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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
21,049
| 184,833
|
28170
|
Discharge summary
|
report
|
Admission Date: [**2199-9-11**] Discharge Date: [**2199-9-27**]
Date of Birth: [**2125-7-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Tape / Benadryl
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Chest discomfort
Major Surgical or Invasive Procedure:
[**2199-9-13**] Left Carotid Stenting
[**2199-9-16**] Coronary Artery Bypass Graft x 2 (Lima to LAD, SVG to
OM)
History of Present Illness:
Ms. [**Known lastname 1511**] is a 74 y/o female admitted to outside hospital on
[**2199-9-4**] with chest discomfort, vomiting and shortness of
breath. Initial EKG showed ST depressions, but cardiac enzymes
were not elevated. She eventually underwent a cardiac cath to
assess coronary disease which revealed three vessel coronary
artery disease. She was then transferred to [**Hospital1 18**] for surgical
intervention.
Past Medical History:
Coronary Artery Disease, Hypertension, Hyperlipidemia, Diabetes
Mellitus, Hypothyroid, h/o Bilateral DVT's (on chronic coumadin
therapy), Pleural disorder ?Sarcoidosis, Gastritis, B12
deficiency, Chronic renal insufficiency, s/p Appendectomy, s/p
Lap cholectomy, s/p Total abdominal hysterectomy
Social History:
Denies tobacco or ETOH use. Lives wth husband.
Family History:
Mother died of MI at age 55. Brother w/ CAD since age 40 and
died in 70's after cardiac surgery. Son died at 14 d/t ASD.
Physical Exam:
Gen: NAD
Neck: Supple, -JVD, -Bruits
Heart: RRR -c/r/m/g
Lungs: CTAB, coarse
Abd: Soft, NT/NT +BS
Ext: Cool, 1+ pedal pulses, -varicosities, -edema
Neuro: A&O x 3, MAE, non-focal
Some rashes on ACW around EKG leads
Pertinent Results:
CNIS [**9-12**]: 1. 60-69% stenosis of the right internal carotid
artery. 2. 80-99% stenosis of the left internal carotid artery.
Echo [**9-16**]: PRE-BYPASS: Left ventricular wall thickness, cavity
size, and systolic function are normal (LVEF>55%). Resting
regional wall motion abnormalities include mild apical
hypokinesis. The aortic valve leaflets(3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There are complex (>4mm) atheroma in the
descending thoracic aorta. Mild tricuspid regurgitation.
POST-BYPASS: Preserved [**Hospital1 **]-ventricular systolic fxn. Trivial MR.
[**Name13 (STitle) **] AI. Aorta intact.
CT [**9-18**]: No acute intracranial hemorrhage. Findings consistent
with small vessel ischemic changes. MRI would be more sensitive
for the detection of acute infarction. CT angiogram demonstrates
no stenosis or aneurysm in the intracranial circulation. Slight
irregularity of the origin of the right vertebral artery may be
atherosclerotic in nature. Normal contrast enhancement seen in
the left common/internal carotid artery stent. Mild stenosis of
the proximal right internal carotid artery. 4 mm left upper lobe
lung nodule. In the absence of history of malignancy, this is
statistically benign. One-year followup may be considered.
CXR [**9-20**]: Allowing for technical changes, no major adverse
interval change has occurred. Bibasilar subsegmental atelectasis
together with bilateral pleural effusions appear relatively
unchanged. The mediastinum appears unchanged. Left-sided
subclavian line is unchanged in position. There is evidence of
prior cardiac surgery.
[**2199-9-27**] 06:15AM BLOOD WBC-8.8 RBC-2.79* Hgb-8.6* Hct-25.4*
MCV-91 MCH-30.9 MCHC-33.8 RDW-15.6* Plt Ct-583*
[**2199-9-26**] 06:00AM BLOOD WBC-7.7 RBC-2.73* Hgb-8.3* Hct-25.1*
MCV-92 MCH-30.4 MCHC-33.1 RDW-15.5 Plt Ct-528*
[**2199-9-27**] 06:15AM BLOOD Plt Ct-583*
[**2199-9-27**] 06:15AM BLOOD PT-18.0* PTT-62.3* INR(PT)-1.7*
[**2199-9-26**] 06:00AM BLOOD PT-15.5* PTT-62.4* INR(PT)-1.4*
[**2199-9-25**] 05:45AM BLOOD PT-14.5* PTT-51.4* INR(PT)-1.3*
[**2199-9-27**] 06:15AM BLOOD Glucose-96 UreaN-20 Creat-1.6* Na-141
K-4.3 Cl-106 HCO3-24 AnGap-15
[**2199-9-26**] 06:00AM BLOOD Glucose-85 UreaN-19 Creat-1.6* Na-140
K-4.4 Cl-105 HCO3-24 AnGap-15
[**2199-9-25**] 05:45AM BLOOD Creat-1.6* K-4.7
[**2199-9-11**] 03:30PM BLOOD Glucose-98 UreaN-26* Creat-1.6* Na-140
K-4.6 Cl-104 HCO3-27 AnGap-14
Brief Hospital Course:
Ms. [**Known lastname 1511**] was admitted from OSH for coronary artery bypass
surgery. She underwent usual pre-operative testing along with
carotid ultrasound. CNIS revealed carotid stenosis and she
ultimately underwent left carotid stenting by vascular surgery
on [**9-13**]. Please see report for details. On [**9-16**] she was
brought to the operating room where she underwent a coronary
artery bypass graft x 2. Please see operative report for
surgical details. She tolerated the procedure well and was
transferred to the CSRU for invasive monitoring in stable
condition. Later on op day sedation was weaned, she awoke
neurologically intact and was extubated. On post-op day one
chest tubes were removed and beta blockers and diuretics were
initiated. She was gently diuresed towards her pre-op weight.
Also on this day she was transferred to the SDU. Early on
post-op day two Ms. [**Known lastname 1511**] had an episode of aphasia. She
underwent an immediate head CT and Neuro consult and was
transferred back to the CSRU. CT was negative and she returned
to baseline neuro status without deficits by arrival to CSRU.
Neurology concluded episode was most concerning for TIA.
Epicardial pacing wires were removed on post-op day four. After
remaining stable in the CSRU for several days without change in
neuro status she was transferred back to the SDU on post-op day
four. She was then started on Heparin with transition to
Coumadin (goal INR of [**12-21**] secondary to h/o bilateral DVT's).
During entire post-op course she was followed by physical
therapy for strength and mobility. She continued to improve
steadily over the next several days without any other post-op
complications. She was discharged on post-op day 11.
Medications on Admission:
Meds at home: Coumadin, Levoxyl, Folate, Colace, Byetta,
Verapamil, Lisinopril, Pravachol, Nexium, Lasix, Celexa
Meds at transfer: Levoxyl, Celexa, Folate, Lopressor, Colace,
RISS, B12, Protonix, Lasix, Zocor, Verapamil, Lovenox,
Lisinopril
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. 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*
3. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*30 Capsule(s)* Refills:*0*
12. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day:
Check INR [**9-29**] with results called to Dr. [**First Name (STitle) **].
Disp:*30 Tablet(s)* Refills:*0*
13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
14. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: 40 mg
daily x 1 week then 40 mg every other day as prior to surgery.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 2
Post-operative Transient Ischemic Attack
Carotid Stenosis s/p Left Carotid Stenting
PMH: Hypertension, Hyperlipidemia, Diabetes Mellitus,
Hypothyroid, h/o Bilateral DVT's, Pleural disorder ?Sarcoidosis,
Gastritis, B12 deficiency, Chronic renal insufficiency, s/p
Appendectomy, s/p Lap cholectomy, s/p Total abdominal
hysterectomy
Discharge Condition:
good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] in 4 weeks
Dr [**Last Name (STitle) 1655**] in [**12-21**] weeks
Dr. [**First Name (STitle) **] in [**11-19**] weeks
Completed by:[**2199-9-27**]
|
[
"593.9",
"745.5",
"458.29",
"285.9",
"272.4",
"435.9",
"414.01",
"276.52",
"250.00",
"433.10",
"997.09",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"00.40",
"99.04",
"00.63",
"36.11",
"36.15",
"39.61",
"00.61",
"00.45"
] |
icd9pcs
|
[
[
[]
]
] |
7932, 7994
|
4165, 5900
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299, 412
|
8428, 8434
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1633, 4142
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1261, 1383
|
6191, 7909
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8015, 8407
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5926, 6168
|
8458, 8729
|
8780, 8959
|
1398, 1614
|
243, 261
|
440, 862
|
884, 1181
|
1197, 1245
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,582
| 138,861
|
29724
|
Discharge summary
|
report
|
Admission Date: [**2132-4-28**] Discharge Date: [**2132-5-3**]
Date of Birth: [**2071-8-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Fatigue and dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2132-4-28**] Mitral Valve Replacement w/ 33mm Medtronig mosaic tissue
valve
History of Present Illness:
60 y/o male with known mitral valve prolapse and regurgitation
who was referred for surgery following echo and cath which
revealed severe mitral regurgitation.
Past Medical History:
Mitral Valve Prolapse and Regurgitation, Congestive heart
failure, Hypertension, Paroxysmal Atrial Fibrillation, Prostate
Cancer s/p radiation therapy, Gastroesophageal reflux disease,
Emphysema, h/o dysphagia, s/p appendectomy, s/p hemangioma
removal from right knee
Social History:
Quit smoking few months ago after 1ppd x 40 yrs. Denies ETOH
use.
Family History:
Sister with MVP.
Physical Exam:
VS: 63 16 123/87 5'[**35**]" 192#
Gen: WD/WN male in NAD
HEENT: NC/AT, EOMI, PERRL, OP benign
Neck: Supple, FROM, -JVD, -carotid bruit
Chest: CTAB -w/r/r
Heart: RRR w/ holosystolic murmur
Abd: Soft, NT/ND, +BS
Ext: Warm, well-perfused, -edema, -varicosities, 2+ pulses
throughout
Neuro: MAE, A&O x 3, non-focal
Pertinent Results:
[**2132-5-3**] 06:35AM BLOOD WBC-7.9 RBC-2.80* Hgb-9.5* Hct-27.7*
MCV-99* MCH-33.9* MCHC-34.2 RDW-14.0 Plt Ct-334
[**2132-4-30**] 03:00AM BLOOD PT-13.5* PTT-29.6 INR(PT)-1.2*
[**2132-5-3**] 06:35AM BLOOD Glucose-100 UreaN-17 Creat-1.0 Na-141
K-4.2 Cl-100 HCO3-31 AnGap-14
RADIOLOGY Final Report
CHEST (PA & LAT) [**2132-5-1**] 8:26 AM
CHEST (PA & LAT)
Reason: evaluate effusion
[**Hospital 93**] MEDICAL CONDITION:
60 year old man s/p MVR
REASON FOR THIS EXAMINATION:
evaluate effusion
CHEST TWO VIEWS, PA AND LATERAL
History of MVR.
Status post MVR. There has been no change in heart size or
mediastinal width since the prior film of [**2132-4-30**]. There
are bilateral pleural effusions and associated bibasilar
atelectasis. No pneumothorax. Allowing for technical
differences, no significant change since prior film other than
removal of left jugular Cordis catheter.
DR. [**First Name8 (NamePattern2) 4075**] [**Last Name (NamePattern1) 5999**]
Cardiology Report ECHO Study Date of [**2132-4-28**]
PATIENT/TEST INFORMATION:
Indication: Intra-op TEE for MVR
Height: (in) 72
Weight (lb): 190
BSA (m2): 2.09 m2
BP (mm Hg): 123/67
HR (bpm): 76
Status: Inpatient
Date/Time: [**2132-4-28**] at 07:17
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW07-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *6.6 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *6.8 cm (nl <= 5.2 cm)
Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: *6.0 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 4.7 cm
Left Ventricle - Fractional Shortening: *0.22 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 55% (nl >=55%)
Aorta - Valve Level: 3.1 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.0 cm (nl <= 3.4 cm)
Aorta - Arch: 2.8 cm (nl <= 3.0 cm)
Aorta - Descending Thoracic: 2.5 cm (nl <= 2.5 cm)
Aortic Valve - LVOT Diam: 2.2 cm
INTERPRETATION:
Findings:
LEFT ATRIUM: Marked LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA
and extending into the RV. Normal interatrial septum. No ASD by
2D or color
Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV
cavity. 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. Normal aortic arch diameter. Normal descending aorta
diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets. Mildly
thickened aortic
valve leaflets (3). No AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets.
Moderate/severe MVP.
Severe mitral annular calcification. No MS. [**First Name (Titles) **] vena contracta is
>=0.7cm
Severe (4+) MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure. The patient appears to be in sinus rhythm. Results
were personally
post-bypass
data
Conclusions:
PRE-BYPASS:
1. The left atrium is markedly dilated. No atrial septal defect
is seen by 2D
or color Doppler.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity
is moderately dilated. 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. The aortic valve leaflets (3) appear mildly thickened with
good leaflet
excursion and trace aortic regurgitation. There is no aortic
valve stenosis.
5. The mitral valve leaflets are mildly thickened. There is
severe mitral
annular calcification around the posterior annulus. The mitral
regurgitation
vena contracta is >=0.7cm. Severe (4+) mitral regurgitation is
seen.
POST-BYPASS:
On the first two attempts to come off bypass a perivalvular leak
was seen
posteriorly. Moderate in nature. 3D echo helped delineate the
exact location
of the perivalvular leak. Third attempt at coming off bypass was
successful.
Patient is receiving an infusion of phenylephrine and
epinephrine and is being
AV paced.
1. Biventricular systolic function is unchanged.
2. Bioprosthetic valve seen in the mitral position. Leaftlets
open well and
the valve appears well seated. There is trace mitral
regurgitation which is
central.
3. Aorta intact post decannulation.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD on [**2132-4-30**] 17:33.
Brief Hospital Course:
Mr. [**Known lastname 71197**] was a same day admit after undergoing all
pre-operative work-up as an outpatient. On day of admission he
was brought to the operating room where he underwent a Mitral
Valve Replacement. Please see op note for surgical details.
following surgery he was transferred to the CSRU for invasive
monitoring in stable condition. Later on op day he was weaned
from sedation, awoke neurologically intact and extubated. On
post-op day one his chest tubes were removed and he was weaned
off of any Inotropes. He was started on beta blockers and
diuretics and gently diuresed towards his pre-op weight. On
post-op day two he was transferred to the telemetry floor for
further care. He continued to progress and had brief runs of AF.
He was
started on coumadin on discharge as he had been on it
previously, but had d/c'd it for a prostate biopsy. His INR and
coumadin dosing will be followed by Dr. [**Last Name (STitle) 5057**]. He was
discharged to home in stable condition on POD#5.
Medications on Admission:
Digoxin 0.25mg qd, Lisinopril 2.5mg qd, Nadolol 20mg qd, Lasix
20mg qod, Prilosec 20mg qd, Advair 250/50 one puff qd, Spiriva
18mcg one puff qd, Aspirin 325mg qd, Lupron
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*1*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
4. 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*
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*1*
6. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: must
have your INR checked on Tuesday ([**2132-5-6**]) and discuss
results with Dr [**Last Name (STitle) 5057**] or Dr [**Last Name (STitle) 71198**] for further instructions.
Disp:*30 Tablet(s)* Refills:*1*
7. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Mitral Regurgitation s/p Mitral Valve Replacement
PMH: Mitral Valve Prolapse and Regurgitation, Congestive heart
failure, Hypertension, Paroxysmal Atrial Fibrillation, Prostate
Cancer s/p radiation therapy, Gastroesophageal reflux disease,
Emphysema, h/o dysphagia, s/p appendectomy, s/p hemangioma
removal from right knee
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. 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.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] in 4 weeks
Dr. [**Last Name (STitle) **] in [**1-19**] weeks
Dr. [**Last Name (STitle) 5057**] in [**12-18**] weeks
Completed by:[**2132-5-5**]
|
[
"427.31",
"V58.61",
"424.0",
"530.81",
"429.1",
"V10.46",
"496",
"401.9",
"305.1",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.39",
"34.04",
"39.64",
"89.64",
"88.72",
"39.61",
"89.68",
"38.91",
"35.23"
] |
icd9pcs
|
[
[
[]
]
] |
8636, 8687
|
6328, 7336
|
352, 432
|
9053, 9059
|
1375, 1759
|
1011, 1029
|
7556, 8613
|
1796, 1820
|
8708, 9032
|
7362, 7533
|
9083, 9751
|
9802, 9979
|
2413, 6305
|
1044, 1356
|
281, 314
|
1849, 2387
|
460, 621
|
643, 912
|
928, 995
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,281
| 120,241
|
48522
|
Discharge summary
|
report
|
Admission Date: [**2169-5-21**] Discharge Date: [**2169-5-23**]
Date of Birth: [**2104-10-14**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
ST elevation MI s/p cath w/ ASA allergy admitted to CCU for
desensitization & monitoring
Major Surgical or Invasive Procedure:
Cardiac catheterization with PCI to LAD
ASA Desensitization
History of Present Illness:
64 yo M w/ hx DMII, hyperchol, HTN presented to [**Location (un) 620**] c/o
[**9-25**] SSCP reportedly w/ 9mm anterior STE on [**Hospital **] transferred to
[**Hospital1 18**] for emergent cath. Started on heparin, integrillin gtt,
and pain and STE resolved while in ambulance. At cath at [**Hospital1 18**],
pt noted to have 99% LAD lesion w/ thrombus, CI 2.6 and PCWP 19.
S/p balloon, but stent deferred secondary to ASA allergy. He
was admitted to CCU for monitoring and plans for ASA
desensitization.
On transfer to the CCU he had no chest pain or shortness of
breath.
Past Medical History:
DMII
hypercholesterolemia
Hypertension
Social History:
smoked 1/2ppd x 12 yrs, d/c'ed 37yrs ago, occassional EtOH, no
IVDU
Family History:
father w/ MI in 50's
Physical Exam:
AF 98.6 HR 71 153/77 20 99% RA
Gen: caucasian M lying in bed flat in NAD
Heart: RRR, S1, S2, no m/r/g
Lungs: CTBLA
Abd: NABS/S/NT/ND/no masses
Ext: no edema
Pertinent Results:
Labs from OSH [**2169-5-21**]:
Na 141 K 4.1 Cl 102 CO2 27
BUN 16 creat 1.4 (baseline 1.1 [**2168-6-6**], [**2167-3-23**]) glu 227
wbc 17.2 hct 43.7 plt 227 INR 1.1 PTT 24
Ca 9.2 Mg 1.8 Alb 4.0 TP 6.6 T.bili 0.7 Alkphos 103 ALT 103 AST
43
CK 260
.
[**2169-5-23**] 07:25AM BLOOD WBC-9.9 RBC-4.38* Hgb-13.8* Hct-39.7*
MCV-91 MCH-31.4 MCHC-34.6 RDW-13.0 Plt Ct-181
[**2169-5-21**] 04:20AM BLOOD WBC-16.7*# RBC-4.52* Hgb-14.2 Hct-41.6
MCV-92 MCH-31.4 MCHC-34.1 RDW-13.0 Plt Ct-202
[**2169-5-23**] 07:25AM BLOOD Neuts-68.9 Lymphs-24.9 Monos-4.1 Eos-1.8
Baso-0.3
[**2169-5-23**] 07:25AM BLOOD Plt Ct-181
[**2169-5-23**] 07:25AM BLOOD PT-13.2 PTT-23.9 INR(PT)-1.2
[**2169-5-21**] 04:20AM BLOOD PT-13.5* PTT-31.2 INR(PT)-1.2
[**2169-5-23**] 07:25AM BLOOD Glucose-210* UreaN-16 Creat-1.0 Na-141
K-4.2 Cl-104 HCO3-28 AnGap-13
[**2169-5-21**] 04:20AM BLOOD Glucose-373* UreaN-19 Creat-1.3* Na-136
K-5.0 Cl-100 HCO3-24 AnGap-17
[**2169-5-22**] 05:50AM BLOOD CK(CPK)-300*
[**2169-5-21**] 04:20AM BLOOD CK(CPK)-399*
[**2169-5-23**] 07:25AM BLOOD CK-MB-5 cTropnT-0.50*
[**2169-5-22**] 05:50AM BLOOD CK-MB-20* MB Indx-6.7* cTropnT-0.47*
[**2169-5-21**] 04:20AM BLOOD CK-MB-26* MB Indx-6.5* cTropnT-0.47*
[**2169-5-23**] 07:25AM BLOOD Calcium-9.1 Phos-2.7 Mg-2.0
[**2169-5-21**] 04:20AM BLOOD Calcium-9.1 Phos-3.2 Mg-1.9 Cholest-165
[**2169-5-21**] 04:20AM BLOOD Triglyc-167* HDL-67 CHOL/HD-2.5
LDLcalc-65
EKG:
[**2169-5-21**] 00:45 @ [**Location (un) 620**]: SR 95bpm, q in II, III, aVF; 4-9mm STE
in V1-V4, 1mm STE V5, 1mm STD in V6; 1mm STD II, 2mm STD III,
aVF;
.
[**5-21**] 2:33 @ [**Hospital1 18**] post-cath: ST 78bpm, q in II, III, aVF, 1-2mm
jpt elevations in V2-3 w/ hyperacute TW;
.
[**2-/2169**] ETT w/ symptoms, s/p p-mibi and stress echo both
reportedly negative
.
[**2169-5-21**] cath:
1. Coronary angiography of this right dominant circulation
demonstrated
one vessel coronary artery disease. The LMCA, RCA, and LCX had
no
angiographically apparent disease. The LAD had a proximal 95%
stenosis
with thrombus, TIMI 3 flow upon entry.
2. Resting hemodynamics after PCI demonstrated elevated filling
pressures with mRAP of 17 mmHg and mPCWP of 25 mmHg. There was
severe
pulmonary hypertension with PASP of 60 mmHg and mPAP of 42 mmHg.
There
was moderate systemic hypertension with SBP of 158 mmHg. The
cardiac
output and cardiac index were preserved 5.6 L/min and 2.7
L/min/m2,
respectively.
3. Successful primary PCI for acute anterior STEMI with baloon
angioplasty using a 3.5x20mm Esprit Rx perfusion balloon. (See
PTCA
comments).
FINAL DIAGNOSIS:
1. One vessel (LAD) coronary artery disease.
2. Elevated filling pressures.
3. Preserved cardiac index.
.
[**2169-5-22**] Echo
1. The left atrium is mildly dilated.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is mildly depressed, EF 50%. Septal
hypokinesis is present.
.
Brief Hospital Course:
64 yo male with history of DMII, hypertension,
hypercholesterolemia, ASA allergy admitted with STEMI s/p cath
with PCI for aspirin desensitization.
.
CAD - He had an STEMI. He had PCI of his LAD on arrival. Post
cath we started sulfinpyrazone 200mg po bid for antiplatelet
activity, plavix, integrillin gtt x 18 hours, statin, beta
blocker ACE inhibitor. He had PCI of his LAD. His enzymes began
to trend down on HD 2. He underwent aspirin desensitization
without complications.
He had an echo that showed an EF of 50% with only mildly
depressed function. He should return for repeat cath in 3 months
and at that time a stent may be placed in his LAD depending on
the findings.
.
CHF - He had elevated filling pressures w/ PCWP 19, and was
diuresed gently. This was likely a result of the MI and brief
depressed cardiac function causing elevated pressures.
.
DMII - We initially held glyburide. He was covered with RISS
while in house. We resumed glyburide at discharge.
.
ARF - His creatinine was elevated on admission to 1.3. This was
felt to be secondary to poor renal perfusion secondary to his
MI. His creatinine returned to baseline on HD 2.
Medications on Admission:
Meds on transfer: NTG, heparin, plavix, integrillin, lopressor
outpt meds: glyburide 10mg po qam 5mg po qhs, lipitor 10mg po
q24h, lisinopril 5mg po q24h
.
Discharge Medications:
1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
2. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Glyburide 5 mg Tablet Sig: One (1) Tablet PO Take 2 tabs QAM
and 1 tab QPM.
Disp:*90 Tablet(s)* Refills:*6*
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
STEMI, s/p cath with PCI of LAD
ASA allergy s/p desensitization
Hypertension
Hypercholesterolemia
Type II Diabetes
Discharge Condition:
Good
Discharge Instructions:
Please take all your medications as prescribed.
Follow up with Dr. [**Last Name (STitle) **] in 6 weeks.
Return to the ER or call Dr.[**Name (NI) 9388**] office if you have chest
pain, dizziness, SOB or other concerning symptoms
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in 6 weeks.
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name12 (NameIs) **] Where: [**Name12 (NameIs) **] Date/Time:[**2169-9-11**] 9:30
|
[
"414.01",
"584.9",
"272.4",
"V14.6",
"250.00",
"V58.67",
"410.11",
"401.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"88.53",
"88.56",
"36.01",
"99.12",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
6323, 6329
|
4359, 5510
|
359, 421
|
6497, 6503
|
1408, 3944
|
6780, 6981
|
1193, 1215
|
5717, 6300
|
6350, 6476
|
5536, 5536
|
3961, 4336
|
6527, 6757
|
1230, 1389
|
230, 321
|
449, 1028
|
1050, 1091
|
1107, 1177
|
5554, 5694
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,619
| 165,576
|
52560
|
Discharge summary
|
report
|
Admission Date: [**2137-7-18**] Discharge Date: [**2137-7-25**]
Service: MEDICINE
Allergies:
Ampicillin / Cephalexin
Attending:[**First Name3 (LF) 1070**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: [**Age over 90 **] yo F Russian speaking with MMP including CKD, HTN, s/p
colon ca, COPD presents after fall however, her only complaint
is for breast pain. She was walking on route to Bathroom and
sustained mechanical fall stating that she usuall walks with a
cain and has poor vision. She denied any LOC, CP, palpiations,
lhd, dizzyness prior to fall. She was unable to get back up, but
was able to crawl to the door to get help. She was reportedly
down for several hours, some neighbors found her and helped her
up and to hospital.
.
In ED, BP 178/100, HR 76, RR 20, 99%RA. CK 58. CT head no
hemorrhage. CT spine, no fracture. She recieved Levaquin 250 mg
X 1 for possible pna on CXR.
.
Upon arrival to floor, she denies any pain. Only complaint is
right breast pain X 2-3 days which is similar to when she had an
abscess 3 years ago. No recent trauma, cuts. no discharge. No
pain any where else.
Past Medical History:
Gout
Hypercholesterolemia
hypertension
Colon CA
Mild LV systolic and diastolic dysfunction.
LVEF 50% with baseline mid inferior hypokinesis. Moderate
LAE/mild [**Last Name (un) **]/mild symmetric LVH (echo [**2132**]).
COPD
Depression
Psoriasis
Eosinophilia
Social History:
Lives at home alone with 2 home health aides, sister in the
same building, son in [**Name2 (NI) **], no EtOH, no tobacco
Family History:
NC
Physical Exam:
GENERAL: no acute distress. No pain at rest.
HEENT: OP clear, MMM
HEART: Regular rate and rhythm with 2/6 systolic murmur at the
right upper sternal border.
BREAST: R breast nipple missing/inverted, no expressible
discharge, 2 inch diameter ryethema and tenderness around
nipple. possible fluctuance
LUNGS: Clear to auscultation.
ABDOMEN: Soft, nontender, nondistended. Scar from colectomy
EXTREMITIES: Hips with full ROM not limited to pain. Strength
[**4-22**] LE.
Pertinent Results:
[**2137-7-18**] 05:57PM BLOOD WBC-13.8*# RBC-4.51 Hgb-12.2 Hct-38.9
MCV-86# MCH-27.0 MCHC-31.4 RDW-16.9* Plt Ct-183
[**2137-7-21**] 05:42AM BLOOD Neuts-76.2* Lymphs-10.1* Monos-4.4
Eos-9.1* Baso-0.3
[**2137-7-19**] 06:40AM BLOOD PT-14.6* PTT-26.5 INR(PT)-1.3*
[**2137-7-21**] 05:42AM BLOOD PT-14.0* PTT-130.0* INR(PT)-1.2*
[**2137-7-22**] 04:00PM BLOOD PTT-88.5*
[**2137-7-24**] 06:45AM BLOOD PTT-26.0
[**2137-7-18**] 05:57PM BLOOD Glucose-111* UreaN-37* Creat-1.8* Na-142
K-4.8 Cl-108 HCO3-25 AnGap-14
[**2137-7-20**] 08:28PM BLOOD Glucose-131* UreaN-35* Creat-1.8* Na-139
K-5.7* Cl-107 HCO3-24 AnGap-14
[**2137-7-24**] 06:45AM BLOOD Glucose-99 UreaN-43* Creat-1.8* Na-138
K-4.3 Cl-108 HCO3-25 AnGap-9
[**2137-7-18**] 05:57PM BLOOD cTropnT-0.01
[**2137-7-20**] 09:26AM BLOOD CK-MB-NotDone cTropnT-0.01
[**2137-7-20**] 08:28PM BLOOD CK-MB-NotDone cTropnT-0.01
[**2137-7-18**] 05:57PM BLOOD Calcium-10.0 Phos-3.3 Mg-2.0
[**2137-7-24**] 06:45AM BLOOD Calcium-9.3 Phos-4.1 Mg-2.2
Brief Hospital Course:
The patient was admited for a fall. In ED,her vital signs were
within normal range except an elevated BP of 178/100. CT head
did not show hemorrhage and CT of spine did not show a fracture.
CXR was concerning for PNA and she recieved Levaquin 250 mg X 1.
On admission she c/o of breast pain,and was treated for mastitis
with Clindamycin. She has currently received a 6 day regimen of
this mediciation and may continue for four more days. An
outpaitent mamogram of the breast bilaterally was recommended
again as the patient has yet to follow up on prior abnormal
mammogram.
.
In the hospital she was was noted to have HR in 150's. Rate
control was difficult to control on the floor and the patitent
required transfer to the MICU. In the MICU she was closely
monitored without any events. She was started on a Diltiazem
drip and was transitioned to oral verapramil. Also, based on a
CHADS score of 2 she was started on heparin drip. She remained
stable in the MICU and so she was transfered back to the floor.
.
In the wards the patient did not demonstrate signs of Afib on
telemetry monitoring or cardiovascular decompensation on
physical exam and she remained stable. She was transitioned from
verapramil to metoprolol for rate control. Appropriate control
was achieved with Metoprolol at 75 mg [**Hospital1 **]. This regimen appeared
sufficient for appropriate blood pressure control.
.
Because of the risk of bleeding secondary to this patients fall,
Heparin ggt was dicontinued. It was reasoned that the risk of
bleeding overweighed the risk of stroke secondary to
Afib/thrombus.
Medications on Admission:
ALLOPURINOL 100 mg Tablet - 1 Tablet(s) by mouth once a day
ASPIRIN - 81MG Capsule, Delayed Release(E.C.) - TAKE ONE TABLET
EVERY DAY
BUSPIRONE [BUSPAR] - 5 mg Tablet - one Tablet(s) by mouth twice
a
day
CLOTRIMAZOLE - 1 % Cream - apply under breasts once a day
LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth qam
LORAZEPAM [ATIVAN] - 0.5 mg Tablet - one Tablet(s) by mouth at
bedtime
MATRESS PAD - - apply to bed daily for urinary incontinence
788.30
METOPROLOL TARTRATE [LOPRESSOR] - 50 mg Tablet - [**12-19**] Tablet(s)
by
mouth twice a day
NITROGLYCERIN - 0.4MG Tablet, Sublingual - TAKE ONE TABLET Q5MIN
FOR CHEST PAIN
NITROGLYCERIN [NITRO-DUR] - 0.1 mg/hr Patch 24 hr - one patch on
AM/ off PM
POLYETHYLENE GLYCOL 3350 [MIRALAX] - 100 % Powder - 17 grams by
mouth daily
UNDERWEAR LINER - - for urinary incontinence 788.30 (5 per day)
VERAPAMIL - 40 mg Tablet - 1 Tablet(s) by mouth three times a
day
Medications - OTC
ASCORBIC ACID [VITAMIN C] - (Prescribed by Other Provider: [**Last Name (NamePattern4) **].
[**Last Name (STitle) 18685**] - 500 mg Tablet - Tablet(s) by mouth once a day
CARBAMIDE PEROXIDE [DEBROX] - 6.5 % Drops - 3 drops each ear
twice a day
DOCUSATE SODIUM [COLACE] - 100 mg Capsule - one Capsule(s) by
mouth twice a day
MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth once a day
SENNOSIDES [EX-LAX (SENNOSIDES)] - 15 mg Tablet - one Tablet(s)
by mouth daily prn constipation
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
4. Buspirone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Clotrimazole 1 % Cream Sig: One (1) Topical once a day:
apply under breast once a day.
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual q5min as needed for chest pain.
9. Nitro-Dur 0.1 mg/hr Patch 24 hr Sig: One (1) Transdermal
qam/ off pm.
10. Miralax 100 % Powder Sig: 17 gr PO once a day: 17 gr by
mouth qd.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] of [**Location (un) 583**]
Discharge Diagnosis:
Afib
HTN
Mastitis
Discharge Condition:
Stable
Discharge Instructions:
You were admited after a fall, which we fond to be not related
to undelying disease. While in the hospital you were found to
have atrial fibrilation and we controlled your heart rate with
medications that slow the rate down. We are discharging you on
one such medication which is called Lopressor. This medicaiton
was also used to help control your blood pressure. You were
also found to have infection of your breast that was treated
with antibiotics (Clindamycin).
Please be aware that we changed your outpatient medication
regimen from Verapramil to Lopressor.
Please return to the ED or call you regular doctor if you have
any of the following: chest pain, shortness of [**Last Name (un) **],
lightheadedness, palpitations/rapid hear rate, syncope/faining,
fever, chills, cough, rash, or any other complaint that is
abnormal for you.
Followup Instructions:
Please make sure to follow up with your regular physician, [**Name10 (NameIs) **]
[**Last Name (STitle) **], who also came to see you in the hospital.
Also please make sure to keep the following appointments:
1. Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 1401**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2137-8-1**] 4:00
2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12902**], MD Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2137-8-15**] 10:45
3. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2967**], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2137-9-26**] 1:30
Completed by:[**2137-7-25**]
|
[
"272.0",
"427.31",
"564.00",
"V10.05",
"496",
"585.9",
"696.1",
"403.90",
"611.71",
"E885.9",
"274.9",
"793.80",
"611.0",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6944, 7021
|
3123, 4708
|
236, 242
|
7083, 7092
|
2122, 3100
|
7981, 8693
|
1615, 1619
|
6167, 6921
|
7042, 7062
|
4734, 6144
|
7116, 7958
|
1634, 2103
|
192, 198
|
270, 1177
|
1199, 1459
|
1476, 1599
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,425
| 113,539
|
25875
|
Discharge summary
|
report
|
Admission Date: [**2189-2-23**] Discharge Date: [**2189-3-2**]
Date of Birth: [**2136-8-26**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Patient admitted for weight reduction surgery.
Major Surgical or Invasive Procedure:
Status Post Laparoscopic Gastric Bypass with umbilical hernia
repair with mesh. On [**2189-2-25**] patient taken back to operating
room for bleeding.
History of Present Illness:
[**Known firstname **] has class III morbid obesity with weight of 317.9 lbs as
of
[**2188-11-24**] (his initial screen weight on [**2188-8-5**] was 309.9 lbs),
height of 71 inches and BMI of 44.3. His previous weight loss
efforts have included self-diets and monitoring. He has not done
any formal programs, taken prescription weight loss medications
or used over-the-counter ephedra-containing appetite
suppressants/herbal supplements. His weight at age 21 was 200
lbs
his lowest adult weight with his highest weight being his
current
weight of 317.9 lbs.
Past Medical History:
PMH: HTN, IDDM, severe OSA on CPAP (on 11), dyslipidemia, GERD,
ED [**2-2**]
testosterone deficiency, OA/joint pain (esp R knee), umbilical
hernia, acute pancreatitis (hospitalized [**2-/2187**]), trigger finger
release [**2185**], osteotomy [**2166**], ?ligament repair
Social History:
He used to smoke one pack per day cigarettes for 17 years quit
in [**2172**], no recreational drugs, has 4 bottles of beer weekly,
drinks 12- ounce cup of
coffee 3-4 times a day and has 12-ounce diet soda daily. He is
currently unemployed but occasionally does minimal home repairs.
He is married living with his wife age 50 a software engineer
and their 2 sons ages 24 and 27.
Family History:
Family history is noted for father deceased age 72 of heart
disease
(CHF); mother deceased age 38 of pneumonia and EtOH abuse; has 4
siblings with one sister age 53 living with obesity and another
with EtOH abuse.
Physical Exam:
His blood pressure was 146/76, pulse 78 and O2 saturation 97%
room air. On physical examination [**Known firstname **] was casually dressed in
no distress. His skin was warm, dry, few skin tags and acneiform
lesions, no rashes. Sclerae were anicteric, conjunctiva clear,
pupils were equal round and reactive to light, fundi normal with
sharp optic disks no retinal hemorrhages, mucous membranes were
moist, tongue pink and the oropharynx was without exudates or
hyperemia. Trachea was in the midline and the neck was supple
without adenopathy, thyromegaly or carotid bruits. Chest was
symmetric and the lungs clear to auscultation bilaterally with
good air movement. Cardiac exam was regular rate and rhythm with
normal S1 and S2, no murmurs, rubs or gallops. The abdomen was
obese but soft and non-tender, non-distended with normal bowel
sounds, no masses, there is 4 cm large reducible umbilical
hernia, no incision scars. There was no spinal tenderness or
flank pain. Lower extremities were noted for bilateral mild
venous insufficiency, trace edema and no clubbing. There was no
evidence of joint swelling or inflammation of the joints. There
were no focal neurological deficits and his gait noted light
limp.
Pertinent Results:
[**2189-2-24**] 07:05AM BLOOD WBC-12.3*# RBC-3.30*# Hgb-9.9*#
Hct-29.2*# MCV-88 MCH-29.9 MCHC-33.9 RDW-14.4 Plt Ct-386
[**2189-2-24**] 03:50PM BLOOD WBC-10.9 RBC-3.08* Hgb-9.3* Hct-27.0*
MCV-88 MCH-30.2 MCHC-34.5 RDW-14.5 Plt Ct-321
[**2189-2-25**] 06:00AM BLOOD WBC-11.4* RBC-2.50* Hgb-7.5* Hct-21.6*
MCV-87 MCH-30.0 MCHC-34.6 RDW-14.7 Plt Ct-277
[**2189-2-25**] 09:20AM BLOOD Hct-22.0*
[**2189-2-26**] 02:04AM BLOOD WBC-10.7 RBC-2.84* Hgb-8.6* Hct-24.9*
MCV-88 MCH-30.2 MCHC-34.5 RDW-15.1 Plt Ct-256
[**2189-2-27**] 05:45AM BLOOD WBC-10.5 RBC-2.83* Hgb-8.5* Hct-25.0*
MCV-88 MCH-30.1 MCHC-34.1 RDW-15.5 Plt Ct-249
[**2189-3-1**] 08:35AM BLOOD WBC-10.2 RBC-2.97* Hgb-8.8* Hct-25.8*
MCV-87 MCH-29.8 MCHC-34.2 RDW-15.1 Plt Ct-340
[**2189-2-28**] 06:05AM BLOOD Glucose-111* UreaN-19 Creat-0.5 Na-141
K-3.7 Cl-104 HCO3-28 AnGap-13
[**2189-2-24**] UGI [**2-24**]
IMPRESSION: Free passage of oral contrast from the gastric pouch
into the
non-dilated loops of jejunum, without evidence of anastomotic
leak at the
gastrojejunostomy.
UGI [**2189-2-26**]
Free passage of contrast into the gastric pouch without evidence
of leak. However, severe stenosis of the gastrojejunal
anastomosis with
minimal passage of contrast into the jejunum. Free reflux of the
gastric
pouch contents into the upper esophagus. The patient was kept in
a semi-
upright position for concern of aspiration.
KUB [**2189-2-27**]
No remaining contrast seen within the area of the gastric pouch.
Residual contrast seen within the colon to the level of the
rectum.
R Duplex [**2189-2-27**]
Duplex and color Doppler demonstrate no right upper extremity
DVT
either acute or chronic.
Brief Hospital Course:
Patient admitted and underwent a laparoscopic gastric bypass on
[**2189-2-23**]. He tolerated the procedure well, however his
postoperative course was complicated by a low urine output and a
falling hematocrit. His hct. dropped from 29.2 to 21.6 so it was
decided to take him back to the operating room for open
abdominal exploration
with clot evacuation and Gastrostomy tube procedure. He
recovered in the intensive care unit for approximately 24 hours
and then was transferred back to floor. His blood level remained
stable and he was progressed from a stage one to stage 3 diet
without problems.
We will discharge him to home with follow up with Dr. [**Last Name (STitle) **]
and the bariatric clinic. He will go home with a g-tube and
instruction has been given to him regarding this. He will also
go home with metformin and 25 units of glargine qHS [**First Name8 (NamePattern2) **] [**Last Name (un) **].
He will monitor his blood sugars and speak/visit with his
endocrinologist in one week.
Medications on Admission:
Lisinopril 40', Felodipine 10', Metoprolol 50'', HCTZ 25', NPH
15U qAM/15U qnoon/20U qPM, Lispro ISS, Metformin 1000''; Crestor
10', Omeprazole 20', ASA 81', Viagra 100''prn, MVI
Discharge Medications:
1. Roxicet 5-325 mg/5 mL Solution Sig: [**5-10**] ml PO every four (4)
hours as needed for pain.
Disp:*500 ml* Refills:*0*
2. Colace 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a day as
needed for constipation.
Disp:*500 ml* Refills:*0*
3. Actigall 300 mg Capsule Sig: One (1) Capsule PO twice a day:
Please take for 6 months. You must open capsule and place in
drink.
Disp:*60 Capsule(s)* Refills:*5*
4. Zantac 15 mg/mL Syrup Sig: Ten (10) ml PO twice a day: Please
take for one month.
Disp:*600 ml* Refills:*0*
5. Diabetes Regimen
Please check your fingerstick blood sugars 4 times a day andn
log. Please hold your NPH insulin and follow up with your
primary care or endocrinologist in one week. You may continue
your metformin.
6. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day:
Please crush.
7. Felodipine 10 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
8. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day:
Please crush.
9. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day:
Please crush.
10. Crestor 10 mg Tablet Sig: One (1) Tablet PO once a day:
Please crush.
11. HCTZ
Please hold and follow up with your primary care in one week to
assess need.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Obesity
Discharge Condition:
Stable.
Discharge Instructions:
Discharge Instructions: Please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.
Diet: Stay on Stage III diet until your follow up appointment.
Do not self advance
diet, do not drink out of a straw or chew gum.
Medication Instructions:
Resume your home medications, CRUSH ALL PILLS.
You will be starting some new medications:
1. You are being discharged on medications to treat the pain
from your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
2. You should begin taking a chewable complete multivitamin with
minerals. No gummy vitamins.
3. You will be taking Zantac liquid 150 mg twice daily for one
month. This medicine prevents gastric reflux.
4. You will be taking Actigall 300 mg twice daily for 6 months.
This medicine prevents you from having problems with your
gallbladder.
5. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
6. You must not use NSAIDS (non-steroidal anti-inflammatory
drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and
Naproxen. These agents will cause bleeding and ulcers in your
digestive system.
Activity:
No heavy lifting of items [**10-15**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18800**], RD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2189-3-12**] 1:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], MD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2189-3-12**] 2:00
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18800**], RD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2189-4-24**] 9:00
Please follow up with your primary care provider [**Name Initial (PRE) **]/or
endocrinologist in one week.
Completed by:[**2189-3-2**]
|
[
"998.11",
"250.00",
"530.81",
"327.23",
"272.4",
"553.1",
"401.9",
"V85.4",
"E878.2",
"V64.41",
"285.1",
"715.36",
"278.01",
"607.84",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.19",
"53.42",
"44.38",
"54.19"
] |
icd9pcs
|
[
[
[]
]
] |
7433, 7439
|
4946, 5947
|
360, 512
|
7510, 7520
|
3273, 4923
|
9699, 10354
|
1808, 2023
|
6176, 7410
|
7460, 7460
|
5973, 6153
|
7568, 8134
|
2038, 3254
|
274, 322
|
9342, 9676
|
540, 1099
|
7479, 7489
|
8159, 9330
|
1122, 1395
|
1411, 1792
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,536
| 127,047
|
31886
|
Discharge summary
|
report
|
Admission Date: [**2111-9-17**] Discharge Date: [**2111-10-28**]
Date of Birth: [**2048-2-16**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
ABD PAIN
Major Surgical or Invasive Procedure:
[**9-17**]
Selective celiac arteriogram, celiac stenting, abdominal and
pelvic arteriogram (CPT codes [**Numeric Identifier 7534**], [**Numeric Identifier 7535**], [**Numeric Identifier 25533**] and [**Numeric Identifier 24945**]).
Failed attempt to cross SMA occlusion
[**9-17**]
Exploratory laparotomy.
[**9-20**]
PROCEDURE:
1. Exploratory laparotomy.
2. Small bowel resection.
3. Small bowel anastomosis x2.
4. Ileocolic anastomosis.
5. [**Last Name (un) **] gastrostomy.
6. [**State 19827**] patch abdominal closure.
[**9-25**]
PROCEDURE:
1. Reopening of abdomen.
2. Resection of small bowel anastomoses x3.
[**9-28**]
PROCEDURE:
1. Exploratory laparotomy.
2. Small bowel resection.
3. Tube jejunostomy.
4. Abdominal closure.
[**10-16**]
PROCEDURE:
Hickman catheter insertion.
History of Present Illness:
Patient is intubated and is therefore unable to communicate
verbally. History is based on medical records provided by [**Hospital1 **] and Dr.[**Name (NI) 74774**] exploratory
laparoscopy notes. This 63 yo female had a laparoscopic
cholecystectomy on [**2111-9-14**] and was discharged home on the same
day symptomatic (symptoms not mentioned). On the morning of
[**2111-9-16**], the patient began to experience severe abdominal pain,
which became worse and she was seen at [**Hospital3 **]/[**Hospital1 74775**] in [**Hospital1 1806**], MA where a CT scan showed an ileus with no
evidence of any other abnormality and a small amount of fluid in
the gallbladder fossa, consistent with the previous surgery.
She has a past medical history of vascular disease with a
carotid artery stenosis and coronary artery disease. She had an
ERCP because of stones in the bile duct and had been referred
for a semi-urgent cholecystectomy and had undergone an
uneventful laparoscopic cholecystectomy.
The findings at surgery upon opening the patient's abdomen, the
small bowel in the superior mesenteric distribution was
considered "dusky", although
completely and not frankly gangrenous. The operative site
appeared with no evidence of any bile leak and all staples in
place. There was no free fluid in the peritoneal cavity. It
was elected to close the patient, start the patient on heparin,
and refer her to vascular service.
The superior mesenteric artery has a non-dopplerable pulse, but
there is a palpable pulse in the splenic and the common hepatic
artery. The aorta is considered markedly stenosed
Past Medical History:
PMH: PVD, L subclavian stenosis s/p bypass, HTN, ^chol, COPD,
s/p appy, s/p tonsillectomy, seizure d/o, CVA '[**08**], bilateral CEA
Social History:
Married female living with husband. Unknown occupation status.
Smokes cigarettes: unknown amount, denies alcohol/illicit drug
use
Family History:
n/c
Physical Exam:
fragile female
a/o
nad
cta
rrr
abd j / g tube sites inact, clean
Pulses: Fem DP PT
Rt 2+ mono mono
Lt 2+ mono mono
Pertinent Results:
[**2111-10-16**] 09:52PM BLOOD
WBC-10.7 RBC-3.57* Hgb-10.8* Hct-32.9* MCV-92 MCH-30.3 MCHC-32.9
RDW-15.0 Plt Ct-341
[**2111-10-13**] 03:06AM BLOOD
PT-16.2* PTT-45.8* INR(PT)-1.5*
[**2111-10-20**] 05:45AM BLOOD
Glucose-82 UreaN-23* Creat-0.6 Na-133 K-4.4 Cl-105 HCO3-23
AnGap-9
[**2111-10-18**] 06:01AM BLOOD
ALT-7 AST-10 AlkPhos-105 TotBili-0.5
[**2111-10-20**] 05:45AM BLOOD
Calcium-8.6 Phos-4.3 Mg-2.0
[**2111-10-7**] 09:40AM
URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.011
URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
URINE RBC-[**3-2**]* WBC-0-2 Bacteri-0 Yeast-NONE Epi-0
[**2111-10-9**] 11:52 am STOOL Site: STOOL CONSISTENCY: LOOSE
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2111-10-10**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
[**2111-10-16**] 9:17 PM
CHEST (SINGLE VIEW); CHEST FLUORO WITHOUT RADIOLOGI
Reason: INSERTION HICKMAN LINE UNDER FLUORO
FINDINGS: Two fluoroscopic spot films are obtained in the OR
during placement of a central venous line. These limited films
reveal right subclavian and right internal jugular venous
catheters extending to the cavoatrial junction. No pneumothorax
is visualized.
[**2111-10-7**] 3:26 PM
BILAT UP EXT VEINS US
Reason: Please do a formal study of bilat. UE - look for DVT
UPPER EXTREMITY ULTRASOUND: Grayscale and color Doppler
ultrasound examinations of bilateral internal jugular,
subclavian, axillary, brachial, basilic, and cephalic veins was
performed. There is an occlusive thrombus of the right cephalic,
which extends into the right subclavian although this vessel is
not occluded. The extension of the subclavian exhibits
echogenicity suggestive of organization. Remaining veins
demonstrate normal wall-to-wall color flow, compressibility, and
waveforms.
IMPRESSION: Occlusive thrombus in the right cephalic vein which
extends into the right subclavian vein without causing
occlusion.
Brief Hospital Course:
[**9-17**]: PT ADMITTED TAKEN STAT TO THE OR:
Selective celiac arteriogram, celiac stenting, abdominal and
pelvic arteriogram (CPT codes [**Numeric Identifier 7534**], [**Numeric Identifier 7535**], [**Numeric Identifier 25533**] and [**Numeric Identifier 24945**]).
Failed attempt to cross SMA occlusion.
[**9-17**]
Selective celiac arteriogram, celiac stenting, abdominal and
pelvic arteriogram (CPT codes [**Numeric Identifier 7534**], [**Numeric Identifier 7535**], [**Numeric Identifier 25533**] and [**Numeric Identifier 24945**]).
Failed attempt to cross SMA occlusion
Exploratory laparotomy.
There was no evidence of soilage of bowel contents in the
abdomen.
[**9-20**] - the patient was taken for a planned second look operation
by Dr. [**Last Name (STitle) **], She had been hemodynamically stable during the
interim period.
There were several areas of small bowel requiring resection
PROCEDURE:
1. Exploratory laparotomy.
2. Small bowel resection.
3. Small bowel anastomosis x2.
4. Ileocolic anastomosis.
5. [**Last Name (un) **] gastrostomy.
6. [**State 19827**] patch abdominal closure.
Transfered back to the CVICU - intubated / pt required
resusitation by meds and fluid
[**9-25**] - patient did begin spiking fevers, reexploration, washout
and closure were indicated.
Bilious ascites with some fecalized material was encountered.
Inspection revealed that the two small bowel anastomoses had
broken down with the beginning of leakage of intestinal
contents.
Vascular surgery was notified intraoperatively and did come into
the OR. All potentially viable lengths of small bowel were
preserved.
PROCEDURE:
1. Reopening of abdomen.
2. Resection of small bowel anastomoses x3.
[**9-28**] - pt spiked fevers again,
Upon entering the abdomen, there was a sulcus free within the
intestinal cavity from a perforation of 1 of the closed loops of
small bowel. Anadditional 18 cm of small bowel was identified
and found to be nonviable.
PROCEDURE:
1. Exploratory laparotomy.
2. Small bowel resection.
3. Tube jejunostomy.
4. Abdominal closure.
Since that time, the patient has been stable. [**Hospital 74776**]
transfered to the VICU, then the floor.
Pt required Pain consult to wean of PCA. PCA was removed and
pain control was maintained using a fentanyl patch with percocet
elixir for breakthrough.
The patient has had copious output from her Gtube and Jtube,
managed with a variety of colostomy-style appliances.
[**10-16**] - She requires agressive fluid and electrolyte repletion,
It was decided to put a permanent line in
PROCEDURE:
Hickman catheter insertion.
Pt had multiple cx's taken during this hospital sty. Her AB were
broad coverage. Prior to discharge her Antibiotics were stopped.
The morning after she spiked a temperature. No obvious sources
of infection. CT abdomen done which showed small collection in
the abdomen, decreased in size from previously. However, no
ring enhancing with air. Patient was transferred to the General
Surgery team for continued management of this problem.
[**2111-10-4**] PERITONEAL FLUID {neg}
[**2111-10-9**] ESCHERICHIA COLI, CIPROFLOXACIN - <=0.25 S
[**2111-10-9**] ANAEROBIC CULTURE: NO ANAEROBES ISOLATED.
[**2111-10-14**] [**Female First Name (un) **] ALBICANS, Fluconazole SENSITIVE.
During her last week in the hospital she was afebrile and
without complaint. Her TPN and fluids were titrated with her
urine output and her G and J tube output to maintain her net
fluid balence as neutral.
Medications on Admission:
[**Last Name (un) 1724**]: dilantin, aggrenox, lorazepam, albuterol,, advair,
lovastatin
Discharge Medications:
1. Acetaminophen 650 mg Suppository [**Last Name (un) **]: One (1) Suppository
Rectal Q6H (every 6 hours) as needed.
2. Cyclobenzaprine 10 mg Tablet [**Last Name (un) **]: One (1) Tablet PO TID (3
times a day) as needed.
3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (un) **]: 5-10 MLs
PO Q4H (every 4 hours) as needed.
4. Fentanyl 100 mcg/hr Patch 72 hr [**Last Name (un) **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
5. Clopidogrel 75 mg Tablet [**Last Name (un) **]: One (1) Tablet PO DAILY
(Daily).
6. Nystatin 100,000 unit/mL Suspension [**Last Name (un) **]: Five (5) ML PO QID
(4 times a day): THRUSH / DC when THRUSH IS GONE.
7. Miconazole Nitrate 2 % Powder [**Last Name (un) **]: One (1) Appl Topical PRN
(as needed).
8. Prochlorperazine Edisylate 5 mg/mL Solution [**Last Name (un) **]: One (1)
Injection Q6H (every 6 hours) as needed.
9. HICKMAN CATHETER
Heparin Flush Hickman (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
11. Enoxaparin 80 mg/0.8 mL Syringe [**Last Name (STitle) **]: One (1) Subcutaneous Q
24H (Every 24 Hours).
12. Levetiracetam 500 mg/5 mL Solution [**Last Name (STitle) **]: One (1) Intravenous
Q12H (every 12 hours).
13. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB, wheeze.
14. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Last Name (STitle) **]: One (1)
Inhalation Q6H (every 6 hours) as needed for SOB, wheeze.
15. Lorazepam 2 mg/mL Syringe [**Last Name (STitle) **]: 0.5 mg 0.5 mg Injection Q4H
(every 4 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
Small Bowel ischemia
Discharge Condition:
Good
Discharge Instructions:
CALL OR GO TO THE ER IF
Signs and symptoms
Although there are different types of intestinal ischemia, signs
and symptoms are most often perceived as having a sudden (acute)
or gradual (chronic) onset.
Signs and symptoms of acute intestinal ischemia typically
include:
Sudden abdominal pain that may range from mild to severe
An urgent need to move your bowels
Frequent, forceful bowel movements
Abdominal tenderness or distention
Blood in your stool
Nausea, vomiting
Fever
Chronic intestinal ischemia, in which blood flow to the
intestines is reduced over time, is characterized by:
Abdominal cramps or fullness, beginning within 30 minutes after
eating and lasting for one to three hours
Abdominal pain that gets progressively worse over weeks or
months
Fear of eating because of subsequent pain
Unintended weight loss
Diarrhea
Nausea, vomiting
Bloating
CALL OR COME TO THE ER IF:
WOUND CARE:
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your wound(s).
New pain, numbness or discoloration of your lower or upper
extremities (notably on the side of the incision).
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2111-11-24**] 10:45
Follow-up with Dr. [**Last Name (STitle) **] [**2111-10-29**] @ 2pm telephone #
[**Telephone/Fax (1) 600**]
|
[
"285.9",
"401.9",
"789.59",
"287.5",
"272.0",
"579.3",
"557.0",
"453.8",
"338.28",
"E878.3",
"997.4",
"567.22",
"780.39",
"496",
"998.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"00.46",
"39.50",
"45.73",
"46.39",
"54.63",
"45.62",
"39.90",
"88.72",
"45.72",
"45.93",
"38.93",
"43.19",
"99.04",
"99.15",
"88.47",
"54.91",
"45.61",
"45.91"
] |
icd9pcs
|
[
[
[]
]
] |
10732, 10815
|
5241, 8731
|
324, 1118
|
10880, 10887
|
3257, 5218
|
12294, 12560
|
3072, 3077
|
8870, 10709
|
10836, 10859
|
8757, 8847
|
10911, 11801
|
3092, 3238
|
276, 286
|
11814, 12271
|
1146, 2751
|
2773, 2908
|
2924, 3056
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,016
| 116,805
|
11182
|
Discharge summary
|
report
|
Admission Date: [**2166-10-16**] Discharge Date: [**2166-10-24**]
Date of Birth: [**2100-6-16**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old
male with a significant history of coronary artery disease
who presented to the [**Hospital1 69**]
with a positive stress test on [**10-3**] for cardiac
catheterization. His cardiac catheterization revealed
3-vessel disease and a right-dominant system. Left main
coronary appeared angiographically normal. The left anterior
descending artery had 90% stenosis, the left circumflex had a
90% proximal stenosis, the right coronary artery was
completely occluded proximally with distal collateral filling
from the conus branch and left-to-right collaterals.
Hemodynamics showed elevated left ventricular end-diastolic
pressure and systolic arterial hypertension.
He was subsequently referred for a coronary artery bypass
graft which was performed on [**2166-10-6**] with left
internal mammary artery to left anterior descending artery,
saphenous vein graft to first obtuse marginal, saphenous vein
graft to first diagonal. His left circumflex was not grafted
because of poor touchdown sites; therefore, he was taken to
the catheterization laboratory where they performed a
successful percutaneous transluminal coronary
angioplasty/stenting of the proximal and middle circumflex.
His postoperative course was complicated by atrial
fibrillation which was originally treated with amiodarone but
switched to procainamide due to transaminitis. Thereafter he
converted to normal sinus rhythm. He was treated with
aspirin and Plavix and discharged on [**10-16**].
After discharge, the patient was home for a few hours and
developed shortness of breath and bradycardia and was brought
back to the Emergency Room. Upon arrival to the Emergency
Room he was intubated secondary to poor oxygenation from
congestive heart failure. He was admitted to the
Cardiothoracic Surgery Service, and his cardiac enzymes were
cycled. A.m. enzymes revealed a creatine kinase of 310. He
was then taken to the catheterization laboratory where he was
found to have a thrombosed left circumflex stent distal to
the obtuse marginal graft. The lesion received Angio-Jet and
an intra-aortic balloon pump was placed, and the patient was
transferred to the Coronary Care Unit.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Coronary artery disease.
3. Status post hip fracture.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Procainamide 750 mg and 500 mg
alternating doses p.o. q.i.d., Plavix 75 mg p.o. q.d.,
Lasix 20 mg p.o. q.d. times five days, Lipitor 20 mg p.o.
q.d., Lopressor 12.5 mg p.o. b.i.d., Percocet p.r.n., [**First Name5 (NamePattern1) 233**]
[**Last Name (NamePattern1) 1002**] 20 mEq p.o. b.i.d. times five days.
PHYSICAL EXAMINATION ON PRESENTATION: On admission
temperature was 99.3, pulse of 109, blood pressure 102/42,
oxygen saturation 100% on CPAP with pressure support of 10,
PEEP of 5, FIO2 50%, tidal volume 450 cc with a respiratory
rate of 19 on propofol and dopamine and Integrilin drips. In
general, the patient was intubated and sedated. Head, ears,
nose, eyes and throat revealed pupils were equal and reactive
to light. No jugular venous distention. Sclerae were
anicteric. Bilateral carotid bruits. Heart had sinus
tachycardia, a [**2-11**] holosystolic murmur radiating to the
axilla. Lungs were clear to auscultation anteriorly. The
abdomen was soft, hyperactive bowel sounds. Extremities
revealed pulses by Doppler, surgical incision on the lower
extremities healing well. Lines: A right arterial and
venous sheaths, left arch sheath.
LABORATORY DATA ON PRESENTATION: White blood cell
count 15.4, hematocrit 25.8, platelets 358. Sodium 137,
potassium 4, chloride 101, bicarbonate 11, creatinine 0.9,
BUN 11. INR 1.4, PTT 32.6, PT 14.3. Magnesium 1.5.
Creatine phosphokinase 310, MB 20. Urinalysis had positive
nitrites, moderate bacteria.
RADIOLOGY/IMAGING: Electrocardiogram from [**2166-10-16**]
revealed sinus bradycardia with normal axis and intervals,
new T wave inversions in I, aVL, II, III, and aVF, V2 through
V6 with ST depressions in V4.
[**2166-10-16**], post intervention revealed normal sinus
rhythm at 102 with no changes from prior electrocardiograms.
HOSPITAL COURSE: While on the Coronary Care Unit the
patient was successfully extubated and intra-aortic balloon
pump was removed. The patient's course in the Coronary Care
Unit was complicated by two episodes of paroxysmal atrial
fibrillation which was converted with intravenous
procainamide and DC cardioversion. He was eventually
switched to oral procainamide and remained in normal sinus
rhythm throughout the rest of his stay in the Coronary Care
Unit. He will need to be reassessed for potential
anticoagulation if he were to convert to atrial fibrillation.
Additionally, he had episodes of chest pain which were not
associated with any electrocardiogram changes and relieved by
sublingual nitroglycerin. He was noted to have a pericardial
friction rub and was treated with indomethacin. Once his
vitals stabilized he was resumed on Lopressor and captopril.
At the time of discharge he remained free of chest pain.
His urinary tract infection was treated with 7-day course of
ciprofloxacin; [**1-9**] blood culture bottles grew
coagulase-negative Staphylococcus. He was treated with
vancomycin for four days, but that was discontinued in light
of no fever spikes and other culture bottles showing no
growth. Surveillance cultures were drawn 48 hours after
discontinuing vancomycin. They had not grown anything at the
time of discharge. It was likely that the one positive blood
culture was due to a skin contaminant. Per Interventional
Cardiology recommendation, the patient was to be continued on
Plavix 150 mg p.o. for two month.
From and Endocrine standpoint the patient continued to have
elevated serum glucose levels. He was put on an insulin
sliding-scale while in the hospital. However, he will need
to be evaluated for diabetes on an outpatient basis since he
has clearly demonstrated fasting blood sugars greater than
126 on several occasions.
The patient was seen by Physical Therapy, and they evaluated
him as having good potential for returning to baseline
functional status. He will need to be enrolled in a cardiac
rehabilitation program upon return to his home in Bermuda.
MEDICATIONS ON DISCHARGE:
1. Lopressor 100 mg p.o. b.i.d.
2. Procainamide 500 mg p.o. q.i.d.
3. Plavix 150 mg p.o. q.d.
4. Aspirin 325 mg p.o. q.d.
5. Captopril 37.5 mg p.o. t.i.d.
DISCHARGE DIAGNOSES:
1. Myocardial infarction secondary to in-stent thrombosis of
left circumflex stent, status post Angio-Jet and restenting.
2. Paroxysmal atrial fibrillation.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: Home.
[**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 5219**]
Dictated By:[**Name8 (MD) 5753**]
MEDQUIST36
D: [**2166-11-29**] 21:23
T: [**2166-12-3**] 07:28
JOB#: [**Job Number 35987**]
(cclist)
|
[
"411.0",
"V45.81",
"427.31",
"790.7",
"599.0",
"785.51",
"410.71",
"996.72",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.01",
"36.06",
"37.23",
"99.61",
"88.55",
"37.61",
"99.20",
"37.64"
] |
icd9pcs
|
[
[
[]
]
] |
6633, 6803
|
6451, 6612
|
2505, 4310
|
4329, 6425
|
6818, 7152
|
158, 2340
|
2362, 2478
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,593
| 169,494
|
4187
|
Discharge summary
|
report
|
Admission Date: [**2109-10-7**] Discharge Date: [**2109-10-9**]
Date of Birth: [**2039-8-22**] Sex: F
HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old
female with a past medical history of type 2 diabetes
mellitus, end-stage renal disease (on hemodialysis),
peripheral vascular disease (status post below-knee
(status post myocardial infarction times two) who was
transferred from [**Hospital1 **] for arteriovenous graft
removal.
The patient was recently admitted to [**Hospital1 190**] for low back pain in [**2109-8-27**]. She was
found to have a compression fracture with questionable
for rehabilitation three weeks ago.
On Friday, [**10-4**], the patient was noted to have pus
draining from her old right arteriovenous fistula graft.
Blood cultures and wound cultures were drawn, and the patient
was started on vancomycin. On Saturday, the patient was
communicative but seemed more confused than normal. The
confusion worsened on Sunday. The patient reportedly had
chills but no fever.
Today, the patient went for hemodialysis and was noted to
have [**2-28**] positive blood cultures that grew
methicillin-resistant Staphylococcus epidermidis, and a wound
culture that grew methicillin-susceptible Staphylococcus
aureus. The patient was given a second dosing of vancomycin.
The patient was also noted to have a blood sugar of 39 and
was given a half ampule of D-50. Reportedly, the patient had
not received insulin that morning. Her INR which on Friday
was noted to be 2.9 was measured as 7.4 and later greater
than 11.5. The patient was also noted to have an evaluated
bilirubin and alkaline phosphatase.
The patient was transferred to [**Hospital1 188**] for removal of arteriovenous graft. The patient was
admitted to Surgery attending, Dr. [**Last Name (STitle) **]. The patient became
unresponsive on the surgery floor and was noted to have
systolic blood pressures in the 70s; reportedly baseline is
between 80 and 90. The patient was bolused with intravenous
fluids which increased the systolic blood pressure to the 80s
and was transferred to the Medical Intensive Care Unit for
closer observation of blood pressures.
The patient reportedly had not been eating well over the past
three weeks and also had been having diarrhea.
PAST MEDICAL HISTORY:
1. End-stage renal disease (on hemodialysis Monday,
Wednesday and Friday for two years).
2. Status post right arteriovenous graft placement in
[**2108-8-27**].
3. Status post multiple thrombectomies and graft revisions;
last thrombectomy was [**2109-6-27**].
4. The patient has a positive lupus anticoagulant antibody
that was recently tested.
5. Coronary artery disease; status post myocardial
infarctions, last one in [**2108-12-28**]. Status post
catheterization in [**2108-12-28**] which showed 3-vessel
disease and required a percutaneous coronary intervention of
the left anterior descending artery.
6. Congestive heart failure with an ejection fraction of
25%; catheterization showed severe systolic and diastolic
dysfunction.
7. Atrial fibrillation.
8. Ventricular tachycardia; status post automatic internal
cardioverter-defibrillator in [**2108-12-28**].
9. Type 2 diabetes mellitus; now insulin dependent.
10. Peripheral vascular disease; status post right
below-knee amputation.
11. Peripheral neuropathy.
12. Hypertension.
13. Asthma.
14. Gastroesophageal reflux disease.
15. Status post cholecystectomy.
16. Status post appendectomy.
17. Sarcoma; status post excision in [**2084**].
18. Osteoarthritis.
19. Degenerative joint disease with chronic back pain.
20. Status post gastric bypass.
ALLERGIES: Allergy to IODINE, CLINDAMYCIN, and FERRALET.
MEDICATIONS ON ADMISSION: Renagel 1200 mg p.o. t.i.d.,
Lipitor 10 mg p.o. q.d., Nephrocaps, Protonix, [**Doctor First Name **],
Isordil, amiodarone, Neurontin, Coumadin (which was held
since [**9-26**]), Plavix, Lidoderm, Tylenol No. 3, Colace,
Senna, Dulcolax, calcitonin, Vioxx.
SOCIAL HISTORY: A retired social worker at [**Hospital3 18242**]. An ex-smoker; quit 35 years ago. She denies
alcohol use.
FAMILY HISTORY: Family history is positive for coronary
artery disease, diabetes mellitus, and seizures.
PHYSICAL EXAMINATION ON PRESENTATION: On admission, the
patient was unresponsive to voice but grimaced to pain.
Temperature was 97.1, blood pressure was 87/48, pulse was 74,
respiratory rate was 17, pulse oximetry was 98% on 2 liters.
An obese elderly woman in no acute distress. Pupils were
equal, round, and reactive to light. Sclerae were anicteric.
Mucous membranes were dry. No jugular venous distention. A
regular rate and rhythm. Normal first heart sound and second
heart sound. A [**1-2**] holosystolic murmur at the left lower
sternal border. A tunnel dialysis catheter in the right
chest. Lung examination revealed poor respiratory effort,
diffuse rales. The abdomen was soft, hypoactive bowel
sounds, diffuse mild tenderness. No rebound. Extremities
revealed trace edema, 1+ dorsalis pedis pulses on the left, a
right below-knee amputation. A fluctuant mass at the right
arteriovenous graft site with ulceration and drainage of pus.
An ulcer on the left lower extremity without discharge. A
decubitus ulcer on the sacral region. Deep peroneal ulcer
with purulent discharge.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories
were pertinent for an elevated alkaline phosphatase and
bilirubin; most of which was total bilirubin which was
measured at 3. Also INR came back at 24.7.
HOSPITAL COURSE/PLAN:
1. INFECTED ARTERIOVENOUS GRAFT: The patient went for
surgery the following day. The graft was removed. The
patient persisted to remain hypotensive after graft
placement.
2. HYPOTENSION: Question whether this was sepsis versus
hypovolemia. The patient was initially given bolus fluids;
however, eventually required dopamine for pressures. This
was eventually switched to Levophed, and later she was put on
Vasopressin with some success getting off the Levophed;
however, the patient remained requiring Vasopressin until she
expired.
3. INFECTIOUS DISEASE: The patient was treated for
methicillin-susceptible Staphylococcus aureus and
methicillin-resistant Staphylococcus epidermidis. She was
started on vancomycin and gentamicin. She was initially
started on Flagyl, but this was discontinued. It was felt
that the patient likely had intervascular infection and at
some point would need an echocardiogram; or at some point
evaluation to see if her dialysis catheter was infected.
4. ELEVATED INR: The patient was given 8 units of fresh
frozen plasma with correction of INR. This suggested it was
likely due to decrease synthesis rather than destruction.
The patient was also given vitamin K. Her coagulations were
followed. She required one bag of platelets and five bags of
packed red blood cells. Access was obtained through the left
internal jugular site, and the patient persisted to
bleed/ooze from this site during her entire hospital course.
The oozing did improve, however, as her INR corrected.
5. PULMONARY SYSTEM: The patient was electively intubated
for airway protection. She remained intubated until after
surgery; at which point in time she was attempted to be
extubated. However, the patient became hypoxic, and the
family signed do not intubate order. Unable to intubate the
patient. The patient went into hypoxic-induced ventricular
tachycardia. She was not resuscitated, as she was made do
not resuscitate, and the patient expired.
6. GYNECOLOGY: Her peroneal ulcer was examined. No signs
of abscess.
7. RENAL SYSTEM: The patient went for hemodialysis the
following day. She was continued on her renal medications.
Firstly, after dialysis, she was volume overloaded, and
because of her hypotension, we were unable to remove fluids
from her. It was likely that this contributed to her
hypoxemia.
8. CARDIOVASCULAR SYSTEM: The patient was discontinued on
the Plavix for the upcoming surgery. She was hypotensive and
was bolused carefully. However, it appeared that she had
gone into congestive heart failure to some extent as her
chest x-ray showed signs of fluid overload. The patient had
atrial fibrillation; however, she was supratherapeutic on her
INR, and Coumadin was held. Amiodarone was held as it was a
possible cause of her elevated liver function tests.
For her elevated liver function tests, the patient had a
right upper quadrant ultrasound and Doppler. It did not show
any signs of [**Last Name (un) **]-occlusive disease or obstruction.
The patient's mental status waxed and waned during the course
of her admission. She required sedation when she was on the
ventilator.
9. DIABETES: She was started on an insulin sliding-scale;
however, she remained hypoglycemic during most of her
admission and required several D-5 ampules.
On her final day of the hospital course, family had a meeting
with the medical team and discussed wanting to extubate the
patient. The patient's poor prognosis was discussed with the
family as she likely had intravascular infection; however, it
was made clear that if she were extubated, she had a very good
chance of becoming hypoxic. This was understood by the
family who still wanted to extubate the patient. They indicated
that it had been the patient's expressed desire to avoid a
prolonged time on mechanical ventilation.
The patient was extubated, and within one hour after
extubation she became even more unresponsive and went into
ventricular tachycardia. The patient expired 30 minutes
later.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D.
[**MD Number(1) 3091**]
Dictated By:[**Name8 (MD) 9508**]
MEDQUIST36
D: [**2109-10-13**] 17:06
T: [**2109-10-14**] 14:32
JOB#: [**Job Number 18243**]
|
[
"443.9",
"038.11",
"250.80",
"403.91",
"V45.82",
"707.0",
"427.31",
"996.73",
"428.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.43",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
4125, 9843
|
3725, 3981
|
147, 2282
|
2305, 3698
|
3998, 4108
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,450
| 157,731
|
15579
|
Discharge summary
|
report
|
Admission Date: [**2112-9-12**] Discharge Date: [**2112-9-19**]
Service: Vascular
CHIEF COMPLAINT: Abdominal aortic aneurysm, symptomatic 7 cm
in size. Information was obtained from the patient and
daughter. The patient is fairer historian.
HISTORY OF PRESENT ILLNESS: A 79-year-old non diabetic white
male with a history of congestive heart failure,
hypertension, hypercholesterolemia with a partial
thyroidectomy status post TURP was found to have a pulsatile
abdominal mass on routine exam by his primary care physician
one month ago. There was some tenderness on palpation on
initial exam per patient.
A CT of the abdomen was obtained at [**Hospital 1474**] Hospital two
weeks ago. The patient developed hives secondary to the
intravenous contrast and was treated with Benadryl with some
relief and prednisone. The patient was referred to Dr.
[**Last Name (STitle) 1391**].
He was seen in the office on [**2112-9-7**]. The patient now denies
any abdominal or back pain. He does complain of a six month
history of bilateral calf claudication, left greater than
right.
PAST MEDICAL HISTORY:
1. Congestive heart failure a year ago with bilateral
pneumonia
2. Hypertension
3. Hypercholesterolemia
4. Right fifth finger fracture dislocation
5. History of goiter
6. History of pneumonia
7. History of hepatitis when in the military service
PAST SURGICAL HISTORY:
1. Partial thyroidectomy right lobe at [**Hospital1 2025**]
2. TURP at [**Hospital 1474**] Hospital
3. Appendectomy at the age of 20
4. Right saphenous vein excision 20 years ago
ADMISSION MEDICATIONS:
1. Verapamil 120 mg [**Hospital1 **]
2. Singulair 10 mg at hs
3. Cosopt drops 1 both eyes [**Hospital1 **]
4. ...............
5. Vitamin C
6. Zinc
7. Tums prn
8. Nitroglycerin 0.3 mg sublingual prn
9. Nabumetone 500 mg at hs
SOCIAL HISTORY: Retired radiology technologist. He is 79
years old. He is married, lives with his wife. Ambulates
independently. He is a former smoker. He used to smoke two
to three packs per day x30 years. Rare alcohol use.
PHYSICAL EXAM:
VITAL SIGNS: 97.6??????, 142/74, 82, 18, O2 saturation 96% on
room air.
GENERAL APPEARANCE: Alert, cooperative white male in no
acute distress.
HEAD, EARS, EYES, NOSE AND THROAT: Unremarkable.
PULSES: Carotids are palpable without bruits. Radials are
palpable bilaterally. Abdominal aorta is palpated without
bruit, without tenderness. Femoral pulses are palpable
bilaterally. Popliteal pulses are non palpable. Pedal
pulses are dopplerable signals bilaterally.
CHEST: Clear lungs. Heart is regular rate and rhythm
without murmur. Heart sounds are distant.
ABDOMEN: Remarkable for a pulsatile mass in the lateral to
the umbilicus on the left.
EXTREMITIES: Unremarkable.
RECTAL: External hemorrhoids, normal sphincter tone, smooth
prostate. Stool is guaiac negative.
NEUROLOGIC: Unremarkable.
PREOPERATIVE LABS: CBC: White count 5.2, hematocrit 41.8,
platelets 169,000. BUN 12, creatinine 0.8, potassium 4.3,
glucose 106. PT, INR and PTT were normal.
IMAGING: Electrocardiogram is a normal sinus rhythm with a
V-rate of 68, normal axis. There are no acute change
indicative of ischemia. Chest x-ray was unremarkable.
HOSPITAL COURSE: The patient was admitted to the
preoperative holding area on [**2112-9-12**]. He underwent an
abdominal aortic aneurysm repair with an aortobifemoral
bypass and right iliac aneurysm ligation. He tolerated the
procedure well and was transferred to the PACU in stable
condition. The patient had an epidural placed
intraoperatively for analgesia control. Postoperative check,
he was afebrile, hemodynamically stable. .............. was
30/14.
CVP 7, O2 saturation was 95%, on face mask 70%. His
postoperative hematocrit was 39.1, BUN 13, creatinine 0.8,
potassium of 3.8 which was supplemented. Calcium, magnesium
and phosphorus were normal. Electrocardiogram was without
acute changes. Chest x-ray was no pneumothorax.
Electrolytes were repleted. The patient continued to do well
and was transferred to the VICU for continued monitoring and
care.
Postoperative day 1, epidural remained in place. Epidural
was not working appropriately and he was given additional
medications intravenously. .............. finalized, he
remained stable. His hematocrit remained stable. His
abdominal exam was unremarkable. Wounds were clean, dry and
intact. The PCA was continued. The patient was begun on
antihypertensives which he had been on preoperative. He
remained NPO. The nasogastric tube was removed he remained
in the VICU.
Postoperative day 2, he continued on perioperative Ancef. He
was on nitroglycerin 5 mg per kg per minute for systolic
hypertension. He remained afebrile. Systolic pressure
156/64. Hematocrit 28.6. Continued on epidural and PCA.
Aggressive therapy was begun. He remained NPO. Protonix was
given intravenously. I felt that the ............... was
second to hemodilution and diuresis was begun. He remained
in the VICU. There was some mild confusion which we felt was
related to narcotics and his dosing was adjusted.
Postoperative day 3, the patient's confusion and agitation
improved with the use of Ativan. A-line was discontinued.
His hematocrit remained stable at 29.2. He did have bowel
sounds on exam. PCA was discontinued and he was begun on
oral analgesic agents. Hydralazine was added to his
antihypertensive regimen. Diuresis was continued and he
remained on nitroglycerin for systolic hypertension.
Postoperative day 4, he was weaned off the nitroglycerin.
His exam was remarkable for passing flatus. Abdomen was soft
and nondistended. Wounds were clean, dry and intact. He had
warm extremities and dopplerable DPs and PTs bilaterally.
Clears were begun and ambulation was begun. Physical therapy
saw the patient. His epidural was discontinued. They felt
that if he remained over the weekend working with PT that he
would be able to be discharged to home, but should have
continued home PT.
The patient was discharged in stable condition. Wounds
clean, dry and intact. He was tolerating regular food. He
should follow up with Dr. [**Last Name (STitle) 1391**] in one week's time to have
his routine postoperative visit follow up along with groin
skin clips removed. The abdominal skin clips were removed
prior to discharge and the wound was Steri-Stripped.
DISCHARGE MEDICATIONS:
1. Keflex 500 mg q6h. This will be continued as the patient
follows up with Dr. [**Last Name (STitle) 1391**] in one week's time.
2. Percocet tablets 1 to 2 q 4 to 6 hours prn for pain.
3. Metoprolol 50 mg [**Hospital1 **], hold for systolic blood pressure
less than 100, heart rate less than 60
4. Hydralazine 50 mg q6h, hold for systolic blood pressure
less than 110
5. Eyedrops 2% timolol 0.5% with Dorzolamide 2% drops one
both eyes [**Hospital1 **]
DISCHARGE DIAGNOSES:
1. Symptomatic abdominal aortic aneurysm, status post
resection with aortobifemoral and right iliac aneurysmal
ligation
2. Postoperative confusion secondary to narcotics, improved
3. Hypertension controlled
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2112-9-19**] 12:01
T: [**2112-9-19**] 12:09
JOB#: [**Job Number 45063**]
|
[
"443.9",
"401.9",
"442.2",
"293.0",
"441.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.52",
"38.44",
"03.90"
] |
icd9pcs
|
[
[
[]
]
] |
6881, 7367
|
6399, 6860
|
3245, 6376
|
1601, 1836
|
1394, 1578
|
2084, 3227
|
112, 257
|
286, 1096
|
1118, 1371
|
1853, 2069
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,162
| 100,147
|
6146
|
Discharge summary
|
report
|
Admission Date: [**2114-11-18**] Discharge Date: [**2114-11-19**]
Date of Birth: Sex:
Service:
DIAGNOSIS: Right temporal intracranial mass.
HISTORY OF THE PRESENT ILLNESS: This is a 53-year-old
gentleman who presented with vertigo and ringing in his ears
and headache since [**Month (only) 359**]. He had had a C-scan and MRI with
and without gadolinium at an outside hospital, where he was
diagnosed to have a 3-cm x 3-cm intracranial right temporal
mass. He was referred to the [**Hospital1 188**] for further evaluation.
HISTORY OF THE PRESENT ILLNESS: The patient has history of
headache, ringing of ears, and vertigo since [**Month (only) **] to
early [**Month (only) 359**]. There was no history of nausea, vomiting,
visual disturbance, diplopia, or seizures. There was no
evidence of weakness or tingling or numbness anywhere.
On admission, the patient was found to have a mass with edema
around it and bleeding surrounding the tumor. He was
admitted to the Intensive Care Unit for blood-pressure
control
and anti-seizure medication therapy and for close monitoring.
Further workup revealed left lung mass and adrenal mass;
preliminary diagnosis of carcinoma of the lung with extensive
metastasis had been made. Further workup was required. The
patient expressed explicit desire to be home on [**Holiday **] Eve
until [**Holiday **] and had no intentions of staying in the
hospital on [**Holiday **] Day. Therefore, he was started on
high-dose Decadron for anti-edema measures. He was
discharged home on high-dose Decadron. He will be having
further followup. He us scheduled for CT guided lung biopsy
on the [**3-22**] in the [**Hospital Unit Name 1825**] at 9:30 am. He
is also to continue on Decadron 8 mg p.o. q.6h. for two days
and 6 mg Decadron q.6h. for two days followed by 4 mg
Decadron q.6h. until he meets with Dr. [**Last Name (STitle) 724**] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
in the Brain [**Hospital 341**] Clinic on [**2114-11-26**].
Based on the tissue diagnosis, the patient will be having
eyelid surgery and chemotherapy or chemotherapy or
radiotherapy, which is to be decided. The patient was also
given strict instruction to contact us at the earliest date
if there is any change in his mental status or in the
severity of his headache.
ALLERGIES: The patient is allergic to LIPITOR AND SULFA. A
new allergy to DILANTIN was documented.
DISCHARGE MEDICATIONS:
1. Zantac 150 mg p.o.b.i.d.
2. Depakote 350 mg p.o. three times a day.
3. Decadron starting at 8 mg, tapering down to 4 mg p.o.
q.6h. until further followup and further plans will be made.
The patient is also noted to have a past medical history of
coronary artery disease with three-vessel stenting and
angioplasty; hypertension; diabetes mellitus, for which he
takes Insulin.
DISCHARGE CONDITION: The patient is awake, alert, oriented,
but no localizing signs, no focal lesions. The patient is
fully aware of the risks of him being discharged. The
patient is willing to go home.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 14-120
Dictated By:[**Last Name (STitle) 22910**]
MEDQUIST36
D: [**2114-11-21**] 10:43
T: [**2114-11-21**] 12:44
JOB#: [**Job Number 24026**]
|
[
"414.01",
"348.8",
"305.1",
"786.6",
"V45.82",
"401.9",
"255.9",
"250.01"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
2886, 3300
|
2481, 2864
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,923
| 165,076
|
44701
|
Discharge summary
|
report
|
Admission Date: [**2118-7-22**] Discharge Date: [**2118-8-5**]
Date of Birth: [**2038-5-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
rash
Major Surgical or Invasive Procedure:
Lumbar puncture
PEG placement
History of Present Illness:
This is a 80 yo Laotian speaking female with PMH significant for
osteoporosis, s/p L total hip replacement [**1-3**], s/p L hip
debridement and hardware removal [**7-3**] who presented with rash in
the setting of having been on multiple antibiotics in the past
3-4 weeks and L hip wound infection. The pt was originally
admitted to [**Hospital 882**] Hospital in late [**Month (only) 205**] with swelling and
infection of the left hip for which the patient was transferred
to [**Hospital1 18**] ortho. The patient was admitted [**2118-6-28**] to [**2118-7-18**] for
drainage and removal of hardware as well as treatment of
multiple decubitus ulcers noted on her coccyx and L hip.
Superficial swab cultures revealed only rare coag negative staph
and deep swabs revealed nothing. The patient was on a number of
abx regimens during this admission including Vancomycin,
Ertapenem, Zosyn, Meropenem (x 1 day), CTX and Flagyl with the
mainstay of therapy being Vanco, CTX, and Flagyl (until
[**2118-7-15**]). The patient was discharged to home with PT and family
care off antibiotics, afebrile, hemodynamically stable.
.
The patient represented to the hospital with rash and
accomanying fever and headache. The rash started on the trunk
and spread to the extremities and face, sparing the palms and
soles. Per family report, the patient (Patient is [**Country **] speaking,
minimally verbal and demented at baseline) was reporting diffuse
pain everywhere, but was without cough, diarrhea, N/V, SOB, CP.
Vitals in ED eval were 103.2, 102/94, 108, 97% on RA. Given
rash, fever, and headache an LP was performed that was not
consistent with meningitis. The patient had received Vanco and
CTX in the E.D. prior to LP for meningitis coverage.
Past Medical History:
osteoporosis
dementia, mostly nonverbal at baseline
h/o vasovagal event in past
s/p L hip DHS [**1-3**]
Social History:
-Lives with daughter, no tobacco/EtOH
-Laotian speaking (mostly nonverbal [**12-30**] dementia)
Family History:
Non-contributory
Physical Exam:
PE
VS: 100.1 Tm 101.1 119/64 101 22 100% RA
Gen: In fetal position, poorly responsive.
Integ: Diffuse macular rash over the neck, trunk, arms and legs.
No petechiae. Pressure ulcers over L and R hips as well as
decubitus region.
CV: Tachycardic. Regular rhythm. Normal S1 and S2.
Pulm: CTA b/l.
Abd: Soft, nontender, nondistended
Pertinent Results:
[**2118-7-22**] 01:30PM WBC-13.6*# RBC-3.70* HGB-10.2* HCT-30.7*
MCV-83 MCH-27.5 MCHC-33.1 RDW-16.1*
[**2118-7-22**] 01:30PM NEUTS-83.9* LYMPHS-8.3* MONOS-3.9 EOS-3.4
BASOS-0.4
[**2118-7-22**] 01:30PM PLT COUNT-365#
[**2118-7-22**] 01:30PM ANISOCYT-1+ MICROCYT-1+
[**2118-7-22**] 01:30PM GLUCOSE-183* UREA N-15 CREAT-0.9 SODIUM-140
POTASSIUM-3.2* CHLORIDE-104 TOTAL CO2-27 ANION GAP-12
[**2118-7-22**] 01:40PM LACTATE-3.5*
[**2118-7-22**] 01:30PM ALT(SGPT)-27 AST(SGOT)-35 ALK PHOS-182*
AMYLASE-51 TOT BILI-0.3
[**2118-7-22**] 01:30PM LIPASE-27
[**2118-7-22**] 01:30PM ALBUMIN-2.6* CALCIUM-8.0* PHOSPHATE-2.5*
MAGNESIUM-2.0
[**2118-7-22**] 02:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2118-7-22**] 02:50PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-SM
[**2118-7-22**] 02:50PM URINE RBC-[**1-30**]* WBC-[**1-30**] BACTERIA-FEW YEAST-MANY
EPI-0-2
[**2118-7-22**] 03:00PM LACTATE-2.6*
[**2118-7-22**] 04:30PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-2* POLYS-0
LYMPHS-0 MONOS-0
[**2118-7-22**] 04:30PM CEREBROSPINAL FLUID (CSF) PROTEIN-26
GLUCOSE-63
.
EKG: Sinus tach @105, nl axis and intervals. No ST changes.
.
CXR: LUL pneumonia
.
Head CT: No intracranial hemorrhage or mass effect. Stable
parenchyma since [**2118-1-14**].
Brief Hospital Course:
80 y.o. nonverbal Laotian-understanding only woman with
dementia, s/p surgical debridement and hardware removal of L hip
p/w fever, diffuse macular rash, pressure ulcers and LUL
pneumonia on CXR.
.
1) Fever. Consistent with either drug rash fever, [**12-30**] osteo at
site of ulcers or LUL pneumonia. LP without signs of infection,
and no UTI. All blood cultures were negative. Pt continued on
CTX for LUL pneumonia, restarted on Vancomycin for possible
osteomyelitis/soft tissue infection at site of ulcers. Completed
12 day course of Vancomycin. CTX swiched to levaquin for
treatment of PNA. Repeat CXR was also significant for L
retrocardiac opacity. While in MICU, IV antibiotic coverage
broadened to include IV Flagyl and Meropenum (see below) as pt c
continued fevers, leukocytosis, and hypotension which were
subsequently d/c'd as pt clinically improved. The pt was kept on
Levaquin for a 10 day course of treatment for PNA. Had low grade
fever to 100.5 on day of discharge, however subsequently
defevesced and remained AF. The pt was discharged home to
complete a 10 day course of Levaquin.
.
2) Rash - Seen by dermatology who believed that rash was likely
[**12-30**] drug rash as pt had had exposure to a number of antibiotics
over the past month. Pt with no other exposures for etiology of
rash. The pt was continued on Vancomycin and CTX and later added
on Flagyl, Meropenum, and Levaquin with improvement in drug
rash. Was given clobetasol cream which was eventually d/c'd and
given sarna lotion prn. The rash subsequently resolved during
hospital course.
.
3) Hypotension - During hospital course, pt became hypotensive
with SBPs in the 70-80s, was transferred to the MICU as was not
responded well to IVF boluses. In the MICU, never required
pressors and was IVF boluses were continued. As pt still c
leukocytosis and occasional low grade fevers, antibiotics were
broadened to include Vancomycin, Meropenum, and Flagyl.
Subsequently with decreased WBC, remained AF, BPs stable and did
not require further IVF boluses. Meropenum and Flagyl were d/c'd
as only source isolated on pt was LUL and L retrocardiac PNA and
possible soft tissue infection [**12-30**] decub ulcers and open L hip
wound. Pt was called out of MICU and transferred to floor for
further management. No further episodes of hypotension while on
the floor.
.
4) Altered mental status - Per family, pt's baseline is alert to
self; however not oriented to place or date. Occasionally verbal
c family, will speak in [**11-29**] word sentences. On admission, it was
thought that PNA may be playing a role. There no acute CVA on
CT, LP without infection, TSH wnl. Upon discharge, the pt was
near her baseline per her family. Was more awake, occasionally
spoke in 1 or 2 word sentences in Laotian.
.
5) Decub ulcers - The pt has stage III R trochanteric and sacral
decub ulcers as well as open L hip wound. Started on Vancomycin
for possible soft tissue infection/osteomyelitis given fevers
and leukocytosis, X 12 days. Seen by woundcare nurse who
recommended wet to dry dressing changes tid without accuzyme
until more granulation tissue present.
.
5) Anemia - Iron studies consistent with anemia of chronic
disease (low iron, low TIBC, high ferritin). During hospital
course, Hct initially hovering around pt's baseline of high 20s;
however noted to slowly trend down. Hemolysis labs mixed with
low haptoglobin, elevated LDH, but nl total bilirubin. Guiaic
negative, no frank episodes of BRBPR, melena, hematochezia.
.
6) Thrombocytopenia - Plt count noted to trend down from
baseline in 200s, down to as low as 130s with elevated PTT, but
nl INR/PT. DIC labs significant for possible chronic smoldering
DIC picture. HIT Ab negative. Plt count eventually drifted back
up to upper 100s, low 200s with normalization of PTT.
.
7) B/L pleural effusions - Pt became increasingly fluid
overloaded on exam during hospital course and CXR significant
for b/l pleural effusions. Was diuresed successfully with Lasix
20 IV prn to keep I/O negative. No h/o CHF.
.
8) FEN - Pt started on tube feeds as failed swallow study [**12-30**]
AMS. Malnourished at baseline with low albumin. Per family, is
fed soft foods at home. At family mtg, agreed to PEG placement
for long-term nutritional needs as per daughter and HCP, pt had
expressed that she did not want to die prior to admission. PEG
placed successfully by GI and tube feeds started X 24 hrs.
.
9) PPX. PPI, Bowel regimen, SC Heparin.
.
DNR/DNI but pressors ok per HCP (daughter [**Name (NI) 95643**] [**Name (NI) 95642**]
[**Telephone/Fax (1) 95644**]).
.
The pt was discharged home in stable condition with visiting
nursing services. The family is very involved in the pt's care
and were instructed to continue levaquin to complete a 10 day
course, instructed on wound care, and instructed on how to
properly feed pt through PEG.
Medications on Admission:
SQ Heparin
Fosamax x 1 dose
................
Antibiotic history
Vancomycin [**6-28**]->[**7-15**]
Ertapenem [**6-28**]->[**6-29**]
Zosyn [**6-29**] x1
Zosyn [**6-29**] x1
Meropenem [**6-29**]->[**6-29**]
Zosyn [**6-29**]->[**7-3**]
CTX [**7-1**]->[**7-15**]
Flagyl PO [**Date range (1) 9463**]
Flagyl IV [**7-8**]->[**7-15**]
=============
Vanco [**7-23**]->[**8-2**]
CTX [**7-22**]->[**7-23**]
Ceftaz [**7-23**]->[**7-24**]
Levoflox [**7-24**]->[**7-25**]
Flagyl [**7-24**]->[**7-28**]
Meropenem [**7-25**]->[**7-28**]
Levaquin [**7-30**] -->
Discharge Medications:
1. Promote with Fiber Liquid Sig: Seventy Five (75) cc PO
per hour: Tube feeds @ 75 cc/hr X 16 hrs daily, flush with 150
cc free water q4h. If tolerates 75 cc/hr X 16 hrs X 2 days, may
increase TF rate to 100 cc/hr, cycle for 12 hrs. .
Disp:*2250 cc* Refills:*2*
2. Enteral Pump Set Misc Sig: One (1) Miscell. once a day.
Disp:*1 pump set* Refills:*2*
3. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) mL PO BID
(2 times a day).
Disp:*600 mL* Refills:*2*
4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
Disp:*90 mL* Refills:*2*
6. nutrition
Needs outpatient f/u with nutrition to follow up tube feeding
recommendations, possibly increase tube feed rate so they are
only running overnight (12 hrs).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Pneumonia
Drug Rash
status post L hip debridement and hardware removal
Osteoporosis
Dementia
Discharge Condition:
Stable.
Discharge Instructions:
Please follow up with your primary care physician [**Name Initial (PRE) 176**] 1 week.
Please take all medications as instructed. You are on an
antibiotic called Levofloxacin for treatment of a pneumonia. You
will need to take it as directed for 3 more days.
Please continue tube feeds via PEG tube as instructed by nurses.
You will need dressing changes to your wounds once a day. A
visiting nurse will come by periodically to assist with this.
Return to the hospital if you experience fevers, chills, night
sweats, chest pain, shortness of breath, abdominal pain, nausea,
vomiting, diarrhea, altered mental status.
Followup Instructions:
Please follow up with your primary care physician [**Name Initial (PRE) 176**] 1 week.
A visiting nurse will come by to help assist with your wound
care and feeding needs.
Completed by:[**2118-8-5**]
|
[
"458.9",
"276.52",
"486",
"707.03",
"511.9",
"733.00",
"780.09",
"263.9",
"693.0",
"294.8",
"784.3",
"276.0",
"599.0",
"285.29",
"E930.8",
"276.8",
"287.30",
"998.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.22",
"03.31",
"38.93",
"99.04",
"43.11",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
10451, 10509
|
4108, 8960
|
317, 348
|
10645, 10654
|
2749, 3991
|
11324, 11528
|
2366, 2384
|
9554, 10428
|
10530, 10624
|
8986, 9531
|
10678, 11301
|
2399, 2730
|
273, 279
|
376, 2109
|
4000, 4085
|
2131, 2236
|
2252, 2350
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,530
| 167,410
|
54922
|
Discharge summary
|
report
|
Admission Date: [**2114-9-2**] Discharge Date: [**2114-9-15**]
Date of Birth: [**2062-12-12**] Sex: M
Service: MEDICINE
Allergies:
morphine
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
tunneled dialysis line placement
paracentesis
History of Present Illness:
51 M hemachromatosis and EtOHism with cirrhosis, discharged from
OSH after MSSA bacteremia, tense ascites and encephalopathy
following a cholescystectomy for gallstones. He was treated with
oxacillin for two weeks and d/ced on the [**8-23**]. He was readmitted
on [**2022-8-25**] with weakness, pain and decreased UOP, possibly
secondary to abdominal compartment syndrome. Paracentesis on
[**2114-8-27**] at [**Hospital3 **] Hospital removed 6L, BP improved. His
creatinine on admit was 4 (from 1) and rose to 10.2 and he was
transferred to [**Hospital1 18**] for CVVH.
Past Medical History:
- Alcoholic and Iron Overload Cirrhosis complicated by ascites,
encephalopathy and variceal bleed.
- per patient, two months ago had large volume hemetemesis at
the beach, no eval
- noted to develop fluid distension 2 weeks ago after chole
- encephalopathic in the hospital
- Cholecytectomy in [**Month (only) 205**] with complications:
- hepatic decompensation
- MSSA wound infection with bacteremia
- Malnutrition
- History of hypertension
- History of Depression
- s/p thyroidectomy [**11-15**]
- s/p left rotator cuff repair
- s/p removal of left neuroma
- s/p left lower extremity nerve release
Social History:
History of heavy alcohol use since he was 13yo, last drink was
[**2114-7-30**]. He smokes [**1-8**] ppd. No drug use.
Family History:
Significant for diabetes.
Physical Exam:
Admission Physical Exam:
Vitals:98.5, 100/44, 86, 17, 96%RA
General: Alert, oriented x3 in NAD, resting comfortably at 30deg
in bed
HEENT: Sclera anicteric, dry mmm, Thrush coating tongue and onto
hard pallate
Neck: supple, JVP not elevated, no LAD
CV: RRR,2/6 systolic murmur at apex radiating to the axilla, no
rubs or gallops appreciated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: protuberant, soft, not tense, normoactive bowel sounds
GU: no foley
Ext: warm, well perfused, 3+pitting edema to the knees
bilaterally, trace DP pulses bilaterally, brisk cap refill
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact. No asterixis
Discharge Physical Exam:
Vitals - 99.0 95/43 73 29 99%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, with a [**2-12**]
holosystolic murmur, LUSB, without radiation
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, hepatosplenomegaly, liver
edge 3cm below the costal margin. Dressings CDI.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: [**Last Name (LF) 3899**], [**First Name3 (LF) 13775**]. No asterixis.
Pertinent Results:
Admission Labs:
[**2114-9-2**] 10:00PM GLUCOSE-82 UREA N-61* CREAT-10.1* SODIUM-134
POTASSIUM-5.9* CHLORIDE-100 TOTAL CO2-18* ANION GAP-22*
[**2114-9-2**] 11:08PM TYPE-ART TEMP-37.1 PO2-75* PCO2-26* PH-7.43
TOTAL CO2-18* BASE XS--4 INTUBATED-NOT INTUBA
[**2114-9-2**] 05:20PM ALT(SGPT)-25 AST(SGOT)-51* ALK PHOS-178* TOT
BILI-0.8
[**2114-9-2**] 05:20PM ALBUMIN-2.7* CALCIUM-8.4 PHOSPHATE-6.5*
MAGNESIUM-2.4
[**2114-9-2**] 05:20PM WBC-7.4 RBC-3.07* HGB-9.4* HCT-29.8* MCV-97
MCH-30.6 MCHC-31.5 RDW-17.7*
[**2114-9-2**] 05:20PM NEUTS-57.3 LYMPHS-29.4 MONOS-9.9 EOS-2.2
BASOS-1.2
[**2114-9-2**] 05:20PM PLT COUNT-142*
[**2114-9-2**] 05:20PM PT-13.1* PTT-38.8* INR(PT)-1.2*
Discharge Labs:
[**2114-9-15**] 08:02AM BLOOD WBC-4.8 RBC-2.81* Hgb-8.7* Hct-27.1*
MCV-97 MCH-31.0 MCHC-32.0 RDW-18.3* Plt Ct-115*
[**2114-9-15**] 08:02AM BLOOD Plt Ct-115*
[**2114-9-15**] 08:02AM BLOOD PT-14.3* INR(PT)-1.3*
[**2114-9-15**] 08:02AM BLOOD Glucose-94 UreaN-28* Creat-6.3*# Na-135
K-3.7 Cl-97 HCO3-31 AnGap-11
[**2114-9-15**] 08:02AM BLOOD TotBili-1.5
[**2114-9-15**] 08:02AM BLOOD Calcium-8.4 Phos-2.5* Mg-1.9
[**2114-9-5**] 05:52AM BLOOD calTIBC-143* VitB12-[**2008**]* Folate-GREATER
TH Ferritn-36 TRF-110*
[**2114-9-3**] 04:06AM BLOOD TSH-1.0
[**2114-9-3**] 04:06AM BLOOD Cortsol-22.3*
[**2114-9-11**] 06:33AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV
Ab-NEGATIVE IgM HBc-NEGATIVE
[**2114-9-4**] 01:24AM BLOOD HIV Ab-NEGATIVE
[**2114-9-11**] 06:33AM BLOOD HCV Ab-NEGATIVE
Brief Hospital Course:
51 yo M w/ PMH of cirrhosis [**2-8**] to alcohol and hemachromatosis
who was undergoing treatment for MSSA bacteremia s/p CCY who
developed renal failure requiring dialysis who was transferred
from an OSH for further management.
#Renal failure - Patient was recently treated for MSSA
bacteremia s/p cholecystectomy with oxacillin. He represented to
OSH 2 days later found to have weakness, pain and decreased
urine output. He was also noted to be hypotensive. His
creatinine increased to 10 at which point he was transferred to
[**Hospital1 18**] for further management and CVVH. Initially there was
concern for possible HRS so he was fluid challenged with albumin
and initially treated with octreotide and midodrine. At the
OSH, his UA was negative. He had an abdominal ultrasound which
showed normal sized kidneys without evidence of obstruction. He
initially underwent CVVH in the ICU, and was eventually able to
transition to HD given that he was no longer hypotensive s/p the
removal of 4 L of fluid after a paracentesis. Per renal, his
renal failure was likely due to ATN. He was started on dialysis
and tolerated this well. Given that he is currently dialysis
dependent, he did not continue midodrine and octreotide.
Tunneled line was placed on [**9-12**]. PPD negative [**9-13**]. HD schedule
Tu/Th/Sa. He was started on nephrocaps and calcium acetate
# Cirrhosis- Patient has a cirrhosis due to hemachromatosis and
alcohol complicated by hepatic encephalopathy. His MELD on ICU
admission was 22 and remained in the 20s. He was continued on
his lactulose and rifaximin, and Hepatology was consulted to aid
in recommendations for his cirrhosis. EGD performed [**9-6**] showed
2 stage 1 varices and findings suggestive of Barrett's esophagus
although no biopsies were taken. Hemochromatosis genetic screen
sent and showed that he was HOMOZYGOUS FOR THE C282Y MUTATION.
His hepatitis serologies were negative. He had 3 theraputic
paracentesis during this admission, the last paracentesis was on
[**9-14**] removing 4.5L. The patient was counseled about the
importance of a low salt diet and complete sobriety. He should
follow up with hepatology (Dr. [**Last Name (STitle) **] in 1 month, and have a
repeat EGD in 1 year.
# Hypotension- His hypotension was felt in the ICU to be most
likely secondary to tense ascites. Significant improvement of
hypotension after therapeutic paracentesis (4L removed) on [**9-3**].
Given improvement of blood pressure following drop in
intra-abdominal pressure, hypotension was most likely secondary
to poor venous return due to intra-abdominal hypertension. At
OSH, he was stated on Zosyn for concerns for bacteremia and
sepsis, but blood, urine, and peritoneal cultures from there as
well as our own were negative, and he had already completed a 2
week course of antibitoics for MSSA bacteremia, therefore
antibiotics were discontinued. He was briefly on pressors while
in the MICU, but was able to wean off quickly. TSH and Cortisol
level were normal. Blood pressure remained stable mostly in the
90s.
# Hypoventilation- Overnight on [**9-5**] when abdomen tense. SOB
improved with sitting up in a chair. No fevers, chills or cough.
ABG showed moderate hypoxemia. Likely due to tense ascites
causing decreased volume of ventilation. Improved with
paracentesis.
# MSSA bacteremia- Patient was origianlly treated with oxacillin
at the OSH with a total 2 weeks of antibiotics. Given that
patient presented with shock physiology he was initially
maintained on broad spectrum antibiotics with Vanc and Zosyn.
Cultures from OSH and here were negative for bacteremia. At this
point hypotension seems most likely secondary to abdominal
compartment syndrome. As such, all antibiotics in the MICU at
[**Hospital1 18**] were DC'ed, and a TTE done in house did not show any
vegetations.
# Anemia- Dropped as low as 22.5. No overt signs of bleeding,
negative stool guiac. Likely multifactorial. Hct improved on the
floor and remained stable in the high 20s throughout the rest of
his course.
# EtOH abuse- Patient given thiamine and folate. The importance
of avoiding all alcohol and the risks associated with drinking
were discussed with the patient. Social work provided him with
outpatient resources.
# Malnutrition- On admission the patient has a low albumin of
1.9, likely both secondary to liver disease and poor nutrition
in setting of alcohol abuse. Nurtition was consulted and made
recommendations to increase calorie intake, with low phos and
salt intake and 2L fluid restriction
# Hypothyroidism- TSH within normal limits. Continued home
levothryroxine dose.
# Depression- continued home zoloft. Given trazodone 12.5mg po
qhs prn insomina
# Access- patient had PICC line and HD line in place on
admission. We replaced the PICC line while the patient was in
the ICU. We replaced the HD line with a more permanent tunneled
line while on the floor. He underwent mapping for a left arm AV
fistula.
TRANSITIONAL ISSUES
- HD schedule Tu/Th/Sa
- EGD with biopsy in 1 year
- Vaccinate for Hep A and B as outpatient
- HCC surveillance every 6 months with AFP and abdominal US
- no additional labs pending
- patient full code during this admission
Medications on Admission:
MEDICATIONS AT HOME:
lisinopril 40 mg po daily
levothyroxine
ativan
zoloft
flagyl 3 times daily
oxacillin
aldactone
folate
lactulose
thiamin
multivitamin
rifaximin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 8 hours Disp
#*60 Tablet Refills:*0
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Lactulose 30 mL PO TID
RX *lactulose 10 gram/15 mL 30 mL by mouth three times a day
Disp #*3000 Milliliter Refills:*0
4. Levothyroxine Sodium 137 mcg PO DAILY
RX *levothyroxine [Levothroid] 137 mcg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
5. Nephrocaps 1 CAP PO DAILY
RX *B complex-vitamin C-folic acid [Nephrocaps] 1 mg 1
capsule(s) by mouth daily Disp #*30 Capsule Refills:*0
6. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
7. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
8. Sertraline 150 mg PO DAILY
RX *sertraline [Zoloft] 100 mg 1.5 tablet(s) by mouth daily Disp
#*45 Tablet Refills:*0
9. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
10. Calcitriol 0.25 mcg PO DAILY
RX *calcitriol 0.25 mcg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
11. Calcium Acetate 667 mg PO TID W/MEALS
RX *calcium acetate 667 mg 2 tablet(s) by mouth TID with meals
Disp #*180 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Cirrhosis
Renal failure
Sepsis
Secondary Diagnoses:
hypothyroid
depression
alcohol abuse
gastroesophageal reflux disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure caring for you while you were admitted to
[**Hospital1 18**]. You were admitted because you had a bacterial infection
in your blood and very low blood pressure requiring care in the
ICU at [**Hospital3 **] Hospital. While in the ICU, your kidneys failed
and you needed continuous hemofiltration which required transfer
to [**Hospital1 18**]. Your bacterial infection was treated with antibiotics
and your blood cultures were negative by discharge. Your liver
failure, which is due to your alcoholism and hemachromatosis,
led to fluid build up in your abdomen and the pressure caused
worsening of your low blood pressure and difficulty breathing.
This was relieved with repeated paracentesis (draining the fluid
with a needle) and fluid being taken off with regular dialysis.
You had a endoscopy procedure which showed two stage one varices
and mucosal dysplasia which needs to be followed up with another
endoscopy with Dr. [**Last Name (STitle) 42375**] in one year. You also developed a
fungal infection which was treated with Nystatin and resolved by
discharge.
You had a tunnelled line placed under anesthesia to protect
your access for hemodialysis. You will need to remain on
dialysis as an outpatient, your current schedule is Tuesday,
Thursday and Saturday.
You should stop drinking all alcohol. The social worker has
provided you with the following resources:
1) [**Location (un) 3244**] [**Last Name (un) 23328**] Outpatient Counseling Centers offers addiction
counseling on a sliding scale basis. The phone number for
[**Location (un) 3244**] is [**Telephone/Fax (1) 70467**]. The closest one to you is located in
[**Location (un) 9101**] at [**Hospital1 112171**].
In order to get an appointment, please call the Central Intake
Department for Outpatient Admissions at [**Telephone/Fax (1) 112172**]
(this is the extension for admissions). They will carry out an
intake on the phone, and then will set up a diagnostic
appointment at a counseling center location closest to the
patient's house (this will most probably be the one in [**Location (un) 9101**]).
Once the patient goes in for an appointment, they will go over a
financial agreement which will include a sliding scale fee
structure.
2) [**Hospital3 **] Human Services (part of [**Hospital3 **] Health), in [**Location (un) 9101**]
at [**Telephone/Fax (1) 112173**] may offer sliding scale counseling services for
addictions.
INFORMATION RE: REFILLING YOUR PRESCRIPTIONS:
Due to the type of insurance you have (Health Safety Net) you
will need to get all your medications filled at the Care Plus
Pharmacy here at [**Hospital1 18**]. The contact information is as follows:
([**Hospital1 112174**]
[**Location (un) 86**], [**Numeric Identifier 6425**]
Each time you need to get your medications filled, you will need
to call [**Hospital1 18**] financial assistance office at [**Telephone/Fax (1) 112175**] to get
a clearance form for your medications to be paid for. This call
must be made on the same day that you pick up your medication.
Unfortunately, the pharmacy is not able to mail your medication
to you at home.
If you need any assistance with this process you can call the
medication assistance counselor, [**First Name4 (NamePattern1) 7346**] [**Last Name (NamePattern1) 16471**] at [**Telephone/Fax (1) 21384**].
The following changes have been made to your medication regimen.
Please START taking
- calcium acetate 667 mg by mouth 3 times daily with meals (a
new kidney medication to regulate your phosphate levels)
- calcitriol 0.25 mg daily (to help regulate your calcium)
- nephrocaps 1 tab daily (a vitamin)
- pantoprazole 40 mg daily (for your acid reflux)
Please STOP taking
- lisinopril
- aldactone
Please take the rest of your medications as prescribed and
follow up with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 1988**].
Followup Instructions:
Department: Primary Care
Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8049**]
When: Dr. [**Last Name (STitle) 79813**] office is working on a follow up appointment for
you in [**4-15**] days after your hospital discharge. You will be
called by the office with your appoinmtment date and time.
Location: [**Doctor Last Name **] RIVER MEDICAL ASSOCIATION
Address: [**Hospital1 25492**], [**Location (un) **],[**Numeric Identifier 7398**]
Phone: [**Telephone/Fax (1) 14935**]
Department: LIVER CENTER
When: WEDNESDAY [**2114-10-17**] at 1:40 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2114-9-17**]
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59,392
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Discharge summary
|
report
|
Admission Date: [**2146-2-10**] Discharge Date: [**2146-2-23**]
Date of Birth: [**2062-8-27**] Sex: F
Service: MEDICINE
Allergies:
Hydrochlorothiazide
Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
[**2146-2-12**] Open reduction internal fixation of L femur
History of Present Illness:
(obtained from floor team and ortho notes, as patient is
intubated): 83 y/o F with COPD (2L home O2 by NC), RA (on
chronic prednisone), hypertension, recent T LHA, initially
transferred to medical floor from OSH on [**2-10**] for hip fracture.
She is now s/p [**Month/Year (2) 24785**] of L periprosthetic femur fracture,
transferred post-operatively to MICU for hypotension and
inability to wean ventilator in the PACU. She initially
presented on [**2-10**] after tripping over oxygen tubing in her
kitchen. She called EMS, who brought her to [**Hospital3 19345**] ED. There, she had a negative head CT, and her INR was
> 5. Hip films revealed left hip fracture, and she was
transferred to [**Hospital1 18**] for further management.
.
At [**Hospital1 18**], repeat head CT was negative for acute abnormalities.
Films of her LLE revealed periprosthetic femoral fracture. She
was seen by ortho, who recommended admission to medicine service
for management of supratherapeutic INR. BP on transfer to the
floor was reportedly 95/58.
.
She was taken to the OR today for [**Hospital1 24785**]. EBL 1000 cc.
Post-operatively, the patient's blood pressure trended down.
Flow sheets indicate BP as low as 85/45. She remained intubated
as she was pulling small tidal volumes in the OR. Her ventilator
settings were changed from CPAP to CMV at 1700, when she
appeared to be using accessory muscles to breathe. She spiked
fevers in the PACU to 101.9. She reportedly had episodes of SVT
that resolved without intervention. Medications given in PACU
included morphine (total 4 mg IV), acetaminophen 650 mg,
enoxaparin 40 mg SC, kefzol 1g IV, and hydrocortisone 100 mg.
.
On arrival to the MICU, the patient matained her blood pressure
on phenylephrine 4 mcg/kg/min. She later went into a sustained
SVT, with a drop in her blood pressure. The rhythm initially
appeared regular on telemetry, and adenosine 6 mg was given
without effect. 12 lead ECG was obtained, showing rapid afib
with RVR. She was given metoprolol 5 mg and amiodarone 150 mg
push without any appreciable change in her heart rate or rhythm.
She was cardioverted unsuccessfully x3 attempts. A subclavian
line was placed, and amiodarone gtt was started.
Past Medical History:
L hip hemiarthroplasty for fracture [**10/2145**] @ [**Hospital3 **]
COPD (on home O2- 2L NC @ night and w/activity during day)
RA (on Prednisone)
HTN
Osteoporosis
Afib on coumadin, chemical conversion w/sotalol *in setting of L
hip fracture
CHF*recent diagnosis w/L hip fracture
Social History:
Lives alone in apartment. Had VNA coming 3x/week s/p L hip
fracture, on hold now. Quit smoking 30 yrs ago. Denies EtOH,
drugs. 2 daughters who live in [**Name (NI) **]. Used walker at home with
ambulation.
Family History:
Non-contributory
Physical Exam:
ADMISSION:
Vitals: T: 97.5 BP: 128/61 P: 72 R: 20 O2: 96% on 2L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: diffuse decr breath sounds, no wheezes or crackles,
absence of L breast tissue
CV: RRR, no murmurs, rubs, gallops
Abdomen: soft, non-distended, bowel sounds present, tenderness
in L hip area when palpating the abdomen
Ext: Warm, well perfused, cannot move L leg [**3-2**] severe pain,
+ttp in hip area, no redness, swelling or warmth in L hip,
+swan-neck deformities in bilat hands
Neuro: oriented x3, CNII-XII intact, movement and strength of
LLE inhibited [**3-2**] pain, sensation intact throughout
Skin: scattered ecchymosis on bilat arms
.
ADMISSION TO MICU:
VS: Temp:101.3 BP:135/67 HR:91 RR:15 O2sat:100%
Ventilator: Assist control @ 500x14, PEEP 5, FiO2 50%
GEN: intubated, awake, NAD
HEENT: PERRL, EOMI, anicteric, ETT in place. No JVD. No cervical
lymphadenopathy
RESP: Mild bibasilar crackles, no wheeze or rhonchi
CV: RRR, nl S1/S2, no S3/S4/M/R
ABD: softly distended, NT, NABSx4, no masses or
hepatosplenomegaly. No rebound tenderness or guarding
EXT: no c/c/e. +dopplerable DP pulses bilaterally
SKIN: Various areas of ecchymosis including left neck, right
upper extremity. No rashes
NEURO: Awake and alert despite sedation. Nodding head,
responding to questions, squeezing fingers and wiggling toes on
command. PERRL, EOMI.
.
DISCHARGE:
VS: 99.1 99.0 148/65 71 24 93% 2.5L NC FSBG 136
General: Elderly woman sitting in chair near nurses station, no
acute distress.
HEENT: Sclera pale, anicteric, MMM, oropharynx clear, poor
dentition.
Neck: Supple, JVP not elevated, no LAD
Lungs: CTABL. No wheezes, crackles, rales, rhonchi.
CV: Regular rate, normal rhythm, no murmurs, rubs, gallops
Abdomen: soft, non-distended, bowel sounds present, non-tender
Ext: WWP, with brisk capillary refill. No cyanosis, clubbing or
edema. Lateral incision with staples along L femur, clean, dry,
intact. No overlying erythema, ecchymosis, draining or
induration. Swan-neck deformities in bilat hands, deformed
bilateral ankles.
Neuro: Oriented x2 (person, place), CNII-XII intact.
Skin: Scattered ecchymosis on bilat arms and legs, with skin
breakdown proximal to left olecranon process.
Pertinent Results:
LABS ON ADMISSION:
[**2146-2-10**] 05:40PM BLOOD WBC-9.8 RBC-3.47* Hgb-10.7* Hct-31.8*
MCV-92 MCH-30.8 MCHC-33.6 RDW-15.1 Plt Ct-240
[**2146-2-10**] 05:40PM BLOOD Neuts-82.2* Lymphs-11.9* Monos-5.3
Eos-0.3 Baso-0.2
[**2146-2-10**] 05:40PM BLOOD PT-48.4* PTT-32.8 INR(PT)-5.3*
[**2146-2-13**] 03:50AM BLOOD Fibrino-556*
[**2146-2-11**] 09:45AM BLOOD Ret Aut-3.5*
[**2146-2-10**] 05:40PM BLOOD Glucose-134* UreaN-41* Creat-1.1 Na-144
K-4.0 Cl-99 HCO3-38* AnGap-11
[**2146-2-11**] 05:30AM BLOOD LD(LDH)-207 CK(CPK)-66 TotBili-0.7
DirBili-0.2 IndBili-0.5
[**2146-2-11**] 05:30AM BLOOD CK-MB-3 cTropnT-0.02*
[**2146-2-10**] 05:40PM BLOOD Calcium-10.0 Phos-3.7 Mg-1.6
[**2146-2-11**] 05:30AM BLOOD calTIBC-257* Hapto-92 Ferritn-112
TRF-198*
.
LABS ON DISCHARGE:
[**2146-2-23**] 05:35AM BLOOD WBC-11.4* RBC-3.40* Hgb-10.3* Hct-31.1*
MCV-92 MCH-30.3 MCHC-33.2 RDW-18.3* Plt Ct-429
[**2146-2-23**] 05:35AM BLOOD PT-11.9 PTT-26.4 INR(PT)-1.0
[**2146-2-23**] 05:35AM BLOOD Glucose-133* UreaN-33* Creat-1.0 Na-140
K-4.4 Cl-100 HCO3-34* AnGap-10
[**2146-2-20**] 04:15AM BLOOD ALT-31 AST-27 LD(LDH)-421* AlkPhos-100
TotBili-1.2
[**2146-2-23**] 05:35AM BLOOD Calcium-10.1 Phos-3.3 Mg-2.3
[**2146-2-22**] 04:35AM BLOOD Type-ART pO2-74* pCO2-48* pH-7.45
calTCO2-34* Base XS-7
[**2146-2-23**] 12:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
[**2146-2-23**] 12:00PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2146-2-23**] 12:00PM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-0
[**2146-2-23**] 12:00PM URINE CastHy-6*
[**2146-2-23**] 12:00PM URINE Mucous-RARE
.
IMAGING:
ECG: Sinus rhythm at 84 bpm. NA/NI. +TWI in V2-V5, +TWF in V1.
Sub-mm ST depressions in V4.
.
[**2-10**] ECG: Sinus rhythm. Diffuse T wave changes which are
non-specific. No previous tracing available for comparison.
.
[**2-10**] CXR: Limited study as above. There is an eventration of the
right hemidiaphragm of indeterminate acuity. Otherwise, no acute
pulmonary process.
.
[**2-10**] Bilateral hip film: Normal right hip. Question possible
fracture, age indeterminate, of the left parasymphyseal superior
pubic ramus. Apparent left femur fracture due to immobilization
device which limits evaluation of the pelvis as above.
.
[**2-10**] Left femoral film: Mid distal femoral diaphyseal fracture
as detailed above.
.
[**2-12**] LLE fluoro: Thirty five intraoperative spot views. Compared
with the recent study of [**2146-1-31**]. A left hip prosthesis is in
place as before. Oblique fracture of the femoral diaphysis is
redemonstrated. Multiple spot views demonstrate placement of a
slotted plate, multiple screws and cerclage wires. Later images
appear to demonstrate good alignment of fracture fragments. See
operative note.
.
[**2146-2-15**] RUQ U/S: (prelim) Limited portable examination, however,
no significant intrahepatic biliary dilatation noted.
.
TTE: Moderate pulmonary hypertension with mildly dilated and
hypokinetic RV as well as moderate functional tricuspid
regurgitation. Normal global and regional left ventricular
systolic function.
.
CTA Chest [**2-13**]:IMPRESSION:
1. No PE or acute aortic syndrome.
2. Moderate bilateral pleural effusions with associated
atelectasis, worse on the right than the left.
Brief Hospital Course:
**OUTSTANDING ISSUES:
-Please check CBC within the next week; WBC minimally elevated
at 11.4 AM of discharge, pt afebrile. UA on day of discharge
negative, urine culture negative.
.
83 y/o F with a history COPD (baseline 2L home O2 requirement),
RA (on chronic prednisone 2.5 mg daily), hypertension, CHF,
recent T LHA c/b CHF and afib who was initially transferred to
medical floor from OSH on [**2-10**] for L periprosthetic femur
fracture w/elevated INR, now s/p [**Month/Year (2) 24785**] on [**2-12**] with postoperative
transfer to the MICU for hypotension and weaning off the vent;
pt extubated on [**2-21**], transferred to the floor the evening of
[**2-22**] in stable medical condition.
.
# s/p [**Month/Year (2) 24785**] L Femur: Patient underwent [**Month/Year (2) 24785**] for left femur
fracture on [**2-12**]. Per orthopedic surgery, she should remain
non-weight bearing on LLE until follow-up. Will continue ppx
Lovenox 40mg SC daily until INR reaches 2.0-2.5 on coumadin.
Patient denying pain, would recommend Tylenon prn. Staples
removed on POD 12 prior to discharge.
.
# Hypotension: Resolved, present in post-operative period in
setting of blood loss during [**Month/Year (2) 24785**] on [**2-12**]. Required ongoing
post-operative vasopressor support which necessitated transfer
to the MICU. Initially multiple possible etiologies, including
hypovolemic (significant decrease in hgb/hct, despite two unit
RBC transfusion this morning), sepsis (fevers in setting of
recent surgery), adrenal insufficiency (on chronic
glucocorticoid therapy), or cardiogenic (given ECG changes and
SVT). CVP was low and IVF was given with some improvement in her
MAPs and decreased pressor requirement. Stress dose
glucocorticoids were started with improvement and sedation was
weaned which also helped. CTA was negative for PE and TTE
showed RV hypokinesis suggesting that she may be more volume
responsive. Eventually the pressors were weaned off with IVF
boluses and her home anti-hypertensives were reinitiated. Her
steroids were also weaned back to her home dose (which she takes
for rheumatoid arthritis).
.
# Unstable SVT: Resolved. Patient w/hx of atrial fibrillation in
setting of recent L hip fracture, as chemically cardioverted on
sotalol. Upon presentation to the MICU s/p [**Name (NI) 24785**], pt remained in
afib w/RVR not responsive to single dose of lopressor.
Hypotension limited amount of AV nodal blockade we can attempt.
Home sotalol was held and Amiodarone load was started with
resultant conversion to sinus rhythm. She then had bradycardia
and amiodarone had to be discontinued. She flipped back into
Afib with RVR multiple times and a dilt gtt was intermittently
used for rate control. Eventually the patient was transitioned
back to her home dose of sotolol which was uptitrated to 80 mg
po bid as she developed a.fib with RVR on the home dose of 80 mg
daily. Pt being discharged on increased dose of sotalol. Pt was
initially w/supratherapeutic INR at time of admission; coumadin
was held and reversed in setting of pre-op period and dropping
hct, which was likely due to bleeding at site of fracture. Pt
was started on lovenox and coumadin post-operatively; coumdadin
restarted on [**2-22**] at lower than home dose, 1mg daily. Lovenox
40mg SQ daily should be continued for DVT ppx until INR at goal
of 2.0-2.5 x 48 hours per orthopedic surgery.
.
# Chronic diastolic congestive heart failure: recently diagnosed
2 months ago near time of initial L hip fracture, normal LVEF
and valves per report from PCP. [**Name10 (NameIs) **] discharged on home Lasix
40mg daily.
.
# HCAP: The patient had difficulty being weaned from the
ventilator post-operatively and her respiratory status was
further compromised by presumed HCAP for which she was treated
with vancomycin and zosyn, to be [**2146-2-20**]. CTA was negative for
PE. She was diuresed and slowly weaned from the ventilator with
extubation accomplished on [**2-21**]. She was subsequently weaned
back to baseline supplement O2 requirement on NC.
.
# Anemia: Significant hct drop between PACU and arrival on
floor. Baseline hct unknown. MCV trending down, potentially
pointing towards blood loss. hcts remained stable post-op.
Hemolysis labs were unremarkable.
.
# Rheumatoid arthritis: Initially continued PO prednisone but
with hypotension was transitioned to stress dose glucocorticoids
as above. As her hypotension resolved, she was placed back on
her home dose prednisone and discharged hemodynamically stable
on home dose of prednisone.
.
Comm: daughters [**Name (NI) **] ([**Telephone/Fax (1) 89727**]) and [**Doctor First Name 6480**] ([**Telephone/Fax (1) 89728**])
Code: DNR/DNI on admission. Code status reversed for procedure
then changed back per discussion with patient and daughters on
[**2-22**].
Medications on Admission:
Coumadin 2mg one day, 2.5mg the next day, skip 2 days, then
repeat Lasix 40 mg daily
Prednisone 2.5 mg [**Hospital1 **]
Sotalol 80 mg daily
Protonix 40 mg daily
Amlodipine 5 mg daily
Discharge Medications:
1. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
2. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. prednisone 2.5 mg Tablet Sig: One (1) Tablet PO twice a day.
4. sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
8. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily): Please d/c once INR between 2-2.5 for 48 hours.
9. calcium carbonate 400 mg (1,000 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO three times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehab in [**Hospital1 189**]
Discharge Diagnosis:
Primary: left femur fracture
Secondary: COPD, atrial fibrillation, rheumatoid arthritis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 17132**],
You were admitted for fracturing your left leg. You had it
repaired by orthopedic surgery. Please have your INR checked
daily; your coumadin was held at first as your INR was too high.
It is being restarted at a lower dose; the dosage may be changed
to reach a goal INR of 2 to 2.5 for your atrial fibrillation.
.
Please make the following changes to your medications:
- INCREASE sotolal to 80mg by mouth twice a day for your heart
rate
- START Lovenox (enoxaparin) 40mg injection once a day to
prevent blood clots until your INR is between 2 and 2.5
- START vitamin D and calcium to strengthen your bones
.
Please continue all other medications as prescribed.
Followup Instructions:
Department: ORTHOPEDICS
When: TUESDAY [**2146-3-8**] at 12:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
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"790.92",
"714.0",
"276.3",
"496",
"427.89",
"733.00",
"V49.86",
"E885.9",
"458.9",
"E849.0",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.72",
"96.6",
"79.35"
] |
icd9pcs
|
[
[
[]
]
] |
14570, 14641
|
8761, 13564
|
289, 351
|
14773, 14773
|
5471, 5476
|
15673, 15990
|
3131, 3149
|
13797, 14547
|
14662, 14752
|
13590, 13774
|
14950, 15328
|
3164, 5452
|
15357, 15650
|
241, 251
|
6227, 8738
|
379, 2587
|
5490, 6208
|
14788, 14926
|
2609, 2890
|
2906, 3115
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,523
| 150,743
|
18856
|
Discharge summary
|
report
|
Admission Date: [**2192-12-31**] Discharge Date: [**2193-1-12**]
Date of Birth: [**2109-7-31**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
angina/progressive dyspnea
Major Surgical or Invasive Procedure:
[**2193-1-7**] Off pump coronary artery bypass(LIMA to LAD, SVG to
OM1, SVG to OM2)
left heart catheterization, coronary angiogram, left
ventriculogram
History of Present Illness:
This 83year old white female with history of triple vessel
disease has previously undergone stenting to the circumfle
artery (3/[**2191**]). She reports that over the past several weeks
she has developed progressively worsening dyspnea, orthopnea,
and palpitations, equivalent to anginal symptoms in [**2191**] prior
to the stent. In the ED she received SL NTG and Plavix but
refused aspirin. EKG showed ST depressions in III, AVF, V5-6
new compared to old. Cardiac enzymes were negative. Cardiac
catheterization confirmed three vessel disease and cardiac
surgery was consulted for evaluation for operation.
Past Medical History:
Hypertension
Hyperlipidemia
Seizure disorder
s/p Hysterectomy
s/p cholecystectomy
s/p Right breast lumpectomy
s/p Tonsillectomy
Anxiety disorder
Social History:
Last Dental Exam:1 month ago, Has all own teeth
Lives with:alone. Fire dept calls her daily and checks in on
her
Occupation:volunteers at senior center/active lifestyle
Tobacco: 20 pack year smoking history. Quit in [**2173**]'s
ETOH:denies
Family History:
Brother had MI aged 48. Sisters had MI aged 52 and 77.
Physical Exam:
Admission:
T= 98 BP= 171/69 HR=60 RR=18 O2 sat= 100%RA
Height: 5'4" Weight:128lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA []- left cataract EOMI [x]
Neck: Supple []- enlarged nodular thyroid Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] - occas irreg beats Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: +2/cath site Left:+2
DP Right: +2 Left:+2
PT [**Name (NI) 167**]: +2 Left:+2
Radial Right: +2 Left:+2
Carotid Bruit none Right: +2 Left:+2
Pertinent Results:
OFF-PUMP CABG:1. The left atrium is moderately dilated. No
thrombus is seen in the left atrial appendage.
2. A left-to-right shunt across the interatrial septum is seen
at rest. A small secundum atrial septal defect is present.
3. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. The left ventricular
cavity size is normal for the patient's body size.
4. The right ventricular free wall is hypertrophied. The right
ventricular cavity is mildly dilated with normal free wall
contractility.
5. There are simple atheroma and calcification in the ascending
aorta by TEE and epi9aortic scan. There are complex (>4mm)
atheroma in the aortic arch. There are complex (>4mm) atheroma
in the descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened (?#). There is no aortic valve
stenosis. No aortic regurgitation is seen.
7. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
Dr. [**Last Name (STitle) **] was notified in person of the results.
POST Off-pump CABG, there is preservation of normal
biventricular systolic function. LVEF is now 65% The MR, TR are
unchanged.
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) **] [**2193-1-7**] 12:18
[**2193-1-11**] 05:45AM BLOOD WBC-13.4* RBC-3.08* Hgb-9.4* Hct-26.4*
MCV-86 MCH-30.6 MCHC-35.6* RDW-13.4 Plt Ct-285
[**2193-1-9**] 05:35AM BLOOD WBC-13.6* RBC-3.36* Hgb-10.3* Hct-29.2*
MCV-87 MCH-30.7 MCHC-35.4* RDW-14.7 Plt Ct-192
[**2193-1-11**] 05:45AM BLOOD Glucose-121* UreaN-11 Creat-0.7 Na-132*
K-3.0* Cl-95* HCO3-31 AnGap-9
[**2193-1-9**] 05:35AM BLOOD Glucose-131* UreaN-9 Creat-0.6 Na-131*
K-4.3 Cl-98 HCO3-26 AnGap-11
[**2193-1-12**] 07:15AM BLOOD Na-136 K-3.6 Cl-99 HCO3-30 AnGap-11
Brief Hospital Course:
She was admitted on [**12-31**] from the ER for EKG changes and
orthopnea, as well as palpitations. Enzymes were negative and
she received Plavix. Cardiac catheterization revealed severe
triple vessel disease .Plavix washout done and she underwent
surgery with Dr. [**First Name (STitle) **] on [**1-7**]. See operative note for
details.
She was transferred to the CVICU in stable condition on
phenylephrine and Propofol drips. She was extubated that
evening, pressors were weaned off and transferred to the floor
on POD #1.
Chest tubes and pacing wires were removed per cardiac surgery
protocol. Beta blockers were resumed and diuresis towards her
preoperative weight was begun. Beta blocker doses were increased
for rate control and BP. An echocardiogram was performed on POD
3 due to persistent sinus tachycardia. No pericardial effusion
was present and the LV function was intact at 55%.
She was changed to oral diuretics for a week course at discharge
and was progressing well. Her edema was essentially resolved and
her lungs were clear. She was cleared by physical Therapy who
worked with her after transfer to the floor. She was discharged
home with VNA care on medications listed elsewhere.
Arrangements were made for follow up and restrictions, wound
care and medications were discussed prior to discharge.
Medications on Admission:
Metoprolol tartate 100mg [**Hospital1 **]
Olmestartan 40 daily
Amlodipine 10mg daily
Nexium 40mg daily
Trileptal 300mg [**Hospital1 **]
Simvistatin 10mg daily
Plavix 75mg daily
Discharge Medications:
1. Aspirin 81 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:*0*
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
5. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
6. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
Disp:*225 Tablet(s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 1
weeks.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary Artery Disease
s/p coronary artery bypass grafting
Seizure disorder
gastroesophageal reflux
s/p Hysterectomy
s/p cholecystectomy
s/p Right breast lumpectomy
s/p Tonsillectomy
s/p Anxiety disorder
Hyperlipidemia
Hypertension
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 766**] [**2193-2-4**] @ 1:00 PM [**Telephone/Fax (1) 170**]
Primary Care Dr.[**Last Name (STitle) 1057**] in [**1-27**] weeks [**Telephone/Fax (1) 14331**]
Cardiologist Dr. [**Last Name (STitle) **] in [**1-27**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2193-2-4**] 1:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2193-1-12**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"37.22",
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icd9pcs
|
[
[
[]
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7048, 7103
|
4353, 5681
|
348, 502
|
7381, 7477
|
2360, 4330
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1329, 1574
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,276
| 167,413
|
33299
|
Discharge summary
|
report
|
Admission Date: [**2164-7-13**] Discharge Date: [**2164-7-24**]
Date of Birth: [**2111-10-26**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Iodine / Bactrim / Penicillins / Lidocaine / Quinine /
Flagyl / Phenothiazines / Plavix / Cephalexin / Nortriptyline /
Trazodone / Beta-Adrenergic Blocking Agents /
Anticholinergics,Other
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
ETOH intoxication, ?assault
Major Surgical or Invasive Procedure:
None
History of Present Illness:
52 yo F found in chair, has not moved for 5 days [**12-31**] weakness
adn total body pain due to "assault by a loved one".
police/security involved in ER. +ETOH. Per pt she started
drinkin a large bottle of vodka x1 week atleast in setting of
husband leaving her. She reiterates that her husband "did not do
this to me". She states she was sober for many years regarding
ETOH abuse and recently relapsed. She denies any other drug use
and is unclear how she fell, when she fell or if anyone hurt
her. When asked whether she intentionally try to hurt herself or
kill herself with drinking-she states yes. Pt has SI, does have
a past h/o depression but no therapist, no friends or family. Pt
is very tremulous, diffuse body pain, is having trouble with
confusion and can not recall events.
.
ED COURSE: Initial VS 98.7 HR 112 BP 114/70 16 100%RA, FS 40-
1amp dextrose. reiterating myasthenia [**Last Name (un) 2902**] and multiple
surgeries, did not give further h/o injuries. CTH/cspine/torso
neg. attempted to clear cspine clinically, however pt with TTP
everywhere. recommended [**Location (un) **] J and follow up with spine: pt
refusing [**Location (un) **] J. for torso scan pt refused iv contrast [**12-31**] hx
of all rxn reportedly anaphylactic; lactate elevated to 5.2,
received s/p 2L IVF. now on 3rd liter, banana bag.;
intermittently hypoglycemic in ER, received banabag d5ns.; abx
recomended for unknown events/hx. pt refuses [**12-31**] to "allergic to
everything"; received morphine 2mg IV x1. Admit for further
evaluation and management.
Past Medical History:
-ETOH abuse
-?myasthenia [**Last Name (un) 2902**]
-multiple abdominal surgeries, chest surgery
-hx of bladder prolapse
-extensive psychiatric history w/inpatient treatment
Social History:
-Lives [**Location (un) 6409**], husband left now in [**Name (NI) 108**]. Two children
ages 30s, now in jail. Denies having any other family or friends
in area.
-Extensive ETOH h/o-drinking large bottles of vodka, smokes
>1ppd x many years
-Denies any IVDU or other drugs
Family History:
-NC
Physical Exam:
VS: 99.4 BP 127/60 HR 87 RR 18 88%RA 93%4L FS 159
GEN: tremulous, distressed and confused
HEENT: dry MM, poor dentition with several teetch missing, large
echymosis L eye, PERRL symmetric pupils 4mm-->3mm
RESP: CTABL, no crackles, end expiratory wheezing; substernal
chest surgical scar well healed
CV: Reg Nml S1, S2, no M/R/G
ABD: Soft, ND, tender throughout, no guarding, no rebound, large
suprapubic surgical scar well healed, umbilical surgical scar
well healed, +BS
EXT: RLE edema up to knee, warm, with scab on R knee, L LE
without edema, 2+DP pulses b/l
BACK: echymosis over R scapula, diffuse tenderness throughout
back, no surgical scars noted, echymosis over R shoulder
NEURO: Alert, tremulous, consfused, oriented to self only,
"doctor" unclear of place or time, gait not assessed, normal
sensation, not cooperating for full neuro eval-weak due to pain
2-3/5, ptosis b/l lids, 3+reflexes b/l
At the time of discharge, her exam was stable with decreased
pain around her ecchymoses. Her bruises were healing, and she
was able to ambulate independently.
Pertinent Results:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2164-7-14**] 02:59AM 6.7 3.54* 11.9* 36.7 104* 33.5* 32.4 14.1
116*
[**2164-7-13**] 02:15AM 6.9 3.91* 13.1 40.5 104* 33.4* 32.2 14.1
192
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2164-7-13**] 02:15AM 83.4* 12.5* 3.6 0.2 0.4
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2164-7-14**] 02:59AM 116*
[**2164-7-13**] 02:15AM 192
[**2164-7-13**] 02:15AM 12.4 26.6 1.0
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2164-7-19**] 06:50AM 4.4
[**2164-7-18**] 07:05AM 108* 8 0.5 139 3.9 106 24 13
[**2164-7-17**] 11:38AM 110* 7 0.5 139 3.0* 104 26 12
[**2164-7-16**] 07:15AM 116* 5* 0.5 141 4.11 109* 22 14
(MODERATELY HEMOLYZED)
[**2164-7-14**] 02:59AM 144* 8 0.6 145 3.6 108 24 17
[**2164-7-13**] 03:46PM 107* 7 0.6 142 3.3 107 21* 17
ENZYMES&BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2164-7-19**] 06:50AM 29 17 338* 134* 0.4
[**2164-7-16**] 07:15AM 93* 128* 836* 273* 1.2 MODERATELY
HEMOLYZED
[**2164-7-14**] 02:59AM 63* 134* 504* 170* 259* 63 0.9
[**2164-7-13**] 03:46PM 189*
[**2164-7-13**] 02:15AM 72* 172* 217* 306*
OTHER ENZYMES & BILIRUBINS Lipase
[**2164-7-17**] 11:38AM 30
[**2164-7-16**] 07:15AM 171* MODERATELY HEMOLYZED
[**2164-7-14**] 02:59AM 148*
[**2164-7-13**] 02:15AM 175*
CPK ISOENZYMES CK-MB cTropnT
[**2164-7-13**] 02:15AM 0.011
[**2164-7-13**] 02:15AM 9
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2164-7-19**] 06:50AM 2.8 1.9
[**2164-7-18**] 07:05AM 8.0* 2.6* 2.1
[**2164-7-17**] 11:38AM 8.0* 3.2 1.4*
[**2164-7-16**] 07:15AM 2.7* 8.4 2.1* 1.71 MODERATELY
HEMOLYZED
[**2164-7-14**] 02:59AM 2.4* 8.2* 2.4* 2.0
[**2164-7-13**] 03:46PM 8.4 2.5*# 2.1
[**2164-7-13**] 02:15AM 2.9* 8.5 5.1* 1.8
HEMATOLOGIC VitB12
[**2164-7-13**] 02:15AM 1081*
DIABETES MONITORING %HbA1c
[**2164-7-13**] 02:15AM 5.0
PITUITARY TSH
[**2164-7-13**] 02:15AM 0.64
HIV SEROLOGY HIV Ab
[**2164-7-19**] 07:45PM Negative
NEUROPSYCHIATRIC Lithium
[**2164-7-13**] 02:15AM 0.2*
TOXICOLOGY, SERUM AND OTHER DRUGS ASA Ethanol Acetmnp Bnzodzp
Barbitr Tricycl
[**2164-7-13**] 02:15AM NEG 120*1 NEG NEG NEG NEG
BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calTCO2 Base XS Comment
[**2164-7-13**] 03:41PM ART 65* 34* 7.46* 25 0
[**2164-7-13**] 12:59PM [**Last Name (un) **] 255* 31* 7.49* 24 2
[**2164-7-13**] 03:00AM 7.32*
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Lactate Na K Cl
calHCO3
[**2164-7-13**] 12:59PM 1.2
[**2164-7-13**] 06:14AM 3.6*1
[**2164-7-13**] 03:00AM 28* 5.2* 144 3.8 100 19*
HEMOGLOBLIN FRACTIONS ( COOXIMETRY) Hgb calcHCT O2 Sat COHgb
MetHgb
[**2164-7-13**] 03:41PM 11.7* 35 91 1.1 0.1
CALCIUM freeCa
[**2164-7-13**] 12:59PM 1.08*
[**2164-7-13**] 03:00AM 1.02*
IMAGING:
-Head CT-Neg for ICH or acute process
-C-Spine-No acute fx or malalignment.
-Sinus CT: No fracture or dislocation. Prominent left
zygomaticofrontal suture.
-R LENI: No evidence of DVT.
-TORSO CT:
1. No fracture or solid organ injury.
2. Fatty Liver.
-CXR: No consolidation
-L LENI: No evidence of DVT
-KUB: 1. No evidence of bowel obstruction. 2. Urine-filled
bladder, concerning for urinary retention.
.
MICRO:
[**2164-7-21**] 11:30 am URINE Source: Catheter.
**FINAL REPORT [**2164-7-23**]**
URINE CULTURE (Final [**2164-7-23**]):
PROTEUS VULGARIS. 10,000-100,000 ORGANISMS/ML..
GRAM NEGATIVE ROD #2. ~3000/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS VULGARIS
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 256 R
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
URINE CULTURE (Final [**2164-7-19**]): NO GROWTH.
Blood Culture, Routine (Final [**2164-7-19**]): NO GROWTH.
Brief Hospital Course:
52 yo F with depression, prior SI/SA, found in her apartment
after being assaulted, ETOH intoxication, she called 911 and was
brought in by EMS to [**Hospital1 18**] ED.
.
#. Psych: Pt with extensive Psych history, depression, prior
suicide attempts. She intially was intoxicated and refusing
care. It seems that after her assault she spent 4 days in her
apartment drinking alcohol possibly as a suicide attempt, pt
stated she was trying to "end it". Ultimately she was admitted
to [**Hospital1 18**]. With time she revealed that she was raped and beaten
by her husband. She referenced that he was looking for some sort
of pills, and left when he found them. She is recently separated
from her husband and it is not clear if they still live together
or not. She says that her husband *may* have beaten her in the
past, but she cannot be certain. She also reported that she has
been a patient at [**Hospital 11786**] Hospital for prolonged periods of
time, but that she does not currently see a psychiatrist. Her
time in the MICU was characterized by periodic panic attacks,
periods of paranoia, and periods when she was clearly
halucinating. However, she is was seen by Psychiatry on
admission and followed throughout her course. She was initially
treated with Ativan for withdrawal. She subequently was started
on haldol. Her mental status improved markedly with less
delirium. On [**7-20**] her haldol was discontinued due to urinary
retention. She subsequently became more paranoid and delusional.
She was medically cleared since [**7-20**] awaiting psych placement
after voiding on her own-see below. She remained on medical
service until [**7-24**] due to urinary retention as noted below. She
became more delirius and suicidal since discontinuation of
haldol standing dose. She was intermittently medicated with
ativan and haldol(she refused on several occasions) for her
increasing delirium and agitation. She was admitted to inpatient
psych team on [**7-24**]. Pt also noted to be more difficult with
staff with inappropriate comments to MDs caring for her.
.
#. ETOH intoxication: ETOH abuse, ETOH level 102 in ED, received
banana bag in ED and again in the MICU. She was given valium
based on a CIWA scale, supplements of thiamine and folic acid,
and maintained on telemetry. Tox screen was only positive for
etOH, and no other substances. She had no further episodes of
withdrawal.
.
#. Hypoglyecemia: ? h/o DM vs. starvation; FS initially in ED
was 40 she was given dextrose and her FS on arrival to floor
159, however pt not eating for several days at home. She
remained euglycemic throughout her hospitalization and had no
further hypoglycemic episodes.
.
#. Assault/trauma: Full body imaging negative for fracture, pt
refusing prophylatic rx given for h/o of sexual; assualt,
refusing protective measure with J-collar. bruises noted on
back. Pt has received pain medication PRN in the MICU. She has a
high narcotic tolerance and prior h/o Opiod abuse. She received
oxycodone 5mg prn for pain control with good effect. She had no
evidence of fractures as noted above.
.
#. ?Rape: Uhcg neg, SANE nurse evaluated pt in the MICU. SW
involved since admission, HIV test was negative. SW involved
throughout her admission for coping/support.
.
#. +SI: Prior h/o depression, suicidal with plan and attempt as
described above-wanted to end things, stated she was ashamed
that wasn't able to make it on her own without husband. She has
been with a 1:1 sitter and suicide precautions this admission.
Psych is following closely. CW is following closely.
.
#. Delirium: Pt initially refused all care, waxed and waned
throughout admission. Followed closely with episodes of mental
clarity and intermittent hallucinations-most prominent during
initial admission. She was treated with small dose of Haldol
0.5mg TID with good effect. She subsequently developed urinary
retention. Haldol was d/c'd [**7-20**], she acutely decompensated with
agitation and psychotic delusions that her husband was going to
find her, she was refusing medication and threatening to leave
AMA on [**7-20**]. She was intermittently medicated with ativan and
haldol through [**7-24**], thereby being admitted to inpatient psych
for further management.
.
#. Myasthenia [**Last Name (un) 2902**]: Pt has a distant history of MG. She was
treated with thymectomy. At this time she says that her weakness
is similar to her MG symptoms. She has not had a flare since her
surgery decades ago. Neurology evaluated her on admission but
she was not cooperative to be tested for strength. She also
refused vital capacity and NIF. In the MICU, pt also refused NIF
& VC. ABG notable PaCO2 <40, she was not hypercapnic. There is
no evidence of weakness that cannot be accounted for by her
assault. She remained on Room air without hypoxia, and no
hypercapnia on ABG. She was ambulating independently on [**7-19**].
.
#. Urinary retention: On [**2164-7-18**] pt was noted to have pelvic
discomfort as well as a firm palpable mass, as well as some
distension noted on exam. A KUB was done and indicated a
distended bladder. A foley was placed and 2 L of urine was
drained. A voiding trial was attempted on [**7-19**], but was
unsuccessful and the foley was replaced. The etiology of this
urinary retention is unclear, but one possibility is that it may
be a side effect of her Haldol (known for anticholinergic
effects) or also trauma related as noted above. It was
discontinued on [**7-20**], along with her foley for another voiding
trial. She remained with urinary retention. Etiology thought
[**12-31**] narcotics, constipation, UTI. Pt had non-clean catch UA she
was treated for a UTI for proteus on Uculture. Course of cipro
to be completed by Friday, [**7-27**]. Urology evaluated pt and
recommended foley for 3 weeks in setting of urinary retention
most likely due to overdistended bladder/weak bladder in setting
of trauma. Per Urology-keep foley in x3 weeks, pull foley,
followed by voiding trial. Resume cipro x3 days only when foley
pulled.
.
#. Weakness/decompensation: Pt down x5 days at least, PT saw pt
several times. She ambulated independently prior to discharge to
inpatient psych.
.
#. FULL CODE
.
#. Privacy: Do not discuss any details of patient, or even
acknowledge her hospitalization with any friends or family
members, especially her husband
#. Dispo: To psych inpatient facility
Medications on Admission:
MEDICATIONS:
[**Last Name (un) 1724**]: Per pharmacy contacts (per psych notes)
1. Clonzapam 1mg 4x/d
2. Li 3caps of 200mg 2x
3. Buspirone 2 tab (10mg) 3x
4. Hydroxyzine 325mg 2x/d
5. Zolpidem 1 @bed time
6. Oxycodon-acetominophen 10-325
7. Oxycodin 20mg [**Hospital1 **]; 10mg [**Hospital1 **]
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
7. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
11. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
-assault
-ETOH intoxication
-Delirium
-SI/SA (with ETOH)
-Urinary retention
.
Secondary:
-Depression
-Myasthenia [**Last Name (un) **]
-thymectomy
-multiple abdominal surgeries
-bladder prolapse s/p repair
Discharge Condition:
Stable, tolerating POs well, walking independently, foley in
place for urinary retention (per Urology recs).
Discharge Instructions:
You were admitted after an assault and alcohol intoxication. You
had extensive CT scans that did not show a fracture anywhere.
Psychiatry followed you closely while you were on the medical
service. Urology also evaluated you and you will need a foley
for a few weeks to help with your bladder.
.
If you have chest pain, difficulty breathing, confusion,
headaches, visual changes, hallucinations, or thoughts of
wanting to hurt yourself, please call your physician or go to
the emergency room.
.
Your medications will be directed by your Psychiatry team.
You were started on cipro for a urinary tract infection will
complete treatment on friday -[**2164-7-27**].
When the foley is discontinued you should be on cipro for 3
days-per Urology recommendations.
Followup Instructions:
Follow up with your Psychiatrist as directed by your current
Psychiatry team.
.
Follow up with your Primary Care Physician [**Last Name (NamePattern4) **] [**11-30**] weeks
following your discharge.
Follow up with Urology in [**11-30**] weeks after your discharge.
Completed by:[**2164-7-24**]
|
[
"599.0",
"285.9",
"265.1",
"305.1",
"788.20",
"E968.9",
"358.00",
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"273.8",
"251.2",
"921.0",
"924.8",
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"276.2",
"787.91",
"041.6",
"571.1",
"311",
"303.00",
"787.20",
"E967.3",
"291.0",
"V62.84",
"564.00",
"922.31"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
15811, 15826
|
8120, 14496
|
487, 494
|
16085, 16196
|
3685, 8097
|
17000, 17296
|
2578, 2583
|
14847, 15788
|
15847, 16064
|
14522, 14824
|
16220, 16977
|
2598, 3666
|
420, 449
|
522, 2077
|
2099, 2273
|
2289, 2562
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,538
| 107,099
|
1352
|
Discharge summary
|
report
|
Admission Date: [**2165-12-29**] Discharge Date: [**2166-1-4**]
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
difficulty speaking, R sided weakness
Major Surgical or Invasive Procedure:
IV tPA
History of Present Illness:
Mrs. [**Known lastname 7157**] is a [**Age over 90 **]-year-old right-handed woman, presenting
with Right sided weakness at 5 PM on a background of
hypertension, nephrectomy unilateral renal cell carcinoma
([**2151**]),
hypercholesterolemia.
The patient was at her communicative and mobile baseline on the
day of admission. he was having tea with her daughter when her
face suddenly became blank and she attempted to speak, making a
couple of
sounds, then became completely mute. she slumped over to the
right into a chair without falling or any injury. This was at 5
PM. EMS was called and she was brought to [**Hospital1 18**]. Her initial
vitals including SBP of 217 mmHg. She has been hypertensive to
190s over the last couple of weeks. Code stroke was called on
arrival at 5:11 PM. We (Neurology) were at the bedside within 5
minutes.
Time Code Stroke called: 17:11
Time Neurology at baseline for evaluation: 17:16
Time (and date) the patient was last known well: [**2165-12-29**], 17:00
NIH Stroke Scale Score: 22
Contraindications to t-PA: Hypertension, will control
t-[**MD Number(3) 6360**]: Yes
Time given: 18:00
I was present during the CT scanning and reviewed the images as
they were captured.
NIHSS:
1a. Level of Consciousness: 0
1b. LOC questions: 2
1c. LOC commands: 1
2. Best gaze: 1
3. Visual: 1
4. Facial palsy: 3
5a. Motor arm, left: 0
5b. Motor arm, right: 4
6a. Motor leg, left: 0
6b. Motor leg, right: 3
7. Limb ataxia: 0
8. Sensory: 1
9. Best language: 3
10. Dysarthria: 0
11. Extinction and inattention: 2
CT scan revealed hypodensity in the left basal ganglia. Exam and
imaging, were consistent with dense L MCA. She was given IV tPA
at 6:00pm. Interventional was considered but given the size of
the infarct, not undertaken.
Past Medical History:
- Depression
- Hypertension
- Hypercholesterolemia
- Valvular heart disease, with recent clinical heart failure
- Daughter denies prior stroke, irregular heart
- Renal cell carcinoma, s/p unilateral nephrectomy
- Renal failure, recently 2.0, now 2.4 two days ago
Social History:
Smoking: No.
Alcohol: Occasional.
Drugs: No.
Education and Language: Russian only.
Functional Baseline: Some assistance.
Family History:
Unable to be obtained
Physical Exam:
Physical Exam on Admission:
Vitals: HR 85 BPM; BP 177/97 mmHg; O2Sat 99 % 2L; RR 18 BPM
General Appearance: Restless.
HEENT: NC, OP clear, MMM.
Neck: Supple. No bruits. Normal ROM.
Lungs: CTA bilaterally. Normal respiratory pattern.
Cardiac: Regular. Normal S1/S2. No M/R/G.
Abdominal: Soft, NT, BS+.
Extremities: No edema, warm, normal capillary refill. Peripheral
pulses normal.
Skin: Normal appearances.
Neurologic Examination:
Mental status:
Level of Arousal: Awake. Normal level of arousal and alertness.
Attentiveness: Attentive. Globally aphasic.
Cranial Nerves:
I: Not tested.
II: Pupils symmetric, round and reactive to light, 3 to 2 mm
bilaterally. Visual fields are full to confrontation. Fundi are
normal.
III, IV, VI: Extraocular movements full, conjugate. Gaze
preference to left, not overcome with OCR.
V, VII: Right UMN facial paresis.
VIII: Orients to voice.
IX, X: unable
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius are of normal bulk and
strength bilaterally.
XII: unable
Tone and Bulk: Tone is normal throughout (arms, legs, neck).
Muscle bulk is normal.
Power: Left at least [**5-14**] throughout spontaneously.
Right UE extensor, LE elevates of bed spontaneously.
Sensation: Decreased on right to pain.
Coordination and Cerebellar Function: No major ataxia.
Gait: Unable
PHYSICAL EXAM AT TIME OF DEATH (3:40am on [**1-4**])
GEN: elderly woman with pale skin lying in bed, not moving
HEENT: pupils fixed and dilated
CV: no heart beat auscultated or palpated
PULM: no breath sounds auscultated or palpated
EXT: cool, clammy, not moving
Pertinent Results:
[**2165-12-29**] 07:22PM %HbA1c-5.6 eAG-114
[**2165-12-29**] 07:14PM URINE HOURS-RANDOM
[**2165-12-29**] 07:14PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2165-12-29**] 05:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2165-12-29**] 05:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-600
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2165-12-29**] 05:50PM URINE RBC-<1 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-0
[**2165-12-29**] 05:50PM URINE HYALINE-1*
[**2165-12-29**] 05:50PM URINE MUCOUS-RARE
[**2165-12-29**] 05:26PM CREAT-2.4*
[**2165-12-29**] 05:26PM estGFR-Using this
[**2165-12-29**] 05:24PM GLUCOSE-109* NA+-139 K+-4.0 CL--108 TCO2-22
[**2165-12-29**] 05:15PM UREA N-53* TOTAL CO2-21*
[**2165-12-29**] 05:15PM ALT(SGPT)-16 AST(SGOT)-25 LD(LDH)-268*
CK(CPK)-93 ALK PHOS-139* TOT BILI-0.1
[**2165-12-29**] 05:15PM CK-MB-5 cTropnT-0.05*
[**2165-12-29**] 05:15PM ALBUMIN-3.6 CALCIUM-8.7 PHOSPHATE-5.5*
MAGNESIUM-2.4 CHOLEST-215*
[**2165-12-29**] 05:15PM VIT B12-490
[**2165-12-29**] 05:15PM TRIGLYCER-257* HDL CHOL-61 CHOL/HDL-3.5
LDL(CALC)-103
[**2165-12-29**] 05:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2165-12-29**] 05:15PM WBC-9.4 RBC-3.54* HGB-11.2* HCT-32.6* MCV-92#
MCH-31.5 MCHC-34.3 RDW-15.4
[**2165-12-29**] 05:15PM NEUTS-67.0 LYMPHS-24.1 MONOS-4.5 EOS-4.1*
BASOS-0.3
[**2165-12-29**] 05:15PM PLT COUNT-305
[**2165-12-29**] 05:15PM PT-11.5 PTT-21.1* INR(PT)-1.0
Noncontrast CT head [**12-29**]:
IMPRESSION: No hemorrhage or evidence of acute major vascular
territory
infarction. Consider MRI for strong clinical concern.
Noncontrast CT head [**12-29**]:
IMPRESSION: Subtle edema in the left basal ganglia, concerning
for early
acute infarction. No hemorrhage.
Brief Hospital Course:
Ms. [**Known lastname 7157**] was admitted to the ICU s/p IV tPA and observed
overnight. She continued to aphasic with dense right
hemiparesis. Given the poor prognosis and premorbid patient
wishes not to have feeding tube, family meeting was held with
daughter HCP and patient status was changed to CMO. She was
transfered to the floor on [**12-30**]. Palliative care was consulted
and recommended Morphine 5-10 mg SL Q1 prn, Hyoscyamine 0.125 mg
SL QID:PRN excess secretions, Zydis 5 mg SL TID prn agitation.
She remained stable and comfortable on this regimen. She died
peacefully at 3:40am on [**1-4**].
Medications on Admission:
Medications - Prescription
AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day
ATENOLOL - 50 mg Tablet - 1 Tablet(s) by mouth twice a day
ATORVASTATIN - 10 mg Tablet - one Tablet(s) by mouth once a day
DARBEPOETIN ALFA IN POLYSORBAT [ARANESP (POLYSORBATE)] - 25
mcg/0.42 mL Syringe - inject s/c every 3 weeks
ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit Capsule - 1 Capsule(s)
by mouth qmonth
FLUTICASONE - 50 mcg Spray, Suspension - one spray intranasal
each nostril qd
FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth twice a day
HYDROCORTISONE [PROCTOSOL HC] - 2.5 % Cream - one unit rectally
once a day hs
LIDODERM - 5% Adhesive Patch, Medicated - USE AS DIRECTED
LISINOPRIL - 40 mg Tablet - one Tablet(s) by mouth once a day
LORATADINE - 10 mg Tablet - one Tablet(s) by mouth once a day
OLOPATADINE [PATANOL] - 0.1 % Drops - 1-2 drops ou three times a
day as needed for prn allergy
PANTANOL - 0.1% - TWICE A DAY TO BOTH EYES FOR ALLERGIES
SYRINGE - 1 ML SYRINGE - AS DIRECTED
TOLTERODINE [DETROL LA] - 2 mg Capsule, Ext Release 24 hr - one
Capsule(s) by mouth once a day
VENLAFAXINE - 150 mg Tablet Extended Rel 24 hr - 1 Tablet(s) by
mouth every morning
VENLAFAXINE [EFFEXOR XR] - 37.5 mg Capsule, Ext Release 24 hr -
1
Capsule(s) by mouth every morning in addition to a150-milligram
capsule
Medications - OTC
ACETAMINOPHEN - 500 mg Tablet - 1 Tablet(s) by mouth once-twice
a
day
DEXTRAN 70-HYPROMELLOSE [ARTIFICIAL TEARS] - Drops - 2 drops
ou
twice a day
MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - 1
Tablet(s) by mouth every morning
Discharge Medications:
N/A pt expired on [**1-4**]
Discharge Disposition:
Expired
Discharge Diagnosis:
L MCA stroke
Discharge Condition:
N/A pt expired on [**1-4**]
Discharge Instructions:
N/A. pt expired on [**1-4**]
Followup Instructions:
N/A, pt expired on [**1-4**]
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"403.90",
"434.91",
"272.0",
"342.91",
"585.9",
"V10.52",
"V49.86",
"348.5",
"428.0",
"427.31",
"V45.73",
"784.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
8308, 8317
|
6029, 6640
|
289, 298
|
8374, 8403
|
4169, 6006
|
8480, 8603
|
2525, 2548
|
8256, 8285
|
8338, 8353
|
6666, 8233
|
8427, 8457
|
2563, 2577
|
212, 251
|
326, 2085
|
3137, 4150
|
2592, 2973
|
3012, 3121
|
2997, 2997
|
2107, 2371
|
2387, 2509
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,354
| 118,243
|
38903
|
Discharge summary
|
report
|
Admission Date: [**2104-5-19**] Discharge Date: [**2104-5-26**]
Date of Birth: [**2049-8-22**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Syncope, seizure
Major Surgical or Invasive Procedure:
[**2104-5-22**] Right Frontal crani for mass x 2 resection
History of Present Illness:
This is a 54 year female with past medical history of
hypertension and osteoporosis, who presents as a transfer from
OSH s/p syncope and seizure, and with abnormal head CT. In
summary, the patient was reportedly attending a funeral today
when she had a syncopal episode and fell. She was sent to
[**First Name4 (NamePattern1) 189**]
[**Last Name (NamePattern1) **] Hospital for further evaluation. Shortly following
admission, she was found slumped over and unresponsive in a
chair, and subsequently seized. Resolved with Ativan. Continued
to seize 1-2 times later in the evening. Received a total of
14mg of Ativan. Intubated for increasing mental status changes
and lethargy. Transferred to [**Hospital1 18**] for continued care.
Past Medical History:
1. Hypertension
2. Osteoporosis
Social History:
She works as a registered nurse at the Home Away from Home. She
is a former smoker. She quit over 15 years ago but has about 30
pack year hx. Her HCP is
her husband and she is DNR per her husband.
Family History:
She has no hx of cancers and FH only notable for maternal aunt
who was diagnosed
with breast cancer in her 60's.
Physical Exam:
On Admission:
PHYSICAL EXAM:
O: T: 101.8 BP: 119/76 HR:76 R:20 O2Sats: 100%t
Gen: WD/WN, comfortable, NAD. Off sedation, agitated.
HEENT: NC/AT Pupils: PERRLA EOMs N/A
Extrem: Warm and well-perfused.
Neuro:
Mental status: Intubated. No EO
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 2mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: N/A
V, VII: N/A
VIII: N/A
IX, X: Gag reflex Present
[**Doctor First Name 81**]: N/A
XII: N/A
Motor: Normal bulk and tone bilaterally. No abnormal movements.
Moves all extremities x 4 purposefully, equally, when off
sedation.
Toes downgoing bilaterally.
On Discharge:
Awake, alert and oriented to person, place and date. Face is
symmetric, tongue with a slight left deviation. Full strength
and sensation throughout. Wound is clean, dry and intact without
signs of infection.
Pertinent Results:
[**2104-5-19**] CT Head:
IMPRESSION: There are two rim-enhancing lesions peripherally
located within the right frontal lobe, as described above, with
associated vasogenic edema and mass effect. The inferior lesion
demonstrates a punctate focus of hemorrhage. While the superior
lesion does abut the dura, it lacks characteristic dural tail,
making meningioma a less likely consideration. Moreover, the
more inferior lesion does appear intra-axial on coronal and
sagittal reformatted images. Differential diagnosis
includes metastatic disease versus abscess.
[**2104-5-19**] MRI Brain w/ & w/o:
1. Two enhancing right frontal lesions most consistent with
metastases with surrounding vasogenic edema and right frontal
sucal effacment.
2. 2mm leftward shift of midline structures.
CT Torso:
1. No definite evidence of malignancy. Consolidation within the
superior
segment of the left lower lobe may represent infection, but
there is a
slightly more rounded appearance inferiorly, and consider repeat
chest CT
following treatment. Prominent left-sided intrapulmonary lymph
nodes may be reactive.
2. Gallbladder sludge.
3. Gas tracking in the posterior subcutaneous tissues and
extending into the left paraspinal musculature and left psoas
muscle. Findings are likely
related to pressure erosion. There is no focal fluid collection.
4. Trace pelvic free fluid. Slightly limited evaluation of the
pelvis due to motion artifact, but no gross abnormalities are
identified.
CT head [**2104-5-22**]:
Expected postoperative appearance status-post right craniotomy.
Unchanged 2mm leftward shift of midline structures
MRI brain [**5-23**]:
1. Two curvilinear foci of residual enhancement of the right
frontal lobe. Continued attention on followup studies is
recommended.
2. Interval resection of the two right frontal lesions.
Persistent,
unchanged right frontal edema and 2 mm leftward shift of midline
structures.
3. No evidence of acute infarct.
Brief Hospital Course:
This is a 54 year old F in her usual state of health until an
episode of syncope and seizure. OSH CT revealed a brain mass
with vasogenic edema. Patient was transferred to [**Hospital1 18**] where a
Head CT was repeated- again showing a two rim-enhancing lesions
peripherally located within the right frontal lobe with
associated vasogenic edema and mass effect. Pt was admitted to
the ICU under Dr.[**Name (NI) 9034**] care. A Brain MRI was done on
[**2104-5-19**] which showed two enhancing right frontal lesions most
consistent with metastases with surrounding vasogenic edema and
right frontal sulcal effacement
A CT Torso was done on [**5-19**], which was negative for any primary
lesion or mets, but did show ground glass opacity in RUL.
She was consented and pre-oped, and went to the OR for resection
of this mass on [**5-22**]. The procedure went well without
complications. The preliminary pathology report was metastatic
carcinoma. She remained in the PACU overnight for Q1 hour neuro
checks post-op. CT head was negative for hemorrhage.
She was stable on [**5-23**] and she was transferred to the Step down
unit. Her Foley and A-line was discontinued. She had an MRI.
PT and OT were ordered. She was cleared for home on [**5-26**] with PT
outpatient needs.
Medications on Admission:
1. Ecotrin 81m Daily
2. Pepcid 20mg [**Hospital1 **]
3. Lopressor 25mg Daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
4. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every
Sunday).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: max APAP 4g/24hrs.
7. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
9. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*0*
10. Outpatient Physical Therapy
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Right sideded frontal brain masses
Discharge Condition:
Neurologically stable
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
General Instructions/Information
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures have been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been prescribed Keppra for anti-seizure medicine,
take it as prescribed.
?????? You are being sent home on steroid medication(taper to 2mg
twice daily), make sure you are taking a medication to protect
your stomach (Prilosec, Protonix, or Pepcid), as these
medications can cause stomach irritation. Make sure to take
your steroid medication with meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
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: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
??????Please return to the office in [**10-30**] days (from your date of
surgery) for removal of your sutures and a wound check. This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**6-9**]
at 11:30. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**]
of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number
is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????Please follow up with medical oncology. You should be receiving
a call from them once pathology has been finalizined. If you do
not hear from them by Friday [**5-30**] please call Dr. [**First Name (STitle) **] at
[**Telephone/Fax (1) 86318**] to schedule an appointment or if you have any
questions
Completed by:[**2104-5-26**]
|
[
"780.39",
"431",
"401.9",
"198.3",
"V15.82",
"162.8",
"733.00",
"693.0",
"348.4",
"348.5",
"E935.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
6831, 6914
|
4464, 5740
|
336, 397
|
6993, 7015
|
2496, 2512
|
8969, 10069
|
1450, 1564
|
5868, 6808
|
6935, 6972
|
5766, 5845
|
7123, 8946
|
1608, 1811
|
2268, 2477
|
280, 298
|
425, 1164
|
1860, 2254
|
2521, 4441
|
1593, 1593
|
7030, 7099
|
1186, 1219
|
1235, 1434
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,483
| 164,281
|
6228
|
Discharge summary
|
report
|
Admission Date: [**2157-3-23**] Discharge Date: [**2157-3-28**]
Date of Birth: [**2101-9-15**] Sex: F
Service: PLASTIC
Allergies:
Iodine-Iodine Containing / Codeine / Lanolin / wool
Attending:[**First Name3 (LF) 5667**]
Chief Complaint:
Recurrent incisional hernia
Major Surgical or Invasive Procedure:
1)Exploratory laparotomy with lysis of adhesions
2)Bilateral component separation repair; Placement of SurgiMend
mesh 25 x 15 cm.
History of Present Illness:
55 year old woman with recurrent incisional hernia repair w/
component separation. Previous incisional hernia repair w/ mesh
in [**2150**] after surgery for incarcerated hernia w/ SBO (no bowel
resection).
Past Medical History:
1. Morbid obesity. She had evidently weighed over 525 pounds
and lost weight after gastric bypass.
2. Hypothyroidism.
3. Hypercholesterolemia.
4. Fatty liver.
5. GERD.
.
PSH: Hysterectomy, appendectomy, cholecystectomy, tonsillectomy,
RYGBP ([**2142**]), repair incarcerated incisional hernia repair w
mesh ([**2150**])
Social History:
She is a former smoker, upwards of two and a half packs per day.
She denies alcohol or drugs. She is currently unemployed.
Family History:
Significant for heart disease and gallbladder cancer.
Physical Exam:
Pre-procedure physical exam as documented in Anesthesia Record
[**2157-3-23**]:
Pulse: 75/min
Resp: 18/min
BP: 124/76
Afebrile, 97.5
.
General: pleasant female, nad
Mental/psych: a/o
Airway: as documented in detail in anesthesia record
Dental: Other (perm bridge)
Head/neck Range of motion: Free range of motion
Heart: RRR 1/6 sys murmur
Lungs: Clear to auscultation
Abdomen: healed incisions; wearing binder; hernia, diffuse mild
tenderness (pt says her usual, chronic pain)
Extremities: no ankle edema
Pertinent Results:
[**2157-3-23**] 07:13PM URINE MUCOUS-RARE
[**2157-3-23**] 07:13PM URINE CA OXAL-FEW
[**2157-3-23**] 07:13PM URINE HYALINE-9*
[**2157-3-23**] 07:13PM URINE RBC-65* WBC-2 BACTERIA-NONE YEAST-NONE
EPI-0
[**2157-3-23**] 07:13PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-NEG
[**2157-3-23**] 07:13PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.040*
[**2157-3-23**] 07:13PM URINE HOURS-RANDOM CREAT-246 SODIUM-15
CHLORIDE-15
[**2157-3-23**] 07:41PM PLT COUNT-171
[**2157-3-23**] 07:41PM WBC-5.2 RBC-3.84* HGB-12.1 HCT-36.9 MCV-96#
MCH-31.4 MCHC-32.6# RDW-14.1
[**2157-3-23**] 07:41PM CALCIUM-9.3 PHOSPHATE-3.5 MAGNESIUM-1.5*
[**2157-3-23**] 07:41PM estGFR-Using this
[**2157-3-23**] 07:41PM GLUCOSE-147* UREA N-7 CREAT-0.6 SODIUM-139
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-30 ANION GAP-10
[**2157-3-24**] 04:11AM BLOOD WBC-6.0 RBC-3.56* Hgb-11.6* Hct-34.2*
MCV-96 MCH-32.5* MCHC-33.9 RDW-14.4 Plt Ct-208
[**2157-3-24**] 04:11AM BLOOD Glucose-112* UreaN-5* Creat-0.5 Na-140
K-5.0 Cl-106 HCO3-28 AnGap-11
[**2157-3-24**] 04:11AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.1
[**2157-3-24**] 04:11AM BLOOD VitB12-824 Folate-GREATER TH
[**2157-3-24**] 04:11AM BLOOD TSH-0.23*
[**2157-3-25**] 04:07AM BLOOD WBC-10.5 RBC-3.78* Hgb-12.2 Hct-35.9*
MCV-95 MCH-32.2* MCHC-34.0 RDW-14.1 Plt Ct-194
[**2157-3-25**] 04:07AM BLOOD Glucose-94 UreaN-7 Creat-0.4 Na-142 K-3.7
Cl-105 HCO3-26 AnGap-15
[**2157-3-25**] 04:07AM BLOOD Calcium-9.1 Phos-2.0*# Mg-1.7
[**2157-3-26**] 04:38AM BLOOD WBC-9.0 RBC-3.64* Hgb-11.8* Hct-34.3*
MCV-94 MCH-32.4* MCHC-34.4 RDW-14.1 Plt Ct-192
[**2157-3-26**] 04:38AM BLOOD Glucose-75 UreaN-7 Creat-0.4 Na-143 K-3.6
Cl-105 HCO3-28 AnGap-14
[**2157-3-26**] 04:38AM BLOOD Calcium-9.1 Phos-2.0* Mg-1.8
.
MICROBIOLOGY:
[**2157-3-23**] 7:13 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2157-3-26**]**
MRSA SCREEN (Final [**2157-3-26**]): No MRSA isolated.
.
[**2157-3-24**] 4:11 am SEROLOGY/BLOOD CHM S# [**Serial Number 24250**]B RPR ADDED
[**3-24**].
**FINAL REPORT [**2157-3-25**]**
RAPID PLASMA REAGIN TEST (Final [**2157-3-25**]):
NONREACTIVE.
Reference Range: Non-Reactive.
.
RADIOLOGY:
Radiology Report BILAT LOWER EXT VEINS Study Date of [**2157-3-26**]
6:40 PM
IMPRESSION:
1. No evidence of DVT, though the calf veins were not seen.
2. Small left-sided [**Hospital Ward Name 4675**] cyst.
.
CARDIOLOGY:
Cardiovascular Report ECG Study Date of [**2157-3-23**] 6:49:34 PM
Atrial bigeminy at an overall rate of 108 beats per minute with
rate-related aberration resulting in a ventricular bigeminal
pattern. Right bundle-branch block. Diffuse non-specific ST
segment flattening in the lateral leads. Compared to the
previous tracing of [**2151-4-3**] atrial ectopy, bigeminy and overall
tachycardia are new. Computed QRS duration is wider.
Non-specific repolarization abnormalities are similar on the
non-aberrantly conducted beats.
Brief Hospital Course:
Ms. [**Known lastname **] is a 55yo female with recurrent ventral hernias at
prior incision sites who was admitted to ICU after OR repair for
decreased urine output. Below is her ICU course.
.
#Oliguria- Most likely this is due to hypovolemia in the setting
of a prolonged operative case with a significant amount of
incensible fluid loss. Her FeNa on admission is 0.03% suggesting
a pre-renal etiology. She was given continued boluses of LR
while in the unit and her UOP increased appropriately. At time
of discharge from the unit she was making over 50cc/hr of urine.
.
#Post Op [**Name (NI) 1622**] Pt initially had an epidural catheter in place
for pain control infusing dilaudid and bupivacaine. Acute pain
service followed her and assisted with management. She initially
was complaining of pain and she was given a bolus of dilaudid in
her epidural catheter but this was not helping. At this point,
the epidural was kept in place with bupivacaine only infusing
and patient was started on a dilaudid PCA for overnight. The
following day her epidural catheter was removed and her dilaudid
PCA was discontinued due to new onset of delerium/paranoia.
Pain control was switched to PO medications and patient was
restarted on many of her home pain medications.
.
#Delerium-Thought to be related to anesthesia, IV pain
medications and ICU admission. Treated conservatively with
Psych consult and discontinuation of IV pain medications and
epidural. Her sister was asked to come to the ICU and remained
at patient's bedside throughout the day on POD#1 to provide
emotional support and a sense of safety to patient. Patient
showed gradual improvement with supportive measures and returned
to her baseline.
.
# S/P hernia repair- Surgical incision site was clean without
evidence of infection. 4 JP drains were in place draining a
bloody serous fluid. Gen [**Doctor First Name **] and Plastic [**Doctor First Name **] following along
for assistance in post op management. She was tolerating a clear
liquid diet prior to discharge from the unit. Her Hct remained
stable. We continued Ancef per surgery recs.
.
#Hypothyroidism- continued levothyroxine.
.
#Prophylaxis- Patient was maintained on heparin subcutaneous and
then lovenox injections during her hospital stay. She was
assisted out of bed to chair and assisted to ambulate as soon as
she was able.
.
By post-operative day #3, patient showed clear clinical
improvement and was transferred to the floor. She was noted to
have some tachycardia and elevated blood pressures so was
started on low dose hydrochlorothiazide (12.5mg qd) on [**3-26**]
which she tolerated well. By post-operative day #5, patient was
alert and oriented and back to baseline mental status. She was
voiding large amounts of urine freely. She was able to walk
around unassisted and walk up stairs. Her abdominal incision
was clean and intact without evidence of infection. JP drains x
4 were draining serous fluid. Her abdominal binder was in place
and her pain was well controlled on her discharge pain
medication regimen. Patient was discharged home on POD#5 per
discharge plan.
Medications on Admission:
aspirin 81 mg daily
levothyroxine 100mg po QD
lidocaine topical patch 5% (700 mg patch) 2 per day
Nabumetone (relafen) 500 mg po BID prn
Gabapentin 300 mg QID for abd pain
Baclofen 10mg tab x 2 tabs QID for abd pain
Amitriptyline 25mg tab x 3 tabs at HS
Prilosec 20mg po BID
Simvastatin 40 mg po QD
Tramadol 50 mg TID
restoril 30 mg po QHS prn
clobetasol ointment prn (not currently using)
nystatin ointment prn (not currently using)
MVI
Calcium citrate
flaxseed oil (stopped)
glucosamine
omega 3
miralax
metamucil
cholecalciferol.
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*2*
3. baclofen 10 mg Tablet Sig: Two (2) Tablet PO QID (4 times a
day).
4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
Disp:*100 Tablet(s)* Refills:*2*
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
6. amitriptyline 25 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
7. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
9. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily) for 30 days.
Disp:*30 Capsule(s)* Refills:*0*
10. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. cefadroxil 500 mg Capsule Sig: One (1) Capsule PO twice a
day for 10 days: Take for as long as drains in place. Refill as
needed.
Disp:*20 Capsule(s)* Refills:*1*
12. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) injection
Subcutaneous once a day for 7 days.
Disp:*7 syringes* Refills:*0*
13. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation: Over the counter laxative.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA
Discharge Diagnosis:
1) recurrent incisional hernia
2) Oliguria
3) Delerium
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted on [**2157-3-23**] for incisional hernia repair with
component separation. Please follow these discharge
instructions.
.
Personal Care:
1. You may remove your dressings after 48 hours post surgery.
2. Clean around the drain site(s), where the tubing exits the
skin, with soap and water.
3. Strip drain tubing, empty bulb(s), and record output(s) [**1-28**]
times per day.
4. A written record of the daily output from each drain should
be brought to every follow-up appointment. your drains will be
removed as soon as possible when the daily output tapers off to
an acceptable amount.
5. You may shower 48 hours after surgery but do not bathe in a
tub until cleared by Dr. [**First Name (STitle) **].
6. You should wear your abdominal binder at all times.
.
Activity:
1. You may resume your regular diet.
2. DO NOT lift anything heavier than 5 pounds or engage in
strenuous activity until instructed by Dr. [**First Name (STitle) **].
.
Medications:
1. HOLD your daily baby aspirin and your nabumetone (relafen)
for now. You may ask Dr. [**First Name (STitle) **] at your follow up appointment when
you may re-start these medications.
2. You may take your oxycodone as needed for moderate to severe
pain.
3. Take your antibiotic as prescribed.
4. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication. You may use a different
over-the-counter stool softener if you wish.
5. Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
6. do not take any medicines such as Motrin, Aspirin, Advil or
Ibuprofen etc
.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: [**First Name (STitle) **] with chills, increased redness,
swelling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s) or drain(s).
3. [**First Name (STitle) **] greater than 101.5 oF
4. Severe pain NOT relieved by your medication.
.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, [**First Name (STitle) **] greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
DRAIN DISCHARGE INSTRUCTIONS
You are being discharged with drains in place. Drain care is a
clean procedure. Wash your hands thoroughly with soap and warm
water before performing drain care. Perform drainage care twice
a day. Try to empty the drain at the same time each day. Pull
the stopper out of the drainage bottle and empty the drainage
fluid into the measuring cup. Record the amount of drainage
fluid on the record sheet. Reestablish drain suction.
.
ISSUES TO DISCUSS WITH YOUR PCP:
[**Name10 (NameIs) 24251**] you were hospitalized, a thyroid stimulating hormone
(TSH) level was drawn to monitor thyroid function. Your level
was slightly low at 0.23. You have been maintained on your home
dose of levothyroxine (100mcg). Your PCP will need to further
monitor your TSH level.
-You had some elevated heart rates and elevated blood pressures
while you were an inpatient. Your resting heart rate had
improved by time of discharge to 80-95. Your blood pressure
remained elevated so you were maintained on a low dose of
hydrochlorothiazide (12.5mg daily). You have been given a
prescription for 30 days of this medication after which time
your PCP may decide to renew or increase this medication or
discontinue it.
-Please bring your daily vital signs log/report from the
visiting nurse to your appointment with your PCP.
[**Name10 (NameIs) **] were not maintained on your lidoderm patches or your
neurontin while in hospital. These may not be necessary any
longer given that your hernia was repaired. You should discuss
this with your PCP.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern1) 6751**], MD
Phone:[**Telephone/Fax (1) 6742**]
Date/Time: [**2157-4-5**] 11:15
.
Please follow up with your Primary Care Provider [**Name Initial (PRE) 176**] 1 month.
Completed by:[**2157-3-28**]
|
[
"788.5",
"278.00",
"338.29",
"276.52",
"272.4",
"297.1",
"796.2",
"571.8",
"568.0",
"327.23",
"V15.82",
"553.21",
"785.0",
"338.18",
"E938.2",
"292.81",
"V45.86",
"244.9",
"E935.2",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.59",
"53.61",
"03.90"
] |
icd9pcs
|
[
[
[]
]
] |
10010, 10061
|
4860, 7980
|
340, 472
|
10160, 10160
|
1816, 4837
|
14526, 14804
|
1221, 1277
|
8562, 9987
|
10082, 10139
|
8006, 8539
|
10311, 14503
|
1292, 1797
|
272, 302
|
500, 708
|
10175, 10287
|
730, 1062
|
1078, 1205
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,106
| 198,606
|
47278
|
Discharge summary
|
report
|
Admission Date: [**2164-6-8**] Discharge Date: [**2164-6-13**]
Date of Birth: [**2111-12-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain/SOB
Major Surgical or Invasive Procedure:
CABGx4 [**6-8**]
History of Present Illness:
52 yo F with chest pain and SOB
Past Medical History:
HTN,
Hyperlipidimia
ventral hernia
colon polyps s/p R colectomy
Social History:
Married, 7 children, unemployed
Moved from D.R. one year ago.
Family History:
No tobacco
Social ETOH
Physical Exam:
HR 64 RR 13 BP 150/84
NAD
Heart RRR, no m/r/g
Lungs CTAB
Abdomen benign
Extrem warm, no edema
Pertinent Results:
[**2164-6-13**] 05:33AM BLOOD WBC-11.8* RBC-3.13* Hgb-9.1* Hct-27.6*
MCV-88 MCH-29.0 MCHC-32.8 RDW-15.1 Plt Ct-330
[**2164-6-13**] 05:33AM BLOOD Plt Ct-330
[**2164-6-13**] 05:33AM BLOOD UreaN-19 Creat-1.0 K-4.5
CHEST (PA & LAT) [**2164-6-12**] 7:57 PM
CHEST (PA & LAT)
Reason: asssess for effusions/infiltrates
[**Hospital 93**] MEDICAL CONDITION:
52 year old man s/p cabg-known broken sternal wire
REASON FOR THIS EXAMINATION:
asssess for effusions/infiltrates
Improved aeration of lungs bilaterally. Inferior most sternal
wire again fractured, but no lateral displacement to suggest
dehiscence. Residual linear atelectasis of left base.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 100093**] (Complete)
Done [**2164-6-8**] at 9:15:12 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2111-12-29**]
Age (years): 52 M Hgt (in): 66
BP (mm Hg): 135/78 Wgt (lb): 200
HR (bpm): 76 BSA (m2): 2.00 m2
Indication: Intraoperative TEE for CABG procedure
ICD-9 Codes: 786.05, 786.51, 440.0, 424.0
Test Information
Date/Time: [**2164-6-8**] at 09:15 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: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW2-: Machine: aw2
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Peak Pulm Vein S: 0.8 m/s
Left Atrium - Peak Pulm Vein D: 0.7 m/s
Left Ventricle - Septal Wall Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 35% >= 55%
Aorta - Annulus: 2.1 cm <= 3.0 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.6 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 10 mm Hg < 20 mm Hg
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - A Wave: 0.5 m/sec
Mitral Valve - E/A ratio: 2.00
Findings
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: Moderate-severe regional left ventricular
systolic dysfunction. Moderately depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
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.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
Prebypass
1. No atrial septal defect is seen by 2D or color Doppler.
2.There is moderate to severe regional left ventricular systolic
dysfunction with hypokinesia of the apex, apical and mid
portions of the anterior, anteroseptal and septal walls. Overall
left ventricular systolic function is moderately depressed
(LVEF= 35%).
3.Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the descending thoracic aorta.
5.The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person
of the results on [**2164-6-8**] at 830am.
Post bypass
1. Patient is in sinus rhythm and receiving an infusion of
phenylephrine and epinephrine.
2. Biventricular systolic function is unchanged.
3. Mild mitral regurgitation persists.
4. Aorta intact post decannulation.
Brief Hospital Course:
He was taken to the operating room on [**6-8**] where he underwent a
CABG x 4. He was transferred to the ICU in stable condition on
epinephrine, propofol and phenylephrine drips. He was extubated
postoperatively, but required BiPap/cpap for sleep apnea
overnight during his hospital stay. He was transferred to the
floor on POD #2. Chest tubes and wires were pulled without
incident. CXR showed broken inferior sternal wire. He otherwise
did well postoperatively, and was ready for discharge home on
POD #5.
Medications on Admission:
Simvastatin 20', Atenolol 100', Omega3 1000', ASA 325', NTG-prn
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 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 With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
s/p CABGx4(LIMA-LAD, SVG-Diag, SVG-0M, SVG-PDA)[**6-8**]
PMH: CAD, HTN, ^chol, Vetral hernia, Colonic polyps, s/p Rt
colectomy
Discharge Condition:
stable
Discharge Instructions:
Keep wounds clean and dry, no lotions, creams or powders to
incisions. Shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Followup Instructions:
wound clinic in 2 weeks
Dr [**First Name4 (NamePattern1) 1528**] [**Last Name (NamePattern1) 100094**] [**Telephone/Fax (1) 3581**] in [**2-19**] weeks
Dr [**Last Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) **] 2 weeks
Completed by:[**2164-6-13**]
|
[
"272.4",
"998.31",
"401.9",
"414.01",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.13",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6813, 6871
|
5150, 5659
|
289, 308
|
7042, 7051
|
706, 1022
|
7359, 7620
|
552, 576
|
5773, 6790
|
1059, 1110
|
6892, 7021
|
5685, 5750
|
7075, 7336
|
4048, 5127
|
591, 687
|
235, 251
|
1139, 3999
|
336, 369
|
391, 456
|
472, 536
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,836
| 110,535
|
14243
|
Discharge summary
|
report
|
Admission Date: [**2127-10-30**] Discharge Date: [**2127-11-10**]
Date of Birth: [**2046-10-11**] Sex: M
Service: SURGERY
Allergies:
Percocet
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
contained rupture of aortic
aneurysm.
Major Surgical or Invasive Procedure:
[**2127-10-30**] Repair of contained ruptured AAA
History of Present Illness:
The patient is an elderly male who presented
several weeks ago with a contained rupture of aortic
aneurysm. Due to his age and comorbidities we attempted an
endovascular repair. This was successful in a sense that it
stopped the rupture, but he had a persistent type 1 endoleak.
He decided that he wanted to go home for a week or two and
think about it and then return for essentially elective
removal of the graft and repair of his aortic aneurysm. This
was going to be difficult case because the Zenith graft has
suprarenal fixation. In addition to seal the graft, there is
a Palmaz stent that bridges across the mesenteric vessels and
there is an additional Zenith cuff. In addition, he only has
a functioning left kidney.
Past Medical History:
PMH: CABG in [**2-/2117**] with an LIMA to LAD and vein graft to the
first diagonal, obtuse marginal, and right coronary arteries
Carotid stenosis s/p bilateral carotid endarterectomies
COPD
hyperlipidemia
hypertension
mild congestive heart failure
anxiety
rotator cuff tear
sleep apnea
Social History:
FH: non-contributory
Family History:
SH: No ETOH or smoking. He is a remote smoker.
Physical Exam:
VS: T 98.9 P 71 BP 124/70 RR 18 O2 sat 96%
AAOX3, NAD
HENT: wnl
Heart: RRR, no murmur
Lungs: CTA, B/L
Abd: Incision with staple intact, minimal drainage, soft,
non-tender
Ext: warm and dry,
Pulses: Fem DP PT
Rt 2+ 1+ mono
Lt 2+ 1+ tri
Pertinent Results:
[**2127-11-7**] 03:52AM BLOOD WBC-8.7 RBC-3.14* Hgb-9.9* Hct-28.2*
MCV-90 MCH-31.5 MCHC-35.1* RDW-14.7 Plt Ct-276
[**2127-11-7**] 03:52AM BLOOD Plt Ct-276
[**2127-11-9**] 06:25AM BLOOD Glucose-113* UreaN-15 Creat-1.3* Na-141
K-3.9 Cl-106 HCO3-27 AnGap-12
PORTABLE CHEST X-RAY [**2127-11-6**]:
FINDINGS: Cardiomediastinal contours appear unchanged. New
poorly defined
opacities have developed in the mid and lower lungs bilaterally
with a
somewhat nodular quality, possibly representing airways disease
from
aspiration or infection. A dependent distribution of pulmonary
edema in the setting of underlying COPD is an additional
consideration. Improving aeration at left base is likely a
combination of improving atelectasis and effusion. Baseline
pleural thickening persists at right lung base with possible
superimposed small pleural effusion. Asymmetric biapical
thickening is unchanged dating back to [**2123-5-22**] and attributed
to scarring.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: [**Doctor First Name **] [**2127-11-6**] 2:51 PM
CT Torso without contrast [**2127-11-10**] - no official read
Brief Hospital Course:
[**2127-10-30**] Patient was admitted via holding room and taken to OR
for scheduled elective repair of contained ruptured AAA. Patient
recovered in the CV ICU intubated, with PA catheter in place,
patient was sedated and on pressors and insulin drip.
[**2127-10-31**] Remains in the ICU with pressors, sedated, and
intubated.
[**2127-11-1**] Remains in the ICU, weaned from vent and extubated.
Borderline urine output strted on low dose Lasix.
[**2127-11-2**] Remains in ICU, PA line pulled back to CVL. Continue to
diurese gently. Started on beta blocker and Amiodarone for
frequent irregular HR and atrial ectopies. Physical therapy
consult for out of bed to chair.
[**2127-11-3**] Remains in ICU, good urine output, HR controlled with
Amiodarone drip and IV Lopressor.
[**2127-11-4**] Off all drips, remains NPO- distended abdomen, HR and
respiratory stable. Transferred to [**Hospital Ward Name 121**] 5 VICU for further
observation. Hct drifting down, transfused with 2 unts of PRBCs,
continue to diurese gently.
[**2127-11-5**] Afebrile, VSS, no acute events. Started po's.
[**2127-11-6**] No acute events, Lasix prn. Monitor creatinine peaked
at 1.7 ([**11-1**]). Seen by Social work for coping support.
[**Date range (1) 42332**] No acute events, now on ADAT, continue to work with
physical therapy.
[**11-10**]- Rehab screen for dispo. CT- torso without contrast-report
not available wet red by Dr. [**MD Number(4) 42333**] concerning. Discharged
to rehab in stable condition.
Medications on Admission:
Aspirin 325 mg po qd
Zocor 80 mg po qd
Plavix 75 mg po qd
Metoprolol 50 mg po TID
Albuterol inhaler qid
Fluticasone-Salmeterol 250-50 [**Hospital1 **]
Tiotropium bromide 18mcg qd
Vicodin
Amlodipine 10 mg po qd
Simethicone
Senna
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
as needed for hypertension.
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day) as needed.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO every six (6) hours as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]-[**Location (un) **]
Discharge Diagnosis:
AAA s/p open repair
COPD
High Cholesterol
HTN
History of mild CHF
anxiety
sleep apnea
Discharge Condition:
Stable
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**6-29**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**2-23**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over incision, rinse
and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2127-11-25**] 1:30
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 11767**] Date/Time:[**2128-2-2**] 10:40
Completed by:[**2127-11-10**]
|
[
"441.3",
"401.9",
"780.57",
"496",
"V45.81",
"272.0",
"996.74",
"414.00",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.44"
] |
icd9pcs
|
[
[
[]
]
] |
5777, 5841
|
3012, 4509
|
309, 361
|
5971, 5980
|
1806, 2989
|
8720, 9048
|
1485, 1535
|
4788, 5754
|
5862, 5950
|
4536, 4765
|
6004, 8267
|
8293, 8697
|
1550, 1787
|
232, 271
|
389, 1119
|
1141, 1430
|
1446, 1469
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,684
| 162,438
|
37692
|
Discharge summary
|
report
|
Admission Date: [**2121-8-20**] Discharge Date: [**2121-9-1**]
Date of Birth: [**2050-1-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Shellfish Derived
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Acute myocardial infarction
Major Surgical or Invasive Procedure:
[**2121-8-22**] Coronary Artery Bypass Graft x 4
(LIMA-LAD,SVG-PDA,SVG-Diag,SVG-OM)
placement of Intraaortic Balloon [**8-21**]
Coronary artery angioplasty [**8-20**]
left heart catheterization, coronary angiography [**8-20**]
History of Present Illness:
This 71 year old white male with past medical history of
hypertension who presented to [**Hospital3 **] on [**8-19**] with
cough and left shoulder pain for 2 days. EKG there revealed
possible IMI and the patient was transferred emergently for
cardiac catheterization. Of note, he received a Xylocaine
injection earlier that day for what was believed to be muscles
spasms in his shoulder.
Past Medical History:
Hypertension
Gout
s/p pilondydal cyst removal
s/p tonsillectomy
Social History:
Race:Caucasian
Last Dental Exam:2 months ago
Lives with:wife
Occupation:Retired
Tobacco:denies
ETOH:denies
Family History:
Father died of ruptured aorta age 59, brother with "heart
problems"
Physical Exam:
admission:
Pulse:103 Resp:18 O2 sat:96 RA
B/P Right:101/68 Left:
Height: 5'9" Weight:120.2 kg, 264 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] 2+ LE Edema
Varicosities: None [x]
Neuro: Grossly intact[x]
Pulses:
Femoral Right:1+ Left:1+
DP Right:1+ Left:1+
PT [**Name (NI) 167**]:1+ Left:1+
Radial Right:2+ Left:2+
Carotid Bruit Right:- Left:-
Pertinent Results:
[**8-20**] Cath: 1. Selective coronary angiography in this right
dominant system
demonstrated 3 vessel diseased. The LMCA had mild plaquing. The
LAD had
80% ostial stenosis with a total occlusion in the mid portion of
the
vessel. Collaterals from the acute marginal of the RCA filled
with
distal LAD. The Cx had a 90% stenosis of the ostium and an 80%
stenosis
in the mid portion of the vessel. The OM2 branch of the Cx had a
total
occlusion. The RCA had a total occlusion in the mid portion of
the
vessel. 2. Limited resting hemodynamics revealed a central
aortic pressure of 133/97 mmHg. 3. Successful PTCA of the acute
OM2 occlusion with a 2.0mm balloon with 50% residual stenosis.
[**8-21**] Carotid U/S: Right ICA stenosis <40%. Left ICA stenosis
<40%.
[**8-22**] Echo: Pre CPB: The left atrium is moderately dilated. No
thrombus is seen in the left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. The left ventricular
cavity is mildly dilated. There is severe regional left
ventricular systolic dysfunction. There is an inferobasal left
ventricular aneurysm. There is akiniesis of the inferior wall
and hypokinesis of the remaining segments (LVEF = 20 %). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the aortic root. There are simple
atheroma in the ascending aorta. There are simple atheroma in
the descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is a
trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) 914**] was
notified in person of the results.
Post CPB: On infusions of epi, levophed, milrinone, amiodarone,
and while AV pacing, improved global LV systolic function, LVEF
now 30%, with improvement of anterior & lateral walls. MR is now
trace, IABP is 5 cm below the left subclavian artery. Aortic
contour is normal post- decanulation.
[**2121-8-20**] 04:00AM BLOOD WBC-18.5* RBC-4.75 Hgb-13.9* Hct-41.2
MCV-87 MCH-29.3 MCHC-33.8 RDW-13.7 Plt Ct-237
[**2121-8-23**] 12:54PM BLOOD WBC-15.2* RBC-2.84* Hgb-8.6* Hct-24.0*
MCV-85 MCH-30.2 MCHC-35.8* RDW-14.5 Plt Ct-102*
[**2121-9-1**] 06:10AM BLOOD WBC-12.3* RBC-3.49* Hgb-10.4* Hct-31.8*
MCV-91 MCH-29.9 MCHC-32.8 RDW-15.2 Plt Ct-244
[**2121-8-20**] 04:00AM BLOOD PT-13.8* PTT-57.7* INR(PT)-1.2*
[**2121-9-1**] 06:10AM BLOOD PT-16.6* INR(PT)-1.5*
[**2121-8-20**] 04:00AM BLOOD Glucose-218* UreaN-22* Creat-0.9 Na-139
K-4.2 Cl-102 HCO3-22 AnGap-19
[**2121-8-24**] 03:21AM BLOOD Glucose-108* UreaN-19 Creat-0.7 Na-138
K-4.2 Cl-106 HCO3-26 AnGap-10
[**2121-9-1**] 06:10AM BLOOD Glucose-95 UreaN-28* Creat-0.8 Na-140
K-4.7 Cl-106 HCO3-27 AnGap-12
[**2121-8-25**] 08:55PM BLOOD ALT-43* AST-37 LD(LDH)-735* AlkPhos-58
Amylase-35 TotBili-1.8*
Brief Hospital Course:
Mr. [**Known lastname 84490**] was transferred for a cardiac catheterization. Cath
revealed severe three vessel disease and he underwent PTCA of
the second obtuse marginal. The following day he developed
recurrent ischemia and underwent placement of an IABP. He was
stabilized and on [**8-22**] he was brought to the operating room
where he underwent an coronary artery bypass graft x 4. Please
see operative report for surgical details.
He weaned from bypass on epinephrine, Levophed, Milrinone and
the IABP. He had a significant fluid requirement and Vasopressin
was added to his regimen to stabilize his hemodynamics. He
gradually improved and on POD 2 with lower Levophed and
epinephrine requirements the IABP was removed without incident.
Chest tubes were removed. He did have transient atrial
fibrillation which responded nicely to Amiodarone with
conversion to sinus rhythm. All above drugs were weaned off by
post-op day three. Ace-inhibitor was started for pre-op
myocardial infarction. Also on this day he was weaned off
sedation, awoke neurologically intact but very confused and
extubated. Tube feedings were begun earlier and continued.
Diuresis was begun. Captopril was changed to Lisinopril and
Coreg given due to his poor left ventricular function. On POD 6
he was able to swallow thick foods without difficulty and tube
feeds were stopped. He was oriented to events, more alert
although slightly still confused.
On POD 7 he was transferred to the telemetry floor for further
care. Physical and Occupational therapy worked with him for
conditioning and strength. They recommended additional
rehabilitation. Coumadin was started per cardiologist Dr.
[**Last Name (STitle) 1911**] for low EF (titrate for INR around 2). An
echocardiogram was performed on [**9-1**] to evaluate his
post-operative ejection fraction. Later on this day he was
discharged to rehab with the appropriate medications and
follow-up appointments.
Medications on Admission:
Lopressor 50mg po BID
"Muscle Relaxer" PRN
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:*30 Tablet(s)* Refills:*0*
3. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Niacin 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
10. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days: Please follow BUN/Cr. Assess patient after 1 wk. [**Month (only) 116**]
decrease but will need to continue diuretic for low EF.
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 7 days: Please adjist accordingly.
12. Norflex 100 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO daily ().
13. Warfarin 2 mg Tablet Sig: 1-2 Tablets PO once a day: Please
adjust dose for INR around 2 for low EF (based on cardiologist
Dr.[**Name (NI) 1912**] recommendations).
Discharge Disposition:
Home With Service
Facility:
N/A
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
Acute Myocardial Infarction
Congestive heart failure
sever left ventricular dysfunction
Past medical history:
Hypertension
Gout
s/p pilondydal cyst removal
s/p tonsillectomy
Discharge Condition:
good
Discharge Instructions:
shower daily, no baths or swimming
no lotions, creams or powders to incisions
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name11 (Name Pattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6955**] in [**12-6**] weeks ([**Telephone/Fax (1) 22629**])
Dr. [**First Name (STitle) **] [**Name (STitle) 1911**] at [**Location (un) **] (cardiologist) for first
available appointment. ([**Telephone/Fax (1) 2037**]
please call for appointments
Completed by:[**2121-9-1**]
|
[
"427.31",
"401.9",
"413.9",
"278.01",
"274.9",
"414.01",
"428.21",
"518.5",
"240.9",
"428.0",
"458.29",
"287.5",
"486",
"786.2",
"424.0",
"410.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.61",
"00.40",
"00.66",
"96.71",
"88.56",
"39.61",
"38.93",
"96.6",
"36.15",
"37.22",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
8491, 8525
|
4846, 6784
|
310, 538
|
8803, 8809
|
1940, 3681
|
9213, 9664
|
1182, 1251
|
6877, 8468
|
8546, 8695
|
6810, 6854
|
8833, 9190
|
1266, 1921
|
243, 272
|
566, 955
|
8717, 8782
|
1058, 1166
|
3691, 4823
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,043
| 172,930
|
32557
|
Discharge summary
|
report
|
Admission Date: [**2141-7-6**] Discharge Date: [**2141-7-12**]
Date of Birth: [**2087-11-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Unresponsiveness
Major Surgical or Invasive Procedure:
Femoral CVL.
PICC line.
History of Present Illness:
Mr. [**Known lastname 40503**] is a 53 year old M with PMH of chronic vent/trach
recent admission for VAP, severe COPD, prior L CVA with residual
R-sided weakness, seizure disorder, depression and schizophrenia
who presents from rehab after being found unresponsive
overnight. According to notes the patient was checked on at 430
and found unresponsive in his bed. He did not respond to
sternal rub. He was taken off of the ventilator and bagged with
improvement in mental status. He was then found unresponsive
again at 7am and brought to [**Hospital1 18**] for further evaluation.
Mr. [**Known lastname 40503**] was discharged from MICU [**Location (un) **] on [**7-3**]. He was
admitted hypotensive and hypoxic and found to have ventilator
associated PNA. Sputum and BAL cultures grew Pseudomonas and
Stenotrophomonas. He was treated with cefepime, tobramycin, and
high dose Bactrim all of which he was still taking at time of
presentation. He was also noted to have frequent mucus plugging
requiring suctioning. He was also hypotensive with SBPs in the
70s related to sepsis vs. adrenal insufficiency. Of note he was
also followed by psychiatry during his hospitalization for
concern of suicidal ideation. He was noted to have right sided
pleural effusion with collapse improved after IR guided
thoracentesis.
In the ED the patient's vital signs were T 98.8, BP 86/53 , HR
98, RR 16 , O2 sat 97-100% on AC 500/12/.[**5-15**]. On arrival he was
alert and oriented x 2, interactive. Respiratory was called and
he was placed on the ventilator. He was noted to be hypotensive
to the systolic 70s-80s. He initially refused a line and IVF
was given through PICC. Labs notable for elevated WBC count to
19.5 with 91% neutrophils. Lactate 1.9, first set of cardiac
enzymes negative. UA negative. CXR showed alight proximal
migration of right-sided PICC line with tip now terminating
within the mid subclavian vein, persistent right middle and
lower lobe collapse, increased patchy airspace opacities at the
left lung base which could represent pneumonia or aspiration.
Given persistent hypotension, patient acquiesced to central
access and a femoral line was placed. He received 2L IVF with
improvement in systolic BPs to 100s. He was also given a dose
of Vancomycin and Dexamethasone 10mg IV x1 in the ED. He then
became diaphopretic with a fixed gaze, minimally responsive BP
188/84 R18, 99 % per report he desatted to the 80s but this was
not reported. He was 2 mg ativan IV x1 given history of
seizures. he then became AAOx3 and did not recall the event. No
urinary or fecal incontinence or tonic clonic activity noted.
He is being admitted to ICU for mechanical ventilation and
hypotension.
Of note, patient has been on a ventilator since [**Month (only) 359**] for
respiratory failure secondary to severe COPD. He was found to
have a RML and RLL collapse and paratracaheal LAD as well as
chronic right pleural effusions at that time.
Past Medical History:
Past Medical History:
- Chronic vent/trach/PEG for hypercarbic respiratory failure at
the beginning of [**2140-10-10**], ?reportedly due to COPD
exacerbation
- Severe COPD, home O2 dependent in the past
- Per rehab admission note, questionable old granulomatous lung
disease with calcified hilar LAD
- Remote L CVA with residual right sided weakness
- New onset generalized TC seizures on [**2140-11-5**] per rehab neuro
note, thought to be [**2-11**] post-CVA and metabolic abnormalities (on
transfer from rehab on Keppra, Depakote)
- Diabetes mellitus, on 16U Lantus at rehab and RISS
- Depression
- Schizophrenia, on effexor and risperdal
- Past h/o EtOH abuse
- GERD
- Afib/sinus tach
- Pseudomonas PNA resistant to cephalosporins and quinolones
[**1-17**]
- [**2140-12-19**] TTE: LVEF 50-60% w/dilated right ventricular cavity
and depressed right ventricular systolic function
- h/o diverticulitis
- h/o questionable old granulomatous lung disease with calcified
hilar LAD.
Social History:
Divorced. Former smoking. h/o etoh abuse. Was living at a rehab
facility prior to admission.
Family History:
Non-contributory
Physical Exam:
General Appearance: No acute distress, Overweight / Obese, trach
in place
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Poor dentition, trach
in place
Cardiovascular: Distant heart sounds
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Rhonchorous: )
Abdominal: Soft, Non-tender, Bowel sounds present, Obese, G tube
c/d/i
Extremities: Right: Absent, Left: Absent
Musculoskeletal: Muscle wasting
Skin: Not assessed, No(t) Rash:
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Oriented (to): person, place, month, Movement:
Purposeful, Tone: Not assessed
Pertinent Results:
Trop-T: 0.03 -> <0.01
143 105 11
-------------< 180
4.6 33 0.5
CK: 12 -> flat
Ca: 8.9 Mg: 1.8 P: 3.6
.
WBC: 19.5
HCT: 32
PLT: 433
N:91.3 L:4.1 M:3.9 E:0.5 Bas:0.3
.
PT: 13.5 PTT: 23.3 INR: 1.2
.
Trends:
WBC down to 4.7
HCT stable
Creatinine stable
.
Lactate 1.9
.
[**7-6**] Sputum:
GRAM STAIN (Final [**2141-7-7**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): BUDDING YEAST.
RESPIRATORY CULTURE (Preliminary):
MODERATE GROWTH OROPHARYNGEAL FLORA.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. 2ND
MORPHOLOGY.
GRAM NEGATIVE ROD #3. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| PSEUDOMONAS AERUGINOSA
| |
AMIKACIN-------------- 16 S
CEFEPIME-------------- 8 S 4 S
CEFTAZIDIME----------- 4 S 8 S
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ =>16 R <=1 S
MEROPENEM------------- 8 I 2 S
PIPERACILLIN---------- 8 S 32 S
PIPERACILLIN/TAZO----- 8 S 16 S
TOBRAMYCIN------------ =>16 R <=1 S
.
[**2141-7-6**] 9:18 pm CATHETER TIP-IV Source: PICC.
**FINAL REPORT [**2141-7-9**]**
WOUND CULTURE (Final [**2141-7-9**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >15 colonies.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 2 S
Brief Hospital Course:
Mr. [**Known lastname 40503**] is a 53 year old male with PMH of chronic vent/trach,
severe COPD, prior L CVA with residual R-sided weakness, and
recent admission for VAP who presents from rehab after being
found unresponsive.
1)Unresponsiveness - Unclear etiology, initially suspicous for
infection and he was treated with vancomycin after his PICC was
removed and tip culture was positive for coag negative staph.
His blood cultures remained negative after 48 hours so his
vancomycin was discontinued. He had no further episodes of
unresponsiveness during this admission.
2)Hypotension - He continued to have intermitent, asymptomatic
episodes of hypotension with SBP in the 80's- 90s. Possible
contributing factors include volume depletion, adrenal
insufficiency and autonomic insufficiency. His blood pressure
responded to IVF boluses. In addition, he likely was not
receiving adequate daily volume intake so he was started on free
water via Gtube to total 1L daily. For his adrenal
insufficiency he was continued on hydrocortisone but was tapered
from 100mg IV q8 to 50mg IV Q8 to chronic dose of 20mg qam and
5mg qpm. Could also have autonomic instability secondary to
diabetes contributing to his hypotensive episodes.
3) Pneumonia - On admission he was still being treated for his
recent positive sputum cultures on his previous admission which
were positive for pseudomonas and stenotrophomonas. During his
hospitalization he completed his course of cefepime, tobramycin,
and high dose Bactrim. He had no evidence of new infiltrate on
imaging.
4)COPD/chronic vent/trach - he had no acute issues during his
admission and he was weaned on his ventillator settings. He was
discharged on a trach collar at 8 l/min. He should follow up
with pulmonology as an outpatient for further weaning of his
ventillator settings.
5)Right leg pain: His leg pain pain was similar to the chronic
pain he has had for years, for which he is on chronic narcotics.
He was continued on acetaminophen and oxycodone PRN for pain.
6)Recent history of suicidal ideation: During last admission
was followed by psychiatry and had a 1:1 sitter. Patient denies
any suicidal or homocidal ideation during this admission. He
was continued on his outpatient psychiatric regimen including
risperidone and effexor. He would likely benefit from further
psychiatric care and medication adjustment given his continued
depressed mood.
7)Type 2 Diabetes mellitus: He was continued on glargine and
humalog sliding scale.
8)Seizure disorder: Continued on levetiracetam and depakote. No
acute issues during this hospitalization.
9)Constipation: he was continued on bowel regimen of lactulose
PRN, colase and senna.
10) Schizophrenia: Continue outpatient dose of risperidone
11)F/E/N: Tube feeds via PEG with Probalance Full strength; Goal
rate: 70 ml/hr
Flush w/ 250 ml water q6h. His free water flushes were
increased as he appeared to become dehydrated and hypotensive on
tube feeds alone.
12) PPx: proton pump inhibitor for stress ulcer prophylaxis, SC
heparin for DVT prophylaxis
13) Access:He had a right femoral line during his admission to
complete his antibiotic course. This was discontinued on
discharge following completion of his antibiotic course.
14) Communication: Guardian [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 46208**], fax
[**Telephone/Fax (1) 75910**].
15) Code: Full. He has a guardian.
Medications on Admission:
Bisacodyl 5 mg Tablet 2 Tab DAILY
Heparin 5,000 unit/mL subq TID
Acetaminophen 325 mg Tablet 1-2 Tablets PO Q6H PRN
Risperidone 2 mg Tablet PO BID
Venlafaxine 75 mg Tablet [**Hospital1 **]
Divalproex 125 mg Capsule, Sprinkle 7 Capsule TID
Lansoprazole 30 mg Tablet,Rapid Dissolve PO DAILY
Ipratropium Bromide 0.02 % Solution 1neb INH q6H PRN
Levetiracetam 100 mg/mL 250mg PO bid
Albuterol 90 mcg/Actuation 1 puff q6H PRN
Folic Acid 1 mg Tablet DAILY
Hexavitamin 1 Cap PO DAILY
Docusate Sodium 100mg PO BID
Senna 8.6 mg Tablet 1 tab PO BID
Chlorhexidine Gluconate 0.12 % Mouthwash 15ML Mucous membrane
[**Hospital1 **] Trazodone 50 mg Tablet HS
Insulin Glargine 10units subq hs
Insulin sliding scale
Ibuprofen 100 mg/5 mL Suspension 200-400 mg PO Q4H PRN pain.
Lactulose 30ML PO Q8H PRN
Acetylcysteine 20 % 1-10 MLs q6H PRN thick secretions
Trimethoprim-Sulfamethoxazole 160-800 mg Tablet 4Tablet PO BID
(last dose [**2141-7-14**])
Oxycodone 5 mg/5 mL Solution 5mg PO Q8H PRN
Tobramycin Sulfate 300mg Inj Q24H (last dose planned for
[**2141-7-7**])
Cefepime 2 gram Recon Soln 2 inj Q8H for 10 days (last dose
[**2141-7-12**])
Hydrocortisone 50mg IV Q8H x 5 days (last day [**2141-7-8**])
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day/Year **]: One Hundred (100) mg
PO BID (2 times a day).
2. Senna 8.8 mg/5 mL Syrup [**Month/Day/Year **]: Ten (10) ml PO at bedtime.
3. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day/Year **]: 5000 (5000)
units Injection TID (3 times a day).
4. Dulcolax 10 mg Suppository [**Month/Day/Year **]: One (1) suppository Rectal
once a day as needed for constipation.
5. Risperidone 2 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times a
day).
6. Divalproex 125 mg Capsule, Sprinkle [**Month/Day/Year **]: Eight Hundred
Seventy Five (875) mg PO TID (3 times a day).
7. Venlafaxine 75 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times
a day).
8. Acetaminophen 325 mg Tablet [**Month/Day/Year **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
9. Nexium 40 mg Capsule, Delayed Release(E.C.) [**Month/Day/Year **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. Combivent 18-103 mcg/Actuation Aerosol [**Month/Day/Year **]: Two (2) puffs
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
11. Folic Acid 1 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily).
12. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Month/Day/Year **]: Four
(4) Tablet PO BID (2 times a day): last day [**2141-7-14**].
13. Ipratropium Bromide 0.02 % Solution [**Month/Day/Year **]: One (1) neb
neb Inhalation Q6H (every 6 hours).
14. Albuterol Sulfate 1.25 mg/3 mL Solution for Nebulization
[**Month/Day/Year **]: One (1) neb Inhalation every four (4) hours.
15. Acetylcysteine 20 % (200 mg/mL) Solution [**Month/Day/Year **]: Two (2) ML
Miscellaneous Q6H (every 6 hours) as needed.
16. Hydrocortisone 10 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO QAM.
17. Hydrocortisone 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO QPM.
18. Lactulose 10 gram/15 mL Syrup [**Month/Day/Year **]: Thirty (30) ML PO Q8H
(every 8 hours) as needed.
19. Insulin Glargine 100 unit/mL Solution [**Month/Day/Year **]: Ten (10) units
Subcutaneous at bedtime.
20. Insulin Lispro 100 unit/mL Solution [**Month/Day/Year **]: as directed
Subcutaneous four times a day: according to sliding scale.
21. Oxycodone 5 mg/5 mL Solution [**Month/Day/Year **]: Five (5) mg PO every [**6-18**]
hours as needed.
22. Chlorhexidine Gluconate 0.12 % Mouthwash [**Month/Day (3) **]: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).
23. Therapeutic Multivitamin Liquid [**Hospital1 **]: Five (5) ML PO
DAILY (Daily).
24. Levetiracetam 100 mg/mL Solution [**Hospital1 **]: Two [**Age over 90 1230**]y
(250) mg PO BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Primary - Unresponsiveness
Secondary -
1. COPD with chronic vent support with trach.
2. Recent ventilator associated pneumonia
3. Diabetes mellitus
4. Seizure disorder
5. Schizophrenia.
Discharge Condition:
Fair
Afebrile
Blood pressure 90's - 100's, blood pressure is responsive to IVF
and hypotensive episodes most likely due to volume depletion
On trach collar at 8 l/min.
Discharge Instructions:
You were admitted to the hospital because you were not waking up
at your rehab facility. In the hospital your blood pressure was
low and you were found to have an infection from your IV line.
You were treated with antibiotics and your IV line was replaced.
You have completed your IV antibiotics and do not need to take
these any longer. The only antibiotic that you are still taking
is the bactrim. The last day that you need to take this
antibiotic is [**2141-7-14**], then you will no longer be taking
antibiotics.
You were discharged on trach collar at 8 l/min.
Please call your doctor or return to the hospital if you have
any concerning symptoms including chest pain, trouble breathing,
fevers, loss of consciousness or any other worrisome symptoms.
Followup Instructions:
You will continue to be followed by the doctors [**First Name (Titles) **] [**Last Name (Titles) 1099**] Hospital.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
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"E879.9",
"295.90",
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"536.42",
"482.1",
"564.00",
"285.9",
"311",
"496",
"518.83",
"041.11",
"V46.11",
"438.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.49",
"96.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
15168, 15223
|
7851, 11273
|
339, 365
|
15453, 15625
|
5298, 5849
|
16436, 16690
|
4486, 4504
|
12511, 15145
|
15244, 15432
|
11299, 12488
|
15649, 16413
|
4519, 5279
|
5890, 7828
|
283, 301
|
393, 3357
|
3401, 4360
|
4376, 4470
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,973
| 195,578
|
4024+55533
|
Discharge summary
|
report+addendum
|
Admission Date: [**2180-10-25**] Discharge Date: [**2180-10-31**]
Date of Birth: [**2120-10-31**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Imuran / Cephalosporins / Sulfonamides / Reglan /
Latex / Ampicillin / Lactose
Attending:[**First Name3 (LF) 7281**]
Chief Complaint:
Fever
Rigors
Cellulitis
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
Ms. [**Known lastname 17759**] is a 59 year-old female type I DM complicated by
renal failure, s/p two renal transpants (most recent [**5-/2161**]) and
pancreatic trasplant x2 (most recent [**6-26**]) admitted for fever.
She was recently admitted [**2180-10-14**] with acute cellular rejection
of pancreas transplant manifested as abdominal pain and
elevated pancreatic enzymes. She was given high-dose steroids
and ATG in house, her kidney function improved and pancreatic
enzymes fell, and she was discharged on increased doses
including prednisone 20 mg daily and tacrolimus 3 mg [**Hospital1 **].
.
Ms. [**Known lastname 17759**] was doing well at home where she lives alone with
an 8h/day PCA. She followed up with her nephrologist [**10-23**], who
decreased her prednisone to 15 mg and started Rapamune. The
patient did decrease the prednisone but has not yet started the
Rapamune.
.
This morning, Ms. [**Known lastname 17759**] [**Last Name (Titles) 5058**] at 4 AM with rigors, chills,
nausea, and generally feeling awful. She also had one episode
of diarrhea. She lay down in bed. She then noticed R leg
redness, pain, and swelling. She denies any trauma to the area
or recent breaks in the skin. She took her temperature and noted
it to be 102. She presented to the ED.
.
In the ED, initial VS: T 101.8, BP 110/50, HR 92, RR 17, O2 98%
RA
Exam notable for leg cellulitis. She was hypotensive to the
70s/40s. She received 1 L NS with improvement to 90s/100s. She
has received an additional 1L. She also received metronidazole,
levofloxacin, and vancomycin. Transplant nephrology was made
aware of the admission. She also received tacrolimus (home
dose), zofran, acetaminophen, hydrocortisone 100 mg. Liver and
gallbladder US WNL. Transplant US also unchanged. Recent VS
99.8, HR 103, BP 92/65, RR 18, 100% on 2L.
.
In the MICU, Ms. [**Known lastname 17759**] says she feels much better after the
antibiotics and tylenol. She states that her pain is much
improved, the redness has decreased, and her nausea is gone.
She denies abdominal pain or further diarrhea. She also denies
chest pain or shortness of breath. She denies dysuria.
Past Medical History:
# Diabetes mellitus type I
-- c/b neuropathy, retinopathy, dysautonomia
# Autonomic neuropathy
# Sleep disordered breathing
-- Unable to tolerate CPAP; uses oxygen 2L NC at night
# Osteoporosis
# Hypothyroidism
# Pernicious anemia
# Cataracts
# Glaucoma
# Anemia of CKD, on Aranesp
# R foot fracture c/b RLE DVT
# Chronic LLE edema
# Recurrent E. coli pyelonephritis
# s/p renal transplant ([**2157**])
-- c/b chronic rejection
-- second renal transplant ([**2160**])
# s/p pancreas transplant
-- with allograft pancreatectomy ([**5-/2174**])
-- redo pancreas transplant ([**6-/2175**])
# s/p anal polypectomy ([**5-/2176**])
# s/p bilateral trigger finger surgery ([**8-/2178**])
# s/p left BKA ([**8-/2179**])
Social History:
Child psychiatrist, on disability. Lives alone in [**Hospital1 8**]. Has
a PCA 8h/day. Ambulatory with a prosthesis. Denies alcohol,
tobacco, or illicit drug use.
Family History:
Noncontributory
Physical Exam:
Physical exam on discharge:
VS: T 98, HR 85, BP 124/54, RR 15, O2 100% on RA
Gen: NAD. Alert and oriented x3. Pleasant and cooperative.
Resting in bed. Quiet voice.
HEENT: NCAT. PERRL, EOMI, anicteric sclera. MMM, OP benign.
Neck: Supple. JVP not elevated. No cervical lymphadenopathy.
CV: RRR. Normal S1, S2. No M/R/G appreciated.
Chest: Respiration unlabored. CTAB. No wheezes, rhonchi, or
rales.
Abd: Soft, nontender. RLQ scar (pancreas), nontender. LLQ scar
(kidney), nontender. Normal bowel sounds.
Ext: Left BKA. RLE trace edema, very mild erythema from just
above ankle to midway to knee, primarily on the anterior
surface. Mild tenderness DP pulse not palpable but doppler-able
Skin: No ecchymoses or other lesions noted.
Neuro: CN II-XII grossly intact. L pupil surgical, R reactive.
Pertinent Results:
1. Labs on admission:
[**2180-10-25**] 08:50AM BLOOD WBC-8.1 RBC-3.17* Hgb-10.1* Hct-30.8*
MCV-97 MCH-31.9 MCHC-32.8 RDW-15.4 Plt Ct-154
[**2180-10-25**] 08:50AM BLOOD Neuts-96.6* Lymphs-2.6* Monos-0.1*
Eos-0.6 Baso-0.1
[**2180-10-25**] 08:50AM BLOOD PT-11.1 PTT-21.8* INR(PT)-0.9
[**2180-10-25**] 08:50AM BLOOD Glucose-80 UreaN-39* Creat-1.2* Na-137
K-3.4 Cl-102 HCO3-26 AnGap-12
[**2180-10-25**] 08:50AM BLOOD ALT-14 AST-22 LD(LDH)-181 AlkPhos-57
Amylase-114* TotBili-0.4
[**2180-10-25**] 08:50AM BLOOD Lipase-54
[**2180-10-25**] 08:50AM BLOOD cTropnT-<0.01
[**2180-10-26**] 04:28AM BLOOD Calcium-7.7* Phos-2.2* Mg-1.4*
[**2180-10-26**] 04:28AM BLOOD tacroFK-8.6
[**2180-10-26**] 08:34PM BLOOD Vanco-17.2
[**2180-10-25**] 09:18AM BLOOD Lactate-1.6
.
2. Labs on discharge:
[**2180-10-31**] 05:06AM BLOOD WBC-2.6* RBC-2.92* Hgb-9.4* Hct-29.6*
MCV-101* MCH-32.2* MCHC-31.8 RDW-15.6* Plt Ct-186
[**2180-10-31**] 05:06AM BLOOD PT-11.2 PTT-27.6 INR(PT)-0.9
[**2180-10-31**] 05:06AM BLOOD Glucose-86 UreaN-34* Creat-1.1 Na-139
K-4.6 Cl-114* HCO3-19* AnGap-11
[**2180-10-31**] 05:06AM BLOOD ALT-8 AST-15 AlkPhos-46 TotBili-0.2
[**2180-10-31**] 05:06AM BLOOD Calcium-8.6 Phos-4.1 Mg-1.4*
[**2180-10-30**] 07:05AM BLOOD Vanco-19.6
.
3. Imaging/diagnostics:
- RLE LENI ([**2180-10-25**]): No right lower extremity DVT.
- Renal transplant U/S ([**2180-10-25**]): No evidence of hydronephrosis
or perinephric fluid collection in left lower quadrant
transplanted kidney. Mildly elevated resistive indices, not
significantly changed from
[**2179-3-15**] and [**2179-2-8**].
- Liver or gallbladder U/S ([**2180-10-25**]): IMPRESSION: Distended
gallbladder without other secondary findings of acute
cholecystitis. Top normal common bile duct, without significant
change since CT of [**2180-10-9**].
- Pancreas transplant U/S ([**2180-10-27**]): Unremarkable appearance of
the right lower quadrant transplant pancreas without
peripancreatic fluid or ductal dilatation. Normal-appearing
pancreatic vascularity.
- CXR (11/3/1): No acute cardiopulmonary process.
Brief Hospital Course:
Ms. [**Known lastname 17759**] is a 59 year old woman s/p kidney and pancreas
transplants, on immmunosupression, admitted with R leg
cellulitis and gram negative bacteremia.
.
#. Bacteremia: Blood culture was positive for Gram negative rods
(E. Coli) in four out of four bottles on admission. Initially
hypotensive, responsive to fluids in ICU. Afebrile, vital signs
stable throughout remember of hospital course. Given history of
chronic steroid use, treated with stress dose steroids, then
quitckly tapered. Source of GNR bacteremia unclear, but unlikely
to be from LE cellulitis. Given allergy profile, treated with
Ciprofloxacin with clinical improvement. Patient to complete 14d
course of Ciprofloxacin on discharged.
.
# Cellulitis: Right leg cellulitis, source unclear. [**Name2 (NI) **] vascular
compromised on exam. Treated with renally-dosed Vancomycin with
clinical improvement. PICC line placed. To continue IV
Vancomycin on discharge to complete 14-day course.
.
# Renal/Pancreas Transplant: Ultrasound unchanged for
transplanted pancreas or kidney. Tacrolimus dose adjusted
accordingly based on tacolimus level. Her amylase lipase
continued to decline following recent treatment for pancreas
rejection and normalized. Did not resume Rapamycin due to recent
GNR bactrmia. Continued on valcyclovir and nystatin prophylaxis.
Blood sugars Monitored with QID finger sticks and placed on
humalog sliding scale and diabetics diet. Did not require
insulin while inpatient.
.
# Hypertension: Doxazosin and hydralazine were held in the
setting hypotension. Should be restarted as outpatient.
.
# Phantom leg: Continued on gabapentin 100mg [**Hospital1 **].
.
# Hypothyroidism: Continued on Levothyroxine 100 mcg alternating
with 112 mcg PO daily.
.
# Glaucoma: Continued on Brimonidine, Dorzolamide-Timolol, and
Methazolamide.
.
# Anemia: Chronic issue, secondary to pernicious anemia. Hct
stable throughout hospital course.
.
# Hyperlipidemia: Continued on home Simvastatin 20mg PO daily.
Medications on Admission:
levothyroxine 100 mcg alternating with 112 mcg daily
simvastatin 20 mg daily
risendronate 35 mg weekly
brimonidine .15% eye gtt q12h
dorzolamide-timolol drops [**Hospital1 **]
restasis .05% eye gtt daily
methazolamide 50 mg tid
ASA 81 mg daily
folate 800 mcg dailyh
omega-3 fatty acids [**Hospital1 **]
gabapentin 100 mg [**Hospital1 **]
Creon 2 caps TID ac
prednisone 20 mg daily
tacrolimus 3 mg daily
valganciclovir 450 mg daily
doxazosin 1 mg [**Hospital1 **]
hydralazine 10 mg q6h prn HTN
docusate 100 mg [**Hospital1 **] prn
pantoprazole 40 mg daily
nystatin 5 mL QID
humalog SS
loperamide prn
loratadine prn
Discharge Medications:
1. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
5. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
6. methazolamide 50 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. folic acid 800 mcg Tablet Sig: One (1) Tablet PO once a day.
9. gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
10. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
11. prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
12. tacrolimus 5 mg Capsule Sig: One (1) Capsule PO once a day.
13. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
PRN.
15. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
16. nystatin 100,000 unit/mL Suspension Sig: Five (5) ml PO four
times a day.
17. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a week.
18. Restasis 0.05 % Dropperette Sig: One (1) drop for each eye
Ophthalmic at bedtime.
19. omega-3 fatty acids 1,000 mg Capsule Sig: One (1) Capsule PO
twice a day.
20. insulin lispro 100 unit/mL Solution Sig: Please see sliding
scale Subcutaneous PRN: Please see sliding scale attached.
21. loperamide 2 mg Tablet Sig: Three (3) Tablet PO PRN.
22. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for itching.
23. doxazosin 1 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for hypertension.
24. hydralazine 10 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for hypertension.
25. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 14 days: Through [**2180-11-8**] for 2 week
course. .
Disp:*18 Tablet(s)* Refills:*0*
26. vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg
Intravenous every twenty-four(24) hours for 14 days: Please
continue until [**2180-11-8**] for 2 week course.
Disp:*9 vials* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Cellulitis
Gram negative bacteremia
H/O Diabetes mellitus type I
Kidney and pancreas transplant
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:
Ms. [**Known lastname 17759**], you were admitted to the [**Hospital1 827**] because you developed fever, rigors, and
cellulitis on your leg. We found E. coli in your blood culture
and treated you with Ciprofloxacin and Vancomycin for the
cellulitis. You got better. Ultrasound of your transplanted
kidney and pancreas were normal. A PICC line was placed so you
can finish your course of IV Vancomycin after discharge.
.
We made the following changes to your medications:
STARTED:
- vancomycin IV 1g every 24 hours through [**2180-11-8**] (14-day
course)
- ciprofloxacin 500 mg by mouth every 12 hours through [**2180-11-8**]
(14-day course)
Followup Instructions:
Department: TRANSPLANT CENTER
When: MONDAY [**2180-11-6**] at 1 PM
With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: SLEEP UNIT NEUROLOGY
When: MONDAY [**2180-11-6**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6855**], M.D. [**Telephone/Fax (1) 6856**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2180-11-8**] at 11:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 10084**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 7284**]
Completed by:[**2180-10-31**] Name: [**Known lastname 2825**],[**Known firstname 2826**] Unit No: [**Numeric Identifier 2827**]
Admission Date: [**2180-10-25**] Discharge Date: [**2180-10-31**]
Date of Birth: [**2120-10-31**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Imuran / Cephalosporins / Sulfonamides / Reglan /
Latex / Ampicillin / Lactose
Attending:[**First Name3 (LF) 2828**]
Addendum:
Change to medications:
There was an error in the list of discharge medications.
-Tacrolimus 5 mg po BID (rather than qd as listed).
This change has been communicated to the patient and she did not
miss a dose of tacrolimus as a result of this error.
[**First Name8 (NamePattern2) 2829**] [**Last Name (NamePattern1) **], MD [**First Name (Titles) **]
[**Last Name (Titles) 2830**]-1, Internal Medicine
[**Pager number 2831**]
Discharge Disposition:
Home With Service
Facility:
[**Company 720**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2832**]
Completed by:[**2180-11-1**]
|
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"272.4",
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
[]
]
] |
14518, 14687
|
6446, 8444
|
380, 401
|
11703, 11703
|
4376, 4384
|
12553, 14495
|
3523, 3541
|
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|
11584, 11682
|
8470, 9086
|
11886, 12329
|
3556, 3556
|
3584, 4357
|
12358, 12530
|
317, 342
|
5150, 6423
|
429, 2590
|
4398, 5131
|
11718, 11862
|
2612, 3326
|
3342, 3507
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,317
| 128,461
|
47791
|
Discharge summary
|
report
|
Admission Date: [**2183-2-19**] Discharge Date: [**2183-2-24**]
Date of Birth: [**2129-5-16**] Sex: M
Service: [**Last Name (un) **]
HISTORY: The patient is a 53-year-old male with a history of
diabetes mellitus, endstage renal disease, who is status post
hemodialysis catheter 4 days prior to his death. Initially
there was the dialysis catheter at one point placed in the
right common carotid. This was repaired with the assistance
of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of vascular surgery as well as Dr.
[**First Name (STitle) **] of transplant surgery, the attending surgeon of
record. The patient had been doing well on the floor
postoperatively with the exception of blood sugars that had
been difficult to manage. He was found by nursing between 4
and 5 a.m. unresponsive, asystolic without a blood pressure.
Code blue was called. ACLS was initiated for 30 minutes with
chest compressions, epi x2, atropine x2, insulin, D50 shock
x1. Pulse, blood pressure returned. The patient remained
unresponsive following event. CT/ CTA were done of the head
and neck to evaluate for dissection. CTA was negative for
dissection, however CT demonstrated infarct of bilateral
occipital lobes and subacute thalamic infarcts bilaterally.
Neurology was called. No significant brain stem reflexes were
found. The patient was intubated, no sedation was given in
the event and not responsive to noxious stimuli and had
bilateral papilledema and poor prognosis. The patient is a 53-
year-old male with past medial history significant for CHF
with an EF of 35%, insulin dependent diabetes mellitus x2,
triopathy, chronic renal insufficiency awaiting transplant.
He is on hemodialysis. Hepatitis C, hypertension, high
cholesterol, hyperparathyroidism.
MEDICATIONS AT HOME:
1. Reglan.
2. Nexium.
3. Coreg.
4. Glargine.
On [**2-24**] after extensive discussion was undertaken with
the family with both the doctor attending, ICU attending, Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 26687**], Dr. [**First Name (STitle) **], a decision was made to withdraw all
care as the patient was declared brain dead after brain death
examination. The ventilator was withdrawn and the patient
expired shortly after.
Time of death was recorded as 8:56 p.m. on [**2183-2-24**].
Medical examiner was notified and Dr. [**Last Name (STitle) **] of the medical
examiner's office declined the case, however autopsy
permission was granted by [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Known lastname **] and autopsy was
to be performed expeditiously as there were still no clear
etiology as per the asystolic event that lead to an anoxic
brain injury and eventual brain death and demise in this
patient.
On the night of [**2183-2-24**], I declared the patient after
withdrawal of support.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Last Name (NamePattern1) 7823**]
MEDQUIST36
D: [**2183-2-24**] 21:34:53
T: [**2183-2-24**] 22:42:26
Job#: [**Job Number 100908**]
|
[
"571.5",
"998.2",
"272.0",
"V58.67",
"998.12",
"401.9",
"275.41",
"427.5",
"250.83",
"V49.83",
"434.91",
"070.54",
"585.6",
"V56.0",
"428.0",
"348.1",
"250.53",
"250.43",
"362.01",
"588.81",
"425.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"96.71",
"38.99",
"99.60",
"39.31",
"96.04",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
1816, 3137
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,285
| 198,743
|
44077
|
Discharge summary
|
report
|
Admission Date: [**2152-1-4**] Discharge Date: [**2152-1-10**]
Date of Birth: [**2072-5-20**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Ticlid / Lipitor
Attending:[**First Name3 (LF) 52022**]
Chief Complaint:
Left hip pain
Major Surgical or Invasive Procedure:
Left total hip arthroplasty
Central line placement
History of Present Illness:
79 yo man complaining of long-standing disabling left hip pain
due to severe
degenerative arthritis.
Past Medical History:
CAD, s/p CABG '[**35**], multiple stents (last [**3-26**])
[**3-26**]:
1. Two vessel coronary artery disease.
2. Patent LIMA -> LAD. SVG -> OM totally occluded. SVG ->
D1 90% lesion.
3. Moderate systolic dysfunction with LVEF 31%.
5. Successful stenting of the SVG-D1.
A-fib (paroxysmal)
HTN
Hyperlipidemia
Chronic anemia
Prostate CA s/p XRT (over 10 years ago), s/p TURP [**1-12**]
S/p discectomy [**9-26**]
Right total hip arthroplasty
Social History:
No etoh/tob/drugs. Patient lives alone. His wife is very ill and
lives in a nursing home. Daughter [**Name (NI) **] lives nearby.
Family History:
NC
Physical Exam:
Gen-Alert/oriented, NAD
VS-afebrile/Vss
CV-irreg, irreg S1/S2
Lungs- CTA bilat
Abd-soft NT/ND
EXT-LLE:Incision clean/dry/intact. +[**Last Name (un) 938**]/FHl/AT, +DPP
Pertinent Results:
[**2152-1-4**] 12:29PM GLUCOSE-152* LACTATE-2.2* NA+-140 K+-3.9
CL--111
[**2152-1-4**] 12:29PM freeCa-1.27
[**2152-1-4**] 12:13PM WBC-10.6# RBC-4.03* HGB-12.4* HCT-34.6*
MCV-86 MCH-30.9 MCHC-35.9* RDW-15.5
[**2152-1-4**] 10:32AM HGB-10.7* calcHCT-32
Brief Hospital Course:
79 yo man complaining of severe, disabling left hip pain.
Patient has been followed by Dr. [**Last Name (STitle) **] in [**Hospital 6669**] clinic. It
had been decided in clinic that patient would have an elective
left total hip arthroplasty. Patient was admitted on [**2152-1-4**]
for an elective left total hip arthroplasty. Of note, several
days pre-operatively, patient had anginal symptoms with no EKG
changes. Patient was taken to surgery and remained
hemodynamically stable. Patient was taken post-op to medical ICU
for close monitoring in the setting of CAD. In the unit patient
remained hemodynamically stable. Patient's PCP/cardiologist
Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] had followed the patient closely as well.
Patient was transferred to the orthopedic floor in stable
condition on [**2152-1-5**]. Patient remained stable, HCT did drop on
[**2152-1-7**] to 28 from 30. Patient was given PRBC and HCT bumped
appropriately. Patient continued to progress appropriately with
physical therapy. Patient was discharged in stable condition.
Medications on Admission:
NTG SL prn
Lovastatin 20mg
Oxazepam 10mg
Niacin 500mg
InnPRan XL 80mg [**Hospital1 **]
Amlodipine 5mg
Sertraline 100mg [**Hospital1 **]
ASA 325mg Daily
Discharge Medications:
1. Lovastatin 20 mg Tablet Sig: One (1) Tablet PO qd ().
2. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed.
3. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO QD ().
4. Sertraline 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Propranolol 80 mg Capsule, Sustained Action 24HR Sig: One (1)
Capsule, Sustained Action 24HR PO DAILY (Daily).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
10. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
11. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime for 3
weeks: Goal INR 2.0
-Please check INR 2x weekly.
-Please have HO adjust dose to meet goal INR.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Osteoarthritis Left hip
Exertional angina
Discharge Condition:
stable
Discharge Instructions:
Please cont with full bearing Left leg with walker assist. Cont
with physical thearpy. Oral pain medication as needed. Please
keep incision clean/dry. Please call/return if any fevers,
increased discharge from incision, chest pain, or trouble
breathing.
Physical Therapy:
Activity: Activity as tolerated
Right lower extremity: Full weight bearing
Left lower extremity: Full weight bearing
-posterior hip dislocation precautions please.
Treatments Frequency:
Please keep incision clean/dry.
-Suture to be removed at follow-up appt.
-Goal INR 2.0, please check INR 2x weekly. Please have HO adjust
dose to meet goal INR.
-Upon d/c from rehab please have INR results call to
[**Telephone/Fax (1) 9118**] attn [**Doctor Last Name **] Brown
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11642**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2152-2-3**] 1:00
Please call this week to schedule follow-up appt. with PCP
[**Last Name (NamePattern4) **].[**Last Name (STitle) **] [**0-0-**]
|
[
"238.7",
"V10.46",
"715.95",
"V45.82",
"427.31",
"V15.3",
"401.9",
"413.9",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.51",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
3836, 3921
|
1592, 2673
|
295, 348
|
4007, 4016
|
1310, 1569
|
4808, 5091
|
1103, 1107
|
2875, 3813
|
3942, 3986
|
2699, 2852
|
4040, 4294
|
1122, 1291
|
4312, 4483
|
4505, 4785
|
242, 257
|
376, 478
|
500, 939
|
955, 1087
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,323
| 156,689
|
52379
|
Discharge summary
|
report
|
Admission Date: [**2130-2-3**] Discharge Date: [**2130-2-11**]
Date of Birth: [**2060-12-5**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
progressive shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is a 69 year old gentlemen with history of
emphysema, SCC diagnosed in [**8-/2129**] s/p left upper lobectomy and
s/p neoadjuvant chemoradiation, PE/DVT in [**11/2129**], pericardial
effusion w/ tamponade requiring pericardial windown in [**1-/2130**],
s/p IVC filter placement who presents from clinic with SOB and
CTA showing multiple PEs and LLL pneumonia. On note, in early
[**Month (only) **] patient developed a DVT with pulmonary embolism, and he
was admitted to [**Hospital1 18**]. At taht time, he was started on lovenox.
Subsequently, he was readmitted for a left upper lobectomy on
[**2129-12-20**]. He was discharged [**12-28**]. At that point, he was
anticoagulated with Coumadin. He subsequently developed
gradually progressive shortness of breath, which eventually
became quite profound. He presented to the ER on [**2-7**]/2 and was
initially felt to have pneumonia, but at the time of admission
was found to have a pericardial effusion with tamponade in the
setting of a supratherapetuic INR to 15. He had a pericardial
drain place and a total of 1 liter of bloody fluid was removed.
However, then appeared to be continued loculated pericardial
fluid so eventually a sub-xiphoid pericardial window was
performed and an IVC filter was placed.
.
During the hospitalization, he had runs of afib/aflutter and was
started on metoprolol 25mg tid. He was seen in house by Dr.
[**First Name (STitle) **], a cardiolgist, for further evaluation of afib/flutter.
Mr. [**Known lastname **] continued to have frequent runs of rapid atrial
flutter mostly along with some AFib, some of which were
symptomatic. Metoprolol could not be tolerated up any further
due to low blood pressure. Therefore, he was started on
amiodarone 400mg [**Hospital1 **] for one week and then 200mg [**Hospital1 **] for 3 weeks
and then 200mg daily. 2 days after starting the amio, the
atrial arrhythmias decreased significantly and he was more
ambulatory with less dyspnea. During that hospitalization,
decision was made to discontinue Warfarin given difficulty with
maintaining therapeutic INR and multiple recent surgeries.
Patient was discharged with Aspirin 325mg qd for
anticoagulation.
.
Over the last several days, patient has had progressive SOB. He
states VNA saw him on Monday and he was 88% on RA and started on
O2. His O2 req increased to 3.5 L. Even with O2, he becomes
SOB after walking only 15 feet. Patient was seen in clinic.
CTA was done and showed RML and RLL lobe pulmonary embolisms,
LLL PNA, trace pericardial effusion.
.
In the ER, initial vitals were: 99.1 84 124/73 32 95% 2L.
Later, patient triggered for tachypnea to 30s on 2L, speaking in
full sentences 89% on RA. Heparin ggt was started with a bolus.
A bedside TTE showed trace effusion but no RV collapse. Of
note, atrius cardiologist perfomed a TTE in clinic which was
normal. For pneumonia, patient was started on
Vancomycin/Levaquin.
.
On the floor,patient feels comfortable at rest without SOB.
Denies recent cough, fevers/chills, rhinorrhea. Has not had any
brbpr, no dark stools, no nausea, no dysuria, no swelling in the
legs. Does note he went for check up and had mild infection at
sternum incision for which he completed a course of keflex.
.
Review of Systems:
(+) Per HPI
Past Medical History:
PAST ONCOLOGIC HISTORY:
PET CT [**2129-8-10**]: FDG-avid LUL large 49x40mm lung lesion is seen
highly concerning for lung cancer. There are FDG-avid
prevascular lymph nodes, as follows: 27 x 19 mm and 18x14mm.
There is a prominent lymph node in the left peritracheal area
measuring 18x12mm (not FDG-avid) and non-specific.
.
Bronchoscopy [**2129-8-22**]: obtained tissue for pathology which
revealed invasive squamous cell carcinoma (stage IIIa)
.
[**2129-9-9**]: left VATS and lymph node biopsy to complete staging work
up. No pleural metastases were noted but there were bulky level
6 lymph nodes, which were positive for metastatic carcinoma on
frozen sections; final pathology showed poorly differentiated
squamous cell carcinoma with extensive necrosis histologically
similar to the prior lung sample.
.
[**9-/2129**]: Started cisplatin and VP-16 as well as radiotherapy as
neoadjuvant treatment before a definitive surgery
.
PAST MEDICAL/SURGICAL HISTORY:
Emphysema
Bipolar disorder
Patello-femoral syndrome
Squamous cell lung carcinoma (as above)
Pulmonary embolism/DVT in [**11/2129**]
Afib/aflutter
.
Left VATS with biopsy of peri-aortic lymph node [**2129-9-9**]
Left thoracotomy, left upper lobectomy, mediastinal lymph node
dissection, and buttressing of bronchial staple line with
intercostal muscle [**2129-12-20**]
Subxiphoid pericardial window [**2129-1-11**]
Social History:
Lives with wife at home. 75 pack-year smoking history, quit [**2-10**]
yrs ago, drinks 3 glasses of EtOH/week and denies use of illegal
drugs
Family History:
Mother died of pancreatic cancer, father had Parkinsons. No
other history of cancer or blood clotting disorders
Physical Exam:
Physical Exam on Admission:
Vitals - T 97.5 BP 110/70 HR 68 RR 24 02 sat 94 on 3L
GENERAL: NAD
SKIN: warm and well perfused, no excoriations or lesions, no
rashes;
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
MMM, good dentition, nontender supple neck, no LAD, no JVD
appreciated
CARDIAC: RRR, S1/S2, no mrg; incsion on sternum well healed, not
erythematous
LUNG: crackles in RLL, decreased breath sounds in LLL
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
Pertinent Results:
Labs on Admission:
[**2130-2-3**] 03:50PM WBC-14.2* RBC-4.55* HGB-11.8* HCT-38.9*
MCV-86 MCH-26.0* MCHC-30.4* RDW-15.6*
[**2130-2-3**] 03:50PM NEUTS-84.8* LYMPHS-7.3* MONOS-3.2 EOS-4.3*
BASOS-0.4
[**2130-2-3**] 03:50PM GLUCOSE-113* UREA N-20 CREAT-1.1 SODIUM-133
POTASSIUM-5.4* CHLORIDE-101 TOTAL CO2-21* ANION GAP-16
[**2130-2-3**] 03:58PM LACTATE-2.9* K+-4.9
[**2130-2-3**] 04:00PM PT-13.0* PTT-25.5 INR(PT)-1.2*
.
Imaging
TTE [**2130-2-3**]:
1. There is borderline left ventricular hypertrophy.
2. Overall left ventricular ejection fraction is normal, with
an estimated LVEF of 55-60%.
3. There is subtle septal flattening in systole in one off-axis
view , which can be consistent with right ventricular pressure
overload, but is nondiagnostic
4. The right ventricle is top normal in size.
5. The right ventricular systolic function is normal.
6. Tricuspid valve appears structurally and functionally normal.
Mild-moderate regurgitation is seen. Mild-moderately elevated
PA systolic pressure, estimated at 47 mmHg above RA pressure.
7. There is no pericardial effusion.
8. The inferior vena cava is normal, with normal respirophasic
movement indicating normal right atrial pressure.
9. No prior [**Location (un) 2274**] report available for comparison. Discussed
result w/ Dr [**Last Name (STitle) 30186**]. Albeit not classic for acute PE,
clinical correlation is advised.
.
CTA [**2130-2-3**]:
-Acute pulmonary emboli in the right middle lobe, into segments
of the right lower lobe.
-Status post left upper lobectomy.
-Extensive peripheral groundglass and air space disease
throughout the right lungand in the superior segment of the left
lower lobe, with the appearance of earlyconsolidating pneumonia.
-Unchanged pretracheal adenopathy.
-Small pericardial effusion.
.
CT CHEST WITH CONTRAST [**2130-1-10**]: Findings: A large pericardial
effusion, with attenuation characteristics of bloody or
exudative fluid has developed, impinging on the right atrium and
right ventricle, suggesting cardiac tamponade. Severe
consolidation in the post-operative left lung, extending from
the superior segment to the upper regions of the basal segments
has worsened, and extensive consolidation in the right lung is
largely new, in the anterior segment of the right upper lobe,
the right middle lobe, and the right lower lobe, most pronounced
in the superior segment.
.
ECHO [**2130-2-10**]
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is unusually small. Overall left ventricular
systolic function is normal (LVEF 60%). The right ventricular
free wall is hypertrophied. The right ventricular cavity is
dilated There is abnormal diastolic septal motion/position
consistent with right ventricular volume overload. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. The tricuspid valve leaflets
are mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion. If
clinically indicated, a transesophageal echocardiographic
examination is recommended to rule out vegetations.
IMPRESSION: No definite vegetations seen. Intercurrent
development of moderate pulmonary hypertension,
moderate-to-severe tricuspid regurgitation and right heart
chamber enlargement concerning for acute right heart strain.
Consider acute pulmonary embolism.
Brief Hospital Course:
69 year old male with history of emphysema, SCC diagnosed in
[**8-/2129**] s/p left upper lobectomy and s/p neoadjuvant
chemoradiation, PE/DVT in [**11/2129**], pericardial effusion w/
tamponade requiring pericardial window in [**1-/2130**], s/p IVC filter
placement who presented from clinic with SOB and CTA showing
multiple PEs and multifocal right sided pneumonia.
.
Pt was initially admitted to OMED service and started on heparin
drip for the PEs, and given ceftriaxone, vanco and levoflox for
the pneumonia. He then became hypoxic and was transferred to the
[**Hospital Ward Name 332**] ICU for further monitoring. He required intubation for
worsening respiratory status, which was initially felt to be
mostly related to pneumonia. There was also a concern for
diffuse alveolar hemorrhage so he underwent a bronchoscopy
showing minimial bleeding. Heparin drip was stopped as it was
felt his bleeding risk was higher than PE risk given his filter.
His respiratory status and chest xray began to improve initially
on broad spectrum antibiotics. On the evening of [**2130-2-10**], he
became acutely tachycardic up to 140s, felt to be in atrial
flutter. An echo was obtained showing a severe amount of
tricuspid regurg. Overnight his clinical status worsened
significantly, with rising lactate and worsening electrolytes. A
ferritin level was checked and found to be [**Numeric Identifier 42344**], then >[**Numeric Identifier 4856**]
on recheck. Unclear etiology but likely due to some systemic
inflammatory process that was contributing to underlying shock.
Her family was updated on the poor prognosis and the decision
was made to withdraw treatment and make the patient CMO. He
passed away with family at bedside.
Medications on Admission:
senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).
docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
lithium carbonate 300 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 3 weeks: Please begin on [**2130-1-26**].
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Shock
Pulmonary Emboli
Pneumonia
Discharge Condition:
Deceased
Discharge Instructions:
NA
Followup Instructions:
NA
|
[
"427.31",
"196.1",
"038.9",
"427.32",
"V12.55",
"V12.51",
"162.3",
"492.8",
"285.9",
"V66.7",
"V15.82",
"276.2",
"785.51",
"785.52",
"486",
"296.80",
"V45.76",
"518.81",
"415.19",
"995.92",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.97",
"96.72",
"33.24",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
11841, 11850
|
9586, 11308
|
334, 340
|
11926, 11936
|
6059, 6064
|
11987, 11992
|
5233, 5347
|
11814, 11818
|
11871, 11905
|
11334, 11791
|
11960, 11964
|
5362, 5376
|
3644, 3657
|
263, 296
|
368, 3625
|
6079, 9563
|
3679, 5056
|
5072, 5217
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,594
| 132,028
|
13078
|
Discharge summary
|
report
|
Admission Date: [**2105-12-17**] Discharge Date: [**2105-12-18**]
Date of Birth: [**2043-3-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Right ventricular infarct
Major Surgical or Invasive Procedure:
Intra-aortic balloon pump
History of Present Illness:
62 yo M with K-ras WT moderately-differentiated mixed
carcinoid/mucinous appendiceal adenocarcinoma metastatic to
peritoneum with peritoneal carcinomatosis s/p FOLFOX, FOLFIRI,
iritecan and most recently C3D15 Cetuximab ([**2105-11-26**]), s/p
colonic stent placement [**2105-12-7**] for malignant obstruction, also
s/p LRD-Renal Xplant [**2080**], HCV, x-fer from [**Hospital 47**] [**Hospital1 **] for management of large inferior wall STEMI with
BMS to prox RCA, with revascularization resulting in TIMI-1 flow
caused by cardiogenic shock. Pt was hypotensive during procedure
requiring pressors due to large infarct of his right-dominant
system, on Dopamine, Levo and Neo, with IABP in place and
temporary pacer.
.
Per pt's wife, he had been complaining o intermittent abdominal
pain for several days with recent [**Hospital1 2025**] admissions (discharged
[**11-30**] and [**12-16**]) for management of colonic obstruction, first
with NGT decompression, then with palliative stenting (on
[**12-7**]). He again complained of severe abdominal pain radiating
to his back, nausea and vomiting, so was taken to local ED in
[**Location (un) 47**] for evaluation. Initial EKGs showed ST elevations in
II,III,AVF concerning for inferior STEMI so pt was taken
emergently to catheterization lab where 100% thrombotic proximal
occlusion to large dominant RCA was seen. Pt was in cardiogenic
shock on arrival to cath lab w/ BP ~80s. Cath showed R-dominant
system w/ 100% prox thrombotic occlusion in RCA and 90% culprit
stenosis in proximal to mid vessel treated with single BMS.
Scattered thrombi throughout distal vessels (large PDA and2
large PL branches). Final flow was TIMI 1. As pt was
progressively bradycardic thorughout procedure, temporary pacing
wire was placed via R femoral vein. RV pacing at 80bpm. After
placement of BMS, pt went into runs of NSVT which broke
spontaneously. Pt was given amiodarone bolus and rhythm was
stabilized. IABP placed at 1:1. Pt required intubation in CCU
and 3 pressor support. On arrival to CCU, pt was intubated but
not sedated, unresponsive to commands or painful stimuli, had
bilateral fixed blown pupils, mottled skin, and cold
extremities. ABG on arrival: 7.05/33/65 on PS 5/5 w/ FIO2 100%.
.
On the floor, he is not responsive to verbal or tactile
stimulation.
Past Medical History:
ONC HISTORY:
pt underwent an appendectomy for acute appendicitis in
[**2100-5-21**]. Pathology from the procedure showed a mixed tumor
containing carcinoid and adenocarcinoma invading the appendiceal
wall and penetrating through the visceral peritoneum (pT4) with
perineural and venous invasion. The tumor involved the proximal
resection margin. An MRI of the abdomen on [**2100-6-6**] showed
fatty infiltration of the liver, but no evidence of metastatic
disease. On [**2100-6-9**], he underwent right hemicolectomy and
regional lymphadenectomy. Pathology showed goblet cell carcinoma
in the mesenteric fat and a <2 mm focus of GIST in the cecal
wall near appendiceal stump. Thirteen pericolonic lymph nodes
removed and were negative, rendering him stage II (pT4 pN0 M0).
The resection margins were negative. Mr. [**Known lastname 3012**] was treated with
weekly adjuvant 5-FU and leucovorin from [**0-0-0**],
but treatment was discontinued after five weeks because of
diarrhea and an increase in his creatinine. He was subsequently
followed with serial no[**1-/2103**], after which his insurance refused to pay for additional
studies. In [**1-/2104**], Mr. [**Known lastname 3012**] reports developing abdominal pain
and hematochezia. Later that month, he became increasingly
fatigued and anemic despite using Procrit. A colonoscopy on
[**2104-2-18**] showed a partially circumferential 3-cm mass located
11-13 cm proximal to the anus which appeared to be a metastatic
lesion growing through the bowel rather than a primary lesion. A
CT scan of the abdomen on [**2104-2-24**] revealed peritoneal
carcinomatosis most evident in the omentum, a small amount of
ascites, and rectal wall thickening consistent with the mass
seen on colonoscopy. A chest x-ray on [**2-27**] was negative, and on
[**2104-2-29**], a percutaneous biopsy of an omental lesion revealed
moderately differentiated metastatic mucinous adenocarcinoma,
consistent with metastatic colon cancer.
.
PAST MEDICAL HISTORY:
Kidney transplant [**2080**] from living related donor, doing well.
Renal failure was due to E. coli infection.
Hepatitis C
Osteoarthritis
Benign brain tumor which caused partial paralysis of the face on
the right side.
Social History:
SOCIAL HISTORY: Married. No coffee or alcohol or tobacco.
Family History:
Noncontributory
Physical Exam:
VS: afebrile, BP 110/79 on 3 pressors, HR 70s (paced, IABP),
SaO2 100% on PS [**6-20**]
GEN: intubated, not sedated, unresponsive to commands or painful
stimuli
HEENT: fixed dilated pupils b/l, unresponsive to light
CV: paced, HR 70s, IABP in place
LUNGS: coarse ventilated BS, bibasilar crackles
ABD: +BS soft, well-healed surgical scars from hemicolectomy
EXT: no peripheral edema, 1+ distal pulses, multiple pedal
excoriations L>>R
NEURO: intubated, unresponsive
Pertinent Results:
Admission labs:
[**2105-12-17**] 07:59PM WBC-37.3*# RBC-4.08* HGB-11.6* HCT-37.6*
MCV-92 MCH-28.4 MCHC-30.9* RDW-17.2*
[**2105-12-17**] 07:59PM NEUTS-78* BANDS-14* LYMPHS-3* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2105-12-17**] 07:59PM PT-15.0* PTT-37.9* INR(PT)-1.3*
[**2105-12-17**] 07:59PM CALCIUM-6.4* PHOSPHATE-5.6*# MAGNESIUM-1.7
[**2105-12-17**] 07:59PM CK-MB-181* MB INDX-8.5* cTropnT-9.27*
[**2105-12-17**] 07:59PM ALT(SGPT)-76* AST(SGOT)-304* CK(CPK)-2127*
ALK PHOS-115 TOT BILI-0.7
[**2105-12-17**] 07:59PM GLUCOSE-233* UREA N-34* CREAT-3.8* SODIUM-133
POTASSIUM-6.6* CHLORIDE-107 TOTAL CO2-12* ANION GAP-21*
[**2105-12-17**] 08:08PM TYPE-ART PO2-63* PCO2-44 PH-7.05* TOTAL
CO2-13* BASE XS--18
[**2105-12-17**] 09:01PM TYPE-ART TEMP-35.3 PEEP-5 O2 FLOW-100 PO2-65*
PCO2-33* PH-7.18* TOTAL CO2-13* BASE XS--14 INTUBATED-INTUBATED
[**2105-12-17**] 10:45PM TYPE-ART TEMP-35.6 PEEP-8 PO2-67* PCO2-29*
PH-7.25* TOTAL CO2-13* BASE XS--12 INTUBATED-INTUBATED
VENT-SPONTANEOU
[**2105-12-17**] 10:45PM LACTATE-5.6*
.
Echo
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is
moderate regional left ventricular systolic dysfunction with
severe hypokinesis/akinesis of the inferior and inferolateral
walls and hypokinesis of the inferior septum. The remaining
segments contract normally (LVEF = 35 %). The right ventricular
cavity is moderately dilated with severe global free wall
hypokinesis. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. Trace aortic regurgitation
is seen. The mitral valve leaflets are structurally normal. Mild
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is top normal. There is no pericardial
effusion. There is prominent ascites.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional systolic dysfunction c/w CAD (proximal RCA distribution
leading to RV infarction as well). Mild mitral regurgitation.
Brief Hospital Course:
1. CARDIOGENIC SHOCK- Etiology of cardiogenic shock is large RV
infarct (proximal RCA) of a large R-dominant system, leading to
hypotension that requires use of 3 vasopressors. Pt intubated
but not initially sedated; sedation would prove necessary later
on. Pt initially unresponsive w/ fixed dilated pupils b/l,
repeat exam w/ some purposeful movement, pt able to squeeze
hands b/l and wiggle toes b/l on command.
The patient received atorvastatin, aspirin,and plavix.
Integrillin was run for 18 hours. Serial ABGs were taken;
bicarbonate was given and ventilator settings adjusted based on
acidosis. Th epatient required continues use of 3 vasopressors
levophed, dopamine and neosynephrine, initially and a fourth was
later added. The patient's pressure was further supported by an
intra-aortic balloon pump.
The patient's family kept the patient full code until son [**Name (NI) 4036**]
could arrive from [**Doctor First Name 26692**]. Given the patient's prognosis,
the patient's family then agreed to withdraw pressor support.
Shortly thereafter, the patient expired.
.
2. METABOLIC ACIDOSIS- [**3-17**] lactic acidosis as lactate >7 from
ischemia and hypotension. Repleted bicarbonate and treated
hyperkalemia with Ca gluconate, bicarb, insulin, and glucose.
.
3. MUCINOUS APPENDICEAL ADENOCARCINOMA- mixed carcinoid/mucinous
tumor metastatic to peritoneum, (peritoneal carcinomatosis) s/p
FOLFOX, FOLFIRI and irinotecan/cetuximab (stopped for diarrhea
and disease progression, respectively). Per Heme/Onc fellow pt's
disease has progressed beyond further chemotherapeutic options
and likely focus will be on palliative efforts. Pt has
palliative colonic stent in place as recurrent obstruction not
responding to NGT decompression. Heme/Onc saw patient and
family; no further heme/on treatment provided.
.
4. ACUTE ON CHRONIC RENAL FAILURE- Chronic allograft nephropathy
now complicated by multifactorial acute renal insufficiency,
with recent chemotherapeutic regimen nephrotoxicity combined
with decreased renal perfusion from hypotension [**3-17**] inferior
wall MI and cardiogenic shock contributing to acute
decompensation. Contrast nephropathy from catheterization
unlikely to present so acutely. Patient w/ poor UOP.
CVVH not an option, as family not interested in that care.
Medications on Admission:
AMLODIPINE [NORVASC] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth daily
DIPHENOXYLATE-ATROPINE - 2.5 mg-0.025 mg Tablet - 1 Tablet(s) by
mouth q3-4h as needed for prn diarrhea
EPOETIN ALFA [EPOGEN] - 20,000 unit/mL Solution - 20,000 units
subcutaneously twice weekly
INSULIN LISPRO [HUMALOG] - (Prescribed by Other Provider) - 100
unit/mL Solution - Sliding scale
LORAZEPAM - 0.5 mg Tablet - [**2-14**] Tablet(s) by mouth q4-6 h as
needed for prn anxiety/nausea
PREDNISONE - (Prescribed by Other Provider) - 5 mg Tablet - 1.5
Tablet(s) by mouth once a day
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet - 1
Tablet(s) by mouth once a day
CARBOXYMETHYLCELLULOSE-GLYCERN [OPTIVE] - (Prescribed by Other
Provider) - 0.5 %-0.9 % Drops - 2 gtt(s) ou twice a day
MULTIVITAMIN - (Prescribed by Other Provider) - Capsule - 1
Capsule(s) by mouth daily
Discharge Medications:
None. Patient expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Death secondary to cardiogenic shock from myocardial infarction.
Discharge Condition:
The patient expired.
Discharge Instructions:
None.
Followup Instructions:
None.
|
[
"410.81",
"198.89",
"197.6",
"560.89",
"197.5",
"428.9",
"276.2",
"584.5",
"785.51",
"V10.05",
"996.81",
"E878.0",
"583.9",
"276.7",
"789.59",
"070.70"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
10859, 10868
|
7587, 9877
|
343, 370
|
10976, 10998
|
5544, 5544
|
11052, 11060
|
5026, 5043
|
10812, 10836
|
10889, 10955
|
9903, 10789
|
11022, 11029
|
5058, 5525
|
278, 305
|
398, 2703
|
5560, 7564
|
4712, 4934
|
4966, 5010
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,314
| 118,246
|
45008+58802
|
Discharge summary
|
report+addendum
|
Admission Date: [**2157-9-21**] Discharge Date: [**2157-10-3**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
hypotension, hematuria
Major Surgical or Invasive Procedure:
CVL placement with subsequent removal
History of Present Illness:
Mr. [**Known lastname 3314**] is a 85 yo male recently discharged from [**Hospital1 18**] to
an extended care facility after being treated for hypoxia,
hyponatremia, and acute renal failure. He was found to have an
aspiration pneumonia and was given a two week course of
Levo/Flagyl during his last admission. In addition, the pt was
persistently hypoxic with room air oxgyen saturation 90-91%, and
was discharged on one liter oxygen via NC. Per the rehab notes,
the pt had an episode of worsening hypoxia and hematuria and was
brought to the ED. While in the ED, the pt became transiently
hypotensive with a BP of 70's systolic (initially 100/60). The
pt received blood and fluids, and BP improved to 90's. A SC CVL
was placed, and urine/ blood cultures were sent.
.
In the ICU, the patient remained normotensive following blood
transfusions plus IVF. In fact, the ICU team believed that some
of his hypoxia could be due to fluid overload, so he did receive
some diuresis. He was started on Vanc/Zosyn/levo on admission,
but he levofloxacin was discontinued on [**9-22**] as his urine
legionella was negative. He had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim test in the ICU
which was < 9 at 2 hours, so he was started on steroids. These
were subsequently discontinued as the patient had no evidence of
sepsis and was able to maintain his blood pressure following
fluid resuscitation. In addition, the patient's hematocrit has
remained stable after two units of PRBCs. He was seen by his
usual hematologist, Dr. [**Last Name (STitle) **], who feels as though his
hematuria is chronic and would likely not require further
intervention unless the patient's anemia was severe. In
addition, the patient was evaluated by urology who have
recommended continued Foley use.
Past Medical History:
-Metastatic prostate Cancer: diagnosed in [**2-22**], currently not on
therapy, does not want chemotherapy. By bone scan, known mets
in thoracic and lumbar spine, ileums, right proximal femur,
clavicles and ribs. + lung nodules, + abdominal LAD. Followed by
Dr. [**Last Name (STitle) **] in heme-onc
-Benign prostatic hypertrophy s/p TURP
-Bladder calculi s/p removal
-Dyslipidemia
-Mild AI
-Gastritis by EGD
Social History:
Widowed, 3 sons (2 in [**State 2690**], one here). Previously lived at
[**Location (un) **] retirement community. Used to own a small hardware
store. Quit
tobacco in [**2096**]. Rare alcohol. No drugs. Now coming from NH
unit at [**Location (un) **]
Family History:
Brother with [**Name (NI) **] cancer
Physical Exam:
T 96 PO BP 100/50 HR 88 RR 20 O2 sat 89% on RA, inc to 94% 2LNC
GEN:awake, A&OX3, thin but not cachetic. Speaking full
sentences.
HEENT: Wearing glasses. atraumatic, pupils small 1-2 mm, equal.
EOMI, no nystagmus. Tongue somewhat dry. Oropharynx w/out
exudate but w/ thick brown coating on tongue.
NECK: JVD 8 cm, no LAD
CV: irregular rhythm, normal rate, 2/6 SEM radiating to apex
LUNGS: occasional crackles bilaterally
ABD: soft, nt, nd, positive BS
EXT: warm, dry. 2+ pitting edema to thighs. No rash but
scattered scabs & ecchymoses.
NEURO: A/O X3, no focal deficits. Moving all extremities.
Speaking clearly & in full sentences as above
Pertinent Results:
Labs notable for elevated proBNP, elevated AP, elevated
creatinine to 1.5 (1.0 at discharge) and decreased hct to 28.4
from mid 30's.
.
[**2157-9-20**] CXR: Increased left retrocardiac opacity in comparison
to prior exam, which may represent an area of volume loss or
consolidation.
.
[**2157-8-31**] LUNG SCAN:
Perfusion images in the same 8 views show demonstrate
subsegmental defects in the right upper lung and defects in the
bases
Chest x-ray shows patch infiltatrates and yesterday's CXR
reveals pleural effusions. The above findings are consistent
with a low likelihood ratio for recent pulmonary embolism.
IMPRESSION: Low likelihood ratio for recent pulmonary embolism.
.
[**2157-9-2**] RUQ US: No evidence of cholelithiasis.
.
[**2157-9-1**] ECHO: The left atrium is mildly dilated. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF 70%). Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. The
right ventricular cavity is dilated. Right ventricular systolic
function appears depressed. The aortic root is mildly dilated.
The ascending aorta is mildly dilated. The aortic arch is mildly
dilated. There are focal calcifications in
the aortic arch. The aortic valve leaflets (3) are mildly
thickened. There is a minimally increased gradient consistent
with minimal aortic valve stenosis. Trace aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Trivial mitral regurgitation is
seen. The left ventricular inflow pattern suggests impaired
relaxation. The tricuspid valve leaflets are mildly thickened.
There is mild pulmonary artery
systolic hypertension.
.
[**2157-9-7**] video swallow: no evidence of aspiration
.
Renal US ([**9-22**]): No evidence of hydronephrosis or stones. Likely
hematoma/clot seen within bladder.
.
CXR ([**9-20**]): Increased left retrocardiac opacity in comparison
to prior exam, which may represent an area of volume loss or
consolidation.
.
CXR ([**9-21**]): Tip of the new right subclavian line projects over
the upper right atrium. Mild interstitial pulmonary edema has
worsened exaggerated by slightly lower lung volumes due to
persistent bibasilar atelectasis. Heart size top normal. Small
left pleural effusion increased. No pneumothorax. Tracheal
deviation is probably a function of upper thoracic scoliosis and
tortuous head and neck
vessels.
.
CXR ([**9-26**]): There is a thoracic scoliosis convex to the right.
There is cardiomegaly with pulmonary vascular engorgement and
bilateral pleural effusions consistent with CHF. In addition,
there are bibasilar opacities, left greater than right, with
obscuration of the left hemidiaphragm likely due to a
combination of left pleural effusion and atelectasis or
consolidation in the left lower lobe. The findings are similar
to those noted on the prior study of [**2157-9-21**] but with
probable increased patchy opacity at the right lung base. The
previously noted right subclavian CV line has been removed.
.
Lower extremity ultrasound ([**9-27**]): No evidence of DVT
bilaterally.
.
Chest CT ([**9-29**]): 1. There are bilateral moderate-sized pleural
effusions with adjacent atelectasis. In conjunction with
ground-glass opacity and areas of intralobular septal
thickening, these findings are consistent with CHF. 2. There are
diffuse osseous sclerotic metastases, as identified on recent
bone scan from [**2157-9-2**].
.
CXR ([**9-29**]): There is no significant change in the appearance of
the normal heart and bilateral pleural effusions as well as the
left lower lobe consolidation which is most likely _____
atelectasis but there is improvement of the bilateral pulmonary
edema.
.
Renal ultrasound ([**9-30**]): 1. No evidence of hydronephrosis. 2.
Layering echogenic material in urinary bladder that most likely
represents presence of hemorrhage.
.
Labs prior to discharge notable for platelets 46,000, WBC 12.3,
creatinine 3.3, BUN 64, INR 1.6, albumin 2.8
.
Microbiology: C. diff negative X 2
Sputum culture pending but multiple organisms on gram stain from
[**10-1**]
MRSA in urine from [**9-20**] but not present on repeat urine culture
[**9-28**]
Brief Hospital Course:
Mr. [**Known lastname 3314**] is an 85 yo male with history of metastatic
prostate cancer, bladder varices, and chronic bladder
obstruction who presents as a transfer from the MICU for
hypotension, now resolved, and hematuria, thought to be chronic.
At this time, he and his family would like to pursue palliative
care measures.
.
* After an extensive discussion between Dr. [**First Name (STitle) **] [**Name (STitle) **], the
patient, and the patient's son, it was decided that they would
not like to have any further studies or lab draws. The patient's
current problems of acute renal failure and thrombocytopenia in
conjunction with hypoxia have an unclear etiology. We have tried
various interventions without success. The Palliative Care team
has evaluated the patient, and the patient's wishes are to
return to Tower [**Doctor Last Name **]. His prognosis is very poor, likely [**12-25**]
weeks, and he should therefore be evaluated by the local Hospice
team that serves Tower [**Doctor Last Name **]. The patient's primary oncologist,
Dr. [**Last Name (STitle) **], recommended palliative care/Hospice as a viable
option after his review of Mr. [**Known lastname 40282**] case last week. As
the patient's primary goal of care at this point is comfort,
extraneous medications were discontinued.
.
# Acute renal failure: The patient's creatinine is climbing and
was 3.3 yesterday. The Renal service evaluated the patient and
suspect acute tubular necrosis in this patient. However, it is
difficult to provide fluids to the patient as he has congestive
heart failure with hypoxia as well. The Urology team was
involved and changed Mr. [**Known lastname 40282**] foley catheter over the
weekend due to concern for obstruction. This foley should remain
in place due to clot/hematoma seen within the bladder. However,
a clear, reversible cause of renal failure was not found in this
gentleman. He did not initially respond to fluid boluses, and we
were hesitant to further diurese him due to his rapidly rising
creatinine.
.
# Metastatic prostate cancer: The patient has known metastatic
prostate cancer with bony metastases. His pain is typically
well-controlled. We are discharging him on a regimen of tylenol
around the clock with an order for additional if his pain is not
well-controlled. In addition, the patient has morphine elixir
ordered for severe pain.
.
# Hypoxia: The patient was admitted to the hospital on 1 L via
nasal cannula. His oxygen requirements have also increased for
unclear reasons. He does have congestive heart failure evident
on chest CT, but due to his renal failure, we did not feel
comfortable diuresing him. He does not have evidence of deep
venous thromboses. He currently has a productive cough, for
which he should continue to receive guaifenesin and
dextromethorphan. He should also continue on albuterol/atrovent
nebs and saline nebs to assist in sputum expectoration.
.
# Thrombocytopenia: The patient's platelet count has continued
to decline. He has likely low-grade DIC versus TTP/HUS. This is
likely related to his underlying malignancy. It is also possible
that he has some marrow infiltration, though his WBC and RBC
counts are not as low as one would expect with this. He has
chronic hematuria and some bloody sputum production, but he does
not have other active bleeding.
.
# Swallowing difficulties: The patient reports that he is having
difficulty swallowing. However, it is unclear to me whether this
represents true difficulty swallowing or disinterest in eating.
He does drink Boost shakes, so these or an appropriate
alternative should be provided to him. I emphasized that he
could eat whatever he would like. We did give him Ritalin for
several days in an attempt to increase his appetite. This did
not have much effect, so have discontinued this medication.
.
# Anxiety/sleep: The patient should remain on remeron at night
for sleep. I have also ordered ativan to use as needed should
the patient become anxious.
.
# Communication- [**Name (NI) 3065**] [**Name (NI) 3314**], [**First Name3 (LF) **] [**Telephone/Fax (1) 96220**], is his
healthcare proxy.
.
# code status: The patient clearly has stated that he is a
DNR/DNI and has appropriate paperwork to this effect. It is my
understanding that both he and his son are agreeing on a DO NOT
HOSPITALIZE order. The patient's prognosis is very poor, on the
order of a few weeks. Therefore, the focus of this patient's
care should be comfort measures. He should be evaluated by the
Hospice team at Tower [**Doctor Last Name **].
Medications on Admission:
atorvastatin
colace
lopressor
asa
oxycodone
guaifenesin
albuterol
heparin SC
zolpidem
lasix
tylenol
pantoprazole
Discharge Medications:
1. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed.
3. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours).
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) treatment
Inhalation Q4H (every 4 hours).
5. Acetaminophen 160 mg/5 mL Solution Sig: 650 mg PO every
eight (8) hours as needed for pain: Maximum of 4 g total of
acetaminophen in one day.
6. Morphine 10 mg/5 mL Solution Sig: Five (5) mg PO Q4-6H (every
4 to 6 hours) as needed for pain.
7. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane
PRN (as needed) as needed for sore throat.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment
Inhalation Q6H (every 6 hours).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for anxiety/discomfort.
11. Saline nebulizer as needed to promote easier expectoration
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] - [**Location (un) 620**]
Discharge Diagnosis:
Metastatic prostate cancer
Chronic hematuria
Hypotension, resolved and likely secondary to dehydration
Acute on chronic renal failure
Thrombocytopenia
Discharge Condition:
Hemodynamically stable, on 35% FiO2 via face mask, afebrile
Discharge Instructions:
Please take your medications as prescribed. Please let the
nursing staff at your facility know if you are uncomfortable so
that measures can be taken to make you more comfortable.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2157-10-3**] Name: [**Known lastname **],[**Known firstname 33**] Unit No: [**Numeric Identifier 15374**]
Admission Date: [**2157-9-21**] Discharge Date: [**2157-10-3**]
Date of Birth: [**2071-11-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 391**]
Addendum:
Please note that above nursing facility referred to as Tower
[**Doctor Last Name **] should in fact be [**Location (un) 4641**]. Thanks.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 4641**] - [**Location (un) 407**]
[**Name6 (MD) 116**] [**Name8 (MD) 117**] MD [**MD Number(1) 392**]
Completed by:[**2157-10-3**]
|
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"196.1",
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"280.0",
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"428.0",
"585.9",
"041.11",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
14841, 15044
|
7803, 12340
|
285, 324
|
13908, 13970
|
3585, 7780
|
2868, 2906
|
12504, 13617
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13734, 13887
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12366, 12481
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2921, 3566
|
222, 247
|
352, 2150
|
2172, 2583
|
2599, 2852
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,975
| 186,444
|
6159
|
Discharge summary
|
report
|
Admission Date: [**2153-7-26**] Discharge Date: [**2153-8-8**]
Service: MEDICINE
Allergies:
Reglan
Attending:[**First Name3 (LF) 2474**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 24054**] is a [**Age over 90 **] year old man with history of chronic
aspiration pneumonia, congestive heart failure, diabetes, atrial
fibrillation, with recent admission for aspiration pneumonia,
presenting with fever and respiratory distress. Patient was
discharged from [**Hospital1 18**] on [**2153-7-18**] and completed a course of
clindamycin on the day of admission.
Per pt's report, patient had been doing "ok" (per new baseline)
until yesterday morning, when he felt "palpitations". He reports
a productive cough that became worse than at the time he left
the hospital, but denies any fevers or chills.
Per ED report, patients wife was concerned he was having
difficulty breathing and was less responsive than before. EMS
was called and found him to be with 86% O2 saturation on room
air.
In the ED, Temp 101.6, HR 89, BP 139/58 RR 25 100% NRB. Patient
given IV Vancomycin and Zosyn for aspiration pneumonia. Placed
on non-rebreather and admitted to MICU for futher monitoring.
Past Medical History:
1. CHF: EF 55% with moderate MR, and PFO, last echocardiogram
[**10/2151**]
2. CAD s/p CABG(LIMA, SVG=>ramus, SVG=>l-PDA) [**2147**]
3. Diabetes mellitus, on insulin
4. Atrial fibrillation: on aspirin
5. Chronic renal insufficiency: baseline SCr in mid 2s
6. Hypertension
7. H/O CVA
8. H/O autoimmune hemolytic anemia:
9. Chronic left pleural effusion
Social History:
Mr. [**Known lastname 24054**] lives with his wife. [**Name (NI) **] is a former smoker but quit.
Occassional EtOH. States has home VNA about once per month.
Family History:
Positive for DM in his brother, sister, and father
Physical Exam:
On admission:
Temp: 95.7 HR: 83 BP: 160/75 RR: 15 O2 Sat: 90%
GEN: Elderly cachetic gentleman in no acute distress
HEENT: EOMI, PERRL, anicteric sclera
CV: Regular rate, Normal S1, S2 and loud S4,
LUNGS: Decreased air movement with rhonchi bilaterally
ABD: Soft, non tender, non distended, normoactive bowel sounds
EXT: No clubbing, cyanosis or edema
Pertinent Results:
[**2153-8-7**] 10:25AM BLOOD WBC-9.3 RBC-2.89* Hgb-9.4* Hct-29.0*
MCV-101* MCH-32.7* MCHC-32.5 RDW-15.1 Plt Ct-210
[**2153-8-7**] 10:25AM BLOOD Glucose-224* UreaN-32* Creat-2.0* Na-142
K-3.7 Cl-107 HCO3-25 AnGap-14
[**2153-8-7**] 10:25AM BLOOD Calcium-7.9* Phos-3.0 Mg-1.9
[**2153-8-2**] 04:10PM BLOOD Type-ART pO2-69* pCO2-41 pH-7.45
calTCO2-29 Base XS-3 Intubat-NOT INTUBA
.
CXR: [**8-5**]
FINDINGS: In comparison with the study of [**7-26**], there is some
increasing
opacification at the left base consistent with some combination
of pleural
effusion, atelectasis, and possibly even consolidation.
Obliquity of the
patient makes it difficult to determine whether there has been
any shift of the mediastinum to this side. Right-sided pleural
effusion is unchanged in this patient with midline sternal
sutures, the top of which is broken
inferiorly.
.
CT: [**8-5**]
IMPRESSION:
1. New large filling defect within the left main stem bronchus
and
extending distally likely represents a large inspissated mucous
plug resulting in the near complete collapse of the left lung.
Bronchoscopy should be considered.
2. No significant interval change in a moderate-to-large
nonhemorrhagic
bilateral pleural effusions with adjacent compression
atelectasis. No new
opacities to suggest pneumonia.
3. Unchanged atherosclerotic disease involving the aorta and
coronary
circulation.
Brief Hospital Course:
Mr. [**Known lastname 24054**] is a [**Age over 90 **] year old man with history of congenstive
heart failure, coronary artery disease, diabetes, chronic left
pleural effusion, presenting with fever, respiratory distress
and leukocytosis. He was diagnosed with aspiration pneumonia.
He was started on antibiotics but continued to have increasing
difficulty breathing. Speech and swallow was consulted and the
patinet did not want a peg tube. A chest X-ray showed an
increasing opacity of the left lung. A follow up CT scan showed
a large mucus plug in the left main stem bronchus with resultant
atelectasis of the left lung. Pulmonary was consulted por
possible bronchoscopy. They said he was a poor candidate for
bronching and recomended chest physical therapy.
.
He continued at a stable amount of respiratory distress. A
family meeting was scheduled for [**8-9**]. On [**8-7**] the patient
started to desat into the 80s on 5 liters nasal cannula. He
required a veturi mask to maintain his oxygen saturation.
palliative care was consulted. His condition did not improve and
he was changed to care measures only. A house officer was
called into his room on [**8-8**] at 9:35pm to pronounce his death.
The family was notified and declined an autopsy.
.
Problems:
Respiratory distress: Given recent history of multiple
admissions for aspiration pneumonia, leukocytosis, and
infiltrate on chest x-ray, this most likely represents new
aspiration pneumonia / pneumonitis. He was started on Vancomycin
and Zosyn for hospital aquired pneumonia. His sputum cultures
grew E. Coli and his antibiotics were narrowed to ceftriaxone.
The patient improved, but developed tachypnea and spiked a fever
to 101 on [**2153-8-4**]. The patients antibiotics were broadened to
back to vancomycin and zosyn and blood cultures were sent. The
patients CXR showed increasing opacity of the left lung. A
CT-chest w/o contrast was performed and showed a large mucus
plug in the left main stem cause atelectasis of the left lung.
His pleural effusions remained stable. Pulmonary was consulted
and recommended chest physical therapy.
.
Low Urine Output: His urine output steadily declined. He was
continued on mild fluid replacement.
.
Change in Mental Status: Pt has been lethargic and confused, but
mental status has improved. Pt continues to be fatigued. was
on remeron and ritalin now stopped, and on IVF to correct
hypernatermia.
.
Diarrhea: Pt with loose BM, but improving. Pt has been on broad
spectrum antibiotics. C. diff studies were negative. His
diarrhea improved.
.
Depression: Seen by PPC to discuss goals of care. Pt and
family feel that quality of life is most important. Diet
restrictions may be contributing to depression. Pt and family
aware of risk of apsiration with eating.
.
Hypernatermia: Likely due to dehydration and lack of free water.
Pt eating now, but not significant amount. Will encourage free
water intake and continue mild fluid replacement.
.
Diastolic CHF: Last EF was >55%. CHF could be contributing to
respiratory symptoms. Pt with bilateral pleural effusions on
CXR. Tenuous fluid state with decreasing urine output. Goal is
to keep hydrated without causing an increase in pulm edema with
worseing shortness of breath.
.
A-fib: Pt has refused anti-coag in the past. Irregular, but
rate controlled Will cont metoprolol for rate control. Aspirin
stopped as short term risks outweigh long term benefit.
.
DM: Pt with elevated blood sugars towards end of hospital stay.
Sliding scale was adjusted and then stopped when he was made CMO
.
CKD Stage IV: Patient with worsening ceratinine and decreaing
urine output. Patient would not be a good candiate for
dialysis. Fluids replaced lightly with goal being not to
increase pulmonary edema.
Medications on Admission:
Furosemide 40mg PO
Metoprolol 37.5mg PO BID
Aspirin 81mg
B12 1000 mg
Vitamin D 800 units daily
Insulin NPH 8 units in AM
Folic Acid
Nitro PRN
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory failure resulting in death.
Aspiration pneumonia
CHF: EF 55% with moderate MR, and PFO, last echocardiogram
[**10/2151**]
CAD s/p CABG(LIMA, SVG=>ramus, SVG=>l-PDA) [**2147**]
Diabetes mellitus, on insulin
Atrial fibrillation: on aspirin
Chronic renal insufficiency: baseline SCr in mid 2s
Hypertension
H/O CVA
H/O autoimmune hemolytic anemia:
Chronic left pleural effusion
Discharge Condition:
Expired
Discharge Instructions:
none
Followup Instructions:
none
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**] MD, [**MD Number(3) 2478**]
|
[
"787.91",
"V15.82",
"599.0",
"585.9",
"428.0",
"428.30",
"745.5",
"250.00",
"276.0",
"934.8",
"V45.81",
"414.00",
"507.0",
"311",
"511.9",
"V66.7",
"E915",
"403.90",
"V12.54",
"293.0",
"V58.67",
"424.0",
"518.81",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7668, 7677
|
3673, 5904
|
221, 227
|
8107, 8116
|
2278, 3650
|
8169, 8305
|
1832, 1885
|
7639, 7645
|
7698, 8086
|
7473, 7616
|
8140, 8146
|
1900, 1900
|
174, 183
|
255, 1265
|
1914, 2259
|
5919, 7447
|
1287, 1640
|
1656, 1816
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,314
| 108,439
|
1955
|
Discharge summary
|
report
|
Admission Date: [**2143-6-17**] Discharge Date: [**2143-6-30**]
Date of Birth: [**2086-2-20**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
weakness, inability to speak
Major Surgical or Invasive Procedure:
IV tPA
Cerebral angiogram with attempted clot extraction
Trach placement
PEG
History of Present Illness:
Neurology at bedside for evaluation after code stroke activation
within: 1 minutes (I was near the room already when "Code
stroke"
was paged, and at bedside in less than a minute)
Time (and date) the patient was last known well: 11:42am
NIH Stroke Scale Score: 18
t-[**MD Number(3) 6360**]: YES
Time t-PA was given 13:00 (24h clock)
I was present during the CT scanning and reviewed the images
instantly within 20 minutes of their completion.
NIH Stroke Scale score was 18:
1a. Level of Consciousness: 0
1b. LOC Question: 2
1c. LOC Commands: 0
2. Best gaze: 1
3. Visual fields: 0
4. Facial palsy: 3
5a. Motor arm, left: 0
5b. Motor arm, right: 2
6a. Motor leg, left: 2
6b. Motor leg, right: 3
7. Limb Ataxia: 1
8. Sensory: 0
9. Language: 2
10. Dysarthria: 2
11. Extinction and Neglect: 0
History of Present Illness:
[**Known firstname **] [**Known lastname **] is a 57 year-old man who was BIBA for weakness
and inability to speak. A code stroke was called on arrival, and
I was in the room in time to hear report from EMS. Later, his
brother provided some collateral information. He was reportedly
in his USOH earlier today, except for an intermittent headache
over the past few days.
EMS reports they were called to the walkway around [**Country **] Pond
because Mr. [**Known lastname **] was slumping to the left with "right eye
droop," non-verbal on their arrival. They received the call at
11:42am. He had been seen at [**Hospital 882**] Hospital 2wks prior after
falling on his head; two sutures to a forehead laceration; Head
CT
reportedly normal at that time. He presented to [**Hospital3 **]
a
few days ago with concern for neurologic symptoms possibly
seizure, but the details are unknown. He has c/o [**5-30**] headache
for the past few days. His brother [**Name (NI) 892**] ([**Telephone/Fax (1) 10786**]) [**Name2 (NI) 10787**]ed
and clarified that he had just dropped off the pt at J.Pond to
walk. He was driving away when pt. called him and said that his
side was weak. He came back and called the ambulance. tPA
contraindications were reviewed with the brother (none were
identified), and bleeding risk were explained. Regarding the
fall
2wks ago, [**5-21**] clinic note says that pt. had a "bruise around
right orbit. Fell getting out of a car, lost balance; no LOC."
and that "alcohol was involved."
Review of Systems: via nods and head-shakes, pt denies headache.
endorses diplopia. cannot speak.
Past Medical History:
Depression/Anxiety/Panic Attacks; [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]=Psychiatry; SSRI
Insomnia (on trazodone)
Bladder Obstruction
Plantar Fascia Release
"LOW NORMAL" VITAMIN B12
COLONOSCOPY [**2140**], INCONPLETE PREP: NEEDS REPEAT
HERNIATED DISC: NECK (C56/67 disc bulge, contacting the ventral
cord on prior imaging)
ALCOHOL ABUSE: RECOVERING
HYPERLIPIDEMIA (on statin)
HEPATITIS C TREATED
Chest pain
Chronic foot pain with plantar fasciitis
Borderline hypertension
GERD on PPI, H2 blocker found ineffective
Social History:
unemployed: custodian (brother says he is living on disability
payments at present). four brothers and one sister and he lives
with brother. unmarried: no children. Brother says pt used to
run
marathons (years ago).
- never smoked.
- h/o Alcohol abuse in recovery: Formerly six to eight drinks at
a time one day a week. 9 years sober in the past, recently
started drinking again per brother.
- denies history of substance abuse / IVDU
Family History:
mother died: 92 respiratory problems,had an MI in her 70s
father died at age 72 throat cancer, long history of smoking
brother: heart attack: age of 57
no family history of sudden cardiac death
Brother denies FH of Neurologic disease.
Physical Exam:
Physical Examination on Admission:
General: Lying in ED stretcher, appears anxious. Breathing
somewhat irregularly, puffing air through flaccid right side of
lips.
HEENT: Normocephalic. Mucous membranes are moist. Facemask O2
Neck: Supple. No carotid bruits I can appreciate. No LAD.
Pulmonary: Lungs CTA anteriorly. Non-labored.
Cardiac: Regular, bradycardic (50), normal S1/S2.
Abdomen: Soft, non-tender, and non-distended. Mildly obese.
Extremities: Warm and well-perfused. 2+ radial, DP pulses.
Skin: no gross rashes or lesions noted.
Neurologic examination:
Mental Status:
Eyes open, alert, follows commands with head and LUE;
comprehension seems intact. No speech.
-Cranial Nerves:
II: PERRL, 3.5 to 2mm and brisk. Does not reliably blink to
threat on either side. Seems distressed by prolonged fixation or
eye opening (shuts eyes frequently).
III, IV, VI: EOM conjugate at rest, lying perhaps 10 deg off the
midline to the right. On attempted Rightward gaze, the left eye
does not adduct fully and the right eye beats (fast-phase) to
the
left). On attempted Leftward gaze, the left eye does not abduct
more than a few degrees past midline. Does not look up/down for
me on command.
V: Facial sensation intact (patient nods) to pin bilaterally.
VII: No ptosis. Left NLF and lips flaccid (pt huffs breaths
through unsealed lips). Smile is assymetric (L-facial droop).
Brows and eye-closure appear strong.
VIII: Hearing grossly intact.
IX, X, XII: Does not open mouth or protrude tongue on command.
[**Doctor First Name 81**]: Does not lift R trap (Left full).
-Motor:
Right arm only slight movement at the fingers, which are
hypertonic (flexed) and not flaccid. At one time, however, he
lifted the arm in a flexed position with gross ataxia
(subsequently unable). LUE full at the delt, tri/[**Hospital1 **], WE/FE/grip,
no pronator drift of LUE. Can move toes of both legs R>L. At one
point lifts LLE AG, not right. Legs tone is increased
bilaterally.
-Sensory: nods intact to LT/pin in all four extremities.
-Reflexes (left; right): pathologically brisk in both patellars,
with few beats of clonus bilaterally and briskly upgoing toes.
-Coordination: No ataxia of LUE on FNF; gross ataxia of RUE the
one time he was able to lift it AG.
-Gait: unable
Physical Exam on Discharge:
General: awake and alert, NAD
HEENT: NCAT. Trach in place, c/d/i. Tongue with dark red
scabbing over R side.
Pulmonary: Lungs CTAB, coarse breath sounds
Cardiac: RRR, no m/r/g.
Abdomen: Soft, non-tender, and non-distended.
Extremities: Warm and well-perfused
Skin: no rashes or lesions noted
Neurologic examination:
Mental Status: Awake and alert, able to follow commands and
answer yes/no questions appropriately by blinking eyes/nodding
head.
-Cranial Nerves:
PERRL 3 to 2mm. Eyes deviated slightly toward R at baseline.
Able to look toward right somewhat with left-beating nystagmus.
Unable to look toward left. Preserved vertical eye movements.
Minimal voluntary mouth movement but able to yawn.
-Motor: Spastic quadriplegia, more hypertonic in legs than arms.
Intermittent low-amplitude tremors of all extremities.
-Sensory: reports sensation to light touch in all extremities
-Reflexes: brisk b/l, both toes upgoing
-Coordination: unable to assess
-Gait: unable to assess
Pertinent Results:
[**2143-6-17**] 08:01PM HCT-35.5*
[**2143-6-17**] 07:08PM TYPE-ART PO2-200* PCO2-45 PH-7.35 TOTAL
CO2-26 BASE XS-0
[**2143-6-17**] 07:00PM PT-13.0* PTT-26.3 INR(PT)-1.2*
[**2143-6-17**] 01:15PM URINE HOURS-RANDOM
[**2143-6-17**] 01:15PM URINE GR HOLD-HOLD
[**2143-6-17**] 01:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.037*
[**2143-6-17**] 01:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2143-6-17**] 12:30PM UREA N-15
[**2143-6-17**] 12:30PM LIPASE-35
[**2143-6-17**] 12:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2143-6-17**] 12:30PM WBC-5.9 RBC-4.43* HGB-13.8* HCT-41.2 MCV-93
MCH-31.1 MCHC-33.4 RDW-13.1
[**2143-6-17**] 12:30PM PT-10.6 PTT-23.4* INR(PT)-1.0
[**2143-6-17**] 12:30PM PLT COUNT-321
[**2143-6-17**] 12:30PM FIBRINOGE-292
[**2143-6-17**] 12:28PM CREAT-0.9
[**2143-6-17**] 12:28PM estGFR-Using this
[**2143-6-17**] 12:27PM COMMENTS-GREEN TOP
[**2143-6-17**] 12:27PM GLUCOSE-120* NA+-138 K+-3.8 CL--104 TCO2-24
ECG: Sinus bradycardia, rate 50. Otherwise, no abnormalities
CT/CTA/CTP [**6-17**]:
IMPRESSION:
1. Occlusion of the right vertebral artery from its origin to
the C6 level. Occlusion of the distal cervical right vertebral
artery and of the basilar artery. These findings may represent
proximal dissection with distal thromboembolism, or proximal
thrombosis with distal embolism.
2. No evidence of acute intracranial abnormalities on
non-contrast head CT. MRI would be more sensitive for an acute
infarction.
3. The CT perfusion study is limited by artifacts. Ischemia in
the posterior fossa cannot be excluded.
Cerebral angiogram [**6-17**]:
IMPRESSION: [**Known firstname **] [**Known lastname **] underwent cerebral angiography which
revealed
occlusion of the right vertebral artery with thrombus in the
basilar artery. An attempt to recanalize the right vertebral
artery with the intention of stenting it was unsuccessful.
Transthoracic echo [**6-18**]:
IMPRESSION: No ASD or PFO seen. Normal global and regional
biventricular systolic function. No pulmonary hypertension or
clinically-significant valvular disease seen.
MRI/A [**6-18**]:
IMPRESSION:
1. Bilateral pontine infarctions, worse on the left. Caudal
midbrain is also involved.
2. Occlusion of the right vertebral artery and the left
vertebral artery
distal to PICA. No flow detected in the proximal basilar
artery.
3. No hemorrhage or mass effect.
MRI [**6-22**]:
IMPRESSION: Brainstem infarct is again identified and may
slightly more
superior extension or unchanged due to differences in slice
selection. Small other infarcts are again seen as noted before.
No change in mass effect is seen. Flow void is now visualized
in the distal right vertebral artery, which may indicate
recanalization.
CXR [**6-27**]:
FINDINGS: Compared to the previous radiograph, the monitoring
and support devices, including the tracheostomy tube, are
unchanged. The lung volumes have slightly decreased. Increase
in extent of a pre-existing retrocardiac atelectasis.
Otherwise, unchanged appearance of the lung parenchyma and the
cardiac silhouette.
Brief Hospital Course:
57y man with hx of borderline HTN, hyperlipidemia, and prior
ETOH abuse who initially presented as a code stroke with right
sided weakness and inability to speak. CT head was negative; CTA
revealed absence of flow in the basilar, with proximal occlusion
of the dominant right vert and distal ?occlusion of the (left
post-PICA). He was taken to [**Doctor First Name 10788**] but access to the right
vertebral could not be obtained. Post-procedure course was
complicated by failed angioseal X 2 with bleeding from R femoral
artery which required cisatricurium paralysis overnight (to
limit movement and rebleeding). Heparin gtt was stopped given
these complications but was subsequently restarted considering
the tight stenotic basilar.
.
ICU course ([**2143-6-18**] - [**2143-6-29**]):
.
# Neuro:
Cisatricurium was stopped and patient was maintained sedated on
propofol. He was started on Neosynephrine with BP goal 140-180.
Heparin was eventually restarted with PTT goal 50-70 after 48hrs
once bleeding in b/l groins had stopped in the hopes of
maintaining flow through the basilar.
.
He was weaned off propofol and extubated on [**2143-6-19**] which was
noted to be difficult, requiring CPAP mask and concern for
airway protection/lack of gag. However overnight on [**2143-6-20**] he
was noted to have b/l rigidity and myoclonic jerking. His
respiratory status subsequently deteriorated and he was
reintubated and restarted on propofol.
.
Given that extubation seemed unlikely in the near future, a
trach was placed on [**6-22**] after discussion with his family.
.
On [**6-22**] his exam was noted to have worsened with decreased
movement of his left side. He was also noted to have
intermittent rigidity with tonic stiffening and shaking of his
limbs. A repeat MRI confirmed extension of pontine infarct.
Heparin gtt was switched to aspirin, BP allowed to autoregulate.
.
Currently he is plegic other than preserved blinking, vertical
eye movements, and some minimal head movements consistent with
locked in syndrome. He is awake and alert and able to follow
commands and answer yes/no questions appropriately. Speech
therapy has been consulted for asssistance with communication
techniques, and PT and OT are involved as well. He is on aspirin
325mg and pravastatin 80mg. He was started on clonazepam 1mg TID
on [**6-24**] for rigidity with some improvement. He was subsequently
started on baclofen 10mg TID on [**6-27**].
.
# CV:
He was maintained on telemetry monitoring. BP was allowed to
autoregulate with hydralazine prn SBP > 180.
.
# Pulm:
He was initially extubated on [**6-19**] and maintained on CPAP.
However he decompensated with difficulty managing his secretions
and desaturation and later that night and was reintubated. A
trach was placed on [**6-22**]. He remained stable on CPAP and
subsequently was weaned to trach mask, on which he has been
stable since [**6-26**].
.
# ID:
He began to spike fevers and was initially started on Vancomycin
on [**6-21**] for empiric coverage. CXR showed pulmonary effusions but
no clear infiltrate. Sputum cx from [**6-19**] showed MSSA and his
antibiotics were narrowed to Nafcillin on [**6-24**]. He continued to
spike intermittent fevers. Repeat sputum cx from [**6-23**] grew MSSA
as well as serratia. Abx were broadened to Cefepime on [**6-24**] and
subsequently changed to Vanc/Cipro on [**6-25**] (to be continued for
10 days through [**7-5**]). UA's and cultures have been negative and
blood cultures are negative to date.
.
# Gastrointestinal / Nutrition:
NGT was placed and tube feeds were started on [**2143-6-19**]. PEG
placement was discussed with the patient and his family who are
all in agreement with proceeding. ACS was consulted and peg was
placed. He was continued on his home protonix.
.
# Consults:
PT/OT were consulted for range of motion exercises. Speech
therapy was consulted to help with communication techniques.
.
# Code status: FULL code, confirmed with family. Family and
patient in favor of PEG placement.
.
He was transferred to the step-down unit on [**2143-6-29**]. Placement
was found at a facility on [**2143-6-30**]
[ AHA/ASA Core Measures for Ischemic Stroke ]
1. Dysphagia screening before any PO intake? (X) Yes - () No
2. DVT Prophylaxis administered? (X) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(X) Yes - () No
4. LDL documented? () Yes - (X) No - TG 492, unable to calculate
5. Intensive statin therapy administered? (for LDL > 100) (X)
Yes - () No
6. Smoking cessation counseling given? () Yes - (X) No (Reason
(X) non-smoker - () unable to participate)
7. Stroke education given? () Yes - () No
8. Assessment for rehabilitation? () Yes - () No
9. Discharged on statin therapy? (X) Yes - () No (if LDL >100,
Reason Not Given: )
10. Discharged on anti-thrombotic therapy? (X) Yes (Type: (X)
Antiplatelet - aspirin 325mg () Anticoagulation) - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - (X) No - n/a
Medications on Admission:
1. CITALOPRAM 40mg daily (confirmed by brother)
2. ESOMEPRAZOLE MAGNESIUM [NEXIUM] - 40mg EC daily (brother
said
"Prilosec").
3. PRAVASTATIN - 20mg daily (confirmed by brother)
4. ASPIRIN - 81mg daily (confirmed by brother)
5. TRAZODONE 300mg qhs (confirmed by brother)
6. (per OMR) DICLOFENAC SODIUM - 50 mg Tablet, Delayed Release
(E.C.) - 1 Tablet(s) by mouth twice a day
7. MELATONIN - (Prescribed by Other Provider) - 3 mg Tablet -
1
Tablet(s) by mouth bedtime
Discharge Medications:
1. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for wheezing.
3. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
4. acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q8H (every 8 hours) as needed for pain.
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
10. oxycodone 5 mg/5 mL Solution Sig: 5-10 mg PO Q4H (every 4
hours) as needed for pain: hold for rr less than 12 .
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for constipation.
12. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO DAILY (Daily) as needed for constipation.
13. baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
14. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
15. ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: Four
Hundred (400) mg Intravenous Q8H (every 8 hours): Through [**7-5**].
16. vancomycin in D5W 1 gram/200 mL Piggyback Sig: 1000 (1000)
mg Intravenous Q 8H (Every 8 Hours): Through [**7-5**].
17. hydromorphone 2 mg/mL Syringe Sig: 0.5-1.5 mg Injection Q3H
(every 3 hours) as needed for pain: hold for over-sedation .
18. sodium chloride 0.9 % 0.9 % Parenteral Solution Sig: Ten
(10) ML Intravenous PRN (as needed) as needed for line flush:
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
19. insulin regular human 100 unit/mL Solution Sig: Sliding
Scale Injection ASDIR (AS DIRECTED).
20. hydromorphone 2 mg/mL Syringe Sig: 0.5-1.5 Injection Q3H
(every 3 hours) as needed for pain.
21. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Bilateral pontine infarcts
Right vertebral/basilar occlusion
Hypertriglyceridemia
Discharge Condition:
Mental Status: Awake and alert.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Neurologic exam: Awake and alert, able to follow commands and
communicate by blinking eyes. No spontaneous movement except
blinking/vertical eye movements and slight head nodding/turning.
Eyes deviated somewhat to R with horizontal nystagmus. Able to
look toward right minimally, unable to look to left. Hypertonic
throughout (LE>UE) with intermittent tremors/myoclonus of all
extremities.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to [**Hospital1 69**] on [**6-17**], [**2143**] due to right sided weakness and inability to speak. You
were found to have a stroke in the left side of your brainstem.
You received IV tPA and were subsequently taken for a cerebral
angiogram which showed blockage of one of the arteries in your
neck leading to a major artery in your brain. The blockage was
unfortunately not able to be removed. You were admitted to the
neuro ICU for close monitoring. Over the next few days your
stroke worsened to involve both sides of your brainstem. You had
a tracheostomy tube placed to help protect your airway and a
gastrostomy tube placed to give you nutrition.
We made the following changes to your medications:
Increased aspirin to 325mg daily
Increased pravastatin to 80mg daily
Started Vancomycin and Ciprofloxacin to treat your pneumonia
(will finish [**7-5**])
Started clonazepam 1mg three times a day and baclofen 10mg three
times a day to help with the stiffness and pain in your arms and
legs
If you experience any of the below listed danger signs, please
call your doctor or go to the nearest Emergency Department.
It was a pleasure taking care of you during your hospital stay.
Followup Instructions:
Please return to the neurology clinic in 6 weeks.
Dr. [**First Name (STitle) **]
Office Phone: ([**Telephone/Fax (1) 7394**]
Office Location: [**Location (un) **] 127
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2143-6-30**]
|
[
"507.0",
"781.94",
"E879.8",
"272.1",
"272.4",
"693.0",
"041.11",
"263.9",
"300.01",
"998.11",
"434.11",
"V12.09",
"530.81",
"780.52",
"518.81",
"401.9",
"344.81",
"333.2",
"784.51",
"433.31",
"285.9",
"E930.5",
"041.85"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10",
"31.1",
"88.42",
"88.41",
"96.72",
"88.44",
"31.42",
"93.90",
"33.23",
"43.11",
"96.6",
"88.48"
] |
icd9pcs
|
[
[
[]
]
] |
18383, 18449
|
10682, 15678
|
334, 412
|
18574, 18574
|
7449, 10659
|
20394, 20703
|
3897, 4133
|
16202, 18360
|
18470, 18553
|
15704, 16179
|
19137, 19863
|
6907, 7430
|
4148, 4169
|
6442, 6735
|
19892, 20371
|
2783, 2863
|
266, 296
|
1260, 2764
|
4184, 4689
|
18589, 18722
|
6760, 6760
|
18739, 19113
|
2885, 3428
|
3444, 3881
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,422
| 166,085
|
54465
|
Discharge summary
|
report
|
Admission Date: [**2162-2-12**] Discharge Date: [**2162-2-20**]
Date of Birth: Sex: M
Service: [**Company 191**]
CHIEF COMPLAINT: Change in mental status.
HISTORY OF PRESENT ILLNESS: The patient is a 51 year old
white male with a history of type 2 diabetes mellitus,
hypertension, quadriplegia secondary to cervical spine
abscess and hepatitis C, who presents from [**Hospital3 4339**]
after three days of change in mental status. The patient was
transferred to the SICU for management of severe
hyponatremia. Per outside records, the patient is a resident
of a chronic care facility and at his baseline is very alert.
Reportedly the patient has had decreasing serum sodium levels
and had been placed on fluid restriction of 3000cc per day
with which he has been very noncompliant. For the three days
prior to admission, the staff had noticed a progressive
change in mental status until the day of admission when he
was found very confused and lethargic with a garbled speech.
Laboratories revealed a sodium of 97. The patient was
subsequently transferred to [**Hospital1 188**] Emergency Department where severe hyponatremia was
verified. Urine osoms returned at 407. The patient was
started on 3% sodium chloride at 42 cc/hour. The patient has
no documented history of hypovolemia, diarrhea, syndrome of
inappropriate diuretic hormone, hypothyroidism or adrenal
insufficiency. His only new medication as Celexa which was
started on [**2162-2-5**].
PAST MEDICAL HISTORY:
1. Type 2 diabetes mellitus.
2. Quadriplegia secondary to cervical spine cyst/abscess.
3. Obesity.
4. History of polysubstance abuse.
5. Chronic obstructive pulmonary disease.
6. Hepatitis C.
7. Depression.
8. History of urinary tract infection.
9. Hypertension.
PAST SURGICAL HISTORY:
1. Status post appendectomy.
2. Status post cholecystectomy.
SOCIAL HISTORY: The patient smoked one pack per day times
many years. He has no history of alcohol use. He is
divorced. He is a resident of [**Hospital3 4339**].
FAMILY HISTORY: Father has type 2 diabetes mellitus.
MEDICATIONS ON ADMISSION:
1. Albuterol two puffs q8hours.
2. Baclofen.
3. Dulcolax 10 mg once daily.
4. Brimonidine Ophthalmic Solution.
5. Clonidine 0.1 mg once daily.
6. Diltiazem CD 180 mg once daily.
7. Enalapril 10 mg p.o. three times a day.
8. Flonezalide two puffs twice a day.
9. Ibuprofen 600 mg p.o. q6hours.
10. NPH 50 units q.a.m. and 45 units q.p.m.
11. Lantaprost eye drop solution.
12. Loratadine 10 mg p.o. twice a day.
13. Famotidine 20 mg p.o. once daily.
14. Losartan 50 mg p.o. twice a day.
15. Maalox p.r.n.
16. Flovent two puffs twice a day.
17. Opatadine Ophthalmic Solution.
18. Zinc.
19. Sodium Chloride tablets.
PHYSICAL EXAMINATION: On admission, temperature was 98.3,
heart rate 97, blood pressure 182/76, respiratory rate 20,
oxygen saturation 97% on five liters. In general, this was a
very somnolent middle age male who was responsive to loud
voice. Face was plethoric. Head, eyes, ears, nose and throat
examination - The pupils are equal, round, and reactive to
light and accommodation. Extraocular movements are full.
The oropharynx revealed no lesions, however, appeared dry.
The neck was supple with no lymphadenopathy and no jugular
venous distention. The heart examination was regular rate
and rhythm, no murmurs, rubs or gallops. Lung examination -
loud snoring sounds, otherwise clear to auscultation. No
wheezes. The abdomen was soft, obese, with positive bowel
sounds. Suprapubic catheter in place. A pump in the left
lower quadrant. Extremities - decreased muscle tone. Feet
were contracted, no cyanosis, clubbing or edema. There was
2+ pedal pulses. Rectal examination - four large deep crater
decubitus ulcers which appeared to probe to bone.
Neurologically, the patient moves upper extremities, minimal
lower extremity movement. The patient is arousible, however,
not cooperative with examination.
LABORATORY DATA: On admission, Chem7 revealed a sodium 98,
potassium 4.9, chloride 65, bicarbonate 23, blood urea
nitrogen 10, creatinine 0.3, glucose 221. Complete blood
count revealed white blood cell count 23.2, hematocrit 40.8,
platelet count 518,000, 90% neutrophils, 0% bands, 6%
lymphocytes. INR was 1.1. Urinalysis showed specific
gravity of 1.025, [**6-1**] red blood cells, [**2-24**] white blood
cells, otherwise negative. Urine osom 409. Urine
electrolytes were sodium less than 10, potassium 33, chloride
less than 10, urine creatinine 50, urine urea 578, serum
ammonia level 37, serum acetone level negative. Serum osom
220.
Chest x-ray showed no acute cardiopulmonary process.
Electrocardiogram showed normal sinus rhythm with normal
axis, nonspecific conduction delay, no ST changes, no T wave
inversion. Electrocardiogram was unchanged from a prior from
[**2152-12-23**].
HOSPITAL COURSE:
1. From a fluid and electrolyte standpoint, the patient
presented with severe hyponatremia with a serum osmolality of
220 and a urine osmolality of 409. The serum osmolality of
220 verified hyposmolar hyponatremia. His dry mucous
membranes suggested an element of hypovolemia as well,
however, his blood urea nitrogen/creatinine ratio did not
suggest significant volume depletion. His elevated urine
osmolality suggested syndrome of inappropriate diuretic
hormone. Possible etiologies considered were hypothyroidism
and adrenal insufficiency. Gastrointestinal losses of
hypovolemia such as diarrhea and vomiting were considered
less likely. Given the severity of his low sodium and his
mental status changes, the patient was treated with
hypertonic saline with subsequent increase in his serum
sodium from 98 on admission to 104 by hospital day number
one. His sodium continue to improve and the hypertonic
saline was discontinued and the patient was later started on
a one to 1.5 liter fluid restriction with continued
resolution of his hyponatremia. On the day of discharge, his
serum sodium was 135. The recent addition of Celexa to his
medical regimen was felt to be possible cause of his syndrome
of inappropriate diuretic hormone. The renal service was
consulted and agreed with the plan for hypertonic saline with
a transition to fluid free water restriction as his sodium
and mental status improved.
2. Cardiovascular - On the evening of [**2162-2-14**], the patient
became progressively more somnolent and began breathing more
agonally. Arterial blood gas was done which showed
progressive hypercarbia and the patient was intubated for
hypercarbic respiratory failure. After intubation, the
patient became hypotensive requiring the addition of Levophed
for a systolic blood pressure in the 60s. The etiology of
the hypotension was not entirely clear, however, given that
he also was febrile at the time a distributive etiology
perhaps sepsis was felt to be the cause. The patient was
started on broad spectrum antibiotics with Levofloxacin and
Vancomycin. His fever workup included blood cultures one out
of four positive for gram positive cocci and enterococcus
with greater than 100,000 colonies, however, with a
urinalysis which showed no nitrites and no leukocyte esterase
raising suspicion for colonization of the suprapubic catheter
without active infection. The patient was, however,
continued to be treated with Levofloxacin and Vancomycin was
later discontinued as his fever curve trended down and the
identification of the organism from the blood culture was
coagulase negative Staphylococcus which was felt to be a
contaminant.
3. Renal - The patient has a history of type 2 diabetes
mellitus. He was treated with NPH insulin and sliding scale
insulin and was eventually returned to his outpatient dose.
4. Neurologic - From a neurologic standpoint, the patient
has a history of quadriplegia and came in with a Baclofen
pump. This was continued while he was in house. While he
was intubated in the Intensive Care Unit, Fentanyl infusion
was used for sedation.
5. Infectious disease - As previously stated, septic shock
was considered to be possible cause of the patient's
hypotension which did require pressors. Chest x-ray showed
multifocal opacities which was suggestive of aspiration
pneumonia. He was treated with Levofloxacin with good
response as well as with chest physical therapy given his
quadriplegia. As previously stated, he also was noted to
have an Enterococcus urinary tract infection which was
sensitive to Levofloxacin.
CONDITION ON DISCHARGE: Fair.
DISCHARGE DIAGNOSES:
1. Hyponatremia secondary to syndrome of inappropriate
diuretic hormone.
2. Hypotension.
3. Hypercarbic respiratory failure.
4. Aspiration pneumonia.
5. Enterococcal urinary tract infection.
6. Type 2 diabetes mellitus.
MEDICATIONS ON DISCHARGE: These will be dictated as a
discharge summary addendum.
DISCHARGE PLAN: The patient was discharged to his chronic
care facility, [**Hospital3 4339**]. The accepting physician
at the chronic care facility was contact[**Name (NI) **] prior to his
discharge and accepted the patient. He will follow-up with
renal p.r.n.
[**Name6 (MD) 3488**] [**Last Name (NamePattern4) 3489**], M.D. [**MD Number(1) 3490**]
Dictated By:[**Name8 (MD) 9130**]
MEDQUIST36
D: [**2162-6-3**] 17:25
T: [**2162-6-8**] 21:05
JOB#: [**Job Number 111471**]
|
[
"599.0",
"253.6",
"707.0",
"038.9",
"518.81",
"V53.09",
"344.00",
"070.54",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.72",
"38.93",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
2056, 2094
|
8521, 8748
|
8775, 8832
|
2120, 2742
|
4878, 8468
|
1808, 1872
|
2765, 4861
|
159, 185
|
214, 1490
|
8849, 9346
|
1512, 1785
|
1889, 2039
|
8493, 8500
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,962
| 186,417
|
25215+57442
|
Discharge summary
|
report+addendum
|
Admission Date: [**2195-9-24**] Discharge Date: [**2195-12-30**]
Date of Birth: [**2140-9-28**] Sex: M
Service: SURGERY
Allergies:
Amphotericin B
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Transfer from Bombay with fevers, perihepatic fluid collection,
acute pancreatitis, line sepsis, pleural effusions, and bile
leak
Major Surgical or Invasive Procedure:
[**2195-9-25**]- 1. Exploration of retroperitoneal area.
2. Drainage of retroperitoneal and intra-abdominal
abscesses
- flank approach.
[**2195-10-20**]- 1. Bronchoscopy.
2. Left pleuroscopy with pleural drainage and pleural
biopsy.
[**2195-10-31**]- 1. Extended right colectomy with end ileostomy and
mucous
fistula.
2. Drainage of liver abscess.
3. Peripancreatic necrosectomy
4. Drainage of retroperitoneal abscess.
5. Feeding jejunostomy tube placement.
[**12-22**] ERCP with biliary stent removal
History of Present Illness:
The patient is a 54-year-old man with a protracted course of
intra-abdominal complications following a liver resection in
Bombay on [**2195-7-31**] for an intrahepatic cholangiocarcinoma
(T2N0M0). He was discharged home on postoperative day nine, then
re-admitted on postoperative day eleven for fever and
perihepatic fluid collection, which was subsequently drained by
a pigtail catheter (cultures positive for Klebsiella, MRSA, and
Citrobacter). He was discharged on postoperative day fifteen,
then readmitted postoperative day nineteen for an MRCP, which
showed no biliary leak. A stent was placed by ERCP on
postoperative day twenty one for biliary drainage and a pigtail
catheter was again placed to drain his perihepatic collection.
Following his ERCP, he developed acute pancreatitis. His
pancreatitis and fluid collection improved with conservative
management and IV antibiotics. On [**2195-9-9**] however, he developed
[**Female First Name (un) 564**] line sepsis. He later developed a right pleural
effusion which was drained multiple times with different sized
chest tubes. He continued to spike fevers and his white blood
cell count remained elevated over 18. A CT scan on [**2195-9-22**]
showed that his right retrocolic collection was spreading. He
was subsequently transferred to the [**Hospital1 **] SICU on [**2195-9-24**].
Past Medical History:
hypertension
Social History:
noncontributory
Family History:
noncontributory
Physical Exam:
Vitals: 98.6, 105, 166/89, 27, 99%
General: fatigued, no acute distress
HEENT: normocephalic/atraumatic, pupils equal round and reactive
to light, extraoccular movements in tact
Lungs: clear to ascultation bilaterally, serous straw-colored
drainage from chest tube site on the right
Heart: tachycardic, regular rhythum, normal S1S2
Abdomen: soft, distended, slightly tender especailly in the
right flank, right flank induration, bowel sounds positive
Drains: right hepatic pigtail, right chest tube
Pertinent Results:
[**2195-9-24**] 10:29PM BLOOD freeCa-1.17
[**2195-10-31**] 10:23AM BLOOD freeCa-0.94*
[**2195-11-1**] 12:41AM BLOOD freeCa-1.35*
[**2195-11-1**] 05:20PM BLOOD freeCa-1.18
[**2195-11-5**] 03:13AM BLOOD freeCa-1.22
[**2195-11-8**] 09:17PM BLOOD freeCa-1.05*
[**2195-11-11**] 02:55PM BLOOD freeCa-1.11*
[**2195-11-14**] 06:00PM BLOOD freeCa-1.11*
[**2195-11-15**] 09:53PM BLOOD freeCa-1.06*
[**2195-11-20**] 02:01PM BLOOD freeCa-1.18
[**2195-9-24**] 10:29PM BLOOD O2 Sat-94
[**2195-9-25**] 03:41PM BLOOD Hgb-10.8* calcHCT-32 O2 Sat-97
[**2195-10-31**] 11:41AM BLOOD Hgb-9.2* calcHCT-28
[**2195-10-31**] 12:00PM BLOOD Hgb-9.7* calcHCT-29
[**2195-11-1**] 08:39PM BLOOD Hgb-11.7* calcHCT-35 O2 Sat-80
[**2195-11-1**] 10:27PM BLOOD O2 Sat-97
[**2195-11-6**] 05:03PM BLOOD Hgb-11.3* calcHCT-34
[**2195-11-12**] 10:04AM BLOOD O2 Sat-98
[**2195-11-14**] 06:00PM BLOOD O2 Sat-98
[**2195-11-17**] 05:44PM BLOOD O2 Sat-96
[**2195-9-24**] 10:29PM BLOOD Lactate-1.1
[**2195-10-31**] 08:22AM BLOOD Glucose-115* Lactate-1.9 Na-129* K-2.6*
Cl-92*
[**2195-10-31**] 10:51AM BLOOD Glucose-136* Lactate-3.6* Na-134* K-2.6*
Cl-94*
[**2195-10-31**] 11:41AM BLOOD Glucose-132* Lactate-6.1* Na-131* K-2.7*
Cl-97*
[**2195-11-1**] 03:35AM BLOOD Lactate-3.8*
[**2195-11-1**] 11:31AM BLOOD Lactate-4.8*
[**2195-11-2**] 12:40PM BLOOD Lactate-4.3*
[**2195-11-5**] 03:13AM BLOOD Lactate-1.5
[**2195-11-5**] 03:14PM BLOOD K-4.1
[**2195-11-6**] 05:03PM BLOOD Glucose-153* K-3.4*
[**2195-11-10**] 01:41AM BLOOD K-4.3
[**2195-11-12**] 10:04AM BLOOD Glucose-110*
[**2195-11-13**] 05:33AM BLOOD Glucose-106* Lactate-0.7 K-3.3*
[**2195-11-17**] 05:44PM BLOOD Glucose-110* Na-134* K-3.1* Cl-106
[**2195-9-24**] 10:29PM BLOOD Type-ART pO2-69* pCO2-36 pH-7.46*
calHCO3-26 Base XS-1
[**2195-9-25**] 03:41PM BLOOD Type-ART Tidal V-736 pO2-113* pCO2-41
pH-7.42 calHCO3-28 Base XS-2 Intubat-INTUBATED Vent-CONTROLLED
[**2195-10-21**] 07:50PM BLOOD Type-ART pO2-96 pCO2-51* pH-7.30*
calHCO3-26 Base XS--1 Intubat-NOT INTUBA
[**2195-10-31**] 12:54PM BLOOD Type-ART Tidal V-720 FiO2-53 pO2-167*
pCO2-30* pH-7.58* calHCO3-29 Base XS-7 Intubat-INTUBATED
Vent-CONTROLLED
[**2195-10-31**] 01:50PM BLOOD Type-ART Rates-/10 Tidal V-720 FiO2-45 O2
Flow-1 pO2-196* pCO2-35 pH-7.54* calHCO3-31* Base XS-7
Intubat-INTUBATED Vent-CONTROLLED
[**2195-10-31**] 05:04PM BLOOD Type-ART pO2-153* pCO2-61* pH-7.35
calHCO3-35* Base XS-6 Intubat-INTUBATED
[**2195-10-31**] 09:12PM BLOOD Type-ART pO2-148* pCO2-45 pH-7.45
calHCO3-32* Base XS-7
[**2195-11-1**] 12:41AM BLOOD Type-ART pO2-101 pCO2-45 pH-7.39
calHCO3-28 Base XS-1
[**2195-11-1**] 11:31AM BLOOD pO2-142* pCO2-48* pH-7.36 calHCO3-28 Base
XS-1
[**2195-11-1**] 05:20PM BLOOD Type-ART pO2-114* pCO2-50* pH-7.35
calHCO3-29 Base XS-1
[**2195-11-1**] 10:38PM BLOOD Type-MIX
[**2195-11-2**] 12:28AM BLOOD Type-ART pO2-111* pCO2-42 pH-7.36
calHCO3-25 Base XS--1
[**2195-11-2**] 02:30AM BLOOD Type-ART pO2-143* pCO2-44 pH-7.38
calHCO3-27 Base XS-0
[**2195-11-4**] 02:41AM BLOOD Type-ART pO2-146* pCO2-39 pH-7.50*
calHCO3-31* Base XS-7
[**2195-11-4**] 04:14PM BLOOD Type-ART pO2-141* pCO2-49* pH-7.41
calHCO3-32* Base XS-5
[**2195-11-5**] 10:48AM BLOOD Type-ART pO2-147* pCO2-54* pH-7.37
calHCO3-32* Base XS-4
[**2195-11-5**] 03:14PM BLOOD Type-ART pO2-167* pCO2-49* pH-7.42
calHCO3-33* Base XS-6
[**2195-11-7**] 10:51AM BLOOD Type-ART pO2-141* pCO2-59* pH-7.32*
calHCO3-32* Base XS-2
[**2195-11-7**] 03:57PM BLOOD Type-ART pO2-116* pCO2-51* pH-7.37
calHCO3-31* Base XS-3
[**2195-11-9**] 04:52AM BLOOD Type-ART pO2-128* pCO2-37 pH-7.49*
calHCO3-29 Base XS-5 Intubat-INTUBATED
[**2195-11-9**] 09:39PM BLOOD Type-ART pO2-144* pCO2-34* pH-7.52*
calHCO3-29 Base XS-5
[**2195-11-11**] 03:23AM BLOOD Type-ART pO2-141* pCO2-38 pH-7.43
calHCO3-26 Base XS-1
[**2195-11-11**] 02:55PM BLOOD Type-ART pO2-175* pCO2-36 pH-7.41
calHCO3-24 Base XS-0
[**2195-11-12**] 03:37AM BLOOD Type-ART pO2-152* pCO2-36 pH-7.42
calHCO3-24 Base XS-0
[**2195-11-12**] 09:25PM BLOOD Type-ART pO2-145* pCO2-37 pH-7.42
calHCO3-25 Base XS-0 Intubat-INTUBATED
[**2195-11-13**] 05:33AM BLOOD Type-ART pO2-120* pCO2-42 pH-7.39
calHCO3-26 Base XS-0
[**2195-11-14**] 12:40PM BLOOD Type-ART pO2-103 pCO2-49* pH-7.41
calHCO3-32* Base XS-4
[**2195-11-14**] 06:00PM BLOOD Type-ART pO2-127* pCO2-57* pH-7.39
calHCO3-36* Base XS-8
[**2195-11-15**] 08:43AM BLOOD Type-ART pO2-141* pCO2-44 pH-7.46*
calHCO3-32* Base XS-7 Intubat-INTUBATED
[**2195-11-15**] 02:08PM BLOOD Type-ART pO2-102 pCO2-44 pH-7.46*
calHCO3-32* Base XS-6
[**2195-11-15**] 04:20PM BLOOD pH-7.43 Comment-GREEN TOP
[**2195-11-16**] 02:46PM BLOOD Type-ART pO2-106* pCO2-47* pH-7.46*
calHCO3-34* Base XS-8
[**2195-11-17**] 11:20AM BLOOD Type-ART pO2-61* pCO2-43 pH-7.47*
calHCO3-32* Base XS-6
[**2195-11-18**] 03:58AM BLOOD Type-ART pO2-69* pCO2-38 pH-7.48*
calHCO3-29 Base XS-4
[**2195-11-18**] 01:34PM BLOOD Type-ART pO2-150* pCO2-30* pH-7.46*
calHCO3-22 Base XS-0
[**2195-11-20**] 02:01PM BLOOD Type-ART pO2-164* pCO2-37 pH-7.45
calHCO3-27 Base XS-2
[**2195-9-27**] 09:32AM BLOOD Vanco-9.7*
[**2195-10-2**] 05:52AM BLOOD Vanco-9.8*
[**2195-11-1**] 09:09AM BLOOD Cortsol-5.5
[**2195-11-1**] 10:10AM BLOOD Cortsol-5.6
[**2195-9-24**] 09:19PM BLOOD TSH-1.9
[**2195-11-1**] 07:30AM BLOOD TSH-3.6
[**2195-10-31**] 06:00AM BLOOD Ammonia-46
[**2195-9-24**] 09:19PM BLOOD Triglyc-207*
[**2195-11-4**] 02:28AM BLOOD Triglyc-213*
[**2195-9-24**] 09:19PM BLOOD calTIBC-170* Ferritn->[**2190**] TRF-131*
[**2195-11-9**] 04:19AM BLOOD calTIBC-143 Ferritn-GREATER TH TRF-110*
[**2195-9-24**] 09:19PM BLOOD Albumin-2.7* Calcium-7.9* Phos-2.4*
Mg-1.9 Iron-25*
[**2195-9-25**] 05:00AM BLOOD Albumin-2.4* Calcium-7.8* Phos-3.0 Mg-1.9
[**2195-9-25**] 05:32PM BLOOD Calcium-7.8* Phos-2.5* Mg-1.6
[**2195-9-27**] 02:41AM BLOOD Albumin-2.2* Calcium-7.1* Phos-2.0*
Mg-1.7
[**2195-9-29**] 04:34AM BLOOD Albumin-2.4* Calcium-7.6* Phos-1.6*
Mg-1.8
[**2195-9-30**] 04:01AM BLOOD Calcium-7.7* Phos-2.4* Mg-1.7
[**2195-10-2**] 01:59AM BLOOD Calcium-7.3* Phos-2.6* Mg-1.8
[**2195-10-4**] 05:54AM BLOOD Calcium-7.5* Phos-1.8* Mg-1.6
[**2195-10-9**] 05:15AM BLOOD Calcium-7.5* Phos-1.8* Mg-1.7
[**2195-10-9**] 08:50AM BLOOD Calcium-8.0* Phos-1.7*
[**2195-10-19**] 05:05AM BLOOD Albumin-2.5* Calcium-7.8* Phos-1.5*
Mg-1.8
[**2195-10-20**] 09:32AM BLOOD Calcium-7.4* Phos-2.4* Mg-1.6
[**2195-10-27**] 06:00AM BLOOD Albumin-1.9* Calcium-7.2* Phos-2.2*
Mg-1.9
[**2195-10-29**] 04:59AM BLOOD Albumin-2.4* Calcium-7.6* Phos-1.5*
Mg-1.7
[**2195-11-1**] 03:18AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.1
[**2195-11-1**] 07:30AM BLOOD Albumin-1.6* Calcium-8.2* Phos-3.1 Mg-1.8
[**2195-11-2**] 02:10AM BLOOD Albumin-1.5* Calcium-8.0* Phos-3.2 Mg-2.1
[**2195-11-2**] 11:57AM BLOOD Albumin-1.6* Calcium-7.8* Phos-3.3 Mg-1.9
[**2195-11-3**] 02:28PM BLOOD Mg-2.3
[**2195-11-4**] 02:28AM BLOOD Albumin-1.6* Calcium-8.3* Phos-4.1 Mg-2.2
[**2195-11-6**] 03:27AM BLOOD Calcium-7.9* Phos-3.2# Mg-1.8
[**2195-11-6**] 11:30AM BLOOD Mg-1.9
[**2195-11-7**] 10:39PM BLOOD Calcium-6.9* Mg-1.7
[**2195-11-8**] 04:16AM BLOOD Calcium-7.4* Phos-2.1* Mg-2.0
[**2195-11-9**] 09:13PM BLOOD Calcium-7.0* Mg-1.8
[**2195-11-10**] 04:59AM BLOOD Albumin-1.6* Calcium-7.5* Phos-2.3*
Mg-1.9
[**2195-11-11**] 02:27PM BLOOD Calcium-6.8* Phos-2.4* Mg-1.7
[**2195-11-11**] 08:49PM BLOOD Calcium-6.8* Phos-2.5* Mg-1.9
[**2195-11-12**] 10:49PM BLOOD Calcium-6.8* Mg-1.6
[**2195-11-13**] 11:55PM BLOOD Calcium-7.0* Phos-1.9* Mg-1.5*
[**2195-11-14**] 04:31AM BLOOD Calcium-7.0* Phos-1.8* Mg-1.7
[**2195-11-15**] 10:13AM BLOOD Mg-1.5*
[**2195-11-16**] 04:09AM BLOOD Albumin-2.1* Calcium-7.4* Phos-2.4*
Mg-1.8
[**2195-11-17**] 03:08AM BLOOD Calcium-7.8* Phos-2.5* Mg-1.7
[**2195-11-19**] 02:18AM BLOOD Calcium-7.8* Mg-1.6
[**2195-11-18**] 01:17PM BLOOD Calcium-7.8* Mg-1.7
[**2195-11-21**] 03:34AM BLOOD Calcium-7.7* Mg-1.7
[**2195-11-22**] 03:30AM BLOOD Calcium-7.9* Mg-1.5*
[**2195-11-24**] 10:30AM BLOOD Calcium-8.0* Mg-1.5*
[**2195-11-11**] 02:27PM BLOOD CK-MB-NotDone cTropnT-0.01
[**2195-11-11**] 08:49PM BLOOD cTropnT-<0.01
[**2195-9-24**] 09:19PM BLOOD Lipase-98*
[**2195-9-25**] 05:00AM BLOOD Lipase-83*
[**2195-9-28**] 01:30AM BLOOD Lipase-55
[**2195-10-31**] 08:41PM BLOOD Lipase-8
[**2195-11-2**] 02:10AM BLOOD Lipase-6
[**2195-11-8**] 04:16AM BLOOD Lipase-135*
[**2195-11-9**] 04:19AM BLOOD Lipase-382*
[**2195-11-11**] 02:27PM BLOOD Lipase-194*
[**2195-11-12**] 03:30AM BLOOD Lipase-188*
[**2195-11-20**] 01:38PM BLOOD Lipase-71* GGT-448*
[**2195-9-24**] 09:19PM BLOOD ALT-35 AST-65* LD(LDH)-517* AlkPhos-900*
Amylase-36 TotBili-1.6* DirBili-0.6* IndBili-1.0
[**2195-9-25**] 05:00AM BLOOD ALT-26 AST-39 AlkPhos-748* Amylase-34
TotBili-1.5 DirBili-0.8* IndBili-0.7
[**2195-9-25**] 05:32PM BLOOD ALT-33 AST-56* AlkPhos-790* Amylase-35
TotBili-1.5
[**2195-9-27**] 02:41AM BLOOD ALT-26 AST-39 LD(LDH)-212 AlkPhos-457*
Amylase-26 TotBili-1.5
[**2195-9-28**] 01:30AM BLOOD ALT-22 AST-31 LD(LDH)-224 AlkPhos-402*
Amylase-23 TotBili-1.5
[**2195-9-29**] 04:34AM BLOOD ALT-22 AST-34 LD(LDH)-264* AlkPhos-415*
Amylase-23 TotBili-1.6*
[**2195-9-30**] 04:01AM BLOOD ALT-18 AST-28 AlkPhos-379* TotBili-1.4
[**2195-10-1**] 04:01AM BLOOD ALT-17 AST-25 AlkPhos-401* TotBili-1.3
[**2195-10-2**] 01:59AM BLOOD ALT-13 AST-21 AlkPhos-329* TotBili-1.1
[**2195-10-29**] 04:59AM BLOOD ALT-18 AST-32 AlkPhos-352* Amylase-12
TotBili-0.6
[**2195-10-31**] 03:15PM BLOOD ALT-11 AST-20 AlkPhos-89 Amylase-23
TotBili-2.3*
[**2195-11-1**] 03:18AM BLOOD ALT-12 AST-23 AlkPhos-82 Amylase-21
[**2195-11-1**] 07:30AM BLOOD ALT-8 AST-19 AlkPhos-79 TotBili-0.7
[**2195-11-4**] 02:28AM BLOOD ALT-8 AST-15 AlkPhos-243* Amylase-8
TotBili-0.7
[**2195-11-5**] 02:47AM BLOOD ALT-15 AST-36 AlkPhos-563* Amylase-13
TotBili-0.7
[**2195-11-6**] 03:27AM BLOOD ALT-42* AST-65* AlkPhos-642* TotBili-0.9
[**2195-11-11**] 03:08AM BLOOD ALT-35 AST-48* AlkPhos-391* Amylase-74
TotBili-1.4
[**2195-11-11**] 02:27PM BLOOD ALT-45* AST-68* CK(CPK)-10* Amylase-54
TotBili-1.3
[**2195-11-11**] 08:49PM BLOOD CK(CPK)-9*
[**2195-11-15**] 03:17AM BLOOD ALT-34 AST-35 AlkPhos-673* TotBili-0.9
[**2195-11-16**] 04:09AM BLOOD ALT-29 AST-29 AlkPhos-719* Amylase-25
TotBili-0.9
[**2195-11-20**] 01:38PM BLOOD ALT-27 AST-33 AlkPhos-763* Amylase-32
TotBili-0.6
[**2195-9-24**] 09:19PM BLOOD Glucose-104 UreaN-9 Creat-0.6 Na-136
K-4.5 Cl-101 HCO3-24 AnGap-16
[**2195-9-25**] 05:00AM BLOOD Glucose-96 UreaN-8 Creat-0.6 Na-137 K-3.5
Cl-104 HCO3-26 AnGap-11
[**2195-9-25**] 05:32PM BLOOD Glucose-101 UreaN-9 Creat-0.6 Na-135
K-3.5 Cl-102 HCO3-23 AnGap-14
[**2195-9-26**] 02:11AM BLOOD Glucose-78 UreaN-9 Creat-0.6 Na-135
K-3.2* Cl-102 HCO3-25 AnGap-11
[**2195-9-27**] 02:41AM BLOOD Glucose-119* UreaN-7 Creat-0.6 Na-132*
K-2.9* Cl-98 HCO3-28 AnGap-9
[**2195-9-28**] 01:30AM BLOOD Glucose-98 UreaN-7 Creat-0.5 Na-134 K-3.3
Cl-98 HCO3-28 AnGap-11
[**2195-9-29**] 04:34AM BLOOD Glucose-84 UreaN-7 Creat-0.5 Na-134 K-3.5
Cl-96 HCO3-31 AnGap-11
[**2195-9-30**] 04:01AM BLOOD Glucose-85 UreaN-5* Creat-0.5 Na-133
K-3.3 Cl-97 HCO3-30 AnGap-9
[**2195-10-1**] 03:02PM BLOOD Glucose-92 UreaN-5* Creat-0.7 Na-134
K-4.1 Cl-99 HCO3-29 AnGap-10
[**2195-10-2**] 01:59AM BLOOD Glucose-106* UreaN-5* Creat-0.6 Na-136
K-3.5 Cl-101 HCO3-28 AnGap-11
[**2195-10-8**] 06:00AM BLOOD Glucose-103 UreaN-7 Creat-0.5 Na-135
K-3.3 Cl-96 HCO3-31 AnGap-11
[**2195-10-9**] 05:15AM BLOOD Glucose-124* UreaN-8 Creat-0.6 Na-131*
K-3.1* Cl-94* HCO3-31 AnGap-9
[**2195-10-9**] 08:50AM BLOOD Glucose-102 UreaN-7 Creat-0.6 Na-132*
K-3.9 Cl-95* HCO3-30 AnGap-11
[**2195-10-13**] 06:10AM BLOOD K-3.3
[**2195-10-19**] 05:05AM BLOOD Glucose-102 UreaN-4* Creat-0.5 Na-130*
K-3.7 Cl-95* HCO3-25 AnGap-14
[**2195-10-20**] 09:32AM BLOOD Glucose-116* UreaN-6 Creat-0.6 Na-128*
K-3.5 Cl-96 HCO3-26 AnGap-10
[**2195-10-21**] 06:15AM BLOOD Glucose-104 UreaN-5* Creat-0.5 Na-131*
K-3.8 Cl-98 HCO3-26 AnGap-11
[**2195-10-21**] 09:00PM BLOOD Glucose-124* UreaN-5* Creat-0.5 Na-131*
K-3.9 Cl-96 HCO3-25 AnGap-14
[**2195-10-29**] 04:59AM BLOOD Glucose-108* UreaN-6 Creat-0.5 Na-136
K-2.9* Cl-93* HCO3-36* AnGap-10
[**2195-10-31**] 06:00AM BLOOD Glucose-83 UreaN-8 Creat-0.6 Na-136
K-2.8* Cl-92* HCO3-37* AnGap-10
[**2195-10-31**] 03:15PM BLOOD Glucose-89 UreaN-7 Creat-0.5 Na-140
K-2.5* Cl-99 HCO3-29 AnGap-15
[**2195-10-31**] 08:41PM BLOOD Glucose-82 UreaN-8 Creat-0.4* Na-138
K-3.2* Cl-102 HCO3-29 AnGap-10
[**2195-11-1**] 11:09AM BLOOD Glucose-144* UreaN-9 Creat-0.6 Na-134
K-3.7 Cl-101 HCO3-25 AnGap-12
[**2195-11-1**] 05:22PM BLOOD Glucose-104 UreaN-9 Creat-0.7 Na-135
K-4.3 Cl-103 HCO3-23 AnGap-13
[**2195-11-1**] 10:20PM BLOOD Glucose-160* UreaN-10 Creat-0.7 Na-133
K-4.2 Cl-100 HCO3-24 AnGap-13
[**2195-11-2**] 11:57AM BLOOD Glucose-159* UreaN-10 Creat-0.6 Na-132*
K-3.8 Cl-101 HCO3-23 AnGap-12
[**2195-11-2**] 11:57AM BLOOD Glucose-138* UreaN-11 Creat-0.6 Na-135
K-4.0 Cl-101 HCO3-28 AnGap-10
[**2195-11-3**] 01:57AM BLOOD Glucose-132* UreaN-12 Creat-0.6 Na-137
K-3.7 Cl-102 HCO3-28 AnGap-11
[**2195-11-4**] 04:06PM BLOOD Glucose-127* UreaN-18 Creat-0.6 K-4.6
[**2195-11-5**] 02:47AM BLOOD Glucose-163* UreaN-20 Creat-0.6 Na-144
K-3.9 Cl-107 HCO3-32 AnGap-9
[**2195-11-6**] 03:27AM BLOOD Glucose-142* UreaN-25* Creat-0.5 Na-145
K-3.5 Cl-110* HCO3-31 AnGap-8
[**2195-11-6**] 11:30AM BLOOD UreaN-25* Creat-0.4* K-3.5
[**2195-11-6**] 03:01PM BLOOD Glucose-145* K-3.5
[**2195-11-8**] 04:16AM BLOOD Glucose-90 UreaN-23* Creat-0.5 Na-139
K-3.7 Cl-106 HCO3-29 AnGap-8
[**2195-11-8**] 12:21PM BLOOD K-3.5
[**2195-11-9**] 04:19AM BLOOD Glucose-131* UreaN-18 Creat-0.4* Na-137
K-3.9 Cl-106 HCO3-27 AnGap-8
[**2195-11-10**] 02:48PM BLOOD Glucose-122* UreaN-18 Creat-0.4* K-4.4
Cl-107 HCO3-24
[**2195-11-11**] 03:08AM BLOOD Glucose-114* UreaN-19 Creat-0.4* Na-135
K-4.1 Cl-106 HCO3-23 AnGap-10
[**2195-11-11**] 02:27PM BLOOD Glucose-119* UreaN-21* Creat-0.5 Na-134
K-4.0 Cl-106 HCO3-24 AnGap-8
[**2195-11-11**] 08:49PM BLOOD Glucose-105 UreaN-20 Creat-0.4* Na-136
K-3.9 Cl-107 HCO3-23 AnGap-10
[**2195-11-12**] 03:02PM BLOOD Glucose-119* UreaN-16 Creat-0.4* Na-135
K-3.6 Cl-103 HCO3-23 AnGap-13
[**2195-11-13**] 02:42AM BLOOD Glucose-106* UreaN-14 Creat-0.3* Na-134
K-3.9 Cl-103 HCO3-25 AnGap-10
[**2195-11-13**] 03:58PM BLOOD Glucose-87 UreaN-12 Creat-0.3* Na-134
K-4.5 Cl-101 HCO3-27 AnGap-11
[**2195-11-13**] 11:55PM BLOOD Glucose-95 UreaN-11 Creat-0.3* Na-134
K-3.7 Cl-101 HCO3-27 AnGap-10
[**2195-11-15**] 03:17AM BLOOD Glucose-107* UreaN-13 Creat-0.4* Na-135
K-3.7 Cl-96 HCO3-31 AnGap-12
[**2195-11-15**] 10:13AM BLOOD Glucose-139* K-4.0
[**2195-11-15**] 09:00PM BLOOD K-4.3
[**2195-11-18**] 03:37AM BLOOD Glucose-126* UreaN-12 Creat-0.4* Na-132*
K-4.0 Cl-98 HCO3-28 AnGap-10
[**2195-11-18**] 01:17PM BLOOD K-5.0
[**2195-11-20**] 01:38PM BLOOD Glucose-134* UreaN-13 Creat-0.4* Na-134
K-3.9 Cl-100 HCO3-27 AnGap-11
[**2195-11-22**] 05:47PM BLOOD Na-132* K-4.3 Cl-100
[**2195-11-23**] 03:49AM BLOOD UreaN-14 Creat-0.4* K-3.9
[**2195-11-24**] 10:30AM BLOOD K-4.1
[**2195-10-31**] 10:45AM BLOOD Fibrino-340
[**2195-10-31**] 12:00PM BLOOD Fibrino-208
[**2195-10-31**] 01:31PM BLOOD Fibrino-189
[**2195-11-1**] 11:09AM BLOOD Fibrino-266
[**2195-11-1**] 05:22PM BLOOD Fibrino-285
[**2195-11-2**] 02:10AM BLOOD Fibrino-334
[**2195-9-24**] 09:19PM BLOOD PT-14.4* PTT-24.2 INR(PT)-1.4
[**2195-9-25**] 05:00AM BLOOD PT-14.9* PTT-27.1 INR(PT)-1.5
[**2195-9-27**] 02:41AM BLOOD PT-14.3* PTT-32.2 INR(PT)-1.4
[**2195-9-28**] 01:30AM BLOOD PT-13.6* PTT-29.4 INR(PT)-1.2
[**2195-9-28**] 01:30AM BLOOD Plt Ct-381
[**2195-9-29**] 04:34AM BLOOD Plt Ct-480*
[**2195-10-1**] 04:01AM BLOOD Plt Ct-392
[**2195-10-2**] 01:59AM BLOOD Plt Ct-349
[**2195-10-6**] 05:30AM BLOOD Plt Ct-366
[**2195-10-9**] 05:15AM BLOOD Plt Ct-334
[**2195-10-19**] 05:05AM BLOOD Plt Ct-344
[**2195-10-19**] 09:45AM BLOOD PT-15.0* PTT-30.0 INR(PT)-1.5
[**2195-10-24**] 07:48PM BLOOD Plt Ct-322
[**2195-10-25**] 08:35AM BLOOD Plt Ct-282
[**2195-10-26**] 06:15AM BLOOD Plt Ct-267
[**2195-10-27**] 11:00AM BLOOD PT-14.0* PTT-26.6 INR(PT)-1.3
[**2195-10-31**] 10:45AM BLOOD PT-14.0* PTT-30.5 INR(PT)-1.3
[**2195-10-31**] 10:45AM BLOOD Plt Ct-124*
[**2195-10-31**] 11:35AM BLOOD PT-14.5* PTT-32.6 INR(PT)-1.4
[**2195-10-31**] 11:35AM BLOOD Plt Ct-103*
[**2195-10-31**] 01:31PM BLOOD PT-13.9* PTT-30.6 INR(PT)-1.3
[**2195-10-31**] 01:31PM BLOOD Plt Ct-85*
[**2195-10-31**] 03:15PM BLOOD PT-13.8* PTT-31.0 INR(PT)-1.3
[**2195-11-1**] 12:31AM BLOOD PT-15.1* PTT-38.4* INR(PT)-1.5
[**2195-11-1**] 12:31AM BLOOD Plt Ct-88*
[**2195-11-1**] 03:18AM BLOOD PT-14.4* PTT-32.8 INR(PT)-1.4
[**2195-11-1**] 11:09AM BLOOD Plt Ct-129*
[**2195-11-1**] 05:22PM BLOOD PT-15.2* PTT-35.0 INR(PT)-1.5
[**2195-11-1**] 05:22PM BLOOD Plt Ct-125*
[**2195-11-1**] 10:20PM BLOOD PTT-37.6*
[**2195-11-2**] 11:57AM BLOOD PT-15.3* PTT-39.8* INR(PT)-1.6
[**2195-11-2**] 11:57AM BLOOD Plt Ct-95*
[**2195-11-4**] 02:28AM BLOOD Plt Ct-100*
[**2195-11-4**] 04:06PM BLOOD PT-14.0* PTT-32.4 INR(PT)-1.3
[**2195-11-5**] 02:47AM BLOOD Plt Ct-125*
[**2195-11-6**] 03:27AM BLOOD PT-14.0* PTT-26.2 INR(PT)-1.3
[**2195-11-8**] 04:16AM BLOOD PT-15.3* PTT-28.3 INR(PT)-1.6
[**2195-11-8**] 04:16AM BLOOD Plt Ct-137*
[**2195-11-11**] 03:08AM BLOOD PT-13.9* PTT-29.4 INR(PT)-1.3
[**2195-11-11**] 03:08AM BLOOD Plt Ct-192
[**2195-11-12**] 03:30AM BLOOD Plt Ct-196
[**2195-11-13**] 02:42AM BLOOD PT-14.0* PTT-28.5 INR(PT)-1.3
[**2195-11-15**] 03:17AM BLOOD PT-14.2* PTT-28.0 INR(PT)-1.4
[**2195-11-15**] 03:17AM BLOOD Plt Ct-290
[**2195-11-20**] 01:38PM BLOOD Plt Ct-278
[**2195-11-23**] 03:49AM BLOOD Plt Ct-318
[**2195-9-24**] 09:19PM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-OCCASIONAL Polychr-NORMAL Target-1+
Envelop-1+
[**2195-10-29**] 04:59AM BLOOD Hypochr-1+ Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL
Polychr-OCCASIONAL Schisto-OCCASIONAL
[**2195-11-12**] 03:30AM BLOOD Poiklo-1+
[**2195-9-24**] 09:19PM BLOOD Neuts-90.0* Bands-0 Lymphs-8.3*
Monos-1.5* Eos-0.1 Baso-0.1
[**2195-10-19**] 05:05AM BLOOD Neuts-80.2* Lymphs-13.8* Monos-4.9
Eos-1.0 Baso-0.1
[**2195-10-29**] 04:59AM BLOOD Neuts-83* Bands-2 Lymphs-7* Monos-4 Eos-3
Baso-0 Atyps-1* Metas-0 Myelos-0
[**2195-11-6**] 03:27AM BLOOD Neuts-84.5* Lymphs-9.5* Monos-5.9 Eos-0
Baso-0.1
[**2195-11-11**] 02:27PM BLOOD Neuts-89* Bands-6* Lymphs-2* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2195-11-12**] 03:30AM BLOOD Neuts-86.8* Lymphs-7.0* Monos-3.9 Eos-2.1
Baso-0.2
[**2195-11-16**] 04:09AM BLOOD Neuts-80.6* Lymphs-12.1* Monos-5.1
Eos-2.0 Baso-0.2
[**2195-9-25**] 05:00AM BLOOD WBC-16.7* RBC-4.03* Hgb-10.6* Hct-32.4*
MCV-80* MCH-26.2* MCHC-32.6 RDW-17.1* Plt Ct-321
[**2195-9-25**] 05:32PM BLOOD WBC-23.6* RBC-4.01* Hgb-10.6* Hct-32.9*
MCV-82 MCH-26.3* MCHC-32.1 RDW-17.0* Plt Ct-352
[**2195-9-26**] 02:11AM BLOOD WBC-26.7* RBC-3.98* Hgb-10.5* Hct-32.1*
MCV-81* MCH-26.5* MCHC-32.8 RDW-17.0* Plt Ct-348
[**2195-9-27**] 02:41AM BLOOD WBC-21.8* RBC-3.61* Hgb-9.4* Hct-29.0*
MCV-80* MCH-26.1* MCHC-32.5 RDW-17.4* Plt Ct-347
[**2195-9-27**] 09:32AM BLOOD Hct-32.9*
[**2195-9-28**] 01:30AM BLOOD WBC-20.9* RBC-3.80* Hgb-10.1* Hct-30.5*
MCV-80* MCH-26.5* MCHC-32.9 RDW-17.2* Plt Ct-381
[**2195-9-29**] 04:34AM BLOOD WBC-18.2* RBC-3.74* Hgb-9.8* Hct-29.8*
MCV-80* MCH-26.2* MCHC-32.9 RDW-17.2* Plt Ct-480*
[**2195-9-30**] 04:01AM BLOOD WBC-22.8* RBC-3.83* Hgb-10.1* Hct-31.4*
MCV-82 MCH-26.3* MCHC-32.1 RDW-17.1* Plt Ct-445*
[**2195-10-1**] 04:01AM BLOOD WBC-21.2* RBC-3.44* Hgb-8.9* Hct-28.4*
MCV-83 MCH-25.9* MCHC-31.3 RDW-17.4* Plt Ct-392
[**2195-10-8**] 06:00AM BLOOD WBC-19.7* RBC-3.32* Hgb-9.0* Hct-27.2*
MCV-82 MCH-27.1 MCHC-33.1 RDW-16.0* Plt Ct-351
[**2195-10-9**] 05:15AM BLOOD WBC-14.8* RBC-3.11* Hgb-8.4* Hct-25.8*
MCV-83 MCH-27.0 MCHC-32.5 RDW-16.2* Plt Ct-334
[**2195-10-11**] 11:35AM BLOOD WBC-16.4* RBC-3.09* Hgb-8.2* Hct-25.3*
MCV-82 MCH-26.4* MCHC-32.2 RDW-15.9* Plt Ct-342
[**2195-10-12**] 05:23AM BLOOD WBC-15.2* RBC-3.15* Hgb-8.2* Hct-26.2*
MCV-83 MCH-26.0* MCHC-31.2 RDW-16.1* Plt Ct-364
[**2195-10-20**] 09:32AM BLOOD WBC-13.2* RBC-2.87* Hgb-7.9* Hct-24.0*
MCV-84 MCH-27.7 MCHC-33.0 RDW-16.8* Plt Ct-350
[**2195-10-21**] 06:15AM BLOOD WBC-13.0* RBC-3.33* Hgb-9.1* Hct-28.9*
MCV-87 MCH-27.3 MCHC-31.5 RDW-16.3* Plt Ct-343
[**2195-10-21**] 09:00PM BLOOD WBC-11.9* RBC-3.46* Hgb-9.5* Hct-29.8*
MCV-86 MCH-27.5 MCHC-32.0 RDW-16.3* Plt Ct-347
[**2195-10-26**] 06:15AM BLOOD WBC-12.5* RBC-3.02* Hgb-8.3* Hct-25.9*
MCV-86 MCH-27.7 MCHC-32.3 RDW-17.1* Plt Ct-267
[**2195-10-27**] 06:00AM BLOOD WBC-9.4 RBC-3.30* Hgb-9.3* Hct-28.5*
MCV-86 MCH-28.1 MCHC-32.5 RDW-16.7* Plt Ct-247
[**2195-10-28**] 10:32AM BLOOD WBC-12.4* RBC-3.76* Hgb-10.7* Hct-32.2*
MCV-86 MCH-28.4 MCHC-33.1 RDW-16.2* Plt Ct-202
[**2195-10-31**] 03:15PM BLOOD WBC-11.2* RBC-3.87* Hgb-11.7* Hct-32.3*
MCV-84 MCH-30.1 MCHC-36.1* RDW-15.1 Plt Ct-136*#
[**2195-10-31**] 08:41PM BLOOD WBC-15.3* RBC-3.65* Hgb-10.9* Hct-30.6*
MCV-84 MCH-29.7 MCHC-35.5* RDW-15.3 Plt Ct-119*
[**2195-11-1**] 10:20PM BLOOD WBC-28.9* RBC-3.74* Hgb-11.2* Hct-32.8*
MCV-88 MCH-29.8 MCHC-34.1 RDW-16.3* Plt Ct-124*
[**2195-11-2**] 02:10AM BLOOD WBC-31.0* RBC-3.86* Hgb-11.5* Hct-33.5*
MCV-87 MCH-29.9 MCHC-34.5 RDW-16.2* Plt Ct-130*
[**2195-11-2**] 11:57AM BLOOD WBC-27.3* RBC-3.53* Hgb-10.9* Hct-30.9*
MCV-88 MCH-30.8 MCHC-35.2* RDW-16.2* Plt Ct-96*
[**2195-11-5**] 02:47AM BLOOD WBC-11.5* RBC-3.49* Hgb-10.2* Hct-32.2*
MCV-92 MCH-29.1 MCHC-31.6 RDW-15.9* Plt Ct-125*
[**2195-11-6**] 03:27AM BLOOD WBC-9.4 RBC-3.50* Hgb-10.3* Hct-32.7*
MCV-93 MCH-29.4 MCHC-31.4 RDW-15.7* Plt Ct-117*
[**2195-11-7**] 04:24AM BLOOD WBC-8.7 RBC-3.35* Hgb-9.9* Hct-31.7*
MCV-95 MCH-29.6 MCHC-31.3 RDW-15.8* Plt Ct-130*
[**2195-11-8**] 04:16AM BLOOD WBC-13.2* RBC-3.40* Hgb-10.2* Hct-31.9*
MCV-94 MCH-30.0 MCHC-32.0 RDW-15.9* Plt Ct-137*
[**2195-11-9**] 04:19AM BLOOD WBC-16.4* RBC-3.27* Hgb-9.8* Hct-29.9*
MCV-91 MCH-29.9 MCHC-32.7 RDW-15.9* Plt Ct-138*
[**2195-11-10**] 04:59AM BLOOD WBC-17.0* RBC-2.79* Hgb-8.4* Hct-25.8*
MCV-92 MCH-30.3 MCHC-32.7 RDW-16.3* Plt Ct-166
[**2195-11-11**] 08:49PM BLOOD WBC-16.2* RBC-2.98* Hgb-9.1* Hct-27.2*
MCV-91 MCH-30.4 MCHC-33.3 RDW-15.8* Plt Ct-187
[**2195-11-12**] 03:30AM BLOOD WBC-15.4* RBC-3.21* Hgb-9.9* Hct-29.7*
MCV-92 MCH-30.7 MCHC-33.3 RDW-15.7* Plt Ct-196
[**2195-11-13**] 02:42AM BLOOD WBC-17.8* RBC-3.00* Hgb-9.1* Hct-27.7*
MCV-92 MCH-30.5 MCHC-33.0 RDW-15.6* Plt Ct-232
[**2195-11-14**] 06:03PM BLOOD WBC-15.8* RBC-3.02* Hgb-9.1* Hct-27.8*
MCV-92 MCH-30.2 MCHC-32.7 RDW-15.1 Plt Ct-303
[**2195-11-15**] 03:17AM BLOOD WBC-13.9* RBC-2.89* Hgb-8.6* Hct-26.7*
MCV-92 MCH-29.9 MCHC-32.4 RDW-15.0 Plt Ct-290
[**2195-11-16**] 04:09AM BLOOD WBC-14.0* RBC-3.35* Hgb-10.1* Hct-30.3*
MCV-91 MCH-30.1 MCHC-33.3 RDW-15.6* Plt Ct-301
[**2195-11-20**] 01:38PM BLOOD WBC-13.3* RBC-3.53* Hgb-10.4* Hct-32.1*
MCV-91 MCH-
29.5 MCHC-32.4 RDW-14.8 Plt Ct-278
[**9-25**] CT A/P - Gross intraabdominal inflammatory changes as
described above. The appearances are more suggestive of gross
inflammatory change possibly with areas of fat necrosis than
fluid collection which is amenable to percutaneous drainage.
Proximity to the upper right colon would raise the possibility
at least of prior colonic injury. A delayed CT scan could be
obtain to evaluate the right colon with oral contrast.
2. Low-density area in the lateral subcapsular aspect of the
previous
resection with no residual fluid attenuating biloma in the
region of the
pigtail catheter.
3. There are small bibasilar pleural effusions. The right chest
drain lies
above the remaining fluid.
4. Number of subcentimeter hypodensities in the liver which are
indeterminate.
[**9-29**] CT A/P - Interval reduction in size of the component of the
collection recently drained in the right posterolateral
retroperitoneum and subcutaneous tissues.
2. There persists multiloculated low density
collections/phlegmon in the
inferior midline retroperitoneum, left posterior inferior
retroperitoneum and superior left pelvis.The largest collection
in the right upper quadrant extends anteroinferiorly from the
region of the pancreatic head. This collection contains several
air locules which may be due to communication with recently
drained component or possibly sepsis.
3. Small amount of intra-abdominal ascites, slightly larger in
the interval.
4. Small bibasilar pleural effusions and minor bibasilar
atelectasis,
unchanged.
[**10-2**] CT A/P -Mild interval reduction in size of the
multiloculated collections within the mesentry and
retroperitoneum as described.
2. Two dominant areas that may be amenable to additional
percutaneous
drainage, one located in the right upper quadrant just inferior
to the
pancreatic head and the other, a fluid attenuating locule
measuring up to 5 cm in the left retroperitoneum anterior to the
site of recent pigtail catheter insertion.
3. Bibasilar lung effusion and posterior basilar atelectasis
unchanged. Mild interval reduction in the amount of
intraabdominal ascites
[**10-4**] CTA - 1) Study limited by suboptimal contrast bolus but
there is no major central pulmonary embolism.
2) Small, new left-sided pneumothorax. Phoned to Dr. [**Last Name (STitle) 43107**].
3) Bilateral pleural effusions/atelectasis, slightly increased
compared to the prior study.
4) Pigtail catheter in the area of the hepatic resection with
surrounding
inflammatory changes is not significantly changed.
[**10-7**] Cytology reportsHighly atypical cells present suspicious
for malignancy
[**10-9**] Hepatic US - No evidence of a hepatic fluid collection.
2. Echogenic liver suggestive of fatty infiltration. More
advanced liver
disesase and other types of liver disease, including
cirrhosis/fibrosis,
cannot be excluded by ultrasound in the presence of fatty
infiltration.
3. Moderate ascites
[**10-14**] CT A/P - . Persistent complex collection in the right upper
quadrant posteriorly just inferior to the pancreatic head that
has not been drained by the previously inserted right
percutaneous catheter. Following discussion with Dr. [**Last Name (STitle) 468**],
this collection was subsequently drained with a percutaneous
catheter.
2. The other components of these collections more inferiorly in
the right
posterior abdomen, midline retroperitoneum, and superior left
pelvis are
stable in the interval. No residual collection adjacent to the
left lower
abdominal catheter tip, this was subsequently removed.
3. Moderate amount of intra-abdominal ascites.
4. Moderate left basal pleural effusion and some atelectasis of
the dependent left lower lobe. A small right basal pleural
effusion
[**10-17**] CT A/P - Modest interval decrease in size of
infrapancreatic collection following percutaneous catheter
placement. Otherwise, unchanged appearance of multiple
intraabdominal fluid collections.
2. Unchanged mild-to-moderate ascites.
3. Persistent moderate bilateral pleural effusions, left greater
than right, with compressive atelectasis of the left lower lobe
[**10-20**] Left pleural tissue-Fibroadipose tissue and fibrous
connective tissue with focal chronic inflammation and
fibroblastic proliferation.
2. Unremarkable skeletal muscle.
3. No evidence of malignancy
[**10-21**] CT A/P-No evidence of pulmonary embolism.
2. Moderate-sized left-sided pneumothorax.
3. Significant change in the complex collection in the right
upper quadrant posteriorly just inferior to the pancreatic head
as well as the surgical site of hepatic resection.
4. Interval increase in the amount of ascites.
5. Stable small bilateral pleural effusions.
[**10-25**] CT A/P -Three pigtail catheters and a Penrose drain within
four stable-appearing abscess collections, as described above.
2. Injection of the inferiormost drain demonstrates
communication with the
right colon. This catheter is in very close proximity to the
bowel wall and may or may not perforate the colonic wall itself.
3. Interval increase in the size of the subcutaneous abscess
located between the middle and inferior pigtail catheter entry
sites.
4. Large amount of free fluid, unchanged from prior exam
[**10-25**] Fluroscopy Abd - Filling of the ascending colon upon
injection of the inferior pigtail catheter. This catheter is in
very close proximity to the ascending colon. It cannot be
determined if this catheter has actually perforated the colonic
wall.
2. No filling of the superficial abscess collection to suggest
communication the peritoneal abscesses.
3. Injection of the middle and superior pigtail catheters
demonstrating the peritoneal abscess collections seen on CT scan
[**10-27**] CT A/P - Catheter exchange and repositioning into the right
lateral
subdiaphragmatic/perihepatic collection. There is now 12 French
catheter in situ and aspiration yielded 25 cc of purulent
material.
2. Paracentesis drained 2500 mL of serous ascites
[**10-31**] Path - Ileocolectomy and colon segment (A-Q):
1. Organizing fat necrosis and hemorrhage, around the cecum and
separate segment of colon. The ileal segment colonic mucosa are
free of disease.
There is no tumor.
II. Necrotic abdominal tissue (R):
1. Necrotic tissue.
2. No tumor.
[**11-6**] RUQ US - Limited study. No evidence of biliary ductal
dilatation
[**11-9**] CT A/P - New bilateral pleural effusions with adjacent
atelectasis.
2. Resolution of the right subcutaneous abscess and collection
in the
bed. Decrease in the amount of the free fluid within the
abdomen.
3. Overall decrease in the collection in the mesentery and left
pelvis.
Decrease in size in the subcutaneous left collection.
4. No new collections were seen
[**11-10**] US [**Doctor First Name 11929**] LE - No evidence for deep vein thrombosis.
[**11-27**] CT A/P - Stable residual small collections/inflammatory
phlegmon in the right posterior retroperitoneum and left
posteroinferior retroperitoneum as described. One of the small
left posterior pelvic collections is smaller in the interval. No
new collections are demonstrated. Surgically placed catheter
remain in good position.
2. Biloma drain in good position. A small (2.5 cm) lentiform
hypodensity
adjacent to the catheter tip.
3. Small amount of residual intra-abdominal ascites.
4. Open midline laparotomy wound without associated collection
on CT.
5.Small bibasilar effusions with associated dependent
atelectasis
[**12-15**] CT A/P - Overall interval improvement compared to recent
study of [**2195-11-27**], including almost complete resolution
of intraabdominal ascites and improvement at the lung bases.
2. Some residual phlegmon located mainly in the right posterior
retroperitoneum, lower preaortic and left posterior inferior
retroperitoneal regions is mostly stable compared to the prior
CT. Small (4 x 2 cm) fluid- attenuating locule in the right
upper quadrant at the site of previous drain tip.
3. Small bibasilar pleural effusions and minor atelectasis in
the dependent lung bases.
[**12-22**] - bile duct stent was negative for malignant cells
[**12-22**] ERCP - A fistulotomy site was noted above the orifice of
major papilla. 2. The biliary stent was noted to have migrated
into the bile duct. 3. The common bile duct, common hepatic
duct, residual intrahepatic ducts were filled with contrast and
appeared normal. The course and caliber of the structures are
normal with no evidence of extrinsic compression, no ductal
abnormalities, no leak, and no filling defects.
4. The biliary stent could not be removed on balloon sweep of
the bile duct. Therefore, a Sohendra stent remover was used to
retrieve the migrated biliary stent from the bile duct into the
duodenum. A snare was used to remove the biliary stent
[**12-23**] KUB- No evidence of free air or retroperitoneal air
[**12-25**] CT A/P - Minor residual localised fluid-attenuating
collection (likely small biloma measuring less than 3.1 cm AP x
1.4 cm transverse) at the hepatic resection site/ pigtail [**Last Name (un) **]
site (most of which was even present pre- [**Last Name (un) **] removal.
2. Small residual hypoattenuating collections and associated
phlegmon in the retroperitoneum are stable.
3. Minor bibasilar pleural effusion and bibasilar posterior
atelectasis.
Minimal ascitic fluid in the right upper quadrant
Brief Hospital Course:
The patient was admiited to the [**Hospital1 18**] SICU on [**2195-9-24**] as a
transfer from Bombay. He presented with a right chest tube
draining a pleural effusion. He had a right pigtail catheter
draining a biliary leak in his abdomen. He was started on
Meropenem, Vancomycin, and Caspofungin empirically. A CT scan
on hospital day two demonstrated findings more suggestive of
gross inflammatory change (possibly with areas of fat necrosis)
than a fluid collection which is amenable to percutaneous
drainage. The proximity to the upper right colon raised the
possibility at least of prior colonic injury. It also showed a
low-density area in the lateral subcapsular aspect of the
previous resection with no residual fluid attenuating previous
biloma in the region of the pigtail catheter. In additon, there
were small bibasilar pleural effusions. That day, he underwent
an exploration of the retroperitoneal area with drainage of
retroperitoneal and intra-abdominal abscesses via a flank
approach.
This operation was performed by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**]. The objective
of this operation was to determine whether or not we could
maximize drainage out through the flank and whether or not we
could get further control of the retroperitoneal sepsis. The
patient suffered no overt blood loss during the procedure and
was taken back directly to the surgical intensive care unit
stable. His chest tube was removed in the operating room. The
patient spiked a fever to 102.5 on postoperative day one. Tube
feeds were started. Tube feeds were held postoperative day
three due to postoperative ileus. He was started on Zosyn for
Pseudomonas which grew from his abscess culture. Meropenem was
discontinued. A CT on postoperative day four showed interval
reduction in size of the component of the collection recently
drained in the right posterolateral retroperitoneum and
subcutaneous tissues. However, there were persistent
multiloculated low density collections/phlegmon in the inferior
midline retroperitoneum, left posterior inferior retroperitoneum
and superior left pelvis. The largest collection in the right
upper quadrant extends anteroinferiorly from the region of the
pancreatic head. This collection contains several air locules
which may be due to communication with recently drained
component or possibly sepsis. Following those results, a
percutaneous pigtail catheter was inserted into the largest
collection in the right upper quadrant (12 French) and 10 French
pigtail catheter was inserted into the posterior left
retroperitoneal collection. Samples sent for culture. On
postoperative day five, tube feeds were resumed. He tolerated
clears. A CT scan from postoperative day seven demonstrated a
mild interval reduction in size of the multiloculated
collections within the mesentry and retroperitoneum. It also
showed two dominant areas that may be amenable to additional
percutaneous drainage, one located in the right upper quadrant
just inferior to the pancreatic head and the other, and a fluid
attenuating locule measuring up to 5 cm in the left
retroperitoneum anterior to the site of recent pigtail catheter
insertion. In addition, it showed bibasilar lung effusion and
posterior basilar atelectasis unchanged. Mild interval reduction
in the amount of intraabdominal ascites. He then had CT guided
drainage of his left lower retroperitonela collection. On
postoperative day eight, one of his drains "fell out."
Vancomycin was discontinued. He was transferred to the floor.
On postoperative day nine, a CT ruled out a pulmonary embolism,
however there were bilateral pleural effusions/atelectasis,
slightly increased compared to the prior study. On
postoperative day ten, he was transfused one unit of RBCs for
anemia of chronic disease. A CT scan from postoperative day
eleven showed that the intra-abdominal and retroperitoneal
collections were marginally smaller in the interval. The
collection from the lower left retroperitoneal area from which
the drainage catheter has displaced is smaller compared to
previous imaging. There was a recurring biloma in the right
subdiaphragmatic space, moderate left basal pleural effusion
which has enlarged in the interval, and a mderate amount of
intra-abdominal ascites, unchanged. In addition, under the
supervision of the thoracic surgery service, using
CT-fluoroscopic guidance and a right lateral intercostal
approach, a 22- gauge Chiba needle was advanced into the
collection in the right subdiaphragmatic space. Aspiration
yielded yellow bile, a sample of which has been sent for
biochemical and microbiological analysis. Using a coaxial
technique parallel to this needle, a 10 French multipurpose
pigtail catheter was inserted into the collection. Tip placement
was confirmed by CT and initial aspiration yielded 30 cc of
bile. Following this, 250 mL of serous ascites was drained from
the ascitic fluid along the left flank following aseptic
technique and local analgesia. Sample of the ascites was also
sent for microbiological culture. Postoperative day fourteen,
the patient toleated a regular diet. He was febrile to 102.3.
An ultrasound showed no evidence of a hepatic fluid collection,
and an echogenic liver suggestive of fatty infiltration. More
advanced liver disesase and other types of liver disease,
including cirrhosis/fibrosis, could not be excluded by
ultrasound in the presence of fatty infiltration. On
postoperative day fifteen, his central venous line was changed
over a wire. Tube feeds continued to run. Linezolid was
started for VRE in his abscess. Caspofungin was discontinued.
He complained of spigastric discomfort and dysphagia, so
nasogastric suction was resumed. His diet was resumed
postoperative day sixteen. Lasix was started for peripheral
edema on postoperative dy seventeen. His NG tube was removed on
postoperative day eighteen. A CT scan from postoperative day
nineteen showed a persistent complex collection in the right
upper quadrant posteriorly just inferior to the pancreatic head
that has not been drained by the previously inserted right
percutaneous catheter. Following discussion with Dr. [**Last Name (STitle) 468**],
this collection was subsequently drained with a percutaneous
catheter (Using CT fluoroscopic guidance, a 22-gauge Chiba
needle was advanced into the remaining collection in the
posterior right upper quadrant collection using a right lateral
approach. This collection is located just cranial to the one
previously drained percutaneously just inferiorly. Initial
aspiration yielded purulent material, a sample of which is being
sent for analysis. Using coaxial technique, a 10 French
multipurpose pigtail catheter was advanced into this collection.
The formed tip was confirmed within the collection. Initial
aspiration yielded 30 cc of purulent material. The abscess
cavity was irrigated with sterile saline). The other components
of these collections more inferiorly in the right posterior
abdomen, midline retroperitoneum, and superior left pelvis were
stable in the interval. No residual collection adjacent to the
left lower abdominal catheter tip, this was subsequently
removed. There was a Moderate amount of intra-abdominal ascites,
along with moderate left basal pleural effusion and some
atelectasis of the dependent left lower lobe, and a small right
basal pleural effusion. On postoperative day twenty two, a CT
scan showed modest interval decrease in size of infrapancreatic
collection following percutaneous catheter placement. Otherwise,
unchanged appearance of multiple intraabdominal fluid
collections and persistent moderate bilateral pleural effusions,
left greater than right, with compressive atelectasis of the
left lower lobe. On postoperative day twenty five, Dr. [**First Name (STitle) 4667**]
[**Doctor Last Name **] performed a bonchoscopy and left pleuroscopy with pleural
drainage and pleural
biopsy. The biopsy was negative for malignancy. A left
subclavian line was placed. On postoperative day 26/1, a CT
scan showed no evidence of pulmonary embolism, moderate-sized
left-sided pneumothorax, significant change in the complex
collection in the right upper quadrant posteriorly just inferior
to the pancreatic head as well as the surgical site of hepatic
resection, interval increase in the amount of ascites, and
stable small bilateral pleural effusions. On postoperative day
30/5, an abdominal son[**Name (NI) **] with fluoroscopy showed filling of
the ascending colon upon injection of the inferior pigtail
catheter. It could not be determined if this catheter has
actually perforated the colonic wall. There was no filling of
the superficial abscess collection to suggest communication the
peritoneal abscesses. There was injection of the middle and
superior pigtail catheters demonstrating the peritoneal abscess
collections seen on CT scan. A CT scan from that same day
showed three pigtail catheters and a Penrose drain within four
stable-appearing abscess collections. Injection of the
inferiormost drain demonstrates communication with the right
colon. This catheter is in very close proximity to the bowel
wall and may or may not perforate the colonic wall itself.
There was an interval increase in the size of the subcutaneous
abscess located between the middle and inferior pigtail catheter
entry sites. There was also a large amount of free fluid,
unchanged from prior exam. On postoperative day 31/6, there was
successful therapeutic paracentesis of approximately 1.6 liters
of ascites. On postoperative day 32/7, the ICU team performed a
CT guided catheter exchange and repositioning into the right
lateral subdiaphragmatic/perihepatic collection. A new 12 French
catheter was placed in situ and aspiration yielded 25 cc of
purulent material. Paracentesis drained 2500 mL of serous
ascites. In addition, there was successful placement of a
post-pyloric feeding tube and tube feeds were started. This
tube fell out and was successfully replaced on postoperative day
35/10.
On postoperative day 36/11, the following operations were
performed by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**]: 1. Extended right colectomy with
end ileostomy and mucous fistula. 2. Drainage of liver abscess.
3. Peripancreatic necrosectomy 4. Drainage of retroperitoneal
abscess. 5. Feeding jejunostomy tube placement. This operation
was performed because we did not have sufficient control of this
sources of sepsis. Tis operation was well tolerated. On
postoperative day two, an echocardiogram showed a dilated left
atrium, with overall left normal left ventricular systolic
function (LVEF 50-55%). An ultrasound from postoperative day six
showed no evidence of biliary ductal dilatation. To update the
patient's ICU condition, on postoperative day seven ([**2195-11-7**]),
the patient was sedated on Lorazepam with Fentanyl for pain.
Clonidine was added. He did not require pressors and in fact he
was on Metoprolol for control of tachycardia. He was intubated
on pressure support. He was tolerating tube feeds. His TPN was
being weaned. Lasix was used to get the patient two liters
negative. He was on Meropenem (18), Linezolid (27), Ceftazidime
(8), and Caspofungin (1). His temperature was 103 despite these
antibiotics. His white blood cell count was 13.2. Ceftazidime
was stopped and Aztreonam was started on postoperative day
eight. A CT scan from postoperative day nine demonstrated new
bilateral pleural effusions with adjacent atelectasis,
resolution of the right subcutaneous abscess and collection,
decrease in the amount of the free fluid within the abdomen,
overall decrease in the collection in the mesentery and left
pelvis, and decrease in size in the subcutaneous left
collection. His TPN was stopped postoperative day ten. His
central venous line was changed over a wire. On postoperative
day thirteen, Caspofungin was discontinued. Meropenem was
changed to Imipenem. He was extubated on postoperative day
fifteen. A swallow evaluation on postoperative day sixteen
suggested advancing diet to oral liquids, which we did and which
was tolerated by the patient, although his intake was minimal.
Aztreonam was discontinued. His abdominal wound was debrided at
the bedside by Dr. [**Last Name (STitle) 468**] on postoperative day seventeen. Tube
feeds were running at goal on postoperative day eighteen. His
Lasix drip was weaned. On postoperative day twenty, his left
arterial line was changed over a wire. Lasix was stopped
postoperative day twenty four. His Foley was discontinued. He
was transferred to the floor in good condition (afebrile with
stable vital signs). Linezolid was discontinued on
postoperative day twenty five. His wound was debrided at the
bedisde by Dr. [**Last Name (STitle) **].
On POD61/26 patient had tube feeds cycled, to encourage PO
intake during the day. Calorie counts were instituted by
nutrition to follow the patient's nutritional intake on a daily
basis. Patient continued on imipenem as long as drains were
still in the patient, with NS wet to dry wound care for his
abdominal wound that continued to granulate inward. The patient
remained afebrile during the next several days of
hospitalization, as his tube feed nutrition was optimized, PO
intake encouraged, and wet-to-dry dressing changes for the
abdominal wound continued. Imipenem was discontinued on POD
69/34, and Physical therapy began to work with the patient
during this time to improve his mobility and regain strength and
endurance. On POD 73/38, patient had wound vac placed on
abdominal wound to speed granulation and epithelialization of
wound. The vac appeared to be operating appropriately, until
drainage consistent with that of the patient's jp site was
noticed to drain from the right lateral flap of the abdominal
wound, and the decision was made to discontinue its usage, and
NS dressing changes were resumed. Out of concern for the
drainage, a CT was obtained that showed a questionable fistulous
collection between the RUQ JP site and the skin, though overall
the CT scan showed interval improvement in ascites and fluid
collections. The patient continued aforementioned hospital
course with decreased TF as PO intake improved, and noted
improvement in drainage from right lateral wound edge, while
remaining afebrile. The last JP began to be removd on [**12-17**], as
it was advanced from insertion site 4 inches. Patient discharge
planning discussions were initiated, and it was determined that
the patient would be discharged to a fellow physicians home,
where the patient would care for much of his own dressings. The
JP was again advanced on POD 84/49, where it was also determined
that the patients biliary stent placed in [**Country 11150**] would need to be
removed prior to patient's discharge from this hospital. ERCP
was consulted, and on POD 86/51, patient underwent ERCP with
biliary stent removal by Dr. [**Last Name (STitle) **]. The patient had some pain
following the procedure that was well-controlled by a single SC
injection of dilaudid without further complications. The patient
did have a febrile episode to 101.7 on POD 87/52 for which
patient was started back on imipenem. A repeat CT scan was
obtained on [**12-25**] which was negative for acute processes, and
showed interval improvement from the scan on [**12-15**]. Imipenem was
discontinued on [**12-24**] and patient persisted with low-grade
fevers into [**12-27**]. Patient was discharged on [**12-27**] and will
follow up with Dr. [**Last Name (STitle) 468**].
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Metoprolol Tartrate 25 mg Tablet Sig: 2.5 Tablets PO BID (2
times a day).
Disp:*150 Tablet(s)* Refills:*2*
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
6. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day
for 2 weeks.
Disp:*42 Tablet(s)* Refills:*0*
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*1*
9. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime)
as needed.
Disp:*30 Tablet(s)* Refills:*0*
10. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
12. Polyvinyl Alcohol 1.4 % Drops Sig: Two (2) Ophthalmic
twice a day: 2 drops to affected eye PRN .
Disp:*2 bottles* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Intrahepatic cholangiocarcinoma
Discharge Condition:
Stable
Discharge Instructions:
Please return to hospital ER for fever greater than 101.4, for
increasing abdominal pain, worsening nausea/vomiting, inability
to maintain PO intake, or signs of wound infection: increasing
redness, swelling, tenderness, warmth, or purulent drainage
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 468**] in 2 weeks. Please call
[**Telephone/Fax (1) 476**] to schedule an appointment.
Completed by:[**2195-12-27**] Name: [**Known lastname **],[**Known firstname 11286**] Unit No: [**Numeric Identifier 11287**]
Admission Date: [**2195-9-24**] Discharge Date: [**2195-12-30**]
Date of Birth: [**2140-9-28**] Sex: M
Service: SURGERY
Allergies:
Amphotericin B
Attending:[**First Name3 (LF) 4987**]
Addendum:
On day of intended discharge, the patient was febrile to 101.6.
However, his fever resolved within two days with antibiotics.
He will be discharge in fair and stable condition.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 136**] Homecare
[**Name6 (MD) 116**] [**Last Name (NamePattern4) 4988**] MD [**MD Number(1) 4989**]
Completed by:[**2195-12-30**]
|
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icd9cm
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[
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[
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icd9pcs
|
[
[
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53058, 53259
|
34870, 50449
|
404, 1009
|
52034, 52043
|
3023, 34847
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|
2472, 2489
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51979, 52013
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52067, 52318
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2504, 3004
|
235, 366
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1037, 2387
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2409, 2423
|
2439, 2456
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,909
| 132,817
|
34910
|
Discharge summary
|
report
|
Admission Date: [**2135-12-23**] Discharge Date: [**2135-12-28**]
Date of Birth: [**2054-1-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4611**]
Chief Complaint:
Serial HCT monitoring, Status Post Mechanical Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is an 81 year-old male with history of metastatic
prostate cancer (followed by Dr. [**Last Name (STitle) **] on Docetaxel, DVT on
coumadin, CKD (baseline Cr 1.7) presenting with left flank pain,
epigastric pain, and worsening fatigue after sliding down 5
stairs at home yesterday. The patient reports that he was
walking up a flight of stairs in his home on the day prior to
admission when he suddenly slipped, falling on his left side.
Denies LOC or head strike. He denies any preceding symptoms
including SOB, CP, dizziness, lightheadedness, unilateral
weakness or numbness. He remained on the ground for
approximately one hour until his tenant helped him to his feet.
He was able to climb the stairs with the assistance of his
tenant, in an effort to reach his bedroom.
.
The following morning, the patient reports increased pain in his
epigastrum, left flank, and LLE. He states that he has had
ongoing pain in these regions for months, however he notes an
exacerbation in the pain since the fall. Of note, the patient
initiated chemo with docetaxel on [**2135-12-15**]. The patient notes
worsening fatigue since initiation of the chemotherapy. He was
transfused 1U PRBC on [**12-20**] for wrosening anemia.
.
In the ED inital vitals were 98.1 88 128/59 16 (unable to get an
O2 sat). The patient underwent CT torso, which showed hemorrhage
in large left renal cyst, abdominal free fluid (not evidence of
hemoperitoneum), and fractures of left 7th-11th ribs. Plain
films of femur, knee, elbow and shoulder did not reveal any
acute fractures. Surgery evaluated patient and felt that there
was no acute surgical issue. Hemorrhage into renal cyst appeared
contained per their report. He received Albuterol, ipratropium,
acetaminophen and 5mg of morphine. The patient was given 1U
PRBCs, and an additional unit was hanging at the time of
transfer. Vitals at the time of transfer were: 173/76 96 98% RA.
.
On arrival to the ICU, the patient reports continued pain in his
left leg and left flank.
.
Past Medical History:
Past Medical History:
- CKD (baseline 1.6-1.7)
- HTN
- LLE DVT
- Avascular necrosis of the left hip
.
Oncology History:
- Metastatic prostate cancer diagnosed in [**2123**] after developing
bladder obstruction. He underwent TURP and was started on
Lupron. He presented to clinic with metastatic disease and a PSA
>1000. He started ketoconazole, hydrocortisone, and finasteride
on [**2132-10-9**]. Mr. [**Known lastname 18330**] completed radiation therapy for bulky
right inguinal lymphadenopathy in [**2132**]. He received pamidronate
on [**2133-3-12**]. He has since been on several different regimens.
Social History:
Born in [**Country 3594**], moved to US in [**2087**]. Lives in [**Location 686**] with
his wife. Is independent at home. Has 1 daughter. Smoked < 1ppw
from [**2084**]-[**2089**]. Very rare EtOH use. No illicit drug use.
Family History:
No FH of malignancy, clotting, or bleeding that he knows of.
Physical Exam:
ON ADMISSION:
Vitals: T: 99.2 BP: 145/65 P: 94 R: 18 O2: 98%RA
General: Alert, oriented, no acute distress
HEENT: MMM, swelling of left lower lip in region of trauma
Neck: supple, JVP not elevated
Lungs: Good air movement, scattered expiratory wheezing b/l
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic murmur
Abdomen: soft, mildly tender in epigastrum, non-distended, bowel
sounds present, no rebound tenderness or guarding
Ext: 2+ edema in LLE, left leg > right
ON DISCHARGE:
Vitals - T:98.7, 150/61, 78, 16 98%RA
GENERAL: NAD
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, poor dentition, nontender supple neck, no
LAD, no JVD. lower lip is swollen, but no bleeding.
CARDIAC: RRR, S1/S2, [**2-13**] holosystolic murmur
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, no cyanosis, significant
pitting edmea in the LLE, grossly swollen compared to right
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
Pertinent Results:
ADMISSION LABS:
[**2135-12-23**] 01:00PM BLOOD WBC-0.7*# RBC-2.46* Hgb-6.7* Hct-20.5*
MCV-84 MCH-27.1 MCHC-32.4 RDW-15.4 Plt Ct-202
[**2135-12-23**] 01:00PM BLOOD Neuts-56 Bands-1 Lymphs-25 Monos-17*
Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0
[**2135-12-23**] 01:00PM BLOOD PT-17.2* PTT-35.3 INR(PT)-1.6*
[**2135-12-23**] 01:00PM BLOOD Glucose-109* UreaN-46* Creat-2.8*# Na-136
K-5.1 Cl-102 HCO3-24 AnGap-15
[**2135-12-23**] 08:36PM BLOOD Calcium-8.4 Phos-3.8 Mg-1.7
[**2135-12-24**] 03:24AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
.
DISCHARGE LABS:
[**2135-12-28**] 08:00AM BLOOD WBC-2.9*# RBC-2.91* Hgb-7.9* Hct-25.0*
MCV-86 MCH-27.0 MCHC-31.4 RDW-16.7* Plt Ct-279
[**2135-12-28**] 08:00AM BLOOD Glucose-94 UreaN-15 Creat-1.3* Na-134
K-4.9 Cl-105 HCO3-23 AnGap-11
[**2135-12-28**] 08:00AM BLOOD Calcium-8.2* Phos-2.5* Mg-1.7
.
CT ABD & PELVIS:
1. Hemorrhage in large left renal cyst.
2. Abdominal free fluid, not evidence of hemoperitoneum.
3. Fractures of left 7th-11th ribs.
4. Innumerable pulmonary nodules and diffuse hypodensities in
liver,
concerning for metastates.
5. Diffuse osseous metastatic disease and lymphadenopathy,
unchanged.
.
X-ray L Femur, L knee:
Diffuse sclerotic metastatic dz in L hemi-pelvis. Unchanged
sclerosis of L femoral head c/w avascular necrosis. No acute fx
or dislocations.
.
X-ray shoulder, elbow:
No acute fracture or dislocation. No joint effusion.
.
CT HEAD:
No acute intracranial abnormality.
.
CT C-SPINE:
No acute fracture or dislocation. Severe degenerative changes of
cervical spine. Sclerotic changes in left 3rd rib, consistent
with metastatic disease.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
The patient is an 81 year-old male with history of prostate
cancer (followed by Dr. [**Last Name (STitle) **] on Docetaxel, DVT on coumadin,
CKD (baseline Cr 1.7) presenting with left flank pain,
epigastric pain, and worsening fatigue after sliding down stairs
at home. Found to have hemorrhage of a large left renal cyst
requiring brief ICU admission for hemodynamic monitoring.
Patient's course was complicated by chemotherapy induced
neutropenia. He was ultimately discharged to rehab for
continued treatment.
.
ACTIVE ISSUES
#. Status Post Fall: Strictly mechanical per patient report.
Evidence of trauma includes hemorrhage in large left renal cyst,
abdominal free fluid (no evidence of hemoperitoneum), and
fractures of left 7th-11th ribs. Was seen by trauma surgery who
felt there were no acute surgical issues. No other fractures or
dislocations based on imaging. Low suspicion for syncopal event
leading to fall, though patient does endorse intermittent
dizziness with standing suggestive of orthostasis. His coumadin
was initially held but restarted after stable hematocrits.
Physical therapy consult felt paitient would benefit from
ongoing inpatient rehab post discharge.
.
#. Anemia: No evidence of acute blood loss. Hemorrhagic renal
cyst contained within capsule based on imaging. Suspect
worsening anemia may be related to taxotere (Nadir - 7 days).
HCT trending down prior to presentation and received 1 unit
PRBCs as outpatient on [**12-20**]. Now s/p 2 units PRBCs in emergency
department. ACS was consulted and recommended consultation of
urology. Urology commented that if no hematuria and HCT is
stable, there is nothing to do but let the hemorrhage resolve on
its own. Difficult to tell if the free fluid is a urinoma or
not, the only imaging that could potentially tell the difference
is a CT with contrast with delayed phase to look for
extravasation, would only be indicated if he develops a fever,
UTI or hematuria - as he was stable with no hematuria, evidence
of UTI, or hematuria this was not done. His coumadin was
initially held, and his hematocrit was trended q8hrs. His
coumadin was restarted on HD 2.
#. Bacteremia: Patient had one set of positive blood cultures
from day of admission growing coagulase negative staphylococcus.
In the setting of persistent fevers and neutropenia, he was
started on vancomycin this was discontinued once ANC had
recovered. patient deferevesed and did not require additional
antibiosis. No additional cultures were positive, although
cultures from [**12-23**], [**12-24**], and [**12-25**] were pending at the time
of discharge.
#. Neutropenia: Likely secondary to taxotere as around nadir
period of 7 days, patient was treated supportively until counts
recovered.
#. [**Last Name (un) **]: Suspect pre-renal etiology in setting of poor PO intake
over last few days. Patient's creatinine clearence improved with
IV fluids.
.
#. DVT on coumadin: INR was subtherapeutic at 1.6 on admission.
Coumadin was initially held due to renal hemorrhage, but
restarted at home dose of 6 mg QD prior to discharge INR was
2.7. Patinet will need weekly INR checks at rehab and will
continue weekly checks with his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].
.
#. L flank/leg pain: Leg pain likely secondary to diffuse osseus
disease in setting of metastatic pancreatic cancer. Rib pain
secondary to fractures. He was continued on his home pain
regimen (oxycontin and oxycodone). He was gicen incentive
spirometry and pulmonary toilet.
.
#. Metastatic prostate cancer: Recently initiated on taxotere on
[**2135-12-15**]. Followed by Dr. [**Last Name (STitle) **], has follow up on [**1-5**] when he
was supposed to recieve next cycle of chemo. will likely be
delayed 1-2 weeks per Dr. [**Last Name (STitle) **].
.
TRANSITIONAL ISSUES
-code: full code
-Pt will need weekly INR checks, done by PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].
-final blood culture results were pending at the time of
discharge
Medications on Admission:
AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth daily
DES - (Prescribed by Other Provider) - Dosage uncertain
FINASTERIDE - 5 mg Tablet - 1 Tablet(s) by mouth daily
HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 Tablet(s) by mouth once a
day
OXYCODONE - 5 mg Tablet - 1 or 2 Tablet(s) by mouth every three
to four hours for pain
OXYCODONE [OXYCONTIN] - 15 mg Tablet Extended Release 12 hr - 1
Tablet(s) by mouth twice a day
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth
as
needed every 6 hours for nausa
WARFARIN [JANTOVEN] - 6 mg Tablet - 1 Tablet(s) by mouth daily
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D] - (Prescribed by Other
Provider) - Dosage uncertain
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. finasteride 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).
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
6. warfarin 2 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
7. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*10 Adhesive Patch, Medicated(s)* Refills:*2*
9. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11729**] Nursing Care Center
Discharge Diagnosis:
PRIMARY:
-Mechanical Fall
-Hemorrhagic Renal Cyst
-Neutropenic Fever
-Metastatic Prostate Cancer
SECONDARY:
- Chronic Kidney Disease (baseline 1.6-1.7)
- Hypertension
- Left lower extremity deep vein thrombosis
- Avascular necrosis of the left hip
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital. You were admitted for evaultion after falling at
home. You had a CT scan and x rays that did not show any
fractures. You were noted to have a small bleed in your kidney
and were therefore observed overnight in the intensive care
unit. Your bleeding was not significant and you continued to
recieve your coumadin. You also had very low white blood cell
levels as a result of your reccent chemotherapy and were given
antibiotics while you were having fevers. This was stopped once
your fevers stopped. You were also seen by our physical
therapists who felt you would benefit from rehab before being
safe to be at home. Once you are discharged from rehab you will
need to see Dr. [**Last Name (STitle) **] your primary care doctor to have your
coumadin levels (INR) checked.
The following changes were made to your medications:
-START lidocaine 5% patch applied to the left chest daily until
pain resolves
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2136-1-5**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 3217**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2136-1-5**] at 12:00 PM
With: [**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], RN [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11813, 11880
|
6218, 10226
|
359, 366
|
12173, 12173
|
4512, 4512
|
13361, 14026
|
3288, 3350
|
10950, 11790
|
11901, 12152
|
10252, 10927
|
12356, 13338
|
5119, 5960
|
3365, 3365
|
3856, 4493
|
268, 321
|
394, 2404
|
5969, 6172
|
4528, 5103
|
3379, 3842
|
12188, 12332
|
2448, 3033
|
3049, 3272
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,802
| 106,569
|
17485
|
Discharge summary
|
report
|
Admission Date: [**2190-11-8**] Discharge Date: [**2190-11-12**]
Date of Birth: [**2149-10-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
1. Flexible bronchoscopy
2. Endotracheal intubation
3. Rigid bronchoscopy
4. Tracheostomy
History of Present Illness:
41 yo female with PMH primary airway amyloidosis presents one
week after dilatation of left main bronchus for further
management by interventional pulmonary.
.
Pt has primary airway amyloidosis diagnosed in [**2188**]. She has had
respiratory symptoms of SOB since age 22, initially thought be
[**1-11**] asthma until a few years ago. Her major symptoms of airway
amyloidosis are episodes of SOB and wheezing that can last weeks
to months. Her disease course has been complicated by tracheal
narrowing at several levels and is s/p tracheal and left main
bronchus stents ([**2187**]). In [**2188**], left main stent removed d/t
granulation tissue and breakdown of stent, then replaced.
Underwent 10 days of low-dose radiation therapy to lung in [**2188**].
In the summer of [**2189**], the patient's SOB and wheezing worsened.
She underwent elective tracheostomy, and in [**2190-8-11**], had
her left main bronchus stent removed. The tracheostomy was
removed in [**Month (only) 359**].
.
Pt was recently admitted to [**Hospital1 18**] from [**Date range (1) 46801**] for worsening
SOB. She had recently undergone 2 bronchoscopies in North
[**Doctor First Name **] which were unable to open up her narrowed left main
bronchus. She underwent bronchoscopy here with excision of
granulation tissue in the left main bronchus, balloon dilatation
x3 in the distal left main, and the application of mitomycin C.
Procedure was without complications. Purulent drainage was seen
after excision of granulation tissue. Pt was treated with 10 day
course of Levo and 1 day course of Flagyl (could not tolerate)
for possible post-obstructive pneumonia. Pt then returned on
[**11-1**] and had balloon dilation of the distal left main times
two.
.
Pt presents today for additional intervention of left main
bronchus. Pt states that for a few days after the procedure last
week, her breathing felt better. Over the past week, she has
gradually become increasingly short of breath and wheezy. Feels
this is slightly worse than baseline. She can walk distances,
but becomes easily SOB and needs to walk slowly. She
occasionally get SOB at rest and occasionally wakes up at night
SOB; she cannot sleep on her left side. Pt complains of chest
and back "soreness" which is chronic. Has a chronic cough x 1
year that is occ productive of thick mucousy sputum.
.
Past Medical History:
1. Pulmonary amyloidosis: symptomatic since age 22, initially
thought to be asthma. Diagnosed in [**2188**]. See HPI for more
details. Followed by Dr. [**Last Name (STitle) **] at [**Hospital1 2177**] and by Dr. [**Last Name (STitle) **] at [**Hospital1 18**].
.
2. GERD. Well-controlled on pantoprazole.
.
3. Surgical history: s/p C-section X1 and tubal ligation, both
in [**2182**].
Social History:
The patient is a former nurse, who now works for her state
health department running diabetes programs. She used to be a
runner, and has continued to exercise as much as possible
throughout the duration of her illness. She has not run in over
a year. She lives in [**Doctor First Name 5256**] with her two daughers, ages
7 and 13, and her husband.
.
The patient drinks alcohol once every 2 months, but it makes her
respiratory tract dry and makes breathing more difficult. She
never smoked or used IV drugs. She is sexually active with her
husband and is s/p tubal ligation ([**2182**]).
Family History:
Father: DM [**Name (NI) **], heart disease, s/p CABG, B/L leg amputation.
Maternal grandfather: lung cancer (was a smoker)
Physical Exam:
On Admission:
VS: afebrile, p90, 127/62, 18, 96%RA
Gen: very pleasant woman, in no acute respiratory distress
HEENT: PERRL, [**Name (NI) 3899**], MMM
Neck: supple, non-elevated JVP
CVS: RRR, nl s1 s2, no m/g/r
Lungs: diffuse high-pitched inspiratory and expiratory wheezes
throughout. no crackes
Abd: soft, NT, ND, +BS
Ext: no edema bilaterally, warm and well-perfused, 2+DP
On Transfer to Floor:
Vitals:
Tm 98.8 (past 24 hours) HR 70-80s (up to 110s with trach care)
BP 80-110s/30-40s (105/50) RR 12-19 94-100% on RA
I/O 1125 IVF + 900 propofol +125 fentanyl / 2150 urine + 60
emesis
Gen: reclining in bed, cheeks flushed, pleasant, NAD, able to
communicate by mouthing words and writing
HEENT: MMM, PERRL, erythema on cheeks bilaterally
CV: regular, no mrg
Lungs: clear, no wheezes, no rhonchi
Abd: soft, NTND, +BS
Ext: w/wp, no edema, 5/5 strength, sensation intact
Neuro: aox3
Pertinent Results:
Admission Labs
[**2190-11-8**] 03:30PM WBC-7.2 RBC-4.01* HGB-10.8* HCT-31.1* MCV-78*
MCH-27.0 MCHC-34.9 RDW-14.3
[**2190-11-8**] 03:30PM PLT COUNT-284
[**2190-11-8**] 03:30PM GLUCOSE-94 UREA N-12 CREAT-0.8 SODIUM-140
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-26 ANION GAP-13
[**2190-11-8**] 03:30PM CALCIUM-9.1 PHOSPHATE-5.7* MAGNESIUM-1.9
[**2190-11-8**] 03:30PM PT-13.1 PTT-23.0 INR(PT)-1.1
CXR ([**11-9**])
FINDINGS: AP single view of the chest obtained with the patient
in upright position demonstrates the presence of an ETT in the
trachea terminating approximately 2 cm above the carina. Both
lungs are well aerated and demonstrate normal pulmonary
vasculature. No evidence of pneumothorax is present. The lateral
pleural sinuses are free. Comparison is made with the next
previous chest examination dated [**2190-10-28**] at which time
complete white out of the left lung was noted. This was
consistent with obstruction of the central left-sided airway
where a stent had been placed. Considerable left-sided
mediastinal shift with compensatory hyperinflation of the right
lung was present. All of these findings have now normalized and
no new parenchymal infiltrates can be seen. Also the position of
the left-sided main bronchus stent is now in close vicinity to
the midline.
IMPRESSION:
Normalization of left-sided pulmonary white out on apparently
patent central bronchial stent. No new infiltrates and no
pneumothorax.
CXR ([**11-10**])
IMPRESSION: Low lung volumes. Interval tracheostomy placement.
Operative Report ([**11-10**]):
PROCEDURE: Flexible bronchoscopy.
Attempt of stent placement.
Prolonged case.
ASSISTANT: [**Name6 (MD) 19185**] [**Name8 (MD) 19186**], M.D.
POSTOPERATIVE DIAGNOSES: Very severe supra glottic narrowing
due to granulation tissue and edema.
Patent left main stem bronchus.
DESCRIPTION OF PROCEDURE: Consent was obtained from the
patient 12 hours prior to the procedure. The questions
related to the procedure were answered adequately and the
patient signed the consent.
ANESTHESIA: General endotracheal anesthesia.
PROCEDURE IN DETAIL: The patient was brought to the
operating room after which the rigid bronchoscope was
advanced through the oral cavity and the endotracheal tube
was seen in the supraglottic area, entering the trachea
through the vocal cords. At the moment the balloon was
deflated, and the gradual fill of the endotracheal tube was
being performed by anesthesia under direct vision, through
the telescope, a rigid bronchoscope size [**10-22**] was advanced.
It was noted that the supraglottic area was very edematous
and infact, there was also a lot of granulation tissue and it
was even hard to pull the endotracheal tube cephalad.
Therefore, the attempt to pull the endotracheal tube was
aborted and the rigid scope was removed. At that moment, 40-
10 [**Name2 (NI) 48833**] stent was well lubricated and it was placed in the
endotracheal tube. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] catheter was used to advance
that stent to the middle of the tube and the fiberoptic
bronchoscope prior to that was advanced into the endotracheal
tube and the endotracheal tube was pushed all the way to the
carina. The tube was manipulated and it was pushed in the
left main stem bronchus and wedged in that position. In that
position, there was an attempt made to push the stent with
the [**Doctor Last Name **] catheter and deploy the left main stem bronchus
which failed because the stent got encroached at the end of
the endotracheal tube. At that moment, the procedure was
aborted because basically the patient had occluded central
airway and fortunately, the patient did not desaturate.
Oxygenation was always above 94 percent. Dr. [**First Name (STitle) 4667**] [**Doctor Last Name **]
from thoracic surgery was called in and the anterior area of
the neck was draped and an open tracheostomy was performed by
Dr. [**First Name (STitle) **] [**Doctor Last Name **] on thoracic surgery. Note that when Dr.
[**Last Name (STitle) **] reached the trachea, there was evidence of severe
scarring inside the trachea, two rings below the cricoid
cartilage. Successful placement of a size 8 tracheostomy
tube was placed and the patient was extubated. The
bronchoscope was advanced through the tracheostomy tube and
it was in good position. There was patency of the distal
airways.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Less than 10 cc.
The patient was transferred to the medical Intensive Care
Unit on the ventilator.
Speech/Swallow ([**11-12**]):
RECOMMENDATIONS:
1. Pt is not able to currently wear the PMV. She will pursue
f/u
of this once the trach has been downsized, likely with
medical team in NC. See above for details.
2. Po diet as tolerated, regular solids, thin liquids.
Brief Hospital Course:
Pulmonary
The patient was admitted for bronchoscopy and left main stem
stent placement. She went to the OR on [**2190-11-8**] but her airways
were too edmatous for placement of a stent. She was admitted to
MICU after her bronch on [**2190-11-8**] because they did not extubate
her post op given concern of edema. She did well overnight and
the next day on the ventilator.
She spiked a fever on [**2190-11-10**] and had some thick white
secretions in her ETT. She was started on levofloxacin and
vancomycin empirically with concern for MRSA given her history
of repeated procedures and hospitalizations. She was treated
with IV levofloxacin and vancomycin three days and was sent home
to complete a 14 day course of oral levofloxacin and linezolid.
The etiology of her fever is unclear but felt likely to be
pulmonary infection. She defervesced and her CXR was negative.
Blood cultures were negative on discharge. Urine cultures were
negative. Sputum cultures have grown out staph aureus but
sensitivities were still pending; the previous sputum culture
from [**Month (only) 462**] had grown out MSSA.
She returned to the OR on [**2190-11-10**] for placement of a left main
stem bronchus stent. The Internventional Pulmonary team was
unable to deploy a stent through her ETT, and it became lodged
in the tube. CT surgery was called to perform an emergent
tracheotomy during the case. She was kept on the ventilator
overnight and was weaned the next morning; she did well post
extubation. She will keep the tracheostomoy in place for a few
weeks and let it mature. She may return for another attempt for
stent placement at a later date; interventional pulmonary felt
that she was stable for discharge and will follow up with her
regarding future management. Speech and swallow came to see her
regarding a PMV; she was not a candidate at this time, but will
follow up in the future regarding this. Along with the course
of antibiotics, she was discharged with an albuterol inhaler to
be used as needed.
Heme - The patient was noted to have an Fe deficiency anemia,
with a normal ferritin and TIBC. She had been stable with a
hematocrit in the 20s for several months. Fe repletion was
initiated and she was guiac negative on discharge.
GI - The patient has a history of GERD; she was maintained on
protonix during hospitalization.
FEN
The patient was advanced to a house diet by discharge; she was
seen by speech and swallow.
Prophylaxis - The patient was ambulatory on discharge, she had
been kept on heparin SQ for DVT prophylaxis, continued on her
PPI, kept on a bowel regimen, and had tylenol for pain with
oxycodone for breakthrough.
Communication - The patient and her mother were involved in her
care and management plans.
Medications on Admission:
Nexium 40mg qd
Ferrous sulfate 325mg qd
Colace 100mg [**Hospital1 **]
just completed 10 day course of Levofloxacin
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*2 inhalers* Refills:*0*
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
4. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain for 5 days.
Disp:*20 Tablet(s)* Refills:*0*
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day
for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Pulmonary amyloidosis
Secondary diagnosis:
GERD
Discharge Condition:
Stable
Discharge Instructions:
1. Please keep all follow up appointments.
2. Please take all medications as prescribed.
3. Seek medical attention for fever, shortness of breath,
increased/different chest pain from baseline, or other
concerning symtpoms.
Followup Instructions:
Please follow up with your pulmonologist within 1-2 weeks. Dr.
[**Last Name (STitle) 19186**] from Interventional Pulmonology will be in touch with
you regarding follow up as well. His clinic number is
[**Telephone/Fax (1) 3020**].
|
[
"280.9",
"530.81",
"518.81",
"517.8",
"277.3",
"519.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"33.22",
"98.15",
"96.05",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
13421, 13427
|
9698, 12437
|
334, 427
|
13539, 13547
|
4867, 9675
|
13820, 14057
|
3823, 3947
|
12602, 13398
|
13448, 13448
|
12463, 12579
|
13571, 13797
|
3962, 3962
|
275, 296
|
455, 2794
|
13511, 13518
|
13467, 13490
|
3976, 4848
|
2816, 3202
|
3218, 3807
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,027
| 144,464
|
8266
|
Discharge summary
|
report
|
Admission Date: [**2131-3-12**] Discharge Date: [**2131-3-18**]
Date of Birth: [**2048-1-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
Hematuria
Major Surgical or Invasive Procedure:
cystoscopy
History of Present Illness:
The patient is an 83y/o gentleman with a past medical history of
aortic stenosis s/p bioprosthetic AVR, PAF on coumadin s/p TURP
approximately 3 weeks ago presenting with hematuria. The patient
reports that 1 week prior to presentation he passed 2 large
blood clots with urination with small amount of bleeding. He had
no further episodes of gross hematuria until this am. This am he
reported an inability to urinate since 3AM with gross blood and
clots. The patient presented to [**Hospital1 18**] ED where he underwent
foley placement with continuous bladder irrigation for several
hours and reported heamturia cleared. INR 1.6. He was sent home
on bactrim and foley in place with Urology follow up schedule
for [**3-12**].
.
The patient represented to ED with recurrent hematuria from
foley, continued pain and decreased urine output. On arrival to
ED, initial vitals: T 97.7 HR 83 BP 145/62 98% on RA. He was
found to have a HCT of 23.2. T&S sent. He was given ceftriaxone
1gm IV, morphine 4mg IVX2, diluadid 1mg IV. Urology was
consulted and the a rouche catheter was placed with subsequent
successful irrigation. INR found to be 3.1 and Cr 1.8. 2U PRBC
ordered.
.
On arrival to the medical floor, the patient reports pain at
foley catheter site. Denies CP/SOB. Foley in place irrigative
dark pink urine.
Past Medical History:
Aortic stenosis s/p Aortic valve replacement with
[**Last Name (un) 3843**]-[**Doctor Last Name **] tissue heart valve [**2124**]
CAD s/p PCI to RPDA
Rheumatic fever
Paroxysmal atrial fibrillation
Hypertension
Hyperlipidemia
TIA 10-12 years ago
Benign prostatic hypertrophy
Subdural hematoma in [**2111**]
Status post cataract removal
Status post evacuation of a subdural hematoma
Social History:
He lives with his wife and daughter in [**Name (NI) 3786**]. He quit smoking
25 years ago and had a 25 pack year smoking history. He drinks
one drink per day.
Family History:
Non-contributory
Physical Exam:
Vitals: T 96.4, HR 88, BP 114/55, RR 20, O2 99% 3L NC
Gen: pleasant, NAD
CV: RRR, nl s1/s2, no MRG
RESP: CTAB, no WRR
ABD: soft, NT/ND, NABS
EXT: no edema
GU: rouche foley in place draining dark pink urine, clots
present in bag
Pertinent Results:
[**2131-3-12**] 11:52PM CK(CPK)-74
[**2131-3-12**] 11:52PM CK-MB-NotDone cTropnT-0.02*
[**2131-3-12**] 11:52PM DIGOXIN-1.5
[**2131-3-12**] 11:52PM PT-19.3* PTT-23.0 INR(PT)-1.8*
[**2131-3-12**] 09:05PM HCT-23.3*
[**2131-3-12**] 03:10PM GLUCOSE-151* UREA N-42* CREAT-2.2* SODIUM-138
POTASSIUM-5.0 CHLORIDE-107 TOTAL CO2-23 ANION GAP-13
[**2131-3-12**] 03:10PM CALCIUM-8.1* PHOSPHATE-3.5 MAGNESIUM-2.4
[**2131-3-12**] 03:10PM WBC-8.9 RBC-2.88* HGB-7.6* HCT-23.6* MCV-82
MCH-26.6* MCHC-32.4 RDW-15.5
[**2131-3-12**] 03:10PM PLT COUNT-203
[**2131-3-12**] 03:10PM PT-21.6* PTT-25.3 INR(PT)-2.0*
[**2131-3-12**] 12:27AM GLUCOSE-139* UREA N-39* CREAT-1.8* SODIUM-140
POTASSIUM-4.6 CHLORIDE-109* TOTAL CO2-21* ANION GAP-15
[**2131-3-12**] 12:27AM estGFR-Using this
[**2131-3-12**] 12:27AM WBC-8.1 RBC-2.86* HGB-7.6*# HCT-23.2*
MCV-81*# MCH-26.4*# MCHC-32.6 RDW-15.4
[**2131-3-12**] 12:27AM NEUTS-75.3* BANDS-0 LYMPHS-16.5* MONOS-7.1
EOS-0.8 BASOS-0.3
[**2131-3-12**] 12:27AM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL
OVALOCYT-OCCASIONAL
[**2131-3-12**] 12:27AM PLT SMR-NORMAL PLT COUNT-217
[**2131-3-12**] 12:27AM PT-31.4* PTT-150* INR(PT)-3.1*
[**2131-3-11**] 08:16AM PT-17.9* PTT-24.9 INR(PT)-1.6*
[**2131-3-11**] 08:16AM URINE COLOR-Red APPEAR-Cloudy SP [**Last Name (un) 155**]-1.020
[**2131-3-11**] 08:16AM URINE BLOOD-LG NITRITE-POS PROTEIN->300
GLUCOSE-100 KETONE-15 BILIRUBIN-LG UROBILNGN-2* PH-8.5* LEUK-LG
[**2131-3-11**] 08:16AM URINE RBC->50 WBC-0 BACTERIA-OCC YEAST-NONE
EPI-0
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2131-3-17**] 03:20PM 6.3 3.33* 9.8* 29.2* 88 29.5 33.7 16.9*
145*
Source: Line-PICC
[**2131-3-16**] 04:52AM 6.0 3.24* 9.5* 27.8* 86 29.4 34.2 16.3*
128*
3
[**2131-3-15**] 04:18AM 7.1 3.15* 9.0* 26.3* 83 28.4 34.1 16.8*
144*
Source: Line-picc
[**2131-3-14**] 08:16PM 27.8*
Source: Line-picc
[**2131-3-14**] 01:38PM 27.5*
Source: Line-picc
[**2131-3-14**] 04:04AM 8.7 2.92* 8.3* 23.9* 82 28.4 34.7 16.1*
131*
ADDED RETIC CT 10:59AM
[**2131-3-13**] 09:15PM 23.8*
[**2131-3-13**] 02:00PM 10.0 2.81* 7.8* 22.8* 81* 27.8 34.2 16.1*
164
[**2131-3-12**] 09:05PM 23.3*
[**2131-3-12**] 03:10PM 8.9 2.88* 7.6* 23.6* 82 26.6* 32.4 15.5
203
[**2131-3-12**] 12:27AM 8.1 2.86* 7.6*# 23.2*1 81*# 26.4*# 32.6
15.4 217
NOTIFIED [**Name6 (MD) **] [**Name8 (MD) 259**] RN EW @ 1251AM [**2131-3-12**]
READBACK COMPELTE
VERIFIED BY REPLICATE ANALYSIS
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2131-3-12**] 12:27AM 75.3* 0 16.5* 7.1 0.8 0.3
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr Ovalocy
[**2131-3-12**] 12:27AM 2+ 1+ OCCASIONAL NORMAL 1+ OCCASIONAL
OCCASIONAL
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2131-3-17**] 03:20PM 145*
Source: Line-PICC
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino
[**2131-3-14**] 04:04AM 182
FIB ADDED 10:58AM
HEMOLYTIC WORKUP Ret Aut
[**2131-3-14**] 04:04AM 2.3
ADDED RETIC CT 10:59AM
LAB USE ONLY
[**2131-3-17**] 03:20PM
Source: Line-PICC
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2131-3-17**] 03:20PM 821 17 1.3* 139 4.5 109* 24 11
Source: Line-PICC
[**2131-3-16**] 04:52AM 821 17 1.3* 139 4.3 109* 24 10
3
[**2131-3-15**] 04:18AM 851 24* 1.4* 139 4.3 110* 25 8
Source: Line-picc
[**2131-3-14**] 04:04AM 881 34* 1.8* 139 4.5 109* 25 10
[**2131-3-12**] 03:10PM 151*1 42* 2.2* 138 5.0 107 23 13
[**2131-3-12**] 12:27AM 139*1 39* 1.8* 140 4.6 109* 21* 15
IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES
ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2131-3-12**] 12:27AM Using this1
Using this patient's age, gender, and serum creatinine value of
1.8,
Estimated GFR = 36 if non African-American (mL/min/1.73 m2)
Estimated GFR = 44 if African-American (mL/min/1.73 m2)
For comparison, mean GFR for age group 70+ is 75 (mL/min/1.73
m2)
GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2131-3-13**] 02:20PM 1151
Source: Line-PICC
NEW REFERENCE INTERVAL AS OF [**2130-12-11**];UPPER LIMIT (97.5TH %ILE)
VARIES WITH ANCESTRY AND GENDER (MALE/FEMALE);WHITES 322/201
BLACKS 801/414 ASIANS 641/313
CPK ISOENZYMES CK-MB cTropnT
[**2131-3-16**] 04:52AM 3 0.06*1
3
[**2131-3-13**] 02:20PM 6 0.04*1
Source: Line-PICC
[**2131-3-12**] 11:52PM NotDone2 0.02*1
ADDED DIG AT 0056 04 06 10
CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
NotDone
CK-MB NOT PERFORMED, TOTAL CK < 100
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2131-3-16**] 04:52AM 2.8* 7.8* 2.6* 2.3
3
[**2131-3-15**] 04:18AM 7.5* 2.7 2.5
Source: Line-picc
[**2131-3-14**] 04:04AM 7.8* 2.8 2.4
[**2131-3-12**] 03:10PM 8.1* 3.5 2.4
CARDIAC/PULMONARY Digoxin
[**2131-3-12**] 11:52PM 1.5
ADDED DIG AT 0056 04 06 10
LAB USE ONLY LtGrnHD GreenHd EDTA Ho RedHold
[**2131-3-12**] 12:27AM HOLD
[**2131-3-12**] 12:27AM HOLD1
HOLD
DISCARD GREATER THAN 4 HOURS OLD
Blood Gas
BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calTCO2 Base XS
[**2131-3-14**] 01:54PM [**Last Name (un) **] 7.39
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Lactate Na K Cl
[**2131-3-13**] 03:23AM 158* 1.6 136 5.1 105
HEMOGLOBLIN FRACTIONS ( COOXIMETRY) Hgb calcHCT
[**2131-3-13**] 03:23AM 6.3* 19
CALCIUM freeCa
[**2131-3-14**] 01:54PM 1.11*
.
.
GENERAL URINE INFORMATION Type Color Appear Sp [**Last Name (un) **]
[**2131-3-11**] 08:16AM Red1 Cloudy 1.020
ABN COLOR [**Month (only) **] AFFECT DIPSTICK
DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone Bilirub
Urobiln pH Leuks
[**2131-3-11**] 08:16AM LG POS >300 100 15 LG 2* 8.5* LG
MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE
RenalEp
[**2131-3-11**] 08:16AM >50 0 OCC NONE 0
MISCELLANEOUS URINE Eos
[**2131-3-13**] 03:28AM NEGATIVE 1
Source: Catheter
NEGATIVE NO EOS SEEN
[**2131-3-11**] 08:16AM
Chemistry
URINE CHEMISTRY Hours UreaN Creat Na
[**2131-3-13**] 03:28AM RANDOM NONE DETEC1 NONE DETEC2 154
Source: Catheter
NONE DETECTED
VERIFIED BY RECOVERY
SUSPECT INVALID SAMPLE
NONE DETECTED
VERIFIED BY RECOVERY
HIGHLY UNLIKELY THAT THIS IS REALLY URINE
OTHER URINE CHEMISTRY Osmolal
[**2131-3-13**] 03:28AM 282
.
.
MICROBIOLOGY:
[**2131-3-11**] 8:16 am URINE Site: CATHETER
**FINAL REPORT [**2131-3-12**]**
URINE CULTURE (Final [**2131-3-12**]): NO GROWTH.
.
.
Radiographic Studies:
Renal Ultrasound ([**2131-3-12**])
INDICATION: Patient is an 83-year-old male with recent TURP for
benign
prostatic hypertrophy now admitted with hematuria and
obstruction secondary to hematoma within the bladder. Evaluate
for hydronephrosis.
EXAMINATION: Renal ultrasound.
COMPARISONS: Comparison is made to remote ultrasound from
[**2120-9-21**].
FINDINGS:
The right kidney measures 11.4 cm.
Left kidney measures 11.5 cm.
There is no evidence of hydronephrosis or nephrolithiasis.
.
Re-demonstrated are multiple cysts. The largest in the right
kidney measures 9.7 x 8.6 and is well circumscribed and
completely anechoic with features compatible with a simple cyst.
No internal vascularity is demonstrated. In addition, smaller
cysts are noted on the right including a 2.8 x 2.7 cm simple
cyst seen arising from the right upper pole, and a 2.9 x 2.3 cm
cyst arising from the right lower pole. In addition, multiple
simple cysts are noted on the left with the largest being within
the right lower pole measuring 4.6 x 4.1 cm.
.
Pre-void images of the bladder are provided. There is extensive
amount of
heterogeneous echogenicity demonstrated within the bladder most
compatible
with known history of blood clot. A Foley catheter is noted
within the
bladder. There is prostatic hypertrophy with the prostate
measuring up to 6.8 x 6.2 x 5.5 cm for a calculated prostatic
volume of 121 cc.
IMPRESSION:
1) Multiple simple cysts seen within both kidneys, otherwise
unremarkable
appearance of the kidneys with no evidence of hydronephrosis.
2) Extensive heterogeneity seen within the bladder compatible
with known
history of blood clot within the bladder.
3) Prostatic hypertrophy measuring up to 121 cc.
CXR ([**2131-3-13**])
HISTORY: Aortic stenosis, to evaluate for pulmonary edema.
FINDINGS: In comparison with study of [**2125-9-26**], the degree of
enlargement of the cardiac silhouette is less. No definite
pleural effusions or vascular congestion at this time. No acute
focal pneumonia. Obliquity of the patient somewhat obscures
detail of this patient who has intact midline sternal wires.
Transthoracic Echocardiogram ([**2131-3-14**])
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is moderate symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. The aortic root is mildly dilated at the
sinus level. A bioprosthetic aortic valve prosthesis is present.
The aortic valve prosthesis appears well seated, with normal
leaflet motion and transvalvular gradients. No aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. There is moderate valvular mitral stenosis (area
1.5cm2). No mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
.
IMPRESSION: Well seated, normally functioning bioprosthetic
aortic valve. Moderate mitral stenosis. Moderate pulmonary
artery systolic hypertension. Symmetric left ventricular
hypertrophy with preserved regional and global biventricular
systolic function.
.
CLINICAL IMPLICATIONS:
The patient has moderate mitral stenosis. Based on [**2126**] ACC/AHA
Valvular Heart Disease Guidelines, a follow-up echocardiogram is
suggested in [**12-9**] years. Based on [**2127**] 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.
Brief Hospital Course:
83M h/o AFIB, on coumadin, s/p recent TURP, admitted with
hematuria, hypotension.
.
# hypotension - admitted to floor initially, but transferred to
ICU for hypotension, most consistent with acute blood loss
aneima. ECG unremarkable. Troponin weakly positive
(0.02->0.06), felt likely [**1-9**] demand. His INR was reversed with
2U FFP. SBPs resolved with IVFs and ultimately required 11U
PRBCs as detailed below. He was empirically treated with
ciprofloxacin despite negative blood and urine cultures at
urology request.
.
# hematuria - s/p TURP 3 weeks prior to admission, with
significant bleeding requiring ICU stay, no pressors, but 11U
PRBC transfusion as below. Pt initially had Rouche catheter and
3 way CBI. It was unclear why bleeding was occuring 3 weeks
after procedure, though this was also in the setting of INR of
3.1. The patient was maintained on CBI (initially at 3L/hr) and
would occasionally occlude the catheter with clot. This usually
could be resolved with simple irrigation, but did require his
foley catheter to be changed out twice. When his foley would
occlude, his bladder would become distended with irrigant fluid
and would cause the patient significant discomfort.
.
the patient was evaluated by the urology service, who reported
significant clot still in bladder. the irrigation was slowly
lowered to 1500ml/hr, though intermittent clot continued to be
noted in the foley. Urology took the patient to the OR for
cystoscopy on [**2131-3-16**], and evacuated clot and cauterized the
bleeding, friable prostate. CBI was contiued post-op for 1d.
The patient received one dose of IV vancomycin prior to the
procedure for SBE prophylaxis. On POD#2, CBI was discontinued
by urology, and the 3rd port of his foley was clamped. He was
discharged home with instructions to maintain this foley in
place and continue ciprofloxacin empirically until he
followed-up with Dr. [**Last Name (STitle) 770**] in [**Hospital 159**] Clinic within 7 days of
his discharge. pt agreed to be followed by home VNA to assist
with foley care.
.
# acute blood loss anemia - during his intensive care unit stay,
the patient required 11 units of pRBCs to be transfused, last
transfusion on [**2131-3-15**]. His coumadin and aspirin were held, he
received FFP as above.
.
initially, hematocrit stable around 23 despite transfusion, but
bumped appropriately to 27 and remained stable at that level
prior to transfer to the medical floor. upon arrival to the
medical floor, HCT remained stable for 72 hours, and was 29 on
[**2131-3-17**], prior to discharge on [**2131-3-18**].
.
# paroxysmal atrial fibrillation - pt was continued on
amiodarone, digoxin. metoprolol was initially held in setting
of bleeding, but resumed at reduced dosage (12.5mg po qdaily),
given relative hypotension. The patient was noted to be in NSR
throughout his stay in the MICU.
.
after extensive discussion regarding the risks/benefits of
resuming anticoagulation with the patient and his daughter,
[**Name (NI) **], pt was discharged home off of coumadin, and aspirin, and
instructed to resume these on [**2131-3-23**] when he follows up with
Dr. [**Last Name (STitle) 770**]. He was instructed to scheduled a follow-up
appointment with his primary care physician, ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], md
[**Telephone/Fax (1) **]), no later than [**2131-3-23**] to discuss resuming
coumadin/aspirin. he will also follow-up with his cardiologist,
dr. [**Last Name (STitle) **], as per his previousy scheduled appointment.
.
# acute kidney injury - creatinine increased to 2.2 on
admission, felt most likely [**1-9**] hypovolemia vs. obstruction.
renal ultrasound was performed and did not show obstruction but
did show blood in the bladder. His outside hospital records
were obtained that showed a baseline creatinine of 1.8. His
home regimen of lasix was held. After discussion with his
daughter, he had been on an ACE inhibitor as recently as [**2-14**],
this was not restarted. His creatinine trended down to a nadir
of 1.4 at the time of transfer from the MICU, and was 1.3 on
discharge.
.
he was instructed to follow-up with his PCP no later than
[**2131-3-23**] to have BUN/CRE checked and discuss resuming his usual
regimen of lasix if his CRE remained stable.
.
# CAD s/p PCI - initially, aspirin and metoprolol were held
given acute bleeding. he was ultimately restarted on lower
dosage metoprolol (decreased to 12.5mg [**Hospital1 **]), and zocor, after
being seen by Dr. [**Last Name (STitle) **], the patient's cardiologist.
.
# chronic diastolic congestive heart failure - pt denied h/o
CHF, but was on lasix at admission. he underwent TTE which
revealed preserved EF (60%), E/A,<1, consistent with diastolic
CHF. TTE otherwise revealed well seated, normally functioning
bioprosthetic aortic valve. Moderate mitral stenosis. Moderate
pulmonary artery systolic hypertension. Symmetric LVH. he was
clinically euvolemic on discharge, and given resolving ARF, was
discharged off of his usual regimen of lasix, with instructions
to maintain low salt diet, weigh himself daily, call his PCP
should his weight increase >2lb/day to discuss restarting his
lasix. Otherwise, he will f/u with his PCP no later than
[**2131-3-23**] and discuss resume his lasix, as well as ACE-inhibitor,
which was discontinued in [**2-14**] for unclear reasons, per
daughter.
.
# hyperlipidemia - continued on statin.
.
# hypertension, benign - as above, pt was discharged on reduced
dosage of metoprolol 12.5 mg po bid as per his cardiologist.
.
# h/o TIA, CVA '[**21**], h/o SDH '[**11**] - pt does not recall, per
daughter, in [**2121**], vision difficulty, unclear if embolic, seen
at [**Location (un) 511**] Baptise. aspirin and coumadin were held as
above.
.
# BPH - pt admitted on tamsulosin, which was continued. per
urology, he was started on finesteride, and oxybutinin. he will
follow-up with urology as above.
.
# access - a RUE PICC was placed in ICU, and removed prior to
discharge.
# code - pt was DNR/DNI.
# comm - daughter, [**Name (NI) **], [**Telephone/Fax (1) 29319**].
Medications on Admission:
Cordarone 200 mg Tab Oral 1 Tablet(s) Once Daily
Coumadin 5 mg Tab Oral 1 Tablet(s) Once Daily
Ecotrin -- 81 Qday
Flomax 0.4 mg 24 hr Cap Oral daily
Lanoxin 125 mcg Tab Oral 1 Tablet(s) Once Daily
Lasix 40 mg Tab Oral 1 Tablet(s) Daily
Metoprolol Tartrate 25 mg Tab Oral 1 Tablet(s) Twice Daily
Magnesium Oxide 400 mg Tab Oral 1 Tablet(s) Once Daily
Prilosec OTC 20 mg Tab Oral 2 Tablet, Delayed Release daily
Omeprazole 40 mg Cap, Delayed Release daily
Rhinocort Aqua 32 mcg/Actuation Nasal Spray Nasal 1 Spray,PRN
Zocor 40 mg Tab Oral 1 Tablet(s) Once Daily
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
5. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day.
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
10. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Outpatient Lab Work
please have lab work drawn on your visit with your primary care
doctor, no later than [**2131-3-23**], including BUN/CREATININE, and
CBC. please have the results reviewed by your primary care
physician. [**Name10 (NameIs) **] call dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) **] to
arrange this.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
primary:
hematuria
BPH
acute blood loss anemia
acute renal failure
secondary:
paroxysmal atrial fibrillation
s/p prosthetic AVR
CAD s/p PCI
diastolic CHF
HTN
h/o CVA, SDH.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
you were admitted to the hospital with hematuria, felt due to
coumadin and your recent prostate procedure. you received 11
units of blood, and underewnt cystoscopy, at which time friable
bleeding tissue was addressed by urology.
.
you are being dishcarged home, off of coumadin, aspirin, and
lasix, with a foley catheter in place.
.
you will need to follow-up with urology within 7 days of
discharge, you will need to call Dr. [**Last Name (STitle) 770**], in the [**Hospital 159**]
Clinic upon arriving home to schedule this appointment.
.
you will also need to follow-up with your primary care physician
[**Name Initial (PRE) 176**] 7 days of your discharge to discuss restarting your
lasix, discuss why you are not on an ACE inhibitor, and and
follow-up your blood count and renal function.
.
the following changes were made to your medication regimen:
1. your lasix was discontinued. you should weigh yourself
daily, and call your primary care physician if your weight
increases by >2 lb /day, to discuss restarting this.
2. your coumadin is being held. you should restart this
medication no later than [**2131-3-23**] or when you see Dr. [**Last Name (STitle) 770**].
3. your aspirin is being held. you should restart this
medication no later than [**2131-3-23**] or when you see Dr. [**Last Name (STitle) 770**].
4. your metoprolol dose was decreased to 12.5mg once daily.
5. you were started on finasteride.
6. you were started on a short course of antibiotics,
ciprofloxacin for 7 days, or until you see Dr. [**Last Name (STitle) 770**].
7. you were started on a short course of oxybutinin for bladder
spasm.
Followup Instructions:
upon arriving home, you will need to follow-up with urology
within 7 days of discharge, you will need to call Dr. [**Last Name (STitle) 770**],
in the [**Hospital 159**] Clinic at ([**Telephone/Fax (1) 7707**] upon arriving home to
schedule this appointment. you should be seen no later than
[**2131-3-23**].
.
upon arriving home, you will also need to follow-up with your
primary care physician [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) **], within 7
days of your discharge to discuss restarting your lasix, discuss
why you are not on an ACE inhibitor, and and follow-up your
blood count and renal function. please call him to schedule
this appointment. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], md [**Telephone/Fax (1) **]
.
please follow-up with Dr. [**Last Name (STitle) **] at your previously scheduled
appointment. you can discuss with him restarting your lasix
also.
|
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5,829
| 146,295
|
30836
|
Discharge summary
|
report
|
Admission Date: [**2135-6-11**] Discharge Date: [**2135-6-28**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Neck pain
Major Surgical or Invasive Procedure:
ACDF C5-6
Pacemaker placement [**Company **] VVI
History of Present Illness:
87 y/o man s/p fall evening [**6-10**]. Unwitnessed; no recall of
details surrounding this event. Imaging shows unstable C-spine
fx C5-6.
Past Medical History:
HTN
a.fib
bronchitis
depression
h/o multiple falls
hypercholesterolemia
s/p CVA
syncope
Social History:
Was living at home independently until incident. Son involved in
care.
Family History:
N/C
Physical Exam:
General:
VS: 96.9 151/88, HR97 (tele with afib with RVR) RR18 94%RA
Skin: no rashes
HEENT: PERRL, +cataracts, EOMI, OP with thick dry mucous,
severely dry MM
Neck: in soft collar; anterior cervical incision clean, dry and
intact
Chest: CTAB,
Cards: [**Last Name (un) 3526**], [**Last Name (un) 3526**] no m/r/g
Abd: +BS, NTND
Ext: no edema
Neuro: AAOx3, CN 2-12 grossly intact, 5/5 strength throughout,
sensation intact to light touch, coord r. alt. m.
Pertinent Results:
[**2135-6-22**] 10:10AM BLOOD WBC-6.5 RBC-3.53* Hgb-11.4* Hct-34.1*
MCV-96 MCH-32.3* MCHC-33.5 RDW-14.3 Plt Ct-210
[**2135-6-21**] 06:14AM BLOOD WBC-5.5 RBC-3.63* Hgb-11.8* Hct-34.5*
MCV-95 MCH-32.6* MCHC-34.3 RDW-14.1 Plt Ct-209
[**2135-6-17**] 01:46AM BLOOD WBC-4.5 RBC-3.32* Hgb-10.9* Hct-31.8*
MCV-96 MCH-32.8* MCHC-34.2 RDW-13.8 Plt Ct-201
[**2135-6-22**] 10:10AM BLOOD Glucose-139* UreaN-29* Creat-PND Na-144
K-3.7 Cl-109* HCO3-26 AnGap-13
[**2135-6-13**] 03:31PM BLOOD CK(CPK)-184*
[**2135-6-12**] 10:43PM BLOOD CK(CPK)-319*
[**2135-6-11**] 09:00AM BLOOD CK(CPK)-675*
[**2135-6-12**] 10:43PM BLOOD CK-MB-5 cTropnT-0.02*
[**2135-6-22**] 10:10AM BLOOD Calcium-8.9 Phos-2.0* Mg-2.2
.
C-Spine MRI:
FINDINGS: At C5-6 level, there is widening of the anterior disc
space identified with increased signal in this region on
inversion recovery images. In addition, there is buckling of the
ligamentum flavum visualized posteriorly with subtle increased
signal in the interspinous region. Findings are indicative of
ligamentous disruption both in the anterior and posterior
portion of the spine. In addition, there is a large prevertebral
hematoma identified extending from C2 to the upper thoracic
region. There is no evidence of intraspinal hematoma seen. There
is increased signal identified within the spinal cord at C4-5
level which could be related to cord edema or contusion.
Multilevel degenerative changes are seen at other levels in the
cervical region extending at C3-4, C4-5, C6-7 and C7-T1 level
with mild anterolisthesis of C7 or T1.
Of concern is absence of flow void within both vertebral
arteries in the cervical region. This is best visualized on
axial T2-weighted axial images which show high signal is seen
within both vertebral arteries. These findings are indicative of
extremely slow flow or occlusion of both vertebral arteries.
IMPRESSION:
1. Probable extension injury with disruption of the anterior
longitudinal and the intraspinous and nuchal ligaments in the
region of C5-6 level.
2. Large prevertebral hematoma in the cervical region.
3. Abnormal signal within both vertebral arteries in the neck
suspicious for slow flow or occlusion. MRA or CTA would help for
further assessment.
4. Multilevel degenerative changes in the cervical region.
5. Focus of increased signal within the spinal cord at C4-5
level suspicious for cord edema/contusion.
Brief Hospital Course:
Brief Hospital Course:
.
Mr. [**Known lastname 72979**] was admitted to the Trauma service after being
evaluated in the EW and found to have an unstable C5-6 fracture
dislocation. It was his lone injury and he was admitted and
given a floor bed. Transfered to floor & had episode of
deliriumsundowning, continually trying to get out of bed.
Scheduled for surgical repair of C-spine [**6-12**] but INR was 2.3
and procedure deferred until [**6-13**]. In holding area was noted to
be gurgling, still confused. Decision made to electively
intubate, done in OR with fiberoptic scope/surgical airway
back-up. Intermittently bradycardic and an EP consult was
sought. Tachy/brady syndrome was observed and a pacemaker was
placed by EP [**6-13**]. At this time he was stable for an anterior
cervical discectomy and fusion C5-6. Post-opertively he was
transfered back to the T/SICU for further care. While there, he
had significant episodes of tachycardia & bradycardia and
required placement of a pacemaker because of this.
.
He was eventually transferred to the wards, where he had
difficulty swallowing and continued delirium. A Geriatrics
consult was sought for a possible CVA leading to his difficulty
swallowing. A CT of the head was obtained which showed no
evidence of acute intracranial process. He was [**Hospital 72980**]
transfered to the Geriatrics service for further managment.
.
Shortly after transfer to the medicine wards, pt he became
dyspneic in the settig copious oral secretions. He was found to
have pneumonia (likely aspiration) and was transferred to the
MICU for treatment of PNA and copious secretions. He was
initially treated with levo/flagyl for probable aspiration PNA;
this was then broadened to vanc/Zosyn. Pt did not require
intubation/pressors in MICU. Rather, he was weaned off oxygen
and was treated for HTN.
While in the MICU, the MICU team met with the family to discuss
the pt's overall prognosis and review the pt's goals of care.
They explained that the pt's aspiration/dysphagia was likely a
complication from the sugery, and that the pt would not likely
regain his swallowing function. Given the degree of the pt's
injury, including the possibility that he may not be able to
walk again and his inability to take PO (at least for the
foreseeable future), the pt decided that pursuing agressive care
would not fit with his wishes or goals. His son corroborated
these feelings. Another meeting was had with the family and the
medicine [**Hospital1 **] team on [**2135-6-27**] (following transfer out of the
MICU). During this meeting, the son reiterated his and his
father's wish to move to hospice care. He explained that they
understand that the pt could at some point regain swallowing
function. Yet, waiting for that possibility would be not be in
line with his wishes and goals. As the pt stated on [**2135-6-26**], he
feels "the end is near...I have lived a good life." He then
expressed his wish to be out of the hospital setting and to
enjoy what time he has left.
.
He was treated with care and comfort measures only prior to
discharge. At time of discharge, pt had very dry mucous
membranes for which he was receiving supportive care. He denied
having any pain.
Medications on Admission:
coumadin
lipitor
citalopram
Discharge Medications:
1. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q4HR ().
2. Lorazepam 0.5 mg Tablet Sig: 1-4 Tablets PO Q4-6H (every 4 to
6 hours) as needed.
3. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO Q1-2H
() as needed.
4. Artificial Saliva 0.15-0.15 % Solution Sig: 1-3 MLs Mucous
membrane DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
Hospice House
Discharge Diagnosis:
Cervical spondylosis and C6 fracture dislocation at C5-C6.
Tachycardia/Bradycardia syndrome
Discharge Condition:
Good
Discharge Instructions:
Please continue to take your pain medication with an over the
counter laxative. Call the clinic if you notice any redness or
discharge from the incision site. Call the clinic for any
additional concerns. Please wear the hard collar when
ambulating and the soft collar when in bed.
Followup Instructions:
Please follow up in the Spine Clinic in the [**Hospital Ward Name 23**] Bldg Floor
#2 on Wednesday, [**6-29**]. Call [**Telephone/Fax (1) 11061**] to schedule an
appointment.
|
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"997.4",
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"E880.9",
"518.5",
"V58.61",
"401.9",
"787.2",
"721.0",
"805.05",
"276.0",
"427.31",
"507.0",
"293.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.81",
"38.93",
"96.04",
"99.15",
"37.71",
"03.53",
"81.62",
"81.02",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
7251, 7291
|
3617, 6822
|
272, 323
|
7427, 7434
|
1199, 3571
|
7767, 7946
|
705, 710
|
6900, 7228
|
7312, 7406
|
6848, 6877
|
7458, 7744
|
725, 1180
|
223, 234
|
351, 490
|
512, 601
|
617, 689
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,242
| 130,340
|
31824
|
Discharge summary
|
report
|
Admission Date: [**2148-1-23**] Discharge Date: [**2148-1-26**]
Date of Birth: [**2093-11-5**] Sex: M
Service: MEDICINE
Allergies:
Vicodin / Percocet
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
fever/rigors
Major Surgical or Invasive Procedure:
None
History of Present Illness:
54yoM with h/o poorly controlled DM2 and right ankle
osteomyelitis [**2-22**] fracture in [**2143**], currently on
dapto/flagyl/cipro who presents with right ankle pain, "redness
around and drainage" from the PICC area, new leukocytosis and
left shift.
.
Recently, the patient was admitted to the [**Hospital1 18**] on [**2147-12-26**] for
right ankle osteo, and discharged home with a planned 6 week
course of IV daptomycin and PO ciprofloxacin. He was seen on
[**1-5**] by post discharge follow up at which point he was
compliant with his medications, preforming wound changes QOD,
and still had severe pain but overall felt improved. He was seen
in the [**Hospital1 **] ED and then the [**Hospital1 18**] ED on [**1-10**] with fever, but
discharged when they noted a normal white count and no other
signs of infection besides his chronic osteo. On [**1-13**], he
re-presented to [**Hospital1 **] with increasing right ankle pain and fever
to 102 where he was found to have an elevated WBC with left
shift. Right ankle xray was unchanged. He had an MRI which
showed improvement in osteo without mention of invovlement of
tibia. During his stay, he was offered BKA (the only definitive
treatment for his disease) but he declined. Flagyl was added,
his leukocytosis resolved, and he was discharged home with plans
for ongoing outpatient follow-up.
.
PICC placed last Friday, saw clear fluid draining from his arm
on saturday. VNA came on sat am to change the dressing and
thought it didnt look right. He had rigors and sweats this
morning at 6am. Pain in his right ankle worsened so he
presented to [**Hospital1 **] again today. He was found with a FSBS in the
400's and was started on a insulin gtt. They transferred back
to [**Hospital1 18**] for further workup.
.
In the ED, initial VS were: 97.6 90 110/62 18 98% 2L. Elevated
lactate with borderline BP's so warranted ICU admission.
Insulin drip was stopped. Received 1 gram of tylenol, 4grams of
IV morphine, and 2.5L of IVF. CVL was placed. Most recent
vitals prior to transfer were 100.1 87 92/59 12 96% on RA.
.
On arrival to the MICU, he reports right ankle pain and feeling
sad.
Past Medical History:
-Diabetes melitus: poorly controlled, hgA1c on [**2147-12-26**] was 15.6%
-Chronic right calcaneal osteomyelitis [**2-22**] trauma (fell off
roof)
-Chronic pain ([**2146-7-28**]) previously on narcotics
-Cardiac Arrest in [**1-/2146**] with CPR done
-Chest wound from CPR (septic from osteo of toe)
-- CT ([**2146-11-25**]) showed presternal mass of 4.5x2.8 cm presternal
rim-enhancing fluid collection with internal gas concerning for
an abscess
-- s/p debridement of R chest wall and a resection of cartilage
of 6th rib with VAC dressing placement on [**2147-1-9**].
-Depression
-L1-L2 fracture
-Hyperlipidemia
-? COPD
-Chronic headache
-MVA with concussion [**2-25**]
Social History:
He lives with his wife, previously worked in contruction
although does not work presently. quit smoking 1 year ago,
smoked 5 cig/day x 30 years. Denies EtOH or drug use.
Family History:
Father with pancreatic cancer, mother with breast cancer,
brother with esophageal cancer.
Physical Exam:
Admission exam
100.1 87 92/59 12 96% on RA.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Discharge exam:
VS: T 97-98 BP 106-136/60-90 HR 70-80 RR 18 O2 Sat 97% RA
GEN: NAD, non toxic appearing
NECK: Supple, JVP 5cm above the RA
CV: RRR, normal S1/S2, no S3/S4, no m/r/g
PULM: CTAB, no increased WOB
ABD: NABS. Mild TTP in the b/l lower quadrants, no rigidity,
rebound or guarding.
EXT: RLE with gross deformity, warm to the touch, 1+ DPs,
hyperpigmentation c/w chronic venous stasis. There is a well
healing eschar without discharge. Trace edema, no erythema.
NEURO: A/Ox3, non focal.
Pertinent Results:
Admission labs
[**2148-1-23**] 12:30PM BLOOD WBC-19.3*# RBC-4.40* Hgb-13.3* Hct-39.1*
MCV-89 MCH-30.1 MCHC-33.9 RDW-13.3 Plt Ct-242
[**2148-1-23**] 12:30PM BLOOD Neuts-95.6* Lymphs-2.8* Monos-1.0*
Eos-0.4 Baso-0.3
[**2148-1-23**] 12:30PM BLOOD Glucose-266* UreaN-20 Creat-1.1 Na-138
K-3.9 Cl-102 HCO3-22 AnGap-18
[**2148-1-23**] 12:30PM BLOOD ALT-48* AST-28 AlkPhos-108 TotBili-0.5
[**2148-1-23**] 12:30PM BLOOD Lipase-18
[**2148-1-23**] 05:03PM BLOOD Lactate-1.5
[**2148-1-23**] 12:46PM BLOOD Glucose-252* Lactate-4.0*
Discharge labs
[**2148-1-26**] 07:33AM BLOOD WBC-7.8 RBC-4.03* Hgb-12.3* Hct-36.4*
MCV-91 MCH-30.4 MCHC-33.6 RDW-13.6 Plt Ct-223
[**2148-1-26**] 07:33AM BLOOD Glucose-106* UreaN-17 Creat-0.7 Na-139
K-4.0 Cl-101 HCO3-33* AnGap-9
[**2148-1-24**] 05:22AM BLOOD Lactate-1.5
Studies
[**2147-1-23**] CXR: Right internal jugular line has been inserted with
its tip at the level of mid SVC. Heart size and mediastinum are
unremarkable. There is substantial increase in the diameter of
the vasculature, consistent with vascular
engorgement/interstitial pulmonary edema. No focal
consolidations to suggest infectious process noted. There is no
pneumothorax. No sizeable pleural effusion is seen.
Brief Hospital Course:
Primary Reason for Admission: Mr [**Known lastname **] is a 54yoM with h/o
poorly controlled DM2 and right ankle osteomyelitis [**2-22**] fracture
in [**2143**], sternum osteomyelitis [**2-22**] CPR, currently on
dapto/flagyl/cipro, who presents with right ankle pain, "redness
around and drainage" from the PICC area, and +SIRS criteria.
.
Active Problems:
.
# Fevers: Likely [**2-22**] PICC site infection. He does have chronic
osteomyelitis, and to date has refused the definitive treatment,
which is BKA. He initially improved on his current abx
(dapto/flagyl/cipro), and has gotten worse since PICC placement.
He received zosyn in the ED. In the MICU his PICC was pulled and
he was started on dapto/zosyn. Lactate trended down from 4.0 to
1.5 after 3L NS, and he remained afebrile, so he left the MICU
within 24 hours. He remained afebrile for the remainder of his
course. His PICC tip culture was negative and blood cultures
were negative at the time of discharge. ID was consulted and
recommended resuming home Dapto/Cipro/Flagyl as they felt his
fever was [**2-22**] PICC site infection and not failure of antibiotics
for chronic osteo. Of note, his ESR has been downtrending, most
recently 38 in [**2147-12-21**]. A new PICC was placed and he was d/c'ed
with home IV therapy. He will f/u with surgery at [**Hospital1 2025**] on [**2148-1-30**]
for a second opinion regarding BKA vs salvage and will make a
final decision regarding future management of osteo at that
time. He will then see his PCP to discuss his decision for
definitive management.
.
# Right ankle osteo: Pt would likely benefit from BKA, but has
been resistant to this idea to date. He is scheduled to see a Dr
[**Last Name (STitle) **] [**Name (STitle) 2025**] who specializes in ankle infections, and if there are no
options from this doctor, he likely will proceed with BKA. ID
was consulted and recommed new PICC line and resuming
Dapto/Cipro/Flagyl for chronic calcaneal osteomyelitis.
Definitive management per above.
.
Chronic Problems:
.
# Diabetes: Continue home dose of NPH, and continue RISS.
Hyperglycemia likely [**2-22**] underlying infection.
.
# Depression: continue home dose citalopram
.
# Smoking: encourage patient to quit. Nicotine patch while
in-house.
.
Transitional Issues: Pt was d/c'ed home with VNA for infusion
services. He will see a surgeon at [**Hospital1 2025**] on [**2148-1-30**] regarding BKA
vs salvage and will then make a final decision regarding ongoing
management of his chronic calcaneal osteomyelitis. He will see
his PCP after his consultation at [**Hospital1 2025**] to discuss his decision
and plan for next steps in management.
Medications on Admission:
1. daptomycin 460mg q24h
2. Cipro 500 mg PO twice a day
3. Flagyl 500 mg Tablet PO three times a day
4. citalopram 40 mg Tablet PO once a day.
5. NPH insulin human recomb 38 units subcutaneously qAM, 40U qPM
6. Humalog 100 unit/mL Cartridge SS qid
7. nicotine 14 mg/24 hr Patch 24 hr daily
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. daptomycin 500 mg Recon Soln Sig: One (1) 460mg Intravenous
every twenty-four(24) hours.
4. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day.
7. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO twice a
day: with meals .
8. diclofenac potassium 25 mg Capsule Sig: Three (3) Capsule PO
twice a day as needed for pain.
9. insulin lispro 100 unit/mL Cartridge Sig: One (1) 10 units
Subcutaneous three times a day: please inject 10 units with
breakfast, lunch and dinner and use sliding scale as directed.
10. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: One (1) units Subcutaneous twice a day: inject 38 units
with breakfast and 40 units with dinner as directed.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Primary Diagnosis:
PICC site infection
Secondary Diagnosis:
Chronic Calcaneal Osteomyelitis
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr [**Known lastname **],
It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted for a fever. We performed
blood cultures that showed no bateria in your blood. We feel
your fever was due to a small infection around your PICC site.
We removed your PICC and replaced it with a new line. We feel
you are safe to return home on antibioitcs.
During this admission, we made no changes to your medications.
Followup Instructions:
Department: [**Hospital3 249**]
When: FRIDAY [**2148-2-2**] at 2:10 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11917**] [**Name8 (MD) **], 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
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2148-2-14**] at 11:30 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2148-3-26**] at 8:40 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"731.3",
"038.9",
"V12.53",
"250.80",
"999.31",
"784.0",
"731.8",
"305.1",
"995.91",
"V58.67",
"E879.8",
"730.17",
"272.4",
"514",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
9886, 9937
|
5875, 8128
|
290, 297
|
10084, 10084
|
4642, 5852
|
10722, 11677
|
3380, 3472
|
8867, 9863
|
9958, 9958
|
8552, 8844
|
10267, 10699
|
3487, 4125
|
4141, 4623
|
8149, 8526
|
238, 252
|
325, 2477
|
10018, 10063
|
9977, 9997
|
10099, 10243
|
2499, 3176
|
3192, 3364
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,864
| 186,167
|
41669
|
Discharge summary
|
report
|
Admission Date: [**2143-8-28**] Discharge Date: [**2143-9-4**]
Date of Birth: [**2071-11-22**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / clindamycin / Levaquin
Attending:[**First Name3 (LF) 31014**]
Chief Complaint:
STEMI
Major Surgical or Invasive Procedure:
cardiac catheterization with drug eluting stent x1 to the right
coronary artery.
History of Present Illness:
Ms. [**Known lastname 90583**] is a 71 year-old lady with a past medical history of
type 2 diabetes, hypertension, hyperlipidemia, obesity
presenting from PCP's office after a syncopal episode/Code blue
event, found to have inferior STEMI, now s/p 1 DES to mid-RCA
for 90% occlusion. At her PCP's office, the patient had
apparently been complaining of nausea and lightheadedness prior
to the episode. Per Atrius note, patient was sitting in the
waiting room and slumped over in her chair, witnessed by MA.
Patient was unresponsive and had "no heart rate." Chest
compressions were started, code was called. Pads were placed,
heart rate 114 in atrial fibrillation, patient spontaneously
regained conciousness, was alert and oriented. She was given
ASA 325 mg.
.
At 14:40, while en route to [**Hospital1 18**] with EMS, EKG showed ST
elevations in II, III, aVF and V3-V6, with reciprocal
depressions in I and aVL. On arrival to the [**Hospital1 18**] ED at 14:57,
initial EKG had similar findings also with Q waves ST depression
in V2. Patient was taken to the Cath Lab, where initial vital
signs were BP 149/114 HR 40s RR 20 SaO2 96% 2L. FSBS was noted
to be in the 500s. Access was attempted through RFA and RRA,
and eventually gained through LFA at 15:42. She was found to
have a mid-LAD elsion of 50-60% with extension into the diagnoal
branch and TIMI 3 flow into the distal LAD, LCx with moderate
luminal irregularities in the mid-vessel, and a calcified RCA
with 90% stenosis, which was stented with 1 DES. For her
bradycardia during the procedure, a temp wire was placed at the
RV apex and paced 70 bpm, and for her hypotension, dopamine drip
was started at 5-15 mcg/kg/min.
.
On arrival to the CCU, initial vital signs were 96.2 101/58 127
36 86%. The patient was agitated and turning cyanotic. She was
minimally responsive with sats in the 60-70%s. She was bagged.
Femoral and carotid pulse were not palpable. One chest
compression was attempted and she bolted upright in bed.
Subsequent vital signs were 95/42 113 33 100% 2L.
.
Of note, patient had been discharged from [**Hospital1 18**] with bilateral
cellulitis and acute renal failure. On discharge, her
lisinopril, lasix, and atenolol had been held. Lisinopril and
Lasix were restarted on [**8-16**], but atenolol was still held.
Additionally, she was noted to have a rash that was hypothesized
to be secondary to antibiotics.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None prior
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- DM2 uncontrolled with renal complications and right toe
amputations
- Obesity
- HTN
- Peripheral Edema
- Cellulitis
- Cataracts
- Hyperlipidemia
- Right toes amputated [**2136**]
Social History:
30 pack year smoker, quit [**2127**]. No Etoh, no illegal or
herbal/OTC drugs. Retired [**2133**], used to clean rooms in a hotel.
Married x2, 2nd husband died in [**2127**]. Now single. Lives with a
girl-friend [**First Name5 (NamePattern1) 17**] [**Name (NI) 90584**] [**Telephone/Fax (1) 90585**]). She eats a very
unhealthy diet, with a lot of hamburger. Does no exercise. Pt
does not leave the house often, mostly sits and watches TV. She
does not cook or clean.
Family History:
mother died of MI in 80's, had HTN and t2DM. Father died in 70's
of MI, had diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 96.2 95/42 113 33 100% 2L
GENERAL: NAD, Oriented x3. Mood, affect appropriate.
Comfortable, obese.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of to angle of jaw while flat/supine.
CARDIAC: RRR, nl S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Anteriorly, CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, obese, NTND. Normoactive bowel sounds.
EXTREMITIES: No edema. No femoral bruits. Right toes amputated.
Post cath check: distal pulsus intact with doppler, no bruits
aprpeciated, no hematoma.
SKIN: Extensive cellulitis on legs bilaterally, keratinosis and
edema of lower extremities c/w impaired lymphatic drainage.
PULSES:
Right: Carotid 2+ Radial 2+ DP 1+ PT dopp
Left: Carotid 2+ Radial 2+ DP dopp PT dopp
.
DISCHARGE PHYSICAL EXAMINATION:
Vitals - Tm/Tc:99.2/98.7 HR:72-75 BP: 109-148/50-56 RR: 20-24 02
sat: 97% RA
In/Out:
Last 24H: 1550/2195
Last 8H: 100/350
Tele: SR, no sig VEA
GENERAL: no acute distress
HEENT: mucous membs moist, no lymphadenopathy, unable to assess
JVD [**12-19**] body habitus.
CHEST: CTABL no wheezes, no rales, no rhonchi, [**Month (only) **] at bases.
CV: S1 S2 nl, no M/R/G
ABD: soft, non-tender, obese, BS normoactive.
EXT: [**12-20**]+ pitting edema, yellow/tan plaques that pt states is
chronic, some plaques falling off, no open areas. right foot
with no toes. DPs, PTs 1+
NEURO: CNs II-XII intact. 3/5 strength in U/L extremities.
Speech clear.
SKIN: no rash or open areas. Has excoriated areas under breasts.
Pertinent Results:
Admission labs:
[**2143-8-28**] 03:00PM BLOOD WBC-16.3*# RBC-4.77# Hgb-13.7 Hct-41.5#
MCV-87 MCH-28.7 MCHC-33.0 RDW-12.4 Plt Ct-200
[**2143-8-28**] 03:00PM BLOOD Neuts-80.2* Lymphs-15.7* Monos-3.5
Eos-0.2 Baso-0.4
[**2143-8-28**] 03:00PM BLOOD PT-13.1 PTT-21.9* INR(PT)-1.1
[**2143-8-28**] 03:00PM BLOOD Glucose-563* UreaN-50* Creat-1.6* Na-136
K-4.6 Cl-98 HCO3-24 AnGap-19
[**2143-8-28**] 04:00PM BLOOD CK(CPK)-330*
[**2143-8-28**] 03:00PM BLOOD cTropnT-1.46*
[**2143-8-28**] 03:00PM BLOOD Calcium-10.6* Phos-4.8* Mg-1.8
[**2143-8-28**] 10:51PM BLOOD Lactate-2.2*
.
Relevant labs:
[**2143-8-28**] 04:00PM BLOOD cTropnT-1.35*
[**2143-8-28**] 10:39PM BLOOD CK(CPK)-665*
[**2143-8-28**] 10:39PM BLOOD CK-MB-44* MB Indx-6.6* cTropnT-4.18*
[**2143-8-29**] 04:18AM BLOOD CK(CPK)-527*
[**2143-8-29**] 04:18AM BLOOD CK-MB-31* MB Indx-5.9 cTropnT-4.34*
[**2143-8-30**] 04:00AM BLOOD ALT-16 AST-36 LD(LDH)-325* CK(CPK)-163
AlkPhos-49 TotBili-0.4
[**2143-8-30**] 04:00AM BLOOD CK-MB-9 cTropnT-2.28*
[**2143-8-29**] 11:35AM BLOOD Cortsol-33.6*
[**2143-8-30**] 04:00AM BLOOD Hapto-172
[**2143-8-29**] 04:25AM BLOOD Lactate-1.3
[**2143-8-29**] 08:38PM BLOOD Lactate-0.6
[**2143-8-30**] 04:13AM BLOOD Lactate-0.7
.
Discharge labs:
[**2143-9-4**] 05:05AM BLOOD WBC-10.8 RBC-3.88* Hgb-11.1* Hct-33.9*
MCV-87 MCH-28.7 MCHC-32.8 RDW-12.9 Plt Ct-270
[**2143-9-4**] 05:05AM BLOOD Glucose-103* UreaN-32* Creat-1.0 Na-142
K-4.3 Cl-108 HCO3-26 AnGap-12
[**2143-9-4**] 05:05AM BLOOD Calcium-8.3* Phos-3.4 Mg-1.7
Imaging:
[**2143-8-28**] Cardiac Cath:
1. Coronary angiography in this right-dominant system revealed
one-vessel disease. The LMCa had no angiographically apparent
disease.
The LAD had a 50-60% stenosis in the mid vessel and a large
diagonal
branch had an ostial 50-60% stenosis. The LCx had moderate
luminal
irregularities. The RCA was calcified and had a distal hazy 90%
stenosis.
2. Resting hemodynamics revealed mildly elevated left- and
right-sided
filling pressures, with an RVEDP of 15 mm Hg and a PCWP of 18 mm
Hg.
There was moderate pulmonary arterial systolic hypertension,
with a
PASP of 50 mm Hg. The cardiac index was preserved at 2.7
L/min/m2. There
was no gradient upon pullback of the catheter from the left
ventricle to
the aorta.
3. Successful PTCA and stenting of the distal RCA with a 2.5 x
15 mm
Promus [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 7930**] to 2.75 (see PTCA comments).
4. Successful placement of temporary pacing wire (see PTCA
comments).
5. Successful RFA AngioSeal (see PTCA comments).
FINAL DIAGNOSIS:
1. Inferior STEMI.
2. One-vessel coronary artery disease.
3. Mildly elevated left- and right-sided filling pressures with
a preserved cardiac index.
4. Successful PCI of the distal RCA with a 2.5 x 15 mm Promus
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 7930**] to 2.75 mm.
5. Successful LFA AngioSeal.
.
[**2143-8-28**] TTE:
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is mildly dilated with mild global free wall hypokinesis.
The mitral valve leaflets are mildly thickened. Physiologic
mitral regurgitation is seen (within normal limits). The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension.
IMPRESSION: Suboptimal image quality due to body habitus. Left
ventricular systolic function is probably normal, a focal wall
motion abnormality cannot be excluded. The right ventricle is
not well seen but may be mildly dilated and hypokinetic.
Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2143-7-17**],
suboptimal quality persists. The right ventricle may be
dilated/hypokinetic on BOTH studies. The estimated pulmonary
pressure is higher on the current study.
.
[**2143-8-28**] Chest x-ray:
The lung volumes are low. Moderate cardiomegaly with signs of
mild
interstitial fluid retention. Calcified structure projecting
over the right lung apex, potentially belonging to the right
first rib. No major pleural effusions, but areas of bilateral
basal atelectasis are seen. No evidence of pneumonia.
.
[**2143-8-29**] Cardiac cath:
Selective coronary angiography of the RCA in this right dominant
system
demonstrated no flow limiting coronary artery disease with TIMI
3 flow
and a widely patent RCA stent. Due to concerns regarding
multiple IV
contrast loads in a short perior of time in this patient with
baseline
renal dysfunction, and the lack of ischemic changes other than
inferior
ST elevations, the LMCA/LAD/LCX were not assessed. Resting
hemodynamics
revealed mildly elevated right and left sided filling pressures
with a
mean RA pressure of 13 mmHg, a RVEDP of 14 mmHg, and a LVEDP of
18 mmHg.
The cardiac output/index were normal at 6.3/3.2. The systemic
vascular
resistance was low normal at 813 dynes-sec/cm5 and the pulmonary
vascular resistance was normal at 114 dynes-sec/cm5.
FINAL DIAGNOSIS:
1. Patent RCA stent with TIMI 3 flow in the RCA
2. Mildly elevated right and left sided filling pressures
3. Normal cardiac output/index
4. Low normal systemic vascular resistance.
.
[**2143-8-29**] TTE:
Patient is on dopamine. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function appears grossly normal. The
inferior and posterior walls were not well-visualized. The RV is
not well seen. An epicardial fat pad is seen. A pericardial
effusion cannot be excluded.
.
[**2143-8-29**] TTE:
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 and posterior walls. The right
ventricular free wall thickness is normal. The right ventricular
cavity is dilated with depressed free wall contractility
(primarily due to severe infundibular hypokinesis). The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. There is no pericardial effusion.
.
[**2143-8-29**] Lower extremity U/S:
No son[**Name (NI) 493**] evidence of right or left lower extremity DVT
with the above limitations.
.
[**2143-8-29**] Non-contrast CT abd/pelvis:
Right thigh edema/ecchymosis without evidence for active
hemorrhage or focal fluid collection.
.
[**2143-8-31**] Chest x-ray:
The right PICC line tip is at the level of the proximal right
atrium and
should be pulled back approximately 3 cm to place it at the
cavoatrial
junction. The Swan-Ganz catheter inserted through the femoral
approach is
noted, located slightly higher than expected most likely still
within the main pulmonary artery. Interstitial pulmonary edema
is seen as well as bibasilar atelectasis and most likely present
bilateral pleural effusions.
Brief Hospital Course:
Ms. [**Known lastname 90583**] is a 71 year-old lady with a past medical history of
type 2 diabetes (last hgbA1c 12.4%), hypertension,
hyperlipidemia, obesity presenting from PCP's office after a
syncopal episode/Code blue event, found to have RCA STEMI, now
s/p 1 DES to mid-RCA for 90% occlusion, with phsiology
suggestive of RV infarction. Hospital course also complicated
by anemia, hyperglycemia and a subclincal UTI.
.
.
ACTIVE ISSUES:
# STEMI: From 90% occlusion of RCA with RV infarct physiology.
Most likely, her syncopal episode and bradycardia were related
to inferior MI and increased vagal tone. Culprit lesion was
stented with 1 DES. Initially, the patient was hemodynamically
unstable with episodes of afib with RVR alternating with
bradycardia along with hypotension requiring dopamine, IV fluid
and two units PRBCs, due to preload dependence. She was
monitored on telemetry with restoration and maintenance of sinus
rhythm. She was weaned off dopamine, with stable blood
pressures. Her medical management was optimized with initial
integrillin drip, then aspirin 325 mg daily, clopidogrel 75 mg
daily, atorvastatin 80 mg daily and aggressive blood glucose
control. Once blood pressures were stable, the patient was also
started on metoprolol and lisinopril. Post-cath TTE showed LVEF=
45 % secondary to hypokinesis of the inferior and posterior
walls. At the time of discharge, the patient was chest
pain-free and hemodynamically stable. Her medications at
discharge were adjusted to include as many generic medications
as possible but clopidogrel is essential for the next year and
there is no generic equivalent. She will need a social work
consult to help her with medications.
.
# Anemia: During this hospitalization, the patient was noted to
have a slowly down-trending hematocrit, which was attributed to
peri-procedural bleeding. There were no other obvious sources
of bleed. She was transfused two units PRBCs with good
response. Hematocrit was stable upon discharge.
.
# Hyperglycemia/diabetes: Patient has very poorly controlled
diabetes at her baseline with A1C of 12.5. She was supposed to
be on glargine with humalog SS at home, but for financial and
compliance reasons she only took humalog, and only
intermittently. In setting of STEMI, her blood glucose was
controlled aggressively with an insulin drip. [**Last Name (un) **] consult
provided advice and teaching re: [**Hospital1 **] 70/30 dosing. Additionally,
the patient received education regarding her diet but admits she
eats what she wants. She has a f/u appt with [**Hospital **] clinic in
[**Month (only) 1096**].
# Asymptomatic UTI: Patient was noted to have 10-100K colonies
of pan-sensitive proteus in her urine, but was asymptomatic. No
treatment was pursused. Subsequent urine culture only grew 1000
colonies, which is not significant
.
CHRONIC ISSUES:
# CKD: Documented history of this problem. Creatinine was
stable, and all medications were renally-dosed
.
TRANSITIONAL ISSUES:
- please evaluate whether medications at home will be affordable
to pt.
- pt needs VNA with social worker at home after discharge
- please help pt replace cane with seat that was lost here
- please check fingersticks before meals and adjust NPH/regular
dosing for target blood sugar of 120.
Medications on Admission:
1. lovastatin 40 mg PO daily
2. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
3. ammonium lactate 12 % Lotion Sig: One (1) Appl Topical as
directed
4. calcium carbonate 650 mg calcium (1,625 mg) PO daily
6. Lantus 25 units SC qHS
7. Humalog SSI
8. triamcinolone acetonide 0.025 % Cream Sig: One (1) pea sized
amount Topical twice a day for 5 days: apply to itchy rash on
buttocks, do not apply to face, genitals, or hands.
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. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for groin, under pannus.
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. lovastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY AT 1400
().
8. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: Forty (40) units Subcutaneous before breakfast and dinner.
9. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
10. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One
(1) Tablet PO twice a day.
11. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
12. mupirocin calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
13. atenolol 25 mg Tablet Sig: 0.5 Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
Life Care Center at [**Location (un) 2199**]
Discharge Diagnosis:
Inferior ST elevation myocardial infarction
Hypertension
Poorly Controlled Diabetes Mellitus
Chronic Kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**].
You had a heart attack and a blockage was found in the right
coronary artery. This blockage was cleared and a drug eluting
stent was placed in the artery to prevent it from blocking
again. Your heart rate was low and you required a pacing wire to
keep your heart rate up temporarily. You will be on aspirin and
clopidogrel (Plavix) every day for at least one year and
possibly longer. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking Plavix and
aspirin unless Dr. [**Last Name (STitle) 911**] tells you it is OK to do so. You risk
having another heart attack if you do not take Plavix and
aspirin daily. Your blood sugars were very high here and we
adjusted your insulin to a combination short and long acting
version to better contol your blood sugars.
.
We made the following changes to your medicines:
1. START aspirin to prevent another heart attack
2. START clopidogrel (Plavix) to prevent the stents [**Last Name (un) 834**]
clotting off. This is extremely important to take this medicine
daily, do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking this medicine unless
Dr. [**First Name (STitle) **] tells you to. This is very important to prevent another
heart attack.
3. Resume atenolol to lower your heart rate
4. Change glargine insulin to 70/30 insulin twice daily to lower
your blood sugar. Please take before breakfast and dinner.
5. Decrease the lisinopril to 10 mg daily
6. Increase the furosemide (Lasix) to 40 mg in the morning and
20 mg at 2pm to get rid of extra fluid in your legs.
7. STart miralax to prevent constipation
8. Start calcium with vitamin D to prevent bone breakdown.
9. STart tylenol as needed for pain.
Followup Instructions:
Department: Diabetes medicine
When: [**2143-10-31**] at 2:00 PM
With: Dr. [**First Name4 (NamePattern1) 2411**] [**Last Name (NamePattern1) 90586**], Phone: [**Telephone/Fax (1) 9670**]
Best Parking: [**Street Address(1) 592**] Garage
.
Department: PODIATRY
When: MONDAY [**2143-10-7**] at 2:00 PM
With: [**Hospital 1947**] CLINIC (SB) [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
.
Name: [**Last Name (LF) 2257**], [**First Name3 (LF) **] B. MD
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2258**]
*It is recommended that you follow up with Dr. [**Last Name (STitle) 2257**] in [**2-20**]
weeks. His staff are working on an appointment for you. Please
call his office in a couple of days to get your appointment
information.
|
[
"403.90",
"276.2",
"427.89",
"414.01",
"V15.81",
"V15.82",
"041.6",
"585.9",
"458.8",
"272.4",
"599.0",
"V49.72",
"285.1",
"416.8",
"459.81",
"V58.67",
"250.42",
"410.41",
"V60.2",
"427.31",
"278.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.45",
"36.07",
"00.66",
"89.64",
"00.40",
"88.56",
"38.97",
"37.23",
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] |
icd9pcs
|
[
[
[]
]
] |
17911, 17982
|
12855, 13283
|
304, 387
|
18142, 18142
|
5979, 5979
|
20122, 21098
|
4242, 4330
|
16641, 17888
|
18003, 18121
|
16167, 16618
|
10977, 12832
|
18325, 20099
|
7196, 8502
|
4345, 4355
|
3443, 3527
|
5254, 5960
|
15848, 16141
|
259, 266
|
13298, 15703
|
415, 3333
|
5995, 7180
|
18157, 18301
|
3558, 3741
|
15719, 15827
|
3355, 3423
|
3757, 4226
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,497
| 166,871
|
26334
|
Discharge summary
|
report
|
Admission Date: [**2196-12-5**] Discharge Date: [**2196-12-15**]
Date of Birth: [**2129-5-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on Exertion
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Graft x 1 (SVG to OM), Mitral Valve
Repair w/ 32mm CE Annuloplasty Band
History of Present Illness:
Delightful 67 y/o male with a known heart murmur for many years
followed by serial echocardiograms. Most recent echo in [**Month (only) 359**]
showed worsening Mitral Regurgitation with an EF of 55%. A
cardiac cath also showed a 60% Ostial LCX lesion. He was seen as
an outpatient and admitted for elective cardiac surgery.
Past Medical History:
Hypertension
Hypercholesterolemia
Chronic Obstructive Pulmonary Disease
Interstitial Lung Disease/Pulmonary Fibrosis
Osteoarthritis
s/p Right Inguinal hernia repair
Social History:
Retired Firefighter. Quit smoking greater than 30 years ago.
Quit drinking approximately than 13 years ago.
Family History:
Father died at 64 s/p CABG
Physical Exam:
VS: 85 14 161/81 71" 210#
General: WDWN male in NAD
Skin: Warm, Dry -lesions
HEENT: EOMI, PERRL, NC/AT
Chest: CTAB -w/r/r
Heart: RRR, +S1S2, [**3-23**] holosystolic murmur at LLSB
Abd: Soft, NT/ND, +BS
Ext: War, well-perfused, -edema or varicosities
Neuro: A&O x 3, non-focal, MAE
Pulses: BFA 2+, BDP/BPT 1+
Pertinent Results:
[**2196-12-5**] 12:57PM BLOOD WBC-20.2*# RBC-2.73*# Hgb-8.9*#
Hct-26.0*# MCV-95 MCH-32.8* MCHC-34.3 RDW-13.5 Plt Ct-96*
[**2196-12-15**] 08:00AM BLOOD WBC-18.9* RBC-3.33* Hgb-10.8* Hct-30.3*
MCV-91 MCH-32.3* MCHC-35.5* RDW-14.8 Plt Ct-391
[**2196-12-15**] 08:00AM BLOOD PT-13.8* INR(PT)-1.3
[**2196-12-15**] 08:00AM BLOOD Glucose-104 UreaN-15 Creat-0.9 Na-134
K-4.9 Cl-99 HCO3-22 AnGap-18
Echo [**2196-12-14**]: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is mildly dilated. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is mildly/borderline
depressed. The right ventricular cavity is dilated. Right
ventricular systolic function appears depressed. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The aortic root is
moderately dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. A mitral valve
annuloplasty ring is present. Mild to moderate ([**12-20**]+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. The end-diastolic pulmonic regurgitation velocity
is increased suggesting pulmonary artery diastolic hypertension.
There is a small to moderate sized pericardial effusion. There
are no echocardiographic signs of tamponade. Echocardiographic
signs of tamponade may be absent in the presence of elevated
right sided pressures.
CXR [**2196-12-14**]: Patient is status post CABG and median sternotomy
wires are again seen. Cardiomediastinal silhouette is stable.
The patient has severe emphysema and pulmonary fibrosis, which
have been described. Accounting for differences in technique,
there is no change in the diffuse opacity which spares the left
upper lung zone most likely representing suerimposed congestive
heart failure. No pneumothorax is identified.
CT [**2196-12-14**]: 1. Acute asymmetric interstitial pneumonitis
superimposed upon a background of severe emphysema and pulmonary
fibrosis. In the setting of recent CABG and mitral valve repair,
diagnostic considerations include drug toxicity, asymmetric
pulmonary edema, unilateral lung injury, and less likely
infection. 2. Moderate pericardial effusion and small right
pleural effusion. 3. Likely reactive mediastinal lymph node
enlargement. 4. Low attenuation lesions within the liver that
are too small to characterize.
Brief Hospital Course:
As mentioned in the HPI patient was seen as an outpatient and
was a same day admit. He was brought directly to the operating
room where he underwent a coronary artery bypass graft x 1 and
mitral valve repair. Please see op note for surgical details.
Patient tolerated the procedure well and was transferred to the
CSRU in stable condition on Neo-Synephrine and Propofol. Later
on op day pt was weaned from mechanical ventilation and sedation
and was extubated. He was neurologically intact. On post op day
one, inotropes were weaned off and he was in stable condition
and was transferred to telemetry floor. Diuretics and b blockers
were started per protocol. Post op day two he had a low HCT
(24.6) and was transfused one unit of blood. Also received 1
unit on post op day seven. At time of discharge HCT was 30.3. On
post operative day three his chest tubes and epicardial pacing
wires were removed. Over the remaining hospital course patient
continued to make a slow recovery secondary to pulmonary issues
(prior lung dz/pulm. effusion). He continued to require oxygen
via nasal cannula and had repeated oxygen desaturation with
ambulation despite IS, Nebs, C&DB, and diuretics (discharge
weight was approxiamtely 3 kg over admit weight). Pulmonary team
was consulted. He also had transient episodes of Atrial
Fibrillation starting on post op day six which were intitally
converted with Lopressor. He was eventually started on Coumadin
with a goal INR 1.5-2. On post op day eight patient had an echo,
CXR, and CT. Please see pertinent results. Despite continued
efforts to improve pulmonary status, the patient's family
requested transfer to [**Hospital6 2752**] for ongoing care.
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5700**] has accepted him for ICU care at [**Hospital 2586**]. Ongoing issues were discussed with him by [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 65172**] PA. Will need coumadin dosing today after transfer.
Medications on Admission:
Spiriva
Diovan 80mg qd
Lipitor 10mg qd
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation 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. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Furosemide 20 mg IV BID
12. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours).
13. Coumadin 2 mg Tablet Sig: 1-2 Tablets PO once a day: Check
INR and titrate for a goal INR of 1.5-2. Dosing per [**Hospital 2586**] team.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 1
Mitral Regurgitation s/p Mitral Valve Repair
Hypertension
Hypercholesterolemia
Chronic Obstructive Pulmonary Disease
Interstitial Lung Disease/Pulmonary Fibrosis
Discharge Condition:
stable
Discharge Instructions:
Do not lift greater than 10 pounds for 2 months.
Make follow-up appointments.
If you notice any redness or drainage from incisions, or develop
fever greater than 101 please contact office.
[**Name2 (NI) **] take shower. Wash incisions with water and gentle soap and
pat dry. No baths. Do not apply lotions, creams, ointments or
powders to incisions.
Do not drive for 1 month.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] in 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 6254**] in [**1-21**] weeks
Dr. [**First Name (STitle) **] in [**12-20**] weeks
Completed by:[**2196-12-15**]
|
[
"427.31",
"515",
"401.9",
"414.01",
"272.0",
"424.0",
"997.1",
"492.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"39.61",
"35.12"
] |
icd9pcs
|
[
[
[]
]
] |
7427, 7442
|
4174, 6152
|
342, 438
|
7708, 7716
|
1491, 4151
|
1120, 1148
|
6241, 7404
|
7463, 7687
|
6178, 6218
|
7740, 8118
|
8169, 8377
|
1163, 1472
|
283, 304
|
466, 791
|
813, 979
|
995, 1104
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,918
| 172,284
|
41855
|
Discharge summary
|
report
|
Admission Date: [**2156-8-31**] Discharge Date: [**2156-9-4**]
Date of Birth: [**2109-9-7**] Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
headache and L-sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
46 year-old female with past medical history of "borderline
hypertension" diagnosed several years ago, but never followed
and
not on medications. She flew from [**Country 14635**] yesterday for a
complany
meeting, here in [**Location (un) 86**]. Patient states she was sitting in a
meeting when she had the acute onset of R sided headache
(temporal) and then inability to move her left arm, along with
left arm numbness. She did not try to stand, but believes her
leg felt weak and numb as well. She went to an OSH ED within 45
minutes of the event. At the OSH a CT head demonstrated R sided
thalamic bleed and a CTA was negative for AVM or vascular
malformation. She had a systolic blood pressure in 170s.
She denies recent illnesses, coughs, colds, diarrhea, or recent
headaches prior to today.
Past Medical History:
Borderline hypertension
Social History:
Lives in [**Country 14635**] with family. Denies tobacco,
occasional social alcohol. Works as a scientist at a
pharmaceutical company.
Family History:
Father died of a stroke in his early 60's.
Mother is still alive, with known hypertension.
Physical Exam:
ADMISSION PHYSICAL EXAM:
PHYSICAL EXAM:
T 98.2 HR 80 BP 144/87 RR 16 O2 100% 2L Nasal Cannula
General: Awake, cooperative, NAD.
Head and Neck: no cranial abnormalities, no scleral icterus
noted, mmm, no lesions noted in oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs clear to auscultation bilaterally
Cardiac: regular rate and rhythm, normal s1/s2. No murmurs,
rubs,
or gallops appreciated.
Abdomen: soft, non-tender, normoactive bowel sounds, no masses
or
organomegaly noted.
Extremities: 2+ radial, DP pulses bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
slowly. Unable to spell world backwards (English is not native
language). Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name high frequency objects (in English).
Speech
was not dysarthric. Mild left-sided neglect. Calculations
intact. Registered [**1-29**] and recalled [**1-1**] at 5 minutes.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1.5mm and brisk. Visual fields full on bedside
testing with red pin. Funduscopic exam revealed no papilledema,
exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: Mild left facial droop, musculature intact.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and sternocleidomastoid
bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Left-sided pronator drift.
No rigidity. No adventitious movements, such as tremors, noted.
No asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 4+ 4+ 4+ 4+ 5 5 5- 4 4+ 4 5- 5- 5-
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: Decreased pinprick left arm to mid-bicep. Normal
graphesthesia.
-Deep tendon reflexes:
[**Hospital1 **] Tri [**Last Name (un) 1035**] Pat Ach
L 3 3 2 3 2
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Not tested
Pertinent Results:
ADMISSION LABS:
[**2156-8-31**] 04:20PM BLOOD WBC-29.1* RBC-4.59 Hgb-14.1 Hct-42.7
MCV-93 MCH-30.8 MCHC-33.2 RDW-12.4 Plt Ct-363
[**2156-8-31**] 04:20PM BLOOD Neuts-94.4* Lymphs-3.7* Monos-1.2*
Eos-0.5 Baso-0.2
[**2156-8-31**] 04:20PM BLOOD PT-12.2 PTT-23.2 INR(PT)-1.0
[**2156-8-31**] 04:20PM BLOOD Glucose-98 UreaN-12 Creat-0.5 Na-137
K-4.1 Cl-102 HCO3-23 AnGap-16
[**2156-9-1**] 02:31AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.0 Cholest-192
[**2156-9-1**] 02:31AM BLOOD %HbA1c-5.4 eAG-108
[**2156-9-1**] 02:31AM BLOOD Triglyc-71 HDL-62 CHOL/HD-3.1 LDLcalc-116
[**2156-8-31**] 04:20PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
DISCHARGE LABS:
WBC 11, Hgb 14.6, Plt 347, Na 137, K 3.8, Cl 104, HCO3 24, BUN
10, Cr 0.6, Gluc 103
IMAGING:
CXR [**2156-8-31**]: IMPRESSION: No acute cardiopulmonary process.
CT HEAD [**2156-8-31**]: IMPRESSION: Stable appearance of right thalamic
hemorrhage, now with a small amount of intraventricular
extension.
CT HEAD [**2156-9-2**]: IMPRESSION: Stable appearance of right
posterior internal capsule and thalamic hemorrhage.
MRI/A:
FINDINGS:
MRI: There is no short interval change with regard to the left
thalamic
hemorrhage, measuring 27 x 23 mm in an axial projection.
Moderate mass effect with distortion of the third ventricle and
minimal midline shift is stable in appearance. Mild extension
into the ventricular system is seen with blood products layering
in both posterior horns. However, size and configuration of the
ventricles is stable and there is no evidence of hydrocephalus.
The hemorrhage has expected perilesional edema; it is not
associated with territorial infarct. 3D time-of-flight, T2
images and contrast-enhanced MP-RAGE sequences do not suggest an
associated DVA or vascular malformation. The bleeding displays
expected intrinsic T1 hyperintensity but there is no additional
contrast enhancement that might suggest an underlying mass.
An additional focus of susceptibility is seen in the right
parieto-occipital junction, likely representing a focus of prior
microbleed.
There is no abnormal leptomeningeal enhancement. The flow voids
of the
principal intracranial vessels are preserved. The visualized
paranasal
sinuses and mastoid air cells are clear. The orbits and osseous
structures
are unremarkable.
MRA: The intracranial internal carotid, vertebrobasilar, and
anterior, middle and posterior cerebral arteries are patent with
normal contrast enhancement and branching pattern. There is no
evidence of stenosis, occlusion, or aneurysm.
IMPRESSION:
1. No progression of right thalamic hemorrhage with discrete
interventricular extension and blood products layering in the
bilateral posterior horns. No new hydrocephalus.
2. No evidence of associated mass or vascular malformation.
3. An additional focus of susceptibility in the right
parieto-occipital
junction, likely representing previous microbleed.
TTE (echocardiogram) [**2156-9-3**]: The left atrium is normal in size.
No thrombus/mass is seen in the body of the left atrium. No
atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). No masses or thrombi
are seen in the left ventricle. There is no left ventricular
outflow obstruction at rest or with Valsalva. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. No
masses or vegetations are seen on the aortic valve. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. There is borderline
pulmonary artery systolic hypertension. No vegetation/mass is
seen on the pulmonic valve. There is no pericardial effusion.
Brief Hospital Course:
[**Known firstname 90894**] [**Known lastname 90895**]-[**Known lastname 90896**] is a 46 yo woman with PMHx significant for
borderline HTN (SBP of 135's) who presented from an OSH with a
thalamic hemorrhage.
[] Intraparenchymal Hemorrhage - The patient had a R thalamic
IPH. Her initial SBP was 170. Cerebral venous sinus thrombosis
was a potential etiology, but her imaging was not entirely
consistent with this. There was no evidence of vascular
abnormality and no history or external signs suggesting
malignancy. Her initial leukocytosis resolved quickly,
suggesting a potential spurious laboratory finding. This bleed
may be related to a cavernoma for which we are recommending a
repeat MRI/MRA in 1 month from discharge. She remained
normotensive and without any worsening of her symptoms or
examination. She will need physical therapy in [**Country 14635**]. She may
not fly for at least 10 days, aroudn [**9-10**]
[] Cardiac - EKG showed no signs of LVH, so we got an echo to
help determine if she had any systemic signs of hypertension.
The echo showed no major abnormalities. She did have elevated
diastolic BP before she left and we started Hydrocholorothiazide
at 25mg daily.
[] Leukocytosis - WBC on admission 26, quickly trending down to
9. We felt that this was likely a stress response rather than
infectious process as she has not gotten ABx or any treatment to
explain the decrease. She remained afebrile throughout this
admission.
NO PENDING STUDIES
TRANSITIONAL CARE ISSUES:
[ ] She needs a repeat MRI/MRA in 1 month to evaluate the
possibility of a vascular malformation/cavernoma underlying the
hemorrhage.
Medications on Admission:
None
Discharge Medications:
1. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Intracerebral hemorrhage (parenchymal, thalamic)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neurologic - Awake, alert, oriented, speech fluent, left arm and
leg mild weakness.
Discharge Instructions:
Dear Ms. [**Known lastname 90897**],
You were seen in the hospital because you had a bleed in your
brain. The bleed was in an area called the thalamus that helps
to control the strength of your left side. The bleed caused you
to have some left-sided weakness, for which you will need
rehabilitation to get stronger. We suspect that the bleed was
either related to a vascular malformation (a cavernoma) or high
blood pressure. However, your blood pressure has not been
elevated and has not required medication while you were here in
the hospital. You will need to have physical therapy when you
get to [**Country 14635**], as well as a repeat MRI in 1 month.
For safety, please do not fly until after [**2156-9-10**] due to your
recent hemorrhage.
If you are in the United States in [**Month (only) **], please see Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] in the [**Hospital 18**] [**Hospital 4038**] Clinic. Please call [**Telephone/Fax (1) 10676**]
prior to your appointment to update your insurance/demographic
information with Registration if you can see Dr. [**Last Name (STitle) **] in the
[**Hospital 4038**] clinic.
If you are not in the United States, please have your primary
care doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) 14635**] order an MRI/MRA of the Brain (magnetic
resonance imaging and magnetic resonance angiography) in one
month from now to reevaluate the area of the bleed/hemorrhage.
If you experience any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room.
It was a pleasure taking care of you on this hospitalization.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**],
Date/Time:[**2156-10-6**] 4:30, [**Hospital Ward Name 23**] 8, [**Hospital1 18**] [**Hospital Ward Name 516**] [**Location (un) 90898**]
|
[
"288.60",
"401.9",
"781.94",
"729.89",
"228.02",
"431"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9789, 9795
|
7957, 9436
|
341, 348
|
9897, 9897
|
3887, 3887
|
11803, 12098
|
1398, 1490
|
9653, 9766
|
9816, 9876
|
9624, 9630
|
10133, 11780
|
4547, 7934
|
2580, 3868
|
1545, 2122
|
272, 303
|
9462, 9598
|
376, 1181
|
3904, 4531
|
9912, 10109
|
1203, 1229
|
1245, 1382
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,997
| 145,271
|
18313
|
Discharge summary
|
report
|
Admission Date: [**2194-11-19**] Discharge Date: [**2194-11-24**]
Date of Birth: [**2161-7-10**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 50477**]
Chief Complaint:
twin pregnancy
Major Surgical or Invasive Procedure:
C-section
Dilation and evacuation
Supracervical Hysterectomy
History of Present Illness:
33 yo G1P0->2 admitted for scheduled low transverse cesarean
section of twin gestation at term.
Past Medical History:
diet controlled gestation hypertension
cholestasis
Social History:
no alcohol, tobacco, drug use
Physical Exam:
On admission:
97.9 90 18 102/69
NAD
RRR, no M/R/G
CTAB
Abd: soft, NT, gravid
Ext: no calf tenderness
Pertinent Results:
[**2194-11-19**] 08:08AM BLOOD WBC-7.1 RBC-4.44 Hgb-12.1 Hct-36.3 MCV-82
MCH-27.2 MCHC-33.2 RDW-16.1* Plt Ct-175
[**2194-11-19**] 12:00PM BLOOD WBC-9.1 RBC-3.38* Hgb-9.2* Hct-28.2*
MCV-84 MCH-27.3 MCHC-32.7 RDW-15.6* Plt Ct-147*
[**2194-11-19**] 01:14PM BLOOD WBC-9.5 RBC-1.98*# Hgb-5.6*# Hct-16.6*#
MCV-84 MCH-28.5 MCHC-34.0 RDW-16.2* Plt Ct-130*
[**2194-11-19**] 03:56PM BLOOD WBC-13.6* RBC-2.73*# Hgb-7.8*# Hct-22.4*#
MCV-82 MCH-28.6 MCHC-34.7 RDW-14.2 Plt Ct-95*
[**2194-11-19**] 05:30PM BLOOD WBC-12.0* RBC-3.01* Hgb-8.9* Hct-25.2*
MCV-84 MCH-29.7 MCHC-35.5* RDW-13.9 Plt Ct-108*
[**2194-11-19**] 06:00PM BLOOD WBC-7.7 RBC-2.82* Hgb-8.4* Hct-23.0*
MCV-82 MCH-29.9 MCHC-36.7* RDW-13.7 Plt Ct-143*
[**2194-11-19**] 06:30PM BLOOD WBC-5.4 RBC-2.53* Hgb-7.9* Hct-20.8*
MCV-82 MCH-31.1 MCHC-37.9* RDW-13.9 Plt Ct-169
[**2194-11-19**] 08:01PM BLOOD WBC-6.2 RBC-2.84* Hgb-8.5* Hct-22.8*
MCV-80* MCH-29.7 MCHC-37.1* RDW-13.8 Plt Ct-155
[**2194-11-20**] 12:03AM BLOOD WBC-7.6 RBC-2.75* Hgb-8.4* Hct-22.3*
MCV-81* MCH-30.6 MCHC-37.8* RDW-14.4 Plt Ct-137*
[**2194-11-23**] 10:20AM BLOOD WBC-8.0 RBC-3.49* Hgb-10.8* Hct-29.2*
MCV-84 MCH-30.8 MCHC-36.8* RDW-15.1 Plt Ct-210#
[**2194-11-19**] 01:14PM BLOOD PT-15.4* PTT-52.4* INR(PT)-1.3*
[**2194-11-19**] 03:56PM BLOOD PT-14.9* PTT-36.0* INR(PT)-1.3*
[**2194-11-19**] 05:00PM BLOOD PT-16.1* PTT-36.2* INR(PT)-1.4*
[**2194-11-19**] 05:30PM BLOOD PT-15.5* PTT-47.3* INR(PT)-1.4*
[**2194-11-19**] 06:00PM BLOOD PT-14.2* PTT-36.5* INR(PT)-1.2*
[**2194-11-19**] 06:30PM BLOOD PT-14.2* PTT-35.0 INR(PT)-1.2*
[**2194-11-20**] 12:03AM BLOOD PT-13.3 PTT-31.3 INR(PT)-1.1
[**2194-11-20**] 04:32AM BLOOD PT-13.7* PTT-30.1 INR(PT)-1.1
[**2194-11-21**] 08:05AM BLOOD PT-12.1 PTT-27.7 INR(PT)-1.0
[**2194-11-19**] 01:14PM BLOOD Fibrino-136*
[**2194-11-19**] 05:00PM BLOOD Fibrino-120*
[**2194-11-19**] 06:00PM BLOOD Fibrino-270
[**2194-11-19**] 08:01PM BLOOD Fibrino-390
[**2194-11-20**] 12:03AM BLOOD Fibrino-372 D-Dimer-As of [**11-11**]
[**2194-11-20**] 04:32AM BLOOD Fibrino-335
[**2194-11-21**] 08:05AM BLOOD Fibrino-366
[**2194-11-19**] 03:56PM BLOOD Glucose-131* UreaN-21* Creat-0.7 Na-138
K-4.6 Cl-109* HCO3-22 AnGap-12
[**2194-11-19**] 08:08PM BLOOD Glucose-110* UreaN-18 Creat-0.7 Na-142
K-3.2* Cl-106 HCO3-28 AnGap-11
[**2194-11-20**] 04:32AM BLOOD Glucose-103 UreaN-21* Creat-0.8 Na-143
K-4.3 Cl-107 HCO3-31 AnGap-9
[**2194-11-21**] 08:05AM BLOOD Glucose-78 UreaN-25* Creat-0.6 Na-136
K-3.7 Cl-103 HCO3-30 AnGap-7*
[**2194-11-19**] 08:08AM BLOOD ALT-40
[**2194-11-19**] 08:08PM BLOOD AlkPhos-83 TotBili-2.5*
[**2194-11-20**] 04:32AM BLOOD LD(LDH)-322* TotBili-1.7* DirBili-0.7*
IndBili-1.0
[**2194-11-19**] 03:56PM BLOOD Calcium-9.6 Phos-4.1 Mg-1.4*
[**2194-11-19**] 08:08PM BLOOD Calcium-10.5* Phos-4.2 Mg-1.4*
[**2194-11-20**] 04:32AM BLOOD Calcium-8.8 Phos-3.8 Mg-1.7
Brief Hospital Course:
This is a 33-year-old gravida 1, para 0 at 37 and 6 weeks with
IVF twins. Pregnancy was complicated by gestational diabetes
which was well controlled with diet and
cholestasis diagnosed 3 weeks prior to presentation. She had
been on Actigall and had resolution of all symptoms as well as
LFTs which were transiently elevated 2 weeks ago. Pt underwent
uncomplicated scheduled low transvere cesarean section but in
the recovery room she was noted to be expelling some clots. Exam
revealed a fundus at her umbilicus, however, her cervix was
noted to be 4 cm dilated and clots could be felt in the uterus.
They were unable to be expelled at the bedside. She was given
1000 mcg of Cytotec and taken to the operating room after an
ultrasound revealed a uterus full of clots for expulsion of
clots. Her vitals were stable at this time. Her pulse was 98 and
her blood pressure was 90/60. At the time of the D&C, Bakri
balloon was placed.
After the initial D & C, her bleeding was thought to be under
control for a short while, however, soon thereafter she began to
have more bleeding and developed a coagulopathy with blood loss
anemia, low platelets, low fibrinogen and an increased INR. She
was transfused packed red blood cells and fresh frozen plasma,
and was also given multiple uterotonics including Pitocin,
Cytotec, Hemabate and Methergine. This also did not alleviate
the bleeding. Therefore, she was taken back to the operating
room for another dilation and curettage and hysterectomy.
Intraoperatively, vaginal exam revealed persistence bleeding
and atony even after the uterus was evacuated of all clots with
the suction curettage. The decision was made to proceed with
exlorative laparotomy, and supracervical hysterectomy to stop
persistent bleeding from intermittently atonic uterus.
Intraoperatively, the pt received 5 units of packed red blood
cells, 8 units of fresh frozen plasma, 2 units of
cryoprecipitate and 3 six-packs of platelets. The patient
tolerated the procedure well. She remained intubated and was
transported to the intensive care unit for closer monitoring.
In the ICU, pt did very well. Her one day stay in the ICU was
uncomplicated. She never required any pressors. She was
extubated on post-op day one. On POD#1, pt was also transferred
to the floor. On the floor, pt tolerated a regular diet and was
soon ambulating and voiding spontaneously. Pt discharged on
POD#4 in good condition.
Medications on Admission:
Actigall
PNV
Colace
Iron
Zantac
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q3-4H () as needed.
Disp:*40 Tablet(s)* Refills:*0*
2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
3. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained
Release Sig: One (1) Capsule, Sustained Release PO DAILY
(Daily).
Disp:*100 Capsule, Sustained Release(s)* Refills:*2*
4. Breast Pump
Twins
Discharge Disposition:
Home
Discharge Diagnosis:
twin gestation
postpartum hemorrhage, uterine atony
acute blood loss anemia
Two Baby boys, 6#8oz and 6#9oz
Discharge Condition:
good
Discharge Instructions:
No heavy lifting for 6 weeks, No tampons, no intercourse for 6
weeks.
Followup Instructions:
3 weeks with Dr. [**Last Name (STitle) **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 50478**]
|
[
"286.6",
"666.32",
"782.1",
"648.81",
"576.8",
"666.12",
"648.22",
"648.92",
"285.1",
"V27.2",
"648.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"74.1",
"99.04",
"68.39",
"99.05",
"99.07",
"69.52"
] |
icd9pcs
|
[
[
[]
]
] |
6555, 6561
|
3589, 6022
|
305, 368
|
6712, 6719
|
755, 3566
|
6838, 7010
|
6104, 6532
|
6582, 6691
|
6048, 6081
|
6743, 6815
|
629, 629
|
251, 267
|
396, 493
|
643, 736
|
515, 567
|
583, 614
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,295
| 119,035
|
16839
|
Discharge summary
|
report
|
Admission Date: [**2131-2-2**] Discharge Date: [**2131-2-4**]
Date of Birth: [**2080-7-21**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 50 year old
woman with a history of left subclavian artery stenosis with
significant Steal syndrome.
PAST MEDICAL HISTORY: Significant for reflux as well as left
subclavian Steal syndrome.
MEDICATIONS ON ADMISSION: Aspirin 325 p.o. q. day;
Ticlopidine 250 mg p.o. b.i.d.; Pepcid
PAST SURGICAL HISTORY: Status post cholecystectomy; status
post breast biopsy.
PHYSICAL EXAMINATION: Neurological examination, the patient
is awake, alert and oriented times three. Pupils were equal,
round, and reactive to light and accommodation. Extraocular
muscles intact. Face was symmetric. No diplopia. No
pronator drift. Full strength in upper and lower
extremities.
HOSPITAL COURSE: The patient was seen by Dr. [**Last Name (STitle) 1132**] in
regards to the patient's left subclavian stenosis with Steal.
She was taken to the Angiography Suite on [**2131-2-2**]
and she underwent stent angioplasty of the left subclavian
artery. The patient tolerated the procedure well. She was
kept on Aspirin, Ticlopidine and heparin drip. After the
procedure she was kept on neurological checks q. 1 hour over
night. As of the morning of [**2-3**], the patient was
doing well. She was neurologically stable. The heparin was
shut off. The patient was transferred to the floor. She was
continued on her aspirin and Ticlopidine. The patient was
doing well again on [**2-4**], tolerating a regular diet,
voiding on her own. The pain was under control and the
patient was discharged to home.
DISCHARGE MEDICATIONS: The patient will be discharged on her
home medications as well as to continue 325 mg of Aspirin
p.o. q. day and 250 mg p.o. b.i.d. of Ticlopidine.
FOLLOW UP: The patient will follow up with Dr. [**Last Name (STitle) 1132**] in his
clinic in one month.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2131-2-4**] 00:10
T: [**2131-2-4**] 07:04
JOB#: [**Job Number 47478**]
|
[
"435.1",
"435.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"39.90",
"39.50",
"88.49"
] |
icd9pcs
|
[
[
[]
]
] |
1702, 1850
|
408, 473
|
875, 1678
|
497, 554
|
1862, 2197
|
577, 857
|
172, 291
|
314, 381
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,684
| 145,524
|
10837
|
Discharge summary
|
report
|
Admission Date: [**2125-11-8**] Discharge Date: [**2125-11-13**]
Date of Birth: [**2077-10-14**] Sex: M
Service: CT SURGERY
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 35336**] is a 48-year-old
male patient of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**]. The patient is status
post left anterior descending interventions, i.e., repeat
percutaneous transluminal coronary angioplasty in the past,
who was referred for a cardiac catheterization due to
recurrent exertional chest pain. The patient is a
48-year-old diabetic patient who reported new onset of
exertional chest discomfort and shortness of breath in [**2124-2-17**]. He underwent an exercise treadmill test on [**2124-7-12**], which revealed that, after five minutes of exercise on
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol, he complained of shortness of breath, calf
claudication, and had significant electrocardiogram changes.
He did have at that time some mild chest pain as well.
Electrocardiogram had inferolateral ST changes. On [**2124-7-18**],
he had cardiac catheterization at [**Hospital1 190**], where he was found to have an 80% ostial left
anterior descending lesion. There was no other obstructive
disease, however. His ejection fraction was noted to be 65%
at that time. He underwent a successful left anterior
descending DCA as well as percutaneous transluminal coronary
angioplasty and stenting at that time.
In [**2124-11-16**], he was taken back to the catheterization
laboratory because of recurrent exertional symptoms and
anteroseptal ischemia on his exercise treadmill after four
minutes of exercise. Angiography at that time revealed
re-stenosis of the previously-placed left anterior descending
stent. Other angiography revealed diffuse disease in the
distal left anterior descending up to 80% after the origin of
the D2. The circumflex had a minor disease, and the origin
of the RPDA had a 70% stenosis. He underwent successful DCA
as well as getting percutaneous transluminal coronary
angioplasty and brachytherapy of the left anterior descending
stent at that time.
In [**2125-6-16**], he underwent another re-look catheterization
because of again anteroseptal and apical ischemia noted on
his surveillance treadmill test. He was found to have a 90%
restenosis of the left anterior descending stent, along with
a 40% lesion distal to the stent margin. The RPDA had a 70%
lesion as well. He underwent repeat DCA, percutaneous
transluminal coronary angioplasty of the left anterior
descending ostium.
Ov[**Last Name (STitle) 35337**] past several weeks, however, the patient has
developed recurrent angina and it was occurring with walking
short distances, and occasionally when exercising, although
in most cases he was able to bike 30 to 45 minutes on a
stationary bike and feel "well." He was referred for repeat
catheterization and possible coronary artery bypass graft due
to this problem, and was ultimately referred to Dr. [**Last Name (Prefixes) 411**].
On admission, he denied claudication, no orthopnea, no edema,
no paroxysmal nocturnal dyspnea, no lightheadedness. He is
5'7", 248 pounds. Coronary artery disease risk factor
profile included hypertension, hypercholesterolemia,
diabetes.
PAST MEDICAL HISTORY: Significant for depression, coronary
artery disease status post multiple left anterior descending
interventions outlined above. He is diabetic, and has
hyperlipidemia.
PAST SURGICAL HISTORY: Significant for tonsillectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Aspirin 325 mg once daily, Lipitor
10 mg once daily, hydrochlorothiazide 25 mg daily at bedtime,
Toprol XL 50 mg daily at bedtime, Glucophage 500 mg three
times a day, folate 1 mg twice a day, Accupril 80 mg daily at
bedtime, Celexa 20 mg once daily.
LABORATORY DATA: CBC on [**2125-11-6**] revealed a white count of
7,000, hematocrit 42.6, platelet count 204,000. INR .88, BUN
and creatinine of 19 and 0.7.
SOCIAL HISTORY: He is married, and works as a lecturer.
HOSPITAL COURSE: He was admitted and given pre-hydration and
Mucomyst protocol. He ultimately underwent a cardiac
catheterization on [**2125-11-8**] showing severe in-stent
restenosis in the ostial left anterior descending stent, as
well as moderate left circumflex and posterior descending
artery disease, with low normal left ventricular ejection
fraction, estimated to be 40 to 50%.
On [**2125-11-9**], the patient was brought to the operating room,
where he underwent a coronary artery bypass graft x 3,
including left internal mammary artery to left anterior
descending, saphenous vein graft to the posterior descending
artery, as well as saphenous vein graft to obtuse marginal.
His pericardium was left open. He left the operating room
with a right radial arterial line and a right internal
jugular Swan-Ganz catheter. He had atrial pacing wires. He
had a mediastinal and left pleural tube as well. His
cardiopulmonary bypass time was 53 minutes, with an aortic
cross-clamp time of 32 minutes. He came off pump relatively
well. He was extubated on the night of surgery.
By postoperative day number one, he was doing well. He was
started out of bed, chest physical therapy, ambulation. He
was started on lasix, Lopressor and aspirin. His diet was
advanced as tolerated, and his postoperative hematocrit was
noted to be 27.3, with a BUN and creatinine of 17 and 0.6.
His chest tubes were shortly thereafter discontinued.
By postoperative day number two, he had already been
transferred to the floor. He was making excellent progress.
He did have some low-grade temperatures to 100.3, which were
felt to be secondary to pulmonary toileting issues. He was
in sinus in the 80s, with a blood pressure of 110/80. His
pacing wires were thereafter discontinued. His dressings
were taken down from his wounds. He was continued on lasix
20 mg by mouth twice a day as well as Lopressor titrated to a
dose of 25 mg by mouth twice a day.
Over the next several days, he did quite well. He was
working with Physical Therapy aggressively. By postoperative
day number three, the patient was cleared from Physical
Therapy, as he had cleared stairs. His Lopressor was
titrated serially. His preoperative medications were added
back without any difficulty. He had excellent glycemic
control, and was otherwise progressing quite well and had a
remarkably postoperative recovery.
Discharge temperature is 99.7, heart rate 60s and sinus,
blood pressure 100/50, breathing at a rate of 20, room air
saturation 94%. His oropharynx was negative, mucous
membranes were moist. His trachea was midline. He had no
carotid bruits. The lungs were clear but decreased at the
bases, no crackles. His heart sounds were regular rate and
rhythm, normal S1 and S2. His wound was stable. No drainage
was noted. Staples were intact. Otherwise his dressings on
the inferior portion of the wound were clean, dry and intact.
His abdomen was benign. His lower extremities were warm and
well perfused, with no edema.
DISCHARGE MEDICATIONS:
1. Lipitor 10 mg by mouth once daily
2. Hydrochlorothiazide 25 mg by mouth daily at bedtime, to
be on hold, not to be started until after his lasix diuresis
is completed
3. Glucophage 500 mg by mouth three times a day
4. Folate 1 mg by mouth twice a day
5. Accupril 80 mg by mouth daily at bedtime, to be on hold
until seen and evaluated by his primary care [**Provider Number 35338**]. Celexa 20 mg by mouth once daily
7. Lasix 20 mg by mouth twice a day for five days, then stop
and change to hydrochlorothiazide 25 mg daily at bedtime
8. Aspirin 325 mg by mouth once daily
9. Colace 100 mg by mouth twice a day
10. Percocet 5/325 one to two tablets by mouth every four to
six hours as needed
11. Ibuprofen 600 mg by mouth three times a day as needed
with food
12. K-Dur 20 mEq by mouth twice a day for five days, stop
after his lasix diuresis is completed
DI[**Last Name (STitle) 408**]E INSTRUCTIONS: He should follow up with Dr. [**Last Name (Prefixes) 411**] in approximately three to four weeks, and see his
primary care physician in one to two weeks so that his
medications can be serially reviewed and his Accupril and
hydrochlorothiazide be readdressed. The patient is
encouraged to take a diabetic, heart-healthy diet, to follow
his finger sticks for glycemic control in the immediate
postoperative time.
DISCHARGE STATUS: To home.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2125-11-12**] 23:32
T: [**2125-11-13**] 00:00
JOB#: [**Job Number 35339**]
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3512, 3582
|
174, 3295
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|
4038, 4079
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,237
| 130,173
|
23167
|
Discharge summary
|
report
|
Admission Date: [**2106-3-10**] Discharge Date: [**2106-3-17**]
Date of Birth: [**2047-12-9**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 58-year-old female who
is known to our service. She was previously evaluated for
complaints of palpitations and syncope. Her symptoms were
associated with sensation of feeling very weak and somewhat
diaphoretic. After seeking medical attention, an EKG
confirmed atrial fibrillation. Subsequent testing included
TEE which revealed an ICM ASD with left-to-right shunting, RV
and RA were very dilated. She was cardioverted and started on
Coumadin. Today she is admitted prior to surgery planned for
[**2106-3-12**] for minimally invasive ASD repair. She was
admitted today to start Heparin. She has discontinued her
Coumadin on [**2106-3-6**].
Cardiac catheterization prior to admission on [**2106-1-21**] showed an ejection fraction of 60%, an ASD with Qp/Qs of
1.5, a mild MR, and clean coronaries.
PAST MEDICAL HISTORY:
1. ASD.
2. Atrial fibrillation status post cardioversion [**2105-11-24**].
3. Anxiety.
4. Status post removal of lipoma.
5. Status post benign breast mass biopsy.
6. Status post tonsillectomy.
MEDICATIONS AT THE TIME OF ADMISSION:
1. Lopressor 25 mg p.o. b.i.d.
2. Coumadin had been discontinued at [**2106-3-6**]. Prior to
that, she was on 2.5 mg alternating with 7.5 mg daily.
3. Paxil 15 mg p.o. once a day.
4. Klonopin 0.5 mg p.o. 3x a day.
ALLERGIES: She had no known drug allergies.
FAMILY HISTORY: Her family history was noncontributory.
SOCIAL HISTORY: She was married with 1 child and had no
tobacco or social alcohol history.
She had no history of CVA, TIA, migraine headaches, or
seizures. She did have palpitations and some syncopal
episodes prior to this admission.
On exam, she was 5 feet 4 inches tall, 135 pounds, saturating
96% on room air, blood pressure 127/79, sinus rhythm at 74.
She appeared her stated age. She was in no apparent distress.
Her skin and HEENT exams were unremarkable. Her neck was
supple without an thyromegaly, lymphadenopathy, or carotid
bruits. Her heart was regular rate and rhythm with S1, S2
tones and no murmurs, rubs, or gallops. Her lungs were clear
to auscultation bilaterally. Abdomen was soft, nontender,
nondistended with positive bowel sounds, no rebound or
guarding. Extremities were warm without any clubbing,
cyanosis, edema, or varicosities. She had cranial nerves II
through XII intact, alert and oriented times three with a
nonfocal exam. Her pulses were 2+ femoral bilaterally, 2+
radial bilaterally, 2+ DP bilaterally, and 2+ PT bilaterally.
She is admitted for full laboratory studies and to start
Heparin later in the day based on her labs.
On hospital day 2, her labs were as follows: Her sodium 141,
K 4.4, chloride 103, bicarbonate 31, BUN 16, creatinine 0.8
with a blood sugar of 82. White count 5.7, hematocrit 38.6,
platelet count 308,000. PTT 47.3 on Heparin. ALT 17, AST is
23, LDH 188, alkaline phosphatase 75, amylase 70, total
bilirubin 0.9. Her UA was negative.
Blood pressure 108/61 in sinus rhythm at 62. Her exam was
otherwise unremarkable. Patient was very concerned about
panic preoperatively and discussion was had to make sure she
gets her benzodiazepine in the morning if her condition
permits. Heparin was started and on hospital day 2, she was
on 600 units an hour. Was continuing with her Klonopin,
Paxil, and Lopressor therapy.
Sh[**Last Name (STitle) **]also seen and evaluated by case management. On the
17th, additional lab work was a PT of 13.2. She was placed to
be NPO after midnight that evening. On [**3-12**], she
underwent a minimally invasive ASD secundum closure by Dr. [**Last Name (Prefixes) 2545**].
She was transferred to cardiothoracic ICU in stable condition
on a Neo-Synephrine drip at 0.5 mcg/kg/minute. She was weaned
and extubated without incident later that evening. On
postoperative day 1, her white count was 9.3, hematocrit 25,
platelet count 215,000. K 4.1, BUN 11, creatinine 0.7.
Patient's chest tubes were discontinued. She remained on Neo-
Synephrine drip at 0.8 mcg/kg/minute and weaning of that was
begun, and her Foley was discontinued.
On postoperative day 2, her hematocrit dropped slightly to
22, K 3.9. Her Neo-Synephrine was still at 0.7 mcg/kg/minute.
Her central line was to be discontinued once her Neo-
Synephrine was off. She was transfused a unit of pack red
blood cells for her hematocrit.
On postoperative day 3, her Neo-Synephrine had been weaned
off successfully. Her hematocrit dropped to 20.5, and she was
transfused 2 units of pack red blood cells and transferred
out to the floor with a stable blood pressure of 98/47, heart
rate in sinus tachycardia at 100.
On postoperative day 4, she remained in the cardiothoracic
ICU. Her creatinine was stable at 0.7. Her hematocrit rose to
26.8. She had decreased breath sounds on the right and a
chest x-ray was obtained, and she was transferred out to the
floor.
On the floor, she began to work with the nurses and physical
therapists increasing her activity level and ambulating with
PT. She was also encouraged to use her incentive spirometer
for good pulmonary toilet and made very good progress with
her activity level. Her hematocrit rose to 27.9. Her
creatinine was stable at 0.7.
On postoperative day 5, she was discharged to home with VNA
services. She was doing very well. She had decreased breath
sounds in her right base, but otherwise her exam was
unremarkable. Bowel sounds were present. Lungs were otherwise
clear. She was alert and oriented with nonfocal exam. Her
pacing wires and central venous line all had been removed.
Extremities were warm with no edema.
Sh[**Last Name (STitle) 59591**] very well and was deemed ready for discharge
with the following follow-up instructions: She was told to
followup with Dr. [**Last Name (Prefixes) **] approximately 3-4 weeks post
discharge for her postop surgical visit, to followup with Dr.
[**Last Name (STitle) **] in [**12-27**] weeks post discharge, and to followup with her
cardiologist in approximately 1-2 weeks post discharge.
DISCHARGE DIAGNOSES:
1. Status post minimally invasive anteroseptal defect
secundum closure.
2. Atrial fibrillation status post cardioversion [**Month (only) **]
[**2104**].
3. Anxiety.
4. Status post removal of lipoma.
5. Status post benign breast biopsy.
6. Status post tonsillectomy.
DISCHARGE MEDICATIONS:
1. Metoprolol 12.5 mg p.o. twice a day.
2. Lasix 20 mg p.o. twice a day for 5 days.
3. Potassium chloride 20 mEq p.o. twice a day for 5 days.
4. Colace 100 mg p.o. twice a day.
5. Percocet 5/325 1-2 tablets p.o. p.r.n. q.4h. for pain.
6. Vitamin C 500 mg p.o. twice a day.
7. Ferrous gluconate 300 mg p.o. once a day.
8. Ibuprofen 600 mg p.o. q.6h.
9. Clonazepam 0.5 mg p.o. 3x a day.
10. Paxil 15 mg p.o. once a day.
11. Aspirin enteric coated 325 mg p.o. once a day.
The patient was discharged in stable condition on [**2106-3-19**].
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2106-4-12**] 13:39:00
T: [**2106-4-13**] 09:40:34
Job#: [**Job Number 59592**]
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1512, 1553
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6119, 6393
|
6416, 7216
|
165, 975
|
5800, 6098
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997, 1495
|
1570, 5776
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,657
| 176,997
|
13519
|
Discharge summary
|
report
|
Admission Date: [**2145-4-16**] Discharge Date: [**2145-4-18**]
Date of Birth: [**2112-11-14**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Watermelon / Almond Oil
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 21822**] is a 32 yo M w/hx of DM type I, ESRD on HD who
presents with shortness of breath and hypoxemia. Patient has
been in usual state of health. On Thursday morning he noticed
he was more short of breath. Went to HD yesterday and completed
session w/o events (w/ 1.6L ultrafiltration). Unfortunately,
yesterday afternoon/evening developed progressive shortness of
breath worst when lying flat. No reported fevers, chills, night
sweats, productive cough or other complaints. No sick contacts,
recent travel. To patient feels similar to previous admission
in [**Month (only) 958**] when he had dyspnea related to volume overload.
.
In the ED, initial vs were: T99.4 HR 98 BP 185/108 RR18 100.
Initial impression was for pulmonary edema in setting of
diastolic dysfunction and hypertensive urgency. Was given oral
medications/home regimen for treatment of BP. CT Chest
performed that excluded PE, and showed stable ground glass
opacities. Read of CT Chest concerning for infection rather
than volume overload, and patient was covered in ED with vanco.
Zosyn held given PCN allergy. Renal contact[**Name (NI) **] who saw patient
and planning HD on arrival to floor.
.
Prior to transfer to the ICU, patient's VS were: HR 91, 153/86
100% NRB, RR 20.
.
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:
- HTN
- DM I since age 19, seen at [**Last Name (un) **]. Complicated by nephropathy,
gastroparesis, and possibly retinopathy. Recent admissions for
DKA and hypoglycemia.
- ESRD/CKD: thought to be related to HTN and longstanding
diabetes.
Now on hemodialysis T/Th/Sat. Does make urine. Has been listed
on kidney/pancreas transplant wait list since 4/[**2144**].
- Anemia: Thought to be combination of iron deficiency and CKD,
now on epo with dialysis
- Depression
- s/p appendectomy [**7-/2144**]
Social History:
States that he previously drank heavily (30-40 drinks/week) but
has not used alcohol since [**2144-11-14**]. +h/o tobacco use, quit in
[**2142**], relapsed, quit last year and denies tobacco currently.
Denies other drugs. Neg PPD [**2145-2-26**]. Lives with girlfriend.
Family History:
No FH of pancreatitis. Diabetes and heart trouble in
grandfather.
Physical Exam:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, 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:
Labs on admission:
[**2145-4-16**] 03:34AM PLT COUNT-299
[**2145-4-16**] 03:34AM NEUTS-64.7 LYMPHS-25.1 MONOS-7.1 EOS-2.4
BASOS-0.7
[**2145-4-16**] 03:34AM WBC-8.1 RBC-3.73* HGB-11.1* HCT-33.1* MCV-89
MCH-29.7 MCHC-33.5 RDW-14.9
[**2145-4-16**] 03:34AM K+-5.1
[**2145-4-16**] 03:34AM COMMENTS-GREEN TOP
[**2145-4-16**] 03:34AM CK-MB-2
[**2145-4-16**] 03:34AM cTropnT-0.24*
[**2145-4-16**] 03:34AM CK(CPK)-187
[**2145-4-16**] 03:34AM GLUCOSE-289* UREA N-19 CREAT-5.9* SODIUM-131*
POTASSIUM-7.8* CHLORIDE-94* TOTAL CO2-29 ANION GAP-16
[**2145-4-16**] 09:00AM URINE RBC-[**3-12**]* WBC-[**3-12**] BACTERIA-FEW YEAST-NONE
EPI-0
[**2145-4-16**] 09:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-500
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2145-4-16**] 09:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2145-4-16**] 09:00AM URINE cocaine-NEG amphetmn-NEG
[**2145-4-16**] 09:00AM URINE HOURS-RANDOM
[**2145-4-16**] 11:54AM TYPE-ART PO2-92 PCO2-44 PH-7.47* TOTAL
CO2-33* BASE XS-7
[**2145-4-16**] 12:42PM ALBUMIN-3.4* CALCIUM-9.1 PHOSPHATE-4.2
MAGNESIUM-1.7
[**2145-4-16**] 12:42PM CK-MB-2 cTropnT-0.24*
[**2145-4-16**] 12:42PM LIPASE-19
[**2145-4-16**] 12:42PM ALT(SGPT)-21 AST(SGOT)-22 LD(LDH)-269*
CK(CPK)-74 ALK PHOS-88 TOT BILI-0.3
[**2145-4-16**] 12:42PM GLUCOSE-188* UREA N-18 CREAT-6.9* SODIUM-137
POTASSIUM-4.1 CHLORIDE-97 TOTAL CO2-30 ANION GAP-14
.
MICROBIOLOGY:
Blood Cx [**4-16**]: NGTD (not final at discharge)
Urine Cx [**4-16**]: Neg
Legionella Urine Ag [**4-16**] Neg
.
IMAGES/STUDIES:
.
CXR [**2145-4-16**]:
PORTABLE UPRIGHT CHEST X-RAY: There is increased opacity in the
bilateral lungs, which appears more severe at the right base.
This is diffuse and nonfocal, and suggests a diffuse airspace
process. There is no pleural effusion. There is no pneumothorax.
The cardiac contour is enlarged and globular, in keeping with
known pericardial effusion. The mediastinal contour is otherwise
unremarkable. The visualized bones and the upper abdomen
demonstrate no acute abnormality.
IMPRESSION:
1. Enlarged cardiac silhouette, in keeping with known
pericardial effusion.
2. New diffuse airspace opacities, which appears more severe
than right. Lack pleural effusions argue against volume
overload, and a diffuse infectious process is considered more
likely. Other etiologies, including hemorrhage, are not
excluded.
.
CTA [**2145-4-16**]:
FINDINGS: The aorta is normal in caliber and configuration, with
no evidence for acute aortic syndrome. There is adequate
opacification of the pulmonary arterial tree, with no evidence
of filling defect to suggest pulmonary embolus. The main
pulmonary artery is again enlarged, suggesting pulmonary artery
hypertension. There is a moderate pericardial effusion, similar
in size to prior study. The heart is otherwise unremarkable.
Prominent prevascular and pretracheal mediastinal nodes are
again noted. In the lungs, there are diffuse ground-glass,
somewhat nodular opacity, seen predominantly in the lower lobes
with relative sparing of the apices. This is improved compared
to [**2145-3-21**]. More consolidative processes at the bases
have improved. While there is slight septal thickening,
suggesting that a component of this may represent pulmonary
edema, the lack of effusion argues against attributing this
strictly to volume overloada, and infectious etiologies remain
strong consideration. The trachea and central airways are patent
to the subsegmental level, without endobronchial lesions
identified. The esophagus appears normal. There is no acute
abnormality identified in the upper abdomen.
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
lesions.
IMPRESSION:
1. No evidence for acute aortic syndrome or pulmonary embolism.
2. Extensive ground-glass, nodular opacities throughout both
lungs, most predominant in the lower lobes, remain most
concerning for infection. Other diagnostic considerations
include pulmonary edema (given history of renal failure and HTN)
or pulmonary hemorrhage. Findings are improved. There is
prominent pretracheal and prevascular lymph nodes again present,
possibly reactive.
3. Moderate pericardial effusion, stable.
4. Prominent main pulmonary artery, again suggestive of
pulmonary hypertension.
Brief Hospital Course:
Mr. [**Known lastname 21822**] is a 32 y/o M w/ DM, ESRD on HD, HTN who presents
with acute onset dyspnea and hypertensive urgency.
.
# Dyspnea/Hypoxemia:
The patient was admitted to the MICU given his respiratory
distress. The most likely cause was felt to be hypertension
precipitating diastolic dysfunction and pulmonary edema. There
was likely a significant component of volume-overload to this
presentation as blood pressure, respiratory status and oxygen
requirement decreased post-hemodialysis with removal of >3L
fluid. A CTA demonstrated ground glass opacities with possible
infectious etiology so he was initially covered with broad
spectrum antibiotics. Blood cultures negative, urine legoinella
negative, and clinical status improved with fluid removal so
antibiotics stopped on day 2. The patient was weaned rapidly
from non-rebreather to room air post-dialysis, and did not
require supplemental oxygen for the remainder of his
hospitalization.
.
# Malignant Hypertension:
His blood pressure was acutely controlled on a nitroglycerin
drip with rapid transition to control on home medications and
removal of fluid with hemodialysis. Hydralazone was
discontinued, as it was felt that it could be contributing to
his complaints of fatigue and depression. Lisinopril was
titrated up from 20 mg to 30 mg daily, and the remainder of his
antihypertensive medications were continued at home doses.
.
# ESRD:
The renal team was consulted on arrival and hemodialysis was
started on the day of admission with removal of 3.3L of fluid.
The next day 400ml were taken off and hemodialysis was stopped
early due to an episode of chest pain. His home medications were
continued. He received epogen and zemplar with HD.
.
# Type 1 Diabetes Uncontrolled with Complications:
Last A1c 7.5 in [**Month (only) 404**]. The patient was continued on his home
regimen of lantus 15 units daily, and humalog sliding scale.
.
# R-Arm Pain:
Thought to be possibly related to AV Graft as having elevated
venous pressures during session, and some clot retrieved at
start of session. Did thrombose graft and had thrombectomy in
past month. However, the pain was worse with movement and
could also be musculoskeletal. The graft functioned well during
dialysis.
.
# Chest pain:
The patient described left sided chest pain that was worse with
inspiration and reproducible with palpation. EKG was unchanged.
Cardiac enzymes were cycled with normal CK and slightly elevated
but unchanged troponins. This was thought to be due to demand
related ischemia in the setting of ESRD. CTA on admission was
negative for pulmonary embolism.
.
# Failure to thrive/weight loss:
Felt most likely to be secondary to depression. The option of
starting an SSRI was discussed with the patient, and he
declined. He was also followed by social work during this
admission.
Medications on Admission:
Hydralazine 25mg PO TID
Lisinopril 20mg PO qday
Calcium Acetate 667mg tablets - 2 tablets TID with meals -> not
taking
Reglan 5mg PO TID - not eating well so using sporadically
Vitamin D 5,000 IU PO qday x 2 weeks -> not taking currently
Calcitriol 0.25mg daily -> not taking
Amlodipine 10mg PO qday
Toprol XL 200mg PO qday
Laisx 80mg PO qday PO qday
Glargine 15 units SC qAM
Humalog sliding scale as below
< 50 0 15
51 100 0 0 0 0 0
101 150 0 0 0 0 0
151 200 0 0 0 0 0
201 [**Telephone/Fax (2) 40889**]1 300 4 0 4 4 2
301 350 6 0 6 6 4
351 400 8 0 8 8 6
> [**Telephone/Fax (2) 40890**] 8
All insulin doses in units
Discharge Medications:
1. Calcium Acetate 667 mg Tablet [**Telephone/Fax (2) **]: Two (2) Tablet PO three
times a day: with meals.
2. Metoclopramide 10 mg Tablet [**Telephone/Fax (2) **]: 0.5 Tablet PO TID W/ MEALS
().
3. Vitamin D 50,000 unit Capsule [**Telephone/Fax (2) **]: One (1) Capsule PO once a
week.
4. Calcitriol 0.25 mcg Capsule [**Telephone/Fax (2) **]: One (1) Capsule PO once a
day.
5. Amlodipine 5 mg Tablet [**Telephone/Fax (2) **]: Two (2) Tablet PO DAILY (Daily).
6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
[**Telephone/Fax (2) **]: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Furosemide 40 mg Tablet [**Telephone/Fax (2) **]: Two (2) Tablet PO DAILY (Daily).
8. Lisinopril 30 mg Tablet [**Telephone/Fax (2) **]: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Lantus Solostar 300 unit/3 mL Insulin Pen [**Telephone/Fax (2) **]: Fifteen (15)
units Subcutaneous qAM.
10. Humalog 100 unit/mL Solution [**Telephone/Fax (2) **]: ASDIR Subcutaneous four
times a day: Please follow [**Last Name (un) 387**] sliding scale.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Pulmonary Edema
Hypertensive Urgency
Diabetes Mellitus Type I - poorly controlled, with complications
ESRD on Hemodialysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You have severe hypertension, and were admitted to the hospital
for low oxygen. We think that your lungs became filled with
fluid because of an episode of severe hypertension. It is very
important to take all of your blood pressure medications and
continue with dialysis. If you decide to stop either of these
treatments, it is likely that you will become very ill and
possibly die.
.
We made the following changes to your home medications:
-STOP Hydralazine
-INCREASE Lisinopril to 30 mg daily
Please take all of your other medications as prescribed.
Followup Instructions:
Please call your kidney doctor, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], within 1-2 weeks.
Tel [**Telephone/Fax (1) 673**]
.
Please also call your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] to see him within [**1-9**]
weeks. Tel [**Telephone/Fax (1) 250**]
.
Department: ADVANCED VASC. CARE CNT
When: WEDNESDAY [**2145-4-21**] at 2:00 PM
With: [**Name6 (MD) 5536**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 5537**]
Building: [**Street Address(2) 7298**] ([**Location (un) 583**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: TRANSPLANT
When: MONDAY [**2145-7-19**] at 2:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
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"280.9",
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icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
12453, 12459
|
7847, 10686
|
319, 326
|
12645, 12645
|
3533, 3538
|
13375, 14328
|
2935, 3004
|
11361, 12430
|
12480, 12624
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10712, 11338
|
12796, 13222
|
3019, 3514
|
13240, 13352
|
1655, 2103
|
260, 281
|
354, 1636
|
3552, 7824
|
12660, 12772
|
2125, 2628
|
2644, 2919
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,003
| 198,073
|
43466
|
Discharge summary
|
report
|
Admission Date: [**2130-2-12**] Discharge Date: [**2130-3-1**]
Date of Birth: [**2072-2-12**] Sex: F
Service: GOLD SURGERY
HISTORY OF PRESENT ILLNESS: This is a 58 year-old female
with a past medical history of diabetes, hypertension and
hypercholesterolemia who presented to the Emergency
Department on the 15th with acute gangrenous cholecystitis.
She was taken to the Operating Room and after difficult
fiberoptic nasal intubation an open cholecystectomy was
performed. Many pigmented gallstones were seen in
gallbladder and bile duct. Cholangiogram was performed with
good flow. The patient was in the PACU to remain intubated
due to difficulty the intubation.
PAST MEDICAL HISTORY:
1. Obesity BMI of 60.
2. Insulin dependent diabetes mellitus.
3. Hypercholesterolemia.
4. Hypertension.
5. Sleep apnea.
6. Nephrolithiasis.
PAST SURGICAL HISTORY:
1. Tonsillectomy.
2. EPP in [**2126**].
3. Lithotripsy.
4. Dilatation and curettage.
SOCIAL HISTORY: Denies tobacco or ethanol use.
ALLERGIES: No known drug allergies.
MEDICATIONS AT HOME:
1. Aspirin 325 mg po q.d.
2. NPH 40 a.m., 44 p.m., regular 10:00 a.m. and 12:00 p.m.
3. Lopressor 25 b.i.d.
4. Metformin one b.i.d.
5. Mevacor 40 q.d.
6. Zantac 150 b.i.d.
7. Zyrtec.
8. Nifedipine ER 90 q.d.
9. Albuterol prn.
PHYSICAL EXAMINATION: Vital signs on presentation 99.4, 93,
135/78, 22, the patient was intubated, sedated. Regular rate
and rhythm. Clear and equal breath sounds. Abdomen was
obese and soft. Wounds, dressings were clean, dry and
intact. JP was with minimal output.
ASSESSMENT/PLAN: The patient is stable status post open
cholecystectomy. Neuro Propofol, GTT, Lopressor. The
patient was mechanically ventilated with nasal intubation,
NPO intravenous fluids, nasogastric tube to low continuous
wall suction and the patient was in the Intensive Care Unit.
The patient had no difficulty immediately on postoperative
day one, continued to be sedated, otherwise afebrile and
vital signs were stable. Her white blood cell count was still
at 17.5. The question of extubation came up on that first
postoperative day. There was also a question of an
endoscopic retrograde cholangiopancreatography would be
urgently needed. The endoscopic retrograde
cholangiopancreatography staff was under the impression that
she would need it pretty urgently. On postoperative day two
the patient had a fever spike to 101.3 and remained to be
sedated and was continued to be intubated. The decision was
try to take her and extubate her. She also underwent an
endoscopic retrograde cholangiopancreatography, which showed
stones in the common bile duct, which were cleared out. On
postoperative day three the patient was extubated and still
had a fever max of 101.2. Otherwise was doing reasonably
well, though continued to be distended. She otherwise looked
quite well and was encouraged to start to ambulate out of
bed.
On postoperative day three the patient continued to do well.
No real issues. It was agreed to send the patient to the
floor when her po were adequate. Postoperative day five the
patient got involved with physical therapy for mobility
training and tolerated the procedure well. Also the patient
was transferred to the floor and the decision was to try to
screen her for rehabilitation. On postoperative day six the
patient's ___________ was discontinued. His PCA was taken
off and placed on po pain control, otherwise she looked well.
No other complaints or events. On postoperative day seven
the patient continued to do better. Her previous temperature
max of 100 came down to 99.6 . She was able to go from out of
bed to chair without any difficulty and there was slight leak
from wound, however, was controlled with dressing changes.
On postoperative day eight, however, the patient began to
complain of decreased sensation and movement of the lower
left extremity, as a result the decision was to get neurology
involved. The assessment of the neurology team was that it
was unknown and due to her risk factors whether she had
suffered a deep cortical frontal parietal stroke due to her
presenting symptoms, therefore CT of the head was done. By
postoperative day nine workup at that point had been
negative. The head CT showed no bleeding or shift. Carotid
ultrasound showed atherosclerosis and the lower extremity
ultrasound showed no deep venous thrombosis. Due to the
patient's habitus it was not possible to do a full MRI.
When the stroke team reevaluate her [**2126**] MRI flare they
stated that there is possibly a chance of a small watershed
infarction having occurred. They recommended continuing
aspirin for stroke prophylaxis and to continue decreasing her
risk factors for her continued cerebrovascular accident.
Neurosurgery was then consulted to evaluate her L spine,
which showed a disc bulge at the L3-4 level with moderate
stenosis. Their assessment was that due to the time of the
foot drop it is possible that this problem arose out of
positioning in the Operating Room versus an exacerbation
distant pathology at the L3-4 level. Multiple follow up CTs
were done, which revealed unlikely compression of fecal sac
on CT and no pelvic masses evident for compressive symptoms.
The recommendation is that the CT scans were equivocal
therefore EMG and nerve conduction study may be required to
do a further workup. The patient was continued to be
screened for rehab. An EMG nerve conduction study was
completed on the [**3-25**]. The electrophysiology
findings in conjunction with examination was most likely
consistent with a subacute severe left sciatic neuropathy.
In addition, there was evidence of a severe generalized
sensory motor polyneuropathy with ________ features. It is
possible that a lower lumbosacral _________ at L5 with
radiculopathy could have been a possible contributing factor.
Meanwhile the patient continued to stay surgically stable and
was screened for rehab.
Along this time it was discovered that the patient's
insurance would rejected her for acute rehab despite her new
presenting issues, therefore it became far more complicated
to find the patient a spot in acute rehab, which would
require for adequate rehabilitation. Finally the patient was
accepted at the [**Hospital 93538**] rehabilitation where she will be
discharged.
DISCHARGE MEDICATIONS:
1. Heparin 5000 units t.i.d.
2. Albuterol 90 micrograms aerosol one to two puffs
inhalation q 6 hours prn.
3. Nifedipine 90 mg tabs SR one tab po q.d.
4. Aspirin 325 mg po q.d.
5. Protonix 40 mg one tab q.d.
6. Percocet 5/325 mg tabs one to two tabs q 4 to 6 hours prn
for pain.
7. Metformin 500 mg tablet two tabs po b.i.d.
8. Atorvastatin 40 mg tab one tab po q.d.
9. Lopressor 50 mg tab _____.5 tabs po b.i.d.
10. Zinc sulfate 220 mg capsule one capsule po q.d.
11. Ascorbic acid 500 mg tabs one tab po b.i.d.
12. Multivitamin capsule one cap po q.d.
13. Tylenol 325 mg take one to two tabs po q 4 to 6 hours
prn for fever or pain.
14. Regular insulin based on an insulin sliding scale.
FOLLOW UP: The patient is to follow up with Dr. [**Last Name (STitle) **].
Please call the office upon discharge for a follow up
appointment.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 8275**]
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2130-3-1**] 08:53
T: [**2130-3-1**] 08:58
JOB#: [**Job Number 93539**]
|
[
"272.0",
"278.01",
"780.57",
"355.8",
"574.80",
"724.3",
"707.0",
"250.00",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"87.53",
"51.88",
"51.22"
] |
icd9pcs
|
[
[
[]
]
] |
6354, 7059
|
1081, 1317
|
883, 973
|
7071, 7458
|
1340, 6331
|
173, 691
|
713, 860
|
990, 1060
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,170
| 114,191
|
35330
|
Discharge summary
|
report
|
Admission Date: [**2181-4-25**] Discharge Date: [**2181-4-30**]
Date of Birth: [**2133-2-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
atrial fibrillation s/p ablation, unable to extubate
Major Surgical or Invasive Procedure:
Atrial Fibrillation s/p ablation
Cardioversion
Intubation
History of Present Illness:
This patient is 48 yo male with a past medical history of
paroxysmal afib, hyperlipidemia, mitochondrial muscular disorder
with gait instability who presented today for an atrial
fibrillation ablation following which he was difficult to
extubate and hypotensive.
The patient was diagnosed with paroxysmal atrial fibrillation in
[**2174**], was cardioverted, started on aspirin and rate controlled.
Next, in [**2177**] he went into afib, was again cardioverted and
started on Propafenone. He had a recent episode of atrial
fibrillation/flutter and was started on Coumadin. He underwent
cardioversion for a third time in [**2181-3-4**]. He saw Dr.
[**Last Name (STitle) **] in electrophysiology consultation on [**2181-3-27**] for
treatment of his atrial fibrillation. He is not felt to be a
good candidate for long-term Coumadin therapy due to his history
of falls secondary to the neuromuscular disorder, and had
pulmonary vein isolation today. In terms of symptoms, per CMI
note, he is reports feeling more fatigued and short of breath
when he is in atrial fibrillation. He denies chest pain,
dizziness or syncope.
Today, the patient had afib ablation. At the end of the case he
was given protamine to reverse his anticoagulation and systolic
blood pressure dropped to the 60's after the protamine requiring
bolused vasopressors. He was also difficult to extubate, likely
secondary to the neuromuscular disorder. An ECHO at the bedside
in the lab showed no effusion. The patient has 3 femoral sheaths
still in place for access until the AM.
.
On floor, patient was intubated and sedated, unable to do review
of systems.
Past Medical History:
- Paroxysmal atrial fibrillation (first in [**2174**] s/p
cardioversion, [**2177**] cardioverted and on propafenone, now more
often recently)
- mitochondrial myotonic dystrophy
- Hyperlipidemia
CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, - Hypertension
CARDIAC HISTORY:
-CABG: no
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: no
Social History:
He is married with no children. He does not smoke but
drinks socially. He is currently on medical disability. He is
from [**Country **], but has been living in america for >10 years.
Family History:
He claims his both parents may have arrhythmias, they are alive
into their 70s. His father may also have a neuromuscular
disorder. He has one sister age 44. [**Name2 (NI) 6419**] his father and his
sister apparently have a slow heart rate, although they do not
have pacemakers at this time.
Physical Exam:
VS: 98.4 hr 79, 91/72, rr 15, 95% on 100% Fi02
GENERAL: intubated and sedated
HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. OG tube and ET tube in
place
NECK: supple, no LAD
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: clear anteriorly and laterally.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. 2 left femoral sheaths, 1 right femoral
sheath.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: b/l pedal pulses palpable
Pertinent Results:
Admission Labs
[**2181-4-25**] 10:58AM BLOOD WBC-7.0 RBC-5.21 Hgb-16.4 Hct-49.4 MCV-95
MCH-31.5 MCHC-33.2 RDW-14.1 Plt Ct-172
[**2181-4-25**] 10:58AM BLOOD PT-28.5* PTT-35.7* INR(PT)-2.9*
[**2181-4-25**] 10:58AM BLOOD Glucose-109* UreaN-14 Creat-0.7 Na-144
K-4.2 Cl-105 HCO3-32 AnGap-11
[**2181-4-25**] 10:04PM BLOOD Type-ART pO2-95 pCO2-52* pH-7.40
calTCO2-33* Base XS-5
.
[**2181-4-26**]
CT chest with contrast:
1. No evidence of pulmonary embolism.
2. Unchanged low lung volumes and atelectasis.
3. Improved visualization of a 6-mm nodular opacity at the right
upper lobe.
Three-month CT followup is recommended.
4. Heterogeneous left thyroid nodule. Consider ultrasound if
warranted
clinically.
.
[**2181-4-26**] Ct chest without contrast:
1. Enlarged left lobe of the thyroid with some low-attenuation
foci.
Consider ultrasound if warranted clinically.
2. Low lung volumes. Parenchymal opacities at the bases are
associated with
volume loss and most suggestive of atelectasis.
3. Minimal retained secretions within the trachea.
4. Mild thickening of the anterior trachea wall, which is
nonspecific
but could potentially be due to a sequelae or prior intubation
or tracheostomy
placement.
5. Mild enlargement of the main pulmonary artery.
.
[**2181-4-28**] Echo:
The left atrium is mildly dilated. No left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). The
right atrium is moderately dilated. The estimated right atrial
pressure is 10-20mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). Transmitral and tissue Doppler imaging suggests normal
diastolic function, and a normal left ventricular filling
pressure (PCWP<12mmHg). The right ventricular cavity is mildly
dilated with normal free wall contractility. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Mild right ventricular cavity enlargement with
preserved global free wall motion. Biatrail enlargement.
CLINICAL IMPLICATIONS:
Based on [**2179**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
[**4-27**] CXR:
Lung volumes are lower with increased bibasilar atelectasis.
Bilateral
pleural effusions, if any, would still be tiny. There is no
other overall
change.
Brief Hospital Course:
48M with history of neuromuscular disorder, paroxysmal atrial
fibrillation s/p ablation complicated by hypotension and
difficulty with extubation.
#Respiratory distress: Patient was difficult to extubate after
case. Extubation was attempted briefly, but since patient was
hypotensive, was sent to CCU. He received 2L IVF in EP lab.
Apparently in prior intubation O2sats had been low likely due to
underlying neuromuscular disorder and baseline as wife said
patient has a lot of am secretions. Patient appeared volume
overloaded on xray so was diuresed with good response. He
tolerated extubation well on [**4-26**] but remained hypoxic. Chest CT
was negative for PE but was consistent with low lung volumes and
atelectasis. Pulm was consulted and reported low NIF consistant
with decreased diaphragmatic weakensss likely [**3-5**] to underlying
neuromuscular disorder. He continued to be hypoxic with
ambulation requring 4L by nasal canula to keep sats at 94%.
Patient will get PFTS and be followed by pulm as outpatient as
his disorder is likely progressing and will need home oxygen at
the very least for now.
#Hypotension: Patient hypotensive after receiving protamine in
the EP lab. Likely protamine reaction, since it can cause
sudden, transient drop in blood pressure. Required minimal
phenylephrine which was weaned off. Afebrile and no white count
so sepsis unlikely. Resolved and beta blocker was restarted.
#Atrial fibrillation: s/p ablation. Has been in sinus since.
Continue coumadin, propafenone and atenolol. Followed INR.
Follow up with EP.
#Mitochondrial Neuromuscular disorder: Likely reason why low
sats with intubation and weak cough post intubation. Should
follow up with neurology as outpatient. Evaluate my physical
therapy who believe he is safe to go home but should get home PT
eval.
Medications on Admission:
Atenolol 12.5mg daily
Propafenone 225mg twice daily
simvastatin 40mg daily
Warfarin 5mg everyday except 7mg on MWF
Aspirin 81mg
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Propafenone 225 mg Capsule, Sust. Release 12 hr Sig: One (1)
Capsule, Sust. Release 12 hr PO twice a day.
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO DAYS
(MO,WE,FR).
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAYS
([**Doctor First Name **],TU,TH,SA).
6. Home Oxygen
3-4L continuous pulsed dose for portability, O2 sat 86% on RA.
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
8. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] VNA
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Atrial Fibrillation
2. Mitochondrial Myotonic Dystrophy
3. Hypoxia
.
SECONDARY DIAGNOSIS:
1. Hyperlipidemia
Discharge Condition:
Stable. Patient is ambulating, tolerating oral intake, and has
returned to his baseline condition.
Discharge Instructions:
You were admitted to the hospital for treatment of your atrial
fibrillation. You underwent a procedure to return your heart to
normal rhythm. You had some difficulty breathing after your
procedure and you were monitored in the intensive care unit for
2 days after your procedure. You are now in a normal sinus
rhythm. We made an appt with Dr. [**First Name (STitle) **] from pulmonology to get
breathing tests. These appts are listed below.
.
We made the following changes to your medication:
1. Increase your aspirin to 325 mg daily
2. Take Ibuprofen for any chest burning or ache that you may
have. If the ibuprofen does not alleviate the symptoms, call Dr.
[**Last Name (STitle) **].
.
Please seek immediate medical care if you develop shortness of
breath, light-headedness, dizziness, loss of consciousness,
fevers, shaking chills, night sweats, abdominal pain, back pain,
or pain in your lower extremities.
.
You will be going home on a monitor to evaluate your heart
rhythm. Please follow the instructions given to you. You will
send strips daily and the monitor will trigger if you go back
into atrial fibrillation.
Followup Instructions:
Please follow-up with your cardiologist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD on
[**2181-5-28**] 3:40.
.
Pulmonology:
Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: ([**Telephone/Fax (1) 513**]
Date/time: Wednesday [**5-16**] at 3:30 with Dr. [**Last Name (STitle) 18309**] on
[**Hospital Ward Name 23**] 7
Pulmonary function tests before the appt at 2:30pm on [**Hospital Ward Name 23**] 7,
Clinical Center, [**Hospital Ward Name 516**], [**Location (un) **]
.
Primary Care:
[**Last Name (LF) **],[**First Name3 (LF) **] Phone: [**Telephone/Fax (1) 74550**] Date/time: [**5-14**] at 3:30pm.
Completed by:[**2181-4-30**]
|
[
"272.4",
"276.6",
"359.21",
"458.29",
"V15.88",
"518.82",
"427.31",
"519.4",
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icd9cm
|
[
[
[]
]
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[
"37.26",
"99.61",
"96.71",
"37.34",
"37.27"
] |
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|
[
[
[]
]
] |
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|
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|
368, 428
|
9305, 9406
|
3659, 5990
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|
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|
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|
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9171, 9243
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2101, 2452
|
2468, 2653
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,399
| 199,267
|
49591
|
Discharge summary
|
report
|
Admission Date: [**2181-7-25**] Discharge Date: [**2181-7-28**]
Date of Birth: [**2124-3-27**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
[**2181-7-25**]: EGD and ERCP
[**2181-7-25**]: IR angiography with embolization
[**2181-7-25**]: IR Right IJ triple lumen line placement
History of Present Illness:
57M with duodenal adenoma underwent endoscopic mucosal
ressection today by ERCP. Patient intially tolerated the
procedure well, but post procedurally developed bright red blood
per rectum and melanotic stools. Patient underwent a second
endoscopy which showed a large adherant clot at the site of the
resection and 4mg of epinephrine was injected into the site with
out obtaining hemostatis. Patient continued to pass melanotic
stools and BRBPR and was emergently transferred to the [**Hospital Unit Name 153**].
Per report patient was not on any blood thinning or platelet
inhibiting medications preprocedurally. HCT prior to procedure
was 44.8 to 38.1. He did not become hypotensive nor tachycardic
while in GI.
.
Upon arrival to the [**Hospital Unit Name 153**] 71, 112/83, 93% on 2L NC. Patinet was
rigorous and actively exsangunating from his rectum with blood
soaked bed sheets. An attempt to place a 16 gauge peripherial
IV was made with out success and patient underwent emergent
placement of trauma line in the right groin. During the
placement of the line patient had several vagal episodes with
passage of bright red stool and dropped his systolic pressures
to the 60s. The massive transfussion protocol was initiated and
the patient given 2 units of pRBCs prior to his systolic
pressures recovering to the 110's systolic. He was brought
emergently from the ICU to IR for attempt at embolization.
.
In the IR suite the 9F right femoral line was confirmed to be
placed in the R femoral artery by fluroscopy. Vascular surgery
was consulted and recommended removing the line and holding
pressure. Patient remained HD stable through out the subsequent
procedure acessed through the left femoral artery with coiling
of the GDA. Patient then had 9F trauma line placed in the right
IJ for access. A thrid unit of pRBCs was transfused while in
the IR suite.
Past Medical History:
GERD
Social History:
- Lives at home with wife, does not smoke
- drinks 2-3 whiskey's a week.
Family History:
Not obtained
Physical Exam:
Physical Exam on Admission to the ICU
Vitals: 71, 112/83, 19, 93% on NC
General: shivering, pale, diaphoretics, mentating well
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: non-tender non distented, active bleeding seen from
rectum
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: moving all extremities.
Physical Exam on Discharge
Tmax: 37.2 ??????C (98.9 ??????F)
Tcurrent: 37.1 ??????C (98.8 ??????F) HR: 72 (61 - 85) bpm BP: 111/67(78)
{103/49(61) - 136/97(104)} mmHg RR: 16 (5 - 22) insp/min SpO2:
97%
General: awake and alert, NAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: minimal epigastric discomfort, soft, non-tender non
distended, bowel sounds present
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; R groin ecchymosis stable
Neuro: moving all extremities.
Pertinent Results:
Labs on Admission
[**2181-7-25**] 08:50AM BLOOD WBC-7.6 RBC-5.04 Hgb-14.9 Hct-44.8 MCV-89
MCH-29.6 MCHC-33.3 RDW-13.1 Plt Ct-212
[**2181-7-25**] 04:14PM BLOOD WBC-12.9*# RBC-4.31* Hgb-13.1* Hct-38.1*
MCV-88 MCH-30.3 MCHC-34.3 RDW-13.1 Plt Ct-258
[**2181-7-25**] 08:50AM BLOOD PT-10.2 PTT-31.5 INR(PT)-0.9
[**2181-7-25**] 08:50AM BLOOD UreaN-21* Creat-1.1 Na-144 K-4.7 Cl-108
HCO3-24 AnGap-17
[**2181-7-25**] 08:50AM BLOOD ALT-33 AST-33 AlkPhos-57 Amylase-64
TotBili-0.3 DirBili-0.0 IndBili-0.3
[**2181-7-25**] 08:50AM BLOOD Lipase-50
Labs on Discharge
Imaging/Procedure:
[**2181-7-25**]
- EGD:
Esophagus: Normal esophagus.
Stomach Contents: Small amount of dark blood was seen in the
stomach. This was suctioned.
Duodenum: Other: Site of endoscopic mucosal resection in the
duodenum is identified. There is a large clot at the site of
EMR. Active bleeding is noted. 12-14 cc of epinephrine is
injected around the clot. Inspite of that some oozing persisted
ath the site of EMR.
Impression: Small amount of dark blood was seen in the stomach.
This was suctioned. Site of endoscopic mucosal resection in the
duodenum is identified. There is a large clot at the site of
EMR. Active bleeding is noted at the site of EMR. 12-14 cc of
epinephrine is injected around the clot. Inspite of that some
oozing persisted ath the site of EMR.
- ERCP:
Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Duodenum: A flat polyp 5 cm in size was identified in the second
portion of the duodenum. The ampulla was clearly identified and
was approximately 2 cm proximal to the polyp. It was not
involved by the polyp. A submosal injection was performed using
methylene blue and saline into the polyp to create a saline
pillow. The polyp was completely removed using piece meal
polypectomy technique.
Major Papilla: Normal major papilla 2 cm proximal to the flat
duodenal polyp.
Impression: A flat polyp 5 cm in size was identified in the
second portion of the duodenum. The ampulla was clearly
identified and was approximately 2 cm proximal to the polyp. It
was not involved by the polyp. A submosal injection was
performed using methylene blue and saline into the base of the 5
cm duodenal polyp to create a saline pillow. The polyp was
completely removed using piece meal polypectomy technique.
- IR procedure (preliminary):
1. Fluoroscopic assisted right femoral access and retrieval.
2. Fluoroscopic assisted left femoral access.
3. Celiac angiogram.
4. Super selective celiac angiogram.
5. GDA coil/gelfoam embolization.
6. Superior mesenteric artery angiogram.
CONTRAST: 120 mL of Optiray were used.
MEDICATION: Moderate sedation was provided by divided doses of
Versed for a total of 4 mg and fentanyl for a total of 200 mcg.
Patient's hemodynamic parameters were continuously monitored by
a trained radiological nurse.
PROCEDURE: Prior to initiation of the procedure, written
informed consent was obtained and preprocedure timeout was
performed. Patient was placed supine on the angiography table
and both groins were prepped and draped in the usual sterile
manner. Under fluoroscopic and palpatory guidance, icropuncture
access to the right common femoral artery was obtained. As the
microwire was advanced, it was noted that the femoral line
placed earlier by the ICU was lateral to the microwire. At this
moment, suspicion for a femoral artery line placement was
raised, and as one of the lumens of the line was open, pulsatile
blood was identified. Subsequently, the access on the right side
was aborted, the needle and microsheath were removed, and 10
minutes of manual compression achieved hemostasis. Following, a
left common femoral approach was obtained. Under fluoroscopic
and palpatory guidance, micropuncture access to the left common
femoral artery was obtained and a 5 French long sheath was
placed. Subsequently, a Cobra 2 catheter was navigated over an
angled Terumo Glidewire into the celiac trunk. As the celiac
trunk was selected, the wire was removed and a DSA run was
obtained. Following this, based on the results of the
angiography, it was decided to catheterize selectively the
gastroduodenal artery. A Renegade microcatheter was navigated
over a 0.16 Headliner into the gastroduodenal artery. Selective
angiograms were obtained. Based on these results, it was decided
to embolize the GDA artery with gelfoam/ coils. The [**Location (un) 6002**]
technique was used, with coils and Gelfoam subsequently over and
over. Coils with the size of 3 x 3, 3 x 4, 1 x 5, 6 x 5 and 3 x
4 were used for a total of 13 coils. Selective angiography after
coil/gelfoam embolization demonstrates no further flow into the
GDA artery. Subsequently, the SMA was catheterized. An
angiography was obtained. There was no evidence of contrast
extravazation. Following this, the catheters were removed. It
was decided to leave the sheath overnight. The long 5F sheath
was exchanged for a short 5F sheath, which was securely sutured
to patient's skin. Patient tolerated the procedure well and was
returned to the ICU in stable condition. No complications
ensued.
FINDINGS:
1. Conventional celiac trunk anatomy.
2. No active extravasation was identified; however, known region
of leeding was supplied by the GDA artery. Multiple selective
and super selective angiograms were obtained, without exactly
identifying the source of bleeding.
3. Successful coil and Gelfoam embolization of the GDA artery,
with a andwich technique, until successful stasis was achieved.
IMPRESSION:
Prophylactic embolization of a GDA artery given patient's
significant duodenal bleeding symptoms.
- IR guided RIJ triple lumen central line placement
PROCEDURE: As this was an emergency line placement and the
patient had previously consented to central line placement 2 hrs
prior, no new consent was obtained. Procedure was explained to
the patient, and subsequent timeout was performed. After
anesthetizing the skin and subcutaneous tissues, a micropuncture
needle was inserted into the right internal jugular vein under
ultrasound guidance. The hard copy ultrasound images were
saved; however, due to technical problems, not transferred to
PACS. A 0.018 nitinol wire was then advanced into the superior
vena cava. After additional anesthesia, a small [**Doctor Last Name **] was made
in the skin. The micropuncture needle was exchanged with the
micropuncture sheath. The inner cannula and nitinol wire were
removed. A 0.035 [**Last Name (un) 7648**] wire was advanced into the inferior
vena cava. The micropuncture sheath was removed initially and 7
French dilator was used over the [**Last Name (un) 7648**] wire. Subsequently,
this dilator was removed and a 12 French dilator was also used.
Finally, the dilator was removed and a triple-lumen trauma line
was placed with its tip positioned in the distal superior vena
cava. The wire and inner cannula were removed. Fluoroscopy
spot image demonstrated the catheter tip in the distal SVC. The
three lumens withdrew blood and were flushed easily. Catheter
was secured with 2-0 silk sutures. Dry sterile dressings were
applied. No immediate post-procedure complications were noted.
The patient tolerated the procedure well.
IMPRESSION:
Successful placement of a triple-lumen internal 9F French trauma
line through the right internal jugular vein approach. The tip
is located in the distal SVC and the catheter is ready for use.
[**2181-7-26**]
- CT abd/pelvis
LUNG BASES: There are small bilateral effusions with associated
atelectasis. There is no focal consolidation or nodule seen.
The heart is normal in size.
ABDOMEN: Limited assessment of the abdomen and pelvis without
intravenous contrast demonstrates no contour abnormality of the
liver, spleen, and bilateral kidneys. No evidence of
hydronephrosis or nephrolithiasis. Small nodule posterior to
the pancreatic body is seen, measuring 1.7 cm, previously seen
on the recent MRI of [**2181-6-25**], whic was characterized as
tuber omentale. Within the tail there is loss of feathery
apperance, corresponding to accessory spleen seen on MRI. Again
seen multiple embolization coils within the GDA territory.
There is minimal stranding around the second segment of the
duodenum and pancreatic head, post-procedure and
embolization.Small amount of high attenuating stranding within
the right anterior pararenal fossa (2:53), without evidence of
hematoma. There is no hematoma. There is contrast within the
gallbladder, consistent with vicarious excretion from the prior
embolization study. The adrenal glands are normal in
appearance. The visualized small and colonic loops of bowel
within the upper abdomen are normal in appearance with no
evidence of abnormal dilatation or wall thickening. There is a
small fat-containing ventral hernia.
PELVIS: The urinary bladder is collapsed and contains a Foley
catheter. Prostate gland is normal in size, and seminal
vesicles are normal. The colonic and small loops of bowel
within the pelvis are normal in ppearance. Tiny bilateral
fat-containing inguinal hernias are noted. There is fat
stranding around the right inguinal region, post-placement of a
femoral line; however, there is no evidence of retroperitoneal
or inguinal hematoma. Atherosclerotic plaques are seen along
the aorta and iliac arteries without aneurysmal dilatation.
OSSEOUS STRUCTURES: Minimal lumbosacral spondylosis without
evidence of destructive lytic lesions. Bilateral pars defect,
more pronounced on the right side.
IMPRESSION:
1. Status post duodenal adenoma removal and GDA embolization.
No evidence of hematoma within the abdomen or pelvis.
2. Minimal stranding around the second segment of the duodenum
and the
pancreas, likely related to post-procedure, however correlation
with biochemical pannel is recommended to assess for potential
pancreatitis.
3. Tiny bilateral pleural effusions with associated
atelectasis.
4. Stranding along the right inguinal region, post-central line
placement, however, with no evidence of retroperitoneal or
inguinal hematoma.
5. Small nodule posterior to the body of pancreas and loss of
feathery appearance within the pancreatic tail, which correspond
respectievely to tuber omentale and accessory spleen seen on the
prior MRI.
Pathology
[**2181-7-25**]
- GI biopsy: pending
DISCHARGE LABS
[**2181-7-28**] 01:51AM BLOOD WBC-15.0* RBC-3.82* Hgb-11.3* Hct-33.4*
MCV-87 MCH-29.6 MCHC-33.9 RDW-14.5 Plt Ct-132*
[**2181-7-28**] 01:51AM BLOOD Glucose-104* UreaN-10 Creat-0.9 Na-141
K-3.3 Cl-105 HCO3-30 AnGap-9
Brief Hospital Course:
57M with duodenal adenoma who underwent endoscopic mucosal
resection by ERCP with post procedural GI bleed.
ACTIVE ISSUES
1. GI bleed: Post-procedure patient developed bright red blood
per rectum and melanotic stools. Patient underwent a second
endoscopy which showed a large adherent clot at the site of the
resection and 4mg of epinephrine was injected into the site with
out obtaining hemostatis. Patient continued to pass melanotic
stools and BRBPR and was emergently transferred to the [**Hospital Unit Name 153**].
HCT prior to procedure was 44.8 to 38.1. An attempt to place a
16 gauge peripherial IV was made with out success and patient
underwent emergent placement of trauma line in the right groin.
During the placement of the line patient had several vagal
episodes with passage of bright red stool and dropped his
systolic pressures to the 60s. The massive transfusion protocol
was initiated and the patient given 2 units of pRBCs prior to
his systolic pressures recovering to the 110's systolic. He
was brought emergently from the ICU to IR for attempt at
embolization. In the IR suite the 9F right femoral line was
confirmed to be placed in the R femoral artery by fluroscopy.
Vascular surgery was consulted and recommended removing the line
and holding pressure. Patient remained HD stable through out
the subsequent procedure acessed through the left femoral artery
with coiling of the gastroduodenal artery. A thrid unit of
pRBCs was transfused while in the IR suite. Hemostasis was
achieved after embolization. His hematocrit was monitored
closely over the next two days and continued to slowly trend
down. Out of concern for hematoma formation at the groin sites
or a retroperitoneal bleed, CT scan was performed which showed
no hematoma or RP bleed; there was no pseduoaneurysm of the
femoral arteries. He was maintained on a IV pantoprazole drip.
Hemoglobin and hematocrit remained stable, and the patient was
discharged with GI follow-up. He should have a repeat CBC in 1
week for monitoring of H/H.
CHRONIC ISSUES
1. GERD: stable during admission.
TRANSITIONAL ISSUES
1. The patient should have a CBC checked in 1 week after
admission for monitoring of H/H. Additionally, he did have an
elevated white blood cell count without signs of infection; this
should be followed with the CBC in a week.
2. Biopsy of duodenal adenoma pathology pending.
Medications on Admission:
"acid reducer," name of medication unknown
Discharge Medications:
1. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*2
2. Outpatient Lab Work
Please check a CBC on [**2181-8-3**] with results faxed to Dr. [**Known firstname **]
[**Name (STitle) 5395**] at [**Telephone/Fax (1) 103723**] (discharge HCT 33, Hgb 11)
ICD-9, 285.1
Discharge Disposition:
Home
Discharge Diagnosis:
Doudenal adenoma
ERCP biopsy hemorrhage
Mistaken insertion of 9French trauma line to the right femoral
artery
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 while you were in the
hospital. You were admitted to the intensive care unit after
having massive bleeding from the biopsy in your small intestine
earlier in the day. You were emergently transfused 4 units of
red blood cells and had the bleeding artery embolized by our
interventional radiologists. You tolerated this procedure well
and had no signs of further bleeding for 2 days afterwards.
During your bleeding a large IV was need to be placed in your
leg in order to transfuse you blood as quickly as possible and
keep your blood pressure up. Unfortunately this "trauma line"
was placed in your right femoral artery and not the vein as
intended. You were seen by our vascular surgeons who removed
the line and felt comfortable that it had healed properly. We
are terribly sorry for this mistake.
Over the next few days you should avoid any heavy lifting or
long distance walking to ensure the leg heals properly. If you
develop any bleeding in your leg, your neck or in your stool
please call your doctor immediately.
You will need to have a blood count checked in a week's time to
ensure that there is no further bleeding. Your hematocrit was
33 and your hemoglobin was 11 at the time of discharge.
Followup Instructions:
Please call Dr.[**Name (NI) 21375**] office in Gastroenterology to schedule
a follow up appointment for your adenoma in 3 months.
Completed by:[**2181-7-28**]
|
[
"458.9",
"288.60",
"V15.82",
"998.11",
"E878.8",
"998.89",
"530.81",
"211.2",
"E876.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"44.44",
"45.30",
"38.97",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
17030, 17036
|
14202, 16589
|
313, 451
|
17190, 17190
|
3637, 14179
|
18616, 18777
|
2491, 2505
|
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17057, 17169
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16615, 16659
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17341, 18593
|
2520, 3618
|
265, 275
|
479, 2356
|
17205, 17317
|
2378, 2384
|
2400, 2475
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,123
| 156,811
|
44949
|
Discharge summary
|
report
|
Admission Date: [**2176-1-21**] Discharge Date: [**2176-1-25**]
Service: GENERAL SURGERY PUPRLE
CHIEF COMPLAINT: Hematochezia.
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **] year-old
woman with dementia, legal blindness and hypertension who
lives in the [**Hospital3 96133**] Home who was found this
morning with maroon and melanotic stool. She was brought to
the Emergency Room where she had several moderate to large
bowel movements with blood and clot in it. She is
hemodynamically stable. She had intravenouses in place at
the time of interview. Her hematocrit dropped from 32.3 to
29 and she received multiple units of blood in the Emergency
Room. She has no fevers or chills. She does acknowledge
some abdominal pain. She does report significant weight loss
over the past year.
PAST MEDICAL HISTORY:
1. Spinal stenosis.
2. Esophagitis.
3. Gastroesophageal reflux disease.
4. History of transient ischemic attack.
5. Hypertension.
6. Iron deficiency anemia.
7. Dementia.
8. Blindness.
9. Colonoscopy in [**2171**] revealed extensive sigmoid
diverticulitis.
PAST SURGICAL HISTORY:
Bilateral cataracts.
SOCIAL HISTORY: Her health care proxy is her daughter. She
told the team that she would want interventions to help her
mother's life if necessary.
FAMILY HISTORY: Noncontributory.
ALLERGIES: No known drug allergies.
MEDICATIONS AT HOMME:
1. Aspirin 81 mg once a day.
2. Colace 200 mg twice a day.
3. Carafate 1 mg twice a day.
4. Niferex 150 mg twice a day.
5. Effexor XR 75 mg once a day.
6. Vicodin one tablet twice a day.
7. Risperdal .7 mg once a day.
8. Multivitamins once a day.
PHYSICAL EXAMINATION: She is afebrile 98.1. Pulse 92.
Blood pressure 165/72. Respiratory rate 16. 97% on room
air. Physical examination in general she is a pleasant
elderly female in no acute distress. Head and neck is within
normal limits. Heart is regular rate and rhythm. Chest is
clear to auscultation bilaterally. Abdomen she has a soft
abdomen with slight suprapubic tenderness. No rebound or
guarding. No definitive masses. Rectal examination shows
bloody stool with no obvious hemorrhoids and no masses.
Extremities palpable pulses bilaterally.
LABORATORY: Hematocrit 32.3, which slowly decreased to 29.
PTT 25 and INR 1.0. Electrocardiogram showed normal sinus
rhythm at 80 and a distant colonoscopy as mentioned before
showed significant diverticulosis.
HOSPITAL COURSE: This is a [**Age over 90 **] year-old woman with lower
gastrointestinal bleed who was determined to have
diverticulosis who had some moderate blood loss per rectum,
but was hemodynamically stable. She was admitted to the
General Surgery Service and monitored under the Intensive
Care Unit with serial hematocrits.
The patient did not continue to bleed per rectum. Her serial
hematocrits revealed a stable hematocrit and she did not need
angiographic location of her bleeding source. On the first
day she received 5 units of packed red blood cells and after
that she did not require anymore blood to keep her
hemodynamically stable. On the third hospital day [**1-23**] the
patient underwent a colonoscopy by the gastrointestinal team.
This colonoscopy revealed significant diverticulosis with no
active site of bleeding. It also revealed significant
internal hemorrhoids. The patient after being observed for
four days is being discharged to home on [**2176-11-24**] in good
condition. She has not required any blood transfusions in
the last four days and has been doing well otherwise.
DISCHARGE MEDICATIONS:
1. Atenolol 25 mg po q.d.
2. Risperdal 0.5 mg po q.d.
3. Aspirin 81 mg po q.d.
4. Colace 200 mg po b.i.d.
5. Carafate 1 gram twice a day.
6. Niferex 150 mg po q.d.
7. Multivitamin po q.d.
8. Effexor XR 75 mg po q.d.
9. Vicodin one tablet po twice a day as needed for pain.
DISCHARGE DIAGNOSIS:
1. Lower gastrointestinal bleeding.
2. Blood loss anemia requiring red blood cell transfusion.
3. Diverticulosis.
4. Internal hemorrhoids.
5. Hypertension.
6. Gastroesophageal reflux disease.
7. Esophagitis.
8. Iron deficiency anemia.
9. Dementia.
10. Bilateral cataract.
11. Status post endoscopy.
12. Status post colonoscopy.
She is recommended to follow up with Dr. [**Last Name (STitle) **] in two to
three weeks and she is being discharged back to her home at
[**Hospital3 96133**] Facility today on [**2176-1-25**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 23652**]
Dictated By:[**Last Name (NamePattern1) 1179**]
MEDQUIST36
D: [**2176-1-25**] 12:10
T: [**2176-1-25**] 12:29
JOB#: [**Job Number **]
|
[
"455.0",
"362.50",
"530.81",
"401.9",
"276.6",
"280.0",
"294.8",
"562.12",
"530.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.34",
"45.23",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
1324, 1658
|
3575, 3858
|
3879, 4688
|
2456, 3552
|
1135, 1157
|
1681, 2438
|
126, 141
|
170, 824
|
846, 1112
|
1174, 1307
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,435
| 176,342
|
45143
|
Discharge summary
|
report
|
Admission Date: [**2200-6-24**] Discharge Date: [**2200-7-22**]
Date of Birth: [**2116-12-10**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
SBO with ischemic bowel
Major Surgical or Invasive Procedure:
[**6-24**]: Exploratory laparotomy with lysis of
adhesions, resection of small bowel, and temporary closure of
abdomen.
[**6-27**]: Small-bowel resection with primary anastomosis
and abdominal closure.
History of Present Illness:
83M presented to his PCP's office on the morning of [**6-24**]
complaining
of one day of worsening abdominal pain and a firm abdomen. He
was sent to the ED where he was noted to be of altered mental
status (AAOx1), had a lactate of 8.3 and was increasingly
tachypneic prompting intubation. At time of this exam, he is
intubated, sedated and on norepinephrine to support his blood
pressure.
Per his wife, he was doing pretty well up until this morning
except for mild complaints of abdominal pain the last day. No
fevers or chills, nausea or vomiting at home.
Past Medical History:
PMH: GERD, HTN, HLD, rectal/colon ca s/p resection, mitral
insufficiency, mild aortic stenosis, right inguinal hernia
PSH: colonic resection (for colon/rectal CA) via lower midline
laparotomy [**2169**], TURP [**2191**]
Social History:
Lives with wife (accompanying him today), 2 children
(daughter lives locally, son in [**Name (NI) **])
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
On Admission:
Vitals: 103 88 90/73 20 100% 2LNC
Gen: Intubated sedated, pupils 2mm->1mm
Card: RRR
Pulm: Vented respirations
Abdomen: well-healed midline surgical scar, firm, distended
nonincarcerated right inguinal hernia
Ext: No edema
On Discharge:
Pertinent Results:
Admission Labs:
[**2200-6-24**] 10:30AM BLOOD WBC-13.1* RBC-5.08 Hgb-15.4 Hct-47.0
MCV-93 MCH-30.4 MCHC-32.8 RDW-14.0 Plt Ct-227
[**2200-6-24**] 10:30AM BLOOD Neuts-67 Bands-20* Lymphs-10* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0
[**2200-6-24**] 04:30PM BLOOD PT-17.6* PTT-34.6 INR(PT)-1.7*
[**2200-6-24**] 10:30AM BLOOD Glucose-179* UreaN-34* Creat-1.5* Na-137
K-5.0 Cl-94* HCO3-19* AnGap-29*
[**2200-6-24**] 10:30AM BLOOD ALT-15 AST-43* AlkPhos-78 TotBili-1.5
[**2200-6-24**] 10:30AM BLOOD cTropnT-<0.01
[**2200-6-24**] 10:30AM BLOOD Lipase-22
[**2200-6-24**] 04:30PM BLOOD Calcium-6.7* Phos-2.0* Mg-1.3*
[**2200-6-24**] 10:44AM BLOOD Lactate-8.3*
[**2200-6-24**] 11:30AM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
[**2200-6-24**] 11:30AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
[**2200-6-24**] 11:30AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.025
[**2200-7-9**] 08:17PM URINE RBC-60* WBC-2 Bacteri-FEW Yeast-NONE
Epi-0
[**2200-7-9**] 08:17PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2200-7-9**] 08:17PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006
[**2200-7-10**] 07:20PM PLEURAL TotProt-1.0 Glucose-139 LD(LDH)-121
Cholest-8
[**2200-7-10**] 07:20PM PLEURAL WBC-41* RBC-14* Polys-5* Lymphs-54*
Monos-0 Meso-4* Macro-33* Other-4*
PERTINENT MICRO
[**2200-7-4**] 4:45 pm BLOOD CULTURE Source: Line-cvl.
**FINAL REPORT [**2200-7-7**]**
Blood Culture, Routine (Final [**2200-7-7**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SECOND MORPHOLOGY.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
[**2200-7-4**] 6:57 pm STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT [**2200-7-5**]**
C. difficile DNA amplification assay (Final [**2200-7-5**]):
Reported to and read back by DR [**First Name8 (NamePattern2) 488**] [**Last Name (NamePattern1) **] [**2200-7-5**] AT
14:07.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
PERTINENT REPORTS:
TTE [**2200-6-24**]
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). Right
ventricular chamber size is normal. Tricuspid annular plane
systolic excursion is depressed (12 mm) consistent with right
ventricular systolic dysfunction. 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 leaflets are moderately thickened. There is
moderate/severe posterior leaflet mitral valve prolapse. An
eccentric, anteriorly-directed jet of Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Hyperdynamic left ventricle. Moderate aortic
stenosis with estimated valve area of 1.1 cm2. Depressed right
ventricular systolic function. Prolapsed posterior mitral valve
leaflet.
CT Torso with Contrast [**2200-6-24**]
Closed loop obstruction in the right lower quadrant with
hypoenhancing loops of bowel and free fluid throughout the
abdomen and pelvis, concerning for bowel ischemia.
CT Head [**2200-6-24**]
1. No acute intracranial process.
2. Chronic left maxillary sinus mucosal disease.
TEE [**2200-6-25**]
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. There are simple
atheroma in the aortic arch. There are complex (>4mm) atheroma
in the descending thoracic aorta. The abdominal aorta is mildly
dilated. There are complex (>4mm) atheroma in the abdominal
aorta. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). Moderate to severe (3+) aortic
regurgitation is seen. There is severe posterior leaflet mitral
valve prolapse. There is at least moderate and probably severe
mitral regurgitation(3+ to 4+) . Due to the eccentric nature of
the regurgitant jet, its severity may be significantly
underestimated (Coanda effect). Moderate [2+] tricuspid
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is a trivial/physiologic
pericardial effusion.
CT Torso [**2200-7-4**]
1. No evidence of an anastomotic leak.
2. Thickening of the sigmoid colon and rectal wall suggestive
for
proctitis/colitis.
3. Large bilateral pleural effusions with associated
atelectasis.
4. 2.5 x 1.9 cm hypodense hepatic lesion at the junction of
segment II and [**Doctor First Name 690**] is incompletely characterized and requires an
ultrasound or MRI for further characterization.
TTE [**2200-7-9**]
Focused, limited views due to the patient's inability to
cooperate:
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). There is moderate aortic
valve stenosis (valve area 1.0-1.2cm2). Aortic regurgitation is
present, but cannot be quantified. The mitral valve leaflets are
mildly thickened. There is moderate/severe posterior leaflet
mitral valve prolapse. Moderate to severe (3+) mitral
regurgitation is seen.
Compared with the prior, complete study dated [**2200-6-24**] (images
reviewed), based on transvalvular gradients and velocity only
([**Location (un) 109**] cannot be calculated currently as a parasternal long axis
view is not available for reliable LVOT measurement), the degree
of aortic stenosis is moderate and possibly underestimated given
limited echocardiographic views.
CT Torso [**7-12**]
1. Bilateral upper and middle lobe pulmonary opacities,
compatible with
infection.
2. Volume overload with pulmonary edema, pleural effusions,
periportal edema,
ascites, and anasarca.
3. Small left pneumothorax.
4. No evidence of bowel obstruction, abscess or fluid
collection in abdomen or pelvis.
CXR [**7-17**]: FINDINGS: In comparison with the study of [**7-15**], the
endotracheal tube and nasogastric tubes have been removed.
Right pleural catheter remains in place and there is no
pneumothorax. Central catheters are in good position.
Cardiac silhouette appears to be more prominent than on the
previous study and there is further fullness of indistinct
pulmonary vessels consistent with worsening pulmonary venous
pressure.
Brief Hospital Course:
Mr. [**Known lastname 7324**] was brought to the ED by ambulance from his PCP's
office where his abdominal pain was worsening and his mental
status was noted to be of mild confusion. On arrival to the ED
he was AAOx1 and tachypneic. He was intubated for airway
protection. A CT scan was consistent with a closed loop bowel
obstruction. He was noted to be hypotensive and placed on
pressors. A central line was placed in the ED and he was rushed
to the operating room for emergent abdominal exploration.
In the OR, he was noted to have a sharply demarcated segment of
ischemic small bowel due to compression from adhesions. This
was resected. Prior to creating an anastamosis, however, his
pressor requirement started to increase, to triple pressors
(levo, neo and vaso). Due to this instability, the abdomen was
packed and the procedure was aborted.
He was volume resuscitated in the ICU post-operatively and
placed on broad spectrum antibiotic (zosyn). He remained on
triple pressors. An echocardiogram (TTE) revealed a 0.6mm2
aortic valve prompting a consult to cardiology for potential
valvuloplasty. He was deemed not a candidate due to his
concommitant aortic insufficiency. His pressors gradually
weaned down to a single pressor, levophed, and he returned to
the OR on [**2200-6-27**] for re-anastamosis and abdominal closure.
Post operatively, his pressor was weaned further and he was
started on a lasix drip to remove excess fluid (noted to be 20
liters positive, though this number is probably in excess as it
does not account for insensible losses). He was extubated on
[**2200-6-29**] only to be reintubated the same night for respiratory
distress. His pressors were weaned off, he was further diuresed
with a lasix drip and 25% albumin, and was successfully
extubated on [**2200-6-30**].
The remainder of his hospital course by problem:
Aortic stenosis and insufficiency: TEE showing a 0.6mm2 valve
area but deemed insuitable for a valvuloplasty due to his aortic
insufficiency. After his surgeries, he had been on the surgical
floor, but had increasing respiratory distress due to volume
overload. He was transferred to the medicine service, and for
several days diuresis was attempted but was limited by SBP's in
the 80-90's, so he was transferred to the CCU. He was on
multiple pressors initially levo/neo/vaso which were weaned as
tolerated. In total, he required pressors for about a week.
His cardic output was calculated with a Swann-Ganz catheter and
found to be high, even when he was hypotensive (CI >6). Thus,
there was no concern that his AS was a cause of his hypotension
and inability to maintain his pressures. His EF was greater
than 55% and a TTE showed severe mitral regurgitation, but a
valve area of 1.0-1.2 consistent with moderate aortic stenosis.
Per cardiology, TTE more sensitive than TEE, and valvuloplasty
not pursued as would not improve valvular surface area. . His
lisinopril and metoprolol were held due to low blood pressures.
LOS fluid balance at time of transfer was -8.7L.
Recurrent Shock: Patient with multiple episodes of hypotension
requiring pressor support with levophed. Unclear etiology of
shock. Swan Ganz catheter placed on [**2200-7-11**]. PAP 64/24 and
PAPm was 39. CO on Levophed was 6.8, and CI was 3.6 with SVR of
1381. Levophed was temporarily disocntinued and CO increased to
12.1 with CI of 6.4 and SVR of 444. Hemodynamics were
suggestive of a non cardiac etiology of his shock, and concern
for sepsis was rasied. An abdominal scan was pursued with
contrast to look for occult abscess or infection, but was
negative. Treated with meropenem empirically (after prior HCAP
treatment with Cefepime/Vancomycin) for possible HCAP sepsis.
The patient continued to have equivocal blood pressures for the
next week, with PRN pressors including Levophed and Vasopressin.
Meropenem course to be completed on [**2200-7-21**].
Recurrent respiratory failure: Intubated on arrival to ED,
extubated post-op on [**2200-6-29**], reintubated 3 times during the
hospital stay for respiratory distress. Eventually
self-extubated and did well after gentle diuresis with lasix
drip. He did have a CT chest which showed bilateral pleural
effusions. He underwent a right thoracentesis with pigtail
catheter placement to help his respiratory status since diuresis
was limited by blood pressures. Ultimate etiology is unclear,
but he did have a presumed HCAP and was treated with
cefepime/vanc but continued to spike fevers until the abx were
changed to meropenem. However, a bronchoscopy did not find any
evidence of infection, only pulmonary edema so it is also
possible that all his respiratory failure was volume related.
Likely worse due to severe mitral regurgitation. On the evening
of [**7-20**], patient's respiratory status acutely worsened after
attempt at NGT was made. Became hypercarboic with rapid shallow
breathing, requiring reintubation. Chest XRAY at that time
showed worsening diffuse bilateral infiltrates concerning for
flash pulmonary edema vs. ARDS vs aspiration pneumonitis.
Pulmonary consult at that time placed for questionable
superimposed ARDS on top of cardiogenic edema.
Neuro: Initially sedated with fentanyl/versed while intubated.
Even once extubated, he remained delirious, and required
frequent re-orientation. While extubated, had episodes of
recurrent delirium/waxing/[**Doctor Last Name 688**].
Small bowel obstruction with ischemic bowel: Taken to the OR on
admission on [**2200-6-24**]. An ischemic portion of small bowel was
resected and his abdomen was left open and bowel in
discontinuity due to HD instability. He returned to the OR on
[**2200-6-27**] for reanastamosis and abdominal closure. Tube feeds were
started on [**2200-7-1**] when he was off pressors but the dobhoff was
"self-dc'd" on [**2200-7-1**]. At this point he was assessed with a
bedside swallow eval in which he did well. He was advanced to a
regular diet. Surgery continued to follow, and per above for
questionable sepsis requested a second CT torso to look for
infectious etiology of his shock. CT torso was unrevealing for
any infectious nidus...
C. diff: He developed diarrhea post-op and C. diff PCR in stool
was positive. He was treated with PO vancomycin 125 mg q6h, his
course should continue for 14 days after finishing the meropenem
for HCAP.
Heme: He was initially placed on heparin SQ but his platelets
(in the 200s on admission) dropped to <100 by HD [**3-30**]. Due to
concern for HIT, this was dc'd and a HIT panel was negative for
heparin-PF4 antibodies. His heparin SQ was restarted at this
point but the next day his platelets dropped further to 60. The
heparin SQ was dc'd again at this point and a serotonin release
assay was sent, it was negative. SQH was restarted on [**2200-7-2**]
and continued throughout the hospital stay. His platelets
recovered to > 200s. It was thought that he was septic causing
the thrombocytopenia.
Metabolic Alkalosis: Duration of hospitalization had worsening
alkalosis due to ongoing diuresis. Had correction with
acetazolamide, potassium supplementation, vasopressin, and
spironolactone.
Hypernatremia: With increased diuresis became increasingly
hypernatremic. Free water flushes instituted with Tube Feeds.
Hyperlipidemia: Continued atorvastatin.
On Hospital Day 28 through 29, multiple family meetings were
held about the patient's goals of care. Ultimately, it was
decided that his care should be focused on comfort instead of
aggressive measures. His care was withdrawn on the evening of
[**7-22**] and he shortly passed thereafter with his family at the
bedside.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from Admission
Note.
1. Atorvastatin 80 mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Aspirin 81 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Metoprolol Succinate XL 12.5 mg PO DAILY
Discharge Disposition:
Expired
Discharge Diagnosis:
Heart Failure
Cardiopulmonary arrest
Cariogenic and septic shock
Discharge Condition:
Diseased
Discharge Instructions:
x
Followup Instructions:
x
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"785.51",
"428.0",
"518.81",
"038.9",
"276.2",
"995.92",
"E915",
"424.1",
"V10.06",
"424.0",
"997.31",
"V45.3",
"557.0",
"E879.8",
"272.4",
"427.31",
"789.59",
"V70.7",
"287.5",
"999.32",
"785.52",
"250.00",
"V10.05",
"933.1",
"428.21",
"401.9",
"008.45",
"551.8",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"53.9",
"96.72",
"54.59",
"96.6",
"88.72",
"45.62",
"45.91",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
16961, 16970
|
8939, 10778
|
336, 540
|
17078, 17088
|
1921, 1921
|
17138, 17278
|
1514, 1629
|
16991, 17057
|
16615, 16938
|
17112, 17115
|
1644, 1644
|
1902, 1902
|
273, 298
|
10807, 16589
|
568, 1132
|
1937, 8916
|
1658, 1886
|
1154, 1377
|
1393, 1498
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,963
| 133,356
|
9153
|
Discharge summary
|
report
|
Admission Date: [**2184-5-23**] Discharge Date: [**2184-6-18**]
Date of Birth: [**2133-7-20**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Bactrim
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
massive lower GI bleed
Major Surgical or Invasive Procedure:
intubation
attempted TIPs revision x2
IVC filter placement
rectal varices embolization
therapeutic paracentesis x 4
History of Present Illness:
50M w/ h/o HIV, [**First Name3 (LF) 13808**], hepatitis C, esophageal varices s/p
multiple bandings who presents with maroon stools x 1 day. He
called EMS who found him to be hypotensive in the field to the
70s. He did not complain of chest pain or belly pain and had not
had any vomiting or hematemesis.
.
In the ED he was given 6L NS and 4U PRBC with increase in his
SBP to the 90s. Of note, 3U were O+ before the blood bank called
the ED to say that he should not have gotten Rh+ blood. He also
received 6 bags of platelets and 2U FFP. A Cordis was placed in
the left groin. He was started on octreotide for presumed
variceal bleeding. He was intubated (with difficulty) and NG
lavage was negative. GI/liver was consulted .
Past Medical History:
-- HIV/AIDS dx in [**2163**], CD4 nadir 95 in [**2179**]
-- H/o zoster
-- H/o positive toxo IgG in [**2180**]
-- H/o positive CMV IgG in [**2180**]
-- H/o positive Hep A ab in [**2183**]
-- H/o positive Hep B core AB in [**2183**] (with neg sAB, neg
antigen)
H/o negative RPR in [**2183**]
-- Negative PPD in [**2183**]
-- Osteomyelitis L knee 10 years ago [**3-5**] IVDA
-- Portal vein thrombosis seen on CT in [**2183**]
-- Hepatitis C, s/p varices, portal gastropathy, splenomegaly
-- Esophageal varices s/p banding
-- Gout (dx age 18; hx of tophi removal; on allopurinol in the
past. Was seen in [**Hospital **] Clinic [**2182-3-5**].)
-- Substance abuse (mostly IV heroin, benzos, cocaine)
[**Hospital **] Medical noncompliance
Social History:
Lives with girlfriend, on [**Name (NI) 31500**]. Smoked 2ppd x 20-30 yrs, no
etoh. H/o IVDA. Recent cocaine use (last 1 week ago), with
frequent 4-5d "binges." Occasional bzd abuse. Denies any etoh
use
Family History:
Non-contributory
Physical Exam:
VS: 98.1, 129/84, 82, 15, 94%
Vent: AC, 18x550, PEEP 5, FiO2 100%
Gen: intubated, sedated but arousable to voice, responds to
commands
HEENT: pupils round and equal, minimally reactive, MM dry
Lungs: ventilator noises obscuring lung exam but CTAB otherwise
CV: RRR, nl S1S2, no m/r/g
Abd: +BS, soft, nontender, distended, tympanitic
Ext: no c/c/e, scars on left foot
Neuro: sedated but responds to voice, moves all extremities
Pertinent Results:
LABS:
[**2184-5-23**] 02:30AM BLOOD WBC-5.8 RBC-3.73* Hgb-10.1* Hct-29.7*
MCV-80* MCH-27.1 MCHC-34.0 RDW-18.0* Plt Ct-159
[**2184-5-23**] 05:53AM BLOOD WBC-3.8* RBC-2.66*# Hgb-7.4*# Hct-21.7*#
MCV-82 MCH-27.8 MCHC-34.0 RDW-17.2* Plt Ct-91*
[**2184-5-23**] 07:31PM BLOOD WBC-7.1# RBC-1.88*# Hgb-5.7* Hct-15.7*#
MCV-84 MCH-30.3 MCHC-36.1* RDW-16.1* Plt Ct-94*
[**2184-5-23**] 08:36PM BLOOD Hct-27.3*#
[**2184-5-25**] 12:30AM BLOOD WBC-3.1*# RBC-2.88* Hgb-8.8* Hct-23.2*
MCV-81* MCH-30.5 MCHC-37.8* RDW-16.0* Plt Ct-50*
[**2184-5-26**] 04:10AM BLOOD WBC-3.3* RBC-2.99* Hgb-9.6* Hct-26.1*
MCV-87 MCH-32.0 MCHC-36.7* RDW-16.0* Plt Ct-66*
[**2184-5-28**] 04:24AM BLOOD WBC-3.8* RBC-3.83* Hgb-11.4* Hct-34.0*
MCV-89 MCH-29.9 MCHC-33.6 RDW-16.4* Plt Ct-77*
[**2184-5-29**] 05:01AM BLOOD WBC-2.2* RBC-3.53* Hgb-10.9* Hct-31.0*
MCV-88 MCH-30.9 MCHC-35.2* RDW-16.7* Plt Ct-59*
[**2184-5-30**] 05:58AM BLOOD WBC-3.3* RBC-3.73* Hgb-11.3* Hct-32.9*
MCV-88 MCH-30.2 MCHC-34.3 RDW-16.7* Plt Ct-65*
[**2184-6-1**] 03:16AM BLOOD WBC-2.8* RBC-3.11* Hgb-9.9* Hct-27.8*
MCV-89 MCH-31.8 MCHC-35.6* RDW-17.2* Plt Ct-68*
[**2184-6-2**] 03:09AM BLOOD WBC-2.2* RBC-3.02* Hgb-9.3* Hct-27.2*
MCV-90 MCH-30.9 MCHC-34.3 RDW-17.4* Plt Ct-72*
[**2184-6-4**] 04:30AM BLOOD WBC-2.1* RBC-2.92* Hgb-9.2* Hct-26.8*
MCV-92 MCH-31.6 MCHC-34.5 RDW-18.6* Plt Ct-74*
[**2184-6-5**] 06:50AM BLOOD Hct-25.6*
[**2184-6-6**] 01:33PM BLOOD WBC-1.9* RBC-3.27* Hgb-10.3* Hct-30.8*
MCV-94 MCH-31.3 MCHC-33.3 RDW-19.5* Plt Ct-57*
[**2184-6-9**] 07:34AM BLOOD WBC-1.2* RBC-2.91* Hgb-9.1* Hct-27.3*
MCV-94 MCH-31.2 MCHC-33.3 RDW-18.9* Plt Ct-55*
[**2184-6-9**] 11:29PM BLOOD Hct-26.9*
[**2184-6-11**] 05:34AM BLOOD WBC-2.4*# RBC-3.12* Hgb-9.8* Hct-29.3*
MCV-94 MCH-31.4 MCHC-33.5 RDW-18.7* Plt Ct-58*
[**2184-6-12**] 03:30AM BLOOD WBC-2.0* RBC-2.86* Hgb-9.1* Hct-26.9*
MCV-94 MCH-31.9 MCHC-33.9 RDW-18.4* Plt Ct-59*
[**2184-6-12**] 10:36PM BLOOD Hct-29.2*
[**2184-6-14**] 03:35PM BLOOD Hct-27.9*
[**2184-6-16**] 04:20AM BLOOD WBC-0.9* RBC-2.69* Hgb-8.3* Hct-25.4*
MCV-94 MCH-30.7 MCHC-32.6 RDW-17.0* Plt Ct-38*
[**2184-6-18**] 05:15AM BLOOD WBC-2.6* RBC-2.74* Hgb-8.4* Hct-25.4*
MCV-93 MCH-30.6 MCHC-33.0 RDW-16.7* Plt Ct-42*
[**2184-5-23**] 02:30AM BLOOD PT-19.7* PTT-31.1 INR(PT)-1.9*
[**2184-5-31**] 09:41AM BLOOD PT-19.4* PTT-32.2 INR(PT)-1.9*
[**2184-6-13**] 05:57AM BLOOD PT-17.3* PTT-31.3 INR(PT)-1.6*
[**2184-6-18**] 05:15AM BLOOD PT-15.3* PTT-29.9 INR(PT)-1.4*
[**2184-6-9**] 07:34AM BLOOD Gran Ct-490*
[**2184-6-16**] 04:20AM BLOOD Gran Ct-430*
[**2184-6-17**] 05:18AM BLOOD Gran Ct-2650
[**2184-5-23**] 05:53AM BLOOD Glucose-166* UreaN-7 Creat-1.0 Na-138
K-3.9 Cl-109* HCO3-22 AnGap-11
[**2184-5-24**] 02:48AM BLOOD Glucose-191* UreaN-8 Creat-0.9 Na-140
K-3.6 Cl-111* HCO3-19* AnGap-14
[**2184-5-26**] 04:10AM BLOOD Glucose-135* UreaN-8 Creat-0.9 Na-139
K-3.5 Cl-109* HCO3-23 AnGap-11
[**2184-5-28**] 04:24AM BLOOD Glucose-104 UreaN-8 Creat-0.9 Na-139
K-4.0 Cl-105 HCO3-28 AnGap-10
[**2184-5-31**] 05:26AM BLOOD Glucose-82 UreaN-12 Creat-1.0 Na-137
K-3.7 Cl-100 HCO3-31 AnGap-10
[**2184-6-2**] 03:09AM BLOOD Glucose-82 UreaN-9 Creat-0.9 Na-135 K-3.5
Cl-102 HCO3-29 AnGap-8
[**2184-6-5**] 05:08AM BLOOD Glucose-79 UreaN-4* Creat-0.9 Na-135
K-3.6 Cl-103 HCO3-27 AnGap-9
[**2184-6-8**] 05:03AM BLOOD Glucose-90 UreaN-5* Creat-0.9 Na-138
K-3.7 Cl-106 HCO3-27 AnGap-9
[**2184-6-13**] 05:57AM BLOOD Glucose-110* UreaN-5* Creat-1.0 Na-134
K-4.1 Cl-101 HCO3-28 AnGap-9
[**2184-6-16**] 04:20AM BLOOD Glucose-118* UreaN-7 Creat-0.8 Na-133
K-4.0 Cl-99 HCO3-32 AnGap-6*
[**2184-6-18**] 05:15AM BLOOD Glucose-100 UreaN-8 Creat-0.9 Na-134
K-3.8 Cl-97 HCO3-30 AnGap-11
[**2184-5-23**] 05:53AM BLOOD LD(LDH)-142 TotBili-1.0 DirBili-0.4*
IndBili-0.6
[**2184-6-2**] 03:09AM BLOOD ALT-12 AST-28 LD(LDH)-155 AlkPhos-40
TotBili-0.5
[**2184-6-8**] 05:03AM BLOOD ALT-8 AST-28 AlkPhos-46 TotBili-0.5
[**2184-6-15**] 06:05AM BLOOD ALT-11 AST-25 AlkPhos-55 Amylase-27
TotBili-0.6
[**2184-6-17**] 05:18AM BLOOD ALT-13 AST-34 AlkPhos-71 TotBili-0.6
[**2184-6-18**] 05:15AM BLOOD ALT-16 AST-41* AlkPhos-84 TotBili-0.4
[**2184-5-23**] 05:53AM BLOOD Hapto-<20*
[**2184-6-18**] 05:15AM BLOOD %HbA1c-5.1
.
.
STUDIES:
[**2184-5-23**] CXR;
There is an endotracheal tube whose tip is 6.6 cm above the
carina.
Nasogastric tube is seen and appropriately sited. Cardiac
silhouette and
mediastinum is normal. Lungs are grossly clear without focal
consolidation or pulmonary overload.
.
.
[**2184-5-23**] TIPS revision:
Unsuccessful TIPS shunt creation in a patient with known main
portal vein occlusion. CO2 portogram unsuccessful. Direct
portogram
demonstrates occlusion at the main portal vein that was not able
to be crossed with a wire. Pressure gradient between portal vein
and right atrium: 46 mmHg.
.
[**2184-5-25**] CXR: Moderate pulmonary edema has progressed
substantially since [**5-24**] accompanied by increasing
small-to-moderate right pleural effusion and mediastinal
vascular engorgement indicating elevated central venous pressure
and/or volume. Heart size remains normal. There is no good
evidence for pneumonia.
.
[**2184-6-3**] CT ABD/PELVIS:
1. Extensive rectal varices as described above, which extend to
the splenic vein.
2. Splenomegaly, unchanged.
3. Large amount of ascites, worsened since the prior study.
4. Portal vein thrombus, once not changed in length, now
appears to involve larger caliber of the vessels than previously
seen. The portal vein thrombus extends to the portosplenic
confluence, and involves the
proximal, anterior and posterior branches of the right portal
vein.
5. Right hepatic lobe relative low density lesion, could be
perfusion related but inadequately assessed on this single phase
study as described above.
.
[**2184-6-9**] TIPS revision:
Unsuccessful TIPS shunt creation in patient with known main
portal vein occlusion and multiple periportal collateral
vessels.
.
[**2184-6-14**] LE USN:
1. RIGHT LOWER EXTREMITY: Non-occlusive debris within the common
femoral and femoral veins, compatible with the sequelae of prior
DVT.
2. LEFT LOWER EXTREMITY: Non-occlusive DVT within the common
femoral and
femoral veins.
.
[**2184-6-14**] IVC FILTER PLACEMENT:
Uncomplicated retrievable IVC filter placement into the
infrarenal vena cava. The filter can be retrieved within two
weeks after its deployment.
Brief Hospital Course:
# massive GI bleed - pt was admitted to the ICU for rectal
bleeding. during the first 24 hours of his ICU stay, Mr.
[**Known lastname **] lost ~8L of bright red blood per rectum. required
transfusion of 20 U pRBCs, 6 units FFP, 2 units cryoprecipatate,
and 2 bags of platelets. Also received ~12L of normal saline. A
left femoral cordis and R IJ triple lumen catheter were placed.
Pt was intubated for air way protection. Upper endoscopy showed
evidence of [**Female First Name (un) **] esophagitis but no source of bleeding.
Patient then went to interventional radiology for an attempt at
angiography and possible TIPS. TIPS not able to be preformed
secondary to occluded portal vein (portal pressure ~40-60).
Patient was started on octreatide drip. Surgery was consulted. A
bedside rigid sigmoidoscopy did not reveal source of bleeding.
He was given a bolus dose of 40 units of IV vasopressin (pushed
by MD) then started on a drip. Bleeding then stopped.
Colonoscopy [**2184-5-25**] showed a large rectal varices that is likely
the source of bleeding. Patient thereafter remained
hemodynamically stable. He was weaned of the octreatide and
vasopressin drips. He was started on nadolol to try to reduce
portal hypertension.
.
pt sent to medical floor on [**5-30**], and was doing well on medical
floor until until the morning of [**5-31**], when had ~500cc BRBPR
while on the commode, with LH/dizzy and SBPs 80s. no
cp/sob/palp. he was treated with 1L IVF with SBP->90s, and
resolution of symptoms. serial hct revealed HCT 32->26, and pt
was given 2U PRBC, 2U FFP, 100mg octreotide SC, and was sent to
the MICU for further management, where flexible sigmoidoscopy
revealed grade 5 hemmoroids, fresh clot, bleeding from rectal
varix, however because of its size, GI was unable to band.
Bleeding spontaneously improved with initiation of octreotide
gtt x 48hrs, and pt was hemodynamically stable.
.
pt was called out to medical service on [**2184-6-4**] with plan to
consider either percutaneous attempt at TIPs revision, despite
portal vein thrombosis versus embolization of rectal varices
with dermabond. Pt underwent vein mapping of rectal varices
which confirmed lack of systemic connection with rectal varices,
thus it was felt safe to proceed with rectal embolization as
emboli would be trapped by portal vein thrombosis.
.
attempt was made to revise TIPs via transjugular approach on
[**2184-6-9**] in interventional radiology, however this was
unsucessful. pt continued to have slow decline in his HCT
(26-30), for which he received an additional 2U PRBC on [**6-5**] and
[**6-9**]. pt was without recurrence of bleeding from the rectum
after his discharge from the ICU.
.
on [**2184-6-10**] pt underwent embolization of his rectal varices with
dermabond injection without complication. he was monitored in
the ICU overnight, without further complication, and returned to
the medical service, where he was without melena or bloody
stools. His HCT remained stable, and he required no further
blood transfusion. In total, pt received 23U PRBC, 15U FFP, 9U
platelets.
.
pt was discharged home on [**2184-6-18**] with plan for follow-up within
1 week with his hepatologist. In addition, he will f/u with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] to discuss repeat embolization.
.
.
# aspiration pneumonia - pt was found to have developed RLL
infiltrate in the setting of intubation, after a febrile
episode, with O2 requirement of up to 3L. He was treated with a
2 wk course of levo/flagyl completed on [**2184-6-7**], and weaned off
of oxygen after arrival on the medical service.
.
.
# bilateral lower extremity DVT - pt was noted to have increased
R>L LE edema on [**2184-6-14**]. LENI's revealed bilateral lower
extremity DVT. given concern about starting pt on
anticoagulation in setting of his rectal bleeding, decision was
made to place IVC filter, which was done without complication on
[**6-14**]. pt was noted to have discoloration of his legs when
dependent, thus he was instructed to keep his legs elevated. he
will follow-up with his hepatologist regarding when to have IVC
filter removed.
.
.
# [**Name (NI) 13808**] - pt not felt to be a candidate for transplant given
ongoing drug use. abdominal ascites reaccumulated during this
admission, for which he received therapeutic paracentesis
[**2184-5-28**], [**2184-6-5**], and again on [**2184-6-17**]. diuretics were initially
held [**3-5**] low SBPs in setting of GIB, however these were
restarted [**6-14**], as SBPs were stable (80-90s), and HCT stable
since [**6-9**]. pt's lactulose was discontinued as he was very
concerned that this would cause BRBPR, and miralax was used
instead. his mental status remained clear, and he was without
encephalopathy during this admission.
.
.
# HIV - pt apparently has not been compliant with medications as
an outpatient, thus his HAART regimen was held. He was
continued on dapsone for PCP prophylaxis, fluconazole for
esophageal candidiasis, and azithromycin qweek for MAC [**Month/Day (4) **]. He
will follow-up with his PCP [**Name Initial (PRE) 176**] 1 week of his discharge
regarding further HIV therapy, as well as workup of his
neutropenia as below.
.
.
# neutropenia - pt noted to be neutropenic on [**6-10**] (wbc 0.9),
etiology was felt most likely related to HIV. after discussion
with pt's PCP, [**Name10 (NameIs) 10245**] made to pursue workup as outpatient, as
given pt's multiple other comorbidities, unclear whether further
treatment of potential malignancies would be possible. pt was
given neupogen 300mg sc x 1 prior to embolization on [**6-10**], with
appropriate increase in WBC to 3.0's. he will f/u with PCP
[**Name Initial (PRE) 176**] 1 week of discharge for further w/u of neutropenia and
HIV treatment as above.
.
.
# IVDU - h/o heroin use, pt continued on methadone. he was
discharged with 1 month supply of methadone. he was given 1
week of oxycodone for back pain.
.
.
# diabetes - pt without previous history of diabetes, though he
has been placed in insulin sliding scale over multiple
admissions. he has had random blood sugars >200 on multiple
occasions, he has generally been requiring ~4U regular insulin
daily. given his variable PO intake, and potential interaction
with his liver dysfunction, pt was instructed to f/u with his
PCP regarding starting diabetic medication.
.
.
# CODE STATUS - pt was DNR/DNI; confirmed with patient on
transfer to MICU. His goals of care this admission were to be
able to return home but he would not want to be intubated,
resuscitated in an emergency or long term situation.
.
.
# DISPO - pt discharged home on [**2184-6-18**] with plan for f/u with
PCP [**Name Initial (PRE) 176**] 1 week regarding his neutropenia, ?diabetes, and HIV
management. He will follow-up with Dr. [**Last Name (STitle) 497**] within 1 week
regarding his ongoing liver disease and to discuss the timeline
of his repeat embolization.
Medications on Admission:
Kaletra
Epizcom
Viread
Allopurinol 300 qd - had not been taking
Dapsone 100 mg qd
Azithromycin 1200 mg q week (on Sundays)
Omeprazole
Spironolactone 50
Lasix 20
Lactulose
Sucralfate
Methadone 60 mg
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
primary:
bleeding rectal varices
cirrhosis
elevated blood sugars
bilateral femoral vein thrombosis
Discharge Condition:
stable, no active bleeding
Discharge Instructions:
You were hospitalized following a large bleed from your rectal
veins. You required amny transfusions to support your blood
pressure. A procedure to stop the bleeding, which involved
injecting a type of glue into the veins, was performed. You will
need to have this procdure repeated as an out-patient. Please
arrange this with Dr. [**Last Name (STitle) 497**].
.
Please take all of your medications as prescribed.
.
An inferior vena cava filter was placed during this admission
because of bilateral blood clots in your legs; the filter is in
place to prevent blood clots from traveling from your legs to
your lungs. You should discuss having this removed with dr.
[**Last Name (STitle) **].
.
Please call your doctor or return to the emergency room if you
have bleeding from your rectum, fevers/chills, nausea/vomiting,
abdominal pain, if you cannot eat, drink, or take your
medications, or you develop any other symptoms that are
concerning to you.
Followup Instructions:
please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**], [**Telephone/Fax (1) 1582**] - an
appointment has been made for you on [**2184-6-25**] at 12PM. you
should discuss having your IVC filter removed with him.
.
please follow-up with your primary care physician (Dr. [**First Name8 (NamePattern2) 803**]
[**Last Name (NamePattern1) **]) on [**2184-6-25**] at 11:15AM. ([**Telephone/Fax (1) 4170**]. you should
discuss utility of starting regular treatment for your elevated
blood sugars.
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5,882
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15832
|
Discharge summary
|
report
|
Admission Date: [**2144-7-16**] Discharge Date: [**2144-7-31**]
Date of Birth: [**2082-11-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
# Fever
# Bacteremia
Major Surgical or Invasive Procedure:
# PICC placement at left upper extremity
# Diagnositic paracentesis
# Paracentesis (3 L)
History of Present Illness:
61M h/o HCV cirrhosis s/p [**2140**] liver [**Year (4 digits) **], [**5-21**] TIPS for
recurrent ascites, [**7-3**] TIPS revision c/b enterobacter cloacae
bacteremia for which pt was completing 14-day meropenem course,
was admitted from rehab for T 101.2F on [**2144-7-15**], with blood
cultures growing GPC in chains at OSH, for which pt received
daptomycin 360mg x 1 dose prior to transfer given VRE history.
.
ED course: T 99.8F, P 80, BP 138/82, R 16. UA and CXR revealed
no infectious source, abdominal exam was benign, and no
significant leukocytosis was noted. ROS in ED significant only
for headache; pt also reported 3-week ongoing nonproductive
cough without dyspnea.
.
On arrival to floor, ROS significant for fatigue, [**4-23**] throbbing
headache x 1 week with associated photophobia but absent other
meningeal signs and symptoms, Given this, LP was deferred to
monitor pt for any further neurological impairment, of which
there were none.
Past Medical History:
# End-stage liver disease [**1-17**] HCV cirrhosis
--[**8-/2141**] [**Year (4 digits) **]
--[**10/2141**] rejection
--[**12/2141**] cholangitis
--[**5-/2144**] TIPS for recurrent ascites
--[**6-/2144**] TIPS redo for occlusion
--Grade I esophageal varices
# DMII post-[**Year (4 digits) **]
# Chronic kidney disease [**1-17**] DMII nephropathy
# Hypertension
# ID: C. Diff [**1-20**], enterococcus bacteremia [**6-20**], VRE bacteremia
[**7-21**]
# Failure to thrive
# Depression
Social History:
# Employment: Retired truck driver
# Personal: Lives with wife [**Name (NI) **] [**Name (NI) **], [**First Name3 (LF) **] [**Name (NI) **]
# Smoking: 20 pack-year history; quit [**2125**]
# Alcohol: Never
Family History:
Noncontributory
Physical Exam:
Vitals: T 99.2, BP 160/85, HR 78, RR 18, O2 97% on RA
.
General: Cachectic, NAD, A&O x 3.
HEENT: NCAT + Dobhoff, nonicteric sclera, poor dentition, MMM
Chest: Few crackles at left base, otherwise CTA
CV: RRR, S1/S2, 3/6 SEM, +JVD
Abdomen: Distended, + BS, soft, nontender to deep palpation,
chevron scar, palpable liver edge.
Extremity: No edema, no asterixis
Rectal: Guaiac-negative in ED
Skin: Dry, flaking
Pertinent Results:
Admission labs:
.
[**2144-7-16**] 09:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2144-7-16**] 09:15PM URINE BLOOD-SM NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-TR
[**2144-7-16**] 09:15PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2144-7-16**] 09:15PM URINE GRANULAR-0-2 HYALINE-0-2
[**2144-7-16**] 07:31PM COMMENTS-GREEN TOP
[**2144-7-16**] 07:31PM LACTATE-0.9
[**2144-7-16**] 06:45PM GLUCOSE-101 UREA N-61* CREAT-2.4*# SODIUM-134
POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-16* ANION GAP-15
[**2144-7-16**] 06:45PM ALT(SGPT)-24 AST(SGOT)-72* LD(LDH)-202 ALK
PHOS-352* AMYLASE-70 TOT BILI-1.1
[**2144-7-16**] 06:45PM LIPASE-102*
[**2144-7-16**] 06:45PM CALCIUM-8.5 PHOSPHATE-3.0 MAGNESIUM-1.9
[**2144-7-16**] 06:45PM WBC-8.7 RBC-3.90*# HGB-11.2*# HCT-33.0*#
MCV-85 MCH-28.7 MCHC-33.9 RDW-18.3*
[**2144-7-16**] 06:45PM NEUTS-90.7* LYMPHS-5.4* MONOS-2.1 EOS-1.6
BASOS-0.2
[**2144-7-16**] 06:45PM PLT COUNT-156
[**2144-7-16**] 06:45PM PT-13.3* PTT-30.2 INR(PT)-1.2*
========================================
Studies:
.
# CHEST (PA & LAT) [**2144-7-16**] 8:32 PM
FINDINGS: There is relatively prominent interstitial markings
suggestive of an edema-like pattern. No definite focal
consolidation is noted although slight confluent opacity is seen
in the retrocardiac left lower lobe. The mediastinum is
unremarkable. The cardiac silhouette size is stable. Small
bilateral pleural effusions are evident. There is no
pneumothorax. A PICC line is again identified. Its distal tip is
stable in the region of the brachiocephalic proximal to the
junction with the superior vena cava. An enteric feeding tube is
again noted with the distal tip in the gastric body. A TIPS is
in place stable.
IMPRESSION: Slight confluent opacity in the retrocardiac left
lower lobe which is likely confluent edema although an early
developing pneumonia cannot be entirely excluded. There is mild
volume overload evident. Repeat radiography following
appropriate diuresis is recommended to assess for underlying
infection.
.
# DUPLEX DOPP ABD/PEL [**2144-7-17**] 10:56 AM
FINDINGS: The lumen of the tips appears patent. The proximal,
mid, and distal aspects of the tips demonstrate velocities of
29, 44 and 99 cm per second respectively, compared with a 69 and
145 cm per second on the previous study. Hepatopedal flow is
noted in the main portal vein with a velocity of approximately
20 cm per second. No flow is identified in the left or right
portal vein. In the liver parenchyma, there is a 2.6 x 1.7 x
1.2 anechoic lesion, present on the previous examinations and
representing a simple hepatic cyst.
IMPRESSION:
1. No flow identified within the left portal vein and in the
right portal vein concerning for thrombosis. CT is recommended
for further evaluation.
2. Decreased velocities within the TIPS.
3. Simple hepatic cyst.
4. Moderate ascites.
.
# ECHO Study Date of [**2144-7-17**]
Conclusions: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF 55%). Right
ventricular chamber size and free wall motion are normal. 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. Moderate [2+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
No vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.
IMPRESSION: No evidence of endocarditis. Symmetric LVH with
preserved global and regional biventricular systolic function.
Mild aortic regurgitation. Moderate mitral regurgitation.
Moderate tricuspid regurgitation. Moderate pulmonary
hypertension. Compared with the prior study (images reviewed)
of [**2144-6-11**], left ventricular function is not as vigorous
(though still in the normal range). Mitral and tricuspid
regurgitation are better visualized, but are probably similar in
severity. Pulmonary pressures have increased.
.
# CT CHEST W/O CONTRAST [**2144-7-18**] 11:30 AM
Findings:Multiple stable heavily calcified irregular pulmonary
nodules in both lungs measuring up to 14 mm are unchanged in
size and appearance and likely represent metastatic
calcification which is not an uncommon finding after recent
liver transplantation. The lungs are otherwise clear. There has
been interval development of moderate right-sided and small
left-sided pleural effusion. The airways are patent up to the
subsegmental level. The heart and great vessels of the
mediastinum are remarkable for aortic valvular and aortic
atherosclerotic calcification. No pathologically enlarged
axillary, mediastinal, or hilar lymph nodes are seen. Visualized
portion of the abdomen are remarkable for TIPS located within
the right posterior portal vein branch, NG tube in the stomach
and metastatic calcification of both renal cortices. No
concerning lytic or sclerotic lesions are noted within bones.
IMPRESSION:
1. New moderate right-sided pleural effusion and small
left-sided pleural effusion.
2. Stable calcified nodules due to metastatic pulmonary
calcification.
3. Ascites.
4. Metastatic calcification of both renal cortices.
.
# DUPLEX DOPP ABD/PEL [**2144-7-18**] 10:54 AM
Color flow and Doppler images of the liver were obtained. The
main portal vein, left protal vein and anterior right protal
vein are all patent. No evident thrombosis is identified. The
TIPS device is connected to the posterior right portal vein. The
lumen of the TIPS appears grossly patent with wall-to-wall flow
identified. The velocities within the TIPS, proximal, mid and
distal portions are 53, 132, and 103 cm/sec. These findings are
mostly consistent with a study that was performed on [**2144-7-7**]. The portal vein velocity measures 52 cm/sec with
appropriate hepatopetal flow. The left portal vein and anterior
right portal venous flow are reversed as expected. The
visualized portion of the liver parenchyma appears grossly
unremarkable.
IMPRESSION:
1. TIPS appears patent with velocities as described above.
2. The main protal vein and left and right portal vein branches
are patent, with reversed flow as expected.
.
# CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST [**2144-7-23**] 1:17
AM
FINDINGS: Direct comparison is made to a prior CT dated
[**2143-10-3**]. As on recent prior chest CT dated [**2144-7-18**], multiple
nodules are identified throughout the lung parenchyma. However,
the current examination reveals areas of more confluent opacity
within the right middle lobe and left lower lobe as well as
increased interstitial thickening. This may represent
infectious etiology or possibly [**Year (4 digits) 1106**] congestion on a
background of chronic lung disease. Patient's known TIPS is
identified. Under the limitations of a non-contrast CT, the
patient's [**Year (4 digits) **] liver, spleen, adrenal glands, pancreas
appear grossly unremarkable. Again, there is abnormally
increased attenuation involving the cortex and possibly outer
medulla of the kidneys bilaterally. This is unchanged since the
prior exam. This likely represents ATN related to a recent
intravenous contrast administration. Recommend clinical
correlation as to the possibility of recent intravenous contrast
administration. Evaluation of the bowel is grossly
unremarkable. The descending and ascending colon demonstrates
questionable minimal wall thickening which is likely related to
the patient's liver disease. Similar findings were seen on the
aforementioned prior abdominal CT scan. A large amount of
ascites is identified. The pelvic structures appear grossly
unremarkable. Again, there is irregularity of the right iliac
crest which appears unchanged since the
aforementioned prior abdominal CT. No further lytic or blastic
bony lesions are seen.
IMPRESSION:
1. Consider infectious etiology or possibly [**Year (4 digits) 1106**] congestion
given the appearance of the lung bases as detailed above.
2. Large ascites is noted.
3. Abnormality of the kidneys suggestive of recent intravenous
contrast administration. Recommend clinical correlation.
4. Minimal prominence of the colonic wall, likely related to
underlying liver disease.
.
# TRANSTHORACIC ECHO [**2144-7-23**]
The left atrium is moderately dilated. There is mild symmetric
left
ventricular hypertrophy. The left ventricular cavity size is top
normal.
Regional left ventricular wall motion is normal. Overall left
ventricular
systolic function is normal (LVEF 55%). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The ascending aorta is mildly
dilated. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Symmetric LVH with preserved global and regional
biventricular systolic function. Mild aortic regurgitation.
Moderate mitral regurgitation. Moderate tricuspid
regurgitation. Moderate pulmonary hypertension. Compared with
the prior study (images reviewed) of [**2144-7-17**], the findings are
similar. Previously reported left ventricular diastolic
dimension was reported as smaller, but (upon remeasurement) is
similar to the one from this study.
.
# ECG [**2144-7-23**] 10:24:20 AM
Sinus rhythm. Left ventricular hypertrophy. Compared to the
previous tracing of [**2144-7-9**] the rate has increased. The T waves
now have a terminal biphasic appearance. The rate has increased.
The T wave changes suggest active anterior ischemia. Followup
and clinical correlation are suggested.
.
# CHEST (PORTABLE AP) [**2144-7-24**] 10:06 AM
CHEST, SINGLE VIEW: A feeding tube coiled is within the stomach.
TIPS again seen. Interval increase in heart size and prominence
of the azygos vein suggests CHF/volume overload. Worsening of
bilateral airspace opacification, most pronounced on the left.
There is no pneumothorax or large pleural effusion.
IMPRESSION: Interval worsening in pulmonary edema and CHF/volume
overload.
.
# CHEST (PORTABLE AP) [**2144-7-26**] 6:16 PM
IMPRESSION: AP chest compared to [**7-23**] through 10:
Severe diffuse pulmonary consolidation and [**Month (only) 1106**] engorgement
has improved since [**7-23**]. Severe cardiomegaly is stable.
Pleural effusion, if any, is minimal. No endotracheal tube is
seen below C6, the upper margin of this film. Feeding tube is
looped in the stomach, which is moderately distended with air
and semisolid material. No pneumothorax.
.
# CHEST (PORTABLE AP) [**2144-7-27**] 10:31 AM
EXAMINATION: Portable upright film of the chest on [**7-27**]. The
nasogastric tube is the same as on [**7-26**], curled upon
itself in the stomach. There is residual fluid and debris in the
stomach. The hepatic stent is noted. The chronic changes
throughout both lungs persist. No obvious effusion is seen. The
findings suggest stable chronic process. If anything, there
appears to be less [**Month (only) 1106**] congestion than there was on [**7-26**].
CONCLUSION: Slight resolution of what appeared to be an element
of pulmonary edema superimposed on chronic bilateral changes.
.
# ECG Study Date of [**2144-7-28**] 10:11:30 AM
Sinus bradycardia. Voltage criteria for left ventricular
hypertrophy.
Compared to tracing of [**2144-7-23**] there is no significant diagnostic
change.
.
# CHEST RADIOGRAPH PERFORMED ON [**2144-7-31**].
FINDINGS: Portable upright chest radiograph is obtained. The
feeding tube is again noted with its tip coiled in the left
upper quadrant. TIPS stent is again noted in the right upper
quadrant. There has been interval improvement in pulmonary
edema. The previously noted areas of parenchymal calcifications
are again noted in the right lung apex and right mid lung. The
heart remains enlarged. Mediastinal contour is unremarkable.
There is no pneumothorax. The visualized osseous structures are
intact. Visualized bowel loops in the upper abdomen are
unremarkable.
IMPRESSION:
1. PICC line noted with tip in the region of the SVC. Feeding
tube tip
coiled in the stomach.
2. Cardiomegaly, with interval improvement in pulmonary edema.
3. Stable appearance of right-sided nodular parenchymal
calcification in the right lung apex and mid lung.
Brief Hospital Course:
61M h/o HCV cirrhosis s/p [**2140**] liver [**Year (4 digits) **] (on sirolimus
only), [**6-20**] TIPS for recurrent ascites, [**6-20**] redo TIPS for
occlusion, complicated by suspected SBP (culture negative, but
PMN 240) and enterobacter bacteremia (treated with meropenem),
admitted [**7-16**] for fevers with OSH blood cultures growing GPC in
chains for which pt was started on daptomycin.
.
# Infection: Pt's blood cultures from peripheral blood draws
yielded vancomycin-resistant enterococcus sensitive to
daptomycin (positive cultures on [**7-10**], [**7-21**], [**7-22**]), and
therefore pt was continued on daptomycin 350 mg q 24 h, with CK
drawn weekly and CrCl monitored (no dose adjustments were
necessary). Pt was also continued on meropenem and completed a
14-day course given h/o enterobacter bacteremia.
.
Pt developed SBP on [**7-22**], and was then changed to tigecycline
given that SBP developed while pt was on daptomycin and
meropenem. Cultures of peritoneal fluid were negative.
.
To evaluate other possible sources of infection, RUE PICC was
removed to culture tip, which was negative. All stool cultures
and C. Diff toxin assays were negative. TTE was negative for
appreciable valvular vegetations. Given bilateral rhonchi on
clinical lung exam, CT chest was performed also to assess
possibility of pulmonary process, but revealed only stable
calcified lung nodules; induced sputum attempt was unable to
elicit adequate sample.
.
Pt was discharged with plan to (1) stop tigecycline on [**8-1**]
after completing a ten-day course, (2) start ciprofloxacin for
continuing SBP ppx on [**8-1**], and (3) start daptomycin (first dose
[**8-2**] - last dose 9/30) to complete a six-week course for VRE
bacteremia.
.
# Flash pulmonary edema: After receiving albumin 100 g for SBP,
pt developed severe SOB on [**7-23**] requiring face mask likely [**1-17**]
CHF, moderate pulmonary artery systolic hypertension, and
resultant flash pulmonary edema. Pt was transfered to the MICU,
aggressively diuresed in the MICU with resolution of SOB.
.
In the MICU, echo demonstrated normal although less vigorous
left ventricular function, stable mitral and tricuspid
regurgitation, and increased pulmonary pressures, leading to CHF
as the likely triggering etiology of pt's SOB. Pt received
diuretics (furosemide, chlorothiazide, metolazone) titrated to
achieve effective diuresis with resolution of SOB.
.
# RUE thrombus: PICC removed from RUE to culture tip (no
significant growth), but pt was found to have an extensive RUE
DVT, occlusive at the cephalic vein, and which was suspected to
be an infective source. For anticoagulation, pt began on
heparin drip, but was changed to enoxaparin because of limited
peripheral IV access and need for IV antibiotics. Warfarin 5 mg
was started and titrated to reach INR [**1-18**]. A new LUE PICC was
placed before dispo to rehab. Pt was discharged with plan to
continue anticoagulation for three months, with follow-up
ultrasound to monitor interval change.
.
# HCV cirrhosis s/p [**Month/Day (3) **]: Pt was initially continued on
home regimen of rifaximin, lactulose, ursodiol, sirolimus, and
mycophenolate, the last of which was was discontinued given pt's
high levels of sirolimus and infected state. Sirolimus levels
were monitored every three to five days per [**Hospital1 18**] protocol.
.
# HTN: Pt's amlodipine was increased to 10 mg daily given SBPs
reaching mid 160s. Pt was continued on metoprolol 50 mg [**Hospital1 **].
Clonidine patch 0.1 mg/week was begun [**7-22**] for better SBP
control, but was discontinued after transfer to MICU in favor of
more precise blood pressure control with metoprolol and
hydralazine, which were continued after return to the floor.
.
# FEN: Pt complained of inability to tolerate tube feeds via
Dobhoff at 80 cc/hr, and therefore these were decreased to 40
cc/hr. Appetite continued to vary, and pt was ultimately
increased to 24-hr tube feeds at 55 cc/hr with Nutren pulmonary
and banana flakes ([**2116**] kcal/90g protein to provide 28 kcals/kg
and approximately 1.3 g/protein/kg). Dronabinol, which had been
started in an effort to improve appetite, demonstrated no
significant benefit, and was discontinued in light of
psychiatric side-effects such as depression.
.
# Depression: Pt's depression continued unimproved despite
fluoxetine 30 mg daily. Fluoxetine was then d/c'd in effort to
improve appetite, and later replaced with mirtazapine 15 mg
daily.
.
# DMII: Pt was continued on humalog sliding scale with no fixed
doses; FS glucose was well-controlled.
.
# Chronic kidney disease [**1-17**] DM nephropathy: Pt was continued on
nephrocaps, calcium carbonate, and vitamin D daily.
.
# Access: Double-lumen PICC placed at LUE on [**2144-7-31**] with tip
properly placed at the SVC.
.
# Code: Full
Medications on Admission:
Sirolimus 1 mg daily
Mycophenolate Mofetil 250 mg [**Hospital1 **]
Pantoprazole 40 mg Tdaily
Meropenem 500 mg q12hr x 7 D
Fluoxetine 20 mg daily
Amlodipine 5 mg daily
Metoprolol Tartrate 50 mg [**Hospital1 **]
Ursodiol 300 mg [**Hospital1 **]
Calcium Carbonate 500 mg Tablet qid
Ferrous Sulfate 325mg daily
B Complex-Vitamin C-Folic Acid 1 mg daily
Rifaximin 400 mg tid
Oxycodone 5 mg 1-2 Tablets PO Q6H PRN
Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H PRN
Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO Q6H
Insulin SS
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. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
6. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours): Hold for more than 4 loose stools/day.
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
9. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a
day: First dose 8/18.
Disp:*30 Tablet(s)* Refills:*2*
10. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) 70 mg injection
Subcutaneous Q12H (every 12 hours): Until INR=2 with warfarin
therapy.
Disp:*60 70 mg* Refills:*2*
11. Sirolimus 1 mg/mL Solution Sig: One (1) 0.5 mg PO DAILY
(Daily).
Disp:*30 ml* Refills:*2*
12. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
13. Tigecycline 50 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours): Last dose on [**8-1**].
Disp:*3 Recon Soln(s)* Refills:*0*
14. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
15. Heparin Flush (Porcine) in NS 100 unit/mL Kit Sig: Two (2)
ML Intravenous DAILY (Daily) as needed: 10 ml NS followed by 2
ml of 100 Units/ml heparin (200 units heparin) each lumen daily
and PRN. Inspect site every shift.
16. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
neb Inhalation Q6H (every 6 hours) as needed for shortness of
breath or wheezing.
17. Sodium Chloride 0.9 % 0.9 % Solution Sig: Three (3) ml
Injection DAILY (Daily) as needed for peripheral IV maintenance.
18. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
19. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
20. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
21. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
22. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mg PO Q4H (every
4 hours) as needed for pain.
23. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
24. Insulin
Humalog sliding scale per insulin order flowsheet included in
discharge paperwork.
25. Daptomycin 500 mg Recon Soln Sig: Three [**Age over 90 1230**]y (350)
mg Intravenous q24h for 6 weeks: First dose 8/19 - last dose
[**9-13**].
Disp:*[**Numeric Identifier 45520**] mg* Refills:*0*
26. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO once a day:
Titrate to INR 2 - 3.
Disp:*30 Tablet(s)* Refills:*2*
27. Outpatient Lab Work
# Please draw INR daily.
# Titrate warfarin therapy to achieve INR [**1-18**].
28. Outpatient Lab Work
# Draw CrCl weekly
# Draw CBC with diff weekly
# Draw all liver function tests weekly
# Draw sirolimus level weekly
# Draw CPK weekly from [**2144-8-2**] - [**2144-8-22**]
# Draw CPK every two weeks from [**2144-8-22**] - [**2144-9-13**]
# Draw aerobic and anaerobic blood cultures on [**2144-8-23**]
# Fax all results to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 4020**] MD, [**Telephone/Fax (1) 1419**]
# Fax all results to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 23170**], RN, [**Telephone/Fax (1) 697**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary diagnosis:
# Vancomycin-resistant enterococcus bacteremia
# Spontaneous bacterial peritonitis
# Acute right upper extremity thrombus
# Flash pulmonary edema [**1-17**] CHF
# Failure to thrive
# Depression
.
Secondary diagnosis:
# HCV cirrhosis
# Diabetes mellitus type II
# Chronic kidney disease [**1-17**] diabetes mellitus type II
# Hypertension
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital because you had a fever and we
found bacteria in your blood (bacteremia). Later, you also
developed spontaneous bacterial peritonitis (infection of the
fluid in your belly). We gave you antibiotics to eliminate
these infections.
.
We also reimaged your liver to confirm that your TIPS and your
liver veins are open. We adjusted the amount of tube feeding
that you receive to 55 cc/hr, 24 hours daily. We discovered you
have a clot in your right arm, and so we also started you on
medicines to make your blood less easy to clot.
.
During your stay, you went to the intensive care unit once
because you you were very short of breath. Your difficulty
breathing was felt to be due to fluid overload. We removed
fluid from you and your respiratory status improved.
.
We are sending you to the rehabilitation facility with new
antibiotics:
# Antibiotic: Tigecycline (last dose 8/18)
# Antibiotic: Ciprofloxacin (start [**8-1**], ongoing)
# Antibiotic: Daptomycin, starting [**8-2**] and ending [**9-13**]
.
We also gave you another new medication for your mood and
appetite called mirtazapine.
.
We changed your amlodipine for your hypertension to a new dose
of amlodipine 10 mg daily.
.
If you experience fevers, chills, nausea, vomiting, severe
abdominal pain, or any other symptoms that you are concerned
about, please contact Dr. [**Last Name (STitle) 497**] and go immediately to the
emergency room.
Followup Instructions:
You have the following appointments:
.
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2144-8-19**]
1:00, [**Hospital Ward Name 517**], [**Hospital1 41690**], [**Location (un) **]
.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2144-8-19**] 2:30, [**Last Name (NamePattern1) 23931**]
.
Provider: [**First Name8 (NamePattern2) 4021**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:
[**2144-9-10**] 9:00
Completed by:[**2144-7-31**]
|
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"041.04",
"453.8",
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"789.5",
"403.90",
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"428.0",
"V09.80",
"585.9",
"790.7",
"V49.83",
"311",
"416.8",
"567.23",
"V42.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"54.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
24251, 24323
|
15322, 20139
|
336, 426
|
24724, 24732
|
2613, 2613
|
26219, 26771
|
2152, 2169
|
20718, 24228
|
24344, 24344
|
20165, 20695
|
24756, 26196
|
2184, 2594
|
276, 298
|
454, 1411
|
24580, 24703
|
2629, 15299
|
24363, 24559
|
1433, 1914
|
1930, 2136
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,933
| 185,774
|
53628
|
Discharge summary
|
report
|
Admission Date: [**2175-11-7**] Discharge Date: [**2175-11-10**]
Date of Birth: [**2104-7-1**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
left sided weakness
Major Surgical or Invasive Procedure:
IV t-PA
History of Present Illness:
71 year old RH man with history of atrial fibrillation,
hypertension, and cad who presents with acute onset of left
sided
weakness at 10:30 PM yesterday. His wife was with him in the
living room when she noticed acute onset of left side facial
droop. She then tried to get him up but he fell over due to left
arm/leg weakness. He then complained that he had a headache and
felt dizzy. His wife gave him 5 mg coumadin but when he did not
feel better, she called EMS. He was taking coumadin but then
stopped it 3 days ago for a tooth extraction yesterday morning.
Past Medical History:
atrial fibrillation
cad
htn
lupus
chf
gi bleed
fe deficiency
Social History:
He is an owner of a printing shop who lives with wife. no
tobacco, occasional etoh, no ivdu.
Physical Exam:
Mental status: Awake and alert, cooperative with exam, normal
affect
Orientation: oriented to person, place
Language: fluent with good comprehension and repetition; naming
intact. + dysarthria but no paraphasic errors
Left sided neglect with eyes deviated to right
Cranial Nerves:
I: not tested
II: Pupils equally round and reactive to light, 4 to 3
mm bilaterally. Left homonymous hemanopsia
III, IV, VI: Eyes deviated to right but Extraocular movements
intact bilaterally without nystagmus.
V, VII: Facial sensation intact and symmetric. left facial droop
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations, intact movements
Motor:
Normal bulk bilaterally. decreased tone on left arm
No tremor
D T B WF WE FiF [**Last Name (un) **] IP Gl Q H AF AE TF TE
Left leg raised against gravity for 5 seconds and no movement of
left arm
Sensation: localizes noxious stimuli on right side and withdraws
at left leg. no movement of left arm to stimuli
Reflexes: 2+/4 throughout
Grasp reflex absent
Toes were downgoing on right and upgoing on left
Coordination: normal on finger-nose-finger on right but unable
to test on left due to weakness
Gait was not assessed as he was unable to wa
Pertinent Results:
[**2175-11-10**] 05:05AM BLOOD WBC-12.0* RBC-5.59 Hgb-15.2 Hct-45.2
MCV-81* MCH-27.1 MCHC-33.6 RDW-14.1 Plt Ct-174
[**2175-11-7**] 12:25AM BLOOD WBC-11.7* RBC-5.45 Hgb-14.8 Hct-43.7
MCV-80* MCH-27.1 MCHC-33.8 RDW-14.2 Plt Ct-164
[**2175-11-8**] 04:21AM BLOOD PT-15.0* PTT-29.8 INR(PT)-1.4
[**2175-11-10**] 05:05AM BLOOD Glucose-95 UreaN-20 Creat-0.7 Na-139
K-4.0 Cl-104 HCO3-24 AnGap-15
[**2175-11-7**] 03:00AM BLOOD ALT-14 AST-16 CK(CPK)-94
[**2175-11-10**] 05:05AM BLOOD Calcium-9.3 Phos-3.4 Mg-1.9
[**2175-11-7**] 08:56AM BLOOD %HbA1c-5.8
[**2175-11-7**] 03:00AM BLOOD Triglyc-84 HDL-39 CHOL/HD-4.1 LDLcalc-103
[**2175-11-9**] 11:45AM URINE Blood-LGE Nitrite-NEG Protein-100
Glucose-NEG Ketone-50 Bilirub-NEG Urobiln-NEG pH-9.0* Leuks-MOD
CT HEAD:
1. Findings consistent with acute right MCA infarction and
thrombus in the proximal right middle cerebral artery.
2. No intracranial hemorrhage or masss effect
CTA:
1. Asymmetry of branching of right MCA artery, vessels otherwise
patent
Carotid duplex;
No carotid stenosis
ECHO:
The left atrium is moderately dilated. The right atrium is
moderately dilated. 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.
Overall left ventricular systolic function is normal (LVEF 70%).
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is moderately dilated. The aortic arch is
mildly dilated. There are focal calcifications in the aortic
arch. 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 borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
Brief Hospital Course:
Pt was found to have a right MCA stroke (cardioembolic in
setting of stopping Coumadin for dental procedure) and was given
IV-tPA in the ER and admitted to the neurology service. He was
registered at [**Hospital1 18**] at 0015. Labs were drawn at 0025 and his
INR was 1.2. CT scan at 0050 showed a dense rt mca, loss of the
insular ribbon and grey white junction elsewhere in the rtmca
territory. Exam at that time was reported to show a NIHscale of
16 primarily due to left sided weakness, sensory deficit and
neglect. He recieved a bolus of 8.2 mg IV tPA at 0135. The
rest of the 73.6 mg was given as a drip.
He was admitted to the N-ICU for observation, neuro checks and
BP montioring. Post-t-PA course was complicated by dental
bleeding (s/p extraction) which resolved spontaneously. He had a
CTA and rpt CT post IV t-[**MD Number(3) 24709**] showed patenet proximal Right
MCA with decreased MCA branching. CT also showed petechial
hemorrhage within infarct. He was started on aspirin [**11-8**].
Because of the small hemorrhage seen on follow up CT, his
Coumadin should be held for one week and restarted on [**11-15**]. He
should continue to take ASA until his INR is therapeutic. Echo
showed no evidence of intracardiac thrombus. Carotid duplex
showed patenet carotids. His blood pressure was initially
controlled with labetalol drip which was converted to oral
metoprolol. ACEI was added for improved BP control. On [**11-9**]
he had an episode of rapid Afib which responded to diltiazem,
Metoprolol dose was increased for better rate control with good
results. On [**11-9**] he was found to have a UTI and left LL PNA.
He was started on Levoquin and has remained afebrile. He had a
video swallow evaluation on [**11-10**]. Diet recommendations for
pureed solids, nectar thick liquids. Maintain aspiration
precautions, alternate between taking bites and sips. He was
seen be PT and OT during his admission and was felt to be an
excellent candidate for rehab. He is now being discharged to
acute rehab facility for continued care.
Medications on Admission:
verapamil 360
lopressor 100
coumadin 2.5-not taking for dental procedure
ativan 2
folate
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. 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*
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Right MCA stroke
Discharge Condition:
Improved: Left hemiparesis, improving
Discharge Instructions:
Please keep appointments as outlined below. You should resume
taking Coumadin on [**11-15**]. Please follow up with your primary
care doctor to have your INR monitored after re-starting
Coumadin. You should continue to take Aspirin until your INR is
therapeutic.
Please return to the Emergency room for worsening visual
symptoms, weakness, numbness, or any other worrisome symptoms.
Followup Instructions:
1. [**Hospital 4038**] Clinic: Dr. [**First Name (STitle) **] [**Name (STitle) 21421**] call to make an appointment
[**Telephone/Fax (1) 657**]
2. PCP: [**Last Name (NamePattern4) **]. [**Doctor Last Name 110148**] follow up with after discharge from
Rehab
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
|
[
"525.10",
"V45.89",
"414.01",
"486",
"401.9",
"599.0",
"342.92",
"427.31",
"434.11",
"710.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
7172, 7244
|
4412, 6473
|
336, 346
|
7305, 7345
|
2544, 3287
|
7779, 8155
|
6612, 7149
|
7265, 7284
|
6499, 6589
|
7369, 7756
|
1153, 1153
|
277, 298
|
374, 942
|
1435, 2525
|
3296, 4389
|
1168, 1419
|
964, 1027
|
1043, 1138
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,934
| 136,753
|
25386
|
Discharge summary
|
report
|
Admission Date: [**2160-7-24**] Discharge Date: [**2160-8-9**]
Service: [**Last Name (un) 7081**]
Briefly, this is an 81-year-old male who presented to an
outside hospital with a right upper quadrant pain and was
found to have a common bile duct stone and gallstone
pancreatitis. He was transferred for ERCP. Patient was
admitted to the medical service and underwent an ERCP on [**7-25**]. It was very difficult, and they were unable to completely
sphincterotomize and clear the common bile duct. Decision was
made to repeat the ERCP the next day. Upon repeat ERCP a
perforation of the esophagus was found approximately 25 cm
from the mouth. The ERCP was aborted and general surgery was
contact[**Name (NI) **]. [**Name2 (NI) **] surgery and thoracic surgery evaluated the
patient. Patient was taken emergently to the operating room
for repair of the esophageal rupture. Patient was taken on
[**2160-7-25**]. Please see the operative report for further
details.
Postoperatively, the patient was transferred to the intensive
care unit. Was slowly weaned from the ventilator. He was able
to be extubated and did quite well from the respiratory
standpoint. He was started on broad-spectrum antibiotics
including vancomycin, Zosyn, and fluconazole, which he
tolerated, and these were stopped after a 14-day course.
Patient had no other infectious issues postoperatively. He
had G-tube and J-tube replaced as well as chest tube and [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 406**] on the right hand side. The G-tube was kept at gravity
and the J-tube was used for feeds. This was advanced to goal.
Ultimately, after passing a swallow evaluation, patient was
cycled at night. At time of discharge patient was tolerating
J-tube cycle feeds during his sleep from 10 p.m. to 7 a.m.
and taking POs after that.
From a pulmonary standpoint, on postoperative day #1, x-rays
revealed a large left effusion. A chest tube was placed in
this, and it was serosanguineous fluid. It was not gastric
contents or chyle. Post chest tube placement patient had a
persistent left apical pneumothorax which ultimately required
a 2nd chest tube to the left chest, which resolved this
pneumothorax. Both the left posterior chest and the left
apical chest tube were removed prior to discharge. Patient
had pain postoperatively which was managed with an epidural.
Ultimately, after epidural was removed patient was started on
Percocet down his J-tube, which he tolerated well, and his
pain was well controlled. Ultimately, he was switched to
Dilaudid for pain control by pill.
Postoperatively, from a cardiac standpoint, patient had
multiple episodes of atrial fibrillation which were converted
using amiodarone. These were all stable and the patient
stayed in sinus rhythm. The decision was made to use
anticoagulation to protect him against repeat episodes of
atrial fibrillation, and he was anticoagulated 1st using
Lovenox and then he was bridged with Coumadin. By time of
discharge his INR was still subtherapeutic and the patient
was kept on Coumadin with Lovenox with goal to check his INRs
and stop his Lovenox once therapeutic. His INR was 1.3 the
day of discharge.
Patient continued to do well and his LFTs were normal
postoperatively, and he tolerated his tube feedings.
Postoperatively, from a GI standpoint, swallow evaluation was
done on postoperative day #10 which showed no leak and a
repair that was completed adequately. Therefore, his right
chest tube was removed. His right [**Doctor Last Name 406**] drain was removed.
The patient was started on liquids. He tolerated this and was
quickly advanced to regular food with Boost supplement. His
white count climbed during his hospital stay. His central
line was changed and repositioned to a left subclavian from a
right IJ, and it started trending back down. He was afebrile
throughout this whole entire hospital course.
GU: Patient had a Foley placed intraoperatively. This was
removed postoperatively. Patient was able to void and had
good urine output.
Patient was taking adequate POs and the tube feeds began
being cycled. Ultimately, the plan was to stop the tube feeds
once the patient was taking adequate POs and clamp the J
tube.
Physical therapy was consulted. Patient worked with physical
therapy. It was felt that the patient would be best served
with [**Hospital 3058**] rehab facility prior to returning to his full
function and be able to return home.
From an ID standpoint patient had a full course of
antibiotics for his perforation. His central line was changed
to a new position and ultimately removed. He was afebrile.
His white count, which was elevated, slowly started trending
down prior to discharge.
From a GI standpoint prior to discharge an MRCP was performed
which showed multiple stones in the gallbladder. No signs of
cholecystitis. Small stone fragments in the distal common
bile duct that were nonobstructing. It was decided that
patient would return after some time in rehab for evaluation
by Dr. [**Last Name (STitle) 6633**] of the general surgery service. Will likely
plan cholecystectomy as an outpatient and possibly a repeat
ERCP by Dr. [**Last Name (STitle) **] either through the G tube or clearance of
his bowel duct intraoperatively. These decisions were to be
made in the office by Dr. [**Last Name (STitle) 6633**] along with the discussion
with the patient as well as Dr. [**Last Name (STitle) **].
Patient is discharged to a rehab facility on [**2160-8-9**],
in stable condition.
His discharging diagnoses include:
1. Perforated esophagus status post esophageal repair.
2. Gallstone pancreatitis status post endoscopic retrograde
cholangiopancreatography x2.
3. Pneumothorax status post chest tube placement.
Patient's discharging medications included senna 1 tab p.o.
b.i.d., Dulcolax 2 tabs p.r. once daily p.r.n., Colace 100 mg
p.o. b.i.d., Dilaudid 1-2 tabs p.o. q.3 hours p.r.n. for
pain, Lovenox 80 mg subcutaneously b.i.d., Lopressor 75 mg
p.o. b.i.d., and Coumadin 5 mg p.o. once daily. Patient is to
have his INR checked once daily until he is adequately
anticoagulated for an INR greater than 2, at which time his
Lovenox can be stopped. Calorie count should be done to
assess whether the patient needs continued tube feeding.
The G tube and J tube shall stay in place for at least 6
weeks. Postoperatively, prior to removal, this will be done
by Dr. [**Last Name (STitle) **]. Patient is instructed to follow up with Dr.
[**Last Name (STitle) **] in [**2-7**] weeks for evaluation and wound management.
Patient is instructed to follow up with Dr. [**Last Name (STitle) 6633**] in 2
weeks time for discussion about cholecystectomy and operative
planning. Follow up with Dr. [**Last Name (STitle) **] in [**2-7**] weeks for further
planning. Patient is discharged in stable condition.
[**Name6 (MD) 4667**] [**Name8 (MD) **], M.D. [**MD Number(2) 39921**]
Dictated By:[**Doctor Last Name 11225**]
MEDQUIST36
D: [**2160-8-9**] 11:54:54
T: [**2160-8-9**] 12:40:45
Job#: [**Job Number 63465**]
|
[
"574.91",
"998.2",
"997.1",
"512.1",
"577.0",
"511.9",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85",
"34.04",
"38.93",
"43.19",
"42.82",
"96.6",
"42.23",
"86.74",
"46.39",
"99.61",
"96.07"
] |
icd9pcs
|
[
[
[]
]
] | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,033
| 113,551
|
43276
|
Discharge summary
|
report
|
Admission Date: [**2183-1-22**] Discharge Date: [**2183-1-25**]
Date of Birth: [**2148-4-23**] Sex: M
Service: MICU MEDICINE
MICU STAY/HISTORY OF PRESENT ILLNESS: The patient is a
34-year-old male, with poorly controlled hypertension of
unclear etiology, who was discharged yesterday after a 2-week
stay for the same presenting symptoms of nausea, vomiting,
abdominal pain and hypertension. The patient did well after
discharge and then after eating breakfast in the morning
developed his same nausea and vomiting. The patient was
unable to take any medications. The patient presented to the
Emergency Department with abdominal pain no different than
prior abdominal pain episodes. The patient had no bowel
movement changes, no fevers or chills, no hemoptysis, no
bright red blood per rectum, no headaches or vision changes.
In the Emergency Department, the patient was treated with a
Nitro drip and prn labetalol, as well as morphine and ativan.
When nausea and pain were under better control, the patient
still had increased blood pressure in the systolics of 200s.
The patient tolerated doses of blood pressure medication on
the floor. However, despite maximal Nitro drip and
labetalol, the patient's blood pressures remained in the
200s. The patient was, therefore, transferred to the MICU
for closer monitoring of his blood pressure.
PAST MEDICAL HISTORY:
1. Type 1 diabetes.
2. Gastroparesis.
3. Malignant hypertension.
4. Autonomic neuropathy.
5. CAD.
6. Chronic renal insufficiency, baseline 1.7-1.9.
7. History of [**Doctor First Name **]-[**Doctor Last Name **] tears.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Aspirin 81 qd.
2. Protonix 40 qd.
3. Clonidine patch.
4. Erythromycin.
5. Sertraline 50 qd.
6. Reglan 10 q 6 h.
7. Lopressor 150 [**Hospital1 **].
8. Lisinopril 10 [**Hospital1 **].
9. Glargine 5 q hs.
10.Ativan 2 prn.
11.Morphine prn.
12.Amlodipine.
SOCIAL HISTORY: The patient lives in [**Location 686**]. No
alcohol. No tobacco. Unemployed.
PHYSICAL EXAM: Afebrile, heart rate 97, blood pressure
140s-220s/100-130s, 100% on room air.
GENERAL: Fatigued, mildly ill-appearing, in no apparent
distress.
HEENT: Anicteric. OP clear.
NECK: Supple with no lymphadenopathy.
ABDOMEN: Positive bowel sounds, soft, nontender,
nondistended, no hepatosplenomegaly, no rebound tenderness.
CV: Regular rate, no murmurs.
CHEST: Clear to auscultation bilaterally.
EXTREMITIES: No clubbing, cyanosis or edema, 2+ pulses
bilaterally.
PERTINENT LABS ON ADMISSION: CBC - WBC count 8.5, crit 34.3.
Otherwise, his Chem-7 and CBC were unremarkable.
SUMMARY OF HOSPITAL COURSE - 1) UNCONTROLLED HYPERTENSION:
By [**2183-1-24**], the patient was taken off all of his IV
antihypertensives, including IV Nitro and labetalol. The
patient was transitioned to his home dose PO medications of
lisinopril, Lopressor, Norvasc and a clonidine patch.
Etiology of his malignant hypertension still remains a
mystery, and has been seen by multiple specialists in the
past. The diagnosis of pseudopheochromocytoma was
entertained, and urine studies were pending on discharge. On
discharge, the patient's blood pressure was maintained on his
home regimen of lisinopril, Lopressor, Norvasc, and a
clonidine patch with the blood pressures in the 120s-130s.
The patient additionally had no episodes of nausea or
vomiting approximately 12 hours before discharge.
2) GI: Nausea, vomiting and abdominal pain were controlled
with his home doses of Reglan, ativan, erythromycin, morphine
and Protonix.
3) DIABETES TYPE 1: The patient is on glargine 8 U q hs and
Humalog.
4) RENAL: The patient's creatinine was at baseline on
discharge.
5) ACCESS: The patient has a port-A-Cath in place.
6) CODE STATUS: The patient remained full code throughout
this admission.
CONDITION ON DISCHARGE: The patient was discharged to home
without any nausea or vomiting, and resolution of his
hypertensive episode. The patient was discharged on his
admission medication regimen for hypertension.
DISCHARGE STATUS: The patient was discharged in stable
condition to home.
DISCHARGE DIAGNOSES:
1. Malignant hypertension.
2. Type 1 diabetes.
3. Anemia of unknown etiology.
4. Chronic renal insufficiency.
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg po qd.
2. Pantoprazole 40 mg po qd.
3. Clonidine 0.2 mg per 24 h patch q week.
4. Erythromycin 350 mg po q 6 h.
5. Sertraline 50 mg po qd.
6. Lisinopril 10 mg po bid.
7. Amlodipine 5 mg po qd.
8. Metoprolol 150 mg SR qd.
9. Reglan 5 mg/ml solution 1 injection q 6 h.
FOLLOW-UP PLANS: The patient is to follow-up with his PCP [**Last Name (NamePattern4) **]
[**2-14**] weeks on discharge.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) **]
Dictated By:[**Name8 (MD) 22260**]
MEDQUIST36
D: [**2183-3-4**] 13:50
T: [**2183-3-4**] 14:04
JOB#: [**Job Number 93221**]
|
[
"401.0",
"593.9",
"311",
"250.61",
"276.5",
"536.3",
"337.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4127, 4238
|
4261, 4546
|
2030, 2513
|
4564, 4955
|
185, 1369
|
2528, 3811
|
1391, 1916
|
1933, 2014
|
3836, 4106
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,523
| 116,674
|
51220
|
Discharge summary
|
report
|
Admission Date: [**2173-7-10**] Discharge Date: [**2173-7-23**]
Date of Birth: [**2107-7-24**] Sex: M
Service: MEDICINE
Allergies:
IV Dye, Iodine Containing Contrast Media
Attending:[**Doctor First Name 3298**]
Chief Complaint:
back pain x 3 days
Major Surgical or Invasive Procedure:
1. Renal angiography.
2. Intravascular ultrasound.
3. Left renal artery stenting
4. Temporary HD cath placement
5. Double-lumen tunnelled cath placement
History of Present Illness:
Mr. [**Known lastname 25067**] is a 65 y/o gentleman with a known large
thoracoabdominal aortic dissection discovered after presenting
to the [**Hospital6 1708**] with an episode of back pain
in 12/[**2172**]. Of note, that hospitalization was
complicated by acute renal failure, but he was treated
conservatively with blood pressure controlling agents and
hydration, and his renal function returned to [**Location 213**]. He has
had intermittent back pain on one side or the other since then,
but his pain has never been this severe. The pain started
getting
worse 3-4 days ago. It seems to be located on both sides of his
abdomen and both flanks. It is not alleviated or exacerbated by
anything. He also reports decreased appetite over the past [**4-6**]
days, and decreased fluid intake as well. The abdominal pain is
not worsened by eating or drinking. He had some nausea and a
large episode of nonbilious emesis yesterday. He also says that
he has not made much urine over the past 4-5 days. He does
report some R sided sciatica but denies any claudication or
symptoms of rest pain. He also denies F/C, N/V, CP or SOB.
Presentation also notable for patient having noted less urine
output.
ROS: Positive per HPI, otherwise unremarkable.
Past Medical History:
1. Aortic Dissection
2. HTN
3. Hyperlipidemia
4. Anxiety
5. OA
6. Obesity
Social History:
Etoh: drinks occasionally; last had about [**1-3**] pint liquor 3d
prior to admission.
Tob: smokes 1 ppd intermittently.
Drugs: No RDA
Family History:
No aneurysms or end stage renal disease.
Physical Exam:
ADMISSION EXAM:
Vital Signs: Temp: 96.6 RR: 18 Pulse: 98 BP: 126/91
Neuro/Psych: Oriented x3, Affect Normal, NAD.
Neck: No masses, Trachea midline, Thyroid normal size,
non-tender, no masses or nodules, No right carotid bruit, No
left
carotid bruit.
Nodes: No clavicular/cervical adenopathy, No inguinal
adenopathy.
Skin: No atypical lesions.
Heart: Regular rate and rhythm.
Lungs: Clear, Normal respiratory effort.
Gastrointestinal: Non distended, Guarding or rebound, No
hepatosplenomegally, No hernia, No AAA, abnormal: Slight
hepatomegaly. b/l flank pain. no palpable masses or tenderness
over the aorta.
Rectal: Not Examined.
Extremities: No popiteal aneurysm, No femoral bruit/thrill, No
RLE edema, No LLE Edema, No varicosities, No skin changes.
.
DISCHARGE EXAM:
Vitals: 98.1, 97.6, 120-169/88-101, 55-61, 18-20, 98-99% on RA.
I-1.1L, O-3.9L, o/n 750cc
General: AOX3. no acute distress, lying comfortable in bed.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Pertinent Results:
ADMISSION LABS:
CBC with DIFF:
[**2173-7-10**] 08:30PM BLOOD WBC-8.2 RBC-4.70 Hgb-14.0 Hct-39.8*
MCV-85 MCH-29.7 MCHC-35.1* RDW-13.8 Plt Ct-182 Neuts-69.7
Lymphs-20.2 Monos-4.3 Eos-4.5* Baso-1.2
.
COAG:
[**2173-7-10**] 08:30PM BLOOD PT-12.0 PTT-25.6 INR(PT)-1.0
.
CHEM:
[**2173-7-10**] 08:30PM BLOOD Glucose-91 UreaN-36* Creat-5.3* Na-142
K-3.7 Cl-99 HCO3-26 AnGap-21* Calcium-9.3 Phos-4.6* Mg-2.3
.
LIVER FUNCTION ENZYMES:
[**2173-7-11**] 03:02AM BLOOD ALT-23 AST-56* AlkPhos-71 Amylase-85
TotBili-0.3
[**2173-7-11**] 03:02AM BLOOD Lipase-41
.
OTHER:
[**2173-7-10**] 08:30PM BLOOD cTropnT-<0.01
[**2173-7-13**] 11:12AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2173-7-13**] 11:12AM BLOOD HCV Ab-NEGATIVE
.
DISCHARGE LABS:
CBC:
[**2173-7-22**] 07:48AM BLOOD WBC-4.9 RBC-3.60* Hgb-10.3* Hct-29.8*
MCV-83 MCH-28.7 MCHC-34.6 RDW-13.9 Plt Ct-358
.
CHEM:
[**2173-7-22**] 07:48AM BLOOD Glucose-86 UreaN-45* Creat-8.8*# Na-138
K-4.9 Cl-98 HCO3-30 AnGap-15 Calcium-8.9 Phos-4.9* Mg-2.0
.
IMAGING:
EKG ([**2173-7-10**]): Sinus rhythm. The tracing is marred by baseline
artifact. Right bundle-branch block. Left anterior fascicular
block. Consider prior
inferolateral myocardial infarction. No previous tracing
available for
comparison. Clinical correlation is suggested.
.
DUPLEX US ([**2173-7-10**]):
IMPRESSION:
1. Intact bilateral renal perfusion.
2. Bilateral simple renal cysts.
.
Renal US ([**2173-7-10**])
RENAL ULTRASOUND: The right kidney measures 12.6 cm, and the
left kidney
measures 10.6 cm. There is a 3.4 x 3.3 x 3.3 cm simple cyst in
the right interpole, and a 5.1 x 4.6 x 4.0 cm simple cyst in the
left upper pole. No renal stones, [**Name (NI) 79068**] evidence
masse, or hydronephrosis. Color flow images show perfusion to
the main, lobar, and interlobar arteries and veins. Doppler
waveforms are normal in the bilateral renal arteries, with
resistive indices of 0.6-0.7 on the right and 0.65 on the left.
There is no free fluid.
IMPRESSION:
1. Intact bilateral renal perfusion.
2. Bilateral simple renal cysts.
.
ECHO ([**2173-7-11**])
IMPRESSION: Aneurysm of the aortic arch and descending thoracic
aorta with dissection involving the distal arch and extending
into the descending thoracic aorta.
.
Portable CXR ([**2173-7-12**])
IMPRESSION:
1. Dilated, tortuous arch and descending thoracic aorta, which
may relate to known aortic dissection. This can be evaluated
with a dedicated chest CTA if this has not been performed
previously (reference images on our system do not include the
chest).
2. Left sided central venous catheter in appropriate position.
3. Bilateral low lung volumes and left lower lobe platelike
atelectasis.
Right central venous line terminates in the proximal SVC.
Brief Hospital Course:
HISTORY: This is a 65M with h/o of known type B aortic
dissection from the brachiocephalic to the internal iliac, HTN,
who ran out of bp medication and found to be hypertensive. Also
had a 90% left renal artery stenosis and obtained a stent
placement. He developed ARF and was started on HD. Double lumen
tunnelled cath was placed prior to d/c for out-patient HD
(M/W/F). He was d/ced home in stable condition.
.
ACTIVE PROBLEMS:
#ACUTE RENAL FAILURE: Most likely due to ischemic ATN due to
severe Left renal artery stenosis. However, it is unclear why pt
would have ARF with intact right renal perfusion. Pt is s/p left
renal artery stent placement. He will continue plavix and ASA to
prevent stent thrombosis. Duration of therapy will be determined
by vascular as out-patient. Pt was dialyzed x5 as an in-patient.
He had a RIJ tunnelled cath placed on [**2173-7-22**]. He will have
outpatient HD M/W/F. He will followup with PCP and renal for
return of renal function.
.
#AORTIC DISSECTION: stable on imaging. He will need to have
strict BP control with SBP < 140.
.
INACTIVE PROBLEMS:
#HYPERTENSION: SBP goal of 140. Pt had been noncompliant with
antihypertensive for several months prior to admission, but
admission BP was only mildly elevated at 126/91. BP meds
adjusted to labetalol 400mg TID, amlodipine 10mg daily and
clonidine 0.3mg TID prior to d/c.
.
#DELIRIUM: Currently alert and oriented, HD-stable. Delirium in
TICU, etiology unknown, ?ETOH withdrawal. Was given 2.5mg
Zprexa, haldol 5mg x2, 4-pt restraint, 10IV haldol. No
resolution with haldol, but lorazepam 5mg was helpful. Pt was
briefly placed on CIWA protocol with minimal valium
requirements.
TRANSFER OF CARE:
1. Continue to follow Type B aortic dissection on imaging
2. Continue to monitor return of renal function
3. Close followup of management hypertension. Consider
outpatient adjustment of anti-hypertensive regimen.
4. Pt is NOT immunized for Hepatitis B (HbsAb negative), please
followup with PCP for immunization
5. Bilateral simple renal cyst noted on US.
Medications on Admission:
1. Clonidine patch 0.1 top qweek
2. Norvasc 10mg po daily
3. Labetalol 400mg po TID--> had not taken in 2mos
4. Simvastatin 10mg po daily
5. ASA 81 mg po daily
6. MVI po daily
Discharge Medications:
1. labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. multivitamin Capsule Sig: One (1) Capsule PO once a day.
7. calcium acetate 667 mg Capsule Sig: Three (3) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*270 Capsule(s)* Refills:*2*
8. clonidine 0.3 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
9. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Daignosis
1. Acute renal failure
2. Aortic dissection
3. Hypertension
.
Secondary Diagnosis:
1. Dyslipidemia
2. Anxiety
3. Osteoarthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 25067**],
It was a pleasure taking care of you when you were admitted for
acute renal failure due to a 90% blockage in your left renal
artery. The vascular surgeon placed a stent in this artery. You
also have a known chronic aortic dissection which is stable. You
were found to have acute renal failure. You were dialyzed four
times. The kidney doctors [**Name5 (PTitle) **] [**Name5 (PTitle) **] [**Name5 (PTitle) **] need dialysis as an
out-patient.
.
It is very important to maintain appropriate blood pressure
control at home. You may do normal activity but should not
lift, push or pull more than 60-70lbs given your aortic
dissection. Please keep follow up appointment with the vascular
surgeon for your renal stent and make an appointment with your
cardiologist to f/u on your chronic dissection.
.
The antihypertensive regimen you will go home with are:
1. labetolol 400mg: you will take this three times a day.
2. amlodipine 10mg: you will take this once a day
3. clonidine 0.3mg: you will take this medication three times a
day.
.
Other new medications you will go home with are:
1. Plavix (clopidogrel) 75mg: you will take it once a day until
you see the vascular surgeons. This medication will prevent
clotting at your stent.
2. Calcium Acetate [**2163**] mg: you will take this three times a day
with meals
3. Colace 100mg: you will take this medication twice a day to
help soften your stool. Stop the medication if your stool
becomes too loose.
.
Medications that you will continue with are:
1. Simvastatin 10mg: you will take one pill daily for lowering
of your cholesterol
2. Aspirin 81mg: you will take one pill daily.
3. Thiamine and folate containing Multivitamin: take one MVI
daily.
Followup Instructions:
Scheduled Appointments:
Provider DIALYSIS,SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2173-7-23**]
7:30
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 19604**]
Phone: [**Telephone/Fax (1) 3530**]
When: Thursday [**7-29**] at 12PM
Department: VASCULAR SURGERY
When: WEDNESDAY [**2173-8-25**] at 10:30 AM
With: VASCULAR LMOB (NHB) [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: VASCULAR SURGERY
When: WEDNESDAY [**2173-8-25**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD [**Telephone/Fax (1) 2625**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
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icd9pcs
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1873, 2011
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,284
| 122,706
|
32458
|
Discharge summary
|
report
|
Admission Date: [**2113-10-4**] Discharge Date: [**2113-10-26**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 552**]
Chief Complaint:
Non-responsiveness
Major Surgical or Invasive Procedure:
[**2113-10-4**] - Intubated in ED of [**Hospital1 18**], admitted to [**Hospital Unit Name 153**] &
mechanically vented
[**2113-10-5**] - s/p Double lumen PICC placement, Left basilic, 60 cm
insertion length
[**2113-10-7**] - s/p Bronchoscopy
[**2113-10-10**] - Patient extubated
[**2113-10-11**] - Patient re-intubated
[**2113-10-16**] - Patient extubated
History of Present Illness:
This is a [**Age over 90 **] year-old female with a history of CAD s/p MI, HTN,
DM, hypothyrodism, depression, CVA (non-verbal at baseline)
discharged from [**Hospital1 18**] on [**2113-10-3**] after hospital course for
respiratory failure requiring MICU stay related to acute on
chronic diastolic/systolic HF who presents from NH with
tachycardia, increasing secretions, and tachypnea non-responsive
to supplementatal oxygen. Given patient's baseline status,
history obtained from ED records and ED resident. Per report,
patient was found unresponsive to verbal or painful stimulation,
with pale skin and diaphoretic by the staff at NH. EMS was
called and patient presented to [**Hospital1 18**] ED.
In the ED, VS T 98.6 BP 122/63 HR 92 RR 53 O2Sat 88% on RA.
Patient was placed on a NRB with saturations improving to 100%
but no improvement in RR. Patient's family was contact[**Name (NI) **] and
patient was intubated at their request. Patient received
levofloxacin 750mg IV, Etomidate 20mg, Succinylcholine 120mg,
4mg versed, and Ceftriaxone 1gm. Patient then found to be
febrile to 101.4 and with heme positive coffee ground secretions
in NGT. Guiac negative stool rectally. GI was contact[**Name (NI) **] and
recommended initiation of pantoprazole 40mg IV BID.
Sent to floor on [**2113-10-17**]. Triggered for hypoxia, low UOP, ? of
aspiration & returned to [**Location 153**] on [**2113-10-18**]. Pt was found to have
worsening bilateral pleural effusions L>R, left main stem
bronchus obstruction (secretions) with associated almost
complete left lung collapse. Rectal mushroom catheter placed for
liquid stool.
Returned to 11R on [**2113-10-21**].
Past Medical History:
1. Coronary artery disease, s/p MI, s/p 4 stents placed [**Month (only) 205**]
[**2111**] at [**Hospital1 2025**]
2. CHF, systolic and diastolic dysfunction (Cardiologist -
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10302**], MD)
3. Hypertension
4. Diabetes mellitus type 2, with h/o hypoglycemia
5. s/p CVA ([**9-/2111**]), right basal ganglia, cerebellar, left MCA
territory, nonverbal at baseline
6. Seizure disorder NOS
7. Dementia
8. Macular degeneration, legally blind
9. s/p G-tube placement (all nutrition via G-tube per GI)
10. Hypothyroidism
11. Hyperlipidemia
12. Anemia of chronic disease
13. Depression
14. h/o UTIs ([**3-/2113**] admission for MDR E. coli infection)
15. h/o Stool impaction
16. splenic/hepatic nodules, per CT
17. h/o PNA ([**1-/2113**] admission)
18. Osteopenia
Social History:
From [**Hospital1 **] NH. Son is HCP. [**Name (NI) 4084**] smoked, minimal prior alcohol
use, no illicit drugs. Of Latvian descent and has devoted
children. Lives at [**Hospital1 **] senior care. Retired from working at
histology lab at [**Hospital1 2025**]. Was very independent prior to CVA.
Family History:
Noncontributory
Physical Exam:
ADMISSION PE:
============
Vitals: T: 97.6 BP: 123/58 HR: 79 RR: 14 O2Sat: 100% on AC 550
RR 14 PEEP 5
FiO2 40%
GEN: intubated and sedated
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis
NECK: upable to appreciate JVD, carotid pulses brisk, no bruits,
no cervical lymphadenopathy, trachea midline
COR: RRR, HS distant, no M/G/R appreciated
PULM: coarse BS throughout, occasional expiratory wheeze
ABD: Soft, NT, ND, +BS, no HSM, no masses, G-tube without
erythema
EXT: No C/C/E, cool to touch
NEURO: intubated, sedated Patellar DTR +1. Plantar reflex
downgoing.
SKIN:+ left abdominal dry crusting lesions in dermatomal
distribution
Pertinent Results:
On Admission:
[**2113-10-4**] 03:15PM FIBRINOGE-400
[**2113-10-4**] 03:15PM PT-18.7* PTT-33.9 INR(PT)-1.7*
[**2113-10-4**] 03:15PM PLT COUNT-268
[**2113-10-4**] 03:15PM NEUTS-89.4* LYMPHS-5.1* MONOS-5.3 EOS-0
BASOS-0.2
[**2113-10-4**] 03:15PM WBC-12.1* RBC-4.25 HGB-12.5 HCT-39.9 MCV-94
MCH-29.4 MCHC-31.3 RDW-19.1*
[**2113-10-4**] 03:15PM HAPTOGLOB-158
[**2113-10-4**] 03:15PM ALBUMIN-3.1*
[**2113-10-4**] 03:15PM cTropnT-0.11*
[**2113-10-4**] 03:15PM LIPASE-20
[**2113-10-4**] 03:15PM ALT(SGPT)-48* AST(SGOT)-156* LD(LDH)-1134*
CK(CPK)-90 ALK PHOS-79 TOT BILI-0.7
[**2113-10-4**] 03:15PM GLUCOSE-254* UREA N-67* CREAT-1.6* SODIUM-145
POTASSIUM-6.6* CHLORIDE-112* TOTAL CO2-23 ANION GAP-17
[**2113-10-4**] 03:31PM LACTATE-2.4* K+-4.8
[**2113-10-4**] 04:55PM URINE RBC-0-2 WBC->50 BACTERIA-MANY YEAST-MANY
EPI-0-2
[**2113-10-4**] 04:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2113-10-4**] 04:55PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.012
[**2113-10-4**] 10:37PM TYPE-ART PO2-54* PCO2-34* PH-7.45 TOTAL
CO2-24 BASE XS-0 -ASSIST/CON INTUBATED
[**2113-10-4**] 10:37PM LACTATE-1.9
[**2113-10-4**] 05:57PM TYPE-ART PO2-432* PCO2-38 PH-7.39 TOTAL
CO2-24 BASE XS--1
IMAGING:
=======
CXR on [**2113-10-4**]
Persistent left pleural effusion with associated atelectasis.
Superimposed consolidation at the left lung base cannot be
excluded. The
right lung remains well aerated.
CT of the head w/o contrast on [**2113-10-4**]:
No intracranial hemorrhage or acute abnormalities. Chronic left
temporoparietal infarct. Enlarged ventricles suggesting
normal-pressure
hydrocephalus.
CT of abdomen and pelvis on [**2113-10-8**]
CT ABDOMEN: Small bilateral pleural effusions, left greater than
right, have increased. There is also mild bibasilar atelectasis,
left greater than right. Dense coronary artery calcifications
are unchanged. Likely non-calcified pleural plaque at the right
lung base between right ribs 10 and 11 is unchanged. Absence of
intravenous contrast limits evaluation of the abdominal
parenchymal organs and vasculature. Mild-to-moderate ascites
throughout the abdomen is new. There is diffuse anasarca within
the soft tissues. Liver is grossly unremarkable. There is no
biliary ductal dilatation. Mild gallbladder wall edema is likely
secondary to ascites. Gallbladder is not distended. Pancreas
remains fatty and atrophic. Scattered periportal and
gastrohepatic lymph nodes measure up to 8 mm in size, not
meeting CT criteria for pathologic enlargement. Spleen is
diminutive, but otherwise unremarkable. Non-contrast appearance
of the kidneys is unremarkable. G-tube remains in place within a
nearly completely decompressed stomach. Intra-abdominal loops of
bowel are
unremarkable. There is no sign of obstruction. Diffuse
atherosclerotic
calcification of the abdominal aorta and its branches is
unchanged. There is no free intraperitoneal air.
CT PELVIS: Pelvic loops of large and small bowel are
unremarkable. Rectal
tube is in place. Foley catheter is in place within decompressed
bladder.
Small amount of air remains within the dorsal aspect of the
bladder, likely related to instrumentation. Previously noted
rectal stool impaction has resolved. Diffuse osteopenia is
unchanged. Multilevel degenerative changes in the thoracolumbar
spine are stable. There is no fracture. There is no osseous
lesion suspicious for malignancy.
Echocardiogram on [**2113-10-11**]:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is severely
depressed (LVEF= 20-30 %) secondary to extensive apical akinesis
(with focal dyskinesis), anterior septal akinesis, and
hypokinesis of the rest of the left ventricle with relative
sparing only of the basal inferior and posterior segments. The
right ventricular free wall is hypertrophied. The right
ventricular cavity is dilated with focal hypokinesis of the
apical free wall. 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 to moderate
([**2-1**]+) mitral regurgitation is seen. [Due to acoustic shadowing,
the severity of mitral regurgitation may be significantly
UNDERestimated.] The tricuspid valve leaflets are mildly
thickened. The supporting structures of the tricuspid valve are
thickened/fibrotic. Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. The end-diastolic pulmonic regurgitation velocity
is increased suggesting pulmonary artery diastolic hypertension.
The main pulmonary artery is dilated. The branch pulmonary
arteries are dilated. There is a trivial/physiologic pericardial
effusion.
BRONCHOSCOPY:
============
[**2113-10-7**] - Findings: thick mucopurulent secretions in mainstem
bronchi L>R. Impression: Bronchopneumonia, Respiratory Failure
DISCHARGE LABS:
==============
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2113-10-24**] 05:07AM 7.5 3.91* 11.9* 37.0 95 30.5 32.2 20.5*
228
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2113-10-26**] 05:10AM 190* 59* 1.0 140 4.8 105 29 11
Brief Hospital Course:
On arrival to the [**Hospital 332**] Medical ICU patient was febrile, with
increased WBC, edema and bilateral consolidation on CXR. She was
found with hypoxemic respiratory failure thought to be due to
volume overload and hostpial-acquired pneumonia. She was
originaly diuresed and started on Vancomycin/Cefepime. Patient
was bronched on [**2113-10-7**], not growing any bacteria from
sputum. When cultures came back positive for Staph aureus
cefepime was stopped. Patient was extuabted on [**2113-10-10**].
However, after <24 hours she required re-intubation due to
worsening infiltrates on CXR, hypoxia and hypothermia.
Infectious disease was curbside and suggested
vancomycin/meropenem since she is widely known for her multiple
visits (Day 1 [**2113-10-12**]). Patent's respiratory status has been
improving and she was extuabted on [**2113-10-16**]. Patient was
stable in the ICU for 30 hours prior to transfer to the floor.
She is breathing on shevel mask and occassionaly has apneic
periods and [**Last Name (un) 6055**]-Strokes respiration, which are normal at her
baseline since the stroke 2 years ago. During those episodes
patient de-sats up to 88% and within seconds goes back up to
98-100%.
During [**Hospital Unit Name 153**] course patient was worked up for etiologies of
worsening CHF, including multiple cardiac enzymes, telemetry and
EKGs. She has a baseline LBBB, which was unchanged from before.
Her echocardiogram showed worsening EF at ~15% and MR [**First Name (Titles) **] [**Last Name (Titles) **] (EF
reported 20-25%, but worse than pior echo of ~15%). Patient's
ideal weight was hard to achieve due to poor urine output.
Patient required standing doses of lasix (at home) and extra IV
doses to maintain adequate fluid balance.
On admission patient had increased creatinine up to 1.6 from her
baseline of 1.0. Most likely due to CHF exacerbations and poor
renal flow. It was corrected with adequate fluid/balance
management.
Patient started with watery diarrhea during first days of
admission. She was c. dif negative x3. Diarrhea resolved by its
own. Patient required rectal tube and was having an output of
~3L/day. Now patient improved. Stool studies negative.
Patient had some coffee ground emesis on arrival, which were
thought to be due to NG placement. Her HCT was table and she was
guaiac negative.
ICU COURSE [**0-0-0**]
Hypoxemic respiratory failure: Patient with MRSA PNA and VAP PNA
on vamcomycin/meropenem (last day [**10-22**]) with known
[**Last Name (un) 6055**]-[**Doctor Last Name **] breathing, whith worsening of her pleural
effusions and colapse of the left lung. Patient got CT scan of
the chest that confirmed above findings. Patient responded to
NRB, pulmonary therapy and aspiration and mild diuresis.
Post ICU [**10/2113**]-9/25/[**2113**]
1. CHF: Cardiac enzymes were repeated and negative, EKG done
without changes from prior, BNP was >70,000. BP medications were
continued and patient was diuresed based on UO, kidney function,
tachypnea, lung sounds and VS. She becomes dehydrated with
diuretics and is managed within a very narrow therapeutic
window, with difficulty in managing her tendency to go into pulm
edema, which requires lasix and then easily going into ARF from
lasix use. She should be maintained on lasix 40 mg qod as
judged appropriate by the above parameters.
2. Hyperkalemia/ARF: On the floor she developed hyperkalemia to
5.5 and was treated with kayexalate and IVF at 50cc/hour for one
liter. Her K on dc was 4.8, and BUN/cr had improved also.
3. End of life issues: A palliative care consult was done. They
will follow up by calling her son. I spoke with her son on the
phone on [**2113-10-26**] and explained the options for his mother as
she becomes more compromised. I emphasized her poor quality of
life and her negligible potential for any meaningful recovery.
I encouraged him to speak to the staff at [**Hospital1 599**] of [**Location (un) 55**]
about Comfort Measures and Hospice Care.
4. Mental Satus: opens eyes at times, does not track,
non-verbal, occ moves r side sponatneously. Two Head CTs [**10-4**] and
[**10-22**] were neg for acute changes.
5. Diabetes: Please Check blood sugars Q6hrs and cover with
sliding scale
6. Herpes zoster: T7-T8 deratome. Completed Valtrex course.
Non-active now.
7. Seizure h/o: On Keppra; continued. Posibly due to CVA.
8. ?Depression: She continues of Effexor but the reason she is
taking it is unclear. If there is no known indication for it it
should be stopped.
9. Hypothyroidism: continuing outpatient regimen.
10. Stage II decubitus ulcer: wound care continued.
FEN: TF through G tube.
PPx: PPi, bowel regimen, heparin SC
Code: DNR, may be intubated
Comm: [**Name (NI) **] [**Name (NI) **] [**Name (NI) 75756**] (HCP) [**Telephone/Fax (1) 75757**]-2248.
Medications on Admission:
Bisacodyl 5 mg Tablet PO DAILY as needed.
Senna 8.6 mg PO BID as needed.
Heparin SC TID
Timolol Maleate 0.25 % One Drop Ophthalmic [**Hospital1 **]
Venlafaxine 37.5 mg One Tablet PO BID
Metoclopramide 10 mg One Tablet PO BID
Aspirin 81 mg One Tablet PO DAILY.
Docusate Sodium 50 mg/5 mL Liqui PO BID
Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid PO DAILY
Levetiracetam 100 mg/mL One PO DAILY
Levothyroxine 125 mcg One Tablet PO DAILY
Insulin Regular Human 100 unit/mL AS DIRECTED.
Carvedilol 12.5 mg One Tablet PO BID
Furosemide 40 mg/5 mL Solution PO DAILY
Lisinopril 10 mg (2) Tablet PO DAILY
Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One Inhalation PRN for wheezing.
Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One Inhalation Q6H
(as needed for wheezing.
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
2. Venlafaxine 37.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
3. Levothyroxine 125 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
4. Timolol Maleate 0.25 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
5. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Levetiracetam 100 mg/mL Solution [**Hospital1 **]: One (1) PO daily ().
7. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical PRN
(as needed).
8. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: One (1)
Injection ASDIR (AS DIRECTED).
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. Carvedilol 6.25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2
times a day).
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as
needed.
12. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q6H (every 6 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
Primary Diagnoses:
=================
Hypoxemic Respiratory Failure requiring intubation & mechanical
ventilation
Heart Failure
MRSA pneumonia with acute oxygen desaturation on [**2113-10-18**]
UTI
Acute Renal Failure
Secondary Diagnoses:
===================
s/p CVA, non-verbal @ baseline
CAD, h/o MI
Htn
Diabetes II
Coffee-ground emesis
Coagulopathy
Elevated LFTs
Elevated troponins, felt to be demand ischemia
Hypothyroidism
Decubiti
Depression
Discharge Condition:
Stable (patient's baseline): tachypneic at times, intermittent
upper extremity edema, no meaningful communication, opens eyes,
does not track, no purposeful movements, appears comfortable.
Discharge Instructions:
You were admitted to the hospital because you were found at your
Nursing Facility to be unresponsive, with a fever & had trouble
breathing necessitating intubation and admission to the ICU.
Adhere to 2 gm sodium diet
Followup Instructions:
Provider: [**Name10 (NameIs) 6122**] WEST OUTPATIENT RADIOLOGY Phone:[**Telephone/Fax (1) 8243**]
Date/Time:[**2114-1-2**] 9:00, please cancel this appt. if the family
decides not to re-evaluate.
Please continue discussion with son regarding a DNI order. The
ICU staff and I have spoken with him recommending against
re-intubation. I have advised him to consider CMO and Hospice
Care.
|
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"96.6",
"33.24",
"96.72",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
16508, 16598
|
9564, 14370
|
281, 639
|
17090, 17281
|
4178, 4178
|
17547, 17937
|
3490, 3507
|
15239, 16485
|
16619, 16837
|
14396, 15216
|
17305, 17524
|
9276, 9541
|
3522, 4159
|
16858, 17069
|
223, 243
|
667, 2327
|
4192, 9260
|
2349, 3163
|
3179, 3474
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,237
| 173,451
|
35120
|
Discharge summary
|
report
|
Admission Date: [**2150-8-2**] Discharge Date: [**2150-8-10**]
Date of Birth: [**2109-5-30**] Sex: F
Service: MEDICINE
Allergies:
Iodine / Codeine / Reglan / Ketorolac / Oxycodone /
Hydromorphone Hcl
Attending:[**First Name3 (LF) 5129**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Upper endoscopy with attempted balloon dilatation of Nissen
fundoplication / gastroesophageal junction.
History of Present Illness:
[**Known firstname 450**] [**Known lastname **] is a 41 yo woman with a history of DM type 2,
HTN, HL, stroke, OSA, spinal stenosis, arthritis, asthma, and
GERD here with left sided chest pain radiating to her left arm.
The patient was in her USOH until 3 months prior to this
admission when she noted intermittent palpitations and chest
discomfort. The patient was not concerned about this chest
discomfort until about 2 weeks prior to this admission when she
noticed increasing left sided chest pain accompanied by
worsening dyspnea and wheezing causing her to decrease her
mobility, which is low at baseline. 2 days prior to admission,
the patient noted worsening of the left sided chest pain growing
from [**4-5**] to [**9-5**] pain, continued radiation down the left arm,
and associated diaphoresis and decrease in her peak flow from
350 at baseline to 170s even after using albuterol nebulizers.
Of note, patient typically uses 3 albuterol nebulizers as need
for wheezing over the course of the day. Over the past 2 days,
she required up to 4 nebulizers in one morning and noticed
minimal improvement of her symptoms. The patient's chest pain
was constant and distinct from the symptoms of reflux associated
with GERD. Of note, the patient has been hospitalized in the
past for this type of chest pain.
.
The patient was brought by EMS to the [**Hospital1 18**] ED. En route she
received NTG, aspirin with only minimal improvement of chest
pain. In the ED she was afebrile, but tachycardic to 100s. She
received IV fluids, morphine for pain control with good effect.
She also received IV dilaudid and had an allergic reaction which
was treated with benadryl with good effect. She was admitted to
the medicine floor for further workup
.
On ROS, patient denied headache, changes in vision, fever,
chills, night sweats, abdominal pain, changes in her chronic
back pain or changes in her neuropathy, left sided weakness.
Remainder of ROS as per HPI
Past Medical History:
-DM2, diagnosed in [**2135**], on insulin
-Asthma
-HTN
-Nissen fundoplication [**2142**]
-OSA
-Ganglion cyst removal [**2141**]
-Left ankle stabilization [**2145**]
-Right ankle stabilization [**2147**]
-CVA in [**2140**] with residual left sided weakness
-Eczema
-Mitral valve prolapse
-Deafness, left ear
-HL
-Diabetic peripheral neuropathy
-Oligomenorrhea
- Seasonal, drug, and food allergies. Food allergies to oats,
wheat, rice, green beans, chocolate, ketchup.
Social History:
Patient denies tobacco, etoh, IVDU. Patient is a former pre-K
teacher who has been on disability since [**2133**]. Currently lives
on [**Location (un) 470**] apartment and uses a walker to get around. Is being
evaluated by [**Location (un) 86**] Housing for placement in a single level
apartment. Married, no children.
Family History:
Significant for 7 aunts on her mother's side with type 2 DM with
significant insulin resistance. Mother with HTN and DVT. Sister
and brother in good health. Does not know about her father's
health.
Physical Exam:
VITALS: 97.9 BP 103/66 HR 103 RR 22 O2 SAT:98% on RA
GENERAL: Obese woman, lying in bed with moderate work of
breathing.
SKIN: Warm, eczematous rash visible on face, some excoriations
visible on forearms bilaterally.
HEENT: NCAT, MMM, oropharynx clear. PERRL
NECK: supple, no masses, no LAD
HEART: RRR, normal S1, S2, no murmurs, gallops or rubs
LUNGS: Expiratory and inspiratory wheezes throughout lung fields
bilaterally.
CHEST: patient with tenderness to palpation over left
parasternal chest wall.
ABDOMEN: Obese, soft, nontender, nondistended. No HSM
EXTREMITIES: No lower extremity edema, tenderness to palpation
of calf muscles up to knee bilaterally. DP pulses 2+
bilaterally. No ulcerations.
Neuro: A&O x 3, strength decreased on left leg and arm, CN 2-12
intact
Pertinent Results:
HEMATOLOGY AND CHEMISTRIES
[**2150-8-2**] 10:10AM BLOOD WBC-8.3 RBC-4.19* Hgb-10.4* Hct-33.6*
MCV-80* MCH-24.8* MCHC-31.0 RDW-15.5 Plt Ct-499*
[**2150-8-2**] 10:10AM BLOOD Neuts-54.1 Lymphs-37.4 Monos-5.3 Eos-2.6
Baso-0.5
[**2150-8-3**] 06:37PM BLOOD Lactate-3.5*
[**2150-8-4**] 02:04AM BLOOD PT-11.7 PTT-33.7 INR(PT)-1.0
[**2150-8-2**] 10:10AM BLOOD Plt Ct-499*
[**2150-8-2**] 10:10AM BLOOD Glucose-368* UreaN-11 Creat-1.0 Na-135
K-4.3 Cl-98 HCO3-24 AnGap-17
[**2150-8-10**] 07:00AM BLOOD WBC-10.0 RBC-3.42* Hgb-8.5* Hct-27.9*
MCV-82 MCH-24.8* MCHC-30.3* RDW-16.1* Plt Ct-422
[**2150-8-10**] 07:00AM BLOOD Glucose-207* UreaN-8 Creat-0.7 Na-139
K-4.2 Cl-101 HCO3-28 AnGap-14
.
VENOUS BLOOD GAS
[**2150-8-3**] 06:37PM BLOOD Type-[**Last Name (un) **] Temp-35.6 pO2-55* pCO2-37
pH-7.37 calTCO2-22 Base XS--3 Intubat-NOT INTUBA
.
CARDIAC ENZYMES
[**2150-8-2**] 10:10AM BLOOD CK(CPK)-132
[**2150-8-2**] 09:15PM BLOOD CK(CPK)-113
[**2150-8-3**] 05:50AM BLOOD CK(CPK)-81
[**2150-8-2**] 10:10AM BLOOD CK-MB-3
[**2150-8-2**] 10:10AM BLOOD cTropnT-<0.01
[**2150-8-2**] 09:15PM BLOOD CK-MB-3 cTropnT-<0.01
[**2150-8-3**] 05:50AM BLOOD CK-MB-NotDone cTropnT-<0.01
.
IRON STUDIES
[**2150-8-2**] 10:10AM BLOOD Iron-28*
[**2150-8-3**] 05:50AM BLOOD Calcium-9.5 Phos-3.0 Mg-1.9
[**2150-8-2**] 11:29AM BLOOD D-Dimer-1436*
[**2150-8-2**] 10:10AM BLOOD calTIBC-463 Ferritn-33 TRF-356
.
ENDOCRINE STUDIES
[**2150-8-3**] 05:58PM BLOOD %HbA1c-9.0*
[**2150-8-7**] 10:10AM BLOOD GLUCAGON-PND
.
URINALYSES
[**2150-8-4**] 10:25AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.034
[**2150-8-4**] 10:25AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2150-8-8**] 05:19AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.022
[**2150-8-8**] 05:19AM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-100 Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2150-8-8**] 05:19AM URINE RBC-[**1-29**]* WBC-[**1-29**] Bacteri-FEW Yeast-NONE
Epi-[**5-6**]
.
MICROBIOLOGY
[**2150-8-3**] 5:34 pm MRSA SCREEN (Final [**2150-8-5**]): POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS.
[**2150-8-4**] URINE CULTURE: (Final [**2150-8-5**]) No growth.
[**2150-8-8**] 4:35 am URINE CULTURE (Final [**2150-8-9**]):<10,000
organisms/ml.
[**2150-8-8**] 5:45 am BLOOD CULTURE(Final [**2150-8-14**]): NO GROWTH.
[**2150-8-9**] 3:34 am STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST
(Final [**2150-8-9**]): Feces negative for C.difficile toxin A & B by
EIA.
.
CARDIAC STUDIES
[**2148-8-1**] EKG: Sinus tachycardia. Left ventricular hypertrophy
with associated ST-T wave changes, although myocardial ischemia
and myocardial infarction cannot be excluded. Compared to the
previous tracing the axis has shifted minimally.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
110 118 100 324/411 70 -29 72
.
IMAGING
.
[**2150-8-2**] CXR: IMPRESSION: Low lung volumes with bibasilar
atelectasis, but no superimposed acute cardiopulmonary
abnormality.
.
[**2150-8-3**] LOWER EXTREMITY DOPPLER ULTRASOUND: IMPRESSION: No
evidence of DVT of bilateral lower extremities.
.
[**2150-8-4**] VENTILATION PERFUSION SCAN: IMPRESSION: Limited study
with normal perfusion and ventilation. No evidence of PE.
.
[**2150-8-5**] BARIUM SWALLOW:IMPRESSIONS: 1. Limited exam, but no
gross abnormalities of the esophagus or proximal stomach. 2.
Intact gastric fundoplication, with moderately delayed passage
of barium through the distal esophagus intothe stomach. 3. No
gastric emptying seen during 10-minute exam.
.
[**2150-8-8**]: FRONTAL AND LATERAL CHEST RADIOGRAPH TO EVALUATE FOR
Fever after esophagogastroduodenoscopy. The cardiomediastinal
silhouette is stable. The lung volumes remain low, with no
pleural effusion or pneumothorax as well as with no focal
consolidation to suggest pneumonia. Mild volume overload cannot
be excluded.
.
[**2150-8-8**] ABDOMINAL PLAIN FILMS: The current study that includes
seven views of the abdomen including the decubitus view
demonstrate significant amount of stool within the colon with
dilated right flexure up to 10 cm and no significant dilatation
within the sigmoid and descending colon. The transverse colon is
also dilated up to 11 cm and full of stool. There is contrast
material in left colon and rectosigmoid most likely related to
upper GI series obtained on [**2150-8-5**]. The decubitus view
demonstratesair-fluid level within the stomach and otherwise
are unremarkable. Overall, the picture is consistent with
excessive amount of stool in the colon with no evidence of
obstruction.
.
ENDOSCOPY
.
[**2150-8-7**] UPPER ENDOSCOPY: mild gastritis, otherwise
unremarkable. Attempt made to dilate GE junction with 18mm
balloon was unsuccessful.
.
[**2150-8-7**] PATHOLOGY: Antral mucosal biopsy: Antral mucosa with
chronic inflammation and changes consistent with chemical
gastritis.
Brief Hospital Course:
This is a 41 year woman with a history of DM type 2, HTN, HL,
OSA, spinal stenosis, arthritis, stroke, asthma, and GERD who
presented with left sided chest pain and worsening dyspnea of 2
weeks duration.
.
# CHEST PAIN - Patient's chest pain was unlikely to be secondary
to an ACS given the reproducibility of her chest pain, including
radiation to left arm with palpation on the chest wall. She also
had no concerning ST changed on her EKG and had three sets of
negative cardiac biomarkers. She was monitored on telemetry
without event. The lack of consolidation on CXR, the absence of
fever, sputum, or elevated WBC on admission, made pneumonia an
unlikely cause of chest pain. Her pain was most likely
musculoskeletal in origin given her chronic arthritis. On the
floor the patient was initally on ketorolac for pain control,
but this was later stopped due to concern for stomach
irritation. There was also concern about about possible PE given
her family history of DVT, patient's limited mobility and an
elevated d-dimer in the ED. She was started on lovenox on
admission, but a subsequent ventilation/perfusion scan, albeit
limited due to problems with patient compliance with holding her
breath, showed normal perfusion and ventilation and no evidence
of PE. A PE-CTA was not done due to patient's allergy to iodine
contrast. Her lovenox was stopped on [**2150-8-5**]. The patient's GERD
and dysphagia may also have contributed to her chest pain (see
discussion below).
.
# DYSPNEA/ASTHMA - Patient's dyspnea was likely secondary to
asthma exacerbation in the setting of deconditioning due to
limited movement. Pneumonia was considered unlikely as noted
above. She was treated with a four day course of prednisone,
60mg per day, intially as one dose, then later divided 30mg [**Hospital1 **],
along with standing albuterol and ipratropium nebulizers. She
was continued on her Fluticasone/salmeterol and zafirlukast home
doses. Her breathing improved after her steroid course. She
never required oxygen.
.
# DIABETES - Patient presented with elevated FSBG above 400 over
the past 2 weeks prior to admission. These were likely elevated
secondary to cortisol stress response in setting of increased
chest pain and dyspnea. The FSBGs were elevated further in
setting of steroid treatment of her acute asthma exacerbation.
Due to BS>500 on the floor, [**Last Name (un) **] was consulted and the patient
transfered to the ICU for an insulin drip on [**2150-8-3**]. She
required over 30 units/hr initially. She was later transitioned
to Lantus 80 units [**Hospital1 **] and an aggressive insulin sliding scale.
Her metformin and pramlintide were held while in the ICU. She
was transfered from the MICU to the floor on [**8-6**] after she had
completed her course of prednisone and was no longer on an
insulin drip. On the floor, her Lantus was titrated down to 40
units [**Hospital1 **] with a slightly less aggressive insulin sliding scale.
Metformin and pramlintide continued to be held. Her FSBG ranged
from 100s-250s, even though the patient did not fully adhere to
a diabetic diet on the floor, frequently eating fast food
brought in by friends and family. A glucagon level sent [**2150-8-7**]
to evaluate for possible glucagonoma causing insulin resistance
was pending upon patient departure.
.
# DYSPHAGIA / GERD - s/p Nissen fundoplication in [**2142**]. The
patient also complained of dysphagia and increased reflux when
swallowing solids greater more than with liquids. This was
thought to be partially secondary to diabetic gastroparesis as
patient has long standing diabetes complicated by peripheral
neuropathy. Barium swallow showed decreased gastric emptying but
no esophageal obstruction. The GI service completed an endoscopy
on [**2150-8-7**] that showed mild antral gastritis. An attempt was
made to dilate the gastroesophageal junction with an 18-mm
balloon, but was unsuccessful. The patient was continued on
omeprazole 40 mg [**Hospital1 **], and placed on a diabetic, soft mechanical,
dysphagic diet.
.
# ARTHRITIS, SPINAL STENOSIS, MUSCULOSKELETAL PAIN, PERIPHERAL
NEUROPATHY - The patient was continued on her home pain
medications with the exception of her NSAID (due to increased
stomach pain / gastritis). This included pregabalin,
amytriptiline, acetominophen as needed, and lidocaine patches.
She had an allergic reaction to IV dilaudid in the ED, and to
oral dilaudid in the ICU, so the patient's home prescription of
dilaudid was discontinued and her pain managed with oral
morphine as needed.
.
#FEVER: 1 day following her upper endoscopy, the patient
developed fevers overnight to 102.1, so blood and urine cultures
were sent and CXRs performed to assess for possible pneumonia,
UTI, or bacteremia. Multiple chest radiographs showed continued
low lung volumes, but no evidence of consolidation, and blood
and urine cultures showed no growth. The patient's fever
resolved, and she was afebrile on the day of her departure.
.
#FACIAL NUMBNESS AND TINGLING - On [**2150-8-8**], the patient
developed sudden onset of left facial numbness and tingling and
generalized dizziness and increased generalized weakness in the
setting of fever. Because of a concern for stroke, given the
patient's microvascular disease and past history of stroke,
Neurology was consulted. The patient's symptoms were found to be
within the distribution of her previous stroke and thought to be
secondary to an elevated blood glucose and possible infection.
The patient was continued on cardiac and cerebrovascular risk
factor management regimen including her statin, ASA 325 mg, and
lisinopril end encouraged to adhere to the diabetic diet to help
keep serum glucose levels better controlled. The Neurology
service also recommended obtaining a head CT and
carotid US, but this could not be completed as the patient
eloped.
.
#ABDOMINAL PAIN - On [**2150-8-8**], 1 day following her EGD, the
patient developed diffuse abdominal distention and discomfort
but most prominent in the epigastric region. Ths was thought to
be secondary to insufflation of the GI tract during the
procedure, coupled with low gastric motility likely secondary to
diabetic gastroparesis, and low intestinal motility given the
high narcotic requirements of the patient to control her
musculoskeletal pain. An abdominal plain film confirmed findings
of constipation and the patient was placed on standing bowel
regimen including docusate, senna, and bisacodyl.
#PSYCH - The patient was seen by Psychiatry who felt that the
patient would benefit from starting Celexa 10mg qd and
decreasing Elavil to 50mg qhs. Because the patient was already
taking a benzodiazepine Valium, the patient's Ambien for sleep
was discontinued. Psychiatry stated that they would follow the
patient as an outpatient.
The patient had problems with [**Name2 (NI) **] management during the last 2
days of hospitalization, including throwing a pitcher of water
and threatening staff at 2050 on [**2150-8-9**]. Security and clinical
advisor were involved. The patient wanted to be discharged and
to follow up with licensed social worker and psychiatrist as an
outpatient.
.
# DISPOSITION: The patient left against medical advice on the
morning of [**2150-8-10**] before a treatment plan for that day or
discharge planning could be finalized.
Medications on Admission:
Albuterol Sulfate Nebulization Q4H PRN SOB
Amitriptyline 75 mg Tablet HS
Ammonium Lactate 12 % Cream [**Hospital1 **] for feet
Diazepam 10 mg Tablet TID
Epinephrine [EpiPen] PRN anaphylaxis
Etodolac 300 mg Capsule [**Hospital1 **]
Fluticasone-Salmeterol 500 mcg-50 mcg/Dose [**Hospital1 **]
Hydromorphone 2mg Qday to [**Hospital1 **] PRN pain
Insulin Detemir pen, 60 units HS
Insulin Glulisine [Apidra] SSI
Ipratropium Bromide 0.2 mg/mL (0.02 %) Solution PRN
Ketoconazole 2 % Shampoo 2x per week
Levocetirizine [Xyzal] 5 mg Tablet Qday
Lidocaine 5 % DAILY
Lisinopril 10 mg Tablet daily
Metformin 1,000 mg Tablet [**Hospital1 **]
Omeprazole 20 mg Capsule 2 Capsule(s) [**Hospital1 **] x 1 week then Qday
Potassium Chloride [K-Dur] 20 mEq [**Hospital1 **]
Pramlintide [SymlinPen 60] 1,500 mcg/1.5 mL Pen Injector 120 mcg
before each meal by 5 to 10 minutes
Pregabalin [Lyrica] 150 mg [**Hospital1 **]
Promethazine 25 mg Tablet TID PRN
Simvastatin 20 mg Tablet
Triamcinolone Acetonide 0.025 % Cream
Urea 40 % Cream [**Hospital1 **] for feet
Zafirlukast [Accolate] 20 mg Tablet
Acetaminophen PRN
Aspirin 325 mg Tablet DAILY
Calcium Carbonate 600 mg [**Hospital1 **]
Cholecalciferol (Vitamin D3) 1g Qday
Diphenhydramine HCl 25mg [**Hospital1 **] PRN
Multivitamin Tablet 1 Tablet(s) by mouth
Discharge Medications:
1. Ammonium Lactate 12 % Lotion Sig: One (1) application Topical
[**Hospital1 **] (2 times a day).
2. Diazepam 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for pain.
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) inhalation Inhalation [**Hospital1 **] (2 times a day).
4. Ketoconazole 2 % Shampoo Sig: One (1) Appl Topical 2X/WEEK
(TU,SA).
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical once a day.
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
9. Pregabalin 75 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
10. Triamcinolone Acetonide 0.025 % Cream Sig: One (1) Appl
Topical QD PRN () as needed for itching.
11. Zafirlukast 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3)
Tablet, Chewable PO BID (2 times a day).
14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5
Tablets PO DAILY (Daily).
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) Nebulizer
Inhalation Q6H (every 6 hours) as needed for SOB.
16. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
17. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
18. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
19. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Nebulizer Inhalation Q6H (every 6
hours).
20. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
21. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 6-8 hours as needed for wheezing,
SOB.
Disp:*2 90 mcg/Actuation HFA Aerosol Inhaler* Refills:*0*
22. Hydroxyzine HCl 25 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for itching.
23. Morphine 15 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
24. Amitriptyline 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
25. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
26. Insulin Glulisine 100 unit/mL Cartridge Sig: One (1) dose
per sliding scale Subcutaneous three times a day as needed for
controlling blood glucose levels: Take after each meal, per
sliding scale.
27. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
28. Epinephrine 0.3 mg/0.3 mL Pen Injector Sig: One (1)
injection Intramuscular once as needed for anaphylaxis (severe
allergic reaction): Please call 911 if needed.
29. Insulin Detemir 100 unit/mL Insulin Pen Sig: Forty (40)
units Subcutaneous twice a day: Please take one dose in the
morning and one dose before bedtime.
30. Xyzal 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for itching.
31. Promethazine 25 mg Tablet Sig: One (1) Tablet PO three times
a day as needed for nausea: Please do not drive after taking.
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Primary:
Asthma flare
Uncontrolled Type 2 Diabetes Mellitus
Mild Gastritis
Secondary:
Arthritis
Spinal Stenosis
GERD
Diabetic peripheral neuropathy
Obstructive sleep apnea
Eczema
Discharge Condition:
PLEASE NOTE: PATIENT ELOPED AGAINST MEDICAL ADVICE ON [**2150-8-10**].
Stable, afebrile.
Discharge Instructions:
PLEASE NOTE: PATIENT ELOPED AGAINST MEDICAL ADVICE ON [**2150-8-10**]
WITHOUT RECEIVING FULL DISCHARGE INSTRUCTIONS.
Dear Ms. [**Known lastname **],
It was a pleasure caring for you during this admission. You were
admitted for evaluation and management of your left sided chest
pain, increased difficulty breathing, and high blood sugar
levels. The results of an EKG and several blood tests confirmed
that you did not have a heart attack. Because you had several
risk factors for the development of pulmonary embolism (a clot
in the blood vessels in the lungs) and deep vein thrombosis (a
blood clot in your legs), we initially treated you with the
blood thinner lovenox, but stopped this medication after imaging
studies suggested that pulmonary embolism was unlikely. It
appeared that your chest pain was related to your chronic
arthritis and musculoskeletal pain, so we continued your home
pain management regimen to manage this pain.
Your increased difficulty breathing secondary to an asthma flare
was treated with a four day course of the steroid prednisone and
you were continued on your home medications of
fluticasone-salmeterol, albuterol nebulizers, and ipatropium.
You never required supplemental oxygen and your breathing
returned to your baseline.
On admission it was found that your diabetes was poorly
controlled and that you had finger stick blood glucose levels
persistently above 500, likely secondary to your body's natural
stress response and exacerbated by the additional steroids used
to treat your asthma flare. You were transferred to the
intensive care unit and started on an insulin drip and then
transitioned back to a twice daily basal insulin regimen and a
sliding scale insulin regimen and transferred back to the
hospital floor.
Because you complained of difficulty swallowing, you underwent a
barium swallow study that showed decreased emptying of your
stomach but no blockages in your esophagus (food pipe). You also
underwent an upper endoscopy to evaluate your increased
difficulty swallowing and to assess your Nissen fundoplication
(wrap). An attempt was made to dilate the connection between
your esophagus and stomach, but was not successful. You were
found to have some mild gastritis.
On [**2150-8-8**], you developed a fever, increasing abdominal
bloating, weakness, numbness, and tingling in your face. You
were given acetominophen to control your temperature. Urine
cultures were negative. Blood cultures were drawn and showed no
bacterial growth. Imaging studies showed that you did not have a
bowel blockage, but had lots of stool in your colon consistent
with constipation. Blood tests showed no problems with your
liver or pancreas. Your numbness and tingling in your face was
thought to be related to your recently elevated blood sugars
secondary to poorly controlled diabetes.
We have made the following changes to your medications:
1. We stopped your Etodolac because of stomach irritation,
exacerbation of your gastritis
2. We stopped your hydromorphone because of the allergic
reaction that you had to both intravenous and oral forms.
3. We stopped your metformin.
4. We stopped your Pramlintide (SymlinPen).
5. We increased your Insulin Detemir (Levemir Flexpen) dose to
40 units 2 times a day (in the morning and at bed time).
6. We changed your insulin Glulisine (Apidra) sliding scale
(please see attached sheet).
7. We started you on citalopram for depression.
8. We started you on hydroxyzine tablets for itching
8. We have prescribed an emergency albuterol inhaler for you to
use if you have acute breathing difficulties.
Please take all medications as prescribed and go to all follow
up appointments. Please adhere to an appropriate diabetic diet.
To prevent further diabetic neuropathy, it's important to follow
this diet to keep your blood sugars under control.
Please call your physician or return to the emergency department
if you have increased difficulty breathing, chest pain, fever,
nausea, vomiting, persistently elevated blood sugars, or any
other concerning symptoms.
Dear Ms. [**Known lastname **],
It was a pleasure caring for you during this admission. You were
admitted for evaluation and management of your left sided chest
pain, increased difficulty breathing, and high blood sugar
levels. The results of an EKG and several blood tests confirmed
that you did not have a heart attack. Because you had several
risk factors for the development of pulmonary embolism (a clot
in the blood vessels in the lungs) and deep vein thrombosis (a
blood clot in your legs), we initially treated you with the
blood thinner lovenox, but stopped this medication after imaging
studies suggested that pulmonary embolism was unlikely. It
appeared that your chest pain was related to your chronic
arthritis and musculoskeletal pain, so we continued your home
pain management regimen to manage this pain.
Your increased difficulty breathing secondary to an asthma flare
was treated with a four day course of the steroid prednisone and
you were continued on your home medications of
fluticasone-salmeterol, albuterol nebulizers, and ipatropium.
You never required supplemental oxygen and your breathing
returned to your baseline.
On admission it was found that your diabetes was poorly
controlled and that you had finger stick blood glucose levels
persistently above 500, likely secondary to your body's natural
stress response and exacerbated by the additional steroids used
to treat your asthma flare. You were transferred to the
intensive care unit and started on an insulin drip and then
transitioned back to a twice daily basal insulin regimen and a
sliding scale insulin regimen and transferred back to the
hospital floor.
Because you complained of difficulty swallowing, you underwent a
barium swallow study that showed decreased emptying of your
stomach but no blockages in your esophagus (food pipe). You also
underwent an upper endoscopy to evaluate your increased
difficulty swallowing and to assess your Nissen fundoplication
(wrap). An attempt was made to dilate the connection between
your esophagus and stomach, but was not successful. You were
found to have some mild gastritis.
On [**2150-8-8**], you developed a fever, increasing abdominal
bloating, weakness, numbness, and tingling in your face. You
were given acetominophen to control your temperature. Urine
cultures were negative. Blood cultures were drawn and showed
[INSERT RESULT HERE] Imaging studies showed that you did not
have a bowel blockage, but had lots of stool in your colon
consistent with constipation. Blood tests showed no problems
with your liver or pancreas. Your numbness and tingling in your
face was thought to be related to your recently elevated blood
sugars secondary to poorly controlled diabetes.
We have made the following changes to your medications:
1. We stopped your Etodolac because of stomach irritation,
exacerbation of your gastritis
2. We stopped your hydromorphone because of the allergic
reaction that you had to both intravenous and oral forms.
3. We stopped your metformin.
4. We stopped your Pramlintide (SymlinPen).
5. We increased your Insulin Detemir (Levemir Flexpen) dose to
40 units 2 times a day (in the morning and at bed time).
6. We changed your insulin Glulisine (Apidra) sliding scale
(please see attached sheet).
7. We started you on citalopram for depression.
8. We started you on hydroxyzine tablets for itching
8. We have prescribed an emergency albuterol inhaler for you to
use if you have acute breathing difficulties.
Please take all medications as prescribed and go to all follow
up appointments. Please adhere to an appropriate diabetic diet.
To prevent further diabetic neuropathy, it's important to follow
this diet to keep your blood sugars under control.
Please call your physician or return to the emergency department
if you have increased difficulty breathing, chest pain, fever,
nausea, vomiting, persistently elevated blood sugars, or any
other concerning symptoms.
Dear Ms. [**Known lastname **],
It was a pleasure caring for you during this admission. You were
admitted for evaluation and management of your left sided chest
pain, increased difficulty breathing, and high blood sugar
levels. The results of an EKG and several blood tests confirmed
that you did not have a heart attack. Because you had several
risk factors for the development of pulmonary embolism (a clot
in the blood vessels in the lungs) and deep vein thrombosis (a
blood clot in your legs), we initially treated you with the
blood thinner lovenox, but stopped this medication after imaging
studies suggested that pulmonary embolism was unlikely. It
appeared that your chest pain was related to your chronic
arthritis and musculoskeletal pain, so we continued your home
pain management regimen to manage this pain.
Your increased difficulty breathing secondary to an asthma flare
was treated with a four day course of the steroid prednisone and
you were continued on your home medications of
fluticasone-salmeterol, albuterol nebulizers, and ipatropium.
You never required supplemental oxygen and your breathing
returned to your baseline.
On admission it was found that your diabetes was poorly
controlled and that you had finger stick blood glucose levels
persistently above 500, likely secondary to your body's natural
stress response and exacerbated by the additional steroids used
to treat your asthma flare. You were transferred to the
intensive care unit and started on an insulin drip and then
transitioned back to a twice daily basal insulin regimen and a
sliding scale insulin regimen and transferred back to the
hospital floor.
Because you complained of difficulty swallowing, you underwent a
barium swallow study that showed decreased emptying of your
stomach but no blockages in your esophagus (food pipe). You also
underwent an upper endoscopy to evaluate your increased
difficulty swallowing and to assess your Nissen fundoplication
(wrap). An attempt was made to dilate the connection between
your esophagus and stomach, but was not successful. You were
found to have some mild gastritis.
On [**2150-8-8**], you developed a fever, increasing abdominal
bloating, weakness, numbness, and tingling in your face. You
were given acetominophen to control your temperature. Urine
cultures were negative. Blood cultures were drawn and showed no
bacterial growth. Imaging studies showed that you did not have a
bowel blockage, but had lots of stool in your colon consistent
with constipation. Blood tests showed no problems with your
liver or pancreas. Your numbness and tingling in your face was
thought to be related to your recently elevated blood sugars
secondary to poorly controlled diabetes.
We have made the following changes to your medications:
1. We stopped your Etodolac because of stomach irritation,
exacerbation of your gastritis
2. We stopped your hydromorphone because of the allergic
reaction that you had to both intravenous and oral forms.
3. We stopped your metformin.
4. We stopped your Pramlintide (SymlinPen).
5. We increased your Insulin Detemir (Levemir Flexpen) dose to
40 units 2 times a day (in the morning and at bed time).
6. We changed your insulin Glulisine (Apidra) sliding scale
(please see attached sheet).
7. We started you on citalopram for depression.
8. We started you on hydroxyzine tablets for itching
8. We have prescribed an emergency albuterol inhaler for you to
use if you have acute breathing difficulties.
Please take all medications as prescribed and go to all follow
up appointments. Please adhere to an appropriate diabetic diet.
To prevent further diabetic neuropathy, it's important to follow
this diet to keep your blood sugars under control.
Please call your physician or return to the emergency department
if you have increased difficulty breathing, chest pain, fever,
nausea, vomiting, persistently elevated blood sugars, or any
other concerning symptoms.
Followup Instructions:
PLEASE NOTE: PATIENT ELOPED AGAINST MEDICAL ADVICE ON [**2150-8-10**]
1. Provider: [**First Name11 (Name Pattern1) 2620**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **], PT Phone:[**Telephone/Fax (1) 4832**]
Date/Time:[**2150-8-13**] 9:00
2. Provider: [**First Name11 (Name Pattern1) 2872**] [**Doctor Last Name 2873**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**]
Date/Time:[**2150-8-13**] 11:00
3. Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2150-8-19**] 10:40
Completed by:[**2150-8-19**]
|
[
"296.20",
"626.1",
"716.99",
"V58.67",
"389.9",
"357.2",
"782.0",
"564.00",
"424.0",
"401.9",
"782.3",
"V45.89",
"351.8",
"716.90",
"327.23",
"780.60",
"338.29",
"493.92",
"692.9",
"285.9",
"786.59",
"724.00",
"530.81",
"250.62",
"V12.54",
"535.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
21008, 21027
|
9134, 16433
|
340, 446
|
21251, 21342
|
4276, 9111
|
33313, 33886
|
3270, 3469
|
17770, 20985
|
21048, 21230
|
16459, 17747
|
21366, 24229
|
3484, 4257
|
32128, 33290
|
290, 302
|
474, 2427
|
2449, 2918
|
2934, 3254
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,703
| 185,494
|
45053
|
Discharge summary
|
report
|
Admission Date: [**2172-4-11**] Discharge Date: [**2172-4-20**]
Service: MEDICINE
Allergies:
Bactrim / Procardia
Attending:[**First Name3 (LF) 710**]
Chief Complaint:
Status post fall.
Major Surgical or Invasive Procedure:
ORIF of hip fracture.
History of Present Illness:
85 year-old male s/p fall at rehabilitation facility with left
intertrochanteric hip fracture, s/p ORIF the day of transfer,
admitted to MICU for hypercarbic and hypoxemic respiratory
failure post-procedure. Please see admission note by Dr. [**Last Name (STitle) **]
for more details of initial presentation. Briefly, pt sustained
a L intertrochanteric hip fracture after a mechanical fall. He
went to the OR the day of transfer. for an ORIF.
Postoperatively, he was extubated and developed hypercarbic
respiratory failure. Per the [**Name8 (MD) 13042**] RN, his mental status was
reasonable at the time of extubation - he was able to respond,
lift his head up off the bed, and squeeze a hand. Over the next
30-45 minutes after extubation, he became more lethargic, and
sats dropped to 91%. Repeat ABG was 7.05/81/75 (baseline while
intubated for surgery: 7.30/47/245). Pt was reintubated, which
was described as somewhat difficult and needed a Bougie. RN
notes that she suctioned thick tan sputum.
Past Medical History:
Type 2 DM
h/o known Thoracic Pseudoaneursym of Aorta
HTN
Diverticulosis, s/p partial colectomy
Depression
CRI (1.3-1.7)
Parkinson's disease
Dementia-vascular on MRI [**2162**]
Pacemaker
Social History:
Denies tobbaco,alcohol,IVDA; currently lives in [**Hospital 100**] Rehab
facility
Family History:
Non-contributory
Physical Exam:
VS: 101 65 108/44 18 98% AC 550x18/0.6/5
Gen: intubated, sedated
HEENT: PERRL
CV: RRR, nl S1/S2, 2/6 systolic murmur
Pulm: crackles and coarse breath sounds anteriorly
Abd: soft, NT/ND, +BS, no masses
Ext: L hip dressing in place, serosanguinous fluid on dressing;
good distal pulses
.
Pertinent Results:
Imaging:
CHEST (SINGLE VIEW) [**2172-4-11**] 2:16 PM
IMPRESSION: Unchanged saccular aneurysm arising from the aortic
arch. No evidence of acute cardiopulmonary process.
.
PELVIS (AP ONLY) [**2172-4-11**] 1:53 PM
IMPRESSION: Left intertrochanteric femoral fracture.
.
CT C-SPINE W/O CONTRAST [**2172-4-11**] 1:37 PM
IMPRESSION:
1. No evidence of fracture or malalignment of the cervical
spine.
2. Extensive multilevel degenerative change, unchanged compared
to previous examinations.
3. Heterogeneous, enlarged thyroid gland with dominant nodule.
If clinically indicated, this may be further characterized by
dedicated thyroid son[**Name (NI) 867**].
.
CT HEAD W/O CONTRAST [**2172-4-11**] 1:37 PM
IMPRESSION: No evidence of intracranial hemorrhage. No evidence
of fracture.
.
CHEST (PORTABLE AP) [**2172-4-12**] 5:14 PM
Improved inspiration is visualized on the current study compared
to [**2172-4-11**]. There are no new focal consolidations visualized.
The pulmonary vascular markings are within normal limits. Again
seen is a prominent aortic knob. Pacemaker hardware wires and
tips are unchanged.
.
CHEST (PORTABLE AP) [**2172-4-14**] 10:37 PM
PORTABLE AP CHEST RADIOGRAPH: There has been interval
advancement of the NG tube, and the sidehole is beyond the GE
junction. The left pleural effusion, and left subclavian
aneurysm are stable, and the remainder of the study is not
significantly changed from the prior exam from the same day.
.
PORTABLE ABDOMEN [**2172-4-14**] 8:40 PM
IMPRESSION: NG tube with its sidehole projecting over the
gastric body and its tip projecting over the distal gastric
body.
.
CHEST (PORTABLE AP) [**2172-4-16**] 11:21 AM
IMPRESSION: Mild fluid overload, but no overt pulmonary edema.
Bibasal lung consolidations.
.
Micro:
All blood, urine, sputum cultures: NGTD
Labs:
[**2172-4-11**] 01:05PM BLOOD WBC-8.7# RBC-4.53* Hgb-13.2* Hct-39.5*
MCV-87 MCH-29.2 MCHC-33.4 RDW-15.3 Plt Ct-186
[**2172-4-13**] 09:37PM BLOOD WBC-12.6*# RBC-2.70* Hgb-8.0* Hct-24.4*
MCV-91 MCH-29.7 MCHC-32.8 RDW-15.2 Plt Ct-114*
[**2172-4-15**] 01:55AM BLOOD WBC-9.7 RBC-2.32* Hgb-6.9* Hct-20.4*
MCV-88 MCH-29.7 MCHC-33.8 RDW-15.2 Plt Ct-129*
[**2172-4-17**] 06:55AM BLOOD WBC-7.4 RBC-2.64* Hgb-7.8* Hct-24.0*
MCV-91 MCH-29.6 MCHC-32.5 RDW-15.4 Plt Ct-159
[**2172-4-20**] 07:25AM BLOOD WBC-10.1 RBC-3.41* Hgb-10.3* Hct-30.7*
MCV-90 MCH-30.4 MCHC-33.7 RDW-16.1* Plt Ct-237
[**2172-4-11**] 01:05PM BLOOD PT-13.5* PTT-25.5 INR(PT)-1.2*
[**2172-4-13**] 09:37PM BLOOD PT-14.0* PTT-31.3 INR(PT)-1.2*
[**2172-4-16**] 03:05AM BLOOD PT-13.9* PTT-33.5 INR(PT)-1.2*
[**2172-4-18**] 07:55AM BLOOD PT-12.8 PTT-29.1 INR(PT)-1.1
[**2172-4-20**] 07:25AM BLOOD PT-12.9 PTT-29.4 INR(PT)-1.1
[**2172-4-11**] 01:05PM BLOOD Glucose-210* UreaN-20 Creat-1.1 Na-144
K-4.1 Cl-106 HCO3-28 AnGap-14
[**2172-4-13**] 09:37PM BLOOD Glucose-170* UreaN-30* Creat-1.4* Na-143
K-4.1 Cl-114* HCO3-20* AnGap-13
[**2172-4-16**] 03:05AM BLOOD Glucose-178* UreaN-38* Creat-1.6* Na-144
K-4.1 Cl-112* HCO3-25 AnGap-11
[**2172-4-20**] 07:25AM BLOOD Glucose-180* UreaN-27* Creat-1.1 Na-145
K-4.0 Cl-110* HCO3-26 AnGap-13
[**2172-4-11**] 01:05PM BLOOD CK(CPK)-81
[**2172-4-15**] 01:55AM BLOOD CK(CPK)-838*
[**2172-4-15**] 07:02PM BLOOD CK(CPK)-975*
[**2172-4-16**] 03:05AM BLOOD CK(CPK)-920*
[**2172-4-11**] 01:05PM BLOOD cTropnT-<0.01
[**2172-4-12**] 07:05AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.4
[**2172-4-14**] 04:14AM BLOOD Albumin-2.5* Calcium-7.4* Phos-3.0 Mg-1.9
[**2172-4-18**] 07:55AM BLOOD Calcium-8.8 Phos-2.7 Mg-2.4
[**2172-4-20**] 07:25AM BLOOD Calcium-8.7 Phos-2.8 Mg-2.2
[**2172-4-12**] 03:50PM BLOOD Hapto-230*
Brief Hospital Course:
85 year old with diabetes, dementia, chronic renal failure,
intertrochanteric hip fracture s/p ORIF with hypercarbic and
hypoxemic respiratory failure post-procedure.
.
# Respiratory failure: The patient was reintubated
post-procedure and tolerated extubation the day after the
procedure. The patient's hypercarbic respiratory failure was
likely secondary to altered mental status after surgery and
patient inability to ventilate properly. The patient likely
metabolizes anesthetics slowly in the setting of his renal
failure and advanced age. The patient's hypoxemic respiratory
failure was likely due to left-sided pneumonia and fluid
overload. The patient was given lasix for diuresis. He was
febrile with sputum production and is being treated for
hospital-acquired pneumonia with vancomycin and zosyn. This was
later switched to Augmentin. Blood cultures remain negative.
.
# Left hip fracture: Intertrochanteric, patient is s/p several
falls in the past. s/p L ORIF on [**4-13**]. The patient was followed
by Orthopedics and Physical Therapy, and will require rehab. The
patient was given DVT prophylaxis with lovenox [**Hospital1 **].
.
# Anemia: Hematocrit dropped intra- and post-procedure from
bleeding into hip. The patient was transfused for hematocrit <
21 and received a total of three units PRBC. The patient's
hematocrit subsequently remained stable. No signs or symptoms of
compartment syndrome and patient's CK trending down
post-procedure. The patient had no evidence of GI losses; NG
lavage negative and no stool ouput. Patient has baseline anemia
from anemia of chronic disease and chronic renal failure.
.
# Blood pressure: The patient's antihypertensives were held for
transient hypotension which responded to fluid boluses. The
hypotension was likely due to blood loss. This unlikely
represented sepsis or adrenal insufficiency. The patient was
restarted on his BB and ACE prior to DC. He was not restarted
on his CCB prior to discharge, and this will need to be readded
as needed.
.
# Chronic renal insufficiency: Stable; baseline creatinine
1.4-1.7. The patient's medications were renally dosed.
.
# Dementia/Parkinson's disease: The patient was continued on
pramipexole, donezipil, seroquel, and lexapro. Patient failed
his first Speech and Swallow evaluation with repeat [**4-16**] giving
approval for ground solids and nectar-prethickened liquids. NG
tube was kept in place as the patient has waxing/[**Doctor Last Name 688**] mental
status.
.
# Type 2 diabetes mellitus: The patient's glyburide was held
while NPO. The patient was maintained on QID FS, SSI.
.
# FEN - Ground solids and nectar-prethickened liquids
.
.
After discussion with the patient and the medical staff, all
were in agreement that Mr. [**Known firstname **] [**Last Name (NamePattern1) 5279**] was a suitable candidate
for discharge.
Medications on Admission:
Metoprolol Tartrate 25 mg [**Hospital1 **]
Donepezil 10 mg qhs
Protonix 40 mg daily
Oxycontin 10 mg q 12 hr
Oxycodone prn
Colace 100 mg [**Hospital1 **]
Hep SC
Celexa 20 mg daily
Norvasc 5 mg daily
Iron 325 mg daily
Lisinopril 20 mg daily
Pramipexole 0.125 mg--[**12-17**] tablet qid
Discharge Medications:
1. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY
(Daily).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
8. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
9. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 30 days.
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
14. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
15. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 3 days: started on [**2172-4-17**].
16. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
17. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-17**] Sprays Nasal
QID (4 times a day) as needed for nasal irritation.
18. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold for SBP < 110 or HR < 60.
19. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Hold for SBP < 110.
20. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
PRIMARY:
Left hip fracture
Pneumonia
SECONDARY:
Type 2 DM
h/o known Thoracic Pseudoaneursym of Aorta
HTN
Diverticulosis, s/p partial colectomy
Depression
TURP s/p hernia repair
CRI (1.3-1.7)
Parkinson's disease
Dementia-vascular on MRI [**2162**]
Pacemaker
Discharge Condition:
Afebrile, hemodynamically stable, tolerating POs, ambulating
with assistance.
Discharge Instructions:
Please take all medication as prescribed. Keep all appointments
listed below. If you have chest pain or shortness of breath,
get medical attention immediately. If you have fever, pain or
any general medical questions, please call your doctor or go to
the emergency department.
Followup Instructions:
Please follow up with your PCP [**Name Initial (PRE) 176**] 2 weeks:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 38919**]
|
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icd9cm
|
[
[
[]
]
] |
[
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"96.71",
"00.33",
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icd9pcs
|
[
[
[]
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10588, 10653
|
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|
244, 267
|
10955, 11035
|
1961, 5555
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,994
| 154,581
|
48617
|
Discharge summary
|
report
|
Admission Date: [**2115-8-27**] Discharge Date: [**2115-9-4**]
Date of Birth: [**2046-6-27**] Sex: F
Service: MEDICINE
Allergies:
Motrin / Lipitor
Attending:[**First Name3 (LF) 562**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Endotracheal intubation [**2115-8-27**]
Central line placement [**2115-8-27**]
Temporary dialysis catheter placement left groin [**2115-8-27**]
Hemodialysis
History of Present Illness:
Ms.[**Known lastname **] is a 69 yo female with MMP including [**Known lastname 2182**], ESRD on HD
3X/week, CAD, CHF, HIV, eosinophilic pna, and recently diagnosed
right popliteal DVT without PE on coumadin, who presents from
home with a 1-day history of worsening shortness of breath
following missed hemodialysis yesterday [**2-20**] clotted AV graft.
She describes that she woke up last night with SOB, with some
relief with sitting upright. She describes transient chest
tightness in AM relieved with SLNG X1. No N/V. No pleuritic
discomfort. No diaphoresis. Chronic non-productive cough,
without change. No fever or chills. Some wheezing, not
significantly worse versus usual. No lower extremity edema. She
has been compliant with her medications and low salt diet. Her
last hemodialysis was on [**8-23**]. HD was attempted yesterday
without success [**2-20**] clotted AV graft. She was scheduled for left
UE AV graft thrombectomy today, but presented to the ED with
SOB.
In the ED, initial vitals were T 98.6, HR 102, BP 140/100, RR
32, Sat 93% on room air. Labs remarkable for INR 6.8 (was 5.2
yesterday, Coumadin held last night). Right EJ line placed.
Given elevated INR, transfusion of FFP as initiated, with
subsequent increasing oxygen requirement and eventual sat 91 %
on NRB. She was placed on BiPAP 5/5 with FiO2 0.1, with sat 95%.
MICU admission requested.
Review of labs indicates supratherapeutic INR on multiple
occasions.
Past Medical History:
Past Medical History:
1. CAD s/p NSTEMI [**5-19**], s/p PTCA/stent LCX [**2113**]. Latest
catheterization in [**10-21**] with 2-vessel disease. Persantine MIBI
[**4-22**] without symptoms or EKG changes. MIBI images significant
for severe fixed inferior defect, EF 58%.
2. DM type 2, on NPH.
3. HIV, last CD4 count 940 in [**7-/2115**]
4. ESRD on HD since '[**10**] (M, W, F)
5. CHF, with mixed systolic (EF 45-50%) and diastolic
dysfunction.
6. Severe mitral regurgitation [**2115-6-20**]
7. History of RUL segmental PE in [**11/2114**], on coumadin
([**2114-12-5**]) D/C'd in 06/[**2115**].
8. Recently diagnosed right popliteal DVT [**7-/2115**], restarted on
Coumadin
9. H/o multiple AVF clots, s/p thrombectomies, last in [**2115-1-8**]
9. H/o GIB in the setting of coagulopathy and NSAIDs
10. Eosinophilic pneumonia diagnosed [**4-22**], on chronic
prednisone therapy.
11. Anemia [**2-20**] CRF
12. Vulvar intraepithelial neoplasia diagnosed in [**2113-4-18**].
13. [**Year (4 digits) 2182**] with PFTs with FVC 0.69 (27%), FEV1 0.46 (24%),
FEV1/FVC 92%.
14. History of positive Galactomannan antigen
15. RUL nodules on CT, not FDG avid on PET on [**8-20**]. Etiology
unclear.
16. Vulvar squamous cell carcinoma in situ.
Social History:
Lives in [**Location 686**] with her daughter . [**Name (NI) **] EtOH. Ex-smoker (60
pack-year smoking history)
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAMINATION on admission:
VITALS: BP 142/75, HR 99, RR 28, Sat 100% on BiPAP 5/5 FiO2 0.1
GEN: Tachypneic, unable to speak with full sentences.
HEENT: BiPAP in place. Right EJ in place.
NECK: Unable to assess JVP.
RESP: Poor air entry. Bibasilar crackles. Minimal wheezing. No
bronchial breathing.
CV: S1, S2. Loud SEM at apex radiating to axilla.
GI: BS NA. Abdomen soft and non-tender.
EXT: No pedal edema. Palpable left DP. Unable to palpate right
DP/PT, but warm extremity.
NEURO: Oriented X3.
Pertinent Results:
Relevant laboratory data on admission:
[**2115-8-27**] 10:15AM:
WBC-12.3* RBC-2.53* HGB-10.7* HCT-31.9* MCV-126* MCH-42.5*
RDW-18.6*
NEUTS-87.2* LYMPHS-10.0* MONOS-2.4 EOS-0.4 BASOS-0.1
GLUCOSE-97 UREA N-106* CREAT-11.0*# SODIUM-139 POTASSIUM-5.0
CHLORIDE-86* TOTAL CO2-25 ANION GAP-33*
ALBUMIN-4.0 CALCIUM-8.0* PHOSPHATE-8.2* MAGNESIUM-2.3
ALT(SGPT)-21 AST(SGOT)-25 ALK PHOS-96 AMYLASE-169* TOT BILI-0.2
PT-32.1* PTT-37.5* INR(PT)-6.8
Cardiac enzymes:
[**2115-8-27**] 10:15AM CK-MB-5 cTropnT-0.20*
[**2115-8-27**] 06:19PM CK-MB-6 cTropnT-0.18*
[**2115-8-27**] 09:14PM CK-MB-5 cTropnT-0.13*
IMAGING:
[**2115-8-27**] CXR: Mild CHF. Blunting of right CPA.
[**2115-8-27**] CXR: INDICATIONS: Hypoxia, increasing shortness of
breath.
PORTABLE AP CHEST AT 1610: Comparison is made to the study from
six hours earlier. Heart size remains at the upper limits of
normal. There is minimal pulmonary, vascular engorgement, but
overall, the appearance is improved since the study from six
hours earlier. There are no focal consolidations.
[**2115-8-31**] CXR: Triangular opacity in the right suprahilar lung is
probably atelectasis. Lungs are clear otherwise. Small bilateral
pleural effusions layer posteriorly. Mild cardiomegaly,
unchanged. There is no pneumothorax. There is no retrosternal
hematoma or displaced rib fracture. Configuration of the chest
suggests [**Month/Day/Year 2182**].
EKG on admission: Rate 96 [**Doctor First Name **], regular. Normal axis, normal
intervals. LAA. LVH by voltage criteria. Q in III (old),
non-specific ST changes in anterior leads (old versus
[**2115-7-24**])
EKG on discharge: Sinus rhythm
Lateral ST changes are nonspecific
Since previous tracing of [**2115-8-30**], no significant change
********************
Relevant studies in hospital:
[**2115-8-29**] ECHO: LVEF low normal (LVEF 50%) secondary to
hypokinesis of the inferior and posterior walls. No masses or
thrombi are seen in the left ventricle. Right ventricular
chamber size and free wall
motion are normal. No AR, no AS. (2+) MR, (2+) TR. Moderate
pulmonary
artery systolic hypertension. There is no pericardial effusion.
Brief Hospital Course:
69 yo female with MMP including ESRD on HD, CAD, CHF, severe MR,
and [**Month/Day/Year 2182**], admitted with SOB in setting of missed HD [**2-20**] clotted
AV graft, as well as supratherapeutic INR.
Transfusion of FFP was initiated in the ED to reverse her
coagulopathy and plan for temporary hemodialysis catheter
placement. Unfortunately, she developed worsening hypoxemia with
volume administration, and was placed on BiPAP and admitted to
the ICU for volume overload and respiratory distress. In the
ICU, she developed worsening respiratory distress, and was
intubated emergently on [**2115-8-27**] at 20:10, with succinylcholine
administration for induction. Shortly after intubation, she went
into PEA arrest.
1) PEA arrest: Etiology of PEA arrest attributed to
hyperkalemia, with exacerbation following succinylcholine
administration. She was resuscitated according to the ACLS
algorithms for PEA/asystole/pulseless VT, shocked twice (200
joules and 360 joules)and concomitantly repeatedly treated for
hyperkalemia. Potassium during code 6.9, after therapy. She
recovered a perfusing normal sinus rhythm after about 30 minutes
of resuscitation. EKG post code unchanged. She was started on a
dopamine drip for hypotension, which was slowly weaned off on
[**8-29**]. An echo was obtained on [**8-29**], which revealed a stable EF
at 50%, 2+ MR (improved versus [**6-/2115**]) and moderate PA HTN
(old). She was transferred from the ICU to the floor and
remained hemodynamically stable with no neurologic deficits.
Significant pain in chest from chest compressions, but chest
x-ray after code showed no evidence of PNX, hemothorax, rib
fracture. Supportive management with Dilaudid PO and oxycontin.
Of note, previous bleeding with Ibuprofen (history of acquired
factor VII deficiency, s/p Rx). Avoided Tylenol [**2-20**]
transaminitis. Electrolytes were monitored and she received HD
QOD.
2) Respiratory failure: Attributed to fluid overload in the
setting of missed hemodialysis [**2-20**] clotted AV graft and fluid
administration +/- [**Month/Day (2) 2182**]. She was 4 kg above dry weight at the
time of admission to the ICU. She was initially placed on BiPAP,
then emergently intubated given worsening respiratory distress.
Renal was called emergently following PEA arrest, and she was
emergently dialyzed on [**8-27**].
She was further dialyzed on [**8-28**] with removal of 3 additional
kg, and was succesfully extubated on [**8-28**]. She has been stable
from a respiratory standpoint since then. She was continued on
her chronic out-patient dose of Prednisone 20 mg PO QD and MDIs.
Post-arrest, she was empirically started on Levofloxacin and
Clindamycin (started on [**8-29**]) for coverage of ? aspiration
pneumonia or tracheobronchitis given new sputum production. CXR,
however, negative for infiltrate. Sputum grew GPC, GNR,
pseudomonas, but patient has had psuedomonas in past and is
likely colonized. She completed a 7 day course of antibiotics
but remained afebrile, WBC count at baseline, with no evidence
of PNA on any CXR's.
3) ESRD on HD: As above. Initial placement of dialysis access
deferred given supratherapeutic INR, but eventually placed
emergently following arrest (cordis line placed during code
changed over wire and dialysis cath placed). She was emergently
dialyzed on [**8-27**] at night, then again on [**7-7**], [**9-1**],
[**9-3**]. LUE AV graft thrombectomy on [**8-30**] in PM, at which time
she was transferred to the floor. Her potassium remained stable
and she was given EPO and paricalcitol at dialysis. Her
phosphate was chronically elevated, but once TUMS were changed
to be given with meals, the phosphate fell to 4-5 range.
4) CAD: She was ruled out for MI on admission with serial
cardiac enzymes. EKG pre and post arrest unchanged. Cardiac
enzymes not trended post chest compresssions. ASA, isordil, BB,
and Lisinopril held throughout admission. WILL RESTART BB, ASA,
ISORDIL, AND ACE I ON DAY OF DISCHARGE, AS PATIENT WAS ON ALL OF
THESE MEDICATIONS AT ADMISSION TIME. Pulse and BP stable, but
please monitor at rehab.
5) Coagulopathy: INR 6.8 on admission. She was given 1 [**1-20**] units
of FFP, stopped in the setting of respiratory failure. Vitamin K
given on [**8-29**], and INR down to 2.3 on [**8-30**]. Heparin IV
restarted after thrombectomy for RLE DVT. Coumadin restarted at
same time, initially at 7.5 mg. She reached therapeutic level
quickly so dose was decreased to 5 mg and then 2.5 mg. INR on
discharge 2.1, with goal [**2-21**].
6) DM type 2: Kept on [**1-20**] NPH (12 units QAM) and RISS. Once
patient started eating again, sugars increased. Will DC on 18
units in a.m. and ask rehabilitation facility to monitor
closely. Patient was on ISS while inpatient.
7) HIV: On HAART. Last CD4 well above 200.
8) FEN: Initially NPO, advanced to [**Doctor First Name **]/heart healthy diet/renal
diet. Patient initially had some difficulty eating as she felt
nauseated and vomited up food. Thought to be due to pain meds.
By the time of discharge the patient was keeping most foods
down. Patient was seen by nutrition and it was determine that
she was at nutrition risk. Patient was drinking one can of
Nepro per day and was encouraged to increase to two on the day
of discharge.
9) Transaminitis: LFT's transiently rose in setting of shock
liver, but returned to baseline by discharge with no
intervention needed.
10) Ppx: Maintained on heparin and coumadin. Elevate HOB. PPI.
Bowel regimen.
11) Access: Initially right EJ and RUE 20-gauge peripheral IV.
Left femoral cordis placed during arrest, changed over wire for
temporary dialysis catheter, removed on [**8-30**]). Given 1 dose of
Vancomycin prophylactically on [**8-29**] given dirty line still in
place, but d/c'd on [**8-30**]. Of note, attempt to place right groin
femoral line during code resulted in arterial puncture. Small
hematoma noted, no bruit. U/S done on wrong side, not repeated.
Thrombectomy performed and original AV graft used thereafter for
HD.
12) Code: Full. Has been Discussed with patient.
Medications on Admission:
ASA 325 mg PO QD
Coumadin 7.5 mg PO QD
Bactrim SS 1 tab PO QD 3X/week
Prednisone
Metoprolol 25 mg PO BID
Lisinopril 2.5 mg PO QD
Isordil 10 mg PO BID
Combivent 1 inhalation q 6 hours
Nephrocaps 1 tab PO QD
Protonix 40 mg PO QD
Zidovudine 200 mg PO BID
Nevirapine 200 mg PO BID
Lamivudine 50 mg PO QD
Colace 100 mg PO BID
NPH 25 units QAM
Lispro SS
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
2. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
This is to be tapered slowly.
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Zidovudine 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
5. Nevirapine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Lamivudine 100 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed.
10. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: One
(1) Puff Inhalation Q6H (every 6 hours).
11. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q3-4H
(Every 3 to 4 Hours) as needed for Pain.
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
13. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
15. Epoetin Alfa 10,000 unit/mL Solution Sig: Per protocol
Injection ASDIR (AS DIRECTED).
16. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Paricalcitol 5 mcg/mL Solution Sig: As decided at dialysis
Intravenous 3X/WEEK (MO,WE,FR).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
1) Thrombosis of AV graft used for dialysis
2) S/P PEA arrest d/t hyperkalemia
3) ESRD
Discharge Condition:
Stable. Patient continues to receive HD TID. Breathing has
returned to baseline. Ready for rehabilitation.
Discharge Instructions:
1) Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
2) Adhere to 2 gm sodium diet
3) Please take all of your medications as prescribed
4) Please call your PCP or return to the ED if you have
worsening SOB, chest pain LE edema, nausea, vomiting, fevers,
weight gain.
Followup Instructions:
1) Please follow-up with Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 2393**] in [**1-20**]
weeks after discharge from rehabilitation center.
2) [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Where: LM [**Hospital Unit Name 5628**]
CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2115-9-9**] 2:40
3) [**Name6 (MD) 251**] [**Last Name (NamePattern4) 252**], M.D. Where: [**Hospital6 29**] [**Hospital1 37213**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2115-9-17**] 11:00
4) [**First Name8 (NamePattern2) **] [**Name8 (MD) 4174**], MD Where: [**Hospital6 29**] OBSTETRICS AND
GYNECOLOGY Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2115-9-18**] 1:00
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,964
| 149,073
|
30040
|
Discharge summary
|
report
|
Admission Date: [**2169-5-11**] Discharge Date: [**2169-6-14**]
Date of Birth: [**2098-10-17**] Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
Left adnexal mass
Major Surgical or Invasive Procedure:
Exploratory laparoscopy converted to laparotomy, lysis of
adhesions,
dissection of intraperitoneal cyst, left salpingo-oophorectomy.
Intubation
extubation
PICC line placement and removal.
History of Present Illness:
70 year old woman referred to gyn oncology by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 22552**]
secondary to a
recent discovery of a left adnexal mass. The patient had
complained of persistent lower abdominal pain, and CT of the
abdomen was done at [**Hospital3 4107**] which revealed mild ascites
and a 5 cm left adnexal cyst. There was a calcification noted
on the margin of the cyst. Of note, the patient is s/p left
oophorectomy. She also underwent an MRI of the pelvis, which
suggested that the 5-cm cystic mass may be arising from the
uterine fundus, possibly representing a cystic degenerating
exophytic leiomyoma. The ascites was also noted. She had a few
lab abnormalities that were concerning for malignancy: namely a
CA 125 up to 106, anemia with a hematocrit of 30, and
thrombocytosis with a platelet count in the 800,000 range.
After discussing her options with Dr. [**Last Name (STitle) 2028**], the decision was
made to proceed with surgical intervention for difinitive
diagnosis of this mass. The plan was made for a laparoscopic
approach, although conversion to laparotomy was felt to be a
high risk given her previous surgeries.
Past Medical History:
PAST MEDICAL HISTORY: She has hypertension. Early in [**2169**], she
had a persistent common bile duct stone that caused right upper
quadrant discomfort and it was removed via ERCP. She had a
recent colonoscopy which was normal. She is up to date with her
mammograms, the last one being in 04/[**2168**].
PAST SURGICAL HISTORY: 15 years ago, she had a laparoscopic
cholecystectomy. 10 years ago, she had an open right
oophorectomy. 3 years ago, she had an appendectomy with return
to the OR 3 days later for lysis of adhesions. 2 years ago, she
had a diagnostic hysteroscopy for post-menopausal bleeding which
revealed only atrophy. She has had breast surgery in the past.
OB/GYN HISTORY: She is gravida 3, para 3. She has no history
of
fibroids, pelvic infections or abnormal Pap smears. The last
Pap
smear was in [**1-/2169**] and is reportedly normal.
Social History:
She is retired. She is married. She denies tobacco, drug or
alcohol use.
Family History:
She denies family history of cancer.
Physical Exam:
At admission -
HEENT: Negative.
NECK: Supple, no masses.
CARDIOVASCULAR: Regular rate and rhythm.
RESPIRATIONS: Bilaterally clear.
BACK: No spinal or CVA tenderness.
ABDOMEN: Soft, nontender, well-healed incisions are noted all
over the abdomen. There is no evidence of herniation with
Valsalva.
GROIN: No enlarged lymph nodes.
EXTREMITIES: No clubbing, cyanosis, or edema.
NEUROLOGIC: Alert and oriented x3, cranial nerves II through
XII grossly intact.
PELVIC: Normal external genitalia. Vagina reveals no masses or
lesions. Cervix reveals no mass or lesion. There is no
cervical motion tenderness. Uterus is normal in size and
consistency, and there is no palpable adnexal mass today. There
is no rectal mass on exam.
Pertinent Results:
.
CT Chest and abdomen, [**5-18**]:
1. No evidence of pulmonary embolism or aortic dissection.
2. Large bilateral pleural effusions with associated
atelectasis.
3. Small foci of airspace opacity in the lingula and right
middle lobe, which are concerning for infection.
4. Interval increase in ascites, which continues to measure as
simple fluid density. No evidence of acute blood products within
the abdomen.
5. Inflammatory stranding, and intraperitoneal air in the mid
abdomen, with no discrete abscess. This intraperitoneal air is
likely due to postoperative status, though in this patient with
known enterostomy, extravasated air from the bowel cannot be
excluded.
6. Extremely thinned fascia in the mid abdomen with pockets of
air on both sides in both the subcutaneous tissue and
intraperitoneally. No definite evidence of dehiscence.
7. Enhancement of the peritoneal lining associated with the
ascites is a nonspecific finding, but can be seen in
intra-abdominal infection.
.
TTE: [**5-18**]
Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. There is
severe global left ventricular hypokinesis/akinesis with
relative sparing of the apex. The basal to mid septum is
akinetic. Overall left ventricular systolic function is
severely depressed. Right ventricular chamber size is normal. RV
systolic function is borderline preserved. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve
leaflets are mildly thickened. Mild to moderate ([**1-3**]+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
.
[**5-24**] CT ABD
1. Increased intraperitoneal fluid compared to a few days prior
with successful placement of 2 pigtail catheters, one right
sided and one left sided, without complication.
2. Thrombosis within left gonadal vein
3. 30-mm left omental soft tissue density may represent a focus
of heaped omentum in the setting of copious ascites, though
malignant omental caking cannot be completely excluded.
4. Decreased free intra-abdominal air with a few small foci
persisting. Persistent subcutaneous emphysema without definite
location of the site of patient's enterocutaneous fistula.
5. 29 x 24 cm infrarenal abdominal aortic aneurysm with mural
thrombus.
6. 8-mm low attenuation of spleen inferiorly, not fully
characterized. The differential is broad and includes benign
entities such as hemangioma but can also include infectious and
malignant entities. Evaluation by ultrasound is recommended when
clinically indicated.
7. Diverticulosis without evidence of diverticulitis.
8. Persistent large pleural effusions.
[**2169-6-14**] 06:25AM BLOOD WBC-14.4* RBC-3.55* Hgb-10.0* Hct-29.9*
MCV-84 MCH-28.3 MCHC-33.6 RDW-17.9* Plt Ct-678*
[**2169-6-13**] 12:51AM BLOOD WBC-17.7* RBC-3.50* Hgb-10.1* Hct-29.6*
MCV-85 MCH-29.0 MCHC-34.2 RDW-18.0* Plt Ct-633*
[**2169-6-12**] 04:54AM BLOOD WBC-19.1* RBC-3.69* Hgb-10.1* Hct-31.9*
MCV-86 MCH-27.2 MCHC-31.5 RDW-18.1* Plt Ct-711*
[**2169-5-11**] 02:28PM BLOOD WBC-17.1*# RBC-3.60* Hgb-9.8* Hct-30.0*
MCV-83 MCH-27.3 MCHC-32.7 RDW-17.1* Plt Ct-902*
[**2169-5-18**] 06:38PM BLOOD WBC-12.2* RBC-2.36* Hgb-6.3* Hct-20.6*
MCV-87# MCH-26.6* MCHC-30.4* RDW-18.7* Plt Ct-510*
[**2169-6-11**] 07:35AM BLOOD Neuts-85.5* Lymphs-10.6* Monos-3.4
Eos-0.4 Baso-0.2
[**2169-6-9**] 08:10AM BLOOD Neuts-74.5* Lymphs-15.3* Monos-8.2 Eos-0
Baso-0 Atyps-1.0* Myelos-1.0*
[**2169-5-18**] 08:01AM BLOOD Neuts-94.1* Lymphs-2.0* Monos-2.0 Eos-0
Baso-0 Atyps-1.0* Myelos-1.0*
[**2169-6-8**] 03:40PM BLOOD PT-14.4* PTT-29.5 INR(PT)-1.3*
[**2169-6-8**] 05:46AM BLOOD PT-21.1* PTT-32.7 INR(PT)-2.1*
[**2169-5-18**] 08:01AM BLOOD Fibrino-595*
[**2169-6-13**] 12:51AM BLOOD Glucose-85 UreaN-44* Creat-0.7 Na-139
K-3.9 Cl-103 HCO3-24 AnGap-16
[**2169-5-11**] 02:28PM BLOOD Glucose-153* UreaN-27* Creat-1.5* Na-141
K-3.2* Cl-101 HCO3-18* AnGap-25*
[**2169-6-5**] 05:58PM BLOOD CK(CPK)-14*
[**2169-5-18**] 04:54AM BLOOD ALT-6 AST-23 LD(LDH)-243 CK(CPK)-48
AlkPhos-329* Amylase-25 TotBili-0.2
[**2169-6-5**] 05:58PM BLOOD CK-MB-3 cTropnT-0.03*
[**2169-6-5**] 06:28AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2169-5-18**] 06:38PM BLOOD CK-MB-5 cTropnT-0.11*
[**2169-5-18**] 11:17AM BLOOD CK-MB-4 cTropnT-0.08* proBNP-6698*
[**2169-5-18**] 08:01AM BLOOD proBNP-6426*
[**2169-5-18**] 04:54AM BLOOD CK-MB-5 cTropnT-0.11*
[**2169-6-12**] 04:54AM BLOOD Calcium-8.1* Phos-4.2 Mg-1.8
[**2169-5-18**] 04:54AM BLOOD Albumin-1.8* Calcium-7.8* Phos-2.9 Mg-1.7
UricAcd-5.3
[**2169-5-18**] 08:01AM BLOOD calTIBC-137* VitB12-1035* Folate-GREATER
TH Ferritn-541* TRF-105*
[**2169-6-10**] 02:45PM BLOOD Triglyc-280*
[**2169-5-19**] 02:11AM BLOOD Triglyc-215* HDL-19 CHOL/HD-4.7
LDLcalc-27
[**2169-5-14**] 07:25AM BLOOD TSH-4.9*
[**2169-5-14**] 07:25AM BLOOD T4-7.3
[**2169-6-5**] 07:16AM BLOOD Type-ART Temp-36.8 FiO2-100 pO2-198*
pCO2-26* pH-7.47* calTCO2-19* Base XS--2 AADO2-488 REQ O2-83
Intubat-NOT INTUBA
[**2169-6-6**] 07:45PM BLOOD Lactate-2.7*
[**2169-5-18**] 01:34PM BLOOD Glucose-163* Lactate-2.9* Na-139 K-3.1*
Cl-112
[**2169-5-18**] 11:01PM BLOOD freeCa-1.07*
[**2169-5-18**] 01:34PM BLOOD freeCa-1.11*
[**2169-6-8**] 11:40PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005
[**2169-6-8**] 11:40PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2169-6-8**] 11:40PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
[**2169-5-15**] 05:35PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
[**2169-5-15**] 05:35PM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2169-5-15**] 05:35PM URINE RBC-3* WBC-5 Bacteri-RARE Yeast-NONE
Epi-1
[**2169-5-19**] 02:00PM PLEURAL WBC-278* RBC-775* Polys-12* Lymphs-40*
Monos-29* Eos-1* Meso-5* Macro-13*
[**2169-5-19**] 02:00PM PLEURAL TotProt-1.2 Glucose-228 LD(LDH)-86
Amylase-9 Albumin-LESS THAN
[**2169-5-24**] 12:30PM ASCITES WBC-13* RBC-110* Polys-8* Lymphs-49*
Monos-43*
[**2169-5-24**] 12:30PM ASCITES WBC-2* RBC-167* Polys-20* Lymphs-50*
Monos-20* Mesothe-10*
[**2169-5-24**] 12:30PM ASCITES TotPro-2.3 Glucose-98 Creat-0.7
LD(LDH)-118 Amylase-43 Albumin-LESS THAN Misc-BUN=37 MG/
[**2169-5-24**] 12:30PM ASCITES TotPro-2.2 Glucose-97 Creat-0.7
LD(LDH)-426 Amylase-42 Albumin-LESS THAN Misc-BUN=36 MG/
[**2169-5-14**] 6:45 pm BLOOD CULTURE
**FINAL REPORT [**2169-5-17**]**
AEROBIC BOTTLE (Final [**2169-5-17**]):
SERRATIA MARCESCENS. FINAL SENSITIVITIES.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
SERRATIA MARCESCENS
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 2 S
ANAEROBIC BOTTLE (Final [**2169-5-17**]):
REPORTED BY PHONE TO [**Doctor First Name 1521**] OVERLAND 12R 12:30PM [**2169-5-15**].
SERRATIA MARCESCENS.
IDENTIFICATION AND SENSITIVITIES PERFORMED FROM AEROBIC
BOTTLE.
[**2169-5-14**] 9:35 pm BLOOD CULTURE
**FINAL REPORT [**2169-5-20**]**
AEROBIC BOTTLE (Final [**2169-5-20**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2169-5-19**]):
SERRATIA MARCESCENS. FINAL SENSITIVITIES.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
Trimethoprim/Sulfa sensitivity testing available on
request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
SERRATIA MARCESCENS
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- 2 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 4 S
[**2169-5-15**] 4:24 am SWAB Site: ABDOMEN Source: Abdominal
wound.
**FINAL REPORT [**2169-5-19**]**
GRAM STAIN (Final [**2169-5-15**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
WOUND CULTURE (Final [**2169-5-19**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
ENTEROCOCCUS SP.. SPARSE GROWTH.
GRAM NEGATIVE ROD #1. SPARSE GROWTH.
GRAM NEGATIVE ROD #2. RARE GROWTH.
GRAM NEGATIVE ROD #3. RARE GROWTH.
ANAEROBIC CULTURE (Final [**2169-5-19**]): NO ANAEROBES ISOLATED.
[**2169-5-23**] 11:12 am URINE Source: Catheter.
**FINAL REPORT [**2169-5-24**]**
URINE CULTURE (Final [**2169-5-24**]):
YEAST. >100,000 ORGANISMS/ML..
[**2169-5-19**] 2:00 pm PLEURAL FLUID
**FINAL REPORT [**2169-5-25**]**
GRAM STAIN (Final [**2169-5-19**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2169-5-22**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2169-5-25**]): NO GROWTH.
CT PELVIS W/CONTRAST [**2169-6-12**] 3:00 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: Please look for occult abscesses intraabd. Thanks.
Field of view: 32 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
70 F s/p ex-lap for adnexal mass and enterocut fistula. wil
elevated WBC.
REASON FOR THIS EXAMINATION:
Please look for occult abscesses intraabd. Thanks.
CONTRAINDICATIONS for IV CONTRAST: None.
EXAMINATION: CT abdomen and pelvis.
INDICATION: Status post exploratory laparotomy for adnexal mass
and intracutaneous fistula. Elevated white cell count. Rule out
occult abscess.
COMPARISON: Comparison was made with the previous CT from [**5-15**], [**2169**].
TECHNIQUE: A CT of abdomen and pelvis was performed with axial
images taken from the lung bases to the symphysis pubis. Oral
and IV contrast was administered.
CT CHEST FINDINGS: Bilateral pleural effusions and associated
atelectasis are noted in the lung bases. Below the diaphragm,
note is made of pneumobilia which is likley secondary to the
previous sphincterotomy. There is some sub hepatic fluid noted.
No focal liver lesion. The patient is status post
cholecystectomy. The portal vein is patent.
The spleen contains a cystic lesion in the lower posterior pole
that measures 9 mm in maximum diameter. The adrenals and kidneys
are unremarkable apart from a simple cyst in the mid pole of the
right kidney. The pancreas is unremarkable. The CBD is prominent
in this patient status post cholecystectomy at 11 mm and also
contains some air.
The aorta is calcified and contains some intramural thrombus and
has a maximum dimension of 2.6 cm in transverse x 2.9 cm in AP
diameter. There appears to be contrast in an enterocutaneous
fistula in the lower abdomen in the midline. Some free fluid is
seen in the abdomen. A pocket of fluid is seen in the right side
in the subhepatic area and is reduced in size compared with the
previous CT. Some peritoneal stranding is noted.
CT OF PELVIS FINDINGS: The bladder is catheterized. Some free
fluid is seen in the pelvis.
Bony windows reveal some degenerative change but no suspicious
sclerotic or lytic lesions.
Multiplanar reconstructions were essential in depicting the
anatomy and identifying the pathology.
IMPRESSION:
1. Bilateral pleural effusions and associated atelectases.
2. Pneumobilia, presumed S/P biliary sphincterotomy. Reduced
ascites.
3. Aorta measures 2.9 x 2.5 with some calcification and mural
thrombus.
4. Renal cysts.
5. Enterocutaneous fistula in midline in lower abdomen.
CHEST, SINGLE AP FILM
For PICC line placement.
Tip of PICC line is in distal SVC. There are bilateral pleural
effusions. The interstitial pulmonary edema noted on the prior
study of [**2169-6-4**] is significantly resolved
IMPRESSION: AP chest compared to [**5-30**] through [**6-6**]:
Moderately severe pulmonary edema has changed in distribution
but not in severity accompanied by persistent small bilateral
pleural effusions, accompanied by persistent moderate
enlargement of the cardiac silhouette and left lower lobe
atelectasis. No pneumothorax. Right PIC catheter tip projects
over the origin of the right brachiocephalic vein
CTA chest - IMPRESSION:
1. No pulmonary embolism.
2. Moderate-to-large bilateral pleural effusions unchanged,
together with cardiomegaly and smooth interlobular seotal
thickening is consistent with pulmonary edema.
Cardiology Report ECG Study Date of [**2169-6-4**] 6:24:54 AM
Probable multifocal atrial tachycardia
Probable prior anteroseptal myocardial infarction
Diffuse nonspecific low amplitude T wave changes
Since previous tracing of [**2169-5-20**], tachycardia with further
atrial ectopy
present
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
114 146 78 288/355.71 56 4 89
Cytology Report PERITONEAL FLUID Procedure Date of [**2169-5-24**]
REPORT APPROVED DATE: [**2169-5-26**]
SPECIMEN RECEIVED: [**2169-5-25**] [**-7/2019**] PERITONEAL FLUID
SPECIMEN DESCRIPTION: Received 4ml cloudy yellow fluid with
small
clot. Prepared 1 ThinPrep slide.
Left fluid collection.
CLINICAL DATA: 70 y/o female S/P L. salpingo-oophorectomy with
bowel injury and peritoneal fluid collections.
PREVIOUS BIOPSIES:
[**2169-5-25**] [**-7/2019**] PERITONEAL FLUID
[**2169-5-22**] [**-7/1957**] PLEURAL FLUID
[**2169-5-12**] 07-[**Numeric Identifier 71659**] PERITONEAL WASHINGS
REPORT TO: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DIAGNOSIS: Left Peritoneal Fluid Collection:
NEGATIVE FOR MALIGNANT CELLS.
Hypocellular specimen.
Blood and a few reactive mesothelial cells.
DIAGNOSED BY:
[**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) 10220**], CT(ASCP)
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 29395**], M.D.
Cytology Report PERITONEAL FLUID Procedure Date of [**2169-5-24**]
REPORT APPROVED DATE: [**2169-5-26**]
SPECIMEN RECEIVED: [**2169-5-25**] [**-7/2019**] PERITONEAL FLUID
SPECIMEN DESCRIPTION: Received 3ml cloudy yellow fluid with
small
clot. Prepared 1 ThinPrep slide.
Right peritoneal collection.
CLINICAL DATA: 70 y/o female S/P salpingo-oophorectomy with
bowel
injury and peritoneal fluid collections.
PREVIOUS BIOPSIES:
[**2169-5-22**] [**-7/1957**] PLEURAL FLUID
[**2169-5-12**] 07-[**Numeric Identifier 71659**] PERITONEAL WASHINGS
REPORT TO: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DIAGNOSIS: Right Peritoneal Fluid Collection:
ATYPICAL.
Atypical epithelioid cells, favor reactive mesothelial
cells; inflammatory cells.
DIAGNOSED BY:
[**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) 10220**], CT(ASCP)
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 29395**], M.D.
INC/DRAINAGE ABSCESS COMPLEX [**2169-5-24**] 10:38 AM - IMPRESSION:
1. Increased intraperitoneal fluid compared to a few days prior
with successful placement of 2 pigtail catheters, one right
sided and one left sided, without complication.
2. Thrombosis within left gonadal vein
3. 30-mm left omental soft tissue density may represent a focus
of heaped omentum in the setting of copious ascites, though
malignant omental caking cannot be completely excluded.
4. Decreased free intra-abdominal air with a few small foci
persisting. Persistent subcutaneous emphysema without definite
location of the site of patient's enterocutaneous fistula.
5. 29 x 24 cm infrarenal abdominal aortic aneurysm with mural
thrombus.
6. 8-mm low attenuation of spleen inferiorly, not fully
characterized. The differential is broad and includes benign
entities such as hemangioma but can also include infectious and
malignant entities. Evaluation by ultrasound is recommended when
clinically indicated.
7. Diverticulosis without evidence of diverticulitis.
8. Persistent large pleural effusions.
CT ABDOMEN W/O CONTRAST [**2169-5-15**] 9:54 AM
IMPRESSION:
1. Limited evaluation secondary to the lack of IV contrast
administration. Subcutaneous and small amounts of
intraperitoneal free air consistent with the patient's
post-surgery status. No discrete fluid collection identified. No
oral contrast present beyond the jejunum in the setting of
mildly dilated bowel loops likely represent post-operative
ileus.
2. Prominent anasarca. Abdominal and pelvic ascites.
3. Small amount of perinephric fluid bilaterally.
4. Bilateral pleural effusions with associated compressive
atelectasis, greater than expected, could reflect aspiration or
other infectious process.
RADIOPHARMECEUTICAL DATA:
7.6 mCi Tc-[**Age over 90 **]m MAA ([**2169-5-15**]);
40.4 mCi Tc-99m DTPA Aerosol ([**2169-5-15**]);
HISTORY: 70 year old woman with fever, tachycardia and oxygen
desaturation.
INTERPRETATION:
Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 8 views
demonstrate a
gradient of tracer accumulation, greater in the bases than the
apices. No
segmental or large subsegmental defects are identified.
Perfusion images in the same 8 views show no unmatched defects.
Chest x-ray shows bilateral pleural effusions and mild
interstitial edema.
IMPRESSION: Very low likelihood ratio for acute pulmonary
embolism.
SPECIMEN SUBMITTED: LT. TUBE/OVARY FS, OVARIAN CYST
Procedure date Tissue received Report Date Diagnosed
by
[**2169-5-11**] [**2169-5-11**] [**2169-5-18**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/nbh
DIAGNOSIS:
1. Left tube and ovary (A-D):
1. Serous cystadenoma.
2. Unremarkable ovary and fallopian tube.
2. Ovarian cyst (E):
Peritoneal inclusion cyst/reactive mesothelial proliferation
with necrosis.
Immunostains for calretinin, cytokeratin, and EMA are positive.
Inhibin and CD68 are negative. Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 7108**] reviewed Part 2.
Clinical: Adnexal mass.
Gross: The specimen is received fresh in the OR in a container
labeled with the patient's name, MR number and "left tube and
ovary". The fallopian tube measures 5.5 x 0.4 cm, including the
fimbriated end. The is adherent fat on the ovarian surface.
There are multiple small subserosal white nodules. There is a 5
x 4.5 x 4.5 cm simple cyst which is adherent to the fallopian
tube. The cyst is filled with serous fluid. It is opened to
reveal smooth walled interior. The gross diagnosis by Dr.
[**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 7108**] reads: "Simple cyst and unremarkable fallopian
tube." The specimen is represented in cassettes A-D.
Part 2 is received in formalin in a container labeled with the
patient's name, MR number and "ovarian cyst" and consists of
fragments of tan-white soft tissue measuring 1 x 0.8 x 0.1 cm in
aggregate. The specimen is entirely submitted in cassette E.
By his/her signature above, the senior physician certifies that
he/she personally conducted a gross and/or microscopic
examination of the described specimens(s) and rendered or
confirmed the diagnosis(es) related thereto.
Immunohistochemistry test(s), if applicable, were developed and
their performance characteristics were determined by The
Department of Pathology at [**Hospital1 69**],
[**Location (un) 86**], MA. They have not been cleared or approved by the U.S.
Food and Drug Administration. The FDA has determined that such
clearance or approval is not necessary. These tests are used for
clinical purposes. They should not be regarded as
investigational or for research. This laboratory is certified
under the Clinical Laboratory Improvement Amendments of [**2150**]
(CLIA - 88) as qualified to perform high complexity clinical
laboratory testing.
Cytology Report PERITONEAL WASHINGS Procedure Date of [**2169-5-11**]
REPORT APPROVED DATE: [**2169-5-15**]
SPECIMEN RECEIVED: [**2169-5-12**] 07-[**Numeric Identifier 71659**] PERITONEAL WASHINGS
SPECIMEN DESCRIPTION: Received 35ml pink fluid.
Prepared 1 ThinPrep slide.
CLINICAL DATA: Adnexal mass.
REPORT TO: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DIAGNOSIS: Peritoneal washings:
NEGATIVE FOR MALIGNANT CELLS.
Blood and inflammatory cells only.
DIAGNOSED BY:
[**First Name8 (NamePattern2) 5335**] [**Last Name (NamePattern1) 5336**], CT(ASCP)
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 71660**], M.D.
Brief Hospital Course:
On [**2169-5-11**], the patient underwent exploratory laparoscopy
converted to laparotomy, lysis of adhesions, dissection of
intraperitoneal cyst, and left salpingo-oophorectomy.
Intra-operatively, very dense adhesions were encountered making
the dissection quite difficult. The procedure was complicated
by a small enterostomy which was repaired. Please see op notes
by Dr. [**First Name (STitle) 1022**] and Dr. [**Last Name (STitle) 71661**] for details.
The patient's post-operative course was complicated by
development of an entero-cutaneous fistula, post-operative CHF,
post-operative acute renal failure, and bacteremia. She was in
the ICU from [**5-18**] - [**5-21**] due to Multifocal Atrial Tachycardia,
CHF, and hypoxia requiring intubation, and again from [**Date range (1) 17331**]
for a second CHF exacerbation. Her course is summarized below
by issue:
# CHF, systolic - as noted above the patient was intubated and
in acut eresp failure from CHF. ECHO done revealed poor EF and
wall motion abnormalities, concerning for CAD. Tropomin peak was
> 0.1. She was diuresed and started on a cardiac regimen as
below and was euvolemic at discharge. Cardiology evaluated her
and they recommended follow up in clinic with Dr [**First Name (STitle) 437**] here at
[**Hospital1 18**] and also a repeat ECHO within one month of discharge. This
may be arranged by PCP or cardiologist.
.
# Multifocal strial tachycardia/NSVT - was noted on telemetry.
cardiology did not feel that patient required an ICD at this
time. Again, as above they will follow up in clinic.
.
# Sepsis from serratia bacteremia - this was treated with
flagyl/cipro/vanco for a total of 2 weeks - through to [**2169-6-5**].
Fluconazole was given as well for fungal UTI and course
completed. She had a persistant leucocytosis that was slow to
recover. No new source was found. Another CT abdomen did not
reveal occult abscesses. Per patient and on talking with Dr
[**Last Name (STitle) 22552**] (PCP) - had a borderlie high WBC that he has been
following up since [**December 2168**], usually around 12K. Cultures at the
time of discharge were negative. The final results of cultures
to be followed by PCP. [**Name10 (NameIs) 34887**] check 1 week after dc with PCP was
arranged for.
.
# EC fistula - Gyn onc followed patient here and out-patient
follow up was arranged for at discharge with Dr [**Last Name (STitle) 71662**]. Surgery
follow was also arranged for. They did not recommend surgical
treatment at this time. Wound care VNA was set up at home. The
ovarian cyst was [**Last Name (un) 17066**] on pathology and cytology of ascitis
fluid was positive for atypical cells. Again, will defer to gyn
onc/PCP for follow up and/or further work-up.
.
# Malnutrition - Given albumin of 1.8 - the patient was severely
malnpurished esp with the many medical issues. she was started
on TPN due to poor po intake while here. Nutrition team followed
him and performed a caloric count which was at goal for the
patient. at this time TPN was stopped and PICC removed. Weight
at discharge was about 43 kg. she is advised to follow up PCP
for weekly weight checks to ensure she is not loosing wt in
which case she may need a nutritionist evaluation or alternative
source of supplement feeding.
.
# Anemia: likely due to chronic disease. The hematocrit was
stable at discharge.
.
# AAA - seen incidentally on imaging and a follow up US/CT
should be arranged for at the discretion of the PCP [**Last Name (NamePattern4) **] 6 months.
.
# PT evaluated the patient and after a few treatments determined
that the patient was safe for home discharge with PT and
services.
# Full code.
Medications on Admission:
Hydrochlorothiazide and Vasotec
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*0*
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO twice a day as needed.
Disp:*60 Tablet, Chewable(s)* Refills:*0*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
Disp:*30 Suppository(s)* Refills:*0*
8. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*0*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours as needed for pain or fever.
Disp:*30 Tablet(s)* Refills:*0*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
12. Outpatient Lab Work
[**Last Name (NamePattern4) 34887**] in 1week -- results to be checked by Dr [**Last Name (STitle) 22552**]
([**Telephone/Fax (1) 4475**])
Discharge Disposition:
Home With Service
Facility:
[**Hospital 107**] Hospital VNA
Discharge Diagnosis:
Acute respiratory failure due to Congestive heart failure,
systolic
Sepsis from serratia bacteremia
OOphorectomy for ovarian cyst
Enterocutaneous fistula
MAT with abberency/NSVT
Malnutrition, moderate
Anemia
abdominal aortic aneurysm
Discharge Condition:
Stable
Discharge Instructions:
Return to the hospital if you notice worsening chest pain,
abdominal pain, fevers, chills or any other signs og concern to
you.
Keep your appointments. Take you medicines as prescribed.
You have been diagnosed with heart failure and it is recommended
that you adhere to a low sodium diet. You will require
monitoring of weight regularly. Your primary care doctor will
follow your weight.
Followup Instructions:
Primary care doctor - [**Last Name (LF) **],[**First Name3 (LF) **] B. [**Telephone/Fax (1) 4475**] appointment
on Friday [**2169-6-16**] at 1330
Surgery (for the fistula)-- Dr [**Last Name (STitle) 30330**] on Thursday [**2169-6-29**] -- at 10.45am
Gynecology Oncology - Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Phone:[**Telephone/Fax (1) 7614**] Date/Time:[**2169-6-26**] 11:45
Cardiology - Dr [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] - ([**Telephone/Fax (1) 13786**] --- [**2169-7-3**] at 11AM
|
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[
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|
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14602, 25603
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1729, 2016
|
2592, 2669
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,519
| 167,139
|
32604
|
Discharge summary
|
report
|
Admission Date: [**2186-11-29**] Discharge Date: [**2186-12-7**]
Date of Birth: [**2160-4-22**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
Crohn's Disease
Major Surgical or Invasive Procedure:
Ileocecectomy, exploratory lapartomy
History of Present Illness:
Mr [**Known lastname **] is 26-year-old gentleman with Crohn's ilietis who
presents to the ED complaining of nasuea, bloating, and
abdominal
pain in the setting of known distal terminal ileum phlegmon
being
treated with Cipro, Flagyl and Remicade, and being followed by
GI. Most recent CT scan from [**8-27**] showed about 30-35 cm of
terminal ileal involvement with some proximal dilation. Since
antibiotics were introduced and since being placed on 10 mg/kg
he
had done better, but he was tapering off the antibiotics and
developed some upper respiratory tract symptoms and then
developed some abdominal symptoms, particularly bloating and
diarrhea. Saw GI on [**11-9**], who were concerned about
concommitent
viral infection in the setting of Crohns flair, and had
encouraged a referral to Dr [**Last Name (STitle) **] to discuss surgical
options as has been failing medical therapy.
He presents today after feeling acutely worse by mid-day,
much
different from when he saw GI only one day ago. He states his
nausea, bloating, and reflux symtoms were much worse, and he
'didnt feel right'. He denies fevers or chills, vomiting, chest
pain, or trouble breathing. Last BM at 7pm, loose diarrhea no
blood. +flatus, but not since coming to ER. He states his
abdominal pain is unchanged from baseline, complaining of the
same discomfort in his RLQ from his known phlegmon.
Past Medical History:
PAST MEDICAL HISTORY
1. Crohn's Disease (started Remicade therapy [**4-27**])
2. [**2186-3-9**] PPD negative
3. Asthma
4. Chickenpox.
PSH: None
Social History:
Single, recently moved in with girlfriend in apartment in
[**Name (NI) 583**]. He works as a financial advisor on the [**Hospital3 **].
ETOH-five to ten mixed drinks and beer on the weekends x 8
years.
Denies tobacco or drug use present or remote.
Family History:
Non-contributory
Physical Exam:
T 99.6 73 142/82 16 100%RA
NAD
CTAB
RRR
softly distended and tympanic, mild tenderness RLQ, no rebound
or
guarding, gauiac neg.
no c/c/e
Pertinent Results:
[**2186-11-29**] 02:08PM BLOOD Hct-43.1
[**2186-11-30**] 03:07AM BLOOD Hct-33.4*
[**2186-11-30**] 07:05AM BLOOD WBC-11.9* RBC-3.44*# Hgb-10.0*# Hct-28.8*
MCV-84 MCH-29.1 MCHC-34.7 RDW-13.4 Plt Ct-244
[**2186-11-30**] 03:23PM BLOOD Hct-26.3*
[**2186-11-30**] 05:42PM BLOOD WBC-7.0 RBC-2.77* Hgb-8.0* Hct-22.7*
MCV-82 MCH-29.0 MCHC-35.3* RDW-13.8 Plt Ct-155
[**2186-12-6**] 05:30AM BLOOD Plt Ct-206
[**2186-12-5**] 03:08AM BLOOD PT-14.4* PTT-28.9 INR(PT)-1.2*
[**2186-12-7**] 06:15AM BLOOD K-3.8
[**2186-11-29**] 02:08PM BLOOD K-4.7
[**2186-11-30**] 07:05AM BLOOD Glucose-128* UreaN-22* Creat-1.3* Na-137
K-5.3* Cl-102 HCO3-27 AnGap-13
[**2186-11-30**] 10:02PM BLOOD Glucose-104 UreaN-19 Creat-0.9 Na-138
K-4.6 Cl-105 HCO3-27 AnGap-11
[**2186-12-2**] 05:46AM BLOOD CK(CPK)-981*
[**2186-12-1**] 03:57PM BLOOD CK(CPK)-926*
[**2186-12-1**] 07:00AM BLOOD CK(CPK)-550*
[**2186-12-2**] 05:46AM BLOOD CK-MB-2 cTropnT-<0.01
[**2186-12-1**] 03:57PM BLOOD CK-MB-2 cTropnT-<0.01
[**2186-12-1**] 07:00AM BLOOD cTropnT-<0.01
[**2186-12-7**] 06:15AM BLOOD Mg-1.8
[**2186-12-6**] 05:30AM BLOOD Calcium-8.4 Phos-3.8 Mg-1.9
[**2186-11-30**] 07:05AM BLOOD Calcium-8.0* Phos-4.5 Mg-1.9
[**2186-12-1**] 08:03PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.011
[**2186-12-1**] 08:03PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
.
[**2186-12-1**] 6:56 pm MRSA SCREEN Source: Nasal swab.
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS..
.
CTA [**2186-12-1**]
1. Suboptimal bolus renders this study non-diagnostic for
pulmonary embolus. Within this limitation no central PE is
identified.
2. Right upper lobe patchy consolidation, possibly due to acute
aspiration
or infectious pneumonia.
2. Secretions and mucus plugging in the bronchus intermedius and
right lower lobe bronchi, with postobstructive atelectasis right
middle lobe and collapse of right lower lobe. Left lower lobe is
also collapsed.
3. Moderate ascites.
4. Pneumoperitoneum, probably related to recent surgery.
.
[**12-1**] CXR
No change since previous chest radiograph. Reference to the CT
pulmonary
angiogram of the same date is advised.
.
[**12-2**] CXR
Comparison is made to prior study from [**2186-12-1**].
There is a consolidation at the right base, which has worsened
since the
previous study. This may represent aspiration or developing
pneumonia. The
cardiac silhouette and mediastinum is normal. There are low lung
volumes.
There is some atelectasis at the left base. No pneumothoraces
are seen.
.
[**12-3**] CXR
The findings are slightly more plate like suggesting that this
is atelectasis.
There are no signs for overt pulmonary edema. The cardiac
silhouette and
mediastinum is normal. There are no pneumothoraces.
.
[**12-4**] CXR
In comparison with the study of [**12-3**], there is persistent
opacification at the right base. Although this could merely
reflect
atelectasis, the possibility of supervening pneumonia can
certainly not be
excluded.
.
[**12-5**] CXR
In comparison with study of [**12-4**], there is little overall
change
at the right base. Again, the findings may reflect atelectasis
and small
effusion, though the possibility of supervening pneumonia cannot
be excluded.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to general surgery post-operatively.
Please see the intra-operative report for full details. His
urine output was consistently low with minimal response to IVF
boluses. He had serial hematocrits which were trending down to
a nadir of 22.7 on POD1. On the evening of POD1, he was taken
back to the OR for exploratory laparotomy. Again please see the
intra-operative report for full details.
.
Overnight, POD 1 from his second surgery he then became
tachycardic to 140's, desat'ed to 80's on 4L NC, but recovered
until this morning. At around 11am, he once again became hypoxic
to mid 80's on NC requiring NRB, BP 130's/80's, febrile to
103.0. ABG 7.42/49/68 EKG showed sinsus tachycardia with TWI
laterally. CXR with ? volume overload, gave lasix 10 IV to which
he put out 2500cc. He received nebs w/o improvement and was not
wheezing on exam. It was noted by surgery nursing staff that his
family had been pressing his diluaded PCA for while he was
sleeping. He was drowsy but easily arousable and RR 16. He then
went for CTA, which was negative for PE but showed new
consolidation and lobar colapse. He was then transfered to the
[**Hospital Unit Name 153**]. Of note, he is 14L positive over his LOS.
.
[**2186-12-3**]-
- [**Hospital Unit Name 153**] team & IP agree that pt is getting better on his own and
will hold off on ; needs aggressive chest PT and ability to
clear secretions is limited by pain. CXR today much improved
from prior. Bronch is invasive and can worsen pts underlying
pulmn process (asp PNA post-operative)
- ct abx
- adv diet to clears->fulls as tolerated
- MRSA positive nasal swab, put on contact precautions
[**2186-12-4**]
-[**Name2 (NI) **]ced to regular diet, given Colase for bowel regimen
-Has been walking in the hallway
-Had a bowel movement with fresh blood, Hct 25.1 from 25.7, will
re-check in 6 hours.
-Switched to PO pain regimen
-Hct 23.6 at 2am. Surgery aware, no tachycardia, good UOP. No
further BMs. No transfusion for now, will re-check at 8am.
-Satting well on 4L NC
.
______________________
He returned to the floor and was continued on a regular diet and
oral medications. He was weaned from Oxygen. Staples were
removed and steri strips were placed. he will followup with Dr.
[**Last Name (STitle) **] in [**2-21**] weeks. All d/c paperwork was reviewed and
questions answered.
Medications on Admission:
ALBUTEROL
CIPROFLOXACIN 500 mg twice a day
CYANOCOBALAMIN 500 mcg alternating nostrils weekly
ERGOCALCIFEROL 50,000 unit Capsule - 1 Capsule(s) one pill
weekly
x 8 weeks
REMICADE
METRONIDAZOLE 250 mg twice a day
MULTIVITAMIN
SOY PROTEIN
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: 1-2 puffs Inhalation Q6H (every 6 hours) as
needed for wheeze.
2. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain for 1 weeks: Do not exceed 4g in 24
hours.
.
3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for SOB.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation for 1 months: take with
pain meds.
Disp:*60 Capsule(s)* Refills:*0*
5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed for pain for 2 weeks.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Crohn's Disease
Discharge Condition:
Stable, tolerating po's, ambulating, adeqaute po pain control
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Please call Dr. [**Last Name (STitle) **] at (617) for an appointment in [**1-20**]
weeks.
Scheduled appointments:
Provider: [**First Name11 (Name Pattern1) 2747**] [**Last Name (NamePattern1) 75998**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 463**]
Date/Time:[**2186-12-5**] 8:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6925**] Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2187-1-23**]
9:00
Completed by:[**2186-12-7**]
|
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icd9cm
|
[
[
[]
]
] |
[
"54.12",
"45.73"
] |
icd9pcs
|
[
[
[]
]
] |
9050, 9056
|
5664, 8036
|
328, 367
|
9115, 9179
|
2418, 5641
|
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|
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|
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|
395, 1777
|
1799, 1945
|
1961, 2211
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,730
| 138,164
|
16311
|
Discharge summary
|
report
|
Admission Date: [**2147-5-5**] Discharge Date: [**2147-5-14**]
Date of Birth: [**2075-6-7**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Lipitor
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
epigastric pain, increasing dyspnea on exertion
Major Surgical or Invasive Procedure:
ERCP s/p spincterotomy
EGD x 2
blood transfusion
History of Present Illness:
The patient is a 71 year old Chinese but English-speaking male
with a history of ?renal artery stenosis, chronic renal
insufficiency (Cr 4.8 at [**Hospital1 **]), HTN and DM2 with no known CAD
who presented to [**Hospital 5871**] hospital on [**5-4**] with epigastric pain x
1 week and increasing dyspnea on exertion x 3-4 days. The
patient denies any chest pain but notes that in the past [**2-25**]
days he has difficulty walking a few steps before he feels short
of breath. He lives upstairs and has difficulty walking up 3-4
steps at a time secondary to shortness of breath. He also admits
to increasing lower extremity edema. He uses 2 pillows at night
which has not increased recently.
.
Regarding his abdominal pain, the patient first noted this 1
week ago in the RUQ, epigastrium. He says it only hurts with
palpation. He also noted pain after meals but denies
nausea/vomiting and states that he is tolerating PO. He denies
diarrhea/constipation but states that his stool looks
"yellowish" and that his urine is dark. He denies
pruritus/jaundice. He denies fevers but admits to chills. No
night sweats or weight loss.
.
At [**Hospital1 **], a RUQ U/S was performed which showed dilatation of
the intrahepatic biliary ducts and common bile duct which
measures 1.2 cm. The pancreatic duct was also dilated. The
gallbladder had no stones. The findings were suggestive of
distal CBD stone or mass.
An CXR showed increased lung markings in the right lung.
Furthermore, his labs showed elevated ALP of 186, bili WNL,
amylase 188, lipase 75, WBC 14.2, and BNP [**2055**]. Troponin 0.03,
CK 62.
.
The patient was then transferred to [**Hospital1 18**] for further
evaluation. He was found to be hypertensive to the 200-240 range
despite having taken his am meds. He was given 10 mg IV
hydralazine x 2, lopressor 5 mg IV x 1, and clonidine 0.3 mg X
1. His BP returned to 180.
.
ROS: As above. Denies any cough. Chills but no fevers/night
sweats. No HA/blurry vision.
Family History:
pt was adopted
Physical Exam:
Vitals: T P 57 BP 200/54 RR 16 Sa 100% on RA
Gen: NAD, pleasant Chinese male, mild respiratory distress (pt
denies any shortness of breath), no accessory muscle use
HEENT: PERLA, dirty sclera, anicteric, PERLA, EOMI, bilateral
carotid bruits, no [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 3495**]: RRR, Grade I/VI soft, SEM at RUSB, RRR, S1, S2
Lungs: CTAB
Abdomen: Focal right-sided epigastric pain with palpation, no
rebound/guarding, hyperactive BS, negative [**Doctor Last Name **] sign, no HS
Rectal: Guaiac negative
Ext: +2 pitting edema to bilateral knees, +1 d. pedis
bilaterally
Skin: Mild, erythematous, nonblanching macules on abdomen (new),
nonpruritic
Neuro: CN II-XII grossly intact
Pertinent Results:
Renal Angiogram [**2144**]: 50% R RAS, 14 mm Hg gradient
.
Colonoscopy [**4-14**]: Benign Polyp at 20 cm (polypectomy). Mild
diverticulosis of R colon. Small hemorrhoids
.
EGD [**4-14**]: Non-obstructing esophageal ring in lower esophagus.
Small hiatal hernia. Gastritis (biopsy). Duodenitis.
.
RUQ U/S @ OSH [**5-4**]: dilatation of the intrahepatic biliary ducts
and common bile duct which measures 1.2 cm. The pancreatic duct
was also dilated. The gallbladder had no stones.
.
CXR [**5-5**]: Patchy opacities over lying the right lung concerning
for
pneumonia. If there are no infectious symptoms, bronchoalveolar
carcinoma should be considered.
.
TTE [**5-5**]: 1. There is mild symmetric LVH with normal cavity
size. Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). 2. The
aortic valve leaflets (3) are mildly thickened. 3. The mitral
valve leaflets are mildly thickened. 4. There is a small
pericardial effusion. There are no echocardiographic signs of
tamponade.
.
CT Abd/Pelvis [**5-5**]: Limited study secondary to lack of IV
contrast. Dilated common bile duct without evidence of ductal
stone. Possible prominence of the pancreatic head, but no
definite masses identified. MRCP could be helpful for further
evaluation. Multiple poorly defined patchy opacity seen at the
right lung base, incompletely characterized. Findings are
concerning for pneumonia, however, if there is a lack of
infectious symptoms, bronchoalveolar carcinoma could have a
similar appearance. Followup imaging recommended to document
resolution.
.
MRI Renal/MRCP [**5-5**]: 1. Intra- and extrahepatic biliary
dilatation, down to the level of the ampulla. No filling defects
or stones are identified. Vague area of enhancement is seen in
the expected location of the ampulla. Findings suggest ampullary
stenosis and further evaluation is recommended with an ERCP
examination. Underlying ampullary neoplasm cannot be excluded.
2. Evidence of chronic pancreatitis with moderate stenosis of
the pancreatic duct in the pancreatic head. No definite
pancreatic head mass is identified. This finding can also be
evaluated by ERCP.
3. Moderately distended gallbladder with wall edema. Given the
evidence of third spacing of fluid, this is a nonspecific
finding.
4. Bilateral renal artery stenosis, right side greater than
left.
.
ERCP [**5-8**]: 1. The papilla was extremely tight, consistent with
ampullary stenosis.
2. Limited pancreatogram showed a somewhat ectatic duct,
consistent with chronic pancreatitis. No obvious strictures or
filling defects were seen.
3. The common bile duct was somewhat dilated. There was a
suggestion of small filling defects in the distal duct upon
initial contrast injection, which were not seen when the duct
was more fully filled out. This is consistent with
microlithiasis/sludge. No strictures or evidence of obstruction
were seen.
4. A sphincterotomy was performed in the 12 o'clock position
using a sphincterotome over an existing guidewire. Upon
sphincterotomy, the ampulla appeared somewhat full and bulging.
This area was biopsied with cold forceps for histology to rule
out neoplasm.
5. Microlithiasis was extracted successfully using a 11 mm
balloon.
.
EGD [**5-9**]: 1. Ongoing bleeding at sphincterotomy site. Achieved
hemostasis with submucosal epinephrine injection.
.
EGD [**5-10**]: 1. The sphincterotomy site was again seen actively
bleeding. Upon irrigating and suctioning, clear bile was seen
draining into the duodenum. 2. A 7 Fr gold probe electrocautery
device was applied for hemostasis successfully. The site was
irrigated with saline and no further bleeding was seen.
.
.
[**2147-5-5**] 01:45AM WBC-11.6* RBC-3.52* HGB-10.0* HCT-29.8*
MCV-85 MCH-28.4 MCHC-33.7 RDW-17.1*
[**2147-5-5**] 01:45AM PLT COUNT-281
[**2147-5-5**] 01:45AM PT-12.6 PTT-29.8 INR(PT)-1.1
[**2147-5-5**] 01:45AM NEUTS-78.5* LYMPHS-12.3* MONOS-5.0 EOS-3.7
BASOS-0.4
.
[**2147-5-5**] 01:45AM ALBUMIN-2.9*
[**2147-5-5**] 01:45AM CK-MB-NotDone
[**2147-5-5**] 01:45AM cTropnT-0.03*
[**2147-5-5**] 01:45AM ALT(SGPT)-27 AST(SGOT)-18 CK(CPK)-62 ALK
PHOS-183* AMYLASE-135* TOT BILI-0.3
[**2147-5-5**] 01:45AM LIPASE-134*
.
[**2147-5-5**] 01:45AM GLUCOSE-81 UREA N-67* CREAT-4.7* SODIUM-141
POTASSIUM-4.2 CHLORIDE-113* TOTAL CO2-16* ANION GAP-16
.
[**2147-5-5**] 02:20AM URINE RBC-0-2 WBC-[**6-3**]* BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2147-5-5**] 02:20AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.017
.
[**2147-5-5**] 07:55AM CK-MB-NotDone
[**2147-5-5**] 07:55AM cTropnT-0.02*
[**2147-5-5**] 07:55AM CK(CPK)-53
.
[**2147-5-5**] 08:08AM LACTATE-1.0
[**2147-5-5**] 02:58PM TYPE-[**Known firstname **] PO2-90 PCO2-29* PH-7.36 TOTAL
CO2-17*
.
[**2147-5-5**] 10:00PM CK-MB-3 cTropnT-0.03*
[**2147-5-5**] 10:00PM CK(CPK)-49
Brief Hospital Course:
71M with h/o DM2, HTN, and CRI/RAS who presented with epigastric
pain and increasing DOE with pancreatitis and ? ampullary mass.
Hospital course addressed by problem below:
.
# Abdominal pain: CT abdomen without contrast concerning for CBD
dilation and multiple patchy RLL opacities. He underwent MRCP
c/w ampullary stenosis but no visualized stones in CBD; also c/w
chronic pancreatitis with moderate stenosis in head of
pancreatic duct. He underwent ERCP and sphincterotomy with
biopsy for ampullary stenosis and extraction of small
stones/sludge from CBD. Post-ERCP the patient developed
BRBPR/maroon stools without HD instability. He underwent EGD
showing bleeding at sphincterotomy site; epinephrine was
injected with resolution of bleeding. On [**5-9**] pt noted to have
HCT 24, received 2 units and HCT unchanged. Underwent second EGD
showing continued bleeding at sphincterotomy site.
Electrocautery was used to stop bleeding with transfusion of 4 u
pRBCs. He was sent to the [**Hospital Unit Name 153**] for montioring during
resuscitation given his multiple comorbidities.
Overnight in the [**Hospital Unit Name 153**], his Hct rose from 24->37 with 4u of PRBC.
His respiratory status remained stable and he was afebrile.
His BRBPR ceased and he tolerated PO liquids without any
complaints. His Hct remained stable on the floor.
.
# Shortness of breath: His exam was consistent with CHF on
admission with an elevated JVD and +2 pitting edema to his knees
bilaterally at admission. The most likely etiology for his CHF
was thought to be HTN urgency with his SBP in the 200-240s in
the ED. TTE showed diastolic dysfunction. CXR showed evidence
of RLL PNA. ABG showed good oxygenation, and no A-a gradient.
He was ruled out for MI with serial enzymes. He had no tele
events; d/ced telemetry. He completed a 7 dya course of
levoflox for PNA. He was advised for an outpatient CT scan in 2
months to follow ? of bronchioalveolar carcinoma vs PNA seen in
RLL).
.
# DM2: His glipizide was held while NPO. He was covered with
humalog SS and FS QID.
.
# HTN urgency: This was thought to be related to his bilateral
renal artery stenosis. He was continued on his home meds of
Norvasc 10 mg PO QD and metoprolol 50 mg [**Hospital1 **]. His lisinopril
was stopped in the setting of RAS. He was started on a
clonidine patch to provide better BP control.
.
# Chronic renal insufficiency: His baseline was unknown
baseline. The Renal team was consulted re need for stenting his
renal artery stenosis. He was started on calcitriol and
nephrocaps for PTH 138. SPEP and UPEP wnl. Outpatient
follow-up with Dr [**Last Name (STitle) 1366**] was arranged.
.
# Acute gout: The patient had an acute flare to his R ankle on
[**5-8**]. This quickly subsided with one dose of colchicine and
prednisone 40 mg.
Medications on Admission:
Crestor 10 mg PO QD
Metoprolol 50 mg [**Hospital1 **]
Omeprazole 40 mg QD
Clonidine 0.3 mg PO BID
Norvasc 10 mg PO QD
Lisinopril 20 mg PO QD
Glipizide 10 mg PO QD
Aspirin 325 mg PO QD
Levothyroxine 150 mcg PO QD
Discharge Medications:
1. You should stop taking your Clonidine pills.
2. You should stop taking your lisinopril.
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday): Please place new patch
starting Saturday [**5-20**].
Disp:*4 Patch Weekly(s)* Refills:*2*
8. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
Disp:*30 Capsule(s)* Refills:*2*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day.
12. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
13. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 capsules* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
HTN
CRF
chronic pancreatitis
ampullary stenosis
post-ERCP bleeding
..
DM2
hypothyroidism
Discharge Condition:
stable, tolerating PO diet, ambulating well, BP controlled,
stable Hct.
Discharge Instructions:
Please return if you experience worsened abdominal pain,
shortness of breath, leg swelling, blood in your stool,
black-colored stools, fever >101.5, decreased urination, chest
pain, or any other worrisome symptoms.
.
Please take all medications as directed. You have been started
on a patch form of your clonidine, which is to be worn on the
skin. You should stop taking your clonidine pills. You should
also stop taking your lisinopril. For your kidneys you have
been started on calcitriol. Finally, you should not take
aranesp until you see Dr [**Last Name (STitle) 1366**] in clinic.
Followup Instructions:
Please follow-up with Dr [**Last Name (STitle) **] within 1-2 weeks at
[**Telephone/Fax (1) **]. You should discuss the abnormal finding of a mass
in your right lung with Dr [**Last Name (STitle) **]. You will need a repeat CT
scan of your chest.
.
Please follow-up with Dr [**Last Name (STitle) 1366**] within 2 weeks at [**Telephone/Fax (1) **].
You should not take your Aranesp until you see him.
.
Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Date/Time:[**2147-5-17**] 11:15
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"585.5",
"E879.9",
"576.8",
"428.30",
"574.51",
"428.0",
"440.1",
"285.1",
"244.8",
"486",
"250.00",
"998.11",
"577.0",
"403.91",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43",
"51.88",
"51.85",
"52.11",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
12374, 12380
|
8033, 10848
|
327, 377
|
12513, 12586
|
3169, 8010
|
13226, 13876
|
2397, 2413
|
11110, 12351
|
12401, 12492
|
10874, 11087
|
12610, 13203
|
2428, 3150
|
240, 289
|
405, 2381
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,749
| 117,320
|
20211+20212
|
Discharge summary
|
report+report
|
Admission Date: [**2170-4-1**] Discharge Date: [**2170-4-11**]
Date of Birth: [**2112-4-3**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: This 57-year-old white male has
a history of insulin dependent diabetes, peripheral vascular
disease, and coronary artery disease. He is status post CABG
x 4 on [**2170-3-6**] with LIMA to the LAD, reversed saphenous vein
graft to diagonal, OM and PDA. He had an unremarkable postop
course and was discharged to rehab on [**2170-3-14**]. He now
returns to the Emergency Room complaining of right stabbing
chest pain which began the night prior to admission. There
is inferior sternal wound drainage which began a few days
ago. He had no fever at home, and has had intermittent chest
pain since discharge from rehab. He had his staples removed
5 days ago, and cultures were taken at that time.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post CABG x 4, [**2170-3-6**],
with LIMA to the LAD, reversed saphenous vein graft to the
diagonal, saphenous vein graft to the OM, and saphenous vein
graft to the PDA.
2. History of insulin dependent diabetes.
3. Status post MI.
4. History of peripheral vascular disease.
5. Status post right popliteal pedal bypass in [**2170-1-8**].
6. History of hypertension.
7. History of retinopathy.
8. History of peripheral neuropathy.
MEDICATIONS ON ADMISSION:
1. Captopril 12.5 mg po tid.
2. Lopressor 50 mg po bid.
3. Protonix 40 mg po qd.
4. Levaquin 500 mg po qd.
5. Percocet prn.
6. Lantus 45 U subcu q pm.
7. Humalog sliding scale.
ALLERGIES: He has no known allergies.
SOCIAL HISTORY: He smoked for 10 years and then quit. He
does not drink alcohol.
FAMILY HISTORY: Unremarkable.
PHYSICAL EXAM: He is a well-developed, well nourished white
male who has rigors. His temp was 102.5, heart rate 70,
blood pressure 126/63.
HEENT: Normocephalic, atraumatic. Extraocular movements
intact. Oropharynx benign.
NECK: Supple, full range of motion, no lymphadenopathy or
thyromegaly. Carotids 2+ and equal bilaterally without
bruits.
LUNGS: Decreased breath sounds at the left base.
CARDIOVASCULAR: Regular rate and rhythm, normal S1, S2, with
no rubs, murmurs or gallops.
STERNUM: Stable. The inferior pole has erythema with a 2 mm
opening with purulent drainage.
ABDOMEN: Soft, nontender with positive bowel sounds. No
masses or hepatosplenomegaly.
EXTREMITIES: Without clubbing, cyanosis or edema. His right
foot has a fifth plantar ulcer, and the left heel has a
medial ulcer which were clean without erythema.
LABORATORY: White count on admission 11.2. He had cultures
taken on [**3-27**] which revealed MRSA.
HOSPITAL COURSE: So, he was admitted and started on IV vanco
and Zosyn. He was also seen by vascular surgery who
continued to recommend dressing changes. He continued to
have sternal drainage, and the lower pole of his wound was
opened up on hospital day #1, and he continued to have
profuse drainage. His white count rose to 20,000. He
continued to have low-grade temps.
On [**4-4**], he went to the OR for sternal debridement. He was
transferred to the CSRU in stable condition. Plastic surgery
was consulted, and on [**4-7**], Dr. [**First Name (STitle) **] did a bilateral pec flap
closure of the sternum. The patient tolerated the procedure
well and had a stable postop course. He had his [**3-13**] JP
drains DC'd, and on postop day #4, he was discharged to home
in stable condition with one JP still in place. He will be
followed by plastic surgery in one week to have the drain
removed. He will also be followed by Dr. [**Last Name (STitle) **] in 3 weeks,
and Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 1007**] in [**2-9**] weeks.
DISCHARGE MEDICATIONS:
1. Ecotrin 325 mg po qd.
2. Protonix 40 mg po qd.
3. Lopressor 50 mg po bid.
4. Percocet [**2-9**] po q 4-6 h prn pain.
5. Colace 100 mg po bid.
6. Captopril 12.5 mg po tid.
7. Vancomycin 1,250 mg IV bid x 24 days.
8. Lantus 45 U subcu q hs.
9. Humalog insulin sliding scale.
LABS ON DISCHARGE: Hematocrit 30.1, white count 13,200,
platelets 546,000, sodium 137, potassium 4.4, chloride 102,
CO2 28, BUN 25, creatinine 1.0, blood sugar 141.
DISCHARGE DIAGNOSES:
1. Sternal wound infection.
2. Coronary artery disease.
3. Insulin dependent diabetes.
4. Hypertension.
5. Peripheral vascular disease.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 11726**]
MEDQUIST36
D: [**2170-4-11**] 13:57
T: [**2170-4-11**] 14:25
JOB#: [**Telephone/Fax (2) 54303**]
Admission Date: [**2170-4-1**] Discharge Date: [**2170-4-11**]
Date of Birth: [**2112-4-3**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: This 57-year-old white male has
a history of insulin dependent diabetes, peripheral vascular
disease, and coronary artery disease. He is status post CABG
x 4 on [**2170-3-6**] with LIMA to the LAD, reversed saphenous vein
graft to diagonal, OM and PDA. He had an unremarkable postop
course and was discharged to rehab on [**2170-3-14**]. He now
returns to the Emergency Room complaining of right stabbing
chest pain which began the night prior to admission. There
is inferior sternal wound drainage which began a few days
ago. He had no fever at home, and has had intermittent chest
pain since discharge from rehab. He had his staples removed
5 days ago, and cultures were taken at that time.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post CABG x 4, [**2170-3-6**],
with LIMA to the LAD, reversed saphenous vein graft to the
diagonal, saphenous vein graft to the OM, and saphenous vein
graft to the PDA.
2. History of insulin dependent diabetes.
3. Status post MI.
4. History of peripheral vascular disease.
5. Status post right popliteal pedal bypass in [**2170-1-8**].
6. History of hypertension.
7. History of retinopathy.
8. History of peripheral neuropathy.
MEDICATIONS ON ADMISSION:
1. Captopril 12.5 mg po tid.
2. Lopressor 50 mg po bid.
3. Protonix 40 mg po qd.
4. Levaquin 500 mg po qd.
5. Percocet prn.
6. Lantus 45 U subcu q pm.
7. Humalog sliding scale.
ALLERGIES: He has no known allergies.
SOCIAL HISTORY: He smoked for 10 years and then quit. He
does not drink alcohol.
FAMILY HISTORY: Unremarkable.
PHYSICAL EXAM: He is a well-developed, well nourished white
male who has rigors. His temp was 102.5, heart rate 70,
blood pressure 126/63.
HEENT: Normocephalic, atraumatic. Extraocular movements
intact. Oropharynx benign.
NECK: Supple, full range of motion, no lymphadenopathy or
thyromegaly. Carotids 2+ and equal bilaterally without
bruits.
LUNGS: Decreased breath sounds at the left base.
CARDIOVASCULAR: Regular rate and rhythm, normal S1, S2, with
no rubs, murmurs or gallops.
STERNUM: Stable. The inferior pole has erythema with a 2 mm
opening with purulent drainage.
ABDOMEN: Soft, nontender with positive bowel sounds. No
masses or hepatosplenomegaly.
EXTREMITIES: Without clubbing, cyanosis or edema. His right
foot has a fifth plantar ulcer, and the left heel has a
medial ulcer which were clean without erythema.
LABORATORY: White count on admission 11.2. He had cultures
taken on [**3-27**] which revealed MRSA.
HOSPITAL COURSE: So, he was admitted and started on IV vanco
and Zosyn. He was also seen by vascular surgery who
continued to recommend dressing changes. He continued to
have sternal drainage, and the lower pole of his wound was
opened up on hospital day #1, and he continued to have
profuse drainage. His white count rose to 20,000. He
continued to have low-grade temps.
On [**4-4**], he went to the OR for sternal debridement. He was
transferred to the CSRU in stable condition. Plastic surgery
was consulted, and on [**4-7**], Dr. [**First Name (STitle) **] did a bilateral pec flap
closure of the sternum. The patient tolerated the procedure
well and had a stable postop course. He had his [**3-13**] JP
drains DC'd, and on postop day #4, he was discharged to home
in stable condition with one JP still in place. He will be
followed by plastic surgery in one week to have the drain
removed. He will also be followed by Dr. [**Last Name (STitle) **] in 3 weeks,
and Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 1007**] in [**2-9**] weeks.
DISCHARGE MEDICATIONS:
1. Ecotrin 325 mg po qd.
2. Protonix 40 mg po qd.
3. Lopressor 50 mg po bid.
4. Percocet [**2-9**] po q 4-6 h prn pain.
5. Colace 100 mg po bid.
6. Captopril 12.5 mg po tid.
7. Vancomycin 1,250 mg IV bid x 24 days.
8. Lantus 45 U subcu q hs.
9. Humalog insulin sliding scale.
LABS ON DISCHARGE: Hematocrit 30.1, white count 13,200,
platelets 546,000, sodium 137, potassium 4.4, chloride 102,
CO2 28, BUN 25, creatinine 1.0, blood sugar 141.
DISCHARGE DIAGNOSES:
1. Sternal wound infection.
2. Coronary artery disease.
3. Insulin dependent diabetes.
4. Hypertension.
5. Peripheral vascular disease.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 11726**]
MEDQUIST36
D: [**2170-4-11**] 13:57
T: [**2170-4-11**] 14:25
JOB#: [**Telephone/Fax (2) 54304**]
|
[
"412",
"707.15",
"730.28",
"V45.81",
"998.59",
"E878.2",
"041.11",
"440.23",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"83.82",
"86.28",
"77.61"
] |
icd9pcs
|
[
[
[]
]
] |
6365, 6380
|
8881, 9305
|
8416, 8693
|
6046, 6264
|
7341, 8393
|
6396, 7323
|
8713, 8860
|
4835, 5535
|
5557, 6020
|
6281, 6348
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,695
| 112,110
|
55110
|
Discharge summary
|
report
|
Admission Date: [**2113-6-23**] Discharge Date: [**2113-6-26**]
Date of Birth: [**2060-1-11**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 14802**]
Chief Complaint:
Facial weakness
Major Surgical or Invasive Procedure:
R sided craniotomy for resection of tumor
History of Present Illness:
53M without significant PMH who was noted by his wife to
have a L facial droop at 5:30 this evening. Taken to [**Location (un) 620**],
where, per report of the ED, he was noted to have L LE and UE
weakness as well, though the patient denies this. CT scan done
there and the patient was transferred here. No other
complaints.
Denies HA, LOC. Blurred vision for the last 2 days. Denies
foreign travel.
Past Medical History:
None
Family History:
NC
Physical Exam:
O: T:97.9 BP: 135/76 HR:52 R14 O2Sats 95%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 2->1.5 EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-4**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. 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 [**5-6**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: Normal bilaterally
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Pertinent Results:
MRI Head [**6-24**]
Heterogeneous enhancing mass lesion on the right temporal lobe
as
described in detail above with areas of necrosis and causing
significant
shifting towards the left and mass effect, producing uncal
herniation and
transfalcine herniation.
CT Head [**6-24**]
Status post resection of a right temporal lobe tumor, with
expected post-surgical changes. Mild improvement in the mass
effect and leftward shift of midline structures.
MR HEAD W & W/O CONTRAST [**2113-6-25**]
Status post resection of right temporal lobe mass lesion, with
expected post-surgical changes. Interval improvement in the
mass effect and leftward shift of midline structures. Residual
blood products are visualized in the surgical bed with minimal
dural enhancement, thin subdural hematoma is noted along the
right temporal region, persistent vasogenic edema in the right
temporal lobe
Brief Hospital Course:
Pt was admitted to the neurosurgery service and the ICU for
further care. ON [**6-24**] he was taken to the OR for R sided
craniotomy for tumor resection. He tolerated this procedure well
with no complications. Post operatively a head CT showed no
hemorrhage. He was taken to the ICU for further care including
SBP control and q1 neuro checks. On post op exam his left sided
facial weakness improved. He remained in the ICU overnight and
had no issues. On [**6-25**] he was transferred to the floor and
underwent routine post op MRI. His diet was advanced and he was
mobilized OOB. His foley was DC'd.
On [**6-26**], patient remained stable, his dressing was changed and
PT was consulted for evaluation and stairs. His post op MRI
showed slight interval improvement in midline shift and a thin
SDH was seen in the R temporal region. Persistent vasogenic
edema was also seen. Due to persistent edema, his decadron was
kept at 4mg Q6H. PT recommended the nurse ambulate with patient
since he has been independent while in hospital. Patient was
stable with no dizziness or ataxia. He was discharged home in
stable condition.
Medications on Admission:
None
Discharge Medications:
1. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**1-2**] Tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
2. Phenytoin Sodium Extended 100 mg PO TID
RX *phenytoin sodium extended 100 mg 1 Capsule(s) by mouth three
times a day Disp #*120 Tablet Refills:*2
3. Dexamethasone 2 mg PO REFER TO OTHER INSTRUCTIONS
Please take 4mg Q6H x 2 days, then take 4mg Q8H x2 days, then
3mg Q8H x 2 days, then 2mg Q8H x2 days, then continue 2mg [**Hospital1 **]
until seen in follow up
Tapered dose - DOWN
RX *dexamethasone 2 mg 1 Tablet(s) by mouth please refer to
additional instructions Disp #*90 Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Brain tumor
Discharge Condition:
AOx3. Activity as tolerated. No lifting greater than 10 pounds.
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Dressing may be removed on Day 2 after surgery.
?????? **Your wound was closed with staples or non-dissolvable
sutures then you must wait until after they are removed to wash
your hair. You may shower before this time using a shower cap to
cover your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace) &
Senna while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? **You have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
?????? If you are being sent home on steroid medication, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
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: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101.5?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
Please follow up with Dr. [**Last Name (STitle) **] in 1 week for a wound check.
You may schedule this by calling [**Telephone/Fax (1) 58980**].
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2113-7-10**] at 9:30am. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 5074**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone
number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
Completed by:[**2113-6-26**]
|
[
"191.2",
"348.5",
"348.4",
"729.89",
"784.51",
"V15.82",
"781.94"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
4999, 5005
|
3148, 4272
|
325, 369
|
5061, 5127
|
2244, 3125
|
7252, 7876
|
849, 853
|
4327, 4976
|
5026, 5040
|
4298, 4304
|
5151, 7229
|
868, 1116
|
270, 287
|
398, 805
|
1408, 2225
|
1131, 1392
|
827, 833
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,140
| 150,115
|
36475
|
Discharge summary
|
report
|
Admission Date: [**2144-4-17**] Discharge Date: [**2144-4-21**]
Date of Birth: [**2063-2-19**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Aspirin
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
Endoscopy
History of Present Illness:
81M with localized pancreatic cancer diagnosed in [**2141**] s/p 3
cycles gemcitabine and cyberknife therapy, as well as past ERCP
with CBD stenting in [**2141**] and re-stenting in [**3-/2144**], IDDM,
recently discharged on [**3-31**] after IR embolization of pancreatic
pseudoaneurysm who presented to [**Hospital **] Hospital earlier today
after having 2 black stools last night and 2 this AM. He did not
notice any gross blood in the stool, has no abdominal pain,
nausea/vomiting, hematemesis. He measured his temp to 101 last
night which improved with Tylenol. No loss of appetite or weight
loss, no CP or SOB, no dizziness. He recalls having black stools
in the past but does not remember when. He reports that his INR
has been therapeutic for the past 3 weeks (was supratherapeutic
on previous admission in 5/[**2142**]). Over the past month he has had
intermittent diarrhea and constipation but no melena or blood.
.
He presented to [**Hospital **] Hospital this AM and had INR of 3.63,
Hct 31.4. He had a negative NG lavage. He was given 2 units FFP
with improvement in INR to 2.4 after 2 units FFP. [**Hospital **]
transferred to [**Hospital1 **] given concern from aneurysmal bleed.
.
In the ED at [**Hospital1 **] vitals were 129/58 62 16 100% RA, he was found
to have maroon guaiac + stool on rectal exam. HCT 28.6, INR 2.4,
Plat 127. He was started on protonix drip. Given reported fever
of [**Age over 90 **] yesterday and wrist pain s/p recent fall, ortho was
consulted to evaluate for septic joint. XR did not show wrist
fracture and ortho did not believe this was a septic joint. IR,
GI, gen [**Doctor First Name **] and ERCP were consulted and recommended holding
coumadin and planning for EGD in AM. He was written for 1U FFP
and 1U RBCs but these were not given in the ED.
.
On the floor, pt had no complaints - no N/V, no abdominal pain,
no ongoing bleeding or subsequent stools. He reported being
thirsty, no dizziness or any pain.
Past Medical History:
- Pancreatic CA - s/p plastic, and now metal stenting in duct.
s/p 3 cycles of Gemcitabine with stereotactic XRT. Followed at
[**Hospital **] hospital
- A.Fib, on coumadin
- Colon CA, s/p resection in [**2137**]
- DM II - on insulin
- S/P portacath right chest
- Chronic L>R LE edema, on lasix
- BPH
- Gout
- HTN
Social History:
Non-smoker. No ETOH abuse. Retired engineer. Independent in
all ADLs/IADLs.
Family History:
No CA in family. Not relevant to this hospitalization
Physical Exam:
On admission:
Vitals: T 98.5, BP 107/60, HR 62, RR 20, 95% RA
General: AOX3, in no distress
HEENT: Sclera anicteric, dry oral mucosa, poor dentition
Neck: supple, JVP not elevated, no cervical lymphadenopathy
Lungs: CTA bilaterally, no wheezes or rales
CV: nl S1/S2, RRR, no murmurs
Abdomen: soft, non-tender, non-distended, BS normoactive,
negative [**Doctor Last Name 515**] sign, no rebound/guarding
Ext: brace and wrap over R wrist, hands warm and well perfused,
R foot cooler to touch than L with 2+ distal pulses b/l, good
capillary refill
Pertinent Results:
ADMISSION LABS
--------------
[**2144-4-17**] 05:15PM BLOOD WBC-9.3# RBC-3.19* Hgb-9.9* Hct-28.6*
MCV-90 MCH-31.1 MCHC-34.8 RDW-14.6 Plt Ct-127*
[**2144-4-17**] 05:15PM BLOOD PT-25.1* PTT-29.0 INR(PT)-2.4*
[**2144-4-17**] 05:15PM BLOOD Glucose-93 UreaN-15 Creat-0.6 Na-139
K-3.8 Cl-101 HCO3-31 AnGap-11
[**2144-4-17**] 05:15PM BLOOD ALT-42* AST-48* AlkPhos-240* TotBili-2.6*
[**2144-4-17**] 05:15PM BLOOD Calcium-8.9 Phos-2.1* Mg-1.8 UricAcd-2.4*
.
DISCHARGE LABS
--------------
[**2144-4-21**] 01:11PM BLOOD WBC-4.1 RBC-3.44* Hgb-10.6* Hct-31.4*
MCV-91 MCH-30.7 MCHC-33.6 RDW-14.5 Plt Ct-219
[**2144-4-21**] 05:42AM BLOOD Glucose-163* UreaN-11 Creat-0.7 Na-140
K-3.7 Cl-100 HCO3-35* AnGap-9
[**2144-4-21**] 05:42AM BLOOD ALT-34 AST-43* LD(LDH)-142 AlkPhos-263*
TotBili-2.2*
[**2144-4-21**] 05:42AM BLOOD Calcium-8.9 Phos-2.7 Mg-1.8
.
MICROBIOLOGY
------------
[**2144-4-17**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2144-4-17**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
.
[**2144-4-17**] 6:50 pm URINE Site: NOT SPECIFIED
**FINAL REPORT [**2144-4-18**]**
URINE CULTURE (Final [**2144-4-18**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
.
Time Taken Not Noted Log-In Date/Time: [**2144-4-20**] 10:42 am
SEROLOGY/BLOOD
TAKEN FROM # 64979G,ADDED HELI @ 10:42 AM ON [**2144-4-20**]..
HELICOBACTER PYLORI ANTIBODY TEST (Pending):
.
IMAGING
-------
CT SCAN ABDOMEN/PELVIS
1. In this patient with known pseudoaneurysm of the
gastroduodenal artery,
status post coiling, there is no evidence of revascularization
or active leak from the aneurysm. Mild interval decrease in the
size of the thrombosed aneurysm. The evaluation is slightly
limited due to streak artifact from the coil pack.
2. Variant hepatic arterial anatomy, as described above.
3. Simple left renal cortical cysts and concerning lesion in the
right
kidney at midpole. This may represent a complex cyst, however
enhancement is concerning for papillary renal cell carcinoma,
further evaluation with MRI is recommended.
4. Bilateral small pleural effusions.
5. Mild splenomegaly.
6. Stable aneurysm of the left common iliac artery measuring 3.2
cm, and
ectasia of the right common iliac artery.
.
Right wrist X-ray:
IMPRESSION:
No fracture or dislocation. Evaluation for effusion is limited
on the
radiograph.
.
Chest X-ray on admission:
IMPRESSION:
Small left pleural effusion but no acute cardiopulmonary process
otherwise
identified.
Brief Hospital Course:
81 year old male with localized pancreatic cancer diagnosed in
[**2141**] s/p 3 cycles gemcitabine and cyberknife therapy, as well as
past ERCP with CBD stenting in [**2142**] and re-stenting in [**3-/2144**],
diabetes mellitus, recently discharged on [**3-31**] after IR
embolization of pancreatic pseudoaneurysm who presents with
melena.
.
ACTIVE ISSUES
-------------
# Gastrointestinal bleed: patient had four episodes of melanotic
stool at home with guaiac positive stool on exam. Hematocrit
was stable without transfusions. CTA of the abdomen had no
evidence of extravasation through coiled pseudoaneurysm. No
hematemesis and benign abdominal exam were noted, and stable
hematocrits and negative NG lavage suggested that upper GI
source was less likely, though small shallow ulcerations were
seen in the duodenum on ERCP in 5/[**2143**]. Patient does have
diverticulosis seen on CT in [**2141**] with prior remote episodes of
melenic stool. INR was supratherapeutic slightly on admission to
OSH and previously this month, though patient reports
therapeutic range for past few weeks. Source of bleed seems to
most likely be lower gastrointestinal and differential diagnosis
included diverticular, AV malformation, or less likely internal
hemorrhoids or colon cancer. Last colonoscopy was in [**2141**] and
was reportedly normal per patient. He does have a documented
history of colon cancer s/p resection in [**2137**]. GI did a bedside
endoscopy, showing shallow non-bleeding ulcer, but no active
bleeding. Patient did have a few bloody stools during his
admission, for which no intervention was undertaken. He will
likely need an outpatient colosnoscopy. Hematocrits remained
stable and patient did not require any further transfusion.
Patient was initially put on a pantoprazole drip on admission
which was later switched to IV pantoprazole [**Hospital1 **] and then PO
pantoprazole [**Hospital1 **] for discharge. He will get a CBC soon after
discharge to assure no active bleeding.
.
# Right wrist pain: Pt complained of right wrist pain s/p
mechanical fall 4 days prior to admission with no evidence of
fracture or dislocation on X-ray and low suspicion for a septic
joint. He was evaluated by orthopedics and hand service in the
ED who put a brace on his wrist. Pain was controlled with
oxycodone, which he will continue as an outpatient.
.
INACTIVE ISSUES
---------------
# Pancreatic pseudoaneurysm: on last admission in [**3-/2144**] patient
was found to have a 1.9 mm pseudoaneurysm in the pancreas. It
was suspected to be due to his pancreatic cancer vs radiation
treatments. He underwent successful embolization in [**3-/2144**] and
CTA abdomen on this admission demonstrated thrombosed aneurysm
decreased in size from last imaging, with no signs of
extravasation or leaking. This was determined to be unlikely to
be related to his presenting gastrointestinal bleed.
.
# Biliary obstruction: CBD stent has been placed in [**2141**] with
recent admission in [**3-/2144**] for abdominal pain and worsening
obstructive jaundice, found to have mobilized stent in CBD which
was replaced. No abdominal pain was present during
hospitalization and his liver function tests were improved from
last admission and remained stable, so restenosis is unlikely.
.
# Pancreatic cancer: diagnosed in [**2141**] s/p 3 cycles gemcitabine
and cyberknife therapy. Patient follows at [**Hospital **] Hospital
with no treatments in past year though with complications of
pseudoaneurysm and CBD obstruction likely due to recurrence of
active disease, as seen on most recent PET scan. There was no
evidence of extravasation within his pseudoaneurysm. On CT in
[**3-/2144**], there was evidence of increasing peripancreatic,
gastrohepatic and periportal lymphadenopathy, likely
representing metastatic disease from pancreatic cancer. He was
continued on pancreatic enzymes per his home regimen.
.
# Kidney mass: upon getting a CTA of the abdomen, it was noted
that there was a mass in the right kidney, for which radiology
reported that a carcinoma could not be ruled out. It was
suggested that an MRI be obtained for further classification.
.
# Fever: Per patient he had a temperature of 101 at home,
improved with tylenol. There were no documented fevers since
admission, no leukocytosis, and no localized signs/symptoms of
infection though patient had intermittent diarrhea for past few
weeks with possible evidence of colitis on CT few weeks ago.
Clostridium difficile toxin was checked and was negative. There
was no suggestion of cholecystitis, diverticulitis, pneumonia or
genitourinary infection.
.
# Atrial fibrillation: Patient had been on warfarin and digoxin
on admission. INR was supratherapeutic to 3.4 at the outside
hospital, improved to 2.6 s/p 2 units FFP. INR was 2.4 on
admission to [**Hospital1 18**] with goal <1.5 prior to EGD as above.
Coumadin was held. INR was reversed with 2 units of FFP and 10
mg Vitamin K. Discussion was held with patient and family
regarding risks and benefits of anticoagulation, and it was
decided to discontinue his warfarin.
.
# Diabetes mellitus type 2: patient is on levemir 6 units [**Hospital1 **] at
home. His blood sugars were controlled with sliding scale
insulin during his stay. He will continue his aforementioned
levemir dosing at home.
.
# Gout: no evidence of gouty flare in wrist joint. Patient was
continued on his home dose of allopurinol daily
.
# Hypertension: Home lasix and lisinopril were initially held on
admission given GI bleed and that he was normotensive. These
were restarted following his EGD and he will resume these
medications upon discharge.
.
TRANSITION OF CARE
------------------
# Follow-up: patient will need a CBC after discharge for
evaluation of anemia. He will likely also need an outpatient
colonoscopy. An MRI of the abdomen is also needed to further
classify the mass noted in the patient's right kidney. Patient
has several blood cultures which remain pending at the time of
discharge. His H. pylori antibody test also remains pending.
Patient will follow up with his PCP and oncologist upon
discharge, for which both appointments are scheduled.
.
# Code status: full code, confirmed with patient
.
# Communication: wife cell [**Telephone/Fax (1) 82625**]; home [**Telephone/Fax (1) 82626**]
Medications on Admission:
-Celexa 20 mg Tab 1 Tablet(s) by mouth daily
-Oxycodone (dose uncertain) prn wrist and stomach pain
-Levemir 100 unit/mL Sub-Q 6 units twice a day Morning and
Evening
-Vitamin D 2,000 unit Cap Capsule(s) by mouth once a day
-Allopurinol 100 mg Tab Tablet(s) by mouth once a day
-Lisinopril 5 mg Tab Tablet(s) by mouth once a day
-Imodium A-D 2 mg Tab (dose uncertain)
-Lasix 40 mg Tab Oral 1 Tablet(s) Twice Daily
-Fentanyl patch 50mcg q72h
-loperamide 2 mg QID prn diarrhea
-lipase-protease-amylase 12,000-38,000 -60,000 unit TID w/meals
-potassium chloride 40meq daily
-Warfarin -5mg daily, 7.5mg on WED
-digoxin 125 mcg daily
Discharge Medications:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO every 4-6 hours
as needed for pain.
3. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Imodium A-D Oral
7. loperamide 2 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for diarrhea.
8. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
10. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
12. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Capsule, Delayed
Release(E.C.) PO TID w/ meals.
13. Levemir 100 unit/mL Solution Sig: Six (6) units Subcutaneous
twice a day.
14. Outpatient Lab Work
Please perform CBC on [**2144-4-23**]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Gastrointestianal bleed
Right wrist sprain
Secondary:
Pancreatic cancer
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 82627**],
It was a pleasure taking care of you in the hospital. You were
admitted with bloody bowel movements. An EGD was performed that
did not show any active bleeding. Your bleeding may be due to
aberrant vessels in your pancreatic tumor. You were started on
a medication called pantoprazole that you should continue to
take twice a day to miminize the risk of bleeding. Your
coumadin was also stopped because it is a blood thinner and can
increase the risk of bleeding. It would also likely be
worthwhile for you to get a colonoscopy due to your
gastrointestinal bleeding that you came to the hospital for.
Please follow up with your primary care provider concerning
this.
While you were in the hospital you also experienced some pain in
your right wrist which you had fallen on. You were evaluated by
our orthopedics team and an x-ray did not show a fracture. This
is likely a sprain and you were given a brace to keep your hand
in.
There was a mass noted on your kidney that was found on a CT
scan that was performed during your admission. You should
follow up with you oncologist concerning this finding.
The following changes were made to your medications:
1) START pantoprazole 40mg twice a day
2) STOP coumadin
Followup Instructions:
Name: [**Last Name (un) 17747**],[**Last Name (un) 82622**]
Location: [**Location (un) **] FAMILY DOCTORS
[**Name5 (PTitle) **]: [**Street Address(2) 82623**], STE#202, [**Location (un) **],[**Numeric Identifier 41397**]
Phone: [**Telephone/Fax (1) 59840**]
Appointment: [**Telephone/Fax (1) 766**] [**2144-4-27**] 2:30pm
You are scheduled to follow up with your oncologist on Friday,
[**4-24**].
An MRI of the kidneys should be performed on discharge for ?
complex cyst seen in right mid-kidney, concerning for ?
papillary renal cell carcinoma
|
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icd9cm
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[
[
[]
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[
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icd9pcs
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[
[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,539
| 135,806
|
52181
|
Discharge summary
|
report
|
Admission Date: [**2157-4-1**] Discharge Date: [**2157-4-3**]
Date of Birth: [**2081-9-30**] Sex: F
Service: MEDICINE
Allergies:
Levaquin
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Failure to thrive
Major Surgical or Invasive Procedure:
Paracentesis
Endotracheal intubation
Placement of central venous catheter
Placement of arterial line
History of Present Illness:
75 year old female with history of metastatic breast cancer to
stomach, massive ascites, COPD who presented initially with
decreased appetite, sleeping problems, vomiting and falls. The
pt was noted this afternoon by GI fellow to be unresponsive with
vomitus. The pt was satting in th 50s% on RA, up to 100% with
bag mask ventilation. Her HR was in the 110s, with appearance
of MAT/SVT on monitor. ABG 7.04/77/116 on bag mask ventilation.
Approx 400 cc vomitus was suctioned from OG tube and approx 20
cc vomitus was further suction from the airway. The pt was
subsequently intubated for airway protection.
.
Of note, pt was recently admitted in [**Month (only) 1096**] for DOE found to
have worsening of her COPD. She was scheduled to have a
paracentesis to remove fluid on Monday. In the ED a
paracentesis was performed and 2300cc of serous fluid was
removed.
Past Medical History:
1. Metastatic breast cancer: L mastectomy [**2122**], metastatic by
EGD [**12-11**]--gastic polyp c/w breast ca cells. Tried tamoxifen,
now on Arimidex. Followed by Dr. [**Last Name (STitle) **].
2. Massive Ascites - tapped [**2157-3-14**], cytology negative for
malignancy
3. HTN
4. COPD - last exacerbation [**1-10**]
5. Anemia
6. GERD
7. Osteoporosis
8. EF 50% in [**11-10**]
Social History:
Currently living with two brothers, sister, and son, in
[**Name (NI) **]. Doesn't smoke, no EtOH
Family History:
No history of cancer or heart disease
Physical Exam:
VS: T 92.3 Hr 91 BP 157/74 R 15 Sat 100% on AC Tv380, Rate 14,
PEEP 5, FiO2 100
Gen: cachetic, frail appearing female in NAD
HEENT: dry MM, PERRL
Neck: no lymphadenopathy
Lungs: high pitched diffuse expiratory wheezing, decreased L
sided breath sounds
CV: RRR, nl S1S2, no murmers
Abd: tense ascites increased over the period of several hrs,
positive BS, non-tender, +fluid wave
Ext: knees with healing ulcers surrounded by erythema, warm,
non-tender, 1+ BL LE edema increaseing over several hrs to 2+ as
well as in thighs, BL LE diffusely erythematous with scaling
Neuro: intubated
Pertinent Results:
Admission CXR: No acute cardiopulmonary process.
Admission head CT: No acute intracranial hemorrhage or mass
effect.
Admission C-spine: No evidence of cervical spine fracture.
[**4-2**] RUQ U/S:
1. Moderate amount of ascites.
2. Cholelithiasis without evidence of acute cholecystitis.
Gallbladder wall thickening. No intrahepatic or extrahepatic
biliary ductal dilatation or focal hepatic lesions.
3. Common bile duct stones.
[**4-2**] KUB:
Single supine view of the upper abdomen demonstrates no definite
signs for free intraperitoneal air. There are some surgical
clips seen within the mid and left upper abdomen. There is a
generalized paucity of bowel gas.
[**4-3**] RUQ U/S:
1. Moderate perihepatic ascites.
2. Patent main portal and hepatic veins without evidence of
intraluminal
thrombus.
[**2157-4-1**] 09:20PM BLOOD WBC-7.6 RBC-3.14*# Hgb-10.5*# Hct-32.8*#
MCV-105* MCH-33.6* MCHC-32.1 RDW-22.7* Plt Ct-155
[**2157-4-3**] 04:47AM BLOOD WBC-3.3* RBC-2.74* Hgb-8.8* Hct-29.8*
MCV-109* MCH-32.3* MCHC-29.6* RDW-21.5* Plt Ct-137*
[**2157-4-1**] 09:20PM BLOOD Neuts-82.4* Bands-0 Lymphs-13.6*
Monos-3.8 Eos-0.1 Baso-0.1
[**2157-4-2**] 08:22PM BLOOD PT-16.8* PTT-40.9* INR(PT)-1.6*
[**2157-4-3**] 04:47AM BLOOD PT-19.0* PTT-43.2* INR(PT)-1.8*
[**2157-4-1**] 09:20PM BLOOD Glucose-97 UreaN-45* Creat-1.0 Na-130*
K-4.4 Cl-96 HCO3-21* AnGap-17
[**2157-4-3**] 04:47AM BLOOD Glucose-40* UreaN-41* Creat-1.1 Na-132*
K-3.8 Cl-105 HCO3-17* AnGap-14
[**2157-4-1**] 09:20PM BLOOD ALT-75* AST-104* LD(LDH)-380*
AlkPhos-446* TotBili-3.4* DirBili-2.5* IndBili-0.9
[**2157-4-2**] 08:22PM BLOOD ALT-56* AST-80* CK(CPK)-149* AlkPhos-385*
TotBili-2.8*
[**2157-4-3**] 04:47AM BLOOD ALT-40 AST-55* LD(LDH)-259* CK(CPK)-97
AlkPhos-272* TotBili-2.3*
[**2157-4-1**] 09:20PM BLOOD Lipase-64* GGT-231*
[**2157-4-2**] 08:22PM BLOOD CK-MB-9 cTropnT-<0.01
[**2157-4-3**] 04:47AM BLOOD CK-MB-6 cTropnT-0.04*
[**2157-4-1**] 09:20PM BLOOD Albumin-2.6* Calcium-8.1* Phos-3.3 Mg-2.3
Iron-83
[**2157-4-1**] 09:20PM BLOOD calTIBC-200* VitB12-[**2126**]* Folate-13.9
Ferritn-1641* TRF-154*
[**2157-4-1**] 09:20PM BLOOD TSH-8.9*
[**2157-4-1**] 09:20PM BLOOD Free T4-0.9*
[**2157-4-1**] 09:20PM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND IgM HAV-PND
[**2157-4-2**] 12:51PM BLOOD AMA-PND
[**2157-4-2**] 12:51PM BLOOD [**Doctor First Name **]-PND
[**2157-4-2**] 10:30AM BLOOD PEP-PND
[**2157-4-1**] 09:20PM BLOOD HCV Ab-PND
[**2157-4-2**] 06:45PM BLOOD Type-ART pO2-116* pCO2-77* pH-7.04*
calHCO3-22 Base XS--11
[**2157-4-2**] 06:45PM BLOOD Lactate-4.2*
[**2157-4-2**] 07:04PM BLOOD Type-ART Temp-37 Rates-/14 Tidal V-350
FiO2-50 pO2-167* pCO2-67* pH-7.13* calHCO3-24 Base XS--8
-ASSIST/CON Intubat-INTUBATED
[**2157-4-2**] 07:04PM BLOOD Lactate-2.2*
[**2157-4-3**] 01:43AM BLOOD Type-ART Rates-20/ Tidal V-350 PEEP-5
FiO2-60 pO2-66* pCO2-58* pH-7.15* calHCO3-21 Base XS--9
-ASSIST/CON Intubat-INTUBATED
[**2157-4-3**] 01:43AM BLOOD Lactate-2.0 Na-131*
[**2157-4-3**] 05:00AM BLOOD Type-ART Temp-36.6 Rates-20/ Tidal V-400
PEEP-8 FiO2-70 pO2-231* pCO2-38 pH-7.25* calHCO3-17* Base XS--9
-ASSIST/CON Intubat-INTUBATED
[**2157-4-3**] 05:00AM BLOOD Lactate-3.3*
[**2157-4-3**] 03:59PM BLOOD Type-ART Temp-36.1 Tidal V-350 PEEP-8
FiO2-60 pO2-45* pCO2-40 pH-7.06* calHCO3-12* Base XS--19
-ASSIST/CON Intubat-INTUBATED
[**2157-4-3**] 03:59PM BLOOD Glucose-168* Lactate-8.1* Na-129* K-4.9
Cl-107
[**2157-4-2**] 02:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
[**2157-4-2**] 02:00PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-1 pH-5.0 Leuks-NEG
[**2157-4-2**] 02:00PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE
Epi-<1
[**2157-4-2**] 12:51AM ASCITES WBC-114* RBC-34* Polys-23* Lymphs-1*
Monos-32* Mesothe-3* Macroph-41*
[**2157-4-2**] 12:51AM ASCITES Albumin-<1.0
Peritoneal fluid culture, blood cultures, and urine cultures all
pending at time of patient death
Brief Hospital Course:
Ms. [**Known lastname **] was first admitted for increased ascites,
decreased appetite, nausea, and general malaise and failure to
thrive. Her ascitic fluid had a SAAG>1.1 and demonstrated no
evidence of infection. Her RUQ ultrasound demonstrated
cholelithiasis, but no evidence of cholecystitis. An abdominal
CT was planned, but Ms. [**Known lastname **] refused this test. Hepatitis
and autoimmune serologies were sent, given her mild elevation of
LFTs (mainly a cholestatic picture). There was suspicion that
her ascites could be due to peritoneal or hepatic metastases
from her breast CA, but cytology of ascitic fluid was negative
for malignant cells. She was also found to be hypothyroid with
TSH 8.9 and T4 0.9, and was started on synthroid.
Liver service was consulted on [**4-2**] for ascites, mild
cholestatic picture, and gallstones on U/S. When entering the
room to see patient, the liver fellow noted the patient to be
unresponsive with vomitus on her chin, and SaO2 48%. A Code Blue
was called. Her SaO2 improved to 100% on 100% bag-mask. She was
intubated with etomidate and succinylcholine, and was
transferred to the [**Hospital Unit Name 153**] for further management of likely
aspiration event. ABG at time of transfer was 7.04/77/116.
Overnight, Ms. [**Known lastname 107958**] condition deteriorated. She was
anuric on arrival to the [**Hospital Unit Name 153**], and did not put out significant
urine to 500mL NS bolus. She was given albumin 12.5gm and an
additional 500mL NS bolus, with little effect. Her abdomen
became increasingly tense and distended. Her BP also fell to SBP
80, with little response to 2L NS wide open. A subclavian
central line was placed, and neosynephrine and, eventually
vasopressin, were required to keep her MAP>65. Due to suspicion
of hepatorenal syndrome, octreotide and albumin 25gm [**Hospital1 **] were
started. Abdominal compartment syndrome was also considered. In
the morning, an intraabdominal pressure was transduced and found
to be 20mmHg. A repeat RUQ U/S with doppler was done to r/o Budd
Chiari, and found a patent portal vein with no hyperdynamic
waveform to suggest CHF. As MAPs dropped, it was necessary to
add levophed to keep her BP up.
As Ms. [**Known lastname 107958**] condition rapidly declined, discussions
were held with her daughter and HCP. It was explained that to
continue aggressive treatment would entail further invasive
procedures, such as additional paracenteses, continued
endotracheal intubation, and a likely very prolonged ICU course.
The daughter and multiple other family members agreed that Ms.
[**Known lastname **] would not want to have this aggressive care
continued. She was started on a morphine drip, and all
unecessary medications and tests d/c'ed. She was extubated at
her family's request. Approximately 30 minutes later, housestaff
was called to pronounce her death. She had no pulse, heart
sounds, or breath sounds for 2 minutes. Her family was present,
and requested an autopsy.
Medications on Admission:
1. Albuterol 2 puffs q6h prn
2. Flovent 110MCG 2 puffs [**Hospital1 **]
3. Folic acid 1 mg PO daily
4. Prilosec OTC 20mg PO daily
5. Valium 5mg PO BID PRN
6. Keflex 500mg PO TID Day [**9-15**]
7. Spironolactone 25mg PO Daily
8. Arimidex 1mg PO daily
9. Zometa, Procrit
10. Serevent discus 50mcg [**Hospital1 **]
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Hypotension
Multiorgan failure
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"584.9",
"789.5",
"V10.11",
"285.9",
"496",
"197.8",
"682.6",
"276.1",
"518.81",
"263.9",
"244.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.15",
"54.91",
"96.04",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
9755, 9764
|
6377, 9365
|
285, 387
|
9838, 9848
|
2477, 2537
|
9900, 9906
|
1819, 1858
|
9727, 9732
|
9785, 9817
|
9391, 9704
|
9872, 9877
|
1873, 2458
|
228, 247
|
415, 1286
|
2546, 6354
|
1308, 1689
|
1705, 1803
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,661
| 193,241
|
43134
|
Discharge summary
|
report
|
Admission Date: [**2152-10-20**] Discharge Date: [**2152-10-31**]
Date of Birth: [**2068-5-31**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
left lower extremity discoloration.
Major Surgical or Invasive Procedure:
OPERATION:
1. Ultrasound-guided puncture of right common femoral
artery.
2. Second-order catheterization of left external iliac
artery.
3. Serial arteriogram of left lower extremity.
4. Abdominal aortogram.
PROCEDURES:
1. Left femoral-to-below-knee popliteal bypass graft,
nonreversed greater saphenous vein graft.
2. Angioscopy with valvuloplasty.
History of Present Illness:
84F with dementia presents to [**Hospital **]
Hospital with left lower extremity discoloration of [**12-22**] days
duration. She has not had any pain associated with the
discoloration, no recent trauma to the area. She has continued
ambulating with the aid of a walker and has not had any
neuromuscular dysfunction. She has no history of vascular
disease. She was taken to [**Hospital **] hospital where ABIs were
performed, a heparin drip was started and transferred to [**Hospital1 18**]
for further management.
Past Medical History:
PAST MEDICAL HISTORY: dementia, spinal stenosis, pneumonia,
incontinence, GERD
PAST SURGICAL HISTORY: none
Social History:
SOCIAL HISTORY: previous smoker, quit 30 years ago, lives at
home
with husband
Family History:
FAMILY HISTORY: no vascular history
Physical Exam:
PHYSICAL EXAMINATION
Vitals: T: afeb BP: 110/61 mmHg supine, HR 79 bpm, RR 13 bpm
Gen: Pleasant, calm, disoriented
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, No LAD. JVP low.
CV: PMI in 5th intercostal space, mid clavicular line. RRR.
normal S1,S2. Holosystolic murmur [**1-22**].
LUNGS: CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND. No HSM.
EXT: Blue/discolored and cold L foot to mid dorsal area.
Diminished peripheral pulses.
SKIN: No rashes/lesions, multiple LE ecchymoses.
NEURO: A&Ox1. Pt unable to participate in neuro exam.
PSYCH: Mood was appropriate.
Pertinent Results:
[**2152-10-31**] 05:00AM BLOOD
WBC-10.4 RBC-4.59 Hgb-11.0* Hct-36.5 MCV-79* MCH-24.0*
MCHC-30.2* RDW-21.4* Plt Ct-318
[**2152-10-25**] 01:35AM BLOOD
PT-14.5* PTT-53.1* INR(PT)-1.3*
[**2152-10-31**] 05:00AM BLOOD
Glucose-91 UreaN-13 Creat-0.6 Na-140 K-4.0 Cl-109* HCO3-25
AnGap-10
[**2152-10-31**] 05:00AM BLOOD
Calcium-7.9* Phos-2.4* Mg-1.9
[**2152-10-28**] 10:38PM
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
URINE RBC-38* WBC-6* Bacteri-NONE Yeast-NONE Epi-1
[**2152-10-24**] 3:45 pm MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Final [**2152-10-27**]): No MRSA isolated.
ECHO:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Overall left
ventricular systolic function is severely depressed (LVEF= XX
%). Diastolic function could not be assessed. There is no
ventricular septal defect. The right ventricular cavity is
mildly dilated with moderate global free wall hypokinesis. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Severe [4+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is a very small pericardial
effusion. There are no echocardiographic signs of tamponade.
Echocardiographic signs of tamponade may be absent in the
presence of elevated right sided pressures.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Moderate mitral regurgitation. Dilated, hypokinetic right
ventricle with severe tricuspid regurgitation and at least
moderate pulmonary artery hypertension. Small circumferential
effusion without evidence of tamponade.
CXR:
FINDINGS: As compared to the previous radiograph, there is
unchanged evidence of moderate bilateral pleural effusions and
bilateral basal atelectasis.
Unchanged moderate cardiomegaly. The right internal jugular vein
catheter has not been pulled back, its tip still projects over
the right atrium. To ensure position within the superior vena
cava, the line should be pulled back by 9 cm.
Unchanged appearance of a small right upper lobe atelectasis.
[**2152-10-21**] 7:00 pm URINE Source: CVS.
URINE CULTURE (Final [**2152-10-23**]): <10,000 organisms/ml.
Brief Hospital Course:
[**10-20**]
Mrs. [**Known lastname 92974**],[**Known firstname **] was admitted on [**10-20**] with ischemic left
foot. She agreed to have an elective surgery. Pre-operatively,
she was consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were
obtained, all other preperations were made.
She was started on Heperin drip before her surgery was planned
[**10-23**]
Diag L LE angiography; UE/LE vein mapping; TTE; mitts for
pulling out lines
Sheath was pulled wiht ut diffculty
[**10-24**]
s/p left fem-bk-[**Doctor Last Name **] with GSV
She was prepped, and brought down to the operating room for
surgery. Intra-operatively, she was closely monitored and
remained hemodynamically stable. She tolerated the procedure
well without any difficulty or complication.
Post-operatively, she was intubated and transferred to the CVICU
for further stabilization and monitoring. On dobutamine.
[**10-25**]
Cardiology was consulted
2 PRBCs with Lasix for Hct 24; extubated; Captopril, Carvedilol
started
post Hct 34.8; off dobutamine
[**10-26**]
D/C'd cipro; ADAT; D/C'd swan; ASA/simvastatin started; xfer
VICU
She was then transferred to the VICU for further recovery. While
in the VICU she recieved monitered care. When stable she was
delined. Her diet was advanced. A PT consult was obtained.
[**10-27**]
Diuresed 2L o/n, bolused once for uop 2cc/hr; cards: increase
ACE; hold lasix
When she was stabalized from the acute setting of post operative
care, she was transfered to floor status
[**10-28**]
OOB chair; diuresed for pulm edema on CXR; [**Female First Name (un) **] c/s placed
[**10-29**]
dc captopril to lisin,lasix and diamox given,dc foley, Kefzol
for cellulitis
[**10-30**]
d/c kefzol; start Bactrim DS for cellulitis; D/C'd JP; start po
lasix
On the floor, she remained hemodynamically stable with his pain
controlled. She progressed with physical therapy to improve her
strength and mobility. She continues to make steady progress
without any incidents.
Pt stooloing, secondary to constipation
C diff sent for diarrhea, c - diff negative x 2
[**10-31**]
She was discharged to a rehabilitation facility in stable
condition.
Medications on Admission:
pepcid
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
2. furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TID (3 times a day) as needed for
reflux.
9. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
10. potassium chloride 8 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day.
11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
12. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO twice a
day for 14 days.
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] Nursing & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
Left lower extremity ischemia
Chronic Systolic Dysfunction Left Ventricle - Ejection
Fraction: 15% to 20%, requiring diuresis
Post op delerium
GERD, dementia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**12-22**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
You have a follow up appointment with Dr. [**Last Name (STitle) 1391**] on [**11-15**] at
10:15am. Please call [**Telephone/Fax (1) 1393**] with any questions or
concerns.
Cardiology [**Telephone/Fax (1) 62**]. Dr [**First Name (STitle) 437**], your appointment is [**1041-12-19**]. [**Hospital Ward Name 23**], [**Location (un) 436**] cardiology
Completed by:[**2152-10-31**]
|
[
"E878.2",
"428.0",
"596.54",
"294.8",
"707.19",
"440.23",
"530.81",
"564.81",
"293.0",
"998.59",
"416.8",
"564.09",
"682.6",
"599.0",
"E947.9",
"428.21",
"788.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.42",
"88.48",
"39.29"
] |
icd9pcs
|
[
[
[]
]
] |
8077, 8182
|
4806, 6965
|
342, 706
|
8387, 8387
|
2179, 4783
|
11359, 11740
|
1514, 1536
|
7022, 8054
|
8203, 8366
|
6991, 6999
|
8538, 10927
|
10953, 11336
|
1379, 1386
|
1551, 2160
|
266, 304
|
734, 1254
|
8402, 8514
|
1298, 1356
|
1418, 1482
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,195
| 146,447
|
49805
|
Discharge summary
|
report
|
Admission Date: [**2169-6-30**] Discharge Date: [**2169-7-4**]
Date of Birth: [**2102-1-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
pericardial fluid
Major Surgical or Invasive Procedure:
dual chamber pacemaker placement
pericaridal drain
History of Present Illness:
This is a 68 yo M w/ atrial flutter/fibrillation and sinus node
dysfunction that is s/p dual chamber right sided pacemaker
placement on [**2169-6-30**] complicated by perforation of RV. After
placment of pacer patient's blood presure was 75/palpable. The
did an echo that showed pericardial effusion. Tap drained 220cc
and a drain was placed.
.
Patient was diagnosed with atrial flutter on [**2169-3-27**] by EKG in
which he spontaneously converted to sinus rhythm. Atrial
fibrillation was
diagnosed on [**2169-4-27**] by a holter monitor. The patient has been
experiencing shortness of breath with exertion. Patient would
have to stop in the middle of his walk to catch his breath, this
has been occurring for the past several months. He can walk
about 1 block before becoming SOB.
.
Negative except as noted in HPI.
Past Medical History:
1. CARDIAC RISK FACTORS: Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD: s/p pacemaker placement [**2169-6-30**] complicated by
performation of RV
3. OTHER PAST MEDICAL HISTORY:
Paroxysmal Atrial Flutter
Sinus node dysfunction
Hypertension
Cerebral Palsy with right sided weakness
Multiple prior falls; not a candidate for coumadin
Etoh overuse
BPH
Lumbar spinal compression fracture and cervical spondylosis
11 prior corrective surgeries associated with cerebral palsy as
a
child/young adult
Social History:
Lives at home alone. No VNA survices.
Tobacco history: none
-ETOH: 2 beers a day
-Illicit drugs: none
Family History:
Brother died of MI at 48
Father died of MI at 62
Mother died of MI at 64
Physical Exam:
GENERAL: NAD.
HEENT: Conjunctiva were pink, no pallor or cyanosis of the oral
mucosa. No xanthalesma.
NECK: Supple with JVD to mandible
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: CTAB anteriorly, no w/r/r
ABDOMEN: Soft, NTND.
EXTREMITIES: No edema
SKIN: warm
PULSES:
Right: 2+ radial
Left: 2+ radial
Pertinent Results:
Admission labs:
[**2169-6-30**] 07:25AM BLOOD WBC-8.3 RBC-4.81 Hgb-11.1* Hct-35.2*
MCV-73* MCH-23.1* MCHC-31.7 RDW-19.4* Plt Ct-365
[**2169-6-30**] 07:25AM BLOOD PT-12.5 INR(PT)-1.1
[**2169-6-30**] 07:25AM BLOOD Glucose-102* UreaN-22* Creat-1.3* Na-139
K-3.8 Cl-103 HCO3-28 AnGap-12
.
[**2169-6-30**] Echo:
Overall left ventricular systolic function is 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. There is a moderate sized
pericardial effusion. The effusion is echo dense, consistent
with blood, inflammation or other cellular elements.
IMPRESSION: Moderate echodense pericardial effusions. No prior
studies for comparison.
.
[**2169-6-30**] Echo:
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). with normal free wall
contractility. There is a moderate to large- sized pericardial
effusion. The effusion is echo dense, consistent with blood,
inflammation or other cellular elements. There are no
echocardiographic signs of tamponade.
IMPRESSION: Moderate to large echodense pericardial effusion
without echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2169-6-30**],
effusion is larger. Electrophysiology team was made aware of the
findings at the time of the study.
.
[**2169-6-30**] Echo:
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). with normal free wall
contractility. There is a very small pericardial effusion.
IMPRESSION: Successful pericardiocentesis with a very small
residual pericardial effusion.
.
[**2169-6-30**] CXR:
FINDINGS: A pericardial drain is present. Cardiac silhouette is
enlarged,
but is difficult to assess in the absence of a pre-drainage
radiographs for comparison. Permanent pacemaker is in place,
with leads overlying right atrium and right ventricle. Lungs are
clear, and there is no visible
pneumothorax or pleural effusion.
Brief Hospital Course:
67 yo M w/ h/o afib/aflutter and sinus node dysfunction p/w
pericardial bloody effusion caused by RV perforation from
pacemaker placement
.
# Tamponade/Pericardial effusion: Caused by RV perforation of
pacer. A pericardial drain was placed. Pulsus was monitored
and ranged from [**4-18**]. Patient remained hemodynamically stable,
normotensive. A repeat echo on [**7-1**] did not show fluid
reaccumulation and the drain's output diminished. The drain was
removed [**7-1**]. A third echo on [**7-3**] again did not show
reaccumulation of fluid. Echo also showed mild regional LV
systolic dysfunction with anterolateral hypokinsis (EF 50-55%).
.
# Sinus node dysfunction: PPM placed. He was continued on
metoprolol, but amlodipine was held given above.
#. Afib/flutter: Due to several falls patient is not a candidate
for coumadin and is on plavix. His plavix was held given the
pericardial effusion.
- Plavix should be restarted as an outpatient. Patient will
follow up with his cardiologist and PCP.
.
# HTN: Throughout this admission, patient remained normotensive.
His metoprolol was initially held, but then restarted as
patient remained stable. His amlodipine was held and not
restarted on discharge.
- Amlodipine should be restarted as an outpatient.
Medications on Admission:
AMLODIPINE - (Prescribed by Other Provider) - 10 mg Tablet -
one
Tablet(s) by mouth daily
CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - 75 mg
Tablet - one Tablet(s) by mouth daily
FOLIC ACID - (Prescribed by Other Provider) - 1 mg Tablet - one
Tablet(s) by mouth daily
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 50 mg
Tablet Sustained Release 24 hr - one Tablet(s) by mouth daily
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - one Capsule(s) by mouth daily
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
6. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 3 days: Last day [**2169-7-5**].
Disp:*12 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
Pericardial Effusion; Tamponade
Atrial Flutter
Discharge Condition:
A&Ox3
self-ambulatory
Discharge Instructions:
You were admitted to the hospital because of fluid that
collected around your heart after having a pacemaker placed. We
placed a drain to remove this fluid. A repeat echocardiogram
(ultrasound of the heart) showed that the fluid had been removed
and so we pulled this drain.
We have made the following changes to your medications:
1. Stop plavix. Dr. [**Last Name (STitle) 23246**] will let you know when to restart
this medication.
2. Stop amlodipine. Dr. [**Last Name (STitle) 23246**] will let you know when to
restart this medication.
3. Start iron supplements for iron deficiency anemia. You
should follow up with Dr. [**Last Name (STitle) 40075**] regarding this.
4. Start tylenol as needed for pain. Do not exceed 4grams per
day.
5. Start cephalexin. This is an antibiotic. You should take
this up until [**2169-7-10**].
Followup Instructions:
Please follow up with:
1. Cardiology: [**Last Name (LF) **], [**First Name3 (LF) **] [**Telephone/Fax (1) 82868**]. Appointment
date: [**2169-7-12**]:30am
2. PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 40076**]. Appointment date:
Thursday [**2170-7-20**]:45am.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2169-11-25**]
|
[
"423.3",
"427.31",
"427.81",
"427.32",
"334.1",
"280.9",
"721.0",
"E878.1",
"998.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.83",
"37.72",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
7161, 7210
|
4621, 5891
|
332, 384
|
7310, 7334
|
2434, 2434
|
8220, 8701
|
1931, 2006
|
6464, 7138
|
7231, 7289
|
5917, 6441
|
7358, 7663
|
2021, 2415
|
1314, 1446
|
7692, 8197
|
275, 294
|
412, 1234
|
2450, 4598
|
1477, 1794
|
1256, 1294
|
1810, 1915
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,129
| 193,390
|
12955
|
Discharge summary
|
report
|
Admission Date: [**2148-5-26**] Discharge Date: [**2148-6-4**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Cough with sputum
Major Surgical or Invasive Procedure:
Endotracheal intubation and extubation
Femoral central line placement
Arterial line placement
History of Present Illness:
89 yo Male who was recently discharged home from NEBH few days
back with symptoms of URTI. His symptoms did not improve and
began to have productive cough, intially yellowish then
brownish. Denies any chest pain, nausea, vomiting, sweating.
.
ED vitals were 98.3, irregular at 58, 116/58, 18, 96%/4L. CXRAY
showed atypical PNA. Was started on Azithromycin and
Levofloxacin. He was also hyperkalemic to 6.4. He got Calcium
gluconate, Insulin, D50 amp, Kayexalate. His potassium came down
to 5.6.
Past Medical History:
- Congestive heart failure.
- Ischemic cardiomyopathy.
- CAD
- Atrial fibrillation and atrial flutter
- Pseudogout.
- Hyperlipidemia
- Mitral regurgitation
- Tricuspid regurgitation.
Social History:
Lives at home with his wife. Does not smoke or drink
Family History:
NC
Physical Exam:
Vitals: 96.7, 95%/2L, 110/D, 82, 28
GEN: AOx3
HEENT: unremarkable
Neck: JVD to around 8 cms
HEART: S1/S2, irregular rate, no murmurs appreciable
LUNGS: transmitted coarse breath sounds, no crackles
ABDOMEN: soft/NT/ND
EXT: 2+ pedal edema (chronic)
Pertinent Results:
CHEST (PORTABLE AP) [**2148-5-26**]
Slightly limited examination secondary to very low lung volumes.
Bibasilar atelectasis and ill-defined fluffy, patchy opacities
present in the right lung apex could be reflective of an
underlying multifocal process. Atypical infections should be
considered given the right apical finding.
.
[**2148-5-26**] 05:00PM WBC-8.1 RBC-4.25* HGB-13.4* HCT-39.7* MCV-93
MCH-31.4 MCHC-33.7 RDW-15.0
[**2148-5-26**] 05:00PM NEUTS-73.9* LYMPHS-18.5 MONOS-6.8 EOS-0.5
BASOS-0.2
[**2148-5-26**] 05:00PM PLT COUNT-195
[**2148-5-26**] 05:00PM PT-36.2* INR(PT)-4.0*
[**2148-5-26**] 05:00PM GLUCOSE-105 UREA N-58* CREAT-1.9* SODIUM-141
POTASSIUM-6.4* CHLORIDE-106 TOTAL CO2-27 ANION GAP-14
[**2148-5-26**] 07:09PM K+-5.6*
Brief Hospital Course:
ASSESSMENT AND PLAN:
89 yo M with CAD, CHF admitted for community acquired pneumonia
and hyperkalemia; hospital course also complicated by CHF/volume
overload and hypotension requiring short MICU stay.
.
# Hypotension: Following treatment of his pneumonia (see below),
the patient was aggressively diuresed for persistent volume
overload and peripheral edema. During his diuresis, he began to
experience generalized weakness and fatigue. He also developed
acute onset of fever to 103 and hypotension with altered mental
status. He was bolused with fluids and antibiotics were
started. Cultures were also taken. During the acute event he
was intubated for airway protection (altered mental status) and
extubated approximately 12 hours later. His MICU stay was less
than 48 hours. The differential for this acute episode included
sepsis vs. overdiuresis/dehydration. The episode was also
shortly following a traumatic foley insertion for urinary
retention. No source of infection was found (U/A and culture
clean, CXR not showing infiltrate and sputum negative, blood
cultures negative). He had been getting aggressive diuresis
(weight decreased 10 lbs since admission) and it could be
attributed to this. Given no source, his broad spectrum
antibiotics were discontinued. His volume status is currently
stable.
.
# Community acquired PNA: he presented with cough with sputum,
CXR consistent with atypical pneumonia. Levofloxacin course was
completed. He also has some wheezing of unclear chronicity and
was treated with some nebulizer treatments. He will be sent home
with a prescription for albuterol MDI if needed. Oxygen
saturations remained adequate on room air and with ambulation.
A Legionella urinary antigen was also sent and was negative.
.
# Congestive heart failure: presented with elevated JVP to
around 8 cms and [**1-6**]+ bilateral pedal edema. However he showed
no signs of pulmonary edema by exam and CXR. He was
aggressively diuresed as above, leading to hypotension and acute
renal failure. The aggressive diuresis was thus discontinued
and he was stable with continued asymptomatic volume overload
(no pulmonary edema or dyspnea). His med changes included: d/c
of amiodarone and cardizem, start of digoxin. His ACE inhibitor
is also on hold but will likely be restarted as an outpatient as
blood pressure allows. He will be seeing his cardiologist on
Friday to make further medication changes if needed.
.
# CAD: Toprol was continued. Also on statin and nitro patch.
He is not on a daily aspririn, perhaps because he is on
coumadin-this is unclear.
.
# Atrial fibrillation and atrial flutter: rate controlled.
Amiodarone and cardizem were discontinued; metoprolol and
digoxin continued. He is anticoagulated with coumadin.
.
# Renal Failure: baseline creatinine is 1.3 (on NEBH records),
elevated to maximum 2.2 during diuresis which came down with
fluid resuscitation. 1.1 on day of discharge.
.
# Hyperkalemia: K was elevated at admission without significant
ECG changes. He received kayexalate, calcium gluconate, insulin
and glucose. Serial K levels showed improvement and he did not
require further treatment. Most likely this was due to ARF.
.
# Hyperlipidemia: Lipitor was continued.
Medications on Admission:
Cardizem-CD 120 mg p.o. daily
Celebrex 200 mg p.o. daily
Lasix 40 mg p.o. b.i.d.
Folate 1 mg p.o. daily
Lipitor 10 mg p.o. daily
vitamin D 400 units p.o. daily
Nitro-Dur 0.2 mg patch daily remove at night
Coumadin 2 mg p.o. daily
Protonix 40 mg p.o. daily
Mavik 2 mg p.o. daily
Toprol-XL 50 mg p.o. daily
amiodarone 200 mg p.o. b.i.d.
Discharge Medications:
1. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr 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. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Nitroglycerin 0.2 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal Q24H (every 24 hours).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Celebrex 200 mg Capsule Sig: One (1) Capsule PO once a day as
needed for pain.
8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime: Take
your coumadin as per your regular schedule through Dr. [**Name (NI) 39759**] office.
10. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
Disp:*1 * Refills:*0*
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Digoxin 125 mcg Tablet Sig: [**12-5**] (one half) Tablet PO once a
day. Tablet(s)
15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
Community acquired pneumonia
Hyperkalemia
Congestive heart failure
Hypotension
Renal failure
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital because of pneumonia. You
were treated with antibiotics and intravenous fluids. You also
had some problems with low blood pressure while you were here.
.
You should take all of your medications as prescribed and keep
all of your appointments with your doctors.
.
You should return to the hospital if you feel short of breath or
have chest pain, if you have abdominal pain or diarrhea, or if
you have any new symptoms that you are worried about.
.
Please weigh yourself everyday and come to the hospital if your
weight has increased by more than 3 pounds.
.
We have made a few medication changes while you were here. You
should take your medications as prescribed and followup with Dr.
[**Last Name (STitle) 2912**]. He may make other medication changes at your
appointment.
Followup Instructions:
Please see your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2912**], this week
as scheduled. You appointment is [**6-7**] at 10:30 am. Please
keep this appointment.
|
[
"V58.61",
"427.31",
"443.9",
"458.9",
"424.0",
"486",
"712.30",
"425.4",
"397.0",
"428.0",
"788.20",
"272.4",
"275.49",
"414.01",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7393, 7470
|
2255, 5494
|
279, 375
|
7607, 7616
|
1479, 2232
|
8476, 8681
|
1191, 1195
|
5879, 7370
|
7491, 7586
|
5520, 5856
|
7640, 8453
|
1210, 1460
|
222, 241
|
403, 899
|
921, 1105
|
1121, 1175
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,808
| 198,225
|
39999
|
Discharge summary
|
report
|
Admission Date: [**2189-1-5**] Discharge Date: [**2189-1-8**]
Date of Birth: [**2146-12-23**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
found down with large Right head laceration
Major Surgical or Invasive Procedure:
None
History of Present Illness:
42M who was working at a machine factory where he operates some
heavy machinery and was found down by co-workers with a large
right head laceration, and unresponsive. According to ER records
he began vomiting. He was brought to an OSH and where a Head CT
showed a small R frontal IPH. He was given a bolus of Dilantin
and his laceration was sutured. He was transferred to [**Hospital1 18**] for
further evaluation.
Past Medical History:
ADD
Bladder Spasms ?
Seizures that began about 15 yrs ago, but has been sz free for 8
years. Per Mother there was no known cause to his seizure
activity.
Social History:
Divorced, lives with parents and his two children. Works in a
machine factory operating heavy machinery. No tobacco or ETOH.
Marijuana in past about 8 years ago.
Family History:
noncontributory
Physical Exam:
: T: 97.4 BP: 107/69 HR: 82 R 18 O2Sats 96% RA
Gen: Asleep, arouseable but agitated and aggressive when
stimulated. Repeating "leave her alone." Large right head
laceration with sutures. R eye ecchymosis.
HEENT: R head lac
Neuro:
Mental status: Lethargic but arouseable, uncooperative with
exam,
when stimulated he is yelling, aggressive, and agitated.
Orientation: Yells out "Leave her alone." Does not cooperate
with
questions.
Language: Speech fluent
Cranial Nerves:
Unable to fully assess cranial nerves. Pupils are equal and
reactive - 5 to 3 mm. He opens his eyes to noxious stimulus,
yells out, but is uncooperative with exam. Face appears
symmetric.
Motor: He moves all four extremities to noxious stimulus, all 4
extremities appear antigravity. He does give a "thumbs up"
bilaterally on command but follows to other commands.
Sensation: appears intact as patient reacts to noxious stimulus
by yelling to "leave her alone."
Coordination: Unable to assess
DISCHARGE EXAM:
Non-Focal. Laceration clean, dry, intact.
Pertinent Results:
CT HEAD [**1-5**]
1. L frontal IPH, slightly increased in size to 16 x 10 mm
(2;14); subtle
increase in surrounding edema
2. R frontal (2;21) and L occipital (2;19) IPH stable to min
increase in size
CT HEAD [**1-6**]
Stable Contusions with surrounding edema
Transthoracic Echocardiogram [**1-7**]
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). There is no
left ventricular outflow obstruction at rest or with Valsalva.
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 but aortic stenosis is
not present. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is mild posteior
leaflet mitral valve prolapse. Trivial mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal.
IMPRESSION: No structural cardiac cause of syncope identified.
Dilated aortic root. Preserved global and regional biventricular
systolic function.
Carotid ultrsound [**1-6**]: Final read pending. Prelim - no
carotid stenosis or atherosclerosis
EEG - 24hour: NO seizure
Brief Hospital Course:
Patient presented to [**Hospital1 18**] on [**1-5**] from an OSH for further
evaluation and treatment for intraparenchymal hemorrhage and
right sided head laceration. He was initially agitated and
difficult to exam however he was following commands as he was
giving a "thumbs up" bilaterally. Repeat Head CT on admission
showed slight increase in size of contusions with surrounding
edema. He was admitted to the ICU for frequent neurochecks and
blood pressure control.
On the morning of [**1-6**] during rounds he was noted to be much
more alert and was oriented and following commands readily and
so was transfered to the regular floor. As the patient had an
unwitnessed fall and did not recall events surrounding the fall
a syncope and seizure workup was initiated. Neurology was
consulted and recommended 24hour EEG monitering. As part of a
syncope workup EKG, TTE and carotid ultrasound were performed.
None of these tests revealed any explination for the patient's
syncope.
He was seen by PT who determined he was safe to go home without
services. His Dilantin was discontinued, and he was switched to
Keppra 1gm [**Hospital1 **].
On the morning of [**1-8**], he was ambulating independently,
tolerating a general diet, and had good pain controll. He was
discharged to home on [**1-8**].
Medications on Admission:
Strattera 80mg Qday
Oxybutin
Discharge Medications:
1. atomoxetine 80 mg Capsule Sig: One (1) Capsule PO Daily ().
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral Frontal contusions, Left Occipital contusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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.
?????? If you have been discharged on Keppra (Levetiracetam), you
will not require blood work monitoring.
SEEK EMERGENCY EVALUATION IMMEDIATELY IF YOU EXPERIENCE ANY OF
THE FOLLOWING
?????? 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.
[**First Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
Please Schedule an appointment with Dr. [**First Name (STitle) **] and [**Hospital1 656**] to be
seen in [**6-17**] weeks. You should remain on your Keppra until this
appointment. YOu can call ([**Telephone/Fax (1) 79673**] to schedule this
appointment
PLEASE MAKE AN APPOINTMENT TO HAVE YOUR SUTURES REMOVED IN [**7-19**]
DAYS. THIS CAN BE MADE WITH YOUR PRIMARY CARE PHYSICIAN.
Completed by:[**2189-1-8**]
|
[
"873.42",
"348.9",
"E849.3",
"853.16",
"314.01",
"E888.1",
"345.90"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5442, 5448
|
3617, 4923
|
351, 358
|
5546, 5546
|
2272, 3594
|
6755, 7465
|
1176, 1194
|
5003, 5419
|
5469, 5525
|
4949, 4980
|
5697, 6732
|
1210, 1453
|
2209, 2253
|
268, 313
|
386, 802
|
1696, 2193
|
5561, 5673
|
824, 980
|
996, 1160
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,928
| 153,920
|
27460
|
Discharge summary
|
report
|
Admission Date: [**2112-6-2**] Discharge Date: [**2112-6-23**]
Date of Birth: [**2033-5-25**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
Pt presents with recurrent increasing shortness of breath and
was found to have stridor and was urgently transferred to the
Complex Airway Service at [**Hospital1 **].
Major Surgical or Invasive Procedure:
[**6-3**] OR- rigid bronchocscopy w/ ballloon dilitation &
microdebridement
s/p bronchoscopy, tracheal resection and reconstruction ([**6-6**]),
History of Present Illness:
Mrs. [**Known firstname 50528**] [**Known lastname 67192**] was received in urgent transfer on [**6-3**], [**2112**]. This is a 78-year-old female with a recent history of
a four-vessel
CABG with a complicated postoperative course that included
prolonged intubation and tracheostomy from which she recovered
at
a rehabilitation facility. She was found to have a subglottic
stenosis, and a surgical procedure was performed, the details of
which are not available to me. She presents now again with
increasing shortness of breath and was found to have stridor and
was urgently transferred to the Complex Airway Service at [**Hospital1 **]. We performed a rigid endoscopy today and
found
a typical triangular-shaped high-grade tracheal stenosis at the
level of the first and second tracheal ring. There was no
tracheal web per se and the left lateral as well as the
posterior
wall, as well as the posterior membrane were freely mobile. The
lesion is not amenable to endoscopic intervention but does
require surgical resection.
Past Medical History:
Diabetes Mellitus 2, Coronary artery disease s/p Myocardial
infarction s/p Coronary artery bypass graft x4, repair of
ventricular aneurysm compicated by pneumonia and adult
respiratory distress syndrome, Congestive Heart failure, Atrial
fibrillation,hypertension, acute renal failure, chronic renal
insufficiency, hyperthyroidism, depression, gastric esophogeal
reflux disease, peptic ulcer disease, hypercholesterolemia, h/o
syphillis;
high tracheal stenosis s/p tracheal resection and reconstruction
([**6-6**]),
Social History:
Pt is french creole speaking. Lives w/ daughter, [**Name (NI) 67193**]
[**Name2 (NI) 67194**] ([**Telephone/Fax (1) 67195**]- cell/ home-[**Telephone/Fax (1) 67196**]in [**Location (un) **] apt.
Daughter works 6a-2p, Son is w/ her until 12:30 pm. No tobacco
history
Home services w/ VNA from PACE Program, HHA
uses walker and nebulizer
Family History:
Pt has supportive daughter, son and grand-daughter
Physical Exam:
General: She is an overweight elderly female who is
anxious presently and on heliox. She is placed with on heliox
overnight due to severe stridor and dyspnea, which was felt to
be
anxiety provoked.
VS: 98.2, 68 SR, 120/51, 29, sat 99% on 6 liters with heliox.
HEENT: PERRLA. Sclerae are anicteric. Cervical exam, there is
no
supraclavicular or cervical adenopathy. Her cervical exam
reveals a relatively short neck with a tracheostomy scar just
above the sternal notch below
the cricoid where we previously witnessed a rigid bronchoscopy
by
Dr. [**Last Name (STitle) **], which places the region just below the cricoid and
measuring less than 1 cm in width.
Lungs: Clear to auscultation.
Chest: Thorax is symmetrical without lesions, masses. She has a
well-healed
sternotomy scar. She is stridorous with a respiratory rate of
29.
Cor: Heart is regular without murmur.
Abd: abdomen is benign without masses or tenderness.
Extremities show no clubbing or edema.
Neurologic is grossly nonfocal with intact and appropriate
mental
status, although she is anxious.
Pertinent Results:
CXR [**2112-6-19**]: Moderate-to-severe cardiomegaly and borderline
interstitial edema are unchanged. There is no pneumothorax or
appreciable pleural effusion.
Cardiology Report ECG Study Date of [**2112-6-15**] 9:09:40 AM
Sinus rhythm. Borderline first degree A-V block. Borderline left
axis
deviation with possible left anterior fascicular block. Lateral
myocardial
infarction. Possible old inferior wall myocardial infarction.
Compared to the
previous tracing of [**2112-6-6**] multiple abnormalties persist and
there is no
significant diagnostic change.
ECHO:
Conclusions: [**2112-6-14**]
The left atrium is moderately dilated. There is moderate
symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is
moderately depressed (ejection fraction 30-40 percent) secondary
to extensive severe apical hypokinesis. An apical left
ventricular mass/thrombus cannot be excluded. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
Brief Hospital Course:
79 y/o female w/ Hx CAD, CABG x4, complicated by pna and ARDS
requiring prolonged intubation and tracheostomy ([**2111-11-4**])
admitted to [**Hospital6 28728**] Center w/ severe SOB and chest
pain. Found to have tracheal stenosis and transferred to [**Hospital1 18**]
ICU [**2112-6-2**] for evaluation and treatment.
[**2112-6-3**]- OR for rigid bronch ([**Name8 (MD) 67197**] MD) for the purposes of
tracheal ballon dilation to 12mm and microdebridement of complex
subglottic stenosis of trachea of the first and second ring
which requires surgical resection and repair.
[**2112-6-6**]-tracheal resection and recontruction on [**2112-6-6**] by [**First Name4 (NamePattern1) 951**]
[**Last Name (NamePattern1) 952**], MS.
Febrile 101 post-op and started on antibiotics of levo, kefsol,
flagyl, zosyn [**Date range (1) 33871**].
Bronchoscopy x3 post-op for secretions clearance and evaluation
of anastamosis ([**6-8**], [**6-14**] and [**6-17**]). Course compicated by
respiratory distress requiring reintubation [**2112-6-8**] for upper
airway stridor/ tracheal edema and remained intubated x5 days
until tracheal edema subsided and diuresed. Pt extubated [**2112-6-14**]
and reintubated urgently for secretion/mucoous plugging. Bronch
done for secretion clearance. Pt sedated, rested,diuresed and
r/o MI for hypotension w/ intubation. Pt r/o'd, pulse dose
steroids [**6-16**] in preparation for successful wean and extubation
[**2112-6-17**]. Bronch pre-extubation w/ min secretions and good
anastamosis. Pt remained in ICU for close monitoring, doboff
placed for nutritional support in preparation for swallow eval
[**6-21**]- passed- ground solids, thin liquids, doboff d/c. Physical
Therapy consulted for evaluation and treatment.
Transferred to floor [**2112-6-19**]. Sitter for patient while on floor
to maintain safety of lines and tubes.
[**6-21**]- Antbiotics d/c after 10 day course.
Physical Therapy following patient, now ambulating w/o
difficulty on room air. Disposition planning initiated and PT
evaluation indicates pt sfe to reutrn home w/ daughter.
[**Date range (1) **]- PT and nursing increasing ambulation frequency. Cane
added for support and balance w/ improved steadiness in gait.
PT approved home discharge. Pt discharged in stable condition to
home w/ daughter accompanied by daughter. Services provided by
VNA Pace in pt local area.
Medications on Admission:
lasix 60', enalapril 20'', lipitor 10', paxil 10', norvasc10',
prilosec 20', ASA 325', zantac 150', colace, FeSO4, combivent
INH.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q2-3H (every 2-3 hours) as needed.
Disp:*1 1* Refills:*0*
6. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q2-3H (every 2-3 hours) as needed.
Disp:*1 1* Refills:*1*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
8. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*1*
9. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*1*
10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*1*
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
13. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed.
Disp:*50 50* Refills:*1*
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
Disp:*100 100* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
School of Pace Program
Discharge Diagnosis:
Diabetes Mellitis 2, Coronary artery disease s/p Myocardial
infarction s/p Coronary artery bypass graft x4, repair of
ventricular aneurysm compicated by pneumonia and adult
respiratory distress syndrome, Congestive Heart failure, Atrial
fibrillation,hypertension, acute renal failure, chronic renal
insufficiency, hyperthyroidism, depression, gastric esophogeal
reflux disease, peptic ulcer disease, hypercholesterolemia, h/o
syphillis;
high tracheal stenosis s/p tracheal resection and reconstruction
([**6-6**]),
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Name (NI) 1816**]/ Thoracic Surgery office ([**Telephone/Fax (1) 170**]) for:
fever, shortness of breath, chest pain, difficulty getting
secretions up w/ coughing.
Take medication as stated on discharge instructions.
Ambulation 3-4 times per day for 15-20 minutes each episode.
Continue w/ your walking and exercises ongoing.
Followup Instructions:
Call Dr.[**Name (NI) 1816**]/ Thoracic Surgery office ([**Telephone/Fax (1) 170**]) for an
appointment in 14 days.
Completed by:[**2112-6-24**]
|
[
"428.0",
"278.00",
"478.74",
"E912",
"244.9",
"518.81",
"519.02",
"519.1",
"250.00",
"478.6",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22",
"96.05",
"33.24",
"96.04",
"31.99",
"96.72",
"31.79",
"31.42",
"96.6",
"38.93",
"31.5"
] |
icd9pcs
|
[
[
[]
]
] |
9283, 9336
|
5190, 7552
|
496, 643
|
9894, 9900
|
3764, 5167
|
10285, 10430
|
2611, 2663
|
7732, 9260
|
9357, 9873
|
7578, 7709
|
9924, 10262
|
2678, 3745
|
289, 458
|
672, 1703
|
1725, 2242
|
2258, 2595
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,040
| 121,280
|
26254
|
Discharge summary
|
report
|
Admission Date: [**2163-11-25**] Discharge Date: [**2163-12-15**]
Date of Birth: [**2097-3-18**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 15344**]
Chief Complaint:
Fever and abdominal pain.
Major Surgical or Invasive Procedure:
1. Sigmoid colectomy/Low anterior resection with end colostomy
and Hartmann's procedure.
2. Feeding jejunostomy
3. Wound re-exploration
History of Present Illness:
66 F with known metastatic renal cell carcinoma, was admitted on
[**2163-11-25**] with fever and worsening abdominal pain. She had been
scheduled for a left debulking nephrectomy on [**2163-11-28**].
Past Medical History:
1. emphysema/COPD
2. osteoporosis
3. fibrocystic breasts
4. s/p appendectomy
5. s/p ovarian cystectomy
6. s/p shoulder surgery
7. stage IV renal cell carcinoma
Social History:
non-contrib
Family History:
non-contrib
Physical Exam:
Temp 98.2, HR 104, BP 118/60, RR 16, SaO2 94% on 3 liters NC.
Gen: A&O x3, comfortable.
Chest: CTA bilaterally, slightly diminished bases. Mildly
tachycardic, S1 S2.
Abdomen: Incision c/d/i. Soft, non-tender, mildly distended.
Extremities: 1+ pedal edema, improving.
Pertinent Results:
[**2163-12-15**] 06:15AM BLOOD WBC-13.5* RBC-2.79* Hgb-7.7* Hct-23.2*
MCV-83 MCH-27.5 MCHC-33.0 RDW-14.8 Plt Ct-449*
[**2163-12-15**] 06:15AM BLOOD Neuts-90.1* Lymphs-5.8* Monos-3.1 Eos-1.0
Baso-0.1
[**2163-12-15**] 06:15AM BLOOD Hypochr-1+
[**2163-11-25**] 04:30PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2163-12-15**] 06:15AM BLOOD Plt Ct-449*
[**2163-12-15**] 06:15AM BLOOD Glucose-126* UreaN-21* Creat-0.4 Na-139
K-3.8 Cl-102 HCO3-32 AnGap-9
[**2163-12-13**] 05:57AM BLOOD ALT-13 AST-18 AlkPhos-130* Amylase-132*
TotBili-0.2
[**2163-12-13**] 05:57AM BLOOD Lipase-87*
[**2163-12-15**] 06:15AM BLOOD Calcium-8.1* Phos-3.6 Mg-1.6
Brief Hospital Course:
Ms. [**Known lastname 42326**] was admitted on [**2163-11-25**] to the urology service under
the care of Dr. [**Last Name (STitle) 4229**]. A CXR showed a left pleural effusion and
LLL atelectasis. She was placed on Zithromax for a presumed LLL
pneumonia. Over the next 2 days, her blood cultures from the ED
grew gram negative rods. Gentamycin was added, and plans for the
OR were cancelled. A medicine consult was obtained to help work
up her bacteremia, continued tachycardia, new hypoxia on RA, and
ongoing emesis. A CTA of her chest showed no evidence of a PE
but increasing bilateral pleural effusions. On [**2162-11-29**], Ms.
[**Known lastname 65022**] care was transferred to the medical service due to her
multiple medical problems.
Surgical consultation was obtained for abdominal distension
and pain. CT scan confirmed a colonic perforation with stool
and PO contrast in the abdominal cavity. After much
deliberation by the patient and family, it was decided to
undergo operative intervention. The patient was brought
emergently to the operating room and had a sigmoid colectomy/LAR
with end colostomy and Hartmann's procedure and jejunal feeding
tube placement. For details of this, please see the previously
dictated operative note.
Post-operatively, the patient did well and remained in the ICU
for vent weaning. On post-operative day #2, the patient was
noted to have copious serous drainage from the inferior aspect
of her wound. The wound was locally explored and fascia was
intact. Continued drainage, however, prompted re-evaulation of
the entire wound in the operating room which was found to be
intact. For details of this, please see the previously dictated
operative note.
Otherwise, the patient had a fairly unremarkable hospital
course. She extubated uneventfully and was transferred to the
floor. She tolerated jejunal tube feeds and bedside and video
swallow evaluation showed some risk of aspiration which is
controlled via chin tuck maneuver. The stoma is healthy and
functions well. IV antibiotics were continued for a two week
course, and transitioned to PO for an additional one week.
Neuro: fentanyl patch, Roxicet elixir for pain control
Respiratory: Mucomyst nebs to help mobilize secretions,
humidified O2 for comfort
CV: Lopressor for beta-blockade, although she has been
persistently tachycardic pre and post-op
GI: tube feeds for nutritional support, ground solids/thin
liquids per nutritional recommendation
GU: Lasix for diuresis of peri-op fluids, continue to re-assess
need
Heme: hematocrit stable at 24
ID: Levaquin, fluconazole and Flagyl to continue for one week
Endocrine: insulin sliding scale for glucose control
Medications on Admission:
Ativan 0.5"' prn, percocet prn, morphine IR 15"
Discharge Medications:
1. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) Nasal DAILY (Daily).
2. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q4-6H (every 4 to 6 hours) as needed.
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Six
(6) Puff Inhalation Q4H (every 4 hours) as needed.
4. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl
Ophthalmic PRN (as needed).
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for anxiety.
8. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days: total of seven days - last doses on
[**2163-12-20**].
11. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 7 days: total of seven days - last doses on
[**2163-12-20**].
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO DAILY (Daily) for 7 days:
hold for K>4.5
- while pt. taking lasix .
14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): for a total of seven days - last doses to be given
on [**2163-12-20**].
15. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscell. Q6H (every 6 hours) as needed.
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Sigmoid-rectal perforation. Stage IV renal cell carcinoma.
Discharge Condition:
Stable.
Discharge Instructions:
around feeding tube site, or any other concern
- pt. may eat a ground food and thin liquids diet; taking 2 sips
of fluid between each bite of food and tucking chin when
swallowing liquids.
- repeat video swallow evaluation should be obtained in 2 weeks
time
- Pt. should resume home medications
- Pt. may take a sponge bath
- dressing over central line site may be removed [**2163-12-16**]
- [**Name8 (MD) 138**] MD or return to ER if T>101.5, chills, nausea, vomiting,
chest pain, shortness of breath, erythema/pus around feeding
tube site, or any other concern
- Patient has been been on Lasix for diuresis of peri-operative
fluids. Please continue to assess need for ongoing diuresis.
Followup Instructions:
pt. should call Dr.[**Name (NI) 30985**] office at ([**Telephone/Fax (1) 10820**] to set up
a follow-up appointment in 2 weeks time.
Completed by:[**0-0-0**]
|
[
"562.10",
"496",
"790.7",
"733.00",
"196.2",
"568.0",
"189.1",
"273.8",
"197.6",
"707.05",
"428.0",
"518.5",
"567.21",
"998.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.59",
"96.04",
"96.6",
"46.73",
"96.72",
"88.73",
"54.12",
"99.15",
"46.39",
"38.93",
"48.62",
"86.09"
] |
icd9pcs
|
[
[
[]
]
] |
6545, 6624
|
1976, 4660
|
351, 488
|
6728, 6738
|
1262, 1953
|
7475, 7635
|
945, 958
|
4758, 6522
|
6645, 6707
|
4686, 4735
|
6762, 7452
|
973, 1243
|
286, 313
|
516, 717
|
739, 900
|
916, 929
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,434
| 125,597
|
54328
|
Discharge summary
|
report
|
Admission Date: [**2117-6-13**] Discharge Date: [**2117-6-24**]
Date of Birth: [**2061-3-27**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
[**2117-6-18**] Open reduction, internal fixation left acetabular
fracture with 7.3-mm screws.
History of Present Illness:
53M s/p fall while trimming tree (10-15ft) fell on base of tree.
?LOC, complaining of L hip and L chest pain. Injuries: ribs [**2-5**]
frx, grade I splenic lac x 2 .comminuted L pelvic/femur fx. with
active extrav.
Past Medical History:
Hep C Cirrhosis (Child-[**Doctor Last Name 14477**] score 8 = class B)
Social History:
Family reported that they live in [**Location (un) 1411**]
and pt works as a Real Estate Appraiser. Wife reported that
earlier today pt was standing on a ladder cutting tree limbs
when
one of the limbs fell off and hit the ladder causing pt to loose
his balance and fall to the ground. Family recounted how
relieved they were that pt did not hit the concrete when he fell
to the ground.
Physical Exam:
Discharge Physical Exam
Expired; no carotid/vemoral pulses, no heart sounds audible, no
respirations auscultated
Pertinent Results:
[**2117-6-13**] 12:55PM FIBRINOGE-61*
[**2117-6-13**] 12:55PM PLT SMR-VERY LOW PLT COUNT-71*
[**2117-6-13**] 12:55PM PT-18.6* PTT-43.6* INR(PT)-1.7*
[**2117-6-13**] 12:55PM WBC-5.6 RBC-3.60* HGB-12.9* HCT-37.6*
MCV-104* MCH-35.9* MCHC-34.4 RDW-16.9*
[**2117-6-13**] 12:55PM freeCa-1.08*
[**2117-6-13**] 12:55PM HGB-13.9* calcHCT-42 O2 SAT-78 CARBOXYHB-2
MET HGB-0
[**2117-6-13**] 12:55PM GLUCOSE-104 LACTATE-2.9* NA+-143 K+-3.3*
CL--106 TCO2-26
[**2117-6-13**] 12:55PM PH-7.33* COMMENTS-GREEN TOP
[**2117-6-13**] 12:55PM ASA-NEG ETHANOL-73* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2117-6-13**] 12:55PM ALBUMIN-2.6*
[**2117-6-13**] 12:55PM LIPASE-169*
[**2117-6-13**] 12:55PM ALT(SGPT)-45* AST(SGOT)-104* ALK PHOS-121*
TOT BILI-2.3*
[**2117-6-24**] 09:05AM BLOOD WBC-11.2* Hct-23.0* Plt Ct-39*
[**2117-6-24**] 04:16AM BLOOD Hct-22.5*
[**2117-6-24**] 01:47AM BLOOD WBC-11.1* Hct-21.5* Plt Ct-42*
[**2117-6-24**] 09:05AM BLOOD Plt Ct-39*
[**2117-6-24**] 09:05AM BLOOD PT-46.1* PTT-87.7* INR(PT)-5.2*
[**2117-6-24**] 09:05AM BLOOD Glucose-77 UreaN-70* Creat-2.5*# Na-145
K-4.2 Cl-108 HCO3-23 AnGap-18
[**2117-6-24**] 01:47AM BLOOD Glucose-123* UreaN-63* Creat-1.2 Na-143
K-4.0 Cl-106 HCO3-22 AnGap-19
[**2117-6-24**] 01:47AM BLOOD ALT-28 AST-114* AlkPhos-63 TotBili-62.1*
DirBili-42.0* IndBili-20.1
[**2117-6-23**] 02:02AM BLOOD ALT-32 AST-113* AlkPhos-74 TotBili-56.4*
DirBili-39.6* IndBili-16.8
[**2117-6-13**] 12:55PM BLOOD ASA-NEG Ethanol-73* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
[**6-13**] IR for embolization. (10 hrs), rec'd 3 units FFP and 3
units PRBC. multiple int and ext iliac branches on left with
active extrav. treated with gel foam slurry and coils. At end of
procedure single small site of bleeding still seen unable to
access on left. Also had some cross filling to this site of
right int iliac (likley obturator) branch. If still unstable and
bleeding not controlled, can re attempt tomorrow (got high dye
load during todays procedure). right groin closed with angioseal
and held pressure.
[**6-14**]: intubated, R IJ CVL placed
[**6-14**] 2330: coags up, hct down, tachy. given FFP x 2, RBCs x 1.
[**6-15**]: started TF, held for residuals; hct stable anemia 22.5;
[**6-16**]: TLS spine clear per trauma, failed trial of PS
[**6-17**]: extubated, doing well, started on reglan and e-mycin
[**6-19**]: Started on Lasix drip, and Albumin x3 doses, free water
D5W 60cc/h
[**6-20**]: Free water increased to 85 cc/hr, then to 110 cc/hr, then
to 125cc/hr for persistently rising Na. Persisent Jaundice, AMS.
[**6-21**]:Added 200mL free water in NGT q6, Na improving to 150 from
153; continued lasix gtt, albumin TID; started on bowel regimen
[**6-22**]: Hepatology input No transplant; Vit K; TF ; Added
Rifaximin; Albumin d/ced; U/S no tappable fluid
[**6-23**]: In evening, UOP trended down to minimal, Cr 1.2 from 0.6.
Lasix gtt dc'ed, Albumin 500 cc given. post-pyloric feeding tube
placed.
[**6-24**]: significant deterioration, made CMO, lost vital signs,
labored respirations, expired roughly 2:30PM
Discharge Medications:
-
Discharge Disposition:
Expired
Discharge Diagnosis:
Death secondary to hepatic failure exacerbated by pelvic
fracture with hemorrhage and 'shock liver'.
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2117-6-24**]
|
[
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icd9cm
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,899
| 138,319
|
30153
|
Discharge summary
|
report
|
Admission Date: [**2124-2-6**] Discharge Date: [**2124-2-10**]
Date of Birth: [**2061-7-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
hypotension, afib with RVR
Major Surgical or Invasive Procedure:
BIPAP, central line placement (left IJ)
History of Present Illness:
62M h/o CAD, s/p MI [**2122**], IDDM, ESRD, s/p failed xplant [**2117**],
HTN, hyperlipidemia presented from OSH with hypotension and
hypothermia presumed [**1-7**] septic physiology.
.
Pt was in USOH until 7pm [**2124-2-5**], when pt felt acutely SOB at
rehab, was found to be in afib with RVR rate 156. No chest pain,
no palpitations, no dizziness, no lightheadedness. no fevers, no
chills, + SOB, but no cough, no sputum production reported. Pt
was given morphiine lasix, NTG, morphine and O2 and xferred to
[**Hospital3 **].
.
At [**Hospital3 **], afib with RVR. Given Ceftaz and timentin at [**Hospital **] hosp. taken to [**Hospital3 **], dx'd with pulm edema, rate
controlled with IV dilt, given asa, started on bipap for low O2
sat (90% on NRB) hypotensive to 70s after given IV dilt, started
on neosynepherine. BNP > 5000. Rate controlled with IV
diltiazem, but remained neo dependent, on bipap, O2 sats 98%. Pt
left [**Hospital3 **] 2301 with BP 102/55, HR 88, RR 26 on BIPAP,
medfligted to [**Hospital1 18**] ED. Interestingly enough, first transfer was
requested to [**Hospital **] for workup of ST elevations--no Beds at
STE's, Dr. [**Last Name (STitle) 3271**] accepted the patient to [**Hospital1 18**].
.
Medflighted to [**Hospital1 18**] ED, code sepsis called, inital BP 85/60;
levophed started, CVP 11, no IVF given, Pt was hypothermic by
rectal temp (96.8), warming blanket placed. levophed titrated up
to 0.15mcg/kg/min with pt continuing to be diaphoretic and
hypothermic, but NAD, and no resp distress. FS glucose 155.
a-line placed. not given any antibiotics in the ED. Admitted to
[**Hospital Unit Name 153**] on levophed gtt, bp 130/62; MAP 69, RR 10, O2 sat 100%NRB,
CVP 12; ScvO2 93%. EKG done in ED showing afib rate 90, L axis,
STE's 1mm V1, 2mm V2, 1mm V3, ST dep, i, avl v5, v6. PT is
asymptomatic. No cough, no SOB, no chest pain, no fevers (but
feels warm), no chills, no dizziness, no lightheadedness, no
abdominal pain, no back pain, no dysuria (although pt does not
make urine)
Past Medical History:
ESRD on HD TIW--MWF, last HD on Friday.
s/p failed kindey xplant [**2117**] at [**Hospital1 2177**], formerly on
immunosuppressives.
anemia (unknown baseline hct)
IDDM
Hypercholesterolemia
Pulm Edema assoc with afib + RVR [**2123-7-6**], hospitalized at [**Hospital1 2177**]
CAD s/p CABG
weight 165lbs
BPH
depression
GERD
HTN
Achilles tendonitis, s/p cortisone injections
CAD, s/p CABG
infected diabetic wound ulcer R shin
PVD
atrial fibrillation, on coumadin, coumadin started 2-3wks ago at
[**Hospital1 **], had episodes of afib in the past, not clear if
chronically in afib or not.
Social History:
divorced. retired [**Hospital Ward Name **] from Shaw's. Does not smoke cigarettes
or use EtOH. Daughter provides family support. Previous care at
[**Hospital1 2177**].
Family History:
NC
Physical Exam:
VS: Temp: 96.5 , T min 96.4 BP:115 / 58 HR: 76 (off pressor) RR:
O2sat 100% 2L NC
GEN: pleasant, comfortable, NAD
HEENT: LIJ precep catheter in place. PERRL, EOMI, anicteric,
MMM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: crackles [**12-7**] way up, bronchial breath sounds R base
CV: irregular, normal S1 and S2, 2/6 systolic murmur best heard
at apex.
ABD: nd, +b/s, soft, nt, pelvic mass palpable (transplanted
kidney).
EXT: no c/c/e. R leg is in an ace wrap [**1-7**] previous recent skin
grafting done at ? [**Hospital6 **] last week.
SKIN: no rashes/no jaundice
NEURO: AAOx3. Cn II-XII intact. .
Pertinent Results:
[**2124-2-6**] 12:31AM GLUCOSE-153* UREA N-38* CREAT-4.5* SODIUM-135
POTASSIUM-6.3* CHLORIDE-96 TOTAL CO2-24 ANION GAP-21*
[**2124-2-6**] 12:31AM CALCIUM-8.8 PHOSPHATE-4.9* MAGNESIUM-2.8*
[**2124-2-6**] 02:15AM ALT(SGPT)-10 AST(SGOT)-15 CK(CPK)-11* ALK
PHOS-64 AMYLASE-29 TOT BILI-0.4
[**2124-2-6**] 02:15AM LIPASE-19
[**2124-2-6**] 12:41AM LACTATE-1.5 K+-5.3
.
[**2124-2-6**] 12:31AM WBC-10.9 RBC-4.01* HGB-10.3* HCT-34.9* MCV-87
MCH-25.7* MCHC-29.6* RDW-19.2*
[**2124-2-6**] 12:31AM NEUTS-89.4* BANDS-0 LYMPHS-5.6* MONOS-4.1
EOS-0.3 BASOS-0.6
[**2124-2-6**] 12:31AM PLT SMR-NORMAL PLT COUNT-331
.
[**2124-2-6**] 12:31AM PT-17.6* PTT-30.2 INR(PT)-1.6*
.
[**2124-2-6**] 02:15AM CORTISOL-29.5*
TSH 3.7
.
[**2124-2-6**] 02:15AM CK-MB-NotDone cTropnT-0.37*
[**2124-2-6**] 09:09AM CK(CPK)-13*
[**2124-2-6**] 09:09AM CK-MB-2 cTropnT-0.29*
[**2124-2-6**] 04:34AM proBNP-GREATER THAN [**Numeric Identifier **]
.
[**2124-2-6**] 06:55AM TYPE-ART TEMP-36.9 PO2-149* PCO2-39 PH-7.45
TOTAL CO2-28 BASE XS-3 INTUBATED-NOT INTUBA
.
BLOOD CX: NO GROWTH TO DATE
.
EKG:
Atrial fibrillation with a controlled ventricular response. ST
segment
elevations in leads VI-V3 up to four millimeters raising concern
of acute
evolving anteroseptal myocardial infarction. Possible prior
inferior wall
myocardial infarction. Intraventricular conduction delay. Left
ventricular
hypertrophy. Inferolateral non-specific ST-T wave changes. No
previous tracing available for comparison.
.
A single AP view of the chest is obtained [**2124-2-6**] at 14:05 hours
and is compared with the prior radiograph performed the same
morning at 08:40 hours. Allowing for technical changes, there is
likely no significant change in the appearances previously
described with bilateral interstitial and alveolar opacities,
more marked on the right side and consistent with asymmetric
edema or fluid overload. Tubes and lines are unchanged.
Left-sided pleural effusion unchanged.
.
AP UPRIGHT CHEST: The patient is status post median sternotomy
and CABG. The tip of a right subclavian dual lumen central
venous catheter terminates in the mid right atrium. The heart
size is top normal. The vascular pedicle width is increased well
as the caliber of the pulmonary vasculature. There is perihilar
haziness as well as patchy aveolar opacities consistent with
moderate interstitial pulmonary edema. Slightly more confluent
opacities are present in the right infrahilar region. No
pneumothorax is identified. A small left pleural effusion is
likely
IMPRESSION: Moderate pulmonary interstitial edema. More
confluent right infrahilar opacity may be due to dependent edema
or a superimposed process such as acute aspiration.
.
ECHO:
The left atrium is moderately dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). Left ventricular wall thicknesses and cavity
size are normal. There is mild to moderate regional left
ventricular systolic dysfunction with focal hypokinesis of the
basal half of the inferior wall and distal anterior wall and
apex. The remaining segments contract well. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). 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
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction
c/w
multivessel CAD. Mild mitral regurgitation. Left ventricular
diastolic
dysfunction.
Brief Hospital Course:
#) Atrial fibrillation with rapid ventricular response: Beta
blocker increased for rate control. Patient restarted on
coumadin and is therapeutic. Rate has been well controlled on
current regimen.
.
#) Pneumonia: Patient had a fever in the setting of hypoxia and
cough. He was started on levofloxacin/vancomycin and has
defervesced. Plan for a total 7 day treatment course. He is up
to date on his vaccinations and is now stable on room air.
Blood cultures no growth to date, including off hemodialysis
line.
.
#) CHF exacerbation: Patient has a history of similar
exacerbations in the setting of afib with RVR. He has had fluid
taken off with hemodialysis and received BIPAP for support. He
is now stable on room air but has persistent bilateral crackles
[**12-8**] way up. He was started on hydralazine while in house for
improved afterload reduction and is on a nitrate.
.
#) Hypotension: Resolved. Suspect this was iatrogenic due to
multiple vasodilatory agents given in the setting of his flash
pulmonary edema.
.
#) CAD: Positive troponin leak, likely demand ischemia in the
setting of his hypotension. No complaints of chest pain. CK's
flat. + EKG changes. Recommend outpatient follow-up to
consider a stress. Patient on aspirin, statin, BB, and
hydral/nitrate.
.
#) LLE wound. S/p skin grafts for ulcers at [**Hospital3 **]
hospital. Bandaged. Dressing due to be changed tomorrow, per Dr.
[**Last Name (STitle) 71857**] ([**Telephone/Fax (1) 10382**])
.
#) ESRD. Completely anuric. Initially started on CVVHD for
volume issues in the setting of low blood pressure but is now
tolerating his regular hemodialysis sessions. He was continued
on his outpatient regimen.
.
#) DM: Fingersticks good, cont ISS. No standing basal insulin
needed. Restart lantus 20 U SQ qd if continuous sliding scale
requirements.
.
#) Hyponatremia. Resolved with fluid restriction and dialysis.
.
#) FEN: renal/DM diet, 1.5 L fluid restricted.
#) CODE: DNR/DNI
#) Ppx: ppi, pneumoboot
#) Access: L IJ - d/c prior to discharge, R A line - d/c prior
to d/c, right chest wall indwelling dialysis catheter
#) Comm: [**Name (NI) **], [**Name (NI) 6177**] [**Telephone/Fax (1) 71858**]
#) DISPO: discharged back to [**Hospital1 **] House
Medications on Admission:
flomax 0.4mg qd
pyridium 100 [**Hospital1 **]
latus 20sc q am
calcitrol 0.25 mch qd
lopressor 25 qd hold AM's of dialysis
imdur 30qd
nephrocaps
protonix 40
levaquin indefinitely 500 mg orally q 48hrs
percocet PRN severe pain
benadryl 25mg po q6h prn
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
4. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
5. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
6. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
8. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
11. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous QHD (each hemodialysis) for 3 days.
12. humalog insulin sliding scale
1 injection qid:prn
**see sliding scale
13. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
primary:
atrial fibrillation with rapid ventricular response
pneumonia, bacterial
congestive heart failure exacerbation
demand ischemia, recommend outpatient follow-up to consider
stress
hypotension, iatrogenic
secondary:
history of right lower extremity wound
end stage renal disease
type 2 diabetes, poorly controlled with complications
chronic anemia
Discharge Condition:
good: blood pressure stable, stable on room air, afebrile, rate
controlled
Discharge Instructions:
Please monitor for temperature > 101, shortness of breath or
hypoxia, coughing/aspiration, decreased mental status, or other
concerning symptoms.
Followup Instructions:
Please call to schedule follow-up with Dr. [**First Name8 (NamePattern2) 7306**] [**Last Name (NamePattern1) 71859**] within
1-2 weeks to follow-up this hospital admission. Phone: ([**Telephone/Fax (1) 71860**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,829
| 118,249
|
767
|
Discharge summary
|
report
|
Admission Date: [**2130-5-11**] Discharge Date: [**2130-6-2**]
Date of Birth: [**2057-7-28**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Interferons / Latex
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Altered mental status and hypotension/Pneumonia
Major Surgical or Invasive Procedure:
[**2130-5-15**]: Paracentesis
[**2130-5-16**]: Orthotopic Liver transplant
[**2130-5-23**]: Post pyloric feeding tube placement
[**2130-5-23**]: Flexible Bronchoscopy
[**2130-5-24**]: Pleural tap; ultrasound guided right pleuracentesis
[**2130-5-31**]: Post pyloric feeding tube placement
History of Present Illness:
72 year old female with ESLD [**12-27**] HCV cirrhosis admitted to
MICU with AMS and sepsis. Patient was noted to be minimaly
responsive by her family at home and brought to ED where whe was
febrile to 101.4 (103.2 rectal) and developed hypotension to
SBP=70s. Pressors were intiated after IVF rescusitation failed
to improve her hypotension. A paracentesis performed showing
4550 WBC with 72% PMNs. Vanco and zosyn were initiated. CXR
showing infiltrate as well. AMS improved per family. Overnight
neo was added to levophed for her hypotension. She has been
oliguric with urine output of [**9-13**]/hr with an elevated
creatinine. Blood cultures have grown GNR. WBC is 10.9K with 7
bands.
Patient currently comfortable, states her pain is intermittent,
now s/p travel to CT scan she feels a bit more pain than before
going to CT. No nausea or vomiting. She gives a history of a
1-2 days of epigastric pain and intermittent fevers/chills
(unmeasured). States her abdominal girth is increasing and her
clothes aren't fitting. She had a recent admission [**Date range (1) 5568**] for
abdominal pain with negative w/u. No h/o nausea, vomiting,
BRBPR,
black or tan stools. Loose stools at baseline on lactulose. Of
note, aldactone dose recently doubled [**5-3**] for chronci LE edema
and ascites.
Review of systems:
(+) Per HPI Also rt leg intermittent weakness recently
(-) Denies headache, sinus tenderness, congestion. Denies cough,
shortness of breath, or wheezing. Denies chest pain, chest
pressure, palpitations. Denies nausea, vomiting, constipation,
melena, hematochezia, or other changes in bowel habits. Denies
dysuria, frequency, hematuria or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
- ESLD / hep C cirrhosis: believes she acquired Hep C from
needlestick while working as nurse. Failed 2 courses of IFN
therapy. On liver transplant list. Likely past episodes of
hepatic encephalopathy. EGD [**3-/2128**] showed [**12-28**] columns of grade 1
varices.
- Hepatocellular carcinoma (1.8 x 1.6cm on imaging [**11-1**]),
underwent Cyberknife treatment in [**Month (only) **]/[**2128**]
- Single seizure: First ever seizure [**9-/2128**] with preceding sx
of confusion, urinary incontinence. Workup negative. On Keppra
since discharge.
- Diabetes [**10-2**]: FS found to be in high 200's during last
hospitalization. [**Last Name (un) **] consulted, recommended tx'd as if type
- Anti-islet cell, anti-insulin, anti-GAD antibodies negative,
c-peptide WNL.
- Anemia: Baseline Hct ~30. Per pt, anemia due to IFN therapy.
MCV 106.
- Thyroid nodules: All features benign imaging [**9-1**]
- Gastroesophageal reflux diease
- Osteopenia: Worst t-score -1.2 on BMD [**8-2**]
- Essential tremor
- PUD: s/p gastric polypectomy, subtotal gastrectomy
- Cholelithiasis
- S/p b/l salpingo-oopherectomy for cysts [**2126**]
Social History:
She used to work as a nurse. She is divorced with 2 children.
She smoked one-half pack per day for 15 years and stopped 20
years ago. She does not drink alcohol.
Family History:
Mother died of pancreatic cancer, father died of cancer of
unknown type of cancer. Siblings in good health except for one
brother who died of alcohol cirrhosis. No FH of IDDM.
Physical Exam:
97.4 78 105/51 19 97% NC
A&Ox3 but slow speech pattern, appropriate responses, follows
commands appropriately.
+Scleral icterus/jaundic
RRR, no M/G/R
Lungs clear to auscultation bilaterally
Abdomen soft, nondistended, TTP focally at epigastrium, no
rebound or guarding or other concerns of peritonitis. no
palpable masses. +normoactive bowel sounds;
DRE with poor tone, mucus in vault no stool, guaiac negative
No LE pitting edema
Pertinent Results:
On Admission: [**2130-5-11**]
WBC-3.4* RBC-2.29* Hgb-8.2* Hct-25.2* MCV-110* MCH-35.9*
MCHC-32.6 RDW-17.6* Plt Ct-49*
PT-23.7* PTT-45.4* INR(PT)-2.2*
Glucose-103* UreaN-24* Creat-1.7* Na-136 K-4.0 Cl-105 HCO3-23
AnGap-12
AST-71* CK(CPK)-100 AlkPhos-108* TotBili-6.9*
Albumin-2.0* Calcium-7.8* Phos-3.3 Mg-1.3*
Ammonia-76*
On Discharge: [**2130-6-1**]
WBC-3.9* RBC-3.44* Hgb-10.8* Hct-32.2* MCV-93 MCH-31.4 MCHC-33.7
RDW-19.5* Plt Ct-128*
PT-12.1 PTT-23.5 INR(PT)-1.0
Glucose-216* UreaN-44* Creat-1.9* Na-140 K-3.6 Cl-107 HCO3-25
AnGap-12
ALT-66* AST-27 AlkPhos-141* TotBili-1.0
Calcium-9.0 Phos-3.5 Mg-2.6
tacroFK-15.3
Brief Hospital Course:
MICU COURSE:
72 year old female with ESLD/HCV cirrhosis admitted with altered
mental status, hypotension, abdominal pain, and gram negative
rod sepsis.
# Septic Shock: Patient found to have pansensitive klebsiella
bacteremia and enterococcus UTI. She was initially on
vanc/cipro but was transitioned to cefepime for a 14-day course
given the bacteremia. She was weaned off pressors and did well.
Transplant surgery followed the patient while here. She
received a liver on [**5-16**] and was then transferred to the
transplant surgery team.
.
# SBP: Patient has SBP by criteria in setting of normal para
[**4-27**]. Unfortunately, no culture of peritoneal fluid. Received
albumin. Will need lifelong prophylaxis after finished course
with cipro
# Volume overload: Patient became grossly positive while here.
She had rales on exam. She was diuresed with IV lasix with good
response.
# Encephalopathy: Likely [**12-27**] infection or hepatic
encephalopathy. Initially worsened but improved with lactulose
and rifaximin. Her infections were treated appropriately. She
did develop myoclonus on [**5-15**] so the neurology team was
consulted. Prelim etiology of myclonus is toxic-metabolic.
# Coagulopathy: Patient received FFP, cryo and platelets while
here as she developed slightly low fibrinogen but normal fibrin
split products. Also had elevated INR and decreased Hct.
Coags, Hct, platelets were monitored closely. This was resolved
following liver transplant.
# [**Last Name (un) **]: Was likely secondary to decreased perfusion vs ATN from
hypotension. She received volume expansion with blood products
and creatinine returned to [**Location 213**] by [**5-14**]. SBP was treated with
albumin and cefepime.
# ESLD/HCV cirrhosis: ALT, AST, bili, INR at baseline. Now with
evidence of SBP. Patient given rifaximin and lactulose. Her
home doses of spironolactone and lasix were held in the setting
of hypotension. Hepatology team followed patient while she was
here. She was considered appropriately covered and was taken to
the OR for liver transplant on [**5-16**] and then transferred to the
transplant surgery service.
In the immediate post op period, the patient was kept in the ICU
through POD 10. She was kept on Cefepime following transplant to
continue SBP treatment. Blood cultures had been taken on the day
prior to transplant and were returned following the surgery with
Vanco sensitive enterococcus. She was treated with 14 days of
Vancomycin. She remained afebrile throughout the rest of the
hospitalization.
There was some difficulty in getting her extubated, and volume
overload was noted to be present. She underwent aggresive
diuresis with lasix intermittently and then as a drip. She was
extubated successfully, but required re-intubation due to mental
status issues and increased oxygen requirements. She was still
having a small oxygen requirement that continues to be weaned.
The patient has been receiving tube feeds via a Dobhoff feeding
tube in the jejuneum. She has intermittently pulled the tube out
but is discharged with the feeding tube in place. Tube feeds
were changed to accomadate difficult to control blood glucoses.
She was also followed by [**Last Name (un) **] during the hospitalization whio
assisted in blood glucose management.
Medications on Admission:
Mycelex 10 mg. troche 5x daily, Vitamin D 50,000
units, 1 cap weekly, Lantus 4units in the evening, Lispro
Sliding
Scale, Lactulose 30 mL 3x daily, protonix 40 mg. 2x daily,
Propranolol 40 mg 2x daily, mestinon 60 mg. tab daily 2x daily,
rifaximin 400mg 3x daily, Spironolactone 100 mg. daily, calcium
carbonate 600 mg. 2x daily, Travatan 0.004% one drop both eyes
QHS
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily):
Until [**6-4**] then taper to 17.5 mg daily. Follow transplant clinic
taper.
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day): Until consistently ambulatory.
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheeze, sob.
5. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for sbp> 150.
8. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
9. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 2X/WEEK
(TU,FR).
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
11. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
12. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
14. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale Injection four times a day: Please follow enclosed
sliding scale.
15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
16. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Once, [**6-3**]
AM for 1 doses: Please check trough tacro level, give dose then
await dosing recommendation from transplant clinic.
17. Tacro(Prograf)
Hold PM dose on [**6-2**]
Give 1 mg tacro following lab draw morning [**6-3**]. Await further
instructions for tacro dosing
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Hepatitis C Cirrhossis/HCC now s/p orthotopic liver transplant
[**2130-5-16**]
Spontaneous bacterial peritonitis
Malnutrition
Discharge Condition:
Stable
Alert,oriented, slow to answer but accurate
Needs extensive rehab
Discharge Instructions:
Trough Prograf level MUST be drawn and sent on Saturday morning
[**6-3**].
Please call the transplant center at [**Telephone/Fax (1) 673**] for fever,
chills, nausea, vomiting, diarrhea, constipation, inability to
take or keep down food, fluids or medications.
Patient must have labwork drawn and faxed to transplant center
every Monday and Thursday. CBC, Chem 10, AST, ALT, Alk Phos T
bili, Trough Prograf level.
Any medication changes will be under the supervision of the
transplant center
Continue tubes feeds as ordered via Dobhoff feeding tube
Activity per physical therapy recommendations
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2130-6-7**]
1:20
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2130-6-14**]
10:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2130-6-21**]
10:20
BONE DENSITY TESTING Phone:[**Telephone/Fax (1) 4586**] Date/Time:[**2130-7-12**] 11:40
Completed by:[**2130-6-2**]
|
[
"482.0",
"530.81",
"V12.71",
"284.1",
"571.5",
"268.9",
"518.5",
"567.23",
"285.8",
"599.0",
"V10.07",
"250.00",
"333.2",
"733.90",
"286.9",
"070.44",
"995.92",
"241.0",
"276.6",
"V45.89",
"780.39",
"041.04",
"V46.11",
"V16.0",
"785.52",
"511.9",
"038.49",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"33.24",
"96.04",
"93.90",
"00.93",
"33.23",
"50.59",
"34.91",
"54.91",
"38.93",
"96.71",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
10510, 10576
|
5027, 8322
|
339, 629
|
10746, 10821
|
4384, 4384
|
11465, 12067
|
3734, 3911
|
8742, 10487
|
10597, 10725
|
8348, 8719
|
10845, 11442
|
3926, 4365
|
4720, 5004
|
1983, 2396
|
252, 301
|
657, 1964
|
4398, 4706
|
2418, 3538
|
3554, 3718
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,771
| 175,812
|
12714
|
Discharge summary
|
report
|
Admission Date: [**2180-8-29**] Discharge Date: [**2180-9-4**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
Hypertensive urgency/transfer for epidural hematoma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo F (Haitian Creole speaking) w/ h/o dementia, HTN, CHF, AF
on digoxin (not on warfarin) presented to OSH from nursing
facillity after unwitnessed fall, found to have intracranial
hemorrhage at OSH and transferred to [**Hospital1 18**] for neurosx eval.
.
Per daughter, patient in her usual state of health w/ baseline
delerium (A&Ox1 - self, auditory hallucinations, and poor po) on
Sunday when she visited her in nursing facillity. Patient was
w/o complaints, and had no n/v, d/c, cp, sob. At 2AM of day
admission, pt was found down at her nursing facillity after
unwitnessed fall. She was transferred to [**Hospital1 **] where head CT
showed 4mm acute epidural hemorrhage vs subdural hemorrhage
w/very mild midline shift as well as suspected L eye globe
hemorrhage. Pt recv'd ativan 1mg for CT scan. CT c-spine
negative. She was transferred to [**Hospital1 18**] for neuro [**Doctor First Name **] eval.
.
In the ED, initial VS were: Temp: 97.6 HR: 80 BP: 178/80 Resp:
20 O2 Sat: 98. A repeat CT Head demonstrated no interval change
in what was determined to be an epidural hematoma. The patient
was started on nicardipine gtt with target goal of SBP<140. The
nicardipine gtt was stop due to hypotension with SBP in the
90's. Then the patient was transfered to the MICU for BP
monitoring and q4hr neuro check given epidural hematoma.
On arrival to the MICU, the initial vitals were 96.2 80 152/82
16 99% on RA. The patient was given hydralazine 10 IV and
responded with a BP in the 120's/50's.
Past Medical History:
Afib
HTN
CHF
Dementia
Psychosis
s/p cataract sx
s/p ccy
Social History:
- Tobacco: denies
- Alcohol: denies
- Illicits: denies
Family History:
Not pertient in a [**Age over 90 **]F with dementia.
Physical Exam:
Admission Physical Exam:
Vitals: 96.2 80 152/82 16 99% on RA
General: Alert, oriented x 1, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear larger
periorbital hematoma
Neck: supple, no LAD
CV: irregularly irregular rhythm normal rate, normal S1 + S2, no
murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Discharge Physical Exam:
Vitals: 97.0 92 181/91 20 100% on RA
General: Alert, oriented x 1, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear larger
periorbital hematoma; healing laceration
Neck: supple, no LAD
CV: irregularly irregular rhythm normal rate, normal S1 + S2, no
murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Most Recent Labs:
[**2180-9-2**] 11:00AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
[**2180-9-2**] 11:00AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-4* pH-5.5 Leuks-NEG
[**2180-9-2**] 11:00AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
[**2180-9-2**] 11:00AM URINE Mucous-RARE
URINE CULTURE (Final [**2180-9-3**]): NO GROWTH.
.
Admission Labs:
[**2180-8-29**] 08:55AM BLOOD Neuts-81.8* Lymphs-13.5* Monos-3.1
Eos-1.4 Baso-0.2
[**2180-8-30**] 02:12AM BLOOD Plt Ct-134*
[**2180-8-30**] 02:12AM BLOOD PT-14.2* PTT-23.8 INR(PT)-1.2*
[**2180-8-30**] 02:12AM BLOOD Glucose-131* UreaN-22* Creat-0.8 Na-142
K-3.5 Cl-110* HCO3-22 AnGap-14
[**2180-8-29**] 08:35PM BLOOD CK-MB-4 cTropnT-<0.01
[**2180-8-30**] 02:12AM BLOOD Calcium-9.5 Phos-2.1* Mg-1.9
[**2180-8-29**] 08:55AM BLOOD Digoxin-1.1
[**2180-8-29**] 08:44PM BLOOD Type-[**Last Name (un) **] pO2-21* pCO2-32* pH-7.48*
calTCO2-25 Base XS-0
[**2180-8-29**] 08:44PM BLOOD Lactate-2.5*
[**2180-8-29**] 09:25AM BLOOD Glucose-99 Na-146* K-4.6 Cl-QNS
calHCO3-18*
[**2180-8-29**] 08:44PM BLOOD freeCa-1.28
.
EKG [**2180-8-29**]:
Atrial fibrillation. Inferolateral ST-T wave changes consistent
with digoxin effect. No previous tracing available for
comparison.
.
Rate PR QRS QT/QTc P QRS T
74 0 102 346/370 0 33 -110
CXR [**2180-8-29**]:
FINDINGS: Single AP upright portable view of the chest was
obtained. The
patient is rotated to the right. Given this, no focal
consolidation is seen. There is minimal blunting of the left
costophrenic angle which is likely positional, although a trace
effusion cannot be entirely excluded. No evidence of
pneumothorax is seen. The cardiac silhouette is mildly enlarged.
The aorta is calcified and tortuous. No displaced fracture is
seen.
.
IMPRESSION: No focal consolidation. Minimal blunting of the left
costophrenic angle is likely positional, although a very trace
pleural
effusion cannot be excluded. Mild cardiomegaly.
.
CT SINUS/MAXILLARY/MANDIBLE [**2180-8-29**]:
.
FINDINGS: There is extensive soft tissue swelling of the left
periorbital and preseptal region. The left globe contour is
intact with no CT evidence of rupture, but ophthalmology
examination is advised. There is hemorrhage seen within the left
globe both in the anterior and posterior [**Doctor Last Name 1754**]. Vitreous
hemorrhage is seen contiguous with the anterior chamber
hemorrhage. The hemorrhage within the posterior chamber along
the posterior aspect of the globe likely represents choroidal
hemorrhage/detachment as the hemorrhage is seen to cross the
optic nerve. No retrobulbar hematoma is seen. Osseous structures
of the orbits appear intact with no fluid or blood seen within
the paranasal air spaces. Minimal mucosal thickening is seen in
the left maxillary sinus. The cribriform plate is intact.
.
IMPRESSION:
1) Hemorrhage in the anterior and posterior [**Doctor Last Name 1754**] of the left
globe.
Vitreous hemorrhage is seen contiguous with the anterior chamber
hemorrhage. Posterior hyperdensity most likely represents
choroidal hemorrhage/detachment.
Globe appears intact, but direct examination advised.
2) Left periorbital and preseptal soft tissue swelling/hematoma
without
underlying fracture seen. No retrobulbar hematoma.
.
FINDINGS: There is a small 4-mm epidural hematoma seen in the
left
occipitoparietal region with possible subdural hematoma
extension, unchanged from previous outside hospital study. There
are periventricular white matter hypodensities most likely
representing chronic small vessel disease. There is mild
prominence of the ventricles but the sulci are of normal size
and configuration. There is no shift of normally midline
structures.
.
There is extensive soft tissue swelling in the left periorbital
and preseptal region. There is hemorrhage seen within the left
globe in the posterior and anterior chamber as well as the
vitreous. The posterior hemorrhage most likely represents
choroidal hemorrhage. No fractures are observed in the orbital
structure. There is no hemorrhage seen within the orbits or
evidence of extraocular muscle entrapment.
.
There is opacification of several ethmoid air cells on the left,
which most likely represent inflammatory changes; however,
hemorrhage cannot be ruled out. If there is clinical concern for
hemorrhage, temporal bone CT is recommended.
.
IMPRESSION:
1. 4-mm epidural hematoma in the left parieto-occipital region
with possible adjacent subdural hematoma.
2. Hemorrhage in the left globe both in the posterior and
anterior [**Doctor Last Name 1754**]. Posterior hemorrhage most likely represents
choroidal hemorrhage. Globe appears intact. See dedicated
maxillofacial CT for further details.
3. Opacification of a very few left mastoid air cells, most
likely representing inflammation; however, but in the setting of
trauma, hemorrhage and a nondisplaced temporal bone fracture can
not be excluded. If there is clinical concern, temporal bone CT
can be obtained.
.
Head CT [**2180-8-30**]:
.
FINDINGS: Foci of hyperdensity in the left occipitoparietal
region previously described as epidural hematoma are more likely
in the subdural space. The more posterior vertex blood
collection (2a:19) appears centered on and spans an intact
lambdoid suture, making this unlikely to lie in the epidural
space. Both foci of hyperdensity within the occipitoparietal
region are unchanged in size when compared to the prior study.
There is evidence of thin subdural hematoma, unchanged from the
prior study.
.
Mild prominence of ventricles and sulci are unremarkable for the
patient's
age. There is no shift of normally midline structures.
Periventricular white matter hypodensities are unchanged from
the prior study. Soft tissue swelling in the left periorbital,
preseptal region is unchanged. Amorphous material in poster
chamber and hyperdense layering material in dorsal part of the
left globe. No fractures are observed in the orbital structures.
.
Opacification of ethmoid air cells is unchanged. No fractures
are seen in the osseous structures.
.
IMPRESSION:
1. Unchanged foci of extra-axial, likely subdural hemorrhage,
when compared
to the study from [**2180-8-29**].
2. Hemorrhage within the left globe, now incompletely layering.
.
Brief Hospital Course:
[**Age over 90 **]F (Haitian Creole speaking) with baseline dementia/psychosis
presented to OSH after unwitnessed fall with subdural hematoma,
hemorrhage in anterior and posterior chamber of left globe, and
was transferred to [**Hospital1 18**] for management.
.
# Hypertensive Urgency: Patient on nicardipine gtt in the ED
that was stopped secondary to hypotension. Given ICH,
anti-hypertensives titrated w/ a goal of SBP<140, per
neurosurgery. She was switched over to hydralazine IV and
metoprolol IV due to inability to tolerate PO meds. Neuro checks
q 4hrs with no acute changes. Cardiac enzymes were sent and were
negative for acute ischemic event. Patient is paranoid/actively
hallucinating and believes that staff is trying to poison her
and so would not take PO meds. Pt started taking home PO meds
when family administers the medication. Therefore, BP has been
difficult to control, but after she takes her home PO pindolol,
BPs stabilize to SBP 120s. We believe that she is stable to
leave if she continues taking home meds.
.
# Subdural hematoma: Stable on repeat head CT, with no need for
neurosurgical intervention at this time. Neuro exam non-focal,
neuro checks q4 hours throughout hospitalization showed no acute
changes. Blood pressure control as described above. Final Report
of his repeat head CT ([**8-30**]) showed "unchanaged areas of
subdural hematoma when compared to the study from [**2180-8-29**].
Hemorrhage in left globe now incompletely layering."
.
#Episode of unresponsiveness on [**2180-9-1**]: The patient was
unable to be arroused by sternal rub and so an extensive and
emergent unresponsiveness workup ensued. A NCHCT showed no
acute changes. Blood gas was nonrevealing. EKG was unchanged.
Metabolic derangement seemed unlikely as the CHEM 10 was within
normal limits. Infection unlikely as CBC wnl and no fever. The
patient was loaded on dilantin and there was no seizure activity
on EEG. Blood glucose normal. The patient did have some
cogwheeling on exam and had received haldol for hyperactive
delerium about 24 hours before the episode, and so
extrapyrimidal symptoms secondary to dopaminergic medication was
considered; patient treated with benztropine and patient
returned to baseline. Haldol was avoided the remainer of the
admission and home olanzapine dose was resumed prior to d/c. At
time of discharge, patient appeared to be at her baseline
functioning.
.
# L globe hemorrhage: Patient evaluated by optho in the ED and
were initially discussing role for surgery although there was no
acute need. She was placed on vigomox and steroid gtt. Will
continue to monitor. Will start glaucoma gtts and should
continue as outpatient. Patient has outpatient appointment with
opthomology immediately following discharge to be evaluated by
B-scan. Patient should follow up with opthomology pending those
results.
.
# AG acidosis: No ABG done, VBG: 7.48, PCO2 32. Lactate 2.5.
Given IVF. Per daughter has very poor po intake, can be element
of starvation ketosis. No fevers or leukocytosis to invoke
infectious process. Resolved by time of discharge.
.
# Fall: Unclear etiology as fall was unwitnessed. No events on
telemetry.
.
# Dementia: Appears to be at baseline after discussing w/
daughter. [**Name (NI) **] received prn haldol and zyprexa with
inconsistent results throughout admission. Continue psych meds
from Nursing home and have them administered by family members.
.
# Afib: Monitored on telemetry. Not on coumadin. Discharged on
home dose of digoxin.
.
# Urinary retention: patient had difficulty urinating at times
throughout her admission. Straight catheterizations put out
concentrated urine. Patient was not drinking much during her
admission, and so low volume status could have been a
contributor. Urinalysis was unrevealing and urine culture was
negative.
.
Pt was confirmed full code this admission.
Medications on Admission:
1. aripiprazole 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. olanzapine 10 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
Disp:*30 Tablet(s)* Refills:*2*
3. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 1.5 Tablet, Rapid
Dissolves PO HS (at bedtime).
Disp:*45 Tablet, Rapid Dissolve(s)* Refills:*2*
5. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. pindolol 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Aspirin 81 mg PO daily
Discharge Medications:
1. aripiprazole 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. olanzapine 10 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
Disp:*30 Tablet(s)* Refills:*2*
3. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 1.5 Tablet, Rapid
Dissolves PO HS (at bedtime).
Disp:*45 Tablet, Rapid Dissolve(s)* Refills:*2*
5. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. pindolol 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
Disp:*1 bottle* Refills:*2*
11. ciprofloxacin 0.3 % Drops Sig: 1-2 Drops Ophthalmic Q4H
(every 4 hours).
Disp:*1 bottle* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care - [**Hospital1 **]
Discharge Diagnosis:
Primary Diagnoses:
Epidural Hematoma
Subdural Hematoma
Left Eye Globe Hemorrhage
Facial laceration and eccymoses
.
Secondary Diagnoses:
Hypertension
Dementia
Psychosis
Extrapyrimidal Side Effects from Dopaminergic Medications
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert but not appropriately interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 39238**],
.
It was a pleasure taking care of you at [**Hospital1 **].
You were admitted to the hospital after you had a fall.
.
After you fell, you have been diagnosed with multiple bleeds in
your brain and left eye. It is recommended that you control
your blood pressure with your outpatient pinolol. You should
have regular (at least daily) blood pressure checks at your
nursing facility. If your blood pressure is high, your doctor
may want to change or increase the dose of your current
medications.
.
You were taking aspirin 81 mg daily before you came to the
hospital. You should stop taking this medication for the time
being. When your ophthomologist tells you it is safe to restart
this medication, you may do so.
.
You also had an episode while hospitalized in which you could
not wake up. This issue has resolved. It is not certain, but
it seems that some of the medications you received while
hospitalized may have been the reason this happened to you. In
the future, you should avoid one medicine in particular which is
called Haldol or haloperidol.
.
We made the following changes to your meds:
- You will START taking some eye drops.
Followup Instructions:
You have been scheduled for an eye appointment imediately
following discharge today. Depending on what the test shows,
you may need to return to the hospital for treatment.
Otherwise, you should follow up with your ophthomologist as per
their decision.
Completed by:[**2180-9-5**]
|
[
"852.20",
"333.72",
"379.23",
"E939.2",
"348.39",
"363.72",
"788.20",
"E888.9",
"427.31",
"428.0",
"290.0",
"276.2",
"298.9",
"401.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
15663, 15736
|
9465, 13347
|
302, 308
|
16006, 16006
|
3189, 3583
|
17377, 17661
|
2033, 2087
|
14410, 15640
|
15757, 15872
|
13373, 14387
|
16174, 17354
|
2127, 2626
|
15893, 15985
|
211, 264
|
336, 1864
|
3599, 9442
|
16021, 16150
|
1886, 1944
|
1960, 2017
|
2651, 3170
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,739
| 178,685
|
39560
|
Discharge summary
|
report
|
Admission Date: [**2149-9-26**] Discharge Date: [**2149-10-4**]
Date of Birth: [**2089-6-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Bee Sting Kit
Attending:[**Known firstname 922**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
s/p coronary artery bypass grafting x 4 (Left internal mammary
artery grafted to the left anterior descending artery/saphenous
vein grafted to posterior descending artery/obtuse
Marginal/diagnal) on [**2149-9-30**]
History of Present Illness:
60 year old male with history of Coronary artery disease s/p
stents in [**2142**]. He reports progressive chest pain with activity
over the previous 3 weeks, and occasional rest chest pressure.
Cardiac Cath revealed left main/multi vessel coronary disease.
Cardiac surgery was consulted for coronary revascularization.
Past Medical History:
Coronary artery disease s/p stent to LAD, RCA and Cx [**2142**]
Hypertension
Hypercholesterolemia
GERD
Asthma
Past Surgical History:
Abdominal surgery r/t injury in [**Country 3992**] @ age 19 (Shrapnel)
Social History:
Race: Caucasian
Last Dental Exam: 1yr. ago
Lives with: alone
Occupation: retired fire fighter
Tobacco: quit age 19
ETOH: 12 beers/week
Family History:
mother died of MI 62yo
father died MI 82yo
Physical Exam:
Admission Physical Exam
Pulse: 64 Resp: 24 O2 sat: 98% 2L
B/P Right: Left: 131/78
Height: 5'1" Weight: 212lb
General: NAD, WGWN, appears stated age
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] well healed mid-line scar
Extremities: Warm [x], well-perfused [x] Edema- none
Varicosities: None [x]
Neuro: Grossly intact x
Pulses:
Femoral Right: cath site Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left:
no bruits
Pertinent Results:
[**2149-9-30**]
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The descending thoracic aorta
is mildly dilated. The aortic valve leaflets (3) are mildly
thickened. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen.
Epiaortic scan showed no significant atheromatous disease of the
ascending aorta.
POSTBYPASS
Biventricular systolic function remains preserved. There are no
other changes from the prebypass exam.
[**2149-10-2**] 04:45AM BLOOD WBC-10.2 RBC-3.25* Hgb-10.3* Hct-30.2*
MCV-93 MCH-31.6 MCHC-34.0 RDW-12.7 Plt Ct-129*
[**2149-10-2**] 04:45AM BLOOD Glucose-104* UreaN-13 Creat-1.2 Na-133
K-4.4 Cl-98 HCO3-31 AnGap-8
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2149-9-30**] where the patient underwent coronary
bypass grafting x4 with left internal mammary artery to the left
anterior descending coronary, reverse saphenous vein single
graft from aorta to first diagonal coronary artery, reverse
saphenous vein single graft from aorta to second obtuse marginal
coronary artery, as well as reverse saphenous vein graft from
the aorta to the posterior descending coronary artery. See
operative note for full details. Overall the patient tolerated
the procedure well and post-operatively was transferred to the
CVICU in stable condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable on no inotropic or vasopressor
support. Beta blocker was initiated and the patient was gently
diuresed toward the preoperative weight. he was on Plavix
preoperatively for stents to LAD, RCA and Cx and this was
resumed. The patient was transferred to the telemetry floor for
further recovery. Chest tubes and pacing wires were discontinued
without complication. The patient was evaluated by the physical
therapy service for assistance with strength and mobility. By
the time of discharge on POD #4 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged home with visiting nurse
services in good condition with appropriate follow up
instructions.
Medications on Admission:
Plavix 75mg daily
enalapril 5mg daily
Toprol XL 100mg daily
omeprazole 40mg daily
simvastatin 20mg daily
aspirin 325mg daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 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:*65 Tablet(s)* Refills:*0*
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days.
Disp:*10 Tablet(s)* Refills:*0*
10. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 5 days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary Artery Disease
s/p coronary artery bypass grafting x 4 on [**2149-9-30**]
PMH:
s/p stent to LAD, RCA and Cx [**2142**]
Hypertension
Hypercholesterolemia
GERD
Asthma
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage. Trace Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon:Dr. [**Last Name (STitle) 914**] on [**10-21**] at 2pm
Cardiologist:Dr. [**Last Name (STitle) 8579**] on [**10-28**] at 9:30am
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 8522**] in [**12-21**] weeks [**Telephone/Fax (1) 8577**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2149-10-4**]
|
[
"287.5",
"285.9",
"V45.82",
"414.01",
"401.9",
"411.1",
"272.0",
"493.90",
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] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"39.61",
"88.53",
"36.15",
"37.23",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
6060, 6118
|
3016, 4578
|
289, 506
|
6336, 6550
|
2058, 2993
|
7391, 7915
|
1257, 1302
|
4753, 6037
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6139, 6315
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6574, 7368
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1015, 1088
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238, 251
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534, 859
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881, 992
|
1104, 1241
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,956
| 152,193
|
7185
|
Discharge summary
|
report
|
Admission Date: [**2168-8-28**] Discharge Date: [**2168-9-1**]
Date of Birth: [**2117-10-9**] Sex: F
Service: MEDICINE
Allergies:
Beta-Blockers (Beta-Adrenergic Blocking Agts)
Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
One day history of fever and chills
Major Surgical or Invasive Procedure:
None
History of Present Illness:
50 year old female with a history of type 1 DM complicated by
ESRD s/p renal transplant x 2 ([**2145**], [**2164**]), neurogenic bladder
requiring self catheterization and hepatitis C. She was
diagnosed with fungal UTI and completed two week course of
fluconazole yesterday when she was noted to have temperature of
101.1 with chills, nausea and loss of appetite leading her to
present to ED.
ROS positive for headache without neck stiffness or photophobia.
She denies any rashes. She does not have any recent sick
contacts. She has only traveled to [**State 1727**] recently.
In the ED, her initial vitals were 95.7 83 123/80 16 100%RA.
She was noted to have rigors/fever and tachycardia to 130. Labs
notable for leukocytosis to 15.7, creatinine at 1.4 (baseline
1.1, stable tranaminitis and chronic pyuria. She was given
vanc/zosyn and diflucan. She was given 1LNS and admitted to MICU
for further evaluation and management.
In the MICU, she had no further complaints.
Past Medical History:
-Diabetes type 1 with neuropathy nephropathy
-end-stage renal disease status post MI
-status post living-related renal transplant in [**2145**], repeat
living related transplant on [**2164-11-6**] from her brother
-hep C with mildly elevated liver function tests. Biopsy shows
grade I disease.
-Recurrent UTIs in the past, neurogenic bladder with
self catheterization QID
-hypertension.
- [**Hospital1 **]-v pacer implantation for paroxysmal AV block [**2165-10-21**]
-Left 2nd toe amputation [**2166-10-2**]
-LT PT, peroneal PTA [**2166-3-28**]
-RT 1st toe, hallux amputation [**1-8**]
-PTA/stent of LT PT, LT AT PTA [**8-8**]
-RT peroneal, RT tibial PTA [**7-9**]
Social History:
Lives w/ her husband and son; never smoked; does not drink
alcohol or use illicit drugs. Previously worked in commercial
banking, but does not currently work. Is supposed to be off of
her feet in wheelchair but reports she does walk around the
house. Husband works full time but is able to return home
frequently.
Family History:
Non-contributory.
Physical Exam:
Admission Exam:
General: Alert, oriented, uncomfortable and rigoring
HEENT: Sclera anicteric, dry, oropharynx clear
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, tender at left lower quadrant where transplanted
kidney is, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge Exam:
Vitals: Tc-98.1 HR-75-98 BP-121-155/69-85 RR:20 O2:96% RA
Gen: Pleasant woman laying comfortably in bed. Oriented x3.
Cushingoid appearance.
HEENT: MMM. EOMI. PERRL. No photophobia. Sclera anicteric
NECK: Supple. No JVD. RIJ in place, and free from surrounding
signs of infection
CV: RRR. NS1&S2. NMRG
Resp: Clear to auscultation bilaterally
GI: BS+4. Mild TTP in LLQ much improved. soft
Ext: Non-pitting edema of BLE
Pertinent Results:
Admission Labs:
[**2168-8-28**] 06:00PM BLOOD WBC-15.7*# RBC-3.91* Hgb-13.0 Hct-38.7
MCV-99* MCH-33.2* MCHC-33.6 RDW-12.9 Plt Ct-148*
[**2168-8-28**] 06:00PM BLOOD Neuts-91.6* Lymphs-4.3* Monos-3.9 Eos-0.1
Baso-0.1
[**2168-8-28**] 06:00PM BLOOD Plt Ct-148*
[**2168-8-29**] 04:02AM BLOOD Fibrino-445*
[**2168-8-28**] 06:00PM BLOOD Glucose-212* UreaN-36* Creat-1.4* Na-136
K-4.6 Cl-103 HCO3-22 AnGap-16
[**2168-8-28**] 06:00PM BLOOD ALT-74* AST-66* AlkPhos-126* TotBili-0.4
[**2168-8-28**] 06:00PM BLOOD Albumin-4.1
.
Discharge Labs:
[**2168-9-1**] 05:06AM BLOOD WBC-5.5 RBC-2.94* Hgb-9.6* Hct-29.3*
MCV-100* MCH-32.7* MCHC-32.8 RDW-13.0 Plt Ct-111*
[**2168-9-1**] 05:06AM BLOOD PT-10.5 PTT-26.3 INR(PT)-1.0
[**2168-9-1**] 05:30PM BLOOD Glucose-316* UreaN-18 Creat-1.3* Na-138
K-4.5 Cl-103 HCO3-25 AnGap-15
[**2168-9-1**] 05:06AM BLOOD ALT-62* AST-51* AlkPhos-88 TotBili-0.3
[**2168-9-1**] 05:06AM BLOOD tacroFK-10.5
.
Microbiology:
[**2168-8-30**] Blood Culture, Routine-PENDING
[**2168-8-29**] Blood Culture, Routine-PENDING
[**2168-8-29**] URINE CULTURE-FINAL INPATIENT
[**2168-8-29**] Blood Culture, Routine-PENDING
[**2168-8-28**] Blood Culture, Routine-FINAL No growth
[**2168-8-28**] Blood Culture, Routine-FINAL {KLEBSIELLA PNEUMONIAE};
[**2168-8-28**] URINE CULTURE-FINAL {KLEBSIELLA PNEUMONIAE}
.
Studies
[**2168-8-28**] CXR A/P and LAT: No acute cardiopulmonary process.
[**2168-8-29**] Renal transplant U/S: Normal renal transplant son[**Name (NI) **].
[**2168-8-30**] [**Name2 (NI) 16057**]: Isolated loop of dilated bowel, possibly
representing a focal
ileus and be consistent with enteritis or pancreatitis. No
definite evidence of bowel obstruction.
[**2168-8-30**] CT Abd/Pelvis: Pyelonephritis of the transplanted kidney
in the left lower quadrant with 2.7 cm ill-defined organizing
fluid collection in the lower pole. Associated uroepithelial
thickening is present. Despite being collapse, there is bladder
wall thickening and associated stranding is suggesting cystitis.
Atrophic hypoenhancing transplanted kidney in the right lower
quadrant is most consistent with chronic rejection, and is
stable from prior exams. Enlarged heterogeneous uterus may be
due to adenomyomatosis or confluent fibroids. Fluid within the
endometrial canal. Consider a non-emergent pelvic ultrasound
for further evaluation if clinically indicated. Trace bilateral
pleural effusions.
Brief Hospital Course:
50 year old female with a history of type 1 DM complicated by
ESRD s/p renal transplant x 2 ([**2145**], [**2164**]), neurogenic bladder
requiring self catheterization and hepatitis C. She was
diagnosed with fungal UTI and completed two week course of
fluconazole presented with one day of fever and chills. Found to
have sepsis with K. pneumoniae secondary to UG source
.
Active Issues
# Sepsis: Initially treated in ICU as pt had some AMS and fit
SIRS criteria with fever, and tachycardia. Started on empiric
vanc and cefepime. Transferred to liver/renal service after VS
were stabilized. Initially spiked a temperature on the floor,
but antibiotic dosing was subtherapeutic prior to arrival. After
increasing to proper dose she was afebrile. After initial blood
and urine cultures came back positive for K. pneumoniae she was
switched to IV ceftriaxone. Likely source of infection was from
seeding of concomitant pyelonephritis. Follow-up blood cultures
have been negative and pt was asymptomatic at time of discharge.
Discharged on 3 week course of oral ciprofloxacin.
.
#Pyelonephritis: See above. H/o pyelo and recurrent UTI's in the
past, likely from self-catheterization [**3-3**] neurogenic bladder.
CT scan on the floor demonstrated focal pyelonephritis of L.
transplant kidney with no drainable fluid collections. At time
of discharge foley catheter was removed and pt was urinating
without symptoms of infection. Switched to PO ciprofloxacin to
complete a total 3 week course.
.
# Acute kidney injury: Creatinine to 1.4 from baseline of 1.1.
Likely prerenal from above. Decreased with IV fluids
.
Chronic Issues
# Renal transplant: Patient s/p 2 renal transplants and has had
native nephrectomies. She is several years post transplant and
maintained on immunosuppresion with tacro and prednisone. She
reports taking Ca, Vit D and bactrim proph. Tacro dose increased
per nephrology. Prednisone dose initially increased while
in-hospital, but decreased to home dose at time of discharge.
.
# DM1: Continued home lantus and insulin sliding scale. Pt was
hyperglycemic to ~400 just prior to discharge. She was monitored
closely after giving additional humalog, and discharged once BG
<300. Pt was entirely asymptomatic at time of discharge
.
# HCV/transaminitis: H/o HCV and chronic transamonitis. Pt was
at baseline throughout stay.
.
# HTN: BP meds were intitially held in setting of sepsis,
however, diovan was restarted on the floor
.
# PVD: Patient is s/p stenting. Previously on ASA/plavix, now
just ASA.
.
Transitional:
#Repeat blood cultures pending and will need to be followed up
Medications on Admission:
econazole 1 % Cream to affected fingernails twice a day
ezetimibe 10 mg po qdaily
fluconazole 200 mg po qdaily completed yesterday
fosfomycin tromethamine 3 gram Packet 1 Packet(s) by mouth qweek
insulin glargine 20 units at bedtime
insulin lispro sliding scale
metoclopramide 5 mg po BID
omeprazole 20 mg po qdaily
prednisone 4 mg po qdaily
pregabalin 200 mg po BID
tacrolimus 3 mg po BID
valsartan 80 mg po qdaily
aspirin 81 mg po qdaily
cholecalciferol 800 units po qdaily
docusate sodium 100 mg po TID
fish oil-dha-epa 1,200 mg-144 mg po BID
ALLERIGES: Beta-Blockers (Beta-Adrenergic Blocking Agts)
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Ciprofloxacin HCl 500 mg PO Q12H
Take for 18 days.
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*36 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Metoclopramide 5 mg PO BID
5. Omeprazole 20 mg PO DAILY
6. PredniSONE 4 mg PO DAILY
7. Pregabalin 200 mg PO BID
8. Tacrolimus 3 mg PO Q12H
9. Valsartan 80 mg PO DAILY
10. Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
11. Ezetimibe 10 mg PO DAILY
12. econazole *NF* 1 % Topical [**Hospital1 **]
to affected fingernails
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Pyelonephritis complicated by sepsis
Secondary diagnosis:
Diabetes melltius type 1
Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you at [**Hospital1 18**]. You were admitted to
the ICU because of high fever, chills, and rapid heart rate. You
were intially treated with antibiotics through your veins.
Before receiving treatment, your blood and urine were cultured
to look for infection. Both blood and urine grew out the same
organism. This usually indicates that the blood infection was a
result of a urinary infection. Once your heart rate had come
down and fever broke, you were transferred to the [**Doctor Last Name 3271**] [**Doctor Last Name 679**]
service, where you were treated for the duration of your stay at
[**Hospital1 18**]. We took an image of your kidney, which showed a local
area of infection. This is referred to as pyelonephritis.
Once we knew what bacteria was growing in your blood and urine,
we switched you to an antibiotic to take by mouth. Please
continue taking this for 3 weeks total through [**2168-9-18**].
Please decrease your tacrolimus dose from 4mg to 3mg twice a day
You have a follow-up appointment scheduled with Dr. [**Last Name (STitle) **]
on [**2168-9-6**].
Medications to START:
START Ciprofloxacin 500mg [**Hospital1 **] x 18 days (Thorugh [**2168-9-18**])
Medications to change:
Tacrolimus 4mg to 3mg twice a day
Followup Instructions:
Department: TRANSPLANT CENTER
When: TUESDAY [**2168-9-6**] at 1:20 PM
With: [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
|
[
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"V45.02",
"596.54",
"584.9",
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"995.91",
"E878.0",
"250.41",
"250.61",
"357.2",
"V13.02",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
9640, 9646
|
5815, 8417
|
342, 349
|
9795, 9795
|
3398, 3398
|
11234, 11613
|
2391, 2410
|
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|
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2959, 3379
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266, 304
|
377, 1354
|
9735, 9774
|
3414, 3914
|
9810, 9922
|
1376, 2043
|
2059, 2375
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,224
| 155,376
|
43498
|
Discharge summary
|
report
|
Admission Date: [**2201-3-19**] Discharge Date: [**2201-3-31**]
Service:
HISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname **] is an
82-year-old male with CHF secondary to ischemic
cardiomyopathy, CAD, permanent pacemaker for bradycardia with
multiple admissions for CHF, with significant cardiac risk
factors who presents to [**Hospital6 256**]
with crescendo angina. He initially had been scheduled for
an elective catheterization for later in the week of
presentation but he was admitted to the ED with crescendo
angina and went to cardiac catheterization upon presentation.
Mr. [**Known lastname **] presents to the CCU status post catheterization
secondary to pulmonary edema requiring intubation.
Initially, Mr. [**Known lastname **] presented to the ED on the day of
admission complaining of chest pain and shortness of breath
while dressing on the morning of admission. He said that the
pain was relieved with two sublingual nitroglycerin. He
received aspirin prior to his arrival to the ED. His EKG was
paced. He received Lopressor 5 mg IV and then went to the
Catheterization Laboratory. He had an LAD lesion of 80%,
proximal mid 90% distal with 80% high diagonal and left
circumflex had diffuse disease. He had a 60% RCA lesion,
collaterals to the PDA.
While in the Catheterization Laboratory, he was noted to
desat to 87%. He initially had been 99% on room air in the
ER. This hypoxia persisted in the Recovery Room with
increasing respiratory distress. His ABGs showed 7.25, 48,
182, on a nonrebreather mask, consistent with respiratory
acidosis as well as a metabolic acidosis. His bicarbonate
was 16 at that time.
Bedside echocardiogram showed an apical HK. No effusion;
global systolic dysfunction. His blood pressure had
decreased and he was started on dopamine. He was intubated
and taken back to the Catheterization Laboratory. A Swan was
placed and he had right atrial pressures of 19, PA pressures
of 57/27, wedge 30, and a cardiac output of 7 with an index
of 4.36. Natrecor was started and the patient was
transferred to the CCU.
PAST MEDICAL HISTORY:
1. CHF with multiple admissions for heart failure, the last
had been on [**2201-3-9**] to [**2201-3-14**].
2. CAD, last catheterization in 09/89 with two vessel
disease, supranormal EF and diastolic dysfunction. He has
cardiac risk factors of hypercholesterolemia and hypertension
as well as tobacco use. He had a stress echocardiogram in
[**9-1**] which showed a CK of the mid-distal anterior wall,
anterior septum, with an increased heart rate, pacing versus
ischemia. He had an echocardiogram in [**12-1**] with biatrial
enlargement, mild LVH, EF of approximately 35% with 2+ MR and
no pulmonary hypertension. He has a pacemaker DDD for
bradycardia.
3. PVD, status post aortic bifemoral bypass.
4. History of COPD.
5. Depression.
6. Glaucoma.
7. Gout.
ADMISSION MEDICATIONS:
1. Aspirin.
2. Lopressor 25 b.i.d.
3. Imdur 30 q.d.
4. Lisinopril 5 q.d.
5. Lipitor 40 q.d.
6. Lasix 40 q.d.
7. Nitroglycerin sublingual p.r.n.
8. Amiodarone 200 q.d.
9. Risperidone 0.25 mg q.d.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: He lives with his wife. [**Name (NI) **] smokes
approximately one cigarette a day, occasional alcohol.
When he presented to the CCU, he was on aspirin 325 mg q.d.,
Plavix 75 q.d., metoprolol 25 b.i.d. which had been held
while he was on a pressor, Imdur 60 q.d. which was held while
he was on a pressor, Captopril 25 t.i.d., again held while he
was on a pressor. These were restarted after the
catheterization and the visualization except for the
Lopressor with the visualization of his elevated wedge. His
Natrecor when he came to the CCU was 0.01 micrograms per
kilogram per minute. He was on Combivent MDI, Protonix 40
q.d. and Pravastatin.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: On
presentation to the CCU, his temperature was 98, heart rate
65, blood pressure 122/53, saturating 100% on AC 700 by 22
with FI0 of 50% and PEEP of 5. His ABG was 7.47, 25, 207.
His Swan numbers were PA 42/38, PA mean 33. His ins and outs
were 24 in and 11 to 20 out. He was intubated and sedated.
HIs pupils were surgical. No JVP seen in the supine
position. No LAD. Heart: Regular rate and rhythm. No
murmurs, rubs, or gallops, although the examination was
limited by the ventilator. The lungs revealed some bibasilar
crackles laterally. Soft and mild, moderately distended
abdomen, no tympany. No splenomegaly. Positive bowel
sounds. Extremities: He has Dopplerable pulses bilaterally
in the dorsalis pedis position and trace edema. His left leg
was in an immobilizer secondary to the Swan.
LABORATORY/RADIOLOGIC DATA: The laboratories on presentation
to the CCU revealed a hematocrit of 36, white count 13.9, 86%
neutrophils, 11 lymphocytes, platelets 204,000. Sodium 134,
potassium 4.2, chloride 103, bicarbonate 20, gap 14, BUN 34,
creatinine 1.5, platelets 292,000, gap of 14. CKs 178, 144,
175, MBs 6 and each troponin was less than 0.03 times two.
Calcium 7.7, phosphorus 4.3, magnesium 128, lactate 2.0.
Chest x-ray in the ED at presentation showed mild CHF.
HOSPITAL COURSE: The patient is an 82-year-old male with
CAD, CHF, hypercholesterolemia, and hypertension, peripheral
vascular disease, who presents to the CCU status post LAD
stent, whose catheterization was complicated by hypoxic
respiratory failure and hypercarbic respiratory failure with
metabolic and respiratory acidosis. The repeat
catheterization showed no change in his stents but his
filling pressures were increased.
The possible etiology of failure could be the
cardiosupressive effect of the dye versus ischemia at another
site. The bedside echocardiogram during catheterization
showed no evidence of tamponade. The possibilities of
respiratory acidosis could have been from decreased perfusion
without respiratory compensation or decreased respiratory
drive secondary to oversedation. He had been anxious and
repeated multiple sedative doses as well as there being a
communication impediment secondary to the patient's Russian
language for which he does not speak English.
1. RESPIRATORY FAILURE: The patient came to the CCU
intubated; however, he was on Natrecor. He put out negative
1.5 liters over the first 24 hours and was successfully
extubated and in the first 24 hours. His Swan was
discontinued. His mixed venous was 66, cardiac output 3.9,
cardiac index 2.3, PA pressures 43/17. His Natrecor and
dopamine drips were also discontinued in the first 24 hours.
2. CORONARY ARTERY DISEASE: Catheterization number one
showed proximal RCA 60%, proximal LAD 80% tubular, diagonal 1
90% discreet, midcircumflex 70 and 90% diffusely diseased
distal circumflex, 100% discreet OM1 50%, OM2 30%.
The patient had successful PTCA stenting of 80% LAD lesion.
Limited resting hemodynamics revealed a moderately elevated
left ventricular filling pressure with an LVEDP of 21 mmHg in
the setting of normal systemic arterial blood pressure. Left
ventriculography was not performed during this
catheterization and 3VD and moderate left ventricular
diastolic dysfunction.
The patient had a second catheterization to evaluate the
hypoxia that he experienced in the holding room. The
pulmonary artery pressure was 58/28, reduced to 47/25 with
the initiation of Natrecor. Wedge was a mean of 30,
decreased to 21 with the initiation of Natrecor. The
vascular resistance was 696.
Angiography of the left coronary artery demonstrated a widely
patent LAD stent with no change from the previous study. The
commissure showed elevated biventricular pressure with normal
cardiac output.
3. CORONARY ARTERY DISEASE: The patient was continued on
aspirin and Plavix as well as a statin when the patient was
euvolemic. The beta blocker was restarted. The ACE
inhibitor was also slowly titrated up.
4. CONGESTIVE HEART FAILURE: The patient was initially
placed on the Natrecor as previously stated with good
diuresis, extubation, and then on the date of discharge the
patient was 97% on room air. The Natrecor was discontinued
after the first day of treatment. Pulmonary arterial
diastolic pressure was 17 on the second day of
hospitalization after one day of the Natrecor when the
Natrecor and Swan were discontinued.
5. RHYTHM: The patient was AV paced. He is on Amiodarone
for atrial tachycardia.
6. HEMODYNAMICS: The patient's dopamine was weaned off.
His blood pressure was stable. There was no reason for any
inotropic support for the rest of his stay and he had his
beta blocker titrated up without complication.
7. PULMONARY: As stated previously, the patient was
extubated. He experienced some wheezing and some cough on
the day prior to discharge that responded to nebulizers with
decrease of his cough.
8. RENAL: The patient has a history of chronic renal
insufficiency. He received Mucomyst for the dye load. His
creatinine was stable during this hospitalization and 1.3 on
the date of discharge. Baseline had been about 1.6 to 1.8.
9. PROPHYLAXIS: He received subcutaneous heparin and
Protonix.
10. LINES: He had a left femoral Swan that was discontinued
after 24 hours and a left arterial line that was also
discontinued when the patient was extubated.
11. FLUIDS, ELECTROLYTES, AND NUTRITION: His lytes were
monitored and adjusted accordingly with supplementation and
he was on a Heart Healthy CHF low-sodium, less than 2 gram,
diet.
12. PSYCHIATRIC: He was restarted back on Risperidone for
his history of at times of angry outbursts.
He was seen by Physical Therapy who cleared him for home.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease, status post left anterior
descending artery stent.
2. Congestive heart failure.
3. Hypertension.
4. Hypercholesterolemia.
5. Chronic obstructive pulmonary disease.
6. Chronic renal insufficiency.
7. Peripheral vascular disease.
FOLLOW-UP: The patient has follow-up with Dr. [**Last Name (STitle) **] on [**2201-4-13**] and has an appointment to be seen by Social Work at
[**Company 191**], a Russian-speaking individual, to help with anger
management.
DISCHARGE SURGICAL PROCEDURES: CAD, status post left
anterior descending artery stent.
DISCHARGE MEDICATIONS:
1. Aspirin 325 q.d.
2. Plavix 75 mg q.d.
3. Amiodarone 200 q.d. for atrial tachycardia.
4. Pravastatin 20 q.d.
5. Lisinopril 5 q. 9:00 p.m.
6. Atenolol 25 q.a.m.
7. Lasix 40 b.i.d.
8. Clonazepam 0.5 mg p.o. b.i.d.
The Risperidone was discontinued as per the patient's PC, Dr.
[**Last Name (STitle) **]. The patient is also to follow-up with Dr. [**Last Name (STitle) **]
following his hospitalization within two weeks.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 2139**]
Dictated By: [**First Name8 (NamePattern2) 488**] [**Last Name (NamePattern1) **], M.D.
MEDQUIST36
D: [**2201-6-15**] 11:23
T: [**2201-6-20**] 16:34
JOB#: [**Job Number 93616**]
|
[
"411.1",
"443.9",
"414.01",
"401.9",
"518.5",
"272.0",
"496",
"V45.01",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.13",
"36.01",
"88.57",
"37.21",
"88.56",
"37.22",
"96.04",
"96.71",
"38.91",
"36.06"
] |
icd9pcs
|
[
[
[]
]
] |
10285, 11029
|
9683, 10262
|
5185, 9630
|
2899, 3158
|
3861, 5167
|
2109, 2876
|
3175, 3846
|
9655, 9662
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,790
| 199,919
|
22034
|
Discharge summary
|
report
|
Admission Date: [**2178-9-20**] Discharge Date: [**2178-9-28**]
Date of Birth: [**2113-2-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 14385**]
Chief Complaint:
Hepatic failure
Major Surgical or Invasive Procedure:
multiple central line placements and paracenteses
History of Present Illness:
This 65-year-old female patient with a history of chronic
ethanol abuse, hepatitis C, cirrhosis, hypertension, was
transferred from an OSH for a suspected hepatorenal syndrome.
The patient was admitted to the OSH on [**8-22**] for nausea,
vomiting and weakness. She had been abusing alcohol prior to
this admission. She was admitted in stable condition with
significant abdominal distension.
She was found to have the following labs: Hct 34, WBC 7.7, NH3
33, K 3.9, BUN 6, Cr 0.1, albumin 2.9, bili 19.7.
An abdominal U/S revealed ascites.
An EGD performed revealed a gastric ulcer without varices.
She was maintained protonix and given albumin, octreotide and
proamatine. Her bilirubin remained elevated reaching 22.1 and
her NH3 reached 123. She was placed on lactulose. Furthermore,
she developed a urinary tract infection requiring levaquin 250
mg QID.
The patient was transferred to us with a BUN 68 and creatinine
2.5 with a suspicion of hepatorenal syndrome.
Upon arrival the patient was stable but a history was unreliable
as she seemed to be in grade I hepatic failure and was confused
with memory loss. However, she denied any symptoms of shortness
of breath, chest pain, nausea/vomiting, abdominal pain or
urinary symptoms.
Past Medical History:
1. Alcoholic cirrhosis
2. Hepatitis C
3. Hypertension
4. Paroxysmal atrial fibrillation
5. Breast cancer status post right mastectomy
6. Cholelithiasis
7. Hemorrhoids
Social History:
Lives with her husband in [**Name (NI) 13588**]
EtOH abuse
Family History:
Noncontributory
Physical Exam:
T 97.6 BP 106/60 HR 60 RR 22 sat 94 2L
GEN: NAD, somnolent, jaundiced, afebrile
HEENT: icterus, PERLA, no LAD, neck supple
CARDIO: S1S2, no audible m/b/r
PULM: CTAB
[**Last Name (un) **]: obese, distended, NT, no organomegaly
EXTR: 3+ bilateral pitting edema LE, pulses difficult to assess,
warm extremities
NEURO: normal CN, non-focal
PSYCH: A&Ox1, confused, poor short term memory
Pertinent Results:
[**2178-9-20**] 09:30PM WBC-25.3* RBC-3.76* HGB-13.8 HCT-41.9
MCV-111* MCH-36.7* MCHC-32.9 RDW-16.8*
[**2178-9-20**] 09:30PM PLT COUNT-306
Brief Hospital Course:
65-year-old female with alcoholic cirrhosis, HTN, p/w liver
failure from OSH.
Brief Hospital course: She was transferred to the MICU for
further care. The patient suffered from decompensated liver
failure and hepatorenal syndrome, hepatic encephalopathy and
sepsis. In the MICU, her condition continued to deteriorate
despite aggressive care. As she had been recently drinking she
was not a liver transplant candidate. After discussion with the
family, and per their wishes, it was ultimately decided that she
would be DNR/DNI. She died on [**2178-9-28**].
Medications on Admission:
1. Lactulose 30 ml PO TID
2. Midodrine HCl 7.5 mg PO TID
3. Neutra-Phos 2 PKT PO TID
4. Multivitamins 1 CAP PO QD
5. Folic Acid 1 mg PO QD
6. Thiamine HCl 100 mg PO QD
7. Octreotide Acetate 200 mcg SC Q8H
8. Atenolol 50 mg PO QD
9. Pantoprazole 40 mg IV Q24H
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Decompensated liver disease
Sepsis
Hepatorenal syndrome
Discharge Condition:
Deceased
Discharge Instructions:
none
Followup Instructions:
none
|
[
"571.2",
"427.31",
"V10.3",
"303.90",
"038.9",
"276.2",
"584.9",
"401.9",
"599.0",
"570",
"286.7",
"995.92",
"070.71",
"263.9",
"572.4",
"518.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"54.91",
"39.95",
"38.95",
"96.6",
"38.93",
"38.91",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
3435, 3444
|
2634, 3096
|
332, 383
|
3543, 3553
|
2365, 2509
|
3606, 3613
|
1929, 1946
|
3406, 3412
|
3465, 3522
|
3122, 3383
|
3577, 3583
|
1961, 2346
|
277, 294
|
411, 1647
|
1669, 1837
|
1853, 1913
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,422
| 154,325
|
40250
|
Discharge summary
|
report
|
Admission Date: [**2121-12-24**] Discharge Date: [**2122-1-2**]
Date of Birth: [**2039-7-24**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
S/p Fall
Major Surgical or Invasive Procedure:
Peg tube placement on [**2122-1-1**]
History of Present Illness:
82f who is quite active at home and lives with her sister.
Tonight she was taking care of the garbage when she felt
somewhat
dizzy and fell, striking her head. This was witnessed by her
sister. She did not have LOC and was awake and answering
questions when EMS arrived. She was taken to OSH where CT showed
R SDH and R temporal hemorrhagic contusion. At the OSH she
became
more lethargic and was intubated as a result. She was
transferred
to [**Hospital1 18**] for further evaluation. Her sister states she is on ASA
81mg daily but not on plavix or coumadin.
Past Medical History:
Hypertension
Hyperthyroidism
asthma
bronchiectasia
Chronic MAC- that was treated with multiple agents in [**2117**]-[**2118**].
She is folled by pulm
Social History:
lived with sister at home and did all ADLs. As per sister she
was very independent, she was driving and doing choirs around
the house. Per records there is no significant history of EtOh,
tobacco, or other drug use
Family History:
. Per records, no history of stroke.
Physical Exam:
PHYSICAL EXAM:
BP: 198/101 HR: 69 R 16 O2Sats 100
HEENT: Pupils: 2mm and reactive, unable to assess visual fields.
Neck: Supple. C Collar in place.
Extrem: Warm and well-perfused.
Neuro:
Intubated. Gag reflex present. Face appears symetric. Not
following commands. No movement in upper extremities to noxious
stimuli but will grimmace to pain. Withdraws both lower
extremities briskly to noxious.
PE ON TRANSFER TO MEDICINE ON [**2121-12-27**]
VS: HR 80s-90s (in and out of a-fib on tele), 151/84, RR 25, sat
95% on RA
Gen: thin female, sleeping comfortably in bed, arousable to
voice. Following commands and answering questions
HEENT: Pupil on the right is mildly dilated compare to the left,
reactive to light. Intact EOM, Bruising over eyes, anisocoric
Neck: no JVD, no LAD
CV: irregular rhythm, tachycardic, hyperdynamic
Resp: LCTA bil ant, sl diminished at bases with bronchial breath
sounds, no crackles.
GI: soft NTND no HSM, +BS
Ext: no c/c/eNeuro: sleeping but easily arousable, Oriented x
place and person. Responding to calling her name. She was able
to answer simpled questions and is following simple commands.
Moving all 4 extremities.
DISCHARGE PE:
VS: 97.7, (tmax 98.2), 75 (NSR on tele), BP 155/81, 18, 97% on
RA
Gen: thin female, A+ Ox person and place and at times to time in
NAD
HEENT: Pupil on the right 2-3mm minimally reactive compare to L
(unchanged since admission). Intact EOM, Bruising over eyes
resolving
Neck: no JVD, no LAD
CV: RRR, hyperdynamic, no murmurs, normal S1-S2
Resp: LCTA bil, sl diminished at bases with bronchial breath
sounds, no crackles/W/R
GI: soft, NT/ND, no HSM, +BS (small BM today)
Ext: CNII-XII intact except for different pupil size (R>L) and
dysphagia. Oriented x place and person and time at times.
Decrease in short term memory. She answers questions
appropriately. Symmetrical strength bil [**4-21**] bil UE and [**4-21**] on
Bil LE. OOB w/ assist
Skin: Inc on left upper scalp with staples that is C/D/I (needs
to be removed on [**1-4**])
Pertinent Results:
ADMISSION LABS:
[**2121-12-24**] 01:05AM PT-12.6 PTT-24.2 INR(PT)-1.1
[**2121-12-24**] 01:05AM WBC-13.9* RBC-3.73* HGB-11.1* HCT-31.5*
MCV-84 MCH-29.7 MCHC-35.1* RDW-13.3
[**2121-12-24**] 01:05AM GLUCOSE-123* UREA N-21* CREAT-0.9 SODIUM-139
POTASSIUM-3.3 CHLORIDE-99 TOTAL CO2-28 ANION GAP-15
DISCHARGE LABS:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2122-1-2**] 06:25 7.4 3.60* 10.6* 30.5* 85 29.5 34.8 14.1
227
[**2122-1-1**] 11:20 5.8 3.61* 10.7* 31.9* 88 29.7 33.7 13.9
266
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2122-1-2**] 06:25 91.1 15 0.4 138 3.9 106 24 12
[**2122-1-1**] 11:10 100.1 19 0.5 139 4.2 108 25 10
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili [**2122-1-1**] 11:10 57* 68* 71
0.3
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg
[**2122-1-2**] 06:25 8.0* 3.7 1.7
[**2122-1-1**] 11:10 3.1* 8.2* 2.6* 1.9
PITUITARY TSH
[**2121-12-27**] 18:41 0.73
NEUROPSYCHIATRIC Phenyto
[**2122-1-2**] 06:25 11.4
[**2121-12-30**] 07:30 11.0
MICRO:
[**2121-12-27**] 6:35 am URINE Source: Catheter.
**FINAL REPORT [**2121-12-31**]**
URINE CULTURE (Final [**2121-12-31**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
PRESUMPTIVE STREPTOCOCCUS BOVIS. >100,000
ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING:
ECHO ON [**2121-12-24**]:
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. Left ventricular systolic function is hyperdynamic
(EF>75%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no systolic
anterior motion of the mitral valve leaflets. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
Head CT [**12-24**]:
1. A moderate-sized right temporal intraparenchymal hemorrhage,
slightly more organized and mildly larger than the prior study
two hours ago.
2. Right-sided subdural hematoma tracking along the hemispheric
convexity and tentorium.
3. A 4 mm leftward midline shift.
4. Left frontoparietal subgaleal hematoma.
5. Questionable trace intraventricular hemorrhagic extension. No
hydrocephalus.
FINDINGS:
Redemonstrated centered within the right temporal lobe, there is
an area of intraparenchymal hemorrhage that is now slightly
decreased in size measuring 3.9 x 1.9 cm, where on similar
measurements on the most recent prior examination it measured
4.6 x 2.2 cm. Surrounding adjacent edema is similar as compared
to the prior examination. There is a subdural component of
hemorrhage seen immediately adjacent to the right cerebral
convexity and along the right tentorium, that overall, appears
similar in extent since the prior examination. There is a tiny
amount of likely subarachnoid hemorrhage (series 2A: image 21
and series 2A:19) that is also similar in extent since the prior
examination. Layering intraventricular hemorrhage seen within
the occipital horns appears to be slightly improved since the
prior examination. Hemorrhage seen extending to involve the
fourth ventricle on the prior examination, is less conspicuous
on today's examination. The ventricular system, however,
demonstrates interval enlargement since the prior examination,
now the lateral ventricles measuring up to 10 mm where
previously measured up to 7 mm and where the third ventricle
measures 7 mm where previously it measured 6 mm.
There is stable minimal leftward shift of normally midline
structures by
approximately 4 mm. There is some degree of edema in the right
cerebral
hemispshere as before with decreased conspicuity of the CSF
spaces. There has been no interval development of transtentorial
or uncal herniation. There are no new areas of hemorrhage.
Surgical staples are redemonstrated over the left frontoparietal
convexity. The visualized portions of the paranasal sinuses are
stable demonstrating mild mucosal thickening of the ethmoid air
cells and the sphenoid sinuses with the remainder being well
aerated. The mastoid air cells are well aerated.
IMPRESSION:
1. Mild increase in ventricular system size since prior
examination. Close
interval follow-up is recommended.
2. Slight interval decrease in known multicompartmental
hemorrhage with the largest focus, an area of right temporal
intraparenchymal hemorrhage. A few hypodense areas within may
relate to evolution/ less liekly more acute component if there
is h/o anemia/coagulopathy- follow up closely. Some degree of
edema of the right cerebral hemisphere.
3. Slight interval decrease in known intraventricular
hemorrhage.
Brief Hospital Course:
ICU Course:
82 year-old female with HTN, asthma, bronchiectasia,
hyperthyroidism who was admitted to the neurosurgery service on
[**12-24**] with a subdural hematoma after feeling dizzy then falling
while climbing the stairs (witnessed by her sister). She was
taken to OSH where CT showed R SDH and R temporal hemorrhagic
contusion. At the OSH she became more lethargic and was
intubated as a result. She was transferred to
[**Hospital1 18**] for further evaluation. The patient was admitted to the
TSICU for Q1 neuro checks. She was loaded with dilantin, and
transfused with platelets for her history of ASA use. She
remained intubated. Her repeat Head CT in the morning showed a
slight worsening of her IPH. Her exam also slightly worsened,
as she no longer followed commands or moved her LE with
commands. Neurology was consulted, and ordered a Stat CTA
Head/Neck. Neurology recommended that 3% saline be started and
to continue with dilantin. On [**12-25**] She was extubated. She did
well from a respiratory standpoint but her mental status
remained poor. She was transferred to the step down unit on
[**12-26**]. Overnight she was noted on telemetry to be in atrial fib
with a rate in the 120s which spontaneously resolved. Then, on
AM rounds, her HR was as high as 160 and the patient's SBP was
67. She was bolused 250cc and her SBP increased into the 90s but
her HR remained 120-140. Per nursing, her mental status has not
changed during this time. She denies chest pain, shortness of
breath or dizziness. As per her sister she had no prior history
of [**Name (NI) 17584**] or heart problems that she knows of.
.
Of note, the patient had a CT chest which was read as
'Multifocal calcified and noncalcified nodules with associated
fibrosis, bronchiectasis, and patchy opacification most
consistent with chronic mycobacterium avium-intracellulare
infection. Patient is thin, but unable to say (due to confusion)
whether she has had recent cough, sputum production, fever,
nightsweats. As per her sister, she had lung problems with
increase in secreation for the last 3-4 years. She sees a
pulmonologist, Dr. [**Last Name (STitle) 88352**] in [**Hospital6 **] who follows
her. She had recent CT of chest prior to her hospilalization and
had PFTs she was scheduled to f/u with pulm this week. She often
has increase in secreations which is attributed to
bronchiectasis. She was on steroids which were stopped 2-3 weeks
ago, she is uncertain why. Her sister also states that she has a
chronic infection of her lungs.
.
Hospital course on medicine service:
..
#. Atrial Fibrillation with RVR: She has now converted back to
sinus with HR in 70s on Metoprolol 25mg TID. She does not have
prior hx of A-fib and this is likely new onset. She had episode
of Afib with RVR with rates 120s-160s leading to hypotension
that responded to fluids. She also had ST depressions that
normalized with rate control. Her CE were elevated and have
trended down, indicating demand ischemia. She was started on
metoprolol 12.5mg TID and then increased to 25mg TID with
improvement of her HR. Patient has multiple reasons to have
afib; she is predisposed with longstanding hypertension, she is
acutely ill and has a head injury, she also had a high WBC count
and positive U/A and she had electrolyte abnormalities. As well
she is known to have hyperthyroidism and is on PTU. ECHO done on
[**12-24**] showed no structural heart disease and no focal WMA but did
show diastolic dysfunction. Her CHADS score is [**2-19**]. She just
had head bleed so not candidate for anticoagulation at this time
as per neurosurgery. She will be reacess by Dr. [**Last Name (STitle) **] and have
repeat CT in [**Last Name (LF) **], [**First Name3 (LF) **] he will give further recs for ASA or other
types of anticoagulation.
- Cont on Metoprolol tartrate 25mg TID
- d/ced all other anti-hypertensives (HCTZ and hydralazine)
- Repeat lytes and replete as needed
- Currently treating UTI w/ antibiotics
.
# Parenchymal and subdural hematoma: Pt appears to be stable.
Repeat head CT on [**12-27**] showed mild increase in ventricular
size, but sl. decrease in size of bleed. As per neurosurg, she
had repeat head CT that showed overall stable appearance of
multicompartmental hemorrhage without increase in ventricular
caliber. In regards her MS, she is more alert and oriented x 2
(person and place). She remember her home phone # and asked that
I called her sister. She was also asking appropriate questions.
Decrease in short term memory. She failed her swallow eval x 2
which may be r/t brain injury. Her right pupil size 2-3mm,
minimally reactive (unchanged). Moving all ext in bed. Pt has
been on dilantin and level today was 11 within therapeutic range
(goal >10). So will continue at current dose. She will need to
have weekly levels drawn and results sent to Dr. [**Last Name (STitle) **] as per
D/c instructions. Neuro-surgery will continue to follow and she
has appointment on [**2121-2-3**] with neuro surge and for repeat CT.
- Cont dilantin 100mg TID with weekly levels
- Will need to have continue PT, OT and re-eval of her
swallowing
- F/u w/ neurosurgery in [**Month (only) **]
- No anticoagulation for now (including ASA) until re-evaluated
by neurosurg in [**Name (NI) **]
- Pt has staples on left side of skull from laceration and
should be removed on Sunday [**1-4**]
.
# UTI: Uculture now showing >100,000 E.coli pan sensitive. She
had increase in WBC from 11.8->16.7 on [**12-27**], pt was hypothermic
on that AM with temp of 95F. No fevers, noted. WBC now WNL. Pt
had previously Negative UA on admission and she had a foley
placed during this admssion. Her foley was removed on [**12-28**] but
she failed voiding trial and had foley replaced on [**12-29**]. She
was started on ceftriaxone 1gm Q24hours on [**12-27**] and then
switched to cipro once sensitivities were available (today is
day 6 of antibiotics), she will only need two more doses of
antibiotics. Treating for total of 7 days, as complicated UTI
given that pt has foley. Plan is to D/c foley next week on Wed
[**1-8**] given that she fail voiding trial twice and once more
alert and mobile.
- D/ced Ceftriaxone 1 gm Q24hours and chanded to cipro toatl of
7 days ( currently on day 6)
- D/c foley on [**1-8**] if patient fails trial. Replace foley and
follow-up with MD
- If febrile or has any signs of infection repeat UA
.
# CT Lung findings: Ms. [**Known lastname 88353**] has history of MAC with
bronchiectasis. She does have hx of asthama, but no COPD. She
was diagnosed in [**2117**] and at the time she had wt loss and
hemoptsis. She was treated with multi-agents with azithromycin,
rifabutin, and ethambutol from [**2117**]-[**2118**]. Her current symptom is
increase in mucous secreation and has recurrent sinusitis and
she was recommended to have NS rinses and to use flonase. She
also had recent PFTs that showed severe restrictive disease. She
has increase amounts of mucous on the back of her throat at
times. Breathing without difficulty, sats in mid 90s%.
- Humidified O2 to help with secreations since pt is NPO
- Will start on flonase as recommended
- Mouth care Q4hours
- She will need close f/u with pulmonologist as outpatient
.
# L Clavicular fx: This is due to fall. Pt was found to have a
distal clavicular fracture, with the distal fragment slightly
superiorly displaced w/ intact AC joint. She also has a 1st rib
fx seen on CT. Pt has area of ecchymosis on L shoulder and has
no limitation of movement. She states that shoulder hurts, seems
to be more aware of shoulder pain.
- Place sling while she is out of bed for comfort
- Started on oxycodone 2.5mg for severe pain
- tylenol to Q 6hours PRN (LFTs sl. elevated, so would cont to
monitor and limit tylenol to <4Gm per 24hours)
- Cont to monitor LUE for perfusion
.
# HYPOTENSION: Now normotensive. She has hx of hypertension and
was on propanolol and HCTZ as outpatient. She had one episode on
[**12-27**] w/ SBP in 60s on the setting of A-fib with RVR and
receiving HCTZ and possibly due hypovolemia given that she
quickly responded to fluids. She also had recent ECHO w/ dCHF
and may be more preloaded depended. Her HCTZ was d/ced and she
was started on metoprolol for her HR control.
- D/ced HCTZ and propanolol for now
- Cont on Metoprolol as BP tolerates
# Hyperthyroidism: Pt has been on PTU 50mg Qday (held for the
last day since NPO and pnd PEG tube placement). Her TSH is WNL
at 0.73. Will cont PTU at 50mg Qday once PEG is placed.
.
#Dysphagia: As per sister, pt had difficulty swallowing prior to
the accident and had to have small bites and take solids with
liquids to help with swallowing. She has dobhoff tube in place
with tube feeds as recommended by nutrition, due to decrease in
gag reflex. Speech and swallow eval x 2 and failed. she had no
gag reflex and is at high risk for aspiration. She had PEG tube
placed on [**1-1**] and can be used after 3PM on [**1-2**]. Tube feed
recs for per d/c orders an instructions with Fibrosource HN [**Doctor First Name **]
40cc/hr. Uncertain if this will be temporary measure given pt's
brain injury. She will need to continue to be re-evaluated by
speech and swallow in the hopes that her swallow will improve.
.
# Anemia: pt has hx of anemia likely due to chronic disease. Her
Hct has been stable on the low 30s.
-Cont to monitor HCT
.
#Transaminitis: Pt has sl increase in LFTs uncertain what is her
baseline (ALT 57/AST 68) with normal alk phos and tbili.
Possibly due to meds. She denies having any abd pain.
- Changed tylenol from standing to PRN
- Would repeat LFTs in [**2-19**] days
.
# Prophylaxis: DVT: boots, stool softners
.
Communication: Patient and sister ([**Doctor First Name **]) home [**Telephone/Fax (1) 88354**]
Cell phone: [**Telephone/Fax (1) 88355**]
.
#Code status: Full Code confirmed with sister who is HCP
Medications on Admission:
propranolol
HCTZ
PTU
ASA 81mg
Steroids (uncertain about dose up to 2-3 weeks ago)
Discharge Medications:
1. propylthiouracil 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. calcium carbonate 500 mg/5 mL (1,250 mg/5 mL) Suspension Sig:
Five Hundred (500) mg PO TID (3 times a day).
4. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
5. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO HS (at
bedtime).
6. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal [**Hospital1 **] (2 times a day).
7. acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6HRS: PRN as needed for pain.
8. famotidine 40 mg/5 mL Suspension Sig: Twenty (20) mg PO once
a day.
9. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 doses: Last day on [**2122-1-3**]. Tablet(s)
10. phenytoin 100 mg/4 mL Suspension Sig: One Hundred (100) mg
PO every eight (8) hours: Please check dilantin level once per
week.
11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO
every eight (8) hours: Please hold for SBP<100 and HR <60.
12. oxycodone 5 mg/5 mL Solution Sig: 2.5 mg PO every 4-6 hours
as needed for pain: Please hold for sedation and RR<12.
13. insulin regular human 100 unit/mL Solution Sig: One (1)
injection Injection ASDIR (AS DIRECTED): Please follow current
SS and check FSG while pt is on tube feeds.
14. Fibersource HN Liquid Sig: Forty (40) cc/hr PO
continuous: Goal tube feeds at 40cc/hour. Please checkk for
residual Q 4hours and hold for >200cc residual. Water flushes
150cc Q 4 hours .
15. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol: glucose <60.
16. dextrose 50% in water (D50W) Syringe Sig: One (1) amp
Intravenous PRN (as needed) as needed for hypoglycemia protocol:
for glucose <60 or as per hypoglycemia protocol.
17. multivitamin Tablet Sig: One (1) Tablet PO once a day.
18. Humidified O2
PRN: As needed for increase secretions while NPO
19. Mouth care
Q 4 hours while NPO with OP suction as needed
20. Right arm sling
Please place right arm sling while OOB for comfort
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
PRIMARY:
Right Subdural Hematoma
Temporal Contusion
A-fib with RVR
dysphagia
Urinary retention
UTI
Discharge Condition:
Mental Status: Confused - sometimes (oriented x person/place and
occ x time)
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 88353**],
Thank you for allowing us to participate in your care. You were
admitted to the hospital after you had a fall at home and hit
your head. You were found to have a head bleed and you were
closely observed. You have been doing well, but had trouble
swallowing. So you had a tube placed on your stomach for
feeding. You were also found to have an urinary tract infection
for which you are being treated for. We have also attempted to
remove your foley cathter twice and you were unable to void in
your own. So this will need to be removed once you get to
rehabilitation facility. You have also developed an abnormal
heart rythm called atrial fibrilation and you will need to take
medication for this.
We have made the following changes to your medications:
- Started on metoprolol 25mg via NG tube or orally once
tolerating three times per day
- STOP ASPIRIN until this is further discuss with Dr. [**Last Name (STitle) **]
neurologist
- Stop propanolol, hydrochlorothiazide
- Started on Dilantin 100mg three times per day
- Started on Cipro 500mg twice daily (last day today [**2122-1-3**])
This are the neurosurgery recs:
# 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, or
Ibuprofen etc.
# You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**].
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:
# You have an appointment with Dr. [**Last Name (STitle) **], neurosurgeon, on [**2-3**] th. [**2122-2-3**] 09:00a
LM [**Hospital Unit Name **], [**Location (un) **]
NEUROSURGERY WEST
#You will also need to have to have a repeat Cat-scan of your
head on the same day at.
[**2122-2-3**] 08:15a XCT [**Apartment Address(1) 9394**] [**Hospital Ward Name **]
CC CLINICAL CENTER, [**Location (un) **]
RADIOLOGY
.
# Please call your primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 88356**], as
soon as you leave the Rehabilitation facility and schedule an
appointment soon after discharge. He will need to help manage
your new diagnose of atrial fibrilation.
[**Telephone/Fax (1) 88357**]
.
# You will need to have blood work checked and you will need to
have the dilatin levels checked at least once per week and have
result faxed to Dr. [**Last Name (STitle) **] at faxed to [**Telephone/Fax (1) 87**].
# PULMONOLOGIST: It is also very important that you continue to
follow with your pulmonologist for management of your chronic
lung infection. Please call Dr. [**Last Name (STitle) 88352**] in [**Hospital3 **] after
your rehabiliation discharge or within 1 month.
Office Address
[**Hospital3 58713**]
[**Hospital1 8**], [**Numeric Identifier 4293**]
Phone Number: ([**Telephone/Fax (1) 88358**]
Fax Number: ([**Telephone/Fax (1) 88359**]
|
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5,727
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51937
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Discharge summary
|
report
|
Admission Date: [**2156-8-23**] Discharge Date: [**2156-8-26**]
Date of Birth: [**2096-11-3**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 678**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
NG tube placement
History of Present Illness:
59yo M w CAD s/p MI, DM, AFib, ? Hep C, CHF with EF 30-35%, ESRD
on dialysis (Tue/[**Doctor First Name **]/Sat), polysubstance abuse, presents with
fever, altered mental status and abdominal pain. He reports
abdominal pain starting Sunday (1 day PTA), associated with
fever, throat pain, nausea and vomiting. He reports using
cocaine on Saturday. He reports a bloody bowel movement on
Sunday and is still passing gas. He had a tooth removed on
Wednesday and has been on Abx for that, but denies significant
tooth pain. He also reports pain in his right shoulder that was
similar to previous anginal pain.
.
In the ED, initial vs were: 104 124 162/90 34 85. His BP was
stable, but he was febrile and tachypnic satting 85/RA, and put
up to 100% on a NRB. History was difficult to obtain given
waxing/[**Doctor Last Name 688**] mental status. He had abdominal distension and
pain. Rectal exam with guaiac positive pink mucous. A KUB showed
gaseous distention without frank dilation of small bowel loops,
air/stool seen throughout the colon. Head CT unremarkable. CT
scan with IV/PO contrast showed small bowel distention with no
clear transition point and fecalization of TI, thought to be
Ileus versus partial SBO. He was seen by Surgery who recommended
NG tube placement. NG tube produced a small amount of bilious
contents. A right EJ placed. He had a R 18G PIV, then lost,
replaced with a right PIV in hand. He recieved 2.5 L IVF, Vanc x
1 gm, Ceftriaxone x2 gm, Tylenol, Zofran, 1 mg dilaudid. Prior
to transfer, VS: 103 113 30 18 121/74 100/NRB.
.
On the floor, he was feeling more awake. He continued to
complain of throat, arm, and belly pain. He was thristy.
.
Review of systems:
(+) Fever, chills, headache, cough productive of clear sputum,
dyspnea, shoulder pain, nausea, vomiting, abdominal pain.
(-) Denies chest pain or tightness, palpitations. Denied
dysuria. Denied arthralgias or myalgias.
.
After abdominal pain, fever, and repiratory distress was
resolved in the ICU, the patient was transfered to CC7. On the
floor, the patient complained of intermittent 5/10 chest pain.
He said that it was left-sided and worse after eating. He
reported it to be the same pain he gets with heartburn. An EKG
and Troponins were ordered to rule out an MI, and they were both
unremarkable and consistent with his baseline. On the floor, he
had no abdominal pain, was having regular BMs, and was satting
95% on RA.
Past Medical History:
# ESRD on hemodialysis (Tues/Thurs/Sat, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9449**] Dialysis,
[**Location 1268**], [**Telephone/Fax (1) 69669**])
# Type 2 diabetes mellitus
- peripheral neuropathy
# CAD s/p MI (patient cannot recall though [**2155**] cath
unremarkable)
- cardiac catheterization in [**9-/2155**] without flow limiting
stenoses
- MIBI in [**11/2152**] showed reversible defects inferior/lateral
# CHF with EF 30-35% ([**9-/2155**] TEE)
# Atrial fibrillation/atrial flutter s/p Aflutter ablation
[**8-/2153**]
- not on anticoagulation
# h/o atrial tachycardia s/p EPS [**9-21**] and ablation x 2 for L
sided, triggered (not reentrant) Atachs
# Hypertension
# Dyslipidemia: [**9-/2155**] TC 101, LDL 54, HDL 29, TG 112
# History of gastrointestinal bleed:
- Duodenal, jejunal, and gastric AVMs s/p thermal therapy
- diverticulosis throughout colon
# Chronic pancreatitis
# ? Hepatitis C, positive HCV Ab in [**10/2150**], subsequently
negative x 2 [**4-/2154**], [**5-/2154**]
# GERD
# Gout s/p arthroscopy with medial meniscectomy [**5-/2149**]
# Depression s/p multiple hospitalizations due to SI
# Polysubstance abuse: crack cocaine, EtOH, tobacco
- frequent bouts of chest pain following crack/cocaine use
# Erectile dysfunction s/p inflatable penile prosthesis [**5-/2148**]
Social History:
He lives with a female partner named [**Name (NI) 5464**] in [**Location (un) 686**], MA.
42 pack-year smoking history, recently up to 6 cigarettes per
day. He has a history of alcohol abuse, with DTs and
detoxification, with last drink on [**Holiday 1451**] [**2155**]. Pt has
used crack cocaine for years, approx. 2-3x/wk. Last use several
days before admission.
Family History:
Father with alcoholism. Mother with type 2 diabetes, renal
failure, died at age 58. Son with diabetes. Cousin with [**Name2 (NI) 14165**]
cell disease.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Vitals: T: 100.1 BP:95/56 P:98 O2: 98/5L
General: Intermittantly somnilent, but able to relay history
HEENT: Sclera anicteric, dry mucous membranes, NG tube with
bilious contents
Neck: supple
Lungs: Good air movement bilaterally, patchy bibasilar rhonchi
worse on right.
CV: Regular rhythm with mild tachycardia, hyperdynamic S1 + S2,
no murmurs, rubs, gallops
Abdomen: Distended, mild diffuse tenderness. Absent bowel
sounds. No rebound tenderness or guarding.
Ext: Warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
PHYSICAL EXAM ON D/C FROM MICU
Vitals: HR: 94 BP:129/80 RR: 16 sP02: 92% 2 LNC
General: NAD, comfortable
HEENT: Sclera anicteric, dry mucous membranes, PERRLA
Neck: supple, no JVD
Lungs: Good air movement, CTA bilaterally.
CV: Regular rate and rhythm, S1 + S2 clear, no murmurs, rubs,
gallops
Abdomen: +bs, soft, NT, ND. No rebound tenderness or guarding.
Ext: Warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
PHYSICAL EXAM ON DISCHARGE:
Vitals: T: 98.4/98.4 HR 93-97 BP 136-154/70-82 RR 16 Sats 94-96%
on RA
GEN: NAD, comfortable
CV: RRR s mrg. No JVD.
Resp: CTAB
Abd: S, NT/ND, +BS
Ext: WWP, 2+ pulses
Pertinent Results:
[**2156-8-23**] 10:39PM TYPE-[**Last Name (un) **] PO2-110* PCO2-42 PH-7.49* TOTAL
CO2-33* BASE
[**2156-8-23**] 10:39PM LACTATE-2.0
[**2156-8-23**] 10:24PM CK(CPK)-230*
[**2156-8-23**] 10:24PM CK-MB-5 cTropnT-0.46*
[**2156-8-23**] 05:37PM CK(CPK)-246*
[**2156-8-23**] 05:37PM CK-MB-5 cTropnT-0.49*
[**2156-8-23**] 09:00AM PT-15.3* PTT-33.7 INR(PT)-1.3*
[**2156-8-23**] 12:00AM CK(CPK)-183*
[**2156-8-23**] 12:00AM CK-MB-4 cTropnT-0.38*
[**2156-8-22**] 11:59PM PO2-145* PCO2-40 PH-7.48* TOTAL CO2-31* BASE
XS-6
[**2156-8-22**] 11:59PM LACTATE-1.5
[**2156-8-22**] 07:15PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-POS
amphetmn-NEG mthdone-NEG
[**2156-8-22**] 07:15PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.020
[**2156-8-22**] 07:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-250
KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-6.5
LEUK-TR
[**2156-8-22**] 07:15PM URINE RBC->50 WBC-[**6-23**]* BACTERIA-FEW
YEAST-NONE EPI-0-2
TRANS EPI-0-2
[**2156-8-22**] 07:15PM URINE AMORPH-FEW
[**2156-8-22**] 07:05PM GLUCOSE-214* UREA N-51* CREAT-7.6*#
SODIUM-130*
POTASSIUM-5.9* CHLORIDE-88* TOTAL CO2-26
ANION GAP-22*
[**2156-8-22**] 07:05PM ALT(SGPT)-17 AST(SGOT)-19 ALK PHOS-181* TOT
BILI-1.2
[**2156-8-22**] 07:05PM LIPASE-17
[**2156-8-22**] 07:05PM CALCIUM-11.0* PHOSPHATE-4.2 MAGNESIUM-2.2
[**2156-8-22**] 07:05PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt
NEG tricyclic-NEG
[**2156-8-22**] 07:05PM WBC-5.3 RBC-4.43* HGB-11.7* HCT-37.5* MCV-85
MCH-26.4*
MCHC-31.1 RDW-15.9*
[**2156-8-22**] 07:05PM PT-14.9* PTT-30.2 INR(PT)-1.3*
Imaging:
CT Abd/Pel ([**8-22**]): 1. dilated small bowel measuring up to 3.3 cm
noted to level of TI with fecalization of TI. findings
consistent with ileus vs partial SBO. no transition point
identified. 2. LLL airspace opacity may represent aspiration.
infection cannot be excluded. 3. small rt pleural effusion.
.
CXR ([**8-22**]): 1. Small right pleural effusion and mild fluid
overload.
2. Possible retrocardiac opacity. Dedicated PA/lateral
recommended.
.
CXR ([**8-23**]): Interval improvement in the multifocal consolidation
with stable right pleural effusion and new NG tube in
satisfactory position. Mild pulmonary venous congestion.
.
KUB ([**8-24**]): No ileus seen.
.
EKG: Sinus tachycardia @ 125. Left-axis. Inferior Q-waves,
Crochet in V1. Compared to prior the axid is more leftward and
P-wave morphology changed. No significant ischemic changes.
Brief Hospital Course:
#1 Ileus: CT revealed ileus vs. partial SBO, but passing gas &
stool. Unclear etiology, but initially thought to be in setting
of cocaine/opiate use vs adominal infection. No infection
revealed over MICU course. Vanc/zosyn given initially to cover ?
abd infection, dc'd when no infection evolved. Surgery
consulted, NGT placed, pt monitored with serial abd
exams,KUBs,kept NPO. As signs of distension on KUB resolved, and
NGT output decreased, patient NGT was clamped and pulled, and he
was started on a diet of clears. Pt able to tolerate clear
fluids without n/v, and abd pain resolved. Pt advanced to full
diet without difficulty.
.
#2 Dyspnea: Patient presented febrile, tachypnic with
significant O2 requirement and lung base infiltrates. Initially
thought to be PNA, but due to rapid improvement, eventually
thought to be a chemical pneumonitis. The patient was followed
with daily CXR, started on vanc/zosyn initially to cover PNA,
given oxygen as needed, and started on albuterol prn SOB. He
was also placed on aspiration precautions.
.
#3 Presented with altered mental status: likely [**2-16**] substance
use. Pt had a negative head CT, and his mental status returned
to baseline.
.
#4 Chest pain: likely [**2-16**] GERD. Pt describes the pain as
intermittent [**5-23**] pain in the left upper chest that does not
radiate and is worse after eating. The patient experiences the
pain often. Pt had a negative EKG and Troponins. Pain resolved
with Tylenol and PPI.
.
#5 Coronary artery disease: Right arm pain on presentation
thought to be possible anginal equivalent. Recent clean cath.
Cardiac enzymes were trended and he ruled out for MI. He was
given a statin and diltiazem, and his aspirin was held in the
setting of ?GIB and low likelihood of MI. Pt had history of RVR
in absence of dilt, noted to have atrial tachycardia on
admission with borderline bps. Dilt given for rate control.
Currently in sinus, on dilt, ace, asa, statin.
.
#6 Bloody stool: History of AVM and bleeding with
anticoagulation. No frank blood on exam. No blood in NG tube, no
bleeding this admission, however aspirin was held, type and
screen and 3U PRBCs, and PPI started.
.
#7 ESRD on Tu/Th/Sa HD: On admission had missed last HD session
and was s/p contrast in ED. Pt had HD on [**2156-8-24**], 1l removed,
electrolytes, bps wnl after HD. Pt had HD on [**2156-8-26**] as well.
.
#8 Diabetes: HISS in MICU, gfc were controlled.
.
#9 s/p tooth extraction: currently stable. On DOA had one day
remaining in antibiotics, but was covered by abx regimen.
.
#10 Received social work consult given substance abuse.
.
Was full code during admission. Communication was with patient
and HCP [**Name (NI) **] [**Telephone/Fax (1) 107505**]
Medications on Admission:
Per pt medication bag:
Diltizam 240 mg PO daily
Lipitor 20 PO daily
Lisionopril 20 mg PO daily
Vicoden 5/500 Q 3-4 hrs
Amox 500 mg PO TID (3 doses remaining)
Amiodiorone 200 mg PO daily
Hydroxizine 25 mg PO BID
SL NTG prn
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Gabapentin 100 mg Capsule Sig: [**1-16**] Capsules PO at bedtime.
5. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO twice a
day as needed for itching.
6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual prn as needed for chest pain.
7. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
8. Selenium Sulfide 2.5 % Suspension Sig: Apply to skin Topical
10 minutes before shower.
9. Mupirocin 2 % Ointment Sig: Apply to affected skin Topical
two to three times daily.
10. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO once a day.
11. Cinacalcet 60 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Renagel 800 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnoses: ileus, GERD, chemical pneumonitis
Secondary Diagnoses: DM2, CAD, atrial fibrillation, chronic
systolic CHF, HTN, ESRD on hemodialysis, polysubstance abuse
Discharge Condition:
The patient is being discharged in stable condition, with no
abdominal pain, with regular bowel movements, with no fever, and
with intermittent mild chest pain, most likely from GERD.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
You were seen at the [**Hospital1 69**] on
[**2156-8-23**] because you had abdominal pain, a fever, and altered
mental status.
When you came to the Emergency Department, you had a fever and
were very short of breath. We gave you oxygen to help you
breath and we put an intravenous line into your arm so that we
could give you fluids and medicines. We perfomed some imaging
studies to look at what was going on inside your belly. It
looked like things were not moving through your bowels, and that
this was the cause of your belly pain. We placed a tube down
your nose and into your stomach to help decompress the bowels
and this gave you some relief.
Initially, you went to the ICU because of your difficulty
breathing and fever. The doctors thought [**Name5 (PTitle) **] might have an
infection in your lungs and started you on antibiotics. You
improved very quickly, and no longer required supplemental
oxygen to breathe well. You also started having bowel movements
and this helped your belly pain to go away.
On [**2156-8-25**] you were transferred out of the ICU to a different
hospital floor. You had some chest pain that you felt was the
same pain you get after eating from heartburn. We gave you
Protonix and some tylenol and the pain went away. We did
several studies including an EKG and a lab test to look at your
Troponin levels that made us feel comfortable that this was not
a problem with your heart. You received hemodialysis as an
inpatient during your hospitalization.
Please follow up with your NP, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], on [**2156-9-3**], at 10:30 AM. Office phone no.: [**Telephone/Fax (1) 250**]
If you experience the following symptoms: shortness of breath,
chest pain, blood in your stool, fevers, confusion, or any other
worrisome symptoms, please contact your PCP or go to the
Emergency Department.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2967**], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2156-9-3**] 10:30
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**]
Completed by:[**2156-8-28**]
|
[
"412",
"414.01",
"428.0",
"585.6",
"357.2",
"250.60",
"506.0",
"305.90",
"427.31",
"427.32",
"560.1",
"428.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07"
] |
icd9pcs
|
[
[
[]
]
] |
12694, 12752
|
8472, 9545
|
283, 302
|
12970, 13156
|
5863, 8449
|
15192, 15486
|
4494, 4647
|
11473, 12671
|
12773, 12826
|
11225, 11450
|
13180, 15169
|
4662, 4676
|
12847, 12949
|
5675, 5844
|
2016, 2749
|
229, 245
|
330, 1997
|
4690, 5647
|
9560, 11199
|
2771, 4092
|
4108, 4478
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,263
| 120,092
|
35654
|
Discharge summary
|
report
|
Admission Date: [**2145-12-8**] Discharge Date: [**2145-12-13**]
Date of Birth: [**2097-11-16**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
Headache,Nausea and vomiting
Major Surgical or Invasive Procedure:
[**12-8**]: Right Frontal Craniotomy for mass resection
History of Present Illness:
48 year old right handed woman with a history of breast cancer
s/p left mastectomy, radiation, and chemotherapy with known
metastases to the liver, bone, and lung who presents with a 1
month history of bitemporal headaches and a 2 week history of
daily vomiting who was transferred from an OSH with head CT
showing two lesions in the right cerebral hemisphere with
midline shift consistent with metastases.
The patient reports that over the past 1 month, she has had
daily bilateral temporal pressure headaches up to [**8-27**]
intensity. She reports that the headaches would last a minute,
but then she would sleep in bed for the rest of the day. She has
been taking [**Hospital1 **] Tylenol for the headache with some
relief. The headaches would get better when she would lay down,
and there would be no change with Valsalva maneuver. She denied
any photophobia or phonophobia (but her family says she would
sit in a dark room with the headaches). She denies diplopia,
blurry vision, dysarthria, or dysphagia. She denied any
numbness, but reports she has had left arm and hand weakness
even since before the mastectomy for which she receives PT. Her
family reports that she has also had memory loss, including
losing her T pass and forgetting about a present she bought for
a friend. Over the past 2 weeks, she has also had daily episodes
of emesis, which she describes as forceful and yellow-[**Location (un) 2452**] in
color (which is the color of what she has been eating). She
denies any fevers. She came to the hospital today at the urging
of her friend and brother (who say that she often minimizes her
symptoms).
At the OSH ED, vitals on admission were temp 97.0, HR 98, bp
114/76, RR 18, 97%. WBC 7.2, Hct 41, plt 207, Na 145, Cr 0.8.
Head CT (preliminary read) showed at least two lesions in the
right cerebral hemisphere consistent with mets and R to L shift.
Largest at least 2.5 cm, other 1.2 cm. She was given Decadron 10
mg IV x1, Dilantin 1 gm IV x1, and NS at 150 cc/hr. She was
transferred to [**Hospital1 18**]. At [**Hospital1 18**] she has received Zofran 4 mg IV
x1.
Past Medical History:
-Breast cancer s/p left mastectomy, radiation (last in [**5-25**]),
and chemotherapy (last in [**12-26**]), receives care [**Location (un) 81132**]
([**Hospital3 **] in [**Location (un) 246**]), known metastases to the liver,
bone, and lung (discovered in [**8-25**])
Social History:
Social Hx: Patient lives alone with a cat. She lives 1 mile away
from a close friend, and her brother is involved in her care.
She denies any history of cigarette, alcohol, or illicit drug
use.
Family History:
Family Hx: There is no family history of breast cancer. Her
father and mother had heart disease.
Physical Exam:
On Admission:
O: T: 96.8 BP: 95/64 HR: 88 RR: 22 O2Sats: 100% on RA
Genl: Awake, alert, NAD
HEENT: Sclerae anicteric, no conjunctival injection, oropharynx
clear
CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops
Chest: CTA bilaterally anteriorly and laterally, no wheezes,
rhonchi, rales
Abd: +BS, soft, NTND abdomen
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive, speech
is fluent with normal comprehension and repetition; naming
intact to high frequency objects (watch, band), but not to low
frequency objects (clasp). No dysarthria. Registers [**1-18**], recalls
[**1-18**] in 5 minutes. No right-left confusion. No evidence of
neglect.
Cranial Nerves: Pupils equally round and reactive to light, 5 to
4 mm bilaterally. Visual fields are full to confrontation, but
may have slightly decreased vision in the right superior
temporal quadrant. Extraocular movements intact bilaterally
without nystagmus. Sensation intact V1-V3. Patient able to
elevate eyebrows and pucker lips, but has difficulty smiling:
lifts the right side of her mouth more briskly than the left.
Hearing intact to finger rub bilaterally. Palate elevation
symmetric. Sternocleidomastoid full strength bilaterally. Tongue
midline, movements intact.
Motor: Intermittent myoclonic jerks of the right upper extremity
upon extension, no asterixis or tremor. No pronator drift.
[**Doctor First Name **] Tri [**Hospital1 **] WE FE FF IP H Q DF PF
R 5 5 5 5 5 5 5 5 5 5 5
L 5 5- 5- 5 5 5 5 5 5 5 5
Sensation: Intact to light touch in bilteral upper and lower
extremities. No extinction to DSS.
Reflexes: 2+ and symmetric in biceps, brachioradialis, and
knees. 1+ and symmetric in triceps and knees. Toe downgoing on
the left and upgoing on the right.
Coordination: Slowed finger-nose-finger and fine finger
movements on the left, normal on the right.
Gait: Deferred
Pertinent Results:
Labs on Admission:
[**2145-12-8**] 04:55PM BLOOD WBC-9.1 RBC-4.53 Hgb-12.9 Hct-37.1 MCV-82
MCH-28.5 MCHC-34.7 RDW-13.3 Plt Ct-199
[**2145-12-8**] 04:55PM BLOOD Neuts-95.6* Lymphs-3.8* Monos-0.3*
Eos-0.2 Baso-0.1
[**2145-12-8**] 04:55PM BLOOD PT-15.1* PTT-24.3 INR(PT)-1.3*
[**2145-12-8**] 04:55PM BLOOD Glucose-102 UreaN-14 Creat-0.6 Na-143
K-4.1 Cl-107 HCO3-24 AnGap-16
Labs on Discharge:
[**2145-12-11**] 06:25AM BLOOD WBC-7.7 RBC-4.09* Hgb-11.8* Hct-33.9*
MCV-83 MCH-28.7 MCHC-34.7 RDW-13.0 Plt Ct-185
[**2145-12-11**] 06:25AM BLOOD Glucose-92 UreaN-12 Creat-0.6 Na-140
K-4.1 Cl-103 HCO3-26 AnGap-15
[**2145-12-11**] 06:25AM BLOOD Calcium-8.9 Phos-2.5* Mg-2.4
[**2145-12-10**] 07:30AM BLOOD Osmolal-289
IMAGING:
CT Head [**12-8**]:
FINDINGS: There are three ring-enhancing supratentorial
metastatic foci. The largest in the right frontal lobe measures
3.3 x 2.8 cm and demonstrates a large amount of vasogenic edema
with associated 1.5-cm shift of normally midline structures and
leftward subfalcine herniation. A 1.9 x 1.1 cm right parietal
lesion adjacent to the posterior falx demonstrates moderate
vasogenic edema. A right occipital lesion measures 1.2 x 1.1 cm
and demonstrates a moderate associated vasogenic edema. The
basilar cisterns are preserved without evidence of
transtentorial or uncal herniation. The bony calvarium is intact
and there is no evidence of lesion that is suspicious for
infection or metastasis in the calvarium or skull base. The
imaged paranasal sinuses and mastoid air cells are clear.
IMPRESSION: Multifocal right hemisphere metastatic disease with
and left
subfalcine herniation and midline shift as noted above.
MRI Head [**12-8**]:
FINDINGS: Multiple enhancing metastatic lesions identified, with
the largest in the right frontal lobe, again with surrounding
vasogenic edema and leftward subfalcine herniation, not
significantly changed compared to prior study. Enhancing left
parietal lesion, along the falx, and left occipital lesion are
also again identified. Tiny focus of enhancement within the
right ventricle (2:42), possibly represents normal choroid
plexus, although metastatic disease cannot be entirely excluded.
There is no acute hemorrhage. Normal flow voids are identified.
Visualized paranasal sinuses are normally aerated.
IMPRESSION: Multifocal metastatic disease, with leftward
subfalcine
herniation/shift not significantly changed compared to prior
study.
Enhancement of the right ventricle possibly represents normal
choroid plexus, although metastatic disease cannot be entirely
excluded.
MRI Head (post-resection) [**12-9**]:
FINDINGS: The patient is status post right frontal craniotomy.
There is
evidence of residual blood products within the surgical bed as
well as a post-surgical cavity, the previously identified
metastatic lesion on the right frontal lobe apparently has been
removed, vague pattern of enhancement is identified on the left
frontal lobe (image #16, series #13). The other two previously
demonstrated metastatic lesions, one on the right occipital lobe
and the second right parafalcine metastatic lesion are
unchanged. Similar pattern of vasogenic edema is demonstrated,
minimal decrease in the midline shift towards the left,
approximately 9.5 mm of deviation is demonstrated in the axial
projection. Areas of hyperintensity signal related with blood
products are visualized in the DWI maps. Persistent effacement
and shift of the mid brain towards the left and uncal
herniation, unchanged since the prior examination. Normal flow
voids are identified in the major vascular structures. The
orbits, the paranasal sinuses, and the mastoid air cells are
unremarkable. The visualized aspect of the craniocervical
junction appears within normal limits.
IMPRESSION: The patient is status post right frontal craniotomy.
Resection
of the right frontal metastatic lesion, vague pattern of
enhancement is noted in the left frontal lobe as described
above, follow-up is recommended. Two unchanged metastatic
lesions, one on the right occipital lobe and the second right
parafalcine in the convexity. Persistent mass effect and
vasogenic edema with lesser degree of midline shift and
persistent right uncal herniation.
Brief Hospital Course:
The patient is a 48 year old right handed woman with a history
of breast cancer s/p left mastectomy, radiation, and
chemotherapy with known metastases to the liver, bone, and lung
who presented with a 1 month history of bitemporal headaches and
a 2 week history of daily vomiting who was transferred from an
OSH with head CT showing two lesions in the right cerebral
hemisphere with midline shift consistent with metastases. Head
CT at [**Hospital1 18**] showed three ring-enhancing supratentorial
metastatic foci: 3.3 x 2.8 cm in the right frontal lobe, 1.9 x
1.1 cm right parietal lesion, and 1.2 x 1.1 cm right occipital
lesion. They all had associated vasogenic edema, and there was
1.5-cm shift of normally midline structures and leftward
subfalcine herniation. Given the extent of peri-turmoral edema
and her deteriorating neurologic examination (she became
progressively lethargic in the ED), she was taken for emergent
resection. On [**2145-12-8**] she had a right craniotomy for frontal
tumor resection. She tolerated the procedure well without
complication. Post-procedure MRI showed resection of the right
frontal metastatic lesion, vague pattern of enhancement is noted
in the left frontal lobe, two unchanged metastatic lesions: one
on the right occipital lobe and the second right parafalcine in
the convexity. There was persistent mass effect and vasogenic
edema with lesser degree of midline shift and persistent right
uncal herniation.
She was initially on Decadron 6 mg IV q6 hr, but was discharged
on Decadron 4 mg PO q6 hr. She was initially on Dilantin, but
this was changed to Keppra 1000 mg PO bid upon discharge.
Radiation oncology was consulted while she was admitted and
advised whole brain radiation, but the patient preferred to
follow up in [**Hospital3 **] where she has had her breast
cancer treatment.
Medications on Admission:
Tamoxifen 20 mg daily
[**Hospital1 **] Tylenol prn
Discharge Medications:
1. Tamoxifen 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
3. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*2*
8. Outpatient Physical Therapy
Outpatient Physical Therapy
Dx: Right cerebral metastases
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Right Cerebral Metastases
SECONDARY
Breast Cancer
Discharge Condition:
Neurologically Stable
Strength full, CN intact
Discharge Instructions:
General Instructions/Information
?????? 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.
?????? Your wound closure uses dissolvable sutures, you must keep
that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
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: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
***You need to stop by Radiology on the [**Location (un) **] prior to
leaving the hospital, to pick up a CD with your CT and MRI
images to give to your outpatient oncologist.
Follow-Up Appointment Instructions
??????Please return to the office in [**5-27**] days (from your date of
surgery) for a wound check. This appointment can be made with
the Nurse Practitioner. Please make this appointment by calling
[**Telephone/Fax (1) 1669**]. If you live quite a distance from our office,
please make arrangements for the same, with your PCP.
??????You have elected to follow up with your outpatient oncologist
for your radiation treatment. If you would instead like to
follow up at [**Hospital3 **], call [**Telephone/Fax (1) 1844**] for an appointment.
|
[
"198.3",
"V15.3",
"V87.41",
"198.5",
"348.5",
"V10.3",
"348.4",
"197.7",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
12190, 12196
|
9359, 11196
|
350, 408
|
12299, 12349
|
5140, 5145
|
14232, 14988
|
3047, 3145
|
11297, 12167
|
12217, 12278
|
11222, 11274
|
12373, 14209
|
3160, 3160
|
282, 312
|
5531, 9336
|
436, 2528
|
3908, 5121
|
5159, 5512
|
3513, 3892
|
2550, 2819
|
2835, 3031
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,842
| 115,483
|
16257
|
Discharge summary
|
report
|
Admission Date: [**2166-8-4**] Discharge Date: [**2166-8-18**]
Service:
HISTORY OF THE PRESENT ILLNESS: This 81-year-old white male
was referred to [**Hospital1 18**] for cardiac catheterization after a
positive stress MIBI. He has had a history of prior TIAs and
known atherosclerotic disease. He denied any chest
discomfort or shortness of breath and was in his usual state
of health. He did have a pacemaker implanted several years
ago for a rapid heart rate. He had an echocardiogram in [**Month (only) 205**]
which revealed an EF of 35-40%, severe LVH with anteroseptal,
inferoseptal, and inferior hypokinesis and apical akinesis.
The LA was moderately dilated. He had [**11-21**]+ MR, [**11-21**]+ TR,
moderate pulmonary hypertension, minimal AS and trace AI. He
had a positive stress test on [**2166-7-1**] and was referred for
cardiac catheterization.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Infrarenal AAA 4.8 by 4.4 cm.
3. Hypertension.
4. Status post CVA/TIA.
5. Status post bilateral carotid endarterectomies in [**12-21**].
6. History of hyperlipidemia.
7. History of chronic renal insufficiency with a creatinine
of 1.7 to 2 baseline.
8. History of noninsulin-dependent diabetes.
9. Status post pacer placement.
10. Status post appendectomy.
ADMISSION MEDICATIONS:
1. Uniretic 15/25 one p.o. q.d.
2. Lipitor 10 mg p.o. q.d.
3. Toprol XL 25 mg p.o. q.d.
4. Coumadin 4 mg p.o. q.d.
5. Albuterol two puffs q.a.m.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: He lives alone. He quit smoking in [**2108**] and
does not drink alcohol.
REVIEW OF SYSTEMS: Unremarkable.
PHYSICAL EXAMINATION ON ADMISSION: General: He is an
elderly white male in no apparent distress. Vital signs:
Stable, afebrile. HEENT: Normocephalic, atraumatic. The
extraocular movements were intact. The oropharynx was
benign. Neck: Supple, full range of motion. No
lymphadenopathy or thyromegaly. Carotids were 2+ and equal
bilaterally without bruits. Lungs: Clear to auscultation
and percussion. Abdomen: Soft, nontender with positive
bowel sounds and a pulsatile mass. He also had a balloon
pump in place. Extremities: Without clubbing, cyanosis or
edema. Pulses were 2+ and equal bilaterally throughout
except the DP and PT were only Doppler flow.
HOSPITAL COURSE: The patient was admitted for cardiac
catheterization. The patient underwent cardiac
catheterization on [**2166-8-5**]. The left main revealed mild
distal disease, LAD had a proximal 95% stenosis, was heavily
calcified with serial 80% mid and distal stenoses, left
circumflex had a proximal 90% stenosis at the bifurcation of
the left circumflex and OM1 with a questionable occluded
proximal marginal midvessel 80% left circumflex disease. The
RCA had serial diffuse 50-60% stenosis with midvessel 80%
stenosis.
He had a balloon pump placed in the Catheterization
Laboratory and Dr. [**Last Name (STitle) 70**] was consulted. He had carotid
ultrasounds done which revealed no evidence of stenosis.
On [**2166-8-6**], the patient underwent a CABG times three with
LIMA to the LAD, reverse saphenous vein graft to OM, reverse
saphenous vein graft to RPDA. The cross clamp time was 54
minutes. Total bypass time 80 minutes. He was transferred
to the CSIU on Neo, milrinone, and propofol. He was
extubated on postoperative night and he was still on his
milrinone and Neo. He also had his pacemaker interrogated
and the atrial lead was not working appropriately. He will
have this dealt with as an outpatient. He went back into his
chronic atrial fibrillation. He was slowly improving.
On postoperative day number two, he had acute hypoxia and
Pulmonary was consulted. They recommended inhaled steroids.
Following this consult, he had hemoptysis. He had an urgent
intubation and had large clots removed from his airway. He
had hypotension at this time as well. He was re-Swanned.
His cardiac index was stable. This hemoptysis resolved
eventually and he remained sedated and had a slow milrinone
wean for the next couple of days. He was extubated again on
postoperative day number five and required aggressive
respiratory therapy.
He had his chest tubes discontinued on postoperative day
number six. His milrinone was discontinued as well. He was
on levofloxacin for his secretions. He slowly improved,
weaning off his 02 requirement.
On postoperative day number nine, he was transferred to the
floor in stable condition. He continued to improve and was
diuresed. He was also started on nutritional supplements and
he continued to improve. On postoperative day number 13, he
was discharged to rehabilitation in stable condition.
LABORATORY DATA ON DISCHARGE: Hematocrit 29.4, white count
13,300, platelets 347,000. Sodium 139, potassium 4.1,
chloride 104, C02 27, BUN 50, creatinine 1.9, blood sugar 91.
PT 15, INR 1.5.
DISCHARGE MEDICATIONS:
1. Lipitor 10 mg p.o. q.d.
2. Albuterol MDI one to two puffs q.a.m.
3. Combivent one to two puffs q.i.d. p.r.n.
4. Amiodarone 400 mg p.o. b.i.d. times seven days and then
decrease to 400 mg p.o. q.d. times seven days and then
decrease to 200 mg p.o. q.d.
5. Coumadin 1 mg p.o. q.d. for an INR goal of 1.5 to 2.
6. Lasix 20 mg p.o. b.i.d. for seven days.
7. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. q.d. for seven days.
8. Neosporin ophthalmic ointment four times a day to both
eyes for seven days.
FOLLOW-UP: The patient will be followed by Dr. [**Last Name (STitle) 17887**] in
one to two weeks, Dr. [**Last Name (STitle) 1016**] in two to three weeks, and Dr.
[**Last Name (STitle) 70**] in six weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 6516**]
MEDQUIST36
D: [**2166-8-18**] 11:22
T: [**2166-8-18**] 11:25
JOB#: [**Job Number 46365**]
|
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"518.5",
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icd9cm
|
[
[
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[
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"37.61",
"36.12",
"88.44",
"99.62",
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"96.6",
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] |
icd9pcs
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[
[
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4913, 5976
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2344, 4712
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1321, 1526
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4727, 4890
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1639, 1675
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1690, 2326
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901, 1298
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1543, 1619
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,756
| 108,832
|
39234
|
Discharge summary
|
report
|
Admission Date: [**2199-7-13**] Discharge Date: [**2199-7-19**]
Date of Birth: [**2137-7-28**] Sex: F
Service: MEDICINE
Allergies:
aspirin / NSAIDS / Haldol
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
Chief Complaint: AMS
Reason for MICU transfer: hypoxia
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
The patient is a 61 yo F with hx of Schizophrenia, DM2, COPD
last FEV1 60% predicted [**4-18**](with recent hospitalization at
[**Hospital1 18**] [**Date range (1) 70311**] with hypoxemia and UTI). The patient was
reportedly called by her family this AM - when she did not
answer, they were alarmed and called the police who went to her
home. The police found her confused, reportedly "frothing" at
the mouth, incontinent. EMS brought her to [**Hospital1 18**].
In the ED, initial VS were T103.4 P138 BP117/57 RR34 Sat88% nrb.
Her sats eventually improved on high flow/NRB to mid-90s. Then
placed on Bipap with O2 Sat 94%. On exam, she was responsive to
voice, slowed. answering questions appropriately. CXR showed
low lung volumes and previously seen retrocardiac/RLL opacities
due to atelectasis versus infection. She had a urinalysis,
which was floridly dirty. She was given CTX, vanco, azithro and
4 L IVF. On transfer, BP reportedly in the 90s systolic.
On arrival to the MICU, her VS were T100.8 HR110 Sat90 on
60%Hi-Flow, RR22. She is answering all questions. She is fully
oriented to person, place, time, purpose, and can recite phone
numbers for her next of [**Doctor First Name **]. She complains of pain in the right
lower leg which has been ongoing for several weeks. She also
notes dysuria, urinary frequency, and malodorous urine since
[**2199-7-8**]. She did finish a course of cefpodoxime for a recent UTI
several weeks ago. She actually denies shortness of breath
currently, as well as chest pain, chest pressure, pleurisy. She
notes cold-like symptoms of congestion, scant cough, sore
throat, malaise since her last discharge about 3 weeks ago. She
finished her azithromycin and prednisone from her last COPD
exacerbation about a month ago. She remains compliant with home
COPD regimen per her report. She continues to smoke cigarettes
but denies recent marijuana use. No recent sick contacts.
She recently presented similary to [**Hospital1 18**] [**Date range (1) 70311**] with
hypoxemia and UTI and was immediately weaned to 2LNC on arrival
to the MICU. She was treated for a COPD exacerbation with a
prednisone taper and azithromycin course, as well as
Ceftriaxone/cefpodoxime for urinary tract infection that grew
out klebsiella pneumoniae. Note was made at that time of
numerous medication reconciliation issues. She was admitted in
[**3-/2199**] with a fall, possibly secondary to psychiatric
medications and UTI (coag- staph), and had established pulm care
with Dr. [**Last Name (STitle) 575**] since that time.
Spoke with her friend [**Name (NI) 71549**] who speaks with her regularly- she
mentions that her respiratory status has been OK recently.
Past Medical History:
-COPD, exacerbation [**6-/2199**]
-Schizophrenia
-Diabetes mellitus type 2
-Overactive bladder
-HTN
-marijuana/tobacco abuse
-bilateral ureteritis [**6-/2198**]
-s/p fall [**3-/2199**]
-right hand numbness
-resting tachycardia of unclear source
Social History:
Tobacco: 1.5ppd x 50 years
- Alcohol: quit 15 years ago
- Illicits: smokes marijuana frequently (son died of heroin od
2 years ago)
- Housing: Lives alone. PCA visits twice daily
Other son is in and out of jail- patient requested that we do
not contact him.
Family History:
HTN
Physical Exam:
Admission exam
Vitals: T100.8 HR110 Sat90 on 60%Hi-Flow, RR22
General: sleepy but fully oriented to person place time
president purpose
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD
CV: tachycardic without MRG
Lungs: Diffuse inspiratory and expiratory wheezing and rhonchi
heard throughout the anterior and posterior fields. Abdominal
breathing but no other accessory muscles used.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly. Umbilical surgical scar.
Ext: warm, well perfused, 2+ pulses. There is a diffuse patch of
erythema along the right shin that is not well marked, mild TTP.
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally
Discharge exam
PHYSICAL EXAM:
VITALS: 97.3, 100s-120s/70s-80s, 90s-100s, 20, 94% RA i/o
1680/3500
Gen - non-toxic appearing elderly female in NAD
HEENT: PERRL, EOMI, MMM and pink, sclera anicteric
NECK: Supple, no carotid bruits, no JVD
LUNGS: crackles in lung bases more on L than R
HEART: Tachycardic, normal S1/S2, no MRG
ABDOMEN: Soft, NT, NABS, no organomegaly
EXTREMITIES: RLE discoloration medial to the anterior tibia, not
erythematous or swollen. Violaceous in color, non-erythematous,
non-warm, no edema.
NEUROLOGIC: A&Ox3, CNs II-XII intact, strength and sensation
grossly intact
[**Name (NI) 3687**] pt is anxious at baseline and has had panic attacks in
past
Pertinent Results:
Admission labs
[**2199-7-13**] 09:00AM WBC-11.1* RBC-4.93 HGB-14.5 HCT-44.4 MCV-90
MCH-29.4 MCHC-32.7 RDW-16.1*
[**2199-7-13**] 09:00AM NEUTS-85.3* LYMPHS-11.0* MONOS-2.5 EOS-0.9
BASOS-0.3
[**2199-7-13**] 09:00AM GLUCOSE-98 UREA N-11 CREAT-0.9 SODIUM-140
POTASSIUM-4.9 CHLORIDE-103 TOTAL CO2-28 ANION GAP-14
[**2199-7-13**] 09:15AM URINE BLOOD-MOD NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
[**2199-7-13**] TYPE-ART PO2-78* PCO2-55* PH-7.24* TOTAL CO2-25 BASE
XS--4
Relevant labs:
[**2199-7-19**] 05:40AM BLOOD WBC-10.4 RBC-4.87 Hgb-14.3 Hct-43.6
MCV-90 MCH-29.4 MCHC-32.8 RDW-15.9* Plt Ct-283
[**2199-7-19**] 05:40AM BLOOD Glucose-86 UreaN-14 Creat-0.7 Na-141
K-3.8 Cl-100 HCO3-35* AnGap-10
[**2199-7-19**] 05:40AM BLOOD Calcium-9.2 Phos-4.2 Mg-1.9
[**2199-7-18**] 06:10AM BLOOD TSH-4.3*
[**2199-7-16**] 09:45AM BLOOD freeCa-1.15
[**2199-7-16**] 12:41PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005
[**2199-7-16**] 12:41PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
Pertinent Micro/path:
URINE CULTURE (Final [**2199-7-16**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 8 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 128 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Legionella Urinary Antigen (Final [**2199-7-14**]):
TESTING NOT PERFORMED: SPECIMEN RECIEVED IN THE
PRESERVATIVE.
TEST CANCELLED, PATIENT CREDITED.
Reported to and read back by [**First Name4 (NamePattern1) 3347**] [**Last Name (NamePattern1) **] #[**Numeric Identifier 86830**] @1210,
[**2199-7-14**].
[**2199-7-13**] 9:00 am BLOOD CULTURE
**FINAL REPORT [**2199-7-19**]**
Blood Culture, Routine (Final [**2199-7-19**]): NO GROWTH.
[**2199-7-13**] 9:26 am BLOOD CULTURE
**FINAL REPORT [**2199-7-19**]**
Blood Culture, Routine (Final [**2199-7-19**]): NO GROWTH
[**2199-7-13**] 1:49 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2199-7-15**]**
MRSA SCREEN (Final [**2199-7-15**]): No MRSA isolated
[**2199-7-16**] 12:41 pm URINE Source: Catheter.
**FINAL REPORT [**2199-7-17**]**
URINE CULTURE (Final [**2199-7-17**]): NO GROWTH.
2 Pending Blood cultures
Pertinent Imaging:
CXR [**2199-7-13**]: lung volumes low, left retrocardiac consolidative
opacity and rihgt lower lung patchy opacities are increased
compared to prior study, maybe atelectasis though infection
possible. Pulm congestion without frank pulmonary edema. Heart
size WNL. Small bilateral pleural effusions. No pneumothorax.
CXR [**2199-7-16**]: Portable semi-upright AP view of the chest was
provided. The endotracheal tube tip resides 4.7 cm above the
carina. Tip of the NG tube is visualized in the left upper
abdomen. There is diffuse pulmonary edema with probable small
bilateral pleural effusions and hilar engorgement. No
pneumothorax.
CTA CHEST [**2199-7-18**]:
1. No evidence of PE or acute aortic syndrome.
2. Enlarged main trunk, right and left pulmonary arteries are
consistent with chronically increased pulmonary artery pressure.
3. Interval increase of bilateral pleural effusions with
resolution of
bibasilar consolidations from exam performed one month ago.
4. Enlarged multinodular right thyroid lobe is noted and
unchanged with prior
exam from [**2199-6-17**]. Correlation with ultrasound is
recommended.
Brief Hospital Course:
Ms. [**Known lastname **] is a 61yoF with moderate COPD, schizophrenia, DM2,
hypertension and recent hospitalization for COPD exacerbation
and UTI presenting with fevers, hypoxia, and UTI symptoms.
.
Active Diagnoses
# Sepsis of urinary origin: She was hospitalized for COPD
exacerbation last month and presented this admission with cough,
fever, U/A positive for infection and SIRS criteria. CXR with
bibasilar opacities and pleural effusions, however these changes
have been present for several weeks. Improving with Vancomycin
and Zosyn IV starting [**2199-7-13**]. Blood cx pending, but unable to
obtain sputum cx. She was initially on the MICU, but then
transferred to the medicine floor, where she was transitioned to
Levaquin from the other antibiotics. The opacities noted on
chest imaging quickly resolved from admission suggesting against
an infectious process. She was continued on Levaquin to complete
an 8 day course as she was noted to have a UTI this admission.
# COPD Exacerbation: Pt with diffuse wheezing suggesting COPD
exacerbation in setting of possible PNA. Likely triggers
include cigarette smoking versus URI versus ?med noncompliance
(prior compliance issues). Pt was treated with IV solumedrol
and albuterol/ipratropium nebs x1 day. Switched to prednisone
40mg po, spiriva, advair on [**7-13**]. The patient was transferred
from the ICU to the medicine floor, where she had acute dyspnea,
requiring intubation (see below). She was transferred back to
the MICU, where she was treated with Lasix for flash pulmonary
edema and successfully extubated. We continued to wean
supplemental 02 as she is not O2 dependent at home. Albuterol
was changed to Xopenex for tachycardia. She was discharged on a
10 day taper of Prednisone.
.
# Respiratory Distress/Hypoxia: On [**7-17**], the patient was on the
medicine floor and was found by the nurse to be not moving air
well. BP 180s/110s. She sounded wheezy, crackly. She was
given diltiazem and Lasix 20 mg IV, but didn't put out much. She
was hypoxic to the low 80s on NRB and the came up to 87% O2
saturation. A code blue was called. She was intubated with
succinylcholine and propofol. She was transferred back to the
MICU, where she was treated with Lasix for flash pulmonary edema
and successfully extubated. This was likely in the setting of
hypertension so lisinopril restarted at home dose of 20 mg daily
and lasix was started as well at 20 mg daily. She was then
transferred back to the floor. A repeat echo showed new basal
inferolateral hypokinesis but improvement in her Pulmonary HTN.
She was dischared on 20mg of Furosemide daily. F/u with
cardiology was arranged
.
# Urinary tract infection: Pt presented with dysuria and hx of
mult UTIs. UA grossly positive. Antibiotic coverage Vanc/Zosyn
(for HCAP) initially covered this, but these were discontinued
on the floor as described above. Cultures showed Klebsiella,
and for this she was treated with levoquin to complete an 8 day
course.
.
# Right lower leg venous stasis changes: History of frequent
right lower leg cellulitis and chronic venous insufficiency
changes. Presented with tender, erythematous right lower leg.
Treated with Vancomycin initially. Area responded quickly after
1 day abx. Vicodin was used for pain control.
.
# Tachycardia: The patient has a resting heart rate that is
borderline tachycardic (documented in OMR), and this was
worsened by the albuterol. Therefore, the patient was
transitioned from albuterol to levalbuterol, which decreased the
tachycardia. A CTPA was performed which was negative for PE a
TSH was also checked an shown not to be the cause of her
Tachycardia.
.
# HYPERTENSION: Pt remained normotensive during initial MICU
stay. Antihypertensives were held. On the floor the patient was
hypertensive (see Respiratory Distress above). When she was
back in the MICU, she was restarted on her home antihypertensive
lisinopril.
.
Chronic Issues
# SCHIZOPHRENIA: Stable, Continued home meds: risperidone,
buspirone, mirtazipine, clonazipine.
.
# Pulmonary hypertension: Pt with known pulm HTN. Monitored
fluid status to prevent fluid overload. We monitored fluid
status and diuresed as needed.
.
# DIABETES MELLITUS: Pt did have elevated sugars to the 400s in
the setting of solumedrol. We continued to monitor FSG.
Metformin was held, and the patient was placed on ISS while
hospitalized.
.
# TOBACCO ABUSE: Pt counseled on the importance of smoking
cessation. Recommend ordering nicotine patch.
.
Transitional Issues
# Continue to address need for smoking cessation
# Cautious use of drugs that suppress the respiratory drive.
# Close FSG monitoring in the setting of current prednisone use.
# U/S of her thyroid should be performed to re-evaluate
multi-nodular goiter that was incidentally found on CT of chest
Medications on Admission:
MEDICATIONS- could not confirm
1. Lisinopril 20 mg PO DAILY
hold for sbp<100
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. Advair Diskus (250/50) 1 INH IH [**Hospital1 **]
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
5. Clonazepam 1 mg PO QID PRN anxiety
hold for oversedation or rr<10
6. Mirtazapine 30 mg PO HS
hold for oversedation or rr<10
7. Risperidone 4 mg PO TID
8. Fluoxetine 80 mg PO DAILY
9. Baclofen 20 mg PO BID
10. BusPIRone 30 mg PO TID
11. Gabapentin 600 mg PO TID
hold for oversedation or rr<10
12. HydrOXYzine 10 mg PO Q6H:PRN itching
13. Hydrocodone-Acetaminophen (5mg-500mg 1 TAB PO Q6H:PRN pain
hold for oversedation or rr<10
14. Nicotine Patch 21 mg TD DAILY
15. Tolterodine 2 mg PO BID
16. Ranitidine 150 mg PO BID
17. Clobetasol Propionate 0.05% Cream 1 Appl TP [**Hospital1 **]
18. Docusate Sodium 100 mg PO BID
RX *Colace 100 mg twice daily Disp #*30 Capsule Refills:*0
19. PredniSONE 40 mg PO DAILY Duration: 3 Days Start: In am
to be taken through [**6-21**].
RX *prednisone 20 mg daily Disp #*6 Tablet Refills:*0
20. Azithromycin 250 mg PO Q24H Duration: 3 Days
to be taken through [**6-21**].
RX *azithromycin 250 mg daily Disp #*3 Tablet Refills:*0
21. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 5 Days
to be taken through [**6-23**].
RX *cefpodoxime 200 mg twice daily Disp #*10 Tablet Refills:*0
Discharge Medications:
1. Tolterodine 2 mg PO BID
2. Baclofen 20 mg PO BID
3. Gabapentin 600 mg PO Q8H
4. BusPIRone 30 mg PO TID
5. Risperidone 1 mg PO BID
6. Risperidone 4 mg PO HS:PRN agitation
7. Fluoxetine 80 mg PO DAILY
8. Mirtazapine 30 mg PO HS
9. Clonazepam 1 mg PO QID anxiety
Hold for sedation, rr<10
10. Hydrocodone-Acetaminophen (5mg-500mg [**1-7**] TAB PO Q6H:PRN pain
11. GlyBURIDE 10 mg PO BID
12. Lisinopril 20 mg PO DAILY
Hold for SBP<100
13. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
14. Docusate Sodium 100 mg PO BID
15. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
16. Ranitidine 150 mg PO BID
17. Zolpidem Tartrate 10 mg PO ONCE Duration: 1 Doses
18. MetFORMIN (Glucophage) 1000 mg PO BID
19. HydrOXYzine 10 mg PO Q6H:PRN itching
20. Tiotropium Bromide 1 CAP IH DAILY
21. PredniSONE 40 mg PO DAILY
RX *prednisone 10 mg 2 tablet(s) by mouth daily for five days
Disp #*15 Tablet Refills:*0
22. Levofloxacin 500 mg PO DAILY Duration: 2 Days
RX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*2
Tablet Refills:*0
23. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Sepsis of urinary origin
COPD exacerbation
Pulmonary Hypertension
respiratory failure requiring intubation/mechanical ventilation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital with altered
mental status and difficulty breathing. You were initially
admitted to the ICU where your breathing was stabilized and your
mental status cleared. We determined that the cause of your
shortness of breath was due to both fluid in your lungs and
inflammation from your COPD. We have started you on steroids to
decrease the inflammation in your lungs and a diurectic
medication to keep the fluid out of your lungs. We would like
you to follow up with cardiology to help you manage the fluid in
your lungs.
The following changes have been made to your medications:
START:
Prednisone 20mg for 5 more days then 10mg for the following 5
days then stop this medication
Levofloxacin for two more days
Furosemide for the fluid in your lungs
We have made you follow up appointments with both your primary
care physician and [**Name Initial (PRE) **] heart physician as well. It is very
important that you keep these appointments. Also please weigh
yourself daily and alert your doctor if your weight increases by
more than 3 lbs.
Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2199-7-22**] at 3:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (un) 86831**],HABIBULLAH
Address: [**Location (un) **], [**Apartment Address(1) 1823**], [**Location (un) **],[**Numeric Identifier 86832**]
Phone: [**Telephone/Fax (1) 71517**]
Appt: [**7-24**] at 2:45pm
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[
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16810, 16921
|
3106, 3353
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3370, 3633
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41,446
| 194,917
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1855
|
Discharge summary
|
report
|
Admission Date: [**2121-12-8**] Discharge Date: [**2122-1-9**]
Date of Birth: [**2037-8-15**] Sex: M
Service: MEDICINE
Allergies:
Simvastatin / Pravastatin
Attending:[**First Name3 (LF) 1881**]
Chief Complaint:
Progressive weakness, migratory pain and falls.
Major Surgical or Invasive Procedure:
Right Heart Catheterization.
History of Present Illness:
84 year old man with diabetes mellitus II, atrial fibrillation,
MGUS, chronic kidney disease, hypertension, presenting at Dr. [**Name (NI) 10362**] behest with migratory polyarthralgias,
lethargy/fatigue, recent right ear pain, and falling to knees
x2.
.
He was in good health until the past 2 months, when he developed
LE weakness and arthralgias. He was started on steroids for
possible PMR with good effect over the following day. However,
for the past few days the pain has resumed in his wrist
(associated with slight hand swelling) and shoulders, among
other joints. His sx are asymmetric. He is not clear as to
whether there are myalgias, as well. Ear pain is notable on
eating and drinking, which he thinks has reduced his fluid
intake over the last days. He was seen by rheumatology last
week, and his diagnosis remained unclear despite extensive labs,
which were notable for monoclonal gammopathy with positive urine
M-spike. Of note, he also has Bence-[**Doctor Last Name **] proteinurea and
anemia.
.
His main concern currently is right ear pain, not associated
with scalp tenderness, HA, vision changes, but is worse with jaw
movement. He also had two episodes yesterday where he fell to
his knees, with no injury, and unclear if he lost consciousness.
Although he is very fatigued, he denies specific muscular
weakness.
.
On ROS, he also notes decreased urination over the past day,
noting that he is drinking less because it worsens his ear pain.
He denies fever, chills, night sweats, dysuria, hematuria,
frequency, urgency, diarrhea, incontinence, SOB, wheeze, CP,
abd/flank pain, nausea/vomiting, sore throat. He does confirm
nonproductive cough x3 weeks.
.
In the ED, exam showed good strength/tone, no saddle anesthesia
and normal rectal tone, although guaiac positive. Labs notable
for Cr 5.4, Hct 27.2 (near baseline), INR 5.3. CT head and CXR
were obtained and unremarkable. He was given 2L IVF. Vitals
prior to admission were: 97.4 68 108/67 18 95RA.
Past Medical History:
-Question of an inflammatory musculoskeletal condition as above
-DM 2 on insulin since [**2082**], typical A1c around 7.5%
-CKD4 with creat 2.3 (2.5 on [**11-24**])
-HTN, well-controlled
-Bronchiectasis with baseline grossly abnormal CXR
-SSS with intermittent afib and bradycardia
-Chronic anticoag (indication: AF) on coumadin
-Prostate cancer --> radiation therapy [**2118**], normalized PSA
-Radiation proctitis with rectal bleeding --> laser rx
-Malignant melanoma left thigh s/p excision, recent sternal skin
biopsy healing
-Anemia attributed to CKD
-R ingunal hernia
-S/p appy
-S/p L inguinal hernia repair
Social History:
Lives with wife. [**Name (NI) **] 1 son. [**Name (NI) **] tobacco. ~1 drink EtOH/day. The
patient is retired, was employed as an international business
consultant. Married, lives with second wife. [**Name (NI) **] has a PhD in
industrial engineering. He was born in Europe, in Eastern
[**Country 10363**], and has traveled throughout the world over his
lifetime. He came to the United States in [**2068**]. His first wife
died in [**2104**]. He is a very active individual, walks regularly.
He is a former mountain climber, tennis player, and skier. He
enjoyed playing soccer in his younger yrs. He smoked only during
WWII and DC'd in [**2057**] with none thereafter. There is no history
of drug use. He reports consumes espresso and an occasional
cocktail before dinner. Social History: Lives with wife. [**Name (NI) **] 1
son. [**Name (NI) **] tobacco. ~1 drink EtOH/day. The patient is retired, was
employed as an international business consultant. Married, lives
with second wife. [**Name (NI) **] has a PhD in industrial engineering. He
was born in Europe, in Eastern [**Country 10363**], and has traveled
throughout the world over his lifetime. He came to the United
States in [**2068**]. His first wife died in [**2104**]. He is a very
active individual, walks regularly. He is a former mountain
climber, tennis player, and skier. He enjoyed playing soccer in
his younger yrs. He smoked only during WWII and DC'd in [**2057**]
with none thereafter. There is no history of drug use. He
reports consumes espresso and an occasional cocktail before
dinner.
Family History:
Patient reports a history of diabetes only in his maternal
grandmother. His father died at an older age with complications
of infection. There is no familial pattern of malignancy,
hypertension, or heart disease.
Physical Exam:
Vitals (at acceptance in a.m.): T: 98.3 BP: 90/58 P: 106 R: 18
O2: 92%RA Gluc: 267
General: Alert, oriented, no acute distress, well nourished, has
some difficulty rearranging himself in bed
HEENT: Sclera anicteric, PERRL, EOMI, MM dry, oropharynx clear,
TTP posterior right TMJ, no temporal TTP, TMs obscured by
cerumen bilat
Neck: JVP ~15
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Irreg irreg, friction rub noted at LLSB
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Rectal shows
sm ext hemorrhoid, nl tone, sm amt brown stool (not grossly
bloody)
Ext: Cool distally, but otherwise warm, well perfused, 3+ ankle
edema bilat
Neuro: CN 2-12 intact. No saddle anesthesia. Strength 5/5 in all
four ext. Normal muscle bulk and tone. No TTP over spine, hips.
GU: Bladder scan 450ml
Pertinent Results:
LABORATORY INVESTIGATIONS AT ADMISSION
Blood
[**2121-12-8**] 06:30PM BLOOD WBC-8.9 RBC-2.96* Hgb-8.5* Hct-27.2*
MCV-92 MCH-28.6 MCHC-31.1 RDW-15.8* Plt Ct-235
[**2121-12-8**] 06:30PM BLOOD Neuts-88.3* Lymphs-9.6* Monos-2.0 Eos-0
Baso-0
[**2121-12-8**] 06:30PM BLOOD PT-48.9* PTT-55.6* INR(PT)-5.3*
[**2121-12-8**] 06:30PM BLOOD Plt Ct-235
[**2121-12-9**] 06:35AM BLOOD ESR-122*
[**2121-12-8**] 06:30PM BLOOD UreaN-102* Creat-5.4*# Na-133 K-5.0 Cl-98
HCO3-20* AnGap-20
[**2121-12-9**] 06:35AM BLOOD ALT-160* AST-92* LD(LDH)-174 CK(CPK)-57
AlkPhos-195* TotBili-0.4
[**2121-12-8**] 06:30PM BLOOD Albumin-2.7* Calcium-8.3* Phos-4.0 Mg-2.5
[**2121-12-9**] 06:35AM BLOOD Calcium-8.1* Phos-4.1 Mg-2.4 UricAcd-8.3*
[**2121-12-9**] 06:35AM BLOOD VitB12-799 Folate-GREATER TH
[**2121-12-9**] 12:44PM BLOOD [**Doctor First Name **]-NEGATIVE dsDNA-NEGATIVE
[**2121-12-9**] 06:35AM BLOOD CRP-170.1*
[**2121-12-9**] 12:44PM BLOOD C3-130 C4-33
Urine
[**2121-12-8**] 06:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
[**2121-12-8**] 06:30PM URINE Blood-LG Nitrite-NEG Protein-75
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2121-12-8**] 06:30PM URINE RBC->50 WBC-0-2 Bacteri-MANY Yeast-NONE
Epi-0-2
[**2121-12-8**] 06:30PM URINE AmorphX-FEW
[**2121-12-8**] 07:05PM URINE Hours-RANDOM UreaN-553 Creat-133 Na-10
[**2121-12-9**] 12:19PM URINE Hours-RANDOM UreaN-647 Creat-123 Na-<10
TotProt-58 Prot/Cr-0.5
[**2121-12-9**] 12:19PM URINE Osmolal-400
LABORATORY INVESTIGATION DURING THE COURSE OF STAY
WBC remained stable during admission and was 3.3 at discharge
Hct decreased to low of 24.3 on [**12-11**] and then 20.8 on [**12-28**]. It
was 33.8 at discharge.
Platelets declined gradually until [**12-29**] at which point they
dropped to 137 with a low of 101 as of [**1-1**]. It was 91 at
discharge.
INR reached a high of 5.9 on [**12-9**]
PTT reached a high of 150 on [**2123-12-28**] then began to decrease
and was 100.3 as of [**12-31**].
ESR decreased to 85 as of [**12-24**].
Retic was 1.2 on [**12-24**].
Creatinine was at its peak at admission. It was .. at
discharge.
LFTs decreased to within normal on [**12-14**] and then rose with
isoniazid toxicity (AST 339 / ALT 90 on [**1-7**])
Patient had a BNP of 5202 on [**12-9**]. Trops increased from .05 on
[**12-27**] to .12 on [**12-18**] then down to .07 on [**1-1**].
Hepatitis C Antibody negative; Hepatitis B Antigen negative,
Surface antibody positive
[**12-18**] iron studies
iron: 40
TIBC: 204
ferritin 449
TRF 157
hapto 120
B12 799
C-ANCA positive on [**2121-12-9**], confirmed [**12-9**]
CRP decreased: to 24.6 as of [**12-24**]
B2micro: 9.8 on on [**12-11**]
C3 and C4 130 and 33 on [**12-9**]
Quantiferon TB negative [**12-18**]
kappa/lambda 178/101 (1.76) elevated [**12-11**]
[**12-9**] sm antibody negative, GBM negative
UAs:
continued to have large amount of blood, though RBC number
decreased to [**4-10**] RBC as of [**12-25**], +protein 25-100, negative for
UTI.
Prot/Cr radio increased to peak of 0.8 on [**12-22**] and began to
decrease to 0.7 as of [**12-25**].
24 HOUR URINE COLLECTION on [**2122-1-6**]
pH Hours Volume UreaN Creat TotProt Prot/Cr
4 24 400 621 65 93 1.4*
Cultures
Urine [**12-8**] negative
blood 11/6 ASO negative
sputum [**12-15**] insufficient sample
blood 11/12 fungal negative
urine [**12-22**] Klebsiella pneumonia
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**12-23**] BAL
RESPIRATORY CULTURE (Final [**2121-12-30**]):
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
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.
ASPERGILLUS FUMIGATUS. ~[**2112**]/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
FUNGAL CULTURE (Preliminary):
YEAST.
ASPERGILLUS FUMIGATUS.
ID PERFORMED ON CORRESPONDING ROUTINE CULTURE.
ACID FAST SMEAR (Final [**2121-12-24**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) 10364**] [**Last Name (NamePattern1) 10365**] @ 1440, [**2121-12-24**].
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 1441, [**2121-12-24**].
ACIDFAST BACILLI. MODERATE seen on concentrated smear.
ACID FAST CULTURE (Preliminary):
REPORTED BY PHONE TO DR. [**Last Name (STitle) **] AND [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @
1405,
[**2121-12-30**].
AFB GROWN IN CULTURE; ADDITIONAL INFORMATION TO FOLLOW.
SENT TO STATE LAB FOR FURTHER IDENTIFICATION [**2121-12-30**].
GEN-PROBE AMPLIFIED M. TUBERCULOSIS DIRECT TEST (MTD)
(Preliminary):
NEGATIVE FOR M. TUBERCULOSIS BY MTD. AWAIT CULTURE
RESULTS. MTD
PERFORMED AT [**State **] STATE LABORATORY, [**Location (un) **], MA.
RESULT REC'D BY PHONE-SAMPLE WILL BE FINALIZED UPON
RECEIPT OF
WRITTEN REPORT.
IMAGING
CXR
[**12-31**], wet read: continued pulmonary edema and bilateral pleural
effusions, overall stable in
extent since the prior.
11/24
[**12-27**]
11/18
[**12-15**]
[**12-11**]
EKG
[**12-28**]: Artifact is present. Atrial fibrillation with a rapid
ventricular response. Non-specific ST-T wave changes. Compared
to the previous tracing there is no significant change.
11/21
[**12-9**]
[**12-8**]
ECHO
[**12-27**]: There is mild symmetric left ventricular hypertrophy with
normal cavity size and global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mitral regurgitation is present but
cannot be quantified. There is no pericardial effusion.
11/10
[**12-12**]
CT CHEST
[**12-18**]: 1. No good evidence for active tuberculosis. No cavitary
lung lesions. Stable bronchiectatic scarring and central lymph
node calcifications.
2. Several small lung nodules could be post-inflammatory
lesions, unusually small for active pulmonary Wegener's
granulomatosis, but if the patient's clinical situation is
unstable, I would repeat a chest CT in four weeks to monitor
them, and I would not be surprised if most or all of them
disappear. A nonhemorrhagic right pleural effusion and tiny left
pleural effusion have developed since [**Month (only) **], small
pericardial effusion is of indeterminate age,
but not hemodynamically significant.
3. Multiple right rib fractures are well healed.
Kidney biopsy
[**12-15**]: Pauci-immune crescentic glomerulonephritis in the setting
of ANCA positivity
Skin biopsy [**11-27**] left chest
-Squamous cell carcinoma in situ, extending near but not seen at
the examined specimen margins.
-Associated actinic keratosis, extending to a peripheral
specimen margin.
CARDIAC CATH, right heart
[**12-12**]
1. No hemodynamic evidence of tamponade physiology.
2. Mild pulmonary arterial hypertension.
3. Mild right ventricular diastolic dysfunction.
4. Elevated pulmonary capillary wedge pressure consistent with
moderate
left ventricular diastolic heart failure.
SKELETAL SURVEY
[**12-11**]
1. No focal lytic or sclerotic lesion identified.
2. Multiple pulmonary findings consistent with prior
granulomatous disease
such as tuberculosis.
3. Low lying bowel could represent bowel containing inguinal
hernia.
RENAL U/S
[**12-9**]
1. Normal-sized kidneys without hydronephrosis; echogenic cortex
suggests the presence of diffuse parenchymal renal disease.
2. Similar appearance of a bladder wall hypertrophy and enlarged
prostate.
3. Trace perihepatic ascites.
CT head [**12-8**]
No acute intracranial process.
Brief Hospital Course:
SUMMARY
84 year old man with DM, Afib, smoldering multiple myeloma here
with migratory polyarthralgias, lethargy/fatigue, right ear
pain, and found to have acute on chronic renal failure, now
known to be C-ANCA positive with biopsy proven
glomerulonephritis consistent with Wegener's granulomatosis with
primarily renal manifestation. He partially responded to
cytoxan/prednisone.
BY PROBLEM
Acute on chronic renal failure
Anasarca
Initiation of Dialysis
The patient was found to have an acute on chronic renal
failure that had been pre-existing due to the patient's
diabetes. Subsequent studies found the patient to have C-ANCA
positive pauci-immune glomerulonephritis proven on kidney
biopsy, consistent with Wegener's granulomatosis. The patient
received a mini-pulse of 250mg methylprednisolone and cytoxan,
which initially improved his renal failure. He was continued on
cytoxan and prednisone. However, subsequently his renal
function began to deteriorate again and he developed generalized
anasarca with volume overload and dyspnea. He was transferred
to the MICU on [**12-28**] where a temporary HD line was placed and
CVVH was initiated. 9.5 litres were dialysed off and the
patient was discharged back to the floor. However, his
creatinine continued to fail to improve and on [**1-2**] the patient
received a session of hemodialysis and a permanent tunnelled
catheter.
Deconditioning
The patient was proximally weak, primarily in the legs and was
thus discharged to a rehabilitation facility at the
reccomendation of PT
Wegener's granulomatosis with primary renal manifestation,
possibly Cytoxan-Resistant
constellation of musculoskeletal complaints, ear pain and
renal failure was consistent Wegener's granulomatosis that was
diagnosed with C-ANCA positive titer and kidney biopsy.
Steroids and cytoxan were initiated for treatment as above.
Bactrim prophylaxis was also initiated. The patient's symptoms
with the exception of renal failure largely resolved with
treatment.
Pericardial effusion
the patient was found to have a large pericardial effusion on
echo and a friction rub, which was thought to be uremic with
possible hemorrhagic component given supratherapeutic INR on
admission. By discharge this had largely resolved clinically
and by echo with treatment of patient's kidney injury and
Wegener's.
MGUS/MM
Hem./Onc. consultation recommended that this is likely MM not
MGUS given Bence-[**Doctor Last Name **] proteinuria. They expect that this MM is
smouldering/mild given previous electrophoresis. Skeletal
survey revealed no lytic lesions. Significance unclear -
possible that antibody of MM is pathogenic antibody for
Wegener's - at least conceivable. F/u free K/L light chains in
serum are mildly elevated, but the ratio is nearly preserved.
Atrial fibrillation
Admission EKG suggestive of aflutter without rapid ventricular
rate. He was initially overcoagulated, reversed with vitamin K.
His coumadin was held. He was placed on a heparin drip when he
went to the MICU, but had several supratherapeutic PTT's and
developed a GI bleed. This was stopped upon his return to the
floor. He also had several episodes of RVR, which were
controlled with diltiazem as needed. He was not placed on a
standing nodal [**Doctor Last Name 360**] given his history of sick sinus syndrome.
Thrombocytopenia
the patient's platelets began to slowly drop after admission to
the MICU and starting of heparin drip. Etiologies were thought
potentially to be [**3-10**] TB or cytoxan treatment or heparin induced
thrombocytopenia. HIT antibody pending.
Mycobacterium Avium Complex
AFB on Bronchoalveolar Lavage
Latent Tuberculosis
Isoniazid Hepatoxicity
Patient had a history of TB with treatment in sanitarium in
[**2052**]'s Bronchoscopy with BAL was performed on [**12-23**], and AFBs
found on smear. The patient was started on RIPE, however
subsequent testing including quantiferon gold and genetic probe
on smear were negative for mycobacterium tuberculosis. Also,
mycobacterium was a fast grower in culture, also pointing away
from TB. MAC was believed to be likely per infectious disease
consultation. Final decision on treatment was pending genetic
probe on culture from State lab. The patient opted to forego MAC
therapy and the treatment of his latent TB was discontinued
secondary to hepatoxicity
GI bleed
the patient developed a GI bleed with maroon stools, BRBPR and
melena on [**12-31**] after discharge from MICU. GI consultation was
acquired, and heparin infusion was stopped. The patient was
transfused 2 units PRBCs in addition to 2 units received in
MICU. Subsequent stools demonstrated a clearing of blood and
stable hematocrit while off heparin. The bleeding was thought
to be secondary to radiation proctitis for which the patient has
a history of and had received laser photocoagulation.
Anemia
Chronic, close to baseline of high 20s to low 30s. Guaiac
positive initially in ED in setting of elevated INR, although
hemodynamically stable. Receives Darbepoetin monthly. See above
for history of GI bleed.
Diabetes
patient was switched to glargine from previous regimen of NPH
with good control of his blood glucose while inpatient.
TO BE FOLLOWED OUTPATIENT
1) PREDNISONE - on 50 mg daily, renal to set the taper time
2) COUMADIN - restart when stable for Atrial Fibrillation
3) Dialysis dependence? Biopsy showed lots of active
inflammation
4) Cytoxan-Resistant Wegener's ?
Medications on Admission:
ATORVASTATIN [LIPITOR] - 20 mg Tablet - 1 Tablet(s) by mouth
once
a day
DARBEPOETIN ALFA IN POLYSORBAT [ARANESP (POLYSORBATE)] -
(receiving in epo clinic) - 100 mcg/0.5 mL Syringe - inject s/c
once a month
HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 Tablet(s) by mouth once a
day
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day
PREDNISONE - 10 mg once a day with food
WARFARIN [COUMADIN] - 2 mg Tablet - [**2-8**] Tablet(s) by mouth once
a
day as directed by [**Hospital3 **] to maintain inr
FERROUS SULFATE - 325 mg (65 mg Iron) Tablet, Delayed Release
(E.C.) - 1 Tablet(s) by mouth once a day
INSULIN REGULAR HUMAN [HUMULIN R] - 100 unit/mL Solution - 4
units every morning and as needed per sliding scale
MULTIVIT, IRON, MIN NO.8, FA [THERAGRAN-M] - 1,200 mg-360 mg
Capsule - 1 Capsule(s) by mouth once a day
NPH INSULIN HUMAN RECOMB [HUMULIN N] - 100 unit/mL Suspension -
30 units every morning or as directed by md
Discharge Medications:
1. Cyclophosphamide 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*56 Tablet(s)* Refills:*2*
2. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15) Units
Subcutaneous Prior to bed.
Disp:*5 Vials* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*56 Capsule(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*28 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: Two (2)
Tablet PO twice a day for 7 days: Please return to one pill per
day after seven days. .
Disp:*28 Tablet(s)* Refills:*2*
6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*56 Tablet(s)* Refills:*2*
8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*28 Tablet(s)* Refills:*2*
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
11. Insulin Regular Human 100 unit/mL Solution Sig: As sliding
scale Injection Check glucose 4x day and use sliding scale.
12. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
13. Prednisone 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
15. Insulin Sliding Scale
Please see attached for specific sliding scale instruction
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 169**]-Heathwood
Discharge Diagnosis:
Primary Diagnoses
Wegener's Granulomatosis
Acute Renal Failure
Pericardial Effusion
Secondary Diagnoses:
Lower Respiratory Tract Infection
Diabetes, type II, well-controlled
Chronic Renal Failure
Atrial Fibrillation
Mycobacterium Avium Complex
Discharge Condition:
Afebrile, hemodynamically stable, taking full diet, able to
engage in some activities of daily living. Requires short term
rehab stay
Discharge Instructions:
You have Wegener's Granulomatosis, a serious condition that
primarily affects your kidneys. Additionally, you have an
infection called "MAC" that need only be treated should it give
you symptoms. You will need to be closely followed by Drs.
[**Last Name (STitle) **] and [**Name5 (PTitle) **] as well as an infectious disease doctor.
Your medications have changed (doses and instructions are
below):
3. We have stopped your antihypertensives for now:
a. Stop taking lisinopril
b. Stop taking HCTZ
4. These are your medications for Wegener's
a. Prednisone
b. Cyclophosphamide
4. This is a bowel regimen:
a. Colace and senna - you can stop these temporarily for
loose stool.
6. Please take the following medications:
a. Iron supplement (Ferrous sulphate)
b. Vitamin D
c. Pantoprazole (antacid for stomach)
d. Lipitor
e. Nephrocaps (vitamin)
f. Sevalemer - with meals
8. Insulins:
a. Please take 15 units of glargine insulin before bed.
b. We have stopped NPH
c. Continue to use your sliding scale with regular insulin.
You will need to monitor your glucose a little more closely to
begin to make sure that this regimen works well at home.
9. Other medication advice:
Take Tylenol instead of other pain medications, if necessary
(do not use more than [**2112**] mg per day)
Please attend the follow-up appointments listed below.
If you experience decreased urine output, increased swelling,
greater fatigue, increasing weakness, nausea, shortness of
breath, fever, increasing cough, confusion, or any other
concerning symptom, please return to the hospital.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2122-1-15**] 12:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8157**], M.D. Phone:[**Telephone/Fax (1) 1971**]
Date/Time:[**2122-3-19**] 10:45
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name12 (NameIs) **] ID WEST (SB) Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2122-1-19**] 3:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**] MD, [**MD Number(3) 1883**]
Completed by:[**2122-1-11**]
|
[
"569.49",
"518.81",
"446.4",
"V10.82",
"593.2",
"276.50",
"564.00",
"041.3",
"V58.61",
"427.32",
"799.3",
"729.1",
"V12.01",
"V45.89",
"276.6",
"E879.2",
"285.21",
"702.0",
"585.4",
"416.8",
"031.2",
"403.90",
"275.41",
"388.70",
"287.5",
"041.11",
"584.9",
"568.82",
"203.00",
"729.89",
"599.0",
"250.40",
"275.3",
"729.81",
"428.30",
"427.31",
"790.92",
"423.9",
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icd9cm
|
[
[
[]
]
] |
[
"38.95",
"39.95",
"37.21",
"55.23",
"88.76",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
22396, 22456
|
14257, 19718
|
333, 364
|
22745, 22881
|
5738, 10432
|
24532, 25160
|
4609, 4823
|
20699, 22373
|
22477, 22562
|
19744, 20676
|
22905, 24509
|
4838, 5719
|
22583, 22724
|
10961, 14234
|
10468, 10922
|
246, 295
|
392, 2369
|
2391, 3008
|
3812, 4593
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,274
| 150,362
|
2940
|
Discharge summary
|
report
|
Admission Date: [**2196-11-22**] Discharge Date: [**2196-11-28**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4028**]
Chief Complaint:
back pain, pneumatosis on CT
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **]F h/o remote TB, insomnia, anxiety lost to PCP f/u for 5 years
(reportedly has purposefully avoided MD's) p/w 4 days of low
back pain and per family confusion with visual hallucinations,
decreased appetite and decreased PO intake at home also with new
LE edema x 1-2 weeks.
.
In the ED, vitals 99.4, 108, 130/60, 20, 97% RA. Labs notable
for K 2.9, but normal CBC, transaminases, amylase, lipase. U/A
negative, culture pending. CXR with chronic findings of old TB
in R lung and ?new small apical PTX. CT head negative. CT
abd/pel +/- contrast with small bowel pneumatosis and free air
surrounding mesenteric vessels; concern for ischemic bowel.
Surgery consulted but family agreed that patient would not want
surgery regardless of the indication. Blood cx x2 sent and
started on Zosyn/flagyl per surgery. K+ was repleted. IVF
resuscitation with 1L bolus then 125 cc/hr NS. Admitted to MICU.
.
Upon arrival, pt reports resolution of back pain which was worse
with movement and improved when using walker at home. Denies abd
pain, pain worse with eating, flank pain. Tried Aleve at home
for back pain with minimal effect. Also reports recent dizziness
with sitting upright x 1-2 days. Denies dysuria, frequency,
oliguria. No fevers/chills. BM normal with no melena or
hematochezia. No CP/SOB. Had a few unwitnessed "falls" over past
few weeks, but has never been scanned. No LOC.
Past Medical History:
1. History inactive TB treated [**2103**] with pneumothorax right
lung.
2. Decreased hearing.
3. Seasonal allergic rhinitis.
4. Hx of insomnia, anxiety, reactive depression.
5. Hypercholesterolemia.
6. Osteopenia.
Social History:
Widowed. Retired store owner who lives alone, but grandchildren
live upstairs. Former smoker, discontinued in [**2178**]. No alcohol
abuse or drug abuse.
Family History:
Mother died at 88 from senility. Father died of ruptured hernia.
Siblings are healthy, except one died of a heart valve problem.
Physical Exam:
Exam on Admission:
Gen: pleasant, interactive, well appearing elderly woman in NAD
HEENT: OP clear. No exudate. MMM
CV: RRR. No m/r/g
Resp: CTAB
Abd: Soft. NTNTD. +BS. No HSM. No guarding or rebound. No CVAT,
No vertebral/paravertebral tenderness
Ext: Trace to 1+ pitting edema BL
Neuro: Oriented to person, year, place. Not oriented to month or
date
.
On Discharge VS T98.3, BP126/64, HR85, RR16, 98%RA
patient is cachectic-appearing, pleasant at times and agitated
other times, NAD
some tenderness of lower paravertebral muscles bilaterally
Otherwise, exam unchanged
Pertinent Results:
[**2196-11-22**] 02:40PM BLOOD WBC-10.4 RBC-5.87* Hgb-11.6* Hct-37.4
MCV-64* MCH-19.7* MCHC-31.0 RDW-17.9* Plt Ct-308
[**2196-11-22**] 02:40PM BLOOD Neuts-89.5* Lymphs-7.9* Monos-2.4 Eos-0.1
Baso-0.1
[**2196-11-22**] 08:24PM BLOOD PT-16.1* PTT-29.4 INR(PT)-1.4*
[**2196-11-22**] 02:40PM BLOOD Glucose-92 UreaN-30* Creat-0.6 Na-140
K-2.9* Cl-95* HCO3-37* AnGap-11
[**2196-11-22**] 02:40PM BLOOD ALT-30 AST-26 LD(LDH)-340* AlkPhos-158*
Amylase-32 TotBili-0.6
[**2196-11-23**] 12:50AM BLOOD Calcium-6.4* Phos-1.9* Mg-1.5*
[**2196-11-25**] 07:40AM BLOOD TSH-3.8
[**2196-11-25**] 07:40AM BLOOD Free T4-0.81*
[**2196-11-23**] 06:34AM BLOOD Lactate-1.2
.
[**2196-11-22**] Chest X-ray:
AP AND LATERAL CHEST: Extensive pleural thickening, volume loss,
and
rightward mediastinal shift is again identified. While, these
findings are in keeping with the report from the [**2188-4-9**]
chest radiograph, that study noted "shift of the superior
mediastinum" whereas we are seeing complete mediastinal shift
today. There is again evidence for underlying COPD and the left
lung remains clear. Calcification of mediastinal/hilar lymph
nodes is identified, as is a 5 mm calcified pulmonary nodule at
the left lung base. Right midlung calcifications are noted
laterally. No pleural effusion is seen. Atherosclerotic
calcification of the aortic arch is observed.
Multilevel thoracolumbar spondylosis is noted with severe
wedging of T12 and moderate anterior wedging of L2, of unknown
chronicity. Mild degenerative changes of the glenohumeral joints
are noted bilaterally.
IMPRESSION:
1. Chronic pleural thickening, volume loss, and rightward
mediastinal shift, though comparison is limited to the report
from 3/[**2188**].
2. COPD with no definite focal consolidation.
3. Multilevel thoracolumbar vertebral body wedge deformities, of
unknown
chronicity.
.
[**2196-11-22**] CT Head:
FINDINGS: There is prominence of the subdural space along the
left cerebral convexity which likely represents a left subdural
hygroma. There is no shift of normally midline structures and no
acute intracranial hemorrhage or large vascular territoral
infarct is observed. Mild sulcal and ventricular prominence is
consistent with age related atrophy. Mild periventricular and
subcortical white matter hypodensity is consistent with chronic
small vessel ischemic changes. Atherosclerotic calcification and
possible aneurysmal dilatation of the cavernous carotid arteries
are observed bilaterally.
Bone windows reveal no fracture. The imaged portions of the
paranasal sinuses and mastoid air cells appear well aerated.
IMPRESSION:
1. No acute intracranial hemorrhage. Prominence of the left
convexity
subdural space likely represents a subdural hygroma.
2. Possible aneurysmal dilatation of the cavernous carotids
bilaterally.
Nonurgent evaluation with CTA or MRA is recommended.
.
[**2196-11-22**] CT Abdomen/Pelvis:
Final Report
FINDINGS: Volume loss at the right lung base is partially
observed with
scattered pleural calcifications noted.
The liver demonstrates diffuse fatty infiltration without focal
abnormality identified. The spleen, pancreas, and adrenal glands
appear unremarkable. The kidneys enhance symmetrically and
excrete normally without hydronephrosis or hydroureter. A small
right renal interpolar hypodense lesion measures 5 mm and is too
small to characterize but likely represents a cyst.
Atherosclerotic calcification involving the abdominal aorta and
its branches, though the abdominal aorta is of normal caliber.
An irregular collection of extravisceral air is noted adjacent
to small bowel loops in the left mid abdomen, extending into the
mesentery and surrounding mesenteric vessels. This likely
represents a combination of pneumatosis and free mesenteric air.
No portal venous gas is seen and the celiac, superior mesenteric
artery, and inferior mesenteric artery appear patent. There is
no evidence for obstruction as orally administered contrast has
passed through into proximal colonic loops. No leakage of oral
contrast is seen.
.
CT PELVIS WITH CONTRAST: The rectum and sigmoid colon appear
unremarkable
with a Foley catheter present within the bladder. A large
partially calcified heterogeneous fundal exophytic fibroid is
located anteriorly and measures approximately 4.8 x 4.7 cm in
greatest axial dimensions. No free pelvic fluid is seen and no
pathologically enlarged pelvic lymph nodes are observed. Bone
windows reveal multilevel thoracolumbar degenerative changes
with anterior moderate-to-severe wedge compression deformities
involving T12 and L2. Diffuse anasarca and muscle atrophy is
noted.
.
IMPRESSION:
1. Left abdominal small bowel pneumatosis and free air within
the mesentery. Although this is of unclear etiology, ischemic
bowel is of greatest concern.
2. Compression deformities of T12 and L2 are of unclear acuity.
3. Fibroid uterus.
4. Fatty liver.
.
ADDENDUM: There is marked circumferential wall thickening of a
short segment of ascending colon. This is best seen in the
coronal plane (300B:20) and spans approximately 3.0 cm in the CC
direction. Within the bowel lumen there is an ovoid focus of
mesenteric fat with small vessels representing [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]- colonic
intussusception. The ileocecal valve is visualized and appears
distinct from this process.
These findings are concerning for short segmental [**Last Name (un) **]-colonic
intussusception likely secondary to an underlying
mass/carcinoma. Colonoscopy is recommended to evaluation for
underlying malignancy.
.
[**2196-11-23**] Transthoracic Echo:
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. An eccentric, posteriorly directed jet of
moderate (2+) mitral regurgitation is seen. Due to the eccentric
nature of the regurgitant jet, its severity may be significantly
underestimated (Coanda effect). Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Diastolic dysfunction with elevated filling pressures.
At least moderate mitral regurgitation. Mild pulmonary artery
systolic hypertension.
Brief Hospital Course:
1. BACK PAIN:
Unclear if this was due to underlying bowel abnormalities or
T12/L1 compression fracture. Patient was managed with Tylenol
with good effect. She was also tried on a Lidocaine patch for
local symptoms. She was discharged with prescriptions for
Morphine PO and Lidocaine patches to be used 12 hours on, 12
hours off every day.
.
2. PNEUMATOSIS, BOWEL WALL THICKENING:
Imaging suggests ischemic colitis with peri-vascular free air
and possibly some abdominal free air. Also bowel wall
thickening in ascending colon which was a distinct process and
likely represents malignancy such as colon cancer. The family
declined surgical intervention or colonoscopy for further
workup. She was initially started on antibiotics of
Ciprofloxacin and Flagyl. These were stopped on [**2196-11-25**] per
family discussion and decision to move toward hospice care. The
patient's blood cultures were negative, she remained afebrile
and hemodynamically stable. She had no elevation in her white
blood cell count. Her abdomen remained soft and the patient had
minimal tenderness on exam. She had diarrhea which may have
been due to her underlying abdominal problems or side effects of
antibiotics.
.
3. MENTAL STATUS CHANGES:
The patient presented with some confusion and disorientation at
home. During this hospitalization, she continued to have waxing
and [**Doctor Last Name 688**] mental status changes. She was confused at times,
especially at night, and was having visual and auditory
hallucinations. She was given Zyprexa 2.5mg with little effect
and then Ativan 0.25mg PO q6 hours. She had a head CT with no
evidence of bleeding, had no clear signs of infection such as
UTI or pneumonia and no metabolic cause of delerium. Her TSH
was checked and she was slightly hypothyroid but with a normal
TSH. It was felt that her most likely cause for delerium was
her intra-abdominal process with bowel ischemia or perforation
causing free air. She should be managed with Ativan for her
symptoms.
.
4. LOWER EXTREMITY EDEMA:
Due to worsening LE edema, she had an transthoracic
echocardiogram which showed some signs of diastoic dysfunction
but normal ejection fraction. It was felt that her edema was
likely secondary to poor nutritional status and hypoalbuminemia.
.
5. NUTRITION:
The patient was depleted nutritionally on arrival with an
albumin of 2.3. She had not been eating well prior to
admission. Her electrolytes, including potassium, magnesium and
phosphorous were low on admission. These were corrected
throughout course of admission. She was initially started on IV
fluids but these were stopped prior to discharge. She was
encouraged to continue to eat and was provided with Ensure
supplements.
.
6. CODE STATUS:
The patient was DNR/DNI on admission. After several family
meetings, it was decided that she should be made comfortable
given her abdominal CT findings and low likelihood of medical
recovery. She was discharged with hospice services on [**2196-11-28**].
She will continue to follow with her PCP and with hospice
services. IV fluids, electrolyte repletion, medications and
vital sign checks were stopped.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours).
2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Topical DAILY (Daily): 12 hours on, 12 hours off.
3. Ativan 1 mg Tablet Sig: 1-2 Tablets PO q4 hours PRN.
Disp:*5 Tablet(s)* Refills:*0*
4. haldol Sig: Five (5) mg tablets PO q6 hours PRN.
Disp:*5 tablets* Refills:*0*
5. tylenol Sig: 650mg suppository Rectal q4 hours PRN.
Disp:*5 suppositories* Refills:*0*
6. Levsin 0.125 mg Tablet Sig: One (1) Tablet PO q4 hours PRN.
Disp:*5 Tablet(s)* Refills:*0*
7. ativan Sig: One (1) suppository Rectal q6 hours PRN.
Disp:*5 suppositories* Refills:*0*
8. benadryl Sig: One (1) suppository Rectal q6 hours PRN.
Disp:*5 suppositories* Refills:*0*
9. haldol Sig: One (1) suppository Rectal q6 hours PRN.
Disp:*5 suppositories* Refills:*0*
10. reglan Sig: One (1) suppository Rectal q6 hours PRN.
Disp:*5 suppositories* Refills:*0*
11. Compazine 25 mg Suppository Sig: One (1) suppository Rectal
q6 hours PRN.
Disp:*5 suppositories* Refills:*0*
12. Compazine 10 mg Tablet Sig: One (1) Tablet PO q 6 hours PRN
as needed for nausea.
Disp:*5 Tablet(s)* Refills:*0*
13. Morphine Concentrate 20 mg/mL Solution Sig: [**6-28**] ml PO Q1H
(every hour) as needed.
Disp:*5 syringes* Refills:*0*
14. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
Discharge Disposition:
Home With Service
Facility:
Dr [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 14129**] Hospice and Palliative Care
Discharge Diagnosis:
Primary Diagnosis:
1. Pneumatosis
Secondary Diagnoses:
2. Bowel Wall Thickening
3. Poor nutrition
4. Hypokalemia
Discharge Condition:
afebrile, hemodynamically stable, weak
Discharge Instructions:
You were admitted for back pain and found to have air in your
abdomen which was concerning for small bowel perforation or low
blood flow to the intestines. You were also found to have
thickening of your bowel wall which is concerning for cancer.
You and your family did not wish to have surgery and were sent
home with hospice services.
Followup Instructions:
Please follow-up with hospice services and your primary care
provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1683**], as needed.
|
[
"153.6",
"293.0",
"733.13",
"496",
"703.8",
"V12.01",
"569.83",
"560.0",
"733.90",
"272.0",
"273.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.27"
] |
icd9pcs
|
[
[
[]
]
] |
14146, 14310
|
9562, 12711
|
293, 300
|
14468, 14509
|
2894, 4747
|
14895, 15044
|
2159, 2289
|
12767, 14123
|
14331, 14331
|
12737, 12744
|
14533, 14872
|
2304, 2309
|
14387, 14447
|
225, 255
|
328, 1726
|
4756, 9539
|
14350, 14366
|
2323, 2875
|
1748, 1969
|
1985, 2143
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,232
| 115,492
|
39093
|
Discharge summary
|
report
|
Admission Date: [**2151-6-29**] Discharge Date: [**2151-7-3**]
Date of Birth: [**2128-1-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2151-6-29**] - Mitral valve repair (28mm CG Future Annuloplasty Ring)
History of Present Illness:
This is a 23 year old female with known mitral valve prolapse
which was originally diagnosed at the age of 14. She has been
followed closely with serial
echcocardiograms which reveals worsening mitral regurgitation
and now shows evidence of left ventricular dilatation and left
atrial enlargement. Given the above findings, she was referred
for mitral valve repair/replacement. Of note, she recently had a
high-risk pregnancy and delivered without complication. She
currently has IUD which will prevent pregnancy for the next five
years. She is undecided on whether she wants more children but
has elected for a mechanical valve in the event her valve cannot
be repaired.
Past Medical History:
- Mitral Valve Prolapse with Severe MR
- Mild Depression
- Wrist fracture
- G2P1
Social History:
Mother - hypertension. Father - high cholesterol. Denies
premature coronary artery disease.
Family History:
Last Dental Exam: Yearly exams
Lives with: Parents
Occupation: Works in child care center
Tobacco: Never
ETOH: Rarely
Physical Exam:
Pulse: 83 SR Resp: 16 O2 sat: 100% RA
B/P Right: 116/70 Left: 120/71
Height: 66" Weight: 154 lbs
General: WDWN in NAD
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X] Teeth in good repair. OP
Benign;anicteric sclera
Neck: Supple [X] Full ROM [X]; no JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR, Nl S1-S2, IV/VI holosystolic blowing murmur radiates
to carotids
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]no HSM/CVA tenderness
Extremities: Warm [X], well-perfused [X]
Edema-none
Varicosities:None [X]
Neuro: Grossly intact
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit Right:None Left:None
Pertinent Results:
[**2151-6-29**]
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve leaflets are moderately thickened. Moderate to severe (3+)
mitral regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient is in SR, on no infusions.
There is a mitral ring in place with no leak and trace MR.
Residual mean gradient = 3 mmHg.
No AI. Aorta intact.
Preserved biventricular systolic fxn.
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2151-6-29**] for surgical
management of her mitral valve disease. She was taken to the
operating room where she underwent a mitral valve repair using
an annuloplasty ring. Please see operative note for details.
Postoperatively she was taken to the intensive care unit for
monitoring. Over the next several hours, she awoke
neurologically intact and was extubated. On postoperative day
one, she was transferred to the step down unit for further
recovery. She was gently diuresed towards her preoperative
weight. She was started on lopressor and developed prolonged PR
>.30. The lopressor was discontinued w/ normalization of PR
interval. She was tacycardic in the days following and lopressor
was resumed at a lower dosage which she tolerated. The physical
therapy service was consulted for assistance with her
postoperative strength and mobility. her chest tubes and wires
were removed per protocol. She received 1 unit PRBC for post
anemia with HCT 23 with appropriate response in HCT 24.6. She
was cleared for discharge to home by Dr. [**Last Name (STitle) **] for Dr. [**Last Name (STitle) **].
Medications on Admission:
None
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Rohcester Rural District VNA
Discharge Diagnosis:
mitral valve prolapse and regurgitation
s/p mitral valve repair
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
Discharge Instructions:
Shower daily including washing incisions gently with mild soap,
no baths or swimming until cleared by surgeon. Look at your
incisions daily for redness or drainage.
No lotions, cream, powder, or ointments to incisions.
Each morning you should weigh yourself and then in the evening
take your temperature, These should be written down on the chart
.
No driving for approximately one month, until follow up with
surgeon.
No lifting more than 10 pounds for 10 weeks.
Please call with any questions or concerns ([**Telephone/Fax (1) 170**]).
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge of sternal wound.
**Please call cardiac surgery office with any questions or
concerns ([**Telephone/Fax (1) 170**]). Answering service will contact on call
person during off hours.**
Followup Instructions:
You are scheduled for the following appointments
Surgeon:Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**7-29**] at 1pm
Please call to schedule appointments with:
Primary Care: Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 35507**] in [**1-30**] weeks
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 60004**] in [**1-30**] weeks
**Please call cardiac surgery office with any questions or
concerns ([**Telephone/Fax (1) 170**]). Answering service will contact on call
person during off hours.**
Completed by:[**2151-7-3**]
|
[
"427.89",
"311",
"285.9",
"424.0",
"429.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.32",
"35.12",
"38.93",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5308, 5367
|
3015, 4185
|
339, 414
|
5475, 5647
|
2199, 2992
|
6506, 7104
|
1346, 1466
|
4240, 5285
|
5388, 5454
|
4211, 4217
|
5671, 6483
|
1481, 2180
|
280, 301
|
442, 1115
|
1137, 1220
|
1236, 1330
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,363
| 142,100
|
5152
|
Discharge summary
|
report
|
Admission Date: [**2134-1-1**] Discharge Date: [**2134-1-6**]
Date of Birth: [**2058-12-30**] Sex: F
Service: Bloomguard Medicine
HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old
woman with hypertension, hypercholesterolemia,
cardiomyopathy, paroxysmal supraventricular tachycardia and
history of diverticulitis, who is status post elective
colectomy on [**2133-12-24**], who presented to the
emergency room on [**1-1**], one day after being discharged
postoperatively from the hospital. At this time the patient
complained of pleuritic chest pain, dyspnea on exertion,
palpitations. In the emergency room the patient was found to
be tachycardiac, systolic blood pressure in the 190s and a
CAT scan angiogram revealed evidence of a pulmonary embolism.
The patient was started on heparin drip at that time. The
patient had an episode of oxygen desaturation and hypoxia in
the emergency room that was likely due to flash pulmonary
edema. The patient was therefore admitted to the medical
intensive care unit where she was stabilized overnight with
Lasix and noninvasive ventilator assistance (Bi-PAP). The
patient was then transferred to the medicine floor on
[**1-3**]. Upon arrival to the medicine floor the patient
complained of tachycardia and de-conditioning, but otherwise
had no complaints and was breathing comfortably.
PAST MEDICAL HISTORY: Hypertension, hypercholesterolemia,
diverticulitis, status post elective colectomy on [**2133-12-24**], anxiety, history of myocarditis/cardiomyopathy,
status post catheterization unknown time that showed no
coronary artery disease.
MEDICATIONS UPON TRANSFER: Tylenol p.r.n., lisinopril 10
once a day, Diltiazem p.r.n., paroxetine 10 q.d., Colace,
pravastatin, heparin drip, Lasix 20 b.i.d., Coumadin 5
loading dose.
MEDICATIONS AT HOME: Cardizem 240, lisinopril 10,
pravastatin 40, Ativan 0.5, Paxil 10.
SOCIAL HISTORY: Lives in [**Hospital3 **], denies tobacco or other
drug use. Occasionally drinks alcohol socially and the
patient's husband is currently an inpatient at [**Hospital1 **] as well.
DIAGNOSTICS ON ADMISSION: CAT scan angiogram on [**1-1**],
showed pulmonary emboli within the right lower lobe segmental
artery branches and left upper lobe branch. The patient's
CBC was within normal limits, her hematocrit remained stable
in the mid 30 range and was normocytic. The patient's
urinalysis on [**1-1**], was within normal limits without
evidence of infection. The patient's electrolytes were
within normal limits and her cardiac enzymes were less than
0.01 troponin T x3 checks. Echocardiogram completed on
[**2134-1-1**], and then repeat echocardiogram on [**2134-1-4**], revealed normal left ventricular cavity size,
overall left ventricular systolic function moderately
depressed, however, improved slightly between the two dates
of [**1-1**] and [**1-4**]. Also showed 2+ mitral
regurgitation.
HOSPITAL COURSE:
1. Pulmonary embolism: The patient's pulmonary embolism in
a setting of postoperative course likely related to her
decreased mobility perioperatively. The patient was
continued on heparin drip until [**1-5**], after the
patient's INR had been therapeutic for 48 hours. The patient
was loaded on Coumadin beginning on [**1-2**] and at
discharge her INR was fairly stable at a dose of 2.5 Coumadin
q.h.s. The patient is to follow up with Dr. [**Last Name (STitle) 1007**] for
further dosing of her Coumadin and INR checks.
2. Cardiovascular: The patient with history of
cardiomyopathy and paroxysmal supraventricular tachycardia.
The patient's ejection fraction estimated at 20 to 25% on the
echocardiogram on [**1-1**], however, it was estimated to
be slightly improved and had an ejection fraction of 30 to
35% on repeat echo on [**2134-1-4**]. The patient's
slight improvement likely related to her improved overall
status and a depressed ejection fraction on [**1-1**], was
measured during an acute exacerbation of her cardiovascular
status. The patient remained somewhat tachycardia especially
with activity throughout her hospital stay. This was likely
related to deconditioning as well as her recent
cardiovascular decompensation in setting of a pulmonary
embolism. The patient was monitored closely and will be
followed as an outpatient for this. Cardiology was consulted
while the patient was in the hospital and they recommended
starting a beta blocker, which was started on [**1-5**].
The patient was also changed from an ACE inhibitor to
angiotensin to receptor blocker due to side effect of a
cough. Per the cardiology recommendations the patient was
continued on Diltiazem and Lipitor as well as Lasix 40 p.o.
b.i.d. The house staff also spoke to the patient's
outpatient cardiologist and received information from an old
echo, which also showed a global hypokinesis. That
echocardiogram had been performed approximately 3 to 4 months
prior to this admission. The cardiology consult also
recommended that the patient follow up with her outpatient
cardiologist for possible exercise stress test approximately
one month after discharge.
3. Diverticulitis, status post colectomy: The patient's
colectomy site was clean, dry and intact. The patient was
followed by surgery, who performed the operation throughout
her hospital stay.
4. Anxiety: The patient's anxiety likely worsened given her
difficult family issues, with her husband also being in the
hospital as a patient. The patient was maintained on low
dose Ativan as needed.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home with services.
DISCHARGE DIAGNOSES: Pulmonary embolism, cardiomyopathy,
hypertension, hyperlipidemia.
DISCHARGE MEDICATIONS: Furosemide 40 mg p.o. b.i.d.,
Diltiazem 240 mg sustained released p.o. q.d., paroxetine 10
mg once a day, pravastatin 40 mg once a day, Colace 100 mg
tablet twice a day as needed for constipation, losartan 25 mg
p.o. q.d., Warfarin 2.5 mg p.o. q.h.s., metoprolol 12.5 mg
b.i.d., Lorazepam 0.5 mg p.o. b.i.d.
FOLLOW UP PLANS: The patient to follow up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 1007**] within one month. The patient is also to follow up
with her outpatient cardiologist within one month.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1019**]
Dictated By:[**Doctor Last Name 21095**]
MEDQUIST36
D: [**2134-1-11**] 14:08
T: [**2134-1-15**] 08:25
JOB#: [**Job Number 21096**]
|
[
"415.11",
"425.4",
"424.0",
"401.9",
"518.4",
"300.00",
"E878.8",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5592, 5659
|
5683, 6518
|
2927, 5493
|
1824, 1892
|
176, 1359
|
2117, 2910
|
1382, 1802
|
1909, 2102
|
5518, 5570
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,913
| 193,738
|
29449
|
Discharge summary
|
report
|
Admission Date: [**2183-11-21**] Discharge Date: [**2184-1-7**]
Date of Birth: [**2136-12-18**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Nausea
Major Surgical or Invasive Procedure:
MRCP [**11-11**]
History of Present Illness:
46 M s/p crush injury (pinned between 2 trucks), no mvmt or
sensation below umbilicus in ED. S/P ex-lap, SB resection, near
SB enterectomy w/ R colectomy/trach/lumbar fusion. Prlonged ICU
course, d/c'd to Rehab [**2183-11-19**], returns for persistent nausea x
several days, generalized weakness.
Past Medical History:
CAD, DM2, s/p CABG
Social History:
Supportive and involved family network.
Worked as a foreman in construction
Family History:
Noncontributory.
Physical Exam:
PE: VSS, afebrile
Gen: NAD, lying in bed, avoiding motion, NGT in place with TF
going
CV: RRR, no m/r/g
Lungs: CTAB, no w/r/r
Abd: Soft, NTND, +BS
Ext: no c/c/e
Neuro Exam
Mental Status: alert and oriented to person, place, date.
Cooperative and pleasant affect. Speech is fluent, coherent,
appropriate, with good comprehension, repitition and naming.
Good concentration: able to spell WORLD forward and backward,
and no errors on serial subtractions. Able to follow multistep
commands. Registers [**2-7**] and [**2-7**] recall at 1 and 5 minutes. Aware
of current events.
Cranial Nerves: Pupils round. L pupil dilated at 7mm and
non-reactive. R pupil normal, reactive to light. EOMI with no
nystagmus. Peripheral vision intact. V1-V3 sensation intact and
equal bilaterally. Facial movement symmetric. Hearing intact to
finger rub bilaterally. Tongue midline. Neck and shoulder
strength 5/5.
Strength: Good bulk and tone throughout, no abnormal movements,
no clonus.
Pertinent Results:
[**2183-11-21**] 04:45PM GLUCOSE-93 UREA N-26* CREAT-1.1 SODIUM-130*
POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-25 ANION GAP-12
[**2183-11-21**] 04:45PM ALT(SGPT)-172* AST(SGOT)-90* ALK PHOS-353*
AMYLASE-347* TOT BILI-2.7*
[**2183-11-21**] 04:45PM LIPASE-248*
[**2183-11-21**] 04:45PM CALCIUM-8.2* PHOSPHATE-3.5 MAGNESIUM-1.7
[**2183-11-21**] 04:45PM WBC-11.3* RBC-2.49* HGB-7.8* HCT-21.5* MCV-86
MCH-31.2 MCHC-36.1* RDW-15.4
[**2183-11-21**] 04:45PM PLT COUNT-458*
[**2183-11-21**] 04:45PM PT-14.8* PTT-28.4 INR(PT)-1.3*
Cardiology Report ECHO Study Date of [**2183-12-25**]
Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is top
normal/borderline dilated.
Regional left ventricular wall motion is normal. No masses or
thrombi are seen
in the left ventricle. Overall left ventricular systolic
function is normal
(LVEF 60-70%). Tissue Doppler imaging suggests a normal left
ventricular
filling pressure (PCWP<12mmHg). Transmitral Doppler and tissue
velocity
imaging are consistent with normal LV diastolic function. There
is no
ventricular septal defect. Right ventricular chamber size and
free wall motion
are normal. The aortic root is moderately dilated athe sinus
level. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
appear
structurally normal with good leaflet excursion and no aortic
regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
Compared with the findings of the prior study (images reviewed)
of [**2183-11-13**], no major change is evident.
Cardiology Report ECG Study Date of [**2183-12-24**] 1:33:38 PM
Atrial flutter
Since previous tracing of [**2183-12-23**], ventricular rate slower
Intervals Axes
Rate PR QRS QT/QTc P QRS T
89 0 92 370/416.57 0 45 21
CTA CHEST W&W/O C&RECONS, NON-
COMPARISON: CT torso [**2183-11-11**].
IMPRESSION:
1. No evidence for pulmonary embolus.
2. Interval improvement in bibasilar subsegmental atelectasis
and lingular atelectasis/scarring.
3. Unchanged paratracheal and precarinal enlarged lymph nodes
measuring up to 10 mm.
MR HEAD W & W/O CONTRAST
IMPRESSION: No intracranial abnormalities. Since [**2183-10-30**],
resolution of scalp hematoma and paranasal sinus disease.
Improving bilateral mastoid air cell changes.
MRCP (MR ABD W&W/OC); MR 3D RENDERING W/POST PROCESS
IMPRESSION:
1. Unremarkable pancreatic duct. Small amount of fluid around
the head of the pancreas without evidence for injury to the
pancreatic parenchyma.
2. Subcapsular hematoma posterior to the posterior lobe of the
right liver. No intrahepatic biliary dilatation. No parenchymal
hepatic lesions appreciated.
3. Stable right lower pole renal infarction. Simple left hepatic
cyst.
4. Subcapsular splenic hematoma.
MR ORBIT W &W/O CONTRAST [**2184-1-1**] 12:01 AM
IMPRESSION:
1. No findings to explain patient's symptoms involving the right
eye.
2. Questionable short-segment enhancement of the left optic
nerve sheath as described above. This finding has been described
in meningioma, orbital pseudotumor, perioptic neuritis,
sarcoidosis, leukemia, lymphoma, metastases, perioptic
hemorrhage, and Erdheim-[**Location (un) **] disease. However, the validity
of the observation is questionable, in that it is only seen on
one axial and no coronal images, and particularly as it has no
correlation with right sided optic nerve symptoms. Finally, I
cannot detect the questionable left sided hyperintense finding
in the left optic nerve, noted by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], the
nighthawk radiologist, who acknowledged that his observation may
be artifactual, as well, again if the clinical findings do not
correlate with it.
Brief Hospital Course:
#) Nausea/vomiting: For the first week of pt's admission, pt.
had very poor PO intake [**1-9**] nausea, so dobhoff was placed and TF
started. Additionally, TPN was initiated.
On HD 18, pt was taking improved PO calories, so dobhoff was
pulled and pt transitioned to TPN and PO's only.
On HD 15, neurology was consulted to evaluate for a possible
central source for the patient's nausea, which they felt was
unlikely. Recommended MRI of brain for further evaluation which
was NL.
#) Orthostasis/dizziness: Pt. had been feeling somewhat dizzy
when upright and on HD 20, pt. had apparent vasovagal episode
upon standing. Vital signs showed orthostatic changes. This
improved somewhat with more aggressive hydration, then resolved
with initiation of steroids for adrenal insufficiency as above.
#) Atrial flutter/fibrillation: on [**12-23**], pt. had near-syncopal
episode and was found to be somewhat hypotensive (SBP 80's) and
tachycardic (120's) and on EKG/monitor appeared to be in
A.flutter interspersed with A.fib. Rate control was achieved
with IV diltiazem and pt was briefly transitioned to diltiazem
drip. Cardiac enzymes were cycled and were negative. Pt. was
changed from prophylactic to therapeutic lovenox dose at this
time and maintained on this dose throughout rest of
hospitalization. Cardiology was consulted and on [**12-24**],
cardioverted pt with successful return to NSR, which pt
maintained until time of discharge.
#) Blurry vision: On approx HD 14, pt. c/o of some blurriness in
R eye. Ophthalmology was consulted and found that L eye had
persistent pallor of disc (pt. has had no L eye vision since
accident), but that R eye was NL. Pt. had persistence of this
symptom on HD38, so was evaluated formally by ophthalmology
again (at [**Last Name (un) **]) and again was found to have NL exam of R eye.
#) Diarrhea: Pt. had persistent diarrhea throughout
hospitalization, secondary to his short gut s/p resection. This
improved slightly with use of loperamide, psyllium, kaopectate,
and opium tincture as well as dietary changes. Cholestyramine
was also tried, but did not seem helpful so was discontinued.
Pt. was given extensive education on short gut/dietary changes
by nutrition. Unfortunately, at time of d/c patient was still
having diarrhea after most meals, albeit at lower volumes than
previously.
#)Depression: Psychiatry followed patient while in-house,
recommended lexapro, felt pt. was somewhat dispirited but not
suicidal or acutely psychiatrically ill.
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for SOB.
Disp:*1 * Refills:*1*
2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed for SOB.
Disp:*1 * Refills:*1*
3. Bismuth Subsalicylate 262 mg/15 mL Suspension Sig: Sixty (60)
ML's PO four times a day.
4. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
6. Psyllium 1.7 g Wafer Sig: Two (2) Wafer PO TID (3 times a
day).
Disp:*qs Wafer(s)* Refills:*2*
7. Loperamide 2 mg Capsule Sig: Two (2) Capsule PO four times a
day.
Disp:*qs Capsule(s)* Refills:*0*
8. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*qs Tablet(s)* Refills:*2*
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
11. Vitamin B-12 1,000 mcg/mL Solution Sig: One (1) ml Injection
once a week.
Disp:*qs * Refills:*2*
12. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) inj
Subcutaneous Q12H (every 12 hours) for 4 weeks.
Disp:*56 inj* Refills:*0*
13. hospital bed
Please provide patient with hospital bed
14. bedside commode
please provide patient with bedside commode
15. shower chair
please provide patient with shower chair
16. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
17. Opium Tincture 10 mg/mL Tincture Sig: Twenty (20) Drop PO Q
8H (Every 8 Hours).
Disp:*qs * Refills:*2*
18. PICC
PICC line care per protocol
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Left adrenal hemorrhage
Adrenal insufficiency
Discharge Condition:
Stable
Discharge Instructions:
You may experience intermittent dizziness and nausea as you have
while hospitalized. Return to the Emergency room for persistent
fevers, persistent nausea, persistent dizziness, persistent
nausea, vomiting, diarrhea and/or any other symptoms that are
concerning to you.
Take your medications as they have been prescribed.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 519**] in his clinic by calling [**Telephone/Fax (1) 6554**]
for an appointment to be seen in [**12-9**] weeks.
Follow up with Caridology in [**12-9**] weeks. Dr. [**Last Name (STitle) 73**] ([**Telephone/Fax (1) 70712**].
Follow up with Endocrinology in [**12-9**] weeks. Dr. [**Last Name (STitle) **]. ([**Telephone/Fax (1) 70713**].
Opthomolgy - Provider: [**Name10 (NameIs) 6131**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2184-4-1**] 1:30
You have a follow up appointment that was previously scheduled
with Dr. [**Last Name (STitle) 1352**], Orhtopedic Spine Surgery. Phone:[**Telephone/Fax (1) 1228**]
Appointment scheduled Date/Time:[**2184-1-8**] 2:30; [**Hospital Ward Name 516**], [**Location (un) 1385**] [**Hospital Ward Name 23**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2184-1-6**]
|
[
"458.0",
"V45.3",
"V45.81",
"368.8",
"V45.4",
"427.31",
"250.00",
"255.4",
"579.3",
"535.50"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.62",
"99.04",
"96.6",
"45.16",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
10112, 10175
|
5780, 8286
|
322, 341
|
10265, 10274
|
1842, 5757
|
10645, 11626
|
821, 839
|
8309, 10089
|
10196, 10244
|
10298, 10622
|
854, 1026
|
276, 284
|
369, 668
|
1443, 1823
|
1041, 1427
|
690, 711
|
727, 805
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,533
| 166,898
|
17831
|
Discharge summary
|
report
|
Admission Date: [**2114-3-29**] Discharge Date: [**2114-4-11**]
Date of Birth: [**2047-10-19**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
s/p cardiac arrest
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
Per the son, when he was getting ready for work in the morning,
she came into his room and was complaining of trouble breathing.
He says that she sounded very congested, tried to cough but
continued to have difficulty breathing. She then started
gasping/gurgling and lips started turning blue, then she
collapsed in front of him and he called 911. EMS was dispatched
at 7:29am, which was 5 minutes after she collapsed, they arrived
at 7:34 and immediately started CPR. The initial rhythm was
PEA, she received 2 rounds of epi with ROSC at 7:44am, at that
time her rhythm was sinus tachycardia to the 150's. She was
intubated on scene. When she began moving her extremities after
ROSC, she was apparently moving only the right side of her body.
She was initiated on cooling by EMS, and they gave her a dose of
vecuronium.
.
Upon arrival to the ED, EKG was sinus 94, NANI, twi inf, 1/2mm
std laterally. Bedside ultrasound showed no pc effusion, full
IVC, RV wnl, global mild LV hypokinesis, nl aorta, fast neg.
Chem 10 was moderately hemolyzed but significant for K 5.4
bicarb 12, AG 29. CT head was negative for bleed. CT torso
showed no PE but intramural hematoma beginning at aortic arch
immediately distal to origin of
left subclavian artery and ending just above the diaphragm with
active extravasation. Also with assymetric eccentric
hypodensity in the wall of the brachiocephalic artery with
concern for intramural hematoma and bilateral dependent
consolidations and diffuse ground glass opacities suuggesing
aspiration or pneumonia with likely fluid overload. Also noted
to have minimally displaced anterior rib fractures, 4-8th ribs
on the right and 5-9th ribs on the left. Vascular was
consulted and recommended head/neck CTA to assess for extent of
dissection as well as TEE and tight BP control. C-[**Doctor First Name **] was also
consulted. Troponin was negative x1. Initial ABG was
7.03/58/131 and improved to 7.24/42/96. Bcx was sent and she
was given vanc/levo/flagyl given concern for aspiration. VS on
transfer were T 35 HR 68 BP 105/55 on AC vent
.
On arrival to the MICU, her initial VS were: 92.3, 58, 122/66,
100% on AC 400x24, FiO2 of 100%, PEEP of 5.
.
Review of systems: unable to obtain as patient is intubated and
sedated
Past Medical History:
-CAD s/p MI in [**2104**]
-HTN
-HL
-Grave's s/p radioactive iodine ablation now on thyroid
replacement
-Vitiligo
Social History:
moved to the US from [**Country 10181**] over 40 years ago, married with two
children. Previously worked in a factory and in a hospital many
years ago. Occasional glass of wine, no tobacco or illicit
substances, is a Jehovah's Witness, advanced directive stating
no blood products.
Family History:
None that her son is aware of, although the rest of her family
is in [**Country 10181**]
.
Physical Exam:
Admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Discharge:
GENERAL: 66 yo F in no acute distress
HEENT: mucous membs moist, no lymphadenopathy, JVP non elevated
sitting in chair.
CHEST: CTAB, No wheezes or cough.
CV: S1 S2 Normal in quality and intensity RRR, no M/R/G
ABD: soft, non-tender, non-distended, BS normoactive.
EXT: wwpp, no edema, diffuse. DPs, PTs 1+.
NEURO: alert, oriented x [**1-19**], poor short term memory, speech
clear, right eye with old ptosis.
SKIN: no rash or breakdown.
PSYCH: calm, appropriate, cooperative
Pertinent Results:
Admission:
[**2114-3-29**] 08:45AM BLOOD WBC-16.4* RBC-3.96* Hgb-12.6 Hct-40.0
MCV-101* MCH-32.0 MCHC-31.6 RDW-12.9 Plt Ct-242
[**2114-3-29**] 08:45AM BLOOD Neuts-57 Bands-16* Lymphs-24 Monos-1*
Eos-1 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2114-3-29**] 08:45AM BLOOD PT-11.1 PTT-37.2* INR(PT)-1.0
[**2114-3-29**] 08:45AM BLOOD Glucose-327* UreaN-31* Creat-1.1 Na-140
K-5.4* Cl-104 HCO3-12* AnGap-29*
[**2114-3-29**] 08:45AM BLOOD ALT-546* AST-928* LD(LDH)-1537*
AlkPhos-215* TotBili-0.4
[**2114-3-29**] 08:45AM BLOOD cTropnT-0.01
[**2114-3-29**] 08:45AM BLOOD Calcium-8.2* Phos-8.6* Mg-2.5
[**2114-4-4**] 04:25AM BLOOD VitB12-[**2055**]*
[**2114-3-30**] 05:45PM BLOOD Hapto-101
[**2114-4-4**] 04:25AM BLOOD TSH-0.062*
[**2114-4-4**] 04:25AM BLOOD Free T4-1.9*
[**2114-3-29**] 08:56AM BLOOD Type-[**Last Name (un) **] Rates-/14 Tidal V-500 FiO2-100
pO2-131* pCO2-58* pH-7.03* calTCO2-16* Base XS--16 AADO2-525 REQ
O2-88 Intubat-INTUBATED
[**2114-3-30**] 10:15AM BLOOD freeCa-1.19
Discharge Labs:
[**2114-4-10**] 08:25AM BLOOD WBC-8.9 RBC-3.37* Hgb-10.8* Hct-34.3*
MCV-102* MCH-32.1* MCHC-31.5 RDW-17.0* Plt Ct-266
[**2114-4-9**] 06:13AM BLOOD Glucose-87 UreaN-33* Creat-0.8 Na-143
K-3.5 Cl-100 HCO3-30 AnGap-17
Reports:
[**3-29**] TTE:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size are normal. There is moderate to severe regional
left ventricular systolic dysfunction with
hypokinesis/near-akinesis of the basal and mid inferior and
inferolateral segments. Due to suboptimal image quality,
additional wall motion abnormalities cannot be fully excluded.
Right ventricular chamber size is normal. with depressed free
wall contractility. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are mildly thickened. An eccentric, posteriorly
directed jet of moderate (2+) mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is an anterior space which most likely represents a
prominent fat pad.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size and wall thickness with moderate to severe left
ventricular systolic dysfunction and hypokinesis/near-akinesis
of the basal and mid inferior and inferolateral segments.
Depressed right ventricular function. Moderate mitral
regurgitation. Indeterminate pulmonary artery systolic pressure.
.
[**3-29**] CTA:
1. No evidence of type A aortic dissection. A short proximal
segment of the innominate artery appears to be involved with an
intramural hematoma, within which a tiny streak of hyperdensity
may represent contrast. Known descending aortic intramural
hematoma is incompletely imaged on this study.
2. Mild narrowing of left vertebral artery origin and left ICA
origin.
Intracranial and neck vessels are otherwise patent without
evidence of occlusion or focal aneurysm.
3. No acute intracranial process.
4. Incompletely imaged bilateral pulmonary consolidations with
air bronchograms, better evaluated on same-day dedicated chest
CTA
.
[**4-4**] MRI head:
FINDINGS: There is no evidence of acute intracranial hemorrhage,
edema, masses or mass effect. No diffusion-weighted
abnormalities are detected to suggest acute infarction. The
ventricles and sulci are mildly enlarged, consistent with mild
involutional changes. No extra-axial fluid collection is
detected. Mild mucosal thickening is seen in the right sphenoid
and bilateral ethmoid air cells. The major vascular flow voids
are intact. No abnormal enhancement is detected in the
post-contrast images. The post-contrast images are somewhat
limited by motion artifacts. Small right temporal/occipital
scalp hematoma is seen.
IMPRESSION: Somewhat limited study due to patient motion. Within
this
limitation, no acute intracranial abnormality, especially no
evidence of an acute infarction.
CXR [**2114-4-7**] Compared with [**2114-4-6**] 7:58 a.m., the ET tube, NG
tube and right IJ line have been removed. Again seen is
cardiomegaly, left lower lobe collapse and/or consolidation, and
left greater than right effusions, unchanged. Also again seen is
upper zone redistribution and diffusely increased interstitial
markings. Depending on the clinical scenario, this could
represent either CHF or an infectious or inflammatory
interstitial process. The dense opacity in the right lung
laterally is significantly improved, with only faint residua
appreciated. Vertebral body endplate scalloping and T12
vertebral compression fracture again noted. Known rib fractures
not well demonstrated on these views.
[**2114-4-10**] 08:25AM BLOOD WBC-8.9 RBC-3.37* Hgb-10.8* Hct-34.3*
MCV-102* MCH-32.1* MCHC-31.5 RDW-17.0* Plt Ct-266
[**2114-4-9**] 06:13AM BLOOD Glucose-87 UreaN-33* Creat-0.8 Na-143
K-3.5 Cl-100 HCO3-30 AnGap-17
Brief Hospital Course:
Ms. [**Known lastname 49478**] is a 66 y/o F with a h/o CAD s/p MI in [**2104**] with
revascularization, recent minor MVA who presented s/p a cardiac
arrest at home.
.
#) S/P Cardiac Arrest: based on history, a primary respiratory
event was thought to be the likely cause of the PEA arrest.
Patient underwent a CT Torso prior to arrival to the ICU.
Patient was noted to have a pneumonia and was started on
treatment with vancomycin, ceftriaxone, and flagyl for
CAP/Aspiration PNA. She was also noted to have an intramural
hematoma. This was evaluated by vascular surgery and thought to
be chronic and not requiring of an intervention. Recommended
aggressive blood pressure control which required prn esmolol
gtt. Patient was started on post arrest protocol and hypothermia
goal temperature was modified to 34.5C.
.
#2 Acute systolic congestive heart failure: EF 35%. Aggressively
diuresed once BP stabilized, now appears euvolemic. Weight at
110 pounds, this is her dry weight. Lasix at 20 mg daily. Pt
should have daily weights with furosemide adjustment for weight
gain more than 3 pounds in 1 day or 5 pounds in 3 days.
#3 NSTEMI: Patient had history of inferior MI in [**2104**] s/p
revascularization. She was maintained on her ASS, Statin, BB.
Aspirin was held initially for concern fo a bleed. On [**3-31**],
overnight, patient was noted to have ST depression on telemetry.
Over the course of the morning patient became tachycardic and
hypotensive. Antibiotics were broadened empirically for concern
of sespis to Vancomycin, Cefepime, Levoquin, and Flagyl. Review
of previous cardiac catheterization showed severe 3VD and PCI
intervention is not an option. Swan showed PA 55/30, Wedge 20,
CVP 15, CO4.47. In the [**Hospital 49479**] medical management of her STEMI was
undertaken given her known severe 3 vessel CAD and poor surgical
candidacy. She did have intermittent atrial fibrillation with
rates in the 180s in the setting of sepsis, and respiratory
failure. It was decided not to anticoagulate the patient given
that her a fib did not recur after clinical improvement in her
hemodynamics and respiratory status.
.
#4 Multifocal Pneumonia: She was treated with an 8d course of
cefepime for VAP (partial course of vancomycin and flagyl).
.
#5 Delerium and Anoxic Brain injury: NO obvious infarct on brain
MRI.
She has made a good physical recovery but evaluation by
Occupational therapy revealed a low score on a cognitive
assessment scale (see attached note). Her short term memory is
severely impaired at present and she is mildly impulsive with
some perseveration. She experienced some delerium during her ICU
stay requiring Haldol but has not needed any psychoactive
medications in the last 3 days. She was formally independent but
she is not able to stay alone, drive or make medical decisions
at present. A follow up appt has been made with cognitive
neurology after discharge.
Medications on Admission:
- Synthroid 100mcg daily
-Metoprolol succinate 50mg daily
-Aspirin 81mg daily
-Simvastatin 40mg daily
-Diovan/HCTZ 80/12.5mg daily
-Vitamin D [**2101**] units daily
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. Vitamin D3 2,000 unit Capsule Sig: One (1) Capsule PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care - [**Hospital1 **]
Discharge Diagnosis:
Respiratory arrest
NSTEMI
Cardiogenic shock
Multifocal Pneumonia
Acute Systolic congestive heart failure
Aortic Dissection, Type B
Transient atrial fibrillation
[**Doctor Last Name 933**] disease
Hyperglycemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**].
You had trouble breathing at home and collapsed. The EMT's found
that your heart had stopped and was able to get your heart
beating again. You had a breathing tube to help you breathe and
needed medicine to keep your blood pressure up. You developed
pneumonia and were given antibiotics to treat this. You are now
stable but will need physical and occupational therapy to help
you recover. Your heart is weaker after the heart attack and you
had some extra fluid that was removed with diuretics. The fluid
may come back, even with the new medicines. Weigh yourself every
morning, call Dr. [**Last Name (STitle) 17369**] if weight goes up more than 3 lbs in 1
day or 5 pounds in 3 days. Your weight at discharge is 110
pounds and this should be considered your ideal weight.
.
We made the following changes to your medicines:
1. STOP taking Diovan/hydrochlorothiazide
2. INCREASE the aspirin to 325 mg daily
3. STOP taking simvastatin, take atorvastatin instead to lower
your cholesterol.
4. INCREASE the metoprolol to 200 mg daily
5. START taking lisinopril to lower your blood pressure
6. START taking solace to prevent constipation
7. START taking furosemide to remove any extra fluid.
Followup Instructions:
Department: COGNITIVE NEUROLOGY UNIT
When: TUESDAY [**2114-4-24**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 658**], M.D. [**Telephone/Fax (1) 1690**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: CARDIAC SERVICES
When: FRIDAY [**2114-5-4**] at 3:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4511**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please discuss with the staff at the facility a follow up
appointment with your PCP below when you are ready for
discharge.
Name:[**Name6 (MD) 49480**] [**Last Name (NamePattern4) 49481**],MD
Address: [**Street Address(2) 4472**] [**Apartment Address(1) **], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 17368**]
|
[
"785.52",
"507.0",
"785.51",
"V62.6",
"244.2",
"518.81",
"038.9",
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"E879.8",
"995.92",
"427.31",
"412",
"997.31",
"441.01",
"349.82",
"570",
"V49.87",
"428.21",
"428.0",
"401.9",
"276.3",
"709.01",
"807.08",
"272.4",
"V45.82",
"287.5",
"293.0",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.62",
"96.72",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
12915, 12988
|
9175, 12081
|
324, 336
|
13242, 13242
|
4310, 5288
|
14699, 15715
|
3090, 3183
|
12297, 12892
|
13009, 13221
|
12107, 12274
|
13427, 14676
|
5304, 9152
|
3198, 4291
|
2580, 2635
|
266, 286
|
364, 2560
|
13257, 13403
|
2657, 2772
|
2788, 3074
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,920
| 153,113
|
49426
|
Discharge summary
|
report
|
Admission Date: [**2124-4-21**] Discharge Date: [**2124-5-12**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Intubation.
Cardiac Catherization with stent placement.
Swan-Ganz hemodynamic monitoring through the right internal
jugular.
History of Present Illness:
This is an 87 year-old male with history of 3 vessel coronary
disease, congestive heart failure, aortic stenosis, diabetes,
end-stage renal disease not on dialysis who presents with ST
elevation infarction. He was recently admitted with unstable
angina and was discharged 2 days prior to this presentation. He
had been having intermittent chest pain with exertion that
resolved with rest for the past month. The morning of
admission, he had [**8-13**] burning substernal chest pain with
intermittent radiation to the left chest. He came into the
emergency department and was found to have ST elecations
inferiorly. It was felt that he had collateral insufficiency
given inferior ST elevations in the setting of a known occluded
right coronary. Given prior plans for medical management, he
received aspirin, sublinqual nitro x 3, Plavix 600 mg, heparin
srip, lopressor, morphine and ativan. His chest pain resolved
in the emergency department, and he was transferedd to the CCU.
Upon arrival to the CCU, he complained of persistent burning
substernal chest pain, and he EKG had persistent ST elevations
inferiorly with ST elevations in V4 with right-sided leads. He
became acutely hypoxic to the 80s on a non-rebreather. A
bedside echocardiogram showed severely depressed left
ventricular function with preserved right ventricular function.
After discussions with his outpatient nephrologist, covering
cardiologist, and daughters, he was taken emergently to the
catherization lab for a diagnostic and potentially therapeutic
catherization despite the risk of needing dialysis after the [**Month/Year (2) **]
load. He was emergently intubated. He was started on pressors
for cardiogenic shock. Catherization revealed severe stenosis
at the left main trifucation. A stent was placed to the
proximal LAD. He was transfered to the CCU for further
management.
Past Medical History:
1. Coronary artery disease status post an MI [**47**] years ago. A
catherization in [**2115**] showed severe 3 vessel disease. A
decision was made then not to pursue bypass surgery.
Persantine-MIBI on [**4-18**] showed fixed inferior and inferiolateral
perfusion defect.
2. Congestive heart failure with an ejection fraction of 19% on
persantine-MIBI [**2124-4-18**].
3. Aortic Stenosis with a gradient of 41 mmHg in [**5-8**].
4. Diabetes that is diet controlled.
5. End stage renal disease not on dialysis.
6. Hypertension.
7. Hyperlipidemia.
8. Hypothyroidism.
9. Hiatal hernia with gastroesophageal reflux.
10. Status post ressection of the sigmoid colon and rectum for
colon cancer.
11. Prostate cancer with watchful waiting.
Social History:
He is widowed and lives alone. He is independent at baseline.
He is a former smoker and he occasionally drinks alcohol.
Family History:
Non-contributory.
Physical Exam:
Vitals: Temperature: Blood Pressure: Pulse: Respiratory Rate:
Oxygen Saturation:
General: Intubated and sedatied.
HEENT: Pupils equal and reactive, moist mucous membranes,
anicteric sclera.
Pulmonary: Bibasilar crackles anteriorly.
Cardiac: Regular rate and rhythm, s1, s2, with III/VI harsh
systolic crescendo-decrescendo murmur heard thoughout.
Abdomen: Soft, mildly nondistended with decreased bowel sounds.
Extremities: Warm without edema. Dopplerable dorsalis pedis on
the right and posterior tibial on the left. Swan-ganz catheter
in placed at the right groin. Balloon pump in placed at the
left groin. Oozing at both groin sites.
Pertinent Results:
Hematology:
WBC-16.4 HGB-11.0 HCT-32.1 PLT COUNT-195
NEUTS-45.4 BANDS-0 LYMPHS-45.9 MONOS-3.9 EOS-3.8 BASOS-1.1
.
Chemistries:
SODIUM-137 POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-23 UREA N-84
CREAT-4.9 GLUCOSE-92
CALCIUM-9.0 PHOSPHATE-4.5 MAGNESIUM-2.5
.
Coagulation:
PT-13.3 PTT-150 INR(PT)-1.2
.
Arterial Blood Gases:
PO2-215 PCO2-53 PH-7.23 (intubated)
.
Cardiac Enzymes:
CK(CPK)-122 CK-MB-6 MB cTropnT-0.69
.
.
EKG [**2124-4-21**]: Normal sinus rhythm with ST elevations in III and
aVF and ST depressions in I, aVL, V2-V4. Right sided leads had
ST elevations in V4R.
.
.
Echocardiogram (limited views) [**2124-4-21**]: Severely depressed left
ventricular function (EF ~ 15-20%). Preserved right ventricular
function.
.
.
Catherization [**2124-4-21**]: His right coronary was totally occluded.
The left main had an 80% tubular stenosis. The LAD had a 90%
stenosis at the origin and a 70% stenosis at the mid-portion.
The D1 had a 95% ostial stenosis. The circumflex had moderate
disease without any critical lesions. There were collaterals
supplying the right coronary territory.
.
Hemodynamics: He had a cardiac index of 2.1 on dopamine. His
right ventricular end diastolic pressure was elevated at 20
mmHg, and his wedge was elevated at 30 mmHg.
.
Intervention: A drug eluting stent was placed to the left main
and proximal LAD with good resultant flow. A intraaortic
balloon pump was placed.
.
.
Speech and Swallow Assessment [**2124-5-4**]: Moderate delay in
laryngeal valve closure with associated aspiration and
penetration as described above.
Please see also the speech language pathology report within the
notes portion of the medical record for full details,
assessment, and recommendations.
.
.
PICC line placement [**2124-5-8**]: Successful placement of a single
lumen PICC line into the right brachial vein with the tip in the
SVC. The line is ready for use.
.
.
CXR [**2124-5-11**]: IMPRESSION: Increasing cardiomegaly with worsening
moderate pulmonary edema denote cardiac decompensation.
Persistent left lower lobe atelectasis and small bilateral
pleural effusions.
Brief Hospital Course:
This is an 87 year-old gentleman with known 3 vessel coronary
artery disease, congestive heart failure EF 25%, aortic stenosis
([**Location (un) 109**] 0.9 cm2), diabetes who presented with an inferior
ST-elevation myocardial infarction secondary to collateral
insufficiency. He was recently admitted to [**Hospital1 18**] with
complaints of chest pain and found to have significant CAD based
on a Persantine MIBI test, however a cardiac catheterization
could not be performed given the severe acute on chronic renal
failure. This particular hospitalizations was complicated by
multiple factors including cardiogenic shock, septic shock,
repeated episodes of aspiration PNA, and flash pulmonary edema.
After his last episode of hypoxic respiratory failure and
intubation/extubation, the pt was made DNR/DNI after long
discussions with the patient and his family. Soon after he was
medically stabilized and transferred to out of the CCU. However
he suffered another episode of respiratory distress during which
time he was made [**Hospital1 3225**] after discussion with the patient and the
HCP. The details of the hospital course are summarized below.
.
.
CODE STATUS: Prior to admission, the pt was living independently
with intact ADL and IADLS. However, this hospitalization for
STEMI was complicated by episodes of shock and hypoxic
respiratory distress requiring intubation/extubation after which
point the patient was made DNR/DNI. He was stabilized medically
and called out of the ICU on [**2124-5-8**]. However he experienced
another episode of respiratory distress from pulmonary edema on
the evening of [**2124-5-10**]. The following day, a family meeting was
held with the patient and both the patient and the HCP agreed to
become [**Name (NI) 3225**]. He was subsequently transitioned off medical
therapy and instead started on a morphine drip through a
pre-existing PICC line for comfort measures. In addition, the
pt was written for PRN nebulizers and promethazine. If needed,
the pt should also receive a Scopolamine patch.
.
.
1. STEMI: His inferior infarction was attributed to collateral
insufficiency. Initially, there was concern for right
ventricular involvement. However the right ventricle had
preserved function on a bedside echocardiogram. Catherization
confirmed severe 3 vessel disease. At the time of
catherization, CT surgery felt that he was not a surgical
candidate given his multiple comorbidities. Therefore, he
underwent stenting to the origin of the LAD. His CKs peaked at
1351 and trended down post-intervention. He was maintained on
aspirin, Plavix, and Lipitor. When he was weaned from pressors,
he was started on a beta-blocker. This was discontinued upon
commencement of amiodarone. After catheterization, the patient
did not have any complaint of chest pain, nor did he have
concerning EKG changes.
.
2. Hypoxic Respiratory Failure: His initial respiratory failure
was likely secondary to cardiogenic shock in the setting of his
ST elevation myocardial infarction. He required intubation
prior to his catherization. Post-procedure, he developed
copious amounts of dark thick sputum. At that time, he
developed a fever and a white count. He was presumed to have an
aspiration pneumonia as below. He was maintained on the
ventilator while he was on pressors for shock. As his shock
resolved, he became more hypertensive with elevated pulmonary
artery pressures. At that time, he had evidence of pulmonary
edema. He was diuresed prior to extubation. He was
successfully extubated on hospital day 7. On hospital day 9, he
had an episode of hypoxia in the setting of hypertension that
was consistent with flash pulmonary edema. A chest x-ray showed
marked increased in bilateral pulmonary edema. He received
Lasix and metolazone. His symptoms improved with diuresis. On
[**5-5**] he developed respiratory failure secondary to pulmonary
edema and likely aspiration pneumonia, which was treated with
triple antibiotics. His pulmonary edema responded poorly to
attempted diuresis. Mental status waxed and waned but was
generally declining and urine output poor in setting of
aggressive diuresis. Patient and family did not want to pursue
dialysis. Given poor prognosis decision was made with the family
to move toward comfort care/hospice.
.
3. Shock: Initially, he had evidence of cardiogenic shock with a
low cardiac index on dopamine. A balloon pump was placed at the
time of catheterization and he was continued on dopamine. A
Swan-Ganz catheter was placed for hemodynamic monitoring. On
hospital day 3, he had evidence of septic shock give and
elevated cardiac index with a low systemic vascular resistance.
He had developed a fever to 101.3 and a white count of 22. He
did not respond to a cortisol stimulation test and was started
on stress dose steroids. He was started empirically of
vancomycin, levofloxacin, and Flagyl for a presumed aspiration
pneumonia and completed a 10 day course. All cultures remained
negative. Since his cardiac output had improved, the balloon
pump was removed. With the onset of the septic shock, he became
more hypotensive. Therefore, Levophed was started in addition
to the dopamine. Over the next few days, he became afebrile,
his white count trended down, and he was weaned from all
pressors. The Swan-Ganz catheter was subsequently removed. He
has remained hemodynamically stable since that time.
.
4. Atrial Fibrillation: He intermittently went into atrial
fibrillation. On hospital day 9, he had atrial fibrillation
with rapid ventricular rate with associated hypotension. He was
loaded with IV amiodarone. Subsequently, he dropped his
pressures and became bradycardic. He was transitioned to oral
amiodarone and received 2 days of 400 [**Hospital1 **] followed by 400 daily
which at this point will be continued indefinitely. Amiodarone
was discontinued prior to discharge when decision was made to
transition to comfort care.
.
5. Congestive heart failure: A post-intervention echocardiogram
showed an ejection fraction of 15%. He initially had a balloon
pump for support. In the setting of septic shock, he became
total body fluid overloaded and required diuresis with Lasix.
With improvement in his perfusion pressures, he began to
autodiuresis. He did go into flash pulmonary edema on [**5-5**]
which eventually resolved. He has been difficult to diurese
despite multiple attempts with agressive high dose diuretics.
He continues to be total volume overloaded. He will be
discharged on furosemide 60 mg po qd and with morphine for
symptomatic control of dyspnea.
.
6. End-stage renal disease: His renal function had been
deteriorating prior to admission. Discussions were held with
his nephrologist prior to taking him to the catherization lab.
It was felt that the benefit of angiography with possible
intervention outweighed the risk of contrast nephropathy.
Post-procedure, his creatinine trended down with adequate urine
output. On hospital day 3 with the onset of septic shock, his
creatine began to rise. This rise was likely from decreased
renal perfusion. As he was weaned off of the pressors and as
his blood pressure improved, his urine output increased with a
subsequent decrease in his creatinine. Dialysis was discussed
with patient and family but this was not consistent with his
known wishes.
.
7. Ileus: On admission, he had not had a bowel movement in 10
days. Plain films confirmed that his intestines were full of
stool. He received an aggressive bowel regimen. After several
days, a abdominal plain film showed dilated colonic loops. An
abdominal CT confirmed the dilated loops of bowel and showed no
signs of obstruction. Surgery was consulted and felt that this
was consisted with ileus likely secondary to the fentanyl during
sedation. He was decompressed with an NG tube to low suction
and rectal tube. Repeat abdominal plain films showed no further
dilatation. Once he was off of fentanyl sedation, his bowel
sounds improved and he began to move his bowels. He was
maintained on bisacodyl suppositories.
.
8. Aortic stenosis: He has severe aortic stenosis with a
gradient of 64 mmHg and a valve area of 0.9. Volume status was
carefully monitored given this setting.
.
9. Diabetes: His blood glucose was slightly elevated during the
initial periods of septic shock. At that time, he was
maintained on an insulin sliding scale. He was later well
controlled and did not require any additional insulin.
.
10. Prophylaxis: He was maintained on subcutaneous heparin. He
was on a bowel regimen as above. He was maintained on
pantoprazole.
.
11. Access: He initially had a Swan-Ganz through his right
femoral vein. This was resited to the right internal jugular.
The balloon pump was in the left femoral artery. A radial
arterial line was placed when the balloon pump was removed.
Once he was stable off of pressors, the swan and the central
line were removed. He had peripheral IVs. He will be discharged
with PICC line to facilitate morphine administration.
.
12. FEN: He was started on tube feeds on hospital day 3 as he
was still intubated. These were held in the setting of ileus.
He was diuresed as above. He was maintained on tube feeds. As
his mental status improved, he was evaluated for PO intake.
Eventually he underwent video speech and swallow evaluation
which revealed delayed laryngeal closure; it was recommended
that he try ground solids and thickened liquids. Soon after
beginning this, he had likely aspiration event leading to PNA
(see above). After recovering from this, he was maintained on
cautious PO diet. Per family request, he was allowed to have
thin liquids as well. He continues to be at high risk for
aspiration.
.
Medications on Admission:
Aspirin 325 po qd
Plavix 75 po qd
Atorvastatin 80 po qd
Coreg 6.25 po bid
Isosorbide dinitrate 10 po tid
Bumetanide 1 po bid
Cinacalcet 30 po qd
Lanthanum 1000 TID
Epoeitin [**2117**] MWF
Spiriva 18mcg IH qd
Levothyroxine 137 mcg qd
Allopurinol 100 po qod
Pantoprazole 40 po qd
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed.
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
6. picc line care
7. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1) injection
Intravenous Q8H (every 8 hours) as needed.
8. Promethazine 25 mg/mL Solution Sig: 12.5 mg Injection Q6H
(every 6 hours) as needed for nausea.
9. Morphine (PF) in D5W 100 mg/100 mL Parenteral Solution Sig:
drip as needed titrated to comfort ml Intravenous INFUSION
(continuous infusion).
10. Morphine Concentrate 20 mg/mL Solution Sig: Five (5) ml PO
every four (4) hours: Please titrate to comfort.
Disp:*330 ml* Refills:*2*
11. Levsin 0.125 mg/mL Drops Sig: One (1) ml PO every four (4)
hours as needed for secretion.
12. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for anxiety, nausea.
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**3-9**]
hours as needed for fever or pain.
14. Lasix 20 mg Tablet Sig: Three (3) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 5344**] Knoll Nursing & Rehabilitation - [**Location (un) 5344**]
Discharge Diagnosis:
Primary:
1. ST elevation MI
2. Cardiogenic Shock
3. Septic Shock
4. Three vessel coronary artery disease
5. Congestive heart failure
6. Atrial fibrillation
7. Exacerbation of severe chronic kidney disease
Discharge Condition:
Fair, no chest pain, breathing with adequate oxygenation on 2
liter oxygen floor.
Discharge Instructions:
The pt has been designated Comfort Measures Only after
discussions with the patient himself and his HCP. If the pt
were to develop any pain, or respiratory distress, please
increase his morphine drip. In the event that it is not
sufficient he can also be given nebulizers as needed and his
oxygen can be increased as well. The pt should also be given
compazine or an alternative for nausea and levsin for secretions
as necessary. He should not be re-admitted to the hospital as
it is the wish and understanding of the pt and family that his
condition is not reversible.
Please maintain his PICC line via routine care. In the event
that the PICC line malfunctions, it should be discontinued and
he should be given morphine SL as needed instead.
Followup Instructions:
The pt does not need need to follow up with a cardiologist as he
has been designated [**Location (un) 3225**]. He should be followed as necessary in
the facility for titration of his pain medications.
|
[
"038.9",
"410.41",
"507.0",
"785.51",
"V66.7",
"403.91",
"V15.82",
"585.6",
"584.9",
"V10.05",
"518.81",
"V45.3",
"553.3",
"272.4",
"427.31",
"799.02",
"785.52",
"530.81",
"424.1",
"412",
"250.40",
"276.3",
"E935.2",
"995.92",
"285.9",
"428.0",
"185",
"276.2",
"414.01",
"560.1",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.6",
"96.72",
"38.93",
"37.61",
"00.40",
"38.91",
"37.23",
"00.46",
"89.68",
"00.66",
"89.64",
"36.07",
"99.69",
"99.29"
] |
icd9pcs
|
[
[
[]
]
] |
17431, 17540
|
6016, 15745
|
272, 398
|
17796, 17880
|
3904, 4257
|
18678, 18883
|
3208, 3227
|
16074, 17408
|
17561, 17775
|
15771, 16051
|
17904, 18655
|
3242, 3885
|
4274, 5993
|
222, 234
|
429, 2298
|
2320, 3054
|
3070, 3192
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,237
| 156,162
|
15969
|
Discharge summary
|
report
|
Admission Date: [**2120-4-15**] Discharge Date: [**2120-4-26**]
Date of Birth: [**2055-9-16**] Sex: M
Service: Blue Surgery
HISTORY OF PRESENT ILLNESS: This is a 64-year-old gentleman
with a history of severe chronic obstructive pulmonary
disease who was found to have esophageal cancer on endoscopy
and biopsy. He underwent chemotherapy and radiation with
evidence of shrinkage on CT scan. He now presents for
preoperative preparation for his distal esophagectomy and
total gastrectomy.
PAST MEDICAL HISTORY: 1. Esophageal cancer status post
chemotherapy and radiation therapy. 2. [**Doctor Last Name 15532**] esophagus.
3. Chronic obstructive pulmonary disease requiring home O2 at
three liters. 4. Peptic ulcer disease. 5. Coronary artery
disease status post myocardial infarction eight years ago.
6. Ventral hernia not repaired.
MEDICATIONS: 1. Atrovent 2 puffs q.i.d. 2. Flovent 2 puffs
b.i.d. 3. Lasix 20 p.o. q.d. 4. Diltiazem 240 mg p.o. q.d.
5. Theophylline 300 mg p.o. b.i.d. 6. Isosorbide dinitrate
20 mg p.o. b.i.d. 7. Xanax 0.5 mg p.o. q.d. p.r.n. 8.
Protonix 40 mg p.o. b.i.d.
SOCIAL HISTORY: The patient is a significant smoker who
requires home oxygen and does have a history of alcohol in
the past but quit 20 years ago.
PHYSICAL EXAMINATION: He was afebrile at 99.9, heart rate
110, blood pressure stable at 120/60, respiratory rate 24,
and he was 92% on three liters of oxygen. He was in no
apparent distress. He had moist mucous membranes. Pupils
were equally round and reactive to light. Extraocular
movements were intact. His lungs were clear with mild
wheezes and crackles at the bases. His heart was tachycardic
but with no murmurs. His abdomen was soft, nontender,
nondistended. He was mildly obese and had a well-healed
ventral hernia scar. His extremities were warm and well
perfused. There was no clubbing noted.
LABORATORY DATA: On admission his arterial blood gas showed
a pH of 7.45, PCO2 52, PO2 60, bicarbonate 37 and a base
excess of 9. His white count was 6.3, hematocrit 39.1,
platelet count 165. His chemistries showed a sodium of 145,
potassium 2.8, chloride 99, bicarbonate 35, BUN 15,
creatinine 1.0, blood sugar 157. His AST was 27, ALT 23,
alkaline phosphatase 148, total bilirubin 0.6, albumin 4.3.
HOSPITAL COURSE: He was admitted to the hospital and given a
bowel preparation with neomycin and erythromycin and made
n.p.o. for the planned operation.
On [**2120-4-16**] the patient was taken to the operating room where
a distal esophagectomy and total gastrectomy was performed as
well as a jejunostomy tube placement. The patient was
transferred to the surgical intensive care unit
postoperatively. Please see the operative report for
details.
The patient did well in the surgical intensive care unit.
His PCO2 was maintained below 60 with his PO2 maintained
above 60 as well. The patient was put on patient-controlled
analgesia for pain control on postoperative day one after his
epidural had fallen out. He had good pain control at that
time. The patient was able to be extubated immediately
postoperatively and did well. His laboratory values were all
within normal limits. He had good urine output at that time.
He was started on postoperative day one on tube feeds,
Impact with fiber at half-strength, 20 cc an hour. The
patient was doing well on his tube feeds and the Dilaudid PCA
on postoperative day number two. His tube feeds were slowly
increased to 30 cc an hour. He was also started back on his
diltiazem. His PCO2 at that time was 60.
Physical therapy was consulted to evaluate for ambulation and
the patient was found to be doing well from this standpoint.
It was felt that after adequate pain control was obtained the
patient would be able to be successfully able to ambulate
throughout his hospital course and could ultimately go home
when medically stable.
Nutrition was also consulted at that time on [**2120-4-18**] for
evaluation of nutritional needs. It was felt that the
patient would require 90 cc of full-strength Impact with
fiber in order to meet his nutritional needs. His tube feeds
on postoperative day number three were increased again to 50
cc an hour. He continued to improve. His blood gas at that
time also revealed that his PCO2 was in the 50s and his PO2
was in the 50s as well. The patient was maintained on nasal
cannula oxygen throughout his hospital course after
extubation. Aggressive chest physical therapy and pulmonary
toilet were instituted and the patient maintained a good O2
saturation on three liters of oxygen.
The patient was transferred to the floor on [**2120-4-22**]. His
tube feeds were slowly advanced to goal at half strength at
90 cc an hour and the patient was tolerating the tube feeds
well. His blood gases continued to have PCO2 in the 50s and
PO2 in the 50s. The patient was out of bed and ambulating
and doing well at that time. It was decided that the patient
could be increased to two-thirds strength tube feeds after
arriving on the floor due to the fact that the patient was
tolerating his tube feeds.
Physical therapy continued to evaluate him at that time as
well and felt that he was doing well and progressing. The
patient was started on sips on postoperative day six which he
was able to tolerate after an upper GI/small bowel
follow-through was performed. This showed an open
anastomosis with no leak, therefore his nasogastric tube was
removed using mineral oil to lubricate.
On postoperative day number eight his tube feeds were
switched to two-thirds strength and the patient tolerated the
switch well. He was also started on a clear liquid diet
which he was able to tolerate.
On postoperative day eight in the evening he was stared on a
soft solid diet and he continued to improve. On
postoperative day number nine his tube feeds were cycled so
that they would run from 7 PM to 7 AM, giving him two-thirds
strength Impact with fiber at 90 cc an hour and he could be
disconnected from his jejunostomy tube feeds during the day,
allowing him to ambulate. The patient continued to do well
and continued receiving chest physical therapy, and was out
of bed and ambulating. JP teaching was performed and on
postoperative day number 10 the patient was tolerating a soft
solid diet, having six small meals a day. Nutrition had seen
him and had given him nutritional teaching about a soft solid
diet and multiple small meals, and it was decided that the
patient could be discharged home.
The patient was discharged home in stable condition with
services in place, for planned jejunostomy tube feeds at 90
cc an hour of two-thirds strength Impact with fiber. The
patient was also planned to have VNA services for
[**Location (un) 1661**]-[**Location (un) 1662**] drain monitoring and wound check. The patient
was discharged home at that time in stable condition.
DISCHARGE MEDICATIONS:
1. Atrovent 2 puffs q.i.d.
2. Flovent 2 puffs b.i.d.
3. Lasix 20 p.o. q.d.
4. Diltiazem 240 mg p.o. q.d.
5. Theophylline 300 mg p.o. b.i.d.
6. Isosorbide dinitrate 20 mg p.o. b.i.d.
7. Xanax 0.5 mg p.o. q.d. p.r.n.
8. Protonix 40 mg p.o. b.i.d.
9. Tube feeds with the kangaroo pump, Impact with fiber
two-thirds strength at 90 cc an hour to be cycled from 7 PM
to 7 AM.
10. Vicodin for pain control.
DISCHARGE DIAGNOSES:
1. Esophageal cancer status post XRT and chemotherapy now
status post distal esophagectomy and total gastrectomy with
jejunostomy tube placement.
2. [**Doctor Last Name 15532**] esophagus.
3. Chronic obstructive pulmonary disease requiring home
oxygen.
4. Peptic ulcer disease.
5. Coronary artery disease status post myocardial infarction.
6. Ventral hernia repair.
CONDITION ON DISCHARGE: Stable.
DISCHARGE INSTRUCTIONS: He was instructed to follow up with
Dr. [**Last Name (STitle) 957**] in one week's time for wound check, [**Location (un) 1661**]-[**Location (un) 1662**]
drain removal as well as review of pathology. Pathology
reports were not back at the time of discharge.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4007**]
Dictated By:[**First Name (STitle) 12277**]
MEDQUIST36
D: [**2120-4-25**] 11:10
T: [**2120-4-25**] 12:15
JOB#: [**Job Number 45749**]
|
[
"458.2",
"197.8",
"V15.3",
"412",
"496",
"280.0",
"150.8",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.12",
"43.91",
"96.6",
"54.4",
"46.39"
] |
icd9pcs
|
[
[
[]
]
] |
7321, 7688
|
6899, 7300
|
2317, 6876
|
7747, 8248
|
1301, 2299
|
174, 513
|
536, 1129
|
1146, 1278
|
7713, 7722
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,220
| 108,153
|
35888
|
Discharge summary
|
report
|
Admission Date: [**2115-10-23**] Discharge Date: [**2115-11-4**]
Date of Birth: [**2087-12-19**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
Motor vehicle collision w tree
Major Surgical or Invasive Procedure:
[**10-27**] -- Percutaneous tracheostomy and percutaneous endoscopic
gastrostomy
[**10-28**] -- Closed reduction with placement of intermaxillary
fixation
History of Present Illness:
27M restrained driver motor vehicle crash vs tree. Intubated at
scene. Per [**Location (un) 7622**], decerebrate posturing in field with GCS4 &
Cushingoid reflex. On arrival to ED, was GCS4T, intubated, and
received vec/succ for intubation. +Gag. Blood in L ear &
oropharynx.
Past Medical History:
PMH: None
PSH: Right Inguinal Hernia Repair
Medications: None
Allergies: NKDA; (allergy to shrimp, anaphylax)
Social History:
Lives alone, attending college in prep for Law school, active
full time air force national guard, avid hiker/mountaineer. He
was recently hiking in [**Location (un) 3844**] mountains last weekend. No
other recent travel. Never smoker, drinks wine on occasion, no
h/o heavy ETOH use, no known Illicit or IV drug use.
Family History:
Maternal Grandparents-both with CAD, died in their 90's. Parents
both healthy. No FH of blood clots, connective tissue disease or
autoimmune diseases.
Physical Exam:
Upon admission:
Vitals: T 98, BP 117/80, HR 77, R 18 on CPAP, sat 100%
Gen- critically ill, intubated and sedated
HEENT- NC, scattered small abrasions on face, OP clear, MMM
Neck- no carotid bruits.
CV- Distant sounds, RRR, no MRG
Pulm- CTA B
Abd- soft, ND, no HSM, BS+
Extrem- multiple abrasions, no CCE, 2+ DP, PT pulses bilat.
NEUROLOGIC EXAM:
MS- does not follow commands. localizes with left arm to sternal
rub.
CN- pupils miotic 1mm and appear unreactive to light, unable to
view fundi, slow roving eye movements, unable to test dolls as
pt
in C-collar, intact gag, intact corneals bilaterally.
Motor- winces to noxious on the left arm and leg, withdraws left
arm, internally rotates left leg to noxious.
Sensory- intact to noxious.
Reflexes- 2+ on left [**Hospital1 **], tri, braciorad, patellar, 3+ on right
[**Hospital1 **], tri, patellar
Plantar response is upgoing on the right, down on the left
Pertinent Results:
[**2115-10-23**] 03:00AM BLOOD WBC-14.2* RBC-4.77 Hgb-15.1 Hct-42.2
MCV-88 MCH-31.6 MCHC-35.7* RDW-13.2 Plt Ct-281
[**2115-10-23**] 03:00AM BLOOD PT-13.2 PTT-22.6 INR(PT)-1.1
[**2115-10-23**] 06:53AM BLOOD Glucose-78 UreaN-14 Creat-1.0 Na-142
K-4.0 Cl-99 HCO3-29 AnGap-18
[**2115-10-23**] 06:53AM BLOOD Calcium-8.9 Phos-5.2* Mg-2.2
CHEST SINGLE VIEW ON [**2115-11-2**]
FINDINGS: There has been interval decrease in the amount of
intra-abdominal free air. Tracheostomy tube is unchanged in
location. There is a small amount of volume loss versus an early
infiltrate in the left lower lung. Otherwise, the lungs are
clear.
[**2115-10-25**]
EXAMINATION: Non-contrast head CT.
COMPARISONS: Comparison to non-contrast head CT from [**2115-10-24**],
dating back to CTA of the head from [**2115-10-23**].
IMPRESSION:
1. Stable pattern of hemorrhage consistent with diffuse axonal
injury.
Dominant area of hemorrhage within the left subinsular region
with stable
associated mass effect and effacement of the left lateral
ventricle. Areas of
intraventricular hemorrhage stable. No evidence for new
hemorrhage.
2. Multiple fractures of the mandible and right
zygomaticomaxillary complex
fracture which are better evaluated on dedicated CT of the
facial bones from
[**2115-10-23**]. Please refer to CT facial bone report for further
characterization
and recommendations.
[**2115-10-23**]
Cerebral Angiogram
IMPRESSION: The patient underwent cerebral arteriography which
revealed no
evidence of arteriovenous malformations, AVMs or aneurysm, which
could be
responsible for his left putaminal hemorrhage
Brief Hospital Course:
[**2115-10-23**] Medflighted to [**Hospital1 18**] from scene. GCS4. Imaging shows
Diffuse Axonal Injury w/ multiple intraparenchymal hemorrhages
(largest L temporal); Right orbital and mandibular fractures
(body + R ramus). Neurosurgery consulted; bolt placed for ICP
monitoring. Mannitol and Dilantin started. His cervical spine
imaging was negative for any fractures or malalignment; disc
protrusion was noted at C4/5 and Neurosurgery spine recommended
to keep the cervical collar on until follow up in 4 weeks.
[**10-24**] Repeat head CT showed no interval change of intracranial
hematoma. Angio neg for AVM, good flow. ICP pressures <15. TF
started.
[**10-25**] Bolt removed. Post bolt CT: no new hemorrhage. ICPs [**2-6**];
Mannitol dose decreased. Slightly improved mental status, moving
all extremities. Sedation being weaned. U/S performed on right
inguinal area hematoma; showed hematoma with no pseudoaneurysm
or AV fistula.
[**10-26**] Febrile--urine, blood and sputum cultures sent. Imaging
shows LLL pneumonia. Vanc, Cipro, Zosyn started. Mannitol d/ced.
Neurosurgery signs off. Speech consulted for Passy Muir valve
for which he tolerated. Physical and Occupational therapy
consulted. Social work closely following.
[**10-27**] Percutaneous tracheostomy and percutaneous endoscopic
gastrostomy at bedside performed.
[**10-28**] Taken to the operating room by OMFS for closed reduction
with placement of intermaxillary fixation. His jaws were wired
shut. SQH started.
[**10-29**] Ventilator weaning initiated.
[**10-30**] On trach mask. Sputum culture grew pan sensitive staph,
Hflu. Vanco and Zosyn stopped. Continued Cipro for an additional
7 day course. Physical and Occupational therapy consulted.
[**10-31**] Transferred to the regular nursing unit floor. Remains
hemodynamically stable.
[**11-1**] Case management continuing screening for acute rehab
placement.
[**11-3**] Febrile up to 101.8; he was pan cultured, chest xray still
showing a LLL infiltrate and so Vancomycin and Zosyn were
started. His WBC was 19.6 at that time. He does have a
productive cough with copious secretions. Final culture results
are pending but he is currently being treated empirically.
Discussions whether to perform an LP took place between the
trauma team and Neurosurgery.
[**11-4**] WBC down to 14 and temp 100.8. Discussed with neurosurgery
whether they still wanted to do the LP; given that he was
clinically improving the decision was made to hold off as the
infection source was likely from his lungs. His sodium was
intermittently elevated, as high as 155 with ranges from
147-155. He was given free water boluses and his IV fluids were
increased; Na level on [**11-4**] was 152. he was discharged to rehab
facility.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every [**3-3**]
hours as needed for fever or pain.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ML's PO BID
(2 times a day).
3. Senna 8.8 mg/5 mL Syrup Sig: Ten (10) ML's PO at bedtime as
needed for constipation.
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection [**Hospital1 **] (2 times a day).
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. Dilantin-125 125 mg/5 mL Suspension Sig: Six (6) ML's PO
three times a day for 4 weeks.
8. Insulin Regular Human 100 unit/mL Solution Sig: One (1) DOSE
Injection four times a day as needed for sliding scale: see
attached sliding scale.
9. Vancomycin 1000 mg IV Q 12H
10. Piperacillin-Tazobactam Na 4.5 g IV Q8H
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 25750**]
Discharge Diagnosis:
s/p Motor vehicle crash
Injuries:
Diffuse Axonal Injury w/ multiple intraparenchymal hemorrhages
Right orbital fractures
Mandibular fractures (body + R ramus)
Respiratory Failure
Malnutrition
Hypernatremia
Pneumonia
Discharge Condition:
Hemodynamcially stable
Followup Instructions:
Follow up in 4 weeks with Dr. [**Last Name (STitle) **], Neurosurgery. Call
[**Telephone/Fax (1) 1669**] for an appointment. Inform the office that you will
need a repeat head CT scan for this appointment.
Follow up with Dr. [**First Name (STitle) **], OMFS in Surgical [**Hospital 81546**] Clinic
in 2 weeks, call [**Telephone/Fax (1) 55393**] for an appointment.
Follow up in 2 weeks with Dr. [**Last Name (STitle) **], Trauma Surgery. Call
[**Telephone/Fax (1) 600**] for an appointment.
If there are any difficulties scheduling any of the above
appointments please call [**First Name8 (NamePattern2) 17148**] [**Last Name (NamePattern1) 2819**], NP, Trauma Surgery at
[**Telephone/Fax (1) 67547**].
Completed by:[**2115-11-13**]
|
[
"486",
"E878.8",
"263.9",
"518.81",
"802.4",
"E816.0",
"802.6",
"801.30",
"802.24",
"802.38",
"276.0",
"998.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"88.41",
"01.10",
"96.72",
"43.11",
"76.75",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
7709, 7757
|
4019, 6760
|
346, 503
|
8017, 8042
|
2392, 3996
|
8065, 8802
|
1290, 1443
|
6817, 7686
|
7778, 7996
|
6786, 6792
|
1458, 1460
|
276, 308
|
531, 808
|
1474, 1789
|
1806, 2373
|
830, 941
|
957, 1274
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,246
| 139,212
|
43635
|
Discharge summary
|
report
|
Admission Date: [**2119-12-15**] Discharge Date: [**2119-12-16**]
Date of Birth: [**2051-3-12**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Respiratory Failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 68 yo F with end stage pulmonary fibrosis
likely secondary to hypersensitivity pneumonitis, progressively
declining over the last few months. On [**2119-12-6**], the patient
had a transtracheal O2 catheter placed. Since then she
developed mucus plugging with increased coughing. Yesterday
morning her family called 911 because of respiratory distress.
She was brought to an OSH where she was found to be oxygenating
in the low 80's with a decreased mental status. She was
emergently intubated and a chest tube was placed for a tension
pneumothorax. A chest tube was placed and her lung reexpanded
80% by CXR over night. Per report her chest tube was to low
wall suction with serosanguinous output. The records indicate
that they gave her of trial of chest tube to suction prior to
transfer. She has been sedated and mechanically ventilated
(FiO2 .5 and airway pressures in high 20s, low 30s). She
developed an air leak in her chest tube on the evening of
transfer. She is being transferred in at the request of her
family.
Enroute to [**Hospital1 18**], the patient was originally on a propofol drip
but became hypotensive. Levophed was started. The propofol was
stopped and the patient received a given a 600cc bolus. She
then received a total of 650 fenanyl and 1mg midazolam. Chest
tube on suction throughout flight. Decreased urine output. The
patient arrived at [**Hospital1 18**] on the following vent setting: AC 350 x
14 100% FIO2 5 PEEP. The 5 of PEEP was added inflight to [**Hospital1 18**].
Past Medical History:
--Idiopathic diffiuse pulmonary fibrosis, managed on home O2
--Hypersensitivity pneumonitis, diagnosed [**2112**]
--TMJ
--Anxiety, clonazepam at night
--Depression, mantained with mirtazipine and zoloft
--GERD, managed with Dr. [**Last Name (STitle) 2305**]
[**Name (STitle) 93822**]
--Squamous cell ca, skin, LLE
Social History:
She is married, does not smoke cigarettes (quit 40 yrs ago) or
drink alcohol.
Family History:
Brother - cystic fibrosis
Mother - died age 87 [**1-13**] CHF (? lung disease)
Father - died age 64 colon cancer
Physical Exam:
Vitals - HR 93 SBP 94/64 RR 8 O2100% on AC 350 x 14 100% FIO2 5
PEEP
General - sedated, follows simple commands
HEENT - PERRL
Neck - supple, transtracheal catether in place; insertion site
clean, dry, and intact
CV - RRR
Lungs - diffuse rhonchi
Abdomen - soft, NT/ND
Ext - 1+ edema bilateral lower extreities
Pertinent Results:
[**2119-12-16**] ECHO: The right atrium is markedly dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is unusually small. Due to suboptimal technical quality,
a focal wall motion abnormality cannot be fully excluded. The
right ventricular cavity is markedly dilated. There is severe
global right ventricular free wall hypokinesis/akinetic. There
is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The tricuspid valve
leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is a small pericardial effusion. No right
atrial diastolic collapse is seen. No right ventricular
diastolic collapse is seen. Echocardiographic signs of tamponade
may be absent in the presence of elevated right sided pressures.
Compared with the prior study (images reviewed) of [**2119-9-27**],
the right ventricule is more dilated and hypokinetic. The left
ventricle is hyperdynamic and underfilled in the setting of
right ventricular failure. The pericardial effusion is increased
in size, but still small.
[**2119-12-16**] Liver U/S - 1. No evidence of bile duct abnormality.
Gallbladder likely surgically absent. Small volume ascites
noted.
Brief Hospital Course:
The patient is a 68 yo F with end stage pulmonary fibrosis
likely secondary to hypersensitivity pneumonitis s/p TTO
catether placed on [**2119-12-6**] at [**Hospital1 18**]. Yesterday the patient had
respiratory distress at home and was brought to an OSH. She had
a "respiratory arrest" and was emergently intubated. She was
found to have a tension pneumothorax and a right sided chest
tube was placed. She was transferred to [**Hospital1 18**] for further care.
At the time of admission, the patient was found to have been
started on levophed just prior to transfer. Originally it was
though secondary to hypovolemia. The patient was given 4.5L
fluid bolus overnight and was briefly off levophed. 1 hour
later, again became hypotensive and needed a central line placed
and to be restarted on pressors. There was concern about
sepsis, but there was no obvious source. She was started on
vancomycin, ceftazadine, levofloxacin, and flagyl for broad
coverage. During the course of the next few hours, her shock
progressed very rapidly, resulting in essentially two cardiac
arrests (no CPR, but bolus epinephrine required for SBP > 50).
She had profound respiratory and metabolic acidosis; this did
not appear to be mediated by a tension pneumothorax. We
proceeded with femoral arterial access (no palpable radial
pulses), deep sedation, and pharmacologic paralysis. She
stabilized somewhat on pressure control
ventilation and three pressors (levophed, neosyneprine, and
vasopressin) but then nearly arrested again. We proceeded with
an epinephrine gtt and a trial of inhaled nitric oxide to
attempt to unload the right ventricle. This resulted in some
hemodynamic stability, as well as stabilization of the
respiratory component
of her acidosis. We assessed for potentially treatable causes
(tension PTX, cholangitis, etc.) but did not identify any.
Multiple family members came to see Ms. [**Known lastname 5444**]. They
expressed that, given
the extremely high probability of death in this situation -- and
her ongoing quality of life -- Ms. [**Known lastname 5444**] would not want to
continue on life support in the present circumstances. All
questions were answered. After arrival of her family pastor,
vasopressors were reduced and the patient died.
The family agreed to a lung limited autopsy.
Medications on Admission:
Home Medications:
Acetaminophen 325 mg 1-2 Tabs PO Q6H
Albuterol 90 mcg1-2 Puffs Q6H as needed.
Metformin 850 mg [**Hospital1 **]
Ranitidine 150 mg HS
Simethicone 80 mg DAILY
Prednisone 20 mg DAILY
Sertraline 50 mg DAILY
Azathioprine 100/50 mg AM/PM
Sildenafil 25 mg TID
Guaifenesin 600 mg [**Hospital1 **]
Mirtazapine 15 mg HS
Benzonatate 100 mg TID
BActrim 160-800 mg 1 Tablet PO 3X/WEEK (MO,WE,FR)
Clonazepam 1 mg QHS
Dorzolamide 2 % Drops One Drop Ophthalmic [**Hospital1 **]
Meds on Transfer:
Lotrimin topical to vaginal and groin area QID
Prednisone 20mg Daily
ISS
Revatio 20mg TID
Levoxyl 25mcg Daily
Morphine 2mg q2 PRN
Trusopt 1 drop B/L [**Hospital1 **]
Imuran 50mg PM
Imuran 100mg AM
Zoloft 50mg Daily
Protonix 40mg Daily
Combivent
Discharge Medications:
The patient expired on [**2119-12-16**]
Discharge Disposition:
Expired
Discharge Diagnosis:
Septic Shock
Respiratory Failure
Idiopathic pulmonary fibrosis
Tension Pneuothorax
Discharge Condition:
The patient expired on [**2119-12-16**]
Discharge Instructions:
The patient expired on [**2119-12-16**]
Followup Instructions:
The patient expired on [**2119-12-16**]
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"276.4",
"038.9",
"512.0",
"427.5",
"995.92",
"530.81",
"518.81",
"244.9",
"515",
"584.9",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.93",
"00.12"
] |
icd9pcs
|
[
[
[]
]
] |
7268, 7277
|
4089, 6410
|
302, 308
|
7403, 7444
|
2782, 4066
|
7532, 7710
|
2323, 2437
|
7204, 7245
|
7298, 7382
|
6436, 6436
|
7468, 7509
|
2452, 2763
|
6454, 6917
|
243, 264
|
336, 1873
|
1895, 2211
|
2227, 2307
|
6935, 7181
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,492
| 123,242
|
48513
|
Discharge summary
|
report
|
Admission Date: [**2117-3-12**] Discharge Date: [**2117-3-18**]
Date of Birth: [**2038-9-24**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None, ICU monitoring
History of Present Illness:
Ms. [**Known lastname **] is a 78 yo female with HTN, DM, Breast CA on arimidex,
OSA, s/p trach in [**2089**], diastolic CHF, S/p CVA, who was
discharged from [**Hospital1 18**] 3 weeks ago after tongue bleed in setting
of supratherapeutic INR and CHF exacerbation. She was
discharged to rehab where she was not getting lasix. She has
noted increased lower extremity edema over the past few days.
She has had thick yellow secretions lately as well. She endorses
subjective fevers at rehab. She was noted yesterday to desat
and was given lasix 20 and nebs with some improvement. She
desatted again today and was given 40 po of lasix and got a CXR
which showed CHF and was transferred to [**Hospital1 18**] for furhter
management.
.
Upon arrival to the ED, her initial vs were 134/70, 98.5, RR20,
98% on 8L. She got a CXR which showed CHF but could not rule out
bibasilar infiltrates. SHe was suctioned yellow secretions and
desatted to 87% during suctioning. There were concerned she
might need to be vented, so was admitted to the MICU.
.
Upon arrival to the MICU, patient was satting 100% on 35%TCM
(her baseline). She denied symptoms of shortness of breath.
She reports her LE edema improved since yesterday. Patient
reports right sided abdominal discomfort secondary to being
hungry.
.
Past Medical History:
Past Medical History:
- HYPERTENSION
- DIABETES MELLITUS
- BREAST CANCER ddx: Infiltrating ductal carcinoma
- SLEEP APNEA [**2087**]
- S/P tracheostomy [**2089**]. hx acute and chronic resp failure in
[**2077**]'s.
- OSTEOARTHRITIS right knee
- MULTIPLE FALLS
- SYSTOLIC DYSFUNCTION global LV hypokinesis [**2110**] echo: LVEF
50-55%
- ATRIAL FLUTTER [**2102**]
- ATRIAL SEPTAL DEFECT [**2102**]
- MITRAL REGURGITATION [**2102**]
- COR PULMONALE [**2087**]'S
- S/P STROKE
- OBESITY [Notes]
- SPINAL STENOSIS
- LOWER GASTROINTESTINAL BLEED
- [**2111**]: neg colonoscopy
- ACUTE RESPIRATORY FAILURE [**2106**]
Social History:
Normally lives at home, but has been at rehab since last
hospitalization. Denies alcohol, drug or current tobacco use.
Per her sister, she is a former smoker, but unclear what her
pack year smoking history is.
Family History:
DM
Physical Exam:
Vitals: T 98.7, HR 79, BP 137/46, RR 18, 91% on 35% TCM
General: chronically ill appearing
HEENT: Sclera anicteric, MMM, oropharynx clear, no tongue lac
visible
Neck: unable to assess JVP, + trach
Lungs: poor inspiratory effort, Clear to auscultation
bilaterally, no wheezes, rales, ronchi
CV: irregular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, + b/l 2+ pitting edema.
Pertinent Results:
[**2117-3-12**] 10:00AM BLOOD WBC-6.46 RBC-3.40* Hgb-10.4* Hct-33.4*
MCV-98 MCH-30.7 MCHC-31.2 RDW-15.0 Plt Ct-129*
[**2117-3-12**] 10:00AM BLOOD Neuts-79.5* Lymphs-14.9* Monos-4.8
Eos-0.7 Baso-0.1
[**2117-3-12**] 10:00AM BLOOD PT-42.5* PTT-41.9* INR(PT)-4.7*
[**2117-3-12**] 10:00AM BLOOD Glucose-85 UreaN-13 Creat-1.3* Na-147*
K-4.1 Cl-101 HCO3-44* AnGap-6*
[**2117-3-12**] 10:00AM BLOOD ALT-36 AST-36 CK(CPK)-134 AlkPhos-68
TotBili-0.6
[**2117-3-12**] 10:00AM BLOOD Lipase-28
[**2117-3-12**] 10:00AM BLOOD cTropnT-0.07*
[**2117-3-12**] 10:00AM BLOOD CK-MB-4 proBNP-3576*
[**2117-3-12**] 10:00AM BLOOD Albumin-3.2* Calcium-8.3* Phos-3.4
Mg-1.3*
[**2117-3-12**] 10:05AM BLOOD Lactate-0.7
.
Radiology
.
CXR [**3-12**]: IMPRESSION:
1. Cardiomegaly and volume overload with interval increase in
left pleural effusion. 2. Increased density at the lung bases,
left greater than right. Atelectasis or infection cannot be
excluded.
.
Brief Hospital Course:
This is a 78 yo female with diastolic CHF, s/p trach, HTN, DM,
A. fib on coumadin, here with CHF exacerbation.
1. Hypoxia / Hypercarbic respiratory failure. The patient was
initially admitted to the ICU on [**3-12**] with desaturations with
evidence of CHF on CXR and an elevated BNP. She was diuresed
with IV lasix and rapidly improved to normal saturations of
around 100% on 35%TCM (her baseline) with subjective improvement
in her lower extremity edema. She was subsequently transferred
to the floor.
On the floor over the weekend, the patient was able to weaned to
FiO2 of 50% on TCM, tolerating Lasix diuresis. On Sunday,
creatinine increased; Lasix was decreased to 40 mg PO from 40 mg
IV.
Overnight, on the day of transfer, the patient triggered when
she was noted to be hypoxic to the 80s when her trach mask had
fallen off. She was suctioned and FiO2 on trach mask was
increased to 100% with immediate improvement. However, given
new lethargy, an ABG was drawn: 7.33/93/84. Lasix was given
over concern that she had only rec'd one dose of PO lasix in the
morning. CXR was underpenetrated but showed continued pulmonary
edema without any clear evidence of infiltrate. The patient
appeared to wake more, and repeat ABG was 7.31/94/111. At that
time, MICU was called to evaluate. On arrival, the patient was
alert, awake and asking to go to the bathroom. She was able to
use the commode without much difficulty. However, on returning
to bed, she became somnolent, but easily arousable. Continued
to be able to follow commands. Repeat ABG was 7.37/89/73 on
FiO2 of 70%. Her mental status continued to wax and wane which
was a difference from baseline, so she was transferred back to
the MICU for further evaluation. Eventually it was felt that
her hypoxia and hypercarbic respiratory failure was largely due
to a significantly elevated HCO3 (49), likely renal compensation
for her severe contraction alkalosis from diuresis. She was
treated with potassium chloride, arginine chloride, and diamox
with improvement in both her serum HCO3 and CO2 levels, as well
as her overall mental status. Eventually the patient may
require intermittant nocturnal ventillation to help her CO2 from
rising in the setting of her OSA and obesity hypoventillation
syndrome. The patient remained afebrile during her hospital
course and repeated investigations into potential infectious
causes for her hypoxia were negative. The patient continued to
receive albuterol and atrovent nebs as well. The patient would
benefit from continued pulmonology follow-up as an outpatient.
2. Anemia. At baseline. Most recent anemia studies in
[**Month (only) 1096**] consistent with iron deficiency anemia. Prior
colonoscopy shows diverticulosis. The patient was given iron
supplementation and her hematocrits were monitored.
3. Hypernatremia. The patient had a mildly elevated serum
sodium. She was encouraged to drink free water.
4. Renal failure. The patient has a fluctuating baseline, but
her creatinine was generally in the 1.2-1.3 range. However, it
did rise acutely to 1.6 on [**3-17**] and this increase was felt to be
secondary to volume depletion and dehydration from aggressive
diuresis as she was simultaneously oliguric. She was gentley
bolused IVF and her creatinine trended downward thereafter.
5. CAD. On admission the patient had a positive tropnonin with
normal ck, likely demand in setting of renal dysfunction. There
were no acute ekg changes. She was ruled out for an MI and
continued on simvastatin.
6. Thrombocytopenia. Unclear etiology, but the patient has had
a precipitous decline over the last few weeks. This decrease
may be secondary to a medication effect. She does not appear
to have been on heparin at rehab. Her platelets eventually
began trending upward again toward the end of her hospital stay.
7. H/o A. fib. The patient is on coumadin and initially had a
supratherapeutic INR. Her coumadin was initially held, but
restarted when her INR returned to the therapeutic range.
8. HTN. The patient is on lisinopril at home. This medicatin
was held when the patient went into ARF.
9. Breast cancer. The patient was continued on arimidex.
10. Gout. The patient was continued on colchicine.
Medications on Admission:
Calcitriol 0.25 mcg daily
Anastrozole 1 mg daily
Lisinopril 20 mg daily
Simvastatin 10 mg daily
Ferrous Gluconate 325 mg daily
Ranitidine HCl 150 mg daily
Colchicine 0.6 mg [**Hospital1 **]
Docusate Sodium 100 mg [**Hospital1 **]
Senna 8.6 mg PO BID
Coumadin 5-6 mg daily
Duonebs prn
S/p prednisone taper on [**2117-3-6**]
Discharge Medications:
1. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily ().
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed.
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
8. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) inj
Injection TID (3 times a day): D/c if pt is mobile.
11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day.
12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Capsule(s)
13. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day.
14. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
Acute on Chronic diastolic congestive heart failure
Hypernatremia
Supratherpeutic INR
Metabolic alkalosis
Secondary:
Anemia
Hypertension
Gout
Atrial fibrillation
Chronic renal insufficiency
Discharge Condition:
Improved, nonhypoxic on baseline O2 requirement (FiO2 50%),
hemodynamically stable
Discharge Instructions:
We evaluated and treated your shortness of breath in the
hospital by removing some of the excess fluid that built up over
the last few days. After removal of the fluid your breathing
improved as well as the swelling in your legs. We do not think
that your shortness of breath was related to pneumonia as your
breathing improved with removal of the fluid. You also did not
manifest signs of infection during this hospitalization
suggesting that your symptoms were related to fluid overload.
Your CO2 level then became very high and you became more sleep.
This increase is likely related to the removal of fluid and we
treated this with additional medications. You would benefit
from seeing a pulmonologist (lung doctor) on a regular basis.
You may also eventually require assistance from a breathing
machine at night to help support your breathing.
We also noted that your INR was elevated so we held your
coumadin for a few days until your INR was in a range between 2
and 3.
Please call your doctor or return to the ER:
* With worsening of your current symptoms
* Chest pain, shortness of breath, fevers, chills, nausea,
vomiting
* With any new or concerning symptoms
Followup Instructions:
Please follow-up with your scheduled appointments listed below:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5447**], M.D. Date/Time:[**2117-3-19**] 9:10
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4285**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 22**]
Date/Time:[**2117-4-6**] 9:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2117-4-6**]
9:00
Completed by:[**2117-3-18**]
|
[
"428.33",
"585.9",
"V44.0",
"278.00",
"287.5",
"414.01",
"584.9",
"745.5",
"276.0",
"428.0",
"V10.3",
"518.84",
"427.32",
"280.9",
"715.90",
"424.0",
"274.9",
"276.3",
"327.23"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9812, 9878
|
4085, 8342
|
323, 345
|
10122, 10207
|
3132, 4062
|
11429, 11926
|
2546, 2550
|
8715, 9789
|
9899, 10101
|
8368, 8692
|
10231, 11406
|
2565, 3113
|
276, 285
|
373, 1671
|
1715, 2302
|
2318, 2530
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,577
| 154,289
|
30990
|
Discharge summary
|
report
|
Admission Date: [**2124-6-21**] Discharge Date: [**2124-6-27**]
Date of Birth: [**2056-1-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Right lung CA
Major Surgical or Invasive Procedure:
Flexible Bronchoscopy, Esophagoscopy, Right Middle Lobectomy and
Right Lower Lobectomy
History of Present Illness:
Mr. [**Known lastname 634**] is a 68-year-old smoker with a biopsy-proven
endobronchial non-small cell carcinoma in the proximal bronchus
intermedius obstructing the middle and lower lobes. He had an
extensive evaluation which shows limited lung function with an
FEV1 around 50% predicted. He had a cardiopulmonary exercise
test demonstrating a maximum oxygen uptake of almost 18
mL/kg/min. A metastatic survey included a PET scan which showed
hypermetabolism at the primary site in the hilum as well as in
the subcarinal nodes. There was no distant metastatic disease
noted. He has been referred for right middle and lower
lobectomy.
Past Medical History:
Atrial Fibrillation after bronch [**4-1**], rx with meds for 2 weeks
Hypertension
Bronchitis
COPD
GERD
Remote history of non-infectious hepatitis
Social History:
Retired truck driver, widower, lives in Northern [**State 3914**]. Three
children.
Tobacco: 100 pack/year, quit 3 weeks ago
ETOH: [**1-29**] drinks per day
Family History:
Signficant for prostate cancer
Physical Exam:
General: 68 year-old male who appears in no added distress
HEENT: unremarkable
Neck: supple, no lymphadenopathy, JVD flat
Chest: decreased breath sounds on right 1/3 up, left clear to
ausculation
Cardiac: regular, rate & rhythm, normal S1,S2 no murmur/gallop
or rub
Abdomen: bowel sounds positive, abdomen soft
non-tender/non-distended
Extremities; warm, trace edema
Neuro: awake, alert, oriented x 3. Moves all extremities
Pertinent Results:
CXR [**2124-6-26**]: Right-sided chest tube has been removed. Right
apical pneumothorax is without change with apical visceral
pleural line at the fourth posterior rib level, and multiple
loculated hydropneumothoraces also appear unchanged with the
largest located anteriorly in the retrosternal region and in the
mid portion of the chest projecting adjacent to the right heart
border. Moderate-sized right pleural effusion is not
substantially changed, and diffuse pulmonary opacities in the
right mid and lower lungs show slight interval improvement, as
well as subcutaneous emphysema in the right chest wall. Small
left pleural effusion is without change.
[**2124-6-26**]: WBC-9.7, Hgb-10.1, Hct-29.5, Plt Ct-348
[**2124-6-26**]: Glucose-102 UreaN-20 Creat-0.8 Na-140 K-4.7 Cl-105
HCO3-28
Brief Hospital Course:
Mr. [**Known lastname 634**] was admitted on [**2124-6-21**] and taken to the
operation room for successful flexible bronchoscopy,
esophagoscopy, right thorocotomy approach for right middle and
lower lobectomy. He was transferred to the surgical intensive
care unit extubated, with one chest-tube and a pleural [**Doctor Last Name **]. He
was on a neo drip for a brief episode of intraoperative
hypotension. On post-operative day #1 the neo drip was weaned
off and low dose beta blocker was started. On post-operative day
#2 he was transferred to the floor in stable condition. His
hematocrit was 23 and he was transfused 1 unit of packed red
blood cells to a hematocrit of 29. He was slowly diuresed with
intravenous lasix. On post-operative day #3 his epidural was
weaned off and PO pain management was started with good control.
The foley was removed and he voided without difficuly. On
post-operative day #4 the chest tube was removed and on day #5
the [**Doctor Last Name **] drain was removed. He was hemodynamically stable and
remained in sinus rhythm. Physical therapy was consulted and he
continued to make steady progress. He was discharged to home on
post-operative day #6 and will follow up with Dr. [**Last Name (STitle) **] as an
outpatient.
Medications on Admission:
Combivent
Albuterol prn
Nexium 40 mg once daily
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QIDWMHS (4 times a day (with meals and at
bedtime)).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Carcinoma of the right lung s/p Right middle & lower lobectomy
Hypertension
COPD
Atrial Fibrillation
GERD
Discharge Condition:
Good
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if you develop fever,
chills, chest pian, shortness of breath, pain swelling or
redness at your incision site.
- You may shower on Wednesday. After showering, remove your
chest tube site dressings and cover the areas with clean
bandaids daily until healed. The steri-strips on your incision
will fall off in time.
- No swimming or tub bathing for 3-4 weeks.
- Do not drive while you are taking narcotic pain medicine
- Take stool softeners every day you take pain medication:
colace, senna, dulcolax, and mild of magnesia are all good
options
- You should eat a regular diet
- You should continue to do your breathing exercises with the
incentive spirometry, coughing, and deep breathing
- You should remain as active as tolerated and gradually
increase your activity level on a daily basis
- 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. [**Last Name (STitle) **] on [**2124-7-10**] at([**Last Name (NamePattern1) **], [**Location (un) 1385**])12:00 noon.
Please arrive 45 minutes prior to your appointment and report to
the [**Hospital Ward Name 517**] Clinical Center [**Location (un) 470**] radiology dept for a
CXR.
Completed by:[**2124-11-9**]
|
[
"401.9",
"496",
"530.81",
"197.2",
"427.31",
"162.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"40.3",
"32.4",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
4454, 4460
|
2759, 4021
|
335, 424
|
4610, 4617
|
1942, 2736
|
5666, 6000
|
1450, 1482
|
4119, 4431
|
4481, 4589
|
4047, 4096
|
4641, 5643
|
1497, 1923
|
282, 297
|
452, 1091
|
1113, 1261
|
1277, 1434
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,736
| 113,390
|
28964
|
Discharge summary
|
report
|
Admission Date: [**2120-8-1**] Discharge Date: [**2120-8-9**]
Date of Birth: [**2040-6-6**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
Perimesencephalic subarachnoid bleed after falling out of bed
Major Surgical or Invasive Procedure:
None
History of Present Illness:
78M s/p R CVA with trach who presented to outside hospital after
wife heard thump in his room and went in to find him on the
floor. Had left top of head laceration stapled at OSH. CT there
showed ICH. Transferred to [**Hospital1 18**] ED.
Past Medical History:
HTN
stomach CA
CVA 5 yr ago w/ trach
Social History:
no tob, no EtOH, lives with wife
Family History:
Non contributory
Physical Exam:
T: 100.1 BP:98 / 61 HR:103 R18 O2Sats100
Gen: WD/WN, comfortable, NAD, in hard collar, staples in left
top
of head with dried blood
HEENT: Pupils: 3mm ERRLA EOMs appear full but pt not
cooperative
Neck: in hard collar
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake not cooperative with exam
Orientation: nonverbal
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3mm bilaterally.
III, IV, VI: Extraocular movements appear intact bilaterally
without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing difficult to assess
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk bilaterally. Increased tone in [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]
abnormal
movements,
tremors. Strength: no obvious deficits throughout.
Reflexes: Pa Ac
Right 3 0
Left 2 0
Toes downgoing left, upgoing right
Pertinent Results:
[**2120-8-1**] 06:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2120-8-1**] 06:50AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2120-8-1**] 06:50AM FIBRINOGE-165
[**2120-8-1**] 06:50AM PT-12.1 PTT-23.3 INR(PT)-1.0
[**2120-8-1**] 06:50AM PLT COUNT-194
[**2120-8-1**] 06:50AM WBC-15.8* RBC-3.78* HGB-13.3* HCT-36.8*
MCV-97 MCH-35.3* MCHC-36.2* RDW-13.2
[**2120-8-1**] 06:50AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2120-8-5**] 06:15AM BLOOD WBC-8.9 RBC-4.04*# Hgb-13.8* Hct-39.7*#
MCV-98 MCH-34.0* MCHC-34.6 RDW-13.0 Plt Ct-228#
[**2120-8-4**] 03:40AM BLOOD WBC-8.0 RBC-3.16* Hgb-11.1* Hct-30.6*
MCV-97 MCH-35.0* MCHC-36.1* RDW-13.0 Plt Ct-148*
[**2120-8-5**] 06:15AM BLOOD Plt Ct-228#
[**2120-8-5**] 06:15AM BLOOD Glucose-119* UreaN-7 Creat-0.8 Na-139
K-3.9 Cl-99 HCO3-30 AnGap-14
Brief Hospital Course:
Mr [**Known lastname 12330**] was admitted to the ICU for close neurological and
hemodyamic monitoring given his obtunded exam initially on
arrival. He underwent a CTA of his brain to rule out source of
perimesencephalic bleed which was negative for any aneurysm or
AVM. He was seen by cardiology to rule out whether his fall was
related to a syncopal episode. They felt it may be related to
his afib/aflutter and his rate should be better controlled he
was placed on metropolol 25mg [**Hospital1 **].
Neurologically he became more arrousable on a daily basis. By
hospital day three he was following commands and moving all
extremities with full strenght. On hospital day number 4 he was
transferred to the surgical floor. On the evening of his
transfer he began to have episodes of agitation/sundowning. He
was started on a regiman of various atypical antipsychotics
finally finding Seroquel at 12.5mg HS worked well and had no
further episodes of agitation. Geriatrics consult service
helped us manage his behavioral issues.
Speech therapy saw the patient he was cleared to eat a regular
diet and recommended the following with regards to his speech:
. Speak VERY LOUD while looking directly at the patient
2. Help him depress the voicing button on the [**Doctor Last Name **]-[**Doctor Last Name **]
artificial larynx
3. Help him to place the intra-oral tube [**12-4**] way into his mouth
so that the sound can be shaped into audible/intelligible
speech and he can be understood
4. It is impossible to understand all the words produced with an
artificial larynx because it voices all sounds. (Many
sounds such as P, T, K, f, S, etc. are produced without
voice) So, it is easier to understand someone if:
A. You know the subject of conversation
B. He speaks in short phrases
(it can be harder to understand single words)
5. Watch his lips when he speaks, and if you don't understand,
A. Ask him to say it again more slowly
B. Put the tube further in his mouth
c. Clarify the topic
On discharge he was alert, orientated following commands with no
neurological deficits. His last CT was on [**8-2**] and it showed no
new blood.
Medications on Admission:
simvastatin, folic acid, plavix,
prozac, neurontin
Discharge Medications:
1. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
9. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for scalp lac.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QHS (once a day
(at bedtime)).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 245**] [**Hospital6 **], Satellite as [**Hospital1 **] Hospitals,
Hunt Center
Discharge Diagnosis:
Perimesencephalic SAH after fall
Discharge Condition:
Neurologically stable
Discharge Instructions:
Return to ER or call Dr[**Name (NI) 2845**] office if you develop any
neurologic changes such as headache, weakness or mental status
changes.
Followup Instructions:
Follow up in 6 weeks with Head CT in 6 weeks with Dr [**Last Name (STitle) 548**], call
for an appointment [**Telephone/Fax (1) 2992**]
Completed by:[**2120-8-9**]
|
[
"784.3",
"V12.59",
"V10.21",
"780.09",
"852.01",
"401.9",
"873.0",
"E884.4",
"427.31",
"427.32",
"294.8",
"V10.04",
"V44.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6276, 6393
|
2819, 4964
|
378, 385
|
6470, 6494
|
1866, 2796
|
6684, 6850
|
780, 798
|
5066, 6253
|
6414, 6449
|
4990, 5043
|
6518, 6661
|
814, 1083
|
277, 340
|
413, 654
|
1169, 1847
|
1098, 1153
|
676, 714
|
730, 764
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,263
| 159,556
|
18782
|
Discharge summary
|
report
|
Admission Date: [**2128-7-16**] Discharge Date: [**2128-7-20**]
Date of Birth: [**2050-4-1**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Fosamax / Naprosyn
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back and leg pain
Major Surgical or Invasive Procedure:
Posterior lumbar fusion L3-4
History of Present Illness:
Ms. [**Known lastname 51439**] has herniated the disc above her previous L4-5
fusion. She has failed conservative therapy and now presents
for surgical intervention.
Past Medical History:
HTN, Lumbar spondylosis, stenosis, L4/L5 herniation s/p L4-S1
fusion
Social History:
Denies
Family History:
N/C
Physical Exam:
NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at biceps, triceps, wrist extension and
flexion, finger extension and flexion and intrinsics; sensation
intact in all dermatomes; reflexes intact at biceps, triceps and
brachioradialis
BLE- good strength at hip flexion and
extension/abduction/adduction, knee flexion and extension, ankle
dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL; sensation diminished
at L4 dermatome; reflexes intact at quads and Achilles
Pertinent Results:
[**2128-7-17**] 07:10PM BLOOD WBC-14.1* RBC-3.37* Hgb-10.2* Hct-29.7*
MCV-88 MCH-30.4 MCHC-34.5 RDW-13.2 Plt Ct-262
[**2128-7-17**] 01:49AM BLOOD WBC-10.2 RBC-3.40* Hgb-10.4* Hct-29.8*
MCV-88 MCH-30.7 MCHC-35.1* RDW-13.6 Plt Ct-258
[**2128-7-16**] 03:13PM BLOOD WBC-17.0*# RBC-4.17* Hgb-12.7 Hct-36.0
MCV-86 MCH-30.5 MCHC-35.4* RDW-13.5 Plt Ct-270
[**2128-7-17**] 01:49AM BLOOD Glucose-161* UreaN-13 Creat-0.7 Na-136
K-4.3 Cl-103 HCO3-22 AnGap-15
[**2128-7-16**] 03:13PM BLOOD Glucose-140* UreaN-11 Creat-0.7 Na-137
K-3.6 Cl-105 HCO3-25 AnGap-11
Brief Hospital Course:
Ms. [**Known lastname 51439**] was admitted to the service of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] for a
lumbar fusion L3-4. She was informed and consented for the
procedure and elected to proceed. Please see Operative Note for
procedure in detail.
Post-operatively she was administered antibiotics and pain
medication. Her catheter and drain were removed POD 2 and she
was able to advance her diet. Her pain was well controlled and
she remained afebrile throughout her hosptial course. She will
return to clinic in ten days. She was discharged in good
condition.
Medications on Admission:
Atenolol, Traimetene/HCTZ
Ezetimibe
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Multi-Vitamins W/Iron Oral
6. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: Two
(2) Cap PO DAILY (Daily).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of [**Hospital1 1559**]
Discharge Diagnosis:
Lumbar disc herniation L3-4
Post-op hypotnesiton
Discharge Condition:
Good
Discharge Instructions:
Please continue to take your pain medication with an over the
counter laxative. Call the clinic if you notice any redness or
discharge from the incision site. Call the clinic for any
additional concerns.
Physical Therapy:
Activity: Out of bed w/ assist [**Hospital1 **]
when ambulating lumbar corset
Treatments Frequency:
Please continue to change the dressing daily with dry, sterile
guaze.
Followup Instructions:
Please follow up in the Spine Clinic during your previously
scheduled appointments.
Completed by:[**2128-7-20**]
|
[
"401.9",
"722.10",
"726.5",
"996.49",
"721.3",
"458.29",
"E878.1",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.62",
"80.51",
"99.04",
"81.08",
"78.69"
] |
icd9pcs
|
[
[
[]
]
] |
3284, 3400
|
1746, 2354
|
300, 331
|
3493, 3500
|
1176, 1723
|
3947, 4062
|
659, 664
|
2440, 3261
|
3421, 3472
|
2380, 2417
|
3524, 3731
|
679, 1157
|
3749, 3831
|
3853, 3924
|
243, 262
|
359, 527
|
549, 619
|
635, 643
|
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