaterally, warm well perfused
SKIN: Marked hyperpigmentation of legs, arms, buttocks, back
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Pertinent Results:
EKG: V paced rate 58, RBBB, LAD, TWI V1-V2 (old), ST depression
V5-6 (old), Q waves II, III, avF
.
2D-ECHOCARDIOGRAM: [**7-/2203**]
Severe global biventricular dilatation and hypokinesis. EF
20-25%. Diastolic dysfunction. At least mild mitral
regurgitation. Mild aortic regurgitation. \ASD with left to
right flow.
.
CXR: Small left pneumothorax. New right internal jugular
catheter.
.
LABORATORY DATA:
WBC 2.2 Hct 26 Plts 102
129 / 91 / 104 / 235 AGap=17
------------
4.7 / 21 / 4.2 D
Lactate 3.4
BNP:[**Numeric Identifier 101875**]
CK 59 Trop 1.09
.
U/A: 3-5wbcs, trace leuks, mod bacteria, trace ketones, 100
protein
Brief Hospital Course:
68 yo female with h/o CAD s/p CABG, DM, Asthma, presents with
worsening SOB and fatigue.
.
SYSTOLIC CONGESTIVE HEART FAILURE: Pt presents with increasing
dypsnea, BNP 57,925 and evidence of fluid overload on exam with
JVP to 12cm-all suggesting a low output state. Low output state
is also likely exacerbated by her anemia and ASD. She was
started on dopamine as well as lasix drip. Central access was
obtained on admission and discontinued on [**9-23**]. Lasix and
dopamine drips were weaned following a modest diuresis. She was
discharged on increased dose of torsemide and started on
hydrochlorothiazide, with oupatient follow up scheduled.
.
CORONARY ARTERY DISEASE: On admission, she was without chest
pain, EKG unchanged, Trop 1.07 likely in setting of acute renal
failure. She was continued on aspirin, plavix. Her beta
blocker was temporarily held.
.
FATIGUE: She was admitted with significant fatigue that was most
likely multifactorial secondary to chronic heart failure, anemia
and Myelofibrosis. She was transfused 1 U PRBCs, with
significant releif of symptoms.
.
ACUTE ON CHRONIC RENAL FAILULRE: She had a creatinine of 4.2 on
admsission, thought to be likely related to poor forward flow in
the setting of a CHF exacerbation. Her creatinine improved with
diuresis and was 1.6 on discharge.
.
PNEUMOTHORAX: She developed a pneumothorax following RIJ line
placement. This was followed by serial chest x-rays and
resolved spontanously.
.
DIABETES: Diet controlled at home, she was started on an insulin
sliding scale in house.
.
ASTHMA: She was continued on her home nebs
.
MYELOFIBROSIS: She has chronic amemia and a 26 mo prognosis from
myelofivrosis. She is on Aranesp injections weekly at home,
last documented [**9-19**] and missed recent appts. She has a
chronically low Hct and, as a consequence, has been transfused
previously. Likely part of her fatigue/weakness may be [**1-15**]
profound anemia. She was transfused with 1 U prbcs.
Medications on Admission:
albuterol 2 puffs q4h prn
plavix 75mg daily
fluticasone 110mcg 2puffs [**Hospital1 **]
Torsemide 40mg [**Hospital1 **]
Toprol 25mg daily
nitro 0.3mg prn
aspirin 325mg daily
MVI
trazodone 25mg qhs
digoxin 125 mcg qdaily (per d/c summary should be MWF)
spiriva 18mcg capsule i inh daily
docusate sodium 100mg [**Hospital1 **]
Pravastatin 40mg daily
Imdur 30mg daily
Discharge Medications:
1. Torsemide 20 mg Tablet Sig: Three (3) Tablet PO twice a day.
Disp:*180 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
5. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
10. Epogen Injection
11. Danazol 200 mg Capsule Sig: Two (2) Capsule PO twice a day.
12. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
13. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
14. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for insomnia.
15. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: 1-3 tabs
Sublingual q 5 minutes x3 as needed for chest pain: call 911 if
you still have chest pain after 3 doses.
16. Hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO
once a day: Please take 30 minutes before am dose of torsemide.
Disp:*30 Tablet(s)* Refills:*2*
17. Isosorbide Mononitrate 30 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*
18. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO every Monday,
Wednesday and Friday.
Disp:*12 Tablet(s)* Refills:*2*
19. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
20. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO once a day.
Disp:*60 Capsule, Sustained Release(s)* Refills:*2*
21. Outpatient Lab Work
Please check K, BUN, creatinine, Hct on [**2203-10-31**] and call
results to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 250**] and Dr. [**First Name (STitle) 437**] at
[**Telephone/Fax (1) 62**]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Acute on chronic systolic congestive heart failure: [**Last Name (un) **] held [**1-15**]
Increased creatinine, will be restarted after d/c.
Acute Renal Failure
Acute on Chronic Renal Failure
Myelodysplastic syndrome
Discharge Condition:
BUN=89
creat=2.0
K=3.8
hct=29.6
Discharge Instructions:
You had an exacerbation of your congestive heart failure that
caused you to become short of breath. We have adjusted your
medicines and you will be seen in the Congestive Heart failure
clinic here.
Medicine changes:
1.Torsemide was increased to 60 mg twice daily
2. Hydrochlorothiazide was started to take before first am dose
of torsemide
3. Digoxin, Spironolactone and isosorbide were continued.
Please stop taking:
1. Furosemide
2. Metformin
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day
or 6 pounds in 3 days. Adhere to 2 gm sodium diet, information
was given to you at discharge.
Fluid Restriction: 1.5 liters per day or about 7 eight ounce
cups.
.
Please check your blood sugars daily before lunch and keep a log
to show to your doctors.
.
Please call Dr. [**First Name (STitle) 437**] if you have more trouble breathing, fluid
retention, unusual fatigue, chest pain or any other unusual
symptoms.
Followup Instructions:
Cardiology:
Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**]
Date/Time:[**2203-10-31**] 9:30
Provider: [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2203-12-5**] 3:00
Primary Care:
Provider: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. Date/Time:[**2203-11-21**] 11:00
Completed by:[**2203-11-8**]
|
[
"E879.8",
"493.90",
"289.83",
"715.91",
"403.90",
"414.01",
"428.23",
"V45.81",
"585.9",
"272.0",
"V45.82",
"715.96",
"250.00",
"584.9",
"512.1",
"276.1",
"238.75",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9566, 9623
|
4930, 6898
|
314, 338
|
9884, 9918
|
4285, 4907
|
10905, 11433
|
3421, 3531
|
7313, 9543
|
9644, 9863
|
6924, 7290
|
9942, 10882
|
3546, 4266
|
267, 276
|
366, 2099
|
2121, 3107
|
3123, 3405
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,949
| 194,971
|
46798
|
Discharge summary
|
report
|
Admission Date: [**2182-10-28**] Discharge Date: [**2182-11-5**]
Date of Birth: [**2113-2-3**] Sex: F
Service: MEDICINE
Allergies:
Demerol
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Diarrhea, hypotension
Major Surgical or Invasive Procedure:
Right Internal Jugular Venous Line [**2182-10-28**]
History of Present Illness:
Ms. [**Known lastname **] is a 69 year old woman with history of chronic
diarrhea, sarcoid, and atrial fibrillation who presented to the
ED this afternoon with hypotension. She went to her scheduled GI
appointment the afternoon of admission at which time her blood
pressure was found to be 80/40. She was referred to the ED for
further workup.
.
She notes that for the past several weeks, she has felt weaker
and has been less able to move around. She reports that she has
lost > 60 pounds since her diarrhea began in [**Month (only) 216**]. She has
had some nausea, long-standing diarrhea which occurs with any
food, and long-standing dyspnea on exertion. She was recently
treated for a UTI with a 7-day course of ciprofloxacin,
completed 2-3 days ago. She denies current urinary symptoms.
.
In the ED, her vitals were: BP 81/46, HR 70, RR 16, Sat 100%RA.
Her potassium was elevated at 6.1, and she was given calcium
gluconate, dextrose, bicarb, and insulin, along with kayexalate.
Blood cultures were drawn, and she was given dose of
ceftriaxone. In the context of hypotension, hyponatremia, and
hyperkalemia, she was treated for presumed adrenal insufficiency
and given dexamethasone 10mg x 1. Her blood pressure initially
responded to 2L NS with systolic blood pressures in the 110's,
but then it decreased to 80's systolic. She received 4 more
liters of normal saline. A central line was placed. Blood
cultures were drawn, U/A showed moderate leukocyte esterase, and
CXR was negative; she was given one dose of ceftriaxone.
.
Past Medical History:
-Remote history of sarcoidosis.
-Status post ventral hernia repair ~15 years ago
-Status post [**Doctor Last Name 7474**] clip to inferior vena cava ~25 years ago
-Status post total abdominal hysterectomy ~25 years ago
-Status post cholecystectomy ~25 years ago
-Chronic atrial fibrillation status post an AVJ ablation with
permanent pacemaker implantation
-Restless Leg Syndrome
-Chronic pancreatitis
.
Social History:
She lives in [**Location 4288**] with her husband. She drinks socially.
She quit smoking 16 years ago after smoking one pack per day.
Denies illicit drug use.
Family History:
Grandfather with DM. No heart disease/cancer.
Physical Exam:
Physical Exam on Admission:
.
VS: T97.0F, BP 89/38, HR 70, RR 17, Sat 97%RA, CVP 15-26
GEN: Pleasant, mildly uncomfortable, no acute distress
HEENT: PERRL, EOMI, anicteric, dry mucous membranes, OP without
lesions
NECK: no supraclavicular or cervical lymphadenopathy, neck veins
flat; RIJ triple lumen catheter in place
RESP: Mild expiratory wheezes bilaterally
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e, warm, 2+ pulses; trace edema bilaterally
SKIN: no rashes/no jaundice
NEURO: Alert and oriented, conversational
.
Physical Exam on Transfer:
PHYSICAL EXAM:
VS: 95.6 112/65 70 16 98% RA
GEN: soft audible wheezing heard, speaking in complete
sentences, pleasant female sitting in bed
HEENT: EOMI, PERRL, NCAT, OP - no exudate, no erythema, MMM
NECK: no LAD, JVP not elevated
RESP: moderate expiratory wheezing in all lung fields, decreased
air movement, no rales/rhonchi
CV: RRR, nl S1, S2, no m/r/g
ABD: NDNT, soft, NABS
EXT: no c/c/e
SKIN: no rashes noted
NEURO: CN II-XII grossly intact
Pertinent Results:
ADMISSION LABS:
================
14.5
8.4 >------< 397
44.5
MCV 84 Neuts 73.6 Lymphs 17.7 Monos 6.5 Eos 1.2 Basos 1.0
.
PT 51.5 PTT 54.5 INR 5.9
.
126 92 50
-----|-----|----< 84
6.1 16 1.7
.
ALT 15 AST 45 Alk Phos 85 Amylase 59 Lipase 91 Bili 0.5
.
UA: large blood, leukocytes moderate, RBC 0-2, WBC 0-2,
bacteria-occ, epi [**2-4**]
.
PH-7.26* GLUCOSE-38* LACTATE-1.4 NA+-138 K+-4.2 CL--110 TCO2-19*
.
PERTINENT LABS DURING HOSPITALIZATION:
======================================
Fibrinogen 504, FDP 0-10
TSH 0.47, T4 5.4, Free T4 0.87
.
[**2182-10-29**] 02:50AM BLOOD Cortsol-27.0*
[**2182-10-29**] 02:51AM BLOOD Cortsol-7.5
[**2182-10-29**] 03:13PM BLOOD Cortsol-30.0*
[**2182-10-29**] 03:13PM BLOOD Cortsol-35.0*
[**2182-10-29**] 03:14PM BLOOD Cortsol-14.6
[**2182-10-29**] 03:34AM BLOOD Cortsol-7.1
[**2182-10-29**] 06:33AM BLOOD Cortsol-30.8*
[**2182-10-29**] 03:14AM BLOOD Type-ART Temp-36.7 pO2-83* pCO2-21*
pH-7.36 calTCO2-12* Base XS--11 Intubat-NOT INTUBA
.
INR trend: 5.9 - 7.3 - 1.7 - 1.4 - 1.4 - 1.7 - 2.4 - 3.5 - 3.8
Cr trend: 1.7 - 0.7 (then stayed around 0.5 - 0.7 throughout
admission)
.
Fe 52 TIBC 178 Ferritin 498 TRF 137
Vit B12 393 Folate 3.4
.
Carotene - pending
Urine histamine - pending
Tryptase - pending
Plasma histamine - pending
.
MICROBIOLOGY:
==============
[**10-28**] Blood Cx - negative
[**10-28**] Blood Cx - negative
.
FECAL CULTURE (Final [**2182-10-31**]):
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final [**2182-10-31**]): NO CAMPYLOBACTER FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2182-10-31**]): NO E.COLI
0157:H7 FOUND.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2182-10-30**]): FECES
NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
VIRAL CULTURE (Preliminary): No Virus isolated so far.
.
[**10-31**] C. Diff negative
[**11-4**] C. Diff negative
.
STUDIES:
=========
CHEST (PORTABLE AP) [**2182-10-28**]
FINDINGS: Supine AP chest radiograph is obtained. A single-lead
pacer device overlies the right chest with lead tip positioned
in the approximate location of the right ventricle. The lungs
appear clear bilaterally, demonstrating no evidence of pneumonia
or CHF. No pleural effusion is seen. Right apical pleural
thickening is again noted. Cardiomediastinal silhouette is
stable. The visualized osseous structures are intact.
IMPRESSION:
No pneumonia.
.
CHEST PORT. LINE PLACEMENT [**2182-10-28**]
FINDINGS: Single bedside AP examination labeled "supine" is
compared with similar examination obtained some 4.5 hours
earlier. There has been interval placement of a right internal
jugular double-lumen central venous catheter with its tip at the
cavo-atrial junction and no supine evidence of pneumothorax. The
overall appearance of the lungs is unchanged, with right more
than left apical pleuroparenchymal scarring but no definite
focal consolidation. The heart size and pulmonary vessels are
probably unchanged with no posteriorly-layering pleural
effusion. The right-sided unipolar cardiac pacemaker has intact
lead with its tip projected over the RV apex (on this single
view).
.
EKG [**2182-10-28**]
Ventricular paced rhythm. Compared to tracing of [**2182-8-23**] no
significant
change.
TRACING #1
.
EKG [**2182-10-29**]
Ventricular paced rhythm. Compared to tracing #1 on [**2182-10-28**] no
significant change.
TRACING #2
.
CHEST (PA & LAT) [**2182-10-31**]
Heart is moderately enlarged, with particular left atrial
dilatation, and both heart size and mediastinal vascular
congestion have increased since supine images taken on [**10-28**]. There has also been an increase in pulmonary vascular
caliber but no pulmonary edema. Lateral view shows small
bilateral pleural effusion, probably new. No focal pulmonary
abnormality is present. Transvenous right ventricular pacer lead
follows the expected course. No pneumothorax.
.
SMALL BOWEL ONLY (BARIUM) [**2182-11-4**]
FINDINGS: Scout KUB is unremarkable, with incidentally noted 6
mm soft tissue calcification overlying the distal tip of the
coccyx, likely correlating with a pelvic phlebolith on CT from
9/[**2181**]. Barium passes freely through the small bowel, entering
the colon within approximately 35 minutes, relatively faster
than expected. Small bowel caliber, contour, and mucosal pattern
are normal. The terminal ileum is unremarkable.
IMPRESSION: Normal small bowel with relatively fast transit of
barium.
Brief Hospital Course:
Ms. [**Known lastname **] is a 69 y.o. F with a history of chronic diarrhea since
[**2182-7-3**], sarcoid, and atrial fibrillation who presented with
weakness, hypotension, hyperkalemia, and hyponatremia, admitted
to the MICU and then transferred to the medicine floor after
stabilization.
.
# Hypotension: Initially considered Ddx of infection/sepsis
(especially given recent UTI, which was pan-sensitive E. coli on
[**2182-10-9**]), adrenal insufficiency (given electrolyte
abnormalities), and hypovolemia. Baseline cortisol was within
normal limits. Was weaned off of pressors on [**10-29**]. Cultures
were negative. Most likely cause of hypotension was hypovolemia
in the setting of severe chronic diarrhea x 4 months.
.
# Acute renal failure: Creatinine 1.7 on admission with baseline
0.3. Most likely secondary to dehydration/hypotension. Given
IVFs. Renal function monitored during hospitalization and
continued to trend towards her baseline Cr.
.
# Chronic Diarrhea: Extensive workup, including CT, ERCP,
colonoscopy, EGD, and TTG that have been performed without clear
source for diarrhea. [**Month (only) 116**] be secondary to chronic pancreatitis or
osmotic causes of diarrhea and malabsorptive disorders,
including lactose intolerance, celiac disease. C. difficile
toxin x 3 was negative. Tincture of opium was used to control
diarrhea. She also had a rectal tube placed as she had
peri-rectal trauma [**1-4**] chronic diarrhea. Once on the floor, GI
was consulted and several lab tests were sent, including urine
and plasma histamine as well as tryptase and carotene, which
were pending on discharge. Additionally, she had an barium
swallow that was essentially negative with some increased
transit time. IVFs for maintenance until pt started taking
adequate po. Strict I/Os maintained. Her rectal tube fell out
during her hospitalization, but by that time, her diarrhea had
slowed down significantly. By time of discharge, she was able to
tolerate po intake without significant stool output. She was
set up with a capsule study as an outpatient. Antidiarrheals
were prescribed for outpatient management. She was instructed
to continue a lactose free diet. She is to follow up with her
gastroenterologist.
.
# Supratherapeutic INR: Anticoagulated for atrial fibrillation.
INR 5.9 on admission and trended up to 7 and was oozing from
peripheral sites. Thought likely due to nutritional deficiency
in addition to recent ciprofloxacin for recent UTI. She was
given FFP and vitamin K , which decreased her INR to 1.7 at
which time her Coumadin was re-started. Her coumadin dose was
increased to 5 mg x 3 days, and then reduced to her normal
maintenance dose. Her goal INR was [**1-5**]. She was
supratherapeutic upon discharge, but was instructed to follow up
with her PCP for an INR check.
.
# Wheezing: Pt was 95% on RA, but on admission to floor, she had
diffuse wheezing. Per pt, no h/o asthma, COPD. CXR showed
increased mediastinal congestion, no edema, and small bilateral
pleural effusions. Nebulizer treatments were continued as needed
with resolution of wheezing.
.
# Chronic diastolic heart failure: Not seen on most recent echo
from [**Hospital1 18**] ([**2176**]).
Consider echocardiogram as outpatient.
.
# Perirectal trauma: Wound Care team consulted and
recommendations were ordered.
.
# Atrial fibrillation: s/p AVJ ablation with pacemaker with
Coumadin for anticoagulation. Coumadin re-started after INR
corrected as above.
# Chronic pancreatitis: Continued enzyme replacement.
.
# Hyperlipidemia: Continued Tricor.
.
# HTN: Hypertensive at baseline. Antihypertensives were held in
the MICU in the setting of hypotension/dehydration. She was
restarted on her antihypertensives as an outpatient except for
her nitroglycerin patch.
.
# F/E/N: IVFs. Repleted lytes PRN. Insulin sliding scale.
.
# PPx: Held bowel regimen given diarrhea, PPI, Coumadin
.
# Code Status: Full Code
.
# Communication: With patient and with daughter and HCP, [**Name (NI) **]
[**Name (NI) 4027**]:
- cell [**Telephone/Fax (1) 99322**]
- home [**Telephone/Fax (1) 99323**]
.
# Access: PIV
.
# Dispo: Home with close follow up for INR. To get capsule
study as outpatient.
Medications on Admission:
Ultram 50mg TID
Nitro patch 0.01mg on 12 hours, off 12 hours
Protonix 50mg Q12H
Aldactone 25mg daily
Tricor 48mg daily
Lisinopril 5mg daily
Atenolol 50mg daily
Lasix 20mg daily
Viokase 4tab TID with meals
Neurontin 1200mg TID
Propythiouracil 100mg [**Hospital1 **]
Topamax 50mg [**Hospital1 **]
Mirapex 1 tab daily
Potassium 20mg daily
Coumadin 1mg daily
.
MEDICATIONS ON TRANSFER:
MEDICATIONS ON TRANFSER
TraMADOL (Ultram) 50 mg PO TID
Pantoprazole 40 mg PO Q12H
Tricor *NF* 48 mg Oral daily
Viokase 8 4 TAB PO TID W/MEALS
Gabapentin 300 mg PO TID
Propylthiouracil 100 mg PO BID
Topiramate (Topamax) 50 mg PO BID
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
Acetaminophen 325-650 mg PO Q6H:PRN
Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 3 Days
Opium Tincture 10 DROP PO Q4H:PRN
Warfarin 1 mg PO DAILY16
Potassium Chloride 40 mEq PO ONCE Duration: 1 Doses
Ondansetron 4 mg IV Q8H:PRN nausea
Prochlorperazine 10 mg IV TID nausea - Give prior meals
Heparin 5000 UNIT SC TID
Discharge Medications:
1. Tramadol 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. Fenofibrate Micronized 48 mg Tablet Sig: One (1) Tablet PO
daily ().
4. Amylase-Lipase-Protease 468 mg Tablet Sig: Four (4) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
6. Propylthiouracil 50 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
7. Topiramate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
8. Opium Tincture 10 mg/mL Tincture Sig: Ten (10) Drop PO Q4H
(every 4 hours) as needed for diarrhea.
Disp:*qs * Refills:*0*
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day:
please do not take your coumadin until Dr. [**Last Name (STitle) 2204**] says it is
okay.
10. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
11. Outpatient Lab Work
Please draw PT, PTT, INR on Wednesday, [**2182-11-6**] and fax
to attn: Dr. [**Last Name (STitle) 2204**] at [**Telephone/Fax (1) 7922**].
12. Mirapex Oral
13. Aldactone 25 mg Tablet Sig: One (1) Tablet PO once a day.
14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
15. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
16. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
17. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
1. Chronic diarrhea of unknown etiology
.
Secondary Diagnosis:
1. Chronic atrial fibrillation status post an AVJ ablation with
permanent pacemaker implantation
2. Chronic pancreatitis
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted for dehydration due to severe, chronic
diarrhea. You were originally in the intensive care unit, but
once stabilized, you were transferred to the medical floor.
During your hospitalization, you were aggressively rehydrated.
The gastroenterologists saw you while you were in the hospital.
A small bowel follow through was performed that was essentially
normal. Some special labs were drawn and are still pending, but
the GI doctors [**Name5 (PTitle) **] follow up on them when you see them in a few
weeks.
.
Please continue your medications as prescribed, except do not
take the nitroglycerin patch you were on until you see your
doctor. Please keep all your medical appointments. You have
been given a prescription for compazine to be used prior to
meals for nausea. Also, you were started on a lactose free diet
while in the hospital. Please continue this diet -- look for
lactose free milk (i.e. Lactaid) and other lactose free dairy
products.
.
You will have your INR checked tomorrow, Wed, [**11-6**] by the
VNA nurses. They will fax your results to Dr. [**Last Name (STitle) 2204**] who will
let you know when you should resume your coumadin.
.
If you have any of the following symptoms, please call your
doctor or go to the nearest ER: fever>101, chest pain, shortness
of breath, extreme lightheadedness/dizziness, abdominal pain,
chronic diarrhea, bright red blood from your rectum, black
stools, or any other concerning symptoms.
Followup Instructions:
You have been scheduled for an outpatient capsule study with Dr.
[**Last Name (STitle) **] on Tuesday, [**2182-11-19**] in the [**Hospital Ward Name 1950**] Building
no the [**Location (un) 453**] at 7:45 AM. Ask for the motility room/GI
suite. The gastroenterologists will mail you information about
the study and how to prepare for it. If you need to reschedule,
please call [**Telephone/Fax (1) 21304**].
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2204**] (Primary Care) [**Telephone/Fax (1) 2205**]. Dr. [**Name (NI) 97886**] office will call you with your appointment, which
will be next week.
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2182-12-25**]
1:30
Completed by:[**2182-11-10**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
[
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8111, 12302
|
289, 342
|
15206, 15216
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,770
| 103,625
|
44711
|
Discharge summary
|
report
|
Admission Date: [**2198-10-2**] Discharge Date: [**2198-10-17**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7881**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
[**Age over 90 **] yo male with known 3v CAD and multiple prior stents who has
previously refused CABG, SSS s/p PPM, and myelodysplasia who
transferred from [**Hospital1 18**]-[**Location (un) 620**] with chest pain.
He has known 3 vessel CAD with a tight LAD lesion found in [**5-31**]
for which stent placement was not thought possible and he
decline CABG. Since then he has had stable angina responsive to
SL NTG that he gets a few times per week. He typically gets
chest pain with exertion or if HCt drops which is frequent due
to MDS. This morning he had chest pain and pressure which was
relieved with SL NTG but recurred approximately 30 minutes
after. He ended up taking 4 SL NTG before presenting to
[**Hospital1 18**]-[**Location (un) 620**]. He reports that the character of his chest pain
is similar to his prior episodes of angina. He has a history of
NSTEMIs and angina in the setting of anemia. He missed his
epogen dose last week, received a dose yesterday. Per his son,
his baseline Hgb is 13.4 and had dropped to 11.4 upon
presentation to [**Location (un) 620**].
He denies any cough, PND, orthopnea. He does endorse peripheral
edema over the past 1 month for which he has been wearing
compression stockings.
At [**Location (un) 620**], his vitals were 66 149/70 18 97% on RA, 94% on RA.
He became chest pain free with a nitro gtt and Lasix. His
troponin was 0.22 which is his baseline. His CXR showed
pulmonary edema. He also recieved aspirin and Plavix. [**Location (un) 620**]
though he had a CHF exacerbation due to crackles on exam. He
was sent here for admission to cardiology and optimization of
his medications. In our ED, basic labs were sent and ECG looked
unchanged from prior (V-paced with TWI in V1-2). He continued
on a nitro gtt. On transfer to the floor, vitals were 98.5 65
153/66 14 100.
He also has new onset of hematuria today. He does not have a
history of recent foley placement. He has a h/o microscopic
hematuria in the past.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
PAST MEDICAL HISTORY:
Macrocytic anemia- dropped Hgb from 10.8->8.5 due to interrupted
erthropoietin therapy
Myelodysplastic syndrome with macrocytic anemia and mild
thrombocytopenia
Right and left upper lobe nodules
Soft tissue density on the lateral left side of the bladder, ?
neoplasia
Parkinsonism
Hypertension
Psoriasis
S/P appendectomy
Glaucoma
Spinal stenosis
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
1. CAD, s/p stents x 3; s/p 2 Palmaz stents to the mid and
distal LCx in [**2185**], s/p Tristar stent to the mid PDA and PTCA to
distal PDA in [**2188**]; EF was 61%.
2. Sick sinus syndrome s/p DDD pacemaker
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: As above
-PACING/ICD: DDD pacemarker
Social History:
Patient lives with his wife of 67 years at home. His children
are very involved in his care, son is a radiologist. He is
retired from real estate business.
-Tobacco history: Remote, smoked x 7 years in the [**2128**]'s
-ETOH: None (occasional use)
-Illicit drugs: None
Family History:
Father died of MI at age 87. Brother and sister both died of
malignancies in middle age. Daughter currently has malignant
glioma, undergoing treatment. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
VS: T 98.1 BP 154/78 HR 70 RR 20 96% RA
GENERAL: Awake, alert, in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 10cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. III/VI systolic murmur. No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. With loud crackles
bilaterally and soft rhonchi L>R.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Admission Labs:
[**2198-10-2**] 04:15PM WBC-10.7 RBC-3.86*# HGB-13.7*# HCT-42.5#
MCV-110* MCH-35.5* MCHC-32.2 RDW-20.9*
[**2198-10-2**] 04:15PM PLT COUNT-168
[**2198-10-2**] 04:15PM PT-14.5* PTT-29.1 INR(PT)-1.3*
[**2198-10-2**] 04:15PM GLUCOSE-129* UREA N-34* CREAT-1.2 SODIUM-141
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-25 ANION GAP-16
[**2198-10-2**] 04:15PM CK(CPK)-132
[**2198-10-2**] 04:15PM cTropnT-0.21*
Other Pertinent Labs:
[**2198-10-12**] 03:20PM BLOOD Thrombn-10.6
[**2198-10-10**] 03:32PM BLOOD Inh Scr-NEG
Studies:
ECG [**2198-10-2**]: Atrial sensed ventricular paced rhythm rate, 77.
There is no other diagnostic interim change.
Chest Xray [**2198-10-2**]: New interval haziness/blunting at the left
costophrenic angle, which could be due to left small pleural
effusion and adjacent small atelectasis at the left lung base;
however, cannot rule out pneumonia.
TTE [**2198-10-3**]:
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with hypokinesis of the
mid inferolateral and anterolateral walls, and distal anterior,
inferior and apical segments. The remaining segments contract
normally (LVEF = 45 %). No masses or thrombi are seen in the
left ventricle. Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic valve leaflets (3) are mildly thickened.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. Mild (1+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is an anterior space which most likely represents a fat pad.
IMPRESSION: Normal left ventricular cavity size with regional
systolic dysfunction suggestive of multivessel CAD. Moderate
pulmonary artery systolic hypertension. Mild mitral
regurgitation.
Chest Xray [**2198-10-4**]: There is interval development of bilateral
perihilar, right more than left, interstitial linear opacities
continuing toward the lung bases, including the bilateral
subpleural linear opacities as seen in particular in the right
lower lobe, findings that are consistent with interval
development of mild-to-moderate pulmonary edema. Cardiomegaly is
moderate and unchanged. There is no interval development of
mediastinal widening. There is no appreciable increase in
pleural effusion, although small amount of right pleural fluid
is most likely present.
Renal Ultrasound [**2198-10-5**]:
1. Normal-sized kidneys without signs of hydronephrosis. Small
nonobstructive right renal stone is noted.
2. Mucosal-based soft tissue nodule in the right posterolateral
bladder wall suggestive of urothelial neoplasm. Further
evaluation with cystoscopy or MRI would be indicated, when
clinical conditions warrant.
3. Enlarged prostate.
Cardiac cath report: Pending at the time of discharge. Patient
had intervention 2 drug eluting stents placed to proximal LAD
using tandem heart intra-procedure.
ECHO [**2198-10-15**]:
Conclusions
Left ventricular wall thicknesses are normal. There is severe
regional left ventricular systolic dysfunction with akinesis of
the inferolateral wall and severe hypokinesis of the mid to
distal anterior wall and septum. Right ventricular chamber size
and free wall motion are normal. Mild mitral regurgitation.
Compared with the prior study (images reviewed) of [**2198-10-3**],
overall ejection fraction has decreased with worsened function
of the anterior wall, anterior septum and anterolateral wall.
Brief Hospital Course:
#. Angina: He presented with acceleration of his typical angina
symptoms and had unstable angina on admission. He has known 3
vessel CAD and he has declined CABG in the past. His medical
regimen was optimized on admission and included Plavix, full
dose ASA, Imdur SR 60 mg by mouth twice daily, metoprolol, and a
high dose statin. His cardiac enzymes fluctuated during this
admission, and he continued to have anginal symptoms
intermittently throughout the hospitalization. These episodes
were typically responsive to sublingual nitro. After many
discussions, the patient and family decided that his quality of
life is unacceptably poor with his current angina. They decided
to proceed with cardiac catheterization for stenting of his
proximal LAD lesion. He was taken to the cath lab and had a
tandem heart used to place 2 DES to his left main coronary
artery and LAD. He had a slight right groin hematoma after
catheterization that remained stable. He was chest pain free
after the procedure.
#. Pump: On admission, he had a history of 1 month of peripheral
edema and he appeared volume overloaded by chest xray at
[**Location (un) 620**]. He had received IV Lasix before transfer and appeared
relatively euvolemic on admission. He had a TTE after admission
which showed preserved systolic function. He had one episode of
hypoxia, shortness of breath, and increasing volume overload on
physical exam that was responsive to IV Lasix. He
intermittently required low doses of Lasix for pulmonary edema
diagnosed by physical exam and chest xray. During cardiac
catheterization, he had an echo that showed decreased LV
systolic function compared to previous with an LVEF of 20-25%.
He should have a repeat ECHO in [**2-26**] weeks now that he has been
revascularized to assess for improvement in function.
#. Anemia/Myelodysplasia: His hemoglobin remained in the
11.0-12.5 range during this admission. There was some concern
for anemia-induced angina, and his hematocrit was maintained
greater than 33. He was transfused a total of 4 units of blood
during and prior to his cardiac catheterization and continued
his outpatient Procrit injections. His anemia was decreased on
the day of discharge and he received an additional unit of prbcs
with resulting post-transfusion Hct of 31.9.
He should likely have a hematocrit drawn in two days to assess
for any continued drop. He had no change in his groin hematoma
and no evidence of retroperitoneal bleed at the time of
discharge.
#. Acute Renal Failure: His creatinine increased from 1.2 on
admission to 2.9 at its peak. The nephrology service was
consulted and his urine lytes were consistent with prerenal
etiology. It was felt that his acute renal failure was due to
poor forward flow in addition to light diuresis. Renal
ultrasound showed no hydronephrosis. He was given one small
fluid bolus (500cc) to improve his creatinine and 2 units of
blood for anemia. He had an additional 2 units during his
catheterization. His creatinine slowly improved prior to his
catheterization. His cardiac catheterization was delayed
somewhat in order for his renal function to improve. He was
given mucomyst and IV fluids prior to catheterization to prevent
contrast nephropathy. His creatinine was 2.1 on discharge. His
urine output should be followed as there is a risk of contrast
induced nephropathy approximately 2 to 3 days after his
catheterization.
#. Elevated PTT: He was started on subcutaneous heparin during
this hospitalization for DVT prophylaxis and his PTT increased
to approximately 70. The SQ heparin was stopped, and his PTT
remained elevated for approximately 5 days after stopping it.
He had a mixing study that was negative for a factor inhibitor
and his thrombin time was normal. The etiology of his elevated
PTT was not entirely clear, but it was not worked up further for
a specific factor deficiency. It continues to decrease at the
time of discharge.
#. Hematuria: He had hematuria on admission and was found to
have a mass in his bladder on renal ultrasound that was thought
to be the cause of his hematuria. The patient and family did
not want this worked up further.
#. Dysphagia: The patient experienced some dysphagia with his
pills and liquids during his hospitalization. This was thought
to be due to deconditioning and was not worked up further and he
was given Ensure Plus for nutritional supplementation. He was
able to tolerate PO and pills for the remainder of his
admission.
#. Code Status: During this hospitalization, his code status was
DNI but he wanted a trial of chest compressions/shocks but did
not want prolonged resuscitation. This was temporarily
suspended during his cardiac catheterization.
Medications on Admission:
Lisinopril 20mg po daily
Toprol XL 75mg po daily
Pravastatin 80mg po daily
ASA 325mg po daily
SL nitro 0.4mg once daily prn
Plavix 75mg po daily
Isosorbide mononitrate SR 60mg twice daily
Vit B Complex 1 tab po daily
Actonel 35mg po daily
Calcium 600 + D3 1 tab daily
Nascobal 500mcg/0.1mL Nasal Gel - 1 spray qweek
Timolol 2 drops twice daily
Cosopt 2%-0.5% Eye Drops - 1 drop at bedtime
Procrit 40,000 unit/mL injection
Colace 100mg
Zofran ODt prn
Flomax 0.4mg po daily
Discharge Medications:
1. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: Three (3)
Tablet Sustained Release 24 hr PO once a day.
2. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest
pain/pressure: Can take every 5 minutes for 3 doses.
5. Clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): Please take this dose for 1 month. Then take 1 tablet
(75mg) daily.
6. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a
day).
7. B Complex Vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
8. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a week:
Please take this medication at the dose and frequency you were
prior to hospitalization.
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
11. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: [**11-24**] Tablet,
Rapid Dissolves PO every 6-8 hours as needed for nausea.
12. Eye Drops Ophthalmic
13. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: One (1)
Tablet PO once a day.
14. Procrit 40,000 unit/mL Solution Sig: One (1) inj Injection
once a week.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] - [**Location (un) 620**]
Discharge Diagnosis:
Primary Diagnosis:
Coronary Artery Disease
Acute on chronic kidney disease
Secondary Diagnosis:
Anemia
Myelodysplasia
Hematuria
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 due to chest pain. You also
had acute renal failure while you were in the hospital that was
thought to be due to poor forward blood flow from your heart.
You were given both IV fluids and diuresis with IV Lasix
intermittently throughout your hospitalization. You also
received 4 units of blood due to anemia.
You underwent cardiac catheterization with Dr. [**Last Name (STitle) **] and had two
drug-eluting stents placed in your coronary arteries. You had a
hematoma (bruise) in your right groin after the procedure which
did not get bigger. You also worked with physical therapy after
this procedure.\
You were found to have a bladder mass on imaging during this
hospitalization that is likely the cause of your hematuria
(blood in your urine). At you and your family's request, we did
not work this up further. Please discuss this with your
outpatient primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **].
CHANGES to your medications:
-Increased Plavix to 150mg by mouth daily (you should take this
dose for one month and then go down to 75 mg daily; please
discuss this with your cardiologist at your next appointment).
-Stopped your lisinopril due to your low blood pressures and
renal failure. This should be restarted once your kidney
function returns to normal. Please discuss this with Dr. [**First Name (STitle) **]
and Dr. [**Last Name (STitle) 120**].
Please take all of your other medications as you were doing
prior to hospitalization.
Followup Instructions:
You should follow-up with your primary care doctor, Dr. [**First Name (STitle) **].
Please call [**Telephone/Fax (1) 95663**] to make an appointment.
In addition, you should follow-up with your cardiologist, Dr.
[**Last Name (STitle) 120**], in the next 2-3 weeks. Please call his office to
schedule an appointment.
|
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icd9cm
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,409
| 138,510
|
3260
|
Discharge summary
|
report
|
Admission Date: [**2183-11-19**] Discharge Date: [**2183-11-25**]
Date of Birth: [**2108-7-20**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Simvastatin / ibuprofen
Attending:[**First Name3 (LF) 4327**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
s/p pulmonary vein isolation (ablation)
pericardiocentesis
right heart catheterization
History of Present Illness:
75yo female with hx of paroxysmal afib since [**2178**]. She has
failed medical management with sotalol with breakthrough
episodes of afib and underwent PVI in [**2181-6-26**]. She was asx since
that time until mid-[**2183-10-7**]. She had a presyncopal episode
with lightheadedness, n/v x1 at church. She was taken to [**Hospital1 **] and was reportedly in afib with HR of 144, per patient.
Dr. [**First Name (STitle) **], her cardiologist at [**Hospital1 **], did a nuclear stress
test, the results of which are not available from his office.
During this hospitalization, she was started on Pradaxa (she had
previously been taking coumadin), and she reports taht she has
been tolerating Pradaxa well. Since discharge from [**Hospital1 **], she
reports feeling of pain in her sternum once or twice, which she
believes is related to her episodes of afib, but says "it may be
my reflux," and she has not had this pain recently. She denies
more syncope or pre-syncope since her presentation to [**Hospital1 **].
.
The patient was referred for PVI today with Dr. [**Last Name (STitle) **]. The
patient tolerated the procedure will initially but then became
hypotensive and was noted to have significant pericardial
effusion but without tamponade physiology. She was started on
neosynephrine in her procedure, 3.8L of IVF.
.
The patient is otherwise in good health and is fully functional
and independent. In the CCU, she is feeling nauseous, which is
how she feels every time she has anesthesia.
.
On review of systems, the patient endorses exertional calf pain.
She also endorses a nonproductive cough, which she relates to
starting diltiazem. She denies any prior history of stroke, TIA,
deep venous thrombosis, pulmonary embolism, bleeding at the time
of surgery, myalgias, joint pains, hemoptysis, black stools or
red stools. She denies recent fevers, chills or rigors. All of
the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, -Hypertension
2. CARDIAC HISTORY:
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: none
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Paroxysmal atrial fibrillation
Arthritis
Osteoporsis
Left total knee replacement [**10/2180**]
Slow to wake from anesthesia
Acid reflux
Tonsillectomy
History of UTI
Syncope/presyncope
Social History:
Lives with husband and adult son but independent in ADLs.
Retired from being a secretary, no home services.
- Tobacco history: denies
- ETOH: rare (3 times per year)
- Illicit drugs: denies
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Mother: deceased of colon ca in her 60s
- Father: deceased of pna in his 70s
- 2 brothers with afib; one with hx of stroke
- 1 brother healthy
- 2 sons healthy in their 40s
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: T=95.6 BP=131/72 HR=92 RR=14 O2 sat= 96% 2L
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP at mid-neck when lying supine. Negative
Kussmaul's
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits. R femoral bandage
blood stained with no ecchymosis.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS
.
[**2183-11-19**] 05:15PM BLOOD Hct-33.6*
[**2183-11-19**] 11:00PM BLOOD WBC-17.7*# RBC-4.26 Hgb-12.4 Hct-38.7
MCV-91# MCH-29.2 MCHC-32.1 RDW-13.5 Plt Ct-334
[**2183-11-19**] 07:00AM BLOOD PT-12.4 PTT-52.4* INR(PT)-1.1
[**2183-11-19**] 11:00PM BLOOD Glucose-141* UreaN-18 Creat-0.7 Na-144
K-4.1 Cl-114* HCO3-20* AnGap-14
[**2183-11-19**] 11:00PM BLOOD Calcium-8.0* Phos-3.9 Mg-1.7
.
PERTINENT LABS AND STUDIES:
[**2183-11-21**] 04:53AM BLOOD Type-ART pO2-138* pCO2-41 pH-7.36
calTCO2-24 Base XS--1
[**2183-11-22**] 07:55AM BLOOD Type-ART Temp-36.1 pO2-60* pCO2-32*
pH-7.49* calTCO2-25 Base XS-1 Intubat-NOT INTUBA
ECHO [**2183-11-19**] 5:30 PM The estimated right atrial pressure is at
least 15 mmHg. Overall left ventricular systolic function is
normal (LVEF>55%). There is a moderate sized pericardial
effusion measuring 1.2-2.0 centimeters that is most prominent
anteriorly and apically. There is no significant transmitral
inflow respiratory variation. There is brief right atriaL
diastolic collapse consistent with possible early tamponade.
IMPRESSION: Moderate pericardial effusion. Signs of increased
pericardial pressure with the suggestion of possible early
tamponade.
.
ECHO [**2183-11-19**] 9PM The estimated right atrial pressure is at
least 15 mmHg. There is a moderate sized pericardial effusion
measuring up to 1.8 centimeters in greatest dimension with
preferential fluid deposition anteriorly and apically. There is
no clinically significant transmitral inflow respiratory
variation. Brief right atrial diastolic collapse is seen.
IMPRESSION: Moderate pericardial effusion. Brief right atrial
diastolic collapse consistent with possible early tamponade.
Compared with the findings of the prior study, the findings are
similar.
.
PERICARDIAL FLUID ANALYSIS [**2183-11-20**] negative for malignant cells
.
ECHO [**2183-11-20**] Overall left ventricular systolic function is
normal (LVEF>55%). There is a moderate sized, echo-dense
pericardial effusion, measuring up to 2 centimeters in greatest
dimension with preferential fluid deposition anteriorly and
apically. There is the suggestion of transient right ventricular
diastolic collapse in some views, consistent with impaired
fillling/tamponade physiology. IMPRESSION: Moderate sized
pericardial effusion with early tamponade physiology. Compared
with the findings of the prior study the RV is smaller and there
is now echocardiographic evidence of early tamponade.
.
PERICARDIOCENTESIS/ RIGHT HEART CATH [**2183-11-20**]
Pericardiocentesis: was performed via the subxyphoid approach,
using an 18 gauge thin-wall needle, a guide wire, and a
drainage catheter. Right heart catheterization: was performed
using a 5F PA catheter advanced through a 5F venous sheath in
the right femoral vein.
.
ECHO [**2183-11-20**] 3:40am The estimated right atrial pressure is at
least 15 mmHg. Overall left ventricular systolic function is
normal (LVEF>55%). Right ventricular chamber size and free wall
motion are normal. There is moderate pulmonary artery systolic
hypertension. There is a very small pericardial effusion. The
effusion appears circumferential. There are no echocardiographic
signs of tamponade. IMPRESSION: Limited study/Focused views.
Very small, circumferential pericardial effusion without
echocardiographic evidence of tamponade. Compared with the prior
study (images reviewed) of [**2183-11-20**], a moderate sized,
circumferential pericardial effusion with echocardiographic
evidence of pericardial tamponade is no longer seen. Moderate
pulmonary artery systolic hypertension is now appreciated; its
absence/presence was not previously assessed.
.
CXR [**2183-11-20**] There is moderate increased in size of the cardiac
sillouethe. The mediastinum is widened. Bilateral pleural
effusions are large, associated with left greater than right
adjacent atelectasis. There is mild vascular congestion. There
is no evident pneumothorax.
.
CT CHEST [**2183-11-20**]
1. Apparent mediastinal widening on the chest radiograph is
explained by
technical factors and mediastinal congestion. No evidence of
meadiastinal
hematoma or mass lesion.
2. Following pericardiocentesis mild pericardial fluid remains,
no evidence of cardiac tamponade.
3. Bilateral, moderate, posteriorly layering pleural effusions
with no
pleural thickening or enhancement, could be partially
hemorrhagic, exudate or longstanding transudate.
.
CXR [**2183-11-21**] 1. Bilateral pleural effusions with interval
increase in left pleural effusion.
2. Slightly increased mediastinal widening. Attention on
followup is
recommended.
3. Mild vascular congestion is slightly improved.
.
CXR [**2183-11-22**] Bilateral pleural effusions obscure cardiac
silhouette. Thus interval change in its size cannot be entirely
assessed, although no substantial change within this limited
assessment is noted. Mediastinal contours are unchanged. Left
and right perihilar opacities most likely represent mild degree
of pulmonary edema.
.
PERICARDIAL FLUID CULTURE [**2183-11-20**]: staph coag neg
BLOOD CULTURE X 2 [**2183-11-21**]: PENDING
URINE CULTURE [**2183-11-21**]: NEGATIVE
STOOL C DIFF [**2183-11-21**]: NEGATIVE
Brief Hospital Course:
75yo female with pmhx of afib, s/p PVI complicated by
pericardial effusion with tamponade physiology requiring
pericardiocentesis with inadvertent access and injection of dye
into the pleural space, now with pleural effusions, pulmonary
edema, leukocytosis.
.
# HYPOXIA AND ACUTE PULMONARY EDEMA: The patient became acutely
short of breath on [**11-20**] requiring NRB. CXR showed pulmonary
edema with pleural effusions. She was diuresed aggressively but
still had oxygen requirement. There was low suspicion for
pneumonia although the patient did have a leukocytosis, as she
had no localizing symptoms and her CXR was more concerning for
fluid overload secondary to aggressive fluids given during
rescicitation for pericardial tamponade. She did have one
pericardial fluid grow coag negative staph but it was thought to
be likely contaminant.
.
# PERICARDIAL EFFUSION: the patient had a sigificant pericardial
effusion with tamponade physiology which formed after PVI. She
received pericardiocentesis and tolerated the procedure well,
the drain was not left in the pericardium as the patient was
experiencing too much pain [**1-8**] the drain. Her pericardial
effusion has not reaccumulated as seen on informal bedside echo
done after the pericardiocentesis. She did have some positional
pain after the pericardiocentesis, which was thought to be [**1-8**]
pericarditis and the patient was started on colchicine.
.
# LEUKOCOTYSIS: the patient has developed a leukocytosis with a
white count from 16 to 22.9 and then trended down to 10.1. One
culture from pericardial fluid growing GPC although clinically
does not appear to have purulent pericarditis. She has been
afebrile. Her UA is negative, blood cultures no growth to date.
Pulmonary source considered given alveolar findings on imaging
and antibiotics were not given.
.
# Atrial Fibrillation: pt has hx of syncope with paroxysmal afib
and has failed medical management. She is s/p PVI and is
currently in sinus rhythm with atrial ectopy. Had 1 hr episode
of [**Month/Day (2) 5509**] likely due to pericardial irritation s/p drainage which
she spontaneously reverted back to NSR. She was restarted on
diltiazem and did have one episode of afib with [**Last Name (LF) 5509**], [**First Name3 (LF) **] her
dilitazem was increased to 180mg daily and sotalol was also
started.
.
CHRONIC CARE:
# Hyperlipidemia: Continue statin and omega3 fatty acids
.
# GERD: continue pantoprazole
.
TRANSITIONS OF CARE ISSUES:
1. At the time of discharge, blood cultures from this admission
were pending but without growth.
2. We stopped Pradaxa and we restarted Warfarin again to pevent
a stroke until you see Dr. [**Last Name (STitle) 15208**] in [**2183-12-7**]. Dr. [**Name (NI) 15209**] [**Hospital3 **] will monitor your INR for the
next month.
3. We increase your Diltiazem to keep your heart rate low and
prevent atrial fibrillation and this will be managed by your
Cardiologist.
4. You will need to use a cardiac event mornitor ([**Doctor Last Name **] of
hearts) again until you see Dr. [**Last Name (STitle) **] in [**2183-12-7**].
5. Please contact [**Name (NI) 15210**] office regarding INR monitoring
when you get home.
Medications on Admission:
ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth at bedtime
DABIGATRAN ETEXILATE [PRADAXA] - (Prescribed by Other Provider)
- 150 mg Capsule - one Capsule(s) by mouth twice a day
DENOSUMAB [PROLIA] - (Prescribed by Other Provider) - 60 mg/mL
Syringe - twice per year Lat dose [**2183-8-7**]
DILTIAZEM HCL - (Prescribed by Other Provider) - 120 mg
Capsule,
Ext Release 24 hr - one Capsule(s) by mouth once a day
PANTOPRAZOLE - (Prescribed by Other Provider) - 40 mg Tablet,
Delayed Release (E.C.) - one Tablet(s) by mouth once a day in am
ASCORBIC ACID - (Prescribed by Other Provider) - 500 mg
Capsule,
Extended Release - 1 Capsule(s) by mouth daily
CALCIUM CARBONATE-VITAMIN D3 - (Prescribed by Other Provider) -
600 mg-400 unit Tablet - 1 Tablet(s) by mouth twice a day
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D] - (Prescribed by Other
Provider) - Dosage uncertain
MAGNESIUM - (Prescribed by Other Provider) - Dosage uncertain
MILK THISTLE - (Prescribed by Other Provider) - Dosage
uncertain
MULTIVITAMIN-MINERALS-LUTEIN [CEROVITE SILVER] - (Prescribed by
Other Provider) - Tablet - 1 Tablet(s) by mouth daily
OMEGA-3 FATTY ACIDS-FISH OIL [OMEGA 3 FISH OIL] - (Prescribed
by
Other Provider) - Dosage uncertain
Discharge Medications:
1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Prolia 60 mg/mL Syringe Sig: One (1) injection Subcutaneous
2x/ year.
3. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO once a
day.
4. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One
(1) Tablet PO twice a day.
5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO once a day.
6. magnesium 250 mg Tablet Sig: One (1) Tablet PO once a day.
7. milk thistle 200 mg Capsule Sig: One (1) Capsule PO twice a
day.
8. Centrum Silver Tablet Sig: One (1) Tablet PO once a day.
9. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO twice a
day.
10. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
Disp:*30 Capsule, Extended Release(s)* Refills:*2*
12. sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
13. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
14. warfarin 1 mg Tablet Sig: One (1) Tablet PO DAYS
([**Doctor First Name **],MO,TU,WE,TH,FR,SA).
Disp:*30 Tablet(s)* Refills:*2*
15. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
16. Outpatient Lab Work
Please check INR, Chem-7 on Friday [**11-28**] with results to
Dr. [**First Name8 (NamePattern2) 565**] [**Last Name (NamePattern1) **]
131 Ornac JCB #800
[**Location (un) 1514**], [**Numeric Identifier 15211**]
Phone: ([**Telephone/Fax (1) 15212**]
Discharge Disposition:
Home
Discharge Diagnosis:
s/p pulmonary vein isolation (ablation)
pericardial tamponade
Atrial fibrillation
GERD
Dyslipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a pulmonary vein isolation (ablation) procedure to treat
your atrial fibrillation. the procedure was complicated by the
accumulation of blood in the pericardial space around the heart.
This blood is now going away but is causing some inflammation
that may be leading to intermittant atrial fibrillation. You
will be on colchicine to treat this inflammation and Sotolol to
prevent atrial fibrillation.
If you have worsening pain in either groin, fevers, chills or
shortness of breath call Dr. [**Last Name (STitle) **].
If you have light headedness or dizziness and think you are in
atrial fibrillation, please use the event monitor to transmit a
strip, lie down on your bed and rest. A cardiology fellow or the
Holter lab will contact you about your rhythm and what to do
next.
.
We made the following changes to your medicines:
1. START Sotolol to prevent atrial fibrillation
2. STOP Pradaxa, start warfarin again to pevent a stroke until
you see Dr. [**Last Name (STitle) 15208**] in [**Month (only) 404**]. Dr.[**Name (NI) **] [**Hospital 3052**] will monitor your INR for the next month.
3. Increase diltiazem to keep your heart rate low and prevent
atrial fibrillation.
.
You will need to use an even mornitor ([**Doctor Last Name **] of hearts) again
until you see Dr. [**Last Name (STitle) **] in [**Month (only) 404**].
.
Please contact [**Name2 (NI) 15210**] office regarding INR monitoring
when you get home.
Followup Instructions:
Department: CARDIOLOGY, DR [**Last Name (STitle) **]
When: THURSDAY [**2183-12-25**] at 4:40 PM
*[**Location (un) 1514**] office*
.
Name: [**Name6 (MD) 15213**] [**Name8 (MD) **], MD
Specialty: Internal Medicine
When: Wednesday [**12-3**] at 10:30am
Address: 131 ORNAC [**Apartment Address(1) 15214**] JCB BLDG, [**Location (un) **],[**Numeric Identifier 15215**]
Phone: [**Telephone/Fax (1) 15216**]
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31,558
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34036+57893
|
Discharge summary
|
report+addendum
|
Admission Date: [**2150-7-4**] Discharge Date: [**2150-7-22**]
Date of Birth: [**2097-10-25**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Pt presented as a trauma after being thrown 60 feet from a boat
at high speeds and landing on land
Major Surgical or Invasive Procedure:
Tracheostomy, Percutaneous Endoscopic Gastrostomy [**7-16**]
Left VATS, converted to thoracotomy with decortication [**7-15**]
History of Present Illness:
Pt was driving boat while intoxicated, ran the boat aground and
was thrown into rocks along the shore. He suffered multiple
broken ribs on the left side, flail chest, and a T3 transverse
process fracture.
Past Medical History:
None
Social History:
The patient works in Quality Assurance for a company that
manufactures metals for jet planes. He has children. Smokes
1ppd, Consumes 1L vodka/day.
Family History:
The patient has 4 sisters. [**Name (NI) **] denies a family history of cancer
or blood disorders.
Physical Exam:
HR 92 BP 148/91 RR 14 Temp-Hypothermic-not registering
HEENT: Left Cheek abrasion
Neck: C collar, on board
CV: RRR
Resp: Clear b/l, Left CT in place
Abd: Distended
GU: nml tone, no gross blood
Ex: 2+ femoral pulses, 2+ DP, L elbow abrasion
Pertinent Results:
[**2150-7-4**] 02:30AM WBC-18.2* RBC-4.30* HGB-13.3* HCT-40.2 MCV-93
MCH-31.0 MCHC-33.2 RDW-14.1
[**2150-7-4**] 02:30AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2150-7-4**] 02:30AM ASA-NEG ETHANOL-136* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2150-7-4**] 02:30AM URINE RBC-[**6-16**]* WBC-[**3-11**] BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2150-7-4**] 02:28AM GLUCOSE-108* LACTATE-4.3* NA+-145 K+-3.2*
CL--110 TCO2-18*
[**2150-7-4**] 02:30AM ASA-NEG ETHANOL-136* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2150-7-4**] 01:06PM TYPE-ART PO2-77* PCO2-43 PH-7.35 TOTAL CO2-25
BASE XS--1
[**2150-7-4**] 06:09AM TYPE-ART PO2-109* PCO2-54* PH-7.20* TOTAL
CO2-22 BASE XS--7
[**2150-7-4**] 05:29AM GLUCOSE-111* UREA N-15 CREAT-0.9 SODIUM-142
POTASSIUM-4.0 CHLORIDE-111* TOTAL CO2-17* ANION GAP-18
Brief Hospital Course:
52 year-old male admitted on [**2150-7-4**] from trauma bay after he
was ejected from his boat. He had been in a high-speed boating
accident. He had been transferred from [**Hospital **] Hospital, where
a chest tube was placed on his left side. Patient was
hemodynamically stable, however imaging at [**Hospital1 18**] revealed that
he had left-sided displaced rib fractures and a T3 transverse
procese fracture. He was alert and oriented and admitted to the
trauma service in the Trauma-ICU.
Upon admission to the T-SICU, the patient had an epidural placed
for pain management, and the chest tube output was observed on a
daily basis. The patient started to shows signs of ETOH
withdrawl on [**7-6**]. On [**7-8**], the chest tube was placed to
waterseal, but the patient displayed a much-increased work of
breathing. The chest tube output considerably dropped on this
day, while the patient's CXRs continued to worsen. The patient
had another chestt ube placed on the left side on [**7-8**] because a
CT scan indicated worsening pleural effusion and left lung
collapse. The old chest tube was removed because it had been
clogged. The patient was then intubated later that same
evening. A bronchoscopy and BAL was performed that same night.
Vanco/Zosyn were started for empiric therapy. Cultures from the
BAL on [**7-8**] revealed the patient had developed a H flu pneumonia.
The vanc/zosyn was d/c'd and the patient was started on
ceftriaxone and naficillin for the pneumonia and for pleural
fluid cultures growing MSSA.
The patient remained on antibiotics throughout the remainder of
his time on [**Hospital1 18**]. Despite the presence of a new chest tube,
the patient had persistent consolidation on CXR. On [**7-13**], the
patient had a repeat CT of the chest, which showed a large
empyema of the left chest. The patient underwent a VATS
converted to open posterolateral thoracotomy and decortication
by Thoracic Surgery on [**7-14**]. On [**7-15**], the patient underwent
placement of a PEG and tracheostomy. A rib specimen was sent to
pathology and found to have a myeloid predominance. Heme/onc
was consulted and felt as though this was likely a reactive
response to MSSA. If his leukocytosis does not normalize with
resolution of his infection, they recommend that the patient be
seen in the outpatient hematology clinic for further evaluation.
At that time, they would consider performing a bone marrow
biopsy for pathologic review, flow cytometry, and cytogenetic
analysis.
From [**7-15**] to [**7-20**], the patient's chest tubes were managed in the
T-SICU. The posterior chest tube was removed on [**7-18**], and on
[**7-20**], the anterior chest tube was converted to an empyema tube.
The patient's tube feeds were at goal rate on [**7-20**], and the
patient's vent settings were at a PEEP of 5 and pressure support
of 10. The patient worked with physical therpy and occupational
therapy during his time in teh T-SICU. He was moveing all
extremities and communicating with the T-SICU staff on the day
of discharge. The plan for the antibiotics was to complete a
6-week coarse for the empyema.
Medications on Admission:
None
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
4. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q6H (every 6 hours) as needed.
Disp:*2 MDI* Refills:*0*
5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q6H (every 6 hours).
Disp:*2 MDI* Refills:*2*
6. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
11. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed.
Disp:*400 ML(s)* Refills:*0*
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
13. Labetalol 300 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
15. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
Disp:*30 Tablet(s)* Refills:*2*
16. Diazepam 5 mg/mL Syringe Sig: One (1) mL Injection Q6H
(every 6 hours) as needed for anxiety. mL
17. Furosemide 10 mg/mL Solution Sig: Forty (40) mg Injection
[**Hospital1 **] (2 times a day). mg
18. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2)
grams Intravenous Q6H (every 6 hours) for 6 weeks: On week 2 of
6 week course scheduled to end [**2150-8-20**].
Disp:*31 * Refills:*0*
19. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours) for 6 weeks: One week
2 of 6 week course scheduled to end on [**2150-8-20**].
Disp:*31 doses* Refills:*0*
20. Labetalol 5 mg/mL Solution Sig: Two (2) mg Intravenous Q4H
(every 4 hours) as needed. mg
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
1. Fractures of the left second through tenth rib, with two
separate
fractures involving ribs three through eight, leading to a flail
chest.
2. Lung contusion caused by medial displacement of left fifth
rib.
3. Left Scapula Fracture
4. Bilateral loculated pleural effusion left >> right, left
evolving to empyema
5. Thrombus in the left cephalic vein
Discharge Condition:
Minimal vent settings, tolerating tube feeds, pain is well
controlled.
Discharge Instructions:
Diet: Tubefeeding- Replete w/fiber Full strength;
Starting rate: 25 ml/hr; Advance rate by 25 q4h Goal rate: 100
ml/hr
Residual Check: q4h Hold feeding for residual >= : 250
Flush w/ 30 ml water q4h
Abx: You will need to complete a 6 week course of Naficillin and
Ceftriaxone. Scheduled to end [**2150-8-20**]
L-scapula fracture-patient's arm to remain in sling if needed
for comfort and non weightbearing.
Followup Instructions:
-Please call the office of Dr. [**Last Name (STitle) **] (trauma surgery)
[**Telephone/Fax (1) 2981**] to make a followup appointment in the next [**1-7**]
weeks.
Please call the office of Dr. [**First Name (STitle) **] (thoracic surgery) at
[**Telephone/Fax (1) 170**] to make a follow up appointment for 2-3 weeks. You
will need a chest x ray on the day of your appointment. Please
present to [**Location (un) **] of the [**Hospital Ward Name 23**] building for a chest x ray
30 min prior to your appointment
-Heme/Onc-If patient's leukocytosis does not improve with
resolution of empyema, he will need to be seen in outpatient
Heme/[**Hospital **] clinic for further evaluation.
-Ortho-L scapula fracture-Please call [**Telephone/Fax (1) 1228**] to schedule
an outpatient appointment with orthopedics after you have been
discharged from rehab.
Name: [**Known lastname 12662**],[**Known firstname **] W. Unit No: [**Numeric Identifier 12663**]
Admission Date: [**2150-7-4**] Discharge Date: [**2150-7-22**]
Date of Birth: [**2097-10-25**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 203**]
Addendum:
The patient was evaluated by speech therapy on [**2150-7-21**] with the
passe-muir valve in place. The patient passed his bedside
swallow eval and was permitted to take honey-thickened liquids
and pureed foods as a result.
Patient was started on ASA 325 mg q day for high platelet count
on [**7-21**], and his lasix dose was decreased to 20 mg [**Hospital1 **].
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 2314**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 206**] MD [**MD Number(1) 207**]
Completed by:[**2150-7-21**]
|
[
"V64.41",
"453.8",
"811.00",
"861.21",
"510.9",
"518.81",
"038.9",
"807.4",
"805.2",
"511.8",
"995.92",
"482.2",
"E831.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"38.93",
"96.72",
"43.11",
"33.24",
"96.6",
"34.51",
"31.1",
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
10210, 10445
|
2256, 5388
|
413, 542
|
8051, 8124
|
1360, 2233
|
8582, 10187
|
985, 1084
|
5443, 7552
|
7676, 8030
|
5414, 5420
|
8148, 8559
|
1099, 1341
|
275, 375
|
570, 776
|
798, 804
|
820, 969
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,486
| 143,586
|
48455
|
Discharge summary
|
report
|
Admission Date: [**2198-3-7**] Discharge Date: [**2198-3-22**]
Date of Birth: [**2133-2-22**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Adhesive Tape
Attending:[**First Name3 (LF) 10370**]
Chief Complaint:
Respiratory Distress
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
64 year old man with ESRD from FSGS on hemodialysis, CAD
w/stent, CHF with EF 25-30%, HTN and poorly differentiated
cancer (likely NSCLC) with mets to vertebrae who was recently
admitted to [**Hospital Unit Name 153**]/wards in [**1-/2198**] and early [**2-10**] for persistent
respiratory distress who presents with recurrent respiratory
distress. History is taken from records as patient is
intubated. Per report of his caregiver, the patient had not
been doing well at home. He had increasing shortness of breath
and fatigue. He had stopped eating and was not taking any of
his medications. There was no report of fevers, chills, chest
pain. However, his caregiver had noticed occational cough with
blood tinged sputum of uncertain amounts. They were in the
process of arranging hospice care but had not made any final
decisions regarding his overall plan of care. The patient went
to dialysis today but was noted to be dyspneic and short of
breath. There was also noted to be blood tinged cough. EMS
called and he was noted to be lethargic. He was put on a NRB
and reportedly felt better. He was taken to the ED.
In the ED, T 96.6, HR 70, BP 130/82, RR 24, 100%NRB. EKG
unchanged from prior. CXR with ? pulm edema/infiltrate. He was
given Vanco/Levo, as well as [**Month/Year (2) **]. He subsequently became more
tachypneic and lethargic. He was therefore intubated. A L
sublcavian CVL was placed for transient hypotension during
intubation. Initial lactate 7.3, BNP >70K.
Past Medical History:
#. Onc HX: [**12-11**] pre-renal transplant CT scan chest noted
enlarged RML nodule, w/ subcentimeter FDG avid scattered lymph
nodes. Developed neck pain and found to have C2 pathological
fracture, [**11-22**] cytology demonstrated poorly differentiated
carcinoma. Likely non-small cell lung carcinoma, with RML mass
and metastasis to the cervical and sacral spine. The only
manifestation of his disease currently is cervical neck pain,
s/p pathologic fracture and posterior cervical arthrodesis C1-C3
and palliative XRT.
#. Left Common Femoral DVT: small non-occlusive, possibly
chronic DVT and started on coumadin for a goal INR [**1-7**] in [**1-/2198**]
#. CAD s/p angioplasty D1 [**7-10**] and stents to OM2/3 in [**3-11**]
#. ESRD secondary to FSGS on HD (MWF)
#. Hypertension
#. LLE peroneal nerve palsy [**1-6**] GSW to L leg
#. Thalassemia trait
#. h/o Substance abuse (heroin/cocaine); reports none since [**2163**]
#. CHF w/ EF 35% in [**11-11**], EF 25-30% on [**Date Range 113**] [**2198-1-23**]
#. MR - 2+ on [**Month/Day/Year 113**] in [**11-11**]; now found to be 3+ MR [**First Name (Titles) **] [**Last Name (Titles) 113**]
#. Pathological C2 Fx s/p C1-3 Fusion
#. Parotiditis - [**12-12**] (levo/flagyl)
#. CDiff - [**12-12**]
#. HCV - grade 1 inflammation and stage 0 fibrosis on bx [**2-9**]
Social History:
Lives with wife, has 2 sons, used to work in construction, +
smoker 1 PPD for many years quit recently, rare ETOH, no drugs.
Family History:
Brother with CAD, and kidney disease requiring hemodialysis
Physical Exam:
VS: T 97.5, BP 120/76, HR 77, RR 16, 100% AC 550/14, PEEP 5,
Fi02 0.5
Gen: AA male sedated in bed, intubated with neck collar
HEENT: ET tube in place, cervical collar in place, unable to
assess JVP given collar.
Chest: brace over portion of back. bronchial BS bilaterally with
bibasilar crackles, no wheezes
Heart: RRR, normal S1/S2, soft HS, no m/r/g
Abd: Soft, non-tender, non-distended + bowel sounds
Back: Unable to assess given intubated
Ext: No clubbing, cyanosis, edema; 1+ DP pulses bilaterally, L
AV fistula intact, no peripheral edema.
Neuro: sedated, pinpoint pupils, could not assess sufficiently
Pertinent Results:
[**2198-3-7**] 01:30PM PT-45.4* PTT-38.7* INR(PT)-5.1*
[**2198-3-7**] 01:30PM PLT COUNT-252
[**2198-3-7**] 01:30PM NEUTS-88.3* LYMPHS-8.4* MONOS-2.6 EOS-0.6
BASOS-0.1
[**2198-3-7**] 01:30PM WBC-12.1*# RBC-3.45* HGB-8.5* HCT-27.7*
MCV-80* MCH-24.5* MCHC-30.6* RDW-19.2*
[**2198-3-7**] 01:30PM CALCIUM-9.9 PHOSPHATE-5.5*# MAGNESIUM-1.9
[**2198-3-7**] 01:30PM CK-MB-NotDone proBNP-GREATER TH
[**2198-3-7**] 01:30PM cTropnT-0.15*
[**2198-3-13**] 05:50AM BLOOD WBC-19.4* RBC-3.82* Hgb-9.4* Hct-30.2*
MCV-79* MCH-24.5* MCHC-31.0 RDW-19.9* Plt Ct-231
[**2198-3-22**] 06:00AM BLOOD WBC-19.9* RBC-4.53* Hgb-10.7* Hct-35.4*
MCV-78* MCH-23.6* MCHC-30.3* RDW-19.0* Plt Ct-340
[**2198-3-7**] 01:30PM BLOOD PT-45.4* PTT-38.7* INR(PT)-5.1*
[**2198-3-22**] 06:00AM BLOOD PT-23.4* PTT-27.7 INR(PT)-2.3*
[**2198-3-7**] 01:30PM BLOOD Glucose-142* UreaN-39* Creat-5.3* Na-140
K-5.6* Cl-94* HCO3-26 AnGap-26*
[**2198-3-22**] 06:00AM BLOOD Glucose-84 UreaN-27* Creat-3.5*# Na-135
K-4.4 Cl-94* HCO3-29 AnGap-16
[**2198-3-7**] 01:30PM BLOOD CK(CPK)-27*
[**2198-3-8**] 03:00AM BLOOD CK(CPK)-13*
[**2198-3-9**] 05:20AM BLOOD ALT-59* AST-57* LD(LDH)-332* AlkPhos-92
TotBili-0.6
[**2198-3-15**] 08:50AM BLOOD CK(CPK)-8*
[**2198-3-15**] 05:30PM BLOOD CK(CPK)-18*
[**2198-3-7**] 01:30PM BLOOD cTropnT-0.15*
[**2198-3-8**] 03:00AM BLOOD CK-MB-NotDone cTropnT-0.14*
[**2198-3-15**] 08:50AM BLOOD CK-MB-NotDone cTropnT-0.17*
[**2198-3-15**] 05:30PM BLOOD CK-MB-NotDone cTropnT-0.16*
[**2198-3-22**] 06:00AM BLOOD Calcium-10.2 Phos-3.6 Mg-1.6
[**2198-3-7**] 10:32PM BLOOD Type-ART pO2-219* pCO2-44 pH-7.50*
calTCO2-36* Base XS-10
[**2198-3-15**] 08:18AM BLOOD Type-ART pO2-79* pCO2-45 pH-7.50*
calTCO2-36* Base XS-9
[**2198-3-7**] 01:48PM BLOOD Glucose-132* Lactate-7.3* K-5.5*
[**2198-3-7**] 02:40PM BLOOD Glucose-120* Lactate-5.0*
[**2198-3-7**] 10:32PM BLOOD Lactate-1.5
[**2198-3-15**] 08:18AM BLOOD Lactate-1.0
Blood Culture [**3-7**]:
Blood Culture, Routine (Final [**2198-3-15**]):
SENSITIVITIES REQUESTED BY DR. [**Last Name (STitle) 16800**] #[**Numeric Identifier 35351**]
[**2198-3-13**].
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY.
FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
Please contact the Microbiology Laboratory ([**6-/2496**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SECOND MORPHOLOGY.
ISOLATED FROM ONE SET ONLY. FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
Please contact the Microbiology Laboratory ([**6-/2496**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
ERYTHROMYCIN---------- =>8 R =>8 R
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN---------- 0.25 S 0.25 S
OXACILLIN-------------<=0.25 S <=0.25 S
PENICILLIN G----------<=0.03 S <=0.03 S
Repeat Blood Cultures all negative
Urine Cx [**2198-3-16**]
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
Sensitivity testing performed by Sensititre.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ 8 S 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
LINEZOLID------------- 1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TETRACYCLINE---------- 8 I
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- 2 S
VANCOMYCIN------------ =>128 R
C Diff negative x 2
CXR [**3-7**]:
Endotracheal tube is in standard position. Nasogastric tube has
been advanced into the stomach, and left internal jugular
catheter has been withdrawn slightly, terminating at the
junction of the left brachiocephalic vein and superior vena
cava. Cardiac silhouette remains enlarged, but there has been
improvement in the degree of pulmonary edema. Residual airspace
opacities remain more prominent in the right lower lobe than the
left, and likely represent asymmetric edema although a
coexisting pneumonia is also possible in the appropriate
clinical setting. Radiodensity overlying the upper mediastinum
is reportedly related to prior vertebroplasty procedure.
AV fistula ultrasound [**3-8**]:
Patent left upper arm arteriovenous fistula without thrombus.
**TTE [**2198-3-8**]:**
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
moderately dilated. There is severe global left ventricular
hypokinesis (LVEF = 25-30%). The right ventricular cavity is
mildly dilated with mild global free wall hypokinesis. There are
three aortic valve leaflets. The aortic valve leaflets are
moderately thickened. No masses or vegetations are seen on the
aortic valve. There is no aortic valve stenosis. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Moderate (2+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
IMPRESSION: No evidence of endocarditis. Dilated left ventricle
with severe global systolic dysfunction. Mild right ventricular
systolic dysfunction. Mild aortic regurgitation. Moderate mitral
regurgitation.
Compared with the prior study (images reviewed) of [**2198-1-23**],
the findings are similar, although regionality of LV dysfunction
is less apparent on today study - LV systolic dysfunction now
looks global.
CXR [**3-15**]:
As compared to the previous examination, the right-sided
pulmonary opacities appear less dense but more widespread than
on the previous examination. They are no longer confined to the
perihilar areas but diffusely distribute in the entire lung. In
the interval, the retrocardiac atelectasis has slightly
increased in extent. Otherwise, the radiographic appearance is
unchanged, there is no evidence of pleural effusion. There is
unchanged moderate cardiomegaly with subtle signs of
overhydration, in unchanged manner, radiopaque material projects
over the trachea.
Brief Hospital Course:
64 year-old M with ESRD on HD, CAD, metastatic poorly
differentiated cancer (likely NSCLC), s/p vertebroplasty
presenting with acute respiratory failure.
Brief MICU course:
The patient was admitted to the ICU for respiratory failure,
which appeared to be subacute process over several days.
Symptoms were thought to be related to fluid overload given that
the patient missed dialysis on day of admission and CXR was most
consistent with pulmonary edema. (There was a question of a RML
infiltrate, but the patient had no F/C or cough with only mild
leukocytosis.) PE was not felt to be likely given
supratherapeutic INR. ACS was not felt to be likely as EKG and
cardiac enzymes were stable (althouh CE were elevated [**1-6**] renal
insufficiency). The patient symptoms resolved after HD, and he
was transferred to the floor in stable condition with breathing
at baseline (2L O2 for comfort).
UTI:
The patient developed fevers and leukocytosis after his transfer
to the floor. He was initially treated with vancomycin for
possible coagulase negative staph bacteremia. When his repeat
blood cultures failed to grow any bug, the coag negative staph
was thought to be a contaminant. He was switched to
levofloxacin because of concern for pneumonia, but urine
cultures (patient makes a minimal amount of urine daily) ended
up growing E coli and vancomycin resistant enterococcus. Based
on these cultures, his antibiotic was changed to linezolid
(ampicillin was not used because he is penicillin allergic). He
should be continued on linezolid until [**4-3**].
Pump/CHF:
The patient had acute on chronic systolic dysfunction, EF
25-30%. He had signs of fluid overload on CXR, and responded
well to HD, as above. He was continued on a BB and ACEI, as
above.
CAD:
The patient has a history of CAD s/p MI. As above, the patient
was ruled out for acute MI with stable EKG and cardiac enzymes.
The patient was continued on [**Month/Year (2) **], [**Month/Year (2) **], BB, ACE-I, and Imdur.
HTN:
The patient was continued on home antihypertensives with no
acute issues. Given that his BP was well-controlled without
nifedipine, his nifedipine was stopped.
ESRD:
The patient was continued on HD on M/W/F schedule with no acute
issues.
His Phoslo (Calcium acetate) was stopped because of
hypercalcemia, most likely due to his underlying malignancy. A
PTH related peptide was sent and results were pending at the
time of discharge. His phos should be monitored after discharge
and phosphate binders such as sevelamer can be started at the
discretion of his nephrologist.
Metastatic NSCLC:
The patient has metastatic NSCLC with metastases to bone. Prior
plan was to have patient be transitioned to hospice care. The
patient was seen by his primary oncology team and the palliative
care team inhouse, and despite multiple conversations about
hospice, the patient did not feel ready to change his code
status to DNR/DNI. He understands that his best option to go
home is to change his code status and transition to hospice
care. For the present, he is choosing to continue full care and
dialysis, and is therefore being discharged to rehab.
Vertebral fractures:
The patient has a history of C2 fracture s/p C1-C3 fusion and T4
compression fracture s/p vertebroplasty. [**Location (un) 2848**] J collar was
continued, though he is often non-compliant with his collar.
Orthotics was [**Name (NI) 653**], and they confirmed that his collar is
appropriately fitted. The patient was encouraged to wear his
collar as much as possible.
Gluteal ulcers:
Wound care was consulted for recommendations to care for the
patient's ulcers. He was provided care per their
recommendations.
Pain:
Mostly in his neck secondary to the pathologic fractures. The
patient's oxycontin and oxycodone were increased to improve his
pain control. He was also started on standing tylenol, and his
need for the standing dose should be reevaluated over the
upcoming weeks.
DVT:
The patient was continued on coumadin, which was briefly held on
admission for supratherapeutic INR. At the time of discharge,
his INR was therapeutic on his present dose. His INR should be
monitored closely.
Anemia:
The patient has a history of anemia, most likely [**1-6**] renal
disease. Hct remained at baseline of 28-30 with no evidence of
bleeding. He continued to receive Epo with dialysis.
Code: FULL for now. Had extensive discussion with patient's
spouse and HCP [**Name (NI) 102021**] regarding goals of care. The patient
and his spouse understand that he has the option to pursue care
with hospice if he changes his code status.
Medications on Admission:
Calcium Acetate 667 mg PO TID W/MEALS
B Complex-Vitamin C-Folic Acid 1 mg Daily
Ipratropium Bromide 1 inh QID
Guaifenesin (15) ML PO Q6H
Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Inh q4-6
Metoprolol Tartrate 50 mg PO BID
Isosorbide Mononitrate 30 mg PO DAILY
Docusate Sodium 100 mg PO BID
Senna 8.6 mg PO BID
Pantoprazole 40 mg PO Q24H (every 24 hours).
Lisinopril 10 mg PO DAILY
Nifedipine 30 mg PO DAILY
Acetaminophen 500 mg PO Q6H
Epoetin Alfa 10,000 unit/mL HD
Gabapentin 300 mg PO DAILY
Warfarin 2 mg PO
[**Name (NI) **] 75 mg PO Daily
Lidocaine 5 % DAILY to neck
Oxycodone 5 mg PO q 3 hours prn
Simvastatin 20 mg PO once a day.
OxyContin 10 mg q8
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for neck pain: leave on for 12 hours, then take off for
12 hours.
9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours).
11. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once
Daily at 16).
15. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO please
give once daily on dialysis days only. do not give on days the
patient does not have dialysis.
16. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) for 2 weeks.
17. Epoetin Alfa 10,000 unit/mL Solution Sig: 10,000 units
Injection at hemodialysis.
18. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 13 days: last dose due on [**4-3**].
19. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours): hold if
sedated or RR < 10.
20. Oxycodone 20 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for Pain: hold if patient is sedated or RR < 10.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis: Respiratory Failure
Secondary Diagoses: End Stage Renal Disease, Urinary Tract
Infection, Metastatic Lung Cancer, Acute on Chronic Systolic
Heart Failure, Coronary Artery Disease, History of DVT on
anticoagulation
Discharge Condition:
Breathing improved with sat's in 90s on room air to 2L by nasal
cannula.
Discharge Instructions:
You were admitted with respiratory failure, most likely due to
too much fluid in your lungs. You were given dialysis and the
extra fluid was removed. You also were found to have a urinary
tract infection. You were given antibiotics and your fevers
improved.
1. Please take all medications as prescribed.
2. Please attend all follow-up appointments listed below.
3. Please call your doctor or return to the hospital if you
develop fevers greater than 101F, difficulty breathing, chest
pain, shaking chills, or any other concerning symptom.
4. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
***Medication changes***
Started:
Aspirin 81mg daily
Tylenol at 1000mg three times a day
Linezolid 600mg every twelve hours (until [**4-3**])
Stopped:
Nifedipine
Calcium acetate (Phoslo)
Guaifenesin
Increased dose of:
Oxycontin to 20mg every twelve hours
Oxycodone to 20mg every 4 hours as needed for pain.
Followup Instructions:
You have an appointment with your primary doctor:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10477**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2198-3-27**] 9:50
Completed by:[**2198-3-25**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"96.04",
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icd9pcs
|
[
[
[]
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19071, 19141
|
11643, 16243
|
309, 321
|
19420, 19495
|
4048, 11620
|
20498, 20731
|
3343, 3404
|
16953, 19048
|
19162, 19162
|
16269, 16930
|
19519, 20475
|
3419, 4029
|
249, 271
|
349, 1847
|
19182, 19399
|
1869, 3185
|
3201, 3327
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,743
| 196,558
|
44869
|
Discharge summary
|
report
|
Admission Date: [**2107-7-6**] Discharge Date: [**2107-7-13**]
Date of Birth: [**2031-7-16**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / Shellfish Derived
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
L arm swelling and neck pain
Major Surgical or Invasive Procedure:
Left Knee Arthrocentesis
Left brachiocephalic catheterization for clot removal *2
Left brachiocephalic infusion of Alteplase for to treat clot
History of Present Illness:
75 y.o M with recently diagnosed stage III B colon CA, recently
started on chemotherapy presents with L neck discomfort x 2 days
found to have L arm swelling. US + for LIJ clot and sent to ED.
Otherwise no SOB, CP. No sx. H/o L subclavian port. CTA in ED
negative for SVC syndrome. Guiac negative and negative head CT
C1D23 FOLFOX with last dose on [**2107-6-28**].
.
Constitutional: []WNL [+] 20 lb Weight loss [+]Fatigue/Malaise
[-]Fever [-]Chills/Rigors []Nightweats [+]Anorexia
-Eyes: [X]WNL []Blurry Vision []Diplopia []Loss of Vision
[]Photophobia
-ENT: [X]WNL []Dry Mouth []Oral ulcers []Bleeding gums/nose
[]Tinnitus []Sinus pain []Sore throat
-Cardiac: []WNL [-]Chest pain [-]Palpitations [-]LE edema
[-]Orthopnea/PND [-]DOE
-Respiratory: []WNL [-]SOB [-]Pleuritic pain [-]Hemoptysis
[-]Cough
-Gastrointestinal: []WNL [+]Nausea [-]Vomiting [+]Abdominal
pain- mild discomfort at site of surgery [-]Abdominal Swelling
[+]Diarrhea - 1 loose BM q am[-]Constipation [-]Hematemesis
[-]Hematochezia [-]Melena
-Heme/Lymph: [X]WNL []Bleeding []Bruising []Lymphadenopathy
-GU: [X]WNL []Incontinence/Retention []Dysuria []Hematuria
[]Discharge []Menorrhagia
-Skin: [X]WNL []Rash []Pruritus
-Endocrine: []WNL []Change in skin/hair []Loss of energy [+]Cold
intolerance
-Musculoskeletal: []WNL []Myalgias [+]Chronic b/l Foot and L
Knee Arthralgias []Back pain
-Neurological: [ ]WNL [-]Numbness of extremities [-]Weakness of
extremities [-]Parasthesias [-]Dizziness/Lightheaded [-]Vertigo
[-]Confusion [-]Headache
-Psychiatric: [X]WNL []Depression []Suicidal Ideation
-Allergy/Immunological: [X] WNL []Seasonal Allergies
All other ROS negative
Past Medical History:
Oncologic History:
stage IIIB colon cancer with 1 LN/9 +ve in [**4-/2107**] when he
presented with 6 months of of stomach discomfort, bloating,
distension and gas.
Started FOLFOX on [**2107-6-15**]
Other PMH.
HTN
Gout
stage 3 disease kidney disease
abdominal aortic aneurysm
Social History:
Mr. [**Known lastname 487**] is married and lives in [**Location 47**]. He previously
worked as a salesman for a printing business. He retired three
years ago. This is his second marriage. He has 3 children from
his previous marriage and his son is here with him today. He
only
smoked cigarettes for a few months, but drinks several glasses
of
wine each night. He was previously in the Army.
Family History:
His family history is notable in that his mother passed away
from
"old age" at 100 and his father died of heart disease at age 63.
He has five siblings, once of whom died of colon cancer at age
50. He does not know anything else about his family history as
he
is not close with his siblings. He does not know of any other
family history of cancer
Physical Exam:
VS: T = 97.6 P = 76 BP = 126/80 RR = 18 O2Sat = 98%on RA Wt, ht,
BMI
GENERAL: Well appearing male who looks younger than his stated
age.
Nourishment: good.
Grooming: Well groomed
Mentation: Alert, speaks in full sentences.
Eyes:NC/AT, EOMI without nystagmus, no scleral icterus noted
Ears/Nose/Mouth/Throat: MMM, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated. L neck
swelling
Respiratory: Lungs CTA bilaterally without R/R/W
Cardiovascular: RRR, nl. S1S2, no M/R/G noted
Chest: L port site with mild erythema
Gastrointestinal: soft, NT/ND, normoactive bowel sounds, no
masses or organomegaly noted. Well healed midline abdominal
incision
Genitourinary:
Skin: Very heavily suntanned. Multiple moles.
Extremities: L arm edema, 2+ radial, pulses b/l. L DP pulse not
appreciated manually but appreciated with doppler. 2+ R DPP
appreciated. L foot dusky red and but warm.
Lymphatics/Heme/Immun: No cervical, lymphadenopathy noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-sensory: No deficits to light touch throughout.
- Gait, walks with a limp of his left foot but states that this
is secondary to chronic foot problems.
[**Name (NI) **] foley catheter/tracheostomy/PEG/ventilator support/chest
tube/colostomy
Psychiatric: WNL but slightly anxious.
Pertinent Results:
Labs on Admission [**2107-7-6**]
WBC-5.1 RBC-3.96* Hgb-11.7* Hct-34.1* MCV-86 MCH-29.5 Plt Ct-247
Neuts-54.9 Lymphs-27.8 Monos-14.3* Eos-2.3 Baso-0.6
PT-12.5 PTT-24.4 INR(PT)-1.1
UreaN-18 Creat-1.5* Na-136 K-4.0 Cl-98 HCO3-27 AnGap-15
ALT-12 AST-19 AlkPhos-83 TotBili-0.8 DirBili-0.2 IndBili-0.6
TotProt-6.8 Albumin-4.3 Globuln-2.5 Calcium-9.5
D-Dimer-7973*
TSH-2.0
calTIBC-220* VitB12-817 Folate-GREATER TH Ferritn-552* TRF-169*
.
Labs on Discharge [**2107-7-13**]
WBC-3.7* RBC-2.99* Hgb-8.9* Hct-25.8* MCV-86 MCH-29.9 Plt Ct-174
Neuts-55.2 Lymphs-30.4 Monos-10.3 Eos-3.8 Baso-0.3
PT-16.8* PTT-137.7* INR(PT)-1.5*
Glucose-122* UreaN-16 Creat-1.1 Na-143 K-3.0* Cl-109* HCO3-25
AnGap-12
ALT-31 AST-68* AlkPhos-62 TotBili-0.3
Calcium-8.3* Phos-2.2* Mg-1.5*
.
Other Studies:
[**2107-7-6**] Left Venous Upper Extremity: There is acute thrombus
involving the left internal jugular vein. Though patency of the
subclavian, axillary, and brachial veins is identified, there is
loss of phasicity involving the left subclavian vein which would
suggest a more central high-grade stenosis or occlusion, such as
at the brachiocephalic level.
[**2107-7-6**] CT head w/ w/o: 1. No acute intracranial process.
2. No evidence for metastatic disease. MRI is more sensitive for
small
metastases.
[**2107-7-6**] CT Chest w/: 1. Thrombosis of the left internal jugular
vein, left brachiocephalic vein (along the catheter), but no
evidence of SVC thrombosis. 2. Prominence of the ascending aorta
measuring up to 4.2 cm.
3. Incomplete evaluation of atrophic right kidney, multiple
renal cysts, and post-surgical changes involving the transverse
colon.
4. Fluid filled structure adjacent to the pancreatic head may
represent a
small bowel loop, though this region is incompletely imaged
(2:74); cannot
exclude other etiologies for this fluid collection. Recommend
clinical
correlation.
[**2107-7-7**] LLE U/S: No evidence of left lower extremity deep vein
thrombosis.
[**2107-7-7**] L foot x-ray: Three views show no evidence of acute
fracture or dislocation. There is some hypertrophic spurring
dorsally consistent with degenerative change. Substantial
inferior and posterior calcaneal spurs are seen.
[**2107-7-8**] MRI/MRA chest: Occlusion of the left internal jugular,
subclavian, and brachiocephalic vein extending to within 1 cm of
the brachiocephalic/SVC junction.
[**2107-7-11**] EKG: Sinus rhythm. Baseline artifact. Compared to the
previous tracing of [**2107-6-8**] the tracing remains normal without
diagnostic interim change.
[**2107-7-12**] Unilateral subclavian venogram: Persistent clot in
subclavian, although patency improved. Discussed findings with
radiologist. Final read pending.
Brief Hospital Course:
The patient is a 75 year old male with a history of stage III
CKD, HTN, gout recently diagnosed with stage III B colon CA s/p
colectomy C1D23 of FOLFOX who presented with L neck swelling x 2
days along with L arm swelling found to have a L IJ clot.
.
# LIJ Deep venous thrombosis: Probably secondary to underlying
malignancy and catheter. The patient was treated with Heparin IV
and [**Month/Day/Year 95979**]. He was taken to IR for thrombus removal, but IR
was unable to completely remove the clot. However, they stented
his subclavian and he had improved patency. His [**Last Name (un) 90921**]-a-cath can
still be used. He was discharged on Lovenox for at least 3
months. His oncologist will determine the ultimate lenght of
anticoagulation treatment.
# HTN: Decrease lisinopril to 5 mg for now given patient's
decreased po intake, weight loss
.
# Gout: The patient complained of left knee pain. A joint tap
showed many nuetrophils and elevated white count. He was treated
with antibiotics until his cultures confirmed no bacterial
growth. By that time, his knee pain improved and there was no
need to start steroids. We continued him on his home dose of
colchicine.
# Stage III B Colon CA: C1D23 FOLFOX. The patient will have
follow up with his oncologist.
.
# Code status:
FULL code but patient is clear that he would not like a
prolonged attempt at resuscitation if it meant that he could not
have the quality of life and independence that he has now.
Medications on Admission:
Colchicine 0.6 mg Tablet 1 Tablet(s) by mouth daily
Lisinopril 10 mg Tablet 1 Tablet(s) by mouth daily - he has not
taken for 2 days
Prochlorperazine Maleate 10 mg Tablet one Tablet(s) by mouth
every 4-6 hours for nausea
Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for NAUSEA.
Disp:*60 Tablet(s)* Refills:*0*
3. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) mg
Subcutaneous Q12H (every 12 hours).
Disp:*14 syringes* Refills:*0*
5. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain for 5 days.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Angels at Home
Discharge Diagnosis:
PRIMARY:
Blood Clot in the left internal jugular, subclavian, and
brachiocephalic vein
Left Knee Gout
SECONDARY:
Hypertension
Chronic Kidney Disease, Stage III
Discharge Condition:
Stable
Discharge Instructions:
You were admitted due to a clot in your left arm and chest. This
clot was treated with a clot [**First Name5 (NamePattern1) 18701**] [**Last Name (NamePattern1) 95979**] and blood thinner
heparin. You also underwent two procedures to attempt to remove
the clot. Much of the clot has been removed, but some remains.
You will need to be on a medication called Lovenox for at least
3 months.
You were also found to have an exaccerbation of your gout in the
left knee. You have improved on colchicine. You should follow-up
with Dr. [**Last Name (STitle) 2903**] to discuss this issue.
If you develop fevers, vomiting, abdominal pain, chest pain,
shortness of breath, increased swelling in your left arm or any
other concerning symptom please go to the Emergency Room.
MEDICATION CHANGES:
Your lisinopril has been decreased to 5mg daily.
You were started on lovenox for your blood clot.
You have been provided with hydrocodone/tylenol pill for your
knee pain. Please do not drive while taking this medication.
Followup Instructions:
Please follow-up with Nurse [**Name6 (MD) **] FELT, RN
Phone:[**Telephone/Fax (1) 22**] On Date/Time:[**2107-7-20**] 11:00AM in [**Hospital Ward Name **]
CENTER, [**Location (un) **].
Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2903**] on [**2107-7-27**] at
11:45AM [**State **]Office. You need to talk to him soon
and be sure that he knows that you need a pre-authorization form
for your Lovenox sent to your insurance company in order to get
more than a 10 day supply. We let his office know this
information.
Please follow-up with Nurse [**Name6 (MD) **] FELT, RN
Phone:[**Telephone/Fax (1) 22**] On Date/Time:[**2107-7-27**] 8:00AM in [**Hospital Ward Name **]
CENTER, [**Location (un) **].
You will have VNA services with Angels at Home, [**Telephone/Fax (1) 6538**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
Completed by:[**2107-7-13**]
|
[
"403.90",
"996.74",
"274.9",
"453.8",
"196.2",
"153.9",
"585.3",
"734",
"441.4",
"285.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10",
"00.41",
"88.67",
"39.50",
"81.91"
] |
icd9pcs
|
[
[
[]
]
] |
9748, 9793
|
7383, 8846
|
316, 461
|
9998, 10007
|
4680, 7360
|
11063, 12045
|
2855, 3203
|
9118, 9725
|
9814, 9977
|
8872, 9095
|
10031, 10798
|
4284, 4661
|
3218, 4188
|
10818, 11040
|
248, 278
|
489, 2130
|
4203, 4267
|
2152, 2429
|
2445, 2839
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,847
| 123,701
|
28098
|
Discharge summary
|
report
|
Admission Date: [**2130-11-11**] Discharge Date: [**2130-11-28**]
Date of Birth: [**2095-7-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
fever, malaise
Major Surgical or Invasive Procedure:
[**2130-11-16**] AVR ( [**Street Address(2) 11688**]. [**Male First Name (un) 923**] Regent mechanical)/ pericardial
patch repair of annular abscess
History of Present Illness:
This is a 35 y/o male without signif PMH who p/w fever, chills,
and progressive myalgias x 15 days. His symptoms were a/w
dizziness, palpitations, nausea, body aches, and back pain. He
also had night sweats and poor appetite. He was seen at [**Hospital 11507**] Clinic, where he was told he had the flu and given
tylenol and instructed to take in good fluids, which he did. His
symptoms persisted, and 4 days later he was evaluated at
[**Hospital 8**] hospital, where he was again told he had the flu.
Finally a friend referred him to her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], whom he met
on Wednesday. Blood and urine tests were performed and he was
given cipro, which he took on Wed and Thurs. He represented to
Dr. [**Last Name (STitle) **] on Friday where he was told he had a urinary
infection. His antibiotics were switched to amoxicillin. On
Friday night, after taking amox, he developed a new cough,
pleuritic chest pain, and shortness of breath. He went to the
bathroom, had diarrhea x1, and also vomited x 1 (? hemoptysis,
brown-red). These symptoms were new from his previous
fevers/chills/myalgias picture. He was again seen at his PCP's
office today, where temp was 103.2, and by report he looked
unwell. Complained of CP, and was referred to the ED.
.
In ED: 99.5 115 133/55 22 97%RA. Exam showed bilateral basilar
crackles with diaporesis. Possible pericardial rub. No abdominal
tednerness. No pulsus. Labs were significant for CK 1000 MB 10.3
Trop 0.62. WBC count 22.0. LFTs mildly elevated. Laxtate 1.5.
EKG showed sinus tachy with very minimal ST depressions in
V4-V6. Cards was consulted and felt presentation was most c/w
viral myocarditis. Cards fellow performed echo, which showed
probable mild hypokinesis of the apex and distal anterior wall
and mild mitral regurgitation. Blood cultures were drawn and her
received vanc and levo for possible PNA. Pt also received ASA x
1 and lipitor. Dr.[**First Name (STitle) **] was consulted for vegetation on the
aortic valve and valvular replacement secondary to endocarditis.
Blood Cx came back positive for Staph coag neg. He was scheduled
for the OR [**11-16**]. During the overnight period prior to surgery,
Mr.[**Known lastname 13119**] [**Last Name (Titles) 68039**] with acute pulmonary edema. He was
intubated and emergently taken to the OR for an AVR.
Past Medical History:
remote kidney infection
Social History:
Originally from El [**Country 19118**], immigrated in [**2114**]. Works at [**Company 68326**] in fruit division. Non smoker, occasional EtOH. Denies
IVDU. Lives in [**Location (un) **] with family.
Family History:
DM in mom and brother. Aunt with Breast CA
Physical Exam:
5'9" 126.4 kg
VS: 99.8 115 116/43 38 94% 2L --> 96% on 4L
GEN: big young diaphoretic male in NAD
HEENT: NC/AT. MM slightly dry. O/P clear.
NECK: JVP elevated to below angle of jaw. No bruits
COR: tachycardic and regular, unable to appreciate any m/r/g
PULM: crackles at L base otherwise CTAB
ABD: obese S/NT/ND + BS
EXT: WWP, trace edema
NEURO: A+O x 3, grossly non-focal
Pertinent Results:
PRE-BYPASS:
1. No atrial septal defect is seen by 2D or color Doppler.
2. Overall left ventricular systolic function is severely
depressed (LVEF= 15 %).
3. The aortic root is mildly dilated at the sinus level. The
aortic valve is bicuspid. There is no aortic valve stenosis.
Severe (4+) aortic regurgitation is seen. Endocarditic lesions
are noted on both cusps and in the aortic root. Both cusps are
completely destroyed.
4. The mitral valve leaflets are structurally normal. An
eccentric, posteriorly directed jet of Mild to moderate ([**2-1**]+)
mitral regurgitation is seen.
5. There is a trivial/physiologic pericardial effusion.
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] was notified in person of the results.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including Phenylephrine and
Epinephrine
1. A mechanical Valve is well seated in the Aortic position.
Leaflets open well, trace washing jets are noted. No significant
AI. Peak Gradient about 15 mm of Hg.
2. LV function is slightly improved. RV function is unchanged.
3. Aorta is intact post decannulation.
4. Other findings are unchanged.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician [**Last Name (NamePattern4) **] [**2130-11-16**] 09:07
[**Known lastname **],[**Known firstname **] [**Medical Record Number 68327**] M 35 [**2095-7-30**]
Radiology Report CHEST (PA & LAT) Study Date of [**2130-11-27**] 10:46
AM
[**Last Name (LF) **],[**First Name3 (LF) **] TSURG FA6A [**2130-11-27**] SCHED
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 68328**]
Reason: evaluate pleural effusions and atelectasis
[**Hospital 93**] MEDICAL CONDITION:
35 year old man with s/p AVR (endocarditis)
REASON FOR THIS EXAMINATION:
evaluate pleural effusions and atelectasis
Final Report
REASON FOR EXAMINATION: Followup of a patient after aortic valve
replacement.
PA and lateral upright chest radiograph was reviewed in
comparison to multiple
prior chest radiographs dating back to [**2130-11-11**].
The post-sternotomy wires are unremarkable. The replaced aortic
valve is in
expected position. There is no significant short interval change
in bibasilar
atelectasis and small pleural effusion. No evidence of failure
is present on
the current radiograph. There is no pneumothorax or apical
hematoma.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: MON [**2130-11-27**] 1:58 PM
[**2130-11-28**] 02:18AM BLOOD WBC-9.6 RBC-3.58* Hgb-10.5* Hct-30.9*
MCV-87 MCH-29.2 MCHC-33.8 RDW-14.3 Plt Ct-676*
[**2130-11-27**] 12:32PM BLOOD Neuts-69.7 Lymphs-17.3* Monos-7.6
Eos-4.9* Baso-0.4
[**2130-11-28**] 02:18AM BLOOD Plt Ct-676*
[**2130-11-28**] 02:18AM BLOOD PT-30.2* INR(PT)-3.1*
[**2130-11-28**] 02:18AM BLOOD Glucose-104 UreaN-17 Creat-1.2 Na-133
K-4.2 Cl-98 HCO3-28 AnGap-11
[**2130-11-28**] 02:18AM BLOOD Vanco-24.9*
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 68329**]Portable TTE
(Complete) Done [**2130-11-27**] at 4:31:16 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
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: [**2095-7-30**]
Age (years): 35 M Hgt (in): 69
BP (mm Hg): 111/71 Wgt (lb): 268
HR (bpm): 95 BSA (m2): 2.34 m2
Indication: Ao valve Endocarditis. S/p #23 [**Hospital3 9642**] AVR.
ICD-9 Codes: V43.3, 424.0, 424.2
Test Information
Date/Time: [**2130-11-27**] at 16:31 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) 4082**], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**Name2 (NI) 27490**]
[**Last Name (un) 27491**]
Doppler: Full Doppler and color Doppler Test Location: West CCU
Contrast: None Tech Quality: Suboptimal
Tape #: 2008W053-0:55 Machine: Vivid [**8-7**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.3 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.8 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.5 m/s
Left Atrium - Peak Pulm Vein D: 0.7 m/s
Right Atrium - Four Chamber Length: *6.0 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Sinus Level: 3.5 cm <= 3.6 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aorta - Arch: 3.0 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.4 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *2.9 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *34 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 18 mm Hg
TR Gradient (+ RA = PASP): <= 20 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2130-11-17**].
LEFT ATRIUM: Normal LA and RA cavity sizes.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA.
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Low
normal LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Paradoxic septal motion consistent with prior cardiac surgery.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels. Normal descending aorta diameter. No 2D or Doppler
evidence of distal arch coarctation.
AORTIC VALVE: Bileaflet aortic valve prosthesis (AVR). AVR well
seated, normal leaflet/disc motion and transvalvular gradients.
Trace AR. [The amount of AR is normal for this AVR.]
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality - bandages, defibrillator pads or
electrodes. Suboptimal image quality as the patient was
difficult to position. Suboptimal image quality - body habitus.
Conclusions
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size normal.Overall left
ventricular systolic function is low normal (LVEF 50-55%). Right
ventricular chamber size and free wall motion are normal. A
bileaflet aortic valve prosthesis is present. The aortic valve
prosthesis appears well seated, with normal leaflet/disc motion
and transvalvular gradients. Trace aortic regurgitation is seen.
[The amount of regurgitation present is normal for this
prosthetic aortic valve.] The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Well seated bileaflet
aortic valve prosthesis with normal function. Mild mitral
regurgitation.
Compared with the prior study (images reviewed) of [**2130-11-17**],
biventricular systolic function is improved and the heart rate
is slower.
CLINICAL IMPLICATIONS:
Based on [**2129**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis IS recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2130-11-27**] 16:51
Brief Hospital Course:
Admitted from ER [**11-11**]. Blood cultures were sent, cardiology
consulted and an echo was done. Diagnosed with myopericarditis.
Diuresed for pulmonary edema and vanco/gent/cipro continued for
gram positive bacteremia. TEE done [**11-13**] showed bicuspid AV,
severe AI with flail leaflet,and root abscess. PR interval
became prolonged. Dental consult and repeat echo done.Scans
planned to evaluate for septic emboli, but had worsening AI on
echo [**11-15**]. Early AM [**11-16**] developed hypoxia necessitating
urgent intubation, and hypotension requiring pressor support.
Brought emergently to the OR and underwent surgery with Dr.
[**First Name (STitle) **]. Flagyl started for C. diff. Transferred to the CVICU on
Epinephrine, Phenylephrine, Milrinone and Propofol drips to
optimize BP and CO/CI, as Mr.[**Known lastname 13119**] was very vasodilated due
to bacteremic sepsis. Adequate oxygenation required high levels
of PEEP. He initially remained febrile, and surveillance Cxs
were obtained. He remained on Vanco/Gentamicin for coag negative
staph endocarditis, and Flagyl for C. diff. Over the next
several days all inotropes and pressors were weaned to off.
Mr.[**First Name (Titles) **] [**Last Name (Titles) 5058**] neurologically intact, following commands to
verbal cues. POD#3 all sedation was weaned off in an attempt to
possibly extubate. His weaning trial ultimately failed at that
time. He was sedated again and rested with continued aggressive
diuresis. POD#4 CXR showed LLL collapse and he was bronched
therapeutically in the hope of optimizing a successful
extubation. Minimal secretions were noted and all airways were
patent. TTE performed at bedside showed anterior hypokinesis,
unchanged from the previous echo performed on #1, with an LVEF
~25-30%. He was eventually re-extubated on POD 6. The patient
was transferred to the step down unit on POD 8. He made
excellent progress with physical therapy, showing good strength
and balance. He was gently diuresed toward his preoperative
weight. Blood cultures dated [**2130-11-21**] showed no growth. Per
infectious disease recommendations, the patient will be
contninued on vancomycin for six weeks post-op as well as
flagyl.
He had a repeat echo on [**11-27**] which showed the prosthetic valve
is seated well and his EF has improved to 50-55%. He was
discharged to rehab in stable condition on POD#12.
stop [**11-21**]
Medications on Admission:
occasional ibuprofen
cipro ([**11-8**] - [**11-9**])
amoxicillin x 1 ([**11-10**])
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed.
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): Continue while on Vanco. End date:[**12-28**].
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
9. Vancomycin 1,000 mg Recon Soln Sig: 1250 (1250) mg
Intravenous Q 12H (Every 12 Hours): Complete 6 week course. End
date is: [**2130-12-28**].
10. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Titrate for INR goal of 3. Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
s/p AVR/ patch repair of annular abscess
endocarditis
AI
aortic annular abscess
C. diff.
acute diastolic heart failure
Discharge Condition:
good
Discharge Instructions:
shower daily and pat incisions dry
no lotions, creams, or powders on any incision
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100, redness, or drainage
Followup Instructions:
see Dr. [**Last Name (STitle) **] in [**2-1**] weeks
see Dr. [**Last Name (STitle) **] ( cardiology) in [**3-5**] weeks
see Dr. [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appt.
Dr. [**Last Name (STitle) 438**] [**Telephone/Fax (1) 457**] (infectious disease) 3 weeks
weekly CBC, BUN, Cr, LFTs as well as vanc trough faxed to
[**Telephone/Fax (1) 432**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2130-11-28**]
|
[
"746.4",
"998.0",
"719.96",
"424.1",
"790.92",
"428.31",
"429.89",
"276.3",
"421.0",
"518.5",
"276.1",
"038.19",
"427.41",
"285.9",
"995.91",
"427.89",
"008.45",
"V16.3",
"E878.1",
"428.0",
"790.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.64",
"96.72",
"99.62",
"96.05",
"99.07",
"81.91",
"96.04",
"88.72",
"35.22",
"38.93",
"31.42",
"35.99",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
15009, 15088
|
11433, 13837
|
337, 489
|
15251, 15258
|
3605, 5381
|
15514, 16032
|
3152, 3196
|
13971, 14986
|
5421, 5465
|
15109, 15230
|
13863, 13948
|
15282, 15491
|
3211, 3586
|
10994, 11410
|
283, 299
|
5497, 10971
|
517, 2873
|
2895, 2920
|
2936, 3136
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,266
| 117,907
|
8684
|
Discharge summary
|
report
|
Admission Date: [**2182-7-2**] Discharge Date: [**2182-7-4**]
Date of Birth: [**2113-2-28**] Sex: M
Service: MEDICINE
Allergies:
Doxycycline
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
69M PMH ESRD on HD, DM, MIx2, CHF, s/p CABG, p/w fall at home
[**2-4**] weakness and lack of strength. Recent admit to [**Hospital1 18**] early
[**2-6**] with fall, found to be febrile and confused, with pus
expressed near the AV fistula. AV graft felt to be infected and
thrombosed, blood cultures + for MSSA. Admitted to ICU,
vancomycin then oxacillin, with course complicated by decr O2
sat. TEE neg, MRI + cellulitis, - osteo. A MRI of the L shoulder
was - for osteo but ? for septic emboli in lungs. AV graft was
partially removed. During this time, the pt also experienced a
TC seizure. LP, CT EEG were all negative. He was loaded on
dilantin and d/c'd per neuro. While septic, he also experienced
an NSTEMI, incr INR to 4 with neg DIC panel that was responsive
to Vit K, and increased LFT/GGT with neg US. He was d/c'd on 4
weeks of cefazolin. He then returned on [**2-/2107**] with f/c, cough and
SOB. He developed resp distress and was intubated,
vanco/ceft-->ox/ceft for PNA. BAL with 2+ poly but cx neg. He
had pleural effusion, which when tapped revealed transudate. On
this admission, he denied LOC, f/c, cough, CP.
Past Medical History:
ESRD--HD
Kyrle's dz
DM
CHF, EF 20%
CABG [**2164**]
MI x 2--[**2173**], [**2180**]
Afib
Anemia
PVD
CVA
? protein S def
Sz in setting of sepsis
septic AV graft
Social History:
+ tobacco for 50 years
Family History:
NC
Physical Exam:
V: T 100.4 HR 122 AF BP 119/75 (dop/levo) AC 600x12 1.0 Sat
93% PEEP 5
G: Intubated, sedated
HEENT: Intubated, anicteric sclerae, MM dry, PERRL
Lungs: CTA BL
CV: [**Last Name (un) **] S1S2, III/VI SM loudest at apex, no radiation
Abd: Soft, NT, ND, No rebound
Ext: BL blue toes, chronic vascular changes, BL pulses by
doppler, L forearm erythema, AV fistula
Neuro: withdraws to pain B, Babinski neg BL
Pertinent Results:
[**2182-7-4**] 03:42AM BLOOD WBC-21.4* RBC-4.66 Hgb-15.0 Hct-46.6
MCV-100* MCH-32.1* MCHC-32.1 RDW-15.5 Plt Ct-127*
[**2182-7-3**] 06:07PM BLOOD WBC-19.1* RBC-4.46* Hgb-14.4 Hct-44.0
MCV-99* MCH-32.2* MCHC-32.6 RDW-15.6* Plt Ct-141*
[**2182-7-3**] 08:14AM BLOOD WBC-20.2* RBC-4.66 Hgb-14.9 Hct-45.4
MCV-97 MCH-31.9 MCHC-32.7 RDW-15.7* Plt Ct-121*
[**2182-7-3**] 01:25AM BLOOD WBC-20.5* RBC-4.63 Hgb-14.7 Hct-46.0
MCV-99* MCH-31.7 MCHC-31.9 RDW-15.7* Plt Ct-138*
[**2182-7-2**] 08:00PM BLOOD WBC-18.1* RBC-4.71 Hgb-14.8 Hct-46.4
MCV-99* MCH-31.3 MCHC-31.8 RDW-15.6* Plt Ct-115*
[**2182-7-2**] 02:43PM BLOOD WBC-14.2* RBC-4.10*# Hgb-13.3*# Hct-40.3#
MCV-99* MCH-32.6* MCHC-33.1 RDW-15.8* Plt Ct-90*#
[**2182-7-2**] 02:43PM BLOOD Neuts-72* Bands-10* Lymphs-16* Monos-0
Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0
[**2182-7-4**] 03:42AM BLOOD Plt Ct-127*
[**2182-7-3**] 06:07PM BLOOD Plt Ct-141*
[**2182-7-3**] 08:14AM BLOOD Plt Ct-121*
[**2182-7-3**] 01:25AM BLOOD Plt Ct-138*
[**2182-7-3**] 01:25AM BLOOD PT-14.3* PTT-32.4 INR(PT)-1.4
[**2182-7-2**] 08:00PM BLOOD Plt Ct-115*
[**2182-7-2**] 08:00PM BLOOD PT-15.5* PTT-31.3 INR(PT)-1.6
[**2182-7-2**] 02:43PM BLOOD Plt Smr-LOW Plt Ct-90*#
[**2182-7-2**] 02:43PM BLOOD PT-26.5* PTT-36.1* INR(PT)-4.6
[**2182-7-2**] 08:00PM BLOOD Fibrino-378
[**2182-7-4**] 03:42AM BLOOD Glucose-151* UreaN-64* Creat-8.5* Na-133
K-6.8* Cl-95* HCO3-16* AnGap-29*
[**2182-7-3**] 06:07PM BLOOD Glucose-132* UreaN-55* Creat-8.1* Na-134
K-5.4* Cl-95* HCO3-17* AnGap-27*
[**2182-7-2**] 02:43PM BLOOD Glucose-90 UreaN-35* Creat-7.0*# Na-134
K-4.8 Cl-97 HCO3-21* AnGap-21*
[**2182-7-2**] 08:00PM BLOOD ALT-17 AST-27 LD(LDH)-263* AlkPhos-153*
TotBili-0.9
[**2182-7-4**] 03:42AM BLOOD Calcium-6.9* Phos-9.6*# Mg-1.6
[**2182-7-3**] 08:14AM BLOOD Calcium-7.4* Phos-8.0* Mg-1.4*
[**2182-7-3**] 01:25AM BLOOD Calcium-7.0* Phos-6.9* Mg-1.4*
[**2182-7-2**] 08:00PM BLOOD Albumin-3.0* Calcium-7.1* Phos-5.9*
Mg-1.3*
[**2182-7-3**] 06:07PM BLOOD Cortsol-24.6*
[**2182-7-3**] 05:42PM BLOOD Cortsol-19.6
[**2182-7-3**] 01:25AM BLOOD Cortsol-23.1*
[**2182-7-3**] 08:14AM BLOOD Vanco-10.0*
[**2182-7-4**] 03:58AM BLOOD Type-MIX pO2-42* pCO2-51* pH-7.13*
calHCO3-18* Base XS--13
[**2182-7-3**] 07:40PM BLOOD Type-MIX pO2-48* pCO2-44 pH-7.26*
calHCO3-21 Base XS--6
[**2182-7-3**] 06:06PM BLOOD Type-ART pO2-115* pCO2-34* pH-7.34*
calHCO3-19* Base XS--6
[**2182-7-3**] 08:30AM BLOOD Type-MIX Temp-38.0 Rates-[**12-13**] Tidal
V-500 PEEP-5 O2-40 pO2-46* pCO2-46* pH-7.29* calHCO3-23 Base
XS--4 -ASSIST/CON Intubat-INTUBATED
[**2182-7-3**] 02:38AM BLOOD Type-ART Temp-37.4 Rates-[**12-11**] Tidal V-500
PEEP-5 O2-50 pO2-189* pCO2-33* pH-7.36 calHCO3-19* Base XS--5
-ASSIST/CON Intubat-INTUBATED
[**2182-7-3**] 01:34AM BLOOD Type-MIX Temp-37.4 Rates-[**12-11**] Tidal V-500
PEEP-5 O2-50 pO2-42* pCO2-45 pH-7.29* calHCO3-23 Base XS--4
-ASSIST/CON Intubat-INTUBATED
[**2182-7-2**] 05:33PM BLOOD Type-MIX pO2-37* pCO2-46* pH-7.35
calHCO3-26 Base XS-0
[**2182-7-4**] 03:58AM BLOOD Glucose-168* Lactate-7.1* Na-133* K-6.8*
Cl-97* calHCO3-18*
[**2182-7-3**] 08:30AM BLOOD Lactate-2.1*
[**2182-7-3**] 02:38AM BLOOD Lactate-1.8
[**2182-7-3**] 01:34AM BLOOD Lactate-1.9
[**2182-7-3**] 12:20AM BLOOD Lactate-1.8
[**2182-7-2**] 06:18PM BLOOD Lactate-1.9
[**2182-7-2**] 02:44PM BLOOD Lactate-2.8*
[**2182-7-4**] 03:58AM BLOOD Hgb-15.6 calcHCT-47 O2 Sat-60
[**2182-7-3**] 08:30AM BLOOD O2 Sat-72
[**2182-7-3**] 01:34AM BLOOD O2 Sat-69
[**2182-7-2**] 05:33PM BLOOD O2 Sat-66
[**2182-7-4**] 03:58AM BLOOD freeCa-1.05*
Brief Hospital Course:
Pt admitted to ICU. Intubated.
1. Septic shock: GPC thought to be from line infection vs a
pulmonary source. He was started on Vanco CTX, and Gent, with
requirement of pressor support for hypotension. Renal was
consulted and a decision was made to attempt to treat without
pulling the line. The patient was weaned off of pressors.
Discussion with the patient's girlfriend revealed that he had
been having large volume diarrhea prior to being found on the
floor. Further discussion with surgery ensued and pt was slated
to go to the OR on [**7-4**] for evaluation of the infected graft
stump.
In early AM on [**7-4**], pt found to be in asystole. Immediately
started on pressors and IVF for hypotension. Rhythm changed to
Vtach, labs sent and pt found to have hyperkalemia, started on
Bicarb, Insulin, glucose. Rhythm returned to asystole, code
called, pt pronounced deceased at 4:10AM.
Medications on Admission:
Plavix, oxycontin, lisinopril, Imdur, Metoprolol, Lipitor,
Protonix, Neurontin, Amiodarone
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Sepsis
Discharge Condition:
deceased
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"482.49",
"038.19",
"E947.9",
"250.01",
"286.9",
"427.31",
"995.91",
"289.81",
"414.00",
"427.5",
"440.24",
"403.91",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.71",
"96.04",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
6718, 6727
|
5655, 6547
|
286, 292
|
6777, 6924
|
2132, 5632
|
1687, 1691
|
6689, 6695
|
6748, 6756
|
6573, 6666
|
1706, 2113
|
238, 248
|
320, 1450
|
1472, 1631
|
1647, 1671
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,180
| 189,606
|
33695
|
Discharge summary
|
report
|
Admission Date: [**2112-8-2**] Discharge Date: [**2112-8-8**]
Date of Birth: [**2030-4-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Tachypnea and possible aspiration
Major Surgical or Invasive Procedure:
Thoracentesis
PEG tube placement
History of Present Illness:
82 y/o M with h/o HTN, diabetes, atrial fib, recent CVA, s/p
subtotal colectomy for large LGIB [**3-/2112**] with long hospital
course at [**Hospital1 18**] and d/c to rehab. Since departure patient has
had inability to swallow and became lethargic the last couple
days. Also hypoventilation became an issue for unclear etiology.
In this setting patient underwent CTA chest on [**7-30**] which showed
no evidence for PE, but did show atelectasis and large left
sided effusion which appeared as an unchanged effusion .
Lethargy improved off seroquel. Still hypoventilating, was
evaluated by ENT, nothing wrong with trach site, vocal cords
moving well, received few doses of decadron. Concern was for
recurrent aspiration and Dr. [**Last Name (STitle) **] tried doing PEG tube. No
BiPap in last 24 hours.
He was recently admitted to [**Hospital3 3383**] ICU for chief
complaint of altered mental status and his ICU stay was from
[**7-25**]-present. The patient had some intermittent bouts of
delerium and insomnia which have been reasonably controlled with
Seroquel and medication adjustments. He had marked hypercalcemia
on [**2112-7-28**] which was attributed to immobilization and this
hypercalcemia was thought to be partly responsible for some of
his confusion and altered mentation. This was treated with some
bisphosphonates to encourage bone Calcium reabsorption. During
the same timeframe the patient experienced a dramatic drop in
his oxygen saturations from high 90s down to 75% which improved
once he was placed on 5L O2 via NC. He had a BP 174/84, HR 120
RR26 at this time and was c/o SOB. On exam he had decreased lung
sounds at bases and was coughing up white sputum. BP peaked at
192/84 and RR increased to 38. ABG was pH 7.12/103/87 and
patient placed on BIPAP 25/5 with 60% FiO2, he then became
hypotensive and got IVFs to restore his BP. He recovered and was
placed on NC with oxygen sats returning to 90s. Pt had
hypernatremia over last few days treated w/free water flushes.
Noteable studies: He had CXR which showed no signs massive
aspiration but atelectasis on LLL and additional Chest CT showed
left pleural effusion. Sputum culture showed gram negative rods
on prelim report. C. diff culture was negative and EKG showed HR
86, early repolarization which was an older finding. LENIs
showed no DVTs and CTPA was clear of any PEs. Heand and neck CT
also doen during his stay and showed tracheal scars but no other
abnormalities in airway.
.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
melena, hematochezia, chest pain, shortness of breath,
orthopnea, PND, lower extremity edema, cough, urinary frequency,
urgency, dysuria, lightheadedness, gait unsteadiness, focal
weakness, vision changes, headache, rash or skin changes.
Past Medical History:
#. LGIB [**2112-3-29**] - course complicated by need for subtotal
colectomy, anastamotic leak requiring revision, Afib with RVR,
MRSA PNA/Klebsiella Bacteremia, ARF requiring CVVHD, PE and
stroke
#. HTN
#. Hyperlipidemia
#. DM2 diet controlled
#. History of Afib with RVR - not currently anticoagulated per
patient choice despite history of stroke
#. Stroke - Left parietal subcortical infarct [**2112-4-28**]
- probable subacute right posterior temporal and occipital
infarcts as well
#. History of PE - at OSH, concern for HIT - Serotonin release
assay negative
#. History of throat cancer s/p resection + xrt '[**89**]
- s/p empyema w/ CT drainage
- legally blind right eye secondary to injury
Social History:
The patient is widowed. He previously lived alone independently
in [**Location (un) 686**] although more recently has been in extended care
facilities. He previously worked for [**Doctor Last Name **] milk as a machinist.
Family History:
Non-contributory
Physical Exam:
At Discharge:
GEN: pleasant elderly male. NAD.
HEENT: eomi, perrl.
RESP: trace L basilar rales. Some central airway sounds, clear
with cough. Otherwise CTA throughout.
CV: RRR.
ABD: Ostomy in place draining stool. J-tube in place.
Abdominal wound, superficial, weeping. No evidence of infection.
EXT: NO CEE.
Neuro: calm, appropriate.
Pertinent Results:
[**2112-8-8**] 06:25AM BLOOD WBC-7.1 RBC-3.37* Hgb-10.0* Hct-30.8*
MCV-91 MCH-29.7 MCHC-32.5 RDW-16.4* Plt Ct-259
[**2112-8-8**] 06:25AM BLOOD Glucose-127* UreaN-11 Creat-0.9 Na-140
K-3.3 Cl-104 HCO3-29 AnGap-10
[**2112-8-8**] 06:25AM BLOOD Calcium-6.8* Phos-1.9* Mg-1.6
Brief Hospital Course:
82 y/o M with h/o HTN, diabetes, atrial fib, recent PE, recent
CVA, s/p subtotal colectomy for large LGIB [**3-/2112**] with long
hospital course at [**Hospital1 18**] and d/c to rehab p/w altered mental
status [**1-30**] likely aspiration. His respiratory failure was
thought to be related to chronic aspiration and and a large
chronic left sided pleural effusion (present since [**4-5**].) He
had a PEG tube placed, and a repeat speech and swallow
evaluation performed which showed Dysphagia Outcome Severity
Scale (DOSS) rating of level 1, not safe for pos.
.
For his unilateral pleural effusion, he had a bedside
thoracentesis performed with removal of 1L of fluid, which was
transudative. Cytology was sent and was pending at time of
discharge.... He experienced no complications, and his
oxygenation improved to the point that he no longer required
oxygen. He continued to complain of wheezing, and was given
nebulizer treatments. Pulmonary toilet was ordered. He was
encouraged to use his incentive spirometer.
.
In regards to his atrial fibrillation, he remained in sinus
rhythm, and was continued on home dose of metoprolol 12.5mg PO
bid. Risk/benefit profile for anti-coagulation had been
discussed with patient and HCP, and decision had been made to
not anticoagulate with coumadin and not to give ASA given his
LGIB.
.
His mental status changes had resolved on admission. Pt was
alert and oriented times 3, and was cheerful and conversant with
his providers. His neurologic exam was signfiicant for LUE
weakness. He did not have any new neurological deficits.
.
He was maintained on a regular sliding scale.
.
For his subtotal colectomy, he was seen by surgery as inpatient.
He was transferred to the floor and seen by Dr.[**Name (NI) 1482**]
team. Wound care was continued per surgery recommendations. A
wound care/ostomy nurse consult was placed for assistance with
colostomy care.
.
He was fed initially through his Dophoff, with transition to
feeding through his PEG tube on discharge.
Medications on Admission:
Metoprolol Tartrate 12.5 mg PO BID
Dexamethasone 1 mg PO Q12H
Acetaminophen 325-650 mg PO Q6H:PRN
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
Artificial Tears 1-2 DROP BOTH EYES PRN
Ascorbic Acid 500 mg PO BID
Ferrous Sulfate (Liquid) 300 mg PO BID
Miconazole 2% Cream 1 Appl TP [**Hospital1 **]
Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
Lovenox 30mg SQ [**Hospital1 **]
Guaifenesin [**5-7**] mL PO Q6H:PRN
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Year (2) **]: One (1) neb Inhalation Q6H (every 6 hours) as
needed.
2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Month/Year (2) **]: [**12-30**]
Drops Ophthalmic PRN (as needed).
3. Miconazole Nitrate 2 % Cream [**Month/Day (2) **]: One (1) Appl Topical [**Hospital1 **] (2
times a day).
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: One (1) dose PO Q6H
(every 6 hours) as needed.
6. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Last Name (STitle) **]: One (1)
dose PO BID (2 times a day).
7. Ascorbic Acid 90 mg/mL Drops [**Last Name (STitle) **]: One (1) dose PO BID (2
times a day): Note: 500 mg PGT [**Hospital1 **].
Disp:*2 * Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2
times a day).
9. Guaifenesin 100 mg/5 mL Syrup [**Hospital1 **]: 5-10 MLs PO Q6H (every 6
hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
1. Recurrent aspiration pneumonia
2. Unilateral transudative pleural effusion
3. History of ischemic stroke
4. Atrial fibrillation
5. Lower gastrointestinal bleeding
Discharge Condition:
Stable
Discharge Instructions:
If you develop increased trouble breathing, chest pain, blood in
your stool, or increased confusion, please call your primary
care doctor or go to the emergency room.
Followup Instructions:
Please follow up with your PCP/physicians at Rehab facility.
Pt has had borderline low potassium, phos, magnesium. Suggest
checking chemistries in 1 week.
Pt with improving swallow function, but still not safe for PO
intake. Recommend reassess swallow eval in [**1-31**] weeks to assess
for improvements that may allow po intake.
|
[
"272.4",
"250.00",
"V12.51",
"V10.02",
"401.9",
"427.31",
"518.81",
"507.0",
"V12.54",
"V44.3",
"511.9",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.32",
"34.91",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
8481, 8551
|
4894, 6899
|
348, 383
|
8761, 8770
|
4598, 4871
|
8986, 9321
|
4208, 4226
|
7366, 8458
|
8572, 8740
|
6925, 7343
|
8794, 8963
|
4241, 4241
|
4255, 4579
|
274, 310
|
411, 3233
|
3255, 3953
|
3969, 4192
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,148
| 128,125
|
45508
|
Discharge summary
|
report
|
Admission Date: [**2101-3-4**] Discharge Date: [**2101-3-13**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name8 (NamePattern2) 812**]
Chief Complaint:
New Afib
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 89 F w/ pmh of recent admission for lower GI bleed,
hypothyroidism, p/w DOE and new afib. She has noticed an
irregular HR since about Monday and had experienced increased
DOE, although she does have this at baseline. She went to see
her PCP today for [**Name Initial (PRE) **] previously-scheduled visit after recent
admission. He did an EKG which showed afib so he sent her to
the ED. No CP. + Mild SOB at rest but she thinks she has this
baseline from years of smoking. No PND or orthopnea. She
thinks she has had intermittent afib for ? yrs.
.
In the ED, initial vitals 97.9, 132/69, 98, 18 96% on RA. Had
CTA given elevated d-dimer but no PE. Admitted for new afib and
new DOE. Bedside u/s tr ant effusion
Past Medical History:
1. Depression.
2. Hypothyroidism.
3. History of bleeding ulcers 30 years ago.
4. Hysterectomy for uterine cancer.
5. Cataract surgery.
6. Hernia surgery.
7. OA
8. TIA - TMB on R
9. Recent Lower GI bleed
10. Diverticulosis
Social History:
She is widowed. Her husband was an ophthalmologist on-staff here
at [**Hospital1 18**]. She lives alone but has help every day. She walks
with a walker. Quit smoking 1 yr ago but smoked [**12-15**] ppd X 70
yrs. Rare EtOH.
Family History:
Her mother deceased at the age of 89, was healthy. Her father
deceased at the age of 97, was healthy. Her brother had heart
disease and died at the age of 80. Her sons and daughters are
alive and healthy in their 50s.
Physical Exam:
Vitals: T: 98.3 P: 108 BP: 135/82 R: 16 SaO2: 96% on 3L
General: Awake, alert, NAD.
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MMM, no lesions noted in OP
Neck: supple, no JVD appreciated
Pulmonary: Bibasilar crackles
Cardiac: irreg, tachy, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: Trace pedal edema, 2+ radial, DP and PT pulses b/l.
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
Pertinent Results:
MB: 3 Trop-T: <0.01
.
D-Dimer: 1320
.
Trop-T: <0.01
Comments: cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
.
141 105 17
------------< 115
3.7 24 0.7
.
CK: 62 MB: Notdone Trop-T: <0.01
.
TSH:0.31
Other Blood Chemistry:
proBNP: 2901
MCV 77
.
7.5 > 9.5 < 286
---------------
31.5
N:76.1 L:16.8 M:6.2 E:0.5 Bas:0.3
.
ECHO:
The atria are moderately dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Diastolic function could not be reliably assessed
because of atrial fibrillation. Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**12-15**]+) mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild-moderate mitral regurgitation. Moderate tricuspid
regurgitation. Moderate pulmonary hypertension.
.
CTA chest:
IMPRESSION:
1. No evidence of pulmonary embolism or aortic dissection.
2. Marked left and right atrial enlargement, likely related to
tricuspid and mitral valve pathology, perhaps on the basis of
rheumatic heart disease, as evidenced by moderate mitral annular
calcification; the marked left atrial enlargement could
certainly account for atrial fibrillation (is this truly
"new"?).
3. Mild-to-moderate background centrilobular emphysema. 1-2 mm
left upper lobe pulmonary micronodule with high probability of
being benign; in this patient of advanced age, CT follow-up is
likely not necessary.
4. Small left pleural effusion and mild interstitial edema.
.
[**2101-2-25**] EGD w/ small hiatal hernia
.
[**2101-2-25**] Colonoscopy:
Flat Lesions A single medium angioectasia was seen in the cecum
measuring 1.5cm.The angioectasia was cauterized with good
hemostasis.There was slight oozing upon cauterization that was
successfully controlled. Excavated Lesions Multiple diverticula
were seen in the sigmoid and descending colon.Diverticulosis
appeared to be of moderate severity.
Brief Hospital Course:
89 F with hypothyroidism, h/o GIB bleeds who presented with afib
w/ RVR and dyspnea and developed melena and acute blood loss
anemia after aspirin started for afib. Patient had a MICU stay
for the GIB. Hospital course summarize below.
Patient was found to be in afib on admission. She was rate
controlled with metoprolol and started on aspirin only after
long discussion given her recent hospitalization for GIB. She
has a h/o TIA and it was thought that maybe she had PAF and
would benefit from anticoagulation over the risk. After being on
aspirin, she developed melana on [**2101-3-7**] and acute blood loss
anemia with a nadar HCT of 21. She received 7 units of PRBC in
the MICU before her HCT stabilized at 27. She was transferred to
the medical floor at this point. She was prepped and had a
colonoscopy which showed an oozing AVM in the cecum which was
cauderized. She was given 1 more unit of PRBC (total 8units) to
bring HCT up to 30. She will need GI follow up. (During last
recent admission for GIB, she was treated with cauderization of
another AVM in the cecum. An EGD then showed no source of
bleeding.)
.
# Afib: As above, this was thought to be likely paroxysmal given
her history of TIA. She could not have a cardioversion as it was
thought the PAF was going on for at least one week. The cause
of her afib is likely atrial dilitation secondary to lung
disease from tobacco use. She was started on aspirin only given
her history of GIB (rather than coumadin), but as above, this
was complicated by another GIB. She was initially rate
controlled with metoprolol which was discontinued in the setting
of the GIB and restarted once that was stable. She likely can
not be anticoagulated in the near future. This issue of
anticoagulation should be addressed as an outpatient.
Metoprolol was restarted once bleeding was stabilized. She was
discharged on metoprolol 25mg TID.
.
# Dyspnea: Mild acute on chronic diastolic CHF on exam initially
was likely from afib with RVR. CTA in the ED ruled out PE, but
did show some emphysema. ECHO suggested chronic diastolic
dysfunction. Again the BB will help the cardiac function. No
ACEI given no systolic dysfunction and BP range around 100
systolic. Furosemide was started to help control her fluid
status (20mg every other day).
.
# acute blood loss anemia: as above. HCT stable at around 30 at
time of discharge. She also given iron at discharge to help with
the iron deficiency componenet of her anemia.
.
# Hypothyroidism: continued levothyroxine
.
# Depression: continued fluoxetine
Discharged home with PT after PT eval.
Code: full
.
Comm: [**Name (NI) 16901**] [**Name (NI) 10743**] (daughter) [**Telephone/Fax (1) 97098**] office;
[**Telephone/Fax (1) 97099**] cell; [**0-0-**]
.
Medications on Admission:
1. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. 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 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. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
Disp:*15 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Fluoxetine 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnosis:
Atrial fibrillation
acute blood loss anemia
angioectasia in the cecum
Acute on chronic diastolic congestive heart failure
Secondary diagnosis:
diverticulosis
hypothyroidism
h/o Transient ischemic attack
Discharge Condition:
Hemodynamically stable. Ambulatory.
Discharge Instructions:
You were admitted with atrial fibrillation and shortness of
breath and received diuresis to remove fluid. You were also
started on a beta blocker to help control your heart rate and
lasix to control the fluid. Please take your medications as
prescribed.
Often with atrial fibrillation, patients need blood thinners.
You have had significant bleeding complications while on
coumadin in the past and aspirin this time. You should discuss
this further with your cardiologist, gastroeneterologist and
PCP.
.
You had bleeding while on aspirin, which was likely from the AVM
found in your colon. You had colonoscopy and the GI doctors were [**Name5 (PTitle) 97100**] to hopefully stop the bleeding. You had 8 units of PRBCs to
bring your blood levels back up.
.
Please seek medical attention immediately if you develop
increased shortness of breath, fever, chest pain, bleeding or
any other concerning symptoms.
Followup Instructions:
Please make a follow-up appointment with [**Last Name (LF) **],[**First Name3 (LF) 2946**] S.
[**Telephone/Fax (1) 2205**] within the next week.
.
Previously scheduled appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], MD Phone:[**Telephone/Fax (1) 40119**]
Date/Time:[**2101-3-22**] 11:30
Provider: [**Name10 (NameIs) **],ROOM GI ROOMS Date/Time:[**2101-3-22**] 11:30
Provider: [**First Name11 (Name Pattern1) 8122**] [**Last Name (NamePattern4) 8123**], M.D. Phone:[**Telephone/Fax (1) 2977**]
Date/Time:[**2101-4-5**] 11:45
[**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **] MD, DMD [**MD Number(2) 821**]
Completed by:[**2101-3-14**]
|
[
"599.0",
"428.33",
"428.0",
"492.8",
"285.1",
"244.9",
"569.85",
"562.10",
"E935.3",
"427.31",
"V10.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.43"
] |
icd9pcs
|
[
[
[]
]
] |
8647, 8705
|
4945, 7703
|
279, 285
|
8972, 9011
|
2454, 4922
|
9968, 10702
|
1551, 1771
|
8054, 8624
|
8726, 8726
|
7729, 8031
|
9035, 9945
|
1786, 2274
|
231, 241
|
313, 1045
|
8889, 8951
|
8745, 8868
|
2289, 2435
|
1067, 1290
|
1306, 1535
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,358
| 152,765
|
44765
|
Discharge summary
|
report
|
Admission Date: [**2158-1-28**] Discharge Date: [**2158-2-10**]
Date of Birth: [**2092-11-16**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8747**]
Chief Complaint:
L sided weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
65yo man with PMH significant for small cell lung cancer
metastatic to the liver and bone, HTN, hyperlipidemia, OCPD,
presents as a transfer from an OSH with new onset headache, L
hemiparesis, and alteration of consciousness. He presented to
the OSH on [**2158-1-26**] with acute on chronic diffuse abdominal
pain. The day of transfer, his RN found him at 9am with his legs
over the side of the bed, lethargic, incontinent of urine, and
complaining of a new frontal headache. He had a left facial
droop and left hemiparesis. He was taken to the head CT, where
he was found to have a right frontal hemorrhage, reported to be
3.5cm x 2cm. He also had plts of 38 and was transfused one pack
of platelets. He was transferred to [**Hospital1 18**].
On arrival, he endorsed headache and abdominal pain but no other
complaints. His brother noted that he had not been doing as well
recently, but was still looking to fight through his illness. He
has been treated with chemotherapy with fair stability of the
lesions (last CT showing LAD, hepatic mets with no significant
change, but an increased size of the lung lesion), but has had a
60lb weight loss, decreased appetite and po intake, and 4 months
of abdominal pain. He was started on topotecan one week prior to
admission.
Past Medical History:
small cell lung cancer, mets to liver and bone
hypertension
COPD
hyperlipidemia
BPH
ex-lap for gunshot wound
s/p sinus surgery [**2153**]
Social History:
50py tobacco, h/o EtOH
Family History:
unremarkable
Physical Exam:
T98, HR 79sr, BP 115/73, RR 17, SaO2 93/2L
Genl: NAD, sleeping
HEENT: NCAT, MMM, OP Clear
CV: RRR, nl S1, S2, several PVC/PACs appreciated
Chest: CTAB
Abd: soft, NTND, BS+
Ext: warm & dry, not edematous
Neurologic examination:
Mental status: somnolent, able to open eyes and follow simple
commands but will not stay awake. Oriented to name, year, month,
and "hospital," but not which hospital. Will say one or two
words at a time, not complete sentences.
Cranial nerves: pupils equal and symmetric, R gaze preference,
?left hemianopia or hemineglect. Left facial droop. No gag.
Tongue midline.
Motor: R arm full strength, L arm flaccid; R leg full strength,
L leg 1-2/5, able to see contraction of hamstrings and motion of
toes.
Sensory: grimaces to pain throughout
Coord: unable to test
On discharge:
MS: Frequently sleeping (sometimes with eyes open) but arousable
and will follow commands and answer questions appropriately.
Cranial nerves: as above, but gaze at midline.
Motor: R arm and leg full strength; L arm can lift slightly off
bed and can move well at elbow; L leg can lift and hold off bed.
Pertinent Results:
Admission labs:
GLUCOSE-131* UREA N-19 CREAT-1.2 SODIUM-134 POTASSIUM-4.1
CHLORIDE-98 TOTAL CO2-25 ANION GAP-15
freeCa-1.23 CALCIUM-9.3 PHOSPHATE-3.4 MAGNESIUM-2.0
WBC-10.8 RBC-3.28* HGB-10.2* HCT-30.0* MCV-91 MCH-31.1 MCHC-34.1
RDW-19.4* PLT COUNT-65*
PT-12.5 PTT-26.4 INR(PT)-1.1
ALT(SGPT)-19 ALK PHOS-358* AMYLASE-46 TOT BILI-0.5 OSMOLAL-283
LIPASE-29
Discharge labs:
WBC-7.9 RBC-3.44* Hgb-10.8* Hct-32.7* MCV-95 MCH-31.3 MCHC-32.9
RDW-19.3* Plt Ct-333
Glucose-103 UreaN-52* Creat-1.3* Na-142 K-4.1 Cl-106 HCO3-22
Pending labs:
FREE KAPPA AND LAMBDA, WITH K/L RATIO-PND
IMAGING:
Head CT noncontrast: Examination is limited secondary to patient
motion. There is a large hemorrhage in the right fronto-temporal
lobe extending to basal ganglia measuring approximately 6.3 x
2.0 cm with surrounding hypodensity consistent with edema. Just
superior to this large hemorrhage are multiple smaller punctate
foci of hemorrhage. There is mass effect on the right lateral
ventricle with 2 mm of midline shift to the left. There is
probable mild subfalcine herniation. The remaining ventricles
are not dilated. The basal cisterns are patent. The [**Doctor Last Name 352**]-white
matter differentiation is grossly preserved. The surrounding
osseous and soft tissue structures are unremarkable. The imaged
paranasal sinuses are well aerated.
IMPRESSION: Right fronto-temporal intraparenchymal hemorrhage
extending to basal ganglia with surrounding edema with slight
degree of midline shift.
Head MRI w/o & w/contrast: FINDINGS: Today's exam is correlated
with head CT from [**2158-1-28**]. As noted on the
examination, there is a large right frontal temporal
intraparenchymal hemorrhage extending into the basal ganglia.
There is surrounding edema and mass effect upon the ipsilateral
lateral ventricle. There is no evidence of herniation. The
ambient cisterns are present and not effaced. There is no slow
diffusion to indicate an acute infarct.
On series 12, image 388, there is a subtle enhancing lesion in
the right centrum semiovale. This could represent a small
vascular anomaly as opposed to metastatic lesion, given the
absence of adjacent edema. This is separate from the region of
hemorrhage. There is no enhancement in the region of the
intraparenchymal hemorrhage.
IMPRESSION: There is no enhancement in the region of hemorrhage
to indicate that this is from a metastasis.
Small lesion in the right centrum semiovale could be consistent
with a small vascular anomaly versus (less likely) a small
metastasis.
No acute infarcts.
Repeat Head CT [**2158-2-2**]:
Increasing edema since [**2158-1-28**]. Otherwise similar appearance of
large right cerebral hemisphere intraparenchymal hemorrhage.
Repeat Head CT [**2158-2-4**]:
Overall no significant interval change in size of right large
cerebral hemisphere intraparenchymal hemorrhage and associated
mass effect since [**2158-2-2**].
EEG [**2158-2-7**]:
ABNORMALITY #1: A [**3-16**] Hz slow and disorganized background rhythm
was
noted in the waking state, which increased by [**12-13**] Hz with
external
stimulation.
ABNORMALITY #2: The right hemisphere background activity was 1
Hz slower
and of decreased amplitude compared to the left hemisphere
activity.
ABNORMALITY #3: Bursts of generalized moderate amplitude delta
slowing
was noted in the waking state.
BACKGROUND: As above.
HYPERVENTILATION: Contraindicated due to patient's mental
status.
INTERMITTENT PHOTIC STIMULATION: Produced no activation of the
record.
SLEEP: No normal sleep/wake transitions were seen.
CARDIAC MONITOR: An irregularly irregular rhythm was noted, with
an
average rate of 96 beats per minute.
IMPRESSION: This is an abnormal EEG due to the slow,
disorganized
background rhythm, decreased voltage over the right hemisphere
and
bursts of generalized slowing. The slow and disorganized
background
rhythm and bursts of generalized slowing suggest a moderate
encephalopathy. The decreased voltage and slightly slower
background
over the right hemisphere suggests right hemisphere subcortical
dysfunction.
Brief Hospital Course:
65yo man with metastatic cancer presenting as a transfer from an
OSH with new left hemiparesis, decreased alertness, plts <100k,
and a right frontal hemorrhage. Most
likely etiology is hemorrhage from a metastasis in the setting
of thrombocytopenia, though he has no known metastasis there.
Other etiologies include hypertension (though he has not been
terribly hypertensive, his BP does not have to be that high,
especially with the thrombocytopenia, to bleed), hemorrhagic
conversion of stroke; unlikely to be amyloid, trauma, or
vascular malformation. He had an MRI for further evaluation; it
did not clearly demonstrate an underlying metastasis, though it
did show a small lesion in the right centrum semiovale that
might be a metastasis. He was started on decadron and mannitol
and transfused two more packs of platelets to reach goal
plts>100k. Neuro-oncology was consulted. As his repeat head CT
showed significant edema, the decadron was tapered only to 4mg
q12hrs and he was discharged on this dose, to remain stable
until his follow up appointment with neuro-oncology. The
mannitol was weaned off. Given the edema, brain radiation was
determined to be contraindicated at this time by discussions
between Dr. [**Last Name (STitle) 724**] (neuro-oncology) and Dr. [**Last Name (STitle) **] (primary
oncologist), though this may be possible in the future. He will
follow up in the brain tumor clinic with Dr. [**Last Name (STitle) 724**] in 3 weeks
from discharge. Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 27580**]) will need to be
contact[**Name (NI) **] by the extended care facility to assist with
chemotherapy treatment, which will likely be an oral mediation
regimen dosed daily.
Hospital course was also notable for:
1. hypertension - treated with metoprolol and captopril for goal
SBP<140
2. atrial tachycardia - also treated with metoprolol
3. NSVT - improving with treatment of hypokalemia (see below)
4. hypokalemia - On transfer to the floor from the ICU, the
patient was noted to have a drop in potassium over one day from
3.6 to 2.6. He was given 80mEq KCl with rise to 3.6, then an
additional 40mEq, but the next day the K was 3.1. He had no
diarrhea or vomiting. The renal service was consulted. They felt
that the hypokalemia was likely due to urine losses from
polyuria due to administration of mannitol and decadron. He was
started on standing repletion of K (40meq po bid), prn repletion
of Mg (to >2), and the mannitol was discontinued. The K improved
and the daily KCl was gradually tapered.
5. r/o mult myeloma - SPEP and UPEP were sent for concerns about
the quality of the urine. SPEP was negatve; UPEP showed
"MULTIPLE PROTEIN BANDS SEEN, WITH ALBUMIN PREDOMINATING", "TWO
TRACE BANDS ARE SEEN WHICH STAIN WITH KAPPA BUT DO NOT STAIN
WELL WITH FREE KAPPA. IT IS POSSIBLE THAT THESE REPRESENT
BENCE-[**Doctor Last Name **] PROTEIN." As such, serum free light chain assay was
sent and is pending at the time of discharge.
6. pain control - pain was thought to be secondary to multiple
hepatic metastases. It improved with ultram but persisted.
MSContin was started on [**2-8**] and may need to be titrated upward
for pain control.
7. FEN - swallow evaluation was performed and he was able to
tolerate pureed foods and thin liquids. He had poor po intake
when left to himself; he needs feeding supervision to encourage
po intake and has done well with the nurses and aides assisting.
Medications on Admission:
percocet, ambien, prilosec, belladonna, lasix 20 daily,
buproprion 150mg daily, lipitor 40mg daily, terazosin 2mg daily,
lisinopril 10mg daily, serevent diskus, nitro prn
Discharge Medications:
1. Dexamethasone 4 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q12H (every
12 hours).
2. Morphine 15 mg Tablet Sustained Release [**Month/Year (2) **]: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
3. Tramadol 50 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
6. Captopril 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a
day).
7. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg
PO BID (2 times a day).
8. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. Simethicone 80 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet,
Chewable PO TID (3 times a day).
11. Polyvinyl Alcohol 1.4 % Drops [**Last Name (STitle) **]: 1-2 Drops Ophthalmic PRN
(as needed).
12. Artificial Tear with Lanolin 0.1-0.1 % Ointment [**Last Name (STitle) **]: One (1)
Appl Ophthalmic PRN (as needed): apply to left eye at night.
Discharge Disposition:
Extended Care
Facility:
NE [**Hospital1 **] [**Location (un) **]
Discharge Diagnosis:
Right frontal hemorrhage
Right centrum semiovale lesion
Small cell lung cancer
Hypokalemia
Narrow complex tachycardia
Discharge Condition:
Stable; frequently somnolent but arouses and can follow commands
and answer questions appropriately. Left hemiparesis including
the face, arm, and leg, with dysarthria but preserved swallow,
arm movement from the elbow but not the shoulder or much finger
extension, and spontaneous leg movement with some decreased
strength. Also an element of left neglect.
Discharge Instructions:
Take all medications as prescribed.
Follow up with Dr. [**Last Name (STitle) 724**] and Dr. [**Last Name (STitle) **], as well as Dr. [**First Name (STitle) 807**].
Call your doctor or go to the emergency room for any worsening
weakness or difficulty speaking, or any numbness, decreased
alertness, nausea, vomiting, or other concerning symptoms.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 724**]:
Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2158-2-27**]
1:00
Please follow up with Dr. [**Last Name (STitle) **]: Please call 617-63-BRAIN to
schedule an appointment in 3 weeks. Please tell them that you
will need a head CT with and without contrast scheduled as well.
Call Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 27580**]) to arrange oncologic treatment.
Call your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 807**] ([**Telephone/Fax (1) 823**]) when you have finished
rehab.
|
[
"427.89",
"198.5",
"496",
"197.7",
"431",
"287.5",
"162.8",
"401.9",
"276.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12147, 12215
|
7080, 10506
|
334, 340
|
12377, 12737
|
3013, 3013
|
13134, 13796
|
1858, 1872
|
10727, 12124
|
12236, 12356
|
10532, 10704
|
12761, 13111
|
3389, 7057
|
1887, 2091
|
2691, 2817
|
278, 296
|
368, 1640
|
2833, 2994
|
3029, 3373
|
2130, 2343
|
2115, 2115
|
1662, 1802
|
1818, 1842
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,557
| 112,286
|
29702+57653
|
Discharge summary
|
report+addendum
|
Admission Date: [**2129-1-17**] Discharge Date: [**2129-1-27**]
Date of Birth: [**2052-2-13**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Shellfish
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Aortic stenosis
Major Surgical or Invasive Procedure:
[**2129-1-19**] - Core Valve Placement Percutaneous aortic valve
replacement with a 26-mm [**Company 1543**] CoreValve device, model
#MCS-P3-640, serial
#[**Serial Number 71148**].
Balloon aortic valvuloplasty.
History of Present Illness:
This 76 year old white female with known critical aortic stensis
was referred for Corevalve placement as she was deemed a high
risk operative candidate due to heavy calcification of the
aortic annulus.
Core valve data:
EXTREME risk cohort
STS score 5. % (morbid/mortality 27.7 %)
Euroscore 17.6 %
Creat 1.3. CrCl 40
Past Medical History:
critical aortic stenosis
s/p coronary artery bypass
s/p aortic valvuloplasty
Hypertension
Autoimmune Hepatitis with cirrhosis (Child's Class A)
Anemia
subclavian steal phenomenon
Peripheral Vascular Disease
Seizure in [**5-5**] 8. L sided subclavian steal
h/o paroxysmal atrial fibrillation
s/p appendectomy
Social History:
She is retired, married and lives with her husband and 2 adult
children.
She formerly worked at [**Company 2892**] as a telephone operator for 20
years.
She denies tobacco, illicit drug, or ETOH use.
Family History:
There is a strong family history of CAD. Five brothers and
sisters who are currently in their 60s all with CAD. Many of
them
have required CABG.
Physical Exam:
admission:
VS: T 97.2 BP 171/66 P 74 RR 16 O2 100 RA
Weight 149.3 lbs (prior weight 141 lbs)
HEENT: PERRL. No JVD. Carotid bruit vs. radiation of murmur
bilaterally
Neck: The mucous membranes were moist.
Lungs: Clear to auscultation
Cardiovascular: There was no jugular venous distension. S1
was
normal and S2 was diminished. There was a II/VI late peaking
systolic murmur at the left sternal border.
Abdomen: Soft without hepatosplenomegaly
Neurologic Examination: Alert and Oriented x 3
Skin: No CCE. There were no petechia or purpura. There was
no edema.
Pulse: Left radial pulse 1+, right radial pulse 2+, DP/PT 1+
bilat
Pertinent Results:
[**2129-1-25**] 04:14AM BLOOD WBC-6.1 RBC-3.82* Hgb-11.5* Hct-34.6*
MCV-91 MCH-30.0 MCHC-33.1 RDW-15.9* Plt Ct-158
[**2129-1-20**] 04:24AM BLOOD WBC-8.8# RBC-2.69* Hgb-8.6* Hct-25.4*
MCV-94 MCH-31.9 MCHC-33.8 RDW-13.9 Plt Ct-139*
[**2129-1-17**] 06:00PM BLOOD WBC-5.3 RBC-3.23* Hgb-10.7* Hct-30.7*
MCV-95 MCH-33.2* MCHC-35.0 RDW-13.7 Plt Ct-162
[**2129-1-26**] 03:24AM BLOOD PT-25.6* INR(PT)-2.5*
[**2129-1-25**] 04:14AM BLOOD PT-22.0* INR(PT)-2.1*
[**2129-1-24**] 03:58AM BLOOD PT-21.7* PTT-96.6* INR(PT)-2.0*
[**2129-1-23**] 05:58AM BLOOD PT-19.2* PTT-71.9* INR(PT)-1.7*
[**2129-1-22**] 01:48PM BLOOD PT-16.9* PTT-63.2* INR(PT)-1.5*
[**2129-1-22**] 05:09AM BLOOD PT-15.2* PTT-32.0 INR(PT)-1.3*
[**2129-1-26**] 03:24AM BLOOD Glucose-96 UreaN-69* Creat-2.4* Na-131*
K-4.4 Cl-95* HCO3-26 AnGap-14
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 2671**] [**Hospital1 18**] [**Numeric Identifier 71149**]Portable
TTE (Complete) Done [**2129-1-26**] at 12:07:13 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2052-2-13**]
Age (years): 76 F Hgt (in): 61
BP (mm Hg): 96/61 Wgt (lb): 145
HR (bpm): 59 BSA (m2): 1.65 m2
Indication: Aortic valve disease. Left ventricular function.
ICD-9 Codes: 424.1, 424.0, 424.3, 424.2
Test Information
Date/Time: [**2129-1-26**] at 12:07 Interpret MD: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) **], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) **],
RDCS
Doppler: Full Doppler and color Doppler Test Location: [**Location 13333**]/[**Hospital Ward Name 121**] 6
Contrast: None Tech Quality: Adequate
Tape #: 2011W000-0:00 Machine: Vivid q-2
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.2 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.3 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.3 m/s
Left Atrium - Peak Pulm Vein D: 0.7 m/s
Right Atrium - Four Chamber Length: 4.8 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.4 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.2 cm
Left Ventricle - Fractional Shortening: 0.35 >= 0.29
Left Ventricle - Ejection Fraction: 60% to 65% >= 55%
Left Ventricle - Lateral Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.05 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': *22 < 15
Aorta - Sinus Level: 2.2 cm <= 3.6 cm
Aorta - Ascending: 3.1 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *2.3 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *20 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 8 mm Hg
Mitral Valve - E Wave: 1.3 m/sec
Mitral Valve - A Wave: 1.0 m/sec
Mitral Valve - E/A ratio: 1.30
Mitral Valve - E Wave deceleration time: 164 ms 140-250 ms
TR Gradient (+ RA = PASP): *>= 36 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2129-1-20**].
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size.
Normal regional LV systolic function. Overall normal LVEF
(>55%). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Aortic CoreValve. Normal AVR gradient. Mild (1+)
AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild to moderate ([**11-28**]+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Moderate [2+] TR. Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
An aortic CoreValve prosthesis is present. The transaortic
gradient is normal for this prosthesis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**11-28**]+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2129-1-20**],
the left ventricular cavity size is now normal. Function is
normal rather than hyperdynamic. CoreValve prosthesis is in the
appopriate position with normal gradients and mild
per-prosthetic regurgitation. Degrees of mitral regurgitation
and pulmonary hypertension are similar.
Electronically signed by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2129-1-26**] 16:28
?????? [**2120**] CareGroup IS. All rights reserved.
[**Known lastname **],[**Known firstname 2671**] R [**Medical Record Number 71150**] F 76 [**2052-2-13**]
Radiology Report MR HEAD W/O CONTRAST Study Date of [**2129-1-24**]
3:14 PM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2129-1-24**] 3:14 PM
MR HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 71151**]
Reason: ? stroke post [**Hospital **]
[**Hospital **] MEDICAL CONDITION:
76 year old woman with s/p corevalve
REASON FOR THIS EXAMINATION:
? stroke post corevalve
CONTRAINDICATIONS FOR IV CONTRAST:
cr 2.5
Final Report
HISTORY: S/P core valve ? stroke.
TECHNIQUE: MRI brain without contrast, sagittal T1, axial FLAIR,
T2, gradient
echo, diffusion images with ADC maps.
COMPARISON: CT head [**2129-1-20**].
FINDINGS: There are multiple small foci of slow diffusion in the
supratentorium and infratentorium consistent with acute embolic
infarcts.
There is a background of T2 and FLAIR hyperintensity in the
cerebral white
matter consistent with microangiopathic small vessel disease. An
old lacunar
infarct is seen in the right [**Last Name (un) **] internal capsule/putamen.
There is no mass
effect. The ventricles and sulcal configuration are
age-appropriate. There
is no intracranial hemorrhage. The major vascular flow voids are
maintained.
IMPRESSION:
Multiple small areas of slow diffusion in the supratentorium and
infratentorium consistent with acute embolic infarcts.
The study and the report were reviewed by the staff radiologist.
DR. [**Last Name (STitle) 71152**] [**Name (STitle) 71153**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**]
Approved: TUE [**2129-1-25**] 3:29 PM
Imaging Lab
Brief Hospital Course:
Mrs. [**Known lastname 71146**] was admitted to the [**Hospital1 18**] on [**2128-12-17**] for
preoperative work-up for a Core Valve. The Electrophysiology
Service was consulted for evaluation of a new right bundle
branch block. Although it is possible that she may require a
pacemaker following her Core Valve, there was no indication for
preoperative placement of a pacemaker.
On [**2129-1-19**], Mrs. [**Last Name (STitle) 71154**] was taken to the Operating Room where
she underwent placement of percutaneous aortic valve. Please see
operative note for details. Postoperatively she was taken to the
intensive care unit for monitoring. She later awoke
neurologically intact and was extubated. Her medications were
resumed including Plavix. She developed AV nodal re-entry
tacycardia (AVNRT) which converted with Adenosine. As her
transvenous pacer was not capturing, it was readjusted under
fluoroscopy. She experienced another burst of AVNRT which
responded to Adenosine. She later developed atrial flutter which
was rate controlled with diltiazem. The Electrophysiology
Service recommended anticoagulation with the possibility of
cardioversion and amiodarone at some point.
On POD 1 she was briefly apashic and unresponsive. She had some
apashia and mild left sided weakness. A neurology consult was
obtained and head CT was obtained. This revealed hypodensity of
the white matter adjacent to the anterior [**Doctor Last Name 534**] of the rigth
lateral ventricle and some reduced density of the right basalk
ganglia. A subsequent MRI demonstrated multiple small areas of
supratentorial and infratentorial infarcts. She recovered
neurologically.
EP continued to see her and she had episodic supraventricular
arrhythmia and sinus bradycardai with pauses. Medications were
adjusted. She was anticoagulated with Coumadin. The remainder
of her hospital course was essentially uneventful. Prior to
discharge a cardionet was arranged. On POD# 8 Mrs.[**Known lastname 71146**] was
cleared for discharge to [**Hospital3 7665**] in [**Hospital1 3597**]. All follow up
appointments were advised.
Medications on Admission:
FUROSEMIDE - 40 mg daily
METOPROLOL TARTRATE 50 mg twice daily
PRAVASTATIN - 20 mg [**Hospital1 8426**] daily
VALSARTAN [DIOVAN] - 160 mg twice daily
ASPIRIN 81 mg daily
Discharge Medications:
1. valsartan 40 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY (Daily).
Disp:*60 [**Hospital1 8426**](s)* Refills:*2*
2. tramadol 50 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO Q4H (every 4
hours) as needed for pain.
3. amiodarone 200 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO BID (2 times
a day).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. ranitidine HCl 150 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY
(Daily).
6. aspirin 81 mg [**Hospital1 8426**], Delayed Release (E.C.) Sig: One (1)
[**Hospital1 8426**], Delayed Release (E.C.) PO DAILY (Daily).
7. furosemide 20 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO BID (2 times a
day).
8. potassium chloride 10 mEq [**Hospital1 8426**] Extended Release Sig: Two
(2) [**Hospital1 8426**] Extended Release PO BID (2 times a day).
9. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ACHS: per RISS.
10. warfarin 1 mg [**Hospital1 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] DAILY (Daily):
INR goal=[**12-30**] for postop AFib.
11. pravastatin 20 mg [**Month/Day (3) 8426**] Sig: One (1) [**Month/Day (3) 8426**] PO HS (at
bedtime).
12. metoprolol tartrate 25 mg [**Month/Day (3) 8426**] Sig: One (1) [**Month/Day (3) 8426**] PO BID
(2 times a day).
13. hydralazine 25 mg [**Month/Day (3) 8426**] Sig: One (1) [**Month/Day (3) 8426**] PO Q6H (every 6
hours).
14. warfarin 2 mg [**Month/Day (3) 8426**] Sig: One (1) [**Month/Day (3) 8426**] PO once a day.
15. acetaminophen 325 mg [**Month/Day (3) 8426**] Sig: Two (2) [**Month/Day (3) 8426**] PO Q4H
(every 4 hours) as needed for pain, fever.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] - [**Hospital1 **]
Discharge Diagnosis:
Aortic stenosis
hyperlipidemia
s/p Corevalve
periprocedural stroke
s/p coronary artery bypass
s/p appendectomy
peripheral vascular disease
subclavian steal syndrome
autoimmune hepatitis with cirrhosis
cerbrovascular disease
osteoporosis
chronic anemia
siezure disorder
hypertension
Discharge Condition:
Good
Discharge Instructions:
1) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
2) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]) appointment arranged for Fri
[**2129-2-4**] at 1pm
Cardiologist: Dr. [**Last Name (STitle) **] appointment arranged for Fri [**2129-2-4**] at
1pm
Please call to schedule appointments with your
Primary Care Dr. [**First Name (STitle) 17859**] ([**Telephone/Fax (1) 40171**]) in [**3-1**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication :postop Atrial
Fibrillation
Goal INR :[**12-30**]
First draw:[**2129-1-28**]
Completed by:[**2129-1-27**] Name: [**Known lastname 11977**],[**Known firstname 647**] R Unit No: [**Numeric Identifier 11978**]
Admission Date: [**2129-1-17**] Discharge Date: [**2129-1-27**]
Date of Birth: [**2052-2-13**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Shellfish
Attending:[**First Name3 (LF) 1543**]
Addendum:
diagnosis
acute on chronic diastolic heart failure
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] - [**Hospital1 **]
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2129-2-1**]
|
[
"997.1",
"428.33",
"427.89",
"427.0",
"412",
"414.01",
"424.1",
"428.0",
"414.02",
"571.42",
"426.4",
"435.2",
"728.87",
"434.11",
"997.02",
"571.5",
"440.0",
"V58.61",
"V70.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.26",
"35.22",
"35.96",
"37.78",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
15510, 15730
|
9419, 11522
|
325, 542
|
13890, 13897
|
2279, 8125
|
14324, 15487
|
1456, 1603
|
11742, 13479
|
13585, 13869
|
11548, 11719
|
13921, 14301
|
1618, 2072
|
270, 287
|
8157, 9396
|
570, 890
|
2097, 2260
|
912, 1223
|
1239, 1440
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,858
| 147,686
|
9294+56022+56023
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2178-1-20**] Discharge Date: [**2178-1-27**]
Service: BLUE GENERAL SURGERY
The dictating physician was not present for the history and
physical.
HISTORY OF PRESENT ILLNESS: The patient is a 78 year-old
woman complaining of a three day history of right lower
quadrant pain with nausea and vomiting associated with fevers
and diarrhea times one day. The pain increased the night
prior to admission with some back pain. No bright red blood
per rectum. The patient presented to an outside hospital
where the white blood cell count was 25.5000 and with 3
bands. Creatinine was 1.5, triglycerides were 38. Unasyn
was given. The patient was transferred to the [**Hospital1 346**] for surgical evaluation. A CT scan
shoed a phlegmon in the right lower quadrant with a question
of a perforated cecal carcinoma versus appendiceal abscess
versus perforated diverticulum. Also masses were seen in the
left liver lobe. The patient has no prior colonoscopy.
PAST MEDICAL HISTORY: Significant for coronary artery
disease status post a percutaneous transluminal coronary
angioplasty with stent placement in 7/00. Echocardiogram at
that time showed decreased systolic function. Insulin
dependent diabetes mellitus. Hypertension, status post pacer
placement in [**2176**]. Status post exploratory laparotomy with
resultant TAH/BSO for a large right ovarian cystadenoma in
[**2177-2-20**]. Claudication.
MEDICATIONS: Pletal 100 mg b.i.d., Diovan 80 mg po q.d.,
Atenolol 25 mg po q.d., Lasix 40 mg po b.i.d., NPH 87 mg
q.a.m., 80 units q.p.m.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Negative for carcinoma.
SOCIAL HISTORY: Not recorded.
REVIEW OF SYSTEMS: Not recorded.
PHYSICAL EXAMINATION: The patient's temperature is 99.4.
Blood pressure 135/53. Heart rate 104, which is paced.
Respiratory rate 32. Sating 86% on room air, 93% on 2
liters. Examination ill appearing elderly woman. Anicteric
sclera. Mucous membranes dry. Tachycardic with a regular
rhythm. Lungs were clear to auscultation bilaterally.
Abdominal examination was soft, distended, tender, right
lower quadrant mass with guarding. Negative [**Doctor Last Name 515**] sign.
Healed scar. No hernias. No rebound. The patient was heme
negative with brown stool. Extremities showed no clubbing,
cyanosis or edema.
LABORATORIES ON ADMISSION: Sodium 138, potassium 4.2,
chloride 102, bicarb 27, BUN 27, creatinine 1.2, glucose 141,
white count 20.8, hematocrit 35.9, platelets 159. Liver
function tests were essentially within normal limits. Her
urinalysis showed many bacteria. Chest x-ray showed left
lower lobe atelectasis. KUB showed no free air. CT showed a
large right lower quadrant phlegmon contrast throughout the
colon with colonic wall thickening. Electrocardiogram was
paced at 105 with no acute signs of ischemia or
electrocardiogram changes.
HOSPITAL COURSE: The patient was admitted for intravenous
fluid hydration. She was kept NPO. She was put on
Ampicillin, Ceftriaxone and Flagyl and given serial
examinations. Early in the morning of hospital day number
two the patient was clinically deteriorating with worsening
abdominal examination, more distended, more tender and
dyspneic. The patient was taken for emergent laparotomy and
exploration. She was found to have a perforated appendix as
well as an intra-abdominal abscess in the Operating Room.
She had a right colectomy and a biopsies was made of the left
liver lobe. Postoperatively, the patient remained intubated
and was sedated and brought to the Surgical Intensive Care
Unit. She was maintained on antibiotics. The patient was
acidotic with a pH of 7.29 while intubated postoperatively
CO2 48, PAO2 192, bicarb 24, base deficit of negative three.
Her central venous pressure was 4. She was placed on an
insulin drip to maintain her blood sugars. She was thought
to be septic. No pressors were required to maintain her
blood pressure.
The patient began to improve by postoperative day number one.
She was continued to be given aggressive intravenous
hydration. Cardiology was consulted to assess her pacemaker
function and they stated that her pacemaker was working well
with no need for PM interrogation. On postoperative day
number two an attempt was made to wean the patient off the
ventilator on that evening, which was failed. The patient
was kept intubated, however, attempt again was made on the
following day and the patient was successfully extubated.
This time her vital signs continued to remain stable. She
was transferred to the surgical floor. On postoperative day
three the patient was diuresing adequately. She was found to
be slightly dyspneic with some wheezing at the bases. She
was given intravenous Lasix and her symptoms quickly
improved. Diuresis was continued throughout postoperative
day three and postoperative day number four and the patient
did well clinically. Her vital signs remained stable. The
patient continued to do well. On postoperative day five the
patient passed flatus and had a bowel movement and was
started on clear liquids. On postoperative day number six
the patient was advanced to a regular diet. Her vital signs
continued to remain stable and the patient was discharged to
rehab.
DISCHARGE DIAGNOSES:
Status post sepsis and right colectomy and appendectomy. Her
pathological results at the time of discharge were as yet not
available.
MEDICATIONS ON DISCHARGE: Pletal 100 mg po b.i.d., Diovan 80
mg po q.d., Atenolol 25 mg po q.d., Lasix 40 mg po b.i.d.,
NPH 87 units q.a.m., 80 units q.p.m., Percocet one to two
tabs po q 4 to 6 hours prn pain.
DISCHARGE CONDITION: The patient is discharged to rehab in
stable condition. The patient will follow up with Dr.
[**Last Name (STitle) **].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Last Name (NamePattern1) 2649**]
MEDQUIST36
D: [**2178-1-27**] 09:50
T: [**2178-1-27**] 10:03
JOB#: [**Job Number 31830**]
Name: [**Known lastname **], [**Known firstname 5541**] Unit No: [**Numeric Identifier 5542**]
Admission Date: [**2178-1-20**] Discharge Date: [**2178-1-31**]
Date of Birth: [**2099-2-13**] Sex: F
Service:
Dictated By:[**Last Name (NamePattern1) 5543**]
MEDQUIST36
D: [**2178-1-31**] 10:26
T: [**2178-2-2**] 13:35
JOB#: [**Job Number 5544**]
Name: [**Known lastname **], [**Known firstname 5541**] Unit No: [**Numeric Identifier 5542**]
Admission Date: [**2178-1-20**] Discharge Date: [**2178-1-31**]
Date of Birth: [**2099-2-13**] Sex: M
Service:
DISCHARGE SUMMARY ADDENDUM: The patient had some diarrhea
and an episode of vomiting on the day of discharge and hence
was kept in house. The patient was tolerating po diet by the
next day. Vital signs remained stable, afebrile and the
diarrhea decreased. The patient was discharged [**Last Name (un) **] on
[**2178-1-31**] in stable condition. The patient was not discharged
with Levofloxacin or Flagyl.
[**First Name11 (Name Pattern1) 389**] [**Last Name (NamePattern1) 3595**], M.D.
Dictated By:[**Last Name (NamePattern1) 5543**]
MEDQUIST36
D: [**2178-1-31**] 10:26
T: [**2178-2-2**] 13:35
JOB#: [**Job Number 5544**]
|
[
"199.1",
"038.9",
"428.0",
"569.5",
"401.9",
"197.7",
"V45.82",
"250.01",
"540.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.73",
"38.93",
"50.11",
"45.93"
] |
icd9pcs
|
[
[
[]
]
] |
5659, 7375
|
1630, 1655
|
5288, 5424
|
5451, 5637
|
2908, 5267
|
1745, 2355
|
1707, 1722
|
206, 987
|
2370, 2890
|
1010, 1613
|
1672, 1687
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,363
| 159,622
|
5768
|
Discharge summary
|
report
|
Admission Date: [**2166-4-12**] Discharge Date: [**2166-4-17**]
Date of Birth: [**2111-3-9**] Sex: F
Service:
DISCHARGE DIAGNOSES: Upper gastrointestinal bleed status
post MICU transfer.
DISPOSITION: To home.
HISTORY OF PRESENT ILLNESS: Patient is transferred from [**Hospital Ward Name 12053**] Surgical Intensive Care Unit/Medical Intensive Care
Unit to Medicine floor. For the complete MICU course, see
the MICU dictation by [**Doctor Last Name **] [**Doctor First Name **].
This is a 55-year-old female status post aortic valve
replacement on [**2166-4-1**] and was admitted for upper
gastrointestinal bleed which has resolved since secondary to
erosive esophagitis and gastritis with clots which were found
on EGD on [**2166-4-13**] with ulcers initially admitted to the
SICU on [**Hospital Ward Name 516**] but has had intermittent pain since in
the SICU with echo findings consistent with small pericardial
effusion and transferred to [**Hospital Ward Name 517**] Floor to be evaluated
for this questionable effusion per Cardiothoracic Surgery.
There was no plan since once transferred to the [**Hospital Ward Name 517**]
to have any kind of procedure such as pericardiocentesis
done.
Had an echo done after the CT findings which had shown the
pericardial effusion, and echo findings showed small
pericardial effusion with no tamponade physiology. Patient
had no widened pulses since admission and no obvious [**Doctor Last Name 22936**]
triad findings. So, no hypotension, no jugular venous
distention, and no muffled heart sounds.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Status post aortic valve replacement.
4. Outpatient.
5. Depression.
6. Back pain.
7. Ejection fraction 60% with clean coronaries on last
catheterization.
ALLERGIES:
1. Penicillin causes itch.
2. Codeine causes hives.
3. Aspirin causes gastrointestinal upset.
SOCIAL HISTORY: Positive cocaine use but quit six years ago.
Positive tobacco one pack per day times 30 years. Occasional
ethanol use, two to three drinks per week. Lives alone.
FAMILY HISTORY: Noncontributory.
HOME MEDICATIONS:
1. Lopressor 50 b.i.d.
2. Aspirin 325 q.d.
3. Paxil.
4. Vitamin C.
5. Levaquin.
6. Metered-dose inhaler.
7. Lasix.
8. Iron sulfate.
9. Lipitor.
10. Alendronate.
11. Colace.
PHYSICAL EXAMINATION ON ADMISSION ONCE TRANSFERRED FROM SICU:
Temperature 97.6, blood pressure 142/70, pulse 76,
respiratory 20, O2 sat 94% on room air. Fingerstick 95.
Generally, in no acute distress; alert and oriented times
three. HEENT: Moist membrane mucosa. No lymphadenopathy.
Supple neck. Lungs: Clear to auscultation bilaterally with
very mild basilar rales bilaterally. Cardiovascular/Chest:
Regular rate and rhythm; no murmurs; no gallops or rubs; has
a III/VI diastolic murmur best heard at left upper sternal
border; also on chest wall, has mid incision post sternotomy
which is dry and intact with no oozing. Abdomen: Bowel
sounds are present, soft, nontender, nondistended.
Extremities: No clubbing, cyanosis. Neuro: Grossly intact.
LABORATORY DATA ON ADMISSION: White blood cell count 13.5,
which is down from the 18.5, and 34 hematocrit, which has
been about 33, 298 platelets, MCV 90, INR 1.2, PTT 29.4,
sodium 143, potassium 3.5, chloride 112, bicarbonate 24, BUN
8, creatinine 0.7, glucose 86, calcium 7.4, phosphorous 3.0,
magnesium 1.8. Gastrin pending. Helicobacter pylori pending
at the time.
Echo results showed small pericardial effusion but no
tamponade physiology.
[**2166-4-14**] CT chest showed soft tissue density, mild
stranding, and anterior mediastinum. It could be related to
surgical changes. Tiny foci to gas within mediastinum three
weeks following sternotomy with large pericardial effusion,
bilateral pleural effusion, and compressive atelectasis with
right upper lobe pneumonia found on CT.
Since being admitted the patient has had the following
hospital course.
HOSPITAL COURSE:
1. Gastrointestinal bleed: Patient was followed with
hematocrits daily, and her hematocrit has stayed stable since
she has been admitted to this service for the past four days
and has stayed in 30s, between 32 to 34. She was switched
over from intravenous Protonix to p.o. Protonix and continued
on that while on service without any problems. Helicobacter
pylori results came back positive. She was sent home with
Helicobacter pylori treatment.
2. In terms of her chest pain, her chest pain was actually
rule out myocardial infarction while in the MICU and no
obvious cardiac etiology for the chest pain. Most likely was
thought by Cardiothoracic Surgery to be most likely secondary
to her sternotomy and healing process. She is getting pain
medication for the treatment of the chest pain and has had no
EKG changes since has been on service.
3. The pericardial effusion to be followed up with Dr.
[**Last Name (STitle) 911**], her cardiologist, with whom she has an appointment,
and she has remained without any [**Doctor Last Name 22936**] triad while on the
floor, no widened pulses, and no obvious signs of tamponade
physiology. Blood pressure has remained stable.
4. In terms of her coagulopathy that she has had in the ICU
that had resolved, there was no evidence of it while she was
here on the floor.
5. In terms of her aortic valve replacement, given that it
is a bioprosthetic, there was no need for chronic
anticoagulation keeping her hematocrit greater than 30.
6. Hypertension: She was to be started on her beta
blockers, Lopressor 25 b.i.d., and holding her aspirin for
the time being, given that she has had this recent
gastrointestinal bleed.
7. Her pneumonia on chest CT, although afebrile and no
leukocytosis, was treated with Levaquin and was to continue
on Levaquin but since being treated for Helicobacter pylori
when sent out, the Levaquin was stopped.
Tolerated diet. Walked patient on the day of discharge;
satting well; climbing stairs; and walking without any
difficulties; no tachycardia while walking; ambulating
without any difficulties.
DISPOSITION: To home with VNA service.
DISCHARGE CONDITION: Stable.
DISCHARGE INSTRUCTIONS:
1. Was told to avoid all nonsteroidal anti-inflammatory
drugs, Advil, Ibuprofen, aspirin. Okay to use Tylenol for
pain.
2. If symptoms persist, worsen, or new symptoms arise, seek
medical care as soon as possible.
3. Her gastrointestinal follow up was moved up by a few
weeks to be seen on [**2166-5-9**] in the [**Hospital **] Clinic, which
was listed on her sheet, and will be told at time of
discharge.
4. Was also told to call Dr. [**First Name (STitle) 437**], her primary care
physician, [**Name10 (NameIs) **] have an appointment for next week.
5. Other appointments as listed.
FINAL DIAGNOSES:
1. Multiple gastric and duodenal ulcers.
2. Pneumonia on Levofloxacin started on [**2166-4-15**] which was
stopped since she is going to get her Helicobacter pylori
treatment.
MAJOR SURGICAL INVASIVE PROCEDURES: EGD post MICU stay.
DISCHARGE CONDITION: Good.
DISCHARGE MEDICATIONS:
1. Told to avoid nonsteroidal anti-inflammatory drugs and
aspirin.
2. Clarithromycin 500 mg p.o. q. 12 hours.
3. Was initially holding on Amoxicillin, which was going to
check with Attending to see if, given that she has had an
itch with Penicillin, is it okay to actually keep on
Amoxicillin. Most likely will be switched to another
alternate therapy for Helicobacter pylori before discharge.
4. Pantoprazole b.i.d.
5. Metoprolol 25 b.i.d.
6. Percocet one to two tablets p.o. q. 4 to 6 hours and
discuss continuation with primary care physician.
7. Acetaminophen as needed.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D.
Dictated By:[**Name8 (MD) 6112**]
MEDQUIST36
D: [**2166-4-17**] 14:53
T: [**2166-4-17**] 15:26
JOB#: [**Job Number 22937**]
|
[
"401.9",
"531.00",
"041.86",
"423.9",
"532.00",
"584.9",
"V42.2",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
7021, 7028
|
2105, 2123
|
148, 229
|
7051, 7861
|
3967, 6098
|
6153, 6745
|
2141, 3101
|
6762, 6999
|
258, 1568
|
3116, 3950
|
1590, 1906
|
1923, 2088
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,747
| 127,604
|
3918
|
Discharge summary
|
report
|
Admission Date: [**2188-8-28**] Discharge Date: [**2188-9-4**]
Date of Birth: [**2136-2-9**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Exploratory laparotomy, lysis of adhesions, and primary closure
of complex ventral hernia with mesh overlay [**2188-8-29**].
History of Present Illness:
52year old male with complex incisional hernia resulting from
laparotomy for cholecystectomy about 15 years ago. He has
undergone 2 non-durable incisional hernia repairs. He presents
today with 24 hours of diffuse abdominal pain, one episode of
non-bloody emesis this morning. His last BM was approximately
24hr prior and was non-bloody. No fevers, chills.
Past Medical History:
PSHx: Open cholecystectomy in [**2167**] at [**Hospital 1562**] Hospital and
incisional hernia repair in [**2175**] and again at [**Hospital1 1562**] in [**2180**]
complicated by a wound infection, dehiscence, and redo
herniorrhaphy. Left eye enucleation as an infant.
.
PMHx: Adult onset diabetes, anxiety, and obesity.
Social History:
Married one year ago, has three step-children now. Does not
smoke cigarettes and never has, currently not drinking any
alcohol. Reports he did drink but stopped years ago. He is
sexually active, monogamous.
Family History:
Father died of myocardial infarction at age 55. Mother died of
lung cancer at age 51.
Physical Exam:
On Admission:
VS: 99.1, 111, 144/90, 18, 98RA
GEN: agitated, morbidly obese
COR: tachy, no murmur
LUNGS: CTAB
ABD: obese, soft, distended, no rebound, +BS, +guarding,
laparotomy incision healed but with 3 distinct hernias
periumbilically that are 8-15cm in size. No erythema. The right
superior hernia site is most tender and is 10cm in diameter.
EXTREM: 1+ edema, good distal pulses
.
At Discharge:
VS:
GEN: Obese male in NAD.
HEENT: (L)eye prosthesis in place. (R) sclera anicteric. O-P
clear.
NECK: Supple.
LUNGS: CTA(B)
COR: RRR
ABD: Midline incision with staples c/d/i with DSD cover and
abdominal binder. JP patent/intact with serosanginous output.
Obese habitus. Appropriately tender to palpation. Soft/ND.
EXTREM: No c/c/e
NEURO: A+Ox3. Non-focal/grossly intact.
Pertinent Results:
On ADmission:
[**2188-8-28**] 08:32PM TYPE-ART PO2-59* PCO2-39 PH-7.37 TOTAL CO2-23
BASE XS--2
[**2188-8-28**] 08:32PM LACTATE-1.9
[**2188-8-28**] 08:32PM freeCa-1.15
[**2188-8-28**] 08:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-4* PH-6.5
LEUK-NEG
[**2188-8-28**] 08:00PM URINE RBC-0 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2188-8-28**] 12:20PM GLUCOSE-311* UREA N-17 CREAT-0.6 SODIUM-136
POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-23 ANION GAP-19
[**2188-8-28**] 12:20PM ALT(SGPT)-34 AST(SGOT)-15 LD(LDH)-197 ALK
PHOS-71 TOT BILI-1.5
[**2188-8-28**] 12:20PM LIPASE-11
[**2188-8-28**] 12:20PM WBC-15.9*# RBC-5.88 HGB-16.6 HCT-48.1 MCV-82
MCH-28.3 MCHC-34.5 RDW-14.7
[**2188-8-28**] 12:20PM NEUTS-87.5* LYMPHS-8.8* MONOS-2.6 EOS-0.5
BASOS-0.6
[**2188-8-28**] 12:20PM PLT COUNT-293
[**2188-8-28**] 12:20PM PT-12.6 PTT-19.9* INR(PT)-1.1
.
At Discharge:
[**2188-8-30**] 02:04AM BLOOD WBC-9.9 RBC-4.59* Hgb-13.1* Hct-38.6*
MCV-84 MCH-28.5 MCHC-33.9 RDW-14.8 Plt Ct-220
[**2188-8-30**] 02:04AM BLOOD Plt Ct-220
[**2188-9-1**] 03:36AM BLOOD Glucose-201* UreaN-11 Creat-0.5 Na-137
K-3.9 Cl-101 HCO3-24 AnGap-16
[**2188-8-30**] 02:04AM BLOOD ALT-153* AST-55* AlkPhos-103 TotBili-0.9
DirBili-0.3 IndBili-0.6
[**2188-9-1**] 03:36AM BLOOD Calcium-7.8* Phos-2.2* Mg-2.1
[**2188-8-29**] 10:58AM BLOOD Type-ART pO2-87 pCO2-41 pH-7.47*
calTCO2-31* Base XS-5
.
Pathology:
[**2188-8-28**] SPECIMEN SUBMITTED: hernia sack.
DIAGNOSIS:
Hernia sac: Fibroadipose tissue consistent with hernia sac.
Clinical: Specimen submitted: Hernia sac.
Gross:
The specimen is received in saline labeled with the patient's
name, "[**Known lastname 17469**], [**Known firstname **]", the medical record number and "hernia
sac." It consists of multiple fragments of tan-yellow fibrofatty
tissue measuring 18.5 x 12.3 x 1.4 cm in aggregate. There are
no discrete lesions noted. The specimen is represented in
cassette A.
.
Imaging:
[**2188-8-28**] ABD/PELVIC CT W/Contrast:
1. Dilated loops of proximal small bowel with decompressed loops
of distal
small bowel, concerning for obstruction with transition point
within the large ventral wall hernia. Finding posted on the ED
dashboard, and d/w Dr. [**First Name (STitle) 17470**].
2. Hypodensity at the right liver lobe, could be focal fat;
however underlying mass cannot be excluded. MRI can be done for
further evaluation; if clinically warranted.
.
[**2188-8-29**] CXR:
FINDINGS: Endotracheal tube has been re-positioned, now
terminating about 3.5 cm above the carina. Right internal
jugular catheter continues to terminate in the expected location
of the right atrium. Cardiomediastinal contours are unchanged.
Assessment of the lungs is limited due to some degree of
respiratory motion, but there is apparent improvement in
perihilar opacities which have nearly resolved.
.
Microbiology:
[**2188-8-29**] MRSA Screen: negative.
Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation of the aforementioned problem. On [**2188-8-29**], the
patient underwent exploratory laparotomy, lysis of adhesions,
and primary closure of a complex ventral hernia with mesh
overlay, which went well without complication, although it was a
long , complicated surgery (reader referred to the Operative
Note for details). Post-operatively, the patient was admitted to
the SICU for prolonged intubation and ventilation. The patient
arrived in the SICU NPO with an NG tube, intubated requiring
mechanical ventialtion, on IV fluids, with a foley catheter and
a JP drain in place, and Fentanyl IV PRN for pain control. An
abdominal binder was in place and the patient was on strict
bedrest. The patient was hemodynamically stable.
.
A CXR in the SICU found the endotracheal tube positioned towards
the right mainstem, and was pulled back 3 cm. Repeat CXR showed
that the ETT was properly placed. Later on [**2188-8-29**], he was
weaned off mechanical ventilation and extubated without problem,
then placed on a facemask. Give poor pain control, Fentanyl was
changed to a Dilaudid PCA with improved pain control. He was
started on empiric IV Vancomycin, Flagyl and Cipro given
incarcerated bowel. His WBC normalized. He was placed on an
insulin sliding scale with high requirement. [**Last Name (un) **] Diabetes
service was consulted, and followed the patient throughout this
admission. He remained hemodynamically stable.
.
On POD#1, the patient was transferred to the floor, where his
hospital course progressed as expected without complication.
Pain was well controlled on the Dilaudid PCA, which was
transitioned to oral pain medications when he was tolerating a
diet. On POD#3, the NG tube was discontinued and he was started
on clear liquids. Home medications were restarted. His diet was
progressively advanced to a diabetic regular by POD#4, which he
tolerated well. The foley catheter was discontinued on POD#3; he
subsequently voided without problem. IN antibiotics were
discontinued on POD#4. He was out of bed to a chair on POD#1,
and worked with Physcial Therapy until he was ambulating
independently and frequently. The abdominal binder remained in
place at all times except during examination and bathing. The
incision remained clean and intact; the JP drain patent.
.
During this admission, the [**Last Name (un) **] Diabetes team followed his
glycemic control closely, adjusting his insulin regimen
regulary. Labwork was monitored and electrolytes repleted when
necessary. The patient was adherent with respiratory toilet and
incentive spirrometry. He ambualted frequently.
.
At the time of discharge on [**2188-9-4**], the patient was doing
well, afebrile with stable vital signs. The patient was
tolerating a diabetic regular diet, ambulating, voiding without
assistance, and pain was well controlled. He was discharged
home with VNA services for JP drain care. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO once a
day. *
4. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Naprosyn 500 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for pain.
6. Viagra 100 mg Tablet Sig: One (1) Tablet PO As directed.
7. Nystatin 100,000 unit/g Cream Sig: One (1) application to
affected areas Topical twice a day as needed for rash.
8. Diazepam Oral as prescribed by PCP
9. Metformin 1000mg PO BID
10. Lantus Insulin 50units SQ QHS
11. Humalog Insulin Sliding Scale
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain: Do NOT exceed 4gm (4000mg)
acetaminophen daily.
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO once a
day.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. 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*
7. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Naprosyn 500 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for pain.
9. Viagra 100 mg Tablet Sig: One (1) Tablet PO As directed.
10. Nystatin 100,000 unit/g Cream Sig: One (1) application to
affected areas Topical twice a day as needed for rash.
11. Diazepam Oral
12. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) gm in 8oz water or juice PO DAILY (Daily) as needed for
constipation.
Disp:*255 gm* Refills:*1*
13. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
14. Lantus 100 unit/mL Solution Sig: Fifty (50) units
Subcutaneous at bedtime.
Disp:*2 vials* Refills:*0*
15. Insulin Lispro 100 unit/mL Solution Sig: 2-15 units
Subcutaneous As directed by the Humalog Insulin Sliding Scale.
Disp:*1 vial* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1. Complex ventral hernia
2. Small bowel obstruction
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-13**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
.
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:
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 476**] Date/Time:[**2188-9-12**]
9:30. Location: [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**].
.
Please call ([**Telephone/Fax (1) 1921**] to arrange a follow-up appointment
with Dr. [**Last Name (STitle) 5717**] (PCP) in [**1-8**] weeks.
.
Other Appointments:
Provider: [**Known firstname 1955**] [**Last Name (NamePattern1) 17471**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2188-9-4**] 3:15
Provider: [**Name10 (NameIs) **] UNIT Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2188-9-10**]
9:00
Completed by:[**2188-9-4**]
|
[
"278.00",
"560.81",
"552.21",
"300.00",
"V58.67",
"250.00",
"567.21",
"V45.79"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.59",
"53.61"
] |
icd9pcs
|
[
[
[]
]
] |
10599, 10657
|
5267, 8355
|
326, 453
|
10754, 10761
|
2327, 2327
|
13502, 14154
|
1432, 1520
|
9108, 10576
|
10678, 10733
|
8381, 9085
|
10785, 12240
|
12256, 13479
|
1535, 1535
|
3246, 5244
|
272, 288
|
481, 843
|
2341, 3232
|
865, 1189
|
1205, 1416
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,414
| 156,338
|
26040
|
Discharge summary
|
report
|
Admission Date: [**2113-8-26**] Discharge Date: [**2113-9-2**]
Date of Birth: [**2052-11-5**] Sex: M
Service: SURGERY
Allergies:
Cellcept
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Fever to 103.4
Major Surgical or Invasive Procedure:
none
History of Present Illness:
60M with hx of OLT in [**6-6**] recently d/c'd [**2113-8-21**] (s/p urinary
retension) returns with fevers to 103.4 for one day duration.
Pt present to [**Hospital1 18**] ED with fevers along with emesis x 1, mild
periumbilical pain, and low grade aches of B/L elbows and knees.
He denies pains in other joints. Pt denies CP, SOB, suprapubic
pain, diarrhea.
Past Medical History:
PMH:
1) ETOH cirrhosis s/p OLT [**6-6**]
2) h/o ascite
3) SBP on bactrim prophylaxis
4) hepatic encephalopathy
5) s/p umbilical hernia repair
6) urinary retention
7) pseudomonas UTI
Social History:
Lives w/ wife [**Name (NI) **] #[**Telephone/Fax (1) 64674**].
[**Name2 (NI) **] recent ETOH use-> quit in [**September 2112**] after h/o "heavy" use-
won't quantify further
Family History:
Non-Contributory
Physical Exam:
Gen: NAD, AAOx3
101.2, 98, 127/71, 22, 97%RA
HEENT: NC/AT, negative scleral icterus
CV: reg
pulm: CTA B/L
ABD: soft, NT/ND, + BS, negative suprapubic tenderness. Drain
C/D/I, no erythema. Foley cath in place, leg strap bag.
LE: negative joint swelling, 1+ DP pulse B/L
Pertinent Results:
[**2113-8-26**] 03:40PM BLOOD WBC-1.6* RBC-3.34* Hgb-9.7* Hct-27.3*
MCV-82 MCH-28.9 MCHC-35.4* RDW-14.8 Plt Ct-100*
[**2113-8-29**] 05:30AM BLOOD WBC-1.2* RBC-3.11* Hgb-9.2* Hct-25.7*
MCV-83 MCH-29.7 MCHC-35.9* RDW-15.1 Plt Ct-58*
[**2113-9-2**] 01:42PM BLOOD WBC-5.8 RBC-3.18* Hgb-9.2* Hct-26.1*
MCV-82 MCH-28.9 MCHC-35.1* RDW-15.9* Plt Ct-73*
[**2113-8-26**] 03:40PM BLOOD Neuts-25* Bands-8* Lymphs-25 Monos-8
Eos-0 Baso-0 Atyps-1* Metas-32* Myelos-1*
[**2113-8-29**] 05:30AM BLOOD Neuts-64 Bands-2 Lymphs-16* Monos-12*
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-4*
[**2113-8-26**] 03:40PM BLOOD Gran Ct-1270*
[**2113-8-26**] 03:40PM BLOOD PT-14.2* PTT-26.9 INR(PT)-1.3*
[**2113-8-27**] 08:09PM BLOOD PT-17.0* PTT-43.5* INR(PT)-1.6*
[**2113-8-30**] 06:00AM BLOOD PT-17.0* PTT-55.0* INR(PT)-1.6*
[**2113-9-2**] 09:00AM BLOOD PT-31.5* PTT-34.2 INR(PT)-3.4*
[**2113-8-26**] 03:40PM BLOOD Glucose-123* UreaN-13 Creat-1.3* Na-134
K-4.3 Cl-99 HCO3-26 AnGap-13
[**2113-8-29**] 05:30AM BLOOD Glucose-110* UreaN-11 Creat-0.9 Na-136
K-3.5 Cl-110* HCO3-17* AnGap-13
[**2113-9-2**] 09:00AM BLOOD Glucose-152* UreaN-6 Creat-0.7 Na-141
K-3.4 Cl-108 HCO3-24 AnGap-12
[**2113-8-26**] 03:40PM BLOOD ALT-13 AST-20 AlkPhos-88 Amylase-39
TotBili-0.4
[**2113-8-27**] 04:23PM BLOOD ALT-42* AST-66* CK(CPK)-42 AlkPhos-94
TotBili-2.1*
[**2113-8-28**] 05:56AM BLOOD ALT-75* AST-76* AlkPhos-113 Amylase-20
TotBili-0.9
[**2113-8-29**] 05:30AM BLOOD ALT-62* AST-47* LD(LDH)-231 AlkPhos-84
TotBili-0.6
[**2113-8-30**] 06:00AM BLOOD ALT-43* AST-22 LD(LDH)-268* AlkPhos-78
TotBili-0.6
[**2113-8-31**] 05:30AM BLOOD ALT-31 AST-20 LD(LDH)-400* AlkPhos-76
TotBili-0.6 DirBili-0.2 IndBili-0.4
[**2113-9-1**] 05:10AM BLOOD ALT-24 AST-20 AlkPhos-75 TotBili-0.5
[**2113-8-31**] 05:30AM BLOOD TotProt-4.3* Albumin-2.7* Globuln-1.6*
Calcium-8.2* Phos-2.3* Mg-1.3*
[**2113-8-28**] 08:09PM BLOOD Vanco-12.7*
[**2113-8-28**] 04:43AM BLOOD Type-ART Temp-36.1 pO2-116* pCO2-24*
pH-7.43 calTCO2-16* Base XS--5 Intubat-NOT INTUBA
[**2113-8-28**] 04:43AM BLOOD Lactate-1.4
Brief Hospital Course:
HD#1 [**2113-8-26**] - Pt admitted to transplant surgery from [**Hospital1 18**] as
pt p/w fever of 103.4. He was recently admitted for urinary
retention and was discharged on [**2113-8-21**] to be f/u with [**Date Range **]
clinic. He was seen in clinic by Dr.[**Last Name (STitle) 3748**] on [**8-25**] where he had
a post void residual of 600 cc. He was to return to [**Month/Year (2) **]
clinic in two weeks for another trial of void.
Plan:
Cx: blood, urine, CMV viral load collected
ABX: levoquin
Neupogen
Heparin GGT
I/D consult: sepsis most likely due to psuedomonas UTI, start
levo/vanco for to extend coverage to community aq. pneumonia,
flagyl if diarrhea
CT of ABD/PELVIS:
1. No intraabdominal fluid collection to suggest abscess.
2. Right common femoral deep vein thrombosis new compared to the
prior study.
3. Transplant liver with multiple unchanged hypodensities likely
representing cysts versus hemangiomas. The wedge shaped
hypodensity in segment VII of the liver is no longer seen.
4. Low density lesion in the spleen likely representing a cyst
or hemangioma is unchanged.
5. Hyperdensity within the anterior abdominal wall likely
represents postsurgical changes.
HD#2 Tmax 103.9 Tachy
start coumadin
cx:c. diff
repeat neupogen
DVT scan of B/L LE: 1) Partially occlusive, right common femoral
vein thrombus.
2) No DVT within the left lower extremity.
HD#3 AVSS
vanc/zosyn/flagyl
Hep gtt
Pt hypotensive to 70's on floor and transfused 2u PBRCs and 3L
crystalloid. Pt transferred to SICU for pressure support.
HD#4 AVSS
haparin gtt
bld CX:+ pan sensitive pseudomonas.
d/c vanco
lasix 40 IV
HD#[**5-6**] AVSS
coumadin/ hep gtt
HD#[**7-8**] AVSS
d/c heparin
coumadin 3
d/c abxs A.M. on HD#8
INR 3.4 afebrile on D/C
Medications on Admission:
prograf 1 ''
MMF [**1-1**] (study med)
prednisone 2.5mg
valcyte 900'
bactrim ss'
fluc 400'
lasix 40'
protonix'
flomax 0.4'
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
4. Mycophenolate Mofetil 250 mg Capsule Sig: Two (2) Capsule PO
BID (2 times a day): study drug.
5. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
6. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
7. Outpatient [**Name (NI) **] Work
PT/INR
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
uti-pseudomonas
s/p liver transplant [**6-6**]
Right leg dvt
Discharge Condition:
stable
Discharge Instructions:
call transplant office [**Telephone/Fax (1) 673**] if fevers, chills, back
ache, cloudy/foul smelling urine, jaundice, or any questions
resume regular [**Telephone/Fax (1) **] schedule-Mondays & thurdays
Followup Instructions:
Provider: [**Name10 (NameIs) **] UNIT Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2113-9-6**]
8:00
Call Transplant office [**Telephone/Fax (1) 673**] to schedule follow up in 1
week
VNA to draw labs on [**2113-9-3**] and call results to RN transplant
coordinator @[**Telephone/Fax (1) 673**]
Completed by:[**2113-9-5**]
|
[
"284.8",
"V42.7",
"593.9",
"041.7",
"458.9",
"453.40",
"787.91",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6028, 6084
|
3461, 5203
|
282, 289
|
6189, 6198
|
1416, 3438
|
6451, 6777
|
1092, 1110
|
5377, 6005
|
6105, 6168
|
5229, 5354
|
6222, 6428
|
1125, 1397
|
228, 244
|
317, 678
|
700, 884
|
900, 1076
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,274
| 197,097
|
43138
|
Discharge summary
|
report
|
Admission Date: [**2132-8-5**] Discharge Date: [**2132-8-14**]
Date of Birth: [**2083-1-21**] Sex: F
Service: MEDICINE
Allergies:
Betadine / Iodine / Nitroglycerin Transdermal / Gabapentin
Attending:[**First Name3 (LF) 19836**]
Chief Complaint:
Seizure and hypertensive emergency
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
49 y/o female with ESRD s/p 2 failed renal transplants on HD,
chronic HTN, T1DM s/p pancreas transplant, and CAD who presented
to the ED after a witnessed seizure. History is obtained through
hospital records and the patient's husband. At the time of
presentation to the MICU, pt was a poor historian and could not
relate her PMH or home medications.
.
The patient awoke around 3AM on the day of presentation and her
husband described her as confused and talking nonsense. This
episode resolved and the patient returned to sleep. In the AM on
the day of presentation, she was in her bathroom at home and her
husband witnessed a seizure around 7:30AM. He described tongue
biting and foaming of the mouth. He denies any incontinence;
however she does not make much urine and has an ileostomy. She
had tonic movements and her husband grabbed her hands and
lowered her to the ground. She sustained no head injury. EMS was
called and she was brought to the ED. She received Ativan 2 mg
IM which seemed to relieve some of her symptoms.
Past Medical History:
-s/p renal and pancreas transplant ([**2127-2-28**]; 2nd renal
transplant [**2128-3-4**]) for T1DM now with failed renal tx on HD
-CAD s/p CABG [**2-21**]
-Legally blind: cannot see anything in right eye due to diabetic
retinopathy and retinal detachment, and severely limited in left
eye
-Hypertension
-Osteopenia
-Depression
-Gastroparesis
-anemia
-CHF EF 30-35%
-Chronic diarrhea-with Cdiff and toxic megacolon [**10-26**] requiring
colectomy with ileostomy and ileostomy reversal in [**Month (only) 404**] of
[**2129**]
-Ventral hernia repair in [**2130-3-24**]
-history of VRE
-history of zoster (resolved)
-Polyneuropathy, felt to be due to CIDP
-Multiple SBOs
Social History:
Former CCU nurse, retired due to visual loss. 9 pk yr h/o
smoking, quit [**2107**]. No etoh/drugs. Uses walker at baseline.
Lives at home with husband. Manages all of her home meds.
Family History:
Adopted, unknown.
Physical Exam:
T 99 140/80 85 18 98/RA FS = 86
49 y/o female, not cooperative with history and exam. Poorly
answers questions, somnolent; rousable to loud voice and touch
HEENT: NC/AT. MMM. OP clear. Pupils equal and minimally
reactive.
Neck: Supple, no carotid bruits appreciated.
CV: 4/6 systolic murmur at LUSB with minimal radiation to
carotids.
Pulm: CTAB without any wheezes or crackles.
Abd: Soft, question of tenderness, ND, normoactive bowel sounds,
with large midline incision, stoma with stool/gas
Ext: No c/c/e. Evidence of recent vascular procedure on RLE.
Skin: No rashes.
Neuro: Somnolent. CNs difficult to assess secondary to AMS.
Moves all limbs equally, but not on command. Face symmetric.
Pertinent Results:
[**2132-8-5**] 09:12AM
WBC-5.1 RBC-3.25* HGB-12.7# HCT-36.7 MCV-113* MCH-39.1*
MCHC-34.6 RDW-18.9*
PLT COUNT-148*
NEUTS-73.6* LYMPHS-19.6 MONOS-5.4 EOS-1.1 BASOS-0.4
.
[**2132-8-5**] 09:12AM
GLUCOSE-88 UREA N-22* CREAT-5.2*# SODIUM-132* POTASSIUM-4.7
CHLORIDE-90* TOTAL CO2-23 ANION GAP-24*
ALBUMIN-4.2 CALCIUM-9.2 PHOSPHATE-5.2* MAGNESIUM-1.8
ALT(SGPT)-13 AST(SGOT)-22 ALK PHOS-161* AMYLASE-47 TOT BILI-0.4
.
[**2132-8-5**] 09:12AM
ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-POS
.
[**2132-8-5**] 09:12AM
cTropnT-0.10*
.
[**2132-8-5**] 09:29AM
LACTATE-4.4*
.
CT HEAD W/O CONTRAST Study Date of [**2132-8-5**] 10:11 AM
No hemorrhage, mass effect or edema. No significant change from
prior study.
.
ECG Study Date of [**2132-8-5**] 11:07:40 AM
Rate PR QRS QT/QTc P QRS T
91 146 114 400/448.71 75 76 112
.
EEG [**2132-8-7**]
This is an abnormal routine EEG in the waking and drowsy
states due to the presence of multifocal shar regions along with
multifocal mixed frequency slowing seen in the left and right
temporal
regions. The first finding suggests multiple areas of cortical
irritability which could serve as foci for epileptogenesis. The
second
finding suggests areas of subcortical dysfunction. No
electrographic
seizures were noted.
.
Patient refused both LP and MRI
Brief Hospital Course:
In the ED, intial vitals were T 98.8 HR 110 BP 222/125 RR 14 and
100%RA. She was given Ativan IV for a total of 4 mg. She was
given benadryl and Lopressor 5 mg IV x 2 and 25 mg PO. SBP
improved to the 180s. She was transferred to the MICU for BP and
neurological monitoring. Once hemodynamically stable, she was
transferred to the medical floor for continued work-up of her
seizure and hypertensive emergency.
.
# S/p seizure. Seizure activity was not observed while
inpatient. She was initially ruled out for toxic and metabolic
causes with blood toxicology and electrolyte testing. Head CT
was performed upon admit, and on hospital day #2 to assess for
acute intracranial pathology - both of which were negative.
Neurology was consulted and believed that multiple admissions
for confusion and elevated BP may represent missed seizures.
Per neuro recs, Mrs. [**Known lastname 13959**] was initially started on phenytoin
for seizure prophylaxis, but this medication was discontinued
and switched to Keppra once it was noted that phenyoin would
lower her tacrolimus level. Throughout her stay she refused
MRI and LP despite explanation that her immunocompromised state
caused increased concern for an intracranial infection. EEG was
performed and revealed no ongoing seizure. She was discharged
home on Keppra with Neurology follow-up.
- Keppra 37mg po BID
- Neurology follow-up [**Last Name (LF) 766**], [**2132-8-11**].
# Altered Mental Status. When admitted was altered mental
status, initially thought to be a post-ictal state. She was
treated with ativan for her seizure and transferred to the ICU
with some clearing of her mental status, however, by her third
day of hospitalization she continued to have altered mental
status of unclear etiology - whether due to benzodiazepines vs.
TCA withdrawal as her desipramine was held upon admit vs
metabolic vs hypertensive encephalopathy. Electrolyte and ABG
analysis were unrevealing. Hypertension was controlled and her
desipramine was restarted. On the seventh day of admission,
psychiatric consult was obtained and suggested avoiding benzos
and narcotics; and to use the single [**Doctor Last Name 360**] of haldol to control
her agitation. Following implementation of these suggestions,
her mental status improved dramatically and she was clear upon
discharge.
- Unclear etiology. Cleared with avoidance of benzos/narcotics;
haldol used for agitation.
.
# Fluctuating Blood Pressure - Admitted in hypertensive crisis
with BP likely elevated secondary to seizure and question of
recent compliance. Patient stated she take lopressor and
enalapril on a PRN basis at home as she often has low BP. She
takes them when her diastolic is 'greater than 100'. Was then
started on Metoprolol 25mg TID and lisinopril 5mg with good
control for 24 hours. She then became profoundly hypotensive to
SBP 70s, requiring TID midodrine and florinef per her home
regimen. She was normotensive upon discharge and these two
medications were continued.
- Discharged on midodrine and florinef
.
# s/p renal and pancreas transplant ([**2127-2-28**]; 2nd renal
transplant [**2128-3-4**]) for T1DM now with failed renal tx on HD.
Throughout stay was kept on HD schedule MWF and continued on
Bactrim prophylaxis. Renal medications of nephrocaps, procrit,
FeSO4 per HD protocol were continued. Immunosuppression of
imuran, prograf, and prednisone were continued at outpatient
levels. Prograf levels were monitored, and once noted to be low
secondary to phenytoin, the phenytoin was immediately
discontinued. Nephrology Transplant was consulted and
recommended Keppra for seizure management and reloading of
Prograf. Dosing was increased to 4mg po BID. On the day of
discharge, the level was therapeutic and per Transplant
pharmacy, she was discharged on her original dose of 2mg po BID.
- Continue tacrolimus 2mg PO BID
- Follow-up with Renal
- Continue all other outpatient medications as prescribed
.
# CAD s/p CABG [**2-21**]. Initial EKG changes were concerning for
ischemia, but resolved once HTN was controlled, most likely
consistent with demand in the setting of SBPs 220-240. Repeat
EKGs were monitored and cardiac enzymes were followed. CK and
troponin were elevated but were baseline in the setting of ESRD.
No elevation in CK-MB. Was briefly on BB and ACE-I, but both
were d/c due to hypotension.
- Continue outpatient aspirin.
- Instructed to follow-up with PCP concerning BB and ACE-I for
cardio-protection
.
# Asthma. Well controlled while inpatient without evidence of
acute flair.
- Discharge on outpatient medications
.
# Anemia: Chronic. Most consistent with ESRD, on pro-crit as an
outpatient, which was continued while inpatient.
.
# Chronic diarrhea: h/o Cdiff and toxic megacolon [**10-26**]
requiring colectomy with ileostomy and ileostomy reversal in
[**2129-12-24**]. Stoma was managed with routine nursing care.
Immodium was initially PRN, and she continued to have high
volume stoma output. When Immodium was scheduled [**Hospital1 **], stoma
output decreased dramatically and hypovolemia resolved.
- Immodium [**Hospital1 **]
.
#Diabetes Mellitis, Type 1 - Clinical cure s/p pancreatic
transplant. Did not require insulin while inpatient. One FS =
256. Transplant was consulted with concern for pancreas
rejection given period of low tacrilimus levels. Amylase and
lipase were checked and found to be normal. No evidence of
rejection. All AM FS below diabetic levels.
.
FULL CODE
Medications on Admission:
(per husband's documentation)
Prograf 2 mg PO BID
Prednisone 5 mg PO daily
Imuran 25 mg PO QOHS
ASA 81 mg PO daily
Folate 1 mg PO QHS
Bactrim SS 1 TAB PO QMWF
Lopressor 75 mg PO ?PRN
Enalapril 15 mg PO ?PRN
Atrovent INH
Astelin
Flovent
Ventolin INH
Restais gtt
Pred Forte gtt
Acular gtt
Zaditor gtt
Alrex gtt
Benadryl PRN
Tylenol PRN
Pseudophed PRN
Alka-Seltzer PRN
Procrit (at HD)
Iron (at HD)
Zemplar (at HD)
Fosrenol [**2124**] mg PO W/meals
Ambien PRN
Compazine PRN
Claritin 10 mg PO QAM
[**Doctor First Name **] PRN
Ibuprofen PRN
Midodrine PRN
Immodium PRN
Nephrocaps
Desiprimine 150 mg PO QHS
Lomotil PRN
Pepcid 10 mg PO QAM
Simethicone
Clonazepam PRN
Sensipar 30 mg PO daily
Discharge Medications:
1. Procrit 10,000 unit/mL Solution Sig: per HD protocol
Injection per protocol.
2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO QHS MWF.
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO at bedtime.
5. Azathioprine 50 mg Tablet Sig: 0.5 Tablet PO QOHS.
6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. Atrovent 0.03 % Aerosol, Spray Sig: Two (2) Sprays Nasal once
a day.
8. Astelin 137 mcg Aerosol, Spray Sig: Two (2) sprays Nasal once
a day.
9. Flovent HFA 220 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation once a day.
10. Ventolin HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: One
(1) Puff Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
11. Pred Forte 1 % Drops, Suspension Sig: One (1) gtt os
Ophthalmic Q3D.
12. Acular 0.5 % Drops Sig: One (1) gtt os Ophthalmic Q3D.
13. Zaditor 0.025 % Drops Sig: One (1) gtt os Ophthalmic once a
day as needed for conjunctitvis.
14. Zemplar 5 mcg/mL Solution Sig: Per HD protocol per protocol
Intravenous QMWF.
15. FeSO4 Sig: Per HD protocol Per HD protocol Hemodialysis
QMWF.
16. Lanthanum 500 mg Tablet, Chewable Sig: Four (4) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
17. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia. Tablet(s)
18. Compazine 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for nausea.
19. Claritin 10 mg Tablet Sig: One (1) Tablet PO QAM.
20. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO at bedtime.
21. Imodium A-D 2 mg Tablet Sig: 4-8 Tablets PO three times a
day as needed for increased stoma output.
22. Lomotil 2.5-0.025 mg Tablet Sig: Two (2) Tablet PO three
times a day.
23. Pepcid AC 10 mg Tablet Sig: One (1) Tablet PO QAM.
24. Simethicone 125 mg Capsule Sig: Four (4) Capsule PO three
times a day.
25. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for anxiety.
26. Sensipar 30 mg Tablet Sig: One (1) Tablet PO at bedtime.
27. Keppra 250 mg Tablet Sig: 1.5 Tablets PO twice a day: Also
take one additional tablet (250mg) after each HD on MWF.
Disp:*110 Tablet(s)* Refills:*2*
28. Desipramine 150 mg Tablet Sig: One (1) Tablet PO at bedtime.
29. Midodrine 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
30. Florinef 0.1 mg Tablet Sig: One (1) Tablet PO QMWF.
31. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary: Seizure d/o, hypertensive emergency
Secondary: Diabetes mellitis type 1 s/p resolution with
successfull pancreatic transplant, hypotension,
immunosuppression, ESRD, blindness, AMS, asthma, anemia, CAD s/p
CABG, CHF (EF = 30-35%).
Discharge Condition:
Good. Afebrile and normotensive with stable mental status.
Discharge Instructions:
You have been hospitalized for both hypertensive emergency and a
new witnessed seizure. Once admitted you were transferred to
the ICU and treated with blood pressure and antiseizure
medications. You were also seen by Neurology, Psychiatric and
Renal specialists. Once you were stable and your blood pressure
was controlled, you were transferred to the floor. Your
hemodialysis was continued while you were here. On the day of
discharge your blood pressure was well controlled and you had
not had any seizure activity while in the hospital.
.
Return to the emergency department immediately should you have
another seizure, blood pressure not controlled by your current
medications or have any other symptoms that concern you.
.
While in the hospital the following medications have been
changed:
--You were previously on metoprolol (lopressor) 75mg and
enalapril 15mg PRN. While inpatient your blood pressure was
very high requiring daily metoprolol, but then became very low.
We are discharging you on Florinef 0.1mg QMWF and Midodrine 5 mg
PO Q6H. This is your regular dose of Florinef and an increase
in your Midorine dosing. You should follow-up with your on PCP
to discuss this while continuing to monitor your blood pressure
at home and HD.
--Because you have a new diagnosis of seizure disorder, you have
been started on antiseizure medication. You should continue
taking Keppra 375mg po BID each day, with a 250mg extra dose
after each dialysis per Neurology recommendations.
--In the hospital, you were briefly treated with dilantin for
your seizures. This lowered your ProGraf (tacrolimus) level.
Renal transplant recommended briefly increasing your tacrolimus
dosing to get back to therapeutic levels. Today your level is
therapeutic, and so you are being discharged home on your
previous dose of 2mg po BID.
.
Continue all other medications as prescribed.
.
Attend all scheduled outpatient appointments.
Followup Instructions:
Follow-up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],[**Telephone/Fax (1) 3506**]
Wednesday, [**2132-9-17**] at 12pm.
.
Follow-up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (STitle) **], [**Telephone/Fax (1) 250**]
Wednesday, [**2132-9-17**] at 11am.
.
Continue hemodialysis MWF.
.
Call your Renal physician to make [**Name Initial (PRE) **] follow-up appointment in the
next 1-2 weeks to monitor your Prograf levels.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD, [**MD Number(3) 19838**]
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76,618
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Discharge summary
|
report
|
Admission Date: [**2140-4-28**] Discharge Date: [**2140-5-11**]
Date of Birth: [**2065-1-6**] Sex: M
Service: MEDICINE
Allergies:
morphine / Zosyn
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Respiratory failure, mass in left upper lobe
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
This is a 75-year-old gentleman with a pmhx. significant for
malignant bladder cancer s/p elective radical cystectomy/ileal
conduit on [**4-25**], HTN, hyperlipidemia, and new mass-like lesion
obstructing proximal orifice of left upper lobe, who is
transferred from [**Location (un) 28318**], [**State 1727**] for IP evaluation of lung
lesion.
.
Mr. [**Known lastname 56711**] was initially diagnosed with low-grade high-volume
bladder tumor approximately 1 year ago. He had multiple
resections of his tumor, but continued to suffer from gross
hematuria. In preparation for radical cystectomy, patient had
an extensive metastatic evaluation, including chest CT, that
revealed no metastatic disease outside of the bladder. On [**4-25**],
patient went for radical cystectomy; he initially did well but
then developed increased 02 requirements over the next few days
and eventually required reintubation. A repeat CXR showed
evidence of collapse of the left upper lobe, and a repeat CT
scan confirmed collapse and question of a mass (The prior CT
images were reviewed and in retrospect it appeared as though
there was an upper lobe hilar mass i [**2140-3-1**] as well).
Patient underwent bronchoscopy on [**4-27**] and a mass-like lesion
was found obstructing the proximal orifice of the left upper
lobe. Washings were taken but biopsy was not done due to
bleeding. During hospitalization, patient also had fascial
dehiscence and evisceration that required emergent return to the
OR.
.
Patient is now being transferred to [**Hospital1 18**] for Interventional
Pulmonology evaluation of bronchial mass. He is intubated and
on fentanyl boluses. Vitals on arrival were: 100.1, HR: 143,
BP: 119/66, and SPo2 92% on Fi02 70%, 8 driving pressure, 5 of
PEEP.
Past Medical History:
--Bladder CA
--Tracheal mass
--COPD
--HTN
--Hyperlipidemia
--Appendectomy
--Bladder tumor resection
Social History:
Patient has a 60-pack-year history of smoking but is a current
non-smoker. He does not drink alcohol. Other social history
unable to be obtained.
Family History:
Significant for cardiac disease.
Physical Exam:
Admission Exam:
VS: 100.1, HR: 141, BP: 108/64, SPO2 94% on FIO2 70%
GENERAL: Intubated, comfortable, responds to commands
CHEST: Clear anteriorly
CARDIAC: Tachycardic, regular rhythm, no MRG
ABDOMEN: Abdominal wound with sutures in place, no drainage,
tissue is pink, urostomy bag in place, no bowel sounds
EXTREMITIES: 2+ edema in all four extremities, pneumoboots in
place
NEURO: Responds to commands, sedated, looks comfortable
.
Discharge Exam [**2140-5-11**]
VS: Tm99.6 tc98.7 p89 (88-109) BP 146/55 (125-169/51-87) rr13-25
Sa02 92% 4LNC
General Appearance: Alert, attentive, conversational and
pleasant.
HEENT: no oral lesions or ulcers
Skin: diffuse symmetric erythematous macular coalescing rash
over buttocks, groin, medial aspect of upper extremities BL
Cardiovascular: S1/S2, RRR, no MRG
Respiratory / Chest: L>R ronchi with transmitted breath sounds
Abdominal: distension improved, non-tender, bandage over
surgical retention sutures. Midline surgical incision without
drainage. Urostomy with yellow drainage, hypoactive BS
Extremities: Right lower extremity edema: 2+, Left lower
extremity edema: 2+
Neurologic: Conversant, following commands, moving all
extremities
Pertinent Results:
Admission Labs ([**2140-4-28**]):
- ABG:
TYPE-ART PEEP-8 O2-70 PO2-40* PCO2-51* PH-7.32* TOTAL CO2-27
BASEXS-0
- Chem:
GLUCOSE-118* UREA N-34* CREAT-2.3* SODIUM-141 POTASSIUM-4.4
CHLORIDE-106 TOTAL CO2-25 CALCIUM-7.8* PHOSPHATE-3.2
MAGNESIUM-1.8
- LFTs:
ALT(SGPT)-14 AST(SGOT)-44* LD(LDH)-274* ALK PHOS-73 TOT BILI-0.5
ALBUMIN-2.8* [**2140-4-28**] 03:34PM
- CBC:
WBC-11.2* RBC-3.20* HGB-10.2* HCT-29.1* MCV-91 MCH-31.9
MCHC-35.0 RDW-14.5
NEUTS-84.5* LYMPHS-9.9* MONOS-4.9 EOS-0.6 BASOS-0.2 PLT
COUNT-263
- Coags:
PT-12.8 PTT-25.7 INR(PT)-1.1
.
[**2140-5-3**] 03:45PM BLOOD Glucose-114* UreaN-32* Creat-3.5* Na-142
K-3.6 Cl-107 HCO3-28 AnGap-11
DISCHARGE LABS
[**2140-5-11**] 03:28AM BLOOD WBC-9.5 RBC-3.12* Hgb-9.5* Hct-29.1*
MCV-93 MCH-30.5 MCHC-32.7 RDW-13.6 Plt Ct-466*
[**2140-5-10**] 04:17AM BLOOD Neuts-90.3* Lymphs-5.1* Monos-3.5 Eos-1.0
Baso-0.2
[**2140-5-11**] 03:28AM BLOOD Glucose-133* UreaN-27* Creat-1.9* Na-141
K-4.0 Cl-96 HCO3-35* AnGap-14
[**2140-5-10**] 04:17AM BLOOD ALT-16 AST-33 LD(LDH)-333* AlkPhos-67
TotBili-0.2
[**2140-5-11**] 03:28AM BLOOD Calcium-8.0* Phos-3.1 Mg-2.0
Micro:
- BCx ([**4-29**]): negative
- BCx ([**4-29**]): negative
- UCx ([**5-3**]): negative
- UCx ([**5-6**]): negative
- BCx ([**5-7**]): no growth to date [**2140-5-11**]
- Sputum cx [**5-7**]:
GRAM STAIN (Final [**2140-5-7**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2140-5-9**]):
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH.
YEAST. RARE GROWTH. 2ND MORPHOLOGY.
- Sputum Cx ([**4-29**]):
SPUTUM GRAM STAIN:
[**11-22**] PMNs and <10 epi cells/100X field. NO MICROORGANISMS
SEEN.
RESPIRATORY CULTURE (Final [**2140-5-1**]):
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES.
.
Imaging:
CXR [**2140-4-28**]: Followup of the patient with bladder cancer after
radical prostatectomy and new bronchial mass. Portable AP chest
radiograph was reviewed with no prior studies available for
comparison. Current study demonstrates the intubated patient
with the ET tube tip being 5 cm above the carina. The NG tube
tip is in the stomach. There is a large left hilar mass with
left upper lobe atelectasis. The left hemidiaphragm is elevated.
There is a curvilinear lucency surrounding the aortic arch most
likely representing the Luftsichel sign associated with left
upper lobe atelectasis. Right lung demonstrates a right lower
lobe opacity, partially characterized on that study and may
represent infectious process or partial atelectasis. Correlation
with cross-sectional imaging is required. The partial imaging of
the upper abdomen shows bilateral ureteral stents.
.
ECHO [**2140-4-29**]: Suboptimal images. The left atrium is normal in
size. Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF >70%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal.
.
CT ABDOMEN / PELVIS [**2140-5-3**]
1. Status post radical cystectomy and ileal conduit with no
evidence of leak. Small amount of free fluid in the pelvis does
not communicate with
contrast-filled ileal conduit.
2. Fatty liver. Cystic liver lesion in segment II with adjacent
fatty
sparing.
3. Soft tissue lesion narrowing the left main and left upper
lobe bronchus
with left upper lobe atelectasis; incompletely imaged.
4. Cholelithiasis; no evidence of acute cholecystitis.
5. Incidental intramuscular lipoma between the internal and
external left
oblique muscle.
CT CHEST [**2140-5-6**]
FINDINGS:
The patient is intubated, with the ET tube tip being
approximately 4 cm above the carina. The NG tube tip is in the
stomach. The right PICC line tip is at the low SVC.
There are several mediastinal lymph nodes, some of them more
than 1 cm in
diameter. Although they may represent reactive findings, but
they also can be enlarged due to neoplastic involvement giving
the large mass in the left hilus, that appears to be located at
the level of left main pulmonary artery, where it enters the
lungs. The exact dimension of the mass is difficult to estimate
given the lack of contrast, but approximate estimation would be
2.5 x 4 cm. The density of the mass is heterogeneous, with areas
of 14 and 27 Hounsfield units. Currently, the left upper lobe
and left lower lobe bronchi are patent but the lingular bronchus
is not seen and potentially may be obstructed by the presence of
the mass, 4:126. There are extensive areas with interlobular
septal thickening, consistent with volume overload. There are
also posterior segment of left upper lobe, left lower lobe and
right lower lobe opacities which might represent infectious
process. Aspiration would be another possibility.
Postobstructive nature of left upper lobe posterior segment
abnormalities is likely given the previously documented left
upper lobe partial atelectasis.
.
There are no bone lesions worrisome for infection or neoplasm.
.
The imaged portion of the abdomen re-demonstrates low density of
the liver, 2:50, it should be better assessed with ultrasound.
PATHOLOGY [**2140-5-2**]
Left upper lobe, endobronchial biopsy:
Poorly differentiated carcinoma.
.
The specimen contains mostly necrotic tumor in a background of
abundant fibrino-inflammatory exudate. Small groups of viable
cells stain positive for cytokeratin cocktail (AE1/3 and CAM
5.2) and p63. Cells are negative for cytokeratin 7 and
cytokeratin 20. A poorly-differentiated non-small cell lung
carcinoma is favored, although metastasis from a bladder primary
cannot be entirely excluded.
Brief Hospital Course:
This is a 75-year-old gentleman with a pmhx. significant for
bladder cancer s/p radical cystectomy on [**4-25**] at Penobscot
[**Hospital **] Hospital, unable to extubate following the proceedure and
transfered to [**Hospital1 18**] ICU for management, found to have left upper
lobe collapse, and new bronchial mass he was treated with XRT x2
weaned off of the ventilator and returned to Penobscot [**Hospital **]
Hospital per patient and family request.
.
# RESPIRATORY FAILURE: Related to left upper lobe collapse in
setting of bronchial mass. Trigger may have been mechanical
intubation during cystectomy on [**4-25**]. He was bronched by IP, who
was able to open up part of the left upper lobe, which
subsequently re-collapsed on serial chest xray. He required
intermittent high PEEPs and FIO2, posing barriers to extubation.
He was taken for external beam radiation therapy and left upper
lobe subsequently re-expanded. Given high peep and FIO2
requirement there was concern that he would not be able to be
weaned off of the ventilator. After a family discussion the
decision was made to optimize his pulmonary status and extubate
without the plan for re-intubation. He was agressively diuresed
with furosemide 80mg IV BID. He was successfully weaned off of
the ventillator [**5-9**] he was weaned from non-rebreather to 4LNC
which was his oxygen requirement at the time of transfer. He was
discharged on furosemide 40mg PO daily which may need to be
titrated after transfer.
.
# Ventilator associated Pneumonia: He had a low grade
temperature and was started on ventilator associated pneumonia
[**5-6**] with vancomycin and zosyn. Zosyn was changed to levaquin
when patient developed a drug related rash (see below). He will
need to continue vancomycin and levaquin until [**5-14**].
.
# Drug rash: [**5-7**] patient developed confluent erythematous rash
over trunk and groin, no mucousal lesions to suggest TEN/[**First Name8 (NamePattern2) **]
[**Location (un) **] syndrome. Zosyn discontinued as presumed cause of rash
he was treated with hydrocortisone cream and the rash improved
moderately. At the time of discharge, the rash persisted and
involved his groin, anterior chest and abdomen, and medial
aspect of his arms. He should continue hydrocortisone cream for
7 days.
.
# Acute on chronic renal insufficiency: Creatinine 2.0 prior to
transfer and trended up to 3.5. Obstruction ruled out with
negative U/S and Urology confirmed stents patent. CT A/P with
urogram and negative for ileal conduit leak. Fe Urea is 40%
suggesting ATN. Renal was consulted and believed acute
insufficency was related to ATN. Cr improved with diuresis and
avoidance of nephrotoxins, trending down to 1.7 at the time of
discharge.
.
# BRONCHIAL TUMOR: Broncheoscopy performed for left upper lobe
collapse returned tissue consistent with non-small cell lung
cancer however pathology was unable to exclude metastatic
disease from bladder. Patient was seen by Radiation Oncology and
underwent palliative XRT on [**5-4**] and again on [**5-11**] without plans
for further XRT sessions. He will need to have oncology follow
up on discharge with staging of the mass.
.
# BLADDER CANCER: Patient now s/p radical cystectomy with
ureteral stents. Urology followed him during admission, giving
recommendations about post-surgical care. Patient put out well
through his ileal conduit, and pain at incision site gradually
improved, although required treatment with IV Fentanyl as
needed.
.
# RENAL FAILURE: Patient with unknown baseline creatinine. His
creatinine at OSH reached 3.8 in the setting of obstruction from
ureteral stents. Patient's creatinine initially trended down
during admission, but had acute worsening on admission to [**Hospital Unit Name 153**].
Obstruction and ileal conduit leak were ruled out with imaging.
Renal was consulted, who examined his urine sediment and
determined the etiology to be likely ATN. His creatinine
improved.
.
# WOUND DEHISCENCE: Patient with wound dehiscence and
subsequent closure on [**4-27**]. Tissue now looks pink without
purulent drainage. General surgery was consulted and felt wound
was healing well. Recommended tension sutures remain in for
total of 3 weeks. Retention sutures will need to be removed
[**2140-5-19**].
.
# HYPERNATREMIA: Developed hypernatremia during ICU admission,
replaced free water deficit with D5W, with good response of
serum sodium values.
.
# HYPERTENSION: Anti-hypertensives were discontinued in setting
of sedation and acute illness. Amlodipine was restared when
patient was weaned off ventilator.
.
# HYPERCHOLESTEROLEMIA: Patient is not on a statin as an
outpatient; treatment was deferred to outpatient providers
.
# TACHYCARDIA: Upon admission, patient had episodes of afib
with RVR. He responded well to diltiazem and he was started on
diltiazem 90mg QID which was changed to diltiazem 360 XR prior
to transfer. He will need to continue diltiazem as an
outpatient.
.
# GERD: PPI was continued during admission.
COMMUNICATION: [**Name (NI) **] wife [**Name (NI) **], [**Telephone/Fax (1) 89814**]
CODE STATUS: DNR/DNI
ISSUES NEEDING FOLLOWUP:
- Surgical retention sutures on midline abdominal wound need to
be removed [**2140-5-19**]
- Furosemide 40mg PO daily may need to be titrated
- Oncology follow up for staging of left upper pulmonary mass
Medications on Admission:
--Prevacid
--Glucosamine
--Spiriva
--Norvasc 5mg QD
--Metamucil
--Duoneb
--Prilosec
--Multivitamin
--Vitamin A
--Aspirin
Discharge Medications:
1. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) capsule Inhalation once a day.
2. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: Three (3) mL Inhalation four times a day as
needed for shortness of breath or wheezing.
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
5. diltiazem HCl 360 mg Tablet Extended Release 24 hr Sig: One
(1) Tablet Extended Release 24 hr PO once a day: Hold for SBP
<100, HR<60.
6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Hold for SPB <100, HR<60.
7. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours: do not exceed 4000mg acetaminophen.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
10. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
11. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. cortisone 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a
day) for 7 days: Apply to rash on torso and arms BL.
14. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
15. levofloxacin in D5W 750 mg/150 mL Piggyback Sig: Seven
[**Age over 90 1230**]y (750) mg Intravenous Q48H for 3 days: Last dose
given [**5-11**]. Final day [**5-14**].
16. vancomycin 1,000 mg Recon Soln Sig: 1000mg mg Intravenous
once a day for 3 days: Final day [**5-14**].
17. Ondansetron 4 mg IV Q8H:PRN nausea
18. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day:
Hold for SBP<100
.
19. 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.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Respiratory failure
.
Pulmonary edema
Ventilator associated pneumonia
Non-small cell lung cancer
bladder cancer
COPD
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr [**Known lastname 56711**],
As you know, you were transferred to [**Hospital1 18**] after your bladder
surgery for evaluation of respiratory failure. You were treated
with mechanical ventilation and taken for a proceedure to
evaluate your left lung. We took biopsies which suggested that
you have a form of lung cancer in your left lung. You were
treated with radiation therapy to shrink the mass and improve
your respiratory function. With time, you were weaned off of the
ventilator to nasal canula. We treated you with a diuretic
(water pill) called furosemide to help remove fluid from your
lungs, you will need to continue to take this medication after
transfer.
.
Your heart rate increased and you developed an arrythmia called
atrial fibrillation. You were started on diltiazem to help your
heart rate. You will need to continue to take this medication on
transfer.
You developed a rash on your chest and legs which is related to
a medication, Zosyn, the medication was stopped and your rash is
improving, you should inform your healthcare providers that this
medication caused an allergic reaction.
.
At your request, you are being transferred to Penobscot [**Hospital **]
Hospital for further management closer to your home.
.
MEDICATION CHANGES
START Diltiazem
START Furosemide
Followup Instructions:
Please make an appointment to see your primary care provider on
discharge from Penobscot [**Hospital **] Hospital
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"V10.51",
"518.5",
"560.1",
"285.21",
"V44.59",
"403.90",
"427.32",
"V15.82",
"162.3",
"276.0",
"272.0",
"530.81",
"997.31",
"427.31",
"V49.86",
"E930.8",
"585.9",
"584.5",
"693.0",
"518.0",
"272.4",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.6",
"33.22",
"92.29",
"99.15",
"96.72",
"32.01"
] |
icd9pcs
|
[
[
[]
]
] |
17169, 17184
|
9678, 15011
|
321, 335
|
17364, 17364
|
3684, 9655
|
18832, 19074
|
2427, 2461
|
15182, 17146
|
17205, 17343
|
15037, 15159
|
17514, 18809
|
2476, 3665
|
237, 283
|
363, 2123
|
17379, 17490
|
2145, 2246
|
2262, 2411
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,232
| 105,727
|
33290
|
Discharge summary
|
report
|
Admission Date: [**2197-5-26**] Discharge Date: [**2197-6-12**]
Date of Birth: [**2137-10-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
pulmonary edema
Major Surgical or Invasive Procedure:
ERCP on [**5-31**]
AVR (23 mm CE tissue) on [**2197-6-2**]
History of Present Illness:
multiple CHF admissions, flash pulm. edema, adm. to [**Hospital1 **], diuresed and transferred to [**Hospital1 18**] for surgical eval.
Past Medical History:
- Schizophrenia
- Anxiety
Denies any other PMHx, including any cardiac history.
Social History:
Social history is significant for the current tobacco use, about
1 PPD, which he has used for about 44 years. There is no history
of alcohol abuse. He denies any intravenous drug abuse, but
states he has abused "motion sickness" medications in the past.
.
Patient lives independently in an assisted facility with a
roommate. He has no guardian, and makes all of his own
day-to-day decisions. The housing facility is supported by the
Department of Health. He has no known family in the area. At
baseline he walks about one flight of stairs or one block before
getting short of breath (until recently).
Family History:
He denies any family history of premature coronary artery
disease or sudden death.
Physical Exam:
labored breathing
dissuse skin rash
bilat crackles
3/6 systolic murmur
otherwise, unremarkable physical exam on admission
Pertinent Results:
[**2197-6-8**] 05:15AM BLOOD WBC-6.4 RBC-3.09* Hgb-8.9* Hct-26.7*
MCV-86 MCH-28.6 MCHC-33.2 RDW-14.9 Plt Ct-474*
[**2197-6-4**] 01:47AM BLOOD PT-14.8* PTT-32.9 INR(PT)-1.3*
[**2197-6-9**] 05:25AM BLOOD Glucose-90 UreaN-35* Creat-1.6* Na-140
K-4.2 Cl-110* HCO3-21* AnGap-13
[**2197-6-8**] 05:15AM BLOOD Glucose-90 UreaN-36* Creat-2.0* Na-139
K-4.1 Cl-109* HCO3-20* AnGap-14
[**2197-6-7**] 05:10AM BLOOD Glucose-87 UreaN-34* Creat-2.3* Na-137
K-4.1 Cl-107 HCO3-20* AnGap-14
[**2197-5-26**] 09:40PM BLOOD Glucose-111* UreaN-26* Creat-1.0 Na-144
K-4.2 Cl-111* HCO3-24 AnGap-13
CHEST (PA & LAT) [**2197-6-8**] 8:44 AM
CHEST (PA & LAT)
Reason: eval for pleural effusions
[**Hospital 93**] MEDICAL CONDITION:
59 year old man s/p AVR
REASON FOR THIS EXAMINATION:
eval for pleural effusions
INDICATION: 59-year-old male status post AVR. Please evaluate
for pleural effusions.
FINDINGS: PA and lateral chest radiographs reviewed and compared
to [**2197-6-6**]. Post-operative cardiac silhouette is stable. Right
IJ central venous catheter has been removed. Pulmonary
vascularity is normal. Mild blunting at the left costophrenic
sulcus is now noted, and there is slightly worsening left
basilar atelectasis. Lungs are otherwise clear. There is no
pneumothorax.
IMPRESSION: Increasing left basilar atelectasis, and likely
small left pleural effusion.
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 77286**] (Complete)
Done [**2197-6-2**] at 11:16:26 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 1112**] W.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2137-10-6**]
Age (years): 59 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intraoperative TEE for AVR
ICD-9 Codes: 402.90, 440.0, 424.1
Test Information
Date/Time: [**2197-6-2**] at 11:16 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 #: 2008AW4-: Machine: 1
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *6.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Aorta - Ascending: *3.6 cm <= 3.4 cm
Aorta - Descending Thoracic: *2.6 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *4.5 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *82 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 49 mm Hg
Aortic Valve - LVOT diam: 2.2 cm
Aortic Valve - Valve Area: *0.9 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast in the body of the [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Mild symmetric LVH. Moderately dilated
LV cavity. Mild-moderate global left ventricular hypokinesis.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated ascending aorta. Focal calcifications in
ascending aorta. Simple atheroma in aortic arch. Mildly dilated
descending aorta. Complex (>4mm) atheroma in the descending
thoracic aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Moderate-severe AS
(area 0.8-1.0cm2). Moderate (2+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Physiologic MR (within normal
limits).
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
No PR.
PERICARDIUM: Trivial/physiologic 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. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. Left pleural effusion.
Conclusions
PRE CPB 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. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated. There is mild to moderate global left
ventricular systolic dysfunction. Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. There are simple atheroma in the aortic arch. The
descending thoracic aorta is mildly dilated. There are complex
(>4mm) atheroma in the descending thoracic aorta. There are
three aortic valve leaflets. The aortic valve leaflets are
severely thickened/deformed, particularly the left and right
coronary cusps. There is moderate to severe aortic valve
stenosis (area 0.8-1.0cm2). Moderate (2+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened.
Physiologic mitral regurgitation is seen (within normal limits).
There is a trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **]
was notified in person of the results in the operating room at
the time of the study.
POST CPB Normal right ventricular systolic function. Left
ventricle with continued mild to moderate global sytolic
dysfunction. A bioprosthesis is located in the aortic position.
It is well seated and displays normal leaflet function. There is
trace valvular aortic regurgitation. The maximum gradient across
the aortic valve is 54 mm Hg with a mean gradient of 36 mm Hg at
a cardiac output of 7.5 l/m. The effective orifice area of the
valve is 1.6 cm2. The thoracic aorta is intact. No other changes
from pre bypass study..
ERCP BILIARY&PANCREAS BY GI UNIT [**2197-5-30**] 2:40 PM
ERCP BILIARY&PANCREAS BY GI UN
Reason: Please review ERCP images done [**5-30**]
[**Hospital 93**] MEDICAL CONDITION:
Suspected bile ducts stone
REASON FOR THIS EXAMINATION:
Please review ERCP images done [**5-30**]
ERCP BY GI UNIT
INDICATION: 59-year-old man with suspicion for bile duct stone.
COMPARISON: MRCP from [**2197-5-29**].
FINDINGS: Six fluoroscopic images are submitted for evaluation
after ERCP by the Gastroenterologist. The radiologist was not
present at the time of study. There is some marked narrowing at
the distal CBD with some more proximal dilatation. However,
there is no filling defect definitively demonstrated on the
submitted images.
IMPRESSION: Markedly narrowed distal CBD without any evidence of
a filling defect. For further details, see the gastroenterology
report in CareWeb from the same day.
Brief Hospital Course:
59 y/o male presented to OSH in pulmonary edema, was treated
w/diuretics, and transferred to [**Hospital1 18**] on [**2197-5-26**] for surgical
evaluation.
He was admitted to the medical service where he was continued
with diuresis. A GI consult was obtained due to his history of
gallstone pancreatitis, and ongoing dull abdominal pain with
elevated LFT's. He underwent an ERCP on [**5-31**], and a CBD stone
had passed after the procedure. A dental consult was obtained
on [**5-31**], and it was recommended that tooth # 18 be removed.
This did not occur prior to surgery, and the patient was taken
to the OR on [**6-2**] where he underwent an AVR (#23mm CE
pericardial valve). Please see operative report for details of
surgical procedure.
On POD # 1, he was extubated, and hemodynamically stable, but he
was agitated and non-verbal. It was unclear at the time if this
was a neurologic problem vs. psychiatric. Both Neuro & psych
consults were obtained, his psych. meds were altered, and his
mental status improved significantly over the next few days.
His chest tubes and epicardial pacing wires were removed. Head
CT showed no acute process and carotid u/s was normal. He was
transfused for HCT 26. On POD # 4, she was transferred from the
ICU to the telemetry floor. He had returned to his baseline
psych status, and began to progress with physical therapy &
ambulation. He was ready for return to his group home on POD
#10. He will require Pen VK until he is seen by a dentist and
his tooth is extracted, and will need follow up with his
psychistrist as well as with GI for a repeat CT and colonoscopy.
Medications on Admission:
Lisinopril 5'
Colace 100"
Carafate
MVI
Zocor 40'
Folic Acid 1'
Iron 325"
Lasix 40'
ASA 81'
Toprol XL 25'
Nicotine patch
Benztropine 0.5 "'
Discharge Medications:
1. Simvastatin 40 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Folic Acid 1 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Fluphenazine HCl 10 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*0*
4. Valproic Acid 250 mg Capsule [**Month/Year (2) **]: Three (3) Capsule PO Q12H
(every 12 hours).
Disp:*180 Capsule(s)* Refills:*0*
5. Aspirin 81 mg Tablet, Chewable [**Month/Year (2) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
6. Acetaminophen 325 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO Q4H (every
4 hours) as needed.
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*0*
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Norvasc 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. Toprol XL 25 mg Tablet Sustained Release 24 hr [**Last Name (STitle) **]: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
11. Penicillin V Potassium 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
four times a day: until tooth extraction.
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Able VNA
Discharge Diagnosis:
AS
schizophrenia
chronic, systolic CHF
duodenitis
gallstone pancreatitis
HTN
hyperlipidemia
AS
schizophrenia
chronic, systolic CHF
duodenitis
gallstone pancreatitis
HTN
hyperlipidemia
Discharge Condition:
good
Discharge Instructions:
shower daily, no bathing or swimming for 1 month
no creams, lotions, or powders to any incisions
no driving for 1 month
no lifting > 10 # for 10 weeks
Followup Instructions:
with Dr. [**Last Name (STitle) **] in [**4-15**]- weeks
with Dr. [**Last Name (STitle) **] in [**2-12**] weeks
with Dr. [**Last Name (STitle) **] in [**2-12**] weeks
Completed by:[**2197-6-12**]
|
[
"428.0",
"070.54",
"424.1",
"574.50",
"401.9",
"293.9",
"295.92",
"342.90",
"428.23",
"305.1",
"285.9",
"782.1",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.64",
"35.21",
"39.61",
"51.87",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
11897, 11936
|
8546, 10163
|
337, 398
|
12165, 12172
|
1546, 2216
|
12371, 12568
|
1302, 1388
|
10353, 11874
|
7807, 7834
|
11957, 12144
|
10189, 10330
|
12196, 12348
|
1403, 1527
|
282, 299
|
7863, 8523
|
426, 563
|
585, 667
|
683, 1286
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,710
| 139,281
|
30604+57710
|
Discharge summary
|
report+addendum
|
Admission Date: [**2180-7-26**] Discharge Date: [**2180-7-31**]
Date of Birth: [**2114-1-13**] Sex: F
Service: NEUROSURGERY
Allergies:
Clindamycin / Voltaren / Flagyl / Erythromycin Base / Tape /
Demerol
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
LEG PAIN
Major Surgical or Invasive Procedure:
Posterior lumbar fusion L3-S1
History of Present Illness:
This is s 66-year-old woman who had previously undergone a
decompressive operation. She presented with a spondylolisthesis
and coronal deformity and suggestion of instability
preoperatively. For constitutional reasons, a fusion was
deferred at that time. Unfortunately she went on to develop
progressive difficulty with instability and as a result was
treated with aggressive physical therapy. This was unsuccessful
and she now presents for definitive fusion.
Past Medical History:
Cardiovascular Cardiac Testing
Stress ([**9-7**] no [**Month/Year (2) **] changes; no
ischemia; normal LV sys fx without
regional wall motion abnormalities;
perfusion imaging normal EF 63%)
Echo ([**6-6**] normal systolic LV [**Last Name (LF) **], [**First Name3 (LF) **]
60%mild MR and Mild AI)
ECG ([**2179-9-22**] NSR wnl)
Dyslipidemia
Functional capacity (uses walker; mild
SOB [**12-3**] flights; denies CP)
Hypertension (controlled)
Other CardioVascular (was told in past that
she might have had an MI by her PCP...[**Name10 (NameIs) **]
does not show any sign of MI...; normal
stress myoview [**9-7**])
Pulmonary Obstructive Sleep Apnea (uses CPAP)
Other (had pneumonia [**2177**] that developed
into a general septicemia assoc with renal
and cardiac compromise, requiring 3 wks
hospitalisation followed by 2 wk rehab)
Neuromuscular Arthritis / Gout ([**5-8**] C spine flex/ext view;
slight increased mobility at C4-5 on flex/ext;
DJD changes C3-C7 levels)
Other (Parkinsons.. Several falls
since1998...ofter assoc with fractures of
ribs/ femur s/p ORIF left femur7/08)
Endocrine Other (says she runs low Blood sugars)
Gastrointestinal Reflux
Other (some diff swallowing on left;
swallow study [**6-7**] mild dysphagia with
residue at base of tongue; ( see study); no
aspiration;)
Renal Other (renal probs during septicemia [**2177**];
recent creat wnl)
Liver Disease Hepatitis (secondary to voltaren)
Other Pertinent Illness / Injury /
Hospitalizations
1. ([**3-8**] MR cervical spine; DJD; grade I
retrolisthesis C3/C4 >mod/severe canal
stenosis; no abn signal; C6-7 irregular
contour, c/w Schmorl's node)
Pertinent Family Medical History Yes (see above re gt nephew
Social History:
Tobacco use Tobacco Free > 12 months (quit [**2148**])
Alcohol use [qty/frequency] No
Recreational drug use [frequency] No
Family History:
nephew: malignant hyperthermia
Physical Exam:
head: NCAT
ht: rrr, nl s1,s2
lungs cta
abd soft, nt
ext no cce
neuro: motor full
[**Last Name (un) 36**] intact
Pertinent Results:
[**2180-7-26**] 01:05PM HGB-10.5* calcHCT-32
Brief Hospital Course:
Pt was admitted electively to hospital and brought to OR where
under general anesthesia she underwent posterior lumbar fusion.
She tolerated this well, remained intubated and transferred to
ICU. She was extubated the next morning. Diet and activity
were advanced. She had 2 JP drains that were placed intra-op
that were followed for output - they were removed post op day
#3. Her pain med was adjusted for back pain, but leg pain much
improved. Wound clean and dry with staples. Foley was dc'd and
she was able to void spontaneously. PT/OT evaluated and felt
she was appropriate for rehab.
Medications on Admission:
ASA 81 stop
Celebrex
Claritin
Clonazepam 0.5 mg tab,[**12-3**] tab prn)
Elavil (Amitriptyline)
Estrace
Flexeril (Cyclobenzaprine)
Fosamax
Lipitor (Atorvastatin)
Neurontin (Gabapentin)
Other 1 (MS contin 15 ng twice daily)
Percocet (Oxycodone/Acetaminophen) (prn)
Protonix
Prozac (Fluoxetine)
Sinemet (25/100 tab, takes [**12-3**] tab three times daily)
OTCs vit E, ginko, ca++, glucosamine,
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Carbidopa-Levodopa 25-100 mg Tablet Sig: 1.5 Tablets PO TID
(3 times a day).
4. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Amitriptyline 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
8. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
10. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
11. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: One
(1) Inhalation prn ().
12. Methocarbamol 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
13. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for breakthru pain.
Discharge Disposition:
Home With Service
Facility:
Northeast Acute Rehab
Discharge Diagnosis:
lumbar instability
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 [**2180-7-30**]
?????? If you have steri-strips in place ?????? keep dry x 72
hours. Do not pull them off. They will fall off on their own or
be taken off in the office
?????? 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 a family member check your incision daily for
signs of infection
?????? If you are required to wear one, wear cervical collar
or back brace as instructed
?????? You may shower briefly without the collar / back brace
unless instructed otherwise
?????? 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. unless directed by your
doctor
?????? Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
?????? 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, drainage
?????? Fever greater than or equal to 101?????? F
?????? Any change in your bowel or bladder habits
Followup Instructions:
PLEASE HAVE YOUR STAPLES REMOVED [**8-6**] AT REHAB OR RETURN TO THE
OFFICE IN [**9-13**] DAYS FOR REMOVAL OF YOUR STAPLES
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 APPOINTMENT
Completed by:[**2180-7-31**] Name: [**Known lastname **],[**Known firstname 4377**] Unit No: [**Numeric Identifier 12103**]
Admission Date: [**2180-7-26**] Discharge Date: [**2180-7-31**]
Date of Birth: [**2114-1-13**] Sex: F
Service: NEUROSURGERY
Allergies:
Clindamycin / Voltaren / Flagyl / Erythromycin Base / Tape /
Demerol
Attending:[**First Name3 (LF) 2427**]
Addendum:
discharge instructions refined.
Discharge Disposition:
Home With Service
Facility:
Northeast Acute Rehab
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 [**2180-7-30**]
?????? You have steri-strips in place at drain sites . Do not
pull them off. They will fall off on their own or be taken off
in the office
?????? 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 a family member check your incision daily for
signs of infection
?????? 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
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2428**] MD [**MD Number(2) 2429**]
Completed by:[**2180-7-31**]
|
[
"V15.82",
"733.00",
"311",
"338.18",
"756.12",
"724.02",
"V15.88",
"V45.4",
"737.30",
"401.9",
"327.23",
"530.81",
"332.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.62",
"77.79",
"81.08",
"84.52"
] |
icd9pcs
|
[
[
[]
]
] |
7845, 7897
|
2970, 3568
|
342, 374
|
5263, 5287
|
2899, 2947
|
7060, 7822
|
2720, 2752
|
4009, 5125
|
5221, 5242
|
3594, 3986
|
7921, 9474
|
2767, 2880
|
294, 304
|
402, 864
|
886, 2563
|
2579, 2704
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
688
| 197,752
|
20174+57130
|
Discharge summary
|
report+addendum
|
Admission Date: [**2116-2-29**] Discharge Date: [**2116-3-2**]
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: This is an 81 year-old male
resident of the [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] who presented to the Emergency
Room after an episode of coffee ground emesis about 100 cc.
The patient was unable to give a detailed history, but had
been complaining of four days of epigastric pain at the
nursing home, which he currently denied. Vital signs were
stable at the [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]. He had a temperature 98.0,
blood pressure 96/58, pulse 113 and was transferred to the
[**Hospital1 69**]. In the Emergency Room
he had a small amount of melena in his colostomy bag. He has
a history of UC status post colostomy. His hematocrit was
25.6, which was 25 at the nursing home earlier in the day and
in [**Month (only) **] was 36. His vital signs on arrival were heart
rate of 136, blood pressure 96/60. He had transient drop in
his blood pressure to 75/palp. He received 2 liters of
intravenous fluids, 3 units of packed red blood cells and
given his drop of heart rate into the 100s and systolic blood
pressures in 110s to 130s range. An electrocardiogram with
normal T waves in leads, 2, 3, AVF, V5 and V6. 2 units of
packed red blood cells were given and the patient had
increasing amounts of melena in his colostomy bag.
PAST MEDICAL HISTORY:
1. Ulcerative colitis status post colostomy.
2. Coronary artery disease status post coronary artery
bypass graft in [**2115-4-25**].
3. Osteoporosis.
4. Low back pain.
5. Hypertension.
6. Anemia.
7. Depression.
8. Benign prostatic hypertrophy.
9. Chronic obstructive pulmonary disease.
10. Gastroesophageal reflux disease.
11. Dementia.
MEDICATIONS ON ADMISSION:
1. Aspirin.
2. Lipitor.
3. Multivitamin.
4. Protonix.
5. Zoloft.
6. Trazodone.
7. Xanax.
8. Accolate.
9. Megace.
10. Lipitor.
11. Combivent.
ALLERGIES: Sulfas.
SOCIAL HISTORY: He lives at the [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]. He is a
retired rail road worker, previous 68 pack year smoking
history, quit 40 years ago.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 99.2. Pulse
102. Blood pressure 121/59. Respiratory rate 19. Sats 100%
on 4 liters. General, he is awake, alert and oriented times
two, unable to give detailed history, pleasantly demented in
the Emergency Department and in no acute distress. HEENT
pupils are equal, round and reactive to light. Extraocular
movements intact. Membranes were tachy. Neck JVP was flat.
Cardiovascular regular, tachycardic. No murmurs. Diffuse
bilateral rhonchi. Abdomen was melena in the ostomy bag,
positive bowel sounds, nontender, nondistended. Extremities
no lower extremity edema. Neurological examination was
awake, alert and oriented times one. No gross defects
answering yes and no questions .
LABORATORIES ON ADMISSION: White blood cell count 10.3,
hematocrit 25.6, platelets 194, INR 1.4. Chemistries
otherwise normal except BUN of 52, creatinine of 1.0. Liver
function tests were normal. Troponin T less then 0.01.
Total bilirubin 0.2. Urinalysis was negative. Chest x-ray
with congestive heart failure with bilateral pleural
effusions. KUB no free air and no evidence of obstruction.
Electrocardiogram sinus at 106, normalized T waves in 2, 3,
AVF, V5 and V6, left anterior descending coronary artery with
poor R wave progression.
HOSPITAL COURSE: This is an 81 year-old gentleman with a
history of coronary artery disease, hypertension, ulcerative
colitis status post colostomy, gastroesophageal reflux
disease and dementia here with blood loss anemia and severe
esophagitis and hiatal hernia.
1. Blood loss anemia: The patient's baseline hematocrit
around 36, 25 on admission and received a total of 3 units of
packed red blood cells with good response in hematocrit. At
the time of discharge hematocrit was 30 after receiving the 3
units of blood otherwise the patient had negative hemolysis
workup, iron deficiency and anemia workup and was otherwise
stable. The patient eventually went for an
esophagogastroduodenoscopy to evaluate for source of
bleeding. On esophagogastroduodenoscopy they found evidence
of erythema, ulceration and friability in the lower third of
the esophagus compatible with severe esophagitis consistent
with severe reflux disease. He also had a large hiatal
hernia, question whether there was periesophageal versus a
sliding hernia. He will go for an upper gastrointestinal
study to evaluate this for possible surgical intervention if
desired by the patient after study. He also had a question
of an angiectasia in the duodenal bulb, but no other active
sites of bleeding. Secondary to the severe esophagitis the
patient was started on a b.i.d. PPI. Also plans to start on
b.i.d. Sucralfate two hours after each PPI dose. Also was
put on gastroesophageal reflux disease precautions with
plans to elevate the head of the bed greater then 20 degrees
at all times when sleeping and otherwise was tolerating a
regular diet without difficulty.
2. Cough/shortness of breath: Initially the patient came
slightly hypoxic with persistent cough. Plans were for the
patient to continue a ten day course of Levaquin for a
presumed pneumonia. The patient's sputum grew out gram
positive cocci in pairs and were waiting final sensitivities,
however, likely just a community acquired pneumonia and will
continue to treat with Levaquin for ten days.
3. Chronic obstructive pulmonary disease: The patient was
stable and at baseline per his patient. Was started back on
his home regimen of Combivent and Zafirlukast and with
nebulizers prn, but those were not required and the patient
was not requiring oxygen at the time of discharge and
otherwise breathing was stable.
4. Coronary artery disease status post coronary artery
bypass graft: He was ruled out by enzymes and overall doing
well. Likely had some changes on electrocardiogram related
to demand ischemia that resolved after stabilization in the
hematocrit. He did have initial complaints of some chest
pain, but was either severe heartburn reflux disease versus
demand ischemia. The pain resolved after admission and plans
were to restart his aspirin ten days after discharge. The
patient will continue on his Metoprolol.
5. Hypertension: The patient's blood pressure remained
stable on his home dose of Metoprolol.
6. Hyperlipidemia: The patient's cholesterol was stable on
his statin.
7. Depression: The patient was stable on his Zoloft and
Xanax.
8. Code: The patient is DNR/DNI, which was reconfirmed and
his sister [**Name (NI) 2127**] [**Name (NI) 4027**] is his health care proxy.
DISCHARGE CONDITION: Good. Patient ambulating without
difficulty, tolerating a regular diet, stable hematocrit.
DISCHARGE STATUS: Discharged to [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **].
DISCHARGE DIAGNOSES:
1. Blood loss anemia.
2. Severe esophagitis.
3. Gastroesophageal reflux disease.
4. Pneumonia.
5. Chronic obstructive pulmonary disease.
6. Coronary artery disease.
7. Hypertension.
8. Hyperlipidemia.
9. Depression.
DISCHARGE FOLLOW UP: The patient is to follow up with his
primary care physician in seven to ten days.
DR.[**First Name (STitle) 251**],[**First Name3 (LF) **] 11-402
Dictated By:[**Name8 (MD) 264**]
MEDQUIST36
D: [**2116-3-2**] 09:15
T: [**2116-3-2**] 09:14
JOB#: [**Job Number 54232**]
Name: [**Known lastname 3305**], [**Known firstname **] Unit No: [**Numeric Identifier 10096**]
Admission Date: [**2116-2-29**] Discharge Date: [**2116-3-2**]
Date of Birth: [**2034-7-9**] Sex: M
Service: [**Company 112**]
ADDENDUM TO HOSPITAL COURSE: The patient remained in house
after his upper gastrointestinal was started on a po diet,
which he tolerated well. Otherwise was stable. He did have
an episode of lightheadedness on standing, but otherwise was
encouraged to drink po and otherwise asymptomatic and was
otherwise with stable vital signs. He was declared safe for
discharge back to his nursing home. He will have surgery
follow up as an outpatient to evaluate for his paraesophageal
hiatal hernia. He will also be started on Sucralfate two
hours after his proton pump inhibitor for improved control of
his reflux disease.
DR.[**First Name (STitle) 116**],[**First Name3 (LF) **] 11-402
Dictated By:[**Name8 (MD) 1404**]
MEDQUIST36
D: [**2116-3-3**] 09:56
T: [**2116-3-3**] 10:08
JOB#: [**Job Number 10097**]
|
[
"530.82",
"285.1",
"530.12",
"V45.81",
"486",
"733.00",
"428.0",
"530.81",
"556.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
6788, 6986
|
7007, 7243
|
1828, 2002
|
7858, 8667
|
7255, 7840
|
122, 1431
|
2975, 3496
|
1453, 1802
|
2019, 2221
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,488
| 158,526
|
49533+49534+59131
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2153-2-17**] Discharge Date:
Date of Birth: [**2082-12-1**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 70 -year-old female
who presents on transfer from [**Hospital3 7**] for
evaluation of change in mental status and lethargy. The
patient had an admission to [**Hospital3 **] - [**Hospital **] [**First Name (Titles) **]
[**Last Name (Titles) **] earlier in the month of [**Month (only) 958**] for weakness. At that
time she was ruled out for myocardial infarction and was
found to have a normal left ventricular function with an
ejection fraction of 55% by echocardiogram. She was also
noted to have pulmonary hypertension and mitral
regurgitation.
She had a ventilation - perfusion scan at that time which
ruled out pulmonary emboli as a cause of her pulmonary
hypertension. She was found to have matched defects on that
scan. She was put on ACE inhibitors for her mitral
regurgitation. She was discharged to rehabilitation and was
returned on [**2-17**], after staff noted a change in mental
status, coarse tremor, and lethargy, although she remained
responsive. She was also recently diagnosed with
hypothyroidism on her previous admission.
PAST MEDICAL HISTORY: Notable for chronic renal
insufficiency, hypothyroidism, mitral regurgitation, insulin
dependent diabetes, coronary artery disease, anemia of
chronic disease, anxiety, and depression.
ADMITTING MEDICATIONS: Aspirin 325 mg per day, Colace 100 mg
per day, Epogen 4,000 units biweekly, hydralazine 10 mg po
bid, a sliding scale of regular insulin, Synthroid 50 mcg per
day, Niferex, thiamine 100 mg po q day, miconazole 30 mg po q
day.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: The patient was afebrile, blood
pressure was 80/palp. She was lethargic, but responsive to
verbal questions. Examination of the head and neck revealed
normocephalic, atraumatic, pupils are equal, round, and
reactive to light, there is no lymphadenopathy, no jugular
venous distention. Thyroid is mildly enlarged, no nodules.
Lungs were clear to auscultation. Cardiovascular examination
revealed a normal S1, S2, regular rate and rhythm, no rubs,
or gallops. She had a II/VI systolic ejection murmur in the
right upper sternal border. Belly was soft, distended
secondary to obesity, neurologic bowel sounds. She had no
costovertebral angle tenderness. Extremity examination: 2+
pitting edema at the calves, nonpitting edema of the feet.
Neurologic: she was moving all extremities, had a coarse
resting tremor of the arms.
LABORATORY DATA: Laboratory analysis at that time showed a
hematocrit of 30.5, 108 platelets. Urinalysis with 30
protein, 4 white blood cells, no red blood cells, PT of 14.7,
INR of 1.4, PTT of 46.3. Chem 7 was a sodium of 144,
potassium 4.7, chloride of 116, pCO2 of 17, BUN of 79,
creatinine 4.0, glucose of 97. TSH was 24, free T4 was 1.0.
Toxicology screen was negative.
CT scan showed multiple strokes of indeterminate age, not
acute, and diffuse periventricular white matter changes,
likely secondary to small vessel ischemic changes. The
patient underwent a lumbar puncture during which she showed
some seizure activity. She was intubated emergently and
transferred to the Medical Intensive Care Unit for further
care.
HOSPITAL COURSE: In the Medical Intensive Care Unit she was
hypotensive and hypothermic. She became septic with
Enterococcus faecalis. She required pressors. She was
treated with a two week course of vancomycin for
Enterococcus. Relative pancytopenia was noted there.
Hematology / Oncology work up suggested likely
myelodysplastic syndrome. They recommended a bone marrow
biopsy in the future. Electroencephalogram showed moderate
to severe encephalopathy without epileptiform activity. She
was gradually weaned from the ventilator and weaned off
pressors.
She was extubated on [**2-25**] and transferred back to the
Medicine floor. On the floor, neurologic work up continued.
A repeat head CT scan was done, which was unchanged,
demonstrating right frontal, temporal, cerebellar, and left
occipital hypodensities. She was also found to have an
ectatic basilar artery. Lumbar puncture was performed and
CSF analysis demonstrated no white blood cells, normal
protein, normal glucose. Encephalopathy was felt to be due
to a combination of hypotension and sepsis.
An Endocrine consult was obtained for assessment of the HPA
access. No definite abnormalities were found, although
recommendation for MRI of the sellae was encouraged. She was
gradually improving on the floor with improved mental status,
until approximately [**3-1**], when she began hallucinating
and underwent progressive decline. Eventually she became
unresponsive. Clinical suspicion focused on seizure with a
postictal state, versus status epilepticus. She was
transferred back to the Medical Intensive Care Unit on [**3-3**]
when she was found to be hypotension to 68/palp. She was
initially treated with IV hydration, then with IV Decadron
with the presumption that she may be in adrenal crisis.
An electroencephalogram was obtained during that time period
which revealed status epilepticus. The patient was treated
with IV Ativan with good response via electroencephalogram
and transferred to the Medical Intensive Care Unit once
again.
Summary of the ensuing Medical Intensive Care Unit course is
summarized as follows:
1. Neurologic: The patient was found to be in nonconvulsive
status epilepticus upon transfer to the Medical Intensive
Care Unit, and as stated, was treated with Ativan. She was
also loaded with Dilantin and was monitored for several days
with a continuous electroencephalogram until it was felt that
seizure activity had discontinued. She was then slowly
weaned off of her sedation in an attempt to wake her up. Her
mental status remained poor, however. A free Dilantin level
was checked and it was found to be markedly elevated. At
that time all further Dilantin was held under the assumption
that elevated Dilantin was causing her continued decreased
mental status. Over the ensuing three weeks her Dilantin
level very slowly trended down with corresponding increase in
her mental activity, until she was back to near baseline
functioning by the time of discharge.
At the time of discharge, her goal was to have a therapeutic
Dilantin level of between 1.5 and 2.0 on free Dilantin
testing, with levels followed closely and doses adjusted
accordingly. It was also felt that she would continue to
need an MRI scan to further evaluate for cause of her
seizures, as no definite etiology was ever found. She would
also benefit from an MRI of the sellae as per Endocrine to
further assess hypothermia, hypotension, and mild endocrine
abnormalities. MRI was not able to be performed at the [**Hospital3 **] Hospital secondary to the patient's body habitus.
2. Renal: The patient's creatinine was found to be
increased on transfer back to the Medical Intensive Care Unit
to a level 4.0, baseline of 2.5 to 3.0 as an outpatient. It
was felt that this was likely secondary to a hemodynamic
insult, causing acute tubular necrosis. In the setting of
her hypotension on transfer, she was mostly treated with IV
fluids with no response for creatinine. She was bolused
repeatedly and became markedly edematous. Eventually, after
several days, a Swan Ganz catheter was placed which showed a
mixed picture with high filling pressures and a low SER.
She was then diuresed, started on a Lasix drip. This was in
conjunction with the switching of the pressor support from
Neo-Synephrine to Dopamine, led to an increase in her urine
output. Although she was never able to diurese entirely, she
did begin to make urine and creatinine trended down slightly.
However, any attempt to discontinue the Dopamine led to a
markedly decreased urine output level. Despite this she was
transitioned to a regimen which could be continued at a
rehabilitation facility. She was taken off the Dopamine,
taken off the Lasix drip, and placed on Bumex and Zaroxolyn.
Bumex was used secondary to concern about autotoxicity with
Lasix, as the patient has some baseline hearing
abnormalities. Bumex was given with salt poor albumin in
order to increase efficacy. Urine output was judged to be
adequate by the Renal consultation service. She will need
continuous follow up for her renal failure at her
rehabilitation facility and continued assessment of the
efficacy of her diuretics.
3. Cardiovascular: The patient was hypotensive on transfer
back to the Medical Intensive Care Unit. Initially it was
thought that this may result from Addisonian crisis; however,
the patient exhibited no response to stress dose steroids
which were gradually tapered off. Another theory was that
this hypotension was secondary to a Dilantin level, although
this theory was deemed less likely as Dilantin varying
frequently causes hypotension and is normally transient only
at the time of loading. There was, however, another
possibility entertained, was sepsis, although all blood
cultures remained negative during her second day in the
Medical Intensive Care Unit.
She was gradually weaned off pressors over the course of her
stay with blood pressures stabilizing in the 90s. It was
initially felt that her mentation was better with a higher
mean arterial pressure; however, this proved not to be the
case, as she woke fully after the Dilantin level weaned off.
She did exhibit a markedly improved urine output on Dopamine,
however. This cannot be continued outside the Intensive Care
Unit and was discontinued.
4. Endocrine: The patient was recently found to be
hypothyroid based on her presentation with lethargy,
hypothermia, her dose of Synthroid was increased. The
Endocrine service recommended rechecking in two to three
weeks following her discharge from the hospital. The
possibility was also raised at one point of adrenal
insufficiency, although she did not respond to high dose
steroids. She did have low gonadotropins, raising the
possibility of an HPA access problem. The Endocrine consult
service felt this was unlikely, but recommended MRI of the
sellae to further evaluate, which she should have if feasible
at a future date. The patient was also found to have high
estradiols, thought that this was secondary to the high
levels of Dilantin in her system.
5. Pulmonary: The patient was intubated emergently in the
setting of her seizures. Her oxygenation and ventilation
were excellent throughout her Medical Intensive Care Unit
stay. She remained intubated for some time for airway
protection. When she began to awake, she was quickly weaned
off the ventilator and extubated with excellent results. The
patient does, however, likely have obesity hypoventilation
syndrome as well as obstructive sleep apnea. She was tried
on BiPAP, but did not tolerate it and kept removing the mask.
This will probably need further work up as an outpatient.
6. Hematology: The patient was seen by the Hematology
consult service on her initial Medical Intensive Care Unit
stay and based on mild pancytopenia and the appearance of a
peripheral smear, she may benefit from a bone marrow biopsy
at a future date to assess fully for myelodysplastic
syndrome. She was also worked up for antiphospholipid
antibodies and her IgM. The cardiolipin antibody came back
positive, although the Hematology / Oncology service felt
this was not consistent with antiphospholipid antibody
syndrome given her lack of thromboembolic disease.
DISPOSITION: The patient was discharged to a rehabilitation
facility in stable condition.
DISCHARGE DIAGNOSES:
1. Seizures.
2. Hypothyroidism.
3. Hypotension.
4. Hypothermia.
DISCHARGE MEDICATIONS: Include Bumex 1.0 mg IV q day, dosed
with 50 cc salt poor albumin, Tums 500 mg po tid, NPH insulin
5.0 units subcutaneous [**Hospital1 **], Zaroxolyn 10 mg po bid,
Nephrocaps one po q day, Nystatin swish and swallow 5.0 cc to
15 cc po qid prn, Zoloft 50 mg po q day, Prilosec 20 mg po q
day, Synthroid 150 mcg po q day, regular sliding scale,
thiamine 100 mg po q day, Miconazole powder prn, Epogen
10,000 unit subcutaneous Tuesday, Thursday, Saturday.
FOLLOW UP: The patient was to follow up with her new primary
care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) **] at [**Hospital3 **] - [**Hospital **]
[**First Name (Titles) **] [**Last Name (Titles) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] M.D. [**MD Number(1) **]
Dictated By:[**Last Name (NamePattern1) 16123**]
MEDQUIST36
D: [**2153-3-27**] 13:38
T: [**2153-3-27**] 15:35
JOB#: [**Job Number **]
Admission Date: Discharge Date:
Date of Birth: Sex: F
Service:
ADDENDUM: This discharge dictation is dated [**2153-4-17**].
It completes the events of the previous discharge dictation
dated [**2153-3-29**].
Ms. [**Known lastname **] was scheduled for discharge to rehabilitation on
approximately [**3-29**]; however, before leaving the Renal
Service it was decided that the patient would benefit from
continuous venovenous hemofiltration to remove excess fluid,
as she had been 20 liters positive during her hospital stay.
It was initiated and 20 liters were removed over a 3-day
period. Unfortunately, over this same time period she
experienced a decline in her mental status becoming less
responsive (she had been awake and able to talk). It was
unclear why this was occurring. The continuous venovenous
hemofiltration was finally stopped due to low blood pressures
that afternoon; however, the patient had a seizure and was
reintubated for hypercarbic respiratory failure.
An electroencephalogram following this episode showed
question intermittent seizure activity but not status
epilepticus had been seen previously on prior
electroencephalogram. Dilantin was in the "therapeutic
range" throughout this period. An MRI was recommended by
Neurology, but unfortunately due to the patient's body
habitus, an MRI could not be obtained.
HOSPITAL COURSE: The following is a history of the patient's
course since [**4-3**] by system.
1. PULMONARY: The patient continued on the ventilator
alternating between assist control and pressure support.
When her mental status was good, she did well on pressure
support but at times she was lethargic and/or somnolent and
needed to be ventilated by assist control. The patient did
not have any significant problems with either oxygenation or
ventilation on minimal FIO2.
Later in the hospital course, the patient did have a sputum
with 4+ gram-negative rods. Culture from that sample was
still pending at this time. However, because of the
patient's rapid improvement toward the end of her hospital
stay, she was not treated for these gram-negative rods, since
they were thought to be colonizers.
2. NEUROLOGY: The patient was maintained on intravenous
Dilantin with a desired therapeutic range of 7.5 to 9 or a
free Dilantin of 2.5 to 3. It was unclear why the patient
had such a high fraction of free Dilantin; however, on this
new therapeutic range the patient did not have any further
seizure activity. Shortly before transfer to rehabilitation
the patient's Dilantin was changed to p.o. at the same
dosage, which at the time of discharge was 75 mg p.o. b.i.d.
with tube feeds held one hour before and after Dilantin
administration.
At some point in the future, if the technology is available
in the area, an MRI would be useful to further investigate
the cause of the patient's seizure activity.
3. RENAL: The patient was put on dopamine during her
hospital course to improve her urine output. This did
improve her urine output somewhat but not enough to meet her
goal output. Her creatinine leveled off in the 4.5 range
which was significantly above her baseline of 3 to 3.5. Ten
days prior to discharge the decision was made to start the
patient on hemodialysis. This was carried out on a q.o.d.
basis; at each dialysis 3 liters of fluid were removed. Over
this 10-day period the patient had substantial resolution of
her peripheral edema. Two days before discharge, the
patient's Quinton catheter stopped functioning.
Interventional Radiology placed a right internal jugular
Perm-A-Cath for use in future hemodialysis. The patient
continued on Epogen injections.
4. INFECTIOUS DISEASE: The patient never spiked fevers and
was hypothermic throughout her hospital stay. However, due
to her decreased mental status blood cultures were obtained.
Two blood cultures came back positive for coag-negative
Staphylococcus. This proved to be susceptible to vancomycin
but resistant to oxacillin. At about the same time another
blood culture grew enterococcus faecalis and a central line
tip also grew enterococcus. This bug also proved susceptible
to vancomycin. Therefore, on [**4-9**], the patient was started
on a 14-day course of vancomycin. Several days afterward her
mental status improved dramatically. Surveillance cultures
were drawn two to three days after the inception of
vancomycin and remained no growth to date at the time of
discharge.
5. ENDOCRINE: The patient was maintained on intravenous
Synthroid 200 mcg p.o. q.d. The day before discharge, the
patient was changed to p.o. Synthroid.
6. FLUIDS/ELECTROLYTES/NUTRITION: The patient was on tube
feeds which were initially delivered through a nasogastric
tube. Two days before discharge, a G-tube was placed by
Interventional Radiology, and her tube feeds were resumed 24
hours following placement.
7. PROPHYLAXIS: The patient remained on Venodyne boots and
Prilosec.
8. LINES: The patient has a Quinton catheter, a trach which
was placed a week before discharge by Dr. [**First Name (STitle) **] [**Name (STitle) **], and a
Perm-A-Cath placed by Interventional Radiology. The patient
also has a G-tube placed by Interventional Radiology. She
will undergo PICC placement on [**4-17**]. After this is
complete, her Quinton catheter will be removed.
9. CODE STATUS: The patient is full code.
DISCHARGE STATUS: She is expected to be discharged to
[**Hospital1 34648**] on [**2153-4-18**].
CONDITION AT DISCHARGE: She left in stable condition.
MEDICATIONS ON DISCHARGE:
1. Regular insulin sliding-scale.
2. Tums 1 g per G-tube t.i.d.
3. Dilantin 75 mg p.o. b.i.d. with tube feeds held one hour
before and after administration.
4. Nephrocaps 1 tablet p.o. q.d.
5. Zoloft 50 mg p.o. q.d.
6. Prilosec 20 mg p.o. q.d.
7. Thiamine 100 mg p.o. q.d.
8. Miconazole powder p.r.n.
9. Nepro with ProMod at 35 per hour.
10. Epogen 10,000 units subcutaneous every Tuesday,
Thursday, and Saturday.
11. Nystatin swish-and-swallow q.i.d.
12. NPH insulin 8 units subcutaneous b.i.d.
13. Levothyroxine 200 mg p.o. q.d.
14. Vancomycin (dosed for levels less than 15 through
[**2153-4-22**]).
DISCHARGE DIAGNOSES:
1. Seizure disorder.
2. Acute renal failure.
3. Respiratory failure.
4. Diabetes mellitus.
5. Anemia.
6. Change in mental status.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3851**]
Dictated By:[**Name8 (MD) 19393**]
MEDQUIST36
D: [**2153-4-17**] 13:11
T: [**2153-4-17**] 13:41
JOB#: [**Job Number 103610**]
Name: [**Known lastname **], [**Known firstname 1118**] Unit No: [**Numeric Identifier 16619**]
Admission Date: Discharge Date: [**2153-4-19**]
Date of Birth: [**2082-12-1**] Sex: F
Service:
ADDENDUM: Mrs. [**Known lastname **] is expected to be discharged today to
[**Hospital1 **] for rehabilitation. The only change in her
medications will be an increase in her po Dilantin to 100 mg
[**Hospital1 **]. The doctor [**First Name (Titles) **] [**Last Name (Titles) **], Dr. [**Last Name (STitle) 16620**], was contact[**Name (NI) **] and
the Dilantin desired levels and dosing regimen were
discussed. [**Hospital1 **] can check her Dilantin every day except
Sunday and if Sunday levels need to be checked, they will be
sent out to an outside lab. Her levels will be kept between
7.5 and 9.0 and the free Dilantin between 2.5 and 3.0. The
patient also received 75 mg IV Dilantin prior to discharge.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 6658**]
Dictated By:[**Name8 (MD) 5127**]
MEDQUIST36
D: [**2153-4-20**] 08:56
T: [**2153-4-23**] 09:32
JOB#: [**Job Number 16621**]
|
[
"780.39",
"584.5",
"403.91",
"250.40",
"038.0",
"244.9",
"518.81",
"038.19",
"783.3",
"278.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"89.62",
"31.1",
"38.93",
"89.64",
"43.11",
"89.61",
"96.04",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
18933, 20549
|
11728, 12182
|
18286, 18912
|
14108, 18213
|
12194, 14090
|
1724, 3288
|
18228, 18259
|
143, 1204
|
1227, 1701
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,829
| 151,711
|
45210
|
Discharge summary
|
report
|
Admission Date: [**2123-3-18**] Discharge Date: [**2123-4-6**]
Date of Birth: [**2061-11-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine / Heparin Agents
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
1. Acute renal failure
2. Chronic recurrent right pleural effusion
Major Surgical or Invasive Procedure:
[**2123-3-18**] Right VATS decortication
History of Present Illness:
Mr. [**Name13 (STitle) 96616**] is a 61-year-old gentleman with end-stage liver
disease who was noted to have recurrent right-sided effusions
and subsequently developed empyema after treatment of this. This
was managed with a drainage catheter but his lung was not fully
expansile despite several days of conservative management and
antibiotics. Therefore, it was discussed with his primary
liver team as well as the patient that a decortication would be
recommended as he would not be able to be listed for liver
[**Name13 (STitle) **] in the current condition with this empyema.
Past Medical History:
1. Hepatitis C: diagnosed [**2113**], received 7 months IFN treatment,
but was not responsive.
2. Cirrhosis: secondary to Hepatitis C, patient also has history
of long time alcohol use. History of esophageal varices seen on
EGD ([**2115**]), though most recent EGD ([**2121-12-11**]) showed normal
mucosa but gastric varicies on US. Had esophageal varices s/p
TIPS in [**12-3**].
3. Coronary Artery Disease: s/p DES to 70% mid-LAD [**11-30**]
4. Hypertension: uncontrolled, not currently on any medications
5. Substance use: 20 year heroin use history, maintained on
methadone
6. Iron Deficiency Anemia
7. H/o R ankle fracture requiring ORIF
8. Sigmoid diverticulosis on colonscopy [**11/2121**]
Social History:
He lives by himself in [**Location (un) **]. He works as a gardener. He has
a long history of alcohol use, stopped 15 years ago. He has a 30
year smoking history, quit several months ago. He has 20 year
history of heroin use, has been maintained on methadone.
Family History:
Mother died from jaw cancer at very young age, father died from
lung cancer. He has five siblings: one sister died from sudden
cardiac death, the other sister and three brothers are well.
Physical Exam:
VSS:96.9 HR 64 RR 20 BP 94/44 O2 sats 94% room air
General NAD
Cardiac RRR S1 S2
Lungs Left clear bibasilar crackles R>L Right coarse upper love.
ABD: + BS Soft NT
Wound CDI
Extremities: Pitting edema to knee bilaterally
Pertinent Results:
Labs on admission:
[**2123-3-18**] 11:30AM BLOOD WBC-6.9 RBC-2.87* Hgb-8.6* Hct-24.0*
MCV-84 MCH-30.0 MCHC-35.8* RDW-16.2* Plt Ct-124*
[**2123-3-18**] 11:30AM BLOOD PT-18.4* PTT-39.0* INR(PT)-1.7*
[**2123-3-17**] 08:40AM BLOOD Glucose-100 UreaN-33* Creat-2.7* Na-131*
K-4.8 Cl-97 HCO3-24 AnGap-15
[**2123-3-17**] 08:40AM BLOOD ALT-27 AST-85* LD(LDH)-695* AlkPhos-106
TotBili-2.4*
[**2123-3-18**] 05:09PM BLOOD Lipase-41
[**2123-3-18**] 05:09PM BLOOD CK-MB-NotDone cTropnT-0.01
[**2123-3-18**] 10:40PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2123-3-19**] 09:12AM BLOOD CK-MB-9 cTropnT-0.02*
[**2123-3-17**] 08:40AM BLOOD Albumin-3.1* Calcium-8.1* Phos-4.9*
Mg-1.9
[**2123-3-18**] 05:09PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HAV
Ab-POSITIVE
[**2123-3-18**] 05:09PM BLOOD HIV Ab-NEGATIVE
[**2123-3-17**] 08:40AM BLOOD Vanco-19.4
[**2123-3-18**] 03:20PM BLOOD Type-ART pO2-318* pCO2-54* pH-7.28*
calTCO2-26 Base XS--1 Intubat-INTUBATED
[**2123-3-18**] 03:20PM BLOOD Glucose-89 Lactate-1.8 Na-136 K-2.8*
Cl-104
[**2123-3-18**] 03:20PM BLOOD freeCa-0.93*
Labs prior to discharge:
[**2123-4-2**] 04:33AM BLOOD WBC-6.0 RBC-3.61* Hgb-10.8* Hct-31.1*
MCV-86 MCH-30.0 MCHC-34.7 RDW-18.0* Plt Ct-120*
[**2123-3-24**] 06:50AM BLOOD PT-19.0* INR(PT)-1.8*
[**2123-4-2**] 04:33AM BLOOD Glucose-85 UreaN-30* Creat-1.6* Na-131*
K-3.6 Cl-97 HCO3-27 AnGap-11
[**2123-3-25**] 05:00AM BLOOD ALT-14 AST-27 AlkPhos-105 TotBili-4.2*
[**2123-4-2**] 04:33AM BLOOD Calcium-7.8* Phos-3.8 Mg-1.7
Imaging:
CHEST (PORTABLE AP) Study Date of [**2123-3-18**] 4:45 PM:
Intubated, localized pneumothorax at entrance site of chest
tubes. Lung remains ventilated.
VIDEO OROPHARYNGEAL SWALLOW Study Date of [**2123-3-23**] 11:27 AM:
Moderate oropharyngeal dysphagia. Episode of silent aspiration
with thin liquids. For further details, please refer to speech
and swallow
pathologist's note of the same day.
DUPLEX DOP ABD/PEL LIMITED Study Date of [**2123-3-24**] 8:30 AM:
1. No intra- or extra-hepatic biliary dilatation.
2. Patent TIPS demonstrating stable velocities since [**2121-12-31**].
3. Main portal vein velocities are within normal range (between
40 and 60
cm/sec).
LIVER OR GALLBLADDER US (SINGL; DUPLEX DOP ABD/PEL LIMITED
[**2123-3-24**]
1. No intra- or extra-hepatic biliary dilatation.
2. Patent TIPS demonstrating stable velocities since [**2121-12-31**].
3. Main portal vein velocities are within normal range (between
40 and 60
cm/sec).
UNILAT UP EXT VEINS US RIGHT Study Date of [**2123-4-2**] 12:46 AM:
No DVT.
Micro:
Pleural fluid culture [**2123-3-18**]:
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA sensitive to levoflox
and bactrim
Brief Hospital Course:
Patient is a 61M who presented with recurrent right sided
pleural effusion secondary to liver failure complicated by an
empyema. He was counseled that this must be aggressively
treated in order to be listed for liver transplantation.
Patient understood and agreed to proceed. On [**2123-3-18**] patient
underwent a right VATS decortication. Patient tolerated the
procedure well and was transferred to the PACU and then SICU
intubated and requiring neo. Perioperatively patient required 4
units of FFP and 3 units of PRBC. The 3 chest tubes were
immediately placed to suction. He was transferred to the floor
POD5 in good condition. The rest of the hospital course is
summarized by systems below:
Neuro: Pain was well controlled with IV narcotics transitioned
to home does of PO methadone. He did not demonstrate clinical
signs of hepatic encephalopathy during his stay.
Pulmonary: Three chest tubes were immediately put to suction
post op. Daily chest xrays were taken. Patient was extubated
on POD1 without events. On POD2 the basilar and posterior tubes
chest tubes were rotated and pulled back 2 cm while on cont sxn.
On POD5 he was transferred to floor. His chest tubes were
placed to water seal. Patient subsequently inadvertently pulled
out chest tube #1 while working with PT. Drain incision was
closed to exterior. Subsequent CXR was stable. On POD13 his R
CT#3 was replaced with a new chest tube. He did have a residual
right PTX, and patient was replaced on suction. He will require
continuous suction for the next two weeks until f/u with Dr.
[**Last Name (STitle) **] to ensure adequate pleurodesis.
CV: Patient was HD stable during stay. No issues. Patient
received was continued on home dose of lasix and diuresed post
op as appropriate.
GI: Hepatology followed in house. Patient was noted to have a
mildly elevated tbili. Liver u/s with duplex was performed and
was unremarkable. Aldactone was decreased to 50mg per day per
hepatology.
Renal: Creatinine stable. No issues.
ID: ID was consulted and followed daily. Patient had completed
3 week course of empiric abx prior to VATS (vanc/zosyn then
vanc/cipro). Fresh cultures of pleural fluid while off
antibiotics grew Stenotrophomonas sensitive to levofloxacin and
bactrim. Patient initially empirically started on vanc, ceftaz
and cipro post VATS, then switched to levoflox was sensitivities
returned. Patient will stay on levofloxacin (started [**3-26**]/) for
14 days or until chest tubes are removed.
Hem: Perioperatively patient required 4 units of FFP and 3
units of PRBC. POD
Extubated the following post-op day. Patient required 2 more
units of PRBC for HCT of 25 on POD3. He had appropriate post-tx
bumps.
Nutrition: Patient underwent speech and swallow eval. He had mod
dysphagia. Recommended nectar thick liquids and ground solids.
When taking small meds (pills) whole with thickened liquids,
large pills with crushed puree. Q 4hour oral care. Repeat
swallow eval prior to discharge
Medications on Admission:
Ciprofloxacin 400 mg IV Q12H [**3-18**] @ 1856
**Vancomycin 1000 mg IV Q 24H [**3-21**] @ 1041
Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN [**3-18**] @ 1641
Heparin 5000 UNIT SC TID [**3-18**] @ 1641
Ondansetron 4 mg IV Q8H:PRN [**3-18**] @ 1641
Furosemide 40 mg IV DAILY [**3-18**] @ 1641
Potassium Chloride IV Sliding Scale [**3-18**] @ 1707
Calcium Gluconate IV Sliding Scale [**3-18**] @ 1707
Magnesium Sulfate IV Sliding Scale [**3-18**] @ 1707
Insulin SC (per Insulin Flowsheet)
Fentanyl Citrate 25-100 mcg IV Q2H:PRN [**3-18**] @ 1755
Spironolactone 100 mg PO DAILY [**3-19**] @ 1658
Lactulose 30 mL PO TID
Famotidine 20 mg IV Q24H [**3-20**] @ 1416
Albumin 5% (25g / 500mL) 25 g IV 1X Duration: 1 Doses
Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAP>60 or SBP
Docusate Sodium 100 mg PO BID [**3-21**] @ 0821
Methadone 20 mg PO TID [**3-21**] @ 1023
Phytonadione 5 mg PO
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Methadone 10 mg Tablet Sig: six (6) Tablet PO DAILY (Daily).
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours): continue while chest tube in place.
8. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) PO Q8H
(every 8 hours).
10. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for pain.
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) ML Inhalation Q4H (every 4 hours) as
needed.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
1. Hepatitis C: diagnosed [**2113**], received 7 months IFN treatment,
w/out virologic response.
2. Cirrhosis: secondary to Hepatitis C, EtOH. History of
esophageal varices (EGD [**2115**]), s/p TIPS in [**12-3**].
3. Coronary Artery Disease: s/p DES to 70% mid-LAD [**11-30**]
4. Hypertension
5. Substance use: heroin use in past, on methadone
6. Iron Deficiency Anemia
7. H/o R ankle fracture requiring ORIF
8. right sided empyema
Discharge Condition:
deconditioned
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] with questions
concerning chest tube which remains on suction 20 cm H20
indefinitely
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **]
Completed by:[**2123-5-13**]
|
[
"V45.82",
"571.5",
"305.03",
"287.5",
"070.44",
"510.9",
"458.29",
"286.9",
"584.5",
"304.01",
"787.22",
"511.1",
"041.85",
"414.01",
"401.9",
"456.1",
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] |
icd9cm
|
[
[
[]
]
] |
[
"97.29",
"34.52",
"34.06",
"34.09"
] |
icd9pcs
|
[
[
[]
]
] |
10013, 10070
|
5112, 8109
|
358, 402
|
10547, 10563
|
2472, 2477
|
10761, 10837
|
2025, 2214
|
9061, 9990
|
10091, 10526
|
8135, 9038
|
10587, 10738
|
2229, 2453
|
252, 320
|
430, 1012
|
2491, 5089
|
1034, 1731
|
1747, 2009
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,768
| 107,692
|
35497
|
Discharge summary
|
report
|
Admission Date: [**2141-9-11**] Discharge Date: [**2141-9-16**]
Date of Birth: [**2081-4-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Exertional chest pain
Major Surgical or Invasive Procedure:
[**2141-9-12**] - Coronary artery bypass grafting to 4 vessels.
History of Present Illness:
This is a 60 year old male with known coronary artery disease
who presents with increasing exertional angina. Recent stress
testing was notable for shortness of breath after walking for
only three minutes of [**Doctor First Name **] protocol with myoview imaging
revealing inferior wall ischemia. Subsequent cardiac
catheterization showed significant three vessel coronary artery
disease. He is now referred for surgical revascularization.
Past Medical History:
Past Medical History:
Coronary Artery Disease - MI at age 38, PCI [**2120**]
Hypertension
Dyslipidemia
Type II Diabetes - c/b Neuropathy
Morbid Obesity
Atrial Fibrillation - s/p DCCV [**2141-1-22**], now in sinus rhythm
Varicose Veins
Chronic Low Back Pain
Past Surgical History:
- Right Leg Vein Stripping
- Left Total Knee Replacement
Social History:
Occupation: On disability
Lives with: Wife and daughter
[**Name (NI) **]: Caucasian
Tobacco: quit [**2118**], 35+pack year history of tobacco
ETOH: rate
Family History:
Father died of MI at age 78. Paternal Uncle died of MI at age
42.
Physical Exam:
Pulse: 64 Resp: 16 O2 sat: 100RA
B/P Right: 137/81 Left: 139/78
General: Obese male in no acute distress
Skin: chronic venous stasis changes on both lower extremities.
fungal skins lesions noted on abdominal pannus.
HEENT: PERRLA [x] EOMI [x], poor dentition
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema - trace
Varicosities: right leg stripping/severe varicosities of left
lower extremity/left GSV in thigh did not appear grossly
varicosed but large in size/lesser saphenous without
varicosities
Neuro: Right hand dominant. CN 2-12 grossly intact. [**3-28**]
strength.
No focal deficits.Grossly intact
Pulses:
DP Right: 2 Left: 2
PT [**Name (NI) 167**]: 2 Left: 2
Radial Right: 2 Left: 2
Carotid Bruit Right: none Left: none
Allens Test: left hand with positive allens test. normal
flushing
with radial compression. excellent arterial waveform and oxygen
saturations with radial compression
Pertinent Results:
[**2141-9-11**] 08:10PM PT-14.5* INR(PT)-1.3*
[**2141-9-11**] 08:10PM PLT COUNT-224
[**2141-9-11**] 08:10PM WBC-6.5 RBC-4.25* HGB-12.1* HCT-36.6* MCV-86
MCH-28.4 MCHC-33.0 RDW-14.2
[**2141-9-11**] 08:10PM %HbA1c-6.2*
[**2141-9-11**] 08:10PM ALBUMIN-4.4 MAGNESIUM-1.8
[**2141-9-11**] 08:10PM CK-MB-NotDone cTropnT-<0.01
[**2141-9-11**] 08:10PM LIPASE-66*
[**2141-9-11**] 08:10PM ALT(SGPT)-19 AST(SGOT)-16 CK(CPK)-96 ALK
PHOS-36* AMYLASE-41 TOT BILI-0.3
[**2141-9-11**] 08:10PM GLUCOSE-124* UREA N-17 CREAT-1.1 SODIUM-139
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-27 ANION GAP-13
[**2141-9-11**] 09:03PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Diastolic Dimension: 5.3 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.7 cm
Left Ventricle - Fractional Shortening: 0.30 >= 0.29
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Aorta - Sinus Level: *3.9 cm <= 3.6 cm
Aorta - Ascending: 3.3 cm <= 3.4 cm
Aortic Valve - Peak Gradient: 11 mm Hg < 20 mm Hg
Aortic Valve - LVOT diam: 2.4 cm
Findings
LEFT ATRIUM: Normal LA size. No spontaneous echo contrast is
seen in the LAA. Good (>20 cm/s) LAA ejection velocity. No
thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No spontaneous
echo contrast in the RAA. No thrombus in the RAA. Color-flow
imaging of the interatrial septum raises the suspicion of an
atrial septal defect, but this could not be confirmed on the
basis of this study.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Normal regional LV systolic function. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic sinus. Simple atheroma in aortic
root. Normal ascending aorta diameter. Normal aortic arch
diameter. Simple atheroma in aortic arch. Normal descending
aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Minimal AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: Trivial/physiologic 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 patient received antibiotic prophylaxis. The
TEE probe was passed with assistance from the anesthesioology
staff using a laryngoscope. No TEE related complications.
patient.
Conclusions
PREBYPASS:
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 thrombus is seen in the right atrial appendage
3. Color-flow imaging of the interatrial septum raises the
suspicion of an atrial septal defect, but this could not be
confirmed on the basis of this study.
4. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%).
5. Right ventricular chamber size and free wall motion are
normal.
6. The aortic root is mildly dilated at the sinus level. There
are simple atheroma in the aortic root. There are simple
atheroma in the aortic arch. There are simple atheroma in the
descending thoracic aorta.
7. The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. There is a minimally increased gradient
consistent with minimal aortic valve stenosis. No aortic
regurgitation is seen.
8. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen.
9. There is a trivial/physiologic pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results.
POSTBYPASS: On infusion of phenylephrine, sinus rhythm.
Preserved biventricular systolic function with LVEF now 60%.
Trace MR. Aortic contour is normal post decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2141-9-12**] 15:55
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2141-9-11**] for surgical
management of his coronary artery disease. He had been off
coumadin for 5 days prior to admission and heparin was started
for antiocagulation. He underwent preoperative testing including
a carotid duplex ultrasound which showed no significant internal
carotid artery disease. Vein mapping showed patent bilateral
lesser saphenous veins. On [**2141-9-12**], Mr. [**Known lastname **] was taken to the
operating room on [**9-12**] where he had coronary artery bypass
grafting x4 with left internal mammary artery graft to left
anterior
descending, free left internal mammary artery segment to the
first diagonal branch, reverse lesser saphenous vein to the
left-sided posterior descending artery and right-sided posterior
descending artery. His bypass time was 164 minutes with a
crossclamp of 126 minutes. Please see operative note for
details. Postoperatively he was taken to the intensive care unit
for recovery. He did well in the immediate post-op period was
weaned from sedation and extubated on the operative day. He
remained hemodynamically stable and was transferred to the step
down unit on POD1.
All tubes lines and drains were removed per cardiac surgery
protocol. The remainder of his hospital course was uneventful.
Over the next several days his activity level was advanced with
the assistance of physical therapy and nursing staff. On POD
four he was discharged home with visiting nurses.
Medications on Admission:
**Warfarin-dtopped [**9-6**]**, Aspirin 325 qd, Metformin 1000 [**Hospital1 **],
Rhythmol 225 [**Hospital1 **], Imdur 120 (2), Fenofibrate 160 qd, Atenolol
100
qd, Triamterene/HCTZ 37.5/25 qd, Lisinopril 10 qd, Gabapentin
100
tid, Simvastatin 80 qd, Omeprazole 40 qd, Oxycodone 15 qid,
Byetta
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*0*
4. Propafenone 225 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day for
10 days.
Disp:*20 Tablet(s)* Refills:*2*
9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Fenofibrate 160 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
12. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO ONCE (Once)
for 1 doses: take per the office of [**Hospital1 8051**] for afib.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary artery disease s/p CABG
s/p MI/ PCI [**2120**]
Hypertension
Dyslipidemia
Type II Diabetes - c/b Neuropathy
Morbid Obesity
Atrial Fibrillation - s/p DCCV [**2141-1-22**], now in sinus rhythm
Varicose Veins
Chronic Low Back Pain
Right Leg Vein Stripping
Left Total Knee Replacement
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain. Please report all wound issues to
you surgeon at ([**Telephone/Fax (1) 1504**],
2) Report any fever greater then 100.5
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) Please shower daily. Wash wound(s) with soap and water. No
lotions creams or powders to incisions for 6 weeks.
5) Report any drainage from sternal drainage
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) **] in [**12-27**] weeks. [**Telephone/Fax (1) 29252**]
Please follow-up with Dr. [**Last Name (STitle) 8051**] in [**12-27**] weeks.
Please call all providers for appointments.
INR should be drawn on [**9-18**] with results sent to the office of
Dr. [**Last Name (STitle) 8051**] at ([**Telephone/Fax (1) 8052**]. Plan relayed to office nurse
on [**2141-9-15**].
Completed by:[**2141-9-16**]
|
[
"401.9",
"427.31",
"V43.64",
"278.01",
"250.60",
"357.2",
"V45.82",
"V58.61",
"272.4",
"454.9",
"724.2",
"413.9",
"414.01",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"88.72",
"39.61",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
10515, 10574
|
7194, 8695
|
343, 409
|
10907, 10914
|
2645, 7171
|
11406, 11944
|
1428, 1496
|
9040, 10492
|
10595, 10886
|
8721, 9017
|
10938, 11383
|
1181, 1240
|
1511, 2626
|
282, 305
|
437, 879
|
923, 1158
|
1256, 1412
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,780
| 148,448
|
52096+59399
|
Discharge summary
|
report+addendum
|
Admission Date: [**2168-10-24**] Discharge Date: [**2168-11-3**]
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: This is an 80-year-old physician
with three vessel disease, left ventricular dysfunction,
mitral regurgitation, admitted for unstable angina. Similar
episode several months ago. Thrombus in left anterior
descending, without evidence of plaque rupture. Exercising
regularly without angina. Last night, walked in cold wind,
gave the patient angina. During the night, recurrent
episodes at rest, relieved by nitroglycerin.
PHYSICAL EXAMINATION: Heart rate 60, blood pressure 140/80.
Neck: Jugular venous pressure normal. Lungs: Clear to
auscultation. Cardiovascular: II/VI systolic murmur.
Extremities: No edema.
LABORATORY DATA: Troponin less than 0.3, CK 180, MB
negative. Electrocardiogram showed stable, no acute changes.
HOSPITAL COURSE: The patient was admitted on [**2168-10-24**] to the
[**Hospital Unit Name 196**] service, where the patient was continued on his aspirin,
beta blocker, ACE inhibitor, Lipitor and Plavix. He was
brought to the cardiac catheterization laboratory on [**2168-10-25**],
where they found the LMCA with moderate calcification and
distal taper to the left anterior descending/RI/LCX of 70%,
the left anterior descending with an ostial 60% calcified
lesion, the origin of the D1 with a 50% lesion, left
circumflex with a non-dominant vessel ostial 80% with
mid-segment tubular 70% stenosis, and right coronary artery
with dominant vessel proximally.
Due to the extent of the patient's disease, it was decided
that he should proceed with coronary artery bypass graft. On
[**2168-10-28**], the patient was brought to the operating room, at
which time a four vessel coronary artery bypass graft was
performed. The left internal mammary artery was brought to
the left anterior descending, saphenous vein graft to the
diagonal, saphenous vein graft to the obtuse marginal,
saphenous vein graft to the posterior descending artery. The
patient tolerated the procedure well, and was brought to the
Cardiothoracic Intensive Care Unit.
Postoperatively, the patient continued to do well, and was
extubated without incident. The patient maintained his
pulmonary artery pressure at 31/12, CVP of 9, coronary index
was maintained at 2.8, and on a milrinone drip at 0.2.
On postoperative day three, the patient was found to be
maintaining his blood pressure and heart rate without the use
of drips, and he was subsequently transferred to the Surgical
floor. On postoperative day three in the late afternoon, the
patient converted to atrial fibrillation, at which time he
was started on amiodarone of 400 three times a day as well as
given 15 mg of intravenous Lopressor and 2 grams of
magnesium. The patient remained in atrial fibrillation for
the next 48 hours, at which time it was decided to DC
cardiovert the patient.
On postoperative day six, the patient was brought to the EP
unit and was cardioverted using 200 joules. The patient
converted to normal sinus rhythm and tolerated the procedure
well. Amiodarone was subsequently continued.
On postoperative day seven, the patient converted back to
atrial fibrillation and it was believed at that time that the
patient should remain rate controlled, so the amiodarone was
decreased to 200 mg once daily and the patient was started on
his previous dose of atenolol 25 mg once daily. The patient
was heparinized throughout his entire course of atrial
fibrillation and remained heparinized until his INR reached
greater than 2.0.
DISCHARGE STATUS: Good
DISCHARGE DIAGNOSIS: Status post coronary artery bypass
graft x 4 complicated by atrial fibrillation
DISCHARGE MEDICATIONS:
1. Atenolol 25 mg by mouth once daily
2. Amiodarone 200 mg by mouth once daily
3. Warfarin 5 mg by mouth once daily
4. Calcium carbonate 500 mg by mouth twice a day
5. Aspirin 325 mg by mouth once daily
6. Colace 100 mg by mouth twice a day
7. Lasix 20 mg by mouth every 12 hours for one week
8. K-Dur 20 mg by mouth every 12 hours for one week
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 17480**]
MEDQUIST36
D: [**2168-11-2**] 21:06
T: [**2168-11-3**] 00:00
JOB#: [**Job Number 95629**]
Name: [**Last Name (LF) **], [**Known firstname 5204**]/DR. [**Last Name (STitle) 4221**] [**Name (STitle) **]: [**Numeric Identifier 17615**]
Admission Date: [**2168-10-24**] Discharge Date: [**2168-11-3**]
Date of Birth: [**2088-5-5**] Sex: M
Service: CARDIOTHORACIC SURGERY
ADDENDUM: Dr. [**Last Name (STitle) **] was in atrial fibrillation
intermittently following coronary artery bypass surgery;
however, he was discharged in sinus rhythm.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 358**], M.D. [**MD Number(1) 359**]
Dictated By:[**Last Name (NamePattern1) 17616**]
MEDQUIST36
D: [**2168-12-8**] 05:16
T: [**2168-12-13**] 09:45
JOB#: [**Job Number 17617**]
|
[
"414.01",
"427.31",
"997.1",
"426.3",
"401.9",
"410.91",
"424.0",
"272.0",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"36.15",
"36.13",
"39.61",
"37.22",
"37.61",
"99.62",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
3719, 5118
|
3615, 3696
|
896, 3593
|
587, 878
|
138, 564
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,963
| 135,747
|
9148
|
Discharge summary
|
report
|
Admission Date: [**2182-12-20**] Discharge Date: [**2182-12-26**]
Date of Birth: [**2133-7-20**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Bactrim
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
melena
Major Surgical or Invasive Procedure:
EGD
Central Line placement
Blood transfusions
History of Present Illness:
49 yo M with hx of HIV/AIDS, polysubstance abuse (heroin,
methadone, cocaine, klonopin) and Hep C who presented to [**Hospital **]
clinic today with one day hx of "black stool." Pt has a history
of esophageal vaarices, most recently banded in [**12-6**]. In [**Hospital **]
clinic he denied hematemesis, BRBPR, N/V, or lightheadedness.
His SBP was noted to be 90 without evidence of orthostasis. On
rectal exam revealed heme occult positive black stool. Given
history of bleeding esophageal varices, an attempt was made to
send him directly from clinic to the ED for an emergent scope.
While in the ED, HCT was 27.6 (baseline ~35). He was started on
Octreotide (50 mcg bolus) and protonix. Liver was consulted and
decided to scope him in the morning.
.
Currently he feels well w/o complaint. He denies nausea,
vomiting, belly pain, fever, chills, CP, SOB, lightheadedness.
His last heroin use was yesterday. He denies EtOH use (last use
15 yrs ago). Reports occasional cocaine, Methadone (80 mg) and
Klonipin abuse. Was given Keflex for LE cellulitis one week
ago, however, has not taken.
Past Medical History:
1. HIV/AIDS. (Dx [**2163**]. CD4 120 [**12-7**]. Not on HAART since
summer [**2182**] secondary to relapse into drug use. Not taking
prophylactic meds. H/o thrush and zoster, never had PCP, h/o
positive toxo IgG in [**2180**], hx of positive CMV IgG in [**2180**], hx of
negative RPR in [**2180**]. Per ID recs on [**2182-12-20**], he should be
started on dapsone 100 mg daily for PCP [**Name9 (PRE) **] and azithromycin
1200 mg qweek for [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **].)
2. H/O osteomylitis 10 yrs ago (from IVDA) in left foot, left
knee, left MTP joints
3. Gout (dx age 18; hx of tophi removal; on allopurinol in the
past. Was seen in [**Hospital **] Clinic [**2182-3-5**].)
4. Hepatitis C. (dx [**2166**]; Genotype 4a. No hx of jaundice,
ascites, or encephalopathy; pt has esophageal varices s/p
multiple bandings - most recent Novemeber [**2182**])
5. Substance abuse -- heroin IV almost daily, occasional
methadone (has been in methadone programs in his past (last
summer [**2181**]); has also tried inpatient detox programs without
success
6. Chronic knee pain from degenerative joint disease
7. Recent cellulitis - on keflex x 1 week for skin infection
secondary to injection of leg veins and skin popping
Social History:
Smokes 2 PPD x 20 yrs. No current ETOH use (last use 15 yrs
ago). Polysubtance abuse - daily heroin, occasional methadone,
cocaine, and benzos. Contracted HIV and Hep C from IVDA. Lives
alone. Unemployed.
Family History:
Non-contributory.
Physical Exam:
Tc 97.5 BP 98/51 HR 65 RR 14 100% RA, NS at 200 cc/hr
Gen: tired appearing pale male, NAD
HEENT: dry MM, anicteric
Neck: no JVD
CV: RRR, no M
Lungs: coarse breath sounds throughout, expiratory wheezes
troughout
Abd: soft, NT, no ascites, no stigmata of chronic liver
disease, +BS, +splenomegaly
Ext: right LE [**2-3**]+ pitting edema, left w/o edema, palpable DP
pulses, small areas of ulceration over LE's with area of
erythema and warmth of right shin and foot, Left foot with well
healed old scars
Neuro: A&Ox3, no asterixis
Pertinent Results:
[**2182-12-20**] 06:51PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2182-12-20**] 06:30PM GLUCOSE-80 UREA N-23* CREAT-1.1 SODIUM-138
POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-27 ANION GAP-12
[**2182-12-20**] 06:30PM CALCIUM-8.2* PHOSPHATE-4.7* MAGNESIUM-1.9
[**2182-12-20**] 06:30PM ALT(SGPT)-15 AST(SGOT)-21 LD(LDH)-160 ALK
PHOS-59 TOT BILI-0.3
[**2182-12-20**] 06:30PM WBC-1.4* RBC-3.72* HGB-9.3* HCT-27.6*
MCV-74*# MCH-25.1*# MCHC-33.7 RDW-17.5*
[**2182-12-20**] 06:30PM PLT COUNT-67*
[**2182-12-20**] 06:30PM PT-13.6* PTT-23.3 INR(PT)-1.2
[**2182-12-20**] 06:35PM LACTATE-1.6 K+-4.7
.
[**12-21**] Abd US: No intraabdominal ascites. Splenomegaly
.
[**12-21**] RLE US: No evidence of right lower extremity DVT.
.
[**12-22**]: CXR right subclavian line has been
inserted with the tip at the confluence of brachiocephalic veins
and lateral. Clear with PNA/PTX
Brief Hospital Course:
49 yo M with history of HIV/AIDS (CD4 120), Hepatitis C,
bleeding esophageal varices, and heroin and methadone abuse
admitted for eval of melena. The patient was admitted to the
ICU for monitoring and EGD. He underwent EGD and banding x 3 on
[**12-21**]. The Liver team was consulted and recommended 5 days of
IV octreotide at 50 mcg/hr. He received a total of 4 units of
pRBCs and 1 pack of platelets. After this, his Hct remained
stable for the next 3 days. He received PO PPI [**Hospital1 **] and
carafate. He received 2 days of levoflox for SBP [**Hospital1 **] but this
was stopped since there was no evidence of ascites or infection.
On the floor he was started on nadolol; this had to be stopped
after one dose due to aymptomatic bradycardia to the 40s. On
discharge the patient was tolerating POs well, with
non-melenotic stools.
.
The patient's ICU course was complicated by continued heroin
use. He admitted to ingesting heroin and was found to have
heroin on his person, as well as methadone prescribed to another
individual. Security and Administrator Supervisor were
involved. A 1:1 sitter watched the patient after this event and
he was allowed no visitors. [**Name (NI) **] was maintained on methadone 80
mg PO daily (although he is not prescribed this at home). The
Substance abuse nurse met with the patient and discussed
methadone programs with him. The patient was discharged with a
75 mcg fentanyl patch, to last him until Monday. On Monday he
is to report to Habit Management to enroll in a methadone
program. He was strongly warned about the fatal complications
of taking heroin or methadone while on the fentanyl patch. The
patient received a nicotine patch while in house.
.
The patient had been off HAART for his HIV/AIDS for several
months. His CD4 was 128 on [**12-20**]. ID was made aware of
patient's admission (Dr. [**First Name (STitle) **]. We continued to hold his HAART
per ID. He was continued on his dapsone and azithromycin
prophyllaxis for PCP and MAC.
.
His Hepatitis C was stable, without indication of liver failure.
An abdominal US on [**12-21**] showed no ascites or HCC. HIs AFB
from [**2182-7-30**] <1.01, LFTs stable. He received 2 days of SBP
[**Year (4 digits) **] with Levoflox as above.
.
The patient has a cellulitis from skin popping and IVDU. He had
been prescribed Keflex as an out-patient 1 week prior to
admission, but patient has not taken. DVT of right LE was ruled
out with ultrasound. He was started on a 14 days course on
Ancef.
.
A right SC line was placed for access without complication.
This was pulled on day of discharge.
.
He received pneumoboots for left leg and bowel regimen.
Medications on Admission:
none
Discharge Medications:
1. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
5. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours) for 1 weeks.
Disp:*14 Capsule(s)* Refills:*0*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK
(MO).
Disp:*10 Tablet(s)* Refills:*2*
9. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Transdermal
every seventy-two (72) hours for 1 doses.
Disp:*1 patch* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
melena
esophageal varices
cellulitis
substance abuse
....
AIDS
HCV
Discharge Condition:
hemodynamically stable with Hct stable over 4 days. No
melenotic stools. Tolerating PO.
Discharge Instructions:
Please return if you experience black stools, bloody stools,
bloody vomit, fever > 100.5, lightheadedness, or any other
worrisome symptoms.
.
Please take all medications as directed. You have been started
on 2 antibiotics for prevention of infections. You have also
prescribed one week more of an antibiotic for your skin
infection. You have also been started on two medications for
your esophageal varices.
.
You have also been given a prescription for a Fentanyl patch.
You should place the patch on Friday; this will last you until
Monday when you should go to the Habit Management methadone
program. If you take heroin or methadone while on the Fentanyl,
you are at risk of overdosing and this could be fatal.
Followup Instructions:
Provider: [**Name10 (NameIs) **] WEST,ROOM ONE GI ROOMS Date/Time:[**2183-1-14**] 8:30
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2183-1-14**] 8:30
.
Provider: [**First Name8 (NamePattern2) 7805**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2183-1-17**]
9:30
|
[
"572.3",
"682.6",
"715.96",
"042",
"274.9",
"V15.81",
"304.70",
"456.20",
"707.12",
"070.70",
"280.0",
"584.5",
"284.8",
"571.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33",
"99.04",
"99.05",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8381, 8387
|
4509, 7186
|
289, 336
|
8497, 8588
|
3579, 4486
|
9354, 9740
|
2984, 3003
|
7241, 8358
|
8408, 8476
|
7212, 7218
|
8612, 9331
|
3018, 3560
|
243, 251
|
364, 1464
|
1486, 2741
|
2757, 2968
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,802
| 126,982
|
28643
|
Discharge summary
|
report
|
Admission Date: [**2188-3-29**] Discharge Date: [**2188-4-2**]
Date of Birth: [**2124-10-8**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8790**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Left Brachial Plexus Radiation (2 sessions)
History of Present Illness:
63 YO F with metastatic adenocarcinoma, likely from a NSCLC
primary, who presented to [**Hospital1 18**] ED on [**3-29**] with her wife after
experiencing increasing somnolence for two days and difficult
breathing since the evening prior to admission. As her mental
status was depressed at the time of initial interview, most of
the following history was obtained from the chart and from the
pt's wife.
.
Earlier in the week the pt had been doing well, conversing
appropriately and attending medical appointments without
difficulty. On Wednesday, [**2188-3-26**], the pt was initiated on her
first cycle of palliative chemotherapy with
carboplatin-paclitaxel-bevacizumab. The following day, [**2188-3-27**],
she also received Zometa and Neulasta. Around this time, the pt
endorsed some low-grade temperatures, between 100.0 and 100.3.
These subsequently resolved. She then went on to develop the
mental status changes and difficulty breathing described above.
The pt's wife noted that when she would attempt to administer
the pt her medications, she would awake to take them but then
fall asleep before they could even be given. The pt has not had
any recent change in her medications. She has not been noted to
be nauseated or to vomit. She has not complained of any urinary
symptoms. No focal abnormal movements or weakness have been
noted. Her pain has remained under fair control. Due to her pain
and limited weight bearing, the pt has limited mobility at home,
spending much time in bed or in a wheelchair.
.
The patient presented with detailed information concerning her
end of life wishes, including the fact that she is DNR and DNI.
The patient's wife, [**Name (NI) **] [**Name (NI) 1727**], is the her next of [**Doctor First Name **]. ABG
analysis was offered to the patient her spouse in the [**Name (NI) **] and
declined.
.
In the ED, intial vitals were 98.2, 124, 16, 88% RA, 111/76. At
the time of the ED physician examination, she was noted to
desaturate as low as the high 60s on RA. The pt was felt to be
in congestive failure. She was treated with IV Lasix and
morphine. As she remained confused and intermittently agitated,
she was also given Haldol, to which she had a good response. She
was admitted to the [**Hospital Ward Name 332**] ICU for ongoing medical managment and
intensive nursing care.
Past Medical History:
Oncologic history:
Ms. [**Known lastname **] is a 63-year-old white woman with a prior
25-pack-year history of smoking who presented in [**11/2187**] with
evidence of bone and musculoskeletal discomfort. Further
progression of her symptoms led to imaging studies in early
[**1-/2188**] that confirmed evidence of widespread disseminated bone
metastasis. Most of the lesions predominated in her hip bones
and her cervical and thoracic spine. The patient was
significantly symptomatic from these lesions with pain and mild
neurological impairment. It seems based on all imaging studies
that she did not have evidence of overt spinal cord compression.
The remaining of her radiographic imaging studies also showed a
left upper lobe and left hilar lesion in the lung.
.
Due to the patient's symptoms, she was started on palliative
radiation without a diagnosis. She received and completed [**2178**]
cGy of radiation to her right hemipelvis, sacrum, and L5 with
concurrent dexamethasone steroid therapy. Unfortunately, shortly
after completing the initial palliative radiation, the patient
developed upper left extremity neurologic complaints that
prompted initiation of palliative radiation therapy to the C6 to
T5 spine. The patient completed [**2178**] cGy, but contiues to have
pain and left arm/hand weakness.
.
The final pathology of her [**2188-3-5**] bone biopsy disclosed a
carcinoma (likely adenocarcinoma) with the following IHC
profile: positive for CK7 and mammoglobin. Negative stains
include, CK20, TTF-1, GCDFP, ER, PR and HER2 (FISH for HER2 is
pending). Based on all the available radiographic and pathologic
data, it is suspected that the patient has a stage IV carcinoma
that likely represents nonsmall cell lung cancer. The
mammoglobin positive stain (that can he highly specific for
breast cancer), the very high CEA and CA [**05**],29 have been viewed
as perplexing, and are thought to suggest that any therapy for
her carcinoma should at least use some active agents against
breast cancer. The lack of ER/PR staining makes hormone therapy
not an option.
.
PMH:
*extensive skeletal metastises with resultant left upper and
lower extremity weakness, pathologic fracture of right
acetabulum, presumed spinal instability
*s/p XRT to sacrum and pelvis, C6 and T5
*osteoporosis
*prior premalignant oral lesions in both her buccal mucosa and
the floor of the mouth, treated with topical ablations >10 years
ago
depression
*GERD
*allergic rhitis
*prior laparotomy for lysis of adhesions after IUD associated
pelvic inflammatory disease
Social History:
Smoked 1.5 ppd x 21 years. Minimal EtOH. No significant
exposures. Faculty member in family medicine at [**University/College 6022**].
Family History:
The patient's mother died from gastric cancer at age 38. The
patient has a first cousin that had a history of breast cancer
before age 60. The patient's father died at age 80 from
complications of heart disease. There are no other members of
the family that have history of cancer.
Physical Exam:
On admission:
VS: 97.6, BP 111/49, HR 124, RR 18, O2sat 91%
Gen: Moderately ill appearing adult female, no acute distress.
Confused, somnolent, unable to answer most questions.
HEENT: PERRL, EOMI. MMM. Conjunctiva well pigmented.
Neck: Supple, without adenopathy or JVD. No tenderness with
palpation.
Chest: Few crackles at bases bilaterally. Rare wheeze, few
rhonchi.
Cor: Normal S1, S2. Tachycardic. No murmurs appreciated.
Abdomen: Soft, non-tender and non-distended. +BS, no HSM.
Extremity: Warm, 2+ pitting edema over entire LE bilaterally. 2+
DP pulses bilat.
Neuro: Alert, oriented x 1 only. Limited cooperation with neuro
exam. CN 2-12 appear intact. Motor strength intact in all
extremities. Sensation intact grossly.
Pertinent Results:
[**2188-3-29**] 04:10PM BLOOD WBC-9.6# RBC-3.28* Hgb-9.5* Hct-28.8*
MCV-88 MCH-28.8 MCHC-32.9 RDW-16.7* Plt Ct-230
[**2188-3-29**] 04:10PM BLOOD Neuts-80* Bands-14* Lymphs-2* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-1*
[**2188-3-29**] 04:10PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2188-3-29**] 04:10PM BLOOD PT-12.5 PTT-28.2 INR(PT)-1.1
[**2188-3-29**] 04:10PM BLOOD Glucose-116* UreaN-13 Creat-0.5 Na-135
K-4.4 Cl-96 HCO3-32 AnGap-11
[**2188-3-29**] 04:10PM BLOOD Albumin-3.3* Calcium-8.1* Phos-1.8*#
Mg-2.2
[**2188-3-29**] 04:10PM BLOOD ALT-30 AST-26 CK(CPK)-45 TotBili-0.2
[**2188-3-29**] 04:10PM BLOOD CK-MB-NotDone proBNP-1743*
[**2188-3-29**] 04:10PM BLOOD cTropnT-<0.01
[**2188-3-29**] 04:10PM BLOOD TSH-0.48
[**2188-3-29**] 04:10PM BLOOD CEA-3910*
[**2188-3-31**] 06:32AM BLOOD Lactate-1.3
[**2188-3-31**] 06:32AM BLOOD Type-[**Last Name (un) **] pO2-112* pCO2-38 pH-7.46*
calTCO2-28 Base XS-2 Comment-GREENTOP
.
[**2188-3-29**] TTE: The left atrium and right atrium are normal in
cavity size. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. 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 regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is a small circumferential pericardial effusion. There are
no echocardiographic signs of tamponade. There appears to be a
left pleural effusion.
.
[**2188-3-29**] CXR: 1. Interval development of congestive heart failure
with associated moderate left pleural effusion. 2. Known left
upper lobe airspace consolidation compatible with known lung
cancer.
.
[**2188-3-30**] CXR: Again seen is enlargement of the mediastinum
consistent with known left-sided mass; upper zone redistribution
and vascular blurring, suggesting superimposed CHF; increased
retrocardiac density, consistent with left lower lobe collapse
and/or consolidation and elevated left hemidiaphragm; and patchy
opacity at the right base. No gross effusions are identified. No
pneumothorax is detected. IMPRESSION: Essentially unchanged
compared with one day earlier.
.
[**2188-4-1**] CXR: Pulmonary edema has resolved since [**3-30**]. Left
suprahilar mass is unchanged since mid [**Month (only) 547**]. Left lower lobe
consolidation has worsened since [**3-12**] probably atelectasis.
Mild-to-moderate cardiomegaly and pulmonary vascular congestion
remain, small left pleural effusion decreased since [**3-29**].
Brief Hospital Course:
63 YO F with recent diagnosis of metastatic adenocarinoma,
likely NSCLC primary, who presented on [**3-29**] with altered mental
status, dyspnea, and hypoxia.
.
# Goals of care. As the patient was largely unable to make her
own medical decisions during this admission, her wife and her
living will documentation were relied upon to determine her
wishes for care. The patient's wife strongly expressed a desire
for care to be directed to patient comfort with minimal testing
for diagnostic purposes.
.
# Dyspnea, Hypoxia. Given limited testing ability, the patient
was treated for hypervolemia with diuresis as well as
aspiration/post-obstructive pneumonia given her depressed mental
status and lung mass. Her hypoxia responded well and her oxygen
saturations returned to the low to mid-90s on room air as well
as with ambulation. Alternative diagnoses that were not ruled
out given the patient's wishes were pulmonary embolism and
progression of lung based tumor burden. Given that a recent echo
showed a normal EF without signs of diastolic dysfunction, it
was thought that her recent chemo (which included avastin) could
have created a leaky-capillary syndrome that resulted in
pulmonary edema. The day prior to her discharge, she again
developed dyspnea and hypoxia to the high 80s on room air with
diffuse crackles on exam. She responded well to nebs and lasix
with a CXR c/w continued volume overload. Again, given normal
EF, it was not clear if this was in fact related to recent
chemo, bronchospasm, or worsening tumor burden. Given her
dramatic improvement with nebs and lasix, she was discharged
with both medications. She was also given a total course of 10
days of levofloxacin and flagyl for possible aspiration or
post-obstructive pneumonia.
.
# Mental status changes. The patient's mental status
dramatically improved prior to her return home. Prior to her
improvement, her alteration seemed to be most consistent with
acute delirium with profoundly reduced attention and
concentration. Much of this cleared with treatment of her
hypoxia, however, she remained somewhat altered with concern
that she experienced permanent mental status changes during her
several days of hypoxia or, alternatively, may have had a
thromboembolic event or CNS spread of her malignancy. Also
possible was altered mental status as a result of zometa or
neulasta given during recent chemo. Further diagnostic testing
such as head CT, MRI and/or LP were not completed given
HCP-wishes and significant improvement in mental status in the
setting of a seemingly clearing delirium.
.
# Sinus Tachycardia. Appropriate in the setting of possible
infection, hypoxia and malignancy however, with a [**Doctor Last Name 3012**] score
7/moderate, concern for a PE was raised. Given limited testing
ability and with improvement in hypoxia, no Q1S3T3 on EKG, and
patient having been on prophylactic lovenox as an outpatient, a
decision was made to not empirically treat for PE.
.
# Adenocarcinoma w/ brachial plexus invasion, pain. Radiation
oncology was consulted and the patient received one treatment to
her left brachial plexus prior to discharge. Further radiation
was arranged with a plan for a total of 5 fractionations. Her
pain was controlled with up titration of fentanyl patch and prn
morphine IR.
.
On [**4-2**], the patient's mental status had signficantly improved.
She was hemodynamically stable and no longer hypoxic. She was
therefore discharged to home with hospice.
Medications on Admission:
Medications at home:
Lovenox 40 mg daily
Fentanyl patch 75 mcg/hr
Ibuprofen 600 mg TID
Lactulose PRN
Lorazapam 0.5 mg [**Hospital1 **] PRN
Morphine 45 mg PO q4-6 hours PRN pain
Zofran 8 mg TID PRN
Pregabalin 150 mg TID
Prochlorperazine 10 mg q8 hours PRN
Bisacodyl 10 mg daily
Docusate 100 mg [**Hospital1 **]
Senna 2 tabs [**Hospital1 **]
.
Medications on transfer:
Ondansetron 4mg ODT q8h prn
Morphine sulfate IR 15mg PO q2h prn
Enoxaparin 40mg SC daily
Senna 2 tabs PO bid
Docusate 200mg PO bid
Lactulose 30mL PO tid
Fentanyl patch 75mcg TD q72h
Discharge Medications:
1. Nebulizer Machine
Please provide patient with home nebulizer machine. Currently
94% on Room Air.
2. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*7 Tablet(s)* Refills:*0*
3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours).
Disp:*21 Tablet(s)* Refills:*0*
4. Ipratropium-Albuterol 0.5-2.5 mg/3 mL Solution for
Nebulization Sig: One (1) neb Inhalation every four (4) hours as
needed for shortness of breath or wheezing.
Disp:*1 month supply* Refills:*2*
5. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day): hold for loose stool.
6. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day):
hold for loose stools.
7. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous DAILY (Daily).
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for lower extremity [**Hospital1 **], lung crackles (per VNA).
Disp:*30 Tablet(s)* Refills:*2*
9. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for Nausea.
10. Pregabalin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
11. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*2*
12. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
14. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
15. Morphine Concentrate 20 mg/mL Solution Sig: 0.5-1.5 ml PO
q2-3h as needed for breakthrough pain.
16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 269**] Hospice Care
Discharge Diagnosis:
Primary:
Altered Mental Status
Hypoxia
Pneumonia
.
Secondary:
Metastatic Adenocarcinoma of unknown primary (most likely
non-small cell lung cancer)
Discharge Condition:
Fair. Hemodynamically stable.
Discharge Instructions:
You were admitted to the hospital for low oxygen saturations and
altered mental status. You were found to have extra fluid in
your lungs and a likely pneumonia. You were treated with lasix
to remove the extra fluid and antibiotics to treat pneumonia.
You were also given nebulizer treatments which helped to open
your airways.
.
You may continue to take lasix as needed at home if you, your
family, or your hospice nurse [**First Name (Titles) **] [**Last Name (Titles) **] in your legs or
crackles on your lung exam.
.
You should continue to take flagyl and levofloxacin until your
prescription runs out. This will complete a 10 day course of
antibiotics for pneumonia.
.
You should continue to do nebulizer treatments at home if you
become short of breath or notice any wheezing.
.
It is not entirely clear why this event occurred. It may have
been related to the bone medication you received with
chemotherapy or from leaky blood vessels from chemo causing lung
congestion. There are many other factors that may have also
contributed which include pain medications and a possible
aspiration event when your mental status declined.
.
Given your ongoing left arm pain, you had 2 sessions of
radiation. You should continue this treatment for 3 more
sessions per the radiation oncologists. Your fentanyl patch was
also increased from 75 to 100 mcg daily in an attempt to reduce
your breakthrough pain needs. Your lyrica dosing was also
changed to 100mg three times per day.
.
You should otherwise continue your home medications as prior to
this hospitalization.
.
Please call Dr [**Last Name (STitle) 5263**], [**Doctor Last Name **] or your hospice agency for
increased pain, nausea or any other concerning symptoms.
Followup Instructions:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10384**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2188-4-9**] 12:30
[**Name6 (MD) **] [**Name8 (MD) 831**], MD Phone:[**0-0-**] Date/Time:[**2188-4-15**] 9:30
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10384**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2188-4-15**] 12:00
|
[
"427.0",
"338.3",
"198.89",
"707.22",
"162.8",
"V87.41",
"733.00",
"V15.3",
"276.6",
"486",
"V13.51",
"799.02",
"V15.82",
"198.5",
"293.0",
"530.81",
"707.05",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.29"
] |
icd9pcs
|
[
[
[]
]
] |
15209, 15271
|
9257, 12722
|
336, 382
|
15463, 15495
|
6516, 9234
|
17260, 17633
|
5471, 5754
|
13321, 15186
|
15292, 15442
|
12748, 12748
|
15519, 17237
|
12769, 13090
|
5769, 5769
|
275, 298
|
410, 2731
|
5783, 6497
|
13115, 13298
|
2753, 5303
|
5319, 5455
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,243
| 129,703
|
28153
|
Discharge summary
|
report
|
Admission Date: [**2169-3-16**] Discharge Date: [**2169-3-22**]
Date of Birth: [**2088-4-18**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is an 80m who was transferred to [**Hospital1 18**] from OSH with frontal
contusions and interventricular hemorrhage after an unwitnessed
fall. He was originally taken to OSH after his downstairs
neighbor heard the fall and called 911. He has a long history of
frequent falls and ETOH abuse. He currently denies any pain,
weakness in extremities, speech difficulty or visual
disturbances.
Past Medical History:
ETOH abuse, HTN, BPH, Aortic valve replacement, CABG,
Protstate Cancer
Social History:
Lives Alone, ETOH abuse
Family History:
NC
Physical Exam:
BP: 137/55 HR: 66 R 16 O2Sats 98
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRLA 3-2mm EOMs FULL
Neck: C Collar in place, no tenderness to palpation
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person only
Recall: Unable to recall [**2-2**] objects at 5 minutes.
Language: Speech fluent No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-6**] throughout. Right pronator
drift.
Sensation: Intact to light touch bilaterally.
PHYSICAL EXAM UPON DISCHARGE:
awake, alert to self only
PERRL, EOMI
face symmetric, tongue midline
ecchymosis on right temple
no pronator drift
MAE's with good strengths
following commands
Pertinent Results:
CT Head [**3-16**]
1. Slight interval increase in size of small hemorrhagic
contusion in the
left lateral inferior frontal lobe.
2. Stable hemorrhagic foci in the subarachnoid right frontal
lobe and
subependymal right lateral ventricle.
3. Interval increase in amount of dependently layering
ventricular blood,
source unclear. [**Name2 (NI) **] change in ventricle size.Correlate clinically
and for coagulopathy and consider close followup.
Hand x-ray [**3-17**] - : There are two osseous fragments adjacent to
the
volar and ulnar base of the first distal phalanx. One may
represent a
sesamoid, however, the other likely represents an
age-indeterminate fracture. There are moderate degenerative
changes of the IP joint with osteophyte formation as well as
moderate degenerative changes of the triscaphe joint.
Degenerative changes at the first CMC are milder in extent.
Vascular
calcifications are diffuse. Soft tissue swelling about the thumb
is moderate.
[**3-22**] HEAD CT and C SPINE CT- preliminary read no acute changes.
interval resolution of SAH.
Brief Hospital Course:
Patient presented to the ER s/p fall at home as a trasnfer from
an OSH. Upon arrival and assessment he was admitted to the ICU
for further observation and management. Repeat Head CT showed
some increase in the left lateral ventricle IVH however his
clinical exam was improving. He continued in a hard cervical
collar into [**3-17**] and it was decided that he would remain in the
collar for two weeks and then return with imaging to assess
stability.
On the afternoon of 4.15 he was deemed stable for transfer to
the floor for disposition planning. PT and OT consults were
ordered to determine the best disposition for him. There was no
bed available on the floor and the patient stayed another night
in the trauma ICU. A hand x-ray demonstrated right thumb
osseous fx at IP/volar aspect and according to trauma no
splinting or f/u is needed.
On [**3-18**], transfer orders rewritten for transfer to the floor.
The patient keppra ws increased to 750 [**Hospital1 **].The trauma ICU team
reviewed his right hand [**Last Name (un) **] xray which was consistent with
osseus frags at IP/volar aspect and reccomenede there is no need
for splinting of this fracture
On [**3-20**], The patient exam was stable. The patient was oriented
to self and hospital not date, given choices. He continues to
wear a [**Location (un) **] J cervical collar. He was able to moves all
extremities well with good strength. He denied right thumb
discomfort
The patient INR was 1.4. Liver Function Tests were ordered
which showed AP/LDH were slightly elevated. A Social Work
Consult was ordered as the patient lives alone and the daughter
is worried that the patient suffers from self netglect. The
daughter does not feel that he is safe to go home as he is
disoriented and does not eat. The patient serum potassium was
3.6 and repleated serum magnesium was 1.8 both were repleated.
He was evaluated by speech who recommended soft/reg thin
liquids. PT/OT recommened acute rehab.
Now DOD, patient is afebrile, VSS, and currently neurologically
stable. He was given an Aspen collar which he should remain
wearing at all times until follow up. He is tolerating a
soft/thin liquid diet. He is set for discharge to rehab and
will f/o with Dr. [**Last Name (STitle) **] in 2 weeks.
Medications on Admission:
oxybutin, lopressor
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
4. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. levetiracetam 500 mg Tablet Sig: 1.5 Tablets PO BID (2 times
a day).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
parafalcine SDH
IVH
Neck pain
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:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? You have been discharged on Keppra (Levetiracetam), you
will not require blood work monitoring.
?????? Continue to wear your cervical collar at all times. You
may remove it only to change the collar following a shower
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 2 weeks.
??????You will need Flexion/Extension X-rays prior to your
appointment. This can be scheduled when you call to make your
office visit appointment.
Completed by:[**2169-3-22**]
|
[
"414.00",
"816.00",
"305.00",
"V45.81",
"401.9",
"600.00",
"V10.46",
"E888.9",
"851.80",
"294.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6412, 6482
|
3256, 5518
|
317, 324
|
6556, 6556
|
2173, 3233
|
7914, 8224
|
897, 901
|
5588, 6389
|
6503, 6535
|
5544, 5565
|
6731, 7891
|
916, 1086
|
269, 279
|
1993, 2154
|
352, 745
|
1327, 1963
|
6571, 6707
|
767, 840
|
856, 881
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,888
| 198,508
|
46029
|
Discharge summary
|
report
|
Admission Date: [**2136-9-8**] Discharge Date: [**2136-9-11**]
Date of Birth: Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old
female with Parkinson's disease who presented to the
Emergency Room after she was found unresponsive by her
husband. The patient was in her usual state of health
according to her husband until three days prior to admission,
when she complained of lethargy secondary to the heat. The
husband returned from work on the morning of admission at
about 8 a.m. and found the patient unresponsive on the
bathroom floor. She had been well the previous evening at
6:30 p.m. EMS was called and found the patient with a
temperature of 98.7, tachycardic and tachypneic. In the
Emergency Room rectal temperature was 105 degrees, pulse was
112, blood pressure 108/56 and she was satting 97% on 2
liters. She was given a Tylenol suppository and wet towels
for cooling, and two liters of normal saline. CT of the head
was negative. LP was negative. Chest x-ray was negative.
EKG also was negative. The husband denies the patient having
recent febrile illness, diaphoresis, nausea, vomiting or
cough. Denies alcohol use. He says the patient had been
using dietary supplements recently.
PAST MEDICAL HISTORY: Parkinson's disease diagnosed [**2133**].
Her primary neurologist is at [**Hospital6 **]. Sarcoid
inactive for more than 30 years. Anxiety.
ALLERGIES: No known drug allergies.
MEDICATIONS: On admission, Sinemet 25/100 7 tablets q d,
Robaxin 500 mg qid prn, Permax 7 mg q d, Celebrex 200 mg prn,
Tasmar 600 mg q d.
SOCIAL HISTORY: The patient lives with husband, no history
of tobacco, no history of alcohol.
PHYSICAL EXAMINATION: The patient on exam had temperature of
105, pulse 112, blood pressure 108/56, oxygen saturation 97%
on two liters. She appeared moderately obtunded. Her
conjunctiva were injected. Her pupils were equal, round and
reactive light. Her mucus membranes were dry. She had no
jugulovenous distension and no lymphadenopathy. Her neck was
supple. Her heart was regular with no rubs, murmurs or
gallops. Her lungs were clear. Her abdomen was obese with
normal bowel sounds and was soft and nontender. Her
extremities were warm and well perfused with no clubbing,
cyanosis or edema. She had 2+ dorsalis pedis pulses
bilaterally. Neurologically she opened her eyes to command,
and followed simple commands. She was oriented to name. She
was poorly verbal, with slurred speech. Her foot reflexes
had 2+ knee jerks and 2+ biceps and toes were mute
bilaterally.
LABORATORY DATA: White blood cell count 9.6 with 81% polys,
16% lymphs, 3% monos, hematocrit 37.1, sodium 134, potassium
4.5, chloride 97, CO2 19, BUN 23, creatinine 1.4 (baseline
1.1 in [**2135-5-30**]), glucose 251, PTT 26.2, INR 1.4. Urinalysis
revealed large blood, no nitrates, greater than 300 protein,
greater than 250 glucose, greater than 80 ketones, and 0-2
white blood cells. Her ALT was 105, AST 427, amylase was 91
and total bilirubin was 0.9. Her CK on admission was 27,862
with an MB total of 26 and troponin was 0.5. Chest x-ray
suggested a question of infiltrate at the right base. An EKG
revealed sinus tachycardia at a rate of 113 beats per minute
with a normal axis and normal intervals.
HOSPITAL COURSE:
1. Neurology: The patient has a history of Parkinson's
disease and now presents with mental status changes and
slurred speech. She also had some bilateral upper extremity
weakness which was not revealed on the initial exam. An MRI
of the head in addition to the CT of the head was negative.
Neurology was consulted and felt that the mental status
changes and hyperthermia were consistent with a neuroleptic
malignant syndrome. She was started on Dantrolene 3
mg/kg/day dosed tid. Her Sinemet dosing was changed to
Sinemet CR 50/200 q a.m., q noon and q 5 p.m. and regular
Sinemet 25/100 q a.m. She was also put on Pergolide 1 mg po
q 8 hours and Eldepryl 5 mg at 7 a.m. and 12:30 p.m. The
Tasmar was discontinued secondary to an elevation in her
liver function tests. The patient's mental status improved
with hydration and the Dantrolene and on discharge the
patient was felt by her husband to be at or near her
baseline.
2. Hyperthermia: Her hyperthermia was felt to be secondary
to neuroleptic malignant syndrome and/or heat stroke. Her
temperature improved with IV fluids and Dantrolene.
3. Rhabdomyolysis: The patient initially presented with a
CK of 27,862 and peaked at CK of 32,920. Her MB fraction was
consistently negative and troponins were negative. The
patient was given aggressive fluids during her hospital stay.
4. Infectious Disease: The patient was initially treated
with Flagyl for question of aspiration pneumonia, however,
the patient's white blood cell count remained normal and the
patient's temperature also normalized and her lung exam was
clear, therefore the Flagyl was discontinued.
5. Renal: The patient's initial acute renal failure
improved with IV hydration.
6. Increased liver function tests: There were felt to be
secondary to shock liver and/or Tasmar and Dantrolene which
were subsequently discontinued. Her liver function tests
improved prior to discharge.
CONDITION ON DISCHARGE: The patient was discharged in good
condition with home physical therapy. She was to follow-up
with her primary neurologist at [**Hospital6 **].
DISCHARGE DIAGNOSIS:
1. Neuroleptic malignant syndrome.
2. Parkinson's disease.
3. Rhabdomyolysis.
4. Acute renal failure.
DISCHARGE MEDICATIONS: Eldepryl 5 mg at 7 a.m. and 12:30
p.m., Sinemet CR 50/200 q a.m., q noon and q 5 p.m. Sinemet
25/100 q a.m., Pergolide 1 mg po q 8 hours.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D. [**MD Number(1) 3091**]
Dictated By:[**Last Name (NamePattern1) 11548**]
MEDQUIST36
D: [**2136-12-8**] 07:38
T: [**2136-12-9**] 22:04
JOB#: [**Job Number **]
|
[
"507.0",
"276.5",
"E900.0",
"332.0",
"728.89",
"584.9",
"300.01",
"992.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
5564, 5975
|
5433, 5540
|
3318, 5241
|
1722, 3301
|
150, 1259
|
1282, 1603
|
1620, 1699
|
5266, 5412
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,532
| 111,351
|
34296
|
Discharge summary
|
report
|
Admission Date: [**2108-8-13**] Discharge Date: [**2108-8-18**]
Date of Birth: [**2030-9-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
fevers, chills, 15 pounds weight loss, urinary frequency
Major Surgical or Invasive Procedure:
[**2108-8-13**] MV repair ( 30 mm CE band)
History of Present Illness:
77 yo male presented at OSH in [**7-13**] with acute prostatitis
diagnosed by urology with above sx in addition to anorexia and
diaphoresis. ID consult also revealed endocarditis with
hemolytic strep. Started on PCN and gentamycin and transferred
here for eval. then . Dental consult done and preop workup
completed. Discharged home for a few weeks with plan for MVR in
[**8-13**].
Past Medical History:
1. BPH
2. Hypertension
3. Chronic sinusitis
4. Sleep apnea - CPAP
5. s/p splenectomy 53 years ago secondary to trauma
6. Severe degenerative joint disease (shoulder and fingers)
7. S/P hernia repair
endocarditis
MR
prostatitis
Social History:
Widowed. Retired hairdresser, now works at a golf course. Quit
smoking in [**2059**]. Daily alcohol with no more than 2 drinks per
night.
Family History:
NC
Physical Exam:
5'[**09**]" 95.4 kg
HR 86 RR 16 right 130/76 left 130/76
NAD
skin unremarkable
wears glasses
neck supple, full ROM, no carotid bruits appreciated
CTAB
RRR no murmur noted
soft, NT, ND, + BS, scar left abdomen
warm, well-perfused, no edema or varocosities noted
neuro grossly intact
1+ bil. fem/DP/PTs
2+ bil. radials
Pertinent Results:
Conclusions
Prebypass
1. The left atrium is normal in size. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium or
left atrial appendage. No atrial septal defect is seen by 2D or
color Doppler.
2.Left ventricular wall thicknesses and cavity size are normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the ascending aorta. There are
simple atheroma in the descending thoracic aorta.
5.There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. There is no aortic valve
stenosis. Mild (1+) aortic regurgitation is seen.
6. The mitral valve leaflets are moderately thickened. There is
a moderate-sized vegetation with associated calcification on the
posterior leaflet (P2 P3 location) mitral valve. Moderate (2+)
mitral regurgitation is seen. Mitral annulus is 3.4 cm.
[**Known lastname 11991**],[**Known firstname **] [**Medical Record Number 78929**] M 77 [**2030-9-15**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2108-8-17**] 8:13
AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2108-8-17**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 78930**]
Reason: eval for pleural effusions
[**Hospital 93**] MEDICAL CONDITION:
77 year old man s/p MV repair
REASON FOR THIS EXAMINATION:
eval for pleural effusions
Final Report
HISTORY: Status post MV repair, to evaluate for pleural
effusions.
FINDINGS: In comparison with the study of [**8-16**], the PICC line is
poorly seen,
though it still appears to extend to the mid portion of the SVC.
Some low
lung volumes with continued increased opacification at the bases
and poor
definition of the hemidiaphragms.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: FRI [**2108-8-17**] 10:38 AM
Imaging Lab
7.There is no pericardial effusion.
8. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2108-8-13**]
at 830 am.
Post bypass
1. Patient not on any vasoactive infusions
2. LV function remains good (EF 55%) with no wall motion
abnormalities.
3. Annuloplasty ring seen in the mitral position. Trace mitral
regurgitation present.
4. Aortic valve has no regurgitation after bypass.
5. Aortic contours appear smooth after decannulation.
6. Dr. [**Last Name (STitle) **] notified of findings at 1048 on [**2108-8-12**]
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2108-8-13**] 15:01
?????? [**2102**] CareGroup IS. All rights reserved.
[**2108-8-18**] 06:00AM BLOOD WBC-14.2* RBC-2.74* Hgb-8.2* Hct-24.4*
MCV-89 MCH-29.9 MCHC-33.5 RDW-15.8* Plt Ct-343
[**2108-8-13**] 10:43AM BLOOD WBC-26.7*# RBC-2.86*# Hgb-8.6*#
Hct-24.7*# MCV-86 MCH-30.0 MCHC-34.8 RDW-13.8 Plt Ct-247
[**2108-8-13**] 11:34AM BLOOD PT-14.4* PTT-32.9 INR(PT)-1.3*
[**2108-8-13**] 10:43AM BLOOD PT-15.6* PTT-29.3 INR(PT)-1.3*
[**2108-8-18**] 06:00AM BLOOD Glucose-115* UreaN-33* Creat-1.4* Na-140
K-3.6
[**2108-8-13**] 11:34AM BLOOD UreaN-30* Creat-1.5* Cl-105 HCO3-26
Brief Hospital Course:
Admitted [**8-13**] and underwent surgery with Dr. [**Last Name (STitle) **]. Noted to
have a difficult intubation. Transferred to the CVICU in stable
condition on phenylephrine and propofol drips. Had postop shock
with hypotension and epinephrine drip started. This was weaned
over the next day. PICC line was removed on POD #1 and extubated
early that morning. POD #2 Chest tubes removed and he was
transferred to SDU for telemetry monitoring and further
recovery. It was felt that he would require rehab for further
increase in activity and endurance, as well as close monitoring
and antibiotic administration (PCN G 2million units q4h x 2
weeks per ID) for his preoperative endocarditis. H eis scheduled
to follow up with the [**Hospital **] clinic on [**9-6**] for further
evaluation. WBC ct. and chemistry to be checked at rehab 2x
weekly. Mr. [**Known lastname **] has been instructed on all follow up
appointments.
Medications on Admission:
HCTZ 25 mg /Triamterene 37.5 mg daily
finasteride 5 mg daily
flomax 0.4 mg daily
tylenol prn
colace 100 mg [**Hospital1 **]
gentamicin 80 mg IV Q 8hr
heparin flush for PICC
PCN G potassium 3 million units IV q 4 hours
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily). Tablet, Delayed
Release (E.C.)(s)
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
7. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H
(every 6 hours) as needed.
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day.
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day.
10. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
11. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Three (3) ML
Intravenous every eight (8) hours as needed for line flush.
12. Penicillin G Potassium 1,000,000 unit Recon Soln Sig: Two
(2) Injection every four (4) hours for 2 weeks.
Discharge Disposition:
Extended Care
Facility:
Radius @ [**Hospital3 **]
Discharge Diagnosis:
MR s/p MV Repair
endocarditis
BPH
HTN
chronic sinusitis
DJD
sleep apnea/CPAP at night
s/p acute prostatitis
Discharge Condition:
good
Discharge Instructions:
shower daily and pat incisions dry
no lotions, creams or powders on any incision
no driving for one month AND until off all narcotics
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100.5 , redness or drainage
Followup Instructions:
see Dr. [**Last Name (STitle) 31187**] in [**12-7**] weeks
see Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
[**Hospital **] clinic [**2108-9-6**]
Completed by:[**2108-8-18**]
|
[
"427.31",
"998.0",
"327.23",
"421.0",
"401.9",
"424.0",
"518.5",
"E878.1",
"600.00",
"601.0",
"473.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"35.12",
"88.72",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7444, 7496
|
5069, 5994
|
378, 423
|
7648, 7655
|
1618, 3057
|
7940, 8142
|
1257, 1261
|
6263, 7421
|
3097, 3127
|
7517, 7627
|
6020, 6240
|
7679, 7917
|
1276, 1599
|
282, 340
|
3159, 5046
|
451, 834
|
856, 1085
|
1101, 1241
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,575
| 173,752
|
2390
|
Discharge summary
|
report
|
Admission Date: [**2197-6-4**] Discharge Date: [**2197-6-6**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Inability to understand or speak in a meaningful way.
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
85 right-handed man, Cantanese-speaking only, with PMH of
dyslipidimia, smoker, probable Alzheimer's disease who woke-up
today with frontal headache and very significant change in
mental
status, being innatentive and with illogical speech, found to
have acute left temporal-parietal intraparenchymal hemorrhage
with mild surrounding edema.
On his baseline, patient has short tem memory problems for the
past few years (eg. wife says he often forgets what he ate
before
but he has a good memory for childhood events), he, however, can
dress by himself, does not get lost in the streets and he is
oriented to time and place. He lives with his wife and his son.
Yesterday, he did some gardening work and was well when he went
to bed as per his wife. This
morning, he woke-up at 5am, his usual time, and complained of
frontal headache to his wife. His wife noticed that he was not
himself, he did not get his usual morning cup of coffee, he was
speaking to himself, he did not respond to her when she asked
questions and he was completely incoherent in his speech,
illogic. The words he spoke in Cantanese were
meaningless, they did not think he had slurred speech. He would
say sentences like "I go somewhere" or things they would not
understand at all.
Daughter and wife reported that they did not find any evidence
of
weakness, he
could hold objects well but his gait was somewhat unsteady, not
falling to any side.
ROS:
Family denied fever, wt loss, appetite changes, cp,
palpitations, DOE, sob, cough, wheeze, nausea, vomiting,
diarrhea, constipation, abd pain, fecal incont, dysuria,
nocturia, urinary incontinence, muscle or joint pain, hot/cold
intolerance, polyuria, polydipsia, easy bruising, depression,
anxiety, stress, or psychotic sx.
Past Medical History:
-osteoporosis
-no formal diagnosis of Alzheimer's disease, however, he has had
for the past few years short term memory problems (eg. wife says
he often forgets what he ate before but he has a good memory for
childhood events)
-Dyslipidimia (not on medications)
Social History:
Patient is from [**Country 651**], Cantanese-speaking only, he has been in
US for 33 years, retired, used to do yard work, he smokes [**5-31**]
cigarettes/day for 60 years, no alcohol or illicit drug abuse.
Patient lives with his wife and his son.
Family History:
His father had a stroke at 66 yo
Physical Exam:
Exam:
T-97.4 BP-119/63 HR-67 RR-20 100O2Sat
Gen: Lying in bed, somewhat agitated
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, extremely innatentive, could not
follow wvent simple commands such as point to the ceiling, not
oriented to time or place. He could not say the months of the
year, he could not name a watch or thumb. As translated by his
daughter, he would say words that have no meaning in Cantanese
or
"I go somewhere"; "I know". He could not register any word and
could not follow commands to write things. No clear evidence of
neglect.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 3 mm
bilaterally. Unable to examine visual fields due to extreme
innatention. Extraocular movements intact bilaterally, no
nystagmus. Facial movement symmetric. Hearing intact to finger
rub bilaterally. Palate elevation symmetrical. Tongue midline,
movements intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor. He could move all extremeties symmetrically
Mild right pronator drift
Patient could hold both legs up for 20s
Sensation: He retracted bilaterally to noxious stimuli
symmatrically
Reflexes: B T Br Pa Pl
Right 1 1 1 1 1
Left 1 1 1 1 1
Upgoing toes bilaterally.
Coordination: Patient was too innatentive to follow commands
such
as finger-nose-finger normal, heel to shin normal or RAMs
normal.
Gait: Narrow based, mildly unsteady, leaning towards either
side.
Romberg: Negative
Pertinent Results:
NON-CONTRAST HEAD CT: There is a 2.6 x 2.8 cm (axial plane)
hyperdense focus in the left temporal lobe, with surrounding
edema associated with a mass effect in the adjacent sulci,
consistent with acute intraparenchymal
hemorrhage. Minimal adjacent subarachnoid blood is also
demonstrated.
IMPRESSION: Acute left temporal intraparenchymal hemorrhage with
surrounding edema, causing mild mass effect on adjacent sulci,
but no herniation or midline shift.
CT CHEST w/o contrast:
1. Spiculated left upper lobe nodule that is highly suspicious
for lung
cancer, undelayed further workup is required.
2. Small left satellite lesion in the caudal aspect of the
above-mentioned
nodule.
3. Moderate to extensive bilateral emphysema.
4. No lymphadenopathy, no pleural effusion, no adrenal
enlargement.
MRI/MRA;
1. Stable large left temporal lobar hemorrhage with mild
perilesional edema.
No findings to suggest underlying hemorrhagic tumor, infarction,
or AVM.
Although, there is absence of other foci of blooming on
susceptibility
characteristic of amyloid, this can represent amyloid
angiopathy.
2. Stable left supratentorial subdural and subarachnoid
hemorrhage.
3. Stable moderate chronic microangiopathic small vessel
ischemic changes.
Stable mild diffuse parenchymal volume loss.
4. No neurovascular abnormality identified. No evidence for AVM
Brief Hospital Course:
Mr. [**Known lastname **] is a 85 yo Cantonese-speaking RHM with hx dyslipidemia,
tobacco use, and probable Alzheimer's, presenting with frontal
headache and illogical speech, found to have acute left
temporo-parietal intraparenchymal hemorrhage, thought to be most
likely secondary to amyloid angiopathy. The patient was
admitted to the critical care service and monitored. Patient
continued to be have difficulty speaking and comprehending
language. A Cantonese interpreter confirmed his speech was
still illogical at the time of discharge. However, he would
occasionally produce some coherent phrases. He was not oriented
to place or time and was not consistently following commands.
It was thought his exam may be consistent with a Wernicke's
aphasia. However, it is difficult to assess given the language
barrier. The patient's strength has remained intact and will
continue physical therapy upon discharge home. His LDL was 119.
A statin was not started as the etiology of the stroke was
likely secondary to amyloid angiopathy. HbA1c was 6.1.
Also, a CT chest was performed given a nodule seen on routine
CXR at the time of admission. The CT did reveal a spiculated
1.8 x 1.8 cm LUL nodule suspicious for malignancy. The
patient's wife reports the patient is known to have a stable
lung nodule at baseline. When discussing diagnostic and
managment options with the family including possible biopsy and
pending biopsy results the possibility of chemotherapy and/or
radiation, the family wished to defer an aggressive workup at
this time given the patient's recent stroke and current mental
status. It was explained that this workup could be completed as
an outpatient and the patient's PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], was notified of
the CT chest results.
The patient will follow up with his PCP [**Last Name (NamePattern4) **] [**11-25**] weeks and with
Dr. [**Last Name (STitle) **] (neurology) in 1 month.
Medications on Admission:
-calcium vit D 500mg [**Hospital1 **]
-alendronate sodium 70mg
Discharge Medications:
1. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet, Chewable
Sig: One (1) Tablet, Chewable PO twice a day.
2. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
1) Left temporal intraparenchymal hemorrhage, likely secondary
to amyloid angiopathy.
2) Lung nodule concerning for malignancy. Further evaluation to
be scheduled as an outpatient
Discharge Condition:
Not oriented to time or place. Difficulty following commands.
Occasional comprehensible phrases in Cantonese. Moving all
extremities against gravity.
Discharge Instructions:
Patient to be discharged home with home physical therapy and
follow up with Dr. [**Last Name (STitle) **] (neurology) and Dr. [**First Name (STitle) **] (PCP).
Return to the Emergency Department immediately for any new
weakness or numbness or changes in mental status. Also, as
discussed, the cat scan of your chest showed a 1.8 cm x 1.8 cm
nodule in your left upper lobe of your lung that is concerning
for malignancy. You should discuss this with Dr. [**First Name (STitle) **] and if
this nodule is new (or larger) compared to any prior imaging
studies, a thorough evaluation should be completed as an
outpatient.
Followup Instructions:
Neurology; Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2197-7-18**] 3:30 [**Hospital1 18**], [**Hospital Ward Name 23**] [**Location (un) **].
Dr. [**First Name (STitle) **] (PCP); [**Telephone/Fax (1) 12372**]
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"272.4",
"518.89",
"277.30",
"348.5",
"431",
"733.00",
"331.0",
"305.1",
"294.10"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8164, 8221
|
5887, 7852
|
314, 339
|
8446, 8600
|
4516, 4529
|
9267, 9669
|
2689, 2725
|
7966, 8141
|
8242, 8425
|
7878, 7943
|
8624, 9244
|
2740, 3102
|
221, 276
|
367, 2120
|
3598, 4497
|
4538, 5864
|
3141, 3582
|
3126, 3126
|
2142, 2408
|
2424, 2673
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,235
| 150,005
|
39687+58319
|
Discharge summary
|
report+addendum
|
Admission Date: [**2183-9-16**] Discharge Date: [**2183-10-3**]
Date of Birth: [**2130-6-13**] Sex: F
Service: MEDICINE
Allergies:
Clindamycin
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Back and neck pain
Major Surgical or Invasive Procedure:
1. Posterior cervical bilateral laminectomy and facetectomy
of C3 and C4.
2. Bilateral laminectomy of T2 and T4.
3. Bilateral laminotomy of T1 and T3 with facetectomy and
foraminotomy.
4. All decompressions were performed for evacuation of an
epidural lesion.
5. Biopsy bone deep.
6. Biopsy of deep tissue for culture and pathology.
(#[**2-12**] all the same surgery)
7. PICC line
History of Present Illness:
Ms. [**Known lastname 87468**] is a 53 y.o. F with a history of alcoholic
[**Known lastname 87469**] admitted from OSH for epidural hematoma vs abscess.
Around 10 days ago, pt was in the garden weeding when her foot
fell into a ditch. She then fell on her buttox. Ever since the
fall, she has had increasing pain in her neck, along her
vertebrae, shoulders, and bilateral groin. She also reports
episodic numbness and motor weakness in her lower and upper
extremities. Pts symptoms have gotten progressively worse over
the last 10 days. [**Name (NI) 1094**] husband reports that patient has become
more somnolent and confused lately and sleeps often. Sleepiness
has been getting progressively worse. Denies any incontinence,
no vision changes, no abnormal headaches (gets headaches at
baseline). Went to OSH where she was imaged and found to have a
large epidural hematoma vs abscess. She was treated empirically
with vancomycin/ceftriaxone and flagyl. Pt was tranfered to
[**Hospital1 18**] for further workup. She was found to have an elevated INR
1.7, given vit K and 2 [**Location 16678**].
.
On the floor, Vitals were:T 97.8, HR 100, O2=97% on 2L.
.
ROS: Denies fever, chills, night sweats, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria, no incontinence.
Past Medical History:
Alcoholism with history of DTs and seizures in the past
[**Location **] with splenomegaly, mild ascites, secondary to alcohol
Anemia, no improvement with Fe per notes, on Aranesp
Depression
Hypertension
Hypothyroidism
History of pancreatitis
History of GIB
Multiple Sclerosis with clumsiness of hands and feet
DJD
MSSA cervical epidural abscess
Social History:
Alcohol dependence for 15 years.Last drink was 3 days ago. 15
pack year hsitory, currently smokes 8 cig.day. Lives in
[**Location **] with husband and daughter. Used to write/edit for
managed care. Then worked in a bookstore. Currently unemployed.
Family History:
Mother- [**Name (NI) 87469**]
[**Name (NI) 12238**] parkinsons
[**Name (NI) 87470**]
Physical Exam:
ADMISSION EXAM:
VS - Temp 97F, BP , 100HR , 18R , O2-sat 97% RA
GENERAL - NAD, somnolent at times, tremulous
HEENT - EOMI, sclerae anicteric
NECK - supple, no thyromegaly, elevated JVP. Has numerous spider
angiomas on chest and arms bilaterally.
LUNGS - CTA bilat, no r/rh/wh, resp unlabored, no accessory
muscle use
HEART - RRR, systolic murmur appreciated on right and left
sternal border.
ABDOMEN - distended, positive fluid wave (small),enlarged and
palapble spleen, enlarged liver.
EXTREMITIES - no pedal edema, no calf tenderness 2+ peripheral
pulses (radials, DPs)
SKIN - numerous spider angiomas on chest and arms
NEURO - Somnolent, drifting in and out. sensation throughout,
CNs II-XII grossly intact, able to point and flex toes and
squeeze my fingers [**6-11**]. Remainder of neuro exam limited due to
patient's pain. Positive asterixis.
DISCHARGE EXAM:
V T=99.4, HR 94, BP 102/60, RR 16, 96-100%RA
Gen: NAD, comfortable, cervical collar in place
Pulm: CTAB, no crackles, few rhonchi bilaterally
Cardiac: RRR, systolic murmur at left sternal border.
Abd: soft, mildly distended, pos bs- normoactive
Ext: no pedal edema, no calf tenderness
Neuro: decreased LE stregnth bilaterally. sensation throughout.
Pertinent Results:
[**9-16**] MRI L spine:
1. Large posterior epidural collection compressing the spinal
cord from C2 to
T1 and from T2 to T6. The collection persists at the T1 and T2
levels, but
causes less severe mass effect. This could represent either an
epidural
hematoma or an epidural infection. While evaluation is somewhat
limited
without contrast-enhanced images, either a hematoma or an
abscess could show
rim enhancement. There is no evidence of osteomyelitis, but
interspinous
edema is present at C7-T1.
2. Cervical spondylosis, better evaluated on the prior cervical
spine MRI.
3. Mild lumbar spondylosis.
4. Nodular liver, trace ascites, and splenomegaly, suggestive of
cirrhosis and
portal hypertension.
[**2183-9-25**] MRI:
IMPRESSION:
1. Since the previous study there is now more fluid identified
at the
laminectomy site and posteriorly in the cervical and upper
thoracic region
adjacent to the spinous processes with foci of low signal likely
due to air within it. This could be postoperative in nature but
clinical correlation recommended to exclude infection in this
fluid.
2. Enhancement and thin rim of fluid collection posterior to the
spinal cord from C4-C7 and T1 level unchanged from previous MRI.
3. No evidence of prevertebral abscess or abnormal signal within
the spinal
cord.
[**2183-9-19**] CXR:
FINDINGS: Bilateral asymmetrical airspace pattern in the mid and
lower lungs
is more severe on the left than the right, similar to the most
recent prior
radiograph. However, on an earlier radiograph of [**9-18**] at 3
a.m., the
right side was more affected than the left. Considering the
shifting
distribution and concurrent cardiac enlargement, widening of
vascular pedicle
and vascular engorgement, this probably reflects asymmetrical
pulmonary edema.
Recurrent aspiration is an additional diagnostic consideration
for the
lung findings. Moderate left pleural effusion and probable small
right
pleural effusion are not appreciably changed.
CXR [**9-27**]:
Cardiac size is top normal. Diffuse lung consolidations worse in
the left mid
lung are grossly unchanged. There are no new lung abnormalities
or
pneumothorax. There are no large pleural effusions.
[**2183-9-17**] Echo:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). There is a mild resting left ventricular
outflow tract obstruction. The right ventricular cavity is
mildly dilated with normal free wall contractility. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. No masses or vegetations are
seen on the aortic valve, but cannot be fully excluded due to
suboptimal image quality. Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. No masses or vegetations are seen on the
mitral valve, but cannot be fully excluded due to suboptimal
image quality. Mild to moderate ([**2-8**]+) mitral regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
systolic function with resting left ventricular outflow tract
gradient (may be related to resting tachycardia). No
echocardiographic evidence of endocarditis. Mild to moderate
mitral regurgitation. Moderate pulmonary hypertension.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
[**2183-9-30**] U/S abd:
IMPRESSION:
Moderate ascites.
Patent main portal vein with reversed flow.
Splenomegaly (17.7 cm).
Small right pleural effusion.
_______
Micro:
Tissue culture:
[**2183-9-16**] 11:30 pm TISSUE C2-4 DISC.
**FINAL REPORT [**2183-9-21**]**
GRAM STAIN (Final [**2183-9-17**]):
REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 87471**] @ 0325 ON [**2183-9-17**].
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
TISSUE (Final [**2183-9-20**]):
STAPH AUREUS COAG +. MODERATE GROWTH.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final [**2183-9-21**]): NO ANAEROBES ISOLATED.
Sputum Culture [**2183-9-20**] 4:45 am SPUTUM Site: ENDOTRACHEAL
**FINAL REPORT [**2183-9-23**]**
GRAM STAIN (Final [**2183-9-20**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2183-9-23**]):
Commensal Respiratory Flora Absent.
STAPH AUREUS COAG +. SPARSE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
YEAST. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
C. diff neg x3.
Blood Cx neg [**9-16**], [**9-19**], [**9-22**], [**9-29**]
______
Admission Labs:
Admission Labs:
[**2183-9-16**] 06:25AM CRP-219.5*
[**2183-9-16**] 06:25AM WBC-18.6* RBC-3.67* HGB-10.4* HCT-31.5*
MCV-86 MCH-28.4 MCHC-33.1 RDW-15.2
[**2183-9-16**] 06:25AM NEUTS-78* BANDS-0 LYMPHS-7* MONOS-10 EOS-1
BASOS-0 ATYPS-0 METAS-2* MYELOS-2*
[**2183-9-16**] 06:39AM LACTATE-1.3
[**2183-9-16**] 09:05AM PT-18.8* PTT-37.2* INR(PT)-1.7*
[**2183-9-16**] 06:25AM ALT(SGPT)-52* AST(SGOT)-87* ALK PHOS-259* TOT
BILI-1.7*
______
Discharge Labs:
[**2183-10-2**] 05:26
Report Comment:
Source: Line-PICC
COMPLETE BLOOD COUNT
White Blood Cells 8.4 4.0 - 11.0 K/uL
PERFORMED AT WEST STAT LAB
Red Blood Cells 2.74* 4.2 - 5.4 m/uL
PERFORMED AT WEST STAT LAB
Hemoglobin 7.8* 12.0 - 16.0 g/dL
PERFORMED AT WEST STAT LAB
Hematocrit 25.1* 36 - 48 %
PERFORMED AT WEST STAT LAB
MCV 92 82 - 98 fL
PERFORMED AT WEST STAT LAB
MCH 28.6 27 - 32 pg
PERFORMED AT WEST STAT LAB
MCHC 31.2 31 - 35 %
PERFORMED AT WEST STAT LAB
RDW 19.4* 10.5 - 15.5 %
PERFORMED AT WEST STAT LAB
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Count 372 150 - 440 K/uL
PERFORMED AT WEST STAT LAB
PT 21.1* 10.4 - 13.4 sec
PERFORMED AT WEST STAT LAB
PTT 39.0* 22.0 - 35.0 sec
PERFORMED AT WEST STAT LAB
INR(PT) 2.0* 0.9 - 1.1
PERFORMED AT WEST STAT LAB
Glucose 128* 70 - 100 mg/dL
IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES
PERFORMED AT WEST STAT LAB
Urea Nitrogen 15 6 - 20 mg/dL
PERFORMED AT WEST STAT LAB
Creatinine 1.3* 0.4 - 1.1 mg/dL
PERFORMED AT WEST STAT LAB
Sodium 135 133 - 145 mEq/L
PERFORMED AT WEST STAT LAB
Potassium 4.0 3.3 - 5.1 mEq/L
PERFORMED AT WEST STAT LAB
Chloride 108 96 - 108 mEq/L
PERFORMED AT WEST STAT LAB
Bicarbonate 19* 22 - 32 mEq/L
PERFORMED AT WEST STAT LAB
Anion Gap 12 8 - 20 mEq/L
CHEMISTRY
Calcium, Total 7.6* 8.4 - 10.3 mg/dL
PERFORMED AT WEST STAT LAB
Phosphate 3.8 2.7 - 4.5 mg/dL
PERFORMED AT WEST STAT LAB
Magnesium 1.8 1.6 - 2.6 mg/dL
Brief Hospital Course:
Surgical ICU course:
The patient was taken to the OR for washout and decompression of
the epidural abscess (which grew MSSA). She was initially
treated with ciprofloxacin, vancomycin, cefepime, and zosyn
which was narrowed to nafcillin on [**9-25**]. Her SICU course was
complicated by MSSA pneumonia, a left femoral DVT for which she
was intially started on heparin gtt followed by coumadin on
[**9-27**], and confusion felt to be secondary to sedating
medications, potential alcohol withdrawal, and possibly hepatic
encephalopathy (lactulose was discontinued on [**9-20**]). She was
extubated on [**9-26**] and her mental status improved significantly.
She was transferred out of the unit and to the floor on [**9-28**].
Medicine Floor Hospital Course:
# MSSA Epidural Abscess - Pt found to have epidural abscess s/p
decompression and laminectomy, per ortho spine. She was given a
C-spine collar for stability. Pt treated empirically (vanco and
cefepine and cipro) for epidural abscess and then narrowed to
Nafcillin after sensitivities returned positive for MSSA. ID
followed pt in hospital. Pt will continue nafcillin for extended
therapy until she follows up with ortho-spine outpatient. Repeat
X-ray showed stable cervical alignment on [**9-30**]. CRP was trended
during hospitalization to assess resolution of epidural abscess.
CRP 219->100-->76. WBC count trended down during
hospitalization: 32->15->19->10.2. Pt continued to have
recurrent low grade temps (99.9) which was attributed to her
resolving epidural abscess. Blood cultures were negative as of
day of discharge. [**9-17**] TTE negative for endocarditis. RUQ U/S
negative for any biliary infection. Pt will keep C-collar on
until she follows up with ortho-spine within 4 weeks of
discharge. Pt will follow up with ID as well.
**REHAB:
-Continue Nafcillin regimen (day 1=[**2183-9-25**]). She will be on
this for several months, per ortho-spine reccomendations.
-She still has low grade temps of 99.9 which ID team attributed
to resolving epidural abscess.
-Pt needs a pediatric C-Collar. We were unable to provide on for
her at [**Hospital1 18**] since we only have access to adult collars. Please
provide a pedi-collar for her since the adult one is too big.
Thank you.
.
# MSSA Pneumonia - CXR revealed left lower lobe pneumonia
post-op. Sputum from [**9-20**] grew MSSA. Both the epidural abscess
and the pna had the same MSSA infection and were treated
empirically with vanco, cipro and cefepime, followed by
nafcillin after sensitivities returned. Pt's symptoms improved
and she was satting at 96-98% on RA at the time of discharge.
.
# Left femoral DVT/Coagulopathy - Pt has baseline coagulopathy
with elevated INR in setting of cirrhosis and liver dysfunction.
She was given daily DVT prophylaxis. Post op course complicated
by DVT in left femoral vein. Started on therapeutic heparin drip
followed by therapeutic lovanox [**Hospital1 **] injections. She began her
bridge to coumadin on [**2183-10-1**]. Pt will go to rehab on lovenox
60 [**Hospital1 **]/coumadin 2.5-5.0mg daily bridge. She will continue
coumadin therapy for at least 6 months, depending on ortho-spine
and primary care physician's recommendations. Pt had recent
normal endoscopy in [**3-/2183**] with no signs of esophageal varices.
Thus, team felt comfortable continuing anticoagulation for the
next several months. At discharge, INR=2.4 and PTT=43.
**REHAB:
-please continue to trend INR and PTT. She has been overlapped
on both lovenox and coumadin for 48 hrs at time of discharge.
Was getting coumadin 2.5mg daily on day of discharge
-INR goal: [**3-12**] for treatment of DVT.
.
# Diarrhea - Had diarrhea during hospitalization. C. Diff
negative x 3. Likely secondary to antibiotics. Lactulose was
discontinued in setting of diarrhea and was not restarted. When
diarrhea completely resolves, pt should re-start lactulose at
rehab to prevent hepatic encephalopathy. Diarrhea caused K+ and
bicarb wasting and she was repleted daily. Diarrhea improved
over the last few days of hospital course and she was given
yogurt probiotics to help with antibiotic induced diarrhea.
**REHAB:
-consider restarting home lactulose regimen (8 tablespoons/day)
when diahrea resolves.
-still has 4 bm/day, negative workup. Likely from antibiotics.
Recc giving pt probiotics at mealtime.
-Check Lytes, INR, PTT this coming monday and replete as needed.
-Please watch K+ and bicarb, she will likely need to be repleted
regularly (IV form of KCl was found to be more effective at
repleting her then PO since diarrhea). She has baseline low K+
and takes K+ at home regularly 20 mEq/day. Adding back the
spironolactone will also help. On day of discharge, her K=3.5,
we then gave her 40mEq IV KCL. We gave her sodium bicarb tabs
for her diahrea induced non-gap metabolic acidosis. We repleted
for bicarb <20.
.
# Confusion, AMS - Pt had AMS while in the SICU, described as
hallucinations. AMS was not attributed to DT's or alcohol
withdrawal since pt had last drink over 1 week before symptoms
started. She was placed on CIWA protocol anyway, given her
significant alcohol history. Mental status significantly
improved and pt was at baseline at time of discharge. Her home
oxazepam was held and may be restarted at rehab if patient
develops any anxiety or tremulousness. Home lactulose should be
restarted outpatient when pts diarrhea completely resolves to
prevent hepatic encephalopathy.
.
# Alcoholic [**Month/Day (3) **] - Alcohol dependence history. INR 1.5 on
admission, albumin low at 2.2. Was on lactulose chronically at
home but was stopped during hosptialization when pt had acute
diarrhea. Abdominal US was performed and showed moderate
ascites. She was given thiamine, folate, Multivitamin daily.
CIWA protocol was initiated at begining of hospitalization.
**REHAB:
-[**Month (only) 116**] restart lactulose when diarrhea resolves
-[**Month (only) 116**] re-introduce home oxazepam if pt tremulous or anxious.
.
# Anemia - Has chronic anemia, on aranesp at home, likely
related to splenomegaly and alcoholism. Received 5 RBC
transfusions (last [**9-24**]) and multiple blood products while in
the SICU. HCT was stable at 25 at time of discharge. [**Month (only) 116**] resume
home aranesp when leave the hospital.
.
#Renal Insuficiency: Pt came in with Cr=1.5 After fluid
hdyration and surgery, Cr came down to 0.7-1.1 range. In setting
of diarrhea and fluid loss, Cr trended up slowly to 1.3. She was
given lactated ringers and gentle fluid hydration. Renal
insuficiency thought likely to be pre-renal with possibly
underlying chronic renal insuficiency from liver dysfunction.
.
# Hyperglycemia - patient without history of diabetes but was
given ISS for hyperglycemia in setting of tube feeds and
post-op.
.
# Hypothyroidism - Contined home regimen of levothyroxine 50 mcg
daily
.
# Depression - Contined home regimen of Zoloft 150mg daily &
Ritalin 20mg TID
.
# Multiple Sclerosis - Copaxone was held since admission since
there was concern that it might make pt more immunocompromised
in setting of acute infections. Pt should resume copaxone after
meeting with primary care physician and when acute infection is
resolved.
Medications on Admission:
Lactulose 8 tablespoons/day
Furosemide 20mg 4x/day
Spironolactone 50mg TID
Potassium Chloride 20 mEqu
Zoloft 150mg
Ritalin 20mg TID
Thyroxine 0.05mg
Oxazepam 15mg [**Hospital1 **]
Copaxone 20mg injection daily
Aranesp 200mg as needed
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Methylphenidate 10 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
3. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for pruritis, rash.
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Levothyroxine 25 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical HS
(at bedtime) as needed for rash.
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation q 4 hr PRN as needed for
wheezing.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
q 4hrPRN as needed for wheezing.
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
13. Cholecalciferol (Vitamin D3) 2,000 unit Capsule Sig: One (1)
Capsule PO once a day.
14. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO q6hr PRN
as needed for Pain/Fever.
15. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
16. Oxazepam 15 mg Capsule Sig: One (1) Capsule PO BID PRN as
needed for anxiety, tremors.
17. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Goal INR: [**3-12**] for treatment of DVT.
18. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours): Give lovenox until bridge coumadin.
20. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1)
Intravenous Q4H (every 4 hours): Take nafcillin until see
ortho-spine surgeon.
21. HYDROmorphone (Dilaudid) 0.25-1.0 mg IV Q2H:PRN breakthrough
pain
22. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a
day: Give more if needed.
23. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO three
times a day.
24. Aranesp (Polysorbate) 200 mcg/mL Solution Sig: One (1)
Injection PRN as needed for Anemia.
PICC line heparin flush: 2cc.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
PRIMARY
1)Epidural Abscess
2)Deep vein thrombosis
3)Pneumonia
4)Altered mental status
5)Anemia
SECONDARY:
1)[**Hospital1 **]
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:
It was a pleasure providing care for you during your
hospitalization.
You were admitted for an infection in your back, near your
spinal cord, called an epidural abscess. You were treated with
surgery, drainage, as well as antibiotics. You have a collar on
your neck to maintain the alignment of your spine. You must keep
it on at all times. You will follow up with an orthopedic doctor
who will tell you when you may take it off. It is very important
to wear it all day and night.
During your hospitalization, you developed a clot in your leg
(for which you were given blood thinners). You must continue
these blood thinners at rehab. Right now you are taking 2 types
of blood thinners: lovenox and coumadin. Eventually you will
only take coumadin. You must continue to take coumadin for at
least 6 months and follow up regularly at special coumadin
clinics to check your blood and make sure it is thin. Your INR
goal is [**3-12**]. Do not stop taking coumadin until your primary care
doctor or the orthopedic doctor tells you to.
You also had episodes of confusion with altered mental status.
This occured after your surgery and improved during your
hospitalization.
You had diahrea which was thought to be due to your antibiotics.
You tested negative for a diahreal infection. Your diahrea
improved during your hospitalization.
The following changes were made to your medications:
-Vitamins were initially held and then restrated: Vit D [**2173**] U a
day, thimaine, folate.
-Lasix 20mg 4x/day was held
-Spironolactone 50mg TID was held
-Ritalin was initially held and then given
-Oxazepam was held. We gave you lorazepam instead. You can
restart your home oxazepam as needed when you leave the
hospital.
-Copaxone 20mg injection daily was held
-Aranesp 200mg was not given in the hospital. You nay resume
this at rehab.
-Lactulose was held in setting of diarrhea
You may resume your regular home medications when you leave the
hospital. Wait to see your primary care doctor before
re-starting the Furosemide and Copoxone. You may restart your
spironolactone, aranesp, and daily vitamins when you leave the
hospital.
We wish you a wonderful rehabilitation experience.
Followup Instructions:
Department: INFECTIOUS DISEASE
When: TUESDAY [**2183-10-21**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: SPINE CENTER
When: MONDAY [**2183-10-27**] at 1:40 PM
With: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 3736**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Make sure to schedule an appointment with your primary care
doctor shortly after you leave Rehab.
Make sure you also follow up at [**Hospital 197**] clinic after rehab.
Department: INFECTIOUS DISEASE
When: FRIDAY [**2183-11-14**] at 10:00 AM
With: [**Name6 (MD) 1423**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Known lastname 13887**],[**Known firstname **] Unit No: [**Numeric Identifier 13888**]
Admission Date: [**2183-9-16**] Discharge Date: [**2183-10-3**]
Date of Birth: [**2130-6-13**] Sex: F
Service: MEDICINE
Allergies:
Clindamycin
Attending:[**Doctor First Name 376**]
Addendum:
#Renal Insuficiency addendum: Pt Cr=1.5 on admission. Cr then
trended down to 0.7-1.1 after surgery and fluid hydration. Cr
then trended back up gradualy to 1.3 on the last few days of
hospitalization. Unclear etiology: pre-renal vs. nafcillin
nephrotoxocity vs underlying renal insuficiency. Cr should be
carefully monitored outpatient. Should be checked in 2 days and
then again 1 week after. Continue to trend Cr outpatient. If
continues to be elevated, should get a workup. Has liver
dysfunction with low albumin and elevated INR, however her
fluctuating Cr is unlikely consistent with hepatorenal syndrome.
**Rehab and Primary care physician:
[**Name10 (NameIs) 11227**] check Cr in 2 days
-re-check Cr 7 days after
-continue to monitor Cr outpatient, might need workup.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 15**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 377**] MD [**MD Number(2) 378**]
Completed by:[**2183-10-3**]
|
[
"584.9",
"518.81",
"995.91",
"787.91",
"E878.8",
"244.9",
"401.9",
"593.9",
"038.9",
"324.1",
"571.2",
"276.0",
"276.2",
"305.1",
"285.9",
"790.29",
"997.2",
"311",
"286.9",
"789.59",
"453.41",
"303.91",
"340",
"997.31",
"482.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.49",
"03.4",
"38.93",
"03.09",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
27167, 27376
|
12576, 13316
|
292, 687
|
22554, 22554
|
4094, 10635
|
24932, 27144
|
2757, 2844
|
20032, 22291
|
22406, 22533
|
19773, 20009
|
13334, 19747
|
22730, 24909
|
11111, 12553
|
2859, 3709
|
3725, 4075
|
234, 254
|
715, 2106
|
10667, 11095
|
22569, 22706
|
2128, 2475
|
2491, 2741
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,603
| 116,597
|
3677
|
Discharge summary
|
report
|
Admission Date: [**2166-9-2**] Discharge Date: [**2166-9-26**]
Date of Birth: [**2098-12-15**] Sex: M
Service: MEDICINE
Allergies:
Ivp Dye, Iodine Containing / Sulfa (Sulfonamides) / Bactrim
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
weakness, rash (?bactrim allergy), acute respiratory failure.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 67yo M with CAD s/p CABG, DM, PVD, [**Hospital 16627**] transferred from
OSH with ARDS.
.
He initially presented to OSH w/ 3 days history of increasing
weakness and unable to situp and ambulate w/ his walker. He had
some dizziness and some neck pain but no photophobia. He also
had bitemporal headache an anorexia. H ealso had a couple
episode of vomiting but no diarrhea. He also had a
non-productive cough. He noted a fascicular and papular rash on
his bilateral hands, including his palms and trunk and
extremities.
.
Of note, he has chronic yeast infection in his groin. IN the ED,
he was hypotensive to the 80s w/ HR 62 but afebrile (on
b-blocker). He was very ill appearing and dry looking.
.
About 1 wk prior, he was started on bactrim by Dr. [**Last Name (STitle) **] for
ulcer on both feet. He took a few days of bactrim but developed
severe diarrhea as a result of It. He stopped it. He was advised
by Dr. [**Last Name (STitle) **] to resume bactrim b/c of concern of persistent
infection. Upon resuming bactrim, he developed a generalized
rash started initially over his face and spreading to his abd,
his upper and lower ext. The rash was not painful and no itchy.
It then began to itch subsequently.
.
Brief OSH course [**Date range (1) 16628**]:
He was admitted on [**8-29**] w/ profound weakness and worsening renal
fx w/ BUN 78 creat 2.5. Baseline BUN 30-40s. notable labs
initially
WBC 12K, Hct 32.7 Plt 203. 26% band, 2 % eos
Na 142 K 4.0 Bun 78 and creat 2.5. Gluc 159. AST 79, ALT 55, Alk
phos 84. INR 1.1.
EKG initially RBBB w/ non specific ST T wave changes w/ NSR at
62. CXR showed some bilateral patchy infiltrate.
AN LP was attempted in the ED for concern of disseminated
zoster.
.
He was sats 98 % on Ra and BP 98/43 and afebrile. He had an
extensive exfoliate rash on his upper and lower ext. Of note, he
was on bactrim for heel ulcer. He required hypotensive and
required IVF.
.
He was started on diflucan and acyclovir and CTX. Bld cx was
drawn and these have remained negative. One of the exfoliateive
lesion was unroofed and sent for culture. Derm [**First Name9 (NamePattern2) 16629**] [**Last Name (un) **] and
di not believed that it was virla or herpetic and recommended
stopping acyclovir. (of note, he had been given lasix as outpt
meds.). He was noted to be in increasing respiratory distress
1-2 days and was given additional dosage of lasix. (total 3
dosages of 40 IV lasix given on [**8-31**]). He was also seen by ID
who recommended stopping diflucan, acyclovir, CTA. Prednisone
was also started for presumed exfoliate dermatitis. Renal was
also consulted and felt that the rash is likely from bactrim and
sulfa related allergy. and recommended IVF hydration. Despite
attempted diuresis, he developed bilateral infiltrate (diffuse)
and increasing hypoxic respiratory failure. He was emergently
intubated after midnite [**8-31**]. He was sating low 90s w/ FiO2 100
and PEEP of 7.5. Central line was inserted and CVP was 16 w/ BNP
1020. Frothy pinkish secretions were obtained from his ETT
tubes. Cultures were sent. Pt was started on ceftaz 1 q8 and
cipro 400 IV and 1 dose of 1gm vanco given empirically. He was
also started on hydrocort 100 q8 on [**9-1**] AM.
.
Of note pt was recently admitted to the vascular [**Doctor First Name **] service
for L>R ulcer and was planned to have f/u surgery pending
cardiac evaluation.
Past Medical History:
1. CAD- s/p CABG x 3 in [**2158**] at [**Hospital1 112**], last cath [**6-28**] with 80%
stenosis in SVG to OM1 s/p stent placement
2. Aortic stenosis- moderate by [**4-29**] TTE
3. CKD- by report, baseline Cr 1.2, h/o ARF with IV contrast
4. DM- HgA1C 6.4 in [**4-29**]; c/b nephropathy, neuropathy,
retinopathy
5. PVD- b/l ischemic heel ulcers, s/p R foot partial amputation
6. Hypertension
7. Hypercholesterolemia
8. Peripheral neuropathy
9. bilateral carotid stenosis, s/p R CEA [**2161**]
10. OSA- on home BiPAP
11. history of junctional tachycardia
Social History:
He is married. He is a retired quality assurance
engineer. nonsmoker and uses alcohol occasionally
Family History:
(+) FHx CAD: Mother died at age 65 of an "enlarged heart".
Physical Exam:
PHYSICAL EXAM on ADMISSION:
Vitals- p 109 BP 106/44 O2 90% RR 14
AC TV 450 FI O2 100% RR 14 PEEP 5 PIP 34
General- NAD, intubated, sedated, generalized exfoliate
dermatitis
HEENT- PERRL, OP clear w/ dry MMM
Neck- Supple, flat JVD
Pulm- diffuse crackles and rhonchi
CV- RRR, S1 and S2, no m/r/g
Abd- soft, NT, ND +BS
Extrem- cool to touch, poor distal pulses
Neuro- sedated
Brief Hospital Course:
Pt admitted to [**Hospital Unit Name 153**] on [**2166-9-3**] hemodynamically stable, but with
ARDS for further management. Pt was extubated on [**9-15**], but did
poorly on CPAP with trials of high flow ventilation. He elected
to be DNR/DNI on [**9-16**] after extubation, and on [**9-24**] goals of
care where changed to comfort measures only. Pt expired on [**9-25**]
from hypercarbic respiratory failure.
.
.
# respiratory failure: the etiology of pt's ARDS unclear, but is
presumably [**12-26**] bactrim allergy which was being used to treat
?foot cellulitis.
.
Pt did have bandemia at OSH on arrival, but numerous cultures on
presentation to [**Hospital1 18**] and at OSH negative including blood,
sputum, BAL, urine, and foot wounds (left and right) were
negative. On presentation to OSH pt noted to have rash of B LE
and it was thought that he had a bactrim allergy which he was
started on for foot ulcers.
.
Pt intubated at OSH on ~[**9-1**]. His respiratory mechanics
gradually improved with gentle diuresis with lasix gtt + diamox,
and pt was extubated [**9-15**], and transitioned to his home BiPaP
with PS 14/8. After extubation, pt continued to have copious
secretions which improved slowly. He also remained grossly
volume overloaded, and was tolerating only gentle diuresis
(~500-1000cc fluid removal daily), given his severe aortic
stenosis and preload dependence. Pt gradually improved,
tolerating trial of high flow face mask ventilation, with O2
sats 95-100% on 8-15LPM. His secretions were improving on [**9-22**],
and less copious.
.
Blood and sputum cultures, though initially negative [**Hospital1 18**] (pt
previously on vanco/zosyn from OSH for unclear indication, abx
d/c'd [**9-14**]), subseqeuntly were positive for MRSA in blood and
sputum on [**9-17**]. Pt was begun on vanco/zosysn, and switched to
linezolid/meropenem for ?improved lung penetration. however pt
continued to progress off of cpap, and on [**9-24**] decision was made
to change goals of care to CMO. Pt expired on [**9-25**].
.
.
# sepsis - on [**9-19**] pt was noted to be hypothermic. central
line and left a-line were removed earlier that day. source
remained unclear, though ddx included [**Name (NI) 16630**] versus aline/LIJ
central line. Blood Cx subsequently +mrsa. SBPS remained
elevated, and pt was already being treated with a second course
of vanco/zosyn, which was continued. lactate level was
unremarkable. By [**9-22**], pt was afebrile for 48hrs, and without
hypotension. his UOP, however remained, low, and given his
failure to improve from a respiratory standpoint, pt elected to
change goals of care to CMO on [**9-24**] and expired on [**9-25**].
.
.
# CV: pt with h/o CAD s/p CABG [**2158**], last Cath [**6-28**]. This
admission pt with cardiac enzymes x 3 w/ + trop but negative CKs
and these trended down. Thought to be due to demand ischemia
with hypotension. Pt's plavix was d/c'd as pt is >1.5 yrs s/p
cath and has had had guaic pos stools. Aspirin dose decreased
to 81 mg po qdaily, and held pending restarting oral feeding.
On [**9-24**] pt complained of CP, however no new EKG changes were
noted, cardiac enzymes unremarkable compared to prior bump, and
CP resolved within <5 min. On [**9-24**] goals of care were changed
to CMO.
.
b) pump-last ECHO showed decreased EF from [**4-29**] w/ 1+ MR and AS,
now with EF 30-40% and mod-severe AS-attempting diuresis with
diamox and lasix although on this hospitlization, diureses was
complicated by pt's preload dependence. He continued to remain
volume overloaded on [**9-22**], and diuresis was also complicated by
?sepsis physiology. On [**9-24**], decision was made to change goals
of care to CMO.
.
c) rhythmn: had episode of aflutter on admission, digoxin loaded
but not continued. On [**9-20**] pt developed intermittent aflutter
with variable block. This was felt to be [**12-26**] to his pulmonary
processes, rather than ischemia. Plan was to treat underlying
pulmonary process (pna and pulmonary edema) with linezolid,
meropenem and diuresis, however on [**9-24**] decision was made to
change goals of care to CMO.
.
.
# DM2 with complications - pt initially treated with insulin gtt
which was weaned and transitioned to sliding scale coverage with
good fsbs.
.
# Foot ulcers- vascular sugery was consulted regarding pt's foot
ulcer. The wound did not probe to bone. One wound was swabbed
which did not grow anything, and the wound do not appear to be
infected. B/L foot xrays could not r/o osteomyelitis. Pt was
afebrile without white count initially off abx. Spoke with pt's
vascular surgeon, who feels that if wound does not probe to
bone, osteo is unlikely. as this is the case, will continue
wound care, but will not workup further for osteomyelitis.
.
Regarding bilateral lower extremity rash, this was largely
resolved on [**9-20**]. Do not feel that this represents cellulitis,
as it lacks erythema, no wbc, or fever (off abx, or tyelenol).
Plan was for f/u with vascular surgeon as outpatient ([**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] [**-1/1000**]), however pt expired on [**9-25**].
.
.
#ARF- patients creatinine on admission was elevated to approx 2
and had returned to wnl despite continuing to diuresing with
lasix to remove fluid exacerbating respiratory failure. On
[**9-22**] it had started trending upward again with diuresis.
.
.
#Anemia-chronic anemia. Iron studies demonstrate ACD [**12-26**] likely
[**12-26**] DM, CHF. Pt breifly had guaic positive stool upon
presentation, though hct stable after 1 U PRBC. Pt started On
[**Hospital1 **] PPI for ?GIB, however subsequent stool guaic were negative.
Nevertheless plavix was d/c'd.
.
#hypernatremia- pt initially hypernatremic, felt likely [**12-26**] to
hypovolemia and free water deficit. Pt was treated with free
water boluses in TF and d5w once OGT was removed, with
subsequent resolution on [**9-19**].
.
# FEN: s/p extubation pt, evaluation of pt's swallow was
attempted, however he was requiring long periods of CPAP which
made this difficult. If pt does not tolerate face mask for
significant periods of time, plan was to place NGT and use CPAP
on top, despite poor seal. s&s consulted placed, however they
were unable to see pt until after he can tolerate being off of
CPAP for significant periods of time, pt was treated with TPN.
.
.
# DISPOSITION - on [**9-24**] decision was made to change goals of
care to CMO after discussion with pt, and family. on [**9-25**] pt
expired due to hypercarbic respiratory failure.
Medications on Admission:
OUTPATIENT MEDS (per d/c summary [**4-29**]):
Hydrochlorothiazide 25 mg PO qd
Acetazolamide 250 mg PO qd
Lisinopril 10 mg PO qd
Aspirin EC 325 mg PO qd
Metoprolol 12.5 mg PO BID
Citalopram Hydrobromide 20 mg PO qd
Nifedipine CR 30 mg PO qd
Clopidogrel Bisulfate 75 mg PO qd
Papain-Urea Ointment 1 Appl TP qd
Potassium Chloride 20 mEq PO bid
Ezetimibe 10 mg PO qpm
Simvastatin 40 mg PO qpm
Furosemide 80 mg PO bid
.
MEDICATIONS ( on addmission to OSH):
lopressor 25 [**Hospital1 **]
plavix 75 daily
fosamax 75 q sunday
potassium 20 [**Hospital1 **]
lisinopril 20 daily
diamox 50 daily
ECASA 325 daily
celexa 20 daily
lasix 680 [**Hospital1 **]
HCTZ 25 daily
vytorin 10/41 daily
fish oil 1700 [**Hospital1 **]
lantus 18 u qhs
humalog SSI
colace
Discharge Disposition:
Expired
Discharge Diagnosis:
pt expired on [**9-25**].
Discharge Condition:
expired.
|
[
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"327.23",
"V58.67",
"038.11",
"584.9",
"285.29",
"414.8",
"250.60",
"357.2",
"E931.0",
"396.2",
"038.9",
"V45.81",
"792.1",
"707.03",
"112.3",
"518.84",
"398.91",
"583.81",
"995.92",
"427.32",
"250.40",
"707.14",
"585.9",
"276.0",
"403.91",
"693.0",
"482.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.72",
"99.15",
"96.6",
"99.04",
"33.24",
"00.17",
"93.90",
"00.14"
] |
icd9pcs
|
[
[
[]
]
] |
12320, 12329
|
4979, 11526
|
382, 388
|
12398, 12409
|
4502, 4563
|
12350, 12377
|
11552, 12297
|
4578, 4592
|
281, 344
|
416, 3791
|
4606, 4956
|
3813, 4370
|
4386, 4486
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,165
| 128,649
|
48028+48029
|
Discharge summary
|
report+report
|
Admission Date: [**2187-1-4**] Discharge Date: [**2187-1-11**]
Date of Birth: [**2136-8-7**] Sex: M
Service:
HISTORY OF THE PRESENT ILLNESS: The patient is a 50-year-old
male with a history of schizophrenia who had been residing at
a nursing home for several months. The patient was
recently transferred to [**Hospital3 **] Medical Center on
[**2186-11-29**] for laparoscopic cholecystectomy. The
cholecystectomy in addition to an umbilical hernia repair.
The patient's postoperative course was complicated by MRSA
bacteremia, likely secondary to central line infection, lower
extremity cellulitis, and respiratory insufficiency, likely
secondary to volume overload. The patient gradually improved
and eventually needed nocturnal BIPAP for presumed sleep
for infection.
The patient was transferred to back to the nursing home
for continued care and rehabilitation. On [**2186-12-25**],
the patient was found in bed, unable to breathe. He
was found to have a pulse and was mask ventilated and
eventually intubated. This intubation was done by an
in-house anesthesiologist and it was difficult. The etiology
of the respiratory failure was unclear. The initial chest
x-ray did not show any evidence of pneumonia. The patient
was ruled out for a myocardial infarction by serial cardiac
enzymes and serial EKGs. His troponin and enzymes were
negative, although the patient did have a very slight
increase in total CK and CK MB.
The patient is known to have baseline hypercarbia and
noncompliance with his BIPAP. Thus, the etiology of his
respiratory failure is complicated secondary to noncompliance
and the patient's limited respiratory reserve due to prior
right lung surgery and possible pneumonia.
On [**2186-12-22**], the chest x-ray showed increase in
consolidation of the right lung which indicated likely the
development of aspiration pneumonia shortly followed by a
febrile course. The patient was started on vancomycin and
Zosyn. The patient continued to be unable to wean off the
ventilator for over a week and specifically anticipated
length of stay on the ventilator for over two weeks. It was
felt that the patient would benefit from a tracheostomy.
The patient was transferred to [**Hospital3 **] to perform
percutaneous tracheostomy.
PAST MEDICAL HISTORY:
1. Insulin-dependent diabetes mellitus.
2. Hyperlipidemia.
3. Status post cholecystectomy.
4. MRSA-positive sputum at the catheter tip, likely cause of
sepsis.
5. Schizophrenia.
6. Depression.
7. Hypertension.
8. Cellulitis in the bilateral lower extremities.
9. Obstructive sleep apnea, on BIPAP at night on home 02.
10. Status post right lobectomy.
11. Status post thyroidectomy.
12. Thyroid CA.
13. Chronic renal failure.
MEDICATIONS ON TRANSFER:
1. Lasix.
2. Vancomycin.
3. Cefepime.
4. Ativan.
5. Zosyn.
6. Levothyroxine.
7. Combivent.
8. Fentanyl.
9. Heparin.
10. Insulin.
11. Lantus.
12. Protonix.
13. Toprol.
14. Olanzapine.
15. Neurontin.
16. Tylenol.
17. Calcium gluconate.
18. Gemfibrozil.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
98.4, pulse 89, blood pressure 116/63, respiratory rate 22,
95% on ventilator. General: In no apparent distress, alert
and awake. HEENT: The patient was intubated with NG tube in
place. Cardiovascular: Regular rate and rhythm. Normal S1
and S2. No murmurs. Lungs: On the right side, the patient
had scattered rhonchi. The left lung was fairly clear.
Abdomen: Obese, soft, nontender, normoactive bowel sounds.
Extremities: No clubbing, cyanosis or edema.
LABORATORY DATA UPON ADMISSION: White count 5.9, hematocrit
40.9, platelets 323,000. Sodium 151, potassium 4.3, chloride
107, hematocrit 32, BUN 38, creatinine 1.8, glucose 130.
Coagulations: PT 14.9, INR 1.5. Calcium 7.8, magnesium 2.5,
phosphorus 4.3.
The patient had lower extremity duplex studies which were
negative for DVT.
HOSPITAL COURSE: The patient was transferred on pressure
support 15 of 5, tidal volume of 520 at a rate of 16, FI02 of
50%. On [**2187-1-6**], the patient was extubated and
started on BIPAP. The patient continued to improve
remarkably well requiring BIPAP overnight and supplemental O2
during the day. The patient was continued on aggressive pulmonary
toilet and incentive spirometer.
The patient did very well on overnight BIPAP. Postextubation, the
patient received a
follow-up chest x-ray which showed a large right pleural
effusion additionally associated with associated air space
disease at the right lung base.
The patient was continued on a 14 day course of vancomycin
and Zosyn for the patient's pneumonia. The patient's BIPAP
settings were IPAP of 10 and EPAP of 5. The patient
continued to achieve respiratory saturations greater than
95%. The patient was able to ambulate without significant
desaturation on supplemental O2 and continued to improve and
additionally was
treated with Albuterol and Atrovent nebulizers q. six hours
p.r.n. The patient was deemed stable to transfer to the
floor on [**2187-1-6**].
While on the medical floor, the patient was continued with
BIPAP at night, achieving high 02 saturations. The patient
was continued on antibiotics. The patient's white count
continued to trend down. The patient remained afebrile
throughout the hospital course. The patient continued to
tolerate a regular diet. The patient received a PICC line
for continuation of his antibiotics as an outpatient
secondary to the patient's prior lung surgery and recent
pulmonary insult.
A Pulmonary consult was obtained to straighten out the
patient's outpatient pulmonary management and further because
the patient continued to require 02 via nasal cannula,
though he denied
shortness of breath or chest pain and only complained of an
occasional dry
cough. Pulmonary consultation recommended for further
evaluation as the patient was found to have a somewhat
elevated right hemidiaphragm, although this was not likely to
be secondary to decreased lung volume after the patient's
resection for germ cell tumor 20 years prior. Also
considered was possible diaphragmatic paralysis secondary to
phrenic nerve injury at the time of lung injury.
The patient received a repeat chest x-ray which had coarse
vascular markings and Kerley B lines, most suggestive of
congestive heart failure, resolving pneumonia should also be
considered but unlikely given the patient's regimen of
vancomycin and Zosyn.
Pulmonary consult recommended that the patient receive an
echocardiogram. The echocardiogram to evaluate for possible
CHF showed mild LVH with an ejection fraction greater than
55%, normal wall motion secondary to chest physical
examination findings. The patient was also started on p.o.
Lasix 20 mg q.a.m., 40 mg p.o. q.p.m. Also recommended was
that the patient receive a sniff test under fluoroscopy to
evaluate for plegic hemidiaphragm. The examination showed
normal movement of the left hemidiaphragm as expected. The
examination of the right hemidiaphragm, however, was somewhat
limited due to the patient's residual large right-sided
pleural effusion. It was commented that the likely decreased
movement from the right hemidiaphragm could be based on
blunted response to deep inspiration and expiration but the
presence of effusion makes the reaction significantly
difficult to accurately assess.
It was recommended that the patient's study be repeated if
clinically indicated after resolution of the right-sided
pleural effusion.
The patient's blood sugars were continuing to be elevated
while the patient was on the medical floor. The patient's
in-house attending revised diabetic management, switching the
patient's premeal scale to Humalog and starting the patient
on long-acting insulin Lantus at night. The patient's
fingersticks gradually improved until blood sugars were at
around 200.
Secondary to the patient's long-standing history of papillary
carcinoma, the patient was evaluated with a thyroid
ultrasound. The ultrasound showed no residual thyroid tissue
or nodules identified in the thyroid bed. No interval change
from the prior report. No lymphadenopathy in the visualized
portion of the anterior neck. The patient also had TSH drawn
which showed a value of 16, elevated TSH with the patient's
history of thyroid CA was not ideal. The patient's Synthroid
was increased from 150 to 175 to decrease thyroid
stimulation.
At the time of discharge, the patient was alert and oriented
with a good appetite, ambulating without difficulty, denying
chest pain or shortness of breath, under good glycemic
control, requiring BIPAP at night and 02 via nasal cannula
during the day. The patient was medically stable to be
discharged back to rehab.
DISCHARGE DIAGNOSIS:
1. Papillary carcinoma, status post thyroidectomy in [**2175**].
2. Paranoid schizophrenia.
3. Depression.
4. Hypercholesterolemia.
5. Hypertension.
6. Obstructive sleep apnea.
7. Insulin-dependent diabetes mellitus.
8. Status post cholecystectomy.
9. Methicillin-resistant Staphylococcus aureus bacteremia.
DISCHARGE MEDICATIONS:
1. Lorazepam 0.5 to 1 mg IV q. six hours p.r.n. agitation.
2. Zosyn 4.5 mg IV q. eight hours until [**2187-1-19**].
3. Ipratropium bromide nebulizer, one nebulizer every six
hours.
4. Albuterol nebulizer q. six hours p.r.n.
5. Olanzapine 5 mg p.o. q.d.
6. Docusate 100 mg p.o. b.i.d.
7. Neurontin 200 mg p.o. t.i.d.
8. Talopram hydrobromide 40 mg q.d.
9. Finasteride 5 mg p.o. q.d.
10. Lopressor 25 mg p.o. b.i.d.
11. Subcutaneous heparin 5,000 units subcutaneously q. eight
hours.
12. Epogen 6,000 units subcutaneously three times a week,
Monday, Wednesday, and Friday.
13. Protonix 40 mg p.o. q. 24 hours.
14. Acetaminophen 325 to 650 mg p.o. q. 4-6 hours p.r.n.
15. Long-acting insulin Lantus 14 units subcutaneously q.h.s.
16. Levothyroxine 175 micrograms p.o. q.d.
17. Lasix 20 mg p.o. q.a.m., 40 mg p.o. q.p.m.
18. Potassium chloride 20 mg p.o. q.d.
19. Sliding scale insulin as follows: Breakfast, lunch, and
dinner fingerstick 0-65, no units, amp of D50 or [**Location (un) 2452**]
juice, glucose 65-100 2 units of Humalog, 101-150 4 units
Humalog, 151-200 6 units Humalog, 201-250 8 units Humalog,
251-300 10 units of Humalog, 301-350 12 units Humalog,
351-400 14 units Humalog, greater than 400 16 units Humalog
and notify the house officer. Bedtime dosing of Humalog:
Glucose 0-50 0 units, amp of D50 or [**Location (un) 2452**] juice, notify
house officer, 51-100 0, 101-150 0, 151-200 0, 201-250 2
units, 251-300 4 units, 301-350 6 units, 351-400 8 units,
greater than 400 10 units and notify house officer.
FOLLOW-UP PLAN: The patient should see Dr. [**Last Name (STitle) **], the
patient's primary care physician at [**Hospital6 15291**] in one week. The patient should have a follow-up
appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], the patient's
endocrinologist at the [**Hospital **] Hospital, in one week. The
patient should have his TSH and free T4 and thyroglobulin
checked in one week. The patient should have
fluoroscopy-guided sniff test after the patient's pleural
effusion resolves. The patient should also call the
Pulmonary Center for a follow-up appointment for the
remainder of the patient's pulmonary tests. The patient
should call [**Telephone/Fax (1) **] to make an outpatient appointment. The
patient should be seen in two to three weeks.
Dictated By:[**Last Name (NamePattern1) 5924**]
MEDQUIST36
D: [**2187-1-11**] 04:17
T: [**2187-1-11**] 16:49
JOB#: [**Job Number 101305**]
Admission Date: [**2187-1-4**] Discharge Date: [**2187-1-15**]
Date of Birth: [**2136-8-7**] Sex: M
Service:
ADDENDUM: Prior to discharge, per Pulmonary consult
recommendations, the patient received lower extremity duplex
study of both lower extremities, the results of which were
normal compression and augmentation, no evidence of DVT in
either lower extremity.
The patient received a decubitus chest film to evaluate for
layering of fluid. Right side decubitus films showed free
pleural fluid. Impression: Large right-sided pleural
effusion without any evidence of left-sided effusion. No
evidence of empyema.
Given this finding, the patient was taken by Pulmonary for
thoracentesis, ultrasound-guided. On ultrasound, the patient
had inadequate fluid for successful thoracentesis. Thus,
this was not done. Subsequently, the Pulmonary consult
recommended that the patient receive CT angio to rule out
pulmonary embolism. CT of the chest with contrast showed no
left-sided pleural effusion, a small right-sided pleural
effusion, small focal consolidation in the right lower lobe,
no pneumothorax, no evidence of pulmonary embolism.
Conclusion: No evidence of PE, right lower lobe pneumonia
with small right-sided pleural effusion.
The patient also received pulmonary function tests. The
official results are pending at the time of discharge but
showed exceptionally poor restrictive lung disease with
severely reduced FVC, TLC, and DLCO. These results suggest
poor restrictive lung disease and perhaps additional
involvement of the pulmonary parenchyma or vascular
involvement.
DISCHARGE MEDICATIONS ADDENDUM:
1. Vancomycin 1 gram IV q. 24 hours.
2. Change the patient's long-acting insulin Lantus to 22
units subcutaneously q.h.s.
3. Sliding scale insulin should also be changed as follows:
Breakfast, lunch, and dinner with Humalog for the following
blood sugars; 0-65 no insulin, the patient may receive [**Location (un) 2452**]
juice or 1 amp of D50; 66-100 3 units Humalog; from 101-150 5
units; 151-200 7 units; 201-250 9 units; 251-300 11 units;
301-350 13 units; 351-400 15 units; greater than 400 17 units
Humalog and notify house officer. Bedtime Humalog: From
0-65 no insulin, [**Location (un) 2452**] juice or 1 amp D50; 66-200 nothing;
201-250 3 units Humalog; 251-300 5 units; 301-350 7 units;
351-400 9 units; greater than 400 11 units Humalog and notify
house officer.
4. Both Zosyn and vancomycin should be continued until
[**2187-1-19**].
ADDENDUM TO FOLLOW-UP PLAN: The patient would benefit from
outpatient sleep study to evaluate the presence of nocturnal
hypoxia and the patient's BIPAP requirement. The patient
should receive repeat echocardiogram with bubble study to
rule out shunt. The patient should receive repeat pulmonary
function tests after resolution of pleural effusion.
The patient should receive repeat chest CT in six weeks to
evaluate for resolving lung consolidation. The patient's
appointment with Pulmonary Service at [**Telephone/Fax (1) **] should be made
with Dr. [**Last Name (STitle) 575**] in two to three weeks.
DR.[**Last Name (STitle) 16895**],[**First Name3 (LF) **] 12-877
Dictated By:[**Last Name (NamePattern1) 5924**]
MEDQUIST36
D: [**2187-1-15**] 02:12
T: [**2187-1-15**] 14:18
JOB#: [**Job Number 37838**]
|
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48,040
| 134,187
|
40241
|
Discharge summary
|
report
|
Admission Date: [**2117-2-12**] Discharge Date: [**2117-2-19**]
Date of Birth: [**2057-4-20**] Sex: F
Service: MEDICINE
Allergies:
Latex
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Seizure, hyperglycemia
Major Surgical or Invasive Procedure:
Central line placement
History of Present Illness:
59yoF with h/o DM but not on medications, hypothyroidism,
Hyperlipidemia Coronary Artery Disease, and Hypertension
presented to OSH with Altered Mental Status and seizure found to
have HHS and transferred to [**Hospital1 18**] for further management. Per
the patient's daughter over the last few months the patient has
lost a lot of weight, not been able to go 5 mins without using
the bathroom, and has felt fatigued. she was started on a new
thyroid medication in the last few weeks. She was supposed to
see the doctor [**First Name (Titles) **] [**Last Name (Titles) 20212**] but postponed to today. However,
last night she was "not herself" but she said she was fine. This
morning her daughter still thought she was altered but the
patient insisted that she go to work this afternoon at 2pm. at
6:30 a police officer drove the patient home and reported that
she had driven her car into a pole, was confused but had refused
to go to the hospital. Then the patient went to her room and
fell asleep, while her dtr went to get the car (about 1 hour).
After this the daughter insisted they go to the hospital. On the
car ride she began losing consciousness and as they arrived to
the hospital had a seizure. (documented as GTC by OSH). REceived
ativan and dilantin. Head CT normal.
at OSH labs notable for glucose in 1400s and Na 139. ABG 7.19.
Then reportedly became apneic and was intubated at [**Hospital1 **]. Given
SC insulin and insulin gtt at 6 units /hr. Got 4L NS at OSH.
Never hemodynamically unstable
in the ED initial VS: T: AF, BP labile (80-90) when on propofol.
Received 2 more L NS. PCXR showed infiltrate RLL. Patient was
given CTX/VANC/FLAGYL, continue the insulin gtt. na 150 despite
the glucose coming down. VS on transfer: T: HR 80 BP 100/54 100%
on AC 420X26 FiO2100 Peep 5. on arrival to floor patient was
awake and fighting the tube. She was unable to answer questions.
her family was not available to ask historical questions.
ROS per daughter no fevers, viral symptoms, cough, sick
contacts. Losing her hair recently and PCP changed her thyroid
medication to treat it.
Past Medical History:
Diabetes mellitus not on medication
Hypertension
"Holes in her heart s/p surgery"
Hypothyroidism
Hyperlipidemia
Coronary Artery Disease
Social History:
Lives with her daughter, works as a home health aide.
Non-smoker, non-drinker.
Family History:
Mom with diabetes.
Physical Exam:
Admission:
VS: Temp:97 BP:153 /67 HR:99 RR: O2sat 92% on AC 420X16 peep 5
FIo2 100
GEN: Intubated sedated
HEENT: PERRL at 2mm, anicteric, MMM, no jvd, no carotid bruits,
no thyromegaly or thyroid nodules
RESP: crackles at the right base
CV: RR, S1 and S2 wnl, no m/r/g CVP 5
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice
NEURO: Intubated and sedated. Pupils 2mm and reactive. When
sedation off awake and fighting the tube
.
Discharge:
Vitals - Tm: 100.0 Tc:98.8 p:80 (72-97) bp:116/76
(108-118/68-74)rr20 98% RA.
GENERAL: elderly female appearing comfortable and in no acute
distress
HEENT: left trapezius tender and tense, no increased warmpth
CHEST: CTABL no wheezes, no rales, no ronchi
CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or
gallops
ABD: Overweight, non-distended, BS normoactive, soft, non-tender
EXT: no edema. RLE calf swelling, palpable cord posterior to
knee. Positive left sided homman's sign.
Pertinent Results:
Admission labs:
Labs at [**Hospital1 **]:
WBC 10.6, Hct 46, PLt 396
ABG: 7.19/61/175/23 on NRB
Na 139, K 6.2, Cl 97, CO2 22, Gluc 1432, BUN 62, Cr 1.8
Acetone positive
Alb 4.5
Tbili 1.6
Ca [**17**].1
ALT 87, AST 29
.
Labs at [**Hospital1 18**]:
ABG: 7.31 50 328 26 on 500X16, 100, 5
Na:154
K:5.0
Cl:116
Lactate:1.9
.
Na:150 Cl:109 BUN:55 GLUC:931 AGap=18
K:5.4 HCO3:23 Cr:1.6
Ca: 11.1 Mg: 3.7 P: 4.2
ALT: 39 AP: 88 Tbili: 0.5
AST: 31 Lip: 124
WBC: 10.9 Hgb:15.1 PLT:374 Hct:46.9
N:84.2 L:10.6 M:4.2 E:0 Bas:1.1
.
[**2117-2-12**] 12:15AM BLOOD ALT-39 AST-31 AlkPhos-88 TotBili-0.5
[**2117-2-13**] 10:11PM BLOOD %HbA1c-19.4* eAG-510*
[**2117-2-14**] 05:59AM BLOOD Triglyc-278* HDL-45 CHOL/HD-3.8
LDLcalc-71
[**2117-2-12**] 03:48AM BLOOD TSH-4.7*
.
DISCHARGE:
[**2117-2-19**] 06:10AM BLOOD WBC-7.8 RBC-3.09* Hgb-9.9* Hct-29.0*
MCV-94 MCH-31.9 MCHC-34.0 RDW-15.9* Plt Ct-288
[**2117-2-19**] 06:10AM BLOOD PT-13.4 PTT-26.6 INR(PT)-1.1
[**2117-2-19**] 06:10AM BLOOD Glucose-99 UreaN-7 Creat-0.7 Na-139 K-4.0
Cl-107 HCO3-26 AnGap-10
[**2117-2-19**] 06:10AM BLOOD Calcium-8.3* Phos-3.5 Mg-2.3
.
.
MICRO
[**2117-2-16**] Urine culture Negative final
[**2117-2-16**] catheter tip Negative final
[**2117-2-15**] Blood Culture Negative final
[**2117-2-15**] Blood Culture Negative final
[**2117-2-14**] Urine culture Negative final
[**2117-2-13**] Blood Culture Negative final
[**2117-2-13**] Blood Culture Negative final
[**2117-2-12**] Blood Culture Negative final
[**2117-2-12**] Blood Culture Negative final
.
Imaging:
Lower ext dopplers [**2117-2-17**]
FINDINGS: Waveforms in the common femoral veins are symmetric
bilaterally with appropriate response to Valsalva maneuvers. In
the right lower extremity, the common femoral, proximal and mid
superficial femoral veins as well as proximal greater saphenous
are all normal with appropriate compressibility, and
wall-to-wall flow on color analysis. There is
non-compressibility of the distal portion of the superficial
femoral vein as well as of the popliteal vein, with absent flow
on color Doppler analysis, related to deep venous thrombosis in
those locations. Wall-to-wall flow and compressibility is noted
in the posterior tibial and peroneal veins in the right calf.
.
In the left lower extremity, the common femoral, proximal
greater saphenous, superficial femoral and popliteal veins are
normal with appropriate compressibility, wall-to-wall flow on
color analysis and response to waveform augmentation.
Wall-to-wall flow is also seen in the posterior tibial and
peroneal veins in the left calf.
.
IMPRESSION: Right popliteal and distal superficial femoral vein
thrombosis.
.
CXR [**2117-2-13**]
Moderate left pleural effusion has increased and left lower lobe
atelectasis or consolidation has improved. Right lung is grossly
clear. The heart is severely enlarged and dilated pulmonary
arteries are an indication of pulmonary arterial hypertension.
Right jugular line ends in the SVC. No pneumothorax.
.
ECHO [**2117-2-16**]
The left atrium is elongated. The right atrium is moderately
dilated. There is mild symmetric left ventricular hypertrophy
with normal cavity size and regional/global systolic function
(LVEF>55%). The right ventricular cavity is mildly dilated with
borderline normal free wall function. The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are mildly thickened. Moderate [2+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is a very small pericardial effusion.
.
[**2117-2-12**] 6:12 AM
Nasogastric tube has been advanced into the stomach which is
somewhat less
distended with gas, and out of view. Left lower lobe atelectasis
is worsened, right atelectasis improved. Upper lungs clear.
Borderline cardiomegaly stable. Probable pulmonary hypertension.
Upper lungs clear. Right jugular line ends in the mid to low
SVC. No pneumothorax.
.
[**2-13**]: left pleural effusion, likely pulm arterial hypertension
.
CT Head from [**Hospital1 **]: Diffuse cerbral atrophy appropriate for
patient's age, right nasal ganglia calicifactions, no cerebral
ischemia, no ICH, No mass.
.
CT C Spine: No acute fracture or malalignment. degenerative
changes C5-C7.
Brief Hospital Course:
59 yo female with h/o DM admitted with HHS and seizure.
.
# Hyper osmolar hyperglucemic state: The patient has a history
of an elevated BS in clinic a year ago which per her daughter
resolved without treatment. She had not been on medications for
diabetes. Per her daughter she had symptoms of polyuria and
weight loss for several months prior to presentation suggestive
of hyperglycemia. Prior to admission at [**Hospital1 18**], patient was
intubated for airway protection. She was started on an insulin
gtt in the ED which was uptitrated according to [**Last Name (un) **] protocol.
While in the ICU, she was promptly extubated and treated with
insulin drip and IVNS. Her hypokalemia and fluid deficit where
repleted with frequent monitoring. She was started on a D5 gtt
once her BS became <200 to maintain BS 200-300. After a two
admission to the ICU, patient was called out to the general
medical floor.
.
Regarding cause of HHS, most likely this was a slowly developing
hyperglycemia in the setting of uncontrolled diabetes. No
underlying infection or acute insult was detected. Blood and
urine cultures were sent and are pending. CXR did show an
infiltrate which was consitent with aspiration, and per her
daughter she had no clinical symptoms pointing towards PNA.
# Diabetes Mellitus: Ha1C is 19. After admission to general
medical floor from ICU, she was stabalized on an insulin regimen
consisting of glargine at bedtime and prandial humalog with
correction factor. She was given diabetes teaching with the
staff Hatian Creole interpreter and was able to draw up insulin
and administer it without difficulty. She is believed to have
Flatbush diabetes and will need to be on insulin in the acute
phase but may be able to transition to oral agents after two
months. It is recommended that C-peptide be checked in two
months time to determine native insulin production and guide
decision to begin oral hypoglycemics. She was discharged with a
plan for outpatient follow up with the [**Hospital **] clinic.
.
# Respiratory: Patient was intubated secondary to change in
mental status due to her seizure for airway protection. On CXR
has evidence of aspiration with right hilar fluffy infiltrate,
however per her daughter she had no clinical history of
pneumonia prior to her acute event. She remained intubated
overnight and the morning of [**2-12**] her sedation was weaned and she
was successfully extubated. She was initially treated with
vanc, ceftriaxone, and flagyl for a persumed aspiration PNA and
these were continued in the setting of her transient
hypotension. However following extubation, she was without a
leukocytosis or fever and was normotensive once her sedation was
weaned so antibiotics were stopped after extubation on [**2-12**].
.
# Deep vein thrombosis: Beginning HD 4, patient had recurrent
low grade fevers. Infectious work up including CXR, UA and Urine
culture, Blood culture, central line tip culture were all
negative. Lower extremity doplers showed right lower extremity
DVT and patient was started on Enoxaparin and warfarin. Deep
vein thrombosis was explained to patient using the staff Hatian
Creole interpreter and she stated understanding of DVT, risk of
pulmonary embolism and importance of anticoagulation and
frequent INR checks. She was taught how to administer
enoxaparin. She will need to continue enoxaparin until INR is
[**3-11**], and will need to continue warfarin x 3 months, final day
[**2117-5-13**]. She was discharged with a plan for outpatient follow
up in three days and INR checks.
.
# Hypernatremia: Likely in the setting of dehydration from
severe hyperglycemia and corrected is actually higher (164). [**Month (only) 116**]
be reason for seizure as well. Initially worsened from
admission due to decrease in serum glucose. Hypernatremia was
corrected slowly in in the ICU with D5 1/2NS and D5 to decrease
the risk of cerebral edema. On transfer to the general medical
floor, her sodium had corrected.
.
# Seizure: Likely from hypernatremia/hyperosmolar state. No
reoccurance of seizure in the ICU or for remainder of hospital
stay.
.
# Acute Kidney Injury: Unknown baseline. Patient with Cr of 1.6
on admission. Trended down to 1.0 with volume resuscitation.
Likely secondary to prerenal/volume depleption.
.
# Hypercalcemia: Mild and in setting of acute illness and
hyperosmolar state creating intravascular free water depletion.
Normalized with volume resuscitation.
.
# Transient Hypotension: Thought to be related to sedation with
propofol. Resolved with weaning sedation and extubation.
.
# Hypothyroidism: dose is confirmed with PCP as new dose.
.
Comm: with patient and family [**Name (NI) 88336**] [**Telephone/Fax (1) 88337**]
Code: Full
Medications on Admission:
Lasix 20 mg po daily
Fosinopril 40 mg po daily
Levothyroxine 0.1 mg po daily
Lovastatin 20 mg po daily
Flucinonide cream 0.05%
Discharge Medications:
1. enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg Subcutaneous
Q12H (every 12 hours) for 7 days.
Disp:*1260 mg* Refills:*0*
2. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. lovastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day:
Your doctor may adjust this based on your blood tests.
Disp:*60 Tablet(s)* Refills:*0*
6. insulin glargine 100 unit/mL Solution Sig: Thirty Five (35)
units Subcutaneous at bedtime.
Disp:*1 bottle* Refills:*0*
7. Humalog 100 unit/mL Solution Sig: Per instructions below
units Subcutaneous three times a day: 14 units with breakfast
12 units with lunch
12 units with dinner
.
Disp:*1 bottle* Refills:*0*
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
9. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. FreeStyle Lite Meter Kit Sig: One (1) Miscellaneous
four times a day.
Disp:*1 kit* Refills:*2*
11. FreeStyle Lite Strips Strip Sig: One (1) strip
Miscellaneous four times a day for 14 days.
Disp:*56 strips* Refills:*0*
12. syringe (disposable) Syringe Sig: 0.5 cc Miscellaneous
five times a day: [**6-21**]" 31 guage.
Disp:*120 syringes* Refills:*0*
13. lancets Misc Sig: One (1) lancet Miscellaneous four
times a day.
Disp:*120 lancets* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary
Diabetes Mellitus
.
Secondary
Hyperosmolar Hyperglycemic state
Seizure
Deep vein thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms [**Known lastname 88338**],
It was a pleasure taking care of you in your hospital stay at
[**Hospital1 **]. As you know, you had very high blood
sugars, confusion and seizures. You were admitted to the
intensive care unit where you were briefly on a ventilator to
help you breath. We treated your high sugars with insulin and
will be giving you insulin prescriptions to help you control
your sugars at home.
.
You also developed a blood clot in your leg, a deep vein
thrombosis. You will need to thin your blood with injections of
lovenox and pills of coumadin. You will need to have your
coumadin level checked frequently by your primary care provider.
[**Name10 (NameIs) 357**] continue to take both of these medications until your
primary care privider tells you to stop.
.
New medications
Coumadin 10mg by mouth Daily for blood thinning
Lovenox 90mg subcutenously twice a day for blood thinning
Humalog Insulin 12 Units with lunch and dinner
Humalog Insulin 14 Units with breakfast
Glargine insulin 35 Units at bedtime
Followup Instructions:
Please make an appointment to
.
Name: [**Last Name (LF) **],[**First Name3 (LF) **] C
Address: [**Street Address(2) 88339**], [**Location (un) **],[**Numeric Identifier 38978**]
Phone: [**Telephone/Fax (1) 88340**]
Appointment: Monday [**2-22**] 2PM.
**You can walk in to see your doctor between the hours of
2PM-6PM.**
Please bring in your discharge summary to this appointment for
Dr. [**First Name (STitle) **] to review. Thanks.
.
Name: [**Last Name (LF) **], [**Name8 (MD) 32440**] MD
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
Appointment: Tuesday [**2-23**] at 9AM
Please call MassHealth insurance as soon as possible to choose
your plan. Their number is [**Telephone/Fax (1) 88341**]. If you do not fix your
insurance, this appointment will be self pay.
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,405
| 176,527
|
53718
|
Discharge summary
|
report
|
Admission Date: [**2123-9-20**] Discharge Date: [**2123-9-27**]
Date of Birth: [**2079-11-21**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / morphine / cefepime
Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
admit for scheduled chemothearpy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
43yo gentleman with AML here for scheduled admission for cycle 3
HiDAC. Patient has AML-M5a diagnosed [**2123-4-25**] when he
presented with septic arthritis of the right knee and dental
infections. He was found to have clonal loss of Y (usually
considered a favorable cytogenetic finding) and no other
cytogenitic abnormalities (NPM neg, FLT3 Neg) and was treated
with 7+3 daunorubicin (90mg/m2) and cytarabine (100mg/m2/d x
7dCI) on [**5-14**]. Induction was complicated by multifocal PNA
and effusive and constrictive inflammatory pericarditis. Day 30
marrow was negative for disease and he was started on
consolidation with HiDAC on [**2123-6-25**]. This was complicated
by a morbilliform rash and there was some thought that this was
due to cytarabine and the dose was reduced on days 3 and 5 to 2
g/m2. Cycle 2 of High DAC was at full dose (3gm/m2 Q12 day 1,3,5
) he had a minor rash but otherwise tolerated it well with a
brief admission during his nadir for neutropenic malaise and
chills at home (no temperature recorded). He was treated with
broad spectrum antibiotics until his counts recovered and he was
discharged home.
Vitals on arrival: T97.6, BP 130/84, HR 97, RR 18, 100%RA
Currently patient feels well, reports that his energy level is
much improved from when he was discharged [**2123-9-5**]. He complains
of mild constipation, denies fevers, chills, sweats or malaise.
ROS: per HPI, denies headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, diarrhea, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
AML s/p induction with Ara-c/[**Doctor First Name **] and C2 of HiDAC
GERD
Right meniscal tear, s/p right knee arthroscopy, meniscectomy,
and synovectomy [**2123-5-7**]
Recent jaw infection ([**11/2122**])
Social History:
Lives at home with wife and daughter. [**Name (NI) 1403**] as parts manager.
- Tobacco: Quit [**Month (only) 404**]. Previously smoked [**1-25**] PPD since
childhood.
- Alcohol: Rare use (less than once per month).
- Illicits: Remote history of marijuana use. No IVDU.
Family History:
Mother deceased from metastatic breast cancer. Uncle deceased
from lung cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - T97.6, BP 130/84, HR 97, RR 18, 100%RA
GENERAL - male in NAD appears older than chronologic age
HEENT - NC/AT, PERRL, EOMI, L eye strabismus, sclerae anicteric,
MMM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - Lungs are clear to ausculatation bilaterally, moving air
well and symmetrically, resp unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, S1-S2 clear and of good quality
without murmurs, rubs or gallops
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs); knees without effusion or tenderness, full ROM bilaterally
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-29**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric
DISCHARGE PHYSICAL EXAM:
T 97.6 BP 124/70 P 102 RR 18 100%RA
GENERAL - male in NAD appears lying in bed, appear tired
HEENT - NC/AT, PERRL, EOMI, anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - lungs CTAB moving air well.
HEART - nl S1 S2 no m/r/g
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs); knees without effusion or tenderness, full ROM bilaterally
Skin- no rash or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
ADMISSION LABS:
[**2123-9-20**] 10:35AM BLOOD WBC-6.9 RBC-2.91* Hgb-9.4* Hct-26.6*
MCV-91 MCH-32.4* MCHC-35.4* RDW-20.1* Plt Ct-115*
[**2123-9-20**] 10:35AM BLOOD Neuts-64.5 Lymphs-17.6* Monos-14.5*
Eos-2.5 Baso-0.8
[**2123-9-20**] 10:35AM BLOOD UreaN-11 Creat-1.2
[**2123-9-20**] 10:35AM BLOOD ALT-20 AST-17 LD(LDH)-184 AlkPhos-64
TotBili-0.3
RELEVANT LABS:
Coritsol stimulation test
[**2123-9-22**] 04:29AM BLOOD Cortsol-1.1*
[**2123-9-23**] 05:45AM BLOOD Cortsol-1.0*
[**2123-9-23**] 07:00AM BLOOD Cortsol-11.9
[**2123-9-23**] 07:22AM BLOOD Cortsol-15.9
-----------
[**2123-9-25**] 01:45PM BLOOD Cortsol-3.4
[**2123-9-25**] 02:30PM BLOOD Cortsol-13.6
[**2123-9-25**] 03:00PM BLOOD Cortsol-17.5
-----------
[**2123-9-22**] 05:08AM BLOOD Lactate-3.1*
[**2123-9-22**] 10:10AM BLOOD Lactate-1.5
[**2123-9-22**] 05:30PM BLOOD Lactate-1.7
[**2123-9-22**] 09:50PM BLOOD Lactate-1.5
---------------
DISCHARGE LABS:
[**2123-9-27**] 06:35AM BLOOD WBC-4.8 RBC-3.17* Hgb-10.3* Hct-28.3*
MCV-89 MCH-32.4* MCHC-36.3* RDW-17.6* Plt Ct-44*
[**2123-9-27**] 06:35AM BLOOD Neuts-44* Bands-1 Lymphs-24 Monos-11
Eos-20* Baso-0 Atyps-0 Metas-0 Myelos-0
[**2123-9-27**] 06:35AM BLOOD Glucose-81 UreaN-15 Creat-0.9 Na-140
K-3.6 Cl-102 HCO3-31 AnGap-11
[**2123-9-27**] 06:35AM BLOOD ALT-12 AST-11 LD(LDH)-163 AlkPhos-42
TotBili-0.4
[**2123-9-27**] 06:35AM BLOOD Calcium-9.4 Phos-4.2 Mg-2.0
---------------
PERTINENT IMAGING:
[**2123-9-22**] CT abomen/pelvis
TYPE OF THE EXAM: CT of the abdomen and pelvis.
TECHNIQUE: Multiple axial slices were obtained within the
abdomen and pelvis after administration of intravenous contrast
and ingestion of oral contrast. Coronal and sagittal
reconstructions were obtained.
REASON FOR THE EXAM: 43-year-old man with AML, now with fever,
rigors,
hypertension and abdominal pain. Please evaluate for acute
intra-abdominal process.
COMPARISON STUDIES: CT of the abdomen and pelvis, performed on
[**2123-8-28**].
FINDINGS: Imaged through the lung bases demonstrate presence of
bilateral
pleural effusions, tiny, however, new compared to the prior
study. There are hypoventilatory changes to the lung bases.
Partially seen a central venous catheter that terminates within
the right atrium. There is no cardiomegaly. There is no
pericardial effusion.
ABDOMEN: Liver enhances homogeneously with no evidence of focal
masses.
There is no intrahepatic biliary dilatation. Gallbladder is
normal in
appearance with no evidence of focal masses or pericholecystic
fluid. Common bile duct is normal in size. Spleen, pancreas
and bilateral adrenals are normal in appearance. Both kidneys
enhance and secrete normally with no evidence of suspicious
masses, hydronephrosis, nephrolithiasis or urinary obstruction.
Again seen multiple small mesenteric lymph nodes within the mid
abdomen with some stranding of the mesentery, unchanged from the
prior study. There is some new mucosal enhancement within the
cecum and ascending colon with no significant wall thickening.
No significant pericolonic inflammatory stranding is seen.
There is no evidence of abscess or perforation.
PELVIS: The urinary bladder contains a Foley catheter and is
collapsed. The prostate gland is normal in size. There is
minimal amount of fluid within the dependent pelvis. No
evidence of lymphadenopathy. Rectum, sigmoid, descending,
ascending and transverse colon are unremarkable in appearance.
OSSEOUS STRUCTURES: No evidence of destructive lytic lesions.
There is no evidence of blastic metastasis.
IMPRESSION:
1. Minimal mucosal enhancement within the cecum and ascending
colon, new from the prior study, which may represent a
mild/developing typhlitis. There is no pericolonic stranding or
abscess. There are no signs of perforation.
2. Unchanged appearance of fat stranding and small multiple
nodules within the mid mesentery compared to the prior study,
which may represent mesenteric panniculitis.
PERTINENT MICRO:
Blood Culture, Routine (Final [**2123-9-27**]): NO GROWTH.
Blood Culture, Routine (Final [**2123-9-27**]): NO GROWTH.
MRSA SCREEN (Final [**2123-9-24**]): No MRSA isolated.
URINE CULTURE (Final [**2123-9-23**]): NO GROWTH.
PICC WOUND CULTURE (Final [**2123-9-25**]): No significant growth.
C. difficile DNA amplification assay (Final [**2123-9-27**]): Negative
for toxigenic C. difficile by the Illumigene DNA amplification
assay.
Brief Hospital Course:
43M with AML-M5a admitted for scheduled cycle 3 HiDAC
consolidation chemotherapy who was transferred to the [**Hospital Unit Name 153**] of
Day2 for hypotension, fever tachycardia,
# Acute myelogenous leukemia (monocytic): AML-M5a diagnosed
[**2123-4-25**] when he presented with septic arthritis of the right
knee and dental infections. Clonal loss of Y and no other
cytogenitic abnormalities (NPM neg, FLT3 Neg). Had 7+3 dauno and
cytarabine induction, and initiated cycle 3 HiDAC this admission
with the following. Course complicated by [**Hospital Unit Name 153**] transfer for
fever, hypotension, and tachycardia ? sepsis from developing
typhilits ( see below) and diffuse macular puritic rash most
likely secondary to cytarabine ( see below). Given complicated
course this admission, cycle 3 was discontinued. The patient
will follow up with outpatient oncologist Dr. [**Last Name (STitle) 410**] to discuss
further chemotherapy course.
# Sepsis- The patient was transferred to the [**Hospital Unit Name 153**] on [**2123-9-22**] (
day 2 of his HiDAC) with hypotension ( SBPs as low as 70s),
fever 101.6, and tachycardic to the 140s, with associated
rigors. WBC was 13.2 and lactate 3.1 He received agressive
fluid resuscitation. His pressures were stabilized in the [**Hospital Unit Name 153**]
after 13 L IVFs, and did not require pressors. A CT
abdomen/pelvis from [**9-22**] was signficant for mild/developing
typhilitis as the possible infectious source. His PICC was
removed given concern for possible line infection, the tip was
sent for culture, and was ultimately negative. Blood and urine
cultures were negative as well. He was started on Vancomycin,
and Meropenem, remained afebrile, hemodynamically stable, and
transferred back to the floor on [**2123-9-23**]. His Vancomycin was
discontinued on [**9-25**] and Meropenem was discontinued on [**9-26**]. The
patient was transitoned to PO ciprofloxacin and flagyl for
treatment of typhilitis for which he will complete a 5 day
course. During the work up of his hypotension in the [**Hospital Unit Name 153**] the
patient was evaluted for adrenal insufficency. He had a cortisol
stimulation test on [**9-23**] with a borderline suboptimal response,
and low baseline cortisol, and was started on stress dose
steroids. On transfer to the floor the patient was formally
evaluated by endocrine, who recommended a repeat cortisol
stimulation test, since the patient had received dexamethasone
prior to the first test. His stress dose steroid were also
discontinued and a repeat cortisol stimulation test was done
24hours after the patient's last stress dose steroids. The
repeat cortisol stimulation test on [**2123-9-25**] was normal, making
adrenal insufficiency an unlikely cause of the patient's
hypotensive episode.
#Rash: The patient had puritic, diffuse, macular rash, after his
third dose of HiDAC. Of note the patient did not receive
dexamethasone prior to this dose. The rash was most likely a
reaction to the cytarabine, as the patient reported similar
reactions in the past while receiving cytarabine. The patient
used topical triamcinolone cream and diphehydramine PRN and the
rash ultimately resolved prior to discharge
-----------
CHRONIC STABLE ISSUES
#Anal fissure: Improved per patient, no signs of fissure or
peri-rectal abscess on exam. continued with bowel regimen
# Chronic knee pain: Patient had intermittent worsening of
chronic knee pain but symptoms and physical exam were not
concerning for septic joint. Continued home oxycodone as needed.
# GERD: continued PPI.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Docusate Sodium 100 mg PO TID
2. Lorazepam 0.5 mg PO Q6H:PRN nausea
3. Ondansetron 8 mg PO Q8H:PRN nausea
4. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
5. Pantoprazole 40 mg PO Q12H
6. Senna 2 TAB PO BID
7. DimenhyDRINATE 50 mg PO Q6H:PRN nausea
8. lidocaine-hyalur ac-aloe-[**Last Name (un) **] *NF* 2 %-4 Topical TID:PRN
mouth pain
9. Oxycodone SR (OxyconTIN) 10 mg PO HS
10. Potassium Chloride 20 mEq PO BID
11. Prochlorperazine 10 mg PO Q6H:PRN nausea
12. Lidocaine 5% Ointment 1 Appl TP PRN bowel movement
apply small amount externally to affected area prior to bowel
movement
13. Acyclovir 400 mg PO Q8H
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. Docusate Sodium 100 mg PO TID
3. Lorazepam 0.5 mg PO Q6H:PRN nausea
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
6. Oxycodone SR (OxyconTIN) 10 mg PO HS
7. Pantoprazole 40 mg PO Q12H
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Potassium Chloride 20 mEq PO BID
10. Senna 2 TAB PO BID
11. DimenhyDRINATE 50 mg PO Q6H:PRN nausea
12. Lidocaine 5% Ointment 1 Appl TP PRN bowel movement
apply small amount externally to affected area prior to bowel
movement
13. lidocaine-hyalur ac-aloe-[**Last Name (un) **] *NF* 2 %-4 Topical TID:PRN
mouth pain
14. Prochlorperazine 10 mg PO Q6H:PRN nausea
15. Ciprofloxacin HCl 500 mg PO Q12H
total course of 5 days
(last day [**10-1**])
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth 12h Disp
#*8 Tablet Refills:*0
16. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
total course of 5 days
(last day [**10-1**])
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth 8H Disp
#*12 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: acute myelogenous leukemia
Secondary:
gastroesophageal reflux disease
chronic knee pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory
Discharge Instructions:
Dear Mr. [**Known lastname 284**],
It was a pleasure taking part in your care during your
hospitalization at [**Hospital1 18**]. You were admitted for scheduled
chemotherapy for your acute myelogenous leukemia. On day 2 of
your chemotherpay you had low blood pressure, fever, and a fast
heart rate concerning for an infection (sepsis). You were
transferred to the ICU, started on antibiotics, and given a lot
of IV fluids to help increase your blood pressure. A CT scan was
done, which showed a developing infection in your bowel (
typhilitis), for which you will need 5 days of antibiotics. You
also had a rash, which was most likley from the cytarabine, and
has resolved on discharge.You were unable to complete your third
cycle of chemotherapy, and will need to follow up with your
primary oncologist Dr. [**Last Name (STitle) 410**] to discuss your treatment plan.
Followup Instructions:
You should receive a call from Dr.[**Name (NI) 3588**] office to schedule a
follow up appointment. If you do not receive a call by
Wednesday, please call the office to schedule an appointment.
#[**Telephone/Fax (1) 3237**]
|
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"427.89",
"287.5",
"557.0",
"693.0",
"530.81",
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"038.9",
"565.0"
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
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] |
icd9pcs
|
[
[
[]
]
] |
13817, 13823
|
8371, 11937
|
328, 335
|
13965, 13965
|
3967, 3967
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3436, 3948
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