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25,217
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5726
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Discharge summary
|
report
|
Admission Date: [**2169-5-25**] Discharge Date: [**2169-6-23**]
Date of Birth: [**2117-3-1**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Increasing confusion and difficulty with ADLs. Nausea,
Major Surgical or Invasive Procedure:
OLT [**2169-5-28**]
Roux-en-Y hepaticojejunostomy [**2169-6-9**]
T-Tube Cholangiogram [**2169-6-14**]
Biopsy [**2169-6-19**]
History of Present Illness:
Pt. is a 52 y/o with Hep C and EtOH related cirrhosis, s/p OLT
[**2169-2-25**], with failed transplant who p/w confusion. Pt. reports
that he has been noticing that he's felt confused for about 1
week, has trouble interacting with people, feels he needs help
with ADLs. Reports a feeling of "dysequilibrium," which he
describes as dizziness and unsteadiness on his feet. Reports he
started Interferon one week ago and has felt diffusely weak, and
like he has the flu since it started. + Nausea, 2 episodes of
emesis this week, non-bloody.
Denies fevers at home, reports chills since starting ribavirin.
Reports chronic RUQ pain which is unchanged recently and well
controlled with Methadone. Denies BRBPR or melena. No changes
in BM, [**12-26**] daily, no diarrhea or constipation.
Past Medical History:
OLT [**2169-2-25**]
Hepatitis C
Alcoholic Cirrhosis
history of varices in [**2162**]
history of ascites and encephalopathy
Status post interferon, ribavirin and amantadine for 9 months
chronic renal insufficiency
depression
diabetes
Social History:
Patient is separated, lives with his sister. [**Name (NI) **] has 3 grown
children. Smoked until 1 year ago about 20-pack year history.
Patient has a history of alcohol abuse, drank heavily until 9
years ago when he quit. Reports one slip ~1.5 years ago, no
EtOH since then, goes to AA. There is a history of IV drug in
his 20s. +Tattoos.
Family History:
Notable for the fact that his father died of liver cancer in the
background of alcoholic cirrhosis
Physical Exam:
VS: T 99.1 BP 112/68 P 87 R 20 97% on RA FS 154 weight 75.8 kg
Gen: awake and alert, NAD
HEENT: + scleral icterus, PERRL, EOMI
Neck: supple
CV: RRR, no MRG
Lungs: CTAB, no WRR
Abd: distended but not tense, mildly TTP RUQ with no rebound or
guarding, +BS throughout
Ext: 3+ pitting edema to above knees bilat
Skin: + jaundice
Neuro: + bilat tremor with posture but no asterixis, oriented x
3 and appropriate in conversation, can say days of week
backwards and spell world backwards, recall [**2-24**], strength 5/5
throughout, CN 2-12 intact
Pertinent Results:
Labs on Admission:
[**2169-5-25**] 08:40PM GLUCOSE-165* UREA N-15 CREAT-1.2 SODIUM-136
POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-25 ANION GAP-15
[**2169-5-25**] 08:40PM ALT(SGPT)-82* AST(SGOT)-159* ALK PHOS-139*
TOT BILI-23.9*
[**2169-5-25**] 08:40PM ALBUMIN-2.7* CALCIUM-8.0* PHOSPHATE-3.9#
MAGNESIUM-1.6
[**2169-5-25**] 08:40PM WBC-2.0* RBC-3.56* HGB-12.0* HCT-35.7*
MCV-100* MCH-33.7* MCHC-33.6 RDW-17.2*
[**2169-5-25**] 08:40PM PLT COUNT-64*
[**2169-5-25**] 08:40PM PT-18.4* PTT-37.6* INR(PT)-1.7*
Brief Hospital Course:
52 y/o with HCV and EtOH cirrhosis s/p OLT in [**2-27**] with failed
transplant and hepatic encephalopathy
.
Encephalopathy: Etiology of decompensation unclear, pt. has
evidence of old EBV and CMV infection on recent testing. DDx
includes portal v thrombosis, SBP, infection with
toxic-metabolic encephalopathy on top of baseline liver
dysfunction, recurrence of Hep C in transplanted liver.
OLT performed on [**2169-5-28**] when a liver became available. Extubated
on POD 1. Initially liver enzymes trended down. However, at one
week post op, pt developed fever to 101.6 and alk phos and bili
started trending upwards. Abd CT showed patent portal and
hepatic veins and hepatic arteries. 1.4-cm round dense lesion
adjacent to the left hepatic artery and portal vein is
nonspecific, but hepatic artery pseudoaneurysm is in the
differential. Transjugular bx done on [**6-6**] showed
1. mild acute cellular rejection with central and portal
venulitis.
2. Bile duct proliferation with associated neutrophils,
recommend evaluation to rule out biliary obstruction or
ischemia.
3. History of hepatitis C in the donor liver is noted, and some
of the inflammation seen in the portal areas can be attributed
to chronic hepatitis C.
ERCP done on [**6-7**] demonstrated a bile leak and he was taken back
to the operating room on [**6-9**] for a Roux en Y and feeding
jejunostomy placement.
AST/ALT have remained normal, bilirubin has remained around 1.4,
however Alk Phos never normalized and has continued to climb
into the 700's, so bedside liver Bx performed on [**2169-6-19**] showing
same amount of inflammation in the biopsy as in the donor
biopsy. No rejection and no apoptosis to suggest HCV. There is
focal bile duct proliferation and some neutrophils but less than
on the operative biopsy.
Tube feedings were increased to 115 cc/hr and then changed to
cycled feeds. Pt to continue on this at home. Rec'd a short
course of Vanco IV for a suspected cellulitis on the RLQ
abdomen. Changed to Linezolid 600 mg PO BID. Labs will be
checked on outpt basis for WBC and Plt cts.
Hep C therapy was reinitiated using PEG Interferon and
Ribivarin. These medications will be continued on an outpt basis
and followed by Dr [**Last Name (STitle) 497**].
Medications on Admission:
Methadone 10 mg PO BID
Trimethoprim-Sulfamethoxazole SS tab PO DAILY
Pantoprazole 40 mg PO Q24H
Ursodiol 300 mg PO TID
Docusate Sodium 100 mg PO BID
Senna 8.6 mg Tablet PO BID
Escitalopram 10 mg PO DAILY
Prednisone 2.5 mg PO DAILY
Peginterferon Alfa-2a 180 mcg/mL Solution Sig: 0.5
Subcutaneous 1X/WEEK (TU).
Tacrolimus 1 mg PO BID
Buproprion 75 mg PO daily
Humalog Insulin Sliding Scale
Lasix 40 mg PO BID
NPH 12 U QAM
Discharge Medications:
1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
2. CellCept [**Pager number **] mg Tablet Sig: Two (2) Tablet PO twice a day.
3. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Methadone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO once a day:
Until [**6-25**], call for dose on Monday.
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
9. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) 4000
Injection QMOWEFR (Monday -Wednesday-Friday).
10. Insulin Glargine 100 unit/mL Solution Sig: One (1) 8
Subcutaneous at bedtime.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day).
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
14. Ribavirin 200 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary: Hepatic Encephalopathy
Secondary:
Orthotopic Liver Transplant # 1 [**2169-2-25**]
OLT # 2 [**2169-5-28**]
Recurrent Hepatitis C
Alcoholic Cirrhosis
chronic renal insufficiency
depression
diabetes
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor at [**Telephone/Fax (1) 673**] or go to the ER if you
have any worsening confusion, nausea, vomiting, fevers, chills,
abdominal pain, increasing or bloody drainage from incision
site, blood in your stool or dark black stool, or any other
symptoms that concern you.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2169-6-26**]
8:00
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2169-7-3**]
8:40
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2169-7-13**]
8:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] (LIVER CENTER) [**Telephone/Fax (1) 673**] Follow-up
appointment should be in 1 week
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3314**] [**Telephone/Fax (1) 3183**] Follow-up appointment
should be in 3 weeks
Completed by:[**2169-6-23**]
|
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60,050
| 152,893
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47244
|
Discharge summary
|
report
|
Admission Date: [**2132-11-22**] Discharge Date: [**2132-11-27**]
Date of Birth: [**2071-4-14**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Percodan
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
endotracheal intubation, bronchoscopy
History of Present Illness:
This is a 61 yo female with HIV on HAART (last CD4 1359 on
[**9-25**]) and asthma p/w 1 day of dyspnea and non-productive cough
with rhinorrhea. Denied fevers at home, did have sick contact
yesterday. [**Name2 (NI) **] po intake today [**1-8**] feeling unwell and cough.
Tried home flovent and albuterol without benefit.
.
Of note, pt was seen by PCP [**Last Name (NamePattern4) **] [**2132-11-20**] with increased blood
sugars due to changes in her med regimen, muscle aches, and
increase in her asthma sxs and increased use of inhalers. Before
that, she was seen in the ED on [**2132-9-20**] for a flu-like illness,
treated with oseltamivir, although flu swab came back negative.
.
En route to the ED, EMS gave 2 combivent nebs. In the ED,
initial VS were: 99.8 130 158/100 22 100%. Exam with wheezes and
rhonchi, 3rd combivent neb given, also 125mg IV
methylprednisolone and magnesium. Decompensated with hypoxia
requiring NRB, agitation and altered mental status. Given
midazolam, etomidate, succinylcholine and was intubated but
remained with sats in high 80s to low 90s on FiO2 1.0, so
increased PEEP to 12. CXR initially with diffuse opacity,
possible multifocal PNA. Given TMP-SMX and levofloxacin. Second
CXR with ?florid heart failure. Started on NTG drip. CTA chest
being done. Bedside U/S with hypodynamic LV. Access is 3 18g
PIVs. On propofol. Current VS: 130s 170s/90s 94-95% on 430x16,
12, 100%.
.
On the floor, patient is intubated and sedated, so further
history is not possible.
.
Past Medical History:
DMII
HCV
HIV (CD4 1359 [**9-14**], VL undetectable)
SUBARACHNOID HEMORRHAGE (L MCA aneurysm Left middle cerebral
aneursym ==> SAH s/p left pterional craniotomy and microsurgical
clipping of aneurysm and resection of incidental meningioma.
Current deficits: anosmia, agusia, dysarthria, dyscalcula,
dyslexia. CANT HAVE MRI D/T CLIPS)
HEADACHES
HYPERTENSION
PAROTID ENLARGEMENT
ASTHMA
GOITER [**2118**]
ELBOW FRACTURE [**2123-5-7**]
LLE SOFT TISSUE MASS
COLONIC POLYPS [**2128-9-2**]
Depression/anxiety
Social History:
Born [**Location (un) 86**], completed 2 years of college ==> 2 sons ([**2119**]: ages
27, 30) with 2 different fathers. H/o 30 pack-years tobacco;
quit [**2109**]. No ETOH or drugs per OMR. Lives at home per her son.
[**Name (NI) **] hospitalizations, [**Hospital1 1501**] admissions, or known recent abx per
son.
Family History:
Noncontributory
Physical Exam:
Physical exam on discharge:
VS: T:97.9, HR:87, BP:118/83, RR:18, O2sat:100%RA
Gen: alert, breathing normally, in NAD
Neck: JVP 10 cm at 30 degrees
CV: Regular rate and rhythm. No m/r/g.
Pulm: Dependent crackles on right with patient in R lateral
decubitus position.
Abd: +BS. S/NT/ND.
Ext: WWP, no edema.
Pertinent Results:
I. Labs
A. Admission
[**2132-11-22**] 09:15PM BLOOD WBC-8.1 RBC-3.14* Hgb-12.7 Hct-37.0
MCV-118* MCH-40.3* MCHC-34.2 RDW-14.9 Plt Ct-323
[**2132-11-22**] 09:15PM BLOOD Neuts-67.2 Lymphs-26.8 Monos-4.2 Eos-0.7
Baso-1.1
[**2132-11-22**] 09:15PM BLOOD Plt Ct-323
[**2132-11-22**] 09:15PM BLOOD Glucose-167* UreaN-22* Creat-1.0 Na-138
K-3.8 Cl-104 HCO3-22 AnGap-16
[**2132-11-22**] 09:15PM BLOOD ALT-68* AST-56* CK(CPK)-795* AlkPhos-61
TotBili-0.5
[**2132-11-23**] 11:03AM BLOOD Albumin-3.7 Calcium-9.5 Phos-5.4* Mg-1.6
[**2132-11-22**] 09:15PM BLOOD TSH-0.78
[**2132-11-22**] 09:15PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2132-11-23**] 01:20AM BLOOD Type-ART Temp-37.1 pO2-327* pCO2-55*
pH-7.16* calTCO2-21 Base XS--9
[**2132-11-22**] 10:09PM BLOOD Lactate-3.0*
[**2132-11-23**] 01:20AM BLOOD freeCa-1.31
B. Cardiac
[**2132-11-23**] 11:03AM BLOOD CK-MB-4 cTropnT-<0.01
[**2132-11-22**] 09:15PM BLOOD CK-MB-5 cTropnT-<0.01 proBNP-3382*
C. Urine
[**2132-11-22**] 10:25PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.013
[**2132-11-22**] 10:25PM URINE Blood-SM Nitrite-NEG Protein-75
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2132-11-22**] 10:25PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-1
[**2132-11-23**] 02:17PM URINE Hours-RANDOM UreaN-800 Creat-155 Na-22
K-84 Cl-13
[**2132-11-23**] 02:17PM URINE Osmolal-612
D. Discharge
CBC: wbc 6.7, hct 33.3, plt 281
Chem 7: Na 138, L 4.5, Cl 105, HCO3 25, BUN 31, Cr 0.9, Glu 177
Ca 8.7, Mg 1.9, Phos 3.2
.
II. Microbiology
[**2132-11-24**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2132-11-23**] Rapid Respiratory Viral Screen & Culture
Respiratory Viral Culture-PRELIMINARY; Respiratory Viral Antigen
Screen-FINAL INPATIENT
[**2132-11-23**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL;
RESPIRATORY CULTURE-FINAL; FUNGAL CULTURE-PRELIMINARY;
Immunoflourescent test for Pneumocystis jirovecii
(carinii)-FINAL INPATIENT
[**2132-11-23**] URINE URINE CULTURE-FINAL INPATIENT
[**2132-11-23**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2132-11-23**] Influenza A/B by DFA DIRECT INFLUENZA A
ANTIGEN TEST-FINAL; DIRECT INFLUENZA B ANTIGEN TEST-FINAL
INPATIENT
[**2132-11-23**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
.
III. Imaging
.
A. CXR ([**2132-11-22**])
IMPRESSION:ETT and NGT positioned appropriately. Diffuse
pulmonary ground
glass opacities, more confluent at the bases, may represent
atypical infection
such as PCP versus pulmonary edema. Please refer to subsequent
CTA chest for
further details.
.
B. CTA Chest ([**2132-11-22**])
IMPRESSION:
1. Patchy ground-glass opacities distributed across the lung
parenchyma, with associated septal thickening, most compatible
with moderate-to-severe pulmonary edema.
2. Moderate-sized bilateral pleural effusions.
3. Bibasilar consolidations, concerning for pneumonia.
Aspiration is also on the differential given the rapid onset of
symptoms.
4. No pulmonary embolism detected to the subsegmental levels.
5. No dissection.
.
IV. Cardiology
A. EKG
Probable sinus tachycardia. Non-specific ST-T wave changes.
Compared to the previous tracing of [**2132-4-14**] the ventricular rate
is faster. ST-T wave changes are new.
.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
141 0 78 [**Telephone/Fax (2) 100033**]8
.
B. ECHO
The left atrium is mildly dilated. The right atrial pressure is
indeterminate. Left ventricular wall thicknesses and cavity size
are normal. There is severe global left ventricular hypokinesis
(LVEF = 25%). Systolic function of apical segments is relatively
preserved. No masses or thrombi are seen in the left ventricle.
Right ventricular chamber size is normal with mild global free
wall hypokinesis. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is a very small pericardial
effusion primarily around the right atrium.
.
IMPRESSION: Normal left ventricular cavity size with severe
global hypokinesis c/w diffuse process (toxin, metabolic, etc. -
cannot fully exclude multivessel CAD). Pulmonary artery systolic
hypertension. Mild-moderate mitral regurgitation.
Compared with the report of the prior study (images unavailable
for review) of [**2126-6-28**], the findings are new.
.
CLINICAL IMPLICATIONS:
The left ventricular ejection fraction is <40%, a threshold for
which the patient may benefit from a beta blocker and an ACE
inhibitor or [**Last Name (un) **].
Based on [**2128**] 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.
.
Pending cultures (to be followed by PCP):
- blood culture [**2132-11-23**], [**2132-11-24**]: pending
Brief Hospital Course:
61-year-old female with HIV on HAART (last CD4 1359 on [**9-25**])
and asthma presented with one day of dyspnea and non-productive
cough, intubated for hypoxic respiratory failure likely
secondary to pulmonary edema in setting of new cardiomyopathy.
# Hypoxic respiratory failure:
Patient had large component of pulmonary edema on CXR.
Precipitant unclear as cardiac biomarkers negative not
suggestive of ischemia but ECHO showing severe global
hypokinesis consistent with diffuse process with pulmonary
artery systolic hypertension, and mild-moderate regurgitation.
Co-existing infection thought to be less likely with pneumonia
not favored given no fever, leukocytosis; however, a
retrocardiac opacity was noted on CXR. Influenza testing
negative in setting of myalgias, malaise, upper respiratory
systems. Patient was empirically covered for CAP with
ceftriaxone and levofloxacin for empiric infection, which was
subsequently discontinued. She underwent bronchoscopy, which was
grossly unremarkable with bronchial culture and rapid
respiratory viral screen/culture, fungal culture, and PCP were
all negative.
.
She also underwent diuresis with a nitro gtt in the initial
stages. Asthma exacerbation not suggested. Patient underwent
endotracheal intubation with approximately 1-day of respiratory
support and subsequently extubated without issue.
At the time of discharge, patient was on room air with 100%
oxygen saturation
.
# Dilated cardiomyopathy with systolic heart failure: Etiology
of cardiomyopathy considered included toxic metabolic, viral,
and ischemic. Based on EKG, patient does not have overt signs of
ischemic disease. Patient had stress testing in [**2127**] and last
ECHO in [**2125**] not suggestive of above abnormalities.
Echocardiogram demonstrated dilated cariomyopathy with LVEF of
25%. Patient was started on aspirin, carvedilol, and lasix.
Follow-up with heart failure clinic/cardiomyopathy clinic was
made prior to discharge.
.
# HIV: Patient has well-controlled HIV with persistent CD4 > 500
and undetectable VL. She was continued on HAART.
.
# DM: She was continued on SSI in house.
.
# Asthma: She was continued on fluticasone with prn nebs.
.
# Depression/anxiety: She was continued on citalopram.
Medications on Admission:
ALBUTEROL - 90 mcg Aerosol - 2 puffs inhaler q4-6 hours
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs inhaled
q 6h as needed for shortness of breath
CITALOPRAM - 40 mg Tablet - 1 Tablet(s) by mouth once a day
DILTIAZEM HCL [DILT-XR] - 180 mg Capsule,Degradable Cnt Release
-
1 Capsule(s) by mouth once a day
FLUTICASONE - 50 mcg Spray, Suspension - 1 spray intranasal once
a day
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 1
inhalation(s) by mouth twice a day Rinse mouth after use
GLYBURIDE-METFORMIN [GLUCOVANCE] - 2.5 mg-500 mg Tablet - 1
Tablet(s) by mouth twice a day
HYDROCHLOROTHIAZIDE - 25 mg Tablet - [**12-8**] Tablet(s) by mouth once
a day
IBUPROFEN - 800 mg Tablet - 1 Tablet(s) by mouth every eight (8)
hours as needed for pain
LAMIVUDINE-ZIDOVUDINE [COMBIVIR] - 150 mg-300 mg Tablet - one
Tablet(s) by mouth twice a day
LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth once a day
NEVIRAPINE - 200 mg Tablet - 1 Tablet(s) by mouth twice a day
OXYCODONE - 5 mg Tablet - [**12-8**] Tablet(s) by mouth twice a day as
needed for pain
ASCORBIC ACID - 1,000 mg Tablet - 1 Tablet(s) by mouth once a
day
ASPIRIN - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth once a
day
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM WITH VITAMIN D] - 600
mg-400 unit Tablet - 1 Tablet(s) by mouth three times a day
CETIRIZINE-PSEUDOEPHEDRINE - 5 mg-120 mg Tablet Sustained
Release
12 hr - 1 Tablet(s) by mouth twice a day as needed for sinus
symptoms
MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - Tablet - ONE
Tablet(s) by mouth once a day
TERBINAFINE - 1 % Cream - apply to afected area twice a day
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
Disp:*3 inhalers* Refills:*2*
2. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO once a day.
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
4. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*2 inhalers* Refills:*2*
5. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
spray Nasal once a day.
Disp:*2 bottle* Refills:*2*
6. glyburide-metformin 2.5-500 mg Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*2*
7. hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO
once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Combivir 150-300 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
9. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. nevirapine 200 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
12. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
14. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. ascorbic acid 500 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
16. Calcium 600 with Vitamin D3 600 mg(1,500mg) -400 unit
Capsule Sig: One (1) Capsule PO three times a day.
Disp:*90 Capsule(s)* Refills:*2*
17. Lancets,Thin Misc Sig: One (1) Miscellaneous four times
a day.
Disp:*1 pack* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Dilated cardiomyapathy
Congestive heart failure
HIV
Hepatitis C
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 24642**], you were admitted to the [**Hospital1 827**] because you were having difficulty breathing. We
had had to briefly put a breathing tube in you but you got
better and we removed it. You were found to have severe dilated
cardiomyopathy, which means your heart is large and does not
pump well. We gave you medication to get rid of extra fluids in
your body. At the time of discharge, you are able to walk around
and had no trouble breathing.
.
We made the following changes to your medications:
ADDED-
1. Furosemide 20 mg by mouth per day
2. Aspirin 81 mg by mouth per day
3. Carvedilol 12.5 mg by mouth twice a day
Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2132-12-3**] at 9:00 AM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INFECTIOUS DISEASE
When: THURSDAY [**2132-12-18**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 568**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital3 249**]
When: THURSDAY [**2133-1-1**] at 9:20 AM
With: [**Name6 (MD) **] [**Name8 (MD) 13532**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2132-11-27**]
|
[
"425.4",
"518.81",
"799.02",
"416.8",
"070.70",
"401.9",
"428.0",
"424.0",
"V08",
"584.9",
"493.90",
"428.23",
"300.4",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
13956, 14013
|
8080, 10315
|
288, 328
|
14128, 14128
|
3086, 7532
|
14946, 15893
|
2729, 2746
|
11974, 13933
|
14034, 14107
|
10341, 11951
|
14279, 14772
|
2761, 2761
|
7555, 8057
|
2789, 3067
|
14801, 14923
|
241, 250
|
356, 1857
|
14143, 14255
|
1879, 2381
|
2397, 2713
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,881
| 129,474
|
53918
|
Discharge summary
|
report
|
Admission Date: [**2181-11-14**] Discharge Date: [**2181-11-18**]
Date of Birth: [**2143-11-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
Nausea/vomiting/flank pain
Major Surgical or Invasive Procedure:
Femoral Line Placement
History of Present Illness:
The patient is a 37 yo F with no significant PMH p/w nausea,
vomiting, and back pain x 2-3 days. The patient reports that [**3-17**]
days ago, she started having back pain and some nausea.
Yesterdady started feeling febrile. Per report from the
daugther, the patient was shivering and cold this morning and
complained that her "whole body ached". She went to her PCP's
office and "fainted" and was sent to the ER.
.
ROS: Denies chest pain, shortness of breath, abdominal pain. +
dysuria. Per patients cousin, the patient has been complaining
of dizziness and "low blood pressure" over the past 1-2 months.
.
In the ED, initial vital signs were T 101, HR 104, BP 100/66,
RR18, 100%RA. She was found to have an elevated WBC, a lactate
of 3.2, and a positive UA (UCG negative). She received a dose of
cipro 40mmg IV x 1 and 1 L NS. She was monitored in obs and the
plan was to d/c after observation. During the afternoon she
developed chills and received toradol 30mg x 1 and morphine, but
vital signs remained stable. 6 hrs after presentation the
patient was again febrile to 101.5 (BP SBP 140's, normal resp
rate). 2 hours later, the patient was found to have a BP 75/45,
T100.8, HR 111, and a repeat lactate of 0.6. She received 2L NS
and was moved back into the core of the ED. She was subsequently
found to have an SBP in the 50's and was increasingly somnolent
with HR 80's. A urgent right groin line was placed and the
patient was put on levophed 0.3. SBP's were then in the 120's.
Her levophed was decreased to 0.15 and she had received 6L at
the time of transfer to the ICU. She received ceftriaxone 2g x 1
in addition to the cipro for broader coverage.
Past Medical History:
None; s/p 2 uncomplicated vaginal deliveries
Social History:
The patient is divorced. She works as a housekeeper and lives
with her 2 children (ages 16 and 7). She does not smoke or do
illgeal drugs. Occasional ETOH. Excercises vigorously daily.
Family History:
Non-contributory
Physical Exam:
Vitals - 98.6, 88, 113/82, 19, 96%RA
General - patient very sleepy, arousable, but quickly falls back
to sleep
HEENT - PERRL, EOMI
CV - tacycardic, no murmur appreciated
Lungs - CTA B/L
Abdomen - mild lower abdominal tenderness, non-distended, well
healed lower abdominal scar
Ext - no edema, 2+DP/PT pulses bilaterally
Pertinent Results:
[**2181-11-14**] 10:35AM PLT SMR-NORMAL PLT COUNT-237
[**2181-11-14**] 10:35AM NEUTS-91.1* BANDS-0 LYMPHS-5.1* MONOS-3.3
EOS-0.4 BASOS-0.2
[**2181-11-14**] 10:35AM WBC-13.6*# RBC-4.03* HGB-12.8 HCT-36.8 MCV-91
MCH-31.8 MCHC-34.8 RDW-12.8
[**2181-11-14**] 10:35AM GLUCOSE-112* UREA N-8 CREAT-1.0 SODIUM-139
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-24 ANION GAP-17
[**2181-11-14**] 10:45AM LACTATE-3.2*
[**2181-11-14**] 01:36PM URINE RBC-3* WBC->50 BACTERIA-MOD YEAST-NONE
EPI-[**7-22**]
[**2181-11-14**] 01:36PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-MOD
[**2181-11-18**] 07:00AM BLOOD WBC-8.1 RBC-2.95* Hgb-9.2* Hct-26.3*
MCV-89 MCH-31.4 MCHC-35.1* RDW-13.2 Plt Ct-202
[**2181-11-15**] 02:50AM BLOOD Neuts-82* Bands-12* Lymphs-6* Monos-0
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2181-11-18**] 07:00AM BLOOD Glucose-88 UreaN-5* Creat-0.6 Na-140
K-3.9 Cl-106 HCO3-27 AnGap-11
[**2181-11-15**] 08:11PM BLOOD ALT-45* AST-42* LD(LDH)-173 AlkPhos-56
Amylase-23 TotBili-0.3
[**2181-11-16**] 06:01AM BLOOD Albumin-2.7* Calcium-7.9* Phos-1.8*
Mg-2.2
.
CT ABD W&W/O C [**2181-11-15**] 5:12 PM
CT ABD W&W/O C; CT PELVIS W&W/O C
Reason: Please evaluate for obstruction or stone
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
37 year old woman with pyelonephritis and hypotension.
Hypotension now improved but with persistent back pain.
REASON FOR THIS EXAMINATION:
Please evaluate for obstruction or stone
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Pyelonephritis and hypotension. Hypotension,
persistent back pain. Evaluate for stones or obstruction.
COMPARISON: None.
TECHNIQUE: MDCT-acquired axial images of the abdomen and pelvis
were obtained with and without IV contrast. Multiplanar
reformatted images were also displayed.
CT OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST: Large bilateral
pleural effusions, right greater than left, with associated
atelectasis are seen at the visualized lung bases. The liver is
grossly unremarkable. Perihepatic ascites and small amount of
free fluid within the abdomen are noted. Gallbladder wall
thickening noted without evidence of gallbladder distention. The
pancreas appears to enhance homogeneously. The spleen and
adrenal glands appear grossly unremarkable. No renal stones
identified. Multiple foci of hypoenhancement are seen within the
left kidney, consistent with known history of pyelonephritis.
Larger, more rounded lower attenuation lesion measuring upwards
of 2.5 cm seen in left kidney, possibly representing hemorrhagic
cyst, underlying cystic lesion, or more focal area of infection.
No drainable collection seen. Smaller low- attenuation lesions
seen within the kidneys bilaterally possibly represent cysts,
although too small to characterize by CT. There is no evidence
of hydronephrosis.
No abnormally dilated loops of bowel are seen. Small-to-moderate
amount of free fluid is seen throughout the abdomen, with
mesenteric stranding. Scattered retroperitoneal lymph nodes are
seen; however, none appear to meet CT criteria for pathologic
enlargement.
Soft tissue edema is seen consistent with mild anasarca.
CT OF THE PELVIS WITH IV CONTRAST: The rectum and sigmoid appear
unremarkable. Small-to-moderate amount of free fluid is seen
within the pelvis. Foley catheter is seen within the bladder.
BONE WINDOWS: No suspicious lytic or blastic lesions are
identified.
IMPRESSION:
1. Foci of hypoattenuation seen within the left kidney,
consistent with known history of pyelonephritis. More cystic
appearing lesion warrants followup MRI after treatment, or
sooner if patient continues to appear infected. Discussed with
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11679**] on [**2181-11-16**].
2. No evidence of renal stones or hydronephrosis.
3. Moderate ascites, large bilateral pleural effusions, and soft
tissue edema suggesting mild anasarca.
4. Gallbladder wall thickening likely from third-spacing of
fluid; clinical correlation is recommended.
.
CHEST (PORTABLE AP) [**2181-11-16**] 4:12 AM
CHEST (PORTABLE AP)
Reason: please evaluate for interval change
[**Hospital 93**] MEDICAL CONDITION:
37 year old woman with no significant past medical history was
admitted with pyelonephritis and hypotension and now with mild
hypoxia in the setting of aggressive fluid resuscitation.
REASON FOR THIS EXAMINATION:
please evaluate for interval change
INDICATION: 37-year-old woman with hypoxia status post
aggressive fluid resuscitation.
COMPARISONS: Chest radiograph dated [**2181-11-14**].
FINDINGS: A single AP portable upright view of the chest reveals
new bibasilar hazy opacities, suggestive of pleural effusions.
There is new perihilar predominant air space opacity, compatible
with moderate-to- severe pulmonary edema. There is no
pneumothorax and the cardiomediastinal silhouette appears stable
accounting for differences in patient positioning.
IMPRESSION: New pleural effusions and moderate-to-severe
pulmonary edema.
.
RENAL U.S. [**2181-11-18**] 10:32 AM
RENAL U.S.
Reason: ?abscess, please evaluate cyst and interval enlargement
[**Hospital 93**] MEDICAL CONDITION:
37 year old woman with pyelonephritis, being treated, still
spiking
REASON FOR THIS EXAMINATION:
?abscess, please evaluate cyst and interval enlargement
INDICATION: 37-year-old woman with pyelonephritis who is still
febrile despite treatment.
COMPARISON: CT of the abdomen and pelvis from [**2181-11-15**].
RENAL ULTRASOUND: The right kidney measures 13.0 cm. The left
kidney measures 12.7 cm. The areas of hypoattenuation seen on
the recent CT scan in the left kidney are not demonstrated on
the current study. A 7 mm focus of hyperechogenicity in the
lower pole of the left kidney likely represents an
angiomyolipoma, as was also seen on the recent CT. There is no
evidence of drainable fluid collection and no hydronephrosis.
The bladder appears unremarkable. The vascularity within the
left kidney also appears normal.
IMPRESSION: Areas of hypoattenuation seen in the left kidney on
recent CT dated [**2181-11-15**] are not visualized by
ultrasound. As was previously recommended on the CT, followup
MRI after treatment can be performed to evaluate one of the more
cystic-appearing lesions seen on the CT study. if these are
areas of pyelonephritis, it is entirely likely that these will
not be visible on ultrasound.
No drainable fluid collections.
Brief Hospital Course:
37 yo F with no PMH admitted with pyelonephritis complicated by
hypotension requiring levophed now with significantly improved
blood pressure.
1. Hypotension: Patient was hypotensive requiring levophed on
admission and with lactate elevated to 3.2. Hypotension was
thought most likely secondary to septic shock. Etiology thought
likely secondary to pyelonephritis (elevated WBC, lactate
originally 3.6, UA positive, + flank pain). Patient was
aggressively fluid resuscitated with 7.5 L of normal saline and
responded with improvement in BP and decrease in lactate to .9.
CXR was not suggestive of infection and blood cultures have not
yet grown any organisms
2. Pyelonephritis - Patient with significant back pain and
leukocytosis on admission with positive UA. CTU on [**2181-11-15**] was
consistent with pyelonephritis and did not find stones or
obstruction. Patient was started on broad spectrum antibiotics
with ceftriaxone and ciprofloxacin. Urine cultures have not yet
grown any organisms. The patient's ceftriaxone was discontinued
after two days once the patient was afebrile and
hemodynamically stable. She was continued on ciprofloxacin, and
instructed to complete a 14 day course. Of note, a cystic
lesion was observed on the patient's kidney and follow-up with
MRI was recommended for better characterization if she does not
improve.
.
3. Hypoxia: Patient has intermittently decreased SaO2 to high
80s/90s while in MICU. CXR shows moderate to severe pulmonary
edema and bilateral pleural effusions. She was not diuresed,
but was instruced to sit upright. On transfer to the floor, her
oxygen requirement was gradually weaned and she had adequate
oxygen saturation on room air the day before discharge.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days: Take for 1 tablet twice daily for ten more days, stopping
on [**2181-11-27**].
Disp:*20 Tablet(s)* Refills:*0*
3. Combivent 103-18 mcg/Actuation Aerosol Sig: 1-2 puffs
Inhalation qid:prn as needed for shortness of breath or
wheezing: take 2 puffs four times daily as needed for wheezing,
shortness of breath.
Disp:*1 actuation aerosol* Refills:*0*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Pyelonephritis
Septic Shock
Discharge Condition:
good
Discharge Instructions:
You were admitted to the hospital with an infection of your
urinary system called pyelonephritis. While in the hospital,
the infection became so severe as to cause your blood pressure
to drop. You were treated with aggressive fluid resuscitation,
along with pressure increasing medications, in addition to
antibiotics. Your blood pressure resultingly returned to
[**Location 213**].
.
Please return to the hospital if you experience fever, chest
pain or shortness of breath. Please return to the hospital if
you experience worsening back pain.
.
Please contact your PCP [**First Name4 (NamePattern1) 1790**] [**Name (NI) 1789**] [**Telephone/Fax (1) 1792**] to
schedule an appointment for next week.
Followup Instructions:
Please contact your PCP [**First Name4 (NamePattern1) 1790**] [**Name (NI) 1789**] [**Telephone/Fax (1) 1792**] to
schedule an appointment for next week.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]
|
[
"785.52",
"995.92",
"593.2",
"799.02",
"285.9",
"789.59",
"590.80",
"038.9",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11545, 11551
|
9162, 10888
|
345, 369
|
11623, 11630
|
2720, 3978
|
12382, 12668
|
2346, 2364
|
10943, 11522
|
7879, 7947
|
11572, 11602
|
10914, 10920
|
11654, 12359
|
2379, 2701
|
279, 307
|
7976, 9139
|
397, 2060
|
2082, 2128
|
2144, 2330
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,252
| 161,548
|
1243
|
Discharge summary
|
report
|
Admission Date: [**2201-3-5**] Discharge Date: [**2201-3-11**]
Date of Birth: [**2149-10-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest tightness
Major Surgical or Invasive Procedure:
1. [**2201-3-5**] Urgent coronary artery bypass graft x 5 with left
internal mammary artery to left anterior descending artery and
saphenous vein grafts to diagonal 1 and diagonal 2, and
posterior descending arteries and a left radial artery to ramus
.
2. [**2201-3-7**] Left Chest tube placement
History of Present Illness:
51 year old male who is followed by Dr [**Last Name (STitle) **] for his
hypertension. During his most recent cardiology follow-up visit
[**2201-2-10**] he was started on spironolactone 25 mg due to evidence
of LVH by EKG, presence of proteinuria and his family history.
Approximately one week ago he experienced an episode of chest
pain while walking up an incline. He was referred for an ETT
[**2201-3-4**] which revealed marked ischemic EKG changes with
downsloping ST segment depression as well as ST segment
elevation. He was referred for coronary angiography and was
found to have coronary artery disesase and is now being referred
to cardiac surgery for revascularization.
Past Medical History:
-Hypertension
-Sleep apnea, used CPAP for 8 months with no improvement so
self-discontinued
-Proteinuria
-Torn tendon left foot, no surgical intervention
-Cervical lymph node removal as a child
-s/p cyst removed on "head"
Social History:
Race:Caucasian
Last Dental Exam:[**12/2200**]
Lives with:Wife and two children
Contact: [**Name (NI) 5321**] (wife) Phone #[**Telephone/Fax (1) 7770**]
Occupation:Currently works remodeling his home
Cigarettes: Smoked yes [x] Hx: quit in [**2185**], smoked for 15 years
Other Tobacco use:denies
ETOH: < 1 drink/week [x]
Illicit drug use: denies
Family History:
Family History: Father and mother both died at age 67 from heart
attacks; Brother with HTN
Physical Exam:
Admission:
Pulse:54 Resp:18 O2 sat:97/RA
B/P Right:168/86 Left:153/82
Height:5'[**00**]" Weight:250 lbs
General: NAD
Skin: Dry [x] [**Year (2 digits) 5235**] [x] superficial sctarches right thigh
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: Grossly [**Year (2 digits) 5235**] [x] Mild Left lower extremity weakness
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
Discharge:
VS 99.6 86 150/90 18 92%-RA
Gen: NAD
CV: RRR, no murmur. Sternum stable incision CDI
Pulm: diminishes bases bilat
Abdm: obese, soft, NT/ND/+BS
Ext: warm, well perfused. 1+ edema bilat
Pertinent Results:
Admission labs:
[**2201-3-4**] 10:30AM PT-11.1 INR(PT)-1.0
[**2201-3-4**] 10:30AM PLT COUNT-208
[**2201-3-4**] 10:30AM WBC-6.0 RBC-5.03 HGB-14.6 HCT-42.6 MCV-85
MCH-29.1 MCHC-34.4 RDW-13.5
[**2201-3-5**] 09:30AM TRIGLYCER-127 HDL CHOL-32 CHOL/HDL-4.4
LDL(CALC)-84
[**2201-3-5**] 09:30AM %HbA1c-5.9 eAG-123
[**2201-3-5**] 09:30AM ALBUMIN-4.1 CHOLEST-141
[**2201-3-5**] 09:30AM ALT(SGPT)-20 AST(SGOT)-22 ALK PHOS-46
AMYLASE-33 TOT BILI-0.5
[**2201-3-5**] 09:30AM GLUCOSE-154* UREA N-16 CREAT-0.7 SODIUM-138
POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-26 ANION GAP-16
.
Discharge labs:
[**2201-3-10**] 05:23AM BLOOD WBC-6.1 RBC-3.11* Hgb-9.1* Hct-26.8*
MCV-86 MCH-29.1 MCHC-33.8 RDW-13.8 Plt Ct-196
[**2201-3-10**] 05:23AM BLOOD Plt Ct-196
[**2201-3-6**] 01:46AM BLOOD PT-12.6* PTT-36.4 INR(PT)-1.2*
[**2201-3-10**] 05:23AM BLOOD Glucose-114* UreaN-23* Creat-0.7 Na-140
K-4.5 Cl-101 HCO3-32 AnGap-12
[**2201-3-10**] 05:23AM BLOOD Mg-2.4
.
CHEST (PA & LAT) Study Date of [**2201-3-10**] 8:59 AM
FINDINGS: There has been increased aeration of the right lung
with
Preliminary Reportcorresponding reduction in right-sided
atelectasis. There is decreased right basilar pleural effusion.
Left lung appears slightly more inflated with a small increase
in left pleural effusion. There are no areas of focal
consolidation concerning for infection. There is no
pneumothorax. The cardiomediastinal silhouette is stable with no
evidence of pulmonary edema or failure. Right-sided IJ catheter
is seen well positioned terminating within the mid SVC. Sternal
wires are seen in vertical alignment along the midline with no
obvious hardware complications.
IMPRESSION:
No evidence of cardiac failure.
Improved lung aeration bilaterally. Decreased right-sided
pleural effusion, left-sided pleural effusion.
.
[**2201-3-5**] [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
[**Hospital1 **] - Ascending: 3.2 cm <= 3.4 cm
Aortic Valve - Peak Gradient: 4 mm Hg < 20 mm Hg
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Low normal LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
[**Hospital1 **]: Normal ascending [**Hospital1 5236**] diameter. Simple atheroma in
descending [**Hospital1 5236**].
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications.
Conclusions
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is low normal (LVEF
50-55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic [**Hospital1 5236**].
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient is on no inotropes.
Preserved biventricular systolic fxn.
No AI, trace-mild MR.
[**First Name (Titles) **] [**Last Name (Titles) 5235**].
Brief Hospital Course:
Mr [**Known lastname 7771**] was referred to [**Hospital1 18**] for cardiac catheterization
after a positive ETT. The catheterization revealed three vessel
coronary artery disease with normal left ventricular function.
He was then referred to cardiac surgery and brought to the
operating room for emergent coronary bypass grafting. See
operative report for details in summary he had:
1. Urgent coronary artery bypass graft x 5 with left internal
mammary artery to left anterior descending artery and saphenous
vein grafts to diagonal 1 and diagonal 2, and posterior
descending arteries and a left radial artery to ramus.
2. Endoscopic harvesting of the long saphenous vein.
3. Left radial artery harvesting.
His bypass time was 113 minutes with a crossclamp time of 88
minutes. He tolerated the operation well and post operatively
was transferred from the operating room to the cardiac surgery
ICU. He remained hemodynamically stable in the immediate post-op
period, woke neurologically [**Hospital1 5235**] and was extubated. He
remained hemodynamically stable throughout the remainder of the
operative day and on POD1 was transferred to the stepdown floor
for continued post-op recovery and care. At the time of transfer
the patients chest tubes remained in place because of an air
leak. Over the next 24 hours the patient had his chest tubes
removed sequentially as the airleak had resolved. A post pull
chest film showed no apparent pneumothorax. A repeat film was
obtained on POD3 because the patient was complaining of
difficulty taking a deep breath, this Xray revealed a
substantial right pneumothorax and a lateral chest tube was
placed with complete expansion of lung. The remainder of his
hospital course was uneventful, his chest tube was removed on
POD4. He worked with nursing and physical therapy to increase
his strength and conditioning nad on POD6 he was discharged home
with visiting nurses. He is to follow up with Dr [**Last Name (STitle) 7772**] in
1 month. Given his radial artery graft, he should remain on
Imdur to prevent vasospasm.
Medications on Admission:
AMLODIPINE 15 mg Daily
ATENOLOL 100 mg Daily
HYDROCHLOROTHIAZIDE 25 mg Daily
LISINOPRIL 80 mg Daily
LOSARTAN 50 mg Daily
SPIRONOLACTONE 25 mg Daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
5. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
6. lisinopril 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
10. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily) for 5 days.
Disp:*10 Tablet Extended Release(s)* Refills:*0*
11. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day): apply to affected area.
Disp:*14 day supply* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Coronary artery disease - s/p CABG
Postop Pneumothorax - s/p chest tube placement
Hypertension
Sleep apnea
Proteinuria
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Dilaudid
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
left arm: incision w/steri's CDI-large eccymotic area extending
to axilla
Edema 2+ bilat LE
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 one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
.
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Provider: [**Name10 (NameIs) **] CARE CLINIC Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2201-3-19**] 10:30
Surgeon: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2201-3-31**] 2:30
Cardiologist: [**First Name8 (NamePattern2) 2053**] [**Last Name (NamePattern1) 2052**], MD Phone:[**Telephone/Fax (1) 7773**] [**2201-3-31**]
@4:40
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 2789**] in [**4-30**] weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2201-3-11**]
|
[
"414.01",
"V70.7",
"401.9",
"E878.2",
"512.1",
"791.0",
"327.23",
"411.1",
"416.8",
"424.0",
"V17.49",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"34.04",
"37.22",
"36.15",
"36.14",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
10518, 10593
|
6840, 8900
|
326, 624
|
10756, 11056
|
3069, 3069
|
11789, 12519
|
1976, 2053
|
9099, 10495
|
10614, 10735
|
8926, 9076
|
11080, 11766
|
3661, 6817
|
2068, 3050
|
270, 288
|
652, 1334
|
3085, 3645
|
1356, 1580
|
1596, 1944
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,410
| 155,534
|
54156
|
Discharge summary
|
report
|
Admission Date: [**2204-8-22**] Discharge Date: [**2204-9-4**]
Date of Birth: [**2167-8-10**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Tachycardia, hypotension, abdominal pain
Major Surgical or Invasive Procedure:
1. Cardiac catheterization
2. Colonoscopy
3. Esophagogastroduodenoscopy
4. PICC LINE PLACEMENT
History of Present Illness:
Pt is a 37y/o African American female with a history of Crohn's
Disease s/p 2 partial small bowel resections and a history of
CHF with a documented EF of 30% who presented from the stress
test lab with the complaint of resting tachycardia to 180 and
hypotension at SBP 80. The patient had been experiencing
abdominal pain with frequent stools (10-12 per day), with pain
relieved by stooling. Stools were non-bloody, loose, lots of
mucus. Pt stated that these symptoms were similar to what she
gets when she has a Crohn's flare. Her last flare was roughly a
month ago, resulting in a 5 day hospitalization. She has tried
Remicade in the past, but it did not work very well for her.
She has noted a decrease in PO intake along with her frequent
stooling, and feels thirsty all the time. She stated that she
gets dizzy when she stands up quickly. She also noted that she
has had some chest pain in the past weeks to months. Her chest
pain was worse with exertion, was accompanied by SOB, and
improved with rest. The chest pain was non-radiating. This CP
was the reason for her stress test on the day of admission.
Unfortunately, the test was not able to be performed due to her
hemodynamic instability. She has not experienced F/C. She
noted nausea/vomiting if she ate a large meal. She denied
dysuria/hematuria. She noted rectal and abdominal pain as
above, relieved by stooling.
Past Medical History:
1. Crohn's Disease
--s/p ileal colectomy [**2181**], s/p small bowel resection of
neoterminal ileum [**2193**]
--s/p multiple perianal fistulotomy and I&D of perianal
abscesses
--Has been on Remicade (last [**8-6**])
2. Chronic Iron deficiency Anemia
3. CRI (? due to lithium toxicity) s/p renal bx [**2196**]
4. Chronic elevated Alk Phosphatase
5. Schizoaffective D/O
6. s/p Child Abuse with PTSD
7. CHF with EF ~30% via TTE on [**2204-8-21**]
8. Right breast cyst removal [**2185**]
9. History of anemia due to iron and B12 deficiencies.
Social History:
Patient has 12 y.o daughter who lives with the patient's mother.
[**Name (NI) **] mother has custody of the patient's daughter b/c of the
[**Hospital 228**] medical issues. The patient has a residence several
blocks from her mother but spends most of her time recently at
her mother's house. No tobacco, alcohol, or illicit drug use.
Family History:
Mother has non-inflammatory arthritis & hypertension. A sister
has
fibroids. No reported family history of IBD.
Physical Exam:
VS: temp:99.7 pulse:130 BP:107/75 RR:17 SaO2:100% RA
.
Gen: Pleasant AfAm F in NAD, appropriate, conversant.
HEENT: PEERLA, EOMI, OP clear, MM dry. 2cm L posterior cervical
lymph node.
Skin: Evidence of healed fistulas in perianal area, no evidence
of active fistulations.
Chest: CTAB, no CVA tenderness
CV: s1/s2, regular, tachycardic, no murmur/gallop/rub
appreciated
Abd: soft, NT, ND, NABS. No masses or HSM appreciated.
Ext: W/WP. No edema, no palpable cords, no signs of venous
stasis.
Neuro: A&OX3, CN II-XII intact, MAEx4 with full strength 5/5.
Sensation intact to light touch throughout.
Pertinent Results:
[**2204-8-21**] 02:52PM URINE 24Creat-405
[**2204-8-22**] 03:20PM WBC-12.3* RBC-4.11* HGB-11.3* HCT-34.9*
MCV-85 MCH-27.5 MCHC-32.4 RDW-16.7*
[**2204-8-22**] 03:20PM CORTISOL-12.8
[**2204-8-22**] 03:20PM VIT B12-322 FOLATE-GREATER TH
[**2204-8-22**] 03:20PM GLUCOSE-84 UREA N-12 CREAT-1.8* SODIUM-129*
POTASSIUM-6.5* CHLORIDE-101 TOTAL CO2-20* ANION GAP-15
[**2204-8-22**] 04:24PM URINE RBC-[**7-13**]* WBC-[**12-23**]* BACTERIA-MOD
YEAST-NONE EPI-21-50
[**2204-8-22**] 04:24PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD
RADIOLOGY Final Report
UNILAT UP EXT VEINS US RIGHT [**2204-9-2**] 2:25 PM
UNILAT UP EXT VEINS US RIGHT
Reason: dvt Vs cellulitis
[**Hospital 93**] MEDICAL CONDITION:
37 year old woman with hypotension/tachycardia, cardiomyopathy
s/p PICC with increasing RUE edema and pain
REASON FOR THIS EXAMINATION:
dvt Vs cellulitis
INDICATION: 37-year-old woman with increasing right upper
extremity edema.
COMPARISON: [**2204-8-28**], right upper extremity ultrasound.
FINDINGS: As previously identified, there is a large thrombus
extending from the axillary vein into the brachial vein and the
subclavian. There has been no significant change in the short
interval.
RIGHT LOWER EXTREMITY ULTRASOUND: 2D, color and Doppler waveform
imaging was obtained of the right common femoral, superficial
femoral and popliteal veins. Normal compressibility, waveforms
and augmentation was demonstrated. No intraluminal thrombus
identified.
IMPRESSION: No evidence of right lower extremity deep vein
thrombosis.
Mucosal biopsies, two:
A. Ileum:
Chronic active inflammation with ulceration and granulation
tissue. See note.
B. Left colon:
Chronic active inflammation with ulceration and granulation
tissue.
Note: No granulomas, viral inclusions, or dysplasia seen.
Brief Hospital Course:
1. Tachycardia/hypotension/CHF: Initial EKGs revealed sinus
tachycardia up to 160s. Pt was initially given limited fluids in
light of recent EF of 30%. Given her acute decline in EF,
cardiology was consulted and considered catheterization
necessary to r/o ischemia as a cause of this new cardiomyopathy.
Catheterization was performed on [**2204-8-24**] without complications.
On cath she was noted to have: No angiographic evidence of
coronary artery disease. Mild systolic ventricular dysfunction.
Normal left and right sided filling pressures. LVEF was 50%
with mild apical hypokinesis. Workup for other causes of sinus
tachycardia was continued, revealing negative cosyntropin test
for adrenal insufficiency, negative urine catecholamines for
pheochromocytoma. Pt did not present with symptoms c/w sepsis or
anaphylaxis. Lack of pulmonary complaints or findings made PE or
tension PTX unlikely. Lack of pericardial rub, JVD, or pleuritic
CP made tamponade less likely. Pt was noted to have a HCT drop
the day after her cardiac catheterization ([**8-25**]). No source of
bleeding was identified, but due to the patient's tenuous
hemodynamic status she was transferred to the CCU for further
management. A CT scan showed signs of volume overload, but no
evidence of retroperitoneal bleed. A vascular examination of
the RLE catheterization site showed no evidence of hematoma from
the cath. Essentially, no source was identified for the
hematocrit drop, and following transfusion the patient
maintained a stable Hct. Due to continuing fevers and her
Crohn's disease, she was started on Meropenem to cover
translocation of gut bacteria. She continued to have periods of
hypotension and tachycardia, but this was not fundamentally
different from her presenting symptoms. She was transferred
back to the primary medical team on [**8-28**]. From that point
onwards, patient's tachycrdia improved and eventually abated as
her Crohn's disease was adressed and treated. No further acute
cardiac events occurred and patient remained stable on
telemetry.
.
2. Crohn's Disease: On [**8-29**] pt underwent colonoscopy & EGD to
evaluate the status of her Crohn's disease. This revealed
friability, ulceration, erythema, & congestion in the descending
colon, sigmoid colon, & terminal ileum compatible with Crohn's.
There was also friability & erythema in the proximal anal canal.
EGD showed a normal upper GI tract through D3. Per GI
recommendations, pt was started on IV solumedrol for Crohn's
flare and TPN for malnourished state. Diet was advanced as
tolerated to a low-residue, high protein, lactose-restricted
diet. The patient was started on Asacol and Cipro/Flagyl in
light of the flare. Patient was also changed to Prednisone by
time of discharge. The patient was discharged to acute
rehabilitation with instructions to follow up in Dr.[**Name (NI) 110985**]
clinic as directed. The patient was to receive 4 weeks of TPN
at rehab. Patient also received intermittent Blood transfusions
in setting of active crohn's disease and responded
appropriately. Her baseline HCT ranged 28-31. Patient contineud
to have brown guiac positve stool.
.
3. Anemia: Vitamin B12, folate, and iron were administered to
compensate for possible vitamin deficiency anemia due to Crohn's
malabsorption, decreased PO intake, and profuse diarrhea.
Several transfusions of packed RBCs were administered during
hospital course for acute drops in Hct. Iron studies showed low
serum TRF, low TIBC, and high ferritin consistent with anemia of
chronic disease. Protein-calorie malnutrition likely also
contributed to anemia. Erythropoietin was restarted as patient
had been taking this as outpatient.
.
4. RUE DVT: The patient was found to have a RUE DVT that was
likely caused by insertion of a PICC line in the venous anatomy
of the RUE. Vascular Surgery was consulted on the case. It was
decided to anticoagulate the patient for a period of [**4-8**] months,
first with heparin, then transitioned onto Coumadin. Because of
the known inciting incident for the DVT, it can be assumed that
the patient does not have a hypercoaguable state outside of her
Crohn's Disease itself. Patient also had evidence of erythema of
her RUE-felt to be consistent with cellulutis, and given her
immunocompromised state, IV Vancomycin was started to complete a
14 day course. By time of discharge, patient's erythema had
abated. A repeat UE US revealed no progression of DVT.
.
5. Bilateral knee pain/proximal weakness: Shortly before
admission, the patient had recently started seeing a
rheumatologist for her musculoskeletal complaints. Per rheum,
her knee pain is likely [**3-7**] history of obesity with degenerative
changes. Her proximal muscle weakness may be caused by
steroids, a Crohn's myopathy, or a paraneoplastic syndrome. Per
the rheumatologist, this is most likely [**3-7**] steroid myopathy.
While a workup for this knee pain was not pursued during this
hospitalization, the patient should have bilateral weight
bearing knee films obtained as an outpatient to further evaluate
for degenerative joint disease.
.
6. New breast mass: Pt complains of a new breast mass in the L
axilla. This mass was to be evaluated by mammogram as an
outpatient. Pt has had a roughly 150lb weight loss over the past
year and a half, [**Month/Day (2) 2771**] to Crohn's. While a workup for this
breast mass was not pursued during this hospitalization, the
patient should have a mammogram as an outpatient to evaluate the
possible breast mass.
.
7. Schizoaffective disorder: The pt's outpatient medications
were continued. Follow up as outpatient with psychiatrist is
recommended to monitor this condition.
.
8. Edema: Patient showed evidence of total body fluid overload
during her hospitalization, felt secondary to hypoalbumenia,
malnutrition, large volume infusion. The patient received
intermittent doses of lasix with good effect.
.
9. CRI: Cr remained at baseline of 1.1-1.5.
.
10. PPx: Heparin ggt, Coumadin, PRN Bowel Regimen
.
11. Code: Full
Medications on Admission:
ANUSOL-HC 1%--Apply to affected area twice a day as needed
ENSURE PLUS --1 can by mouth three times a day
ENTOCORT EC 3 mg--3 capsule(s) by mouth at bedtime
FERROUS GLUCONATE 325 mg--1 tablet(s) by mouth three times a day
GABAPENTIN 400 MG--One cap by mouth at bedtime
OLANZAPINE 5 MG--4 tablet by mouth at bedtime
PROCRIT 10,000 unit/wk--inject 0.5ml s.q. (5000 units) once per
week per dr. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] (renal) pt brings own medication
THERAGRAN-M --One tablet by mouth every day
VITAMIN B-12 1000MCG/ML--1000mcg sc every day x7 days, then
1000mcg sc qwk x4 wks, then 1000mcg qmon thereafter
QUETIAPINE 125mg PO QHS
Discharge Medications:
1. Olanzapine 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
2. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] (2
times a day).
3. Quetiapine Fumarate 25 mg Tablet Sig: Five (5) Tablet PO QHS
(once a day (at bedtime)).
4. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
5. Morphine 10 mg/5 mL Solution Sig: Five (5) ml PO Q4-6H (every
4 to 6 hours) as needed for abdominal pain: hold for sedation.
6. Insulin Regular Human 100 unit/mL Solution Sig: One (1) as
directed Injection ASDIR (AS DIRECTED).
7. Epoetin Alfa 10,000 unit/mL Solution Sig: 0.5 ML Injection
QMOWEFR (Monday -Wednesday-Friday).
8. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: Two (2)
Capsule PO DAILY (Daily).
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
10. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
11. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 10 days.
13. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): continue till patient see's her GI specialist.
14. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): may need to be adjusted based on INR-once INR [**3-8**], the
heparin ggt should be stopped.
15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed.
16. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous Q 12H (Every 12 Hours) as needed for RUE
cellulitis for 12 days.
17. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: Seven [**Age over 90 1230**]y (750) units Intravenous ASDIR (AS
DIRECTED): as directed based on heparin sliding scale. Continue
till INR [**3-8**] and then DC. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Crohns Disease
Tachycardia
Right Upper Extremity DVT
Vitamin D Deficiency
Chronic Renal Deficiency
Discharge Condition:
stable, afebrile, tolerating PO diet.
Discharge Instructions:
Please take all medications as perscribed. Please keep all
follow up appointments. Please report to the ED with any CP,
SOB, increasing extremity edema, fevers, chills.
Followup Instructions:
Provider: [**Name10 (NameIs) 9977**] Where: [**Hospital6 29**] RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2204-9-7**] 2:20
Provider: [**Name10 (NameIs) 326**] UPPER GI (TCC) RADIOLOGY Where: [**Hospital6 29**]
RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2204-9-12**] 9:00
Provider: [**Name10 (NameIs) **] [**First Name8 (NamePattern2) 11859**] [**Name12 (NameIs) **], MD Where: LM [**Hospital Unit Name 4275**] Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2204-9-12**] 11:30
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 110986**] specialists-[**Telephone/Fax (1) 108325**]-[**9-21**] at
10:30AM.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2204-9-4**]
|
[
"280.9",
"309.81",
"611.72",
"276.5",
"593.9",
"458.9",
"V15.41",
"555.2",
"268.9",
"453.40",
"785.0",
"582.9",
"425.4",
"295.70",
"263.9",
"359.4",
"428.0",
"E932.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"45.25",
"37.23",
"88.56",
"99.04",
"38.93",
"88.53",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
14101, 14180
|
5411, 11433
|
311, 407
|
14323, 14362
|
3523, 4258
|
14579, 15387
|
2769, 2884
|
12147, 14078
|
4295, 4402
|
14201, 14302
|
11459, 12124
|
14386, 14556
|
2899, 3504
|
231, 273
|
4431, 5388
|
435, 1828
|
1850, 2401
|
2417, 2753
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,218
| 155,817
|
19946+19947+19948
|
Discharge summary
|
report+report+report
|
Admission Date: [**2150-12-21**] Discharge Date: [**2151-1-2**]
Date of Birth: [**2082-8-5**] Sex: M
Service: CARD [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS:
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 11726**]
MEDQUIST36
D: [**2151-1-1**] 19:26
T: [**2151-1-2**] 01:01
JOB#: [**Job Number 53793**]
Admission Date: [**2150-12-21**] Discharge Date: [**2151-1-2**]
Date of Birth: [**2082-8-5**] Sex: M
Service: CARD [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: This 68 year old male has known
coronary artery disease and is status post stent in [**2141**] and
had a recent increase in anginal symptoms with a positive
stress test on [**2150-12-18**], and a cardiac catheterization
revealed a 99% left anterior descending, 80% circumflex
lesion and a 99% right coronary artery lesion. His ejection
fraction was 64% and he was referred to Dr. [**Name (STitle) **] for a
coronary artery bypass graft.
PAST MEDICAL HISTORY:
1. History of coronary artery disease status post stent to
the right coronary artery complicated by distal embolization
and myocardial infarction.
2. History of hypercholesterolemia.
3. History of hypertension.
4. Status post cerebrovascular accident in [**2136**] with no
residual.
ALLERGIES: He has no known allergies.
MEDICATIONS ON ADMISSION:
1. Cozaar 100 mg alternating with 50 mg p.o. q. day.
2. Prevacid p.r.n.
3. Tiazac 300 mg p.o. q. day.
4. Ziac 5/6.25 p.o. q. day.
5. Aspirin 81 mg p.o. q. day.
6. Lescol 80 mg p.o. q. day.
SOCIAL HISTORY: He was a smoker in the past. He lives at
home with his wife.
PHYSICAL EXAMINATION: He is a well developed, well
nourished white male in no apparent distress. Vital signs
were stable; afebrile. HEENT examination was normocephalic,
atraumatic. Extraocular movements intact. Oropharynx
benign. Neck was supple; full range of motion; no
lymphadenopathy or adenopathy, or thyromegaly. Carotids two
plus and equal bilaterally without bruits. Lungs were clear
to auscultation and percussion. Cardiovascular examination
was regular rate and rhythm with normal S1 and S2, no rubs,
murmurs or gallops. Abdomen was obese, soft, nontender, with
positive bowel sounds, no masses or hepatosplenomegaly.
Extremities without cyanosis, clubbing or edema.
Neurological examination was non-focal.
He had carotid Dopplers prior to the Operating Room which
revealed less than 40% stenosis bilaterally.
HOSPITAL COURSE: On [**12-23**], the patient underwent a coronary
artery bypass graft times two with left internal mammary
artery to the left anterior descending and reverse saphenous
vein graft to the right coronary artery. He tolerated the
procedure well and was transferred to the CSRU in stable
condition.
He had a stable postoperative night and he was extubated. He
went into atrial fibrillation on postoperative day number
one. On postoperative day two, he was seen by
electrophysiology service and was put on amiodarone and on
postoperative day number five he underwent cardioversion. He
had his chest tube discontinued on postoperative day number
two. Cardioversion was to sinus rhythm.
He was transferred to the floor on postoperative day number
three. He had his pacer wires discontinued on postoperative
day number six. He also had two episodes of urinary
retention and he required Foley and had some hematuria with
that. He was started on Cardura and Urology was consulted
and they recommended sending him home with a leg bag and to
come back in a week to have a void trial. He also was
anticoagulated with hepatin and Coumadin and on postoperative
day number ten he was discharged to home in stable condition.
His labs on discharge were hematocrit of 25.6, white blood
cell count 13,800, platelets 286, sodium 139, potassium 4.4,
chloride 104, carbon dioxide 28, BUN 22, creatinine 1.6,
blood sugar 93, INR pending.
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. twice a day.
2. Percocet one to two p.o. q. four to six hours p.r.n.
pain.
3. Lipitor 40 mg p.o. q. day.
4. Lopressor 100 mg p.o. twice a day.
5. Ecotrin 81 mg p.o. q. day.
6. Norvasc 5 mg p.o. q. day.
7. Levofloxacin 500 mg p.o. q. day times seven days.
8. Amiodarone 400 mg p.o. twice a day times one week; 400 mg
p.o. q. day times one week, and then 200 mg p.o. q. day times
two weeks.
DISCHARGE INSTRUCTIONS:
1. He will be followed by Dr. [**Last Name (STitle) **] in one to two weeks and
he will follow his Coumadin.
2. He will be seen by Dr. [**Name (STitle) 3876**] in four weeks.
3. He also has an appointment with Dr. [**Last Name (STitle) 9125**] of Urology in
one week.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 3116**]
MEDQUIST36
D: [**2151-1-1**] 19:36
T: [**2151-1-2**] 01:04
JOB#: [**Job Number 53794**]
Admission Date: [**2151-12-22**] Discharge Date: [**2151-1-4**]
Date of Birth: [**2082-8-5**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: This is a 68-year-old male with
a history of prior cardiac catheterization in [**2141**]. He had a
70% left anterior descending lesion and a stent to a 90%
right coronary artery lesion at that time. His
catheterization at that time was complicated by distal
embolization, a small clot associated with significant
inferior wall ST elevation.
The patient was managed medically until recently where he
reported shortness of breath and chest pain when he climbs
his stairs at night. He said it did not occur when walking
up the stairs during the day.
In addition, he wakes up in the middle of the night with pain
occasionally. The pain was relieved with sublingual
Nitroglycerin. It started the first week in [**Month (only) 359**],
approximately six weeks prior to admission.
Stress test on [**2150-12-18**], showed a small fixed defect
at the inferior base, moderate inferolateral ischemia, and a
small anteroseptal ischemia, with an ejection fraction of
64%. He had chest pain and drop in his blood pressure during
the test and was referred in for cardiac catheterization.
PAST MEDICAL HISTORY: 1. Prior right coronary artery stent.
2. Coronary artery disease. 3. Cerebrovascular accident.
4. Hypertension. 5. Hypercholesterolemia.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
MEDICATIONS ON ADMISSION: Cozaar 100 mg alternating with 50
mg q.d., Tiazac 300 mg p.o. q.d., Prevacid p.o. p.r.n.,
Lescol 80 mg p.o. q.d., Ziac 5/6.25 mg p.o. q.d., Aspirin 81
mg p.o. q.d.
LABORATORY DATA: Prior to cardiac catheterization white
count was 8.6, hematocrit 44.2, platelet count 237,000;
sodium 144, potassium 5.1, chloride 109, bicarb 31, BUN 21,
creatinine 1.3, blood sugar 98.
[**Last Name (STitle) 53795**]went cardiac catheterization on the day of admission,
[**12-21**]. The catheterization revealed 99% left anterior
descending obstruction, 80% circumflex obstruction, and 99%
obstruction of the right coronary artery. He did receive
Angio-Seal for closure of the right femoral arterial puncture
site. Ejection fraction by the prior stress was 64%. He was
referred to Dr. [**Last Name (Prefixes) **] for coronary artery bypass
grafting.
On the day of catheterization, his creatinine was down to
1.1, potassium of 3.6, hematocrit 36.9, with a white count of
8.3, PT 12.9, INR 1.1, LFTs were normal.
Electrocardiogram showed normal sinus rhythm with no acute
ischemia.
On exam the patient had some right arm weakness which
resolved spontaneously at the time of his cerebrovascular
accident in [**2136**]. He denied any further neurological
symptoms, although he had been told that his carotids were
"partially blocked."'
He denied any asthma, cough, or production of sputum
problems. [**Name (NI) **] did have some gastroesophageal reflux with
occasional ...................
He denied any other diabetes, thyroid, or hematology issues.
On exam he was neurologically grossly intact. His lungs were
clear bilaterally. His heart sounds were normal with S1 and
S2 with no murmur noted. His abdomen was obese, soft,
nontender, and nondistended. His extremities were warm with
positive peripheral pulses and no edema.
The patient was also seen by the CMI attending, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]. Carotid ultrasounds were performed on [**12-22**],
the day prior to surgery, which showed mild plaque in the
right and left internal carotid arteries, with less than 40%
stenosis, as well as tortuous right and left internal carotid
arteries, with normal antegrade flow in both vertebral
arteries.
On[**12-23**] the patient underwent coronary artery bypass
grafting times two by Dr. [**Last Name (Prefixes) **] with a LIMA to the left
anterior descending and a vein graft to the posterior
descending artery. The patient was transferred to the
Cardiothoracic Intensive Care Unit in stable condition.
On the afternoon after the operation, the patient was
lethargic but arousable. The patient was following commands,
and was provided occasional Neo-Synephrine and Nitroglycerin
support on and off. Urine output was good. Lung sounds were
coarse, but the plan was to go ahead and wean and extubate
the patient, as the vent was being weaned at the time. The
patient was extubated without event over night, on
postoperative day #1.
On postoperative day #2, the patient was on an Amiodarone
drip for atrial fibrillation at 0.5 and Neo-Synephrine drip
at 0.75. After administration of the initial Amiodarone, the
patient dropped his urine output and was given a fluid bolus.
Postoperative labs revealed a white count of 24.2, hematocrit
27.5, platelet count 240,000; sodium 136, potassium 4.2,
chloride 105, bicarb 24, BUN 32, creatinine 1.8, blood sugar
105. Creatinine had risen from 1.2 to 1.8.
The heart beat was irregular, as the patient was in atrial
fibrillation. Lungs were clear bilaterally. Abdominal and
extremity exams were benign.
The patient had beta-blocker increased to 25 b.i.d. He was
extubated and had an oxygen saturation of 96%. His exam was
otherwise unremarkable.
Pulmonary toilet was begun, as well as getting out of bed
with Physical Therapy and the nurses.
On postoperative day #3, the patient had a T-max of 99.1??????.
He was in atrial fibrillation with a heart rate of 99 with an
oxygen saturation of 97% on 2 L nasal cannula. Creatinine
came down slightly to 1.7. White count came down to 16.9.
Hematocrit was stable at approximately 25.7. The exam was
unremarkable. The patient's beta-blockade was increased.
The patient remained on Amiodarone drip and a Heparin drip
while he was in atrial fibrillation. An EP consult was
called. The patient continued with Lasix diuresis also at
that time.
The recommendation was to continue the Amiodarone and Heparin
drip and possibly consider giving Coumadin for six weeks,
given his prior cerebrovascular accident and hypertension, in
addition to his current atrial fibrillation.
On postoperative day #4, the patient had a heart rate of 101
and atrial fibrillation with a blood pressure of 127/74 on a
Heparin drip, Amiodarone and Metoprolol. White count
remained stable at approximately 15. He had a hematocrit of
26.
The patient was stable. Beta-blockade was increased to
Metoprolol 75 b.i.d., and adjustments were made to the
Heparin drip, and the patient was transferred out to the
floor in the afternoon on postoperative day #5. The patient
had no complaints.
The patient had atrial fibrillation over night and then went
back into sinus rhythm in the morning in the 90s, with an
oxygen saturation of 94%, with a blood pressure of 124/70.
Creatinine dropped slightly to 1.6. Other labs remained
relatively stable.
The plan was for the patient to get cardioversion. Heparin
was increased to 1300/hr after Heparin bolus was given with a
plan for cardioversion pending the results of the PTT after
the Heparin adjustments were made.
On [**12-28**], the patient had cardioversion performed by
Cardiology without any event or any complications. On
postoperative day #6, the patient had no complaints. He was
back in atrial fibrillation with a heart rate of 78. He was
alert and oriented in no apparent distress. His chest wound
had slight sanguinous oozing in an approximate area of 2 x 2
cm. Heart was regular rate and rhythm, despite going in and
out of atrial fibrillation. Lungs were clear bilaterally.
Follow-up coags were ordered with plans to discontinue the
Heparin drip. Levofloxacin was added in for the drainage at
the sternal incision. Pacing wires were discontinued. Diet
was advanced. The patient was out of bed and ambulating with
Physical Therapy and the nurses. The patient was seen by
Case Management.
On postoperative day #7, the patient was on day #2 of
Levofloxacin and remained on the Heparin drip at 1100, as the
patient was back in atrial fibrillation. Heart rate was 76,
and blood pressure was 140/68. He had an oxygen saturation
of 95% on room air.
His wound exam was unremarkable. The wound was clean, dry,
and intact. There was scant discharge from the wound. The
day prior the wound was cleaned. White count was 12.5.
At that point, the patient was doing well. Coumadin dosing
had begun. The patient continued on a Heparin drip pending
being therapeutic on Coumadin for atrial fibrillation.
The patient was continued on Flomax, and the Foley catheter
was discontinued at midnight with urinalysis sent off to
check.
The patient was seen by Social Work on consult.
Foley was discontinued at 4 a.m., and the patient was able to
void. At that time, over night on [**12-30**], the patient
was back in sinus rhythm with some premature atrial
contractions.
On postoperative day #8, the patient was in sinus rhythm at
81 with a blood pressure of 133/65, with an oxygen saturation
of 97% on room air with an unremarkable exam.
The patient continued on beta-blockade, as well as
Amiodarone. He continued to work on increasing his
ambulation. The patient remained in the hospital so that the
INR could be therapeutic for the atrial fibrillation.
The patient was transfused a unit of packed red blood cells
for a hematocrit of 22.8.
On postoperative day #9, the patient was awake, feeling good.
He was afebrile. Creatinine was stable at 1.6. White count
was 13.8, and hospital course was 25.6 posttransfusion. He
continued with Coumadin therapy with an INR of 1.3 on that
day.
On postoperative day #10, the patient was feeling nauseous
over night and had an episode of rapid atrial fibrillation in
the morning and then went back into sinus rhythm at 67 with a
blood pressure of 140/60. He appeared to be not feeling well
that morning and somewhat tired. His wounds were clean, dry,
and intact. His lungs were clear. His INR rose to 1.6.
Heparin drip was discontinued. Coumadin therapy was
continued. Zofran was given for his nausea.
The EP fellow came back to reevaluate the patient for his
recurrent atrial fibrillation, and they spelled an Amiodarone
protocol for him for his dosing, and the recommendations were
noted.
The patient also had a little bit of drainage from one of the
left saphenectomy sites on postoperative day #11. He had
intermittent rapid atrial fibrillation the day prior. His
exam was otherwise unremarkable.
Lisinopril ACE inhibitor was added with plans set if the
blood pressure were to drop, Norvasc could be discontinued.
Plans were made for outpatient [**Doctor Last Name **] of Hearts monitor.
The patient continued to ambulate. The patient had a little
bit of tenderness in the left leg incision.
On [**1-4**], postoperative day #12, the patient's exam was
as follows: The lungs were clear. Heart was regular, rate
and rhythm without murmur. Incisions were clean, dry, and
intact. The sternum was stable. White count was 13.8,
hematocrit 25.6, platelet count 286,000; sodium 139,
potassium 4.4, chloride 104, CO2 28, BUN 22, creatinine 1.6,
blood sugar 93.
Th[**Last Name (STitle) 11832**] was for the patient to be discharged home with [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **] of Hearts monitor with reporting to Dr. [**Last Name (STitle) 2357**]. t
was instructed to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**1-29**]
weeks and Dr. [**Last Name (Prefixes) **] at four weeks, as well as meeting
the urologist as an outpatient a week after discharge.
DISCHARGE MEDICATIONS: Colace 100 mg p.o. b.i.d., Percocet
[**1-29**] tab p.o. p.r.n. q.4-6 hours, Lipitor 40 mg p.o. q.d.,
Lopressor 100 mg p.o. b.i.d., Ecotrin 81 mg p.o. q.d.,
Norvasc 5 mg p.o. q.d., Levofloxacin 500 mg p.o. x 7 days,
Amiodarone 400 mg p.o. b.i.d. x 1 week, then Amiodarone 400
mg p.o. q.d. x 1 week, then Amiodarone 200 mg p.o. x 2 weeks,
with follow-up with Dr. [**Last Name (STitle) 2357**].
DISCHARGE DIAGNOSIS:
1. Status post coronary artery bypass grafting times two.
2. Atrial fibrillation.
3. Coronary artery disease with prior right coronary artery
stent.
4. Cerebrovascular accident in [**2136**].
5. Hypertension.
6. Hypercholesterolemia.
DISCHARGE STATUS: To home.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 76**]
MEDQUIST36
D: [**2151-6-8**] 10:59
T: [**2151-6-8**] 11:00
JOB#: [**Job Number 53796**]
|
[
"413.9",
"401.9",
"458.29",
"396.3",
"276.6",
"788.20",
"427.31",
"997.5",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.68",
"99.04",
"36.11",
"88.56",
"36.15",
"99.62",
"37.22",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
16603, 16996
|
17017, 17547
|
6510, 16579
|
2587, 4012
|
4479, 5166
|
1759, 2568
|
5195, 6277
|
6300, 6483
|
1672, 1735
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,113
| 165,082
|
22715+57314
|
Discharge summary
|
report+addendum
|
Admission Date: [**2158-1-16**] Discharge Date: [**2158-1-24**]
Date of Birth: [**2081-5-6**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Unwitness fall down stairs while intoxicated; SAH seen on CT at
OSH.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
77yoM s/p unwitnessed fall down stairs, positive EtOH, with SAH
seen on head CT at OSH. HD stable, AOx1 on arrival.
Past Medical History:
HTN
EtOH use
Social History:
4 drinks / day
Lives with wife, both avid social drinkers
Family History:
N/A
Physical Exam:
98.0 65 118/68 20 100%NRB
[**Last Name (LF) **], [**First Name3 (LF) 2995**] to commands, one word answers, AOx1. +EtOH
PERRLA, EOMI, CNII-XII; ATNC
Midline sterum, midline trachea, CTA-B
RRR
Pelvis stable, no step-off on back
ABD: NT/ND, soft; FAST neg, guaiac neg, nl tone
EXT: +contusion on R shoulder. No other step-off, deformity,
+ pedal pulses B, no gross neuro deficits.
Pertinent Results:
[**2158-1-16**] 03:20AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2158-1-16**] 03:20AM PT-12.4 PTT-28.0 INR(PT)-.9
[**2158-1-16**] 03:20AM WBC-9.8 RBC-3.84* HGB-12.1* HCT-34.4* MCV-90
MCH-31.6 MCHC-35.3* RDW-14.1
[**2158-1-16**] 03:20AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2158-1-16**] 03:20AM ASA-NEG ETHANOL-275* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2158-1-16**] 11:07AM WBC-7.1 RBC-3.23* HGB-10.0* HCT-28.5* MCV-88
MCH-30.8 MCHC-34.9 RDW-14.1
[**2158-1-16**] 09:27PM HCT-27.2*
[**2158-1-16**] 11:07AM GLUCOSE-121* UREA N-14 CREAT-0.7 SODIUM-138
POTASSIUM-3.4 CHLORIDE-104 TOTAL CO2-25 ANION GAP-12
[**2158-1-17**] 02:13AM BLOOD WBC-7.6 RBC-3.08* Hgb-10.1* Hct-27.0*
MCV-88 MCH-32.7* MCHC-37.3* RDW-14.7 Plt Ct-166
[**2158-1-19**] 05:40AM BLOOD WBC-8.4 RBC-2.93* Hgb-9.1* Hct-25.6*
MCV-87 MCH-31.0 MCHC-35.5* RDW-14.4 Plt Ct-195
[**2158-1-18**] 02:24AM BLOOD CK-MB-6 cTropnT-<0.01
[**2158-1-18**] 08:00PM BLOOD CK-MB-8 cTropnT-<0.01
[**2158-1-19**] 05:40AM BLOOD CK-MB-10 MB Indx-2.4 cTropnT-<0.01
CT head [**1-16**]
IMPRESSION: Multiple bilateral foci of subarachnoid and possible
parenchymal hemorrhage. These do not appear significantly
changed since the prior examination performed two hours ago.
CXR/PXR [**1-16**] IMPRESSION: Unremarkable trauma series.
XR R shoulder [**1-16**] FINDINGS: The distal tip of the right
clavicle has a squared appearance, and is slighlty superiorly
displaced relative to the acromion, with increased spacing. This
has a postoperative appearance, and several osseous fragments
are also seen adjacent to the acromioclavicular joint. Aside
from the acromioclavicular joint, the right shoulder appears
unremarkable, without evidence of fracture or dislocation.
Osteopenia is seen.
CT Cspine [**1-16**] IMPRESSION: Marked degenerative changes of the
cervical spine without evidence of fracture.
CT abd/pelvis [**1-16**] IMPRESSION Note is also made of
subcutaneous soft tissue stranding and hematoma in the
subcutaneous soft tissues posterior to the right buttocks, and
extending as high as the L2 level. Focal blood collection
measures 2.7 x 12.8 x 8.8 cm in size. Within this collection,
there are two curvilinear densities adjacent to the bone--these
could represent small avulsion fragments or possibly focal areas
of blood/contrast extravasation (revised findings discussed with
Dr. [**Last Name (STitle) **] [**2158-1-16**] 10:15 am).
B/L AC JT XR [**1-16**] FINDINGS: There is widening of the
acromioclavicular joint as well as coracoclavicular joint on the
right side consistent with type III ligamentous tear. There are
small bony fragments present adjacent to the lateral edge of the
clavice representing an avulsion fracture. The left side is
unremarkable. Visualized lung apices and ribs are unremarkable.
CT head [**1-17**] IMPRESSION: Subarachnoid hemorrhage, no interval
change.
CT head [**1-18**] s/p fall from bed FINDINGS: The dominant focus
of right Sylvian fissure subarachnoid hemorrhage and
intraventricular blood appears unchanged. There are widened
extraaxial spaces, likely indicative of subdural hygromas. No
new intracranial hemorrhage is detected, although the exam is
slightly limited by the helical technique. No fractures are
identified. There has been no significant interval change.
ECG [**1-18**] Sinus tachycardia. Possible old inferior wall
myocardial infarction. Late transition. No previous tracing
available for comparison.
B/L ANKLE XR [**1-19**] IMPRESSION: Unremarkable frontal radiographs
of the bilateral ankles. Of note, fracture is not typically
excluded with a single radiographic view and if fracture remains
a clinical concern then a complete ankle series would be
recommended.
Brief Hospital Course:
Pt with multifocal SAH on Head CT from OSH and here at [**Hospital1 18**].
The rest of the trauma evaluation was significant for a right AC
jt third degree tear and right buttock hematoma with ?
extravasation of contrast that could be consistant with an
arterial bleed. Pt was observed in the TSICU for 24hrs, with
stable gluteal compartment exam, stable Hcts, and stable
confused AOx1 mental status.
NEURO/PSYCH: Transferred to the floor where night of HD2 patient
became progressively agitated and confused, fell out of bed and
sustained a large right forehead laceration-- he required
several people, four point restraints, and ativan/haldol to
restrain him in bed. Head CT was unchanged, pt was tachycardic
and agitated but not diaphoretic or tremulous, EKG w/ ST depr
laterally, cardiac enzymes unremarkable. Pt maintained on
ativan prn for suspected delirium tremens/ alcohol withdrawal
but remained somnolent without medication throughout HD 4.
Geriatrics and psychiatry involved. HD 5 patient became awake,
ambulating with assistance, AOx3 after only one reminder of
date, and tolerating POs.
ORTHO: R AC jt third degree tear followed by orthopedics, pt
needs to be wearing a sling until followup with orthopedics. HD
3 trauma team informed that OSH ankle films demonstrated a ?
ankle fracture however no s/s of injury on exam and B/L one view
ankle films were negative. No evidence by exam for injury by
ortho and trauma teams, pt does not complain of any pain on
ambulation once awakened, therefore no further radiologic
examination performed.
Medications on Admission:
atenolol 100'
nifedipine 30'
hydrochlorothiazide 37/25'
cialis
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
5. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day) as needed for agitation.
6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours).
7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
8. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
9. Nifedipine ER 30 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
10. Triamterene-Hydrochlorothiazid 37.5-25 mg Tablet Sig: One
(1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
1) Subarachnoid hemorrhage
2) Alcohol withdrawal
3) Agitation/ delirium
4) Right acromioclavicular subluxation
5) Head laceration
Discharge Condition:
fair, improving
Discharge Instructions:
Discharge to rehab facility. Take all medications as prescribed
and keep follow-up appointments as listed below. Also, you
should try to curtail your drinking in order to avoid repeat
incidents.
The stitches in your head should be removed by a healthcare
professional no later than 3 days of discharge and replaced with
steri-strips.
Followup Instructions:
1. Followup with Neurosurgery Dr [**Last Name (STitle) 4696**] in 2 weeks, call
for appointment ([**Telephone/Fax (1) 88**]
2. Followup with Trauma Surgery Dr [**Last Name (STitle) **] in 2 weeks, call [**Telephone/Fax (1) 58822**] for an appointment on a tuesday afternoon
3. FOllowup with Orthopedic Surgery with either Dr [**Last Name (STitle) 2719**] ([**Telephone/Fax (1) 58823**]) or Dr [**Last Name (STitle) 1005**] ([**Telephone/Fax (1) 58824**]) in [**1-6**] weeks (both
names given for a choice, you DO NOT need to see both) call for
an appointment.
3. alcohol rehab numbers, if so desired. Given the injuries
that resulted from this alcohol-related event, we strongly
suggest it.
Name: [**Known lastname 464**],[**Known firstname **] Unit No: [**Numeric Identifier 10837**]
Admission Date: [**2158-1-16**] Discharge Date: [**2158-1-24**]
Date of Birth: [**2081-5-6**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3524**]
Addendum:
Pt stayed in house from [**1-21**] to [**1-24**] because rehab required
24hrs without sitter and without restraints which was
accomplished [**1-22**]. Pt discharged to acute rehab [**1-24**] alert and
oriented x 2 and stable from his head injury.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 2314**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2207**] MD [**MD Number(1) 3525**]
Completed by:[**2158-2-17**]
|
[
"873.0",
"852.00",
"305.01",
"831.04",
"401.9",
"E880.9",
"E849.7",
"922.32",
"291.0",
"285.9",
"E884.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
9548, 9785
|
4952, 6515
|
382, 389
|
7793, 7810
|
1092, 4929
|
8194, 9525
|
663, 668
|
6628, 7516
|
7640, 7772
|
6541, 6605
|
7834, 8171
|
683, 1073
|
274, 344
|
417, 535
|
557, 571
|
587, 647
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,469
| 109,282
|
31315
|
Discharge summary
|
report
|
Admission Date: [**2121-12-26**] Discharge Date: [**2122-1-2**]
Date of Birth: [**2065-9-27**] Sex: M
Service: MEDICINE
Allergies:
Bactrim / Ambien
Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
Intubation/Extubation
Diagnostic paracentesis
History of Present Illness:
56 y/o M with HCV cirrhosis with portal hypertension,portal
hypertensive gastropathy, ascites with recurrent paracenteses (
last [**12-10**]) and encephalopathy transferred from an OSH initial
presenting with altered mental status. According to the OSH
notes the patient's mental status has been gradual declining [**5-12**]
days preadmission. His wife was giving increasing doses of
lactulose last night and patient was having bowel movements,
though was sleepy. He was found to be obtunded on the day of
admission and EMS was called, at arrival to the OSH he was
intubated for airway protection and sedated with Vecuronium. The
patient was given lactulose and zosyn . He recieved a CT of the
head which was negative. Patient thought to have UTI leading to
hepatic encephalopathy at the OSH. Ammonia level was up to 230
at OSH. On transfer to [**Hospital1 **] he became agitated was given 2mg Push
of IV Midazolam.
.
Of note according to the patient's wife he has been taking "more
and more" oxycodone recently, last time being [**Hospital1 766**], (his wife
took away his oxycodone at that time) because of increasing back
pain. He took approx. 30 pills in [**3-12**] days according to his
wife. [**Name (NI) 766**] night he was disoriented and confused. He also was
constipated for approx. 3 days until teus morning when his wife
start making sure he was taking his lactulose and his BM
stabilized at 3-4/day. During the last three days pre-admission
he has been oriented and interactive though sleepy. His wife
found him this morning obtunded and unresponsive. She denies he
has had any fevers or cough in the last few days. Of note last
week the patient felt nauseous for 2 days and vomtited a unknown
number of times with worsening back pain. The nausea and back
pain improved with oxycodone.
.
In the ED, initial vs were: Temp:98.2 HR:130 BP:156/110 Resp:16
O(2)Sat:100 intubated RR 24, O2Sat 100% on AC 500x16 PEEP 5
.
Patient received a diagnostic paracentesis to assess for SBP
which was negative. He also recieved 30g Lactulose X 1.
.
On the floor, Vitals: T:98.8 BP:149/71 P:105 R:23 18 O2: 100% ,
the patient was intubated and a ABG was obtained. The patient
was switched to pressure support from assist control.
.
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,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
- Hepatitis C genotype 1, on liver transplant list,
non-responder to pegylated interferon and ribavirin
- Pulmonary embolism (diagnosed [**12-16**]), on warfarin until [**5-/2121**]
- Hypertension
- Depression
- Anxiety
- Migraines
- Cellulitis
- Obesity
- Left ankle fracture
- Colonic polyps
- L2+L3 compression fractures, s/p kyphoplasty
Social History:
- Employment: Case manager at the VA, working with dual
diagnosis and substance abuse counseling
- Spent years in and out of jail for selling drugs
- Tobacco: Smoked 1ppd age 11 to 25
- EtOH: Former heavy use. Last drink was [**11/2110**]
- Illicits: Marijuana, PCP, [**Name10 (NameIs) 57131**], LSD, and heroin in the
past. Sober since [**2110**].
- Married to wife [**Name (NI) **] (RN)
Family History:
No family members have experienced fevers in the past few weeks,
although children have had several tick bites. Father deceased
(48 [**Name2 (NI) 1686**]) from emphysema and mother deceased from 'old age.' No
family history of malignancy.
Alcoholism in several family members.
Physical Exam:
On admission:
VS: T=100.9, BP=128/66, HR=95, RR=18, O2 sat=97% RA
GENERAL: well-appearing middle aged male in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 8 cm
CARDIAC: RRR, normal S1, S2. No m/r/g.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. Liver edge palpable with slight ttp.
EXTREMITIES: No c/c/e.
SKIN: No rash appreciated near bite sites (right clavicle and
midline abdomen).
Pertinent Results:
On admission:
[**2121-12-26**] 08:57AM BLOOD WBC-8.4 RBC-4.35* Hgb-11.2* Hct-33.4*
MCV-77* MCH-25.7* MCHC-33.5 RDW-18.6* Plt Ct-66*
[**2121-12-26**] 08:57AM BLOOD Neuts-84.7* Lymphs-8.7* Monos-4.4 Eos-1.7
Baso-0.5
[**2122-1-2**] 05:00AM BLOOD WBC-1.8* RBC-3.17* Hgb-8.6* Hct-24.9*
MCV-79* MCH-27.0 MCHC-34.3 RDW-18.4* Plt Ct-26*
[**2122-1-1**] 07:12AM BLOOD Neuts-61 Bands-0 Lymphs-27 Monos-7 Eos-5*
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2122-1-1**] 07:12AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-3+
Macrocy-NORMAL Microcy-3+ Polychr-NORMAL Ovalocy-3+ Tear
Dr[**Last Name (STitle) 833**].
[**2121-12-26**] 08:57AM BLOOD PT-15.1* PTT-28.8 INR(PT)-1.3*
.
[**2121-12-26**] 08:57AM BLOOD Glucose-151* UreaN-20 Creat-1.3* Na-136
K-5.2* Cl-103 HCO3-25 AnGap-13
[**2121-12-30**] 03:10PM BLOOD Glucose-84 UreaN-20 Creat-1.7* Na-134
K-4.3 Cl-100 HCO3-29 AnGap-9
[**2121-12-31**] 05:10AM BLOOD Glucose-101* UreaN-20 Creat-1.5* Na-138
K-3.7 Cl-102 HCO3-28 AnGap-12
[**2122-1-1**] 07:12AM BLOOD Glucose-85 UreaN-20 Creat-1.4* Na-138
K-3.8 Cl-105 HCO3-25 AnGap-12
[**2122-1-2**] 05:00AM BLOOD Glucose-93 UreaN-19 Creat-1.3* Na-132*
K-3.9 Cl-104 HCO3-24 AnGap-8
.
[**2121-12-26**] 08:57AM BLOOD ALT-50* AST-60* AlkPhos-182* TotBili-1.9*
[**2121-12-26**] 08:57AM BLOOD Lipase-38
[**2121-12-26**] 08:57AM BLOOD Albumin-3.8 Calcium-8.8 Phos-4.2 Mg-2.3
[**2121-12-28**] 03:10AM BLOOD calTIBC-386 Hapto-51 Ferritn-27* TRF-297
[**2121-12-26**] 10:50AM BLOOD Ammonia-131*
.
[**2121-12-26**] 08:57AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
[**2121-12-26**] 05:38PM BLOOD Type-ART Temp-37.1 Tidal V-700 PEEP-5
FiO2-50 pO2-107* pCO2-35 pH-7.44 calTCO2-25 Base XS-0
Intubat-INTUBATED
[**2121-12-26**] 09:40AM BLOOD Lactate-2.4*
[**2121-12-26**] 05:38PM BLOOD freeCa-1.11*
.
[**2121-12-26**] 09:50AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.029
[**2121-12-26**] 09:50AM URINE Blood-LG Nitrite-NEG Protein-75
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR
[**2121-12-26**] 09:50AM URINE RBC-[**12-27**]* WBC-0-2 Bacteri-MOD Yeast-NONE
Epi-0-2
[**2121-12-26**] 09:50AM URINE Mucous-RARE OvalFat-MOD
[**2121-12-26**] 09:50AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
[**Month/Day/Year 57131**]-NEG amphetm-NEG mthdone-NEG
[**2121-12-26**] 09:50AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.029
[**2121-12-26**] 09:50AM URINE Blood-LG Nitrite-NEG Protein-75
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR
[**2121-12-26**] 09:50AM URINE RBC-[**12-27**]* WBC-0-2 Bacteri-MOD Yeast-NONE
Epi-0-2
[**2121-12-26**] 09:50AM URINE Mucous-RARE OvalFat-MOD
[**2121-12-31**] 07:42PM URINE Hours-RANDOM UreaN-539 Creat-137 Na-36
K-49 Cl-11
[**2121-12-31**] 07:42PM URINE Osmolal-410
[**2121-12-26**] 09:50AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
[**Month/Day/Year 57131**]-NEG amphetm-NEG mthdone-NEG.
.
[**2121-12-26**] 09:47AM ASCITES WBC-248* RBC-523* Polys-13* Lymphs-18*
Monos-43* Mesothe-2* Macroph-22* Other-2*
.
[**2122-1-1**] 07:12AM BLOOD PT-16.9* INR(PT)-1.5*
[**2122-1-2**] 11:00AM BLOOD PT-16.7* INR(PT)-1.5*
.
IMAGING
CXR [**2121-12-26**]:
IMPRESSION: Endotracheal and nasogastric tubes in appropriate
position as
detailed above. Very limited evaluation of the lungs given the
profoundly low lung volumes. There is, however, extensive patchy
opacity at the left lung and aspiration versus pneumonia is
highly likely.
.
CT head w/o contrast [**2121-12-26**]:
IMPRESSION: No acute intracranial process. Nasal secretions
likely related
to intubated status.
.
RUQ ultrasound [**2121-12-26**]:
IMPRESSION:
1. Cirrhotic liver. Previously seen liver cyst and enhancing
lesions are not identified on the current study.
2. Patent main portal vein.
3. Stable splenomegaly.
4. Stable thickening of the gallbladder wall, likely secondary
to hyperproteinemic state.
CULTURE DATA
Time Taken Not Noted Log-In Date/Time: [**2121-12-26**] 9:40 am
BLOOD CULTURE TRAUMA/ARREST SET#1.
**FINAL REPORT [**2122-1-1**]**
Blood Culture, Routine (Final [**2122-1-1**]): NO GROWTH.
[**2121-12-26**] 9:47 am PERITONEAL FLUID
TRAUMA/ARREST ,PERITONEAL FLUID..
**FINAL REPORT [**2122-1-1**]**
GRAM STAIN (Final [**2121-12-26**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2121-12-29**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2122-1-1**]): NO GROWTH.
[**2121-12-26**] 9:50 am URINE Site: CATHETER
TRAUMA/ARREST,CATHETER\.
**FINAL REPORT [**2121-12-27**]**
URINE CULTURE (Final [**2121-12-27**]): NO GROWTH.
[**2121-12-26**] 8:55 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2121-12-28**]**
GRAM STAIN (Final [**2121-12-26**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2121-12-28**]):
SPARSE GROWTH Commensal Respiratory Flora.
Brief Hospital Course:
56 y/o M with HCV cirrhosis with portal hypertension, portal
hypertensive gastropathy, ascites with recurrent paracenteses
(last [**12-10**]) and encephalopathy transferred from an OSH with
altered mental status and intubated for airway protection.
.
#Altered Mental status- Given the patient's history hepatic
encephalopathy is the most probable cause. The differential of
this acute encephalopathy includes infection, drug overdose, or
GI bleeding.The patient currently has no signs of GI bleeding.
The patient has been afebrile and currently has no leukocytosis.
On OSH records the patient had a UA indicating a UTI, however on
the UA we obtained the results did not indicate a active UTI.
The patient also has been taking increasing amounts oxycodone in
the last week which is a possible etiology causing his acute
hepatic encephalopathy. He also has evidence of left lung field
opacities which are consistent with pneumonia or aspiration.
Therefore it could have been the patient developed a pneumonia
in the last few days as an outpatient or aspirated recently
given his altered mental status and intubation. He was started
empirically on levofloxacin for PNA this was discontinued after
6 days for pancytopenia. Sputum cx negative. CT head was
negative for acute bleed or stroke and no history consistent
with seizure like activity. All sedative drugs were stopped. He
was stabilized in the MICU and extubated w/o complication, and
transferred to the general liver wards.
He noted to have mild flap on transfer. Patient received a
diagnostic paracentesis to assess for SBP which was negative.
Lactulose and rifaximin restarted. Urine and blood cx negative.
MS continued to improve w lactulose and he reached MS baseline
on the day after transfer out of the MICU with noted resolution
of asterixis at that time as well.
.
#Respiratory Status - The patient was on assist control on
transfer and recently transitioned to pressure support with a
stable ABG after. Will ensure the patient is ventilating
appropiately by following his minute ventilation . Will attempt
to wean off the propofol to assess his mental status more
appropiately. He was extubated successfully on [**12-27**]. Pt was
comfortable on room air at time of transfer to general floor.
.
#Pneumonia- Has X ray evidence with left lung field opacities,
though no leukocytosis or fevers. Could be community acquired or
aspiration as etiology. He was covered w levofloxacin for
empiric pna on [**12-26**] and this antibiotic was discontinued after
6 days for negative sputum, blood, and urine cultures. He also
was asymptomatic. Pt developed pancytopenia 4 days after
initiation of levofloxacin.
.
#Thrombocytopenia- According to our records the patient's
platelet count is typically between 50-100. Platelet count noted
to downtrend 2 days after initiating levofloxacin. He did not
require transfusion of platelets. Would expect resolution of
suppression w abstinence from antibiotics. Plan to monitor on
outpt setting w labs after discharge. Pt was informed to seek
medical attention if febrile, or active bleeding.
.
#Anemia- According to the patient's history he has a microcytic
anemia, and currently is consistent with baseline hematocrit. On
admission pt had no active signs of gastrointestinal bleeding.
He was guaiac negative on general floors. Pancytopenia developed
on [**12-28**] and pt noted to have downtrending Hct [**3-11**] suppression
from levofloxacin. He was transfused 2units of packed RBCs
during his stay w/o any sign of active bleeding. Hct stable at
time of discharge.
.
#Cirrhosis- On admission, this pt was on the transplant list
however given his recent drug use/oxycodone abuse, it was
decided to inactive him at the Tuesday transplant meeting on
[**2121-12-30**]. Pt and family was notified. Pt scheduled for outpt
therapeutic paracentesis in next 2 weeks after discharge. RUQ
u/s shows patency and moderate ascites. No para indicated given
no interval increase in abd girth or ascites and poor amt of
fluid available on [**12-10**] outpt attempt at para.
.
# [**Last Name (un) **]: Acute increase from baseline 1.2 to 1.7 on [**12-30**]
attributed to diuretics, poor po intake prior to admission.
Diuretics were held and he was administered volume challenge
with albumin dosed 1gm/kg x 2 days and 75g x 1 day. Creatinine
downtrended close to baseline at time of discharge. Plan to
follow up at clinic appt. Diuretics were held and plan to assess
and restart at appt f/u w Dr. [**Last Name (STitle) 497**] in 2 weeks.
.
#Substance abuse: Pt admits to abuse of oxycodone prior to
admission. Social work consulted on admission and provided
resources for follow up and referral to transplant psychiatry.
Opioids, narcotics, and benzodiazepines were avoided during his
stay. He was discharged on a temporary amount of seroquel per
inpt psychiatry recommendation prn insomnia. He was advised to
follow up with outpt PCP for assessment and discussion about
further sleep aides. Was advised to avoid any potentially
addictive medications. Consider antidepressant as outpt.
Medications on Admission:
Ergocalciferol (vitamin D2) 50,000 unit Capsule
one Capsule(s) by mouth weekly for 12 weeks [**2121-10-21**]
Furosemide 40 mg Tablet 1.5 Tablet(s) by mouth once a day.
Lactulose 10 gram/15 mL Solution 60 cc(s) by mouth three times a
day.
Lidocaine 5 % (700 mg/patch) Adhesive Patch, Medicated
2 Adhesive(s) DAILY (Daily) Apply one to lower back, one to
mid-back. Leave on 12 hours, off 12 hours.
Midodrine 5 mg Tablet 1 [**2-8**] Tablet(s) by mouth 3 times a day
Oxycodone 5 mg Capsule 1 Capsule(s) by mouth four times per day.
Potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
1 Tab(s) by mouth once a day
Rifaximin [Xifaxan] 550 mg Tablet 1 Tablet(s) by mouth twice a
day [**2121-10-15**]
Spironolactone 50 mg Tablet 3 Tablet(s) by mouth once a day
Testosterone [AndroGel] 1.25 gram per Actuation (1 %) Gel in
* OTCs *
Calcium carbonate-vitamin D3
500 mg (1,250 mg)-400 unit Tablet
1 Tablet(s) by mouth twice a day
Magnesium oxide 400 mg Tablet 2 Tablet(s) by mouth twice a day
Discharge Medications:
1. Calcium 500 With D 500 mg(1,250mg) -400 unit Tablet Sig: One
(1) Tablet PO twice a day.
2. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. midodrine 2.5 mg Tablet Sig: Three (3) Tablet PO three times
a day.
5. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day).
6. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Opioid overdose
Hepatic encephalopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for altered mental status that
appear related to the oxycodone you ingested. You were also
confused which is likely related to constipation secondary to
the painkillers. You required admission to the intensive care
unit for monitoring and were given antibiotics for a presumed
pneumonia found on chest xray.
You will need to continue these oral medications for a full 7
day course (day 1 on [**12-26**]).
.
For your recent substance abuse, social work was consulted and
they have provided you with resources for recovery and
rehabilitation. It is essential that you abstain from drug and
alcohol abuse given your significant liver disease.
.
The following changes were made to your medications:
Restarted midodrine for your kidneys and blood pressure.
Stopped oxycodone, sedatives
Stopped lasix and spironolactone (water pill)
Started seroquel to assist in sleep. You received a temporary
supply, any sleep aides, painkillers, or other potentially
addictive medications will need to be managed by one physician.
[**Name10 (NameIs) 357**] address this issue with your PCP.
.
It is important that you avoid any addictive medications
including sedatives, opioids/high potency painkillers, or
benzodiazepines.
.
Please follow up with your physicians as stated below.
*You need to make an appt with your pcp for sometime in the next
week.*
Followup Instructions:
Department: TRANSPLANT
When: WEDNESDAY [**2122-1-7**] at 1:20 PM
With: TRANSPLANT [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2122-6-17**] at 11:40 AM
With: [**First Name11 (Name Pattern1) 3972**] [**Last Name (NamePattern4) 3973**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]
|
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54,613
| 180,028
|
50511
|
Discharge summary
|
report
|
Admission Date: [**2140-9-19**] Discharge Date: [**2140-9-29**]
Date of Birth: [**2064-11-4**] Sex: M
Service: MEDICINE
Allergies:
Lovenox
Attending:[**First Name3 (LF) 3256**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Discussed patient w primary team resident. In brief, this is a
75yo M PMHx DM, ESRD on HD, anoxic brain injury, recent
hospitalization for PNA presenting now w AMS. Patient was
recently admitted [**Date range (1) 5356**] with chief complaint AMS, was found
to have a Rsided consolidation, treated for HCAP with vanco and
cefepime w subsequent improvement in mental status. Of note,
patient did not ever demonstrate objective signs of systemic
infection on that admission (no fever, leukocytosis). Per
report, after discharge to rehab facility, patient was noted to
have leaking stools in diaper. At scheduled HD session today,
patient reported to have AMS and was referred to [**Hospital1 18**] ED after
completion of HD.
.
In ED initial vital signs were 88 192/87 16 100%10LNRB. He
triggered for AMS. Workup was notable for FS 139, unchanged
NCHCT. UA demonstrated 10 WBCs, few bacteria. CXR w/o acute
changes. Patient was given cipro for presumed UTI and was
admitted to medicine service. Vital signs prior to transfer
from ED were 99.8 100 215/85 17 100%RA. On arrival to the floor
patient was noted to have SBP 210s and was non-verbal. SBP
improved to 200 w nitropaste. Patient was evaluated by ICU
resident for persistent HTN and possible AMS.
.
In the ICU, patient denied CP, SOB, HA, dizziness. Given
limited responsiveness, review of systems was limited, however
he denied
cough, shortness of breath, chest pain, abdominal pain, nausea.
Past Medical History:
- CKD stage V, on HD MWF
- HTN
- DM II
- Anoxic brain injury
- Severe peripheral neuropathy
- Glaucoma
- Depression
Social History:
Lives at [**Hospital3 537**] in JP.
niece/HCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (3) 105203**] 043
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.5 89 187/79 16 100%RA
General: tonic/clonic jerking, moaning yes or no answers
HEENT: PERRL, Sclera anicteric, MM dry
Neck: supple, no JVD, no LAD
Lungs: CTA bilaterally, no wheezes, rales, ronchi
CV: RRR, II/VI systolic murmur at apex
Abdomen: Soft, NT/ND, no rebound/guarding, naBS
GU: +Foley
Ext: WWP, 2+ pulses, no c/c/e, +LUE fistula c/d/i
NEURO: AOx1, follows directions slowly, exam limited by ability
to comply, 2+ patellar reflexes
.
DISCHARGE PHYSICAL EXAM:
T: 98.4 (Tm 99.4) HR 73 (70s-80s) BP 178/pulse
(118-178/pulse-76)
RR 20 SaO2 100% RA (96-100%RA)
FSBS: <-[9H]- 302 <-[2H]- 203 <-[9H]- 313 <-[12H]- 445 <-[6H]-
263
General: NAD, answers questions and follows instructions
HEENT: MMM, +cataracts, PERRL, clear oropharynx without tongue
plaque
Neck: supple, no carotid bruits, flat neck veins
Lungs: Anteriorly, slightly diminished breath sounds at b/l
bases, end-inspiratory rales at bases bilaterally
CV: RRR, continuous murmur at LSB louder in systole to III/VI at
LLSB.
Abdomen: Soft, NT/ND, no rebound/guarding, normactive bowel
sounds Ext: WWP, 2+ DP, no c/c/e, +LUE fistula audible w/
palpable thrill NEURO: Following commands. Open eyes and mouth,
squeezes them closed when examiner tries to open them. Squeezes
examiner's hands bilaterally.
Pertinent Results:
ADMISSION LABS
[**2140-9-19**] 11:45PM GLUCOSE-204* UREA N-22* CREAT-4.6* SODIUM-137
POTASSIUM-3.6 CHLORIDE-93* TOTAL CO2-29 ANION GAP-19
[**2140-9-19**] 11:45PM CK(CPK)-129
[**2140-9-19**] 11:45PM CK-MB-4 cTropnT-0.31*
[**2140-9-19**] 11:45PM CALCIUM-9.5 PHOSPHATE-3.3 MAGNESIUM-2.2
[**2140-9-19**] 11:45PM WBC-8.7 RBC-3.83* HGB-9.6* HCT-30.9* MCV-81*
MCH-25.1* MCHC-31.2 RDW-17.8*
[**2140-9-19**] 11:45PM PLT COUNT-296
[**2140-9-19**] 07:15PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2140-9-19**] 07:15PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.011
[**2140-9-19**] 07:15PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-300
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-LG
[**2140-9-19**] 07:15PM URINE RBC-51* WBC-10* BACTERIA-FEW YEAST-NONE
EPI-0
[**2140-9-19**] 03:05PM LACTATE-1.1 K+-3.4*
[**2140-9-19**] 03:00PM ALT(SGPT)-15 AST(SGOT)-20 ALK PHOS-97 TOT
BILI-0.3
[**2140-9-19**] 03:00PM LIPASE-13
[**2140-9-19**] 03:00PM WBC-8.3# RBC-4.08* HGB-10.1* HCT-32.2*
MCV-79* MCH-24.8* MCHC-31.4 RDW-17.8*
[**2140-9-19**] 03:00PM NEUTS-82.9* BANDS-0 LYMPHS-10.3* MONOS-5.4
EOS-1.1 BASOS-0.3
[**2140-9-19**] 03:00PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-OCCASIONAL
MACROCYT-2+ MICROCYT-OCCASIONAL POLYCHROM-1+
SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL
[**2140-9-19**] 03:00PM PT-12.0 PTT-27.3 INR(PT)-1.0
.
DISCHARGE LABS
[**2140-9-29**] 06:29AM BLOOD WBC-6.7 RBC-3.28* Hgb-8.3* Hct-26.0*
MCV-79* MCH-25.4* MCHC-32.1 RDW-16.1* Plt Ct-251
[**2140-9-29**] 06:29AM BLOOD Glucose-113* UreaN-18 Creat-3.5*# Na-140
K-3.4 Cl-95* HCO3-37* AnGap-11
[**2140-9-29**] 06:29AM BLOOD Calcium-8.9 Phos-4.1 Mg-1.9
[**2140-9-28**] 07:13AM BLOOD Vanco-17.5
.
MICROBIOLOGY:
MRSA screen [**2140-9-19**]: No MRSA isolated.
Urine culture [**2140-9-20**]: No growth.
Urine culture [**2140-9-22**]: No growth.
Blood culture [**2140-9-22**]: No growth.
Blood culture [**2140-9-23**]: Pending.
Blood culture [**2140-9-27**]: Pending.
Blood culture [**2140-9-27**]: Pending.
C. difficile antigen [**2140-9-28**]: Negative.
.
IMAGING
CXR [**2140-9-19**] - No acute cardiopulmonary processes
.
CT head non-contrast [**2140-9-19**] - Evaluation is severely limited
due to motion artifact. However, there is no evidence of acute
intracranial hemorrhage, edema, shift of normally midline
structures, or large vascular territorial infarction. Again is
prominence of the ventricles and sulci, consistent with
age-related cortical atrophy. No acute fractures are noted.
However, fluid is again noted throughout bilateral sphenoid
sinuses, greater on the left than the right. The remainder of
the visualized paranasal sinuses and mastoid air cells are
clear.
IMPRESSION: Severely limited study due to motion artifact, but
no gross
intracranial injury.
.
CXR [**2140-9-22**]: As compared to the prior examination, an
esophageal catheter has been advanced with side port now just
beyond the gastroesophageal junction. A right-sided PICC is
unchanged with tip reaching the mid-to-low SVC. No new focal
parenchymal opacity is seen. No pleural effusion or
pneumothorax. The cardiomediastinal silhouette is unchanged.
Surgical clips projecting over tthe mid abdomen are unchanged.
.
CXR [**2140-9-24**]: As compared to the previous radiograph, there is
a subtle newly appeared opacity at the right lung base. This
opacity could represent recent aspiration. Otherwise,
unremarkable appearance of the lung parenchyma. No pulmonary
edema. No pleural effusions. No pneumothorax. Normal course of
the monitoring and support devices.
.
CXR [**2140-9-25**]: Bibasilar consolidations have worsened, consistent
with worsening bilateral aspiration pneumonia. There is no
evident pneumothorax or large pleural effusions.
Cardiomediastinal contours are normal. NG tube tip is in the
stomach. Right PICC is in standard position. Multiple surgical
clips project in the upper mid abdomen.
.
CXR [**2140-9-27**]: Bibasilar consolidations have slightly increased.
No pleural effusion, pneumothorax, or pulmonary edema is seen.
The cardiomediastinal silhouette is within normal limits. Right
PICC is unchanged with tip in SVC. An esophageal catheter has
been removed. Multiple surgical clips project over the upper and
mid abdomen.
.
RELEVANT STUDIES:
EEG [**2140-9-19**]: This EEG continues to give evidence for a moderate
diffuse encephalopathy. There were no clear focal or
lateralizing features. There was some suggestion of cycling
although that may just be part and parcel of the more diffuse
encephalopathy. No clear epileptic activity identified.
Brief Hospital Course:
Mr. [**Known lastname 1058**] is a 75 year old gentleman, with a past medical
history of DM, ESRD on HD, anoxic brain injury and recent
hospitalization for PNA, presented with uncontrolled
hypertension, encephalopathy and shaking motions, who was
initially admitted to the ICU with a question of hypertensive
urgency, then stabilized and was transferred to the floor. His
hospital course was complicated by aspiration pneumonia and high
blood glucose.
.
.
Active issues:
# Uncontrolled hypertension - Initially had question of
hypertensive urgency. The patient was admitted with SBP 215
requiring transfer to ICU; given HD on day of admission unlikely
volume overload; likely secondary to medications not being
administered prior to HD or after (as he was in ED). Since his
altered mental status was thought to be related to high blood
pressure, hypertension was initially controlled aggressively
with IV hydralazine, while his home PO regimen of amlodipine,
lisinopril, isosorbide dinitrate and carvedilol was held. After
the patient was transferred to the floor, an NG tube was placed,
and home blood pressure medications were administered through
NG, after which pt had adequate blood pressure control. After
removal of NGT, the patient was able to tolerate PO
antihypertensives and blood pressure was better-controlled.
Additionally, ultrafiltration of several hundred CCs during
hemodialysis sessions relieved volume overload and helped
stabilize blood pressures.
.
# Encephalopathy with shaking motions - Patient with an anoxic
brain injury, with baseline AOx1, presented with concern for
encephalopathy in setting of hypertension and shaking motions;
concern initially for hypertensive encephalopathy, but did not
resolve with improved BP; seizure activity considered, but
24-hour video EEG monitoring showed no evidence of seizures, and
likelihood low given occurrence only when patient was talking;
no focal neuro signs or acute process on non-contrast head CT;
no focal infection to suggest toxic metabolic; no new
medications changes and Utox negative making drug effect
unlikely; per discussion with HCP, patient has had subacute
onset of AMS and increased lethargy. The patient was initially
NPO given altered mental status, then transitioned to thin
liquids and pureed solids per speech and swallow, but switched
back to NPO as pt had new bilateral lower lobe opacities
concerning for aspiration pneumonia. During his course on the
floor, the patient's mental status gradually improved, as he was
treated with empiric broad-spectrum antibiotics (vanc/Zosyn) for
aspiration pneumonia. At the time of discharge, he was no
longer tremulous, and he was able to participate in
conversations with full sentences. His olanzapine and
gabapentin were held during hospital course given concern for
altered mental status and discontinued upon discharged.
.
# Bilateral lower lobe pneumonias - During his hospital course,
the patient developed bilateral lower lobe consolidations after
an NG tube had been placed for administration of PO meds during
waxing and [**Doctor Last Name 688**] mental status. He was treated with a
seven-day course of intravenous vancomycin and Zosyn for empiric
broad coverage of aspiration pneumonia. His oxygen saturations
and low-grade fevers improved. At time of discharge, he was
afebrile with oxygen saturation in the 90s on room air.
.
# Labile blood glucose - During admission, the patient was
continued on SS humalog, as he had at home. His blood sugar,
however, was not well-controlled, and he required better
baseline control with glargine. Glargine was started at 5 units
at bedtime along with humalog sliding scale with improvement in
blood sugars.
.
.
Chronic issues:
# Depression - The patient's citalopram and olanzapine were
initially held while he was NPO. Additionally, a Neurology
consultation recommended continuing to hold olanzapine, as it
may have contributed to rigidity that the patient had on
presentation. Thus, only his citalopram was restarted when he
was able to take medications PO.
.
# ESRD on HD - The patient continue hemodialysis three times a
week, with ultrafiltration as tolerated. While he was NPO, his
nephrocaps and sevelamer carbonate were held, but these were
restarted when the patient was able to tolerated PO medications.
.
# Glaucoma - Documented history of this problem. The patient
was continued on his home doses of brimonidine and levobunolol.
.
# Chronic Pain - While he was NPO, the patient's home gabapentin
and acetaminophen were held. His pain was controlled with a
lidocaine patch. Even after the patient was tolerating PO
medications, his gabapentin was held, per advice of Neurology,
since this medication may have contributed to his altered metal
status.
.
# GERD - Omeprazole was initially held while NPO, but then
restarted when he was able to tolerate PO medications.
.
.
Transitional issues:
- Follow up urine cytology and consider bladder
ultrasound/cystoscopy as outpatient. Patient has had persistent
hematuria this and last admission with concerns for possible
underlying bladder cancer
- Full code per discussion w HCP three times during this
admission, will likely need to be readdressed as underlying
process is better evaluated
- Patient will likely benefit from effort to improve
communication at transition of care, as well as disease course
expectations (to help minimize future rehospitalizations)
Medications on Admission:
1. amlodipine 10mg daily
2. lisinopril 40mg daily
3. citalopram 20mg daily
4. isosorbide dinitrate 10 mg TID
5. B complex-vitamin C-folic acid 1 mg daily
6. sevelamer carbonate 800mg [**Hospital1 **] w meals
7. brimonidine 0.2 % Drops [**Hospital1 **]
8. levobunolol 0.25 % [**Hospital1 **]
9. gabapentin 300mg qHD
10. acetaminophen 500mg QOD
11. lidocaine patch daily to left knee
12. omeprazole 20mg daily
13. olanzapine 5mg Tablet, [**Hospital1 **] prn
14. humalog sliding scale
15. cefepime 1g daily ([**9-15**] - [**9-21**])
16. vancomycin 1g qHD ([**9-15**] - [**9-21**])
17. carvedilol 6.25mg [**Hospital1 **]
Discharge Medications:
1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. isosorbide dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
5. levobunolol 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
6. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply
to left knee. 12 hours on, 12 hours off.
7. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO QODHS
(every other day (at bedtime)).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
11. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
12. insulin glargine 100 unit/mL Solution Sig: Five (5) units
Subcutaneous at bedtime. units
13. brimonidine 0.2 % Drops Sig: One (1) drop Ophthalmic twice a
day.
14. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous four
times a day: sliding scale; please see attached.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
Primary
Altered Mental Status
.
Secondary
Hypertensive urgency
Aspiration pneumonia
Chronic renal failure
Diabetes Mellitus II
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 1058**],
It was a pleasure taking care of you while you were in the
hospital. You were admitted to [**Hospital3 **] Hospital [**Hospital1 **]
Center due to confusion after your hemodialysis session and you
were found to have dangerously high blood pressure.
.
We looked for a source of infection, and you were found to have
pneumonia on chest x-ray and your confusion improved as we gave
you antibiotics. Your blood pressure improved when we were able
to give you your home blood pressure medications. Neurology
evaluated you while you were in the hospital, and you did not
have any evidence of seizures when neurology looked at your
brain waves with an EEG.
.
Please continue taking your home medications, along with the
following changes:
1.) START insulin glargine 5 units at bedtime
2.) STOP olanzapine
3.) STOP gabapentin
4.) INCREASE lisinopril to 40mg daily
Followup Instructions:
You will be seen by a doctor at your long-term care facility.
You also have the following eye appointment.
Department: [**Hospital3 1935**] CENTER
When: TUESDAY [**2140-10-18**] at 10:30 AM
With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"356.9",
"285.9",
"507.0",
"348.1",
"250.00",
"V45.11",
"403.91",
"780.97",
"365.9",
"599.0",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
15460, 15531
|
8077, 8534
|
290, 296
|
15702, 15702
|
3460, 8054
|
16799, 17250
|
2106, 2125
|
14168, 15437
|
15552, 15681
|
13527, 14145
|
15882, 16776
|
2165, 2615
|
12982, 13501
|
229, 252
|
8549, 11784
|
324, 1784
|
15717, 15858
|
11800, 12961
|
1806, 1924
|
1940, 2090
|
2640, 3441
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,838
| 105,075
|
38453+58225
|
Discharge summary
|
report+addendum
|
Admission Date: [**2175-1-26**] Discharge Date: [**2175-2-3**]
Date of Birth: [**2110-9-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest pain, progressive DOE
Major Surgical or Invasive Procedure:
[**2175-1-26**] Cardiac cath
[**2175-1-27**] Coronary artery bypass grafting x5, with the left
internal mammary artery to left anterior descending artery, and
reverse saphenous vein graft to the posterior descending artery,
diagonal artery, and sequential reverse saphenous vein graft to
the first and second obtuse marginal artery.
History of Present Illness:
64 yo Chinese man (Mandarin) with a history CAD, s/p prior
attempt of RCA stenting in [**2167-11-9**] while in [**Country 651**]
complicated by dissection and subsequent IMI, now with angina at
very low exertion. A stress MIBI completed in [**2174-11-8**]
demonstrated a moderated inferior wall defect with partial
reversibility and hypokinesis. His ECG demonstrated prior
inferoposterior MI with inferior Q waves and tall R waves. He
has continued to experience chest pain since his MI, which
occurs only with exertion usually after walking 5 minutes at a
slow pace and sooner if he walks briskly. He has not had to use
nitroglycerin and it resolves with rest. He also reports a rapid
heart beat when he has the chest pain, but can occur without the
chest pain. He denies any lower extremity edema, orthopnea, PND,
dyspnea on exertion, palpitations, lightheadedness, dizziness,
presyncope, or syncope. He was admitted today for left heart
catherization and found to have 3 vessel disease. Csurg was
consulted for evaluation for CABG.
Past Medical History:
Coronary artery disease s/p Mycoardial infarction
Diabetes Mellitus
Hypertension
Dry skin
Right lower leg injury
Mild CVA
Social History:
Race: Chinese (Mandarin speaking)
Last Dental Exam:over two year ago, permanent upper partial,
lower permanent dentures
Lives with: He emigrated 2 years ago from [**Country 651**]. He is a
retired teacher and lives in [**Location 27256**] with his wife and
daughter [**Name (NI) **]. His daughter speaks [**Name2 (NI) 483**].
Contact: daughter [**Name (NI) **] [**Name (NI) **] (cell) [**Telephone/Fax (1) 85591**]
Occupation: Retired teacher
Cigarettes: Smoked no [x] yes [x] last cigarette _1998____ Hx:
Other Tobacco use:none
ETOH: < 1 drink/week [x] [**2-14**] drinks/week [] >8 drinks/week []
Illicit drug use - none
Family History:
No history of premature CAD or sudden cardiac death.
Physical Exam:
Pulse:80 SR Resp: 16 O2 sat:98% on RA
B/P Right: Left:135/73
Height:5'4" Weight: 175#
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 [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ []last BM [**1-26**]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: yes left lower leg
Neuro: Grossly intact [x]through interpreter
Pulses:
Femoral Right:+2 Left:+2
DP Right:+2 Left:+2
PT [**Name (NI) 167**]:doppler Left:Doppler
Radial Right: +2 Left:+2
Pertinent Results:
[**2175-1-26**] Cardiac cath:
Left ventriculography: mitral regurgitation; LVEF %;
Coronary angiography: right dominant
LMCA: No angiographically-apparent CAD.
LAD: Mid vessel long 60-70% stenosis. Origin diagonal 40%.
LCX: Proximal 50% before large OM1. Lower pole large OM1 with
focal 80% stenosis and upper pole origin 50% stenosis,
RCA: Proximal 20%, distal diffuse total occlusion with faint
right to right collaterals and left to right collaterals
robustly fill the PDA retrogradely where there is a mid vessel
50% lesion.
.
[**2175-1-26**] Carotid U/S: Right ICA <40% stenosis. Left ICA <40%
stenosis.
.
[**2175-1-27**] Echo: PREBYPASS: Normal LV systolic function with LVEF >
55%, no segemental wall motion abnormalities. The left atrium is
normal in size. Left ventricular wall thicknesses and cavity
size are normal. 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
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no pericardial effusion. Normal coronary sinus. Intact IAS. No
clot seen in LAA.
POSTBYPASS: Preserved LV systolic function. No segmental wall
motion abnormalities. No dissection seen after aortic cannula
removed. Otherwise unchanged.
.
[**2175-1-31**] CXR: Heart size is normal. Mediastinal silhouette is
stable. There is improved aeration of the left lower lobe with
minimal area of atelectasis present. There is no pneumothorax
and appreciable pleural effusion demonstrated. No pulmonary
edema is seen. Wedge compression fractures are noted on the
lateral view, unchanged since [**2175-1-26**].
Brief Hospital Course:
Mr. [**Known lastname **] was admitted following his cardiac cath which revealed
severe three vessel coronary artery disease. He underwent
pre-operative work-up after cath and on [**1-27**] he was brought to
the operating room where he underwent a coronary artery bypass
graft x 5. Please see operative report for surgical details. He
was then transferred to the CVICU for invasive monitoring in
stable condition. Within 24 hours he was weaned from sedation,
awoke neurologically intact and extubated. Patient remained in
the ICU for several days for aggressive pulmonary toilet. In
addition had periods of agitation and confusion but resolved
quickly and never had any focal deficits. On post-op day three
he was transferred to the step-down unit for further care. Chest
tubes and epicardial pacing wires were removed per protocol. He
worked with physical therapy for strength and mobility. Over
next couple of days he appeared to be doing well and was
discharged to home on post-op day five with the appropriate
medications and follow-up appointments. He does not have
insurance to cover VNA services and will contact office
immediately of any concerns.
Medications on Admission:
ISOSORBIDE MONONITRATE 30 mg once a day
LOSARTAN 50 mg Tablet once a day
METFORMIN 1500 mg Tablet Extended Release once a day
METOPROLOL SUCCINATE 50 mg Tablet Extended Release daily
SIMVASTATIN 20 mg Tablet once a day
ASPIRIN 325 mg Tablet once a day
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. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. metformin 500 mg Tablet Extended Release 24 hr Sig: Two (2)
Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*60 Tablet Extended Release 24 hr(s)* Refills:*2*
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
10 days.
Disp:*10 Tablet(s)* Refills:*0*
7. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO BID (2 times a day) for 10 days.
Disp:*40 Tablet Extended Release(s)* Refills:*0*
8. Ultram 50 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 5
Past medical history:
s/p Mycoardial infarction
Diabetes Mellitus
Hypertension
Dry skin
Right lower leg injury
Mild CVA
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema Trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**2175-3-9**] at 3:45p
Cardiologist: Dr. [**Last Name (STitle) 171**] on [**2175-3-8**] at 2:40p
Wound check: [**Hospital Unit Name **], [**Hospital Unit Name **] on [**2175-2-9**] at 10:45a
Please call to schedule appointments with your
Primary Care Dr. [**First Name9 (NamePattern2) **] [**Name (STitle) 437**] in [**4-13**] 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:[**2175-2-1**] Name: [**Known lastname **],[**Known firstname 13593**] Unit No: [**Numeric Identifier 13594**]
Admission Date: [**2175-1-26**] Discharge Date: [**2175-2-3**]
Date of Birth: [**2110-9-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 135**]
Addendum:
Mr.[**Known lastname **] was kept in the hospital for confusion, impulsivity, an
episode of hypotension in which further observation was
warranted. Narcotics were discontinued. His lasix was stopped
and beta-blocker decreased. He continued to progress and on
POD# 7 Dr.[**Last Name (STitle) **] cleared him for discharge to home. All follow up
appointments were advised.
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**]
Completed by:[**2175-2-3**]
|
[
"V70.7",
"413.9",
"401.9",
"414.01",
"V15.82",
"780.09",
"250.00",
"458.29",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.14",
"36.15",
"39.61",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
10455, 10617
|
5144, 6301
|
337, 671
|
7911, 8134
|
3287, 5121
|
9057, 10432
|
2538, 2593
|
6603, 7658
|
7708, 7769
|
6327, 6580
|
8158, 9034
|
2608, 3268
|
270, 299
|
699, 1735
|
7791, 7890
|
1896, 2522
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,469
| 193,149
|
6328+55745
|
Discharge summary
|
report+addendum
|
Admission Date: [**2167-7-12**] Discharge Date: [**2167-7-15**]
Date of Birth: [**2100-4-6**] Sex: F
Service:
Ms. [**Known lastname 24483**] has had the chief complaint of nausea and
vomiting for two days. She is a 67-year-old woman with a
past medical history of congestive heart failure, ejection
fraction approximately 17% with multiple medical problems,
including myocardial infarction status post coronary artery
bypass graft in [**2155**], as well as peripheral vascular disease,
status post left lower extremity bypass graft, peptic ulcer
disease, anemia, osteomyelitis, status post left
calcanectomy, left foot and recurrent cellulitis of lower
extremities. She presented to the Emergency Department with
nausea and vomiting x2 days. Emesis was biliary, positive
nausea, vomiting, after eating. Fingerstick showed blood
sugar 119 to 110, fever to 102??????.
The patient was alert and oriented x3, but the blood pressure
was noted to be 83/28 in the Emergency Department. She was
given 500 cc of bolus of normal saline without increase in
her blood pressure. She was then given 1 liter of normal
saline without increase in blood pressure. The patient was
then started on Dopa 5 mcg with increased blood pressure
100/60. The patient was initially given ceftriaxone and
Flagyl for broad coverage in the Emergency Department. The
patient also received Zofran and droperidol for nausea and
vomiting.
PAST MEDICAL HISTORY:
1. Congestive heart failure, ejection fraction 17%, moderate
mitral regurgitation, moderate to sever tricuspid
regurgitation
2. Myocardial infarction status post coronary artery bypass
graft in [**2155**]
3. Peripheral vascular disease status post left lower
extremity bypass graft with stenting and percutaneous
transluminal coronary angioplasty of that graft in [**4-/2167**]
4. Anemia
5. Peptic ulcer disease
6. Osteomyelitis
7. Cerebrovascular accident in '[**57**] and '[**61**]
8. Diabetes mellitus
9. Diabetes tryopathy
10. Retinopathy
11. Neuropathy
12. Retinopathy
13. Status post trach secondary to subglottic stenosis in
[**2162**]
14. Recurrent cellulitis secondary to chronic left heel ulcer
15. Chronic renal insufficiency with baseline creatinine of
1.5 to 1.8
PHYSICAL EXAM IN EMERGENCY DEPARTMENT:
VITAL SIGNS: Temperature 100.2??????, heart rate 67, blood
pressure 80s/30s going up to 100/60, respiratory rate 20, 97%
on room air
GENERAL: Ill appearing, obese female in no acute distress,
alert and oriented x3.
HEAD, EARS, EYES, NOSE AND THROAT: Right surgical pupil.
Neck supple. No icterus. Positive tracheotomy.
CARDIOVASCULAR: No murmurs, rubs or gallops, S1, S2.
LUNGS: Bibasilar crackles, but otherwise were clear to
auscultation.
ABDOMEN: Soft, nontender, nondistended, positive bowel
sounds.
EXTREMITIES: Bilateral left lower extremity ulcers, no
purulent changing. The patient had a left foot ulcer and
pink muscle below can be visualized.
RECTAL: Guaiac negative per Emergency Department.
ALLERGIES: THE PATIENT IS ALLERGIC TO CODEINE AND MORPHINE.
MEDICATIONS:
1. NPH 50 units subcutaneous [**Hospital1 **] with regular insulin
sliding scale
2. Lipitor 10 mg q hs
3. Aspirin 325 qd
4. Digoxin 0.125 q hs
5. Iron sulfate 325 qd
6. Hydralazine 25 qid
7. Prilosec 20 qd
8. Metoprolol XL 25 [**Hospital1 **]
9. Lasix 40 qd
10. Nitroglycerin patch 0.2%
The patient was admitted to SICU at the [**Hospital Ward Name 516**]. She was
found to have a urinary tract infection with Escherichia coli
greater than 100,000 colonies forming in it. Urinary tract
infection and gram positive cocci in her blood, 2 of 4
bottles, which at the current time have been identified as
being coagulase negative. Final identification and
sensitivities are pending. The patient ruled in for non Q
wave myocardial infarction as well, having CPKs of 197 and
troponin of 4.3, peak troponin of 11.6.
SICU COURSE: Dopamine drip was turned off on the 29th.
Blood pressure was systolic blood pressure to 120s. Troponin
trended down to 7.4 and CK to 150 in both and continued to
trend downward. The patient was hemodynamically stable, had
a T-max of 100.7 and at the time of leaving the SICU of 99.
The patient was transferred out of the SICU onto the floor on
the [**9-13**].
ADMISSION LABS: Sodium 134, potassium 4.8, chloride 94,
bicarbonate 24, BUN 36, creatinine 2.0. White count 16.2,
94.9 neutrophils, 11.9 hemoglobin, 35.1 hematocrit. INR 1.2,
PT 12.9, PTT 26.3. Urine cultures - Escherichia coli greater
than 100,000 on [**2167-7-12**]. Urinalysis had moderate leukocyte
esterase, 11 to 20 white blood cells, few bacteria. CKs were
197, 232, 204 and then 150. Troponin 10.6, 11.6 and then
7.4. Digoxin level was 1.3.
DISCHARGE DATE LABS: White blood cell count 5.9, neutrophils
75.2, hematocrit 29.9, hemoglobin 9.1 stable from 9.2 the day
before and 30.4 the day before. Platelet count was 236.
Smear showed hypochromasia and microcytosis. Glucose 153,
BUN 40, creatinine 1.4, sodium 131, potassium 40, chloride
95, bicarbonate 26, anion gap 14, magnesium 2.1. Vancomycin
level on the [**9-14**] was 16.4.
ADMISSION IMAGING: Chest x-ray at the time of admission -
stable cardiomegaly, congestive heart failure, linear
markings in lingula consistent with atelectasis.
Electrocardiogram - sinus bradycardia 63 beats per minute, PR
prolongation, left axis deviation, AV conduction delay. Left
ventricular hypertrophy with poor R-wave compression, no
acute changes from previous studies with exception of
increased ST depression, T-wave #1 with slight increase and
ST depression and T-wave inversion in AVL suggesting possible
lateral ischemia.
HOSPITAL COURSE: The patient is a 67-year-old woman with a
past medical history of myocardial infarction, status post
coronary artery bypass graft, peripheral vascular disease,
status post left bypass graft, congestive heart failure with
an ejection fraction of 17%, diabetes mellitus,
cerebrovascular accident x2, lower extremity cellulitis, foot
ulcer on left foot, osteomyelitis of left calcaneus,
spontaneous left calcanectomy, tracheostomy, chronic renal
insufficiency who presented to [**Hospital1 **] Hospital
with decreased blood pressure resistant to intravenous fluids
with gram negative rods/Escherichia coli and urinary tract
infection with greater than 100,000 colonies forming and
positive cocci and clusters at this time, coagulase negative,
pairs and in clusters in blood cultures was a rule in non
Q-wave myocardial infarction, post troponin, negative MB
fraction of CKs, coronary artery disease, non Q-wave
myocardial infarction. Troponins and CKs are trending down
from peak on the [**9-12**]. The patient was initially on
Lovenox after the acute event. The patient was continued on
Ecotrin 325 po qd, Lopressor 12.5 mg po bid which was
increased to 25 mg po bid.
The patient is not and should not receive ACE inhibitor. She
does not tolerate them due to chronic renal insufficiency.
She is also receiving Lipitor 20 mg po q hs. The patient has
sublingual nitrates prn, is not receiving po nitrates,
Isordil on a regular basis due to slightly low blood
pressure.
Congestive heart failure - The patient is on 40 mg of Lasix
po qd.
Pulmonary - The patient has been saturating well, 96% on 2
liters and weaning her off O2.
Renal - chronic renal insufficiency - The patient's
creatinine has improved since her admission.
Gastrointestinal - Protonix 40 mg po qd
Endocrinology - The patient on NPH insulin currently, to at
full dose at 18 units a.m. and 7 units q hs, will increase to
25 in a.m. and keep the same 7 q hs.
Intravenous ceftriaxone 1 gm intravenous qd for a total of
two weeks. The patient requires 11 more days of treatment
after discharge for urinary tract infection. Vancomycin -
The patient has received doses on the 28th, 29th and 30th.
The patient received 1 gm intravenous. Level was checked on
the 30th. It was 16.4. Her .............. estimated to be
30 at the time. Her renal function is improving and requires
rechecking of the trough level for dosing. That level would
be checked here at the hospital at 4 p.m. a half an hour
before her next scheduled dose. If the patient is discharged
to short term rehabilitation prior to 4 p.m. today, the
patient requires checking of the vancomycin level and dosing
according to that level, probably 1 gm following that level
of the Vancomycin today. Cultures and sensitivities are
pending final identification and sensitivity of the gram
positive rods and pairs and clusters found in her blood. The
vancomycin obviously can be changed go less broad coverage
pending return of those cultures.
Prophylaxis - the patient has been on subcutaneous heparin
5000 units q 12, but has been up walking to the bathroom and
will be receiving rehabilitation in her placement and the
subcutaneous heparin should not be needed in discharge. She
also received Colace and Tylenol prn.
DISCHARGE CONDITION: Good
DISCHARGE MEDICATIONS:
1. Ecotrin 325 mg qd
2. Lopressor 25 mg [**Hospital1 **]
3. Isordil 10 mg po tid, hold if systolic blood pressure is
less than 110
4. Lasix 40 mg po qd
5. Ceftriaxone 1 mg qd x11 days
6. Vancomycin 1 gm qd intravenous for gram positive
bacteremia, pending for today and probably tomorrow. Please
check vancomycin level at 4 p.m. prior to giving patient her
dose of 1 gm today and adjust the dosing tomorrow based on
that level.
7. NPH 25 q a.m., 7 q hs
8. Protonix 40 mg qd
9. Colace 100 mg po bid
10. Tylenol prn for fever and pain
FOLLOW UP LABS THAT NEED TO BE CHECKED TODAY:
1. Culture and sensitivity of the organism here at [**Hospital1 **]. I can be [**Name (NI) 653**], [**Name (NI) **] [**Name (NI) **],
([**Telephone/Fax (1) 24484**], beeper #39-515, and I will gladly look for you
to see if the results have come back from the lab in terms of
the specific identification and sensitivities of the
organism, most likely Staphylococcus epidermis, but we do not
have a positive ID, nor a positive sensitivity on the
organism as of yet.
2. Vancomycin level should be checked today at 4 p.m. prior
to giving the patient 1 gm of vancomycin intravenous today
and then dosing of the vancomycin if she remains should
remains on it should be based on that level that is drawn
today or the patient may be switched to less broad coverage
based on the return if it is Staphylococcus epidermis and it
makes sense that the source would be Staphylococcus epidermis
given not a contaminant for the gram positive cocci given the
lesions on the patient's leg, the scratching and the
cellulitis that she had had. Again, if there are any
questions, please feel free to contact [**Name (NI) **] [**Name (NI) **] at
39-515.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8145**], M.D. [**MD Number(1) 13930**]
Dictated By:[**Last Name (NamePattern1) 24485**]
MEDQUIST36
D: [**2167-7-15**] 11:22
T: [**2167-7-15**] 14:13
JOB#: [**Job Number 24486**]
Name: [**Known lastname 4156**],[**First Name3 (LF) 4157**] Unit No: [**Unit Number 4158**]
Admission Date: Discharge Date: [**2167-7-15**]
Date of Birth: Sex:
Service:
DISCHARGE MEDICATIONS:
1. Lopressor 25 mg PO b.i.d. hold for systolic blood
pressure less than 100, heart rate less than 55.
2. Lasix 40 mg p.o.q.d.hold for systolic blood pressure less
than 100.
3. Ecotrin 325 mg p.o.q.d.
4. Protonix 40 mg p.o.q.d.
5. Lipitor 20 mg p.o.q.h.s.
6. Insulin NPH 25 units subcutaneously IV q.a.m.; 7 units
subcutaneously IV q.h.s..
7. Ceftriaxone 1 gram IV q.d. times 11 days.
8. Vancomycin one gram IV q.d. times one day. The dose is
based on a Vancomycin trough, based on ?????? hour prior to the
dose, today, [**2167-7-15**].
9. Isordil 10 mg p.o.t.i.d. PO hold systolic blood pressure
less than 110 and then sliding scale regular insulin coverage
for the patient.
FOLLOW-UP CARE: The patient should followup Dr. [**Last Name (STitle) 4159**], at
[**Telephone/Fax (1) 1730**] in two weeks as followup for her non-Q-wave
myocardial infarction.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 11-688
Dictated By:[**Last Name (NamePattern4) 4160**]
MEDQUIST36
D: [**2167-7-15**] 11:35
T: [**2167-7-15**] 14:17
JOB#: [**Job Number 4161**]
|
[
"038.49",
"707.14",
"585",
"599.0",
"425.4",
"041.4",
"584.9",
"410.71",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8957, 8963
|
11235, 12334
|
5680, 8935
|
4288, 5662
|
1456, 4271
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,852
| 179,760
|
11591
|
Discharge summary
|
report
|
Admission Date: [**2159-8-25**] Discharge Date: [**2159-9-21**]
Date of Birth: [**2116-10-25**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
left groin infection
Major Surgical or Invasive Procedure:
[**2159-8-25**] - Incision and debridement of groin and scrotum, left,
with extension on the perineum
[**2159-8-26**] - Re-exploration, debridement, extension of incisions
and repacking.
[**2159-8-27**] - Serial debridement with addition of thigh and lateral
and posterior abdominal wall repacking with application of a
vacuum-assisted closure dressing.
[**2159-8-28**] - Debridement and repacking of groin, perineal and
scrotal wounds with application of a V.A.C. dressing.
[**2159-8-30**] - 1. I&D and debridement of left flank. 2. Washout and
debridement of scrotum and groin. 3. Pulse lavage of all areas.
[**2159-9-1**] - 1. Incision left groin. 2. Excision soft tissue left
thigh.
3. Irrigation and drainage. 4. Incision of scrotum and drainage
of pus.
[**2159-9-4**] - Serial debridement, scrotal exploration and washout,
application of VACs to groin, thigh and flank incisions.
[**2159-9-7**] - Removal of VAC, washout and replacement of VAC
dressings. Minimal pulse irrigation and debridement.
[**2159-9-13**] - 1. Debridement of scrotum, groin and abdomen. 2.
Delayed primary closure of scrotum (25-cm). 3. Delayed primary
closure abdomen (30-cm). 4. Delayed primary closure of one
(30-cm). 5. Split-thickness skin graft to groin and abdomen (250
cm sq).
History of Present Illness:
42M w/ h/o morbid obesity developed left groin pain [**2159-8-21**]. Saw
his PCP, [**Name10 (NameIs) 1023**] diagnosed epididymitis and prescribed PO
antibiotics. His infection progressed to involve his left groin
and he presented to [**Hospital1 18**] ED on [**8-25**] when he was diagnosed with
necrotizing soft tissue infection of the groin/perineum.
Past Medical History:
PMH: morbid obesity
PSH: laparoscopic Roux-en-Y gastric bypass '[**53**], ex-lap for SBO
[**1-30**]
Social History:
No tobacco use. He smokes an occasional cigar, rare alcohol
use. No drug use.
Family History:
n/c
Physical Exam:
On Admission
Temp 99.2, HR 123, BP 135/97, RR18, O2 99% on RA
Gen: NAD, Alert and Oriented
non-jaundiced
HEENT: NC/AT, no scleral icterus
CV: RRR, no carotid Bruits
RESP: CTAB
ABD: Soft, ND, NT, Obese
GU: Guiac negative, prostate non-tender, no peri-rectal abscess
Left groin ecchymosis and induration, tender with scrotal
involvement, no fluctuance and no hematoma appreciated
Pertinent Results:
[**2159-8-25**] 10:10AM BLOOD WBC-24.5*# RBC-5.11 Hgb-15.4 Hct-41.9
MCV-82 MCH-30.2 MCHC-36.9* RDW-12.8 Plt Ct-275
[**2159-8-25**] 10:10AM BLOOD Neuts-76* Bands-8* Lymphs-7* Monos-9
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2159-8-25**] 10:10AM BLOOD PT-16.5* PTT-29.5 INR(PT)-1.5*
[**2159-8-25**] 10:10AM BLOOD Glucose-119* UreaN-14 Creat-1.3* Na-134
K-3.8 Cl-91* HCO3-30 AnGap-17
[**2159-8-25**] 03:19PM BLOOD Calcium-7.3* Phos-2.6* Mg-1.1*
[**2159-8-25**] 2:05 pm SWAB LEFT GROIN.
STAPH AUREUS COAG |
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- =>16 R
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
[**2159-8-28**] 6:50 pm SPUTUM Source: Expectorated.
STAPH AUREUS COAG + |
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- =>16 R
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
[**2159-8-30**] 11:00 am SWAB LEFT SCROTUM WOUND.
STAPH AUREUS COAG + |
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- =>16 R
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
[**2159-9-1**] 12:30 pm TISSUE Site: GROIN LEFT GROIN
STAPHYLOCOCCUS, COAGULASE NEGATIVE |
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
PENICILLIN G---------- =>0.5 R
[**2159-9-13**] 10:10 am TISSUE LEFT GROIN.
KLEBSIELLA PNEUMONIAE
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 16 I
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- 2 S
[**2159-9-16**] 7:19 am SWAB Source: Left flank wound.
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| ENTEROBACTER CLOACAE
| |
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S =>64 R
CEFTRIAXONE----------- <=1 S =>64 R
CEFUROXIME------------ <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN---------- 32 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
Brief Hospital Course:
Since admission, he has been treated with VAC dressing and
serial debridement/ washouts (see operative notes for detail).
The most recent debridements, on [**9-4**] and
[**9-1**] were both significant in that pockets of pus were found.
Both Plastic and general surgery were in volved in the serial
bebridements and infal reconstruction/ skin grafts. ID also
followed closely and made recommendations for his antibiotic
course while in house and for discharge. Pt was discharged on
[**9-21**] after final reconstruction with skin grafts adhering well
and no sign of uncontrolled active infection. Pt was discharged
tolerating a regular diet, on PO antibiotics and pain control,
and ambulating.
Medications on Admission:
None
Discharge Medications:
1. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours): Continue through [**2159-9-27**].
Disp:*13 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*65 Tablet(s)* Refills:*0*
4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): Finish all medication.
Disp:*17 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA Eastern MA ([**Hospital1 3494**] VNA)
Discharge Diagnosis:
left groin, lower abdomen and scrotal abscess and
necrotizing fasciitis.
Discharge Condition:
Good
Discharge Instructions:
Please call your surgeon if you develop chest pain, shortness of
breath, fever greater than 101.5, foul smelling or colorful
drainage from your incisions, increasing redness or swelling,
severe abdominal pain or distention, persistent nausea or
vomiting, inability to eat or drink, or any other symptoms which
are concerning to you.
No tub baths or swimming. You may shower. If there is clear
drainage from your incisions, cover with a dry dressing.
Activity: No heavy lifting of items [**9-12**] pounds until the
follow up appointment with your doctor.
Medications: Resume your home medications. You should take a
stool softener, Colace 100 mg twice daily as needed for
constipation. Pain medication may make you drowsy. No driving
while taking pain medicine.
Followup Instructions:
Please call the office of Dr.[**Last Name (STitle) 5385**] with Plastic Surgery at ([**2159**] to schedule a follow-up appointment.
Please call the office of Dr.[**Last Name (STitle) **] with General Surgery at
([**Telephone/Fax (1) 376**] to schedule a follow-up appointment.
|
[
"V45.86",
"995.91",
"608.4",
"038.12",
"682.2",
"728.86",
"584.5",
"608.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.62",
"55.23",
"86.22",
"83.39",
"86.69"
] |
icd9pcs
|
[
[
[]
]
] |
7147, 7219
|
5756, 6450
|
335, 1602
|
7336, 7343
|
2641, 5733
|
8156, 8437
|
2223, 2228
|
6505, 7124
|
7240, 7315
|
6476, 6482
|
7367, 8133
|
2243, 2622
|
275, 297
|
1630, 1986
|
2008, 2110
|
2126, 2207
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,994
| 123,284
|
20939
|
Discharge summary
|
report
|
Admission Date: [**2109-8-5**] Discharge Date: [**2109-8-13**]
Service: CSURG
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Mrs. [**Known lastname 6164**] has had a known murmur for 3 years, followed by
serial echos for AS, now has echo findings of increasing aortic
stenosis.
Major Surgical or Invasive Procedure:
[**8-5**]
s/p AVR-19mm supra annular CE Magna Pericardial valve
s/p CABGx3-LIMA-LAD, SVG-OM, SVG-PDA
History of Present Illness:
Mrs. [**Known lastname 6164**] has had a known murmur of AS for 3 years, now she
presents with increasing fatigue and chest tightness with
exertion. Cardiac catheterization showed AVA0.7cm2, peak AV
gradient 46mmhg, 90%LAD, 70%Cx, 50%RCA.
Past Medical History:
AS
CAD
HTN
elevated cholesterol
OA
LLE varicosities
s/p TAH
s/p appendectomy
s/p L eyelid surgery
Carotid US [**5-28**]-[**Country **] <50% stenosis, [**Doctor First Name 3098**] normal, good bilateral
vertebral flow
Social History:
Lives with her son and his wife. She has a remote history of
tobacco use, and drinks alcohol on rare occasions
Family History:
Her mother died at age 76 of CHF and CA
Her father died at 76 of CHF
Physical Exam:
physical exam [**2109-8-12**]
Temp 99.8 P63 SR BP137/58 RR16 RASpO295%
Neuro:Awake, alert, orientedx4; strength 4/4 upper extremity and
lower extremity, equal bilaterally
CV:RRR, no rub or murmur
Resp:breath sounds clear bilaterally, no wheezing, rhonchi or
rales
GI:+bowel sounds, soft, non-tender, non-distended, tollerating a
regular diet
Extremities:1+piting edema, warm, well perfused. Vein harvest
site clean, dry and intact.
Sternal incision-steri strips intact, wound clean and dry,
sternum stable
CXR7/19-L pleural effusion; CXR [**8-13**]-decreased L pleural
effusion
Pertinent Results:
[**2109-8-12**] 09:00AM BLOOD WBC-6.8 RBC-3.50* Hgb-10.3* Hct-30.5*
MCV-87 MCH-29.5 MCHC-33.8 RDW-14.3 Plt Ct-252
[**2109-8-12**] 09:00AM BLOOD PT-12.8 PTT-27.3 INR(PT)-1.1
[**2109-8-12**] 09:00AM BLOOD Plt Ct-252
[**2109-8-13**] 06:20AM BLOOD Glucose-90 UreaN-26* Creat-1.1 Na-141
K-5.1 Cl-106 HCO3-27 AnGap-13
Brief Hospital Course:
Mrs. [**Known lastname 6164**] was taken to the operating room on [**2109-8-5**] with
Dr.[**Last Name (STitle) 1290**] and underwent AVR with 19mm supraannular CE Magna
Pericardial valve and a CABGx3, with LIMA-LAD, SVG-OM, and
SVG-PDA. The total CPB time was 180 minutes, cross clamp time
was 152 minutes. She was transported to the intensive care
unit in stable condition on Levophed and Propofol drips. Please
see the operative note for full details.
She was weaned and extubated from mechanical ventillation on the
evening of POD#0. She required nitroglycerin for control of
hypertension, was started on lopressor and lasix and was
transfered out of the intensive care unit on POD#2.
In the morning of POD#3, she worked with physical therapy
without difficulty. Her epicardial pacing wires were removed
without incident. During the afternoon of POD#3, she was noted
to have significant weakness and discordination of her L arm. A
neurology consult was obtained, a stat MRI was performed, which
was negative for acute ischemia or injury, and per the neurology
recomendation, the patient was transfered to the ICU for
neosynephrine infusion to increase the patient's blood pressure
as her symptoms had almost resolved by the time the MRI was
complete. It was felt that this was a TIA, and as the patient's
exam had returned to baseline by the next day, no further
work-up was required. It was recomended to allow the patients
blood pressure remain >120, and continue the aspirin and plavix.
Mrs. [**Known lastname 6164**] was transfered from the ICU to the floor on POD#5.
On POD#7, she was noted to have mild hyperkalemia at 5.5 which
decreased to 5.1 on POD#8. She also had a CXR on [**8-12**] which
showed an increased L effusion. Her lasix dose was increased and
on [**8-13**], her CXR showed a decreased L effuision.
On POD#8, she was cleared for discharge to rehab.
Medications on Admission:
Zocor 10mg po qd
Univasc 7.5mg po qd
Naproxen 500mg po qd
ginko
Atenolol 25mg po qd
Citracal/Vitamin D
Lutein
Slo-Mag
Geritol
Estra C
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
once a day as needed for constipation.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
9. Naproxen 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) as needed.
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO QD (once
a day).
11. Moexipril HCl 7.5 mg Tablet Sig: One (1) Tablet PO QD (once
a day).
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO bid for 10 days.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) 731**]
Discharge Diagnosis:
aortic stenosis
coronary artery disease
status post coronary artery bypass grafting
status post aortic valve replacement
transient ischemic attack
Discharge Condition:
good
Discharge Instructions:
you may take a shower and wash your incisions with mild soap and
water
do not apply lotions, creams, ointments or powders to your
incisions
do not swim or take a bath for 1 month
do not drive for 1 month
do not lift anything heavier than 10 pounds for 1 month
Followup Instructions:
follow up with Dr.[**Last Name (STitle) 1683**] in [**1-25**] weeks
follow up with Dr. [**Last Name (STitle) 55681**] in [**1-25**] weeks
follow up with Dr. [**Last Name (STitle) 1290**] in [**3-28**] weeks
Completed by:[**2109-8-13**]
|
[
"276.7",
"414.01",
"435.9",
"272.0",
"511.9",
"401.9",
"V15.82",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.64",
"36.12",
"99.04",
"35.21",
"89.62",
"39.61",
"89.61",
"89.64",
"88.72",
"38.91",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
5287, 5386
|
2188, 4073
|
411, 513
|
5576, 5582
|
1850, 2165
|
5890, 6127
|
1166, 1236
|
4258, 5264
|
5407, 5555
|
4099, 4235
|
5606, 5867
|
1251, 1831
|
219, 373
|
541, 781
|
803, 1021
|
1037, 1150
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,454
| 142,306
|
39248
|
Discharge summary
|
report
|
Admission Date: [**2121-6-4**] Discharge Date: [**2121-6-11**]
Date of Birth: [**2063-7-9**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Increasing headache and vomiting
Major Surgical or Invasive Procedure:
R burr hole craniotomy for evacuation of SDH [**2030-6-3**]
R hemicraniectomy [**2121-6-6**]
History of Present Illness:
HPI: 57M with h/o recent right parieto-occipital subdural
hematoma and facial fractures sustained on [**2121-5-22**] after binge
drinking and being asaulted presents to ED today after being
discharged from the hospital [**2121-5-26**] with new onset headache,
nausea and vomiting. Mr. [**Known lastname 86862**] reports he was feeling well
until yesterday when he began to experience new headache and
nausea. He presented to his PCP who prescribed codeine for the
headache. However, the pain and vomiting continued today at
which time he presented to an OSH ED where a CT scan was
interpreted as increase in his prior SDH with an
acute-on-chronic
component and slightly increased midline shift to 1cm. He was
transferred to [**Hospital1 18**] for further evaluation.
Notably the patient states he completed his antibiotic course
for
facial fractures this morning, which is on schedule. His
dilantin level was 15.1.
Past Medical History:
Hep C, EtOH abuse
Social History:
EtOH abuse
Family History:
Non-contributory
Physical Exam:
On Discharge:
AVSS
NAD
answering questions appropriately, dysarthric and garbled speech
AxOx4 (one day off on date)
Surgical blind L eye at baseline, R EOMI, PERRL
symmetric chest rise, breathimg comfortable on RA
Soft abdomen s/p BM
cooperative with exam, normal affect.
Dense L hemiparesis; no movement upon command. No appreciable
sensation upon testing. Withdraws to nailbed stimulus bilat.
Upgoing babinski On L. Downgoing R.
Motor strength full and complete on R.
Distal extrems wwp, 2+cr Bilat. 1+ DP, 2+ R U bilat.
Pertinent Results:
[**6-4**] NCHCT
When compared to previous CT scan there is an increase in size
of R chronic SDH with resulting increase in midline shift to
11mm
[**6-4**] NCHCT
1. New right frontoparietal parenchymal and overlying
subarachnoid hemorrhage,
with associated vasogenic edema and mass effect.
2. Significant decrease in the size of the right subdural
collection, with no
change in the overall degree of shift of midline structures.
[**6-5**] NCHCT
Interval expansion of the right frontoparietal parenchymal and
overlying
subarachnoid hemorrhage with increase in associated vasogenic
edema and mass effect.
2. Increase of the midline shift compared to prior study.
CT HEAD W/O CONTRAST [**2121-6-6**]
1. Status post right frontal craniectomy and evacuation of
hemorrhage.
Significantly decreased size of the inferior hematoma.
Unchanged size of the superiorly located hematoma. There is a
large collection of intra-axial air in the region of the
inferiorly located hematoma.
2. No change in midline shift.
3. Slightly improved appearance of the basal cisterns.
3. Ill-defined low density in the right frontal and right
occipital lobes
that could represent edema
CT HEAD W/O CONTRAST [**2121-6-9**]
Continued decrease in mass effect and stable overall appearance
of right hematoma evacuation surgical bed with a pneumocephalus,
residual
hematoma components, and ill-defined hypoattenuation. No new
hemorrhage
Brief Hospital Course:
Pt was admitted to the neurosurgery service and was kept NPO in
preparation for surgical evacuation. On [**6-4**] he underwent a R
sided burr hole craniotomy for evacuation of SDH. He tolerated
the procedure well. Post operatively he was transferred to the
ICU for close monitoring. On Post op exam it was noted that he
had a new facial and some difficulties with speech. A CT was
performed immediately which showed new intraparynchymal
hemorrhages in the right frotal and parietal lobe. Patient
remained in the ICU, a repeat CT the following day showed slight
expansion of the hematomas.
Patient then underwent a R hemicraniectomy on [**2121-6-6**] and was
transferred back to the ICU for continued care. Mannitol 25mg
q6h was started postoperatively and diet was advanced. The pt
recieved a helmet and dressing changes demonstrated a well
healing incision. On [**6-8**], q2h neurochecks and tube feeds were
started w/ goal of 50/hr. Chemical DVT prophylaxis with SubQ
heparin was begun as well. On [**6-9**], mannitol was decreased to
25g Q8H for 2 doses. His exam improved, he was now following
commands on the R side and w/d on the L side to noxious stimuli.
He was transferred to the SDU. Speech and swallow was consulted
to advance his diet and PT/OT for evaluation. He was found to
have a UTI and was started on cipro.
His diet was advanced. He began tolerating soft POs without
complication.
On [**6-10**] patient was transfused 1unit platelets for acute
neurosurgical postoperative concern for continued
thrombocytopenia. The platelets increased as expected. The
incision was clean and dry upon discharge. The patient was
discharged the following day with no acute issues. He will
require extensive rehabilitation and will follow-up in 4 weeks
for evaluation if his craniectomy with a CT-head.
Medications on Admission:
1. Acetaminophen 325-650 mg PO q6h prn pain
2. Amoxicillin-Clavulanic Acid 875 mg PO Q12H Duration: 14 Days
First day = [**2121-5-22**]
Last day = [**2121-6-4**]
3. Docusate Sodium 100 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. Phenytoin Sodium Extended 100 mg PO TID
6. Nadolol 20 mg PO DAILY
7. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain, headache
2. Artificial Tears 1-2 DROP LEFT EYE PRN irritation
3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
4. Ciprofloxacin HCl 500 mg PO Q12H Duration: 2 Days; finish
[**6-13**]
5. Docusate Sodium (Liquid) 100 mg PO BID
6. Heparin 5000 UNIT SC TID
7. Nadolol 20 mg PO DAILY
8. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN headache
10. Phenytoin (Suspension) 100 mg PO Q8H
11. Senna 1 TAB PO BID:PRN Constipation
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Subdural hematoma
Intraparnchymal hemorrhage
Left hemiplegia
Dysphasia
Cerebral edema secondary to hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
***You staples should be removed at rehab on [**2121-6-14**]
?????? 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 was closed with sutures. You may wash your hair
only after sutures and/or staples have been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your injury, you may
safely resume taking this only after follow up with Dr.
[**Last Name (STitle) 739**] and his approval.
?????? **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**].
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**], to be seen in 4weeks.
??????You will need a CT scan of the brain without contrast.
You staples should be removed at rehab on [**2121-6-14**]
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2121-6-17**]
|
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icd9cm
|
[
[
[]
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] |
[
"01.25",
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"01.31",
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icd9pcs
|
[
[
[]
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] |
6240, 6310
|
3488, 5296
|
339, 434
|
6464, 6464
|
2048, 3465
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8234, 8649
|
1471, 1489
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5701, 6217
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6331, 6443
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5322, 5678
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6640, 8211
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1504, 1504
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1518, 2029
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267, 301
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462, 1385
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6479, 6616
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1442, 1455
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,497
| 178,882
|
49543
|
Discharge summary
|
report
|
Admission Date: [**2142-1-5**] Discharge Date: [**2142-1-11**]
Date of Birth: [**2060-12-20**] Sex: M
Service: MEDICINE
Allergies:
Hydrochlorothiazide
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
A Fib with RVR
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is an 81 year old man with multiple medical
problems transferred to ICU for suctioning to protect airway.
He has multiple medical problems, including complicated post-op
course after CABG on [**11-25**], recently discharged to [**Hospital 100**] Rehab,
who presents with increasing lethargy and rising white blood
cell count for further evaluation and workup. His most recent
admission included MVR/CABG with post-op course complicated by
pneumothorax s/p R CT, respiratory distress, left pleural
effusion s/p thoracentesis, mental status changes, MSSA
pneumonia/bacteremia, tracheostomy/PEG, diarrhea. During that
hospitalization, he completed a course of Flagyl (empiric for C.
diff, ultimately negative), ciprofloxacin (for Enterobacter in
the sputum), and nafcillin (for MSSA pneumonia/bacteremia). At
rehab, he was being treated for cellulitis/abscess around the
tracheostomy site (with wound dehiscence), as well as for MRSA
in sputum, with vancomycin. His white blood cell count has been
rising, and ID consult at rehab was concerned for mediastinitis.
In addition, he has had a change in mental status since his
recent hospitalization (per his family).
Initial WBC was 22 with 88% neutrophils, no bands. His CT head
was negative for bleeding but revealed evidence of sinusitis.
His CT torso revealed b/l pleural effusions, L>R, but no
evidence of mediastinitis or fluid collection. He was on
vancomycin already for MRSA in sputum at rehab, and this was
continued to cover for cellulitis. Flagyl was added for emperic
coverage Cdiff. He triggered on the floor twice for Afib with
RVR, which responded to IV nodal agents (15mg dilt and 5mg
metoprolol). He also was requiring frequent suctioning from his
trach and thus was transferred to MICU for increased nursing
needs.
Past Medical History:
- CAD s/p MV repair/CABG on [**2141-11-24**], complicated post-op
course; post CABG echo demonstrated EF 55%
- S/p trach/PEG
- Hx of MSSA pneumonia/bacteremia
- Diabetes - A1c 7.3 in [**2141-9-2**]. alb/Cr ratio 800 in [**2141-10-2**].
- Hypertension
- PVD - sx of claudication, seen on MRA
- Iron-deficiency anemia - Hct around 30, no colonscopy
- Spinal stenosis
Social History:
Social history is significant for quitting tobacco over 35 years
ago. There is no current alcohol abuse. Worked in a cemetery;
never married; never had kids.
Family History:
Father died of influenza, mother died of old age. There is no
family history of premature coronary artery disease or sudden
death.
Physical Exam:
VS: T 96.7F, BP 158/37, HR 84, RR 20, Sat 100% on 60% FM
Gen: Cachectic, trach, no acute distress
HEENT: EOMI, PERRL, MM dry
Neck: no JVD
CV: Irregularly irregular, tachycardic, no murmurs appreciated
Resp: Rhonchorous throughout b/l
Chest: Midline sternotomy scar clean, mild erythma near trach,
eschar near trach site, no purulent discharge
Abd: +BS, soft, ND/NT, no peritoneal signs
EXT: LE's warm, no lower extremity edema. Left necrotic heel
ulcer, Left great toe necrosis (dry), left anterior ankle ulcer
(open), and right foot erythema.
NEURO: Oriented to hospital, [**2142**]
Pertinent Results:
STUDIES:
CT Chest/Abd/Pelvis [**2142-1-5**]: 1. Slight increased overlap of the
osseous structures at the sternotomy site suggests the
posibility of movement. 2. Large left pleural effusion with
complete left lower lobe collapse, which is stable. There may be
a loculated component to the left pleural effusion and there is
suggestion that the effusion may be entirely simple. There is
increased size of a now moderate right pleural effusion. 3. No
fluid collection in the mediastinum surrounding the tracheostomy
site. 4. Dense three-vessel coronary artery calcification and
abdominal atherosclerotic plaque. 5. Stable right
nonobstructing colonic inguinal hernia and new left colonic
inguinal hernia. Neither bowel loop protrudes significantly into
the respective inguinal canals and there is no sign of
obstruction or entrapment. Correlate with clinical exam. 6.
Stable right [**Month/Day/Year **] nodule. 7. Interval development of tiny
stones in the gallbladder.
CT Head [**2142-1-5**]: 1. No acute intracranial abnormality detected.
2. Near-total opacification of the mastoid air cells bilaterally
which has increased since previous study. There is an air-fluid
level within the left maxillary sinus with aerated secretions
which is also noted in study from [**Month (only) **] which may be
consistent with acute sinusitis.
ECHO [**2142-1-8**] - The left atrium is mildly dilated. Left
ventricular wall thicknesses and cavity size are normal. There
is mild regional left ventricular systolic dysfunction with mild
hypokinesis of the inferior wall. The remaining segments
contract normally (LVEF = 50-55 %). Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. A mitral valve annuloplasty ring is present.
Mild (1+) mitral regurgitation is seen. There is borderline
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction
with good global function. Mild mitral regurgitation. Borderline
pulmonary artery systolic hypertension. Bilateral pleural
effusions. CLINICAL IMPLICATIONS:
Based on [**2141**] 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.
[**2142-1-10**] RUQ U/S - The liver is normal in echotexture without
focal lesion identified. There is no intra- or extrahepatic
biliary dilatation with the common bile duct measuring 3 mm. The
gallbladder is not distended and there is no pericholecystic
fluid or wall edema. In comparison to the previous study there
is significantly less sludge. A tiny echogenic shadowing foci in
the dependent portion of the gallbladder could represent a few
crystals. IMPRESSION: No evidence of acute cholecystitis.
Interval improvement in gall bladder sludge, but not complete
clearing.
MICRO:
[**2142-1-7**] Sputum -
GRAM STAIN (Final [**2142-1-7**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): BUDDING YEAST.
_________________________________________________________
STAPH AUREUS COAG +
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- =>4 R
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S 4 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- 8 I
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- =>128 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
Brief Hospital Course:
81yo M with complicated recent hospitalization now with altered
mental status, cellulitis at tracheostomy site, Afib with [**Hospital 26875**]
transferred to ICU for airway protection/suctioning.
THE PATIENTS FAMILY HAS CONSENTED TO DO NOT HOSPITALIZE ORDER.
They feel the patient would not want further interventions. The
plan is to complete the current course of antibiotics but that
no further interventions should be performed. Maintain the
current level of care including his medications, but it anything
were to deteriorate in his health he would not want further
care. (The patients sister [**Name (NI) 714**] [**Name (NI) 103630**] is his HCP and can
be reached at [**Telephone/Fax (1) 103631**]).
Resp: Underwent tracheostomy during last hospitalization, now on
60% TM with thick secretions. CT chest with b/l pleural
effusions, L > R, with surrounding atelectasis, and question of
small infiltrate. Per [**Hospital 100**] Rehab, he was being treated with
Vanco for MRSA in his sputum. Requiring frequent suctioning per
floor nursing. He needs to be mainted on vancomycin for a
complete 14 day course (day #1=[**2142-1-5**]). He should be dosed for
level <20. Please check levels daily at rehab.
On [**2142-1-10**], pseudomonas grew from his sputum and he was started
on tobramycin and will need to complete a 14 day course. Also,
during his hospital course he had a left sided thoracentesis
(1.5 L taken off). The pleural fluid was transudative, likely
secondary to CHF. He should continue to be diuresed at rehab.
He is currently on lasix 20mg IV TID. The dosing frequency
should be increased for a goal urine output of -500cc-1L
negative per day until he reaches his dry weight. He was able
to be weaned from 70% O2 to 35% O2 during his ICU stay. This
should further be weaned as tolerated at rehab.
ID: Elevated WBC, no fever. Originally thought to have a
cellulitis around his trach site, but the thoracics team felt
that his site was not infected. He was started on Vanco/Unasyn
for MRSA and GNR's in the sputum. The Unasyn was stopped on
when the GNR's grew pseudomonas. He was switched to tobramycin
(day 1=[**2142-1-10**]) and will need to complete a 14 day course. He
also was c diff positive during this admission and was started
on flagyl. He should complete a 14 day course (day 1 should be
considered the last day of all other antibiotics). We did
consider biliary sources of infection because his LFT's were
slightly elevated, but a RUQ U/S was unremarkable. Vascular
surgery examined his feet ulcers and felt there was no evidence
of infection.
Atrial fibrillation. The patient had numerous episodes of A fib
with RVR during this hospital course. Metoprolol was uptitrated
to 100 QID with better rate control, but still in the low 100's.
He was then started on digoxin with great response. His HR was
then stable in the 70's.
Transaminitis. The patient did not have abdominal pain and a CT
abdomen was neg for evidence of choledocholithiasis, although
gallstones seen on scan. We proceded with a RUQ U/S that was
unremarkable. This should be followed up as an outpatient.
LE ulcers: Appear dry and necrotic on heels, but open on
anterior feet. We consulted the wound care team who gave the
following recommendations. Heels off bed surface at all times.
Waffle Boots to both lower legs. Moisturize B/L LE's and feet,
periwound tissue [**Hospital1 **] with Aloe Vesta Moisture Barrier Ointment.
Commercial wound cleanser or normal saline to cleanse all
wounds. Pat the tissue dry with dry gauze. B/L lower legs and
feet: Keep ulcers dry and eschar intact. Apply moisture
barrier ointment to the periwound tissue with each DRG change.
Apply a dry protective dressing, ABD's, with Kerlix wrap, change
daily. We also had vascular surgery evaluate his feet and they
felt that there was no evidence of infection. At some point in
the future he may be a potential candidate for amputation but
not at this time. He can follow up with vascular surgery in
clinic.
Diabetes. The patient had a number of hypoglycemic episodes
during his hospital course. His home lantus (50 units) was
held. He was restarted on 10 units of lantus daily because of
hyperglycemia and this was eventually increased further to
25units. This should be titrated up as needed to maintain blood
sugars between 120-150.
Medications on Admission:
- Colace 100mg [**Hospital1 **]
- Aspirin 81mg daily
- Metoprolol 100mg TID
- Atorvastatin 80mg PO daily
- Prilosec 20mg daily
- Lantus 50 units subQ QHS
- Lispro sliding scale q6h
- Warfarin 2mg PO daily
- Tramadol 50mg Q6H PRN
- Ipratropium-Albuterol 1-2puffs INH Q6H PRN
- Captopril 50mg TID
- Furosemide 20mg daily
- Hydralazine 5mg TID
- Vancomycin 1g daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) unit PO BID (2
times a day).
3. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Hospital1 **]:
One (1) neb Inhalation Q6H (every 6 hours) as needed.
4. Tramadol 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6
hours) as needed.
5. Atorvastatin 40 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
6. Captopril 25 mg Tablet [**Hospital1 **]: Three (3) Tablet PO TID (3 times
a day).
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO QID
(4 times a day): hold for SBP <90 or HR<55.
9. Warfarin 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
10. Vancomycin 1000 mg IV Q 24H
1st day [**1-6**]
no Vanco dosing until Vanco level <20
11. Heparin Flush Midline (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
12. Digoxin 125 mcg Tablet [**Month/Day (1) **]: 0.5 Tablet PO DAILY (Daily).
13. Ipratropium Bromide 0.02 % Solution [**Month/Day (1) **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
14. Furosemide 10 mg/mL Solution [**Month/Day (1) **]: Twenty (20) mg Injection
QID (4 times a day): please hold if SBP<90 or if creatinine
bumps.
15. Tobramycin 200 mg IV Q24H
16. Insulin Glargine 100 unit/mL Solution [**Month/Day (1) **]: Twenty Five (25)
units Subcutaneous once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Atrial fibrillation with RVR
Bilateral Pleural Effusions
C Diff positive
MRSA Pneumonia
Respiratory distress
Discharge Condition:
Stable; oxygenating well on FIO2 35% TM.
Discharge Instructions:
You were admitted to the hospital with respiratory distress and
elevated HR. You had developed fluid build up in your lung
likely secondary to your elevated heart rate. We performed a
thoracentesis which is a procedure to remove fluid from your
lung. We were then able to decrease the amount of oxygen you
have needed to breath. We also increased your heart medications
to get your heart rate under better control. The dose of your
captorpil and metoprolol were both increased. We also started a
new medication called digoxin which was heldful in keeping your
heart rate under good control.
THE PATIENTS FAMILY HAS CONSENTED TO DO NOT HOSPITALIZE ORDER.
They feel the patient would not want further interventions. The
plan is to complete the current course of antibiotics but that
no further interventions should be performed. Maintain the
current level of care including his medications, but it anything
were to deteriorate in his health he would not want further
care.
At rehab:
-- He needs to be mainted on vancomycin for a complete 14 day
course (day #1=[**2142-1-5**]). He should be dosed for level <20.
Please check levels daily at rehab.
-- He was started on tobramycin on [**2142-1-10**] for pseudomonas
growing in his sputum. He should complete a 14 day course.
Peak and trough levels should be checked daily and the dose
adjusted accordingly.
-- He should continue to be diuresed at rehab. He is currently
on lasix 20mg IV TID. The dosing frequency should be increased
for a goal urine output of -500cc-1L negative per day until he
reaches his dry weight. He was able to be weaned from 70% O2 to
35% O2 during his ICU stay. This should further be weaned as
tolerated at rehab.
--He also was c diff positive during this admission and was
started on flagyl. He should complete a 14 day course (day 1
should be considered the last day of all other antibiotics).
--Wound care per instructions in the D/C summary
--Metoprolol was uptitrated to 100 QID with better rate control.
HE was started on digoxin and is currently well controlled on a
dose of 0.0625 daily.
-- He was restarted on coumadin prior to discharge. His INR was
1.5 today. Please adjust dose as needed (he was on 2mg prior to
this admission). Please check INR daily until level between
[**2-4**].
Followup Instructions:
--Please make an appointment to see Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] or Dr [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 2450**] within 1 week of discharge from rehab
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
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icd9cm
|
[
[
[]
]
] |
[
"96.6",
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icd9pcs
|
[
[
[]
]
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14282, 14348
|
7762, 12119
|
302, 308
|
14501, 14544
|
3485, 5729
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16881, 17239
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2731, 2864
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248, 264
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336, 2150
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2555, 2715
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,469
| 198,014
|
28751
|
Discharge summary
|
report
|
Admission Date: [**2141-9-3**] Discharge Date: [**2141-10-6**]
Date of Birth: [**2100-7-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
Bronchoscopy with lung biopsy
MRCP
History of Present Illness:
41M with history of deafness who presents with 3-4 months
history of cough, DOE and chest pain and recent episodes of
hemoptysis, found to have large hilar mass on CT.
.
The patient was in his USOH until approximately 3-4 months ago
when he developed a cough productive of white sputum, severe
left-sided chest pain radiating to his back, as well as
progressive dyspnea on exertion. He was seen multiple times in
the [**Hospital6 6689**] ER and diagnosed with pneumonia and
treated with courses of antitbiotics. His symptoms progressed
over the last several months and he lost his appetite and lost a
significant amount of weight. During his last visit on [**2141-8-24**],
he had a Chest CT which revealed a left hilar mass with no
mediastinal LAD. The hilar mass was encasing and narrowing the
left main pulmonary artery and multiple central bronchi and
primary anterior branches. It was suggested that this could be
carcinoma with metastasis.
.
Over the day prior to presentation, the patient developed
hemoptysis, prompting him to return to the ER [**2141-9-1**]. He notes
two episodes, the last of which he produced approximately a
"cupful" of blood clots and bright red blood. According to the
consultation note at the OSH, he estimated that the blood was
approximately half [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 69494**] cup filled with bright red blood. He
was admitted and underwent bronchoscopy on [**2141-9-1**] with biopsy
that presumptively shows small cell lung CA.
.
He describes his chest pain as sharp [**11-14**] left-sided chest pain
that he thought was from a heart attack, though this was ruled
out. This pain is non-exertional and radiates to his back and
abdomen. He reports occasional fevers to above 100, chills and
sweats. He also reports loss of appetite with a 32 pound weight
loss in [**3-10**] months (from 150->118). He also endorses nausea and
vomiting, without hemetemesis. He has occasional upper abdominal
pain. He reports significant fatigue and generalized weakness.
He denies orthopnea, PND, palpitations, edema.
Past Medical History:
Recent stab wound to the head with hematoma
HTN
Deafness
Social History:
Social Hx: The patient grew up in the [**Location (un) 86**] area, recently
moved to [**Location (un) 6691**] nine months ago. He has worked several jobs,
including painting and as a cooking assistant. He is married
with five children. Has history of cocaine use, last two months
ago. Also smokes marijuana. Smoked 1 PPD for 15-20 years, quit
two weeks ago. Drinks about one beer per day. He was
incarcerated in [**2145-10-10**] for domestic violence. No sexual
contacts other than wife. [**Name (NI) **] IVDA. Reports negative HIV test six
months ago.
Family History:
No lung diseases or cancer. Father died at 79 from probable
stroke. Mother alive with DM.
Physical Exam:
Vitals: T 97.4 BP 112/78 HR 94 RR 20 97% RA
Gen: Cachectic African American man, in NAD
HEENT: PERRL, EOMI, mmm, OP clear
Neck: supple, FROM, no JVD
Lung: decreased breath sounds in left lower lung fields,
otherwise CTA bilaterally
Cor: RRR, nml S1S2, no m/r/g
Abd: NABS, soft NTND
Ext: no c/c/e
Pertinent Results:
Chemistries:
[**2141-9-2**] 09:15PM GLUCOSE-87 UREA N-10 CREAT-1.0 SODIUM-139
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-27 ANION GAP-14
[**2141-9-2**] 09:15PM ALBUMIN-4.0 CALCIUM-9.7 PHOSPHATE-3.6
MAGNESIUM-2.0
LFTs:
[**2141-9-2**] 09:15PM ALT(SGPT)-12 AST(SGOT)-29 CK(CPK)-162 ALK
PHOS-89 AMYLASE-184* TOT BILI-0.2
[**2141-9-2**] 09:15PM LIPASE-251*
Cardiac Enzymes:
[**2141-9-2**] 09:15PM cTropnT-<0.01
[**2141-9-2**] 09:15PM CK-MB-3
CBC:
[**2141-9-2**] 09:15PM WBC-8.8 RBC-4.43* HGB-14.3 HCT-40.6 MCV-92
MCH-32.3* MCHC-35.3* RDW-12.8
[**2141-9-2**] 09:15PM NEUTS-68.4 LYMPHS-25.6 MONOS-3.2 EOS-1.8
BASOS-1.1
[**2141-9-2**] 09:15PM PLT COUNT-288
STUDIES:
CTA ([**Hospital1 18**] [**2141-9-3**]): Large left hilar mass extending to the
mediastinum, with narrowing of the pulmonary arteries and left
bronchial branches. Post-obstructive airspace opacity - could
reflect post-obstructive consolidation or though alveolar
hemorrhage is not excluded (givne history of hemoptysis. No PE.
CT ([**Hospital1 **] MC [**2141-9-1**]): Known life hilar mass with question
of lymphangitic spread, low attenuation in the liver, too small
to characterize
Bronch ([**Hospital1 **] MC [**2141-9-1**]): Significant narrowing of the left
mainstem bronchus by extrinsic compression, as well as mucosal
thickening. Mucosa in the LMB was thickend and erythematous and
abnormal appearing. Three need aspirates performed.
EKG ([**Hospital1 18**]): Sinus tach at 100 bpm, normal axis, RAD, non-sig Q
waves in III and aVF, slight ST elevations in V2-3
Brief Hospital Course:
41 yoM w/ 20 pk yr tob h/o, weight loss, night sweats, found to
have large left hilar mass c/w SCLC.
.
ICU Course:
#SCLC -
Patient had bronchoscopy at OSH with biopsy consistent with SCLC
on [**9-1**]. He was transferred to [**Hospital1 18**] on [**9-2**] for further w/u and
second opinion. At the [**Hospital1 18**], he had a repeat CTA with similar
findings. He had a bone scan with abnormal areas of increased
tracer uptake in the posterior left parietal skull and right
lateral 2nd rib. He had an MRI of his head notable for multiple
enhancing lesions within the brain consistent with metastatic
disease. He was started on decadron per onc/rad onc. He was seen
by Pulmonary who suggested sending sputums for cytology and
treating for postobstructive pna seen on f/u CXR. The slides
from the OSH were received and felt to be c/w SCLC so a family
meeting was held and it was decided to start chemo on [**9-8**] and
proceed with xrt after the 2nd cycle of chemo.
Patient with squamous cell lung cancer with metastases to brain
and pancreas. During [**Hospital 228**] hospital course, tumor spread
very quickly to encompass most of right lung. Patient was then
intubated. Patient's treatment for squamous cell lung cancer was
on hold due to his pancreatitis, ventilator requirement, and
acute illness. Given patient's continued pancreatitis, heme-onc
was again consulted who recommended that chemotherapy would
likely not be an option for this patient due to his continued
illness. Family was made aware of this and preferred that
patient would not receive further treatment.
# Pancreatitis -
Patient had abdominal pain, nausea, and vomiting. Found to have
elevated amylase and lipase secondary most likely to pancreatic
metastases of his primary tumor. Given the continued elevated
amylase and lipase, hematology-oncology did not believe
chemotherapy would be an option for him. CT abdomen show
diffusely edematous and enlarged pancreas. Ultrasound did not
show any gallstone. His HIV status is negative. He then had a
MRCP that show mass in pancreatic duct.Patient received 4L of NS
on [**2141-9-11**]. He received another 3L this morning. He started to
develop respiratory distress and increasing oxygen
requirement(90% on 2L, 93% on 4L, 90% on FM and then 94% on
NRB). ABG show 7.42/34/64. He was transferred to ICU for
management of respiratory distress.
Medicine service hospital course after transfer from ICU on
[**2141-9-29**]:
# Comfort measures only: patient not in distress,normal resp
rate, did not check daily vitals
Acetaminophen
Haloperidol
Lorazepam
Morphine Sulfate, titrate to comfort
Scopolamine Patch
# Respiratory failure
s/p extubation in ICU, sats low prior to transfer
# SCLC
No treatment options
# MRSA
No antibiotics given goals of care.
# Dispo
Mother, [**Name (NI) **] [**Name (NI) 11333**], is representative payee [**Telephone/Fax (1) 69495**].
Medications on Admission:
1000 ml 1/2NS
D5 Levofloxacin 500 mg PO Q24H
D5 Flagyl 500 mg po tid
Albuterol 0.083% Neb Soln 1 NEB IH Q6H
Benzonatate 100 mg PO TID
Dexamethasone 4 mg IV Q6H
Hydromorphone 0.5-1 mg SC Q3-4H:PRN
Hydromorphone 2-4 mg PO Q4H:PRN
Insulin SC
Discharge Medications:
None
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Squamous Cell Lung Cancer
Small cell lung cancer with metastases to brain/skull/rib
Respiratory failure
Pancreatitis
.
Hypertension
Stab wound
Congenital Deafness
Discharge Condition:
N/A
Discharge Instructions:
None
Followup Instructions:
None
|
[
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"519.1",
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"305.1",
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"599.0",
"197.8",
"162.2",
"518.84",
"518.0",
"198.5",
"486",
"389.9",
"790.7",
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.15",
"00.17",
"96.04",
"38.91",
"96.72",
"33.22",
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icd9pcs
|
[
[
[]
]
] |
8330, 8345
|
5125, 8012
|
323, 360
|
8552, 8558
|
3553, 3909
|
8611, 8619
|
3130, 3221
|
8301, 8307
|
8366, 8531
|
8038, 8278
|
8582, 8588
|
3236, 3534
|
3926, 5102
|
273, 285
|
388, 2462
|
2484, 2542
|
2558, 3114
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,620
| 148,993
|
6153
|
Discharge summary
|
report
|
Admission Date: [**2190-2-5**] Discharge Date: [**2190-2-8**]
Date of Birth: [**2116-6-9**] Sex: M
Service: [**Hospital Unit Name 196**]
HISTORY OF THE PRESENT ILLNESS: In brief, this is a
73-year-old male with decompensated congestive heart failure
secondary to idiopathic dilated cardiomyopathy. The patient
has been having increasing dyspnea on exertion, shortness of
breath, PND, orthopnea, and fatigue, despite attempts to
maximize his medical management. The patient was admitted to
the CCU for Natricor drip diuresis status post right heart
catheterization.
At catheterization, the pulmonary capillary wedge pressure
was 30, cardiac output 5.7, cardiac index 2.7, systemic
vascular resistance 814. After 24 hours of Natricor, the
pulmonary artery pressure was 46/16 with a mean of 30 and the
patient was 1.3 liters negative. He was tolerating diuresis
well at the time of his transfer to C Medicine Service. The
patient was also having worsening of his chronic renal
failure recently.
PAST MEDICAL HISTORY:
1. Dilated cardiomyopathy with an ejection fraction of
15-20%.
2. No coronary artery disease by catheterization in [**2184**].
3. Tricuspid regurgitation, mitral regurgitation, mild
aortic stenosis.
4. Pulmonary hypertension.
5. Chronic renal failure followed by Dr. [**Last Name (STitle) **].
6. Chronic anemia.
7. Paroxysmal atrial fibrillation, status post ablation and
pacemaker placement in [**2185**].
8. Congestive heart failure, class B, followed by Dr.
[**First Name (STitle) 2031**].
9. Peptic ulcer disease from note.
ADMISSION MEDICATIONS:
1. Hydralazine 10 mg p.o. t.i.d.
2. Lasix 80 mg p.o. b.i.d.
3. Aldactone 25 mg p.o. q.d.
4. Amiodarone 200 mg p.o. q.d.
5. Carvedilol 0.5 mg p.o. b.i.d.
6. Digoxin 0.25 mg four times a week.
7. Aspirin 81 mg p.o. q.d.
8. Coumadin 2.5 mg Monday, Wednesday, and Friday, 1.25 mg
Tuesday, Thursday, Saturday, and Sunday.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS AT THE TIME OF TRANSFER FROM CCU TO [**Hospital Unit Name 196**]:
1. Natricor 0.01 micrograms per kilogram per minute drip.
2. Aldactone 25 mg p.o. q.d.
3. Amiodarone 200 mg p.o. q.d.
4. Carvedilol 25 mg p.o. b.i.d.
5. Aspirin 81 mg p.o. q.d.
6. Digoxin 0.25 mg q. Monday, Wednesday, Friday, and Sunday.
7. Iron sulfate 325 mg p.o. t.i.d.
8. Lasix 80 mg p.o. b.i.d.
9. Erythropoietin 6,000 units subcutaneously Monday,
Thursday, and Saturday.
10. Coumadin 2.5 mg p.o. q.h.s.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
96.8, blood pressure 97-120 systolic/51-70 diastolic with MAP
ranging from 63-84, pulse 70 beats per minute paced,
respirations 18. General: The patient was lying supine in
bed, in no acute distress. HEENT: No icterus. No pallor.
Neurological: No focal neurological deficits. The patient
was alert and oriented times three. Cardiovascular: Regular
rate and rhythm, III/VI holosystolic murmur best auscultated
at the apex, S3, jugular venous distention 10 cm, positive
bilateral pretibial pitting edema. Pulmonary: Lungs clear
to auscultation with crackles at the right lung base.
Abdomen: Soft, nontender, nondistended, positive bowel
sounds.
LABORATORY DATA: On [**2190-2-6**], the white blood cell count was
4.2, hematocrit 25.4, platelets 160,000, BUN 79, creatinine
3.7, INR 1.8, creatinine decreased to 3.3 on [**2190-2-7**].
EKG showed a paced rhythm at 70 beats per minute.
HOSPITAL COURSE: Please see the first paragraph of this
discharge summary.
After transfer to the [**Hospital Unit Name 196**] Service on the floor, the patient
continued to diurese well at 1.5 to 2 liters negative per
day. His creatinine continued to fall. His blood pressure
remained stable. He remained asymptomatic. The swelling in
his legs noticeably decreased. The patient felt that his
breathing was easier.
A Renal consult was placed and they advised to continue
diuresis. EP consult was also placed for consideration of
placement of a biventricular pacer but since the patient had
significant clinical improvement this was deferred.
DISCHARGE STATUS: The patient is stable for discharge home
with services to help administrate his erythropoietin
injections.
DISCHARGE MEDICATIONS:
1. Erythropoietin 6,000 units subcutaneously Monday,
Thursday, and Saturday.
2. Aldactone 25 mg p.o. q.d.
3. Amiodarone 200 mg p.o. q.d.
4. Carvedilol 25 mg p.o. b.i.d.
5. Aspirin 81 mg p.o. q.d.
6. Coumadin 2.5 mg p.o. q.h.s. Monday, Wednesday, and
Friday, 1.25 mg p.o. q.h.s. Tuesday, Thursday, Saturday, and
Sunday.
7. Digoxin 0.25 mg p.o. Monday, Wednesday, Friday, and
Sunday.
8. Lasix 80 mg p.o. b.i.d.
9. Iron sulfate 325 mg p.o. t.i.d.
DISCHARGE DIAGNOSIS:
1. Dilated cardiomyopathy with ejection fraction of 15-20%.
2. No coronary artery disease by cardiac catheterization in
[**2184**].
3. Tricuspid regurgitation, mitral regurgitation, mild
aortic stenosis.
4. Pulmonary hypertension.
5. Chronic renal failure.
6. Chronic anemia.
7. Paroxysmal atrial fibrillation, status post ablation and
pacemaker placement in [**2185**].
8. Congestive heart failure, class III.
9. Peptic ulcer disease.
FOLLOW-UP: The patient is to follow-up with Dr. [**First Name (STitle) 2031**] as
directed.
[**Known firstname **] [**Last Name (NamePattern4) 4582**], M.D. [**MD Number(1) 4992**]
Dictated By:[**Last Name (NamePattern1) 2582**]
MEDQUIST36
D: [**2190-2-7**] 12:42
T: [**2190-2-8**] 16:00
JOB#: [**Job Number 24044**]
|
[
"427.31",
"428.0",
"425.4",
"416.8",
"396.2",
"285.9",
"397.0",
"585"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"88.53",
"00.13",
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
4238, 4692
|
4713, 5516
|
3455, 4215
|
1601, 2499
|
2514, 3437
|
1039, 1578
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,125
| 111,908
|
4447
|
Discharge summary
|
report
|
Admission Date: [**2148-9-19**] Discharge Date: [**2148-10-6**]
Date of Birth: [**2097-5-15**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
RCC with new pancreatic head mass
Major Surgical or Invasive Procedure:
1. Exploratory laparotomy.
2. Gastroenterostomy (antecolic retrogastric
isoperistaltic).
3. Open cholecystectomy.
4. Extended adhesiolysis.
5. Ileocolic bypass (by Dr. [**Last Name (STitle) 1924**].
6. Appendectomy.
History of Present Illness:
51M PMH of aggressive renal cell carcinoma s/p R nephrectomy.
Metastatic disease to the lungs and s/p chemo with solid tumor
recurrence. On recent imaging, the head of his pancreas was
found to have a necrotic gas-filled appearance consistent with a
metastatic lesion there which had necrosed.
Past Medical History:
Onc Hx: diagnosed with kidney cancer in [**5-/2147**] when he presented
with hematuria and abdominal pain. The CT showed a large right
renal mass and he underwent nephrectomy on [**2147-6-6**].
Nephrectomy showed an 11 cm tumor with invasion into the
perinephric tissues and major veins, with clear cell histology,
Furhman nuclear grade 2. His preoperative workup had revealed
pulmonary emboli requiring anticoagulation. CT scans following
nephrectomy showed recurrence in the
nephrectomy bed site as well as increased mediastinal
lymphadenopathy. He received HD IL-2 treatment in [**2147-9-1**]
without response. He was enrolled in the phase I
avastin/sorafenib trial initiating treatment in [**11-5**].
PAST MEDICAL HISTORY:
1. Status post partial colectomy after perforated bowel
secondary to a motorcycle accident.
2. Status post right knee surgery.
3. Status post left knee arthroscopy.
4. History of pulmonary emboli on anticoagulation.
Social History:
Social History:
He works in the telecommunication industry and often drives for
hours at a time.
Remote ETOH hx
Tob: 1 ppd x 30 years
Married and lives with wife and 7 yr old child
Family History:
Family History:
Father and uncle with lung CA
[**Name (NI) **] with [**Name2 (NI) 499**] CA
Sister with lung problems
[**Name (NI) **] family hx of kidney cancer
Physical Exam:
On discharge:
AVSS
Well-developed, thin 51yo male
NCAT, NAD
EOM full, anicteric, non-injected sclera
Neck supple, no LAD
Chest clear bilaterally
Heart regular without murmurs
Abdomen, soft, moderate incisional tenderness, midline incision
has been opened in multiple areas and is packed with iodoform
dressing, it is granulating well and does not have any
surrounding erythema and minimal induration, normal bowel
sounds, there are no drains in place
LE warm, well perfused, no edema
Pertinent Results:
[**2148-10-4**] 04:51AM BLOOD WBC-9.5 RBC-2.42* Hgb-7.1* Hct-22.2*
MCV-92 MCH-29.3 MCHC-32.0 RDW-17.8* Plt Ct-611*
[**2148-10-5**] 07:09AM BLOOD PTT-51.4*
[**2148-9-27**] 03:48PM BLOOD AT III-56*
[**2148-10-4**] 04:51AM BLOOD Glucose-130* UreaN-24* Creat-0.8 Na-136
K-4.7 Cl-105 HCO3-23 AnGap-13
[**2148-10-4**] 04:51AM BLOOD Calcium-9.2 Phos-4.3 Mg-2.5
[**2148-9-23**] 8:01 am SWAB Source: Abdomen.
**FINAL REPORT [**2148-9-27**]**
GRAM STAIN (Final [**2148-9-23**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2148-9-25**]):
[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION. SPARSE
GROWTH.
ANAEROBIC CULTURE (Final [**2148-9-27**]): NO ANAEROBES ISOLATED.
.
SPECIMEN SUBMITTED: APPENDIX & GALLBLADDER.
Procedure date Tissue received Report Date Diagnosed
by
[**2148-9-19**] [**2148-9-19**] [**2148-9-25**] DR. [**Last Name (STitle) **]. BELSLEY/vf
Previous biopsies: [**-6/2171**] 11 TH RT RIB, RT KIDNEY.
DIAGNOSIS:
I. Appendix:
Appendix, no diagnostic abnormalities recognized.
II. Gallbladder (C-D):
Chronic cholecystitis.
Cholelithiasis.
Clinical: Recurrent kidney cancer.
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2148-9-22**] 12:00 PM
CTA CHEST W&W/O C&RECONS, NON-
Reason: assess for PE
IMPRESSION:
1. Segmental right middle lobe pulmonary artery pulmonary
emboli.
2. Fluid-filled distal right lower lobe bronchus with associated
atelectasis.
3. Focal ground-glass opacity within the right lower lobe which
could represent either aspiration or early pneumonia.
.
CHEST (PORTABLE AP) [**2148-9-24**] 4:16 AM
CHEST (PORTABLE AP)
Reason: RML AND rll atelectasis s/p significant time on Bipap;
any i
The right internal jugular line tip is in low SVC. The NG tube
tip is in the stomach. The IVC filter is in expected position.
There is no interim change in the appearance of right middle and
right lower lobe atelectasis. There is unchanged basal
atelectasis in the left lower lobe. Small left pleural effusion
cannot be excluded. The upper lungs are unremarkable.
.
CT ABDOMEN W/O CONTRAST [**2148-9-26**] 9:12 AM
IMPRESSION:
1. Mild-to-moderate interval increase in amount of
intra-abdominal free fluid. A few small pockets of hyperdense
fluid along the anterior abdominal wall adjacent to incisional
site are likely small postoperative hematomas.
2. Interval increase in size to a known invasive pancreatic head
mass. No significant interval change to retroperitoneal/right
nephrectomy mass. Please note, overall examination is limited
due to lack of IV and oral contrast.
3. Interval placement of suprarenal IVC filter.
4. Probable bilateral, right greater than left, basilar
atelectasis with areas of adjacent patchy ground-glass
opacities. Superinfection/aspiration pneumonitis cannot be
excluded.
5. Gastric tube with its tip in the fundus. Nonvisualization of
GJ tube mentioned in history.
.
CHEST (PORTABLE AP) [**2148-9-28**] 4:26 AM
IMPRESSION:
Small bilateral pleural effusions and bibasilar atelectasis.
Slight interval worsening in bilateral airspace opacities.
Diagnostic considerations again include pneumonia.
.
Brief Hospital Course:
Pain: Chronic opioid user for pain, post-operatively the pt had
severe abdominal pain, out of proportion to his abdominal exam,
which remained relatively soft, although distended, throughout
his hospitalization. On POD8, APS was consulted after pain
control could not be achieved using a fentanyl gtt at
300mcg/hour, dilaudid
PCA@0.75mg/q6mins, clonidine patch in the ICU. APS transitioned
the pt to a ketamine infusion at 10-15mg/h, with dilaudid PCA
and clonidine patch. Before discharge the patient was
transitioned to a PO regimen that included methadone 20mg tid,
dilaudid 8-10mg q3h prn, and clonidine and fentanyl patches. On
discharge the pain was well-controlled.
PE: On POD3, the pt developed acute dyspnea with tachypnea,
requiring non-rebreather and CPAP to maintain adequate
oxygenation. He was transferred to the SICU, where his
respiratory failure could be appropriately managed. Once
stabilized, a PE protocol CTA was done and demonstrated a
segmental right middle lobe pulmonary artery pulmonary embolus.
The pt was started on a sub-therapeutic heparin drip (goal PTT
50-60) and vascular surgery was consulted to put in a
supra-renal IVC filter, which they did on POD4. On POD5, PPD1,
a flex bronch with therapeutic aspiration was done with much
improvement in the pt's respiratory status. By POD8, the pt's
respiratory status had improved and the pt was transferred to
the floor. Supplemental oxygen was weaned, and on discharge the
pt did not require any supplemental oxygen. The heparin drip
was discontinued on POD15, and he was discharged without any
anticoagulation due to the risk of bleeding from the pancreatic
tumor.
Elevated glucose: Throughout his hospitalization, the pt had
elevated blood glucose measurements between 100-200mg/dl. The
pt was discharged without insulin, but it was recommended that
he follow up the week of discharge with his primary care
physician for management of this issue.
ID: Intraoperatively, there was some stool spillage into the
abdomen so the pt was placed on broad spectrum antibiotics.
After spiking a fever on POD___, antibiotics were changed to
vancomycin and zosyn. The pt was pan-cultured, and blood and
urine cultures were negative, as was the CXR. Cultures from the
midline incision fluid were sent and grew back [**Female First Name (un) **] albicans,
but no organisms were found on gram stain. Throughout the
remainder of the hospitalization, the pt remained afebrile on
vanc/zosyn and this regimen was continued for the duration. On
discharge, the pt were transitioned to augmentin for a 2 week
course.
GI: [**Name (NI) **], pt had a prolonged ileus. He was
receiving TPN. In the ICU, the pt passed one bowel movement, but
upon transfer to the floor, he was not passing any flatus. By
POD13, he began passing gas and his diet was advanced from sips
to clears, which he tolerated well. His abdominal exam
continued to improve with diminishing distention. He was
transitioned to full liquids on POD14 after having a successful
bowel movement, and on POD15 he did well with a regular diet and
his TPn was weaned off. His was discharged on a diabetic diet
on POD16, having regular bowel movements without nausea.
Medications on Admission:
zestril 2.5', norvasc 10', oxycontin 90bid, oxycodone 15q3-4prn,
synthroid 100', ativan 1-2prn, ambien qhs, wellbutrin, zantac
150", miralax prn
Discharge Medications:
1. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
Disp:*4 Patch Weekly(s)* Refills:*0*
2. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Methadone 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*0*
8. Bupropion 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q6H (every
6 hours) as needed.
10. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
11. Zestril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
12. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day.
13. Zantac 150 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Home With Service
Facility:
VNA of [**Location (un) 86**]
Discharge Diagnosis:
metastatic RCC, pancreatic mass
Discharge Condition:
stable
Discharge Instructions:
Activity as tolerated
Regular diet
OK to shower
Follow up with Dr. [**Last Name (STitle) **] in 2 weeks.
Call Dr.[**Name (NI) 2829**] office with any questions.
You should call your PCP to arrange an appointment in [**3-3**] days.
Your home blood pressure medication was not started because your
blood pressure has not been elevated during this
hospitalization.
You should take 14 days of augmentin as directed.
You should change your dressing twice daily, using iodoform
packed within the wound.
Followup Instructions:
Make an appt with
[**Hospital 19083**] Care Center
Office Phone: ([**Telephone/Fax (1) 19084**] Office Fax: ([**Telephone/Fax (1) 19085**]
and with
Oncology/Hematology Office Phone: ([**Telephone/Fax (1) 19086**]
Your PCP next week.
Completed by:[**2148-10-8**]
|
[
"197.5",
"401.9",
"V10.52",
"197.4",
"415.11",
"997.4",
"197.6",
"568.0",
"560.1",
"197.8",
"574.10",
"933.1",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"96.05",
"47.19",
"38.93",
"45.93",
"38.7",
"51.22",
"54.59",
"44.39"
] |
icd9pcs
|
[
[
[]
]
] |
10615, 10675
|
6002, 9203
|
347, 569
|
10751, 10760
|
2760, 5979
|
11305, 11572
|
2094, 2241
|
9398, 10592
|
10696, 10730
|
9229, 9375
|
10784, 11282
|
2256, 2256
|
2270, 2741
|
274, 309
|
597, 893
|
1645, 1863
|
1895, 2062
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,838
| 131,671
|
33555
|
Discharge summary
|
report
|
Admission Date: [**2126-3-15**] Discharge Date: [**2126-3-22**]
Date of Birth: [**2101-1-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Agitation
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 25yo man with bipolar and polysubstance abuse who is a
bryerwood for heroin detox (on methadone). He reports he was
using 50bags iv heroin daily, denied using anything else(but see
below). Mother reports he started scratching himself after
girlfriend broke up with him. Parents took him to ER.
.
He recalls feeling suicidal and going to [**Hospital1 **] but doesn't
know
how he got here or recall his hospitalization there. Per
[**Hospital1 **] nurse he was admitted 5 days ago for detox from
benzos and heroin and was becoming increasingly manic and
agitated. Last night he had a confrontation with another patient
and received stat IM meds after making a weapon with a tonic
bottle wrapped in a sock. Detox regiment was Valium and
methadone tapers. Total
methadone received 80mg. Yesterday received valium 5x3, Lithium
300bid, Lamictal 200bid, Stelazine 3mg in am/1mg pm, Vistaril
25am/50hs, Ativan 2x2 for agitation, stat IM
Ativan2/Zyprexa10/Benadryl50. This morning pt. was confused,
didn't know where he was, ataxic.
.
He was transferred to the [**Hospital1 18**] ED. Initial VS were 98, hr 118,
111/61, 16RR, 99%. He punched a security guard. In the ED he
had a negative head CT. He received olanzipine 10mg IM x3, and
haldol 5mg/ativan 2mg. He had a psych consult who felt that he
medically not stable to evaluate but did sign a section 12. He
had a toxicology consult. They felt that he was "classically"
anticholenergic. For now recommending to avoid anticholinergics
given anticholinergic toxidrome and agitatin and to use benzos
preferentially. He received 2mg IV x3 in the ED.
?Physiostigmine? Because of somnolence and 4 pt restraints he
was admitted to the ICU.
.
Past Medical History:
PMH: Hep C, asthma.
.
Past Psych Hx: Pt. (unreliable) reports suicide attempt by
walking in front of a car 6 years ago, doesn't recall
hospitalizations. Sees a psychiatrist in [**Location (un) 8973**], can't
remember name. Mother reports he was hospitalized at [**Doctor Last Name **]
.
MHC
last year after suicide attempt and diagnosed with Bipolar Dis.
He's been followed by Dr. [**Last Name (STitle) 3265**] in [**Location (un) 8973**], prescribed
Lamictal 100 [**Hospital1 **] and Valium (dose unknown).
Social History:
Substance use: In addition to abusing Valiums and 50bags/day
heroin mother reports he's been smoking crack. Last use valium
was [**2126-3-8**]. Longest sobriety 3 years 2 years ago, bought
Suboxone on the street.
.
SH: Mom reports he was a "good kid" until drug problems in past
few years. But he did not graduate h.s. and she admits he may
have been using drugs by then. She reports he's never been to
jail but had probation once.
Physical Exam:
T: 95.6 BP: 131/77 P: 86 RR: 19 O2 sats: 100%RA
Gen: Restrained in leather 4 points, sleepy but arousable
HEENT: op with very dry mucous membranes, pinpoint pupils in the
dark, not responsive to light
Neck: supple
CV: RRR no m/r/g
Resp: CTAB
Abd: +BS, NTND, soft
Ext: 2+ pulses
Skin: flushed
Neuro: oriented to hospital, [**2126-3-9**], but not to specific
date/hospital name. 5/5 strength.
psych: still actively suicidal
Pertinent Results:
ADMISSION LABS:
[**2126-3-15**] 09:30AM BLOOD WBC-11.0 RBC-5.62 Hgb-15.2 Hct-45.3
MCV-81* MCH-27.0 MCHC-33.6 RDW-12.9 Plt Ct-277
[**2126-3-15**] 09:30AM BLOOD Neuts-55.3 Lymphs-34.4 Monos-4.3 Eos-5.1*
Baso-0.8
[**2126-3-15**] 09:30AM BLOOD Plt Ct-277
[**2126-3-15**] 09:30AM BLOOD Glucose-86 UreaN-11 Creat-1.2 Na-141
K-4.2 Cl-104 HCO3-27 AnGap-14
[**2126-3-15**] 09:30AM BLOOD CK-MB-2 cTropnT-<0.01
[**2126-3-16**] 04:15AM BLOOD Albumin-4.4 Calcium-9.4 Phos-3.1 Mg-2.3
[**2126-3-15**] 09:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2126-3-15**] 09:30AM BLOOD Lithium-0.6
[**2126-3-18**] 11:53AM BLOOD Type-[**Last Name (un) **] pH-7.42
[**2126-3-18**] 11:53AM BLOOD Lactate-0.9
[**2126-3-18**] 11:53AM BLOOD freeCa-1.22
.
DISCHARGE LABS:
[**2126-3-19**] 06:25AM BLOOD WBC-9.1 RBC-5.45 Hgb-15.1 Hct-44.7 MCV-82
MCH-27.7 MCHC-33.7 RDW-12.3 Plt Ct-266
[**2126-3-19**] 06:25AM BLOOD Plt Ct-266
[**2126-3-19**] 06:25AM BLOOD Glucose-97 UreaN-16 Creat-1.1 Na-143
K-3.9 Cl-108 HCO3-27 AnGap-12
[**2126-3-19**] 06:25AM BLOOD ALT-39 AST-27 LD(LDH)-166 AlkPhos-71
TotBili-0.3
[**2126-3-19**] 06:25AM BLOOD Calcium-9.7 Phos-3.6 Mg-2.1
URINE.
[**2126-3-16**] 10:59AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006
[**2126-3-16**] 10:59AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
[**2126-3-16**] 10:59AM URINE RBC-8* WBC-<1 Bacteri-FEW Yeast-NONE
Epi-0
CT HEAD W/O CONTRAST [**2126-3-15**] 4:00 PM
.
NON-CONTRAST CT HEAD: No intra- or extra-axial hemorrhage, shift
of normally midline structures or mass effect is identified.
[**Doctor Last Name **]-white matter differentiation is preserved throughout
without evidence of major vascular territorial infarct. The
paranasal sinuses and mastoid air cells are unremarkable.
.
IMPRESSION: No acute intracranial abnormality.
CHEST (PORTABLE AP) [**2126-3-17**] 8:43 AM
.
FINDINGS: The lungs are clear. Bony structures are intact.
Cardiac silhouette and mediastinum is normal.
.
IMPRESSION:
.
Normal study of the chest.
Brief Hospital Course:
25 y/o m Hepc, polysubstane abuse, bipolar d/o transferred for
anticholinergic toxicity s/p IM psych meds for aggitation and
violent behavior. Patient had a several day course in the
medical ICU where he was restrained until his sensorium cleared.
Only supportive measures were given. Lamictal and lithium were
held. CIWAs were monitored. Lithium 300mg was started day of
discharge.
.
HOSPITAL COURSE:
.
MEDICALLY CLEARED for outpatient substance abuse program.
.
# Bipolar disorder: . Psychiatry service followed along.
Lamictal and lithium were held while he was inpatient. He was
treated with lithium 300mg [**Hospital1 **], zyprexa and valium. Patients
outpatient psychiatrist is Dr. [**Last Name (STitle) 3265**] in [**Location (un) 8973**].
# Mental Status changes: It was felt that patients mental
status, was completely related to the large amount of
anticholinergics the patient had received during his episode of
violent aggitation. Patient was monitored in the MICU. Head CT
was negative for acute pathology. Patient had a negative
infectious work up. Neg UA and neg CXR. Patients sensorium
cleared on [**2126-3-14**] and he was transferred to the floor where he
was monitored by a 1:1 sitter. No periods of aggitation while on
the general medical [**Hospital1 **]. Medical team feels that patient is
MEDICALLY CLEARED in regards to this issue.
.
#Leukocytosis: Patient had leukocytosis of uncertain etiology,
as high as 13.5. The leukocytosis resolved prior to discharge,
may have just been peripheral demargination in response to
stress.
.
#Valium withdrawal: Patient was weaned off of valium during
hospital course. CIWAs over last 24h prior to discharge were 1
to 2. No PRN valium or haldol needed. Patient was discharged on
valium 5mg PO BID standing.
.
#Aggitation: Patient has history of violent aggitation, striking
security guard in [**Hospital1 18**] ED. Patient was apparently altered from
medications during this occurrence. He does not recall the
event. Also history of pt making threats and creating weapon at
prior psych hospitalization, which was initial need for IM
sedation, and transfer to [**Hospital1 18**].
-Pt was aggitated during his MICU course, but in the last 24
hours prior to discharge did not need any additional medication.
Patient was continued on Zyprexa 5mg PO BID standing. Haldol 5mg
IV QID:PRN acute agitation, but not needed in last 24 hours.
.
# Asthma: Patient did not have an oxygen requirement. On
physical exam he was not wheezy. During his stay he did receive
some PRN nebulizer treatments. He takes albuterol PRN q 6H.
.
# Hepatitis C: This issue was not addressed during this
inpatient stay. Patient will need to follow up with a medical
doctor in regards to this issue.
.
# DISPO: Patient was evaluated on [**3-19**] by BEST team for transfer
to inpatient psychiatric facility.
.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8952**] MD
Medications on Admission:
Lamictal 200mg [**Hospital1 **]
Lithium 300mg [**Hospital1 **]
cogentin 1.5mg QHS
Valium 10mg QHS
Discharge Medications:
1. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day): [**Month (only) 116**] titrate off with withdrawal.
2. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day).
3. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
4. Diazepam 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
6. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) Injection
QID (4 times a day) as needed.
7. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
every six (6) hours: as needed for shortness of breath.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
-Aggitation
-Anticholinergic toxicity
-Delirium
-Bipolar disorder
.
Secondary Diagnosis.
-Hepatitis C
-Asthma
-Polysubstance Abuse disorder.
Discharge Condition:
Stable, CIWA 1, not needing any PRN medications for withdrawal
protocols or aggitation
Discharge Instructions:
Mr. [**Known lastname 77775**] you were transferred to [**Hospital1 18**] for aggitation and
anticholinergic toxicity. You received a large amount of
sedating medications prior to arrival at [**Hospital1 18**]. You received
supportive care in the ICU until the effects of these
medications wore off.
.
We did not find any infectious or metabolic cause for your
confusion.
.
You were restarted on lithium 300mg twice a day for your bipolar
disorder.
.
We highly recommend that you stop smoking. We have given you a
prescription for nicotine patches.
.
If you have any similar episodes of confusion or aggitation
please seek professional help at the nearest emergency room or
call 911.
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **].
[**Last Name (STitle) 77776**] [**Telephone/Fax (1) 40468**]. You have to follow up with Dr.
[**Last Name (STitle) 77776**] for your hepatitis C.
.
You have an appointment for psychiatric evaluation as follows:
Monday [**2126-3-25**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20756**], LICSW
1pm
[**Hospital **] Hospital
[**Location (un) 77777**]
[**Location (un) 8973**], MA
[**Telephone/Fax (1) 77778**].
You have an appointment for intake for Intensive Outpatient
Program:
Tuesday [**3-26**] at 7:30am
SSTAR Treatment Center
[**Last Name (NamePattern1) 77779**]
[**Location (un) 8973**]
[**Telephone/Fax (1) 77780**]
Please call me Monday if you have any questions.
[**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) 12471**], LICSW
[**Telephone/Fax (1) 57081**]
|
[
"288.60",
"305.1",
"276.2",
"296.89",
"493.90",
"E941.1",
"070.70",
"780.97",
"E849.7",
"304.01",
"292.81",
"304.11",
"292.0",
"307.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9360, 9366
|
5598, 5983
|
325, 332
|
9570, 9659
|
3505, 3505
|
10391, 11282
|
8662, 9337
|
9387, 9387
|
8539, 8639
|
6000, 8513
|
9683, 10368
|
4282, 5021
|
3059, 3486
|
276, 287
|
360, 2061
|
5030, 5574
|
3521, 4266
|
9406, 9549
|
2083, 2593
|
2609, 3044
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,259
| 111,485
|
12626
|
Discharge summary
|
report
|
Admission Date: [**2188-9-18**] Discharge Date: [**2188-10-2**]
Date of Birth: [**2111-12-1**] Sex: M
Service: MEDICINE
Allergies:
Phenytoin / Decadron
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Atrial Fibrillation
Major Surgical or Invasive Procedure:
IVC filter [**2188-9-19**]
Pacer placement [**2188-9-23**]
Atrio-ventricular juncion ablation [**2188-10-1**]
History of Present Illness:
Mr. [**Known lastname 39015**] is a 76yo gentleman with h/o AFib not on coumadin
s/p recent craniotomy for resection of meningioma who presents
with recurrent AFib with RVR.
The patient was admitted to the cardiology service at [**Hospital1 18**] from
[**Date range (1) 17433**] with AFib/RVR. His medications were adjusted such that
he was discharged on metoprolol 50mg [**Hospital1 **], Amiodarone 200mg
daily, and digoxin 0.125 every other day. His blood pressure was
stable on this regimen and he was noted to be bradycardic in the
40s-50s. On the day of admission, his heart rate went back up to
130s-140s despite receiving his medications as ordered and
[**Hospital1 **] sent him to the ED.
In the ED, initial vitals were 97.1 130 123/77 17 95% RA. Tm was
99.9. He was given diltiazem 10mg IV without effect; increasing
dose to 20mg did not control HR. He was then put on diltiazem
gtt, which was increased to 15mg/hr without decreasing his HR.
His SBP remained in the 110s.
He is not able to answer ROS.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, - Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Afib s/p ablation on coumadin - Had Aflutter ablation [**2188-7-16**]
Atypical recurrent right frontal meningioma s/p radiation and
chemotherapy. Most recent resection [**2188-8-21**].
GERD
Hypothyroidism
Social History:
Per OMR, unable to answer questions. Married with two children.
Used to smoke a pack a day but quit in [**2151**]. Used to drink beer
but stopped when he was put on Coumadin.
Family History:
Per OMR, unable to answer questions. Family History: Mother died
at 80 from stroke. Father died at 60's, unclear cause. Bother
died 60 from lung cancer.
Physical Exam:
VS: Afebrile. Heart rate in 80s. BP 120/78.
GENERAL: NAD. Breathing well on room air. Moving all four
extremities.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple. No JVD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Regular heart rate. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: +Kyphosis. Resp were unlabored, no accessory muscle use.
CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: +PEG tube. Soft, NTND. No HSM or tenderness. Abd aorta
not enlarged by palpation. No abdominial bruits.
EXTREMITIES: Left lower extremity edema to knee.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 1+ PT 1+
Left: Carotid 2+ DP 1+ PT 1+
Pertinent Results:
CBC:
[**2188-10-2**] WBC-5.9 RBC-3.65* Hgb-11.6* Hct-33.4* Plt Ct-343
[**2188-9-17**] WBC-7.7 RBC-4.00* Hgb-12.9* Hct-36.4* Plt Ct-299
Coags:
[**2188-10-2**] PT-14.9* PTT-31.1 INR(PT)-1.3*
[**2188-9-17**] PT-13.2 PTT-25.8 INR(PT)-1.1
Chemistry:
[**2188-10-2**] Glucose-114 UreaN-12 Creat-0.9 Na-137 K-3.9 Cl-102
HCO3-29 AnGap-10
[**2188-9-17**] Glucose-127 UreaN-13 Creat-0.8 Na-136 K-3.9 Cl-103
HCO3-26 AnGap-11
[**2188-10-2**] Calcium-8.6 Phos-3.3 Mg-2.3
[**2188-9-18**] Calcium-8.2* Phos-2.1* Mg-2.1
LFTs:
[**2188-9-27**] ALT-35 AST-22 AlkPhos-77 Amylase-25 TotBili-0.3
CE:
[**2188-9-26**] CK(CPK)-49
[**2188-9-18**] CK(CPK)-36*
[**2188-9-26**] CK-MB-NotDone cTropnT-<0.01
[**2188-9-18**] CK-MB-NotDone cTropnT-<0.01
[**2188-9-17**] cTropnT-<0.01
TSH:
[**2188-9-27**] TSH-1.4
CXR [**2188-9-17**]: There is cardiomegaly which is stable. There is no
evidence of pleural effusion or consolidation. The lungs are
clear. The osseous structures are unremarkable.
ECHO [**2188-9-18**]: There is mild symmetric left ventricular
hypertrophy. 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
dilated with borderline normal free wall function. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. The mitral valve leaflets are structurally normal.
Physiologic mitral regurgitation is seen (within normal limits).
There is an anterior space which most likely represents a fat
pad.
Compared with the prior study (images reviewed) of [**2188-8-22**],
there is no pericardial effusion on the current study (the prior
study mentioned an effusion but this appearance may have been
due to a fat pad). The other findings are similar.
BILAT LOWER EXT VEINS [**2188-9-18**]: Extensive left lower extremity
deep vein thrombosis extending from the common femoral to the
calf veins. No DVT in the right lower extremity.
CT HEAD: FINDINGS: Examination is stable in comparison to
[**2188-9-25**]. The patient is status post resection of right frontal
lobe meningioma, with severe encephalomalacia in the surgical
site. There is persistent small foci of pneumocephalus, and
hyperdensity within the right frontal lobe, that was felt to
represent likely subacute hemorrhage. There is a stable small
extra-axial hyperdense collection overlying the right frontal
lobe. No new hemorrhage, shift of midline structures or vascular
territory infarct is identified.
Periventricular and deep white matter hypodensities, consistent
with small
vessel disease are stable. There is a soft tissue density within
the right
frontal lobe that is unchanged. Visualized paranasal sinuses and
mastoid air cells are otherwise well aerated.
IMPRESSION: Unchanged appearance of post-surgical changes, with
hyperdensity in the right frontal lobe resection bed. No new
mass effect or hemorrhage.
CAROTID ARTERY U/S:
Duplex evaluation was performed of both carotid arteries.
Minimal plaque is identified. On the right, peak systolic
velocities are 71, 85, and 88 in the ICA, CCA, and ECA
respectively. The ICA to CCA ratio is 0.8. This is consistent
with less than 40% stenosis.
On the left, peak systolic velocities are 66, 66, and 79 in the
ICA, CCA, and ECA respectively. The ICA to CCA ratio is 1. This
is consistent with less than 40% stenosis.
There is antegrade flow in both vertebral arteries.
IMPRESSION: Minimal plaque with bilateral less than 40% carotid
stenosis.
Brief Hospital Course:
76 year old male with history Atrial Fib s/p recent craniotomy
for resection of meningioma who presents with recurrent AFib
with RVR from [**Hospital **] Rehab. Patient was recently admitted for
A Fib with RVR.
# Atrial Fibrillation with RVR: Presented with HR 130s. Started
on Diltiazem drip in ER. On floor increased Amiodarone 400 mg
from 200 mg once a day, decreased Metoprolol 50 mg [**Hospital1 **] to 25 mg
[**Hospital1 **], and slowly weaned Diltiazem drip. Patient's third admission
for A Fib with RVR (120-130s), when converts enters sinus brady
(40s-50s). Decided pacer best option as we could then increase
rate control medications without worrying about brady-junctional
rhythm. Discussed with Neurosurgery, can monitor meningioma with
CT scan instead of MRI. Pacer placed on [**2188-9-23**], no complications
from procedure. Triggers for A Fib include infection, PE,
ischemia, recent surgery and thyrotoxicosis. Troponin negative
and no ischemia changes on EKG. CXR no sign of infection. Free
T4 increased last admission and consequently decreased
Levothyroxine 37.5 mg (TSH level normal). Patient had recent
neurosurgery [**2188-8-21**]. Patient still having persistent A-Fib
after pacer placement. Pt became hypotensive most likely from
increasing dose of beta blocker.
Brief MICU course: Pt transfered to MICU for low blood pressure
unresponsive to fluid bolus after increasing metoprolol to 75mg
three times a day. Received 6 liter of NS without responding to
fluids. He was started on an esmolol drip which converted him
to sinus rhythm. His blood pressure increased to 100-120/50-60
and his HR decreased to 60s. He was transfered back to the
flood on metoprolol 25mg three times a day.
On the floor he converted back into A-fib within 24 hours. His
rate remained in the 120s-140s despite increaing his metoprolol
to 100 three times a day. The decision was made to ablate his
atrial ventricular junction and have him be pacer dependant. He
under went successful ablation on [**2188-10-1**]. Since then he has
been at a constant rate of 80 with no events on telemetry.
# Deep Vein thrombosis: Patient's left leg swollen and warm on
admission. BILAT LOWER EXT VEINS demonstrated extensive left
lower extremity deep vein thrombosis extending from the common
femoral to the calf veins. No DVT in the right lower
extremity. Patient started on Heparin drip. Placed IVC filter
[**2188-9-19**]. Due to patient's neurosurgery history was concerned
that at some point patient's anticoagulation whould have to be
stopped. Patient could not be anti-coagulated since his
neurosurgery on [**2188-8-21**]. Per neurosurgery have to wait one month
post-op to re-start coumadin ([**2188-9-21**]). Coumadin was re-started
for A Fib and DVT s/p pacer placement on [**2188-9-23**], bridge on
Heparin drip. Because of re-bleed on heat CT anticoagulation
was stopped. It was discussed with neurosurgery who did not
think the bleed was significant and coumadin was restarted.
# Urinary tract infection: Developed hematuria. Ua demonstrated
signs of infection (+ nitrates + leukocytes, 11 WBC, moderate
bacteria). Urine culture positive E. Coli. Started 5 day course
of Bactrim from [**2188-9-20**] until [**2188-9-24**].
# Paraphimosis: Developed [**2188-9-20**] and immediately reduced by
Urology. Bacitracin for 3 days. Most likely related to patient
tugging at foley.
# Meningioma status post 5th resection on [**8-21**]: For full
meningioma history please see Dr.[**Name (NI) 6767**] note on [**2188-7-16**]. His
Keppra was continued for seizure prophylaxis. Kept head of bed
elevated. On [**2188-9-25**] Patient had a questionable TIA. His mental
status was wanning and it appeared as though he could not move
his left side. A head CT revealed a new focus of hemorrhage.
After the CT he began moving all four limbs spontaneously.
Anticoagulation was stopped in setting of new bleed.
Neurosurgery said there was not enough to intervene at this
time. We treated like a TIA and started him on high dose
statin. A repeat head CT two days later showed no increase of
the bleed. A family meeting was held on [**10-1**] to discuss his
overall prognosis. His code status was changed to DNR/DNI. The
decision was to attempt to get him to a rehab hostpital with the
possibility of hospice later.
.
# HTN: Well controlled, continued lisinopril and metoprolol.
.
# Hypothyroidism: TSH and free T4 checked on last admission.
Continue 37.5 mg levothyroxine.
.
# DM: Regular insulin sliding scale only.
.
#. Nutrition: Continue PEG tube with tube feeds. If patient
clinically improves and develops a will to eat, it would be
reasonable to obtain a speech and swallow evaluation and try
oral feeds.
.
# Code status: changed to DNR/DNI at family meeting on [**2188-10-1**].
.
# Medication changes:
1) Amiodarone 200mg daily
2) Atorvastatin 40mg daily
3) Stopped digoxin
4) Metoprolol changed to 50mg twice a day.
5) coumadin at 4mg daily.
6) Levothyroxine 37.5mg daily
7) Fametodine changed to lansaprazole 30mg daily.
8) Started Tamsulosin 0.4 mg daily
Medications on Admission:
Digoxin 125mcg every other day
Lisinopril 10mg daily
Metoprolol 50mg [**Hospital1 **]
Amiodarone 200mg daily
Keppra 1000mg [**Hospital1 **]
Levothyroxine 37.5mcg daily
Famotidine 20mg [**Hospital1 **]
NPH 14 units QAM, 12 units QPM
Humalog SS
Docusate
Senna
Nystatin 5ml TID
Discharge Medications:
1. Keppra 1,000 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
2. Lisinopril 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
3. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: 100 mg PO BID (2
times a day).
4. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Last Name (STitle) **]: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
7. Levetiracetam 500 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2
times a day).
8. Levothyroxine 75 mcg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY (Daily).
9. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2
times a day).
10. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed.
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
12. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H
(every 6 hours) as needed.
13. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection ASDIR (AS DIRECTED).
14. Lidocaine HCl 2 % Gel [**Last Name (STitle) **]: One (1) Appl Mucous membrane PRN
(as needed).
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
16. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
twice a day.
17. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
18. Warfarin 2 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Once Daily at 4
PM.
19. Atorvastatin 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
Atrial Fib
DVT (left leg)
Secondary:
meningioma s/p frontal craniotomy [**2188-8-21**]
diabetes
hypertension
hypothyroidism
GERD
Discharge Condition:
Fair. Stable vitals and HR.
Discharge Instructions:
You were admitted to the hospital for a fast, irregular heart
rate. You had a pacemaker placed on [**2188-9-23**]. On admission we
found you had a blood clot in your left leg. A filter was placed
to prevent a clot in your lungs (pulmonary embolism).
You developed an infection in your urine during the admission
and that was treated with antibiotics.
You continued to have the fast heart rate despite medicaitons.
Because of [**Last Name (un) **] your blood pressure dropped and you were
transered to the intensive care unit for 2 days. You were
stabalized and transfered back to the floor.
A repeat CT scan of the head showed a small bleed around the
area of surgery. Your anticoagulation was immediatly stopped.
The neurosurgical team said it was not enough to intervene on.
A repeat CT showed that the bleed had stabalized. Because of
this you were restarted on coumadin.
You had a procedure done where they ablated the
atrio-ventricular junction of the heart to slow the heart rate
down. After the procedure your heart was at a regular rate.
We have made the following changes to your medications:
1) Your Metoprolol dose is now 25mg two times a day
2) Your Amiodarone dose is now 200mg daily
3) Stopped digoxin
4) Coumadin 4mg daily
5) Atorvastatin 40mg daily
Otherwise please take medications as prescribed.
Return to the ER if you experience dizziness, feeling like you
will pass out, chest pain, shortness of breath, bleeding or any
other concerning symptoms.
Attend the appointments below we have made for you:
1) CAT SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2188-10-7**] 8:30
2) Dr.[**Last Name (STitle) **] of Cardiology on [**2188-10-16**] at 10:20am [**Hospital 273**], [**Location (un) **] CC7 CARDIOLOGY.
Followup Instructions:
Please attend the following appointments:
1) You have a CT SCAN scheduled [**2188-10-7**] 8:30am at Radiology, CC
CLINICAL CENTER, [**Location (un) **]. Following this, you have an
appointment with Dr. [**Last Name (STitle) **] of Neurosurgery at 9:30am [**2188-10-7**] in
the LM [**Hospital Unit Name **], [**Location (un) **] NEUROSURGERY WEST.
2) You have an appointment with Dr.[**Last Name (STitle) **] of Cardiology on
[**2188-10-16**] at 10:20am [**Hospital6 29**], [**Location (un) **] CC7 CARDIOLOGY.
3) Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**]
Date/Time:[**2188-10-27**] 1:00
|
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icd9cm
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3,347
| 128,247
|
45956
|
Discharge summary
|
report
|
Admission Date: [**2152-9-14**] Discharge Date: [**2152-9-20**]
Date of Birth: [**2094-12-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
left sided weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 57 year-old male with a history of NSCLA lung cancer
with brain mets, known pontine lesion, who presents with hypoxia
and worsening L sided weakness (arm, leg and facial droop).
Patient was [**Last Name (un) 4662**] to the ED by his wife after she noted
worsening left sided weakness on the am of admission that has
been progressing over the last week. When she was unable to get
him out of bed, she called EMS.
.
Of note, patient was seen by his PCP [**Last Name (NamePattern4) **] [**2152-9-7**] for left arm
weakness and reported coughing episodes with liquids. During
that visit, his PCP noted more slurred speech and was suspicious
for aspiration. An outpatient MR [**First Name (Titles) **] [**Last Name (Titles) 93516**] his known pontine
lesion was scheduled for the day of admission and an outpatient
speech and swallow was planned. His wife noted that he had a
persistent cough w/sputum production last week which she feels
is improved over the past few days. There have been no fevers or
chills, nausea, vomiting, diarrhea. He has urinary frequency at
baseline.
.
In the ED, VS T 99 HR 77 BP 99/67 RR 20 POx 87% on RA which
improved with NRB to 100%. A Head CT was negative for acute
change. A CTA demonstrated multifocal PNA for which he received
a dose of cefepime and levofloxacin. It was negative for PE.
.
ROS: The patient [**Last Name (Titles) **] any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
melena, hematochezia, chest pain, shortness of breath,
orthopnea, PND, lower extremity oedema, cough, urinary
frequency, urgency, dysuria, lightheadedness, headache, rash or
skin changes.
Past Medical History:
- Nonsmall cell lung cancer with metastases to brain, s/p VATS
to right lower lung on [**2150-7-24**], surgical resection of brain
tumor on [**2141-12-19**], s/p whole brain irradiation from [**2142-1-8**] to
[**2142-2-5**]; now with pontine metastases getting Cyberknife
treatments
- Hypothyroidism
- Depression/Anixety
- CAD s/p CABG [**2139**]
- Non sustained VT on Amiodarone
- Ischemic cardiomyopathy with EF of 20-30% [**8-3**] by echo
- Bilateral cataract surgery
- Erectile dysfunction
- Avascular necrosis of right humerus
- S/P Cholecystectomy
- S/P Right shoulder surgery x 2
- Tremor
Social History:
He is married. He has 3 children between the ages of 20-30. He
used to work for NSTAR and has a history of asbestos exposure.
He smoked 2-1/2 packs per day for 20 years, but quit 10 years
ago. He does not drink alcohol.
Family History:
There is no family history of breast, ovarian, uterine, colon,
or lung cancer. His brother did have pancreatic cancer at the
age of 70. His mother died at age 83. He does not know of any
specific medical problems that she had. His father
died at age 52 of a myocardial infarction. He also had a sister
who died of an aneurysm.
Physical Exam:
Vitals: T:97.6 BP:93/58 HR:74 RR:14 O2Sat: 94% on 3L NC
GEN: Chronically ill, well-nourished, no acute distress
HEENT: EOMI, pupils 4mm, right briskly reactive, left minimally
reactive, sclera anicteric, no epistaxis or rhinorrhea, MMD, OP
w/ white plaques on tongue/hard palate
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: HS distant, RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: scattered rhonchi left >right, no wheezing or rales
ABD: obese, Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords, WWP
NEURO: alert, oriented to person, place, and time. repeatedly
asking same questions. speech slurred. tongue deviates to left,
left eye lids weak. Strength in left upper/lower extremity [**4-1**].
Strength on right [**5-1**]. Hyperreflexic at
petellar/achilles/brachial on left. Plantar reflex upgoing on
left.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
=========
[**Month/Day (1) **]
=========
Ct head [**9-14**] - IMPRESSION: 1. No new focus of edema or other
acute intracranial abnormalities
identified.
2. The known right pontine lesion is better visualized on MRI.
MRI is more
sensitive in the detection of mass lesion.
CTA chest [**9-14**] - IMPRESSION:
1. New air space consolidation involving the right upper and
left lower
lobes. As these findings were not present on [**2152-8-17**], this
findings are
most consistent with multifocal pneumonia.
2. Stable emphysema and post-surgical changes of right lower
lobectomy.
3. Right upper lobe nodules, not changes, suggestive of small
airways
infection.
hip x-ray - no evidence of acute fracture
forearm x-ray - IMPRESSION: No evidence of fracture or
dislocation
[**9-14**] chest x-ray IMPRESSION: Left lower lobe patchy opacity
concerning for pneumonia. Second ill-defined focus in the right
upper lobe may represent a second focus of infection.
=========
Labs
=========
[**2152-9-14**] 01:15PM BLOOD WBC-8.8 RBC-3.72* Hgb-12.2* Hct-34.9*
MCV-94 MCH-32.8* MCHC-35.0 RDW-16.1* Plt Ct-77*#
[**2152-9-14**] 01:15PM BLOOD Neuts-68 Bands-9* Lymphs-5* Monos-3 Eos-0
Baso-1 Atyps-0 Metas-5* Myelos-6* Promyel-1* Hyperse-2* NRBC-1*
[**2152-9-14**] 01:15PM BLOOD PT-12.7 PTT-22.4 INR(PT)-1.1
[**2152-9-14**] 01:15PM BLOOD Plt Smr-VERY LOW Plt Ct-77*#
[**2152-9-14**] 01:15PM BLOOD Fibrino-1029*#
[**2152-9-14**] 01:15PM BLOOD Glucose-92 UreaN-19 Creat-0.8 Na-137
K-3.6 Cl-101 HCO3-23 AnGap-17
[**2152-9-14**] 01:15PM BLOOD LD(LDH)-507* CK(CPK)-35* TotBili-1.1
[**2152-9-14**] 01:15PM BLOOD cTropnT-0.02*
[**2152-9-14**] 01:15PM BLOOD Calcium-8.4 Phos-2.7 Mg-1.9
[**2152-9-14**] 01:15PM BLOOD Hapto-729*
[**2152-9-14**] 01:15PM BLOOD Digoxin-1.1
[**2152-9-14**] 01:22PM BLOOD Lactate-1.5
Brief Hospital Course:
# LLL PNA/Aspiration - Per wife, multiple coughing episodes with
liquids over last 2 weeks, though believes cough worst last
week. Likely etiology of aspiration in the setting of
progressive neurological decline. Patient was on levofloxacin
and flagyl for a few days, but stopped on [**9-17**] when CXR
demonstrated a rapid resolution of right sided opacity unlikely
to be consistent with infectious etiology. Patient was not
febrile and did well without antibiotics. He passed his speech
and swallow evaluation, and no specific dietary restrictions
were given.
.
# Nonsmall cell lung cancer with known pontine mass: New left
sided weakness, slurred speech, multiple neurologic
abnormalities concerning for worsening metastatic disease. MRI
did not demonstrate worsening disease. Patient was kept on
steroids in house and discharged on steroids to be followed up
by Dr. [**Last Name (STitle) 26981**] to discuss steroid taper as an outpatient.
.
# Oral Thrush: Likely [**1-29**] long-standing steroids. Continued on
nystatin swish and swallow.
.
# Thrombocytopenia: Off from baseline at 77. INR 1.1. DIC labs
negative. No transfusions were necessary during hospital stay.
Platelet count trended up until discharge to 171.
.
# Hypothyroidism: Continued outpatient regimen of thyroid
replacement.
.
# Depression/Anixety: Continued paroxetine and held Clonazepam
given confusion.
.
# CAD s/p CABG [**2139**], EF of 20-30% [**3-4**] by echo: No evidence of
chest pain or volume overload. Dig level therapeutic and digoxin
was continued. Held aspirin in setting of thrombocytopenia, but
restarted at discharge. Continued propanolol while in house.
.
# H/o Non sustained VT: Continued Amiodarone and monitored on
telemetry without event.
.
# Code: DNR/DNI
Medications on Admission:
AMIODARONE - 200 mg Tablet [**Hospital1 **]
ASPIRIN - 81MG Tablet daily
CLONAZEPAM [KLONOPIN] - 0.5mg [**Hospital1 **]
DEXAMETHASONE - 4 mg qAM 2mg QPM
DIGOXIN - 125 mcg Tablet - daily
FOLIC ACID - 1 mg Tablet daily
GEMFIBROZIL - 600 MG TABLET - [**Hospital1 **]
LEVOTHYROXINE - 100 mcg Tablet - daily
PAROXETINE HCL [PAXIL] - 40 mg Tablet daily
PROCHLORPERAZINE EDISYLATE [COMPAZINE] - 10 mg Tablet - q6 hours
prn
PROPRANOLOL - 20mg [**Hospital1 **]
SIMVASTATIN [ZOCOR] - 40 mg Tablet - daily
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Propranolol 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
5. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) for 7 days: Please follow up with Dr. [**Last Name (STitle) 3274**] regarding
duration of Dexametheasone at this dose. Follow his
instructions.
Disp:*21 Tablet(s)* Refills:*0*
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
11. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
12. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day.
13. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO twice a
day.
14. Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary: Nonsmall cell lung cancer
.
Hypothyroidism
Depression/Anixety
CAD s/p CABG [**2139**]
Non sustained VT on Amiodarone
Ischemic cardiomyopathy with EF of 20-30% [**3-4**] by echo
Bilateral cataract surgery
Erectile dysfunction
Avascular necrosis of right humerus
S/P Cholecystectomy
S/P Right shoulder surgery x 2
Resting Tremor
Discharge Condition:
stable, afebrile
Discharge Instructions:
You presented to the hospital with left sided weakness and
difficulty breathing. Your left weakness was felt to be
secondary to the brain lesions from lung cancer. An MRI was
obtained and showed this to be stable since the last MRI. You
were started on high dose steroids and you should continue these
steroids until you see Dr. [**Last Name (STitle) 3274**] again. Your difficulty
breathing was likely due to aspiration. You were started on
antibiotics for a few days, but they were stopped because it was
not felt that you had a lung infection. You did well off of
antibiotics for 3 days prior to discharge.
.
Please continue all other medications as prior to this
admission, other than the increased steroids.
.
You will be discharged home with home physical therapy and a
home aid.
.
Please seek immediate medical attention if you develop chest
pain, shortness of breath, worsening cough, fevers, chills,
worsening weakness, loss of conciousness or any other change
from your baseline health status.
Followup Instructions:
Someone from Dr.[**Name (NI) 3279**] office will contact you regarding an
appointment for next week. Currently you have an appointment on
[**2152-9-21**], and you should keep this appointment unless you can
reschedule within 7 days.
.
Provider [**First Name8 (NamePattern2) 251**] [**Name9 (PRE) **], MD Phone:[**0-0-**] Date/Time:[**2152-9-21**]
9:00
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12766**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2152-9-21**] 9:00
Provider [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3281**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2152-9-21**] 10:00
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
Completed by:[**2152-9-26**]
|
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|
[
[
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|
2665, 2890
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,258
| 126,556
|
919
|
Discharge summary
|
report
|
Admission Date: [**2112-4-11**] Discharge Date: [**2112-4-25**]
Date of Birth: [**2041-7-25**] Sex: F
Service: GREEN [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient is a 70 year old
female who presented with a five day history of nausea and
vomiting associated with abdominal pain. The patient was
unable to tolerate a liquid diet and complained of
constipation on admission. The patient last had a
colonoscopy in [**2110-12-17**] which demonstrated adenomatous
polyps in the mid-descending colon. The patient had one
similar episode of nausea and vomiting with abdominal pain
that was peristaltic in nature one year prior to presentation
which resolved after an enema in the emergency room. The
patient otherwise denied chest pain, dysuria, melena,
hematochezia or any other symptoms. She did complain of
occasional shortness of breath.
PAST MEDICAL HISTORY: Coronary artery disease, MI.
Peripheral vascular disease. Atrial fibrillation.
Osteoporosis. Hyperlipidemia. Breast cancer. Asthma.
Hypothyroidism. History of UTIs. Adenocarcinoma of the
rectum. Congestive heart failure with ejection fraction of
50 percent.
PAST SURGICAL HISTORY: Left mastectomy. Low anterior
resection in [**2108**]. Open reduction and internal fixation of
the right tibia. Aortic-femoral bypass. Bilateral THR.
Left femoral endarterectomy Dacron angioplasty.
MEDICATIONS ON ADMISSION: Amiodarone 200 mg p.o. q.d., Imdur
10 mg p.o. t.i.d., Advair one to two puffs q.12 hours p.r.n.,
albuterol one to two puffs q.six hours p.r.n., alendronate 5
mg p.o. q.day, nitrofurantoin, aspirin 325 mg p.o. q.day,
Lopressor 25 mg p.o. q.day, folic acid 1 mg p.o. q.day,
vitamin B-12 100 mcg p.o. q.day, multivitamin one tablet p.o.
q.day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient had a history of a 40 pack year
smoking history and quit five years ago.
PHYSICAL EXAMINATION: On admission temperature 99.0, pulse
81, blood pressure 137/76, respiratory rate 16, oxygen
saturation 97 percent in room air. In general, the patient
was a well-developed, well-nourished, Caucasian female in no
acute distress. HEENT pupils equal, round, reactive to
light, anicteric, extraocular muscles intact. Neck supple,
midline, no lymphadenopathy or tenderness. Chest lungs were
clear to auscultation bilaterally. Cardiovascular regular
rate and rhythm, positive S1, S2, no murmurs, rubs or
gallops. Abdomen soft, tender in the left lower quadrant
mostly, but evidence of diffuse tenderness. No masses, no
organomegaly. Rectal positive stool, guaiac positive, no
masses. Extremities warm and well perfused, no edema,
nontender.
LABORATORY DATA: On admission white blood cell count 4.4, 32
bands, hematocrit 42.7, platelets 273. INR 1.2, PT 13.2, PTT
25.9. ALT 17, AST 19, alkaline phosphatase 106, total
bilirubin 0.5. Sodium 131, potassium 4.1, chloride 91,
bicarb 22, BUN 28, creatinine 0.9, glucose 140. Calcium 9.7,
magnesium 1.7, phosphate 4.0. Lactate 1.0. KUB showed
dilated small bowel with positive air fluid levels. CT
angiogram previously ordered by patient's pulmonologist showed
no evidence of pulmonary embolus, but an enlarged gallbladder.
EKG ST depressions in leads V5 to V6, biphasic T waves in V2
and V3, normal sinus rhythm at 84 beats per minute with normal
axis.
IMPRESSION: The patient is a 70 year old female with a
history of coronary artery disease, atrial fibrillation,
breast cancer, asthma, hypothyroidism and adenocarcinoma of
the rectum, who presents with nausea and vomiting, abdominal
pain and the presence of air fluid levels on KUB. The
admitting diagnosis was potential small bowel obstruction.
HOSPITAL COURSE:
1. FEN/GI. The patient was admitted to the surgery service
with the admitting diagnosis of possible small bowel
obstruction. She was made NPO and an NG tube was placed and
IV fluids were administered. Due to her clinical lack of
improvement the patient was taken to the operating room on
[**2112-4-12**] where she underwent exploratory laparotomy and lysis
of adhesions for high grade small bowel obstruction. The
surgery itself was uncomplicated and she had minimal blood
loss.
The patient's postoperative course was complicated by
hypotension post-op as well as congestive heart failure. The
patient required about 10 liters of intravenous resuscitation
immediately post-op. She subsequently developed congestive
heart failure and atrial fibrillation which were treated with
IV furosemide and IV amiodarone for rate control and she
converted to normal sinus rhythm. She diuresed well with
furosemide, but due to her persistent respiratory distress
and increasing oxygen requirements, she was transferred to
the MICU for further, more careful monitoring.
The [**Hospital 228**] hospital course was also complicated by fever
which reached a maximum temperature of 101.8 on [**4-12**]. Blood
cultures were obtained and are negative to date. She also
had anemia with hematocrit of 27 for which she received one
unit of packed red blood cells.
The patient's aggressive diuresis continued. At one point
Lasix was held due to episodes of hypotension. Again,
hypotension responded to fluids and Lasix was restarted
without incident. The patient's oxygen was weaned down from
a nonrebreather to 1 liter at the time of this dictation.
Her diet was advanced slowly and by the time of discharge she
was passing flatus, had bowel movements, was not nauseous,
was tolerating a regular diet.
The patient had an echocardiogram which showed an ejection
fraction of 55 to 60 percent. There was also focal right
ventricular hypokinesis with trivial mitral regurgitation.
Overall it was within normal limits.
The patient had repeat chest x-ray which showed interval
improvement in her congestive heart failure.
The patient's electrolytes were repleted as necessary. Her
pain was well controlled with oral pain medications. She did
develop loose stools at one point, but Clostridium difficile
toxin was negative.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: Rehabilitation facility ([**Hospital 100**] Rehab
Facility).
DISCHARGE DIAGNOSES:
1. Small bowel obstruction.
2. Postoperative atrial fibrillation.
3. Coronary artery disease.
4. Hypercholesterolemia.
5. Congestive heart failure.
6. Asthma.
DISCHARGE MEDICATIONS:
1. Albuterol one to two puffs q.four to six hours p.r.n.
2. Fluticasone propionate two puffs b.i.d. p.r.n.
3. Advair 50 mcg one puff q.12 hours p.r.n.
4. Metoprolol 12.5 mg p.o. b.i.d.
5. Amiodarone 200 mg p.o. q.d.
6. Bisacodyl 10 mg suppository p.r.n.
7. Protonix 40 mg p.o. q.d.
8. Colace 100 mg p.o. t.i.d.
9. Ibuprofen 400 mg p.o. q.six hours.
10. Furosemide 20 mg p.o. b.i.d.
11. Zofran 4 mg q.four to six hours p.r.n. nausea.
FOLLOWUP: The patient was instructed to follow up with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in two weeks.
[**First Name11 (Name Pattern1) 4952**] [**Last Name (NamePattern1) 4953**], M.D. [**MD Number(1) 4954**]
Dictated By:[**Name8 (MD) 6206**]
MEDQUIST36
D: [**2112-4-25**] 08:29
T: [**2112-4-25**] 09:13
JOB#: [**Job Number 6207**]
cc:[**Hospital6 6208**]
|
[
"E878.8",
"414.01",
"518.0",
"428.0",
"560.1",
"789.5",
"427.31",
"560.81",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.15",
"38.91",
"96.07",
"38.93",
"54.59"
] |
icd9pcs
|
[
[
[]
]
] |
6156, 6322
|
6345, 7223
|
1423, 1803
|
3705, 6022
|
1193, 1396
|
1929, 3688
|
189, 880
|
903, 1169
|
1820, 1906
|
6047, 6135
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,699
| 146,513
|
8160+55917
|
Discharge summary
|
report+addendum
|
Admission Date: [**2188-6-13**] Discharge Date: [**2188-7-8**]
Date of Birth: [**2131-5-14**] Sex: F
Service: CARDIAC SURGERY
CHIEF COMPLAINT: Worsening dyspnea on exertion.
HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old
female with a history of chronic obstructive pulmonary
disease and prior tobacco use who presented with a long
history of dyspnea on exertion and new onset angina. She had
an outpatient cardiac catheterization that revealed
three-vessel coronary artery disease, aortic stenosis, and
pulmonic stenosis. She denied having any history of
cerebrovascular accident, transient ischemic attack, or
atrial fibrillation. She also has no history of orthopnea or
paroxysmal nocturnal dyspnea. She does have occasional lower
extremity edema and reports claudication with 2-3 blocks of
walking occurring bilaterally in her calves.
PAST MEDICAL HISTORY: 1. Obesity. 2. Chronic obstructive
pulmonary disease. 3. Spinal stenosis. 4. Back pain.
PAST SURGICAL HISTORY: L3-4 laminectomy.
MEDICATIONS AT HOME: Aspirin, Lipitor, Vioxx, Oxycodone,
Singulair, Albuterol.
PHYSICAL EXAMINATION: General: The patient was noted to be
an obese, older female, in no acute distress. HEENT: There
was no carotid bruit. Lungs: Clear to auscultation
bilaterally. Heart: Regular, rate and rhythm. Abdomen:
Obese. Extremities: Warm with trace edema. Palpable pulses
bilaterally.
LABORATORY DATA: On admission white blood cell count was 9,
hematocrit 37, platelet count 310, BUN and creatinine 21 and
0.7.
HOSPITAL COURSE: The patient was admitted through Same Day
Surgery to the Cardiac Surgery Service. On [**2188-6-13**], she
was taken to the operating room where she had an aortic valve
replacement, pulmonic valve replacement, coronary artery
bypass grafting times three. Her aortic valve was a 21 mm CE
pericardial valve, and her pulmonic valve is a 23 mm CE
pericardial valve. Her grafts are LIMA to left anterior
descending, saphenous vein graft to OM, and saphenous vein
graft to posterior descending artery. The patient's
procedure itself was unremarkable other than a
cardiopulmonary bypass time of 214 min with a cross-clamp
time of 182 min.
Postoperatively the patient was taken intubated to the
Cardiac Surgery Intensive Care Unit. During and after her
operation that evening, she required transfusion with
multiple units of blood products. She ultimately received 7
U of packed red blood cells, 6 [**Location 16678**], and 2 U of
platelets. That evening, her cardiac index remained low, and
she required a Dobutamine drip to maintain her cardiac
output. In addition, she required resuscitation with
approximately 8 L of intravenous fluids.
The next day, the fluid started to mobilized with the aid of
intravenous Lasix. The patient was extubated, but by the
second postoperative day, she developed some respiratory
distress, and she had to be urgently reintubated. Around
this time, she also developed rapid atrial fibrillation that
was controlled with Amiodarone, and she had a five-second
period of asystole that spontaneously resolved.
Slow progress was made through several of the next days of
her hospitalization. She was atrially paced for some time
while her Amiodarone was being loaded. Her mediastinal chest
tube and [**Location (un) 1661**]-[**Location (un) 1662**] drains were discontinued on the third
postoperative day. The following day, her Swan-Ganz catheter
was removed, and the day after that, her pleural chest tube
was removed.
The remainder of the patient's 12 days in the Intensive Care
Unit were occupied with a very long and difficult ventilator
wean. On multiple occasions, she had copious, thick, white
secretions that had to be suctioned. In addition, on her
13th postoperative day, [**6-26**], she had an episode of
plugging that required that her endotracheal tube be
unclogged with the passage of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] catheter. Two days
after this, the patient required an emergent bronchoscopy
where a copious amount of mucus and clot was retrieved from
her pulmonary tree. Finally the patient was extubated on
[**2188-7-2**]. After that time, she maintained her own
airway without problems.
Soon thereafter, she was transferred to the hospital where
preparations were made for her transfer to rehabilitation.
The remainder of the patient's hospitalization is dictated by
systems.
1. Neurologic: The patient was intubated and sedated with a
Fentanyl and Versed drip. Once she was extubated, the
patient had occasional episodes of anxiety that were
adequately managed with oral Ativan. In general the patient
was an awake, alert, oriented, and responsive, and is
appropriately involved in her own care.
2. Cardiovascular: The patient had multiple episodes of
rapid atrial fibrillation while in the Intensive Care Unit.
She was loaded on intravenous Amiodarone and was subsequently
switched to Amiodarone via her tube feed. In addition, she
received Lopressor after her episodes of paroxysmal atrial
fibrillation continued. The decision was made to
anticoagulated her. She was started on a Heparin drip on
postoperative day #14. Upon arriving on the hospital floor
approximately a week later, this was weaned to off, and she
was started on a Coumadin regimen. At the time of transfer,
the patient had been in sinus rhythm for several days, but it
was felt that her anticoagulation should continue until we
demonstrate that she is no longer at risk of developing
paroxysmal atrial fibrillation.
In addition on [**7-6**], there was a questionable episode of
ventricular tachycardia. It was unsure whether or not this
was an artifactual element of the monitor. She may or may
not have had a ten-beat run of ventricular tachycardia;
however, this spontaneously resolved, and we never observed a
recurrence.
3. Pulmonary: The patient had a very long, slow, difficult
ventilator wean that was complicated by multiple episodes of
thick mucus secretion and mucus plugging. By the time the
patient arrived on the hospital floor, her chest x-ray
demonstrated no infiltrate and no increasing pulmonary
congestion. There was a question as to whether or not she
may still be a bit hypervolemic, and for the few episodes of
increased work of breathing that she had on the floor, she
responded well to intravenous Lasix. In addition, she was
maintained on an oral dose of Lasix. It was unclear whether
or not she will need to continue this indefinitely as an
outpatient, but she will certainly need to be on it for at
least the next 7-10 days.
4. Gastrointestinal: The patient was maintained on tube
feed through a ................. catheter while in the
Intensive Care Unit. Once she was extubated, her
................. was removed. She was evaluated by Speech
and Swallow who felt that she was capable of adequately
managing oral intake. Her diet is currently a heart-healthy
diet that she is allowed to take with supervision. Close to
her end of her Intensive Care Unit stay, it was noted that
she had gone several days without moving her bowels. She was
given a very aggressive bowel regimen that included Magnesium
Citrate, Lactulose, and several enemas. This gave her
copious diarrhea that required a mushroom rectal catheter.
Ultimately the diarrhea subsided after her first day on the
floor, and her rectal tube was removed. Her stool became
more formed, and she was started on Colace.
5. Genitourinary: The patient kept a Foley catheter during
the entire time in the Intensive Care Unit. It was removed
after approximately one day on the floor. She is now able to
void spontaneously without any difficulty.
6. Skin: The patient has a small decubitus ulcer around the
area of her sacrum. It is approximately 5-6 cm in diameter
and has two very small areas of superficial ulceration. The
patient does not wish to be placed on an air mattress, as she
feels it limits her mobility and is aware that she needs to
be turned frequently and to keep off the small of her back
when at all possible.
7. Infectious disease: The patient had multiple regimens of
antibiotics while in the Intensive Care Unit. Primarily she
was on Vancomycin and Levofloxacin. She was on these for
several days in the immediate postoperative period, and when
her pulmonary secretions worsened after they were
discontinued, a few days later the patient had her episodes
of mucous plugging, and her antibiotics were restarted.
During this time, her white count peaked at approximately
24,000. As her Levaquin was continued, her white count
greatly diminished. We never did have a positive culture on
her other than in the immediate postoperative period where
she grew the Hemophilus non-influenzae from her endotracheal
culture study.
As the patient was being prepared for discharge, her white
count continued to decrease; it was approximately 15,000 on
[**2188-7-7**]. We estimate that she may need upwards of
another week of oral Levaquin therapy to adequately clear any
pathogens that may remain in her lungs.
8. Hematology: The patient was on a Heparin drip for
prevention of clot formation during her paroxysmal atrial
fibrillation episodes. This was subsequently switched to
Coumadin. We have not found the optimal dosing of her
Coumadin at this time. We believe that she may need
approximately 2.5 to 3.0 mg p.o. q.h.s. In addition, we do
not believe that she needs DVT prophylaxis, as she is
currently anticoagulated on Coumadin.
DISPOSITION: The patient is transferred to rehabilitation.
DISCHARGE MEDICATIONS: Amiodarone 400 mg p.o. q.d.,
Lopressor 25 mg p.o. b.i.d., hold for heart rate less than 60
or systolic blood pressure less than 100, Zantac 150 mg p.o.
b.i.d., enteric coated Aspirin 325 mg p.o. q.d., Singulair 10
mg p.o. q.d., Vitamin C 500 mg p.o. q.d. (this may be
discontinued if the patient's nutrition improves), Coumadin
2.5 mg p.o. q.d., Lasix 20 mg p.o. b.i.d., Potassium Chloride
20 mEq p.o. b.i.d., Ativan 1 mg p.o. q.4-6 hours p.r.n.,
Percocet 5/325 [**1-23**] p.o. q.4-6 hours p.r.n., Dulcolax 10 mg
p.o. p.r. q.d. p.r.n., Milk of Magnesia 30 cc q.6 hours
p.r.n., Tylenol 650 mg p.o. q.4-6 hours p.r.n., Albuterol
metered dose inhaler 1-2 puffs p.o. q.4 hours p.r.n.
On [**2188-7-7**], this summary is dictated in anticipation of
her transfer to rehabilitation.
FOLLOW-UP: She is asked to follow-up with her primary care
physician in approximately two weeks at which time she may
require changes in her medication regimen. In addition, we
asked that she see Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] in approximately
four weeks.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease status post coronary artery
bypass grafting times three.
2. Aortic stenosis and pulmonic stenosis, now status post
replacement of aortic and pulmonic valves with tissue
prostheses.
3. Rapid atrial fibrillation, now controlled.
4. Prolonged respiratory failure, now corrected.
5. Chronic obstructive pulmonary disease.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 9638**]
MEDQUIST36
D: [**2188-7-7**] 12:34
T: [**2188-7-7**] 13:15
JOB#: [**Job Number 29047**]
Name: [**Known lastname 5080**], [**Known firstname **] Unit No: [**Numeric Identifier 5081**]
Admission Date: [**2188-6-13**] Discharge Date: [**2188-7-10**]
Date of Birth: [**2131-5-14**] Sex: F
Service: Cardiac
DISCHARGE SUMMARY ADDENDUM: Ms. [**Known lastname **] was discharged to Life
Care of [**Hospital **] rehabilitation facility on [**2188-7-10**].
Her discharge was delayed by a few days due to bed
availability. She had no major interval changes in her
hospitalization from the time of original dictation.
Her primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], was
contact[**Name (NI) **] regarding this patient's hospitalization. She was
given a brief appraisal of the major events and was also told
the patient is being discharged on Coumadin. She has agreed
to follow her Coumadin and anticoagulation status after she
is discharged from rehabilitation. Dr. [**Last Name (STitle) **] can be
reached at [**Telephone/Fax (1) 5082**].
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 681**]
Dictated By:[**Last Name (NamePattern1) 1295**]
MEDQUIST36
D: [**2188-7-10**] 16:01
T: [**2188-7-14**] 08:12
JOB#: [**Job Number 5083**]
|
[
"424.1",
"496",
"427.31",
"707.0",
"424.3",
"414.01",
"428.0",
"518.81",
"278.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61",
"96.6",
"36.12",
"96.72",
"35.25",
"96.04",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
9605, 10669
|
10690, 12626
|
1576, 9581
|
1062, 1121
|
1021, 1040
|
1144, 1558
|
165, 197
|
226, 878
|
901, 997
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,241
| 135,229
|
19122+57018
|
Discharge summary
|
report+addendum
|
Admission Date: [**2120-9-12**] Discharge Date:
Date of Birth: [**2066-5-10**] Sex: M
Service:
CHIEF COMPLAINT: Transferred from outside hospital for
gastrointestinal bleeding.
HISTORY OF PRESENT ILLNESS: This is a 54 year old male with
a long history of alcohol abuse transferred from [**Hospital3 6265**] to [**Hospital1 69**] for
suspected gastrointestinal bleeding. The patient was
originally admitted to the outside hospital on [**2120-9-3**],
with complaints of several weeks of increased lethargy,
weakness, jaundice, increased abdominal girth and pain, dark
urine and increased edema. The patient was initially with a
sodium of 127, potassium of 2.1, creatinine of 2.3 and a
total bilirubin of 18.5. Albumin was noted at 2.8 and INR of
1.55.
The patient had an abdominal ultrasound on [**9-4**] showing
fatty infiltration of the liver and mild splenomegaly.
Portal vein flows could not be assessed and a moderate amount
of abdominal ascites was present. The patient had a
paracentesis with removal of 5.5 liters of fluid. White
blood cell count was shown to be 76 and cultures were
positive for coagulase negative Staphylococcus. The patient
was started on Zosyn for empiric subacute bacterial
peritonitis. Cytology was negative for malignant cells.
The patient had a hepatic panel showing negative for
hepatitis A, B or C. The patient was given lactulose for
changes in mental status. Initial hematocrit was 37.0,
however, patient had persistently heme positive stools.
Mental status improved throughout the initial hospital course
and creatinine decreased to 1.0. The patient was started on
Lasix and Aldactone and gradually increased his creatinine to
3.1 on the day of transfer.
A CT scan of his abdomen and pelvis on [**9-11**] showed a small
scarred liver, diffuse abdominal ascites and unremarkable
spleen. The patient had black tarry stools and ultimately
went for esophagogastroduodenoscopy which revealed multiple
pre-pyloric gastric nonbleeding ulcers; no varices. The
patient was continued on tube feeds and started on triple
therapy for Helicobacter pylori. The patient with a
persistently increased creatinine of 3.0 to 3.6 which was
felt secondary to hypovolemia and not hepatorenal syndrome.
Renal was consulted. The patient was changed to
..........coverage and was transferred to the floor on [**9-14**].
PAST MEDICAL HISTORY:
1. Alcoholism.
2. Post-traumatic stress disorder post Viet Nam war.
3. Liver failure with encephalopathy.
4. Gastrointestinal bleeding.
MEDICATIONS ON TRANSFER:
1. Albumin 25%.
2. Octreotide.
3. Primaxin.
4. Multivitamin.
5. Thiamine.
6. Folate.
7. Protonix.
MEDICATIONS AT HOME:
1. Motrin.
2. Gas-X.
SOCIAL HISTORY: Significant for alcohol, one pint of vodka
per day times 25 years. Last drink was on [**9-3**]. Denies
tobacco and denies any drug use. The patient currently prior
to admission was living with friends, however, he is
currently divorced. He has to sons.
FAMILY HISTORY: Mother died at age 89 of old age. Father
died of diabetes mellitus. The patient has two brothers who
are alcoholic.
LABORATORY: Relevant laboratory values: Peritoneal fluid
showed white blood cell count of 645, red blood cells of 75,
39% polys, total PMNs of 260. Albumin was 1.0, glucose 162,
total protein 1.9. SAAG was greater than 1.1, which is
consistent with portal hypertension. Bilirubin on admission
was 22.6 which had decreased to 11.2 at the time of
discharge, and trending down. Creatinine 3.6, decreased to
1.3 and 1.4, stable. No further episode of gastrointestinal
bleeding noted. Hematocrit was stable at 36.0. Due to poor
synthetic liver function, the patient's PT and PTT were 15.9
and 40.3 with an INR of 1.7. Blood cultures remained
negative.
HOSPITAL COURSE: The patient was called out from the
Medical Intensive Care Unit for admission for
gastrointestinal bleeding. Esophagogastroduodenoscopy as
above showed nonbleeding ulcers. The patient was put on
therapy for Helicobacter pylori; no further evidence of
gastrointestinal bleed noted. On the Floor, the patient was
treated for multiple problems:
1. CIRRHOSIS: The patient with a large volume ascites
resulting in right hydrothorax, increased shortness of breath
and nausea and vomiting with associated constipation.
Paracentesis was performed, removing three liters of fluid.
This fluid was positive for SBP with PMNs greater than 260.
The patient was treated with a ten day course of intravenous
Ceftriaxone. Albumin was repleted. The patient received
37.5 mg of albumin, not high dose albumin. As the patient's
creatinine became stable, the patient was started on
diuretics (Aldactone and Lasix), and renal function on
discharge was stable to 1.3 to 1.4. Total bilirubin was
monitored daily and was found to be decreasing from initially
23.0 down to 11.0.
During hospitalization, the patient's mental status had
significantly improved. Daily weights were monitored and the
patient gained weight daily until diuretic therapy was
initiated. The patient was also continued on Ursodiol,
Pentoxifylline, multivitamins in light of poor hepatic
function.
2. LUMBAR COMPRESSION FRACTURE: The patient was seen to have
a compression fracture of L2 and L4 with a burst type
compression fracture at L4 causing 25% spinal stenosis.
Neurosurgery was consulted and the fracture was deemed to be
stable. The patient did not demonstrate any neurological
signs. Neurological function remained intact. The patient
with good rectal tone. No reports of bladder or bowel
incontinence. Lumbar compression fracture was thought to be
due to a fall that the patient sustained prior to admission.
A thoracolumbar spine brace was constructed for the patient.
He was instructed to wear this brace at all times unless
lying in bed.
Per Neurosurgery, the patient was able to undergo Physical
Therapy while wearing the brace. At the time of discharge,
the patient did not demonstrate any neurologic symptoms.
Strength was four plus out of five bilaterally. Deep tendon
reflex were intact. No paresthesias were noted.
3. RENAL: Creatinine improved to approximately 1.3 to 1.4;
creatinine remained stable at this level for approximately
one week. Therefore, the patient was started on Aldactone
and Lasix. The patient was likely to be intervascularly
depleted, however, diuretics were necessary to address
current status with volume overload. Diuretics were titrated
as renal function tolerated. The patient requires standing
dose diuretics to prevent reaccumulation of ascitic fluid.
4. NUTRITION: The patient has a poor nutritional status
with a large ascites, causing him to have occasional nausea,
vomiting and constipation. However, the patient was
symptomatically controlled with Zofran and Lactulose. The
patient was seen in the hospital by a Nutritionist for diet
supplementation. Although the patient was on a 1.5 liter
fluid restriction, his overall p.o. intake was poor.
During hospitalization the patient has been encouraged to
drink supplemental shakes. His diet includes low sodium,
normal protein diet.
5. HYPONATREMIA: The patient's urine sodium decreased to
126, however, this improved on a 1.5 liter fluid restriction
thought to be due to the patient's poor nutritional status.
Intravenous fluids, on an option of extravasation of the
third disc space was likely. At the time of discharge, the
hyponatremia was corrected and the patient was on a standing
dose of diuretics.
6. PHYSICAL THERAPY: The patient is severely deconditioned
secondary to long hospital course and long history of
alcoholic cirrhosis. The patient with a compression
fracture, however, deemed safe for Physical Therapy per
Neurosurgery only if wearing his spine brace. The patient
will require a long course of rehabilitation and Physical
Therapy upon discharge from the hospital.
7. ALCOHOL ABUSE / COUNSELING: The patient is willing to
accept treatment from counseling. He is aware of his fragile
medical condition and understands the terminal complications
of further alcohol abuse. The family is involved and
supportive and per Hepatology Service, they advised that they
would list the patient as a transplant candidate if able to
abstain from alcohol fro the next six months. The patient
will require this counseling upon discharge from the
hospital.
CONDITION ON DISCHARGE: Fair.
PROGNOSIS: To receive medical care and follow-up.
DISCHARGE MEDICATIONS:
1. Bactrim Single Strength one tablet p.o. q. day for SBP
prophylaxis.
2. Ursodiol 300 mg p.o. twice a day.
3. Pantoprazole 40 mg p.o. q. 12.
4. Pentoxifylline 400 mg p.o. three times a day.
5. Lactulose 30 mg q. two hours; titrate to four to five
bowel movements per day.
6. Miconazole Powder 2% topical four times a day p.r.n.
7. Folic acid 1 mg p.o. q. day.
8. Thiamine 100 mg p.o. q. day.
9. Multivitamin one capsule p.o. q. day.
10. The patient's current diuretic regimen includes
Furosemide 20 mg p.o. twice a day.
11. Spironolactone 50 mg q. day.
DISCHARGE INSTRUCTIONS:
1. Follow-up will be arranged through the Hepatology
Service.
2. The patient is to receive Physical Therapy upon
discharge.
3. The patient is to receive alcohol counseling upon
discharge.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**]
Dictated By:[**Last Name (NamePattern1) 52185**]
MEDQUIST36
D: [**2120-10-5**] 16:11
T: [**2120-10-5**] 16:30
JOB#: [**Job Number 52186**]
Name: [**Known lastname 9512**], [**Known firstname 1340**] Unit No: [**Numeric Identifier 9711**]
Admission Date: [**2120-9-12**] Discharge Date: [**2120-10-7**]
Date of Birth: [**2066-5-10**] Sex: M
Service: [**Hospital1 248**]/MEDICINE
CONCISE SUMMARY OF HOSPITAL COURSE: Please see OMR notes for
discharge addendum of dates [**2120-10-6**], [**2120-10-7**].
[**First Name4 (NamePattern1) 77**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1977**]
Dictated By:[**Last Name (NamePattern1) 5858**]
MEDQUIST36
D: [**2120-10-9**] 13:25
T: [**2120-10-9**] 18:59
JOB#: [**Job Number 9712**]
|
[
"789.5",
"570",
"511.8",
"571.1",
"276.1",
"303.91",
"531.00",
"567.2",
"276.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"96.6",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
3007, 3784
|
8478, 9042
|
3803, 7509
|
9066, 9803
|
2689, 2713
|
7528, 8370
|
9832, 10193
|
133, 199
|
229, 2374
|
2562, 2668
|
2396, 2537
|
2731, 2989
|
8396, 8455
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,825
| 124,993
|
52612
|
Discharge summary
|
report
|
Admission Date: [**2136-10-3**] Discharge Date: [**2136-10-8**]
Date of Birth: [**2057-2-25**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
malaise and abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
79 yo F end stage renal dz, htn, hypothroid, hld who presents
with 5-6 days of N/V and diarrhea. Per daughter pt is not at
baseline and has been having hallucinations "someone trying to
shoot her." She also decribed increasing cough above her
baseline that is non-productive. She has also been feeling that
she is weak all over and more confused with some difficulty
walking. She also complains of whole body aches. She was unable
to go to dialysis today (usually TThSa) because she felt too
weak. Her daughter is a nurse and provides most of the history,
she lives with her son and is normally very indepdent. She
continues to make some urine. Subjective fevers at home. She has
been having increasing difficulty swallowing per family and
coughs frequently when taking PO. She denies any current CP, HA,
brbpr, or hemetemesis, difficulty swallowing/difficulty taking
PO.
In the ED, initial VS were: 19:30 98 78 154/82 18 99% RA. The
patient remained afebrile with HR in the 60s-70s. Her Blood
pressure emained elevated around 150s/80s. She remained >97% O2
saturation. One 18g and one 22g were placed. She remained alert
and oriented x3. She has a fistula in her L arm.
Her initial exam was reportedly notable only for crackles in the
lungs, but a repeat exam revealed diffuse abdominal tenderness.
Thus, the patient underwent CT abdomen and pelvis, which did not
reveal acute pathology. She also was felt to have a swollen leg,
and so underwent CTA, which did not show PE. Her CXR did not
show a clear source of infection. Bedside echo was reportedly
without signs of cardiogenic shock.
The patient received Vancomycin, zosyn, flagyl, 500ml NS,
[**Doctor Last Name **]-dextro, thiamine.
Nephrology was consulted for HD, and were aware of dye load
given with CTA.
She was found to have an elevated lactate in the ED, which
increased to 5.6 but then began to trend down to 5.0 with IVF
(she got 1800cc total). She also had a gap of 18. The patient
was noted to also have a normal chemistry otherwise except for
her elevated creatinine. She had a slight leukocytosis with
normal differential. Her hematocrit and platelets were normal.
She did have a slight elevation in her ALT and AST, her INR was
elevated to 1.4. Her troponin was elevated to 0.04 with normal
CK/MB. UA was obtained. A RIJ was placed and was oozing.
On arrival to the MICU, the patient says that she feels well,
she says that she feels much better than prior.
In speaking to her daughter, she brought her into the hospital
for concern for weakness, deconditioned. Unable to eat.
Forgetting her dialysis day. Hallucinating. The patient is in
the middle of moving from one apartment to another. The cough is
nagging and constant, the daughter says that this interferes
with her sleep. She endorsed coughing to the point of vomiting.
Past Medical History:
- hypertension,
- end-stage renal disease on hemodialysis, (TThSa via left
brachiocephalic AVF made in [**10/2131**])
- congestive heart failure (systolic EF 50% in [**10/2134**]),
- hyperlipidemia,
- osteoarthritis,
- depression,
- anemia,secondary versus tertiary hyperparathyroidism,
- recently developing dementia.
Social History:
Lives with son, but he works all day. Goes to [**Last Name (un) **] for HD.
uses a walker intermittently. She has a home health aide who
comes in for cleaning, etc. Lives in Mission [**Doctor Last Name **].
- Tobacco: denies
- Alcohol: denies
- Illicits: denies
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL
General: AOx3
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2, no rubs
Lungs: bilateral crackles. Air movement bilaterally.
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, 4+/5 strength upper/lower extremities,
grossly normal sensation, gait deferred, finger-to-nose intact
with mild intention tremor
DISCHARGE PHYSICAL
Alert & oriented x3, pleasant, but forgetful.
Gait stable using walker.
Left brachiocephalic fistula intact, +bruit
Pertinent Results:
ADMISSION LABS
[**2136-10-2**] 09:35PM WBC-11.9*# RBC-3.59* HGB-11.0* HCT-34.8*
MCV-97 MCH-30.7 MCHC-31.7 RDW-17.9*
[**2136-10-2**] 09:35PM NEUTS-55.6 LYMPHS-34.8 MONOS-7.0 EOS-2.0
BASOS-0.7
[**2136-10-2**] 09:35PM ALBUMIN-4.0 CALCIUM-9.3 PHOSPHATE-2.8
MAGNESIUM-2.0
[**2136-10-2**] 09:35PM CK-MB-3 cTropnT-0.04*
[**2136-10-2**] 09:35PM LIPASE-57
[**2136-10-2**] 09:35PM ALT(SGPT)-43* AST(SGOT)-43* CK(CPK)-71 ALK
PHOS-101 TOT BILI-0.4
[**2136-10-2**] 09:35PM GLUCOSE-146* UREA N-41* CREAT-6.2*#
SODIUM-139 POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-24 ANION GAP-22*
[**2136-10-2**] 09:40PM LACTATE-3.8*
[**2136-10-2**] 09:50PM PT-15.2* PTT-29.3 INR(PT)-1.4*
LACTATE:
[**2136-10-4**] 01:39 1.8
[**2136-10-3**] 16:16 3.0*
[**2136-10-3**] 13:10 8.2*1
[**2136-10-3**] 10:08 7.0*1
[**2136-10-3**] 09:43 88 7.0*1
[**2136-10-3**] 06:42 5.2*2
[**2136-10-3**] 03:55 5.0*3
[**2136-10-3**] 00:47 5.6*
CARDIAC ENZYMES
CK 71 MB 3 TropT 0.04
[**2136-10-3**] 15:48 3 0.04*1
[**2136-10-2**] 21:35 3 0.04*1
MICROBIOLOGY:
[**2136-10-2**] 11:27PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2136-10-2**] 11:27PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-300
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-2* PH-5.5 LEUK-NEG
[**2136-10-2**] 11:27PM URINE RBC-<1 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-1
[**2136-10-2**] 11:27PM URINE HYALINE-16*
[**2136-10-2**] 11:27PM URINE MUCOUS-RARE
[**2136-10-6**] SEROLOGY/BLOOD RAPID PLASMA REAGIN
TEST-FINAL INPATIENT
[**2136-10-5**] IMMUNOLOGY HCV VIRAL LOAD-PENDING INPATIENT
[**2136-10-4**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2136-10-4**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2136-10-3**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2136-10-3**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL; LEGIONELLA CULTURE-PRELIMINARY; FUNGAL
CULTURE-PRELIMINARY INPATIENT
[**2136-10-3**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2136-10-3**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2136-10-2**] URINE URINE CULTURE-FINAL; Legionella
Urinary Antigen -FINAL EMERGENCY [**Hospital1 **]
[**2136-10-2**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
URINE TOXICOLOGY:
[**2136-10-2**] 11:27PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2136-10-3**] 03:48PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2136-10-3**] 03:48PM ACETONE-TRACE OSMOLAL-290
IMAGING/STUDIES:
ECG: NSR @ 67 bpm, leftward axis and LAFB, LAA, LVH, TWI
laterally, flattened Ts II, poor R-wave progression. Compared to
ECG from [**2134**], appears similar.
[**2136-10-2**] CHEST X-RAY: Consistent with pulmonary vascular
congestion.
Frontal and lateral views of the chest were obtained. The
cardiac
silhouette remains enlarged. Prominence of the pulmonary
arteries is stable. There is mild left base streaky
atelectasis/scarring. There is minimal pulmonary vascular
congestion. Mediastinal contours are stable. No large pleural
effusion or pneumothorax.
[**2136-10-3**] CHEST X-RAY:
IMPRESSION: Status post right IJ central line placement without
evidence of complication; worsening heart failure.
[**2136-10-3**] ECHO: Mildly dilated LA and moderately dilated RA.
Estimated RA pressure at least 15 mmHg. LV size borderline
dilated. LV systoli function severely depressed (LVEF 20%) with
akinesis of the apex and distal LV segments and moderate
hypokinesis remaining seg. Moderate LV thrombus seen. RV mildly
dilated with mild free wall hypokinesis. Mod-severe MR and
mod-severe TR. Severe PA systolic HTN (TR gradient 60). No
pericardial effusion.
[**2136-10-3**] CT chest/abdomen/pelvis w/ contrast:
1. No PE or aortic dissection. 2. Cardiomegaly and pulmonary
edema. 3. Heterogeneous nodule of the left lobe of the thyroid
as described above. 4. Atrophic kidneys with multiple
indeterminate lesions, some of which are cysts, but many of
which are incompletely characterized, so RCC cannot be excluded;
MR may be considered for further characterization. 5.
Descending and sigmoid colonic diverticulosis without
diverticulitis. 6. Periportal edema and decompressed
gallbladder with wall edema, which is a nonspecific finding and
may reflect CHF, hyperproteinemia, or hepatic dysfunction. 7.
Small amount of free fluid in the pelvis, possibly reactive. 8.
Benign-appearing but indeterminate lytic lesion in the right
iliac bone without evidence of cortical disruption.
[**2136-10-3**] CT HEAD
IMPRESSION: Minimal cavernous carotid atheromatous disease,
otherwise normal
[**2136-10-5**] CARDIAC STRESS
IMPRESSION: No significant ST segment changes or anginal
symptoms.
Blunted hemodynamic response to regadenoson. Nuclear report sent
separately.
[**2136-10-5**] PHARMACOLOGIC STRESS
IMPRESSION: 1. No reversible or fixed myocardial perfusion
defects. 2. Severely
enlarged left ventricular cavity size. 3. Decreased left
ventricular function
with calculated EF of 24% and diffuse hypokinesia.
Brief Hospital Course:
79 yo woman with ESRD on dialysis, HTN, admitted for 6 weeks of
worsening cough, posttussive emesis, waxing and [**Doctor Last Name 688**] mental
status, found to have elevated lactate as high as 8 and new echo
with dramatically reduced EF, 3+ TR/MR, mild RV failure,
pulmonary hypertension, and LV thrombus.
# CHF: Pt was found to have new biventricular heart failure (EF
20%) on echo with LV thrombus. [**10/2134**] TTE which showed
systolic dysfunction with EF of 45-50%. DDx includes recent
silent MI (unlikely given lack of qwaves) or balanced ischemia
from 3 vessel disease since stress MIBI was negative (patient is
not a good candidate for CABG per discussion with family,
nephrologist), chronic deterioration of hypertensive
cardiomyopathy, or amyloid cardiomyopathy. Trop 0.04 in ED
without EKG changes, and remained stable. P-MIBI [**2136-10-5**] showed
no reversible or fixed myocardial perfusion defects, diffuse
hypokinesia, EF 24%. Based on this interpretation, we cannot
rule out balanced ischemia, but since patient not candidate for
CABG, it was agreed upon that cardiac catheterization was not
necessary. Per Dr. [**First Name (STitle) 437**], congestive heart failure may be due to
amyloid cardiomyopathy.
- CT of head was negative for any intracranial process, so
patient was given heparin bolus and heparin gtt was started for
LV thrombus, until therapeutic on warfarin.
- Continued home valsartan, started metoprolol at decreased dose
(25mg TID) then uptitrated as tolerated back to home dose
- Cont simvastatin 20 mg PO/NG DAILY
- Cannot get spironolactone given ESRD
- Continue HD for fluid removal qSaTuThu
- Thiamine levels were not drawn prior to starting IV thiamine,
empirically treating with daily thiamine supplementation as wet
beri-beri is on the differential for cardiomyopathy with
elevated lactate.
- Consider outpatient workup of amyloid cardiomyopathy. If
cardiac amyloid were present, most likely this would be from
ESRD or senile, but have not yet ruled out light chain amyloid.
As outpatient, could get SPEP/UPEP, serum light chains, and
immunofixation, but deferred as inpaitnet.
# LV thrombus: Apical hypokinesis and severely depressed LV
function likely cause.
- Heparin gtt bridge until therapeutic on warfarin
# Elevated lactate: Rose to lactate of 8 on day of admission and
then decreased to 1.8 with HD. Etiology of lactate elevation is
unclear.
- Normal serum osms. VBG (pH. 7.45, CO2 40).
- There has been no known infectious process. No leukocytosis,
CXR showed no consolidation, UA negative, blood cultures no
growth. Got Vanc, cefepime, levofloxacin for one day but was
discontinued on HD2 because no evidence of infection. Continued
azithromycin for 4 days for possible atypical pneumonia vs
pertussis given history of 6 weeks of severe cough with
post-tussive emesis
- HIV pending at time of discharge
- Hep serologies pending at time of discharge
- CT abd/pelvis negative for bowel ischemia, transplant surgery
saw and felt no surgical issues
- LV dysfunction without hypotension unlikely to cause this kind
of lactate elevation.
- Other etiologies include toxic ingestions: Patient has
arthritis and dementia but does not endorse taking increased
amounts of over the counter pain medications such as tyelenol or
aspirin. LFTS only mildly elevated. Sertraline toxicity has been
seen in a case study in rats to cause mitochondrial dysfunction
and a lactic acidosis so this is a possibility. Sertraline was
held per toxicology recommendations, but restarted with no new
elevation in lactate. No blood in stool to suggest iron or
colchicine ingestion. Negative serum tox screen.
- Thiamine deficiency can also cause a lactic acidosis. Thiamine
empirically repleted.
# Cough: Cough for a few months with some emesis after coughing
fits. Cough improved with diuresis, most likely etiology is
pulmonary edema. Also possibly viral or pertussis given
increased incidence recently. Sent serum studies for pertussis
to state since swab will be negative 6 weeks out. Rec'd
azithromycin [**Date range (1) 6230**]. Infection control stated that patient
does not need to be on droplet precautions because onset was 6
weeks ago and cough is improved.
# AMS: Was brought in with confusion by her daughter that had
been worsening over the days before admission. Improved during
hospitalization but the patient per report has some baseline
dementia.
# ESRD on HD TThSa schedule: When she was admitted she had
missed a day of dialysis because of fatigue. On [**10-3**] she received
dialysis and then received a partial dialysis on [**10-4**] to get her
back on schedule. Received dialysis [**2136-10-8**] prior to discharge.
# HTN: Kept on home valsartan. Lopressor restarted on [**10-4**] and
uptitrated back to her home dose on [**10-6**].
# HLD: Kept on home dose of simvastatin
# Osteoarthritis: Home tylenol was discontinued because of
concern for toxicity while in the hospital.
# Hypothyroidism: TSH 5.0 and free T4 0.99. Kept on home
levothyroxine.
# Depression: Held home sertraline in hospital for concern of
toxicity and contribution of lactic acidosis. Restarted without
any increase in lactate.
# Anemia: HCT remained stable around 34.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Acetaminophen 650 mg PO Q6H:PRN pain
<4 g per day. Please tell HO if given for T>100.5
2. Simvastatin 20 mg PO DAILY
3. sevelamer CARBONATE 1600 mg PO TID W/MEALS
4. Omeprazole 40 mg PO DAILY
5. Sertraline 150 mg PO DAILY
6. Levothyroxine Sodium 88 mcg PO DAILY
7. Nephrocaps 1 CAP PO DAILY
8. Lidocaine-Prilocaine 1 Appl TP PRN with HD access
9. Metoprolol Tartrate 75 mg PO BID
10. Valsartan 160 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
<4 g per day. Please tell HO if given for T>100.5
2. Levothyroxine Sodium 88 mcg PO DAILY
3. Metoprolol Tartrate 75 mg PO BID
4. Nephrocaps 1 CAP PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Sertraline 150 mg PO DAILY
7. Simvastatin 20 mg PO DAILY
8. Valsartan 160 mg PO DAILY
9. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth DAILY Disp #*30
Tablet Refills:*11
10. Lidocaine-Prilocaine 1 Appl TP PRN with HD access
11. sevelamer CARBONATE 1600 mg PO TID W/MEALS
12. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*3
13. Warfarin 4 mg PO DAILY16
RX *warfarin 1 mg 4 tablet(s) by mouth DAILY Disp #*120 Tablet
Refills:*0
14. Outpatient Lab Work
428.0 Congestive heart failure
Please check INR on or before [**2136-10-11**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
PRIMARY: Congestive heart failure, lactic acidosis, left
ventricular thrombus
SECONDARY: Hypertension, end-stage renal disease,
hypothyroidism, anemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mrs. [**Known lastname 11622**],
It was a pleasure caring for you during your hospitalization for
congestive heart failure and blood clot in your heart.
Please keep the following appointments we have made for you.
MEDICATION CHANGES
- START warfarin, you should have your INR checked on or before
[**2136-10-11**]
- START thiamine 100mg daily
TRANSITION OF CARE
- Please contact Dr. [**Last Name (STitle) **] at [**Hospital3 **]
[**Telephone/Fax (1) 2010**], as soon as you know that you will be sent home
from rehab, so that your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], can
initiate your referral to the [**Hospital3 **]
[**Hospital3 271**].
- You may wish to consider outpatient workup of amyloid
cardiomyopathy as an outpatient. You should discuss this with
Dr. [**Last Name (STitle) **] and your new cardiologist, Dr. [**First Name (STitle) 437**].
Followup Instructions:
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Please contact [**Hospital3 **] as above, so that Dr. [**Last Name (STitle) **]
can refer you to the [**Hospital3 **] [**Hospital 3052**].
Department: CARDIAC SERVICES
When: MONDAY [**2136-10-22**] at 10:00 AM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ADVANCED VASC. CARE CNT
When: MONDAY [**2136-11-12**] at 10:00 AM
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: [**Hospital3 249**]
When: MONDAY [**2136-11-19**] at 11:00 AM
With: [**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**] [**Name8 (MD) **], NP [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Outpatient dialysis unit: [**Location (un) **] [**Location (un) **]
Outpatient nephrologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Schedule: Tuesday, Thursday, Saturday
*You will follow up for your hospitalization with your
nephrologist at your next dialysis day. Any questions or
concerns please call the office at [**Telephone/Fax (1) 5972**].
Completed by:[**2136-10-9**]
|
[
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"277.39",
"715.90",
"403.91",
"V45.11",
"285.9",
"786.2",
"244.9",
"428.0",
"425.7",
"276.2",
"311",
"428.23",
"585.6",
"429.89",
"272.4"
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icd9cm
|
[
[
[]
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[
"39.95",
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icd9pcs
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[
[
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339, 346
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,792
| 119,622
|
1487
|
Discharge summary
|
report
|
Admission Date: [**2125-5-10**] Discharge Date: [**2125-5-11**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
abdominal pain, shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
87 year old Russian-speaking female with history of
hypertension, diabetes mellitus type 2, blindness, history of
CVA with residual right-sided weakness presenting from [**Hospital 100**]
Rehab with nausea abdominal pain on the morning of admission,
s/p emesis x 2 of undigested food and question of aspiration.
Portable chest X-ray at [**Hospital 100**] Rehab showed bilateral effusions
R>L and labs were notable for elevated WBC of 12K. KUB was
performed and was unremarkable. She was given tylenol 1 gram
for noted temperature of 102. O2Sats were noted to be 90% on 2L
NC for EMS.
.
In the ED, initial vital signs were: T 98.2F HR 101 BP 100/56
RR 20 O2sat 100% 15L NRB. On initial evaluation by ED resident,
vitals were as follows: Tm 102.8 PR 95 89/50 24 92%RA. She was
answering questions appropriately, noted to have tenderness to
palpation in the left lower quadrant and suprapubic area. UA
was grossly positive. Portable CXR showed fluffy bilateral
infiltrate and mild cephalization. CT abdomen/pelvis showed no
intra-abdominal pathology but confirmed RLL pneumonia ?secondary
to aspiration, for which she was given a dose of IV vancomycin,
Zosyn, and levofloxacin. [**Hospital **] pressure dropped as low as
70s/50s for which she was given 500cc IVFs x2 to which her [**Hospital **]
pressure responded well. She has also received an extra 500cc
IVFs with antibiotics. EKG showed NSR at rate 90, LAD, normal
intervals, TWI III, TWF avF V3. Vitals in ED prior to transfer:
HR 102 128/57 RR 20 100% on 15L face mask. Prior to transfer pt
began to feel increased rattling in back of throat and increased
shortness of breath; she was placed on BiPap prior to transfer
due to concern for flash pulmonary edema from fluid
administration.
.
On the floor, patient presents on non-rebreather mask. She
reports having no pain.
Past Medical History:
#. Hypertension
#. Diastolic congestive heart failure
#. Type II Diabetes
#. History of stroke with residual R weakness
#. Hypothyroidism
#. Fatty Liver Disease
#. Degenerative Joint Disease
#. GERD
#. Diverticulosis
#. Dysphagia
#. Legally blind
#. Hard of Hearing
Social History:
The patient is currently a resident at [**Hospital 100**] Rehab. She walks
with a walker. She is hard of hearing requiring hearing aids
and also legally blind. Her neice is her HCP and visits her
regularly at the nursing home.
Tobacco: None
ETOH: None
Illicits: None
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM:
Vitals: T: 98.1 BP: 142/81 P: 104 R: 29 O2: 100% NRB
General: Alert, no acute distress, appears tired
HEENT: Sclera anicteric, MM very dry, oropharynx clear with no
lesions noted
Neck: supple, JVP 3 cm above clavicle, no cervical LAD
Lungs: Wheezes present bilaterally and diffusely, light crackles
present at right base, poor air movement bilaterally and
decreased at bases bilaterally
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops audible
Abdomen: soft, non-distended, tender in suprapubic area, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
GU: foley catheter in place
Ext: pneumoboots in place, warm, well perfused, 2+ pulses, no
clubbing, cyanosis or edema
Discharge Exam:
General: Alert, no acute distress, appears tired
HEENT: Sclera anicteric, MM very dry, oropharynx clear with no
lesions noted
Neck: supple, JVP 3 cm above clavicle, no cervical LAD
Lungs: Wheezes present bilaterally and diffusely, light crackles
present at right base, poor air movement bilaterally and
decreased at bases bilaterally
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops audible
Abdomen: soft, non-distended, tender in suprapubic area, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
GU: foley catheter in place
Ext: pneumoboots in place, warm, well perfused, 2+ pulses, no
clubbing, cyanosis or edema
Pertinent Results:
ADMISSION LABS:
[**2125-5-10**] 04:00PM [**Year/Month/Day 3143**] WBC-10.8 RBC-3.78* Hgb-11.1* Hct-32.1*
MCV-85 MCH-29.4 MCHC-34.7 RDW-13.2 Plt Ct-225
[**2125-5-10**] 04:00PM [**Year/Month/Day 3143**] Neuts-68 Bands-11* Lymphs-15* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-0
[**2125-5-10**] 04:00PM [**Year/Month/Day 3143**] Glucose-166* UreaN-16 Creat-1.3* Na-137
K-3.6 Cl-100 HCO3-22 AnGap-19
[**2125-5-10**] 04:00PM [**Year/Month/Day 3143**] ALT-15 AST-29 AlkPhos-75 TotBili-0.9
[**2125-5-10**] 04:00PM [**Year/Month/Day 3143**] proBNP-4193*
[**2125-5-10**] 04:00PM [**Year/Month/Day 3143**] cTropnT-<0.01
[**2125-5-11**] 04:35AM [**Month/Day/Year 3143**] Calcium-7.9* Phos-3.0 Mg-1.7
[**2125-5-10**] 04:12PM [**Year/Month/Day 3143**] Lactate-3.3*
DISCHARGE LABS:
[**2125-5-11**] 04:35AM [**Month/Day/Year 3143**] WBC-9.2 RBC-3.49* Hgb-10.1* Hct-30.5*
MCV-87 MCH-28.9 MCHC-33.1 RDW-12.8 Plt Ct-174
[**2125-5-11**] 04:35AM [**Month/Day/Year 3143**] Neuts-78* Bands-5 Lymphs-11* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0
[**2125-5-11**] 04:35AM [**Month/Day/Year 3143**] Glucose-158* UreaN-18 Creat-1.2* Na-138
K-4.1 Cl-104 HCO3-22 AnGap-16
IMAGING:
CT ABD & PELVIS WITH CONTRAST Study Date of [**2125-5-10**] 5:27 PM
CT ABDOMEN: The liver is homogeneous in attenuation without
discrete masses or lesions. The gallbladder, pancreas, and
spleen are unremarkable. The bilateral adrenal glands have
normal limb thickness without convex margin to suggest mass. The
kidneys are not enlarged and excrete contrast
symmetrically. There is no hydroureter. The stomach, small
bowel, and large bowel are not distended and demonstrate normal
wall thickness. Diverticula are noted throughout the descending
colon, though there is no associated inflammation. No free fluid
or air identified within the pelvis. No mesenteric,
retroperitoneal, or portacaval lymphadenopathy. Atherosclerotic
calcifications are identified throughout the abdominal aorta
without associated aneurysmal change. The aorta, inferior vena
cava, and main portal vein and their major branches are patent.
CT PELVIS: Diverticula are noted throughout the sigmoid colon
without
associated inflammation. Moderate amount of stool is noted
within the rectal vault. The bladder is collapsed around a Foley
catheter. There is no free fluid within the pelvis. No pelvic or
inguinal lymphadenopathy.
OSSEOUS STRUCTURES: Minimal degenerative change is seen in the
lower lumbar spine. No lytic or blastic lesions are identified.
IMPRESSION:
1. Heterogeneous consolidation within the right lower lobe along
with dense material in the right lower lobe bronchioles in
highly suggestive of
aspiration pneumonia.
2. Diverticula without associated inflammation identified. No
acute process seen within abdomen.
CXR:
CHEST (PORTABLE AP) Study Date of [**2125-5-10**] 4:22 PM
IMPRESSION: Low lung volumes. Small bilateral pleural effusions
with
overlying atelectasis. Bibasilar opacities may represent
combination of
effusion, atelectasis, and some pulmonary vascular congestion,
although
infectious process cannot be excluded in the appropriate
clinical setting. Pulmonary vascular congestion.
CHEST (PORTABLE AP) Study Date of [**2125-5-10**] 7:32 PM
(PRELIM READ)
right effusion with dense right basilar consolidation, as seen
on concurrent a/p CT, consistent with pneumonia. mild vascular
congestion. equivocal additional opacity at the left CP angle.
no definite left effusion. no ptx.
Brief Hospital Course:
87 year old Russian-speaking woman with history of hypertension,
DM2, fatty liver disease, hypothyroidism, presenting with
abdominal pain and emesis, found to have RLL pneumonia,
presumably secondary to aspiration.
# Aspiration Pneumonia:
Patient was started on Vancomycin and Zosyn to be continued for
total 8 day course (last day = [**5-17**]) for healthcare associated
pneumonia coverage. Vanc trough should be drawn [**5-12**] in the AM.
# Urinary tract infection:
Patient presented with grossly positive UA. Urine culture
pending on discharge.
She was treated broadly with antibiotics for healthcare
associated pneumonia, as above.
# Abdominal pain:
Patient reportedly had 2 episodes of emesis at rehab and had
been experiencing nausea/vomiting x 1 day. Abdominal CT did not
show any intra-abdominal pathology. Patient may just be
symptomatic from her UTI. Most likely symptoms secondary to
viral gastroenteritis given emesis and history of multiple
members in Rehab being sick and "quarantined."
# ?Acute kidney injury:
Creatinine 1.3 on admission and 1.2 on discharge, likely her new
baseline. Last recorded creatinine 1.0 in [**2122**]. Lisinopril was
held on admission but may be restarted in [**12-31**] days.
# Chronic normocytic anemia:
Hct similar to baseline.
# Chronic diastolic congestive heart failure:
Last echo at [**Hospital1 18**] in [**2121**] with EF 60% but evidence of diastolic
dysfunction.
Lisinopril was held on admission but may be restarted in [**12-31**]
days.
# History of stroke:
Continued home dose aspirin and dipyridamole.
# Hypertension:
Home dose lisinopril held on admission but may be restarted in
[**12-31**] days.
# Diabetes Mellitus Type 2
Home glipizide and pioglitazone was held, and patient was placed
on humalog insulin sliding scale during this hospitalization.
# Hypothyroidism
Patient was continued on home dose levothyroxine.
# Communication:
HCP: [**Name (NI) **] [**Name (NI) 8776**] [**Name (NI) 8777**]: home [**Telephone/Fax (1) 8778**]; cell
[**Telephone/Fax (1) 8779**].
# Code Status:
Patient was DNR but OK to Intubate during this hospitalization.
TRANSITIONAL ISSUES:
- Check vancomycin trough on [**5-12**] in AM. Goal is 15-20, her
current dosing is vancomycin 1 gm IV Q48H
- Continue vancomycin and zosyn until [**5-17**] for a total 8 day
course
- Hold lisinopril on [**5-11**], resume in [**12-31**] days as she was taking
prior to admission (lisinopril 10 mg PO daily)
Medications on Admission:
Aspirin 81 mg PO daily
Dipyridamole 25 mg PO BID
Levothyroxine 25 mcg PO daily
Lisinopril 20 mg PO daily
Simvastatin 40 mg PO daily
Glipizide 5 mg PO BID
Pioglitazone 45 mg PO daily
Omeprazole 20 mg PO daily
Ferrous sulfate 325 mg PO daily
Docusate 100 mg PO BID
Senna 1 tab PO QHS
Bisacodyl 10 mg PO PRN
Artificial tears 1 drop each eye QPM
Discharge Medications:
1. vancomycin in D5W 1 gram/200 mL Piggyback Sig: 1000 (1000) mg
Intravenous Q48H (every 48 hours) for 6 days: last day [**5-17**].
2. piperacillin-tazobactam 2.25 gram Recon Soln Sig: 2.25 gram
Intravenous Q6H (every 6 hours): last day [**5-17**].
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. dipyridamole 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
9. pioglitazone 45 mg Tablet Sig: One (1) Tablet PO once a day.
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
14. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
15. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: One
(1) Drop Ophthalmic DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnosis:
Healthcare Associated Pneumonia
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 8774**],
You were admitted to the Intensive Care Unit because you were
having trouble breathing. You were found to have a pneumonia,
so you were started on IV antibiotics for pneumonia.
Changes to your Medications:
- START Vancomycin 1000 mg IV every 48 hours. You should have
your [**Known lastname **] level of this antibiotic checked on [**5-12**] to make sure
this is the correct dose
- START Zosyn 2.25 gm IV every 6 hours
Followup Instructions:
Please be sure to set up a followup appointment with your
primary care physician at [**Hospital 100**] Rehab
Completed by:[**2125-5-11**]
|
[
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"389.9",
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"571.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11916, 11982
|
7702, 9830
|
287, 293
|
12077, 12124
|
4226, 4226
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4242, 4982
|
12022, 12056
|
12139, 12236
|
2186, 2454
|
2470, 2741
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,444
| 195,909
|
7975+7976
|
Discharge summary
|
report+report
|
Admission Date: [**2168-7-21**] Discharge Date: [**2168-7-22**]
Date of Birth: [**2104-9-5**] Sex: M
Service: PSYCHIATRY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2448**]
Chief Complaint:
??????I wanted to end it all.??????
Major Surgical or Invasive Procedure:
none
History of Present Illness:
62 y/o man with one serious suicide attempt and multiple medical
problems including s/p stroke, DM, CHF, s/p MI who presents from
[**Hospital3 7569**] for evaluation for possible bypass surgery.
On Monday, he became intensely angry after his ??????toothbrush
vanished.?????? He described the tootbrush as ??????special?????? because ??????you
could also floss with it.?????? He mistakenly used his grandson??????s
toothbrush. An argument ensued where he complained that other
items like his deodorant and soap had also ??????vanished.?????? He yelled
at his wife, used derogatory terms with his grandson, smashed a
jar on the counter, and stated that he ??????wanted to end it all.??????
He mentioned ??????I have the means to do so?????? referring to 3+ guns at
home, and also muttered ??????I think I??????ll take you and [**Name (NI) **]
(grandson) with me?????? to his wife and grandson, at which point
they
evacuated the home and called the police. He was found by the
police sleeping, with a fully loaded handgun under his pillow,
and he was hospitalized at [**Hospital3 **] for work-up of chest
pain, where he was found to have NSTEMI and ws transferred to
[**Hospital1 18**] for evaluation by cardiac surgery, which included a cath
with possible cardiac bypass surgery to follow.
When reflecting on the event of anger on Monday, he denies ever
feeling homicidal and states that he ??????would not have had the
guts?????? to complete a suicide and describes himself as ??????foolish??????
for thinking about it; however, he was suicidal with a plan to
use a gun at the time. He is no longer feeling suicidal. 3 guns
at home were confiscated. A fourth shotgun is disassembled in
parts throughout the home; he states no one else is aware of
this
last gun.
His single daughter died of a PE 4 months and he states that he
and his wife are ??????painfully mourning"
He endorses depressive symptoms of hypersomnia (16 hours daily),
poor concentration and energy.
He denied psychotic sx??????s, including AVH, thought insertion or
broadcasting, and paranoia
He denied manic sx??????s and a h/o manic sx??????s.
Past Medical History:
CAD: [**2158**]- stent to prox RCA; [**2161**]-MI with 2 RCA stents; [**2164**] -
MI with PTCA and stent to 90% mid LAD lesion and PTCA to D2;
[**2-25**] - PTCA and brachytherapy to mid-LAD; stents to diag and OM1
branch; [**2166**] - at [**Hospital3 **] - 60% LAD stenosis, no stent
placed.
HTN
morbid obesity
CVA (right MCA) [**2154**] s/p RCEA
NIDDM
COPD
OSA on CPAP
Social History:
Previous Hospitalization: none
Suicide attempts: in [**2155**] after having a stroke, he placed a
shotgun at his chin, pointing upwards, and pulled the trigger,
but the safety was still on, for which he was later grateful.
Assaultive behavior: none
Current treaters: none in mental health
Medication trials: none prior to zoloft
SUBSTANCE ABUSE HISTORY:
EtOH: denies ever using, abstinent his entire life secondary to
hearing other people??????s problems with alcohol
Smoked cigarettes x 20 years, quit 30 years ago
Denies heroin, MJ, cocaine, and all other recreational drugs.
LEGAL HISTORY: none, but wants his guns returned from police
Family History:
No suicide attempts in family and no immediate family members
with psychiatric illness.
Physical Exam:
Appearance: obese white man lying in bed
Behavior: +PMR, infrequent eye contact
Speech: slow, fluent
[**Name (NI) **]: ??????irritated that I am going to psych"
Affect: dysphoric, blunted
Thought process: linear and goal directed
Thought content: no AH/VH, not suicidal or homicidal, no PI/IOR
Insight/judgement: fair / fair
Cognitive Exam:
Oriented to [**Hospital 18**] hospital, on the correct date, season, and day
of week, Registration [**2-25**] immediate and recall [**2-25**] at 3 minutes
with multiple choice, Recites MOYB without error, states
presidents as ??????[**Last Name (LF) 2450**], [**First Name3 (LF) 1806**], [**Doctor Last Name **]??????, 9 quarters in 2.25,
grass/geener- you always want what you can't have
Pertinent Results:
[**2168-7-20**] 05:20PM CK(CPK)-118
[**2168-7-20**] 05:20PM CK-MB-3 cTropnT-0.17*
[**2168-7-20**] 06:40AM GLUCOSE-321* UREA N-31* CREAT-1.2 SODIUM-136
POTASSIUM-3.4 CHLORIDE-92* TOTAL CO2-35* ANION GAP-12
[**2168-7-20**] 06:40AM CK(CPK)-110
[**2168-7-20**] 06:40AM CK-MB-4 cTropnT-0.19*
[**2168-7-20**] 06:40AM CALCIUM-9.1 PHOSPHATE-3.6 MAGNESIUM-2.1
[**2168-7-20**] 06:40AM %HbA1c-15.3* [Hgb]-DONE [A1c]-DONE
[**2168-7-20**] 06:40AM WBC-5.9 RBC-4.61 HGB-13.2* HCT-38.6* MCV-84
MCH-28.7 MCHC-34.3 RDW-14.3
[**2168-7-20**] 06:40AM PLT COUNT-258
Brief Hospital Course:
Patient was transferred to the [**Hospital1 **] 4 Inpatient Psychiatry
Unit on a conditional voluntary Section [**10-4**] and was placed on
15 minute checks. Patient was continued on his Zoloft, though
the dose was increased to 100 mg po qday. Patient denied any
suicidality or homicidality, saying "I would never hurt myself
or my wife." Patient reported feeling guilty for having made
the comments which got him picked up by the police. In
addition, he reported understanding "I have a bad depression and
a big problemand I need help. Many years ago I almost gave
myself a hair cut with a shotgun".
Cardiac: On the first night of patient's hospitalization, he had
chest pain of [**2173-7-1**] intensity lasting for about an hour. The
patient did not report this pain to anyone overnight because
"there was no call button and I didn't want to cause a minor
panic". Patient reports the pain was like an elephant standing
on his chest. This pain is simlar to the pain that he had on
Monday with his NSTEMI. In addition, though patient had refused
CABG while on the medical service he is now strongly
reconsidering and would like to be undergo the workup for the
surgery as he will need "sooner or later, and sooner is probably
better".
Diabetes: Patient's blood sugars have been porrly controlled at
398/342/324 on his current regimen of 65 units Lantus at bedtime
and RISS.
Given patient's active cardiac concerns and desire to be worked
up for CABG, he will be transferred back to Cardiology.
Medications on Admission:
Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
5. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
8. Insulin Glargine 100 unit/mL Cartridge Sig: Sixty Five (65)
units Subcutaneous at bedtime.
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
5. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
8. Insulin Glargine 100 unit/mL Cartridge Sig: Sixty Five (65)
units Subcutaneous at bedtime.
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Axis I: Major Depressive Disorder
Axis II: deferred
Axis III: CAD s/p MI, HTN, obesity, OSA, s/p CVA, NIDDM, COPD
Discharge Condition:
stable
Discharge Instructions:
Pt going to cardiology service
Followup Instructions:
Psych c/s service will continue to follow as needed
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2461**]
Admission Date: [**2168-7-22**] Discharge Date: [**2168-8-3**]
Date of Birth: [**2104-9-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
chest pain while on [**Hospital1 **] 4
Major Surgical or Invasive Procedure:
s/p CABGx3(LIMA-LAD, SVG-RCA, SVG-PDA) [**7-26**]
History of Present Illness:
This is a 63 year old man severe 2VD and multiple caths in the
past with stents and brachytherapy. He was initially admitted to
[**Location (un) **] following chest pain induced by an argument. There he
ruled in for a NSTEMI. He was then transferred here on [**7-19**] and
underwent cath which showed a 90% mid RCA and 100% LAD at the
site of his prior brachytherapy. He was not intervened on since
he has had multiple PCI to the LAD lesion in the past. He was
reffered for CT [**Doctor First Name **], however, the patient initially declined.
Because of his recent h/o HI and SI, he was admitted voluntarily
to the [**Hospital1 18**] psych unit. On his first night there, he developed
[**7-3**] left sided chest pressure overnight for 1 hour. He did not
tell anyone until the afternoon of [**7-22**]. He is now being
transferred back to the [**Hospital Unit Name 196**] service for r/o MI. Also, he is
precontemplative about CABG and would like to undergo the workup
while here.
The paitent currently feels well. He has no CP, SOB, or
pain of any kind. He is apprehensive and thoughtful about the
CABG. He has many quetions that I spent 30 minutes answering. He
would also like to speak with CT [**Doctor First Name **] further. He denies SI or
HI but knows that he is severly depressed.
Past Medical History:
CAD: [**2158**]- stent to prox RCA; [**2161**]-MI with 2 RCA stents; [**2164**] -
MI with PTCA and stent to 90% mid LAD lesion and PTCA to D2;
[**2-25**] - PTCA and brachytherapy to mid-LAD; stents to diag and OM1
branch; [**2166**] - at [**Hospital3 **] - 60% LAD stenosis, no stent
placed.
HTN
morbid obesity
CVA (right MCA) [**2154**] s/p RCEA
NIDDM
COPD
OSA on CPAP
Social History:
Previous Hospitalization: none
Suicide attempts: in [**2155**] after having a stroke, he placed a
shotgun at his chin, pointing upwards, and pulled the trigger,
but the safety was still on, for which he was later grateful.
Assaultive behavior: none
Current treaters: none in mental health
Medication trials: none prior to zoloft
SUBSTANCE ABUSE HISTORY:
EtOH: denies ever using, abstinent his entire life secondary to
hearing other people??????s problems with alcohol
Smoked cigarettes x 20 years, quit 30 years ago
Denies heroin, MJ, cocaine, and all other recreational drugs.
LEGAL HISTORY: none, but wants his guns returned from police
Family History:
No suicide attempts in family and no immediate family members
with psychiatric illness.
Physical Exam:
Vitals: 96.3, 124/70, 65, 92% RA
Gen: Tired appearing man sitting on the edge of his bed and
answering questions full sentences
HEENT: EOMI, PERRLA, MMM, O/P clear
Neck: -LAD/JVD
CV: RRR, s1/s2 wnl, 2/6 systolic ejection murmur in the LUSB
Abd: Obese, NT/ND, + BS
Groin: - bruit/oozing/hematoma
Ext: -C/C/E, decreased LE peripheral pulses b/l, minor cuts to
toes b/l
Pertinent Results:
[**2168-7-22**] 05:34PM GLUCOSE-338* UREA N-35* CREAT-1.6* SODIUM-135
POTASSIUM-4.6 CHLORIDE-95* TOTAL CO2-33* ANION GAP-12
[**2168-7-22**] 05:34PM CK(CPK)-192*
[**2168-7-22**] 05:34PM CK-MB-4 cTropnT-0.16*
[**2168-7-22**] 05:34PM CALCIUM-8.1* PHOSPHATE-7.4*# MAGNESIUM-2.2
[**2168-7-22**] 05:34PM WBC-6.5 RBC-4.75 HGB-13.5* HCT-41.0 MCV-86
MCH-28.4 MCHC-33.0 RDW-14.2
[**2168-7-22**] 05:34PM PLT COUNT-248
[**2168-7-21**] 06:35AM GLUCOSE-240* UREA N-31* CREAT-1.4* SODIUM-138
POTASSIUM-4.0 CHLORIDE-95* TOTAL CO2-35* ANION GAP-12
[**2168-7-21**] 06:35AM CK(CPK)-123
[**2168-7-21**] 06:35AM CK-MB-3 cTropnT-0.18*
[**2168-7-21**] 06:35AM CALCIUM-9.1 PHOSPHATE-4.2 MAGNESIUM-2.2
[**2168-7-21**] 06:35AM WBC-5.3 RBC-4.79 HGB-13.5* HCT-40.8 MCV-85
MCH-28.2 MCHC-33.0 RDW-14.3
[**2168-7-21**] 06:35AM PLT COUNT-284
[**2168-8-3**] 05:55AM BLOOD WBC-6.5 RBC-2.95* Hgb-8.5* Hct-25.1*
MCV-85 MCH-28.7 MCHC-33.9 RDW-14.5 Plt Ct-413
[**2168-8-3**] 05:55AM BLOOD Plt Ct-413
[**2168-8-2**] 09:57AM BLOOD Glucose-170* UreaN-31* Creat-1.3* Na-139
K-4.2 Cl-99 HCO3-32 AnGap-12
[**2168-8-3**] 05:55AM BLOOD UreaN-31* Creat-1.2 K-4.1
[**2168-7-25**] 06:00PM BLOOD ALT-15 AST-20 LD(LDH)-222 AlkPhos-71
TotBili-0.5
[**2168-8-3**] 05:55AM BLOOD Mg-2.0
Brief Hospital Course:
63 yo male with MMP including CAD with multiple caths, COPD,
psych disorder with h/o SI and HI, and DM2 who presented with
chest pain in the context of a family conflict. He ruled in for
NSTEMI and cath revealed 2VD including his LAD and RCA. He
initially refused cardiac surgery and was felt to be suicidal
and required a brief psychiatric admission. After several days
he was felt to be no longer suicidal and was requesting CABG.
He was referred to Dr. [**Last Name (STitle) **] for operative treatment
He was taken to the operating room on [**2168-7-26**] with Dr. [**Last Name (STitle) **] for
a CABGx3, LIMA-LAD, SVG-Diag, SVG-PDA. He was transported to
the ICU in stable condition. Extubated later that evening, and
milrinone wean begun. Swan and CTs removed and follow-up by
psych done. Remained on neosynephrine drip on POD #2. Also
transfused one unit PRBC for Hct of 25. Lasix diuresis started.
Also followed by [**Last Name (un) **] consult for glucose management. Beta
blockade started and transferred to the floor on POD #3. Left IJ
CVL replaced when unable to get peripheral access.Seen and
evaluated by PY on floor and began ambulation. Had nebulizer
treatments fo coarse rhonchi to help with pulm. toilet. Switched
from metoprolol to carvedilol on POD #4. Encouraged to get OOB
and increase ambulation. Pacing wires removed without incident
on POD #4. Stabilized from psych. symptoms. Lasix increased to
TID to help with additional diuresis. He continued to increase
his activity level in the next couple of days and was cleared by
psych for DC to rehab on POD #8. He had some diarrhea after MOM
that was guaic neative and C.Diff. sent. Lasix changed to PO.
[**Last Name (un) **] recommendations appreciated for insulin management. Exam
[**8-3**]: alert and oriented, nonfocal, RRR no murmur, sternal
incis. C/D/I with staples in place. Abd has bowel sounds, 1+
edema LE, leg incis. C/D/I and O2sat 97% on 2L NC. Insulin fixed
dose and sliding scale adjusted by Dr. [**Last Name (STitle) 978**] from [**Last Name (un) **].
Ready for discharge to rehab on [**8-3**]. Awaiting bed
availability.
Medications on Admission:
Insulin SC (per Insulin Flowsheet)Sliding Scale & Fixed Dose
Order date: [**7-22**]
Aspirin EC 325 mg PO DAILY Order date: [**7-22**] @ 2204
Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY hold
for SBP < 100 Order date: [**7-22**] @ 2204
Atorvastatin 80 mg PO DAILY Order date: [**7-22**] @ 2204
Lisinopril 10 mg PO DAILY hold for sbp < 100 Order date: [**7-22**]
@ 2204
Clopidogrel Bisulfate 75 mg PO DAILY Order date: [**7-22**] @ 2204
Metoprolol XL 50 mg PO DAILY Hold for SBP < 105 or HR < 60
Order date: [**7-22**] @ 2204
Ezetimibe 10 mg PO DAILY Order date: [**7-22**] @ 2204
Sertraline HCl 100 mg PO DAILY Order date: [**7-22**] @ 2204
Heparin 5000 UNIT SC TID Order date: [**7-22**] @ 2204
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day). Capsule(s)
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
6. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Albuterol Sulfate 0.083 % Solution Sig: One (1) puffs
Inhalation every 4-6 hours.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
10. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
13. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed.
16. Insulin Glargine 100 unit/mL Solution Sig: Forty Five (45)
units Subcutaneous at bedtime.
17. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: as
directed per sliding scale units Subcutaneous four times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 11496**] - [**Location (un) **]
Discharge Diagnosis:
CAD
s/p CABG
DM
depression
HTN
CRI
h/o CVA
Discharge Condition:
good
Discharge Instructions:
you may take a shower and wash your incision with mild soap and
water
do not swim or take a bath for 1 month
do not drive for 1 month
do not lift anything heavier than 10 pounds for 1 month
do not apply lotions, creams, ointments or powders to your
incisions
Followup Instructions:
follow up with Dr. [**Last Name (STitle) 28583**] in [**12-27**] weeks
follow up with Dr. [**Last Name (STitle) **] in [**2-26**] weeks
follow up with a mental health provider as an outpatient
pt. instructed to call for f/u appt. with [**Hospital **] Clinic at
[**Hospital3 7571**]Med.Ctr
Completed by:[**2168-8-3**]
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64,195
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37073
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Discharge summary
|
report
|
Admission Date: [**2153-7-5**] Discharge Date: [**2153-7-6**]
Date of Birth: [**2093-11-16**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Chief Complaint: Seizure
Reason for MICU transfer: s/p intubation for combative
post-ictal state
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
This is a 58 year old gentleman with a history of recurrent
syncope and systolic heart failure (EF 35%) who presented to the
ED for pre-syncope w/u and was observed to have a tonic clonic
seizure with combative post-ictal state who was intubated for
airway protection.
.
In brief, he reports working outdoors yesterday in 90 degree
weather at his lumber construction company where he works as a
foreman. At 1 Pm he reported feeling light headed almost passing
out prompting him to go to [**Hospital 4199**] Hospital for evaluation.
After inital evaluation, he was going to be admitted for
cardiovascular w/u when he asked to be discharged to [**Hospital1 18**] where
his care is managed.
.
At [**Hospital1 18**] ED, initial vitals were: 98.8 95 151/83 18 98% 2L Nasal
Cannula. Initial labs demonstrated troponin < 0.01, baseline
cbc and unremarkable chem10. His reported presentation appeared
to be consistent with heat syncope. He was observed overnight
in the ED with plan for IV hydration and discharge home in the
morning. This morning he was noted to have a generalized tonic
clonic seizure that lasted approximately 5 minutes which
resolved without intervention. His post ictal state was notable
for being unresponsive to verbal stimuli and significant
combativeness. Six people including security and 6mg IV ativan
did not sedate him. He was noted to desat and was placed on a
non-rebreather. He was ultimately intubated for airway
protection. A CT scan demosntrated no intracranial injury and
mild age inappropriate prominenence of the sulci which appeared
stable compared to prior imaging. A serum and urine tox screens
were added on to his prior samples and were notable for a
positive urine cocaine and negative for etoh. Neurology was
consulted who evaluated and determined the patient and felt the
patients seizure was likely triggered by recent cocaine
ingestion, possible etoh withdrawal (despite negative tox
screen). The description of prior episodes of
syncope/presyncope were felt to unlikely represent seizures and
did not appear to be related to the GTC today. Given absence of
findings on CT scan, his presenting seizure was felt to
represent an induced event rather than primary epilepsy.
Menigitis/encephalitis was considered, however given the absence
of infectious signs and absence of fever, a lumbar puncture was
not immediately recommended or pursued. Admission to the medical
ICU was obtained in the setting of the patients intubated state.
Vitals on transfer were:
Meningitis/Encephalitis, given the lack of infectious
signs/symptoms, is very unlikely in this case but there would be
a low threshold for LP and empiric meningitis coverage if he
were
to develop fever.
.
On arrival: 98.4 73 141/80 95 100% on CMV Fio2 of 50%, RR 18,
PEEP 5 and Tv 500.
.
His wife was called who reported a recent history of 5
syncopal/presyncopal events 'blacking out' in the setting of
abstinence of etoh. Prior w/u at OSH and by his cardiologist
have revealed evidence of cardiomyopathy (EF 35%) attributed to
multivessel CAD vs etoh. He used to drink 30 beers per day but
has cut back to 1 6pack and 2 nips per day. She reports he may
drink additional etoh at work where he is 6am-4pm in the
presence of friends. Unsure if he does cocaine but she is aware
that cocaine does occur at work. During the past 3 days he has
been especially tired at work and has not had any of the beer in
the fridge which is unuual. Believes last drink was a 2 pm two
days ago. Also notes significant decrease in short term memory,
family needs to write notes every where around the house for
directions. Has noted work more stressful given difficulty w/
memory and aging
Past Medical History:
1. Syncope
2. Chronic systolic heart failure (? ischemic vs. alcoholic
cardiomyopathy)
3. Hypertension
4. Dyslipidemia
5. Primary (vs. secondary) prevention of coronary artery disease
6. Overweight
Social History:
- Tobacco: 5pyh, quit [**2117**]
- Alcohol: prior etoh abuse, 6pack lasts 4 days
- Illicits: denies, however cocaine + urine
- Housing: Lives w/ wife, 3 children and 4 grandchildren.
- Employement: foreman for a lumbar company
Family History:
- father: 84, HTN
- mother: d at 66
- 8 brohters and 5 sisters, 2 half sisters -> significant HTN
- Sister: epilepsy
There is no family history notable for stroke, hyperlipidemia,
diabetes, early coronary artery disease, orsudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.4 73 141/80 95 100% on CMV Fio2 of 50%, RR 18, PEEP
5 and Tv 500.
General: Intubated and sedated
HEENT: Sclera anicteric, MMM, oropharynx clear, poor dentition
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, distended, bowel sounds present
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact
Pertinent Results:
ADMISSION LABS:
[**2153-7-4**] 10:50PM BLOOD WBC-4.6 RBC-3.54* Hgb-11.9* Hct-36.2*
MCV-103* MCH-33.7* MCHC-32.9 RDW-12.3 Plt Ct-142*
[**2153-7-4**] 10:50PM BLOOD Neuts-72.1* Lymphs-20.2 Monos-5.6 Eos-1.5
Baso-0.6
[**2153-7-4**] 10:50PM BLOOD Glucose-97 UreaN-16 Creat-0.6 Na-139
K-3.6 Cl-103 HCO3-27 AnGap-13
[**2153-7-5**] 05:22AM BLOOD ALT-91* AST-164* AlkPhos-63 TotBili-1.3
[**2153-7-4**] 10:50PM BLOOD cTropnT-<0.01
[**2153-7-4**] 10:50PM BLOOD Calcium-9.4 Phos-3.4 Mg-1.8
[**2153-7-5**] 06:11AM BLOOD Lactate-2.2*
[**2153-7-5**] 05:10AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012
[**2153-7-5**] 05:10AM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-4* pH-7.5 Leuks-NEG
[**2153-7-5**] 05:10AM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-<1
PERTINENT LABS:
-Serum tox ([**2153-7-5**], 10:50 PM): ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
-Urine tox ([**2153-7-5**], 5:10 AM): bnzodzp-NEG barbitr-NEG
opiates-NEG cocaine-POS amphetm-NEG mthdone-NEG
-Blood cx ([**2153-7-5**]): PENDING
-Urine cx ([**2153-7-5**]): PENDING
EKG ([**2153-7-5**]): NSR, LAD, LVH w/ ST flattening in lateral leads
AP CHEST X-RAY ([**2153-7-5**], prelim read): Endotracheal tube is in
the lower trachea near the carina. An enteric tube traverses
through the stomach. Lung volumes are low. Mild left basilar
atelectasis. The lungs are otherwise without a focal
consolidation, pleural effusion, or pneumothorax.
Cardiomediastinal silhouette appears moderately enlarged.
IMPRESSION:
1. Endotracheal tube appears in the lower trachea near the
carina. Retraction by 2.0 cm is recommended.
2. Moderate cardiomegaly.
NON-CONTRAST HEAD CT ([**2153-7-5**], final): There is no evidence of
acute hemorrhage, edema, large vessel territorial infarction,
shift of normally midline structures. The ventricles and sulci
again appear prominent for the patient's age, but stable.
[**Doctor Last Name **]-white matter differentiation appears well preserved. No
acute fractures are identified. Mild mucosal thickening is noted
in the ethmoidal and right maxillary sinuses.
IMPRESSION:
1. Stable appearance in comparison to the prior study with no
acute
intracranial process identified. If clinical suspicion for an
acute
infarction is high, MR is the recommended study of choice.
2. Again identified is age-inappropriate prominence of sulci and
ventricles.
LIVER/GALLBLADDER ULTRASOUND ([**2153-7-5**]):
IMPRESSION: Echogenic liver consistent with fatty infiltration.
Other forms of liver disease and more advanced liver disease
including significant hepatic fibrosis/cirrhosis cannot be
excluded on this study.
Brief Hospital Course:
HOSPITAL COURSE:
This is a 58 year old gentleman with a history of recurrent
syncope and systolic heart failure (EF 35%) who presented to the
ED for pre-syncope w/u and was observed to have a tonic clonic
seizure with combative post-ictal state who was intubated for
airway protection.
.
ACTIVE ISSUES:
# Seizure: Pt had generalized tonic clonic seizure in ED, most
likely withdrawal seizure in setting of EtOH abstinence x2 days
and polysubstance abuse (UTox positive for cocaine). Resolved
after 5 minutes without any benzodiazepimes. CT head without
acute findings. No prior seizure history but has h/o several
recent unwitnessed syncopal episodes in setting of EtOH
cessation. Patient received one dose of ativan 4mg IV for
agitation while still intubated in MICU; after extubation he did
not require more ativan over next few hours. He was followed by
neurology who initially recommended MRI, EEG and Keppra but
retracted these recs once more clear that this was EtOH
withdrawal seizure. Patient was continued on CIWA with ativan
(can switch to Valium on floor given normal liver synthetic
function and fatty liver but no obvious cirrhosis on RUQ
ultrasound). He did not require any benzodiazepines on HD2 and
he was discharged home.
.
# Syncope: H/o recurrent pre-syncopal/syncopal events in past
year which have all occured in setting of etoh cessation. Some
of the events have been witnessed but no evidence of tonic
clonic activity during the past, no episodes of blacking out, no
loss of bladder control, never had tongue bite or incontinence,
or confusion post episode. He was seen in the outpt setting by
Neurology who felt his sx were not c/w seizure and ordered a CT
scan of his which was unremarkable. Recently had extensive w/u
at [**Hospital 4199**] hospital including TTE and [**Doctor Last Name **] of Hearts which
revealed cardiomyopathy and no evidence of malignant arryhthmia.
He is followed by both neurology and cardiology at [**Hospital1 18**] who
feel sx c/w likely vasovagal. A follow-up TTE with Valsalva
maneuver was negative for a left ventricular outflow tract
obstruction.
.
# EtOH/polysubstance abuse, elevated LFTs: Long h/o EtOH abuse,
per wife cut down considerably in recent years w/ recent effort
at abstience. Etoh level 0 on arrival, UTox positive for
cocaine. Last drink felt to be 2 days ago. LFTs elevated in 2:1
ratio consistent with EtOH hepatitis. Liver synthetic function
intact. RUQ ultrasound showed fatty liver, no nodularity.
Patient received banana bag in ICU, to be followed by PO
folate/MV and 3 days of thiamine 500mg IV BID (given altered
mental status which could represent Wernicke's encephalopathy).
He was discharged on HD with oral thiamine replacement.
.
# Coronary Artery Disease: Systolic Heart Failure: Most recent
TTE demonstrates global sysolic dysfunction w/ apical
hypokinesis and EF 35%. Etiology felt to be multivessel disease
versus cardiomyopathy of etoh. Given positive cocaine on UTox,
also should consider cocaine cardiomyopathy. In the MICU his
home ASA, lisinopril, crestor and metoprolol were continued. He
is scheduled for outpatient cards f/u with Dr. [**First Name (STitle) **] [**Name (STitle) **] on
[**8-6**] but wife requested earlier f/u if possible given pt
noncompliance with appts. Dr. [**Last Name (STitle) **] has arranged for cardiac
cath in the following 2 weeks. The cath lab will call Mr.
[**Known lastname **] with formalized schueduling. The patient was encouraged
to follow-up with all his appointments to demonstrate improved
compliance. At this time, he was not a candidate for PCI give
concern that he would not be faithful to plavix and aspirin.
.
# Airway Protection: Intubated for airway protection in setting
of post-ictal combativeness. In the MICU he received ativan for
agitation due to EtOH withdrawal, and was then extubated to room
air without further issues, good oxygen sats.
.
# Memory loss: family reports patient has had progressive memory
loss over several years. They reportedly have to leave Post-It
notes around the house to remind him to do things. His head CT
showed ventricular enlargement worse than expected for his age.
Could have Korsakoff psychosis [**2-15**] EtOH abuse vs. other form of
dementia. Receiving IV thiamine, will need outpatient workup.
.
# Hypertension: Longstanding hypertension. Wife reports baseline
BPs in 180s/80s and previously over 200 systolic. Continued home
lisinopril and amlodipine.
.
# Depression: Stable per wife. Continued home trazodone and
sertraline.
.
TRANSITIONAL ISSUES:
- pending labs: blood cx x 2 pending
- follow-up: PCP and cardiology
- code: full
- contact: wife [**Name (NI) **] [**Telephone/Fax (1) 83571**]
Medications on Admission:
Aspirin 81 mg p.o. daily
lisinopril 40 mg p.o. daily
amlodipine 10 mg p.o. daily
metoprolol 25mg [**Hospital1 **]
Crestor 40 mg p.o. q.h.s.
omeprazole 20 mg p.o. daily
multivitamin
thiamine 100 mg p.o. daily
folic acid 1 mg p.o. daily
methocarbamol 750 mg p.o. t.i.d. p.r.n.
naproxen 500 mg p.o. b.i.d. p.r.n.
trazodone 50 mg one tablet p.o. q.h.s.
sertraline 50 mg p.o. daily
ketoconazole 2% cream.
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
hold for SBP < 100
3. Amlodipine 10 mg PO DAILY
hold for SBP < 100
4. Metoprolol Tartrate 25 mg PO BID
hold for HR < 60
5. Rosuvastatin Calcium 40 mg PO HS
6. Omeprazole 20 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Thiamine 100 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. traZODONE 50 mg PO HS:PRN insomnia
11. Sertraline 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
1. Seizure, Alcohol Withdrawal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the [**Hospital1 18**] emergency department after a
syncopal event (fainting) while at work. While undergoing
evaluation you suffered a seizure and were combative. You were
mechanically ventilated (a breathing tube was placed) for your
own protection. This breathing tube was removed several hours
later. Your seizure most than likely occured in the setting of
alcohol withdrawal. While we applaud any efforts at cutting
down on alcohol , we encourage you in the future to seek
professional assistance while detoxing as alcohol withdrawal can
cause seizures and even death. Your withdrawal symptoms were
treated with benzodiazepines and your condition improved. A
social worker spoke with you regarding detox and provided you
information regarding [**Hospital 83572**] rehab for detox in the
future.
.
While you were hospitalized, we contact[**Name (NI) **] your cardiologists
regarding your underlying cardiac disease. It is important that
you in the future have a cardiac catheterization - a procedure
that looks at the vessels supply blood to your heart muscles -
to evaluate your heart function. In the setting of a recent
seizure and active alcohol withdrawal, it was not considered
safe to proceed with an invasive procedure during this
admission.
.
It is important that you consider strongly stopping or cutting
down on your alcohol intake. It has considerable negative health
effects on your heart. It is important that if you want to be
considered for further interventions, you follow-up with your
appointments as scheduled or call in advance to re-schedule.
.
The following changes were made to your medication list: none
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: ADULT MEDICINE
When: WEDNESDAY [**2153-7-25**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8471**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
.
Department: ADULT SPECIALTIES
When: MONDAY [**2153-8-6**] at 3:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) 10828**], MD [**Telephone/Fax (1) 1142**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
.
Dr. [**Last Name (STitle) **] has spoken with both the interventional cardiologist
who will perform a cardiac catheterization and the
catheterization facility regarding your upcoming procedure. It
is tentatively planned for the following 1-2 weeks. The lab will
call you next week to formalize scheduling. If you have not
heard from us in 10 days please call Dr.[**Name (NI) 13892**] office.
.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
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icd9cm
|
[
[
[]
]
] |
[
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] |
icd9pcs
|
[
[
[]
]
] |
13684, 13690
|
8127, 8127
|
408, 433
|
13765, 13765
|
5447, 5447
|
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12838, 13239
|
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|
4913, 5428
|
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|
288, 370
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8430, 12645
|
461, 4140
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5464, 6253
|
13780, 13892
|
6269, 8104
|
4162, 4362
|
4378, 4610
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,510
| 120,277
|
16620
|
Discharge summary
|
report
|
Admission Date: [**2180-11-8**] Discharge Date: [**2180-11-17**]
Date of Birth: [**2134-12-22**] Sex: M
Service: [**Company 191**]
CHIEF COMPLAINT: Upper gastrointestinal bleed
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 47097**] is a 45-year-old male
who is status post banding x 5 of his esophageal varices,
which occurred on [**2180-11-8**]. Prior to the [**Hospital 228**]
hospital admission, the patient had a history of "liver
disease" in [**2177**], but denied any history of cirrhosis, denied
any episodes of jaundice. He initially presented to an
outside hospital with complaint of right-sided pain and
jaundice, and several days of black/tarry stools. At the
outside hospital's Emergency Department, his nasogastric
lavage showed bright red blood. The patient was
hemodynamically stable.
The patient was then transferred to [**Hospital1 190**] Medical Intensive Care Unit with a diagnosis
of upper gastrointestinal bleed. He then underwent an
esophagogastroduodenoscopy, which showed esophageal varices
and evidence of a recent bleed. These esophageal varices
were banded x 5. Intravenous octreotide was started. The
patient's hematocrit was serially checked, and transfusions
were given as needed. In addition, for his history of liver
disease (severe ethanol abuse, approximately 750 cc of
whiskey every day), pentoxifylline was started for his
alcohol hepatitis. In addition, on [**2180-11-10**], the
patient's white blood count began increasing, so a
paracentesis was done to rule out SBP. Levofloxacin was then
started for SBP prophylaxis. The patient was hemodynamically
stable, and remained on the octreotide drip, and the patient
was subsequently transferred to the floor from the Medical
Intensive Care Unit.
On arrival to the floor, the patient was afebrile, blood
pressure was 92 to 127/43 to 74, heart rate between 80 to
104, respirations between 15 and 24, and oxygen saturation
between 96 and 98% on 2 liters nasal cannula.
PHYSICAL EXAMINATION: In general, this was an obviously
jaundiced male, who communicated meaningfully. Head, eyes,
ears, nose and throat: Oropharynx was pink, mucous membranes
moist. Cardiovascular: Regular rate and rhythm, I-II/VI
systolic ejection murmur at the left upper sternal border.
Chest: Bilaterally clear to auscultation, left side with
slightly decreased breath sounds, no crackles, no wheezing.
Abdomen: Distended, positive normal bowel sounds, positive
ascites, nontender. Extremities: 4+ pitting edema. Skin:
Obvious jaundice, numerous spider angiomas all over the face,
no rhinophyma.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient has a history of chronic ethanol
abuse for 20 years. He drinks approximately 750 cc (one
fifth) of whiskey a day. He lives alone. He denies any
intravenous drug use. He has smoked approximately one-half
to one pack per day for 25 years. The patient is divorced,
and currently lives alone. He has one son, who lives in
[**State 15946**], and has two sisters. One of his sisters [**First Name8 (NamePattern2) 5969**]
[**Name (NI) 47097**]) is involved in his medical care. His other sister,
[**Name (NI) **] [**Name (NI) 47097**], is estranged from the patient, and is not to be
given any medical information about Mr. [**Known lastname 47097**].
MEDICATIONS: On transfer from the Medical Intensive Care
Unit, include:
1. Lactulose 30 ml every six hours as needed
2. Protonix 40 mg by mouth every 12 hours
3. Multivitamin by mouth once daily
4. Folate 1 mg by mouth once daily
5. Thiamine 200 mg by mouth once daily
6. Levofloxacin 500 mg by mouth every 24 hours
7. Pentoxifylline 400 mg by mouth three times a day
8. Ursodiol 300 mg by mouth three times a day
9. Ativan 2 mg intravenously every four hours as needed CIWA
scale greater than 10
10. Morphine 1 to 2 mg intravenously every four hours as
needed for pain
11. Vitamin K 10 mg subcutaneously once daily for three days
12. Octreotide 50 mcg/hour drip
13. Albuterol/ipratropium one to two puffs every six hours
as needed
14. Tylenol 325 to 650 mg by mouth as needed
LABORATORY DATA: On transfer, white blood count 15,
hemoglobin 10.4, hematocrit 31.5, platelets 140. PT 16, PTT
39, INR 1.9. Sodium 137, potassium 3.6, chloride 106,
bicarbonate 23, BUN 11, creatinine 0.8, glucose 136. Calcium
7.9, phosphorus 1.9, magnesium 1.7, albumin 2.2, ALT 32, AST
123, alkaline phosphatase 389, total bilirubin 29.8, total
iron binding capacity 164, haptoglobin 80, ferritin 212.
Hepatology panels were drawn, which revealed negative
hepatitis B, negative hepatitis C.
IMPRESSION: Mr. [**Known lastname 47097**] is a 45-year-old male with a new
diagnosis of liver failure, alcoholic hepatitis, and
esophageal variceal bleed, status post banding, who is
hemodynamically stable, and able to be transferred to the
floor.
HOSPITAL COURSE BY SYSTEM:
1. Gastrointestinal:
a. Esophageal varices: The patient, after the initial
esophageal varices banding x 5, which occurred on [**2180-11-8**], the patient's hematocrit was checked serially every
12 hours, and it remained stable within a 31 to 34% range.
The patient did not require any additional transfusions while
on the floor. The patient then had a follow-up
esophagogastroduodenoscopy on [**2180-11-16**], which showed
that the patient did not need any more variceal banding, and
that the original procedures were intact. There was no
evidence of any new bleeding. The octreotide drip that was
initiated in the Medical Intensive Care Unit was continued on
the floor for 36 hours. After the octreotide drip was
discontinued, the patient was started on nadolol 20 mg by
mouth once daily. In addition, the patient's Protonix was
continued twice a day. Regarding the patient's esophageal
varices banding, the patient needs to have another follow-up
esophagogastroduodenoscopy in two weeks with Dr. [**First Name (STitle) **]. The
exact day and time and location will be given to the patient,
and will be dictated as a stat discharge summary addendum.
b. Alcoholic hepatitis: The patient's AST/ALT had been
elevated, but trended downward during his floor admission.
The patient was started on pentoxifylline and Ursodiol.
These medications are to be continued as an outpatient. Of
note, the patient's jaundice has not changed during the
admission, and the patient's bilirubin has increased from 30
to 34 during the course of his hospital admission. The
patient did not show any signs of encephalopathy.
2. Hematology: The patient's hematocrit was checked every
12 hours and the patient was transfused as needed while in
the Medical Intensive Care Unit. The patient did not require
any transfusions while on the floor.
3. Infectious Disease: The patient has a good deal of
ascites in his abdomen. Due to a question of infection, the
patient had a paracentesis done in order to investigate for
spontaneous bacterial peritonitis. The peritoneal fluid was
noted to have no leukocytes, and no micro-organisms were
seen. The fluid culture from the peritoneal fluid showed no
growth. The patient was placed on levofloxacin 500 mg by
mouth every 24 hours for SBP prophylaxis.
4. Prophylaxis: The patient was started on Protonix at 40
mg by mouth every 12 hours for an upper gastrointestinal
bleed.
5. Pulmonary: The patient does not have a known history of
asthma, but does have a significant past medical history for
smoking. The patient was placed on albuterol/ipratropium
nebulizers every four to six hours as needed. However, this
patient did not have any respiratory complaints or
complications during this admission. A chest x-ray PA and
lateral was done and showed low lung volumes, and slight left
ventricular prominence, but no evidence for congestive heart
failure. The lungs were clear, and there were no pleural
effusions. There was no pneumonia.
6. Fluids, electrolytes and nutrition: The patient's
electrolytes (calcium, magnesium, potassium) were repleted as
needed. The patient was placed initially on sips, then
clears, then started on a low residue diet. The patient has
tolerated the low residue diet quite well. In addition, a
Nutrition consult was obtained, and the patient was educated
about his diet.
7. Mobility: The patient had a great deal of edema, and
difficulty moving after a prolonged stay in the Medical
Intensive Care Unit as well as on the floor. Physical
Therapy consult was placed. The Physical Therapy consult
felt that the patient presented with improved mobility and
endurance, was able to ambulate without assistance, did not
have loss of balance, and was able to negotiate three flights
of stairs with the rail and with some assistance. Physical
Therapy consult felt that the patient is safe to return home
alone if support is provided for his stairs at home. They
have also recommended that the patient receive home physical
therapy services, and that he ambulate three times a day ad
lib, and be provided support with stairs if the patient is
discharged to home alone. The primary medical team is
amenable with this, and supports this assessment, and will
arrange for home physical therapy services.
8. Psychiatry/ethanol abuse: The [**Hospital 228**] medical
condition, and the seriousness of his upper gastrointestinal
bleed and esophageal varices, was discussed numerous times
with the patient. The patient initially was not amenable to
any sort of alcohol rehabilitation or ethanol counseling.
The patient felt that he would be better off at home, and
refused any sort of treatment or services. At this point in
time, we will provide him with the name and phone number of
alcohol rehabilitation centers that he can call. In
addition, we will continue to provide information for him and
have resources for him if he should wish to obtain ethanol
rehabilitation.
The patient is to be discharged home with services.
DISCHARGE CONDITION: Good
DISCHARGE DIAGNOSIS:
1. Alcoholic liver disease, acute alcoholic hepatitis
2. Esophageal varices, status post banding x 5
3. Upper gastrointestinal bleed secondary to esophageal
varices bleeding
4. Ascites
5. Malnutrition
6. Jaundice
7. Alcoholic cirrhosis
8. Ethanol abuse
DISCHARGE MEDICATIONS:
1. Levofloxacin 500 mg by mouth every 24 hours
2. Nadolol 20 mg by mouth every 24 hours
3. Pentoxifylline 400 mg by mouth three times a day
4. Ursodiol 300 mg by mouth three times a day
5. Lactulose 30 ml by mouth every six hours as needed,
titrate to three to four soft stools per day
6. Protonix 40 mg by mouth twice a day
7. Multivitamin one tablet by mouth once daily
8. Folate 1 mg by mouth once daily
9. Thiamine 100 mg by mouth once daily
10. Combivent one to two puffs every six hours as needed
FOLLOW-UP APPOINTMENTS: Follow up esophagogastroduodenoscopy
in two weeks with Dr. [**First Name (STitle) **], phone number [**Telephone/Fax (1) 2422**]. The
exact date and time will be given to the patient, as well as
dictated in a stat discharge summary addendum. The patient
is not to drink or eat anything after 10 P.M. on the night
preceding the esophagogastroduodenoscopy. This preparatory
schedule will be discussed with the patient as well.
DISCHARGE DIET: Low residue
DISCHARGE SERVICES:
1. VNA
2. Home physical therapy
[**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D.
[**MD Number(1) 7855**]
Dictated By:[**Last Name (NamePattern1) 33390**]
MEDQUIST36
D: [**2180-11-17**] 01:21
T: [**2180-11-17**] 02:20
JOB#: [**Job Number 47098**]
|
[
"263.9",
"530.2",
"571.2",
"276.5",
"571.1",
"456.20",
"789.5",
"303.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"42.33",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
9919, 9925
|
2622, 2640
|
10231, 10744
|
9946, 10208
|
4887, 9897
|
10769, 11550
|
2016, 2605
|
170, 200
|
229, 1993
|
2657, 4860
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,094
| 102,199
|
4528
|
Discharge summary
|
report
|
Admission Date: [**2173-2-24**] Discharge Date: [**2173-2-26**]
Date of Birth: [**2123-9-22**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / Toradol
Attending:[**First Name3 (LF) 11495**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization
RCA stent placement
History of Present Illness:
49 yo male with h/o IMI in '[**67**], HTN, hypercholesterolemia,
former cocaine user, + tob user, s/p PTCA + stent of RCA which
was shown in 4/00 to have mild restenosis, also with poor
medication complicance (not taking BB or Plavix x2 years)
presented to [**Hospital3 417**] Hospital on [**2-13**] with SSCP radiating
to neck and arm, CE neg but persistent CP not relieved by [**Hospital 19298**]
transfered to [**Hospital1 18**] [**2-15**] for PTCA. Last cath [**11-7**] with mild 1VD
with 50% RCA stenosis just proximal to previous minimally
restenosed stent. During hospitalization at [**Hospital1 18**] from [**2-15**] to
[**2-18**], pt was taken to cath showing 70% mild RCA occlusion, but
could not receive drug coated stent d/t aspirin allergy. Pt was
supposed to stay for elective aspirin desensitization in the
MICU prior to stent placement, but chose to leave AMA and follow
up for future elective stenting. He presents now for aspirin
desensitization and cardiac cath.
.
On interview, pt reports decrease in exercise tolerance x 3
weeks and numerous episodes of [**2178-8-15**] SSCP associated wtih SOB
and radiation to he R arm at rest. No associated
N/V/diaphoresis. CP episodes not more with activity. Denies PND,
orthopnea, LE edema. CP episodes last 20-30 minutes, resolved
wtih SLNTG. Denies recent cocaine use.
Past Medical History:
CAD (IMI in 99 s/p RCA stent, angio of jailed PDA in '[**67**], No
increasing CAD 00,00,02,02.
HTN (on atenolol 100mg at home, not taking)
h/o rheumatic Heart Dz in [**2142**] in [**Country 2784**] (after Strep throat)
c/p pericarditis.
Chronic cresendo angina (all started after his Pericarditis)
Hyperlip. Not taking his lipitor
Meniere's dx (deaf in Right ear)
Laminectomy x 2
Social History:
The patient has a one half to two pack per day times 30 years.
The patient drinks roughly 32 ounces of alcohol per day, on
weekends, and sometimes drinks three to four bottles of wine or
hard liquor. No intravenous drug abuse. Denies recent cocaine.
The patient is married with children. He works for the postal
office.
Very noncompliant with meds (on no medications X 2 years).
Physical Exam:
98.6 72 114/81 16 96%RA
Well-app, sitting upright in chair, NAD
No JVD appreciated
No o/p erythema or lesions
RRR, s1s2 nl, no murmurs, 1+ femoral pulses bilaterally without
bruits, R pulse > L. DP 2+ bilaterally
Lungs CTA B
Legs without edema
Pertinent Results:
[**2173-2-24**] 07:06PM WBC-9.2 RBC-4.37* HGB-15.2 HCT-44.0 MCV-101*
MCH-34.7* MCHC-34.5 RDW-12.6
[**2173-2-24**] 07:06PM PLT COUNT-324
[**2173-2-24**] 07:06PM NEUTS-60.8 LYMPHS-30.8 MONOS-4.3 EOS-3.2
BASOS-0.9
.
[**2173-2-24**] 07:06PM GLUCOSE-75 UREA N-12 CREAT-0.7 SODIUM-140
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-27 ANION GAP-13
[**2173-2-24**] 07:06PM CALCIUM-8.9 PHOSPHATE-2.4* MAGNESIUM-2.1
.
[**2173-2-24**] 07:06PM PT-12.5 PTT-36.9* INR(PT)-1.0
.
Left Heart Cath on previous admission ([**2173-2-15**]):
Selective coronary angiography revealed a right-dominant system.
The LMCA, LAD and LCx were all non-obstructed with no evidence
for flow-limiting stenoses. The RCA had a 70% lesion just
proximal to the previously placed stent with minimal instent
restenosis.
2. Left ventriculgraphy was deferred.
3. Resting hemodynamics revealed a mildly elevated central
aortic pressure (systolic 145mmHg).
4. ASA allergy previously documented requires ASA
densensitization prior to drug-coated stenting.
.
Cath [**2173-2-25**]:
1. Selective coronary angiography demonstrated single vessel
disease.
The RCA had an 80% lesion just proximal to the previously placed
stent.
The LMCA, LAD, and LCX were angiographically normal vessels.
2. Successful PCI of the RCA with a 3.0 x 13 mm Cypher DES
(overlapping with the prior stent).
3. Successful closure of the right femoral arteriotomy site
with a 6
French Angioseal device.
Brief Hospital Course:
1. CAD:
- The patient was admitted at night for aspirin desensitization
in preparation for cath the following day. After admission, he
began to complain of [**9-15**] mid L chest pain radiating to the
shoulder and neck. EKG showed non-specific TW flattening in the
inferior leads. The pt was given SL NTG x 3 without effect,
followed by 2mg morphine without effect, followed by
heparin/integrilin and nitro drips. After several hours, the
pain was reduced. The pt was ruled out for MI by enzymes x 3
sets.
- The pt described this pain on the night of admission as
similar to that at home, but more severe. The following morning
he still described himself as having pain -- his "baseline [**4-15**]
chest pain" that has been present for years. He looked
comfortable.
- The patient was begun on aspirin, plavix, and also maintained
on heparin/integrilin drips overnight. He received pre-cath
hydration with D5W/bicarb.
- Aspirin desensitization was begun with aspirin, ranitidine,
and solumedrol. Given his IVP dye rash history, he received
additional solumedrol, pepcid, and benadryl.
- The pt underwent RCA stent with a cipher drug-coated stent the
morning after admission. He had no further c/o chest pain after
cath and was d/c'ed to home wthout complication.
.
2. Hyperlipidemia: Statin was continued during this
hospitalization.
3. FEN - NPO the night of admission, followed by cardiac healthy
diet.
4. Access - PIV
5. Prophylaxis - Heparin and H2 blocker
Medications on Admission:
Discharge Medications from previous admission several days
prior:
.
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO HS
(at bedtime).
Disp:*60 Tablet(s)* Refills:*2*
3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
Disp:*30 Tablet, Sublingual(s)* Refills:*2*
5. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Medications:
1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
5. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. 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*
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Darvocet-N 100 100-650 mg Tablet Sig: One (1) Tablet PO every
4-6 hours as needed for pain for 6 doses.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Chest pain
Discharge Condition:
Stable and improved
Discharge Instructions:
Please call your doctor or return to the ER if you have any
return of chest pain, difficulty breathing, weakness, or
bleeding.
.
Please take all your medications as directed.
.
Please stop smoking.
Followup Instructions:
Please follow up with your cardiologist Dr. [**Last Name (STitle) **] on Monday,
[**3-1**] at 11am. [**Telephone/Fax (1) 3183**]
|
[
"401.9",
"414.01",
"411.1",
"V07.1",
"272.0",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"36.01",
"88.56",
"36.07",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
7483, 7489
|
4240, 5702
|
290, 336
|
7544, 7565
|
2778, 4217
|
7811, 7943
|
6651, 7460
|
7510, 7523
|
5728, 6628
|
7589, 7788
|
2510, 2759
|
240, 252
|
364, 1696
|
1718, 2099
|
2115, 2495
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,667
| 134,577
|
52371
|
Discharge summary
|
report
|
Admission Date: [**2181-8-26**] Discharge Date: [**2181-8-26**]
Date of Birth: [**2130-8-18**] Sex: F
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 1850**]
Chief Complaint:
asystolic arrest
Major Surgical or Invasive Procedure:
intubation,line placement
History of Present Illness:
Pt is a 51 yo lady w/ unknown PMH (recent hospitalization at [**Hospital3 81552**]) who presented by EMS after asystolic arrest at home. Her
husband was carrying her to her commode and she collapsed on the
toilet. He called EMS, she was given epi and atropine in the
field w/ return of rhythm/pulse, she was intubated, and brought
to the ED. Upon arrival, she was started on triple pressors, she
was noted to have a lactic acidosis with pH <7.0, and a surgical
consult was obtained to assess for mesenteric ischemia. It was
thought she was too sick for surgical intervention. She was
continued on pressors/vent and transferred to the [**Hospital Unit Name **] in grave
condition.
Past Medical History:
unknown
Social History:
married, has autistic son age 21, both present
Family History:
unknown
Physical Exam:
BP 80/p P 100
AC 450 x 16 PEEP 5, fio2 100%
cold, clamped down, unresponsive
sluggish, pinpoint pupils
no pulse on presentation to [**Hospital Unit Name **]
Pertinent Results:
[**2181-8-26**] 02:04AM TYPE-ART PO2-57* PCO2-74* PH-6.87* TOTAL
CO2-15* BASE XS--23
[**2181-8-26**] 12:26AM RATES-/20 TIDAL VOL-450 O2-100 PO2-83*
PCO2-61* PH-6.88* TOTAL CO2-13* BASE XS--24 AADO2-595 REQ O2-94
-ASSIST/CON INTUBATED-INTUBATED
[**2181-8-25**] 11:32PM COMMENTS-GREEN TOP
[**2181-8-25**] 11:32PM GLUCOSE-128* LACTATE-12.6* NA+-136 K+-3.8
CL--101 TCO2-12*
[**2181-8-25**] 11:32PM HGB-10.7* calcHCT-32
[**2181-8-25**] 11:25PM UREA N-52* CREAT-1.6*
[**2181-8-25**] 11:25PM AMYLASE-236*
[**2181-8-25**] 11:25PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2181-8-25**] 11:25PM WBC-38.7* RBC-4.24 HGB-10.6* HCT-35.3* MCV-83
MCH-25.0* MCHC-30.1* RDW-15.9*
[**2181-8-25**] 11:25PM NEUTS-52 BANDS-9* LYMPHS-29 MONOS-4 EOS-1
BASOS-0 ATYPS-2* METAS-3* MYELOS-0 NUC RBCS-1*
[**2181-8-25**] 11:25PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL
OVALOCYT-OCCASIONAL BURR-OCCASIONAL
[**2181-8-25**] 11:25PM PLT COUNT-352
.
head CT: IMPRESSION:
1. No evidence of acute intracranial hemorrhage.
2. Large ventricles which are irregular and this is likely a
chronic finding.
3. Sinus disease as described above.
4. Severe deviation of the nasal septum to the left side.
.
ABD/pelvic CT:
severe coronary calcification, bibasilar patchy opacities, sm
right pleural effusion, multiple gallstones; multiple hypodense
areas in spleen (flow vs infarct?); pancreas is enhancing;
significantly small/large bowel dilation-- "shock bowel" seen
all throughout pelvic and abd views; fracture of right inferior
pubic ramus- old-
Brief Hospital Course:
Patient passed away upon arrival to [**Hospital Unit Name 153**]. She was in PEA arrest,
likely secondary to overwhelming lactic acidosis from mesenteric
ischemia. pt's husband and son were in the waiting room, were
notified immediately, and they requested autopsy (state of MA
declined). Attending made aware.
Medications on Admission:
n/a
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
PEA arrest and death
lactic acidosis
mesenteric ischemia
shock bowel
respiratory failure
asystole
Discharge Condition:
death
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**] MD [**MD Number(2) 1851**]
Completed by:[**2181-8-26**]
|
[
"343.9",
"427.5",
"557.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
3389, 3398
|
2995, 3307
|
313, 340
|
3539, 3546
|
1361, 2382
|
3598, 3748
|
1160, 1169
|
3361, 3366
|
3419, 3518
|
3333, 3338
|
3570, 3575
|
1184, 1342
|
257, 275
|
368, 1049
|
2391, 2972
|
1071, 1080
|
1096, 1144
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,060
| 181,746
|
54743
|
Discharge summary
|
report
|
Admission Date: [**2102-6-10**] Discharge Date: [**2102-6-17**]
Date of Birth: [**2031-1-29**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
Intubation
Upper endoscopy with banding of varices
[**Last Name (un) **] tube placement and removal
History of Present Illness:
71yo male with hep C cirrhosis who presents with hematemesis and
syncope. He is visiting from [**Location (un) 311**], [**Location (un) **], where he
apparently has a hepatologist. He syncopized while trying to
make it to the bathroom at a dinner party. On the scene, BPs
were 124/82. He apparently was out for about 30 seconds, and
when he came to he vomited large amounts of blood all over
himself. He reported dark tarry stools for 2-3 days, but no
bright blood. He reported increased abdominal girth.
He was brought to [**Hospital3 **], where initial vitals were
131/84 115 18 97%. He was not altered, but NG lavage brought
up large amounts of bright red blood that did not clear. Hct
33.7, Plt 216, INR 1.38. He was intubated for airway protection
with etomodate/succ and put on fent/versed. He was started on
octreotide and pantoprazole gtts and given ceftriaxone. He was
then transferred to the [**Hospital1 18**].
In the ED, initial VS were: 94 112/70 20 97% on vent. He was
seen by GI who did an endoscopy and placed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. Hct at
30.9. Given 2 units PRBCs. Vitals prior to transfer were 107/72
80s on CMV with O2 sats of 99%.
On arrival to the MICU, patient is intubated and sedated with
[**Last Name (un) **] in place. Bladder pressure 22
Past Medical History:
- hepatitis C cirrhosis
- arthritis
- hypertension
Social History:
He is originally Nigerian but lives in [**Location 311**]. He is visiting
his nephew for a conference of his clan. He ambulates with a
cane because of leg pain. Per his nephew he drinks only socially
and does not drink daily. He does not smoke or take illicit
drugs.
Family History:
unknown
Physical Exam:
admission exam
Vitals: T: BP: P: R: 18 O2:
General: intubated, sedated
HEENT: Sclera anicteric, PERRL, mask over face securing
[**Last Name (un) **] tube
Neck: supple, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: +BS, distended and protuberant. No palpable fluid wave.
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing or cyanosis.
Trace LE edema bilaterally.
Neuro: PERRL. Unable to follow commands.
.
discharge exam
General: AOx3, appropriate, pleasant
Neck: no JVD
CV: RRR, no m/r/g
Lungs: CTAB, no w/r/r
Abd: +BS, distended and firm but not tender
Ext: trace edema in the shins b/l, 2+ pulses
Pertinent Results:
admission labs
[**2102-6-10**] 03:30AM BLOOD WBC-9.6 RBC-3.28* Hgb-10.4* Hct-30.9*
MCV-94 MCH-31.8 MCHC-33.7 RDW-13.9 Plt Ct-243
[**2102-6-10**] 03:30AM BLOOD PT-15.1* PTT-28.8 INR(PT)-1.4*
[**2102-6-10**] 03:30AM BLOOD Fibrino-152*
[**2102-6-10**] 06:00PM BLOOD Glucose-118* UreaN-23* Creat-1.0 Na-142
K-4.7 Cl-110* HCO3-20* AnGap-17
[**2102-6-10**] 03:30AM BLOOD ALT-45* AST-60* AlkPhos-91 TotBili-0.6
[**2102-6-10**] 03:30AM BLOOD Lipase-24
[**2102-6-10**] 03:30AM BLOOD Albumin-2.7*
[**2102-6-10**] 06:00PM BLOOD Calcium-8.7 Phos-4.6* Mg-2.2
[**2102-6-10**] 03:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2102-6-10**] 07:07AM BLOOD Type-ART Temp-36.7 Rates-16/ PEEP-5
pO2-152* pCO2-40 pH-7.38 calTCO2-25 Base XS-0 -ASSIST/CON
Intubat-INTUBATED
[**2102-6-10**] 03:40AM BLOOD Glucose-136* Na-137 K-5.9* Cl-112*
calHCO3-21
[**2102-6-10**] 03:40AM BLOOD Hgb-10.1* calcHCT-30
[**2102-6-10**] 07:07AM BLOOD freeCa-1.10*
.
discharge labs
[**2102-6-17**] 05:05AM BLOOD WBC-8.1 RBC-3.29* Hgb-10.0* Hct-30.5*
MCV-93 MCH-30.6 MCHC-32.9 RDW-13.8 Plt Ct-242
[**2102-6-17**] 05:05AM BLOOD PT-13.2* PTT-30.1 INR(PT)-1.2*
[**2102-6-17**] 05:05AM BLOOD Glucose-76 UreaN-11 Creat-0.8 Na-138
K-3.6 Cl-105 HCO3-24 AnGap-13
[**2102-6-17**] 05:05AM BLOOD ALT-48* AST-67* AlkPhos-113 TotBili-1.0
[**2102-6-17**] 05:05AM BLOOD Calcium-7.9* Phos-2.4* Mg-2.2
[**2102-6-13**] 03:15PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2102-6-12**] 11:00AM BLOOD AFP-126.1*
[**2102-6-10**] 03:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2102-6-13**] 03:15PM BLOOD HCV Ab-POSITIVE*
HCV VIRAL LOAD (Final [**2102-6-14**]):
1,630,663 IU/mL.
.
MICRO
urine culture - no growth
blood culture [**6-12**] and [**6-13**] - no growth
peritoneal culture
GRAM STAIN (Final [**2102-6-13**]):
Reported to and read back by [**First Name8 (NamePattern2) 1037**] [**Last Name (NamePattern1) **] @ 7PM [**2102-6-13**] .
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
FLUID CULTURE (Preliminary):
[**Female First Name (un) **] ALBICANS. SPARSE GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH.
ANAEROBIC CULTURE (Final [**2102-6-17**]): NO ANAEROBES ISOLATED.
peritoneal culture
GRAM STAIN (Final [**2102-6-14**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2102-6-17**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
.
IMAGING
CXR:
1. Endotracheal tube with its tip less than 1 cm from the level
of the
carina, suggest repositioning.
2. Low lung volumes, and cardiomegaly, with bibasilar
atelectasis.
.
EGD
Findings: Esophagus:
Protruding Lesions 5 cords of grade III varices were seen in
the lower third of the esophagus. The varices were not bleeding.
4 bands were successfully placed.
Stomach:
Mucosa: Diffuse continuous granularity, erythema and mosaic
appearance of the mucosa were noted in the whole stomach. These
findings are compatible with Portal hypertensive gastropathy.
Despite pre-EGD erythromycin and multiple attempts at suctioning
the clot, fundus could not be completely visualized. But no
gastroesophageal varices noted near GE junction.
Duodenum: Not examined.
.
KUB
There has been placement of a large caliber tube in the stomach
with a balloon in the region of the body of the stomach. The
distal tip is in the stomach antrum. There are several
non-dilated loops of air-filled small bowel. There is air seen
in the colon. No free intra-abdominal gas is present.
.
CT abdomen and pelvis
1. Liver demonstrates lobulated contour, compatible with
patient's known
history of underlying cirrhosis. Portal vein is thrombosed.
The thrombus extends into the right and left portal veins. There
is possible enhancement of the thrombus, suggestive of tumor
thrombus. The distal left portal vein is opacified. The liver
is of heterogeneous enhancement. Multiple hepatic hypodensities
are present. Ill-defined areas of hypodensities in the liver
may represent infarction or infection in the appropriate
clinical setting.
2. Large amount of ascites.
3. Bowel wall edema of the cecum and ascending colon may
reflect third
spacing, infectious, inflammatory, or ischemic causes.
4. Small bibasilar consolidations, likely atelectasis,
infection or
aspiration.
.
CXR:
The tip of the endotracheal tube has been pulled back and the
tip
is now 3 cm above the carina. There is again seen a left-sided
PICC line with its lead tip in the proximal SVC perpendicular to
SVC wall. There are no pneumothoraces. The heart size is
within normal limits. There is some atelectasis and low lung
volumes at the lung bases. There are likely small bilateral
pleural effusions.
.
Brief Hospital Course:
71yo male with hepatitis C cirrhosis who presented with acute
variceal bleed initially requiring intubation and [**Last Name (un) **]
placement that has since resolved.
.
# Variceal bleed: Presented with hematemesis and initial EGD
was without a clear lesion for intervention but suspected to be
a variceal bleed. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] tube was placed and subsequently
removed once patient stabilized. Repeat EGD showed 5 cords of
grade III varices in the lower third of the esophagus and 4
bands were successfully placed. Patient was transfused a total
of 2 units of PRBCs and since then blood counts remained stable
and he has had no further melena. A CT abdomen and pelvis showed
a portal vein thrombus, and therefore was determined not to be a
TIPS candidate. Patient was started on pantoprazole and
octreotide drips. Pantoprazole was changed to IV BID and
octreotide was continued for 72 hours. He also completed a
course of ceftriaxone for 5 days. Nadolol, oral proton-pump
inhibitor, and sucralafate were started for prophylaxis and
treatment of his recent bleed.
# Abdominal distension: Patient markedly distended on exam. He
was insufflated with quite a bit of air during his endoscopy
with rising bladder pressures, relieved by placement of rectal
tube and decompression of abdominal gas. Bladder pressures
trended down, urine output improved, and abdominal exam
clinically improved. Patient spiked a fever during his stay and
diagnostic paracentesis initially grew coag-negative staph and
[**Female First Name (un) **] albicans. Repeat CT was performed which showed no signs
of perforation so patient was empirically started on fluconazole
for a total of seven days and zosyn for 48 hours. Therapeutic
paracentesis the following day revealed only small pockets of
fluid. 700cc of fluid was drained and this fluid was negative
for any organisms suggesting earlier sample was contaminated.
Patient remained afebrile and without leukocytosis for the
remainder of his stay. His belly remained distended but this was
felt to be potentially more related to tumor burden (see below)
rather than ascites so he was not started on diuretics. Despite
low suspicion for infection, he will continue fluconazole for a
seven day course. He was started on oxycodone for his
discomfort.
# Hep C cirrhosis complicated by ascites and esophageal varices.
Hep C viral load was 1.6 million and Hepatitis B serologies were
negative. Once variceal bleed stabilized, patient was started on
nadolol for prophylaxis. Given no history of encephalopathy or
spontaneous bacterial peritonitis, ciprofloxacin, lactulose and
rifaxamin were not initiated at this time.
# Possible hepatocellular carcinoma - Patient had CT scan which
revealed multiple irregular hepatic hypodensities and portal
vein thrombosis, likely from associated tumor. AFP was elevated
to 126.1. Patient will require further imaging with MRI/MRCP and
discussion of possible treatment of his likely hepatocellular
carcinoma
# s/p intubation: Patient intubated at outside hospital for
airway protection in the setting of GI bleed. When HCTs
stabilized, sedation was stopped and the patient was
successfully extubated.
# Hypertension: He was transitioned to nadolol and his blood
pressures remained well-controlled. His amlodipine was held at
discharge as he was normotensive.
TRANSITIONAL ISSUES
- Further workup and management of his hepatocellular carcinoma
will need to occur in [**Location (un) **]
- Consider initiating diuretics if required for volume
overload/blood pressure control
- Fluconazole course will end on [**6-20**] and sucralafate will end
on [**6-25**]
- The hepatology attending on service was [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD whose
telephone number is [**Telephone/Fax (1) 111934**] and address is [**Location (un) **] [**Location (un) 86**], [**Numeric Identifier 718**]
Medications on Admission:
- amlodipine 10mg daily
- atenolol 100mg daily
Discharge Medications:
1. Fluconazole 400 mg PO Q24H Start: [**2102-6-14**]
RX *Diflucan 200 mg daily Disp #*6 Tablet Refills:*0
2. Nadolol 40 mg PO DAILY
Hold for SBP < 100 or HR < 60
RX *nadolol 40 mg daily Disp #*30 Tablet Refills:*0
3. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
Hold for sedation, RR<12
RX *oxycodone 5 mg every six hours Disp #*20 Capsule Refills:*0
4. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram/10 mL four times a day Disp #*32
Milliliter Refills:*0
5. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg twice a day Disp #*60 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
HCV Cirrhosis
Variceal bleed
.
Secondary
HTN
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 111935**],
You were admitted to the hospital after vomiting blood and
losing consciousness. You had a breathing tube placed to protect
your lungs as we controlled the bleeding. We found that the
bleeding was coming from the esophagus and the stomach and we
controlled the bleeding with banding of the blood vessels.
We also performed a CT scan that showed some fluid in your
abdomen and areas of the liver concerning for liver cancer. We
removed a small amount of this fluid from your abdomen to make
you more comfortable.
Once you are home, you will need a repeat endoscopy in three
weeks to make sure the bleed is healing and an MRI of the liver
to rule out cancer.
Followup Instructions:
Please follow-up with your gastroenterologist in [**Location (un) **] once
you arrive home. You will need to discuss further treatment for
your possible liver cancer as well as repeat endoscopy to
evaluate the the blood vessels in your GI tract.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]
|
[
"456.8",
"456.20",
"112.89",
"401.9",
"571.5",
"285.1",
"780.2",
"155.0",
"276.7",
"276.8",
"537.89",
"041.19",
"785.0",
"070.54",
"716.90",
"789.59",
"452",
"532.90",
"572.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"54.91",
"96.71",
"42.33"
] |
icd9pcs
|
[
[
[]
]
] |
12446, 12452
|
7860, 11773
|
313, 415
|
12549, 12549
|
2908, 5026
|
13453, 13810
|
2138, 2147
|
11871, 12423
|
12473, 12528
|
11799, 11848
|
12732, 13430
|
2162, 2889
|
5548, 7837
|
265, 275
|
443, 1761
|
5500, 5515
|
12564, 12708
|
1783, 1837
|
1853, 2122
|
5061, 5464
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,538
| 154,346
|
35186
|
Discharge summary
|
report
|
Admission Date: [**2160-3-31**] Discharge Date: [**2160-4-11**]
Date of Birth: [**2089-12-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Anemia
Multiple pulmonary nodules, sputum culture [**2160-3-12**] positive for
AFB
Major Surgical or Invasive Procedure:
CT guided biopsy, abdominal mass, gallbladder fossa
Esophagogastroduodenoscopy
History of Present Illness:
70yo Korean-speaking male with history of peri-ambullary
pancreatic cancer s/p resection [**10-27**] (Dr [**Last Name (STitle) 468**] recently
admitted [**Date range (1) 46889**] with symptomatic anemia attributed to
probable chronic GI blood loss. CT torso [**3-11**] notable for
multiple bilateral pulmonary nodules, including cavitary lesions
involving RUL/LLL, multiple hypoattenuating liver lesions
enlarged since [**10-27**], increased dilation of the visualized
pancreatic duct; these findings were considered highly
suspicious of metastatic pancreatic cancer. Testing for
potential infectious etiologies included sputum for AFB,
beta-glucan, and galactomannen returned negative; however on [**3-24**]
HMED service notified that sputum cultures had returned positive
for AFB.
As arranged by Dr [**Last Name (STitle) **] on [**3-17**], pt underwent CT-guided biopsy
of a soft-tissue mass in the gallbladder fossa earlier today,
without reported complication. He received 1 unit PRBC after a
baseline HCT returned at 19.7. Arrives on the floor in stable
condition.
Interviewed via telephonic Korean interpreter. Currently denies
pain or significant discomfort. Reports recent "black" stools,
though (?)partially formed. Describes mild nausea without
vomiting earlier today, now resolved. Has had intermittent
periumbilical discomfort over last several days. Has been
eating frequent small meals, endorses early satiety. Notes
dyspnea on exertion associated with mild light-headedness,
brought on by activity such as taking a shower, but denies
similar symptoms at rest. Endorses mild cough with scant
"mucous" production. Denies recent fever, chills, lymph node
swelling, or weight loss.
Review of systems otherwise negative in detail: denies headache,
visual change, speech difficulties, sore throat, chest pain,
palpitations, dysuria, focal numbness or weakness. Has chronic
left lower extremity discomfort s/p fall and injury in [**2137**].
Past Medical History:
1. Hypertension
2. Hypercholesterolemia
3. Papillary adenocarcinoma of ampulla of Vater, s/p
transduodenal ampullary resection with reimplantation of
pancreatic and biliary ducts and open cholecystectomy with open
common bile duct exploration on [**2158-11-9**]
4. Osteoarthritis
5. H/o rib fracture
6. Remote injury to left lower leg s/p fall in [**2137**]
Social History:
Korean speaking. Non smoker, No Drug use, No alcohol. Lives with
wife in [**Name (NI) 3844**]. Both son and daughter live in [**State 531**]
City: Son [**Known lastname 80295**] [**Telephone/Fax (1) 80296**] (cell); daughter [**Name (NI) **]
[**Telephone/Fax (1) 80297**] (cell).
Family History:
Non-contributory.
Physical Exam:
T:98 / BP:122/70 / HR:98 / RR:18 / O2 sat: 97%RA
GEN: Awake, alert, in NAD
HEENT: Conjunctival pallor, anicteric sclerae, dry mucous
membranes
NECK: No JVP.
CHEST: Crackles at left base, resonant to percussion throughout.
No wheezes.
COR: S1 S2 RRR with I/VI systolic ejection murmur audible at
base.
ABD: Well-healed RUQ surgical scar. Palpable midline epigastric
mass, non-tender. Normal active bowel sounds.
EXT: Lidocaine patches applied to left lower leg. No clubbing,
cyanosis, or edema.
SKIN: No rash.
LYMPH: No cervical, supraclavicular, axillary, or inguinal
lymphadenopathy.
NEURO: Speaking fluently in Korean with telephonic interpreter.
Motor testing [**4-23**] throughout in deltoids, biceps, triceps,
iliopsoas, quadriceps, hamstrings, ankle flexors/extensors
bilaterally. Face appears symmetric. No asterixis. No
pronator drift.
Pertinent Results:
[**2160-3-31**] 09:00AM WBC-6.4 RBC-2.56*# HGB-5.4*# HCT-19.7*#
MCV-77* MCH-21.0* MCHC-27.4* RDW-23.1*
[**2160-3-31**] 09:00AM PLT COUNT-298
.
CT CHEST [**2160-3-11**]:
IMPRESSION:
1. No pulmonary embolism or aortic dissection.
2. However, multiple bilateral pulmonary nodules, with the
largest in the left lower lobe measuring 2.2 x 1.5 cm. Given
history of pancreatic cancer, findings are most likely due to
metastatic disease. Cavitating nodules within the right lobe may
also represent metastatic disease, although infectious
etiologies remain in the differential.
3. Multiple hypoattenuating lesions within the liver which are
increased in size since the previous study of [**2158-10-21**].
This is consistent with progression of metastatic disease.
Increased dilation of the visualized portion of the pancreatic
duct.
.
CT ABD/Pelvis [**2160-3-13**] (without contrast):
IMPRESSION:
1. Pulmonary nodules,(new since [**2158-11-6**]) are better evaluated
on CT chest performed 2 days prior. They are all metastatic
disease until proven otherwise.
2. Several hypodense liver lesions, some of which are new since
[**2158-11-6**], likley represent benign lesions such as cysts and
hemangiomas.
3. Enhancing soft tissue denisty lesion in the gallbladder fossa
and omental nodule are concerning for metastases.
The lesions are amenable to CT guided biopsy
.
CT Head:
FINDINGS: There is no acute hemorrhage, large areas of edema,
large masses or mass effect. The ventricles and sulci are normal
in size and configuration given the patient's age. There is
preservation of [**Doctor Last Name 352**]-white matter differentiation. There is no
evidence of an acute vascular territorial infarct.
Periventricular white matter hypodensities are likely due to
chronic small vessel ischemic changes. A small area of
hypodensity within the right basal ganglia is likely due from
prior lacunar infarct. Visualized paranasal sinuses are clear.
The left mastoid air cells are under-pneumatized and partially
opacified. The right mastoid air cells are clear. Soft tissues
of the orbits and nasopharynx are within normal limits.
IMPRESSION: No acute intracranial process.
.
EGD:
A 2.5 cm mass was found at the area of the papilla.
The lesion appeared malignant and had neovascularization visible
on its surface.
There was fresh blood and clots in the area but no definitive
active bleeding.
Otherwise normal EGD to second part of the duodenum
.
[**2160-4-11**] 06:00AM BLOOD WBC-4.1 RBC-3.83* Hgb-8.4* Hct-29.5*
MCV-77* MCH-21.8* MCHC-28.4* RDW-18.7* Plt Ct-270
[**2160-4-10**] 06:05AM BLOOD Glucose-94 UreaN-27* Creat-0.7 Na-136
K-4.1 Cl-102 HCO3-27 AnGap-11
[**2160-4-9**] 06:45AM BLOOD ALT-12 AST-13 AlkPhos-70 TotBili-0.5
[**2160-4-6**] 06:45AM BLOOD Calcium-8.3* Phos-3.0 Mg-2.1
[**2160-4-2**] 06:30AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2160-4-2**] 06:30AM BLOOD HIV Ab-NEGATIVE
[**2160-4-2**] 06:30AM BLOOD HCV Ab-NEGATIVE
.
Sputum, blood cx negative
Blasto, B Glucan, , Aspergillus, Histo, Quantiferon negative
Brief Hospital Course:
70M korean speaking, h/o peri-ampular pancreatic ca s/p
resection [**10-27**], presenting with recently symptomatic anemia
concerning for GIB, cavitary pulmnonary lesions with AFB+
culture, admitted after elective CT guided biopsy with acute HCT
drop.
.
.
# hypoxia / bradycardia / WCT - on [**2160-4-4**] PM, pt transferred to
ICU in setting of hypoxia, bradycardia during EGD. per
anesthesia, he received atropine for HR 30s, was never
pulseless, though SBP 50s, requiring neo, with subsequent HR
high 100s, and SBP 180s, with ?WCT requiring esmolol. Upon
arrival to the ICU, patient had largely recovered. The event
was attributed to hypoxia in the setting of a brief aspiration
event. He suffered no further events in house and was
transferred to the medical floor in stable condition.
.
# acute blood loss anemia/GI Bleed - He received 2U PRBCs on the
evening of admission with appropriate bump 19->25 [**3-31**]. he was
started on iv ppi, stool guaic was positive, but not grossly
melenic. 2 PIVs were maintained, T&S placed. On [**2160-4-4**], pt
underwent EGD after 3rd AFB smear was negative for TB, which
revealed a papillary mass with clotted blood. The bleeding was
presumed to be due to a small bleeding vessel related to his
malignancy. After evaluation by GI, surgery, and interventional
radiology, they deemed that IR guided embolization should be
attempted if the patient bleeds again. On the floor, his Hct
remained stable at 28 and was maintained on a PPI [**Hospital1 **].
.
# AFB positive sputum culture / pulmonary nodules - concerning
for mTB. on admission, discussed with state lab ([**Telephone/Fax (1) 80301**]),
no culture data yet, received sample [**2160-3-25**], AFB smear was
positive.
.
ID service consulted, pt placed on isolation precautions,
infection control made aware. 3 repeat AFB sputums obtained,
which were ultimately negative. pt denies f/c/ns/weight loss,
however given concern for mTB, he was empirically started on 4
drug therapy on [**2160-4-2**]. HIV negative. hepatitis serologies
unremarkable (hepB sAB positive). LFTs unremarkable.
.
pt seen by opthalmology, with no evidence of color compromise,
and recommendation for once monthly oupt f/u in [**Hospital 2081**] clinic
while on TB meds to monitor vision.
.
on [**2160-4-4**], pt AFB negative x3 smears, therefore isolation
precautions discontinued. his PCP was called on [**2160-4-4**] and
updated regarding hospitalization. per ID, state lab returned
negative mTB probe x1 on culture, though not finalized. given
concern that pulmonary nodules likely do not represent TB,
concern raised for other etiologies, particularly in light
likely future chemotherapy for malignancy.
.
as such, serum sent for crptococcal ag, glucan, galactomanna,
blasto, fungal cultures, and urine for histoplasma, which were
negative. consideration given to possible CT guided biopsy of
lung lesions to confirm malignancy before therapy. after
discussion with his oncologist, this was felt not necessary from
an oncologic perpsective, but would be deferred to ID.
.
His WBC dropped and his mTB regimen was stopped. On [**2160-4-11**] the
state lab reported the swab as MAC, effectively ruling out TB.
However, this will need to be confirmed with DPH prior to
travel.
.
# Hypertension, benign - continued metoprolol.
.
# h/o Atrial tachycardia - during last admission, no recurrence.
continued metoprolol as above.
.
# h/o ampullary cancer / liver nodules / pulmonary nodules -
pathology of gallbladder fossa c/w recurrence of adenocarcinoma
(pt and son [**Name (NI) **] aware). Seen by Dr. [**Last Name (STitle) **] who felt
chemotherapy should be considered once medicallly stable
.
as above, if pulmonary nodules not mTB, may need to consider
other etiologies, particularly given likely plan for chemo per
ID. appreciate ID input, added glucan, galactomannan, histo,
blasto, crypto, fungal cultures to testing, which were negative.
will hold off on additional testing until mTB probe testing
done, if negative, may need bronch/ct guided biopsy of pulmonary
nodules. Given the swab returned as MAC, treatment for this
should be considered prior to initiation of chemotherapy.
.
# hyperbilirubinemia - no RUQ TTP, s/p GB fossa biopsy, no
fever, no other evidence of cholangitis prsently.
- trend LFTs on TB medications, which remained stable.
.
# COMM - [**Doctor First Name **] [**Telephone/Fax (1) **], korean translator 2-0050.
.
TO DO:
- Oncology evaluation for metastatic ampullary cancer
- Check CBC to ensure stability of Hct. If has recurrent GI
bleed must consider INR embolization for bleeding vessel near
ampullary cancer
- Has MAC infection confirmed by MA state lab, NOT mTB.
Sensitivities should be checked but will take sometime.
Consider treatment prior to chemotherapy
- Can call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], ID fellow at [**Hospital1 18**] with any questions
regarding this
([**Telephone/Fax (1) 4170**]
- continue medications
Medications on Admission:
Medications on Admission
Per Medication Reconciliation signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 496**]
[**2160-3-31**]:
1. Metoprolol extended release 25 daily
2. Omeprazole 20 daily
3. Ascorbic Acid 500 daily
4. Colace 100 daily
5. Iron 325 daily
6. Folate 0.4 daily
7. Senna 1 [**Hospital1 **] prn constipation
Discharge Medications:
1. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
8. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic Adenocarcinoma, presumed ampullary cancer
Acute blood loss anemia/GI bleed
Pulmonary lung nodules
MAC infection
Atrial Tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for a biopsy of an abdominal mass near the
gallbladder. As we discussed, this was found to be
Adenocarcinoma, most likely from the ampullary cancer you had
before.
.
You were also found to have anemia and given blood transfusion.
Endoscopy was performed which showed the cause of your anemia as
gastrointestinal from a small vessel, which may be related to
your canncer. This was treated with acid blocking medication
and resolved on its own.
.
You were also found to have lung nodules, either from infection,
bacteria, or due to cancer. After review by the state lab and
DPH, you were found NOT to have tuberculosis. The culture grew
MAC, which may require treatment prior to chemotherapy. Discuss
this with your doctors [**First Name8 (NamePattern2) **] [**Last Name (Titles) 7349**].
.
For your cancer you will need to see an oncologist as soon as
possible to consider treatment. For your bleed you must take an
acid blocker twice daily and monitor for signs of bleeding. For
your noduless we recommend oncology and infectious disease
follow up.
- the culture grew MAC. Please discuss this with your doctor [**First Name (Titles) **] [**Location (un) 80302**].
Medication Changes:
1. prilosec increased to 40mg twice daily
2. iron supplement
Followup Instructions:
you will need to see an Oncologist as soon as possible to
discuss treatment of your cancer.
.
you will need to see an Infectious Disease doctor as soon as
possible to discuss your lung nodules and potential infection
with MAC and need for treatment
|
[
"197.8",
"427.89",
"285.1",
"799.02",
"578.9",
"272.4",
"518.89",
"V10.09",
"458.29",
"031.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.24",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
13462, 13468
|
7122, 12114
|
400, 481
|
13654, 13654
|
4075, 5435
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15101, 15353
|
3170, 3189
|
12508, 13439
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13489, 13633
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12140, 12485
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13805, 14996
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3204, 4056
|
15016, 15078
|
278, 362
|
509, 2475
|
5444, 7099
|
13669, 13781
|
2497, 2856
|
2872, 3154
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,774
| 195,775
|
42284
|
Discharge summary
|
report
|
Admission Date: [**2139-8-10**] Discharge Date: [**2139-8-14**]
Date of Birth: [**2073-9-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
NSAIDS / Pravachol
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Unstable angina
Major Surgical or Invasive Procedure:
Aortic valve replacement, 25-mm Biocor Epic tissue valve [**2139-8-10**]
History of Present Illness:
History of Present Illness: This is a 65 year old male with
history of coronary artery disease and aortic stenosis, recently
complaining of worsening dyspnea on exertion. He has been
followed with serial echocardiograms, with the most recent
echocardiogram revealing severe aortic stenosis(previously
estimated at moderate). Currently, patient is experiencing chest
pain and dyspnea at rest along with excessive fatigue and one
pillow orthopnea. His routine ADL's are severely limited by
dyspnea. He denies history of syncope but has experienced
presyncopal episodes in the past. His chest pain will
occasionally radiate to his left arm and neck. Chest pain
usually subsides with prolonged rest. He will be admitted
directly to [**Wardname 5010**] from our outpatient clinic with unstable
angina and undergo further evaluation prior to surgical
intervention
Past Medical History:
- Coronary artery disease - s/p PCI/stenting [**2124**], [**2135**](records
unavailable at this time)
- History of MI [**2124**], [**2135**]
- Aortic stenosis
- Hypercholesterolemia
- COPD
- Carotid Disease
- Obesity
- History of Paroxysmal Atrial Fibrillation(no longer on
Warfarin)
- History of Asthma, Bronchitis(much improved with Advair)
- Sleep Apnea, uses CPAP
- Hypogonadism
- Benign prostatic hypertrophy
- History of Renal Calculi
- Depression
- Sciatica
- L5 fracture [**2135**]
- CS with radiculopathy
- Degenerative Arthritis
Social History:
Lives with: Wife
Occupation: Disabled school bus driver
Cigarettes: Smoked no [] yes [x] last cigarette [**2132**]
Admits to approximate 20 PYH
ETOH: < 1 drink/week [X] [**12-22**] drinks/week [] >8 drinks/week []
Illicit drug use: Denies
Family History:
Father underwent CABG. Son with aortic stenosis.
Physical Exam:
Pulse: 60 Resp: 18 O2 sat: 99% room air
B/P Right: 151/81 Left: 145/75
Height: 66" Weight: 224 lbs
General: Obese male, appears very short of breath
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x] decreased at bases
Heart: RRR [x] Irregular [] Murmur [] grade 4/6 SEM
Abdomen: Soft [x] ND [x] NT [x] bowel sounds + [x]
Extremities: Warm [x], well-perfused [x]
Edema: trace
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: 1 Left: 1
Carotid Bruit: transmitted murmurs bilaterally L>R
Pertinent Results:
[**2139-8-13**] 05:04AM BLOOD WBC-11.6* RBC-3.72* Hgb-11.3* Hct-31.5*
MCV-85 MCH-30.2 MCHC-35.7* RDW-14.9 Plt Ct-148*
[**2139-8-11**] 02:01AM BLOOD PT-12.0 PTT-26.8 INR(PT)-1.0
[**2139-8-13**] 05:04AM BLOOD Glucose-106* UreaN-18 Creat-0.7 Na-139
K-3.9 Cl-101 HCO3-29 AnGap-13
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2139-8-12**] 10:45 AM
CHEST PORT. LINE PLACEMENT Clip # [**Clip Number (Radiology) 91637**]
Reason: Pt. had a left sided picc line placed,55cm please [**Doctor First Name **]
at
Final Report
CLINICAL HISTORY: 65-year-old man with PICC.
COMPARISON: [**2139-8-10**].
FINDINGS: In comparison to prior examination, the Swan-Ganz
catheter has been
removed. A right-sided IJ is incompletely visualized and seen
terminating
likely in the internal jugular. Left-sided PICC line is new with
its tip 2 cm
from the distal SVC. However, this is difficult to visualize on
this patient.
The lung volumes are extremely low. Cardiomediastinal silhouette
is enlarged
and unchanged. Endotracheal tube has been removed. Bilateral
pleural
effusions are once again seen, along with bilateral atelectasis.
There is
worsening mild pulmonary edema.
The study and the report were reviewed by the staff radiologist.
DR. [**Last Name (STitle) 91638**] [**Name (STitle) **]
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
Approved: WED [**2139-8-12**] 3:34 PM
Brief Hospital Course:
This 65 year old male was admitted on [**8-10**] and underwent aortic
valve replacement with a 25mm St. [**Male First Name (un) 923**] tissue valve. He
tolerated the procedure well and had a cross clamp time of 61
mins and total bypass time of 82 mins. He was transferred to
the CVICU on Neo and Propofol and remained intubated overnight
because he was a difficult intubation. He was extubated early
the next morning and required aggressive respiratory therapy and
diuresis that day. POD#2 his epicardial pacing wires and chest
tubes were discontinued and he was transferred to the floor.He
has hx of PAF and had episodes of intermittent afib
postoperatvely. He was not on coumadin however pre-operatively
and it was started this admission.He will have his coumadin
managed by his cardiologist once discharged from rehab. He
continued to progress and was discharged to rehab on POD#4 in
stable condition to [**Hospital **] nursing and rehab at [**Hospital1 756**]
[**Location (un) 5028**]. Of note the Patinet was found to have 70-79% right
carotid stenosis and 48-49% left carotid stenosis. He was
cleared for surgery and vascular service recommened that he have
f/u cartid ultrasound in 6 months. He was also seen by Dr [**First Name8 (NamePattern2) 2808**]
[**Last Name (NamePattern1) 91639**] from neurology for evaluation of intermittent tingling of
left upper extremity. It was found to be related to a
radiculopathy given his history of cervical spine injury and
recommmended that he follow-up with her as an outpatient.
Medications on Admission:
-Buproprion 100mg daily
-Diltiazem Hydrochloride CD 360mg daily
-Simvastatin 40 mg daily
-Trazadone 50mg daily
-Adviar diskus 250-50mcg [**Hospital1 **]
-Montelukast 10mg daily
-Aspirin 81mg daily
-Tamsulosin 0.4mg daily
-Calcium and Vitamin D daily
-Omeprazole 20mg daily
-Testim 50mg/5gram daily
-Vitamin B daily
-Magnesium oxide 420mg daily
-Potassium chloride 10mEq daily
-Zinc daily
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 756**] Manor Nursing & Rehab Center - [**Location (un) 5028**]
Discharge Diagnosis:
- Coronary artery disease - s/p PTCA [**2124**], PCI/stenting in
[**2135**](taxus stent to OM3)
- History of MI [**2124**], [**2135**]
- Aortic stenosis
- Hypercholesterolemia
- COPD
- Carotid Disease
- Obesity
- History of Paroxysmal Atrial Fibrillation(no longer on
Warfarin)
- History of Asthma, Bronchitis(much improved with Advair)
- Sleep Apnea, uses CPAP
- Hypogonadism
- Benign prostatic hypertrophy
- History of Renal Calculi
- Depression
- Sciatica
- L5 fracture [**2135**]
- CS with radiculopathy
- Degenerative Arthritis
- s/p Right and Left TKR's
- s/p Appendectomy
Discharge Condition:
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. 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: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2139-9-16**] 1:00
Cardiologist: Dr. [**Last Name (STitle) 91640**] [**9-8**]@ 10:15 AM
Please call to schedule appointments with your
Primary Care: Dr. [**Last Name (STitle) 13517**] in [**2-17**] weeks
Neurologist: [**First Name8 (NamePattern2) 2808**] [**Last Name (NamePattern1) 1726**] [**Telephone/Fax (1) 31415**] in [**12-18**] weeks
Vascular surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 1241**] in 6 months -**also
have carotid ultrasound scheduled prior to this appointment**
**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:[**2139-8-14**]
|
[
"723.0",
"424.1",
"715.90",
"257.2",
"327.23",
"V13.01",
"278.00",
"272.0",
"433.30",
"311",
"V15.51",
"600.00",
"V45.82",
"V85.36",
"412",
"414.01",
"427.31",
"493.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"38.93",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
6315, 6417
|
4341, 5876
|
301, 376
|
7061, 7273
|
2879, 4318
|
8114, 8959
|
2099, 2149
|
6438, 7019
|
5902, 6292
|
7297, 8091
|
2164, 2860
|
246, 263
|
432, 1263
|
1285, 1826
|
1842, 2083
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,444
| 199,714
|
16401+16402
|
Discharge summary
|
report+report
|
Admission Date: [**2128-2-1**] Discharge Date: [**2128-2-13**]
Date of Birth: [**2058-9-3**] Sex: M
Service:
HOSPITAL COURSE: Mr. [**Known lastname 5110**] was admitted from the outside
hospital on the [**3-4**] after an extended stay there
for congestive heart failure and respiratory failure with
possibly concurrent septic physiology, he was admitted
directly to the Cardiac Intensive Care Unit, where we
aggressively diuresed him, and ultrafiltered him without any
improvement in his respiratory status. In addition, we
treated him for sepsis with Kefzol and levofloxacin, and we
supported his blood pressure with Levophed and intra-aortic
balloon pump.
He received two cardiac catheterizations and had his right
coronary artery and left anterior descending artery stented
without improvement clinically in his hypoxemia. Following
11 days in the Cardiac Intensive Care Unit with no
improvement, the patient's clinical course, the family
decided to withdraw care. The patient was weaned from his
ventilator on the afternoon of [**2128-2-13**], and he died
within 10 minutes of turning off the ventilator.
DIAGNOSES:
1. Cardiogenic shock.
2. Sepsis.
3. Hypoxemic respiratory failure.
4. Renal failure.
5. Staphylococcal bacteremia.
6. Anemia.
7. Insulin dependent-diabetes mellitus.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**]
Dictated By:[**Last Name (NamePattern1) 11801**]
MEDQUIST36
D: [**2128-2-14**] 12:40
T: [**2128-2-17**] 05:35
JOB#: [**Job Number 46660**]
Admission Date: [**2128-2-1**] Discharge Date: [**2128-2-13**]
Date of Birth: [**2058-9-3**] Sex: M
Service: CARDIAC ICU
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 5110**] is a 69 year-old
gentleman with a complicated past medical history who was
transferred from an outside hospital for persistent
respiratory failure and pulmonary edema. In addition he had
staph aureus bacteremia and possible aortic valve endocarditis.
During his hospitalization he underwent cardiac catheterization
twice with stent placement in multiple coronary arteries and was
aggressively diuresed. A transesopageal echocardiogram
demonstrated no evidence of endocarditis. He was
continued on IV antibiotics for bacteremia of unclear
source. However, his pulmonary edema failed to resolve and on
[**2-13**] his family decided that they would like to make the
patient DNR to withdraw all supportive care except for comfort
measures. On [**2-13**] the ventilator was changed to CPAP and
the patient was administered morphine sulfate intravenously and
he passed away around 3:00 p.m. on [**2128-2-13**] from
respiratory failure. Consent for an autopsy was obtained.
[**First Name4 (NamePattern1) 610**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3812**]
Dictated By:[**Last Name (NamePattern1) 17270**]
MEDQUIST36
D: [**2128-3-26**] 08:38
T: [**2128-3-26**] 12:58
JOB#: [**Job Number **]
|
[
"414.01",
"496",
"785.51",
"428.0",
"518.81",
"038.11",
"424.1",
"410.71",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"34.91",
"36.06",
"88.55",
"99.20",
"88.52",
"36.01",
"37.22",
"89.64",
"00.13",
"37.61"
] |
icd9pcs
|
[
[
[]
]
] |
143, 1740
|
1769, 3047
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,818
| 199,199
|
8514
|
Discharge summary
|
report
|
Admission Date: [**2192-7-30**] Discharge Date: [**2192-8-2**]
Date of Birth: [**2155-12-1**] Sex: F
Service: MEDICINE
Allergies:
Levofloxacin / Iodine; Iodine Containing / Betadine / Percocet /
Morphine
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Respiratory Failure
Major Surgical or Invasive Procedure:
Brochoscopy
History of Present Illness:
36 year-old woman with history of HIV/AIDS (CD4=56) on HAART and
PCP/MAC prophylaxis), metastatic squamous and adenocarcinoma of
the lung (on tarceva) with brain mets and chronic malignant
effusion status post right bronchial stenting [**7-3**], recently
discharged from [**Hospital1 18**] after an admission for pneumonia who
presents from an outside hospital for acute onset shortness of
breath. On arrival to the ED, patient reported worsening
dyspnea and pleuritic chest pain for several days prior to
presenting to the outside hospital, as well as pleuritic left
sided chest pain. Subsequently, the patient was intubated for
respiratory distress. History was limited given the patient was
intubated at the time of evaluation, but she denies chills,
headache, diarrhea, nausea/vomiting, photophobia, or abdominal
pain. She reports progressive dyspnea, worse with exertion,
fever to 101, and cough productive of yellow sputum. She
reports back and neck pain, which is chronic. She reports
compliance with all of her medications, including her HAART and
bactrim/azithro. Patient was slightly hypotensive after
intubation and improved when sedation was weaned.
.
During her last admission for pneumonia in [**2192-6-29**], she was
initially treated with Ceftriaxone and Flagyl, and later
transitioned to Augmentin at the time of discharge. She
underwent thoracentesis, which revealed an exudative effusion
with cells consistent with metastatic adenocarcinoma. Pleural
fluid was culture negative. There was no lung re-expansion so
pleurex catheter was placed. She also underwent bronchoscopy
which revealed complete right main bronchus obstruction, so
right bronchial stenting was performed.
Past Medical History:
1. Both squamous cell and adenocarcinoma of the lung and RUL
lobectomy, with metastatic NSCLC with brain mets, status post
stereotactic radiosurgery to a right cerebellar resection cavity
and a right occipital metastasis, followed by Dr [**Last Name (STitle) 724**]; history
of SVC syndrome; she is being treated with Tarceva for
palliative control of tumor burden
2. HIV diagnosed in [**2173**], contracted status post blood
transfusion from birth of son, c/b PCP, [**Name10 (NameIs) **], and thrush. Also
with history of Lymphoma after having axillary LAD. Last CD4 was
67 on [**2192-5-21**]. Switched to new regimen ~1.5 months ago.
3. Total abdominal hysterectomy for uterine cancer in [**2184**]
4. Carotid artery aneurysm on L
5. Emphysema
6. status post Cholecystectomy
Social History:
Prior 30 pack-year smoking history per records. She drinks
alcohol occasionally. She used marijuana many years ago but
denies any recent illicit drug use. She lives with her husband
and her son.
Family History:
Her father is alive with CAD, mother is alive with CAD and
history of CVA. One of her sisters had ovarian cyst, and one of
her brothers died as an infant from an unknown cause.
Physical Exam:
T = 98.6; HR = 107; BP = 114/66; RR = 24; O2 = 100% (AC:
300/24/5/0.8)
GEN: intubated, appears uncomfortable, alert, NAD
HEENT: PERRL bilat, EOMI bilat, anicteric, MMM
Neck: supple, no LAD, no JVD, + visible pulsating left carotid
(known aneurysm)
CV: RRR, no m/r/g
Resp: decreased breath sounds on right, Left CTA without
crackles, or wheezes anteriorly
Abd: NABS, soft, non-distened, non-tender, no masses
Back/skin: + stage 2 sacral decubitus ulcer
Ext: warm, dry; [**2-2**]+ pitting edema bilaterally
Neuro: A&Ox3, CN II-XII intact, strength intact grossly
Pertinent Results:
On Admission:
11.3>24.7<519
N:91.1 L:4.8 M:3.9 E:0.2 B:0
[**Age over 90 **]|98|15 /88
3.9|35|0.3\
Ca:8.8 Mg:1.9 P:3.3
ALT:8 AST:16 LDH:180 AP:128 [**Doctor First Name **]:23 Lip:12 Tbili:0.3 Alb:2.5
Haptoglobin:424
ABG:7.33/54/111
Lactate:2.9
CK:16 CK-MB:Not done Trop-T < 0.01
UA: Clear, SG:1.011 pH:5.0, small nitrate, rest of dipstick
negative, RBC:0-2 WBC:[**6-8**] Bact:occ Yeast:none Epi:0-2 WBC
casts:0-2
BAL: WBC:0 RBC:0 P:80 L:0 M:0 Macro:20
CXR: Comparison is made to [**2192-7-20**]. There is persistent
complete opacification of the right hemithorax. There is a
persistent right lateral indentation on the trachea. There is
worsening opacity in the left lung with multiple nodules, which
appear slightly larger, although this could be due to adjacent
opacity. Surgical clips are again noted in the right upper
quadrant. Left chest tube remains in place. Appearance of the
right main stem bronchus stent is unchanged.
Brief Hospital Course:
36 year-old woman with history of HIV/AIDS (CD4=56) on HAART and
PCP/MAC prophylaxis), metastatic squamous and adenocarcinoma of
the lung (on tarceva) with brain mets and chronic malignant
effusion status post right bronchial stenting [**7-3**], recently
discharged from [**Hospital1 18**] after an admission for pneumonia who
presents from outside hospital for acute onset shortness of
breath. She was intubated in ED for respiratory distress.
.
1) RESPIRATORY FAILURE: The etiology of her acute respiratory
distress was unclear on admission, but is likely related to a
worsening left sided pneumonia. Other possibilities for acute
decompensation include pulmonary embolism since she is likely
hypercoagulable or and increase in her tumor burden. A chest
CTA was not performed due to her iodine allergy. Upper and
lower extremity ultrasounds were significant for non-occlusive
clots in axillary and subclavian veins bilaterally. Therefore,
the possibility of a pulmonary embolism could not be excluded;
however, she was not started on heparin empirically due to the
presence of brain metastasis. She was started on empiric
antibiotics (vancomycin, azithromycin, ceftriaxone,
metronidazole, and Bactrim) for community acquired pneumonia,
atypical pneumonia, and PCP. [**Name Initial (NameIs) **] bronchoscopy showed a patent
proximal stent in the right mainstem bronchus with tumor
overgrowth as well as diffuse mucosal edema on the left with
thin watery discharged. The bronchial lavage was negative for
PCP, [**Name10 (NameIs) **] Bactrim was stopped. On hospital day 2, she began to
have continued increased oxygen requirement and a chest x-ray
showed increased left lower lobe opacity. Upon talking to the
husband and family, it was decided to see if her respiratory
status improved with the antibiotics. Her respiratory status
continued to decline as she became more hypoxic and more
hypercarbic requiring increased ventilator adjustments. On
hospital day 4, the husband and family decided to withdraw
ventilator support and the patient expired.
2) HYPOTENSION: She had transient hypotension after intubation
that was likely secondary to sedation. However, her clinical
picture was concerning for sepsis given her respiratory failure,
reported fever, and tachycardia. Her lactate was mildly
elevated, but that may be from her HAART medications. Her mean
arterial blood pressure was maintained above 60 with fluid
boluses.
3) HIV/AIDS: Her last CD4 was 56. She was maintained on her
HAART medications throughout the admission.
4) SQUAMOUS/ADENOCARCINOMA OF LUNG: She has metastasis to her
brain and is status post stereotactic radiotherapy. She had
been recently treated with Tarceva. She had tumor occluding her
right mainstem bronchus causing collapse of her right lung that
was stented during her recent admission. She was seen by her
oncologist, Dr. [**Last Name (STitle) 3274**], on this admission who feels that no
further treatment is warranted given the progression of her
disease. Interventional Pulmonary also saw her and felt that
there was no indication for further intervention.
5) CHRONIC PAIN: She was maintained on fentanyl and propofol
drip for pain control.
6) ANEMIA: During her last admission, her baseline hematocrit
was between 24-27. Iron studies last admission, appears to be
combination of iron deficiency and ACD. She was not transfused
since she does not have active coronary disease. Her hematocrit
remained stable throughout the admission.
.
7) FEN: She was initially NPO. Tube feeds were to be started;
however, she was not tolerating po intake through her OG tube.
Her electrolytes were repleted as needed.
.
8) ACCESS: A right femoral line was placed.
9) PROPHYLAXIS: She was maintained on a PPI and subcutaneous
heparin.
10) Code: On hospital day 2, she was made DNR with no pressors,
no shocks, and no antiarrhythmics. On hospital day 4, she was
made comfort measures only. She was extubated and expired.
.
Medications on Admission:
Trimethoprim-Sulfamethoxazole 80-400 mg PO DAILY
Fluconazole 200 mg PO Q24H
Azithromycin 600 mg PO Q SUNDAY/WEDNESDAY
Morphine 10 mg/5 mL PO Q4H
Amoxicillin-Pot Clavulanate 500-125 mg PO Q8H x 13 days
Benzonatate 100 mg PO TID
Lidocaine 5 %(700 mg/patch) Patch QD
Propranolol 20 mg PO BID
Fentanyl 100 mcg/hr Patch 72HR
Fentanyl 75 mcg/hr Patch 72HR
Pantoprazole 40 mg PO Q24H
Tenofovir Disoproxil Fumarate 300 mg PO DAILY
Emtricitabine 200 mg PO Q24H
Stavudine 30 mg PO Q12H
Albuterol Neb Q6H prn
Furosemide 20 mg PO DAILY
Hydrocodone-Acetaminophen 5-500 mg PO Q4-6H prn
Discharge Medications:
None.
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired.
Discharge Condition:
Expired.
Discharge Instructions:
None.
Followup Instructions:
None.
Completed by:[**2192-8-2**]
|
[
"285.9",
"042",
"442.81",
"486",
"V10.11",
"518.81",
"198.3",
"V10.42",
"V10.79",
"197.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.91",
"96.04",
"99.15",
"38.93",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
9511, 9520
|
4877, 8858
|
352, 365
|
9572, 9582
|
3911, 3911
|
9636, 9671
|
3128, 3306
|
9481, 9488
|
9541, 9551
|
8884, 9458
|
9606, 9613
|
3321, 3892
|
293, 314
|
393, 2097
|
3926, 4854
|
2119, 2898
|
2914, 3112
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,927
| 118,547
|
48991+59129
|
Discharge summary
|
report+addendum
|
Admission Date: [**2190-8-12**] Discharge Date: [**2190-8-27**]
Date of Birth: [**2136-6-5**] Sex: F
Service: MEDICINE
Allergies:
Bactrim Ds / Terbutaline
Attending:[**First Name3 (LF) 21990**]
Chief Complaint:
Hypoxia.
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
54 yo female with multiple medical problems including COPD,
asthma, OSA, diastolic LV dysfunction, paroxysmal SVT, DM2
presented from nursing home with acute onset of SOB while
walking to the bathroom. Sat measured and noted to be 89% RA;
she was given an albuterol treatment and O2 sat down to 42% on
2.5LNC, she was then given atrovent treatment and BiPAP with 60
mg prednisone with BP up to 210/110 and O2 sats up to 71-72% on
2.5LNC. While waiting for EMS had 2min episode of CP, describes
like heart burn while at rest no radiation, no N/V, was SOB and
diaphoretic, never had this type of pain before. EMS vitals with
Hr 140's BP 150/60 R20 Sat 100% on RA. She was feeling better
by time they arrived, but was brought in for evaluation anyways.
Of note she was recently tapering prednisone to 20mg qod on
[**7-21**] and has noted increased SOB and fluid recently.
.
In the [**Name (NI) **], pt was found to febrile and in SVT. Vitals in ED were
T 101, HR 155, BP 122/110, 100% 2L. Pt received Adenosine IV and
diltiazem IV. SVT broken with IV Diltiazem. Pt has h/o frequent
episodes of SVT managed with po Diltiazem.
.
She notes worsening dyspnea on exertion last night with non
productive cough, and acutely worse this morning and temps here,
but none at home. No other associated problems, tired, some
weight gain but no LE edema, she says overall compliant with her
BiPAP and nebs. On ROS, pt denies fever or chills. Notes a
nonproductive cough x 3 days. No nausea, vomiting, diarrhea. Has
SOB with exertion, orthopnea, no chaneg in 3pillow orthopnea.
Denies lower extremity swelling. Denies dysuria, melena or
bleeding from below.
Past Medical History:
1. Asthma, s/p multiple hospitalizations and intubations. Now
on home O2
3. Diastolic congestive heart failure with mild (+1)mitral
regurgitation ([**9-11**]).
4. History of paroxysmal supraventricular tachycardia (MAT)
5. Diabetes mellitus.
6. Obstructive sleep apnea on Bipap
7. Hypertension.
8. History of tuberculosis, status post isoniazid treatment.
9. Her last exercise stress test was [**12-14**]; She exericsed for 4
minutes of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4001**] protocol and was stopped for fatigue. Very
limited functional capacity. At peak exercise the patient
reported a [**8-21**] SSCP (resolved with rest by minute 6 in recovery
while sitting). No significant ST segment changes were noted.
Social History:
Patient lives at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]. Has 5 children. Pt has remote
h/o tob use for 2 years 25 years ago. Pt has remote h/o ETOH
abuse for 2 years. Denies current tob, ETOH, drug use.
Family History:
Diabetes in mother and father. One daughter has asthma and is
currently hospitalized for asthma. This daughter serves as her
proxy.
Physical Exam:
Vitals: T 97.9/101 HR 101-155, BP 160/92 R23 Sat 91-95%on 2L
Wt 110kg
Gen: aao, nad, comfortable, able to speak in full sentances.
HEENT: PERRL. EOMI bilaterally. clear OP
Neck: JVD difficult to assess
Lungs: Decreased breath sounds throughout L>R. Crackles at
bilateral bases. diffuse exp wheezes anteriorly.
CVS: Distant heart sounds. RRR. No murmurs, rubs, gallops.
Abd: Obese abdomen. Soft, nontender
Ext: trace pitting edema. 2+ DP pulses bilaterally.
Neuro: Resting tremor of bilateral hands.
Pertinent Results:
Admission labs:
[**2190-8-12**] 12:00PM WBC-7.7 RBC-3.57* HGB-10.5* HCT-31.9* MCV-89
MCH-29.5 MCHC-33.0 RDW-14.3
[**2190-8-12**] 12:00PM PLT COUNT-187
[**2190-8-12**] 12:00PM NEUTS-83* BANDS-4 LYMPHS-2* MONOS-8 EOS-3
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2190-8-12**] 12:00PM PT-12.1 PTT-22.3 INR(PT)-0.9
.
[**2190-8-12**] 12:00PM GLUCOSE-161* UREA N-52* CREAT-2.1* SODIUM-142
POTASSIUM-4.8 CHLORIDE-96 TOTAL CO2-38* ANION GAP-13
[**2190-8-12**] 12:00PM ALT(SGPT)-33 AST(SGOT)-32 LD(LDH)-221
CK(CPK)-33 ALK PHOS-155* AMYLASE-187* TOT BILI-0.3
[**2190-8-12**] 12:00PM LIPASE-51
.
[**2190-8-12**] 05:20PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2190-8-12**] 05:20PM URINE RBC-[**2-13**]* WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0
.
[**2190-8-12**] 07:44PM PO2-33* PCO2-103* PH-7.16* TOTAL CO2-39* BASE
XS-3 COMMENTS-SPECIMEN N
[**2190-8-12**] 08:21PM LACTATE-1.3
[**2190-8-12**] 08:21PM TYPE-ART PO2-308* PCO2-82* PH-7.23* TOTAL
CO2-36* BASE XS-3 INTUBATED-NOT INTUBA
.
-EKG: Regular, narrow complex tachycardia, rate 151. Possibly
2:1 flutter. No ST segment changes.
.
-CXR portable: Opacity at the left lung base, with obscuration
of the diaphragmatic contour, which likely represents
pneumonia. Probable atelactasis at the right lung base.
.
-Repeat CXR PA&lat: No PNA
Brief Hospital Course:
54 yo woman with PMH DM, obesity, mixed obstructive and
restrictive defect admitted to ICU with hypercarbic respiratory
distress.
.
# COPD exacerbation w/hypercarbic respiratory distress: Patient
is a chronic CO2 retainer with baseline CO2>65. She requires
home BiPAP and 2L of O2 by NC, questionable compliance with
treatment. Patient also has 3 day history of dry cough,
decreased PO intake and recent taper in steroids which raises
the possibility of a community acquired pneumonia. Patient
likely close to baseline in terms of resp status. Patient also
with hx of dyastolic dysfunction, crackles on exam, trace edema
therefore likely concomittant element of CHF. Patient was
diuresed with lasix IV 80 mg x 2. Steroids 60 mg daily and
Levaquin for community acquired PNA. She was treated with BiPAP
[**9-15**] at night and O2 by NC during the day (2-2.5L), PRN
nebulizer treatments. Atovaquone started for PCP prophylaxis
given hx of steroid use and allergy to sulfa. Pt was continued
on slow prednisone taper, singulair, and albuterol and atrovent
nebs at the time of discharge.
.
# Fever: Tm=101 in ED with history of 3 days of dry cough, CXR
negative, ?CAP given patient's long term use of steroids. Sick
contacts from [**Name (NI) **]. Blood and urine culturs were drawn in the ED,
no growth todate. Patient treated with Levaquin for presumed
community acquired pneumonia, despite negative CXR. Pt completed
a 10 day course of levofloxacin.
.
# PSVT: Patient has a history of SVT (MAT) in past. Likely
exacerbated by acute episode of SOB, COPD exacerbation. Patient
was converted with Diltiazem, 1x Adenosine in the Ed. She was
continued on home dose Diltiazem PO for rate control and
monitored on telemetry. Pt had transient episodes of PSVT that
self terminated initially. however, the frequency of PSVT
episodes increased and she had several episodes of SVT that
lasted >30 minutes occuring mostly in the night time with oxygen
saturations dropping into the 50s. This increase in frequency
and duration coincided with the dicontinuation of Metoprolol
12.5 [**Hospital1 **] suspected of worsening her pulmonary obstruction. The
episodes of SVT were broken with 10 mg x3 of IV Diltiazem. An
electrophysiology consult was obtained, and on review of
telemetry, Pt. was found be having episodes of atrial
fibrillation, atrial flutter, and atrial tachycardia, which as
she reported, were causing palpitations and dyspnea. She
underwent an ablation procedure, with marked improvement in
these symptoms. Her respiratory state, while still tenuous, did
improve to the point where at rest, she was sat-ing in the high
90s on 2L O2NC. In addition, she has been walking up and down
the [**Doctor Last Name **] without DOE. She has not had arrhythmias on telemetry
monitoring since the ablation. She was discharged on verapamil
and lisinopril; her BB was discontinued.
.
# Chest pain: Patient describes burning "esophageal" sensation,
states she has not had this in the past. Occurred with episode
of SOB. EKG negative for ischemia. Cardiac enzymes were
negative. Started on PPI given history of steroid use and
symptoms of GERD.
.
# Hyperparathyroid: With elevated PTH (chronic). Patient not a
candidate for surgery given resp status. Serum calcium was wnl
and came down further with IVF therapy.
.
# DM2: Stable, continued home regimen of Glargine 40U QHS and
RISS.
.
# CRI: Baseline Cr. 2.0, increased to 2.2. Chronic renal
insufficiency thought to be [**1-13**] nephrosclerosis or hypercalcemia
induced tubular dysfunction. Acute renal failure likely
secondary to CHF, poor forward flow; now improving. At discharge
her Cr was 2.3.
.
# Diastolic LV dysfunction: ECHO [**1-16**] showed mild [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1915**],
LVEF 55%, trivial MR. [**Name13 (STitle) **] has crackles on exam, trave pedal
edema, difficult to assess JVP. Patient was diuresed with lasix
IV 80 mg until euvolemic. She was then continued on home regimen
of cardiac mediations.
.
# HTN: stable, somewhat on high side. Continued on diltiazem
initially then switched to Verapamil. Lisinopril was increased
to 30 mg QD.
.
# Hyperlipidemia: continued on Lipitor
.
# Hyperkalemia: Potassium was 5.4 on admission and 4.8 on
discharge.
.
# Psych: Pt has h/o depression and anxiety. Continued on Prozac,
Buspar.
Medications on Admission:
Diltiazem 480 mg QD
Furosemide 80 mg QD
Lisinopril 10mg QD
ASA 81mg QD
Glargine 40 U QHS
RISS
Prednisone 20mg QOD
Singulair 10mg QD
Spironolactone 25mg QD
Lipitor 20mg QD
Albuterol neb [**Hospital1 **]
Colace 1000mg [**Hospital1 **]
Buspirone 5mg TID
Atrovent neb q 6h
Compazine 10mg [**Hospital1 **] prn
Fluoxetine 20mg QD
Senna prn
Acetaminophen prn
Discharge Medications:
1. Verapamil 360 mg Cap, 24HR Sust Release Pellets Sig: One (1)
Cap, 24HR Sust Release Pellets PO once a day.
Disp:*30 Cap, 24HR Sust Release Pellets(s)* Refills:*2*
2. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atovaquone 750 mg/5 mL Suspension Sig: One (1) PO Q 24H
(Every 24 Hours).
Disp:*30 doses* Refills:*2*
6. Buspirone 15 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
9. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
Disp:*60 Disk with Device(s)* Refills:*2*
12. Prednisone 10 mg Tablet Sig: Five (5) Tablet PO once a day:
Please follow discharge instructions for prednisone taper.
Disp:*100 Tablet(s)* Refills:*1*
13. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
puffs Inhalation four times a day.
Disp:*QS * Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
COPD exacerbation
Asthma
Supraventricular tachycardia
Obstructive sleep apnea
Secondary:
HTN
DMII
CHF (diastolic)
Acute renal failure
Anemia
Discharge Condition:
Stable
Discharge Instructions:
If you have worsening shortness of breath, CP, fever or chills,
nausea, vomiting, call your doctor or return to the emergency
room immediately.
We have changed most of your medications. Take the medications
on your discharge paperwork. Do not take your old medications
unless they are the same as the ones on the discharge paperwork.
Your are to continue a predisone taper as follows:
Take 5 tablets (of 10 mg predisone) a day from the day of
discharge until [**8-26**]. From [**8-27**] to [**9-2**] take 4 tablets a day.
From [**9-3**] to [**9-9**] take 3 tablets a day. Thereafter take 2
tablets each day. Continue to take two tablets each day until
you see Dr. [**Last Name (STitle) 217**].
Followup Instructions:
Follow up with your primary care doctor within 2 weeks of
discharge.
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Where: [**Hospital6 29**]
[**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2190-9-29**] 2:30
Provider: [**Name Initial (NameIs) 9484**]CC2 PULMONARY LAB-CC2 Where: [**Hospital6 29**]
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2190-10-28**]
1:30
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**]
REHAB SERVICES (DYSPNEA) Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2190-10-28**]
2:45
Completed by:[**2190-8-27**] Name: [**Known lastname **],[**Known firstname 194**] Unit No: [**Numeric Identifier 16613**]
Admission Date: [**2190-8-12**] Discharge Date: [**2190-8-27**]
Date of Birth: [**2136-6-5**] Sex: F
Service: MEDICINE
Allergies:
Bactrim Ds / Terbutaline
Attending:[**First Name3 (LF) 16614**]
Addendum:
Pt.'s does of buspirone should be 5mg PO TID, not 15mg PO TID as
written in the original discharge summary.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 49**] - [**Location (un) 50**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6033**] MD [**MD Number(2) 16615**]
Completed by:[**2190-8-27**]
|
[
"278.00",
"493.22",
"584.9",
"518.81",
"401.9",
"427.31",
"427.1",
"599.7",
"250.40",
"252.00",
"276.7",
"593.9",
"389.9",
"486",
"428.31",
"784.7",
"780.57"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.27",
"93.90",
"37.34",
"37.26"
] |
icd9pcs
|
[
[
[]
]
] |
13624, 13852
|
5070, 9390
|
294, 301
|
11697, 11706
|
3687, 3687
|
12451, 13601
|
3013, 3147
|
9793, 11407
|
11523, 11676
|
9416, 9770
|
11730, 12428
|
3162, 3668
|
246, 256
|
329, 1977
|
3703, 5047
|
1999, 2746
|
2762, 2997
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,687
| 110,970
|
27147
|
Discharge summary
|
report
|
Admission Date: [**2148-6-13**] Discharge Date: [**2148-6-25**]
Date of Birth: [**2089-11-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 6169**]
Chief Complaint:
leukocytosis of unclear etiology
Major Surgical or Invasive Procedure:
bedside debridement of failed skin graft from outside hospital
R IJ placement and removal
PICC placement
History of Present Illness:
Patient is a 58M with no significant past medical history who
was admitted from clinic for further evaluation after being
evaluated in Dr.[**Name (NI) 6168**] clinic for WBC of 83.9, with
peripheral smear showing 8% blasts and atypical cells. Patient
reports that 4 weeks ago he developed a large "boil" on his
right thigh, associated with fevers to 104. He reported to an
OSH emergency department where the area was "drained." Was later
admitted, had surgical resection of mass, was also noted to be
anemic. Received 4 units PRBCs total. Had upper and lower
endoscopy which was negative. Received tagged red cell scan
which lit up in area of thigh lesion, but no other
abnormalities. Received skin flap over thigh lesion
subsequently. Had bone marrow biopsy to investigate etiology of
anemia, was told initially that it was normal, but later
informed that it was abnormal. Wife called Dr. [**First Name (STitle) 1557**] for second
opinion.
Of note, patient reports developing a linear-rash bilaterally on
year-ago on his left ankle which was thought to be poison [**Female First Name (un) **].
Rash then spread over lower half of body, over trunk and back,
and legs bilaterally. Tried topical steroids with some relief.
When the above issues were transpiring, patient saw a
dermatologist and was started on oral steroids, and reports
improvement in macular-appearing lesions on his body. Has taken
60mg Prednisone for 8 days so far. Was also on Doxepin for
itching associated with rash.
.
On review of systems, patient denies any abdominal pain, nausea,
vomiting, shortness of breath or chest pain. Reports
unintentional weight loss over 40 lbs over the past year, from
260 to 219. Reports having chills over the last couple of weeks,
and fevers for 4 days as mentioned above. No loss of appetite.
Progressive fatigue, used to work two jobs but quit one of them
due to lack of energy. No melena or hematochezia. No joint pain
or myalgias. No urinary complaints. No headaches.
Past Medical History:
Glaucoma
Social History:
Custodian at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Occasional ETOH. No drug use. 30
year smoking history, at least 3 packs/week.
Family History:
Older sister with some type of cancer, not very close, but wife
will attempt to gain further details.
Physical Exam:
GEN: NAD, comfortable, pleasant
HEENT: Poor dentition. OP clear of lesions. MMM. No cervical or
submandibular lymphadenopathy. No JVD
LUNGS: CTA B/L
HEART: S1S@. II/VI systolic murmur LUSB -> apex.
ABD: + BS. obese. soft, NT/ND. Palpable splenomegaly. Liver 6cm
below costal margin.
THIGH: Two areas of intervention on right thigh, area of skin
graft and area of prior abcess, dressing C/D/I. Will need to
examine further.
EXT: No clubbing or edema. Symmetric distal pulses.
Skin: macular rash over lower back, bilateral legs, well-defined
borders. linear rash on lower extremity, red.
Pertinent Results:
[**2148-6-13**] 10:31PM CK(CPK)-34*
[**2148-6-13**] 10:31PM CK-MB-1 cTropnT-<0.01
[**2148-6-13**] 09:15PM GLUCOSE-211* UREA N-17 CREAT-0.9 SODIUM-135
POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-22 ANION GAP-20
[**2148-6-13**] 09:15PM ALT(SGPT)-34 AST(SGOT)-36 LD(LDH)-353*
CK(CPK)-34* ALK PHOS-129* AMYLASE-71 TOT BILI-0.6
[**2148-6-13**] 09:15PM LIPASE-42
[**2148-6-13**] 09:15PM CK-MB-1 cTropnT-<0.01
[**2148-6-13**] 09:15PM WBC-89.1* RBC-3.31* HGB-8.0* HCT-24.9*
MCV-75* MCH-24.1* MCHC-32.1 RDW-26.8*
[**2148-6-13**] 09:15PM PLT COUNT-103*
[**2148-6-13**] 09:15PM PT-13.1 PTT-26.3 INR(PT)-1.1
[**2148-6-13**] 05:00PM TOT PROT-6.6 URIC ACID-8.2*
[**2148-6-13**] 05:00PM TSH-2.0
[**2148-6-13**] 05:00PM PEP-NO SPECIFI IgG-1344 IgA-187 IgM-66
[**2148-6-13**] 12:30PM GLUCOSE-121* UREA N-16 CREAT-0.7 SODIUM-142
POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-28 ANION GAP-15
[**2148-6-13**] 12:30PM ALBUMIN-3.6 CALCIUM-8.9 PHOSPHATE-4.9*
MAGNESIUM-1.9
[**2148-6-13**] 12:30PM PLT SMR-LOW PLT COUNT-115*
[**2148-6-13**] 12:30PM WBC-83.9* RBC-3.58* HGB-8.5* HCT-26.6*
MCV-74* MCH-23.8* MCHC-32.1 RDW-26.7*
.
([**2148-6-13**]) CXR: IMPRESSION: AP chest reviewed in the absence of
prior chest radiographs: Lungs are fully expanded and clear.
Heart size normal. No pleural abnormality.
.
([**2148-6-14**]) CTA: IMPRESSION: No evidence for PE or dissection.
.
([**2148-6-14**]) Abdominal U/S: 1. Slightly echogenic appearance of
liver, borderline by ultrasound, but consistent with mild fatty
infiltration present on the recent CT. 2. Hypoechoic area near
the gallbladder fossa, suggestive of focal fatty sparing, in
spite of its mass-like appearance. However, for confirmation,
when clinically feasible, a multiphasic CT or MR is recommended
to evaluate further. 3. Splenomegaly.
.
([**2148-6-14**]) ECHO: The left atrium is moderately dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). There is a mild resting left ventricular
outflow tract obstruction in the setting of tachycardia and
hyperdynamic LV function. Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is a trivial/physiologic pericardial
effusion
.
([**2148-6-13**]): Bone Marrow Biopsy
--FISH: An expanded population of myelomonocytic precursor with
increased myeloblasts (12% of total events) is present. These
findings are in keeping with the morphologic diagnosis of
myeloproliferative/myelodysplastic syndrome (MPD/MDS), an
overlap syndrome.
--Bone marrow aspirate and core biopsy:
Markedly hypercellular myeloid-dominant bone marrow with
trilineage dysmyelopoiesis and ringed sideroblasts, consistent
with a myeloproliferative/myelodysplastic syndrome (overlap
syndrome). See note
Note: Though blasts are increased both in peripheral blood and
bone marrow they do not reach levels consistent with acute
leukemia. Nonetheless the presence of 8% blasts in the marrow
aspirate indicative a "progressed" MDS/MPD akin to that of
RAEB-1 MDS. In addition, some of the morphologic findings, such
as peripheral blood monocytosis and increased promonocytes in
the bone marrow raise the possibility of chronic myelomonocytic
leukemia (CMML), perhaps the best well-defined MDS/MPD. However,
no history of monocytosis was elicited and in fact a year ago
the patient reportedly have cytopenia. Moreover, the
neutrophilic and erythroid series exhibit extensive dyspoiesis,
greater than usually seen in CMML with markedly elevated WBC.
Cytogenetic studies may be very helpful in further defining this
condition since translocation of PDGFR is present in a fraction
of CMML patients. Though morphologically atypical for chronic
myeloid leukemia (CML), cytogenetic/molecular studies for
[**Location (un) 5622**] chromosome/bcr-abl need to be performed to rule out
an atypical presentation of CML.
Brief Hospital Course:
Patient is a 58 year-old gentleman who was admitted from clinic
for further management of leukocytosis of 80,000 of unclear
etiology. The following issues were addressed during his
hospital stay:
.
# LEUKOCYTOSIS
Etiology of leukocytosis was multifactorial, including steroid
use, possible infection, and underlying
myeloproliferative/myelodysplastic disorder, with the latter
diagnosis predominating:
- INFECTIOUS: Patient with recent R thigh carbuncle/abscess that
was drained and debrided at outside hospital, then grafted. On
admission, lesion was draining greenish discharge and graft
appeared necrotic. Patient was started on empiric Vanc/Zosyn for
pseudomonal and MRSA coverage. Plastic surgery was consulted and
wound was debrided at bedside. ID was consulted for work-up and
management of fever/wound. After adequate debridement and strict
dressing care, wound appeared to be healing well and antibiotics
were discontinued on [**2148-6-21**]. Patient subsequently developed
fever, and antibiotics were added back to regimen for 2-3 days.
Given clinical improvement and no other localizing sources of
infection, antibiotics were once again tapered. Patient
developed low grade fever thereafter, and it was felt that fever
was due to cytokine release from lysis of cells secondary to
chemotherapy (see below) and not infection. No other localizing
sources for infection could be found, CXR/UA/Blood cultures were
without growth.
- HEME/ONC: Bone Marrow biopsy showed
myeloproliferative/myelodysplastic overlap syndrome. Given
concerns for leukostasis from marked leukocytosis, patient
started on hydroxyurea and prophylactic allopurinol was added to
regimen. Patient had 2 hypoxic episodes, with desaturations to
85% on room air, and 4 liter oxygen requirement. Patient was
transferred to the [**Hospital Unit Name 153**] for further management given concerns of
respiratory demise from leukostasis. Respiratory status
stabilized; patient did not require intubation. Patient was
started on 7-day therapy of low-dose Ara-C continuous infusion,
and tolerated chemotherapy well. Hydroxyurea was titrated as
necessary. Tumor lysis labs were monitored closely. After short
stay in ICU, patient was transferred back to [**Hospital Unit Name 3242**] floor on nasal
cannula. Pulmonology team was consulted, felt that hypoxia was
mainly attributable to fluid overload based on Chest CT
findings. Patient's symptoms improved with diuresis and was
weaned off supplemental oxygen relatively rapidly. Patient
received supportive platelet/RBC transfusions as needed. Patient
tolerated chemotherapy, and leukocytosis responded well.
Splenomegaly decreased on exam. Patient to continue Hydroxyurea
and Allopurinol as outpatient, and will follow-up with Dr.
[**First Name (STitle) 1557**] for further management of MDS/MPS. Bone Marrow Transplant
and XRT to spleen are two options that are being considered.
- DERMATOLOGIC/STEROIDS: Patient had received 8 days of
prednisone 60mg prior to admission for treatment of macular skin
rash. Rash responded well to oral steroids. On admission,
steroids were discontinued. Dermatology was consulted, and felt
that rash was now all post-inflammatory hyperpigmentation
changes. Biopsy was not performed, but OSH report was obtained
by dermatology, and picture was consistent with expected
inflammatory infiltrate. Topical steroids were recommended as
needed, but rash did not worsen and patient was not symptomatic
from it. Oral steroids were later added back to regimen as
adjunctive treatment of underlying myelodysplastic disorder.
These were tapered to 10mg PO BID on discharge.
.
# EPIGASTRIC DISCOMFORT
Patient with episode of diaphoresis and epigastric discomfort on
evening of [**6-13**], with T spike to 101. Suspected that this was due
to plastics manipulation of abscess with SIRS-like response. No
EKG changes, CTA negative for PE or dissection. Patient hsd been
having similar episodes for the past 5-6 days, unclear whether
this was due to underlying leukocytosis cuasing leukostasis, or
GERD. Patient improved with PPI [**Hospital1 **], unclear whether this was
coincidental, as leukocytosis was brought under control
concurrently. Patient was continued on PPI [**Hospital1 **] as outpatient.
.
# PAROXYSMAL ATRIAL FIBRILLATION
3 days after admission, patient went into Afib with RVR to
140s-150s. Cardiology was consulted. ECHO showed preserved EF
with dilated left atrium. Chest CT confirmed presence of fluid
overload. Patient was started on Metoprolol TID for rate control
and diuresed with standing (and then PRN, Lasix). No further
episodes were experienced.
Medications on Admission:
none before recent admission
Doxepin 25 TID (has not taken for last 5 days, was on it for
itch)
Prednisone 60mg PO qd
Prilosec
Drops for glaucoma, does not recall name
Tenovite 0.05% cream for skin lesions
Vicodin for pain, has not taken in several days
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. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours.
Disp:*60 Tablet(s)* Refills:*0*
6. WOUND CARE
site: left thigh; type: leg ulcer; cleansing [**Doctor Last Name 360**]: saline;
dressing: gauze: wet to dry; change dressing: twice a day.
7. PICC line care
Flush with 10 cc normal saline per day followed by 300 units of
herparin. Change dressing Q week.
8. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
AML/MDS
Right leg ulceration
Paroxysmal Atrial Fibrillation Likely [**3-14**] Fluid Overload
Discharge Condition:
Stable
Discharge Instructions:
1. Please keep all follow up appointments.
2. Continue medications as instructed.
3. Seek medical care for any concerning symptoms including
fevers, chills, chest pain, shortness of breath, abdominal pain,
nausea, or any other concerning symptoms.
Followup Instructions:
1. Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], RN Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2148-6-27**] 12:00
2. Provider: [**Name10 (NameIs) 3242**] CHAIR 5 Date/Time:[**2148-6-27**] 12:00
3. Provider: [**Known firstname 1730**] [**Last Name (NamePattern4) 6175**], MD Phone:[**Telephone/Fax (1) 3237**]
Date/Time:[**2148-6-27**] 1:00
Completed by:[**2148-6-26**]
|
[
"427.31",
"786.09",
"780.6",
"782.1",
"276.6",
"996.52",
"707.11",
"530.81",
"365.9",
"238.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"41.31",
"86.28",
"99.25",
"38.93",
"99.04",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
13501, 13553
|
7555, 12166
|
347, 453
|
13689, 13698
|
3409, 7532
|
13996, 14438
|
2684, 2787
|
12471, 13478
|
13574, 13668
|
12192, 12448
|
13722, 13973
|
2802, 3390
|
275, 309
|
481, 2461
|
2483, 2493
|
2509, 2668
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,115
| 136,902
|
12030
|
Discharge summary
|
report
|
Admission Date: [**2180-3-14**] Discharge Date: [**2180-3-17**]
Date of Birth: [**2119-5-1**] Sex: F
Service: GYNECOLOGY
ADMISSION DIAGNOSIS:
Cervical cancer.
DISCHARGE DIAGNOSIS:
Cervical cancer.
HISTORY OF PRESENT ILLNESS: The patient is a 60 year-old
gravida 4 para 4, who recently arrived from [**Male First Name (un) 1056**] who
presented with advanced cervical cancer. Her presentation
symptoms were a malodorous discharge from the vagina. Office
evaluation revealed a large friable cervix and a 5 cm
cervical lesion. She reported one episode of hematuria.
Otherwise her review of systems was negative.
PAST MEDICAL HISTORY: 1. Gastroesophageal reflux disease.
2. Depression.
PAST SURGICAL HISTORY: Left leg surgery due to a fracture.
PAST GYNECOLOGICAL HISTORY: Unremarkable.
PAST OBSTETRICAL HISTORY: Four vaginal deliveries.
MEDICATIONS: Zantac.
ALLERGIES: Aspirin.
FAMILY HISTORY: The patient has a sister with breast cancer
and two sisters with liver cancer. Additionally she has a
brother with brain cancer. She denies any history of uterine
or ovarian cancer.
SOCIAL HISTORY: The patient is from [**Male First Name (un) 1056**]. She
arrived from the United States on [**2180-1-20**]. She is
married and has four children. She does not smoke cigarettes
or drink alcohol.
PHYSICAL EXAMINATION: The patient is a well developed, well
nourished 60 year-old female. Her lungs were clear to
auscultation. There was no supraclavicular adenopathy.
Abdomen was soft, nontender, nondistended. The pelvic
examination revealed a large cervix of approximately 6 to 7
cm in size. The exocervix was friable and excreting a
malodorous discharge.
DATA: An MR [**First Name (Titles) **] [**Last Name (Titles) 3780**] a 3.5 by 5 cm mass within the
cervix that was most likely consistent with cervical cancer.
The cervical biopsy performed on [**2180-3-2**] did not
demonstrate malignancy.
ASSESSMENT: The patient is a 60 year-old multiparous woman
presenting with a large cervical mass measuring 5 cm in
maximal dimension that is most consistent with cervical
cancer. This assessment is supported by the patient's
physical examination as well as the magnetic resonance
imaging. By clinical staging she is cervical cancer stage
1B2. A radical hysterectomy was recommended to the patient.
This procedure was explained in depth and her questions were
answered. Consent for this procedure was obtained.
HOSPITAL COURSE: On [**2180-4-3**] the patient underwent
an examination under anesthesia, cystoscopy, radical
hysterectomy, bilateral pelvic and periaortic lymph node
dissection for stage 1B2 cervical cancer. This procedure was
uncomplicated. The estimated blood loss was 300 cc. The
intraoperative findings included a 5 cm barrel shaped cervix
without clinical invasion of the parametrial tissue.
Cystoscopy [**Year (4 digits) 3780**] no involvement of the bladder mucosa.
During exploratory laparotomy the uterus appeared to be
normal size. The cervical width again appeared to be 6 cm.
For details of the operative procedure please see the
dictated operative note.
The patient did well immediately postoperatively, however,
due to narcotic use the patient's respiratory status became
depressed with respirations at a rate of 10. Her O2 sat was
at the range of 80%. To monitor her closely the patient was
admitted to the Intensive Care Unit overnight with
conservative therapy and appropriate pain management, the
patient's respiratory status improved and she was able to
maintain normal oxygen saturation on nasal cannula oxygen.
On postoperative day number one the patient was transferred
out of the Intensive Care Unit. Her recovery from there on
was unremarkable. By postoperative day number two she was
tolerating a regular diet, ambulating, demonstrating
excellent urine output and exhibited excellent pain control.
On postoperative number three the patient continued to do
well. She was assessed as stable for discharge on [**2180-3-17**].
DISCHARGE MEDICATIONS: 1. Percocet. 2. Motrin. 3.
Colace.
DISCHARGE FOLLOW UP: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5166**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 26060**]
Dictated By:[**Last Name (NamePattern1) 37772**]
MEDQUIST36
D: [**2180-3-17**] 12:04
T: [**2180-3-20**] 05:40
JOB#: [**Job Number 37773**]
|
[
"E935.2",
"786.09",
"530.81",
"716.90",
"198.6",
"614.6",
"180.0",
"568.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"57.32",
"68.6",
"65.61",
"40.3"
] |
icd9pcs
|
[
[
[]
]
] |
930, 1115
|
4039, 4089
|
198, 216
|
2471, 4015
|
734, 913
|
4101, 4453
|
1353, 2453
|
159, 177
|
245, 633
|
656, 710
|
1132, 1330
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,867
| 163,028
|
49168
|
Discharge summary
|
report
|
Admission Date: [**2163-2-23**] Discharge Date: [**2163-3-3**]
Date of Birth: [**2121-3-10**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Keppra
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Intoxication
Major Surgical or Invasive Procedure:
None
History of Present Illness:
41 year old man with past medical history significant for EtOH
abuse, c/b withdrawal seizures, with ? bipolar disorder,
presenting to ED after being found intoxicated and unable to
stand on the street.
Patient was found on city bench by EMS, initially araousable to
verbal stimuli, however noted to be unable to stand. Patient
noted to have laceration along forehead. He was noted to be
hypothermic with core temp 92 to 93F.
.
In the ED, vital signs were initially: 97.2 112/72 89 12 97% RA.
ECG per report demonstrated sinus tachycardia with small [**Doctor Last Name **]
waves. Patient was noted to be dehydrated and serum sodium of
147 and serum alcohol of 414. Patient received 1 L of IV fluid,
and underwent CT of head and neck. Patient was admitted to MICU
for further management. At time of transfer, Temp 98 BP 108/50
105 14 99% RA.
Past Medical History:
- EtOH abuse
- seizure disorder
- Neuropathy
- Hepatitis C
- Multiple head injuries
- Pancreatitis
- Bipolar disorder vs. mood disorder
Social History:
The patient was formerly homeless, has been incarcerated in the
past. Tobacco use, etoh use 1pint per day, past use of illicit
drug use.
Family History:
unable to obtain
Physical Exam:
Tcurrent: 37 ??????C (98.6 ??????F)
HR: 85 (85 - 99) bpm
BP: 98/59(69) {98/59(69) - 99/64(73)} mmHg
RR: 15 (14 - 15) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
General Appearance: Somnolent
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Poor dentition
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Tender: Mild TTP over suprapubic area
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, excoriations on patella bilaterally
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed
Pertinent Results:
==================
ADMISSION LABS
==================
147 | 108 | 6
--------------< 109
3.9 | 25 | 0.6
estGFR: >75 (click for details)
Serum EtOH 414
Serum Benzo Pos
Serum ASA, Acetmnphn, Barb, Tricyc Negative
Serum OSM 411
OSM Gap 108
Predicted OSM with EtOH: 411
([**URL 103144**]/
Appendix/Calculators/OsmoGap.html)
3.0 > 33.0 < 198
N:41.6 L:53.2 M:2.4 E:1.9 Bas:0.9
CK: 169 MB: 3 Tn <0.01
STUDIES:
CT C Spine: No prevetebral soft tissue abnormality, no fracture
or malalignment. No foraminal narrowing / central stenosis.
Extensive bullous change within lung apices captured in field
1. no fracture / malalignment
2. biapical bollous change
CT HEAD
Non contrast CT without edema, mass or hemorrahge.
Encephalomalacia stable on left temporal lobe as in MRI [**5-29**].
Ventricles and sulci normal, tiny left parietal scalp hematoma.
# no acute intracraneal process
ECG: ([**2-22**] 22:53)
Normal sinus rhythm at 83bpm, ther is baseline artifact and no
significant ST segment abnormalities.
CXR [**2163-2-23**]: Heart size is top normal, stable. Mediastinal
position is stable, unremarkable. Lungs are essentially clear.
Bilateral apical lucencies might be consistent with emphysema.
There are no areas of consolidation worrisome for infectious
process or aspiration.
CT scan thoracic/lumbar spine [**2163-2-24**]:
IMPRESSION:
1. Mild convex left curvature of the thoracic spine, otherwise
normal CT study of the thoracic and lumbar spine. No abnormal
paravertebral soft tissue or fluid collection is seen. No
abnormality detected within the spinal canal on CT; however, if
there is concern for abnormality within the spinal canal, MRI
would be recommended for more sensitive evaluation.
2. Mildly sclerotic focus in the right iliac bone, along the
sacroiliac spine, of uncertain etiology but is
well-circumscribed, with non-aggressive features.
3. Bullous emphysematous changes of the upper lobes again noted.
Evidence of prior granulomatous disease in the lungs.
Additionally, with 7-mm spiculated nodule in the left lower lobe
of uncertain etiology. Given emphysematous changes, and size of
this lesion, initial followup CT would be recommended at three
months' time by [**Last Name (un) 8773**] society guidelines.
4. Small pelvic free fluid, incompletely visualized and of
indeterminate clinical significance.
Plain films of left foot [**2163-2-26**]:
FINDINGS: No comparisons available. The soft tissues of the
fifth left digit are swollen. There is a small axial deviation.
The most peripheral to the bony components appear irregularly
margined and slightly sclerotic at their borders. The picture
would be consistent with the degenerative rather than with the
destructive or chronic inflammatory change. There is no evidence
of cortical disruption that would suggest a traumatic origin of
the changes.
Brief Hospital Course:
41 year old man with past medical history significant for EtOH
abuse, c/b withdrawal seizures, with ? bipolar disorder,
presenting to ED by EMS after being found intoxicated on the
street, in fair condition.
# INTOXICATION: On admission, patient was minimally responsive,
with very high EtOH level ~3 hours after transfer to ED,
suggesting exceedingly high levels when found on the street.
Concern for ingestion of secondary substance, however serum osm
gap is exactly that predicted for this degree of EtOH ingestion.
Given history of seizure disorder, would also consider partial
complex seizure at this time, however given pts ability to move
all extremities and become verbally abusive and combative this
was felt to be much less likely. Patient however was started on
CIWA with IV Diazepam shortly after ICU transfer due to severe
diaphoresis and tremulouness. OSH records obtained from last [**Hospital1 2025**]
ED admission 4 days PTA, and prior notes of similar breakthrough
seizures requiring loading with dilantin. Baseline levels of
dilantin were negative, patient was loaded with Phophenytoin and
continued on oral load. Patient was also given IV thiamine and
folate and transitioned over to oral agents and later to
multivitamin.
Patients withdrawal symptoms were appropiately treated and no
withdrawal seizures were observed. Ataxia was noted on physical
exam, and degeneration of cerbellar vermis was noted on prior
MRI imaging, likely alcohol-related. Patient was encouraged to
follow up with recommendations of social work to assist with
alcohol cessation, although was minimally receptive to these
suggestions.
# HYPOTHERMIA / LEUKOPENIA: At presentation thought likely due
to immobilization from EtOH stupor and exposure to cold. Body
temperature normalized with conservative therapy, however in
light of leukopenia pre-emptive infectious workup was pursued
including blood and urine cultures, chest x-ray, sputum cultures
and viral infection workup. WBC continued to trend downward
until ANC was less than ~500 and Patient developed fever after
warming up to 102. He was started on Cefepime / Vancomycin.
Given complaints of back pain, CT Thoracic and Lumbar spine were
obtained which revealed no concerning findings to explain
leukopenia. Blood cultures from admission revealed a single
bottle ([**1-23**]) with corynebacterium, felt to be a contaminant.
Fevers resolved and antibiotics were stopped. The leukopenia
improved slightly prior to discharge (ANC > 500) and was felt
most likely secondary to alcohol abuse.
# FACIAL LAC: Repaired in ED, Tetanus shot given. Unable to
assess for ligamentous neck trauma given profound intoxication
on admission. Patient maintained on [**Location (un) 2848**]-J collar until mental
status improver and there was full ROM and no point tenderness.
CT c-spine and head were negative for acute process. Lesion was
reasonably well-healed at time of discharge.
# SEIZURE DISORDER: As above, patient started on phenytoin given
history of recurrent withdrawal seizures. He had several
episodes of questionable seizure during this admission
characterized by no LOC or incontinence (patient talked through
episodes) but questionable confusion (vs. uncooperative behavior
with answering orientation questions) and muscle jerks. These
movements may have been myoclonic jerks or possibly simple
partial seizure - patient received Ativan, although all events
were self-limited to less than one minute. After speaking with
members of the patient's primary care team, these events may
also have represented the "pseudoseizures" he has had in the
past. He was continued on phenytoin per neurology
recommendations and level was checked and found to be
therapeutic.
# Hepatitis B: Core antibody positive now. Was not checked in
[**2162**] (when surface Ab positive/antigen negative). Patient should
be followed for this finding.
# Spiculated lung lesion: 7-mm lesion was noted on CT scan
(incidental finding). Recommendation per radiology is for follow
up in 3 months by repeat CT scan. Patient was tested for PPD and
found to be positive. He initially reported to team that he had
never been positive in the past. Although the lesion was not
overly concerning for TB, he was placed on isolation precautions
and ruled out for active disease by three negative sputum
samples. Confirmation with his PCP later revealed that he has
been known positive for more than a decade and has already
undergone 4-drug treatment course in late [**2143**].
# Toe pain: The patient complained repeatedly of pain in his
toes. Toes were tender to palpation, with the most tender being
the left pinky toe. Out of concern for ? fracture or gout, plain
film imaging was undertaken of left foot. Other than soft tissue
swelling, no other findings were noted.
# FEN: IVFs / replete lytes prn / regular diet
# PPX: pneumoboots, no indication of PPI / H2 blocker
# ACCESS: PIV
# CODE: Full
Medications on Admission:
The patient was unable to confirm his home medications.
Meds from d/c summary [**5-/2162**]:
Phenytoin 100mg twice a day, and 200mg in the evening
Neurontin 300mg three times a day
Multivitamin
Thiamine
Folic Acid
Tramadol 50mg as needed for shoulder pain every 6 hours
Haldol 3mg twice a day
Meds per PCP [**Name Initial (PRE) 14453**]:
MVI daily
Thiamine 100 mg PO daily
Folic acid 1 g PO daily
Dilantin 200 mg PO BID
Tylenol PRN
Maalox PRN
Colace PRN
Viocase 60-16-60 1 tab TID with meals
Prilosec 40 mg PO daily
Ditropan XL 1 tab daily
Benadryl PRN insomnia
Most likely, the patient was non-compliant with most
medications.
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Phenytoin 125 mg/5 mL Suspension Sig: As directed mL PO three
times a day: 6:00 AM - 4 mL. 2:00 PM - 4 mL. 10:00 PM - 8 mL.
Please provide a 1-month supply.
Disp:*500 mL* Refills:*2*
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever: Please limit to 2 g ([**2153**] mg) per
day.
6. Maalox 200-200-20 mg/5 mL Suspension Sig: Five (5) mL PO
three times a day as needed for heartburn.
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
8. Ditropan XL 5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO once a day.
9. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
- Acute alcohol intoxication
SECONDARY:
- Seizure disorder
- Hepatitis C virus infection
- Cerebellar ataxia
- Peripheral neuropathy
- History of head injury
Discharge Condition:
Mental Status: Confused - sometimes (frequently unable to state
date correctly; poorly oriented to current events)
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted to [**Hospital1 69**] with
confusion and intoxication from alcohol. You were taken to the
ICU where your condition improved. You were then transferred to
the medical wards. While you were here, you had fevers and
received IV antibiotics. Your fevers went away. You were
monitored for alcohol withdrawal and were showing no symptoms of
withdrawal at the time of discharge. You were found to have a
swollen toe, but an x-ray of your toe showed no fracture or
inflammation of the joint.
Please take your medications as prescribed, especially the
Dilantin which will help to prevent seizure. You will need to
[**Hospital1 **] a follow up appointment with your primary care doctor
to review your medications and discuss this admission.
Followup Instructions:
PRIMARY CARE - Dr.[**Doctor Last Name 5118**]
[**Telephone/Fax (1) 5139**]
- Please call your doctor [**First Name (Titles) **] [**Last Name (Titles) **] a follow up appointment
for ~1 week after discharge. You should review your medications
with your doctor and make sure that you understand the
medications that you should be taking.
PULMONARY NODULE
- A CT scan showed a nodule in your lung. The significance of
this nodule is unclear. Please talk with your doctor and make a
plan to [**Last Name (Titles) **] a follow-up CT scan for 3 months from now to
make sure that the nodule has not changed.
Completed by:[**2163-3-16**]
|
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icd9cm
|
[
[
[]
]
] |
[
"86.59"
] |
icd9pcs
|
[
[
[]
]
] |
11931, 11937
|
5222, 10143
|
313, 320
|
12149, 12149
|
2370, 5199
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13184, 13817
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1522, 1540
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11958, 12128
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10169, 10801
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12410, 13161
|
1555, 2351
|
261, 275
|
348, 1191
|
12164, 12386
|
1213, 1351
|
1367, 1506
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,120
| 182,151
|
11590
|
Discharge summary
|
report
|
Admission Date: [**2164-6-27**] Discharge Date: [**2164-6-30**]
Date of Birth: [**2095-6-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
69yo Man with hx of DM2, HTN, dyslipidemia and CAD s/p ant/lat
MI in '[**60**] transferred from [**First Name5 (NamePattern1) 46**] [**Last Name (NamePattern1) 30746**] for mgt of CHF and
PNA. Pt reports 2 weeks of URI sx consisting of cough productive
of green sputum. On the day prior to his presentation to his
PCP, [**Name10 (NameIs) **] had nausea, vomiting and diarrhea and complaints of
dizziness. Seen by PCP and sent to [**First Name4 (NamePattern1) 46**] [**Last Name (NamePattern1) **]. In the ED, a CXR
was read as volume overload vs infiltrate. He was then diuresed
with lasix which led to hypotension requiring BP support with
Dopa. Started on CTX/Azithro. Blood cx taken at OSH grew out
gram pos diplococci and vancomycin was added. He was then
transferred to [**Hospital1 18**] on Dopamine for further management.
.
Pt was admitted to the CCU for management of the pt's
hypotension, ?sepsis and ? CHF exacerbation. In the CCU, pt was
weaned off the dopamine and given his lack of volume overload on
exam, there was no further diuresis. His BP rose to 100s/60s
off pressors and maintained with gentle fluid boluses. When
blood cx returned strep pneumo sensitive to ceftriaxone, azithro
and vancomycin were discontinued.
Past Medical History:
CAD s/p STEMI '[**60**] with stent to prox LAD.
CHF with EF 35%
HTN
Dyslipidemia
Social History:
Works as a salesman. Married and lives with wife and daughters.
Non-[**Name2 (NI) 1818**], does not drink.
Family History:
non-contributory
Physical Exam:
VS 97.9, HR 88, BP 110/70, O2 95% RA
General: sitting up in bed, NAD, pleasant
HEENT: PERRL, EOMI, MMM
Neck: Flat JVP, no bruits
CV: RRR, no murmurs, distant heart sounds
Lungs: coarse crackles bilaterally at bases; no wheezes
Abdomen: + bowel sounds, soft, NT, ND
Ext: Warm, no CCE. DP pulses 2+
Pertinent Results:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2164-6-28**] 03:13AM 13.3*# 3.94* 12.6* 37.3* 95 32.0 33.7
13.9 169
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2164-6-28**] 03:13AM 79* 10* 9* 2 0 0 0 0 0
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr
[**2164-6-28**] 03:13AM NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL
BASIC COAGULATION (PT, PTT, PLT, INR) Plt Smr Plt Ct
[**2164-6-28**] 03:13AM NORMAL 169
.
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2164-6-28**] 03:13AM 111* 33* 1.1 142 3.8 104 27 15
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2164-6-28**] 03:13AM 8.6 2.0* 1.8
.
CHEST (PORTABLE AP) [**2164-6-27**] 1:43 PM
Likely chronic scarring at the left lung base. However, there is
a new opacity in the right cardiophrenic angle as well as in the
left lower lobe suggestive of pneumonia. Clinical correlation is
advised. A repeat film when the patient's symptoms resolve is
recommended. There is no radiographic evidence of CHF.
Brief Hospital Course:
69M with history of DM2, CAD (s/p anterior STEMI [**2160**], EF35%),
here with strep pneumo bacteremia (outside hospital cultures)
and bibasilar pneumonia who developed hypotension after getting
diuresed for presumed CHF.
.
1. Pneumonia: Pt was initially treated with ceftriaxone and
azithromycin for community-acquired pneumonia and Vancomycin was
added when his blood cx grew out GPC in pairs. Once the cx
results returned as strep pneumo, azithro and vanc were stopped.
On day of discharge, he was changed to po levaquin which the
strep pneumo was also sensitive to (per OSH micro lab). Blood
cx at [**Hospital1 18**] were no growth at discharge. Pt will continue
Levaquin for total of 14 days.
.
2. CHF: Pt was EF of 35% on [**2163**] echo. Due to a presumed CHF
exacerbation at OSH, he was diuresed and then became
hypotensive. Pt was likely volume depleted due to vomiting and
diarrhea and then became hypotensive after receiving lasix. No
evidence of volume overload on exam or on CXR. Pt was weaned
off dopamine and received gentle fluid boluses to maintain
MAP>50. Once his BP was back to baseline, his lasix, coreg and
lisinopril were restarted.
.
3. CAD: Pt with MI in [**2160**] s/p stent but no active ischemia.
Continued ASA, statin, BB, ACE-I
.
4. DM: Continued Metformin, Avandia, RISS.
.
Medications on Admission:
Glucophage 1000 [**Hospital1 **]
Avandia 8
Lasix 40 PO BID
Aspirin 325
Coreg 6.25 [**Hospital1 **]
Lisinopril 2.5
Lipitor 20
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Rosiglitazone Maleate 4 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
3. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Metformin HCl 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 8 days.
Disp:*8 Tablet(s)* Refills:*0*
6. Coreg 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1. Strep pneumonia bacteremia
2. Pneumonia
3. Hypovolemia excerbated by diuresis
.
Secondary Diagnoses:
1. CAD s/p STEMI
2. CHF, EF 35%
3. Hypertension
4. Dyslipidemia
Discharge Condition:
good
Discharge Instructions:
Take all medications as prescribed. You have a pneumonia and
bacteria in your blood so please take your antibiotic as
directed. Call your PCP if you experience fevers, chills, abd
pain, nausea/vomiting, shortness of breath.
Followup Instructions:
Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], at [**Telephone/Fax (1) 26647**] to make an
appointment in the next 1-2 weeks.
|
[
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
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5459, 5465
|
3308, 4624
|
325, 331
|
5696, 5702
|
2205, 3285
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5976, 6141
|
1852, 1870
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|
1726, 1836
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,248
| 151,741
|
27741
|
Discharge summary
|
report
|
Admission Date: [**2136-5-16**] Discharge Date: [**2136-5-17**]
Date of Birth: [**2112-6-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
23 y/o with PMH sig for PSA (Cocaine, Xanax, Methadone, Heroin,
prior IVDU), Medflighted to [**Hospital1 18**] after agitation and subsequent
seizure activity noted on a fishing vessel (patient works as a
commercial fisherman). After speaking with patient's mom,
patient has been using drugs since approx age 16, was ?clean up
until 2 weeks ago, when started to begin using again. Mom unsure
which drugs that he's using, but in the past has favored
Methadone, Cocaine, Heroin, Xanax and has had IVDU in the past.
Pt has been using approx for 2 weeks, and went to work on a
commercial fishing boat for the past 3 days or so. Unclear if or
what he was using on the boat. The captain noted increasing
agitation prior to siezure, which then culminated in a TC
seizure with subsequent tongue biting and LOC on boat. Medlight
called, intubated in field and flown to [**Hospital1 18**].
.
Mom also reports son getting into an altercation ~ 1 week-10d
ago in which someone threw a glass at his face, required
stiching (unclear full details).
.
In the ED, initial set of vital signs recorded as T101, HR 90,
BP 154/96, O2 sat 100%. Prior to arrival, received 500 mg
Fentanyl, 100 mg Succ, 19 mg Vec, 24 mg Etom, 2 mg versed, 4 mg
ativan by [**Location (un) **]. Of note, FS 116 in the field. Because of
fever and new onset siezures, in the ED was empirically given 2
gm CTX, 10 mg Decadron, 1 gm Dilantin, 1 gm Vanc, 2 mg Ativan x
6 for "patient restless". In speaking with the ED Resident
caring for the patient, only first round of ativan was for
?seizure activity. Subsequent doses were for patient agitation
(but NOT siezure).
Past Medical History:
Hep C, h/o drug abuse per mom (cocaine, methadone, xanax,
heroin)
No prior h/o siezures or hospitalizations
Social History:
Works as a commercial fisherman, lives at home with parents,
drug use as above, unknown tob/EtOH hx
Family History:
NC
Physical Exam:
PE: AF, 66, 105/47, 15, 99% on PS 10/5
Gen: young man in NAD, intubated and sedated
HEENT: NCAT, 2 mm facial lac over R maxilla, C-collar in place
3 mm pupils (B) that sluggish, several lacs on his nose, and
ecchymosis under R eye
Chest: CTA anteriorly
CVS: RRR, no m/r/g, JVD flat
Abd: soft, NT, ND, + BS, no HSM
Extrem: no c/c, no obvious rash identified, R hand mildly
swollen
Neuro: sedated, moves all extremities
Pertinent Results:
[**2136-5-16**] 09:38AM BLOOD Hct-33.0*
[**2136-5-16**] 05:10AM BLOOD WBC-12.5* RBC-3.48* Hgb-10.2* Hct-28.7*
MCV-83 MCH-29.4 MCHC-35.5* RDW-14.1 Plt Ct-310
[**2136-5-15**] 10:15PM BLOOD WBC-18.8* RBC-4.36* Hgb-12.9* Hct-35.9*
MCV-82 MCH-29.5 MCHC-35.9* RDW-13.5 Plt Ct-338
[**2136-5-16**] 05:10AM BLOOD Glucose-129* UreaN-15 Creat-0.9 Na-141
K-3.9 Cl-110* HCO3-20* AnGap-15
[**2136-5-15**] 10:15PM BLOOD Glucose-115* UreaN-18 Creat-0.9 Na-137
K-3.4 Cl-104 HCO3-21* AnGap-15
[**2136-5-16**] 05:10AM BLOOD ALT-25 AST-23 CK(CPK)-420* AlkPhos-68
TotBili-0.2
[**2136-5-15**] 10:15PM BLOOD ALT-31 AST-33 CK(CPK)-424* AlkPhos-75
TotBili-0.3
.
[**2136-5-15**] 10:15PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-POS amphetm-NEG mthdone-NEG
.
Imaging:
CT C-spine [**5-15**] IMPRESSION: No evidence of acute fracture or
spondylolisthesis. The prevertebral soft tissues are not well
evaluated secondary to endotracheal tube.
.
Head CT [**5-15**] IMPRESSION: No evidence of acute intracranial
hemorrhage, cerebral edema or shift of normally midline
structures.
.
R Hand XR [**5-16**] IMPRESSION: Slightly displaced fracture of the
distal second metacarpal, which on these two views does not
appear intra-articular.
.
Brief Hospital Course:
#Seizure: Patient was intubated in the field for airway
protection. He didn't have any further seizure activity but was
notably restless in bed. He was found to have an elevated WBC
and fever in the ED. He was treated empiracally with
Vancomycin, Ceftriaxone, and DMS. An LP was performed. It was
negative for mengingitis and xanthrochromia. A head CT was
negative for mass lesions or evidence of bleed. A urine tox
screen was positive for cocaine and benzodiazepines. He was
started on valium to cover for possible benzodiazepine
withdrawal. He was transferred to th [**Hospital Unit Name 153**] for further
management. His mother was called and she confirmed that he had
a history of polysubstance abuse including xanax, cocaine,
methadone, and heroin and said that he had admitted to currently
actively using drugs. She denied any significant history of
alcohol abuse. The timing of the patient going fishing and not
having access to xanax was consistent with benzodiazepine
withdrawal. He was extubated without difficulty early the next
day and remained on standing valium to treat benzodiazepine
withdrawal. He did not have any further seizure activity.
He was discharged directly from the [**Hospital Unit Name 153**] in stable condition.
.
#R Hand fracture: Patient was noted to ahve a R hand fracture.
Patient unclear when or how it happened but says that he has
been trying to "[**Doctor Last Name **] it back into place" himself, without
success. He has been taking percocet for pain. Ortho was
consulted and they recommended a cast, which the patient refused
to wear. Advised patient to follow up with either the hand
clinic here at [**Hospital1 **] or with his PCP in [**Name9 (PRE) 1727**].
.
#C spine: Patient was placed in a C-collar in the field. No
obvious fracture noted on films. He was clinically cleared once
he was extubated.
.
#Polysubstance abuse: Discussed negative impact of drugs on
patient's life and strongly advised him to consider stopping.
Medications on Admission:
None
Discharge Medications:
1. Valium 2 mg Tablet Sig: As directed Tablet PO As directed: 1
tablet every 6 hours for 2 days, then 1 tablet every 12 hours
for 2 days, then stop. .
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Benzodiazepine withdrawal
seziures
polysubstance abuse
cocaine abuse
R hand fracture
Discharge Condition:
Stable
Discharge Instructions:
You need to stop using drugs. You are at very high risk of
further medical problems if you continue using drugs, including
seizures, heart attacks, strokes, serious trauma, skin
infections which could lead to irreversible scarring, impotence,
infections including sexually transmitted diseases like
gonorrhea, syphilis, and HIV, withdrawal, and fatal overdoses.
Please consider speaking to your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 67695**]s and/or programs which can help you to stop using
drugs. This is the single most important thing you can do for
yourself and your future.
If you experience any fever, chills, chest pain, blurry vision,
loss of conciousness, or any other concerning symptoms, please
seek medical attention immediately.
You are being discharged with a prescription for valium. Please
take it exactly as ordered, one tablet every six hours for 2
days, then 1 tablet every 12 hours for 2 daysm, then stop.
Followup Instructions:
Please follow up with [**Hospital 67696**] [**Hospital **] HEALTH CENTER. [**Location (un) 10022**]
Office: ([**Telephone/Fax (1) 67697**] or 1-[**Telephone/Fax (1) 67698**]. We have made an
appointment for you on [**6-4**] at 12:30pm Monday with [**First Name4 (NamePattern1) 67699**]
[**Last Name (NamePattern1) **], NP.
Please call our Hand clinic at [**Telephone/Fax (1) 5343**] to make an
appointment to follow-up about your hand fracture. If you
prefer, you call follow up with your primary care doctor [**First Name (Titles) **] [**State **].
|
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[
[
[]
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[
"96.04",
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[
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|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,018
| 135,732
|
46113
|
Discharge summary
|
report
|
Admission Date: [**2110-9-8**] Discharge Date: [**2110-9-12**]
Date of Birth: [**2038-3-18**] Sex: F
Service: NEUROLOGY
Allergies:
Lisinopril
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Aphasia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: The patient is a 72 year old woman with a history of CAD
s/p
CABG x4, hypertension, DM2, hyperlipidemia, and CKD stage IV who
presents feeling shaky and diaphoretic at home, and in the ED
developed aphasia and then a 2 minute witnessed seizure
described
as right beating horizontal nystagmus then right gaze deviation,
clenched mouth, and clicking sounds with her mouth.
Per the EMS report, they found her seated at home at 11:28 am
complaining of shakiness and diaphoresis since this morning. She
reported she was not feeling well, but denied chest pain, SOB,
nausea/vomiting, and cough. She was found to have bp 240/120, HR
124, RR 24, SaO2 100% on RA, FSBG 330. She was oriented x3, no
facial droop, normal speech and grip strength. She appeared
shaky. She was transferred to the [**Hospital1 18**] ED.
While in the ED, FSBG 328. At 12:20 pm, the ED technician came
in
to evaluate the patient, and she was speaking jibberish. He was
asking her orientation questions, and she could appropriately
answer yes/no to her name and location, but when asked to
actually say her name or date "jibberish" came out. She was
evaluated then by the ED resident, who said she was diffusely
shaking in her bilateral arms which appeared like rigors. She
was
nonfocal but per the ED resident was speaking "word salad". A
Code Stroke was called. One minute later she had a witnessed
seizure characterized by right horizontal nystagmus then right
gaze deviation, mouth was clenched back, and making a clicking
sound with her mouth. She had a diffuse tremor or her arms, but
no generalized tonic clonic movements or bowel/bladder
incontinence. She was given Ativan 2 mg IV during the seizure
activity, and the seizure lasted a total of 2 minutes.
Afterwards
she was sleepy. The code stroke was cancelled, but emergent
neurology consult was then called.
Past Medical History:
1. CAD, CABGx4(LIMA->LAD< SVG->RCA, OM, Ramus) [**2106-7-6**]
2. HTN
3. G6PD carrier, does not have the disease.
4. DM2- Per pt, glucose well controlled with last Hgb A1c of 6.
something.
5. CRI (baseline 2.0)
6. Hyperlipidemia
Social History:
She does not smoke or drink alcohol. She is working in security
(desk job) for
[**Doctor Last Name 634**] Reuters.
Family History:
Sister with CAD at age 60s. Mother died of MI
Son has G6PD deficiency
Physical Exam:
VS: temp 98.2, bp 222/119->152/120->187/108, HR 118, RR 20, SaO2
100% on RA
Genl: Sleepy, NAD, arouses to sternal rub
HEENT: Sclerae anicteric, no conjunctival injection, oropharynx
clear
Neck: No nuchal rigidity
CV: Tachycardic, Nl S1, S2, III/VI systolic murmur best at LUSB,
no rubs or gallops
Chest: CTA bilaterally anteriorly and laterally, no wheezes,
rhonchi, rales
Abd: +BS, soft, NTND abdomen
Neurologic examination:
Mental status: Sleepy but arouses to sternal rub, this limits
her
exam. Initially does not follow commands to open eyes or squeeze
hands bilaterally. Initially does not answer orientation
questions, but upon repeat examination says her first name and
her date of birth.
Cranial Nerves: Pupils equally round and reactive to light, 3 to
2 mm bilaterally. Decreased blink to threat on the right. No
obvious facial asymmetry.
Motor/Sensation: Normal tone bilaterally. No observed myoclonus
or tremor. Withdraws bilateral upper and lower extremities to
noxious stimulus.
Reflexes: 2+ and symmetric in biceps, brachioradialis, triceps.
1+ and symmetric in knees, 0 and symmetric in ankles. Toes
downgoing bilaterally.
Gait: Deferred
Pertinent Results:
Labs on Admissions:
[**2110-9-8**] 12:30PM BLOOD WBC-17.1*# RBC-4.81# Hgb-14.1# Hct-44.1#
MCV-92 MCH-29.3 MCHC-31.9 RDW-15.3 Plt Ct-169
[**2110-9-8**] 12:30PM BLOOD Neuts-82.4* Lymphs-12.8* Monos-4.4
Eos-0.1 Baso-0.3
[**2110-9-8**] 12:30PM BLOOD PT-12.4 PTT-25.0 INR(PT)-1.0
[**2110-9-8**] 12:30PM BLOOD Glucose-322* UreaN-54* Creat-3.1* Na-147*
K-3.9 Cl-108 HCO3-22 AnGap-21*
[**2110-9-8**] 12:30PM BLOOD ALT-29 AST-39 LD(LDH)-682* CK(CPK)-483*
AlkPhos-83 TotBili-1.0
[**2110-9-8**] 12:30PM BLOOD CK-MB-7 cTropnT-0.02*
[**2110-9-8**] 10:25PM BLOOD CK-MB-6 cTropnT-0.02*
[**2110-9-8**] 12:30PM BLOOD Albumin-3.6 Calcium-9.1 Phos-3.0 Mg-2.2
[**2110-9-8**] 12:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2110-9-8**] 03:31PM BLOOD Lactate-2.5*
[**2110-9-8**] 01:35PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019
[**2110-9-8**] 01:35PM URINE Blood-LG Nitrite-NEG Protein-500
Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2110-9-8**] 01:35PM URINE RBC-[**11-14**]* WBC-[**2-27**] Bacteri-FEW Yeast-NONE
Epi-[**2-27**]
[**2110-9-8**] 04:13PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-375*
Polys-51 Lymphs-27 Monos-22
[**2110-9-8**] 04:13PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-47* Polys-5
Lymphs-70 Monos-25
[**2110-9-8**] 04:13PM CEREBROSPINAL FLUID (CSF) TotProt-77*
Glucose-175
Labs Prior to Discharge
[**2110-9-12**] 05:10AM BLOOD WBC-10.6 RBC-3.69* Hgb-10.7* Hct-33.0*
MCV-89 MCH-28.9 MCHC-32.4 RDW-16.2* Plt Ct-210
[**2110-9-12**] 05:10AM BLOOD Neuts-70.0 Lymphs-18.3 Monos-5.1 Eos-5.9*
Baso-0.6
[**2110-9-12**] 05:10AM BLOOD Glucose-172* UreaN-54* Creat-3.1* Na-138
K-3.9 Cl-106 HCO3-21* AnGap-15
[**2110-9-12**] 05:10AM BLOOD ALT-84* AST-47* LD(LDH)-415* AlkPhos-87
TotBili-0.4
[**2110-9-12**] 05:10AM BLOOD Albumin-3.1* Calcium-8.1* Phos-3.7 Mg-2.0
[**2110-9-9**] 05:30AM BLOOD Triglyc-156* HDL-40 CHOL/HD-5.5
LDLcalc-148*
[**2110-9-9**] 05:30AM BLOOD %HbA1c-7.5*
Imaging:
FINDINGS: There are extensive confluent T2 hyperintensities
throughout the
bihemispheric white matter, as well as extending into the deep
brain nuclei,
predominantly involving the thalami and to a lesser extent
lentiform nuclei.
Similar signal abnormality is present within the brainstem,
particularly the
dorsal pons and midbrain. Subtle scattered FLAIR hyperintense
foci are also
noted in the cerebellar hemispheres. There is a punctate region
of restricted
diffusion within the left centrum semiovale (series 702, im 22).
The remainder
of the elsions do not demonstrate restricted diffusion. There
are no findings
of intracranial hemorrhage. The ventricles and cerebral sulci
are
unremarkable. There is small amount of fluid/mucosal thickening
in the left
mastoid air cells.
IMPRESSION:
1. Extensive confluent signal abnormality within bihemispheric
white matter,
as well as the deep brain nuclei and brainstem. While the
changes could
relate to severe microvascular disease, some of the lesions are
atypical- in
the right frontal and temporal lobes and bilateral thalami.
Addiitonal
superimposed causes related to inflammatory, infective etiology,
drug-
induced/immunosuppression related conditions are also in the
differential
diagnosis with less likely possibility of neoplastic etiology
for some
lesions. Assessment is limited due to lack of IV contrast, which
could not be
given due to renal failure.
Correlation with labs, LP and a close follow up study if
possible with GAdo
can be considered to assess interval change.
2. Single punctate focus of restricted diffusion within the left
centrum
semiovale compatible with acute infarct which could be either
embolic or
watershed in etiology.
Radiology Report CAROTID SERIES COMPLETE Study Date of [**2110-9-9**]
8:24 AM
Findings: Duplex evaluation was performed of bilateral carotid
arteries. On
the right there is mild heterogeneous plaque in the ICA. On the
left there is
mild heterogeneous plaque in the ICA. Tortuous left ICA.
On the right systolic/end diastolic velocities of the ICA
proximal, mid and
distal respectively are 67/16, 70/18, 80/22 cm/sec. CCA peak
systolic
velocity is 64 cm/sec. ECA peak systolic velocity is 119 cm/sec.
The ICA/CCA
ratio is 1.3. These findings are consistent with <40% stenosis.
On the left systolic/end diastolic velocities of the ICA
proximal, mid and
distal respectively are 69/14, 92/18, 81/17 cm/sec. CCA peak
systolic
velocity is 69 cm/sec. ECA peak systolic velocity is 54 cm/sec.
The ICA/CCA
ratio is 1.2. These findings are consistent with <40% stenosis.
There is antegrade right vertebral artery flow.
There is antegrade left vertebral artery flow.
Impression: Right ICA stenosis <40%.
Left ICA stenosis <40%.
TTE ([**9-10**])
Conclusions
The left atrium is mildly dilated. The interatrial septum is
aneurysmal. No atrial septal defect or patent foramen ovale is
seen by 2D, color Doppler or saline contrast with maneuvers.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. 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. There is a minimally
increased gradient consistent with minimal aortic valve
stenosis. No 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. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: No cardiac source of embolism identified. Mild
symmetric left ventricular hypertrophy with preserved global and
regional biventricular systolic function. Diastolic dysfunction.
Minimal aortic stenosis.
Compared with the report of the prior study (images unavailable
for review) of [**2106-6-30**], the aortic valve is now minimally
stenotic. The other findings are similar.
Radiology Report MRV HEAD W/O CONTRAST Study Date of [**2110-9-9**]
10:01 PM
FINDINGS:
There is narrowing of the left transverse sinus and sigmoid
sinus, reflecting
hypoplasia rather than thrombosis. There is apparent attenuation
of the
superior sagital sinus on the vertical posterior portion
reflecting artifact.
The remainder of the dural venous sinuses are normal. The deep
cerebral veins
are also normal.
IMPRESSION:
No evidence for cerebral venous thrombosis.
Brief Hospital Course:
Ms. [**Known lastname 3175**] is a 72 year old woman with a history of CAD s/p CABG
x4, hypertension, DM2, hyperlipidemia, and CKD stage IV who
presented on [**9-8**] with headache, visual disturbance and a
witnessed seizure in the setting of hypertension.
# Neuro: The patient's initial exam was limited by sleepiness
felt to be post-ictal in nature. Head CT showed a hypodensity
in her left temporal lobe, which was felt to be a chronic
infarct. An MRI/MRA was obtained and showed diffuse white
matter changes as well as bilateral thalamic hyperintensities on
T2 flare. She was admitted to the stroke service. Her blood
pressures were intially in the 160's (systolic) but began to
rise, with minimal response to oral anti-hypertensives. Given
the increasing blood blood pressure with MRI findings, a
decision was made to transfer Ms. [**Known lastname 3175**] to the ICU given the
concern for possible hypertensive encephalopathy. At the ICU,
Ms. [**Known lastname 3175**] was started on IV drip of Nicardipine and blood
pressures stabilized. MRV was done to rule out sinus venous
thrombosis with results showing, no evidence of cerebral venous
thrombosis. Clinically, Ms. [**Known lastname 3175**] started to improve with
improvement of speech with no word finding difficulty. It was
suspected that her episode was due to hypertensive
encephalopathy, in the context of not being able to tolerate her
blood pressure medication during her episode of gastroenteritis
prior to admission. She was restarted on her home blood
pressure regimen, and her mental status improved, with no
deficits on discharge. She did have a very small stroke on MRI,
for which she was switched from ASA to Plavix. She should
continue on her simvastatin, however LFTs were very mildly
elevated on discharge, and should be rechecked in [**12-27**] weeks.
She will need a repeat MRI in 3 weeks to evaluate progression,
and will follow-up with Neurology in 4 weeks.
# Renal: While in the ICU, Ms. [**Known lastname 98113**] renal condition started
to decrease. On admission her creatinine was 3.1. While in the
ICU, the creatinine increased to 3.6.
Renal was consulted made the recomendation that since FeNa 0.4%
was uninterpretable in setting of active diuresis, and FeUrea
28% was consistent with perfusion-related kidney injury the
likely cause of the decreased renal function was likely
malignant nephrosclerosis, and acute worsening of renal function
may be a byproduct of successful lowering of BP to desired
range. The reccomendation was made to treat hypertension with
the same goals and avoid ACE inhibitors/ARBS. On the day of
discharge her creatinine had begun to improve to 3.1. She will
follow-up with her outpatient nephrologist.
#Heme: The patient also missed her regular EPO shot that she
regularly receives in the outpatient setting. Nephrology has
recommended that she hold EPO in the immediate time period given
the potential to increase blood pressures. This will be
readdressed at her outpatient nephrology appointment.
#ID: Urine culture positive for gardnerella vaginalis, received
single dose of metronidazole. Patient was afebrile throughout
hospital course.
Medications on Admission:
Amlodopine 10mg daily
Atorvastatin 60mg daily
Calcitriol 0.25mcg daily
Aranesp every other week
Furosemide 80mg dialy
Ezetimibe 10mg daily
Hydralazine 50m QID
Isosorbide Dinitrate 40mg [**Hospital1 **]
Latanoprost 1 gtt ou at bedtime
Metoprolol 75mg PO BID
Valsartan 320 mg PO daily
ASA 81mg PO daily
FeSO4 325mg PO daily
Humulin 70/30 20u twice daily
MVI
Procrit
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO QID (4 times
a day).
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Twenty (20) units Subcutaneous twice a day.
11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Aranesp (Polysorbate) 100 mcg/0.5 mL Syringe Sig: One (1)
syringe Injection once a month.
13. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
14. Atorvastatin 60mg Daily
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Posterior Reversible Leukoencephalopathy (PRES); hypertensive
encephalopathy
2. Acute Stroke, Ischemic, Left centrum semiovale
3. Acute renal failure (worsening of chronic)
Discharge Condition:
Stable condition. Neurologic exam shows intact attention,
language (naming, comprehension, and repetition); mild Right
pronator drift, 4+/5 strength at bilateral triceps, IP, and HS;
intact sensation; mild hyperreflexia at right patella; all else
normal.
Discharge Instructions:
You were admitted with difficulty speaking and a seizure, which
was found to be due to PRES, an encephalopathy due to
hypertension (high blood pressure). The treatment of this is
control of your blood pressure, which was done in the ICU. Due
to your high blood pressure, you also had worsening of your
kidney function. As a result, we made some changes in your
medications: your Lasix dose was cut in half; your Diovan was
(temporarily) stopped, and your metoprolol was increased. You
should discuss these changes with your PCP as your renal
function improves.
.
In addition, you have been started on Plavix. You may take this
in place of aspirin to prevent future strokes. Finally, you have
been scheduled to have a repeat MRI of the brain as an
outpatient to ensure resolution of the changes we saw. Please
take all medications as directed and keep all follow-up
appointments.
.
If you have any further difficulty speaking, difficulty with
vision, loss of consciousness, weakness, numbness, or facial
droop, please call 911. If you have any questions about your
neurologic care, you may call Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 2574**].
Followup Instructions:
Please call your PCP's office at [**Telephone/Fax (1) 3581**] on Monday to
schedule a follow-up appointment. You should ask to speak to Dr. [**Name (NI) 95215**] nurse, [**Doctor First Name **] M., so that she can schedule you to be
seen in the next week.
.
In addition, you have the following appointments scheduled:
1. RADIOLOGY: Outpatient Head MRI Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2110-10-7**] 3:00
2. Neurology: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2110-10-13**] 1:30
3. Nephrology (Kidney): [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2110-10-15**] 10:00
4. Cardiology: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2111-2-2**] 4:40
.
If you cannot keep any of these appointments, please call the
number listed to re-schedule.
|
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icd9cm
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[
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|
2432, 2549
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,085
| 103,232
|
35244
|
Discharge summary
|
report
|
Admission Date: [**2121-12-2**] Discharge Date: [**2121-12-5**]
Date of Birth: [**2063-8-31**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
bile leak s/p cholecystectomy requiring transfer for [**First Name3 (LF) **]
Major Surgical or Invasive Procedure:
[**First Name3 (LF) **] [**2121-12-2**] with plastic stent placement
History of Present Illness:
58-year-old man with history of HTN, hyperlipidemia, now s/p
laparoscopic cholecystectomy on [**2121-12-1**] at OSH complicated by
major bile leak, was transferred to [**Hospital1 18**] for [**Hospital1 **].
The patient presented to [**Hospital 498**] [**Hospital 2725**] Hospital on [**11-29**] with
RUQ pain, nausea, vomiting, was diagnosed with cholecystitis,
started on levoflox and metronidazole. His WBC was 9.2, Hct 47,
plt 254. Tbili 1.4, AST 270, ALT 270, amylase 271. His abx
regimen was then changed over to ertapenem. On [**11-30**] he
underwent a lap cholecystectomy after which he developed severe
abdominal pain. He went to OR again on [**12-1**] and was found to
have bile peritonitis. Lap chole incisions were used to irrigate
abdominal cavity and 2 JP drains were placed. Abx was changed to
pip-tazo. WBC increased to 13.8 with no left shift. Was
transferred to [**Hospital1 **] for [**Hospital1 **].
On arrival to the ICU, the patient was in no acute distress,
with stable vitals, conversational, but complaining of RUQ
abdominal pain.
ROS: The patient denies any fevers, chills, weight change,
diarrhea, constipation, melena, hematochezia, chest pain,
shortness of breath, orthopnea, PND, lower extremity oedema,
cough, urinary frequency, urgency, dysuria, lightheadedness,
gait unsteadiness, focal weakness, vision changes, headache,
rash or skin changes.
Past Medical History:
HTN, benign
Hyperlipidemia
Bile peritonitis s/p laprascopic cholecystectomy (prior to
transfer)
Social History:
Drinks 2 beers/day. No drug or tobacco use.
Family History:
All family members had gallbladder/gallstone issues with
cholecystectomies. Brother died of lung ca.
Physical Exam:
Vitals: Tm 100.2 Tc 98.5 113/77 P70 R18 95%RA
GEN: Middle-aged man in no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
CV: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: 2 JP drains in place, soft, nontender
EXT: No C/C/E
NEURO: alert, oriented to person, place, and time. Moves all 4
extremities.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
Admission labs:
[**2121-12-2**] 02:34AM BLOOD WBC-10.0 RBC-4.05* Hgb-13.6* Hct-38.1*
MCV-94 MCH-33.6* MCHC-35.7* RDW-12.1 Plt Ct-196
[**2121-12-2**] 02:34AM BLOOD PT-13.5* PTT-28.3 INR(PT)-1.2*
[**2121-12-2**] 02:34AM BLOOD Glucose-104 UreaN-12 Creat-1.2 Na-143
K-3.8 Cl-107 HCO3-27 AnGap-13
[**2121-12-2**] 02:34AM BLOOD ALT-146* AST-85* LD(LDH)-226 AlkPhos-64
Amylase-86 TotBili-1.1
[**2121-12-2**] 02:34AM BLOOD Lipase-90*
[**2121-12-2**] 02:34AM BLOOD Calcium-8.5 Phos-2.4* Mg-2.3
.
.
Discharge:
[**2121-12-4**] 06:50AM BLOOD WBC-7.7 RBC-3.73* Hgb-12.3* Hct-34.8*
MCV-93 MCH-33.0* MCHC-35.4* RDW-11.9 Plt Ct-255
[**2121-12-4**] 06:50AM BLOOD Glucose-95 UreaN-15 Creat-0.9 Na-139
K-3.6 Cl-106 HCO3-24 AnGap-13
[**2121-12-4**] 06:50AM BLOOD ALT-73* AST-32 LD(LDH)-166 AlkPhos-56
TotBili-0.8
[**2121-12-4**] 06:50AM BLOOD Albumin-3.3* Calcium-8.7 Phos-2.5* Mg-2.4
.
Pending (Please follow up)
[**2121-12-2**] 5:46 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
.
.
[**Month/Day/Year **] Report:
Impression: The major papilla appeared normal.
The common bile duct, common hepatic duct, right and left
hepatic ducts,and biliary radicles were filled with contrast
and well visualized. There was no evidence of stricture,
dilation or filling defects.
Cystic stump moderate bile leak identified.
Successful biliary endoscopic sphincterotomy performed in the 12
o'clock position using a sphincterotome over an existing
guidewire.
Successful placement of a 10Fr x 7cm plastic stent in the common
bile duct.
Recommendations:
Follow up for stent removal in 4 weeks.
.
Radiology Read of [**Month/Day/Year **]:
[**Month/Day/Year **]: Eighteen spot fluoroscopic images were obtained by
gastroenterology
without a radiologist present. Initial spot radiographs
demonstrate
indwelling surgical drains and surgical clips. Subsequent
cholangiogram
displayed no gross filling defects in the CBD and filling of the
cystic duct which displayed active extravasation. Proximal left
and right biliary ducts are normal with aberrant insertion of
the right posterior duct into the proximal left hepatic duct.
Final image displays placement of indwelling biliary plastic
stent.
IMPRESSION: Cystic duct stump leak status post stenting. Slight
variant
anatomy as described above.
Brief Hospital Course:
Mr. [**Known lastname 33976**] is a 58-year-old man with history of HTN, HL s/p
laparoscopic cholecystectomy on [**2121-12-1**] at OSH with major bile
leak, s/p 2 JP drain placements was transferred to [**Hospital1 18**] for
[**Hospital1 **].
.
# Bile peritonitis: post-cholecystectomy complication. Already
received abdominal cavity irrigation. Broad-spectrum abx started
on admission. [**Hospital1 **] was done [**12-2**] showing moderate bile leak
identified in the cystic stump. A successful biliary endoscopic
sphincterotomy was performed as well as placement of a 10Fr x
7cm plastic stent in the common bile duct. LFT's trended down.
Zosyn continued until [**12-5**]; no evidence of infection, pt
remained afebrile.
.
Original plan was for pt to be transferred back to [**Hospital1 498**]
[**Location (un) 2725**], however no beds were available in days following [**Location (un) **].
Discussed with Dr. [**Last Name (STitle) 80423**] (referring surgeon), and plan made to
consult [**Hospital1 18**] surgery. Surgery recommended discontinue
antibiotics, and leave drains in place. Pt stable for
discharge, and to follow up with Dr. [**Last Name (STitle) 80423**] as an outpatient
(scheduled [**12-9**]). Pt agreeable to plan.
.
Pt felt progressively better througout hospitalization, with
decreasing abdominal pain. No pain while in bed, and [**6-14**] pain
while up ambulating; improved with oxycodone 10 mg. JP drains
(2) draining only 10cc each over 8 hrs prior to discharge;
non-bilious.
.
# HTN: Blood pressure remained stable in 110's SBP off of BP
meds. BP meds held on discharge; patient to follow up with PCP.
.
# Hyperlipidemia: Simvastatin on hold at this time. Pt to follow
up with PCP.
.
Pt will be provided VNA services for management of
drains/dressing changes.
Medications on Admission:
Home meds:
simvastatin 40 mg qday
lisinopril/HCTZ 10/12.5 mg qday
.
Medications on transfer to [**Hospital1 18**]:
pip-taz
lisinopril/HCTZ (held b/c NPO)
metoprolol IV prn
pantoprazole
hydromorphone
morphine
metoclopramide
ketorolac
Discharge Medications:
1. 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*
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
# Bile peritonitis
Discharge Condition:
stable
Discharge Instructions:
Take your medications as prescribed and follow up with Dr.
[**Last Name (STitle) 80423**], your PCP, [**Name10 (NameIs) **] the [**Name10 (NameIs) **] team for stent removal.
.
Return to emergency department if you develop fever, chills,
nausea, vomiting, increasing abdominal pain, jaundice, redness
around abdominal incisions, if drainage into drains increases
significantly or becomes green (bilious), or any other concern.
Followup Instructions:
Dr. [**Last Name (STitle) 80423**], Surgery: [**12-9**] at 10 am.
.
Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS Date/Time:[**2121-12-30**] 8:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2121-12-30**] 8:30
.
Please call to schedule a follow up appointment with your PCP
within the next several weeks.
|
[
"E878.6",
"567.81",
"272.4",
"401.1",
"997.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85",
"51.87"
] |
icd9pcs
|
[
[
[]
]
] |
7360, 7419
|
4975, 6764
|
393, 464
|
7482, 7491
|
2660, 2660
|
7966, 8374
|
2072, 2175
|
7048, 7337
|
7440, 7461
|
6790, 7025
|
7515, 7943
|
2190, 2641
|
3657, 4952
|
276, 355
|
492, 1874
|
2676, 3623
|
1896, 1994
|
2010, 2056
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,353
| 165,612
|
16916
|
Discharge summary
|
report
|
Admission Date: [**2110-4-5**] Discharge Date: [**2110-4-11**]
Date of Birth: [**2063-1-2**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3021**]
Chief Complaint:
Seizure.
Major Surgical or Invasive Procedure:
[**2110-4-8**] Left Frontal craniotomy.
History of Present Illness:
47 YO M w hypertension, hypothyroidism and renal cell carcinoma
on sutent presenting after likely seizure earlier on the date of
admission. The patient was on vacation with his 3 children (ages
8, 11 and 15) in [**State 3914**]. He was feeling fine until the morning
of admission when he felt he was having a violent dream and
started screaming. His son apparently awoke when he heard the
screaming and saw the patient shaking, his arms in the
decorticate position with blood coming from his nose. The
patient's son tried to position the patient on his side but the
patient fell out of bed to the ground. He scratched his left
upper arm but does not think he sustained any other injuries
upon falling. He continued to shake for another 30-45 seconds
but then stood up and got into bed and fell back asleep. His son
tried talking to him but the patient did not respond. His son
called 911. The patient remembers waking up with a police
officer over him. He vomited twice and noted tongue pain. EMS
arrived and he was taken to [**Hospital 5583**] [**Hospital 12018**] Hospital where
he underwent CT head which showed left frontal edema. He was
given zofran and dexamethasone 10mg IV and transferred to [**Hospital1 18**]
where he gets his usual oncologic care.
Upon arrival to the ED, his VS were: 97 70 140/80 18 99%. His
neuro exam by both the ED physicians and neurology was
unremarkable aside from scattered tongue hematomas. He underwent
repeat CT head which showed left frontal edema c/f underlying
mets given clinical history with recommendation for MRI. He was
given keppra 1000mg PO once. After discussion with neurology and
heme-onc, the patient was felt appropriate for heme-onc
admission with neuro consultation.
.
Upon arrival to the floor, the patient reports essentially
feeling himself. He endorses recent intertriginous groin
irritation which resolved but no other s/s infection. He denies
fevers, chills, night sweats, cough, shortness of breath, chest
pain, abdominal pain, constipation, melena or hematochezia.
Past Medical History:
Hypertension
hypothyroid
.
- [**10/2101**]: Diagnosed when the patient presented with hematuria.
CT scan demonstrated a left renal mass.
- [**2101-11-11**]: Left nephrectomy: 8.5 x 7.5 x 7 cm clear cell
carcinoma of the left kidney, margins clear. Tumor grade [**3-13**].
There was a single pulmonary nodule noted, which was
PET-negative.
- [**3-/2102**]: CT scan demonstrated multiple small pulmonary
nodules
in the right lower lobe, left upper lobe, right lower lobe.
- [**6-/2102**]: Subsequent CT scan demonstrated an increase in the
size of the pulmonary nodule.
- [**9-/2102**]: High-dose IL-2 therapy initiated. Subsequent CT
scans demonstrated slow disease progression.
- [**6-/2103**]: The patient started on SU011248 sunitinib trial. He
subsequently experienced multiple adverse effects of the drugs,
including nausea, vomiting, diarrhea, gastroesophageal reflux
and
headaches; for this reason he elected to continue the drug off
protocol following dose modifications.
- [**2105-6-15**] CT showed disease progression
- [**7-/2105**] resume sutent
- [**2106-8-16**]: sunitinib dose changed from 37.5 to 50 daily (2 weeks
on, 1 week off dosing schedule)
- [**2106-10-15**] VATS with LUL and LLL wedge resection with Dr.
[**Last Name (STitle) 17109**]
- [**2106-10-25**] resumed sunitinib 37.5 two weeks on, one week off with
some treatment interruption due to wound healing, restarted
[**2106-12-20**]
- [**2107-12-26**]: CT showed increasing right upper lobe nodule
- [**2108-2-23**]: underwent right VATS with RUL wedge resection x3 by
Dr. [**Last Name (STitle) **]; pathology consistent with metastatic renal cell
carcinoma, including multiple lymph nodes; resumed sunitinib
[**2108-3-19**]
- [**2108-10-9**]: re-staging CT scan: Interval increase in size of
abnormal soft tissue in the azygoesophageal recess. A
paraesophageal lymph node is also markedly increased in size.
- [**2108-12-3**]: re-staging CT scan: Interval decrease in size of
soft
tissue lesion in the right paraesophageal region. Interval
decrease in size in pulmonary nodules. No new lesions identified
- [**2109-11-26**]: re-staging CT scan: Slight increase in right
paraesophageal mass and left lower lobe pulmonary nodules. No
new
lesions.
- [**2109-6-4**]: re-staging CT scan: Mild interval increase in the
right paraesophageal lymph node mass. Stable left lower lobe
pulmonary nodule. No new metastatic lesions detected in the
chest, abdomen and pelvis
- [**2109-7-29**]: re-staging CT scan: Unchanged size and appearance of
left lower lobe pulmonary nodule and right paraesophageal mass.
No new metastatic lesions are identified.
- [**2109-11-4**]: re-staging CT scan: Interval decrease in size of a
necrotic-appearing azygoesophageal nodal conglomerate and left
lower lobe pulmonary nodule. No new metastatic foci identified.
- [**2110-2-12**] re-staging CT scan shows disease progression in the
chest as well as a new left adrenal lesion.
Social History:
He is a software engineer. He continues to work.
He is married and has 3 children.
Originally from [**Country 2559**].
Denies tobacco and EtOH.
Family History:
No family history of cancer.
Physical Exam:
ADMISSION EXAM:
Vital Signs: 96.6 130/80 80 20 97% RA
GENERAL: Well-developed, obese man in no acute distress.
HEENT: Pupils are equal, round, and reactive to light. No
scleral icterus or conjunctival erythema. Multiple ecchymotic
areas on his tongue. Dried blood in left nares.
NECK: No cervical or supraclavicular lymphadenopathy, supple.
LUNGS: Clear to auscultation bilaterally. No wheezes, rales or
rhonchi.
HEART: Regular rate and rhythm, normal S1 and S2, no murmurs,
rubs or gallops.
ABDOMEN: Large, soft, nontender, nondistended, normal bowel
sounds. No hepatosplenomegaly. No palpable masses.
EXTREMITIES: Warm and well perfused with no peripheral edema,
but no hair growth on calves.
SKIN: No rashes.
NEUROLOGIC: Alert and oriented x3, appropriate mood and affect.
Normal gait, strength, sensation, and reflexes.
Pertinent Results:
ADMISSION LABS:
[**2110-4-5**] 06:00PM
WBC-5.4 RBC-3.81* HGB-13.0* HCT-39.7* MCV-104* MCH-34.2*
MCHC-32.9 RDW-17.5* PLT COUNT-248
NEUTS-81.0* LYMPHS-17.4* MONOS-1.0* EOS-0.3 BASOS-0.3
[**2110-4-5**] 06:00PM GLUCOSE-160* UREA N-13 CREAT-1.1 SODIUM-140
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-22 ANION GAP-18 CALCIUM-9.1
MAGNESIUM-1.7
PT-12.6 PTT-21.6* INR(PT)-1.1
ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
.
[**2110-4-5**] CT HEAD: IMPRESSION: Vasogenic edema in the left
superior frontal lobe. Findings are concerning for underlying
mass lesion, likely a metastasis given the patient's history of
malignancy. MRI with gadolinium recommended for further
evaluation.
.
[**2110-3-24**] CT C/A/P: IMPRESSION:
1. Decrease in size of right periesophageal necrotic soft tissue
mass.
2. Stable size of left lower lobe pulmonary nodule.
3. Stable size of left adrenal nodule.
4. Stable size of hypoenhancing lesion in the lower pole of the
left kidney. Again this may represent a metachronous renal cell
carcinoma.
5. Diffuse fatty infiltration of the liver.
6. Previously seen intramuscular mass within the right
infraspinatus/teres minor muscle is barely visible on today's
study which may be due to slight differences in contrast bolus
timing.
.
[**2110-4-8**] MRI Brain: IMPRESSION: 12 mm x 11 mm enhancing mass at
the left posterior frontal lobe cortex and associated vasogenic
edema and a punctate focus of enhancing lesion in the right
frontal subcortical region consistent with metastatic disease.
No other abnormal enhancing areas are demonstrated.
.
[**2110-4-9**] MRI Brain: IMPRESSION: Status post left frontal
craniotomy for excision of a left frontal enhancing lesion with
residual postoperative changes. Stable tiny punctate enhancing
focus in the right frontal lobe. No evidence of acute
infarction.
.
DISCHARGE LABS:
[**2110-4-11**] 05:45AM BLOOD WBC-6.4 RBC-3.50* Hgb-11.9* Hct-37.0*
MCV-106* MCH-34.1* MCHC-32.3 RDW-16.6* Plt Ct-398
[**2110-4-9**] 03:19AM BLOOD PT-12.5 PTT-20.4* INR(PT)-1.1
[**2110-4-7**] 07:40AM BLOOD Ret Aut-1.9
[**2110-4-11**] 05:45AM BLOOD Glucose-137* UreaN-32* Creat-0.9 Na-140
K-4.6 Cl-106 HCO3-26 AnGap-13
[**2110-4-11**] 05:45AM BLOOD Calcium-8.3* Phos-3.2 Mg-2.5
[**2110-4-7**] 07:40AM BLOOD ALT-55* AST-33 LD(LDH)-253* AlkPhos-60
TotBili-0.4
[**2110-4-5**] 06:00PM BLOOD VitB12-201* Folate-9.7
[**2110-4-7**] 07:40AM BLOOD %HbA1c-6.4* eAG-137*
[**2110-4-5**] 06:00PM BLOOD TSH-0.072*
[**2110-4-5**] 06:00PM BLOOD T4-9.4 Free T4-1.5
[**2110-4-11**] 05:45AM BLOOD INTRINSIC FACTOR ANTIBODY-PND
[**2110-4-6**] 08:44AM BLOOD METHYLMALONIC ACID-Test 143
Brief Hospital Course:
47 yo man with metastatic renal cell CA admitted for a seizure
diagnosed with new left frontal met. CT and MRI confirmed a
left posterior frontal region metastasis. Consultation from
Neurosurgery, Neurology, and Radiation Oncology were made.
Dexamethasone and levetiracetam was started. EEG was done. He
then went for neurosurgical resection and had no complications.
PT/OT felt he needed no services, so he was discharged home on a
steroid taper.
.
# Brain mets: CT and MRI confirmed a left posterior frontal
region metastasis. Consultation from Neurosurgery, Neurology,
and Radiation Oncology were made. Dexamethasone and
levetiracetam was started. EEG was done. He then went for
neurosurgical resection and had no complications. PT/OT felt he
needed no services, so he was discharged home on a steroid
taper. He will need XRT to the surgical bed as an outpatient.
.
# Metastatic renal cell CA: Sunitinib was stopped given
progression of disease. He will follow-up with his primary
oncologist to discuss alternate therapy such as everolimus or
bevacizumab.
.
# Hyperglycemia: Induced by dexamethasone. Improved with taper.
No need for home insulin.
.
# Macrocytic anemia: Vitamin B12 deficiency diagnosed, intrinsic
factor Ab pending. He was started on a loading of vit B12 and
arranged for home IM injections.
.
# Hypertension: Continued outpatient atenolol and lisinopril.
.
# Hypothyroidism: Continued levothyroxine. Free T4 normal.
.
# GERD: Continued PPI.
.
# FEN: Regular diet.
.
# DVT Prophylaxis: Heparin SC.
.
# Precautions: Seizure.
.
# Full code.
Medications on Admission:
ATENOLOL 50mg daily
PROTONIX 1 tablet daily (unknown dose)
HYDRALAZINE - 10 mg Tablet q6 hours prn HTN
LEVOTHYROXINE 175 mg daily
LISINOPRIL 40mg daily
Sutent 50mg daily (last took 1 week ago) - planning to restart
[**4-7**]
ACETAMINOPHEN [TYLENOL] - (OTC) - 325 mg Tablet - 1 Tablet(s)
by
mouth as needed
CALCIUM CARBONATE [TUMS] - (OTC) - Dosage uncertain
LOPERAMIDE [IMODIUM A-D]prn
Discharge Medications:
1. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
2. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
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 for constipation.
8. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One
(1) Injection once a week: Weekly x8 weeks, then monthly.
Disp:*20 injections* Refills:*1*
9. dexamethasone 1 mg Tablet Sig: Three (3) Tablet PO every six
(6) hours for 1 days: taper as follows: 3 mg q 6hrs x 1 day (
day of discharge) then 2 mg q 6hrs for 2 days then 1 mg q6 hrs
for 2 days then 1 mg q 12 hrs x 2 days followed by 1 mg daily x
2 days and then stop. .
10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**7-16**]
hours as needed for pain.
11. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Seizure.
2. Brain metastasis.
3. Metastatic renal cell carcinoma.
4. Vitamin B12 deficiency.
5. Anemia.
6. Hyperglycemia induced by dexamethasone.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for a seizure that was caused by a new brain
metastasis from the kidney cancer. This was seen on CT and MRI
of the brain. You were started on dexamethasone to decrease the
swelling and levetiracetam (Keppra) to prevent additional
seizures. Neurology and Neurosurgery were consulted and, after
review of your case, resection of the brain met was recommended.
You underwent a surgery for a craniotomy and resection of the
brain tumor. Surgery was uneventful. You were also started on
vitamin B12 injections because of a significant deficiency in
B12.
.
MEDICATIONS CHANGES:
1. Dexamethasone (Decadron) decreasing doses every other day.
2. Levetiracetam (Keppra) 1000mg 2x a day.
3. Vitamin B12 1000mcg intramuscular injection weekly x8 weeks,
then monthly.
4. Stop sunitinib (Sutent). A new medication will be given
after discussion with Dr. [**Last Name (STitle) **].
.
PENDING RESULTS:
1. Results of brain tumor pathology.
2. Intrinsic factor antibody to help diagnose pernicious anemia,
a cause of vitamin B12 deficiency.
Followup Instructions:
1. Follow-up with Dr. [**Last Name (STitle) 3929**], Radiation oncology. Please
call ([**Telephone/Fax (1) 8082**] if you are not given an appointment by next
week.
2. Follow-up with Neurosurgery. Please call ([**Telephone/Fax (1) 88**] if
you are not given an appointment by next week.
3. Follow-up with Dr. [**Last Name (STitle) **] [**2110-4-14**].
.
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2110-4-14**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], 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: MONDAY [**2110-4-14**] at 3:00 PM
With: [**Name6 (MD) 5145**] [**Name8 (MD) 5146**], MD, PHD [**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: PSYCHIATRY
When: TUESDAY [**2110-4-15**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5750**], MD [**Telephone/Fax (1) 1387**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 551**]
Campus: EAST Best Parking: Main Garage
|
[
"198.7",
"401.9",
"198.3",
"530.81",
"244.9",
"780.39",
"197.0",
"285.9",
"790.29",
"V10.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59",
"00.39"
] |
icd9pcs
|
[
[
[]
]
] |
12388, 12394
|
9101, 10677
|
311, 352
|
12587, 12587
|
6454, 6454
|
13809, 15153
|
5548, 5578
|
11115, 12365
|
12415, 12566
|
10703, 11092
|
12737, 13786
|
8313, 9078
|
5593, 6435
|
263, 273
|
380, 2411
|
6916, 8297
|
6470, 6907
|
12602, 12713
|
2433, 5371
|
5387, 5532
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,763
| 138,474
|
31762
|
Discharge summary
|
report
|
Admission Date: [**2191-10-1**] Discharge Date: [**2191-10-5**]
Date of Birth: [**2138-1-27**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization with placement of Cypher stent in RCA
History of Present Illness:
Mr. [**Known lastname **] is a 53 year-old male with a history of CAD (s/p CABG
and prior PCI to RCA) who presented to an OSH with chest pain
and was transferred to [**Hospital1 18**] for persistent chest pain.
.
He was in his usual state of health until 4 days prior to
admission. At that time, he went fishing and walked up a large
[**Doctor Last Name **]. He experienced chest discomfort, typical for him, while
doing this. The pain is "squeezing" and is associated with
diaphoresis and nausea. It radiates to his shoulders/arms/neck.
At that time there was some associated SOB, which is not
typical for him. Over the next two days, he continued to feel
unwell, but the pain had subsided. One day prior to transfer,
he experienced "reflux" which he explains is similar to his
cardiac chest pain. This persisted with no relief from 2
percocet. He presented to the OSH for further care.
.
Blood pressure noted to be 130/70, HR 70 and irregular. Initial
troponin I (1:15pm) was 0.09 and the subsequent troponin
(5:05pm) was 0.13. His Serum Cr was 2.1. He was started on
nitro and heparin gtts.
.
Past Medical History:
CAD history:
CABG in [**10/2179**] after large dissection of mid LAD with attempted
stent repair
-LIMA-->LAD
-SVG-->OM1
-SVG-->Diag
Percutaneous coronary intervention:
-RCA: stented in [**2180**]; stented with DES [**2-/2190**]
Cath in [**2-/2190**]
LMCA: normal
LAD: 100% stenosis
LIMA: patent
LCx: small vessel
SVG-->ramus: patent
RCA: 80% eccentric distal stenosis
SVG-->diag: occluded
Other PMH:
1. Diabetes mellitus, on insulin
2. Hypertension
3. Hyperlipidemia
4. Congestive heart failure, systolic dysfunction: EF 35% (echo
[**10/2179**])
5. Complete heart block, s/p [**Company 1543**] DDD pacer [**10/2179**], changed
in [**2-8**] for complete heart block
6. Sternal wound dehiscence s/p muscle flap closure
7. Renal cell carcinoma, s/p left nephrectomy [**2186**]
8. GERD
9. Chronic pain secondary to disk disease
10. Chronic kidney disease
11. OSA
12. s/p CCY
Allergies: PCN
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Blood pressure was 140/89 mm Hg while seated. Pulse was 78
beats/min and regular, respiratory rate was 18 breaths/min and
he was satting 98% on 3L NC. Generally the patient was morbidly
obese. The patient was oriented to person, place and time. The
patient's mood and affect were not inappropriate.
.
There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. The neck was large and
it was difficult to assess JVP. There was an obvious sternal
incision scar and some chest pain with palpation. The
respirations were not labored and there were no use of accessory
muscles. The lungs were clear to ascultation bilaterally with
normal breath sounds and no adventitial sounds or rubs.
.
Cardiac exam revealed no thrills, lifts or palpable S3 or S4.
The heart sounds revealed a normal S1 and the S2 was normal.
There were no rubs, murmurs, clicks or gallops.
.
There was no hepatosplenomegaly or tenderness. The abdomen was
soft nontender and nondistended. The extremities had no pallor,
cyanosis, clubbing; there was 2+ pitting edema bilaterally.
There were no abdominal, femoral or carotid bruits. Inspection
and/or palpation of skin and subcutaneous tissue showed no
stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
[**2191-10-1**] 06:21PM BLOOD WBC-8.0 RBC-4.82 Hgb-13.6* Hct-38.8*
MCV-80* MCH-28.3 MCHC-35.2* RDW-16.1* Plt Ct-150
[**2191-10-5**] 07:10AM BLOOD Hct-39.8* Plt Ct-150
[**2191-10-3**] 07:05AM BLOOD PT-13.0 PTT-23.9 INR(PT)-1.1
[**2191-10-1**] 06:21PM BLOOD Glucose-226* UreaN-32* Creat-1.8* Na-138
K-4.6 Cl-100 HCO3-27 AnGap-16
[**2191-10-5**] 07:10AM BLOOD Glucose-215* UreaN-33* Creat-2.0* Na-138
K-4.7 Cl-100 HCO3-28 AnGap-15
[**2191-10-1**] 06:21PM BLOOD CK(CPK)-111
[**2191-10-1**] 10:53PM BLOOD CK(CPK)-99
[**2191-10-5**] 07:10AM BLOOD CK(CPK)-94
[**2191-10-1**] 06:21PM BLOOD CK-MB-6 cTropnT-0.06*
[**2191-10-4**] 01:15PM BLOOD CK-MB-5 cTropnT-0.05*
[**2191-10-5**] 07:10AM BLOOD Calcium-9.3 Phos-3.7 Mg-2.3
[**2191-10-2**] 06:05AM BLOOD TSH-1.8
EKG demonstrated a v-paced rhythm with right bundle morphology.
There were no obvious ST-T changes.
.
ETT performed on [**2190-1-29**] demonstrated decreased uptake in teh
anterior septal wall with some reuptake, fixed inferior defect,
VL dilation and an EF of 34%.
.
Cardiac cath performed on [**2190-2-11**] right coronary dominance. The
left main was free of disease; the LAD showed a known occlusion
with a patent LIMA; ramus was occluded with an open SVG; LCx was
patent and gave rise to several small marginal branches in the
posterolateral branch. It was free of significant disease. The
RCA showed an 80% focal, high-grade eccentric stenosis. The PD
and PL were free of disease.
.
Cardiac cath [**2191-10-4**]:
The initial angiography revealed an 80% instent
restenosis of the previously placed mid RCA stent. Heparin was
administered for anticoagulation. The initial strategy was to
direct
stent the lesion with a drug eluting stent using minimal amount
of
contrast given renal insufficiency and using previously placed
stent as
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. JR4 provided an excellent support. Choice PT XS wire
crossed
the lesion relatively easily. 3.0 X 18 mm Cypher [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] was
deployed
at 20 atms and postdilated with 3.5 X 12 mm Quantum Maverick at
20 atms
in the mid and proximal stent. There was no residual stenosis,
dissection, embolization or perforation. The patient experience
his
anginal pain with balloon inflations that resolved with
nitroglycerine.
1. Three vessel coronary artery disease. patent LIMA to LAD and
SVG to
D1 graft.
2. Moderate systolic and diastolic ventricular dysfunction.
3. Successful stenting of native mid RCA in stent restenosis
with Cypher
DES
.
Renal ultrasound [**2192-10-2**]:
The right kidney measures approximately 11.3 cm in diameter.
There
is a small, echogenic 9 mm focus within the left pole of the
right kidney,
appears relatively non-shadowing, but most likely represents a
noncalcified stone. No renal masses. Hydronephrosis is
present. There is good corticomedullary differentiation.
Brief Hospital Course:
54 year-old male with history of CAD and multiple risk factors,
admitted with chest pain that had not resolved.
.
1. Chest pain:
Given the high suspicion for ACS, the patient was admitted to
the CCU and put on heparin and nitro drips, without improvement
in his pain. The patient had no EKG changes and his enzymes
were negative. It was felt that his chest pain was most likely
due to GI problems, and he was given a cocktail with maalox and
lidocaine and continued on a PPI and transferred to cardiac
stepdown. He continued to have chest pain, and given his
established extensive disease, he was sent for cardiac
catheterization on [**10-4**]. He was found to have instent 80%
restenosis in his RCA and a Cypher stent was placed. Given that
he described "heartburn" that was sometimes relieved by PPI/GI
cocktail, he was advised to follow-up with a gastroenterologist
near his home in [**Location (un) 3844**] for possible EGD. He was advised
to continue his PPI on discharge.
.
2. Chronic kidney disease:
Pt had prior nephrectomy for renal cell carcinoma as well as
possible medical renal disease from DM and hypertension. His Cr
on admission was 1.8; his ACE inhibitor was held prior to cath,
and he received acetylcysteine with fluids prior to his cath.
In addition, administration of contrast was minimized during the
procedure. His Cr was 2.0 on the day following his cath. He
was instructed to go home on 5mg enalapril daily rather than
[**Hospital1 **]. He will have follow-up with his cardiologist, Dr. [**Last Name (STitle) 72469**]
on [**10-12**]. At that time, his Cr can be checked and his home
dose of enalapril can be adjusted.
.
3. Rhythm:
Patient has a dual pacer without a defibrillator. He was
monitored on telemetry, and had a few episodes of non-sustained
ventricular tachycardia, no more than 13-14 beats. His
electrolytes were closely watched and repleted as needed. In
addition, evaluation of his tracings was notable for two
different QRS morphologies. It was felt that the majority of
the time, his QRS reflected fusion beats caused by his
ventricles being paced just at the time that they were natively
firing. To test this theory, the AV delay in the pacemaker
could be increased to see if his ventricles natively contract.
He was advised to follow-up with his outpatient cardiologist for
further work-up, and an appointment was made for 1 week after
discharge from the hospital. His cardiologist's office was
[**Name (NI) 653**], and his discharge summary and relevant telemetry
tracings will be faxed to them.
.
4. CHF:
His home medicines of lasix and ACE inhibitor were initially
maintained until his enalapril had to be stopped for slight
increase in Cr. His heart failure was essentially stable during
this admission and he did not require diuresis beyond his home
regimen.
Medications on Admission:
Fenofibrate 145mg po daily
Norvasc 10mg po daily
Digoxin 250mcg po daily
ASA 81 po daily
Plavix 75mg po daily
Oxycodone 5-10mg po daily
Lipitor 10mg po daily
Toprol XL 50mg po daily
Aciphex 20mg po bid
Enalapril 5mg po bid
Furosemide 20mg po bid
Clarinex 5mg po daily
Flonase
Insulin--he describes the type as "U", unclear dose
Discharge Medications:
1. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
2. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
3. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
7. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
9. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
10. Aciphex 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
11. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO once a
day.
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day.
13. Clarinex 5 mg Tablet Sig: One (1) Tablet PO once a day.
14. Flonase 50 mcg/Actuation Aerosol, Spray Sig: [**2-8**] sprays
Nasal twice a day as needed for allergy symptoms.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Dx: CAD
Secondary Dx: DM, HTN, Systolic CHF (EF 35%), CRI
Discharge Condition:
Improved. Patient continued to have some chest pain which he
described as 'heart burn.' He was not short of breath or
diaphoretic. He was eating and drinking well and his vital
signs were stable.
Discharge Instructions:
You were admitted with chest pain; it was difficult to decide if
your pain was due to coronary artery disease or acid reflux in
your stomach. A cardiac catheterization was done and a Cypher
stent was placed in your Right coronary artery.
1. Please take all your medicines as prescribed.
2. Please go to your follow up appointments, listed below.
3. Please call your physician or come to the hospital if you
have worsening chest pain, worsening shortness of breath,
fevers, or any other concerning symptom.
4. Please continue your home regimen of insulin.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) 72469**] on [**10-12**] at 1pm.
Please arrange to see a GI doctor for a possible EGD
(endoscopy).
Completed by:[**2191-10-6**]
|
[
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"250.00",
"403.90",
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"530.81",
"327.23",
"V45.01",
"428.22",
"996.72"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.52",
"37.22",
"88.55",
"00.40",
"00.45",
"00.66",
"36.07"
] |
icd9pcs
|
[
[
[]
]
] |
11203, 11209
|
6831, 9657
|
282, 346
|
11319, 11520
|
3917, 6808
|
12124, 12308
|
2544, 2626
|
10035, 11180
|
11230, 11298
|
9683, 10012
|
11544, 12101
|
2641, 3898
|
232, 244
|
374, 1484
|
1506, 2403
|
2419, 2528
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,046
| 116,847
|
50750
|
Discharge summary
|
report
|
Admission Date: [**2195-3-5**] Discharge Date: [**2195-3-13**]
Date of Birth: [**2124-2-1**] Sex: F
Service: MEDICINE
Allergies:
Tetracycline Analogues / Zinc / Optiray 350
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
70F w/ esophageal dysmotility, parkinson's, chronic aspiration
PNA w/ J-tube in place, p/w respiratory distress. Per caretaker,
her respiratory distress began this morning when she found the
patient to be lethargic and with a 02sat of 56%. The [**Last Name (un) 105578**]
notes that, for the last 2 days, the patient was complaning of a
sore throat, productive cough and denied any fever or
chills,hemoptosis, no diarrhea or vomitting. The caretaker notes
that the patient admitted to swallowing a mint this morning.
[**Last Name (un) 4273**] any recent sick contact or change in weight. Caretaker
[**Last Name (un) **] patient had any chest pain and was oriented to self
during the episode. She reports the patient last apiration
pneumonia in [**2193**].
The patient was brought to the emergency departement with EMS.
.
In the ED VS were: T:99.2 HR:103 BP:151/62 RR:22 O2 sat26%. Labs
were notable for: Blood gas:7.32/52/430/28 BaseXS=0, Lacate 2.1,
and troponinT: <0.01. CXR showed a LLL opacity, which may
represent atelectasis, though superimposed infection cannot be
excluded. Pulmonary vasculature is mildly prominent. She
received cefepime and levofloxacin. She was found to be in
respiratory distress with thick secretions and was intubated and
transfered to the MICU.
Past Medical History:
1. Castleman's disease: unicentric. Found incidentally on
splenectomy done for "splenic pain" around [**2176**]. Has had lymph
nodes sampled in past to r/o lymphoma but all have shown
reactive lymph tissue only. Followed by Dr. [**Last Name (STitle) 410**]. (Heme/Onc)
2. anaplastic thyroid cancer s/p radical neck dissection, at
age 15
3. Esophageal webs and esophageal dysmotility. Has had numerous
esophageal dilatations.
4. Recurrent aspiration pneumonias sputum Cx growing
Pseudomonas, MRSA
5. Chronic pulmonary disease
6. MRSA osteomyelitis of olecranan s/p multiple debridements
7. Hx Bipolar d/o
8. GERD
9. Osteoporosis: has broken both hips, left in [**11-7**], right with
failed ORIF and redo at [**Hospital1 2025**]
10. Hx zoster
11. Hx depression, chronic pain
12. HTN
13. Parkinson's disease
Social History:
Retired social worker. [**Name (NI) 6934**] with walker and assistance at
baseline. No Etoh, [**Name (NI) **], drugs. Lives at home w/ 24 hour health
aid. POA = [**Name (NI) **] [**Name (NI) 105568**] (a lawyer).
Family History:
1. Father: HTN, DM, depression, died MI, age 59.
2. Mother: HTN, hypercholesterolemia, died MI, age 82.
3. Sister: HTN
Physical Exam:
ADMISSION EXAM:
VS: T: HR:63 BP:95/41 O2 sat92%
GEN: intubated, sedated. responsive to voice
HEENT: Neck supple, no LAD, JVD below clavicle.
CV:RRR distant heart sound. No murmur rubs or gallops
LUNGS: coarse breath sounds troughout.
ABD:soft, tender to palpation. no rebound, no [**Last Name (un) **]. Jtube
site surrounded by erythematous base,not warm to touch,without
exudates or ulcers of fistula.
EXT: warm and Well perfused,no edema or cyanosis
.
DISCHARGE EXAM:
General: Awake and alert
HEENT: Sclera anicteric, dry MM, 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
Skin: erythma and excoriations surrounding j-tube dressing.
patient with new j-tube
Pertinent Results:
ADMISSION LABS:
[**2195-3-5**] 11:00AM BLOOD WBC-19.7*# RBC-3.59* Hgb-10.8* Hct-33.0*
MCV-92 MCH-30.1 MCHC-32.7 RDW-15.0 Plt Ct-432
[**2195-3-5**] 11:00AM BLOOD Neuts-68 Bands-1 Lymphs-27 Monos-1* Eos-2
Baso-0 Atyps-1* Metas-0 Myelos-0
[**2195-3-5**] 11:00AM BLOOD Glucose-148* UreaN-24* Creat-1.3* Na-137
K-5.2* Cl-100 HCO3-29 AnGap-13
[**2195-3-5**] 11:00AM BLOOD ALT-4 AST-17 AlkPhos-83 TotBili-0.3
[**2195-3-5**] 11:00AM BLOOD Lipase-21
[**2195-3-5**] 11:00AM BLOOD PT-12.9 PTT-21.4* INR(PT)-1.1
[**2195-3-5**] 11:00AM BLOOD Albumin-3.2*
[**2195-3-5**] 11:05AM BLOOD Lactate-1.5
.
DISCHARGE LABS:
[**2195-3-13**] 05:45AM BLOOD WBC-11.4* RBC-3.56* Hgb-10.5* Hct-31.3*
MCV-88 MCH-29.6 MCHC-33.6 RDW-16.1* Plt Ct-380
[**2195-3-8**] 04:28AM BLOOD Neuts-65 Bands-2 Lymphs-16* Monos-9
Eos-7* Baso-1 Atyps-0 Metas-0 Myelos-0
[**2195-3-12**] 06:42AM BLOOD Glucose-84 UreaN-13 Creat-0.7 Na-140
K-4.5 Cl-102 HCO3-32 AnGap-11
.
MICROBIOLOGY:
[**2195-3-5**] Blood Cx: pending
[**2195-3-5**] Sputum Cx:
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
.
Blood Culture, Routine (Final [**2195-3-11**]): NO GROWTH
.
IMAGING: Several CXR please refer to OMR for full list.
Admission [**2195-3-5**] CXR:
1. New left lower lobe opacity, concerning for pneumonia.
2. Small left pleural effusion.
.
Following extubation CXR [**2195-3-10**]:
In comparison with the study of [**3-9**], the endotracheal tube and
nasogastric tube have been removed. Little overall change in the
diffuse
bilateral pulmonary opacifications, consistent with elevation of
pulmonary
venous pressure with bilateral pleural effusions and compressive
atelectasis. The possibility of supervening pneumonia at the
bases cannot be excluded on this image in the appropriate
clinical setting.
Brief Hospital Course:
71 F w/ esophageal dysmotility, parkinson's, chronic aspiration
PNA w/ J-tube in place, p/w respiratory distress c/w aspiration
PNA.
.
While in the MICU, the patient was treated for:
# RESPIRATORY DISTRESS: likely [**2-4**] aspiration event. Patient has
a history of aspiration PNA, her CXR shows new LLL opacity,
elevated WBC 19. The patient most likely diagnosis is an
aspiration pneumonitis which could progress to an aspiration
pneumonia. Patient had a history of PNA with pseudomonas, MRSA
and ESBL and was covered with Vancomycin([**3-5**]-) and Cefepime.
Patient also had an history of UTI with ESBL and cefepime
replaced by Meropenem ([**3-7**]-). The patient remained afebrile
while on drug regimen and WBC trended down from 21.4 to 9.47.
Patent passed SBT and RSBI and was extubated on [**3-9**] and is
stable on nasal canula. During her stay, she developed bilateral
pleural effusion which do not require diuresis at this point.
.
#J-be leak. Patient with a fistula lateral to her Jtube and has
declined surgical intervention. Currently on tube feeds.
.
# Anemia: Hct is 33.0 from a baseline of 38 in [**2194**].
Hemodynamically stable. There was no sign of active bleed
.
# Renal failure: Creatinine increased to 1.3 from a baseline of
1.0 after first dose of vancomycin and stabelize down to 0.9.
.
Course on the medical floor:
# Aspiration pneumonia: Sputum culture grew MRSA. Patient was
treated with Vancomycin and Meropenum for total 8 day course.
She was afebrile throughout her stay. Patient is a very high
aspiration risk. She was instructed not to take anything by
mouth. This was also explained to her health aide. She was
instructed that taking anything by mouth she would aspirate
which could result in death. She was discharged on home O2 NC
for O2 sat > 90% (she already has O2 at home).
.
# J-tube: There was a leak in her j-tube consequently this was
changed by IR. Patient has a fistula lateral to her J-tube and
has declined surgical intervention. Wound care saw her during
her stay and recommendations where made on discharge.
Medications on Admission:
ALBUTEROL SULFATE -
Entered by MA/[**Name2 (NI) **] Staff - 2.5 mg/3 mL (0.083 %) Solution for
Nebulization - 1 ampule(s) via nebulizer three to four times a
day as needed for shortness of breath or wheezing
ATROPINE - 1 % Drops - 2 drops(s) under tongue every 4 hours as
needed for prn for sucretions being administered by VNA
CARBIDOPA-LEVODOPA [SINEMET] - 25 mg-100 mg Tablet - 1 Tablet(s)
by mouth q4hours while awake Please give at 8 am, noon, 4 pm,
and
8 pm daily
ESCITALOPRAM [LEXAPRO] - (Prescribed by Other Provider) - 20 mg
Tablet - 1 Tablet(s) by mouth once a day
ESOMEPRAZOLE MAGNESIUM [NEXIUM PACKET] - 40 mg Susp,Delayed
Release for Recon - 1 packet by mouth once a day use as directed
FENTANYL [DURAGESIC] - 100 mcg/hour Patch 72 hr - apply one
patch
every 72 hours
FENTANYL [DURAGESIC] - 25 mcg/hour Patch 72 hr - 1 q 72 horly
GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth at bedtime
HYDROMORPHONE [DILAUDID] - 2 mg Tablet - 1 Tablet(s) by mouth
four times a day as needed for for pain
IRON POLYSACCH COMPLEX-B12-FA [FERREX 150 FORTE] - 150 mg-25
mcg-1 mg Capsule - 1 Capsule(s) by mouth once a day
LAMOTRIGINE [LAMICTAL] - (Prescribed by Other Provider) - 200
mg
Tablet - 1 Tablet(s) by mouth daily
LEVOTHYROXINE - 75 mcg Tablet - 1 Tablet(s) by mouth daily
LORAZEPAM - (Prescribed by Other Provider) - 1 mg Tablet - 1
Tablet(s) by mouth 1 tablet in a.m. and 2 tablets at H.S
ONDANSETRON HCL - 4 mg Tablet - 1 Tablet(s) by mouth three times
a day as needed for FOR NAUSEA
PRIMIDONE - 50 mg Tablet - 0.5 (One half) Tablet(s) by mouth
daily
PROMETHAZINE - (Prescribed by Other Provider) - 25 mg
Suppository - 1 (One) Suppository(s) rectally three times a day
QUETIAPINE [SEROQUEL] - 200 mg Tablet - 1 Tablet(s) by mouth at
bedtime
SODIUM POLYSTYRENE SULFONATE - Powder - 15 grams by mouth
every
other day
CALCIUM CARBONATE - 200 mg (500 mg) Tablet, Chewable - 1 (One)
Tablet(s) by mouth twice a day
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (OTC) - 400 unit
Capsule - 1 Capsule(s) by mouth twice a day
FERROUS SULFATE [IRON (FERROUS SULFATE)] - (OTC) - 325 mg (65
mg) Tablet - 1 Tablet(s) by mouth once a day
NUTRITIONAL SUPPLEMENT - FIBER [FIBERSOURCE] - (Prescribed by
Other Provider) - Liquid - 1200 calories via tube daily
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Name2 (NI) **]: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB.
2. carbidopa-levodopa 25-100 mg Tablet [**Name2 (NI) **]: One (1) Tablet PO
QID (4 times a day).
3. escitalopram 10 mg Tablet [**Name2 (NI) **]: Two (2) Tablet PO DAILY
(Daily).
4. fentanyl 100 mcg/hr Patch 72 hr [**Name2 (NI) **]: One [**Age over 90 **]y Five
(125) mcg Transdermal Q72H (every 72 hours).
5. gabapentin 250 mg/5 mL Solution [**Age over 90 **]: Three Hundred (300) mg
PO HS (at bedtime).
6. lamotrigine 100 mg Tablet [**Age over 90 **]: Two (2) Tablet PO DAILY
(Daily).
7. primidone 50 mg Tablet [**Age over 90 **]: 0.5 Tablet PO DAILY (Daily).
8. Seroquel 200 mg Tablet [**Age over 90 **]: One (1) Tablet PO at bedtime.
9. hydromorphone 2 mg Tablet [**Age over 90 **]: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
10. levothyroxine 75 mcg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY
(Daily).
11. lorazepam 1 mg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY (Daily).
12. lorazepam 1 mg Tablet [**Age over 90 **]: Two (2) Tablet PO HS (at
bedtime).
13. ondansetron 4 mg Tablet, Rapid Dissolve [**Age over 90 **]: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
14. promethazine 25 mg Suppository [**Age over 90 **]: One (1) Suppository
Rectal Q8H (every 8 hours).
15. cholecalciferol (vitamin D3) 400 unit Tablet [**Age over 90 **]: One (1)
Tablet PO BID (2 times a day).
16. ferrous sulfate 300 mg (60 mg Iron) Tablet [**Age over 90 **]: One (1)
Tablet PO DAILY (Daily).
17. iron-vitamin B complex Oral
18. sodium polystyrene sulfonate 15 g/60 mL Suspension [**Age over 90 **]: One
(1) PO every other day.
19. calcium carbonate Oral
20. esomeprazole magnesium 40 mg Susp,Delayed Release for Recon
[**Age over 90 **]: One (1) PO once a day.
21. atropine 1 % Drops [**Age over 90 **]: Two (2) drops Ophthalmic every four
(4) hours as needed for secretions.
22. nystatin 100,000 unit/g Cream [**Age over 90 **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
23. Fibersource Tube Feeds
Advance tube feeds to cycle @ 80/hr x 18hrs overnight. If she
tolerates increase to 120/hr x 12 hrs.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Aspiration pneumonia
Aspiration
Dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You developed a pneumonia after aspirating a mint. Due to severe
difficulty breathing you required a breathing tube (called
intubation) and was in the ICU for several days. Once your
pneumonia improved your breathing tube was removed. You were
treated with strong antibiotics for 8 days total.
.
DO NOT TAKE ANYTHING BY MOUTH. YOU WILL ASPIRATE AGAIN WHICH
COULD RESULT IN DEATH.
.
When you were here your feeding tube was changed by [**Hospital **].
.
Follow your medication list as printed.
Followup Instructions:
Department: [**State **]When: THURSDAY [**2195-3-19**] at 12:00 PM
With: [**First Name8 (NamePattern2) 8741**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
.
Department: NEUROLOGY
When: WEDNESDAY [**2195-5-6**] at 3:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], M.D. [**Telephone/Fax (1) 541**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2195-3-16**]
|
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"244.9",
"401.9",
"518.82",
"345.90",
"530.81",
"934.8",
"584.9",
"569.81",
"311",
"294.8",
"280.9",
"530.5",
"V15.81",
"332.0",
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] |
icd9cm
|
[
[
[]
]
] |
[
"97.03",
"96.04",
"38.93",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
12534, 12592
|
5925, 7985
|
322, 334
|
12677, 12677
|
3862, 3862
|
13330, 13967
|
2715, 2836
|
10294, 12511
|
12613, 12656
|
8011, 10271
|
12813, 13307
|
4463, 5902
|
2851, 3305
|
3321, 3843
|
261, 284
|
362, 1640
|
3878, 4447
|
12692, 12789
|
1662, 2469
|
2485, 2699
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,675
| 183,842
|
54614
|
Discharge summary
|
report
|
Admission Date: [**2139-6-18**] Discharge Date: [**2139-6-25**]
Date of Birth: [**2093-1-26**] Sex: M
Service: KIRLAND
HISTORY OF THE PRESENT ILLNESS: The patient is a 46-year-old
male with bipolar disorder and schizophrenia, history of
coronary artery disease, status post PTCA and stent in [**2139-1-24**], currently on aspirin and Plavix who presented on
[**2139-6-18**] from [**Hospital1 **] House (inpatient psychiatric facility)
with nosebleeds since [**2139-6-17**] at 8:30 p.m., left greater
than right. No history of trauma, drug use, other inciting
events. The patient has been on aspirin and Plavix since
stent [**1-26**]. The Emergency Room physician tried pressure
without effect. Merocel sponges were placed by ENT Service
but left nare still oozing blood, Epi-Stat catheter placed on
the left side in the Emergency Room. The patient's
hematocrit dropped from 42 to 31. Plavix and aspirin were
held and the patient was given clindamycin IV for
prophylaxis. Epistaxis continued despite Epi-Stat and the
patient received 2 units of packed red blood cells.
REVIEW OF SYSTEMS: The patient denied lightheadedness,
shortness of breath, cough, chest pain, palpitations.
PAST MEDICAL HISTORY:
1. Bipolar disorder with recent psychotic episode.
2. Insulin-dependent diabetes mellitus.
3. Coronary artery disease, status post MI and stent times
two in [**2139-1-24**].
4. Hypertension.
5. Hypercholesterolemia.
6. Leukemia treated in [**2123**] by Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **].
ALLERGIES: The patient is allergic to penicillin (rash,
swelling), Trilafon.
ADMISSION MEDICATIONS:
1. Plavix 15 mg p.o. q.d.
2. Aspirin 325 mg p.o. q.d.
3. Lopressor 25 mg p.o. q.d.
4. Ativan 2 mg p.o. q. eight hours p.r.n.
5. Haldol 5 mg p.o. q. eight hours p.r.n.
6. Depakote 1,000 mg p.o. b.i.d.
7. Risperdal 4 mg p.o. b.i.d.
8. Gemfibrozil 600 mg p.o. b.i.d.
SOCIAL HISTORY: The patient lives at [**Hospital1 **] House (section
XII). The patient is a one pack per day smoker. No ethanol
use. No IV drug use. Occupation: "Baseball player and
cryogenics".
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
98.7, pulse 101, blood pressure 128/56, respiratory rate 12,
saturating 97% on room air. General: The patient was a
pleasant middle-aged male, tangential speech, bloody face, in
no acute distress. HEENT: The extraocular movements were
intact. The pupils were equal, round, and reactive to light,
left nare with Epi-Stat in place and dried blood. Neck:
Supple, no lymphadenopathy, no JVD. Cardiac: Regular rate
and rhythm, normal S1 and S2. No murmurs, rubs, or gallops.
Pulmonary: Clear to auscultation bilaterally. Abdomen:
Nontender, nondistended, soft, normoactive bowel sounds, no
rebound guarding. No masses. Extremities: No clubbing,
cyanosis or edema.
LABORATORY/RADIOLOGIC DATA: On admission, white blood cell
count 8.6, hematocrit 31, platelets 343,000. Sodium 142,
potassium 5.5, chloride 107, bicarbonate 23, BUN 40,
creatinine 1.4, glucose 184.
EKG revealed a normal sinus rhythm, normal intervals, right
atrial enlargement, septal Q waves, T wave flattening in aVL.
HOSPITAL COURSE: 1. EPISTAXIS: The patient underwent a
left sphenopalatine and superior labial artery embolization
on [**2139-6-19**]. During the procedure, the patient received 2
units of packed red blood cells. At that time, a small right
posterior bleed was visualized. The patient underwent a
right sphenopalatine artery embolization on [**2139-6-22**]. The
patient received a total of 6 units of packed red blood cells
and as hematocrit had been stable for over 24 hours since
[**2139-6-22**], the patient was transferred to the general floor on
[**2139-6-23**].
The ENT Service recommended nasal saline irrigation as well
as Afrin for two days with no noseblowing, straining, heavy
lifting for two to three days and avoidance of nose
manipulation. The patient received 36 hours of clindamycin
post nasal packing removal on [**2139-6-23**]. The patient was
discharged without antibiotics.
2. CORONARY ARTERY DISEASE: Status post stent in [**1-26**].
The patient was placed on a beta blocker and gemfibrozil.
Aspirin and Plavix were initially on hold. Aspirin to be
restarted on the discretion of the patient's primary care
physician as an outpatient.
3. PSYCHIATRIC: The patient has a history of bipolar
disorder with psychotic features. The hospital course was
complicated by bouts of the patient's agitation and
psychosis. The Psychiatry Service evaluated the patient and
deemed him not capable of making his own decisions. In the
ICU, the patient's mental status was adequately controlled
with Divalproex, Risperidone, and Haloperidol.
On transfer to the floor, the patient required a one-to-one
sitter. On transfer to the floor, the patient refused
intermittently Haldol and Risperdal doses. We continued to
offer Haldol despite the patient's refusal. On discharge,
the patient was returned to a psychiatric facility at [**Hospital1 **]
House.
4. INSULIN-DEPENDENT DIABETES: The patient was controlled
on [**First Name8 (NamePattern2) **] [**Doctor First Name **] diet and regular insulin sliding scale.
5. HYPERKALEMIA: The patient was noted to have elevated
potassium on admission at 5.1 which was closely monitored and
did not require intervention.
DISCHARGE DIAGNOSIS:
1. Left and right epistaxis.
2. Bipolar affective disorder.
3. Diabetes mellitus type 2.
4. Hypertension.
5. Coronary artery disease.
6. Hypercholesterolemia.
DISCHARGE MEDICATIONS:
1. Divalproex sodium 1,000 mg p.o. b.i.d.
2. Risperidone 4 mg p.o. b.i.d.
3. Gemfibrozil 1 mg p.o. b.i.d.
4. Atenolol 25 mg p.o. q.d.
5. Haloperidol 3 mg p.o. t.i.d. The patient has been
refusing all Haldol during this admission.
6. Oxymetazoline 0.05% spray, one spray nasal b.i.d. for one
day.
7. Sodium chloride 0.65% spray, two sprays to each nare
q.i.d. for four days.
8. Benadryl 25 mg p.o. q.h.s. p.r.n. insomnia.
9. Acetaminophen 325 mg p.o. q. four to six hours p.r.n.
headache.
10. Milk of magnesia 400 mg per 5 milliliters oral suspension
30 cc p.o. q.d. as needed for constipation.
11. Regular insulin sliding scale.
DISPOSITION: The patient was discharged to a psychiatric
facility, [**Hospital1 **] House.
DISCHARGE INSTRUCTIONS: The patient was advised to return to
the Emergency Room if his nose began to bleed and did not
stop with pressure, chest pain, shortness of breath,
lightheadedness, or bright red blood in stool. The patient
was instructed to follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2139-7-2**] at 3:30 p.m. where he would need to address whether to
restart aspirin and Plavix and to have his hematocrit
monitored.
CONDITION ON DISCHARGE: Good.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**]
Dictated By:[**Last Name (NamePattern1) 14605**]
MEDQUIST36
D: [**2139-8-12**] 03:12
T: [**2139-8-15**] 08:03
JOB#: [**Job Number 111714**]
|
[
"401.9",
"414.01",
"276.7",
"250.00",
"784.7",
"285.1",
"V45.82",
"208.90",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.72"
] |
icd9pcs
|
[
[
[]
]
] |
2144, 2183
|
5624, 6357
|
5435, 5601
|
3240, 5414
|
6382, 6832
|
1652, 1925
|
1114, 1205
|
2198, 3222
|
1227, 1629
|
1942, 2127
|
6857, 7138
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,206
| 190,252
|
26528
|
Discharge summary
|
report
|
Admission Date: [**2200-11-6**] Discharge Date: [**2200-11-18**]
Date of Birth: [**2144-7-15**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Bee Sting Kit / Azithromycin / Percocet / Paclitaxel
Attending:[**Attending Info 65513**]
Chief Complaint:
Primary peritoneal cancer
Major Surgical or Invasive Procedure:
Exploratory laparotomy, debulking, TAH-RSO, small bowel
resection, abdominal wall tumor resection
History of Present Illness:
Mrs. [**Known lastname 7568**] is a 56 year old G0 woman with metastatic papillary
serous carcinoma s/p neoadjuvant carboplatin/doxil admitted s/p
ex-lap, TAH-RSO, omentectomy, small bowel resection, and
debulking.
Past Medical History:
Oncology history:
-Diagnosed in [**2200-5-6**]. Underwent a CT abd/pelv. CA-125 was
elevated at 774;
- [**2200-6-6**] had an ex lap and was found to have diffuse peritoneal
carcinomatosis involving 4 quadrants. Biopsy found ovarian
papillary serous carcinoma. Received 6 cycles of [**Doctor Last Name **]/doxil
thereafter.
Past Medical History:
1) Mitral valve prolapse.
2) Atrial fibrillation.
3) Infiltrating ductal carcinoma.
4) Meningioma
Social History:
Denies smoking, alcohol, or drug abuse. She works at the
switchboard at [**Hospital 4415**].
Family History:
Family History: Mother and sisters with breast cancer; father
lung cancer.
Physical Exam:
PHYSICAL EXAM:
AVSS
Gen: NAD
CV: Nl S1+S2
Pulm: Clear to anterior auscultation
Abd: Wound C/D
Ext: 1+ edema bilaterally.
Pertinent Results:
[**2200-11-6**] 09:45PM BLOOD WBC-7.6# RBC-2.98* Hgb-10.0* Hct-29.4*
MCV-99* MCH-33.8* MCHC-34.2 RDW-17.7* Plt Ct-219
[**2200-11-11**] 05:35AM BLOOD WBC-5.8 RBC-2.21* Hgb-7.4* Hct-21.5*
MCV-97 MCH-33.6* MCHC-34.6 RDW-16.5* Plt Ct-207
[**2200-11-12**] 02:56PM BLOOD WBC-8.5 RBC-2.64* Hgb-8.6* Hct-25.4*
MCV-96 MCH-32.6* MCHC-33.9 RDW-17.9* Plt Ct-213
[**2200-11-16**] 03:11AM BLOOD WBC-5.9 RBC-2.50* Hgb-8.2* Hct-24.0*
MCV-96 MCH-32.8* MCHC-34.2 RDW-18.1* Plt Ct-238
[**2200-11-17**] 06:35AM BLOOD WBC-6.7 RBC-2.93* Hgb-9.4* Hct-27.7*
MCV-95 MCH-32.0 MCHC-33.7 RDW-19.0* Plt Ct-275
.
[**2200-11-8**] 11:53AM BLOOD Neuts-82.1* Lymphs-8.9* Monos-8.6 Eos-0.2
Baso-0.2
[**2200-11-15**] 05:59AM BLOOD Neuts-71.0* Lymphs-15.8* Monos-9.8
Eos-2.8 Baso-0.5
.
[**2200-11-6**] 09:45PM BLOOD PT-13.2 PTT-25.0 INR(PT)-1.1
[**2200-11-8**] 07:19PM BLOOD PT-14.3* PTT-32.8 INR(PT)-1.2*
[**2200-11-14**] 09:44AM BLOOD PT-14.4* PTT-26.1 INR(PT)-1.2*
[**2200-11-17**] 06:35AM BLOOD PT-21.6* PTT-32.7 INR(PT)-2.0*
.
[**2200-11-6**] 09:45PM BLOOD Glucose-136* UreaN-17 Creat-0.9 Na-140
K-3.7 Cl-106 HCO3-25 AnGap-13
[**2200-11-11**] 05:35AM BLOOD Glucose-109* UreaN-12 Creat-0.7 Na-138
K-3.3 Cl-101 HCO3-30 AnGap-10
[**2200-11-17**] 06:35AM BLOOD Glucose-107* UreaN-12 Creat-0.8 Na-141
K-4.0 Cl-105 HCO3-27 AnGap-13
.
[**2200-11-17**] 06:35AM BLOOD LD(LDH)-255* TotBili-0.5 DirBili-0.2
IndBili-0.3
.
[**2200-11-6**] 09:45PM BLOOD Calcium-8.2* Phos-4.6* Mg-2.0
[**2200-11-12**] 06:03AM BLOOD Calcium-7.7* Phos-3.0 Mg-1.8
[**2200-11-17**] 06:35AM BLOOD Calcium-7.9* Phos-3.7 Mg-2.1
.
UCX: cx positive for e coli and enterococcus, pansensitive
.
[**11-8**] CXR: FINDINGS: In comparison with study of [**11-3**], there are
substantially lower lung volumes. Specifically, no evidence of
vascular congestion or acute focal pneumonia. There is increased
opacification at the left base in the retrocardiac region,
consistent with atelectasis and effusion. Less marked changes
are seen at the right base.
Brief Hospital Course:
Mrs. [**Known lastname 7568**] is a 56 year old G0 woman with metastatic papillary
serous carcinoma s/p neoadjuvant carboplatin/doxil who was
admitted s/p exploratory laparotomy, TAH-RSO, omentectomy, small
bowel resection and reanastamosis, and excision of abdominal
wall tumor.
.
Her postoperative course was complicated by an episode of atrial
fibrillation on POD#1, which resolved spontaneously. Urine grew
enterococcus and e. coli and she was treated with a 5d course of
macrobid.
.
On POD#8, the heparin was started to help bridge to coumadin.
She was transfused a total of 4u pRBC and her hct was stable
upon discharge.
.
She was discharged home on POD#12 in stable condition.
Medications on Admission:
Sotalol, zofran, protonix
Discharge Medications:
1. sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day).
2. sotalol 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. 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*
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever/ pain.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. warfarin 5 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Advanced ovarian cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call your doctor for:
* fever > 100.4
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* No strenuous activity, nothing in the vagina (no tampons, no
douching, no sex), no heavy lifting of objects >10lbs for 6
weeks.
* You may eat a regular diet.
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No bath tubs for 6 weeks.
* If you have steri-strips, leave them on. They will fall off on
their own or be removed during your followup visit.
* If you have staples, they will be removed at your follow-up
visit.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8244**], MD Phone:[**Telephone/Fax (1) 4775**] Date/Time:[**2200-11-20**]
10:45
.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2200-11-21**]
10:30
.
Provider: [**Name10 (NameIs) 35354**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 5777**]
Date/Time:[**2200-11-24**] 11:30 STAPLE REMOVAL
.
Provider: [**Name10 (NameIs) 35354**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 5777**]
Date/Time:[**2200-12-1**] 1:30
.
Dr. [**Last Name (STitle) **] will follow your INR and help adjust your coumadin
dosing. Please call her office with any questions or concerns.
[**Name6 (MD) 35354**] [**Name8 (MD) **] MD [**MD Number(2) 65515**]
|
[
"198.2",
"997.1",
"285.9",
"599.0",
"424.0",
"V10.3",
"278.01",
"198.89",
"158.8",
"197.4",
"041.4",
"V85.43",
"225.2",
"427.31",
"198.82",
"553.1",
"198.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"65.49",
"96.04",
"45.91",
"96.71",
"54.3",
"68.49",
"54.4",
"45.62"
] |
icd9pcs
|
[
[
[]
]
] |
5052, 5058
|
3522, 4208
|
352, 452
|
5126, 5126
|
1523, 3499
|
6151, 6958
|
1307, 1367
|
4284, 5029
|
5079, 5105
|
4234, 4261
|
5277, 5811
|
5826, 6128
|
1397, 1504
|
287, 314
|
480, 696
|
5141, 5253
|
1064, 1163
|
1179, 1275
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,068
| 192,083
|
7882
|
Discharge summary
|
report
|
Admission Date: [**2165-9-15**] Discharge Date: [**2165-9-18**]
Date of Birth: [**2090-12-5**] Sex: M
Service: MEDICINE
Allergies:
Morphine Sulfate
Attending:[**First Name3 (LF) 11495**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization with Angioplasty of the Right Coronary
Artery
History of Present Illness:
Pt is a 74 y/o man who was d/c from [**Hospital1 18**] on [**2165-9-12**] after an
ileocolectomy and ventral hernia repair for adenocarcinoma of
the ascending colon. He has a PMH significant for extensive CAD
w/ multiple interventions upon the RCA and its branches, HTN,
and hypercholesterolemia. He presented to an outside hospital
today after developing weakness and abdominal pain upon waking
up. He also noted pressure type pain across his chest that is
unlike his previous episodes of angina. He states that he has
been having multiple watery stools everyday for the past few
days and recently completed a course of Keflex.
At the outside hospital, he was afebrile, bradycardic to the
50s, and hypotensive to the 80s. His EKG demonstrated evidence
of an infero-lateral MI with ST elevations in II, III, aVF, V5-6
with reciprocal depressions in I, aVL, V2-3. He was transferred
to [**Hospital1 18**] for urgent catheterization.
At [**Hospital1 18**], his cath showed minimal irregular stenosis of the LAD,
40% hazy LCx after OM1, and a totally occluded RCA distally.
Her distal RCA and PL were both ballooned and refractory clot
was treated with abciximab. He required dopamine in the lab for
hypotension and was transferred to the CCU still on this
pressor.
Past Medical History:
1. HTN
2. AAA repair '[**58**]
3. CAD - cath w/ stenting/rotational atherectomy/brachytherapy
of the RCA/RPL/PDA in 99/00 and an EF 44%
4. Hypercholesterolemia
5. ? COPD
Social History:
Pt notes a 50pk/yr smoking history and quit about 2yrs ago. He
drinks [**3-23**] glasses of wine per day and denies other drug use.
He lives in [**Hospital1 1474**] w/ a roommate and has never been married.
Family History:
Brother had coronary artery disease, status post coronary artery
bypass graft at 57 years. Mother died of congestive heart
failure and rheumatic fever. Father with unknown history.
Physical Exam:
Gen: WNWD man lying in bed in NAD
HEENT: EOMI, PERRLA, O/P clear, MM very dry
Neck: -LAD/JVD
CV: RRR, S1/S2 wnl, -M/R/G appreciated
Lungs: CTA anteriorly
Abd: Soft, non-tender, surgical staples intact, wound C/D/I,
stomach distended and grossly deformed
Ext: -C/C/E, pulses 2+ bilaterally
Neuro: AxO x3
Pertinent Results:
Cardiac Catheterization [**8-23**]:
1. Selective coronary angiography showed a right dominant system
with
one vessel disease. The LMCA was without significant disease.
The LAD
wrapped around the apex and had minor irregularities. The LCX
was
feeding one major OM which was branching and had a hazy 40%
stenosis
after the OM. The OM did not have flow limiting stenoses. The
RCA was a dominant large vessel ond was occluded distally
withing the stent. There was a large PL and PDA system.
2. Limited resting hemodynamics showed a normal pulmonary
pressure (PA mean 24 mmHg). The right and left sided filling
pressures were normal(RVEDP 9 mmHg, PCW mean 12 mmHg). Cardiac
output was normal (CO 4.9 l/min, CI 2.3 l/min/m2)
.
RENAL ULTRASOUND FINDINGS [**8-23**]: The right kidney measures 10.4
cm and the left kidney measures 10.6 cm. There is no
hydronephrosis in either kidney. There are no focal masses in
the kidneys. In the upper pole of the left kidney, there is a
3.2 x 3.0 simple-appearing cyst, demonstrating through
transmission. Normal dromedary hump on the left kidney is
incidentally noted. There are no perirenal fluid collections.
[**2165-9-15**] 6:16 pm STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT [**2165-9-16**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2165-9-16**]):
REPORTED BY PHONE TO [**Doctor Last Name 28370**],I FA6B [**2165-9-16**] AT 1203.
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
Brief Hospital Course:
74 y/o man recently s/p abdominal surgery who presented with an
acute infero-lateral STEMI. His RCA was opened in the lab w/
ballooning and he was transferred to the CCU on dopamine for
hypotension. He was weaned from dopamine drip and transferred to
general medicine floor for further observation. He was continued
on his asa/statin/plavix and his bblocker and ace were
restarted. His Acute Renal Failure on admission resolved with
fluid hydration. His diarrhea was found to be due to C. Diff
infection and he was treated with flagyl. He was seen by the
surgery team for follow up of his colon resection. He had an
episode of confusion while on the general medicine floor during
which he pulled out his foley catheter. This was thought to be
due to ambien, which he took for sleep that night. He had a
short period of hematuria after pulling foley, but this resolved
and he was able to void without difficulty. He had no episodes
of chest pain post procedure and was discharged with follow up
with a cardiologist and prescriptions for ASA, plavix, statin, b
blocker, and ace inhibitor.
Medications on Admission:
Unknown
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO at
bedtime.
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 6 days.
Disp:*18 Tablet(s)* Refills:*0*
6. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
ST Segment Myocardial Infarction of the Right Coronary Artery
Clostridium Difficle Colitis
Chronic Diagnosis:
Hypertension
Coronary Artery Disease
Hypercholesterolemia
Abdominal Aortic Aneurysm
Discharge Condition:
Good, without chest pain. With improvement of his diarrhea, to
finish a total of ten day course of Flagyl on [**2165-9-24**].
Discharge Instructions:
Please call your doctor if you experience any chest pain or
pressure, shortness of breath, heart palpitations, an increase
in the amount of blood in your stool, or if you have difficulty
or pain urinating.
Please ensure that you follow up with all your appointments.
Followup Instructions:
Please follow up with your Cardiologist in the next week.
Please follow up with your Oncologist.
Please follow up with your Surgeon, Dr. [**Last Name (STitle) **].
Please follow up with your Primary Care Physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].
Completed by:[**2165-11-15**]
|
[
"V45.82",
"410.71",
"401.9",
"428.0",
"008.45",
"414.01",
"V10.05",
"272.0",
"441.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.01",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
6005, 6056
|
4162, 5252
|
290, 362
|
6295, 6423
|
2616, 4139
|
6739, 7049
|
2095, 2278
|
5310, 5982
|
6077, 6274
|
5278, 5287
|
6447, 6716
|
2293, 2597
|
239, 252
|
390, 1661
|
1683, 1854
|
1870, 2079
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,887
| 192,628
|
6621
|
Discharge summary
|
report
|
Admission Date: [**2147-8-10**] Discharge Date: [**2147-8-16**]
Date of Birth: [**2089-7-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Phenazopyridine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Discomfort
Major Surgical or Invasive Procedure:
[**2147-8-10**] Three Vessel Coronary Artery Bypass Grafting(left
internal mammary to left anterior descending, vein grafts to
obtuse marginal and posterior descending artery)
Past Medical History:
^chol.
HTN
NIDDM
s/p gastrectomy for gastric ca
s/p abdominoplasty
s/p appy
sleep apnea
arthritis
peripheral neuropathy
hiatal hernia
GERD
depression
b/l cataracts
distant h/o VRE
endometriosis
knee [**Doctor First Name **]
Social History:
.Disabled. Quit smoking in [**2090**] after smoking 16 years. Lives
alone and drinks 1 drink of alcohol weekly.
Family History:
Father died of MI at age 78
Physical Exam:
183/86 62 SR 66" 185#
GEN: NAD
HEART: RRR, Nl S1-S2
LUNGS: Clear
ABD: Benign
EXT: 2+ Pulses, no edema, no varicosities
NEURO: Nonfocal
Pertinent Results:
[**2147-8-15**] 08:05AM BLOOD WBC-4.1 RBC-3.54* Hgb-9.4* Hct-29.0*
MCV-82 MCH-26.7* MCHC-32.6 RDW-14.2 Plt Ct-234#
[**2147-8-15**] 08:05AM BLOOD Glucose-131* UreaN-17 Creat-0.7 Na-140
K-4.4 Cl-97 HCO3-37* AnGap-10
RADIOLOGY Preliminary Report
CHEST (PA & LAT) [**2147-8-15**] 5:29 PM
PA AND LATERAL CHEST RADIOGRAPHS: Again seen are median
sternotomy wires and clips from recent surgery. There is
cardiomegaly, which is stable. There is left lower lobe
atelectasis, which demonstrates slight improved aeration.
Additionally, there is a probable small associated left pleural
effusion. No pneumothorax is seen. Mediastinal contours are
within normal limits. Pulmonary vasculature is normal. Within
the right lower lung zone, there is linear area of density which
may represent an ill-defined area of atelectasis. Degenerative
changes are noted within the thoracic spine.
IMPRESSION: Continued atelectasis within the left lower lobe,
and a probable associated small pleural effusion. Linear opacity
in the right lower lung zone may represent an area of
atelectasis, though early consolidation is not excluded.
Cardiology Report ECHO Study Date of [**2147-8-14**]
LEFT ATRIUM: Normal LA size. Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Normal
regional LV systolic function. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber
size. Normal RV
systolic function.
AORTA: Normal aortic root diameter. Normal ascending aorta
diameter.
AORTIC VALVE: Normal aortic valve leaflets. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. No MR.
TRICUSPID VALVE: Mild [1+] TR. Normal PA systolic pressure.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Left pleural effusion.
Conclusions:
1. The left atrium is normal in size. The left atrium is
elongated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity
size is normal. Regional left ventricular wall motion is normal.
Overall left
ventricular systolic function is normal (LVEF>55%).
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets appear structurally normal with good
leaflet
excursion. No aortic regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. No mitral
regurgitation is
seen.
6.The estimated pulmonary artery systolic pressure is normal.
7.There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2147-8-3**],
no change.
Brief Hospital Course:
Ms. [**Known lastname 25309**] was admitted to the [**Hospital1 18**] on [**2147-8-10**] for surgical
management of her coronary artery disease. She was taken
directly to the operating room where she underwent coronary
artery bypass grafting to three vessels. Postoperatively she was
taken to the cardiac surgical intensive care unit for
monitoring. On postoperative day one, Ms. [**Known lastname 25309**] [**Last Name (Titles) 5058**]
neurologically intact and was extubated. Drains and wires were
removed per protocol. She developed some runs of
supraventricular tachycardia which was treated with beta
blockade. Aspirin and a statin were resumed. On postoperative
day three, she was transferred to the step down unit for further
recovery. She was gently diuresed towards her preoperative
weight. The physical therapy service was consulted for
assistance with her postoperative strength and mobility. The
electrophysiology service was consulted for wide complex
tachycardia which was likely nonsustained ventricular
tachycardia. As her ejection fraction was normal, beta blockade
therapy was maximized and her electrolytes were repleted. Ms.
[**Known lastname 25309**] continued to make steady progress and was discharged
home on postoperative day six. She will follow-up with Dr.
[**Last Name (STitle) **], her cardiologist and her primary care physician as an
outpatient.
Medications on Admission:
Glucophage 500 mg PO TID
Atenolol 50 mg PO daily
Protonix 40 mg PO daily
Lipitor 10 mg PO daily
Lisinopril 20 mg PO daily
ASA 81 mg PO daily
Tramadol 50 mg PO TID
Lorazepam
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
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. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Lopressor 50 mg Tablet Sig: 1.5 Tablets PO three times a day.
Disp:*135 Tablet(s)* Refills:*2*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
7 days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary Artery Disease - s/p coronary artery bypass grafting,
Hypertension, Hypercholesterolemia, Type II Diabetes Mellitus,
Anemia, Sleep Apnea, History of Gastric Cancer s/p Gastrectomy,
Arthritis
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) **] in [**3-22**] weeks.
Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5263**] in [**1-20**] weeks.
Local cardiologist, Dr. [**Last Name (STitle) 171**] in [**1-20**] weeks.
Completed by:[**2147-8-25**]
|
[
"250.00",
"414.01",
"401.9",
"V10.04",
"272.0",
"411.1",
"427.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6659, 6717
|
3730, 5108
|
299, 477
|
6961, 6968
|
1069, 3707
|
7286, 7554
|
869, 898
|
5331, 6636
|
6738, 6940
|
5134, 5308
|
6992, 7263
|
913, 1050
|
243, 261
|
499, 724
|
740, 853
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,174
| 102,821
|
3169
|
Discharge summary
|
report
|
Admission Date: [**2169-8-27**] Discharge Date: [**2169-8-31**]
Date of Birth: [**2103-6-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
LLE erythema and swelling and lightheadedness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
PCP: [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **]
Dr. [**Known lastname **] is a 66 yo man who presents with 2 days of fever
and LLE redness and swelling. He recalls getting a bug bite on
[**8-24**] when out at [**Location (un) 14753**] for the day. On Friday, he developed
redness and swelling of the left anterior lower leg. Friday
night he had high fevers, up to 104, as well as increased
urinary frequency (voiding every hour). No dysuria. He also
notes decreased PO intake for the past 24 hours. Felt
lightheaded when standing on the day of admission and so called
his PCP's office and was referred to the ED. No sick contacts
though his two young grandsons (age 1 and 6) are visiting. No
history of DVT or cellulitis in the past. Denies chest pain,
cough, SOB, abdominal pain, nausea, vomiting.
In the ED, initial vs were: T 97.6, P 64, BP 82/54, R 18, O2 sat
99% on RA. BP was somewhat fluid responsive however would
persistently dip back down to the 80s systolic. After receiving
a total of 5L IVF, his BP stabilized in the high 90s. Left
lower leg was notably erythematous and swollen. Labs notable
for WBC 21.7, lactate 2.1-->2.6 despite IVF, Cr 2.1 (baseline
1.2-1.3). Xray of the left tib/fib was unremarkable without
subcutaneous air. He was given unasyn and vanco and tylenol.
He was admitted to the ICU. The patient had good PO intake, so
he was given free access to fluids and encouraged to drink and
eat. While in the ICU he was continued on Cipro for coverage of
possible UTI and cellulitis and Vancomycin for coverage of
possible MRSA. He was afebrile until 1400 on [**8-27**] when he was
febrile to 101.3. Cellulitis margins did not progress on
current antibiotic regimen. Required bolus of 500cc ivf for
systolic blood pressure in the 100's improved to 120's.
Outpatient hypertension medications and flomax were in icu.
Past Medical History:
Prostate CA-- being observed with watchful waiting
Hypertension
Hyperlipidemia
Social History:
Widowed, lives alone. His only daughter is currently visiting
from [**Location (un) **] with his son-in-law and 2 young grandsons.
Pediatric ID physician at [**Hospital1 2177**]. Quit smoking 10-15 years ago.
Occasional EtOH use.
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 96.5, BP: 98/63, P: 62, R: 15, O2: 95% on 2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Mild bibasilar rales, no wheezes
CV: Regular 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: L anterior lower leg is swollen, erythematous, and mildly
tender to touch; area of erythema appears to be somewhat receded
from the border outlined in the ED; 2+ bilateral pedal pulses,
[**6-20**] lower extremity motor strength bilaterally
Pertinent Results:
On admission:
[**2169-8-26**] 07:20PM WBC-21.7*# RBC-4.67 HGB-14.4 HCT-41.4 MCV-89
MCH-30.8 MCHC-34.8 RDW-13.4 PLT COUNT-247
NEUTS-95.5* LYMPHS-2.0* MONOS-2.0 EOS-0.3 BASOS-0.2
[**2169-8-26**] 07:20PM GLUCOSE-145* UREA N-30* CREAT-2.1* SODIUM-139
POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-25 ANION GAP-17
U/A
[**2169-8-26**] 10:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2169-8-26**] 10:30PM URINE HYALINE-6*
[**2169-8-26**] 10:30PM URINE RBC-0-2 WBC-[**1-5**]* BACTERIA-FEW
YEAST-NONE EPI-0-2
On discharge:
[**2169-8-31**] 06:20AM BLOOD WBC-8.7 RBC-4.31* Hgb-13.4* Hct-38.7*
MCV-90 MCH-31.1 MCHC-34.7 RDW-13.6 Plt Ct-265
[**2169-8-31**] 06:20AM BLOOD Glucose-130* UreaN-12 Creat-1.3* Na-137
K-4.1 Cl-103 HCO3-25 AnGap-13
Imaging:
Tib/fib xray [**2169-8-26**]: 1. No gas in the soft tissues. No
osteolysis.
2. A small fragment below the medial malleolus likely represents
an avulsion injury, age indeterminant, probably old. Correlate
clinically.
Chest PA/Lat [**2169-8-26**]: 1. Left lower lobe airspace opacification
consistent with early pneumonia. 2. Incompletely characterized
suspected lytic lesion of the fourth rib. Consider dedicated rib
series for further characterization.
Left LE US [**8-27**]: No evidence of DVT in the left lower extremity.
Peroneal veins not well seen. PTV well patent.
CT lower extremity with contrast [**8-28**]: Diffuse subcutaneous
edema throughout the left leg and ankle in keeping with
cellulitis. No focal fluid collections.
Foot AP/Lat/Obl left [**8-28**]: Three views of the foot show no
evidence of acute bone or joint space abnormality. No evidence
of calcaneal spurring. Views of the ankle show no acute bone
abnormality. Areas of vascular calcification are seen.
Brief Hospital Course:
Dr. [**First Name (STitle) **] is a 66 year old man presented with two days of
high fever and LLE erythema, swelling, urinary urgency,
hypotension, and now transferred to the floor after a day in ICU
receiving antibiotics and fluid resuscitation.
The swelling of the leg was most likely cellulitis, and he was
ruled out on DVT, necrotizing fasciitis and osteomyelitis. The
patient had hemodynamic improvement and the leukocytosis was
trending downwards on vancomycin and ciprofloxacin, but had a
spike in temperature in the early AM of [**8-28**]. In order to give
the patient more broad spectrum coverage, the patient was
switched from Ciprofloxacin to Unasyn. his blood and urine
cultures remained negative. He was discharged to complete a
course of augmentin.
The patient also initially presented with acute on chronic renal
failure: The patient presented with an elevated creatinine of
1.8 (baseline 1.2). With bolus fluids, treatment of his
infection and increased PO intake, his creatinine reduced to
1.4. BUN/Cr ratio slightly less than 20:1. The patient was
likely pre-renal from likely sepsis vs. volume depletion. His
creatinine improved with hydration and improvement of his blood
pressure, and it trended down to near his baseline on discharge.
His home BP medications were held until a day prior to
discharge, when he was started on amlodipine, valsartan, and
atenolol. Patient was told to re-start on his
hydrochlorothiazide four days after discharge.
Lastly, a lytic bone lesion on CXR: Radiology commented on a
lytic bone lesion on the 4th right rib incidentally found on
CXR. The patient has no symptoms. In addition, the patient might
also have another lytic lesion on the left side. We recommend
dedicated rib series in the future for further characterization.
Medications on Admission:
Atenolol 50mg PO BID
Amlodipine 10mg PO daily
HCTZ 25mg PO daily
Valsartan 320mg PO daily
Atorvastatin 10mg PO qHS
Flomax 0.4mg PO daily
Vicodin 5mg-500mg 1-2 tabs QID prn
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO Q AM ().
8. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-17**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
10. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO every six (6) hours as needed for foot pain for 4 days: Do
Not combine with additional tylenol.
Disp:*32 Tablet(s)* Refills:*0*
11. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis
Septic Shock
Discharge Condition:
Good, afebrile
Discharge Instructions:
You were admitted to the hospital and found to have a cellulitis
infection of your leg, along with fevers and hypotension. You
were supported with fluids and antibiotics. Your blood pressure
returned to baseline and your antihypertensive medications, with
the exception of hydrochlorothiazide, were restarted.
You should continue taking augmentin for seven more days.
You should begin taking hydrochlorothiazide on [**2169-9-3**].
You will be given a prescription for vicodin to treat your foot
pain.
Do NOT take additional acetominophen with this medication, as
the maximum allowed dose of acetominophen is 4000mg daily.
Please continue taking your other medications as prescribed.
Please try to ambulate as tolerated. When at rest, please rest
with your foot raised.
Please call your doctor or return to the hospital if you
experience fever, chest pain, shortness of breath, abdominal
pain, worsening leg redness, bleeding, or any other concerning
symptom.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. Phone:[**Telephone/Fax (1) 277**]
Date/Time:[**2170-1-24**] 10:00
MD: NP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: [**Company 191**],
Date and time: [**2169-9-12**] 11:00am
Location: [**Location (un) 830**] [**Hospital Ward Name 23**] Building [**Location (un) 895**] North
Suite
Phone number: [**Telephone/Fax (1) 250**]
|
[
"285.9",
"038.9",
"185",
"584.9",
"733.90",
"785.52",
"682.6",
"276.8",
"788.42",
"403.90",
"272.4",
"585.2",
"995.92",
"787.91"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8408, 8414
|
5208, 6995
|
360, 366
|
8482, 8499
|
3391, 3391
|
9513, 9964
|
2648, 2666
|
7218, 8385
|
8435, 8461
|
7021, 7195
|
8523, 9490
|
2706, 3372
|
3977, 5185
|
275, 322
|
394, 2280
|
3405, 3963
|
2302, 2382
|
2398, 2632
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,841
| 126,020
|
30118
|
Discharge summary
|
report
|
Admission Date: [**2131-6-18**] Discharge Date: [**2131-6-29**]
Date of Birth: [**2050-6-12**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Lipitor /
Morphine
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
Balloon Valvuloplasty
Retinal Detachment Repair
History of Present Illness:
81F who has a long history of severe aortic stenosis,
hypertension, [**First Name3 (LF) 2182**], hyperlipidemia, and right sided heart
failure p/w SOB. Over the last few days the pt has noticed more
SOB and DOE. She is not on oxygen at home, but started to use
some the morning she came into the ED. Pt admitted to orthopnea
requiring [**3-9**] pillows at night. Her sx gradually worsened which
prompted her to come to the ED. She endorsed a cough, but denied
any chest pain, fevers, chills, or night sweats. She has not
missed any doses of her lasix. She has not eaten any
contraindicated foods. Her only medication change was that she
was started on clindamycin on [**6-12**] for a dental infection. Did
notice some increased swelling in her legs the morning of
admission. In the ED at the OSH, RA sat was 85% on arrival, and
up to mid 90's on 2lnc. RLL infiltrate seen on CXR. Due to h/o
allergies to pcn and sulfa, pt was started on doxycycline and
aztreonam for presumed PNA. She was admitted to [**Hospital1 1516**] service
where she was stable overnight but became acutely more dyspneic
and tachypneic the morning after admission with hypertension to
the 200s. She was given 40mg IV lasix x 2 on floor with no
response. She was started on bipap and transferred to the CCU
for further management. On arrival she got 80mg lasix. Nitro gtt
was started. In regards to her aortic stenosis, she has been
doing well since her valvuloplasty w/ increased exercise
tolerance. She was previously not eligible for the Corevalve
trial given her mitral regurgitation.
.
On review of symptoms, she denies recent fevers, chills or
rigors, diarrhea, constipation. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
syncope or presyncope. She endorses orthopnea and uses 3 pillows
at night. Avoids steps.
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Dyslipidemia, (+)Hypertension
2. CARDIAC HISTORY:
A-flutter s/p ablation c/b complete heart block with BiV pacer
placement
-PERCUTANEOUS CORONARY INTERVENTIONS: BMS to RCA [**2130-3-14**]
-PACING/ICD: dual-chamber pacemaker implantation in [**2126-6-4**] -
[**Company 1543**] Sigma DR.
.
3. OTHER PAST MEDICAL HISTORY:
-[**Company 2182**]
-Possible lupus
-Hypothyroidism
-Macular degeneration
-Obstructive sleep apnea -BiPAP
-Cataracts s/p bil. removal
-Precancerous lesion on tongue
-T5 and T11 vertebral fractures, ~[**2128**]
.
Previous surgeries:
[**2128**] - Resection of pre-cancerous lesion of the tongue
[**2126-6-25**] Attempted AVR (aborted due to severely calcified
ascending aorta and arch)
[**2126-7-1**] - aflutter ablation and pacemaker for sick conduction
system
[**2126**] - Left total knee replacement
[**2119**],[**2123**] - Cataract surgery
Social History:
60 pack/yr history, quit 9 years ago- absence of current tobacco
use. Lives at home on a ranch.
Family History:
There is a family history of diabetes and heart disease but not
hypertension or strokes. Her mother died at age 85 of throat
cancer. Her father died at 64 of cancer but had a prior MI.
Physical Exam:
Physical Exam on Admission:
VS: T= 98.7 BP= 128/41 HR= 62 RR= 32 O2 sat= 93 4LNC
GENERAL: Oriented x2 (names place w/ prompting). Mood, affect
appropriate.
HEENT: R pupil blown. L pupil reactive. no bottom teeth
NECK: no JVD
Chest: R port c/d/i
CARDIAC: [**6-10**] harsh systolic murmur radiating to carotids
LUNGS: mild wheezes bilaterally w/ crackles at bases
ABDOMEN: Soft, NTND. PEG tube c/d/i
EXTREMITIES: 2+ pedal edema bilaterally
SKIN: ecchymoses on all extremeties
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Discharge PE
On RA
otherwise unchanged
Pertinent Results:
Labs on Admission:
[**2131-6-18**] 05:50PM WBC-12.6*# RBC-3.81* HGB-11.3* HCT-35.3*
MCV-93 MCH-29.7 MCHC-32.0 RDW-15.7*
[**2131-6-18**] 05:50PM GLUCOSE-129* UREA N-41* CREAT-1.5*
SODIUM-131* POTASSIUM-5.0 CHLORIDE-96 TOTAL CO2-24 ANION GAP-16
[**2131-6-18**] 05:50PM CALCIUM-8.5 PHOSPHATE-3.4 MAGNESIUM-2.3
[**2131-6-18**] 05:50PM CALCIUM-8.5 PHOSPHATE-3.4 MAGNESIUM-2.3
[**2131-6-18**] 05:50PM CK(CPK)-54
Pertinent Labs:
[**2131-6-19**] 04:38AM BLOOD WBC-9.4 RBC-3.53* Hgb-10.7* Hct-33.1*
MCV-94 MCH-30.4 MCHC-32.5 RDW-15.7* Plt Ct-78*
[**2131-6-19**] 01:01PM BLOOD WBC-13.5* RBC-4.02* Hgb-12.2 Hct-39.2
MCV-98 MCH-30.2 MCHC-31.0 RDW-15.9* Plt Ct-94*
[**2131-6-20**] 04:04AM BLOOD WBC-9.2 RBC-3.21* Hgb-9.6* Hct-29.8*
MCV-93 MCH-29.9 MCHC-32.1 RDW-15.4 Plt Ct-77*
[**2131-6-21**] 11:21AM BLOOD WBC-8.7 RBC-3.11* Hgb-9.5* Hct-29.4*
MCV-94 MCH-30.4 MCHC-32.2 RDW-15.5 Plt Ct-82*
[**2131-6-21**] 09:31PM BLOOD WBC-7.9 RBC-3.16* Hgb-9.5* Hct-29.7*
MCV-94 MCH-30.2 MCHC-32.1 RDW-15.3 Plt Ct-81*
[**2131-6-22**] 05:20AM BLOOD WBC-7.4 RBC-3.16* Hgb-9.3* Hct-29.7*
MCV-94 MCH-29.4 MCHC-31.2 RDW-15.3 Plt Ct-77*
[**2131-6-23**] 04:55AM BLOOD WBC-9.1 RBC-3.30* Hgb-9.9* Hct-31.5*
MCV-95 MCH-29.9 MCHC-31.4 RDW-15.5 Plt Ct-75*
[**2131-6-23**] 07:28AM BLOOD WBC-8.9 RBC-3.23* Hgb-9.5* Hct-30.2*
MCV-94 MCH-29.6 MCHC-31.6 RDW-15.6* Plt Ct-78*
[**2131-6-24**] 05:55AM BLOOD WBC-8.1 RBC-3.16* Hgb-9.3* Hct-29.8*
MCV-94 MCH-29.4 MCHC-31.2 RDW-15.0 Plt Ct-89*
[**2131-6-25**] 04:37AM BLOOD WBC-9.0 RBC-3.46* Hgb-10.0* Hct-32.3*
MCV-93 MCH-29.0 MCHC-31.1 RDW-15.3 Plt Ct-79*
[**2131-6-26**] 05:27AM BLOOD WBC-7.9 RBC-3.50* Hgb-10.2* Hct-32.7*
MCV-93 MCH-29.3 MCHC-31.3 RDW-15.2 Plt Ct-83*
[**2131-6-27**] 06:13AM BLOOD WBC-7.5 RBC-3.50* Hgb-10.2* Hct-32.2*
MCV-92 MCH-29.2 MCHC-31.7 RDW-14.8 Plt Ct-86*
[**2131-6-19**] 04:38AM BLOOD PT-47.3* PTT-45.2* INR(PT)-4.7*
[**2131-6-20**] 04:04AM BLOOD PT-42.8* PTT-39.5* INR(PT)-4.2*
[**2131-6-21**] 11:21AM BLOOD PT-20.1* PTT-29.3 INR(PT)-1.9*
[**2131-6-22**] 05:20AM BLOOD PT-18.8* PTT-38.9* INR(PT)-1.8*
[**2131-6-22**] 05:20AM BLOOD PT-18.8* PTT-38.9* INR(PT)-1.8*
[**2131-6-23**] 04:55AM BLOOD PT-14.7* PTT-31.0 INR(PT)-1.4*
[**2131-6-23**] 07:28AM BLOOD PT-14.5* PTT-20.9* INR(PT)-1.4*
[**2131-6-24**] 05:55AM BLOOD PT-15.2* PTT-32.2 INR(PT)-1.4*
[**2131-6-25**] 04:37AM BLOOD PT-14.0* PTT-28.1 INR(PT)-1.3*
[**2131-6-26**] 05:27AM BLOOD PT-14.1* PTT-40.2* INR(PT)-1.3*
[**2131-6-27**] 06:13AM BLOOD PT-13.8* PTT-29.8 INR(PT)-1.3*
[**2131-6-18**] 05:50PM BLOOD Glucose-129* UreaN-41* Creat-1.5* Na-131*
K-5.0 Cl-96 HCO3-24 AnGap-16
[**2131-6-19**] 04:38AM BLOOD Glucose-140* UreaN-40* Creat-1.3* Na-133
K-4.0 Cl-98 HCO3-26 AnGap-13
[**2131-6-20**] 04:04AM BLOOD Glucose-89 UreaN-43* Creat-1.3* Na-135
K-3.5 Cl-99 HCO3-26 AnGap-14
[**2131-6-21**] 11:21AM BLOOD Glucose-91 UreaN-39* Creat-0.9 Na-142
K-3.6 Cl-106 HCO3-28 AnGap-12
[**2131-6-22**] 05:20AM BLOOD Glucose-206* UreaN-36* Creat-0.9 Na-140
K-3.2* Cl-105 HCO3-26 AnGap-12
[**2131-6-22**] 04:30PM BLOOD Glucose-87 UreaN-31* Creat-0.9 Na-140
K-3.8 Cl-106 HCO3-26 AnGap-12
[**2131-6-23**] 04:55AM BLOOD Glucose-148* UreaN-29* Creat-0.8 Na-141
K-3.6 Cl-108 HCO3-26 AnGap-11
[**2131-6-23**] 07:28AM BLOOD Glucose-174* UreaN-30* Creat-0.9 Na-140
K-4.2 Cl-107 HCO3-24 AnGap-13
[**2131-6-23**] 03:30PM BLOOD Glucose-115* UreaN-28* Creat-0.9 Na-141
K-3.6 Cl-105 HCO3-27 AnGap-13
[**2131-6-23**] 11:59PM BLOOD Glucose-106* UreaN-29* Creat-0.9 Na-141
K-4.0 Cl-105 HCO3-26 AnGap-14
[**2131-6-24**] 05:55AM BLOOD Glucose-97 UreaN-28* Creat-0.9 Na-142
K-3.8 Cl-106 HCO3-28 AnGap-12
[**2131-6-24**] 03:05PM BLOOD Glucose-94 UreaN-26* Creat-0.9 Na-142
K-3.5 Cl-106 HCO3-26 AnGap-14
[**2131-6-25**] 04:37AM BLOOD Glucose-98 UreaN-27* Creat-0.9 Na-140
K-3.9 Cl-106 HCO3-26 AnGap-12
[**2131-6-25**] 05:45PM BLOOD Glucose-172* UreaN-27* Creat-0.9 Na-135
K-3.3 Cl-101 HCO3-26 AnGap-11
[**2131-6-26**] 05:27AM BLOOD Glucose-92 UreaN-28* Creat-0.9 Na-138
K-3.9 Cl-104 HCO3-26 AnGap-12
[**2131-6-26**] 03:41PM BLOOD Glucose-86 UreaN-31* Creat-1.0 Na-138
K-3.4 Cl-104 HCO3-25 AnGap-12
[**2131-6-27**] 06:13AM BLOOD Glucose-97 UreaN-30* Creat-0.9 Na-139
K-4.0 Cl-105 HCO3-25 AnGap-13
[**2131-6-27**] 06:13AM BLOOD Glucose-97 UreaN-30* Creat-0.9 Na-139
K-4.0 Cl-105 HCO3-25 AnGap-13
[**2131-6-18**] 05:50PM BLOOD CK(CPK)-54
[**2131-6-20**] 12:00AM BLOOD CK(CPK)-44
[**2131-6-20**] 04:04AM BLOOD ALT-24 AST-32 AlkPhos-86 TotBili-1.2
[**2131-6-21**] 09:31PM BLOOD CK(CPK)-46
[**2131-6-22**] 05:20AM BLOOD CK(CPK)-32
[**2131-6-18**] 05:50PM BLOOD CK-MB-2 cTropnT-<0.01
[**2131-6-19**] 01:01PM BLOOD CK-MB-2 cTropnT-<0.01
[**2131-6-20**] 12:00AM BLOOD CK-MB-2 cTropnT-<0.01
[**2131-6-21**] 09:31PM BLOOD CK-MB-7
[**2131-6-22**] 05:20AM BLOOD CK-MB-4
[**2131-6-27**] 06:13AM BLOOD Calcium-8.0* Phos-2.8 Mg-2.2
[**2131-6-19**] 12:57PM BLOOD Type-ART Temp-37.2 O2 Flow-8 pO2-99
pCO2-28* pH-7.41 calTCO2-18* Base XS--4 Intubat-NOT INTUBA
Comment-SIMPLE FAC
[**2131-6-19**] 03:06PM BLOOD Type-[**Last Name (un) **] pO2-39* pCO2-41 pH-7.39
calTCO2-26 Base XS-0
[**2131-6-24**] 04:00PM BLOOD Type-[**Last Name (un) **] pH-7.51*
[**2131-6-24**] 04:00PM BLOOD freeCa-1.08*
[**2131-6-19**] 03:06PM BLOOD Lactate-2.2*
Imaging:
CXR [**6-18**]:
The patient has severe aortic valve stenosis as well as large
and distal area of aortic ectasia/aneurysm that appears to be
progressed since [**2126**], but unchanged since [**2130-3-29**].
Pacemaker leads terminate in right atrium and right ventricle.
As compared to the prior study, interval insertion of the right
central venous line, with its tip most likely at the level of
mid-low SVC. There is new right lower lobe consolidation, that
appears to be involving right lower lobe and potentially right
middle lobe that might reflect infectious process. No
definitive pulmonary edema is seen. Right upper lobe opacity is
suspected, although not clearly defined on the current
examination. New, small amount of pleural effusion is noted
bilaterally, left more than right.
TTE [**2131-6-19**]:
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
The right ventricular cavity is dilated with borderline normal
free wall function. [Intrinsic right ventricular systolic
function is likely more depressed given the severity of
tricuspid regurgitation.] The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (valve
area 0.8-1.0cm2). Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Moderate to severe
(3+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. Severe [4+] tricuspid regurgitation is
seen. There is severe pulmonary artery systolic hypertension.
[In the setting of at least moderate to severe tricuspid
regurgitation, the estimated pulmonary artery systolic pressure
may be underestimated due to a very high right atrial pressure.]
There is a trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2130-4-28**],
tricuspid regurgitation is now more prominent.
CXR [**6-19**]:
IMPRESSION: Comparison suggests further progression of
congestive pattern in this patient with marked cardiomegaly,
history of aortic stenosis, and also the parenchymal infiltrates
in the right lower lung persist.
ECHO [**6-22**]:
The left atrium is elongated. 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.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). [Intrinsic
left ventricular systolic function is likely more depressed
given the severity of valvular regurgitation.] There is no
ventricular septal defect. The right ventricular cavity is
moderately dilated with borderline normal free wall function.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Moderate to severe (3+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2131-6-19**], no
change.
Brief Hospital Course:
81F who has a long history of severe aortic stenosis,
hyertension, [**Year (4 digits) 2182**], hyperlipidemia, and right sided heart failure
p/w SOB. She also has a history of mitral valve prolapse and was
evaluated in the past for corevalve but did not meet criteria.
Instead had a balloon aortic valvuloplasty on [**2130-4-27**]. if pt's
current exacerbation is related to worsening AS, then should be
re-evaluated for valvuloplasty vs corevalve.
.
# acute resp failure: Patient hypertensive on transfer to CCU
with acute resp distress suggestive of flash pulm edema in
setting of severe AS. trigger uncertain but is likely the PNA
seen on CXR on admission. No other changes to meds or diet that
would lead to acute decompensation. pt has known aortic stenosis
and is s/p valvuloplasty x 1. Also has RHF here w/ an
exacerbation. has had issues in past with similar episodes. Pt
is v-paced and pacers adjusted to improve ventricular filling.
CE neg for ischemia. Initially was on BIPAP and diuresed with IV
Lasix. Responded well, weaned off Bipap. Was also transiently
on nitro drip for BP control. Increased metoprolol dose to
reduce afterload and work of heart as tolerated. Was treated
for community acquired pneumonia with levofloxacin. Diuretics
were changed to torsemide from furosemide.
.
# AS: pt to be evaled by [**Doctor Last Name **] for valvuloplasty vs corevalve
work up. Manage volume as above. TTE showed severe AS. Made
decision to go ahead with valvuloplasty. The pt underwent
successful valvuloplasty. Contact[**Name (NI) **] [**Name2 (NI) 756**] for assessment for
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 71792**] valve, but at time of discharge the pt had not
been accepted. Dr. [**Last Name (STitle) **] was working on this.
.
# PAF: pt has had issues in past w/ atrial flutter/fib and is
s/p ablation and pacer placement. not currently in a fib. pacer
adjusted to optimize filling. Held coumadin in setting of
supratherapeutic INR, but restarted before discharge. Her INR is
subtherapeutic at time of discharge, and will need to be
monitored at rehab w/ appropriate adjustments as necessary w/
coumadin dose.
.
# PNA: levofloxacin for CAP coverage, dosed 750mg q48h. she
completed a total of 7 days for treatment. she still had
crackles at bases upon discharge, but was weaned to RA.
.
# Acute Renal Failure: likely hypoperfusion in setting of chf
exacerbation. stable at time of discharge.
.
# Hypothyroidism: Continued home synthroid 100mcg daily.
.
# HTN: Metoprolol, was transitioned off lasix to torsemide 40mg
twice daily.
.
# Depression: Continued home prozac.
.
# Eye infection/Retinal detachment: Continued eye drops.
opththo was consulted and completed retinal detachment repair on
[**6-27**]. the surgery was successful. she has a scheduled followup
appointment in one week.
TRANSITIONS OF CARE:
- the pt will be discharged to rehab. she will need to have her
coumadin monitored there as she is subtherapeutic currently.
arrangements with her PCP should be made for monitioring her INR
- the pt required aggressive electrolyte repletion with her new
diuretic regimen. electrolytes should be checked daily at rehab
and potassium supplementation may be needed daily upon
discharge.
- at the time of discharge the pt was not approved for [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 71792**] valve at [**Hospital1 756**]. this is pending and will need to be
re-addressed by Dr. [**Last Name (STitle) **] at a later date.
- f/u appt scheduled with ophthomalogy
Medications on Admission:
lasix 40 mg [**Hospital1 **]
metoprolol succ 12.5 daily
levoxyl 100 mg daily
warfarin 3.5mg daily
prozac 40mg daily
zofran 4mg daily
clindamycin 225 TID (last dose today)
oxycodone 10mg prn
[**Last Name (un) **] 128 eye ointment 4x/day
prenisolone eye drops 1% 4x/day
atropine eye drops 4x/day
Ofloxacin Otic 4x/day
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
5. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
6. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheeze.
8. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
9. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) as needed for nausea.
10. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
11. sodium chloride 5 % Drops Sig: One (1) Ophthalmic QID (4
times a day): R eye.
12. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for pruritis: apply to back.
13. torsemide 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
14. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
15. bacitracin-polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) Appl Ophthalmic QID (4 times a day).
16. scopolamine HBr 0.25 % Drops Sig: One (1) Drop Ophthalmic
[**Hospital1 **] (2 times a day).
17. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic Q3H (every 3 hours).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Nursing & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
Aortic Stenosis
Volume Overload
Pneumonia
Retinal Detachment
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 71791**],
You were admitted for volume overload. You were treated with
diuretics to get excess fluid removed from your body. You were
also found to have a pneumonia and received a complete
antibiotic course during your admission.
You had an episode of respiratory distress requiring a night in
the intensive care unit and bipap to assist your breathing.
You underwent a successful balloon valvuloplasty to treat your
aortic stenosis. There were no complications during this
procedure.
Ophthomalogy was asked to evaluate you during your admission.
You underwent a retinal detachment repair while in-house. The
procedure was successful. Do not rub your right eye or get water
in your eye.
Medications:
START Torsemide 40mg twice daily
START Bacitracin/Polymyxin B Sulfate Opht. Oint 1 Appl RIGHT EYE
QID
START PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE Q3H
CHANGE to Scopolamine 0.25% Ophth Soln 1 DROP RIGHT EYE [**Hospital1 **]
CHANGE to Metoprolol Tartrate 12.5mg twice daily
START Ipratropium Bromide Neb 1 NEB IH Q6H:PRN
STOP [**Last Name (un) **] 128 eye ointment 4x/day
STOP atropine eye drops 4x/day
STOP Ofloxacin Otic 4x/day
STOP Clindamycin 225 TID
If you experience any chest pain, difficulties breathing, or any
other symptoms concerning to you, please call or come into the
ED for further evaluation.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: OPHTHOMALOGY
When: Wednesday [**2131-7-3**] at 8am
With: Dr. [**Last Name (STitle) **]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2131-7-18**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"244.9",
"V85.1",
"V45.82",
"V15.82",
"360.00",
"518.81",
"V45.01",
"396.2",
"V44.1",
"V14.0",
"584.9",
"486",
"V43.65",
"327.23",
"401.9",
"V58.61",
"272.4",
"496",
"311",
"278.00",
"361.9",
"361.05",
"440.0",
"398.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"14.74",
"35.96",
"14.34",
"96.6",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
18381, 18483
|
12791, 15633
|
331, 381
|
18588, 18588
|
4093, 4098
|
20243, 20836
|
3312, 3499
|
16700, 18358
|
18504, 18567
|
16359, 16677
|
18771, 20220
|
3514, 3528
|
2370, 2608
|
288, 293
|
409, 2270
|
4113, 4511
|
18603, 18747
|
15654, 16333
|
4528, 12768
|
2639, 3183
|
2292, 2350
|
3199, 3296
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,673
| 158,011
|
31270
|
Discharge summary
|
report
|
Admission Date: [**2177-7-24**] Discharge Date: [**2177-7-28**]
Date of Birth: [**2108-5-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Ibuprofen / Aspirin / Lipitor / Imdur
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
DOE; angina
Major Surgical or Invasive Procedure:
[**7-24**] CABG x 4 (LIMA->LAD, SVG->OM, SVG->Diag, SVG->PDA)
History of Present Illness:
69 yo male with + ETT [**5-8**] showing a small scarred fixed defect
and large inferolateral and anterolateral mildly reversible
defect with mild peri-infarct ischemia. EF was 54% on perfusion
scan. Has had known CAD since [**2171**]. Referred for CABG
evaluation.
Past Medical History:
GERD
CAD/ACS [**10-3**]
HTN
NIDDM
elev. lipids
gout
obesity
metabolic syndrome
MI
dil. asc. aorta
melanoma
pleural asbestosis
PSH: left ing. herniorrhaphy, removal nasal polyps, removal
melanoma back [**2173**]
Social History:
retired
lives with wife
occasional cigar
drinks [**12-3**] ETOH daily
Family History:
no premature CAD
Physical Exam:
5'8" 250#
NAD with rash on face
EOMI, OP benign, broken dental pin
neck supple, no JVD or carotid bruits appreciated;short,squat
neck
CTAB
RRR S1 S2, no murmur
soft, obese, non-tender, non-distended, no HSM or CVA tenderness
warm, well-perfused, no edema peripherally
no varicosities noted
neuro grossly intact, MAE [**4-5**] strengths, nonfocal exam
Pertinent Results:
[**2177-7-28**] 06:20AM BLOOD WBC-8.5 RBC-3.25* Hgb-10.5* Hct-29.7*
MCV-91 MCH-32.1* MCHC-35.2* RDW-14.3 Plt Ct-204
[**2177-7-28**] 06:20AM BLOOD Plt Ct-204
[**2177-7-28**] 06:20AM BLOOD Glucose-117* UreaN-13 Creat-0.6 Na-136
K-3.8 Cl-98 HCO3-29 AnGap-13
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2177-7-26**] 6:50 PM
CHEST (PORTABLE AP)
Reason: post chest tube removal. ? PTX
[**Hospital 93**] MEDICAL CONDITION:
69 year old man with CABG
REASON FOR THIS EXAMINATION:
post chest tube removal. ? PTX
HISTORY: CABG, question pneumothorax status post chest tube
removal.
chest, 1 vw
Compared with [**2177-7-24**], multiple lines and tubes have been
removed. The patient is status post sternotomy. Prominence of
the cardiomediastinal silhouette is consistent with recent
surgery. There is increased retrocardiac density, consistent
with collapse and/or consolidation. No gross effusion, though a
small effusion, particularly on the left, cannot be excluded. No
pneumothorax is identified. Linear density over the left first
rib appears to represent a rib contour.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Name (STitle) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4343**]
Approved: SUN [**2177-7-27**] 3:50 PM
Cardiology Report ECHO Study Date of [**2177-7-24**]
*** Report not finalized ***
PRELIMINARY REPORT
PATIENT/TEST INFORMATION:
Indication: Intraoperative TEE for CABG
Status: Inpatient
Date/Time: [**2177-7-24**] at 10:21
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW4-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Suboptimal
REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **]
MEASUREMENTS:
Left Ventricle - Ejection Fraction: 40% to 45% (nl >=55%)
Aorta - Valve Level: 3.6 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.9 cm (nl <= 3.4 cm)
Aorta - Descending Thoracic: *2.7 cm (nl <= 2.5 cm)
INTERPRETATION:
Findings:
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: Mildly depressed LVEF.
RIGHT VENTRICLE: Mildly dilated RV cavity.
AORTA: Normal aortic diameter at the sinus level. Simple
atheroma in aortic
root. Mildly dilated ascending aorta. Simple atheroma in
ascending aorta.
Mildly dilated descending aorta. Simple atheroma in descending
aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve
leaflets. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
(2+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic 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. Suboptimal image quality. The patient appears to be
in sinus
the patient.
Conclusions:
PRE-BYPASS:
1. No atrial septal defect is seen by 2D or color Doppler.
2. Overall left ventricular systolic function is mildly
depressed (LVEF= 40-45
%).
3. The right ventricular cavity is mildly dilated.
4. There are simple atheroma in the aortic root. The ascending
aorta is mildly
dilated. There are simple atheroma in the ascending aorta. The
descending
thoracic aorta is mildly dilated. There are simple atheroma in
the descending
thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are mildly
thickened. Trace aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral
regurgitation is seen.
7. The tricuspid valve leaflets are mildly thickened.
POST-BYPASS:
1. Maintained biventricular function.
2. Improvement of mitral regurgitation mild (1+) MR noted.
3. Aortic contours are intact.
3.
[**Location (un) **] PHYSICIAN:
([**Numeric Identifier 73761**])
Brief Hospital Course:
Admitted [**7-24**] and underwent CABG x4 with Dr. [**Last Name (STitle) **].
Transferred to the CSRU in stable condition on phenylephrine and
propofol drips. Extubated that afternoon and transferred to the
floor on POD #1 to begin increasing his activity level. Beta
blockade titrated and gently diuresed toward his preoperative
weight.Plavix restarted as pt. has allergy to aspirin. Chest
tubes and pacing wires removed without incident. Made excellent
progress and cleared for discharge to home with services on POD
#4. Pt. is to make all followup appts. as per discharge
instructions.
Medications on Admission:
plavix 75 mg daily
atenolol 50 mg daily
allopurinol 300 mg daily
gemfibrozil 600 mg [**Hospital1 **]
cozaar 25 mg daily
omeprazole 20 mg daily
metformin 500 mg daily
glyburide 5 mg daily
zocor 20 mg daily
nitro spray 0.4 mg prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. 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*
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:*0*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
6. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
11. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
7 days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
CAD
MI
Obesity
metabolic syndrome
dilated ascending aorta
NIDDM
HTN
hyperlipidemia
pleural asbestosis
melanoma
GERD
gout
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) **] 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 22741**] 1-2 weeks
Dr. [**Last Name (STitle) 12167**] 2-3 weeks
Completed by:[**2177-7-28**]
|
[
"274.9",
"530.81",
"250.00",
"278.00",
"277.7",
"414.01",
"501",
"V10.82",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.13",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7687, 7770
|
5555, 6145
|
316, 380
|
7935, 7943
|
1421, 1809
|
8256, 8443
|
1011, 1030
|
6423, 7664
|
1846, 1872
|
7791, 7914
|
6171, 6400
|
7967, 8233
|
2888, 5456
|
1045, 1402
|
265, 278
|
1901, 2862
|
408, 674
|
5491, 5532
|
696, 908
|
924, 995
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,027
| 128,664
|
7488
|
Discharge summary
|
report
|
Admission Date: [**2205-5-28**] Discharge Date: [**2205-6-5**]
Date of Birth: [**2166-7-13**] Sex: M
Service: MEDICINE
Allergies:
Gabapentin / Trazodone / Codeine
Attending:[**First Name3 (LF) 2108**]
Chief Complaint:
Gastrointestinal bleed
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
History of Present Illness:
The patient is a 38 year old male with PMH significant for
alcohol and polysubstance abuse, who is presenting with
hematemesis and hemoptysis per his report. He has had a 4 day
history of vomiting and coughing up "scant" amounts of blood.
He also has had a 2 day history of chills and productive cough
with RUQ abdominal pain, nausea, and vomiting. Pain "feels like
a fullness" and is without radiation. No relation to meals.
Describes nausea and vomiting after pain, and "chunks" or clots
of red blood hematemesis. Temperature at home of 100.4. He
reports his last EtOH intake was 10-14 days ago, but has
reported different lengths of sobriety to different providers.
This morning he awoke covered in urine and feces, which the pt
reports as "black stools". Denies any aspirin or NSAID use.
.
In the ED, he was afebrile and with stable VS. Exam notable for
rhonchorous breath sounds bilaterally, benign abdomen, and DRE
with faintly Guaiac positive brown stool. CXR was unremarkable,
and head CT showed no acute intracranial process, and diffuse
global atrophy. Labs were significant for Hct of 27.7 (from
baseline low-mid 30s), no thrombocytopenia or coagulopathy,
elevated LFTs (ALT 71, AST 85, Alk Phos 161, TBili 0.6), normal
lipase 22, and negative serum tox screen. Blood Cx were sent x2.
He was given PPI 80mg IV and admitted to the [**Hospital Ward Name 332**] ICU.
.
In the ED, initial vs were: T 99.5, HR 88, BP 132/70, RR 18,
SaO2 95%. Exam was significant for rhonchorous breath sounds
bilaterally which cleared with coughing. Faintly guaiac positive
brown stool. CXR had a questionable infiltrate in the lingula.
Of note, patient did also report a fall with head and left shin
strike several days ago; however, there was no acute bleed on
head CT. He was given IV pantoprazole 80mg and no antibiotics.
.
Labs in the ED were significant for a hematocrit of 27.7 (from
36.9 in 3/[**2205**]). 2 18 gauge IVs were placed. He was typed and
crossed and consented for blood. NGL lavage was unsuccessful
despite multiple attempts. OGL was also attempted and was
unsuccessful. GI was consulted and plans to see the patient. AST
85 ALT 71 LDH 308 Alk Phos 161 TBili 0.6. K was 3.2, for which
he was given 60 meq KCl.
.
VS prior to arrival were HR 90 BP 141/81 RR 27 SaO2 90%2L (while
sleeping).
.
.
Review of sytems:
(+) Per HPI
(-) Denies headache, sinus tenderness. Denied shortness of
breath. Denied chest pain or tightness, palpitations. Denied
constipation or abdominal pain. No recent change in bladder
habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
* Subdural hematoma ([**2204-4-12**]) from fall
* Alcohol and polysubstance abuse
* Hepatitis C virus infection
* Mood disorder with multiple suicide attempts
* ?PTSD, bipolar/anti-social personality/impulse/rage disorders
* Migraines
* Chronic lower back pain
* MVA s/p chest tube placement in [**2200**]
* Seizure disorder since [**08**] yo, alcohol withdrawal seizures
Social History:
He and his wife have been staying with his aunt. [**Name (NI) **] has one
child, who currently lives with his brother and sister-in-law.
When he is not drinking, he is an electrician.
Tobacco: quit smoking 1 week ago
ETOH: 1/5th daily of hard liquour, has been drinking since 9
yo, has h/o DTs and alcohol withdrawal seizures
Recreational drugs: remote marijuana use, denies IVDA
**Of note, pt has a reported history of confabulation and prior
[**Name (NI) **] notes document: ?previous conflicts with wife and reported
recent death of 4 year old son (who lived with brother-in-law).
Wife reportedly had been in Criminal Unit at [**Hospital1 **] for
stabbing brother-in-law in the back. Incarcerated [**2190**]-[**2192**] for
assaulting police office. Past use of cocaine, heroin, opiates,
benzodiazepines.
Family History:
Father was an alcoholic.
Physical Exam:
On admission:
Vitals: T: 98.7, BP: 152/83, P: 73, R: 20 O2: 95% 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,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS
--------------
[**2205-5-28**] 08:15AM BLOOD WBC-4.7 RBC-2.98*# Hgb-8.9*# Hct-27.7*
MCV-93 MCH-29.9 MCHC-32.1 RDW-17.9* Plt Ct-197
[**2205-5-28**] 08:15AM BLOOD Neuts-74.4* Lymphs-20.2 Monos-4.3 Eos-0.6
Baso-0.5
[**2205-5-28**] 09:19AM BLOOD PT-12.6 PTT-32.2 INR(PT)-1.1
[**2205-5-28**] 09:19AM BLOOD Fibrino-853*
[**2205-5-28**] 08:15AM BLOOD Glucose-85 UreaN-6 Creat-0.5 Na-144
K-3.2* Cl-104 HCO3-30 AnGap-13
[**2205-5-28**] 08:15AM BLOOD ALT-71* AST-85* LD(LDH)-308* AlkPhos-161*
TotBili-0.6
[**2205-5-28**] 08:15AM BLOOD Hapto-345*
[**2205-5-28**] 08:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
DISCHARGE LABS
--------------
[**2205-6-4**] 05:45AM BLOOD WBC-5.9 RBC-4.03* Hgb-12.6* Hct-38.3*
MCV-95 MCH-31.2 MCHC-32.8 RDW-17.4* Plt Ct-529*
[**2205-6-4**] 05:45AM BLOOD Glucose-104* UreaN-18 Creat-0.8 Na-139
K-5.0 Cl-102 HCO3-28 AnGap-14
[**2205-6-4**] 05:45AM BLOOD ALT-74* AST-59* AlkPhos-188*
MICROBIOLOGY
------------
[**2205-5-28**] 8:15 am BLOOD CULTURE #2.
**FINAL REPORT [**2205-6-4**]**
Blood Culture, Routine (Final [**2205-6-4**]):
NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA.
PROBABLE AGROBACTERIUM / SPHINGOMONAS SP..
UNABLE TO FURTHER DIFFERENTIATE. MEROPENEM = <= 1.0
MCG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
NON-FERMENTER, NOT PSEUDOMONAS
AERUGINOSA
|
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 2 S
CEFTRIAXONE----------- <=4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM------------- S
PIPERACILLIN---------- 32 I
PIPERACILLIN/TAZO----- <=8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=2 S
Aerobic Bottle Gram Stain (Final [**2205-5-31**]):
GRAM NEGATIVE ROD(S).
Reported to and read back by DR.[**Last Name (STitle) **] ([**Numeric Identifier 27394**]) [**2205-5-31**]
@ 2:42 PM.
[**2205-5-31**] BLOOD CULTURES X 2 NO GROWTH TO DATE
[**2205-6-1**] BLOOD CULTURES X 2 NO GROWTH TO DATE
IMAGING
-------
EGD [**2205-5-28**]:
Medium hiatal hernia
Mucosal tear within hiatal hernia, with oozing of blood and
visible [**Last Name (LF) 12425**], [**First Name3 (LF) **]-[**Doctor Last Name **] tear vs. Dieulafoy lesion;
adjacent hyperplastic area (injection, thermal therapy)
Erosive gastritis in stomach antrum
Otherwise normal EGD to third part of the duodenum
CXR on admission:
IMPRESSION:
Bibasilar, somewhat nodular and interstitial opacities worrisome
for pneumonia or aspiration.
CT head on admission:
IMPRESSION:
1. No evidence of acute intracranial process.
2. Sinus disease with mucosal thickening predominantly in the
sphenoid
sinuses.
3. Diffuse global atrophy.
Brief Hospital Course:
38 yo M with EtOH and polysubstance abuse, HCV, mood and seizure
disorder admitted with a GI bleed and hematemesis due to a
[**Doctor First Name **]-[**Doctor Last Name **] tear.
The patient presented with nausea and vomiting of bloody
material. He was found to have a Hct drop to a nadir of 20 from
a baseline in the mid 30's. He received 2 units of PRBC's. EGD
revealed a mucosal tear within a large hiatal hernia, likely
consistent with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear or less likely a Dieulufoy
lesion. There was an area of adjacent hyperplastic changes and
erosive gastritis. The patient was started on high dose PPI and
maintained NPO. His Hct stabilized and symptomatically he
improved, tolerating a full diet. The patient will continue on
high dose PPI for a minimum of 8 weeks. He requires outpatient
repeat EGD in approximately 8 weeks to evaluate for progress and
to biopsy the area of hyperplastic changes - this did not occur
in the setting of active GI bleeding.
He was counseled by both the social work and psychiatry consult
services on the need to discontinue alcohol use. He expressed
interest in rehab and was discharged to a dual diagnosis
facility. He had no signs of alcohol withdrawal during this
hospitalization and stated he has been sober for 60 days. He
continues on multivitamin, thiamine and folate supplementation.
The patient presented with a productive cough and had a CXR with
report of questionable infiltrate in his lingula. He had low
grade temps to >99. After 2-3 days, his admit blood cultures
returned with 1 out of 2 bottles of GNR's. This was further
speciated as a non fermenter, PROBABLE AGROBACTERIUM /
SPHINGOMONAS. ID was consulted and suggested that there should
be no further therapy for this as this bacteria may be a
contaminant. If he develops any infectious symptoms such as
fever he should be re-evaluated.
The patient has a history of hepatitis C and had a transaminitis
during this hospitalization. His LFT's were consistent with
prior measurements, in the 100-200 range. This is likely due to
the chronic untreated hepatitis C. He requires repeat LFT's in 1
week now back on depakote (see below). He has previously
considered treatment for the hepatitis C though this was
deferred in the past due to [**Doctor Last Name 17577**] alcohol use. As an
outpatient he should also be tested for HIV.
The patient had several ecchymoses from recent falls. He
complained of a headache and had a negative head CT.
The patient has a history of a mood and seizure disorder. He was
seen by the inpatient psych consult service and was restarted on
a modified version of his previous medication regimen including
depakote and remeron. All benzodiazepines were discontinued. Of
note, the patient reports that he was previously taken off of
depakote because of his chronic transaminitis and placed on
tegretol. This writer personally called his pharmacy where he
reported receiving the tegretol and was told that he had no
prescription on record for this and instead did have
prescriptions for depakote. For now he continues on a reduced
dose of depakote given his liver disease. He requires outpatient
follow-up for LFT monitoring and further management of this
issue. The patient does not currently have continuity with any
doctors but [**Name5 (PTitle) **] was encouraged to establish care with a single
doctor [**First Name (Titles) **] [**Last Name (Titles) 17577**] care. He was given information to help
schedule an appointment. In addition for sleep remeron 30mg po
qhs was added, for pain amitryptyline 25mg po qhs was added and
his depakote was increased to 500mg po tid on [**6-3**]. A repeat
level should be drawn in a few days or 1 week.
CHRONIC PAIN: the patient reports chronic pain and high doses of
outpatient oxycodone, from 90-120mg po daily total daily dose
(in 4 divided doses). I have checked with his pharmacy that he
gets all of his medications from per the patient and they have
him last receiving 35 pills of oxycodone 10mg on [**2205-3-13**]. He was
started on oxycodone 10mg po q4hrs prn pain initially on
admission but this was prior to this information regarding his
previous prescriptions. He repeatedly demanded higher doses of
oxycodone but did not show any objective signs of pain, his pain
was related to three prior injuries to his head, arm and leg.
His pain medication was continued at 10mg po q4hrs, he was
initially planning to go to a dual diangosis program but then
decided to go to a partial program instead. I have discussed
tihs issue with him and with addiction consult; I have weaned
his narcotics slightly from 10mg po q4hrs to 10mg po q6hrs. He
was given a supply until his f/u with [**Company 191**], if he makes this
appointment and his f/u w/ PCP he should sign a narcotics
agreement and f/u with pain medicine to find an alternative to
narcotics to treat his chronic pain.
Medications on Admission:
1. Depakote 500 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
2. multivitamin Tablet Sig: One (1) Tablet PO once a day.
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain: Do not take more than 7 tablets per
day (2000mg).
6. ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO every eight
(8) hours as needed for pain: Do not take for more than 7 days.
Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**1-13**]
Tablets PO every eight (8) hours as needed for Headache.
Disp:*54 Tablet(s)* Refills:*0*
5. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
6. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
8. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
9. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO TID (3 times a day).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. oxycodone 10 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for pain.
Disp:*36 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
GI bleed, hematemesis due to [**Doctor First Name **]-[**Doctor Last Name **] tear
Pneumonia
Bacteremia
Alcohol and polysubstance abuse
Mood and seizure disorder
Hepatitis C and transaminitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with vomiting of blood. This was due to a
small tear in the lining of the stomach. Please continue to take
pantoprazole as prescribed for a minimum of 8 weeks. You should
have a repeat endoscopy in 8 weeks to monitor for improvement as
well as to have a biopsy for diagnosis of an abnormal appearing
area within the stomach. In the meantime, you must avoid all
anti-inflammatory medications like ibuprofen or naproxen and
avoid aspirin and all blood thinners.
You should discontinue all alcohol use. Follow-up for alcohol
rehab/cessation counseling as planned. Continue to take the
prescribed vitamins, including thiamine and folate.
You have signs of chronic liver inflammation. Please have your
blood drawn in 1 week to monitor your liver function. Receive
recommendations from a doctor on how to change your depakote
prescription based upon the results. Also, you will need to see
a liver doctor about your hepatitis C.
You should also follow-up with a psychiatrist to continue
monitoring your psychiatric medication prescriptions.
Followup Instructions:
Please follow-up as planned for [**Doctor Last Name 17577**] psychiatric care and
alcohol cessation counselling.
Department: [**Hospital3 249**]
When: THURSDAY [**2205-6-13**] at 9:10 AM
With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Address: [**Location (un) 830**] [**Location (un) 86**], [**Numeric Identifier 718**]
Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This appointment is with a hospital-based doctor as part of your
transition from the hospital back to your primary care provider.
[**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up.
Department: [**Hospital3 249**]
When: FRIDAY [**2205-6-28**] at 3:45 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27395**], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Dr. [**Last Name (STitle) **] is your new physician in [**Name9 (PRE) 191**] and Dr. [**Last Name (STitle) **] works
closely with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**First Name3 (LF) **] both will be involved in
your care. For insurance purposes please indicate Dr. [**First Name (STitle) **]
as your Primary Care Physician.
Department: NEUROLOGY
When: THURSDAY [**2205-7-4**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7025**], MD [**Telephone/Fax (1) 3294**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
You have been placed on a cancellation list for this
appointment. The office will contact you at home with a sooner.
If you have any questions or concerns please call the office.
Orthopedics: ([**Telephone/Fax (1) 2007**]. call for an appointment within 4
weeks of your discharge from the hospital.
|
[
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icd9cm
|
[
[
[]
]
] |
[
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] |
icd9pcs
|
[
[
[]
]
] |
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|
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315, 343
|
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|
3357, 4170
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,191
| 116,326
|
38093
|
Discharge summary
|
report
|
Admission Date: [**2171-9-14**] Discharge Date: [**2171-9-23**]
Date of Birth: [**2088-7-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
fevers, hypotension
Major Surgical or Invasive Procedure:
[**2171-9-14**] Esophagastroduodenoscopy
History of Present Illness:
The patient OPCABG x 4 on [**2171-7-29**]. Post-op course was lengthy
and complicated. He initially was hemodynamically unstable,
requiring vasopressor support. EP saw the patient for
ventricular ectopy. PPM/AICD was not recommended. He continued
to be bradycardic, and would receive a temporary pacer. This
was removed, EP did not feel a PPM was indicated.
He developed a sternal wound infection and was taken to the
operating room by plastic and reconstructive surgery for sternal
plating and bilateral pectoralis flaps. The patient required
re-intubation several times during the [**Hospital **] hospital course,
and eventually received a trach and PEG on [**2171-8-30**]. EVH site was
debrided, and he received a 10 day course of vancomycin. He was
transferred to rehab on POD 45, [**2171-9-12**]. He returned on [**2171-9-13**]
with fever and hypotension. During this hospitalization he was
found to have CDiff in the stool and was placed on appropriate
antibiotics.
His hypotension resolved
Past Medical History:
Coronary Artery Disease s/p off pump coronary artery bypass
grafts
Respiratory failure- s/p Tracheostomy/PEG
Loculated left sided pleural effusion s/p Pigtail toracentesis
Sternal dehiscence s/p sternal debridement,plating,pectoral flap
advancement
Endoscopic vein harvest infection
[**Date Range **] decubitus ulcer
Ischemic cardiomyopathy
Chronic atrial fibrillation
Peripheral vascular disease
Hypertension
chronic obstructive pulmonary disease
Hypercholesterolemia
Social History:
Family History:
Race: Caucasian
Last Dental Exam: edentulous
Lives with: wife (in-law apartment- daughter +fam live nearby)
uses Canadian crutches for ambulation ([**3-12**] OA of knees)
Occupation: retired
Tobacco: 1ppd x 64yrs.
ETOH: occasional
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS - T 102.6, 93/50, HR 70's (atrial fibrillation, Vent - SIMV
TV
500, FIO2 50% Rate 14 PEEP 10
Gen: Eldery male, ill appearing
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: No clear JVD
CV: PMI located in 5th intercostal space, midclavicular line.
Irregularly irregular. normal S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4.
Chest: Wheezing b/l. sternum stable
Abd: distended, patient does not react to deep palpation
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
GJ TUBE CHECK.
One view of the abdomen. There is motion artifact. Contrast
material has
been injected via a gastrostomy tube. Contrast has accumulated
in a small
area in the left upper quadrant, presumably within the gastric
lumen. The
bowel gas pattern is not remarkable. There are degenerative
changes in the
lumbar spine.
IMPRESSION: Limited study demonstrating findings consistent with
placement of the gastrostomy tube in the stomach. See procedure
note.
Admission:
[**2171-9-13**] 08:45PM URINE RBC-[**7-18**]* WBC-0-2 BACTERIA-FEW
YEAST-NONE EPI-[**4-12**]
[**2171-9-13**] 08:45PM URINE BLOOD-LG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2171-9-13**] 08:45PM PT-13.4 PTT-26.7 INR(PT)-1.1
[**2171-9-13**] 08:45PM PLT COUNT-345
[**2171-9-13**] 08:45PM WBC-14.3*# RBC-3.46* HGB-10.5* HCT-32.3*
MCV-93 MCH-30.3 MCHC-32.5 RDW-16.5*
[**2171-9-13**] 08:45PM CALCIUM-9.3 PHOSPHATE-4.9* MAGNESIUM-2.5
[**2171-9-13**] 08:45PM cTropnT-0.11*
[**2171-9-13**] 08:45PM LIPASE-107*
[**2171-9-13**] 08:45PM ALT(SGPT)-67* AST(SGOT)-158* LD(LDH)-327* ALK
PHOS-241* AMYLASE-97 TOT BILI-1.2
[**2171-9-13**] 08:45PM GLUCOSE-135* UREA N-74* CREAT-1.3* SODIUM-142
POTASSIUM-4.2 CHLORIDE-109* TOTAL CO2-22 ANION GAP-15
[**2171-9-13**] 08:51PM LACTATE-1.2 K+-4.1
Discharge:
[**2171-9-23**] 02:54AM BLOOD WBC-8.8 RBC-2.86* Hgb-8.6* Hct-26.4*
MCV-93 MCH-30.1 MCHC-32.5 RDW-17.6* Plt Ct-228
[**2171-9-23**] 02:54AM BLOOD Plt Ct-228
[**2171-9-15**] 03:17AM BLOOD PT-14.1* PTT-29.8 INR(PT)-1.2*
[**2171-9-23**] 02:54AM BLOOD Glucose-86 UreaN-36* Creat-1.0 Na-144
K-4.4 Cl-112* HCO3-22 AnGap-14
[**2171-9-19**] 03:59AM BLOOD ALT-24 AST-23 AlkPhos-124 Amylase-53
TotBili-1.3
[**2171-9-18**] 01:36AM BLOOD Lipase-38
[**2171-9-16**] 5:00 am STOOL CONSISTENCY: WATERY Source: Stool.
**FINAL REPORT [**2171-9-16**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2171-9-16**]):
REPORTED BY PHONE TO [**Doctor First Name 66866**],D @ 16:19, [**2171-9-16**].
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
Radiology Report CHEST (PORTABLE AP) Study Date of [**2171-9-22**]
10:34 AM
[**Hospital 93**] MEDICAL CONDITION:
83 year old man s/p CABG
REASON FOR THIS EXAMINATION: eval for pleural effusions
Final Report
REASON FOR EXAMINATION: Evaluation of the patient after CABG for
pleural
effusions.
Portable AP chest radiograph was compared to [**2171-9-18**].
Tracheostomy tube is in the midline, approximately 7.5 cm above
the carina.
There is no change in the sternal fixation devices appearance.
Cardiomegaly is severe. Retrocardiac consolidations are
bilateral, accompanied by bilateral
pleural effusions. There is no interval worsening of the overall
appearance of the chest.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Brief Hospital Course:
The patient was admitted for workup and management of fever and
hypotension. He was empirically treated with vancomycin and
zosyn. There was question of malposition of G-tube on CT scan,
so urgent EGD was performed. Tube was re-positioned without
complication. Contrast study was negative for extravasation.
Tube feeds were resumed. Wound care was consulted for
evaluation of [**Last Name (NamePattern1) 85030**] pressure ulcer (present prior to
admission).
Pan cultured for fever workup, sputum culture would grow gram
negative rods and stool was positive for c-diff. The patient
was treated with flagyl and zosyn. After several days on Flagyl
the patient continue to have watery stool and PO Vancomycin was
added for treatment of CDiff infection.
Pulmonary status remains tenuous, attempts to wean ventilator to
pressure support ventilation with 5 Peep and 5 Pressure support
were unsucessful. The patient would quickly have an episode of
tachypnea requiring increased pressure support. Interventional
pulmonary was consulted, an ultrasound of pleural space showed
small loculated effusion that was not amendable to drainage.
On hospital day 10 the patient was transferred to rehabilitation
at [**Hospital1 **]-[**Hospital1 8**].
Medications on Admission:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
9. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
10. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
13. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**7-18**]
Puffs Inhalation Q4H (every 4 hours).
14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
4-8 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.
15. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO DAILY
(Daily).
16. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
17. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
18. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QTUES (every Tuesday).
19. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours) as needed for SBP>130.
20. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
21. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
22. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
23. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig:
Four (4) Puff Inhalation [**Hospital1 **] (2 times a day) as needed for COPD.
24. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
twice a day for 10 days.
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day) as needed for prophylaxis.
2. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day) as needed for ----.
3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for prevent thrush.
4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
6-10 Puffs Inhalation Q4H (every 4 hours).
5. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q4H (every 4 hours).
6. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig: One
(1) Inhalation [**Hospital1 **] ().
7. Collagenase Clostridium hist. 250 unit/g Ointment Sig: One
(1) Appl Topical DAILY (Daily): to [**Hospital1 85030**] decub.
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q 8H
(Every 8 Hours).
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): Hold sbp<100 hr<60.
11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 14 days: end date [**9-30**].
12. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 14 days: end date [**10-6**].
Disp:*qs Capsule(s)* Refills:*0*
13. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)). Tablet(s)
14. Pepcid 20 mg Tablet Sig: One (1) Tablet PO once a day.
15. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
16. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).
17. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: Sodium
Chloride 0.9% Flush 10 mL IV PRN line flush Intravenous daily
and PRN: Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN. .
18. Furosemide 10 mg/mL Solution Sig: Twenty (20) mg Injection
once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] TCU - [**Location (un) 86**]
Discharge Diagnosis:
Coronary Artery Disease s/p off pump coronary artery bypass
grafts
Respiratory failure- s/p Tracheostomy/PEG
Loculated left sided pleural effusion s/p Pigtail toracentesis
Sternal dehiscence s/p sternal debridement,plating,pectoral flap
advancement
Endoscopic vein harvest infection
[**Location (un) **] decubitus ulcer
Ischemic cardiomyopathy
Chronic atrial fibrillation
Peripheral vascular disease
Hypertension
chronic obstructive pulmonary disease
Hypercholesterolemia
Discharge Condition:
Tracks, Moves upper extremities
Incisional pain managed with Tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Left Lower leg endoscopic vein site open->pack wet to dry [**Hospital1 **]
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage
2) Please NO lotions, cream, powder, or ointments to incisions
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart
4) No driving for approximately one month until follow up with
surgeon
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2171-10-21**] at
1:00PM
Please call to schedule appointments:
Primary Care: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17859**] ([**Telephone/Fax (1) 40171**]in [**4-11**] weeks
Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 5424**]) in [**4-11**] weeks
Plastic Surgery: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 1416**] in [**4-11**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2171-9-23**]
|
[
"496",
"272.0",
"518.81",
"414.00",
"008.45",
"707.25",
"V44.0",
"443.9",
"427.31",
"414.8",
"707.03",
"511.9",
"V45.81",
"401.9",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"44.13",
"38.93",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
11486, 11560
|
5853, 7094
|
340, 383
|
12076, 12281
|
2912, 5143
|
13052, 13934
|
2195, 2277
|
9470, 11463
|
5183, 5208
|
11581, 12055
|
7120, 9447
|
12305, 13029
|
2292, 2893
|
281, 302
|
5240, 5830
|
411, 1421
|
1443, 1914
|
1930, 1930
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,514
| 177,828
|
15079
|
Discharge summary
|
report
|
Admission Date: [**2145-11-3**] Discharge Date: [**2145-11-23**]
Date of Birth: [**2075-7-6**] Sex: M
Service: CSURG
Allergies:
Diamox Sequels
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
sp resection of complex distal arch/proximal descending aortic
aneurysm w/ deep hypothermic circulatory arrest [**2145-11-3**].
sp tracheostomy/bronchoscopy [**2145-11-17**]
History of Present Illness:
70 M p/w shortness of breath X 2 years. Upon work-up, CXR ?
mediastinal "vascular" mass and B upper lobe pulmonary nodules.
CT [**8-2**] revealed 5.8X4.9 saccular aneurysm of the proximal
descending aorta, calcified atherosclerotic descending aorta.
Past Medical History:
NIDDM
OSA on BIPAP
obesity
CAD sp stent X 2
hypercholesterolemia
HTN
remote malaria
remote spontaneous pneumothorax
BPH
h/o hemorrhoids
Social History:
Tobacco: 1 ppd X 30 [**Month/Year (2) 1686**], quit 25 [**Month/Year (2) 1686**] ago. Rare ETOH.
Family History:
Father dies in 50's-CAD/MI
Mother alive @ [**Age over 90 **] [**Name2 (NI) 1686**] old.
Physical Exam:
Obese, slightly uncomfortable from shortness of breath
PERRLA, EOMI
No JVD/bruits
CTAB
RRR
obese, NT/ND
warm, well perfused
CN II-XII
Pertinent Results:
[**2145-11-22**] 04:26AM BLOOD WBC-8.3 RBC-3.39* Hgb-10.6* Hct-32.3*
MCV-95 MCH-31.3 MCHC-32.8 RDW-15.0 Plt Ct-408
[**2145-11-16**] 03:39AM BLOOD WBC-15.5* RBC-3.95* Hgb-12.2* Hct-37.3*
MCV-94 MCH-30.8 MCHC-32.7 RDW-14.3 Plt Ct-422
[**2145-11-15**] 04:30AM BLOOD WBC-12.5* RBC-4.08* Hgb-12.7* Hct-38.1*
MCV-93 MCH-31.0 MCHC-33.2 RDW-14.2 Plt Ct-385
[**2145-11-4**] 02:45AM BLOOD WBC-5.4 RBC-2.96*# Hgb-9.0*# Hct-25.8*
MCV-87 MCH-30.3 MCHC-34.8 RDW-15.4 Plt Ct-177
[**2145-11-8**] 02:40AM BLOOD WBC-7.9 RBC-3.59* Hgb-11.3* Hct-32.7*
MCV-91 MCH-31.4 MCHC-34.6 RDW-14.4 Plt Ct-153
[**2145-11-18**] 02:44AM BLOOD PT-13.1 PTT-25.5 INR(PT)-1.1
[**2145-11-3**] 05:27PM BLOOD PT-17.8* PTT-33.0 INR(PT)-2.0
[**2145-11-3**] 06:25PM BLOOD Fibrino-194
[**2145-11-22**] 04:26AM BLOOD Glucose-187* UreaN-41* Creat-0.8 Na-147*
K-4.6 Cl-108 HCO3-28 AnGap-16
[**2145-11-4**] 02:45AM BLOOD Glucose-119* UreaN-20 Creat-1.0 Na-143
K-4.5 Cl-109* HCO3-25 AnGap-14
[**2145-11-16**] 03:39AM BLOOD ALT-134* AST-56* AlkPhos-115 Amylase-102*
TotBili-0.6
[**2145-11-17**] 09:46PM BLOOD Type-ART Temp-38.2 PEEP-10 O2-40 pO2-164*
pCO2-38 pH-7.44 calHCO3-27 Base XS-2 Intubat-INTUBATED Vent-IMV
[**2145-11-3**] 09:07AM BLOOD Type-ART Tidal V-800 O2-100 pO2-308*
pCO2-54* pH-7.33* calHCO3-30 Base XS-1 AADO2-363 REQ O2-64
Intubat-INTUBATED Vent-CONTROLLED
[**2145-11-16**] 05:04AM BLOOD Lactate-2.3*
Brief Hospital Course:
[**11-3**]: Admitted to OR (see operative report for details), post-op
to CSRU, initially kept paralyzed and sedated to facilitate
oxygenation and ventilation. Had intrathecal catheter for first
few post-op days for drainage and pain control.
[**11-4**]: bronchoscopy for thick secretions
[**11-5**]: antihypertensives initiated Neurology consult obtained
due to decreased level of responsiveness/movement after
sedation/paralytics stopped. Head CT's X 2 ([**11-5**] & [**11-7**]) showed
no acute bleed nor stroke. MRI on [**11-8**] showed multiple embolic
subacute infarcts, Left > Right. Pt. continued with decreased
movement despite becoming "more awake" over next week. MRI of
TLS spine revealed no cord compression nor intrinsic
abnormality.
Multiple attempts to wean vent over next few days were
unsuccessful, Tube feeding was initiated as pt. was not able to
be extubated.
Had elevated temp., with hypotension requiring neo-synephrine
for a few days. Treated epirically w/Vancomycin & Levofloxacin.
Had 1 positive blood culture (out of 4, felt to be
contaminated, subsequent blood cultures were negative).
Tracheostomy performed on [**11-17**] due to need for continued vent.
support, and slow nature of vent. weaning. Pt. had become more
responsive, but still with significant decrease in movement.
PICC line placed on [**11-19**] for IV access. Has been tolerating
tube feedings well through Dobhoff feeding tube.
Pt. had remained stable for a number of days, on slowly
decreasing vent. support. Spiked temp to 101.8 again (off
antibiotics) on [**11-21**]. While chest x-ray was unremarkable, he
had copious amt. of thick sputum. Previous sputum culture was
positive for pan-sensitive staph. Repeat sputum was the same.
Pt. was re-started on Levaquin for positive sputum (without
x-ray evidence of infiltrate, or elevated WBC). Temp. has
decreased, and pt. now ready for rehab.
Medications on Admission:
ASA 325', metformin 1000", pravachol 20', isosorbide 60',
lopressor 100", accupril 40", HCTZ 25', Doxazosin 2", MVI'
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
3. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Ranitidine HCl 15 mg/mL Syrup Sig: One [**Age over 90 1230**]y (150) mg
PO QD (once a day).
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
QD (once a day) as needed.
6. Trazodone HCl 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime) as needed.
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days: started [**11-22**].
8. Insulin Regular Human 100 unit/mL Cartridge Sig: One (1)
Injection four times a day: as per sliding scale.
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Potassium Chloride 20 mEq/50 mL Piggyback Sig: One (1)
Intravenous PRN (as needed) as needed for K<4.4 and CR<2.0.
14. Humalog 100 unit/mL Solution Sig: One (1) vial Subcutaneous
every four (4) hours: Sliding scale humalog insulin coverage Q 4
hours:
BS 121-140=3Units s/c
BS 141-160=6U s/c
BS 161-180=9U s/c
BS 181-200=12U s/c
BS 201-220=15U s/c
BS 221-240=18U s/c
BS >240=21U s/c
.
Disp:*1 vial* Refills:*2*
15. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: One (1)
vial Subcutaneous every twelve (12) hours: 30 Units s/c Q 12
hours.
Disp:*1 vial* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
proximal descending aortic aneurysm
Discharge Condition:
stable
Discharge Instructions:
Please call physician if experiencing fever/chills,
nausea/vomiting, redness/drainage from the wound site, chest
pain/shortness of breath.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1290**] in 3 weeks; call the office
for an appointment.
Please follow up with Dr. [**Last Name (STitle) **]; call the office for an
appointment.
Please follow up with your PCP/cardiologists within 1-2 weeks
regarding new medications.
Completed by:[**2145-11-23**]
|
[
"V45.82",
"996.74",
"414.00",
"250.00",
"272.0",
"441.2",
"518.5",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"96.6",
"38.45",
"88.72",
"39.61",
"96.05",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
6190, 6260
|
2689, 4593
|
292, 468
|
6340, 6348
|
1297, 2666
|
6535, 6849
|
1038, 1127
|
4760, 6167
|
6281, 6319
|
4619, 4737
|
6372, 6512
|
1142, 1278
|
233, 254
|
496, 748
|
770, 907
|
923, 1022
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
586
| 186,075
|
11562
|
Discharge summary
|
report
|
Admission Date: [**2142-11-22**] Discharge Date:
Date of Birth: [**2079-10-4**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 63-year-old
male experiencing substernal chest pain and diaphoresis on
[**11-12**] after exercise. On [**11-17**] the patient experienced
markedly increased chest pain and shortness of breath,
worsening with exertion. The patient was admitted to
Emergency Room on [**11-20**] for right lower lobe pneumonia and
positive troponin. EKG at that time showed lateral lead ST
depression. Echocardiogram showed ejection fraction of 40%
with inferior and posterior wall motion abnormality and mild
MR.
PAST MEDICAL HISTORY: Significant for hypertension, chronic
back pain and left foot drop. Cath at the time showed the
left main were normal, LAD 90%, mid section occluded, left
circumflex 80% occluded, RCA 100% occluded.
MEDICATIONS: Home medications included Protonix 40 mg po q
d, Aspirin 325 mg po q d, Lopressor 12.5 mg po tid, Diovan 80
mg po q d, Lovenox 100 mg subcu [**Hospital1 **], Colace, Humibid 1200 mg
po bid, Valium 5 mg po q 4-6 hours prn, Albuterol nebs.
HOSPITAL COURSE: The patient was taken by Dr. [**Last Name (STitle) 1537**] to the OR
and underwent CABG times three on [**2142-11-23**] with LIMA to LAD,
SVG to OM and SVG to PDA. Postoperatively the patient did
well. However, the patient was extubated and went off drips
without any incidents. However, we did decide to keep the
patient in the ICU for two extra days because of his pre-op
pneumonia. The patient was on Ceftriaxone since the day of
admission and postoperatively the patient did well, afebrile
and was able to transfer to the floor on postoperative day
#2. The only complication is patient experienced atrial
fibrillation on postoperative day #2, was started on
Amiodarone and was rate controlled with Lopressor. The
patient's vital signs were stable, was never hypotensive and
on the floor patient underwent physical therapy and was
ambulating at level [**4-15**] with assistance. The rest of the
postoperative course was unremarkable and upon discharge the
patient's lungs were clear to auscultation, the incision was
clean, dry and intact, no drainage, no pus. Heart was normal
sinus rhythm and sternum was stable. Upon discharge his
white count was 12.2, hematocrit 29.2, BUN 30, creatinine .9.
DISCHARGE MEDICATIONS: Ceftriaxone 1 gm IV q d times 6 days,
Amiodarone 400 mg po tid times 6 days, then 400 mg po bid
times one week, then 400 mg po q d, Lopressor 12.5 mg po bid,
Albuterol nebs q 4-6 hours prn, Lasix 20 mg po bid times 10
days, Potassium Chloride 20 mEq po bid times 10 days, Valium
5 mg po q 4-6 hours prn, Percocet 1-2 tablets po q 4-6 hours
prn, Aspirin 81 mg po q d, Protonix 40 mg po q d, Lovenox 100
mg subcu [**Hospital1 **]. Upon discharge patient was stable and
afebrile. The patient will be discharged to a rehab facility
and told to follow-up with Dr. [**Last Name (STitle) 1537**] in [**4-15**] weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 186**]
MEDQUIST36
D: [**2142-11-27**] 08:00
T: [**2142-11-27**] 10:59
JOB#: [**Job Number **]
|
[
"486",
"401.9",
"410.31",
"428.0",
"427.41",
"997.1",
"724.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"88.53",
"36.12",
"88.56",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
2412, 3289
|
1179, 2388
|
168, 684
|
707, 1161
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,657
| 194,459
|
26145
|
Discharge summary
|
report
|
Admission Date: [**2195-1-11**] Discharge Date: [**2195-1-16**]
Date of Birth: [**2133-12-30**] Sex: M
Service: [**Year (4 digits) **]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8747**]
Chief Complaint:
Left intracranial hemorrhage
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is unable to give history. History taken from friend and
nursing/ED notes. Patient is a 61 year old man, unknown
handedness, who was transferred to [**Hospital1 18**] ED on [**2195-1-11**] from
[**Location (un) 47**] ED for evaluation and management of left intracranial
hemorrhage after being found confused and aphasic earlier today.
Patient was last seen well around 11am today. He leads a
[**Doctor First Name **] Scientist service and was able to complete service
without any difficulties. Afterwards, he went to clean out an
office nearby. Friends were to meet him there to help. His
friends arrived around 11:30 am. They found him down on the
ground. He was confused, speaking gibberish, and had right
facial droop and weakness of his right side. They opted to take
him to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Scientist nursing center, where he was
observed until just before 2pm, at which time an ambulance was
called.
He arrived at [**Location (un) 47**] [**Hospital1 1281**] at around 2:15 pm. Initial vitals
with BP 118/94, HR 77, RR 18, O2 98%/Ra. He did have BP spike up
to 165/103 and was given 10 mg IV Labetalol. Head CT there
reportedly showed a 3.5 x 2.6 left basal ganglia hemorrhage as
well as a smaller focus of hemorrhage on the right. He was
loaded with Dilantin there.
His wife was spoken to via telephone and reportedly said she
wanted option of surgical intervention if necessary. He was
therefore transferred to our facility.
Past Medical History:
None known. As [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Scientist, he practices faith
based healing.
Social History:
Married. Lives with wife. Wife is in [**State **] on a business
trip but is on her way back to [**Location (un) 86**] area. Unknown habits
history.
Family History:
Unknown.
Physical Exam:
Tc: 99.4 BP: 116/94 HR: 70 RR: 17 O2Sat.: 98%/2L
Gen: WD/WN, comfortable, NAD.
HEENT: NC/AT. Anicteric. MMM.
Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No
carotid bruits.
Lungs: CTA bilaterally. No R/R/W.
Cardiac: RRR. S1/S2. No M/R/G.
Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM.
Extrem: Warm and well-perfused. No C/C/E.
Neuro: Alert and awake. Oriented to self. Speech fluent, pt
loquacious with non-sensical steady stream of words. Naming
intact to high frequency objects but not to low frequency ones.
Speech with many phonemic and semantic paraphasic errors.
Repetition intact. Following midline commands, but not lateral
commands.
Pertinent Results:
CT head [**1-11**]: There is a large area of high attenuation within
the region of the left lentiform nucleus. There is low
attenuation of the periventricular white matter consistent with
chronic microvascular infarction. There is no shift of normally
midline structures or hydrocephalus. The [**Doctor Last Name 352**]-white matter
differentiation remains intact. There is slight asymmetry of the
sulci, with slightly more effacement of the left cerebral sulci.
The osseous structures are normal. There is a polyp versus
mucosal retention cyst in the left maxillary sinus.
CT head [**1-12**]: IMPRESSION: No significant interval change in the
appearance of the intraparenchymal hematoma in the left basal
ganglia.
[**2195-1-11**] 04:10PM BLOOD WBC-16.6* RBC-4.58* Hgb-15.1 Hct-40.5
MCV-88 MCH-32.9* MCHC-37.2* RDW-13.3 Plt Ct-206
[**2195-1-13**] 05:35AM BLOOD WBC-8.6 RBC-4.51* Hgb-14.7 Hct-41.0
MCV-91 MCH-32.6* MCHC-35.8* RDW-13.2 Plt Ct-192
[**2195-1-11**] 04:10PM BLOOD Neuts-90.2* Bands-0 Lymphs-7.3* Monos-2.1
Eos-0 Baso-0.3
[**2195-1-11**] 04:10PM BLOOD PT-13.0 PTT-27.5 INR(PT)-1.1
[**2195-1-11**] 04:10PM BLOOD Plt Smr-NORMAL Plt Ct-206
[**2195-1-11**] 04:10PM BLOOD Glucose-112* UreaN-21* Creat-1.6* Na-142
K-4.1 Cl-107 HCO3-24 AnGap-15
[**2195-1-13**] 05:35AM BLOOD Glucose-96 UreaN-14 Creat-1.5* Na-143
K-3.7 Cl-109* HCO3-24 AnGap-14
[**2195-1-14**] 08:30AM BLOOD Glucose-87 UreaN-12 Creat-1.5* Na-142
K-4.2 Cl-106 HCO3-25 AnGap-15
[**2195-1-15**] 11:25AM BLOOD ALT-39 AST-43* AlkPhos-84
[**2195-1-11**] 04:10PM BLOOD CK(CPK)-108
[**2195-1-11**] 04:10PM BLOOD CK-MB-3 cTropnT-0.01
[**2195-1-14**] 08:30AM BLOOD Calcium-9.3 Phos-2.6* Mg-1.9
[**2195-1-15**] 11:25AM BLOOD Albumin-4.1 Cholest-PND
Brief Hospital Course:
Patient is a 61 year old man with no known PMH who presented
with garbled speech, R hemiparesis and R facial droop, found to
have a L basal ganglia bleed.
1. Neuro: CT scan was done showing low attenuation of the
periventricular white matter consistent with chronic
microvascular infarction as well as a L BG bleed. CT was
repeated the next day and showed no progression of the bleed.
The etiology of the bleed was presumed to be [**3-19**] a combination
of HTN and hypercholesterolemia, although these are difficult to
be certain of given lack of previous medical contact. The
patient was found to have Wernicke's aphasia. His language
improved dramatically over the course of a few days. At the
time of discharge he was able to express himself fully, although
still making some paraphasic errors. His repetition and
comprehension are fully intact. He continues to have a mild R
facial droop. His R hemiparesis improved significantly with R
deltoid and IP muscles improving to [**5-20**]. He was able to walk
without assistance, albeit somewhat unsteady. His cerebellar
exam is unremarkable.
2. HTN - The patient was found to be hypertensive during his
stay with SBP in the 150's, and was started on metoprolol which
was titrated up to 25mg PO BID with improved BP control.
3. Hypercholesterolemia - a lipid panel was sent showing total
cholesterol of 219 and LDL of 158. He was started on lipitor at
10mg daily.
4. Renal Insufficiency - a slightly elevated Cr of 1.5 was
found which remained stable during his admission. A renal U/S
was ordered showing some assymetry with the L kidney being
smaller. He was not started on an ACE-I because of unknown
previous Cr values, but he will be scheduled to follow up with
the [**Month/Day (1) **] clinic to discuss possible imaging for
renovascular disease or possibly initiating ACE-Inhibitor
therapy.
5. FEN - blood sugars were normal throughout admission
6. Dispo - pt refused to go to a rehab facility, wanted to go
home. At the time of discharge, pt was given a walker to aid
with mobility. He will be scheduled for a follow-up head MRI in
6 weeks, follow-up with a [**Month/Day (1) 3390**], [**Name10 (NameIs) **], and referred to the
[**Name10 (NameIs) **] clinic.
Medications on Admission:
none
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Stroke, hemorrhagic
Hypertension
Chronic Renal Insufficiency
Discharge Condition:
stable
Discharge Instructions:
Please take your medications as prescribed. Follow-up with your
neurologist and primary care physician as scheduled. In
addition follow up in the [**Name10 (NameIs) **] (kidney) clinic as
scheduled. Call the radiology department within the next week
to schedule an outpatient MRI in [**6-20**] weeks. Discuss with your
doctor [**First Name (Titles) 3380**] [**Last Name (Titles) **] after that.
Call your doctor or report to the nearest hospital if you
develop any worsening in your speech or if you develop any
weakness, numbness or other concerning symptoms.
Followup Instructions:
Call Dr.[**Name (NI) 12755**] ([**Name (NI) **]) office at ([**Telephone/Fax (1) 7394**] to
schedule a follow-up appointment.
Call the Radiology department at [**Telephone/Fax (1) 327**] to schedule a
follow-up MRI in [**6-20**] weeks.
Provider [**Name Initial (PRE) **] [**Name Initial (NameIs) 3390**]: [**Name10 (NameIs) 23675**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2195-2-6**] 1:30
Provider [**Name Initial (PRE) **] [**Name Initial (NameIs) 10701**]: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7198**], M.D.
Date/Time:[**2195-2-25**] 1:00. You need to call the clinic prior to
appointment to update your registration information.
Completed by:[**2195-1-25**]
|
[
"431",
"401.9",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7241, 7247
|
4659, 6900
|
359, 366
|
7352, 7361
|
2927, 4636
|
7974, 8703
|
2214, 2225
|
6955, 7218
|
7268, 7331
|
6926, 6932
|
7385, 7951
|
2240, 2908
|
291, 321
|
394, 1885
|
1907, 2032
|
2048, 2198
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,346
| 102,717
|
8613
|
Discharge summary
|
report
|
Admission Date: [**2167-4-21**] Discharge Date: [**2167-4-27**]
Date of Birth: [**2108-4-9**] Sex: M
Service: SURGERY
Allergies:
Iron Dextran Complex
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
ESRD
Major Surgical or Invasive Procedure:
Attempted renal transplant/aborted [**2167-4-21**]
History of Present Illness:
59 year-old male with h/o ESRD secondary to DM. Started
dialysis in [**2165-5-15**] via LUE AV graft. Last dialysis was done
[**2167-4-21**]. He has dialysis Tuesday, Thursday, and Saturday.
Typically urinates 4-5 times a day. He is admitted today,
[**2167-4-21**] for a kidney transplant.
Past Medical History:
1. ESRD on hemodialysis, awaiting placement on transplant list
(HD T,Th, Sat)
2. Renal cell carcinoma of left kidney (s/p partial nephrectomy
[**5-17**]) T1, N0, M0. Surveillance MR [**First Name8 (NamePattern2) **] [**2165-5-15**] was negative
for recurrence.
2. CHF (stage II) - diastolic - followed by Dr. [**First Name (STitle) 437**]. Recently
started on carvedilol (end of [**Month (only) 547**])
3. Hypertension
4. DM2, HbA1C 9
5. Hepatitis C
6. HOH
7. Gout
8. Anemia
9. [**Doctor Last Name 15532**]??????s Esophagus
10. Prostate nodule, PSA 2.8 fall [**2164**]
11. Viral Pericardial effusion - [**1-20**]. [**Month (only) 958**] seen by echo to
have resolved. Not thought to be uremic effusion.
Social History:
Lives with sister, previously worked in a hotel, quit after [**Month (only) **]
admission to hospital.
Previous 80 pack year smoking history, quit in [**2165-5-15**].
Previous ETOH history of 1 pint per week, quit in [**2165-5-15**]
Previous crack cocaine use (1-2 times per month), quite in [**Month (only) **]
[**2164**]
Previous heroin use, quite 5-6 years ago
Family History:
Sister- DM
[**Name (NI) **] reported CAD.
Positive for alcoholism.
Mother died of "liver problems"; father died of stroke at 51. He
is unsure of any other medical problems in his family.
Physical Exam:
ADMISSION EXAM:
100.0 88 147/95 20 96% room air
NAD
A&O x 3
RRR
CTA bilaterally
soft, obese, NT, NABS
no cyanosis, cords, edema
DISCHARGE EXAM:
97.3 61 128/65 16 94% room air
NAD
A&O x 3
RRR
CTA bilaterally
soft, obese, NT, NABS
incision clean, dry, intact
no cyanosis, cords, edema
Pertinent Results:
ADMISSION LABS:
[**2167-4-21**] 06:57PM BLOOD WBC-11.2* RBC-4.55* Hgb-12.3* Hct-39.6*
MCV-87# MCH-27.1 MCHC-31.2 RDW-20.9* Plt Ct-416
[**2167-4-21**] 06:57PM BLOOD PT-12.3 PTT-27.4 INR(PT)-1.1
[**2167-4-21**] 06:57PM BLOOD UreaN-24* Creat-8.2*# Na-141 K-4.0 Cl-98
HCO3-26 AnGap-21*
[**2167-4-21**] 06:57PM BLOOD ALT-40 AST-51*
[**2167-4-21**] 06:57PM BLOOD Albumin-4.3 Calcium-9.9 Phos-4.3# Mg-1.9
.
DISCHARGE LABS:
[**2167-4-27**] 08:08AM BLOOD WBC-12.9* RBC-3.88* Hgb-10.6* Hct-33.6*
MCV-87 MCH-27.3 MCHC-31.6 RDW-20.7* Plt Ct-358
[**2167-4-23**] 03:53AM BLOOD PT-11.9 PTT-25.3 INR(PT)-1.0
[**2167-4-27**] 08:08AM BLOOD Glucose-132* UreaN-62* Creat-10.3*#
Na-136 K-4.2 Cl-92* HCO3-26 AnGap-22*
[**2167-4-23**] 03:53AM BLOOD ALT-25 AST-47* AlkPhos-137* Amylase-107*
TotBili-0.3
[**2167-4-23**] 03:53AM BLOOD Lipase-100*
[**2167-4-27**] 08:08AM BLOOD Calcium-8.5 Phos-7.0* Mg-2.2
.
RADIOLOGY Final Report
-59 DISTINCT PROCEDURAL SERVICE [**2167-4-21**] 10:53 PM
CHEST PORT. LINE PLACEMENT; -59 DISTINCT PROCEDURAL SERVIC
Reason: ptx
[**Hospital 93**] MEDICAL CONDITION:
59 year old man with r IJ
REASON FOR THIS EXAMINATION:
ptx
INDICATIONS: 59-year-old man with right internal jugular
catheter.
COMPARISONS: Earlier in the same day.
CHEST, AP PORTABLE: There is a new endotracheal tube, beyond the
thoracic inlet, terminating 4 cm above the carina. A right
internal jugular central venous catheter terminates in the
distal superior vena cava. A new nasogastric tube terminates in
the stomach but there is a sidehole latter immediately at or
above the gastroesophageal junction.
Cardiac and mediastinal contours are unchanged. There is new
focal opacity in the left upper lobe, consistent with aspiration
or pneumonia.
IMPRESSION:
1. Nasogastric tube with side hole latter above the
gastroesophageal junction. 2. New focal opacity in the left
upper lobe with rapid onset, with the differential diagnosis
including aspiration or pneumonia.
Findings discussed with resident covering the patient.
.
RADIOLOGY Final Report
CHEST (PA & LAT) [**2167-4-21**] 6:59 PM
CHEST (PA & LAT)
Reason: pre op kidney [**Hospital 23678**]
[**Hospital 93**] MEDICAL CONDITION:
59 year old man with for kidney tx
REASON FOR THIS EXAMINATION:
pre op kidney tx
INDICATION: 59-year-old man with kidney transplant. Preop
study..
PA AND LATERAL CHEST RADIOGRAPHS: The heart size is at the upper
limits of normal. Mediastinal and hilar contours are stable and
unremarkable. The ill- defined pulmonary vasculature as well as
basilar interstitial opacities are most consistent with stable
vascular congestion. Overall there has been little interval
change compared to prior study.
IMPRESSION: No evidence of pneumonia. Mild vascular congestion.
.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2167-4-22**] 11:58 AM
CHEST (PORTABLE AP)
Reason: infiltrates
[**Hospital 93**] MEDICAL CONDITION:
59 year old man with r IJ
REASON FOR THIS EXAMINATION:
infiltrates
PORTABLE UPRIGHT CHEST, 12:08 P.M.
INDICATION: Followup infiltrate.
FINDINGS: Compared with 5/8 at 11:38 p.m., no significant change
in tube and line positions. The right lung is grossly clear. No
overt CHF.
There has been partial interval clearing of the streaky
atelectasis/infiltrate in the retrocardiac region. There has
also been partial clearing of what appears to be atelectasis in
the left peri/suprahilar region.
.
Cardiology Report ECHO Study Date of [**2167-4-22**]
Conclusions:
The left atrium is mildly dilated. The right atrium is
moderately dilated.
Left ventricular wall thickness, cavity size, and systolic
function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion
abnormality cannot be fully excluded. There is no ventricular
septal defect.
Right ventricular chamber size and free wall motion are normal.
The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and
no aortic regurgitation. The mitral valve appears structurally
normal with
trivial mitral regurgitation. The pulmonary artery systolic
pressure could not
be determined. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2166-4-25**], no
change.
.
RADIOLOGY Preliminary Report
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2167-4-23**] 7:46 PM
CTA CHEST W&W/O C&RECONS, NON-
Reason: CTA CHEST ONLY; eval for PE infiltrates and pulmonary
fibros
Field of view: 36 Contrast: [**Hospital 13288**]
[**Hospital 93**] MEDICAL CONDITION:
59M s/p aborted kidney tx for hypoxia in OR
REASON FOR THIS EXAMINATION:
CTA CHEST ONLY; eval for PE infiltrates and pulmonary fibrosis
CONTRAINDICATIONS for IV CONTRAST: None.
STUDY: CTA OF THE CHEST WITHOUT AND WITH CONTRAST.
INDICATION: 59-year-old male status post aborted kidney
transplant, presenting with hypoxia. Assess for pulmonary
embolism.
COMPARISONS: None.
TECHNIQUE: Non-contrast MDCT axial images were acquired of the
chest. Following administration of intravenous contrast, MDCT
axial images were acquired from the thoracic inlet to the upper
abdomen. Coronal, sagittal, and oblique reformatted images were
then obtained.
CTA OF THE CHEST WITHOUT AND WITH IV CONTRAST: There are no
filling defects present within the main pulmonary arteries or
the segmental branches to the upper lobes bilaterally. However,
given technical difficulties of bolus administration, the lower
lobe arteries cannot be evaluated bilaterally. There is biatrial
enlargement. There is no aortic dissection. There is no evidence
of pulmonary fibrosis. There is a bilateral, dependent
atelectasis. There are mild, streaky opacities within the left
lobe. The lungs are otherwise unremarkable. A prominent
prevascular node measures 9 mm (3:18). There are few prominent
mediastinal nodes, particularly posterior to the esophagus. None
meet criteria for pathology. There are no pathologic hilar or
axillary lymph nodes.
Bone windows demonstrate no lytic or blastic lesions. There are
mild degenerative changes of the mid to lower thoracic spine.
Limited views of the upper abdomen are unremarkable.
IMPRESSION:
1. No evidence of pulmonary embolism within the main pulmonary
arteries and segmental branches to the upper lobes of the lungs.
The segmental arteries to the lower lobes of the lungs are
incompletely evaluated on this examination. A repeat evaluation
could be performed if clinically indicated.
2. No pulmonary fibrosis.
3. Mild, streaky opacities present at the left lung base largely
unchanged compared to the CT torso from [**2166-2-21**].
.
RADIOLOGY Preliminary Report
US ABD LIMIT, SINGLE ORGAN [**2167-4-26**] 12:04 PM
US ABD LIMIT, SINGLE ORGAN
Reason: seroma/hematoma
[**Hospital 93**] MEDICAL CONDITION:
59 year old man with aborted RLQ renal transplant now with cont
drainage from wound despite stitches
REASON FOR THIS EXAMINATION:
seroma/hematoma
LIMITED ABDOMINAL ULTRASOUND
INDICATION: 59-year-old man with aborted right lower quadrant
renal transplant, presenting with drainage from the wound. Rule
out seroma, hematoma.
COMPARISON: Not available.
FINDINGS: Limited [**Doctor Last Name 352**]-scale images of the right lower quadrant
area were obtained. No abnormal fluid collection was identified.
IMPRESSION: No evidence of fluid collection.
Brief Hospital Course:
The patient was admitted to Dr.[**Name (NI) 670**] Transplant Service at
the [**Hospital1 69**] on [**2167-4-21**] for a DCD
renal transplant. For details of the operation, please refer to
the operative report. The operation was aborted
intra-operatively due to unknown cause of hypoxia. The patient
was transferred to the SICU for further care immediately
post-operatively and continued to be intubated. A chest xray a
new focal opacity in the left upper lobe with rapid onset. On
POD 1, he remained intubated and sedated with continuing
improvement of his oxygenation status. His sedation was weaned
in the afternoon and he was successfully extubated without
complications. In the SICU, he underwent HD with 1.8
ultrafiltrate. On POD 2, he was deemed stable for transfer to
the floor. He remained afebrile and his oxygenation status
remained good on 3 liters nasal cannula. His diet was advanced
to clear liquid, which he tolerated well. He underwent HD with
an ultrafiltrate of 2.2 liters. A CTA chest demonstrated no
PEs. On POD 3, he continued to remain afebrile and was
tolerating a renal diet. PFTs were performed. On POD 4, he
continued to remain afebrile and toelrating a renal diet. He
remained stable on room air and continued to have bowel
movements. On POD 5, he remained afebrile and toelrating a
renal die. His wound continued to have serous drainage and 3-0
nylon stiches were placed to better approximate the skin edges.
An abdominla ultrasound was performed which did not demonstrate
any fluid collection. On POD 6, he was deemed stbale for
discharge home with VNA services. He was tolerating a renal
diet, afebrile, ambulating well, and continued to have bowel
movements. Further 3-0 nylon sutures were placed to better
approximate the skin edges to stop the serous drainage. He will
follow-up with Dr. [**First Name (STitle) **]. He will resume his previous HD
schedule.
Medications on Admission:
Allopurinal 100', ASA 81', diltiazem 360', diovan 320',
gabapentin 100"', glyburide 2.5', insulin, lantus 10u qHS,
nephrocaps 1', norvasc 10', prilosec 20", toprol 100', zoloft
100'
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
take while taking pain medication.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
esrd
hypoxia
Discharge Condition:
good
Discharge Instructions:
Please call Dr.[**Name (NI) 670**] office if fever, chills, nausea,
vomiting, incision red/bleeding/draining pus or any questions
No heavy lifting
[**Month (only) 116**] shower
resume Tuesday-Thursday-Sat hemodialysis schedule
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2167-5-1**] 8:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK
Date/Time:[**2167-5-4**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2167-5-4**] 2:40
|
[
"285.21",
"274.9",
"412",
"V45.73",
"V10.52",
"V18.0",
"250.40",
"V15.82",
"V64.1",
"428.30",
"V12.09",
"403.91",
"428.0",
"997.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"33.23",
"54.11"
] |
icd9pcs
|
[
[
[]
]
] |
11963, 12021
|
9528, 11443
|
283, 336
|
12078, 12085
|
2301, 2301
|
12360, 12767
|
1786, 1974
|
11675, 11940
|
8958, 9059
|
12042, 12057
|
11469, 11652
|
12109, 12337
|
2717, 3336
|
1989, 2122
|
2138, 2282
|
239, 245
|
9088, 9505
|
364, 659
|
2317, 2701
|
681, 1387
|
1403, 1770
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,375
| 175,452
|
45222
|
Discharge summary
|
report
|
Admission Date: [**2198-12-12**] Discharge Date: [**2198-12-26**]
Service: NEUROLOGY
Allergies:
Penicillins / Egg
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Transfer from OSH for pontine hemorrhage
Major Surgical or Invasive Procedure:
PEG Placement
History of Present Illness:
Patient is a [**Age over 90 **] yo RHW s/p pacemaker for tachybrady syndrome
who lives in independent/[**Hospital3 **] facility who reports to
have bilateral weakness and increased difficulty walking. She
reports that she walks with either cane or walker at baseline
but
she has been having difficulty getting up out of sitting
position
(chair or toilet) for the past 2 weeks. She denies any other
issues including visual problems, speech trouble, swallowing
trouble or numbness. She went to [**Location (un) 745**] [**Location (un) 3678**] this morning
and was found to have 12mm X 19mm central pontine hemorrhage
hence transferred here for further evaluation. Of note, unable
to load the head image because its CT head of a wrong patient.
Per patient, she has not had any falls. Her last fall was over
1
year ago. She does note that she had a HA about 7 to 10 days
ago
but unable to describe it further. She also notes that she has
been having more mucus but no trouble swallowing. She also
coughs intermittently but no fever/chills, N/V/D or sick
contact.
She also feels that her voice is lower ("more man-like") for the
past 6 months.
Of note, patient lives in assisted/independent living facility
where she gets some assistance with ADLs including showers but
cooks own meals and takes own meds.
Patient appears to give decent hx but may need corroboration
given patient reports to have gone to [**Location (un) 745**] [**Location (un) 3678**] yesterday
when in fact, she went today.
Past Medical History:
1. s/p pacemaker in [**2194**] for tachy/brady syndrome
2. Arthritis
3. GERD
4. Osteoporosis
5. s/p appendectomy
6. s/p T&A
7. Bilateral cataract repair
8. HTN
9. IBS
10. Basal Cell CA excised from the nose int he [**2168**]'s
11. Bilateral cataracts
12. Lactose intolerance
13. Lumbar disc disease
14. Venous insufficiency. Chronic LE venous stasis and
dermatitis.
Social History:
Lives in independent facility - walks with cane or walker.
Receives some assistance with ADLs including showers but cooks
for oneself and takes own meds. Never married and no children.
Next of [**Doctor First Name **] is Judge [**First Name8 (NamePattern2) 1528**] [**Last Name (NamePattern1) **]/POA [**Telephone/Fax (1) 96651**] or
[**Telephone/Fax (1) 96652**], code is DNR/DNI.
Family History:
Patient's older sister lived to 99. Mother and father with
cancer?
Physical Exam:
Per Admitting resident
T 98.6 BP 130/86 HR 70 RR 18 O2Sat 96% RA
Gen: Lying in bed, NAD - thin but comfortable appearing woman.
HEENT: NC/AT, moist oral mucosa but some white plaque on tongue.
Neck: No carotid or vertebral bruit
CV: RRR, 3/6 SEM best heard on RUSB.
Lung: Clear
Abd: +BS, soft, nontender
Ext: No edema but some venous stasis skin changes in both LEs.
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, hospital, but thinks its [**Month (only) **]
although corrects herself to [**Month (only) 1096**] and knows its [**2197**]. Also
known [**Last Name (un) 2753**] is president. Attentive, says DOW backwards.
Speech
is fluent with normal comprehension and repetition; naming
intact. No dysarthria. No right left confusion. No evidence of
apraxia or neglect.
Cranial Nerves:
II: Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Visual fields are full to confrontation.
III, IV & VI: Extraocular movements intact bilaterally but some
upgaze limitation, no nystagmus.
V: Sensation intact to LT and PP.
VII: Facial movement symmetric.
VIII: Decreased hearing, worse on L.
X: Palate elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline, movements intact
Motor:
Diffuse atrophy. No observed myoclonus or tremor. No asterixis
or 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 *
L 5- 5- 5 5 5 5 5 5 5 5 *
*Unable to test PF because patient reports severe pain to
touching bottom of feet.
Sensation: Intact to light touch, vibration, cold and
proprioception throughout but decreased PP loss in stocking
distribution, worse on L than R.
Reflexes:
+2 and symmetric for UEs but none for patellar or Achilles.
Toes upgoing bilaterally
Coordination: Some endpoint dysmetria with FTF.
Gait: Stands with assistance but unsteady gait, unable to stand
on own.
Pertinent Results:
[**2198-12-17**] 06:20AM BLOOD WBC-8.5 RBC-3.71* Hgb-11.7* Hct-35.0*
MCV-94 MCH-31.7 MCHC-33.6 RDW-13.6 Plt Ct-238
[**2198-12-16**] 06:40AM BLOOD WBC-11.5* RBC-3.89* Hgb-12.1 Hct-35.8*
MCV-92 MCH-31.0 MCHC-33.7 RDW-13.5 Plt Ct-213
[**2198-12-15**] 06:15AM BLOOD Neuts-81.0* Lymphs-14.3* Monos-3.8
Eos-0.6 Baso-0.3
[**2198-12-17**] 06:20AM BLOOD Plt Ct-238
[**2198-12-17**] 06:20AM BLOOD PT-16.3* PTT-31.3 INR(PT)-1.4*
[**2198-12-17**] 06:20AM BLOOD Glucose-151* UreaN-21* Creat-0.9 Na-143
K-3.4 Cl-112* HCO3-16* AnGap-18
[**2198-12-16**] 06:40AM BLOOD Glucose-64* UreaN-23* Creat-1.0 Na-144
K-3.6 Cl-111* HCO3-15* AnGap-22*
[**2198-12-17**] 06:20AM BLOOD Calcium-8.1* Phos-2.8 Mg-2.0
[**2198-12-13**] 04:31AM BLOOD %HbA1c-6.0*
[**2198-12-13**] 04:31AM BLOOD Triglyc-83 HDL-46 CHOL/HD-3.7 LDLcalc-107
[**2198-12-13**] 04:31AM BLOOD TSH-0.94
[**2198-12-15**] 06:15AM BLOOD WBC-9.5 RBC-4.02* Hgb-12.8 Hct-37.4
MCV-93 MCH-31.9 MCHC-34.3 RDW-13.3 Plt Ct-238
[**2198-12-17**] 06:20AM BLOOD WBC-8.5 RBC-3.71* Hgb-11.7* Hct-35.0*
MCV-94 MCH-31.7 MCHC-33.6 RDW-13.6 Plt Ct-238
[**2198-12-19**] 05:25AM BLOOD WBC-8.9 RBC-4.17* Hgb-12.8 Hct-38.4
MCV-92 MCH-30.7 MCHC-33.4 RDW-13.4 Plt Ct-229
[**2198-12-20**] 04:10PM BLOOD WBC-7.8 RBC-4.15* Hgb-13.0 Hct-38.3
MCV-92 MCH-31.3 MCHC-34.0 RDW-13.6 Plt Ct-210
[**2198-12-15**] 06:15AM BLOOD PT-14.4* PTT-28.0 INR(PT)-1.3*
[**2198-12-17**] 06:20AM BLOOD PT-16.3* PTT-31.3 INR(PT)-1.4*
[**2198-12-20**] 04:10PM BLOOD PT-16.7* PTT-35.1* INR(PT)-1.5*
[**2198-12-14**] 05:10AM BLOOD Glucose-76 UreaN-24* Creat-1.2* Na-142
K-3.7 Cl-108 HCO3-24 AnGap-14
[**2198-12-15**] 06:15AM BLOOD Glucose-79 UreaN-23* Creat-1.1 Na-143
K-3.6 Cl-108 HCO3-20* AnGap-19
[**2198-12-17**] 06:20AM BLOOD Glucose-151* UreaN-21* Creat-0.9 Na-143
K-3.4 Cl-112* HCO3-16* AnGap-18
[**2198-12-19**] 05:25AM BLOOD Glucose-176* UreaN-14 Creat-0.8 Na-142
K-3.6 Cl-109* HCO3-25 AnGap-12
[**2198-12-19**] 10:01AM BLOOD CK(CPK)-131
[**2198-12-19**] 09:40PM BLOOD CK(CPK)-121
[**2198-12-20**] 09:45AM BLOOD CK(CPK)-102
[**2198-12-19**] 10:01AM BLOOD CK-MB-7 cTropnT-0.35*
[**2198-12-19**] 05:20PM BLOOD CK-MB-6 cTropnT-0.38*
[**2198-12-19**] 09:40PM BLOOD CK-MB-5 cTropnT-0.42*
[**2198-12-20**] 09:45AM BLOOD CK-MB-5
[**2198-12-14**] 05:10AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.2
[**2198-12-16**] 06:40AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.1
[**2198-12-18**] 04:50AM BLOOD Calcium-8.1* Phos-1.6* Mg-1.8
[**2198-12-20**] 04:10PM BLOOD Calcium-8.8 Phos-3.0# Mg-1.7
[**2198-12-13**] 04:31AM BLOOD %HbA1c-6.0*
[**2198-12-13**] 04:31AM BLOOD Triglyc-83 HDL-46 CHOL/HD-3.7 LDLcalc-107
[**2198-12-17**] 06:47AM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-100 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2198-12-14**] 09:15AM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-0.2 pH-5.5 Leuks-NEG
[**2198-12-14**] 09:15AM URINE RBC->50 WBC-0 Bacteri-FEW Yeast-NONE
Epi-0
Na levels
[**12-24**], 8.45 am ,120
[**12-24**], 9.25 pm, 119
[**12-25**], 8.50 am, 120
[**12-25**], 9.30 pm, 121
[**12-26**], 3.35 am, 125
[**12-26**], 9.05 am, 125
Imaging:
CT head [**12-12**]:
1. 16 x 17-mm parenchymal hemorrhage in the central pons, with
mild mass
effect, but patent basilar cisterns. No other area of
intracranial
hemorrhage.
2. Chronic small vessel change.
CT [**12-13**]:
There is no change in a pontine hemorrhage
measuring 1.6 x 1.5 cm (2A:10). There is mild mass effect, but
the basilar
cisterns appear patent. There is no new site of hemorrhage
identified. There
is no shift of midline structures, or evidence of infarction.
There is
prominence of the ventricles and sulci consistent with
age-related parenchymal
involutional change. There is also a pattern of periventricular
hypodensity
consistent with chronic small vessel ischemic change. The
visualized
paranasal sinuses and soft tissues appear unremarkable.
IMPRESSION: No significant change in pontine hemorrhage.
CT [**12-14**]:
Unchanged pontine hemorrhage.
CT [**12-24**]
1. Decrease in size of pontine bleed.
2. Soft tissue prominence in the region of the anterior
communicating artery
may represent anterior communicating artery aneurysm which has
been stable
since [**2194**]; however, if clinically relevant, a CTA or MRA may be
considered
for further evaluation.
CT abdomen [**12-25**] (for placement of G tube)
pending at this time
CXR [**12-14**]
There is mild cardiomegaly. Left transvenous pacemaker leads
terminate in
standard position in the right atrium and right ventricle. Small
bilateral
pleural effusions are larger on the left side, unchanged from
prior studies.
Left lower lobe retrocardiac opacity has increased due to
increasing
atelectasis and an ill-defined faint opacity superior to the
heart is
consistent with aspiration given the provided clinical history.
CXR: [**12-16**]
As compared to the previous examination, the pre-existing small
left-sided pleural effusion has increased. Also increased is the
subsequent retrocardiac atelectasis and blunting of the left
costophrenic sinus. In the right lung, no change is seen.
Unchanged course and position of the pacemaker leads.
CXR [**12-24**]
IMPRESSION: Although left basilar aeration has improved
slightly, opacity at
the right base has slightly worsened, which could represent a
combination of
effusion, atelectasis, and/or infection.
TTE [**12-20**]
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with basal inferior
hypokinesis. The remaining segments contract normally (LVEF =
50%). Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets are moderately thickened.
There is moderate aortic valve stenosis (valve area 1.0-1.2cm2).
Mild (1+) aortic regurgitation is seen. Mild to moderate ([**12-29**]+)
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Moderate calcific aortic stenosis. Mild aortic
regurgitation. Mild to moderate mitral regurgitation. Mild
pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2195-10-16**],
aortic stenosis has progressed slightly (by velocities). There
is now mild aortic regurgitation. Regional wall motion
abnormality is similar on the two studies
Brief Hospital Course:
ICU stay-
Patient is a [**Age over 90 **]yo walker/cane dependent RHW with hx of
tachybrady syndrome s/p pacemaker and likely HTN given on
metoprolol who lives in assisted/independent living facility who
had increased weakness in legs over past 2 weeks without any hx
of falls or trauma and found to have central pontine hemorrhage
at OSH. Patient transferred here for further care but her
initial head CT unable to be uploaded because patient sent
withwrong patient's imaging. However, per report, it measured
12X19mm.
The patient was initially admitted to the ICU given concern of
the location of the bleed. Remarkably, excpet for mild
inattentiveness, the patient had a normal neurological exam.
Given her stability she was transferred to the floor on
[**2198-12-13**].
Floor stay [**12-13**]- [**12-26**]
Neuro
She was closely monitered for development of any new new
neurological signs or symptoms. She was found to drowsy and
confusded on [**12-14**], hence repeat CT scan as well as infective
work up was obtained -UA and CXR which showed lower zone opacity
on left side possibly aspiration. She was seen by Physical and
Occupational therapy who recommended a long term facility for
placement. She was noted to be more drowsy on [**12-24**], hence a
repeat CT head was done which did not show any change in her
bleed. Over all neurologically she remained stable during her
stay.
ID
She was diagnosed with pna on [**12-14**]. Infectious disease recs
were taken and she was started on broad spectrum antibiotics,
given her current ICU stay and high risk of aspiration. She is
allergic to penicillin and hence was started on meropenem,
vancomycin, flagyl IV. She never had fever and responded to IV
antibiotics, her mental status improved and hse became more
alert. She recieved a total of 7 days of antibiotics per ID
recs. Her repeat CXR on [**12-24**] did show a small opacity on RLZ
but it was thought to be atelactasis. She did not have clinical
signs of infection like fever, leucocytosis. This was discussed
with ID and it was decided to hold off on antibiotics and
moniter her clinically.
CVS
She had intermittent tachycardia (has known tachy-brady
syndrome). She was started on meteoprolol and IV metoprolol as
well prn tachycardia. On [**12-19**], she had transient but repetitive
episodes of tachycardia, following which she had mild troponin
leak (0.35-0.42), however CK and CKMB were normal. cardiology
consult was obtained and it was felt that her troponin leak is
mostly due to demand ischemia rather than infarct given normal
CKMB. She was not a candidate for anticoagulation given pontine
bleed and intervention ,given Code status and unfavourable
general medical condition. Aspirin 81 mg was started on [**12-20**]
given underlying cardiac condition. metoprolol was incraesed to
37.5 TID and she underwent 2 D ECHO for assesment of cardiac
function.
GI/Nutrition
Sheb had difficulty in swallow fucntion most likely as a result
of pontine bleed. She failed speech and swallow evaluation and
NG tube was attempted which was difficult owing to strong cough
reflex and absent/ mild gag response. She underwent IR guided NG
placement [**12-18**] which she pulled out and again underwent IR
guided placement on [**12-20**]. nutrition recs were followed for Tube
feeds for adequate calories and hydration. She was finally
considered for PEG tube which was placed on [**12-25**] for nutrition.
Fluids/electrolyes
She was noted to have hyponatremia on [**12-24**]. Her Na dropped from
130 to 120 over period of [**12-29**] days. However she did not have
change in her mental status from her baseline. Work up for
hyponatremia revealed possible SIADH as mechanism. medicine and
renal consults were obtained for management of hyponatremia who
suggested frequent Na checks, free fluid restriction. This
should be closely followed up after discharge. Her TSH was
slightly high and free T4 was ordered which is slightly high s/o
sick euthyroid syndrome
General care
She was monitered on telemerty, with regular neuro checks, DVT
prophy with SC heparin, Stress ulcer proph, PT/OT evaluation.
The goal of care was discussed with health care proxy and PCP
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 656**] and plan was formulated in accordnace with that.
Physical Exam at discharge-
drowsy, responds to verbal commands, she is usually oriented to
person and time and tells that she is in hospital but cannot
tell name of the hospital. Her comprehension is normal and
speech is fluent with intact repetition.
She does not have any other neurological deficts.
Issues pending at discharge-
1. Na needs to be followed closely and she needs to be on fluid
restriction, with Na checked every day for 3-4 days amd salt
tablets need to be adjusted as per na level and fluid status
2. Repeat Thyroid tests in [**4-2**] weeks
Medications on Admission:
1. Omeprazole 20mg daily
2. ASA 325mg daily
3. Metoprolol 25mg daily
4. Loperamide 2mg PRN
5. Lactulose PRN
6. Tylenol PRN
7. Furosemide 20mg PRN
8. Tums PRN
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection twice a day.
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO Q8H
(every 8 hours).
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Sodium Chloride (Bulk) Granules Sig: One (1)
Miscellaneous [**Hospital1 **] (2 times a day) for 1 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 5277**] - [**Location (un) 745**]
Discharge Diagnosis:
1) Pontine hemorrhage
2) Hypertension
3) Pneumonia
4) Hyponatremia, secondary to SIADH
5) Tachybrady syndrome
6) Demand Ischemia
7) Hyperlipemia
Discharge Condition:
Mental Status:Confused - oriented to person, but not place,
fluent speach, no dysarthria, hypometric facial movements
Level of Consciousness: awake, intermittently drowsy arousable
Motor: antigravity throughout
Sensory: limited exam due to mental status
Activity Status:Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
.
1) You were admitted for evaluation of stroke. You had CT/A scan
of your head which showed a hemorrhage in pontine area
(brainstem), likely due to a vascular malformation.
2) Please take your medicines as prescribed. please call 911 or
your doctor if you develop any concerning symptoms.
3) PENDING ISSUES AT DISCHARGE:
-Please have the sodium checked daily for 3-4 days and adjust
salt tabs as needed
-Please have repeat thyroid studies in [**4-2**] weeks
Followup Instructions:
Please follow up in neurology clinic as-
Scheduled Appointments :
Provider [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2199-1-16**] 3:00
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
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icd9cm
|
[
[
[]
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] |
[
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|
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2222, 2607
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,277
| 169,051
|
48787
|
Discharge summary
|
report
|
Admission Date: [**2153-12-3**] Discharge Date: [**2153-12-5**]
Date of Birth: [**2072-12-16**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine / Losartan
Attending:[**Doctor First Name 1402**]
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
This is a 80 year-old Female with a PMH significant for
pulmonary emboli (on Coumadin), pulmonary hypertension and
right-sided ventricular dysfunction, hypertension, previous TIAs
and moderate-to-severe dementia who presented from her
rehabilitation facility ([**Hospital 100**] Rehab facility) with weakness
for the last 3-days. While at rehab, she was empirically started
on Levaquin 250 mg PO daily given a leukocytosis to 12.6,
although afebrile (negative U/A).
.
EMS arrived and the patient was noted to have ST-elevations in
leads II, III and aVF. She was dosed Aspirin 324 mg PO x 1.
Nitroglycerin paste was given in the field with a drop in SBP to
the 80 mmHgs.
.
In the [**Hospital1 18**] ED, initial VS 45 103/44 21 97% RA. An EKG showed
ST-evelations in lead III greater than II, avF, with reciprocal
changes in I, aVL, with TWI in V3-6 with AV-dissociation (CHB).
Cardiology was consulted and Plavix 600 mg PO x 1 with Heparin
gtt was started. Laboratory studies demonstrated WBC 10.1, HCT
35.2%, PLT 532. Potassium 4.5 and magnesium 3.1. Creatinine 2.5
(baseline creatinine 0.9-1.0). Troponin-T 4.14. INR 3.1 (on
Coumadin).
.
Of note, the patient was admitted to the MICU in [**7-/2153**] with
acute hypoxic respiratory failure thought to be acute on chronic
thromboembolic disease with resulting severe pulmonary
hypertension and right ventricular failure (severe RV
dilatation, moderate TR, hypokinetic and dilated right
ventricle). She was evaluated by the Cardiology service given
the finding of a PFO with right-to-left shunt; they recommended
against closure of PFO given need for permanent anticoagulation
for pulmonary emboli anyway. A repeat 2D-Echo in [**8-/2153**] showed
persistent PFO and similar pulmonary pressures (PASP 83 mmHg)
without RV dilatation. She was diuresed aggressively and started
on Sildenafil.
.
On arrival to the CCU, the patient is without significant
complaints.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or pre-syncope.
.
ROS: The patient denies a history of prior stroke/TIA, deep
venous thrombosis or pulmonary embolus. They deny bleeding at
the time of prior procedures or surgeries. Denies headaches or
vision changes. No cough or upper respiratory symptoms. Denies
chest pain, dizziness or lightheadedness; no palpitations.
Denies shortness of breath. No nausea or vomiting, denies
abdominal pain. No dysuria or hematuria. No change in bowel
movements or bloody stools. Denies muscle weakness, myalgias or
neurologic complaints. No exertional buttock or calf pain.
Past Medical History:
CARDIAC HISTORY: Hypertension
* CABG: None
* PERCUTANEOUS CORONARY INTERVENTIONS: None
* PACING/ICD: None
.
PAST MEDICAL & SURGICAL HISTORY:
1. Pulmonary emboli ([**7-/2153**] right upper lobe subsegmental PE -
likely acute; right lower lobe chronic embolism - right upper,
middle and lower perfusion defects on V/Q-scan in [**5-/2153**];
anticoagulated with Coumadin)
2. Patent foramen ovale (bubble study in [**7-/2153**] showed
right-to-left shunting during rest; evaluated by Cardiology with
permanent anticoagulation needs, thus closure was deferred -
repeat 2D-Echo showed persistent PFO)
3. Hypertension
4. Moderate dementia
5. Reflux esophagitis, GERD
6. Transient ischemic attacks (residual deficit of right tongue
deviation), [**2148**]
7. Hiatal hernia
8. Chronic neck pain, spasms (over 20-years)
9. Atypical chest pain episodes (negative prior cardiac stress
testing; [**7-/2148**] non-specific EKG changes and no anginal symptoms
with normal perfusion study, LVEF 72%)
10. Chronic microcytic anemia (upper endoscopy in [**2146**] with
hiatal hernia, otherwise normal study; prior negative
colonoscopy per report)
11. s/p bilateral total knee replacements
12. s/p cataract surgery ([**2144**])
Social History:
Patient lives at [**Hospital3 **] facility, to be with her
husband who requires more care; has two sons [**Name2 (NI) 1158**], HCP and
[**Name (NI) **]). She is a retired bookkeeper. Denies tobacco use or
alcohol use; no recreational substance use.
Family History:
Denies family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; mother died in her 80s of colon cancer
(had CAD); father died at 84 years old of an MI.
Physical Exam:
ADMISSION EXAM:
.
VITALS: see Metavision for details
GENERAL: Appears in no acute distress. Alert and interactive.
Mentating at baseline.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist. No xanthalesma.
NECK: supple without lymphadenopathy. JVD elevated to mid-neck
at 30-degrees. Prominent V-waves.
CVS: PMI located in the 5th intercostal space, mid-clavicular
line. Irregular rate and rhythm, with 3/6 mid-late systolic
murmur heard at LLSB, without rubs or gallops. S1 and S2 normal.
No S3 or S4.
RESP: Respirations unlabored, no accessory muscle use. Clear to
auscultation bilaterally without adventitious sounds. No
wheezing, rhonchi or crackles. Stable inspiratory effort.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs. Abdominal aorta
not enlarged to palpation, no bruit.
EXTR: no cyanosis, clubbing; trace bilateral edema, 2+
peripheral pulses
DERM: No stasis dermatitis, ulcers, scars.
NEURO: CN II-XII intact throughout. Alert and oriented x 2.
Sensation grossly intact. Gait deferred.
PULSE EXAM:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS:
.
[**2153-12-3**] 03:15PM BLOOD WBC-10.1 RBC-4.51 Hgb-11.3* Hct-35.2*
MCV-78* MCH-25.1* MCHC-32.1 RDW-15.9* Plt Ct-532*
[**2153-12-3**] 03:15PM BLOOD PT-31.9* PTT-39.9* INR(PT)-3.1*
[**2153-12-3**] 03:15PM BLOOD Glucose-106* UreaN-77* Creat-2.5*# Na-136
K-4.5 Cl-92* HCO3-29 AnGap-20
[**2153-12-3**] 06:42PM BLOOD ALT-153* AST-126* LD(LDH)-525*
AlkPhos-122* TotBili-0.3
[**2153-12-3**] 03:15PM BLOOD cTropnT-4.14*
[**2153-12-3**] 10:47PM BLOOD CK-MB-9 cTropnT-5.44*
[**2153-12-4**] 06:30AM BLOOD CK-MB-8 cTropnT-5.45*
[**2153-12-3**] 03:15PM BLOOD Calcium-10.1 Phos-4.7* Mg-3.1*
[**2153-12-3**] 06:42PM BLOOD TSH-2.3
.
DISCHARGE LABS:
[**2153-12-3**] CXR (PORTABLE) - pending
[**2153-12-5**] 02:06AM BLOOD WBC-6.8 RBC-4.07* Hgb-10.4* Hct-31.8*
MCV-78* MCH-25.5* MCHC-32.6 RDW-15.7* Plt Ct-477*
[**2153-12-5**] 02:06AM BLOOD PT-21.3* PTT-70.3* INR(PT)-2.0*
[**2153-12-5**] 02:06AM BLOOD Glucose-116* UreaN-61* Creat-1.5* Na-140
K-4.4 Cl-98 HCO3-33* AnGap-13
[**2153-12-5**] 02:06AM BLOOD ALT-88* AST-48* AlkPhos-103 TotBili-0.4
[**2153-12-5**] 02:06AM BLOOD Albumin-3.8 Calcium-9.4 Phos-3.5 Mg-2.9*
[**2153-12-3**] 06:42PM BLOOD TSH-2.3
.
EKG (in the [**Hospital1 18**] ED): AV-dissociation with an atrial rate of 85
bpm and ventricular rate of 45 bpm; ST-evelations in lead III
greater than II, avF, with reciprocal changes in I, aVL, with
TWI in V3-6.
.
2D-ECHO ([**2153-8-23**]): The left atrium is normal in size. The
interatrial septum is aneurysmal. A patent foramen ovale is
present. Left ventricular wall thicknesses and cavity size are
normal. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF > 55%). The right
ventricular cavity is moderately dilated with moderate global
free wall hypokinesis. There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened.
Physiologic mitral regurgitation is seen (within normal limits).
There is severe pulmonary artery systolic hypertension. There is
no pericardial effusion. Compared with the prior study (images
reviewed) of [**2153-7-10**], pulmonary pressures are similar, right
ventricle is not as dilated. IMPRESSION: Severe pulmonary
hypertension. Moderate right ventricular enlargement with
moderate global right ventricular hypokinesis. Mild symmetric
left ventricular hypertrophy. Normal left ventricular function.
.
[**2153-12-4**] 2D-ECHO - The left atrium is mildly dilated. The right
atrium is moderately dilated. The estimated right atrial
pressure is 0-5 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with focal severe hypokinesis
of the basal inferior wall. The remaining segments contract
normally (LVEF = 55 %). The right ventricular cavity is
moderately dilated with moderate global free wall hypokinesis.
[Intrinsic right ventricular systolic function is likely more
depressed given the severity of tricuspid regurgitation.] There
is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. 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. Trace aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. Mild to
moderate ([**12-10**]+) mitral regurgitation is seen. Moderate to severe
[3+] tricuspid regurgitation is seen. There is mild pulmonary
artery systolic hypertension. [In the setting of at least
moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] There is a
trivial/physiologic pericardial effusion.
.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional systolic dysfunction. Right ventricular cavity
enlargement with free wall hypokinesis. Moderate to severe
tricuspid regurgitation. Pulmonary artery hypertension.
Mild-moderate mitral regurgitation c/w papillary muscle
dysfunction.
.
Compared with the prior study (images reviewed) of [**2153-8-23**],
the estimated PA systolic pressure is lower (may be related to
the increase in TR). Mild basal inferior hypokinesis is now
seen. There is also growth of the transmitral E wave and an
absent transmitral A wave.
.
CARDIAC CATH: No prior cardiac catheterizations.
.
MICROBIOLOGY DATA:
[**2153-12-3**] MRSA screen - positive
[**2153-12-3**] URINE CULTURE (Final [**2153-12-5**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
IMPRESSION: 80F with a PMH significant for pulmonary emboli (on
Coumadin), pulmonary hypertension and right-sided ventricular
dysfunction, hypertension, previous TIAs and moderate-to-severe
dementia who presented from her rehabilitation facility ([**Hospital 100**]
Rehab facility) with weakness for the last 3-days found to have
proximal inferior ST-elevation myocardial infarction complicated
by bradycardia and complete heart block.
.
# ACUTE ST-ELEVATION MYOCARDIAL INFARCTION, ACUTE CORONARY
SYNDROME - The patient presents with no prior coronary artery
disease; no prior cardiac catheterizations - has had increasing
weakness and atypical anginal equivalent pain over the last
3-days while at her rehab facility. Her EKG on EMS arrival was
concerning for proximal right coronary occlusion with inferior
lead 2-mm ST-elevations and reciprocal changes (with resulting
AV-dissociation and complete heart block). The patient was given
Aspirin 324 mg PO x 1, Plavix loaded with 600 mg, and started on
a Heparin gtt in the [**Hospital1 18**] ED after cardiology consultation. Her
cardiac biomarkers demonstrated a Troponin of 4.14 but she is
was without chest pain or other complaints on arrival. Cardiac
catheterization was avoided given that the infarct was thought
to be 3-days prior to arrival and her clinical exam was stable
in the setting of medical management. Her cardiac biomarkers
were notable for a Troponin that peaked in the range of 5. We
continued Aspirin 325 mg PO daily, Plavix 75 mg PO daily and
avoided AV-nodal blocking agents given her rhythm concerns
(below). We also avoided nitrate given her prior blood pressure
drop at the outside hospital with nitropaste. We continued the
Heparin gtt for 24-hours until she was transitioned back to
Coumadin dosing at 4 mg PO daily. High dose Atorvastatin was
started and will be continued. She was monitored on telemetry
and serial EKGs were reasrruing. She remained pain-free prior to
discharge.
.
# AV-DISSOCIATION, COMPLETE HEART BLOCK, BRADYCARDIA - The
patient has no prior history of dysrrhytmia or bradycardia per
our records; now with proximal right coronary territory
infarction with resulting EKG findings of bradycardia to the 40s
and AV-dissociation (or complete heart block) that developed
while in the ED. Patient was mentating at baseline without
lightheadedness or dizziness. She received no AV-nodal blocking
agents in the ED (received beta-blocker earlier today). The
etiology of the third-degree block is attributed to the
myocardial ischemia concerns. While in the CCU, her rhythm
improved to Wenkebach vs. AV-conduction delay (first degree
block) and she remained hemodynamically stable. Again,
catheterization was deferred given clinical improvement with
medical management. We did not need to consider transcutaneous
vs. transvenous pacing wire placement given that she had no
signs of worsening bradycardia (< 40 bpm sustained), or
hemodynamic instability, or pre-syncope symptoms, or ventricular
pauses > 3-4 seconds. We did avoid AV-nodal blocking agents at
this time and monitored her via telemetry. On discharge, her
rhythm appeared to be PR-prolonged (first degree block) with
intermittent sinus rhythm.
.
# SEVERE PULMONARY HYPERTENSION WITH RIGHT VENTRICULAR
DYSFUNCTION - The patient has a known history of chronic
thromboembolic disease (in [**7-/2153**] had right upper lobe
subsegmental pulmonary emboli with right lower lobe chronic
embolic disease - on anticoagulation) leading to severe
pulmonary artery hypertension (PASP 83 mmHg in [**8-/2153**]) with
right ventricular dilatation and dysfunction (hypokinetic) and
tricuspid regurgitation (requiring MICU admission in [**7-/2153**]);
also noted to have PFO with right-to-left shunt in 8/[**2152**].
Repeat 2D-Echo showed stable PFO with stable pulmonary artery
pressures. LVEF 55% in [**8-/2153**] with only mild symmetric LV
hypertrophy and normal LV cavity size with normal LV systolic
function. No exam evidence of right-sided systemic volume
overload this admission. Her repeat 2D-Echo this admission
showed evidence of right ventricular dysfunction with
inferior-basal hypokinesis (given her recent RCA territory
infarction) and her LVEF was stable, preserved. We resumed her
home dosing of Lasix 60 mg PO BID. Her Sildenafil will be held
and resumed as an outpatient.
.
# ACUTE RENAL INSUFFICIENCY, ASYMPTOMATIC BACTERIURIA - The
patient presented with a baseline creatinine of 0.9 to 1.0; now
with evidence of acute renal insufficiency to 2.5 mg/dL. Normal
appearing kidneys of previous CT imaging. Now with acute
coronary syndrome and acute ST-elevation inferior myocardial
infarction with known right ventricular dysfunction but presumed
preserved LV function. Etiologies: poor forward perfusion given
right ventricular dysfunction and recent ischemic insult vs.
medication effect vs. acute tubular necrosis vs. intrinsic renal
disease. Urine lytes revealed a low urine sodium and FeUrea of
35% consistent with a pre-renal etiology. She was gently
hydrated given her worsening creatinine and poor right
ventricular function. Her creatinine steadily impoved. Her
urinalysis was mildly positive and a urine culture speciated
pan-resistant E.coli. In discussion with the infectious disease
physicians, given that she had no symptoms and Foley
catheterization, we opted not to treat this colonization.
.
# CHRONIC THROMBOEMBOLIC DISEASE - The patient has a history of
pulmonary embolizations ([**7-/2153**] right upper lobe subsegmental PE
- likely acute; right lower lobe chronic embolism - right upper,
middle and lower perfusion defects on V/Q-scan in [**5-/2153**];
anticoagulated with Coumadin. INR on admission was therapeutic
at 3.1. This has been cited as the etiology of her on-going
pulmonary hypertension and right ventricular failure. Patient
also has known right-to-left heart patent formaen ovale (found
on [**7-/2153**] bubble study). Prior lower extremity ultrasounds were
negative in 8/[**2152**]. Oxygen saturations stable in the ED. We
continued heparinization for ACS/MI as noted above, with
transition to her home Coumadin dosing.
.
# HYPERPARATHYROIDISM - On recent MICU admission, patient was
noted to have hypercalcemia to 10-11.7 (noted since [**2146**]) with
PTH between 83 and 93 consistent with primary
hyperparathyroidism with preserved renal function. She was
started on Cinacalcet given concern for calcium contributing to
mental status changes while she was hospitalized. Endocrinology
evaluated the patient and felt calcium and vitamin D was
treating the condition adequately. We continued her Vitamin D
and Calcium supplementation.
.
# HYPERTENSION - The patient has a reported history of
hypertension; recent clinic notes suggest a blood pressure range
of 107-122 mmHg systolic range; no anti-hypertensives in her
home regimen prior to admission.
.
# PRIOR TRANSIENT ISCHEMIC ATTACK - History of transient
ischemic attack (residual deficit of right tongue deviation),
[**2148**]. No new focal neurologic deficits this admission.
.
# MODERATE DEMENTIA - Appears to be mentating at baseline; will
continue Memantine 10 mg PO BID. We held her
acetylcholinesterase inhibitor (Exelon) given concern for heart
block; this was resumed on discharge.
.
TRANSITION OF CARE ISSUES:
1. No sodium restriction given right ventricle territory
infarction; preload dependent. Restarted Lasix 60 mg PO BID.
3. Twice weekly monitoring of electrolytes given diuretic use,
while at rehab facility.
4. Resume Sildenafil as tolerated for pulmonary hypertension.
5. Monitor INR at least twice weekly with goal INR [**1-11**] while
anticoagulated with Coumadin for prior VTE/PE history.
6. Fall risk while on anticoagulation.
7. Patient had positive urine colonization with pan-resistant
E.coli, without symptoms this admission; treatment for UTI was
deferred. See culture data and consider IV Ceftriaxone treatment
if symptoms arise.
8. Scheduled follow-up with Cardiology and primary care
physician.
9. No pending radiologic studies, laboratory data or
microbiologic data at discharge.
Medications on Admission:
HOME MEDICATIONS (confirmed with rehab records)
1. Memantine 10 mg PO BID
2. Mirtazapine 7.5 mg PO QHS
3. Sildenafil 40 mg PO TID
4. Cinacalcet 30 mg PO daily
5. Senna 17.2 mg PO QHS
6. Milk of magnesia 30 mL PO daily PRN constipation
7. Omeprazole 20 mg PO daily
8. Ferrous sulfate 325 mg PO daily
9. Lasix 60 mg PO BID
10. Acetaminophen 650 mg PO Q6H PRN pain, fever
11. Cholecalciferol 1000 units PO daily
12. Calcium citrate 950 mg PO daily
13. Rivastigmine (Exelon patch) 9.5 mg TD daily
14. Warfarin 4.5 mg PO daily (at 18:00)
Discharge Medications:
1. memantine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. mirtazapine 7.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
3. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
9. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. calcium carbonate 390 mg (1,000 mg) Tablet Sig: One (1)
Tablet PO once a day.
11. rivastigmine 9.5 mg/24 hour Patch 24 hr Sig: One (1) patch
Transdermal once a day.
12. Lasix 20 mg Tablet Sig: Three (3) Tablet PO twice a day.
13. warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day: at
18:00 (total dose 4 mg PO daily).
14. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 tablets* Refills:*0*
15. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
16. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Primary Diagnoses:
1. Acute ST-elevation myocardial infarction with inferior
territory infraction
2. Complete heart block and AV-nodal dissociation
3. Aymptomatic bacteriuria
.
Secondary Diagnoses:
1. History of chronic thromboembolic disease and pulmonary
emboli
2. Patent foramen ovale
3. Hypertension
4. Moderate dementia
5. Reflux esophagitis, GERD
6. Transient ischemic attacks
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Patient Discharge Instructions:
.
You were admitted to the Coronary Care Unit (CCU) at [**Hospital1 771**] on [**Hospital Ward Name 121**] 6 regarding management of your
weakness which was found to be an inferior myocardial infarction
(or heart attack). You were medically managed and no cardiac
catheterization was performed. You heart rhythm was initially
slow and atypical given your heart attack, but this improved
with close monitoring and you did not require a pacemaker
device. You were discharged back to the [**Hospital3 **]
facility given your overall improvement.
.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
.
* Upon admission, we ADDED:
START: Aspirin 325 mg by mouth daily
START: Plavix 75 mg by mouth daily
START: Atorvastatin 80 mg by mouth daily
.
CHANGE: We DECREASED Coumadin from 4.5 to 4 mg by mouth daily.
Your INR will be closely monitored.
.
* The following medications were DISCONTINUED on admission and
you should NOT resume:
DISCONTINUE: Sildenafil
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] YOU
Location: [**Hospital3 **] CENTER FOR AGED
Address: [**Street Address(2) 87279**], [**Location (un) **],[**Numeric Identifier 11143**]
Phone: [**Telephone/Fax (1) 14943**]
** You will see your Primary Care Dr [**Last Name (STitle) **] you return back to
[**Hospital3 **] Center. **
.
Department: CARDIAC SERVICES
When: TUESDAY [**2154-2-5**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**Telephone/Fax (1) 127**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"338.29",
"553.3",
"410.41",
"593.9",
"397.0",
"V12.54",
"745.5",
"530.81",
"723.1",
"426.0",
"294.20",
"280.9",
"416.8",
"V12.51",
"791.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
21733, 21798
|
11635, 19694
|
304, 332
|
22225, 22225
|
5938, 5938
|
24430, 25095
|
4512, 4691
|
20277, 21710
|
21819, 21996
|
19720, 20254
|
22442, 24407
|
6589, 11612
|
4706, 5919
|
22017, 22204
|
256, 266
|
360, 3000
|
5954, 6573
|
22240, 22386
|
3022, 4230
|
4246, 4496
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,623
| 145,176
|
43845
|
Discharge summary
|
report
|
Admission Date: [**2197-7-25**] Discharge Date: [**2197-7-26**]
Date of Birth: [**2125-12-8**] Sex: M
Service: [**Hospital Unit Name 196**]
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
CC:[**CC Contact Info 94172**]
Major Surgical or Invasive Procedure:
s/p Left Carotid Stent Placement
History of Present Illness:
71 y/o male with PMHx mutiple TIAs, CABG Redo, AVR bovine [**1-25**],
multiple PCI, known [**Doctor First Name 3098**] 79% from pre-op CABG US [**11-24**] here s/p
carotid [**Doctor First Name 3098**] stent as part of CREST trial. Pt has hx of multiple
varied neuro symptoms aver past 2 years. Symptoms include
Amaurosis fugax of L eye 2yrs ago, and vertigo 1-2 months ago.
No numbness/weakness, obvious neurologic deficits recently. No
CP, SOB. Pt very active, can do pushups/situps daily. No f/c, no
abd pain,melena, no syncope.
Angiography revealed 99% [**Doctor First Name 3098**] at bifurcation, otherwise [**Country **] is
20%, hypoplastic R vertirbal, normal L vertibral, carebellar,
MCA, ACAs. [**Doctor First Name 3098**] stent with good angiographic results. Pt
comfortable with no complaints s/p stent.
Past Medical History:
CABG x3 [**2186**], Repeat CABG [**1-25**];
AVR bovine (bicuspid)[**1-25**];
PCI's (11 stents)
TIA - amaurosis, vertigo, speech difficulty; last 4min-2hrs,
Osteo arthhritis knees,
[**Name (NI) 1235**] POA, [**Name (NI) 1235**] [**Name2 (NI) **],
pancreatitis,
cholycystemctomy,
hernia repair,
HTN,
Hyperlipidemia
Social History:
Lives in [**Hospital1 789**]
no children
no tobacco use
drinks about 1-2 drinks a day
no drug use
Family History:
non-contributory
Physical Exam:
vs: P 53 RR 12 BP 138/65 O2 sat 97% RA Wt 81kg
Gen: NAD
Heent: Perrla, Eomi, oral pharynx clear
Neck: no carotid bruits
Cardio: RRR S1/S2, II/VI SEM in 2 ICS
Lungs: CTA B/L, midline surgical scar
Abd: soft NTND, NABS
Ext: no edema
Neuro: CN II-XII intact
Pertinent Results:
[**2197-7-25**] 08:00AM GLUCOSE-80
[**2197-7-25**] 08:00AM CK(CPK)-180*
[**2197-7-25**] 08:00AM CK-MB-4
Brief Hospital Course:
1) s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3098**] stent - kept SBP 140-170 with Neo/Nitro prn.
Continued pt on [**Last Name (LF) **] , [**First Name3 (LF) **], statin. Held all other HTN while
in hospital. Pt BP remianed stable overnight and pt was off
Neo/Nitro overnight. Pt did not have any neurological deficits
after the procedure and no complaints of HA, change in vision,
weakness/numbness.
2) CAD - Continued [**First Name3 (LF) **], [**First Name3 (LF) 4532**]. Restart outpatient BP meds upon
discharge
3) FEN - card diet
4) PPX - PPI, bowel regimine
5) [**Name (NI) 11053**] Pt sent home the next day after procedure and setup
for blood pressure check outpatient.
Medications on Admission:
[**Name (NI) **] 325;
Diltiazem 240mg,
metoprolol 100 [**Hospital1 **],
[**Hospital1 **] 75 [**Hospital1 **],
Zocor 60 qd,
Salsalate 750mg [**Hospital1 **];
fish oil 1g;
Calcium with Vit D 600mg;
Rubeprazole 20,
MVI,
Mg,
Vit E,
Glucosamine
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
3. Simvastatin 40 mg Tablet Sig: 1.5 Tablets PO QD (once a day).
Disp:*45 Tablet(s)* Refills:*2*
4. Salsalate 750 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO QD (once a
day).
Disp:*30 Capsule(s)* Refills:*2*
6. Omega-3 Fatty Acids 120-180-1.8 mg-mg-unit Capsule Sig: One
(1) Capsule PO BID (2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
8. Magnesium Oxide 140 mg Capsule Sig: Two (2) Capsule PO QD
(once a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).
Disp:*30 Cap(s)* Refills:*2*
10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO QD (once a day).
Disp:*30 Tablet(s)* Refills:*2*
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left Carotid stenosis s/p stent placement
TIA
s/p CABG with redo and Bovine AVR in 04
Discharge Condition:
stable
Discharge Instructions:
Please report to your primary care physician with any nausea,
vomiting, palpitations, chest pain, shortness of breath. Please
take all medications as perscribed.
Followup Instructions:
[**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **]- you need to see Dr. [**First Name (STitle) **] on [**2197-7-31**]-
CArdiology- [**Hospital 94173**] clinic has been contact[**Name (NI) **] and they
will call you with the appointment time. Please call the clinic
fi you do not hear from the clinic by [**2197-7-27**].
Please set up follow up with your primary care physician [**Name Initial (PRE) 176**]
2 weeks of discharge.
|
[
"V42.2",
"401.9",
"V70.7",
"V45.81",
"433.10",
"V12.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.90",
"39.50",
"88.42"
] |
icd9pcs
|
[
[
[]
]
] |
4625, 4631
|
2111, 2810
|
321, 356
|
4761, 4769
|
1977, 2088
|
4979, 5429
|
1668, 1686
|
3100, 4602
|
4652, 4740
|
2836, 3077
|
4793, 4956
|
1701, 1958
|
252, 283
|
384, 1200
|
1222, 1536
|
1552, 1652
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,073
| 174,038
|
3640
|
Discharge summary
|
report
|
Admission Date: [**2101-12-27**] Discharge Date: [**2102-1-4**]
Date of Birth: [**2024-11-3**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Sulfa (Sulfonamide Antibiotics)
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
76 yo female with Diastolic CHF (EF of 60%), SLE, ESRD on HD,
diverticulosis, CAD on plavix/ASA, known colovaginal fistula,
presents with bright red blood per vagina mixed with feces
starting 9AM this morning while going to the bathroom. Patient
is currently intubated and sedated, but per report, she was in
her usual state of health until this morning w/ no N/V/abd
pain/F/C. Pt has had h/o vaginal bleeding previously, but never
to this extent. She also has a long history of urosepsis [**2-22**]
stool output from vagina, most recently in [**2-/2101**] per [**Hospital1 18**]
records.
Past Medical History:
Diastolic CHF (ECHO [**2098**]: LVEF 60%)
SLE w/ chronic renal insufficiency [**2-22**] focal sclerosis (baseline
Cr 2.5-3.0)
CKD on HD (on Aranesp?)
Atrial fibrillation off coumadin
HTN
CAD s/p CABG ([**2093**]) on plavix
Hyperlipidemia
Gout
Mod-Sev MR
h/o diverticulitis
Rectovaginal Fistula
Osteoporosis
h/o esophagitis
h/o aspiration pneumonia
s/p cholecystectomy
Social History:
Cantonese speaking only.
- Tobacco: none
- Alcohol: none
- Illicits: none
Family History:
Non-contributory
Physical Exam:
Physical Exam on Admission:
GEN: intubated, sedated
PULM: cta b/l but decr BS at left base
CARD: RRR, no m/r/g
ABD: +BS, soft, NTND
EXT: diminished pulses radial and PT/DP
GU/RECTAL: Brown stool, guaiac positive in rectum. Oozing bright
red blood from vagina, no masses or packing on digital vaginal
exam.
Pertinent Results:
Labs on Admission:
[**2101-12-27**] 11:10AM PT-13.0 PTT-28.1 INR(PT)-1.1
[**2101-12-27**] 11:14AM GLUCOSE-115* LACTATE-1.7 NA+-137 K+-4.9
CL--95* TCO2-23
[**2101-12-27**] 12:30PM WBC-6.8# RBC-2.88* HGB-11.0* HCT-34.4*
MCV-119* MCH-38.3* MCHC-32.1 RDW-14.8
[**2101-12-27**] 08:20PM FIBRINOGEN-276
Micro:
[**12-29**] Blood Cx: budding yeast
[**12-28**] Urine Cx: E.Coli
[**12-29**] C.diff negative
Imaging
- CT abd/pelvis [**12-27**]: 1. No definite evidence for active
extravasation in the region of the known colovaginal fistula. 2.
Saccular infrarenal aortic aneurysm measuring up to 3 cm in
diameter is stable in size. 3. Extensive diverticulosis without
evidence for diverticulitis. 4. Atrophic kidneys with multiple
cysts bilaterally consistent with history of end-stage renal
disease.
-Echo [**12-29**]:
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is low normal (LVEF 50%).
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. No masses or
vegetations are seen on the aortic valve, but cannot be fully
excluded due to suboptimal image quality. There is a minimally
increased gradient consistent with minimal aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. An eccentric, posteriorly directed jet of moderate
(2+) mitral regurgitation is seen. Due to the eccentric nature
of the regurgitant jet, its severity [**Known firstname **] be significantly
underestimated (Coanda effect). An echodensity associated with
the anterior mitral leaflet, on its atrial aspect is seen, most
likely representing an acoustic artifact, but a vegetation
cannot be excluded with certainty. The tricuspid valve leaflets
are mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. No vegetation/mass is seen on the
pulmonic valve. Significant pulmonic regurgitation is seen.
There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2101-2-24**], the findings are similar.
If clinically indicated, a transesophageal echocardiographic
examination is recommended. If clinically suggested, the absence
of a vegetation by 2D echocardiography does not exclude
endocarditis.
.
Echo [**1-2**]: Thickened mitral leaflets with moderate to severe
mitral regurgitation, but no discrete vegetation. Mild aortic
regurgitation without discrete vegetation. Moderate pulmonary
hypertension.
.
US AV graft [**1-2**]:
IMPRESSION: No fluid collection or evidence of abscess is seen
at the site of the patient's left arm AV fistula.
Brief Hospital Course:
76 yo F with lupus nephritis, CKD on HD, CAD s/p CABG, HTN,
rectro-vag fistula who presented to the ER with likely GI
bleeding of diverticular source admitted to the MICU for GI
bleed, hypotension and respiratory failure.
.
# GI bleed: The patient presented to the ER with bright red
blood per vagina mixed with feces while going to the bathroom.
The patient has had h/o vaginal bleeding previously, but never
to this extent. She also has a long history of urosepsis [**2-22**]
stool output from vagina from a known rectal vaginal fistula.
CTA did not demonstrate active bleeding. No further BRBPR during
her admission. Gyn, GI and Surgery were consulted in the ER and
followed while in the MICU. The likely source of the bleeding
was deemed to be from a diverticular bleed that was near the
fistular opening. GI did not pursue colonoscopy at this time
given patient's tenuous status. GYN stated the potential for
fistula repair via a sub-total colectomy followed by exision of
the fistula, should the patient stabilize clinically. Patient
had no further bleeding after first night of admission and
hematocrit was stable, but was critically ill throughout her
stay so no surgical intervention or workup of the fistula was
pursued.
.
# Hypoxic respiratory failure: In the ER she received 1.7L of
fluid for hypotension and shortly thereafter the patient
developed acute pulmonary edema and tachypnea. She received
Bipap, nitro SL, and nitro gtt with no improvement. Her BP
dropped to 80's/40's and she was intubated. She was sent to the
MICU for management of her respiratory failure. Thoughts for her
hypoxic respiratory failure included infection, hypervolemia,
CHF exacerbation. Less likely TRALI or ARDS following blood
transfusion since per ED report pt had received fluids prior to
intubation. She remained intubated and sedated until she was
terminally extubated at the decision of her family given her
critical illness and lack of improvement.
.
# Septic Shock: On [**12-29**], pt had positive blood cultures that was
+ for [**Female First Name (un) **] with Urine cx showing E.Coli. Source of blood
infection unclear, thought to be ascending urinary tract,
vaginal infection given fistula or AV fistula source. No
evidence of infection in AV fistula or any lines per transplant
surgery. The patient was started on Micafungin. A TTE was
performed which showed an echodensity and they could not rule
out a vegetation. A TEE did not demonstrate any evidence of
vegetation and AV graft showed no evidence of infection.
Transplant surgery did not think the graft looked infected
either. The patient was given Vanc/Cefepime/flagyl for
broad-spectrum antibiotic coverage, then started on micafungin
when [**Female First Name (un) **] grew in the bloodstream. OB/GYN and ID felt
candidemia [**Known firstname **] be secondary to source from fistula, and blood
cultures cleared after she was started on micafungin. However,
patient remained on double pressors and CVVH during MICU stay.
Stress dose steroids were also tried one day prior to death.
.
# Rectovaginal fistula: The patient has a known diagnosis of
rectovaginal fistula diagnosed in [**2096**]. Surgery, GI, and gyn
consulted. No indication to repair while patient septic and
intubated.
.
# CRF: Given hypotension, Pt did not undergo her usual
Tues/Thurs/Sat HD and instead underwent CVVH for K,H+ clearance.
When initially started on this on [**12-28**], she became hypothermic
to 92 degrees and it was stopped. It was restarted the next day
using a bear hugger and the patient maintained her temperature.
Her medications were renally dosed.
Medications on Admission:
Prednisone 5mg every other day
Plaquenil 200mg daily
Lipitor 5mg daily
Levothyroxine 50mg daily
Renagel 800mg TID
Protonix 40mg daily
Allopurinol 100mg QOD
Metoprolol XL 25mg daily
Torsemide 40mg daily
Plavix 75 mg daily
Colace 100mg daily
B12 2000mg daily
ASA 325mg daily
B Complex/Vitamin C/Folic Acid daily
Vitamin D 1,000 units daily
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Candidemia
2. Septic Shock
3. Gastrointestinal Bleed
4. Rectovaginal Fistula
Discharge Condition:
Expired
Discharge Instructions:
Patient expired
Followup Instructions:
N/A
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
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"428.30",
"619.1",
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"562.12",
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"112.5",
"403.91",
"710.0",
"585.6",
"272.4",
"428.0",
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icd9cm
|
[
[
[]
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[
"39.95",
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icd9pcs
|
[
[
[]
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4698, 8306
|
318, 330
|
8859, 8869
|
1811, 1816
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8933, 9076
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1448, 1466
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8694, 8703
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8756, 8838
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8893, 8910
|
1481, 1495
|
270, 280
|
358, 949
|
1830, 4675
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971, 1340
|
1356, 1432
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,911
| 180,960
|
40606
|
Discharge summary
|
report
|
Admission Date: [**2191-4-18**] Discharge Date: [**2191-4-26**]
Date of Birth: [**2120-9-2**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
PEG tube placement
IR guided PICC placement
History of Present Illness:
71 y/o female, with unknown past medical history and no readily
available records, with decreased responsiveness at home,
brought in by EMS. Per discussion with patient's husband,
patient has dementia and is minimally responsive at baseline.
She is cared for at home by husband and home health aide 8 hours
a day, seven days a week. With regard to her baseline functional
status, she does not ambulate, and is occasionally wheeled to a
wheelchair daily. This has been ongoing for years.
.
She had a similar admission for dehydration at [**Location (un) 745**] [**Location (un) 3678**] 6
mo ago (Na 151). She also had a positive U/A. A feeding tube was
suggested, but patient's husband, the health care proxy,
declined. DNR paperwork was considered, but not signed. She was
provided PT/OT/VNA services through [**Hospital 2255**] HealthCare. [**Name2 (NI) **]
diet has since consisted of a liquid diet with some ensure. She
has not been eating much of this per report, for the past week.
.
Patient reportedly saw PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] on Wednesday,
and was diagnosed with dehydration. Unclear what treatments were
provided. Reportedly, she was becoming more unresponsive and
tolerating less PO over the past few days. EMS was called this
AM and patient was taken to [**Hospital1 18**]. BP of 80s in field. IO placed
by EMS.
.
Initial ED VS - rectal temp 101.8, 94, 122/93, 24, 94% on 4L NC.
Pupils equal and reactive, but not following commands. Labs
notable for sodium of 182 and lactate 5.1. BUN and Cr at 66 and
2.1, respectively, without a baseline.
.
Imaging showed normal head CT (No ICH, no fracture, no large
territorial infarct, no mass effect). EKG showed lateral
depressions V3-V6, and a troponin was added on. Patient was
given rectal aspirin, tylenol, vancomycin and zosyn. She
received 2L IVF prior to transfer. CXR showing no acute process.
UOP was noted to be minimal despite IVF. Foley placed. Bcx
pending.
.
She was felt to be protecting her airway, and was not intubated.
GCS estimated at 9. Access - IO and 20G piv.
Past Medical History:
Dementia
Seziure
Depression
Hypercholestolemia
Contractures
Social History:
cared for by husband [**Name (NI) 382**] at home, with HHA 7 days a week,
declined PEG tube in past. Concern for HCP inability to care for
patient - report filed by HHA.
Family History:
NC
Physical Exam:
On admission:
VS: 98.1, 100, 125/82, 19, 97% RA
GEN: appears uncomfortable, moaning, not following commands
HEENT: PERRL, EOMI, anicteric, MM dry, OP without lesions, no
supraclavicular or cervical lymphadenopathy, flat jvd, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: RRR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e, stage 4 ulcer
SKIN: no rashes/no jaundice/no splinters
NEURO: not following commands, moaning, moving all extremities,
winces to painful stimuli, opens eyes, GCS 9. Downgoing toes
Pertinent Results:
On admission:
[**2191-4-18**] 01:00PM BLOOD WBC-10.7 RBC-4.93 Hgb-16.0 Hct-51.7*
MCV-105* MCH-32.4* MCHC-31.0 RDW-14.4 Plt Ct-143*
[**2191-4-18**] 01:00PM BLOOD PT-17.4* PTT-26.2 INR(PT)-1.5*
[**2191-4-18**] 01:00PM BLOOD Fibrino-483*
[**2191-4-18**] 01:00PM BLOOD UreaN-66* Creat-2.1*
[**2191-4-18**] 01:00PM BLOOD ALT-89* AST-67* CK(CPK)-105 AlkPhos-95
TotBili-1.2
[**2191-4-18**] 01:00PM BLOOD Lipase-109*
[**2191-4-18**] 01:00PM BLOOD CK-MB-2
[**2191-4-18**] 01:00PM BLOOD cTropnT-<0.01
[**2191-4-18**] 01:00PM BLOOD Albumin-4.1
[**2191-4-18**] 01:22PM BLOOD Glucose-150* Lactate-5.1* Na-182* K-3.7
Cl-133* calHCO3-23
CT Head:
NON-CONTRAST HEAD CT: There is no hemorrhage, mass, shift of the
usually
midline structures or large territorial infarction. There is
massive
ventriculomegaly of uncertain etiology. Recommend correlation
with clinical symptoms and correlation with prior studies when
available. Enlargement of the sulci is also noted, suggestive of
some degree of cortical atrophy. However, it is uncertain if the
degree of ventriculomegaly can alone be explained by involution.
Periventricular hypoattenuation suggests small vessel ischemic
disease. There is no skull fracture or scalp hematoma. The
paranasal sinuses and mastoid air cells are well aerated.
IMPRESSION:
1. Severe ventriculomegaly of uncertain chronicity or etiology.
Recommend
correlation with prior imaging and clinical symptoms as normal
pressure
hydrocephalus is not excluded. 2. No intracranial hemorrhage.
.
ANKLE (AP, MORTISE & LAT) LEFT [**2191-4-19**]
No marker to indicate location of concern for osteomyelitis,
though skin ulceration is suggested overlying lateral malleolus.
On single view of this area, a focal area of cortical erosion at
the lateral malleolus
may represent osteomyelitis. If concern for osteomyelitis, could
evaluate
with an MRI.
.
CHEST XRAY [**2191-4-18**]
IMPRESSION: No acute intrathoracic process
.
CHEST XRAY [**2191-4-20**]
IMPRESSION
1. Left lower lobe collapse.
2. Heterogeneous opacities in the mid left lung could be
atelectasis or
pneumonia.
3. Possible small left pleural effusion.
.
CHEST XRAY [**2191-4-22**]
IMPRESSION
1. Equivocally increased left mid and new right upper lung
opacities are most consistent with multifocal pneumonia.
2. Unchanged left lower lobe collapse.
Brief Hospital Course:
HOSPITAL COURSE:
This is a 71 year old lady with end stage dementia with limited
interaction who was admitted for management of hypernatremia and
acute renal failure. Acute renal failure and electrolyte
abnormalities resolved with intravenous hydration. She had a
PEG tube placed for nutrition and code status revision to DNR/I.
Palliative care and social work were consulted to assist family
with goals of care discussion - she was discharged to hospice.
.
ACTIVE ISSUES:
# Goals of Care: Goals of care discussion initiated in the ICU
and continued on transfer to the medical floor. Husband
initially did not feel he was 'ready to let go' and as health
care proxy opted to have a PEG tube placed. Social work and
Palliative care were consulted to assist husband and family
discuss goals of care and introduction of hospice. The husbands
own geriatrician contact[**Name (NI) **] [**Hospital1 18**] social work and the patient
himself regarding hospice care. The patient's husband, was
accepting of more care at home and preferred that his wife
return home rather than remain institutionalized.
.
# Hypernatremia: Patient initially admitted to the MICU due to
sodium of 182 for close monitoring. This was felt to be
secondary to severe dehydration as patient not eating at home.
Her free water deficit estimated to be over 8 L. She was
started on NS @ 125 and D5W @ 70 and in the first 15 hours. Her
fluids were then changed to NS @ 125 alone and her repeat sodium
was 163 so fluids were continued. Her serum sodium corrected to
147. IV hydration was discontinued and remaining 2 L free water
deficit was corrected with PEG tube free water flushes and tube
feeds. Sodium remained stable throughout hospital stay with
nutritional support. Urine output was initially poor but
improved with initial hydration.
.
# Encephalopathy: At baseline (for >5 years) the patient is
bedbound, minimally responsive, does not speak or follow
commands. Per family her mental status was somewhat worse prior
to admission, but back to baseline once she arrived to the ICU.
She received one dose of Vanco/Zosyn in the ED. CT head was
negative for acute change (showed ventriculomegaly) and this
change was felt most likely due to hypernatremia. Infectious
etiologies felt less likely and antibiotics not continued. U/A
negative, blood cultures sent and were negative.
.
# Left lateral malleolus ulcer: Heel ulcer with positive bone
probe in past which primary care physician aware of and has
avoided antibiotic therapy in the past. As part of infectious
work-up in ICU, she was started on vancomycin. An xray of the
ankle revealed only a small focal are of cortical erosion at the
lateral malleolus that may represent osteomyelitis with
suggestion for MRI. Given chronicity of lesion and no evidence
of surrounding skin infection, vancomycin ultimately
discontinued and wound care nurse consulted for management
recommendations.
.
# Multifocal Pneumonia: CXR on admission unremarkable. Repeat
several days later revealed evidence of possible LLL collapse
without pneumothorax. A repeat CXR on [**2191-4-22**] in the setting
of significant IV hydration revealed evidence of a multifocal
pneumonia which may have become apparent in the setting of
hydration. While qualifying for healthcare associated pneumonia,
absence of fever or leukocytosis or cough reassuring. It may be
that aspiration pneumonia (the patient was eating on her own
prior to admission) may have been precipitating reason for
dehydration. She was started on a 7 day course of augmentin.
.
# Thrombocytopenia: Unclear etiology. [**Month (only) 116**] be hemodilutional or
medication side effect. Inital drop with administration of
fluids with improvement over time. Vancomycin discontinued and
DIC labs unrevealing. Underlying thrombocytopenia may secondary
to malnutrition.
.
# Goals of care: changed to DNR/DNI. PEG placed for nutrition
and free water flushes per HCP.
.
# Elevated lactate: 5.4 on admission, and then 1.4 the following
morning after IVF rescuscitation. Suspect relation to
intravascular depletion.
.
# Acute renal failure: Patient presented with creatinine of 2.1
and improved to 1.0 after one night of IVF rescuscitation.
Patient's medications were renally dosed and her urine output
monitored closely. Renal failure resolved.
.
# Weight loss: Patient has been severely demented for several
years with what appears to be a decline over the last 4 months
with a 30-40lb weight loss and poor PO intake. Albumin 2.5.
Family meeting held to discuss goals of care. PEG tube placed
for nutrition after family meeting regarding goals of care.
.
# ACCESS: Patient with diffiult access. In the ED 2 20g
peripherals placed but one infiltrated. Attempted PICC
placement and EJ on the floor but this was unsuccessful. A PICC
line was ultimately successfully placed.
.
# Seizure history: Patient's Keppra switched to IV as she was
not taking PO and did not have a gag reflex. PO keppra
restarted when PEG tube placed.
.
TRANSITIONAL ISSUES
Code: DNR/I, discharged to hospice
Medications on Admission:
- keppra 500 mg [**Hospital1 **]
- simvastatin 40 mg daily
- docusate 200 mg [**Hospital1 **]
- lactulose 20 mg daily
- senekot syrup 5 mL 2x/day
Discharge Medications:
1. Aquacel-AG 1.2-2 X 2 %- Bandage Sig: One (1) Topical once a
day.
Disp:*qS * Refills:*2*
2. Aloe Vesta 2 % Ointment Sig: One (1) Topical once a day.
Disp:*qS * Refills:*2*
3. Kerlix 2 [**12-28**] X 3 -yard Bandage Sig: One (1) Topical once a
day: 1. Apply dry 2 x 2" gauze in between the 4th & 5th toes
2. Cover left ulcer dressing with kerlix.
Disp:*qS * Refills:*2*
4. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day.
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
7. lactulose 20 gram Packet Sig: One (1) PO once a day.
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
9. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
10. Hospice orders
Please screen and admit to hospice. Tubefeeding: intermittent by
gravity.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 3005**] Hospice
Discharge Diagnosis:
Primary
1. Hypernatremia
2. Multifocal pneumonia
Discharge Condition:
Mental Status: Not aware
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.
Discharge Instructions:
[**Known firstname **] [**Known lastname **]-[**Known lastname 1007**] was admitted for hypernatremia likely in the
setting of severe dehydration. She was admitted to the intensive
care unit for management where she was given intravenous
hydration with correction of her electrolyte abnormalities.
While hospitalized, discussion regarding goals of care were
initiated. A percutaneous endoscopic gastrostomy (PEG) tube was
placed to help with nutrition. Our social workers and
palliative care team were consulted to assist with transition of
care.
While she was hospitalized a CXR revealed evidence of a
multifocal pneumonia. While it is unclear what kind of
pneumonia this is, it is possible that an underlying infection
is what caused her to become dehydrated. The pneumonia may be
secondary to aspiration of food products.
The following changes were made to her medication list:
1. START augmentin for total 7 days (end date: [**2191-4-30**])
2. START tube feeds
Followup Instructions:
Primary Care
|
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"730.17",
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
[]
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|
5765, 5765
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325, 370
|
12136, 12136
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4090, 5742
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3451, 4059
|
12151, 12242
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2520, 2581
|
2597, 2769
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,106
| 184,643
|
2052
|
Discharge summary
|
report
|
Admission Date: [**2136-1-21**] Discharge Date: [**2136-1-25**]
Date of Birth: [**2076-7-30**] Sex: M
Service: MEDICINE
Allergies:
Shellfish Derived
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
# PEA arrest
Major Surgical or Invasive Procedure:
None
History of Present Illness:
59 yo man with pmhx CRI (3.7-4.7= baseline), HTN, h/o etoh abuse
initially admitted to [**Hospital3 **] after cardiac arrest at
home. Over the last week, he and his wife have had URI symptoms.
He describes headache, sinus pressure and post-nasal drip with
resultant cough productive of clear/non-bloody sputum.
Otherwise, he was feeling well. Denied dizziness, cp, palp, sob,
abd pain, n/v/d/c, hematochezia, melena, dysuria, muscle/joint
pain or swelling. Wife reports that patient ate pizza and
decided to go to bed early as he usually does. Wife reports she
thought his snoring sounded different and went into the room
where she found him in bed appearing "blue." She tried to arouse
him without success and called 911. Per note, pt initially had a
pulse but was in PEA arrest in the ED and was given epi and
atropine as well as cpr. He then went into VT and was shocked
twice and intubated. He was hypothermic in their ED and was put
on precautions. He was also found to be in worsening renal
failure w/ bun 141 and creatinine 7.1 with acidosis (bicarb 13).
Initial ces were C 232 ckmb 5.7 trop I 0.03. EKG showed wide
complex rhythm with LBBB at rate 100. Patient was transferred to
[**Hospital1 18**] for further care as his doctors are here.
.
On presentation to [**Hospital1 18**] ICU, initial vs were 97.9, 134/57, 103,
97% on [**5-7**] with 50% FIO2, R 21. Patient was wide awake and alert
and oriented. He answered all questions via shaking his head and
writing on notepad. He reported feeling well and asked that the
tube be pulled. Reports travel recently in [**Month (only) **] with his
son, noted no leg swelling after that trip and no sob or cp.
Used ibuprofen- 6 pills total over two days--last used 2-3 days
ago. Pt has had some pruritis for a while on his back, no frothy
urine, metallic taste or change in urine output recently.
Past Medical History:
CKD (baseline 3.7-4.7)
- Atrophic right kidney (of unclear etiology)
- L kidney focal segmental glomerulosclerosis
h/o etoh abuse
h/o parathyroidectomy
- Hypertension
- Hypercholesterolemia
- Obesity
Social History:
occasional cigarette since young and occasional ETOh, married,
project manager for steel company
Family History:
no kidney disease, father with hx of MI age 79
Physical Exam:
Physical Exam on admission to MICU:
VS: Temp: 97.9 BP: 134/57 HR 103: RR 21: O2sat 97%
GEN: pleasant, comfortable, NAD
HEENT: NCAT, PERRL, EOMI, anicteric, MM dry, op difficult to
assess given tube, but no visible lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
thyromegaly or thyroid nodules
RESP: end inspiratory crackles at the bases, no wheezes
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.
RECTAL: deferred
Pertinent Results:
Labs from [**Hospital1 **]:
139 100 141
-----------< 186
3.6 13 7.1
AP 102, ALT 22, AST 42, TB 0.5, Ca 7, mag 3.2, etoh 106, utox
neg,
wbc 12.4 43% pmns, 47% lymphs, crit 30.9, MCV 95, plt 350, INR 1
CK 232 ckmb 5.7 trop I 0.03
lactate pending
bld cx pending
Labs here:
pH 7.20 pCO2 33 pO2 103 HCO3 13
Lactate:0.9
wbc 6.4, crit 27.7, plt 274
PTT 150
bmp and serum osm pending
.
EKG: rate 85, LAD (old), sinus, nl pr and qt, qrs wide.16 with
RBBB morphology which was seen on old ekg--> so left anterior
fasicular block.
Brief Hospital Course:
59 yo man with pmhx CKD, [**Hospital **] transferred from [**Hospital3 **]
with acute on chronic renal failure, acidemia, s/p cardiac
arrest with unknown precipitant.
.
# Acute on chronic renal failure (stage V) - Unclear etiology of
worsening renal failure. Patient's baseline creatinine is
3.7-4.7 and was last checked in [**10-9**]. Hypoperfusion from the
PEA arrest could have cause an acute on chronic picture. Pt did
take NSAIDs which could explain this; no other recently new
nephrotoxic medications. Otherwise, he no evidence of poor po
intake, vomiting or diarrhea to cause a hypovolemic picture. A
renal ultrasound was obtained and was stable with right kidney
atrophy and left kidney within normal limits. Nephrology was
consulted and advised that dialysis was likely not needed this
hospitalization as the patient's creatinine was normalizing. On
discharge, creatinine was 5.9. Lisinopril, allopurinol, and
lasix were discontinued in the setting of acute renal failure.
.
# PEA Arrest- Most likely secondary to his CRF, acidosis and
hypocalcemia. He reports self-discontinuation of calcium and
calcitriol since [**11-9**]. He underwent a V/Q scan during this
hospitalization which showed low-likelihood ratio for recent
pulmonary embolism with multiple matched defects and
redistribution of tracer anteriorly, but no areas of ventilation
perfusion mismatch. CTA could not be used given the patient's
renal failure. Urine protein electrophoresis was pending at the
time of the writing of this discharge summary. Serum protein
electrophoresis was neagtive. The patient denies h/o seizures
however an outpatient EEG may be benificial to evaluate this
possibility.
.
# Respiratory- Patient has metabolic acidosis with respiratory
compensation. CXR was clear on admission. Patient was extubated
without complication and was saturating >94% on RA on the floor.
.
# h/o etoh abuse - Last drink was the day prior to admission. He
has a h/o withdrawl in the past but no DTs. He was palced on a
CIWA scale but never required ativan. He was on a multivitamin,
folate, and thiamine during his hospitalization.
.
# anemia- likely due to anemia of chronic disease from renal
failure. He had a negative hemolysis work-up. His stools were
guaiac negative during his hospitalization. He received epo
injections 3x/week during his hospitalization and was discharged
with the same.
.
# Hyperlipidemia: stable, statin was continued.
.
# HTN: The patient was relatively hypotensive on arrival to the
ICU, however his home metoprolol was restarted on the floor for
BP control. Lasix was discontinued for relative hypokalemia
during the hospitalization. Lisinopril was discontinued in the
setting of acute on chronic renal failure. Both should be
restarted after follow-up with primary care provider and
nephrologist.
.
# gout - Stable. allopurinol was discontinued in the setting of
acute renal failure. It should be restarted after follow-up with
primary care provider and nephrologist.
.
# F/E/N: lytes were repleted prn.
.
# PPx: Bowel regimen, PPI, tranferred on heparin drip which was
discontinued, received heparin subcutaneously on the floor.
.
# Dispo: home
.
# Code Status: Full
.
# Communication: wife [**Name (NI) **] [**Telephone/Fax (1) 11185**], cell [**Telephone/Fax (1) 11186**]
Medications on Admission:
Medications at home:
simvastatin 80 mg qhs
lisinopril 5 mg qd
metoprolol 50 mg qd
allopurinol 100 mg qd
ASA 81 mg qd
furosedime 40 mg qd
.
Meds on transfer:
protonix 40 mg IV QD
tylenol prn
zosyn 2.5 g IV q12
versed and fentanyl prn
heparin gtt
ISS
ASA 325 mg qd
metoprolol 5 mg IV q6
.
Allergies: shellfish--> tongue swelling
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Calcium Acetate 667 mg Tablet Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Capsule(s)* Refills:*2*
4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
Disp:*30 Capsule(s)* Refills:*2*
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) 5000 units
Injection QMOWEFR (Monday -Wednesday-Friday).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
primary:
cardiac arrest
acute on chronic renal failure (stage V)
respiratory arrest
anemia
.
secondary:
hyperlipidemia
hypertension
h/o parathyroidectomy
Discharge Condition:
good
Discharge Instructions:
You were admitted as a transfer from [**Hospital3 **] after
having a cardiac arrest, resulting in intubation and CPR with
shock. Once resuscitated, you were discovered to be in acute
kidney failure and have a worsened anemia. You were monitored
for several days and evaluated by the renal team.
.
You were extubated at [**Hospital1 18**]. Your kidney function improved with
hydration. A kidney ultrasound showed stable atrophy of your
right kidney and no abnormalities in the left kidney. An
ultrasound of your legs showed that you do not have evidence of
clot in your legs. A scan of your lungs showed that you have low
probability of having a clot in your lungs.
.
Changes to your medications:
- we discontinued the lasix in the setting of decreased
potassium
- we discontinued the allopurinol and lisinopril in the setting
of your acute kidney failure; please have this followed-up with
your primary care provider.
[**Name Initial (NameIs) **] we added folic acid, iron, thiamine for dietary
supplementation.
- we also added calcitriol and calcium acetate for calcium
supplementation.
.
At this time, there is no indication for acute hemodialysis, but
you should follow up with Dr. [**Last Name (STitle) 4883**] at the appointment listed
below.
Please call Dr.[**Name (NI) 11187**] office to provide insurance
information before your appointment, [**Telephone/Fax (1) 60**].
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2136-2-6**] 1:00 ([**Hospital Ward Name 23**] Building, [**Hospital 5525**] Medical
Specialties)
.
Please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2903**],
[**Telephone/Fax (1) 2205**], in 1 week
|
[
"285.21",
"584.9",
"275.41",
"403.91",
"274.9",
"585.5",
"276.2",
"427.5",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8161, 8167
|
3807, 7095
|
290, 296
|
8365, 8372
|
3257, 3784
|
9798, 10182
|
2528, 2576
|
7472, 8138
|
8188, 8344
|
7121, 7121
|
8396, 9063
|
7142, 7260
|
2591, 3238
|
9092, 9775
|
238, 252
|
324, 2174
|
2196, 2397
|
2413, 2512
|
7278, 7449
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,746
| 139,397
|
49089
|
Discharge summary
|
report
|
Admission Date: [**2164-10-16**] Discharge Date: [**2164-10-22**]
Date of Birth: [**2083-12-13**] Sex: M
Service: SURGERY
Allergies:
Levaquin
Attending:[**Known firstname 2597**]
Chief Complaint:
Aortic Pseudoaneurysm, leak, abdominal pain.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80M s/p infrarenal AAA repair ([**2145**]), now with aortic
pseudoaneurysm, leak, abdominal pain.
Past Medical History:
- CAD s/p MI in [**2135**] - cath [**6-12**] showing 100% proximal RCA, 40%
proximal LAD, 60% intermedius
- s/p pacemaker placement
- Afib- on coumadin
- Bradycardia in the setting of propanolol
- anemia
- thrombosis of the popliteal artery aneurysm - Fem-[**Doctor Last Name **] bypass
[**2164-5-3**]
- Admission for PNA with hypertensive emergency in [**1-14**]
- AAA repair in [**2145**]
- Guaiac + stool with gastric erosions per EGD [**1-14**]
- Vit B12 deficiency
- Diverticulitis s/p colectomy
- HTN
- CRI with baseline creat 1.2-1.6, h/o pre-renal ARF
- Hyperchol
- Detached retina in [**2141**]
- Gout
- Glaucoma
- h/o EtOH abuse
Social History:
Lives with niece and brother-in-law.
150 pk-yr smoker, but quit 20 yrs ago.
No EtOH for 15 yrs
Family History:
FAMILY HX: He has a strong family history of CAD. His sister had
an MI at 55. Both of his parents had MIs, however he is not sure
how old they were. His father died at 77, mother at 73. His
father had DM. His other sister died of a cerebral hemorrhage
Physical Exam:
PE:
AFVSS
NEURO:
PERRL / EOMI
MAE equally
Answers simple commands
Neg pronator drift
Sensation intact to ST
2 plus DTR
Neg Babinski
HEENT:
NCAT
Neg lesions nares, oral pharnyx, auditory
Supple / FAROM
neg lyphandopathy, supra clavicular nodes
LUNGS: CTA b/l
CARDIAC: RRR without murmers
ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness
EXT:
rle - palp fem, [**Doctor Last Name **], pt, dp
lle - palp fem, [**Doctor Last Name **], pt, dp
Pertinent Results:
[**2164-10-16**]
HCT-28.6*
[**2164-10-16**]
PT-15.8* PTT-33.1 INR(PT)-1.7
[**2164-10-16**]
GLUCOSE-117* UREA N-17 CREAT-1.4* SODIUM-139 POTASSIUM-4.0
CHLORIDE-102 TOTAL CO2-26 ANION GAP-15
[**2164-10-16**]
CALCIUM-8.6 PHOSPHATE-4.0 MAGNESIUM-2.0
[**2164-10-16**]
PLT COUNT-152
[**2164-10-15**]
WBC-5.5 RBC-2.51* HGB-8.0* HCT-24.5* MCV-98 MCH-31.8 MCHC-32.6
RDW-15.3
[**2164-10-17**]
EKG
Atrio-ventricular paced rhythm. Prolonged A-V conduction.
Compared to the
previous tracing of [**2164-10-16**] atrial fibrillation has been
replaced by
atrio-ventricular paced rhythm and prolonged A-V conduction.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
140 0 38 [**Telephone/Fax (2) 103006**] 157
[**2164-10-16**] 4:41 PM
CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS
INDICATION: 80-year-old man with multiple medical issues
including history of abdominal aortic aneurysm repair and
coronary artery disease. Patient now presents with abdominal
pain and guaiac-positive stools. Evaluate.
COMPARISON: CT angiogram abdomen dated [**2164-10-15**].
TECHNIQUE: MDCT imaging of the abdomen and pelvis was performed
following the administration of 150 cc of intravenous Optiray.
Nonionic contrast was administered per protocol. Coronal and
sagittal reformatted images were obtained.
CT ANGIOGRAM ABDOMEN: When compared with prior exams, there are
new small bilateral pleural effusions, right greater than left.
Septal thickening is seen within bilateral lung bases consistent
with fluid overload. There are dense coronary artery
calcifications and signs of prior cardiac surgery.
The liver enhances normally without focal nodules or masses.
There has been a small interval increase in the amount of intra-
abdominal free fluid, particularly surrounding the liver. There
is periportal and gallbladder wall edema. A 7- mm stone is seen
within the gallbladder fundus. The pancreas, spleen, bilateral
adrenals glands are unremarkable. Low-density lesions are again
noted within bilateral kidneys, and are most consistent with
simple cysts.
When compared with prior exam, there has been no interval change
in the size, appearance, contrast-enhancing characteristics of
the aneurysmal sac. At maximum axial dimensions, the sac
currently measures 7.0 x 5.4 x 5.8 cm, compared with 6.7 x 5.4 x
5.7 cm one day earlier. Again, all mesenteric vessels appear
patent. As previously noted, the celiac artery, SMA, bilateral
renal arteries and distal branches are patent. The [**Female First Name (un) 899**] is again
not visualized, presumably related to history of AAA repair.
CT PELVIS WITH ORAL, WITH INTRAVENOUS CONTRAST: Foley catheter
is seen within a partially collapsed bladder. There has been an
interval increase in the amount of intrapelvic free fluid
consistent with volume overload. There is diffuse subcutaneous
edema. There is no inguinal or pelvic lymphadenopathy. There is
no free air.
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
abnormalities. Degenerative changes are seen along the lower
thoracic and lumbar spine.
IMPRESSION:
1. No interval change in size, appearance, or contrast
enhancement characteristics of contained abdominal aortic
aneurysm repair.
2. Interval development of subcutaneous edema, bilateral
effusions, and more prominent signs of volume overload within
bilateral lungs. Interval increase in intra-abdominal free
fluid.
3. Mesenteric vessels remain patent. As previously noted, the
[**Female First Name (un) 899**] is not visualized, presumed related to AAA repair.
Brief Hospital Course:
Pt admitted on 11//[**7-13**] to the SICU
Pt coumadin stopped
BP control initiated
HCT followed
[**Month/Year (2) **] surgery consulted
Pt made NPO
[**2164-10-17**]
CTA ordered
Pt recieves vit k / FFP for reversal
Cardiology consulted
Pt transfused
[**2164-10-18**] - [**2164-10-19**]
Pt c/o chest pain. R/O for MI.
Transfered to the VICU.
Pt allowed OOB
PT evaluation
Pt [**Name (NI) 2827**]
[**2164-10-20**] - [**2164-10-21**]
Pt made DNR / DNI
Coservative management
[**2164-10-22**]
Pt stable for discharge
Medications on Admission:
ASA 81,
Colace 100",
Neurontin 300",
Protonix 40,
allopurinol 300,
Norvasc 5,
Imdur SR 120,
lactulose prn,
timolol gtt,
lisinopril 30,
Advair [**Hospital1 **],
Lasix 40",
Fe 325,
Atrovent qid,
albuterol,
Coumadin 5 Tu/Th/Sat/Sun,
Lipitor 10,
Lopressor 12.5"
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for SBP > 130.
8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
11. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
14. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
17. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
18. Insulin
Insulin SC (per Insulin Flowsheet)
Sliding Scale
Fingerstick QID Insulin SC Sliding Scale
Q6H
Regular
Glucose Insulin Dose
0-50 mg/dL [**12-11**] amp D50
51-159 mg/dL 0 Units
160-199 mg/dL 2 Units
200-239 mg/dL 4 Units
240-279 mg/dL 6 Units
280-319 mg/dL 8 Units
320-359 mg/dL 10 Units
360-399 mg/dL 12 Units
> 400 mg/dL Notify M.D.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
80M s/p infrarenal AAA repair ([**2145**]), now with aortic
pseudoaneurysm, leak, abdominal pain.
Discharge Condition:
Stable
Discharge Instructions:
This information is designed as a guideline to assist you in a
speedy recovery from your surgery. Please follow these
guidelines unless your physician has specifically instructed you
otherwise. Please call our office nurse if you have any
questions. Dial 911 if you have any medical emergency.
.
ACTIVITY:
.
There are no specific restrictions on activity. You should be as
active as is comfortable. Resume driving when you are
comfortable without the need for pain medication.
.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
.
Redness in or drainage from your incisions .
.
New pain, numbness or discoloration of your feet or toes .
.
New abdominal or back pain.
.
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.
.
Exercise:
.
Limit strenuous activity for 4 weeks.
.
Resume driving when you are comfortable without the need for
pain medication.
.
No heavy lifting greater than 20 pounds for the next 7 days.
.
BATHING/SHOWERING:
.
You may shower immediately upon coming home. No bathing.
Dissolving sutures, which do not have to be removed were
probably used. Your wounds are covered with a clear, plastic
dressing which should be left in place for three (3) days.
Remove it after this time and wash your incisions gently with
soap and water.
.
You may have staples.
.
WOUND CARE:
.
Sutures / Staples may be removed before discharge. If they are
not, an appointment will be made for you to return for removal.
.
When the sutures / staples are removed the doctor may or may not
place pieces of tape called steri-strips over the incision.
These will stay on about a week and you may shower with them on.
If these do not fall off after 10 days, you may peel them off
with warm water and soap in the shower.
.
MEDICATIONS:
.
Unless told otherwise, you should continue taking all of the
medications that you were on before surgery. You will be given a
new prescription for pain medication, which should be taken
every three (3) to four (4) hours if necessary.
.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
.
CAUTIONS:
.
NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.
.
Avoid heavy lifting (over 10 pounds) for 4-6 weeks after
surgery.
.
No strenuous activity for 4-6 weeks after surgery.
.
DIET:
.
There are no special restrictions on your diet postoperatively.
Poor appetite is expected for several weeks and small, frequent
meals may be preferred.
.
For people with [**Year (4 digits) 1106**] problems we would recommend a
cholesterol lowering diet: Follow a diet low in total fat and
low in saturated fat and in cholesterol to improve lipid profile
in your blood. Additionally, some people see a reduction in
serum cholesterol by reducing dietary cholesterol. Since a
reduction in dietary cholesterol is not harmful, we suggest that
most people reduce dietary fat, saturated fat and cholesterol to
decrease total cholesterol and LDL (Low Density Lipoprotein-the
bad cholesterol). Exercise will increase your HDL (High Density
Lipoprotein-the good cholesterol) and with your doctor's
permission, is typically recommended. You may be self-referred
or get a referral from your doctor.
.
If you are overweight, you need to think about starting a weight
management program. Your health and its improvement depend on
it. We know that making changes in your lifestyle will not be
easy, and it will require a whole new set of habits and a new
attitude.. If interested you can may be self-referred or can get
a referral from your doctor.
.
If you have diabetes and would like additional guidance, you may
request a referral from your doctor.
FOLLOW-UP APPOINTMENT:
.
Be sure to keep your medical appointments. The key to your
improving health will be to keep a tight reign on any of the
chronic medical conditions that you have. Things like high blood
pressure, diabetes, and high cholesterol are major villains to
the blood vessels. Don't let them go untreated!
.
You should be seen in the office approximately ten (10) days to
two (2) weeks following discharge from the hospital. A CT scan
of the abdomen will have to be preformed just prior to that
visit and this will be scheduled with your visit when you call
the office.
.
Please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit..
Normal office hours are 8:30-5:30 Monday through Friday.
.
PLEASE CALL THE OFFICE WITH ANY QUESTIONS OR CONCERNS THAT MIGHT
DEVELOP.
Followup Instructions:
Follow - up with Dr [**Last Name (STitle) **] in 4 weeks. He can be reached at
[**Telephone/Fax (1) 3121**].
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 5566**] [**Name Initial (NameIs) **]. HEMATOLOGY/ONCOLOGY-CC9
Date/Time:[**2164-12-14**] 10:30
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3627**] [**Name12 (NameIs) 3628**] [**Name12 (NameIs) **] [**Name12 (NameIs) 3628**] (NHB)
Date/Time:[**2164-12-31**] 1:00
Completed by:[**2164-10-22**]
|
[
"266.2",
"441.3",
"401.9",
"274.9",
"272.0",
"414.01",
"427.31",
"593.9",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
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"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
8370, 8449
|
5557, 6090
|
315, 322
|
8591, 8600
|
1990, 5534
|
13911, 14376
|
1241, 1494
|
6398, 8347
|
8470, 8570
|
6116, 6375
|
8624, 10128
|
1509, 1971
|
231, 277
|
10141, 13039
|
13063, 13888
|
350, 450
|
472, 1112
|
1128, 1225
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,260
| 176,006
|
51905
|
Discharge summary
|
report
|
Admission Date: [**2178-7-5**] Discharge Date: [**2178-8-24**]
Date of Birth: [**2134-12-2**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5167**]
Chief Complaint:
increased seizure frequency
Major Surgical or Invasive Procedure:
none
History of Present Illness:
43 year-old woman with a history of TLE, s/p right temporal
lobectomy approximately 20 years ago, extensive psychiatric
illness including PTSD and a prior suicide attempt, who presents
with increased seizure frequency and episodes of left-sided
"weakness." The patient reports that she has had 15 seizures
per
day over the last seven days, as opposed to [**1-28**] daily before
that. She states that they occur all day long, even
interrupting
her sleep. Most of the seizures, involve a rapid "bolt of
electricity" traveling from her head to the left arm, some of
which "return to the head." Occasionally she notes that the
"bolt" will travel directly to her chest; she feels as if she
needs to catch her breath. She states that she has also had
several episodes in which her legs suddenly give way.
Occasionally her knees will buckle and she will crumble to her
knees. At others, she falls on her posterior. She denies loss
of consciousness, shaking, and head trauma with these events.
Over the past five days, she has also had 3 episodes in which
her
left face, arm, and leg have "kicked out" on her. In these
instances, which may last minutes, her extremities may "sit or
do
something else" other than what she had intended. There is
extensive drooling associated with involvement of her left
mouth.
She states that she has had these episodes previously,
particularly at a younger age when her seizures were more
frequent. She states that these episodes have been notably
absent during previous psychiatric hospitalizations.
In terms of triggers, the patient reports that she has
faithfully
taken her medication and denies recent infectious symptoms. She
is sleepier (as sleep has been interrupted) and more depressed
of
late.
She is followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**], and last saw him in [**Month (only) 116**]. At
that time, she reported frequent seizures throughout the first
five months of the year as well. Though Dr. [**First Name (STitle) 437**] considered
Topamax and Zonegran as next choices, she was not willing to try
another medication at the time.
Review of Systems:
She reports suicidal ideation, but without plan. Denies
homicidal ideation. Denies headache, fevers, chills, nausea,
vomiting, diarrhea, cough, diplopia, visual loss, and impaired
comprehension of others. Denies urinary incontinence.
Past Medical History:
Epilepsy (above)
Irregular menses
PTSD from childhood trauma with possible borderline PD
Social History:
Lives in subsidized housing in [**Location (un) 4628**], on disability for
epilepsy. Has smoked [**11-26**] ppd since [**2160**]. Drinks [**11-26**] shots of
alcohol 1-2 times per month. Denies drug use
Family History:
No epilepsy; father d. with parkinson's disease; Breast and
colon ca in family; no cad; siblings in good health; twin sister
neurologically normal
Physical Exam:
Vitals: T 99.6 F BP 99/77 P 110 RR 18 SaO2 100 RA
(last
available)
General: NAD, appears disheveled, smells of tobacco
HEENT: NC/AT, sclerae anicteric, MMM, no exudates in oropharynx
Neck: supple, no nuchal rigidity, no bruits
Lungs: clear to auscultation
CV: regular rate and rhythm, no MMRG
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: warm, no edema, pedal pulses appreciated
Skin: no rashes
Neurologic Examination:
Mental Status:
Awake and alert, able to relay history, cooperative with exam,
somewhat restricted affect, somewhat paranoid
Oriented to person, place, time
Attention: can say months of year backward
Language: fluent, non-dysarthric speech, no paraphasic errors,
naming, comprehension, repetition intact; [**Location (un) 1131**] intact
Calculation: can determine 7 quarters in $1.75
Fund of knowledge: normal
Memory: registration: [**1-26**] items, recall [**12-28**] items at 3 minutes,
[**1-26**] with cues
No evidence of apraxia or neglect
The patient had an event in front of the examiner in which she
went from a position sitting upright, then slumped over to her
left, she was drooling but did respond to her name after calling
it 2-3 times, she was quickly arousable and re-oriented. The
duration of the event was ~1 minute.
Cranial Nerves:
Optic disc margins sharp; Visual fields are full to
confrontation. Pupils equally round and reactive to light, 3 to
2
mm bilaterally.
Extraocular movements intact, no nystagmus. Facial sensation
intact bilaterally. Facial movement normal and symmetric.
Hearing intact to finger rub bilaterally. Palate elevates
midline. Tongue protrudes midline, no fasciculations. Trapezii
full strength bilaterally.
Motor:
Normal bulk and tone throughout. No tremor.
D T B WE FiF [**Last Name (un) **] IP Q H TA [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 938**] EDB
Right 5 5 5 5 5 5 5 5 5 5 5 5 5
Left 5 5 5 5 5 5 5 5 5 5 5 5 5
Sensation: No deficits to light touch, pin prick, temperature
(cold), vibration, and proprioception throughout.
Reflexes: B T Br Pa Pl
Right 2 1 2 2 0
Left 2 1 2 2 0
Toes were downgoing bilaterally.
Coordination: No intention tremor noted. No dysmetria on FNF or
HKS bilaterally. Normal FFM.
Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk on toes, heels, and in tandem without
significant difficulty. Romberg absent.
Pertinent Results:
[**2178-7-14**] 06:05AM BLOOD WBC-4.1 RBC-4.00* Hgb-11.9* Hct-34.7*
MCV-87 MCH-29.8 MCHC-34.4 RDW-13.7 Plt Ct-352
[**2178-7-13**] 05:40AM BLOOD WBC-4.8 RBC-4.07* Hgb-11.9* Hct-34.8*
MCV-86 MCH-29.3 MCHC-34.2 RDW-13.7 Plt Ct-371
[**2178-7-12**] 07:00AM BLOOD WBC-4.2 RBC-4.32 Hgb-12.9 Hct-37.1 MCV-86
MCH-29.9 MCHC-34.9 RDW-13.7 Plt Ct-373
[**2178-7-11**] 07:05AM BLOOD WBC-6.8# RBC-4.31 Hgb-13.1 Hct-37.8
MCV-88 MCH-30.4 MCHC-34.6 RDW-13.9 Plt Ct-378
[**2178-7-10**] 02:56AM BLOOD WBC-4.4 RBC-4.26 Hgb-12.9 Hct-37.0 MCV-87
MCH-30.3 MCHC-34.8 RDW-13.7 Plt Ct-330
[**2178-7-9**] 02:42AM BLOOD WBC-5.5 RBC-4.02* Hgb-12.0 Hct-36.0
MCV-89 MCH-29.9 MCHC-33.4 RDW-13.8 Plt Ct-289
[**2178-7-8**] 05:34PM BLOOD WBC-6.1 RBC-4.35 Hgb-13.1 Hct-38.3 MCV-88
MCH-30.0 MCHC-34.1 RDW-14.0 Plt Ct-318
[**2178-7-8**] 05:40AM BLOOD WBC-9.6 RBC-4.24 Hgb-13.0 Hct-37.5 MCV-88
MCH-30.6 MCHC-34.6 RDW-14.1 Plt Ct-314
[**2178-7-7**] 05:55AM BLOOD WBC-9.1 RBC-4.51 Hgb-13.4 Hct-39.6 MCV-88
MCH-29.7 MCHC-33.8 RDW-14.3 Plt Ct-349
[**2178-7-6**] 06:15AM BLOOD WBC-6.9 RBC-4.21 Hgb-12.9 Hct-36.2 MCV-86
MCH-30.8 MCHC-35.8* RDW-14.2 Plt Ct-317
[**2178-7-5**] 08:50AM BLOOD WBC-7.5 RBC-4.56 Hgb-14.0 Hct-39.0 MCV-86
MCH-30.8 MCHC-36.0* RDW-14.1 Plt Ct-334
[**2178-7-4**] 07:45PM BLOOD WBC-8.3 RBC-4.53 Hgb-13.8 Hct-38.7 MCV-85
MCH-30.6 MCHC-35.8* RDW-14.3 Plt Ct-374
[**2178-7-5**] 08:50AM BLOOD Neuts-77.6* Lymphs-12.9* Monos-7.6
Eos-1.4 Baso-0.5
[**2178-7-14**] 06:05AM BLOOD Plt Ct-352
[**2178-7-13**] 05:40AM BLOOD Plt Ct-371
[**2178-7-12**] 07:00AM BLOOD Plt Ct-373
[**2178-7-11**] 07:05AM BLOOD Plt Ct-378
[**2178-7-10**] 02:56AM BLOOD Plt Ct-330
[**2178-7-9**] 02:42AM BLOOD Plt Ct-289
[**2178-7-8**] 05:34PM BLOOD Plt Ct-318
[**2178-7-8**] 05:40AM BLOOD Plt Ct-314
[**2178-7-7**] 05:55AM BLOOD Plt Ct-349
[**2178-7-6**] 06:15AM BLOOD Plt Ct-317
[**2178-7-5**] 08:50AM BLOOD Plt Ct-334
[**2178-7-5**] 08:50AM BLOOD PT-14.2* PTT-31.5 INR(PT)-1.2*
[**2178-7-4**] 07:45PM BLOOD Plt Ct-374
[**2178-7-14**] 06:05AM BLOOD Glucose-83 UreaN-11 Creat-0.4 Na-137
K-3.6 Cl-101 HCO3-24 AnGap-16
[**2178-7-13**] 05:40AM BLOOD Glucose-87 UreaN-14 Creat-0.5 Na-133
K-3.5 Cl-99 HCO3-24 AnGap-14
[**2178-7-12**] 07:00AM BLOOD Glucose-98 UreaN-10 Creat-0.5 Na-136
K-3.8 Cl-102 HCO3-23 AnGap-15
[**2178-7-11**] 07:05AM BLOOD Glucose-92 UreaN-9 Creat-0.5 Na-136 K-4.3
Cl-103 HCO3-22 AnGap-15
[**2178-7-10**] 02:56AM BLOOD Glucose-106* UreaN-5* Creat-0.3* Na-135
K-3.9 Cl-102 HCO3-22 AnGap-15
[**2178-7-9**] 02:42AM BLOOD Glucose-99 UreaN-8 Creat-0.4 Na-134 K-4.2
Cl-104 HCO3-22 AnGap-12
[**2178-7-8**] 05:34PM BLOOD Glucose-112* UreaN-9 Creat-0.5 Na-134
K-3.5 Cl-100 HCO3-24 AnGap-14
[**2178-7-8**] 05:40AM BLOOD Glucose-101 UreaN-12 Creat-0.5 Na-132*
K-3.4 Cl-98 HCO3-24 AnGap-13
[**2178-7-7**] 05:55AM BLOOD Glucose-98 UreaN-14 Creat-0.6 Na-135
K-3.6 Cl-96 HCO3-23 AnGap-20
[**2178-7-6**] 06:15AM BLOOD Glucose-96 UreaN-10 Creat-0.5 Na-134
K-3.3 Cl-98 HCO3-25 AnGap-14
[**2178-7-5**] 08:50AM BLOOD Glucose-101 UreaN-9 Creat-0.5 Na-134
K-3.5 Cl-97 HCO3-26 AnGap-15
[**2178-7-4**] 07:45PM BLOOD Glucose-98 UreaN-7 Creat-0.6 Na-132*
K-4.1 Cl-97 HCO3-24 AnGap-15
[**2178-7-10**] 02:56AM BLOOD ALT-10 AST-16 AlkPhos-103 TotBili-0.3
[**2178-7-9**] 02:42AM BLOOD ALT-9 AST-13 LD(LDH)-117 AlkPhos-94
TotBili-0.4
[**2178-7-5**] 08:50AM BLOOD ALT-12 AST-19 LD(LDH)-173 AlkPhos-139*
TotBili-0.6
[**2178-7-14**] 06:05AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.5
[**2178-7-13**] 05:40AM BLOOD Albumin-3.9 Calcium-8.8 Phos-4.0 Mg-2.4
[**2178-7-12**] 07:00AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.3
[**2178-7-11**] 07:05AM BLOOD Albumin-3.8 Calcium-8.9 Phos-3.7 Mg-2.2
[**2178-7-10**] 02:56AM BLOOD Albumin-3.8 Calcium-9.2 Phos-3.3 Mg-2.2
[**2178-7-9**] 02:42AM BLOOD Albumin-3.5 Calcium-8.5 Phos-3.5 Mg-2.1
[**2178-7-8**] 05:34PM BLOOD Calcium-8.4 Phos-3.7 Mg-2.3
[**2178-7-8**] 05:40AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.4
[**2178-7-7**] 05:55AM BLOOD Albumin-4.1 Calcium-8.9 Phos-3.9 Mg-2.3
[**2178-7-6**] 06:15AM BLOOD Calcium-8.5 Phos-3.9 Mg-2.2
[**2178-7-5**] 08:50AM BLOOD Albumin-4.5 Calcium-9.4 Phos-3.7 Mg-2.4
[**2178-7-4**] 07:45PM BLOOD Albumin-4.8
[**2178-7-5**] 08:50AM BLOOD TSH-1.6
[**2178-7-8**] 05:40AM BLOOD HCG-<5
[**2178-7-14**] 06:05AM BLOOD Phenoba-18.5 Phenyto-5.2*
[**2178-7-13**] 05:40AM BLOOD Phenoba-19.9 Phenyto-11.5
[**2178-7-12**] 07:00AM BLOOD Phenoba-21.1 Phenyto-14.5
[**2178-7-11**] 07:05AM BLOOD Phenoba-20.9 Phenyto-15.7
[**2178-7-10**] 02:56AM BLOOD Phenoba-20.7 Phenyto-10.9
[**2178-7-9**] 02:42AM BLOOD Phenoba-23.3 Phenyto-13.3
[**2178-7-8**] 05:34PM BLOOD Phenyto-14.8
[**2178-7-8**] 05:40AM BLOOD Phenyto-15.0
[**2178-7-8**] 12:00AM BLOOD Phenyto-15.9
[**2178-7-7**] 05:55AM BLOOD Phenyto-9.5*
[**2178-7-6**] 06:15AM BLOOD Phenyto-14.3
[**2178-7-10**] 02:56AM BLOOD Carbamz-3.1*
[**2178-7-9**] 02:42AM BLOOD Carbamz-3.7*
[**2178-7-8**] 05:34PM BLOOD Carbamz-5.3
[**2178-7-5**] 08:50AM BLOOD Carbamz-7.0
[**2178-7-4**] 07:45PM BLOOD ASA-NEG Ethanol-NEG Carbamz-7.8
Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
Neurology - 43 yo F with hx of epilepsy and variety of
psychiatric diagnoses presented with increased seizure
frequency, by her estimate, to 15-20 seizures per day from her
usual of [**2-28**] seizures per day. In actuality, once connected to
LTM, she was found to have many seizures per hour
electrographically, with behavioral correlates characterized by
short periods of non-responsiveness with some motor movements
including turning of the neck and unilateral arm raising. Her
tegretol level was therapeutic on admission, therefore her AED
regimen was upgraded to Zonegran 100 Qday, Ativan 2 PO Q4hrs,
and she was Dilantin loaded as well. Nonetheless seizures
continued without abation. She was transferred to Unit [**7-8**] to
receive IV Phenobarb load. Ativan was DC'd at that time.
Afterward, she ceased having seizures. She was switched to oral
phenobarb, and zonegran DC'd [**2178-7-8**]. After a few siezure-free
days in the ICU, she was transferred back to the general floor
[**7-10**]. On transfer, tegretol DC'd and dilantin increased to 100,
150, 150 mg TID. Subsequently Tegretol was added back at her
home dose.
Patient began refusing medications, would only take tegretol.
Tegretol increased to 400/200/200 as level was low, patient
refused f/u level. We attempted to change from dilantin to
zonegran for lower side effects, and long acting option.
Patient refused this as well. We did want to continue
phenobarbital as this controlled her seizures well at the
beginning of her admission, but she refused. As of time of
transfer to psychiatry she has been taking her tegretol
regularly with no obvious seizures. Plan for her is to take
tegretol and phenobarb as ordered. If she refuses tegretol we
will either instruct on IM anti seizure medication dosing or we
will facilitate transfer back to the neurology service.
Psychiatry - From a psychiatric standpoint, patient was paranoid
and has psychosis. Psychiatry service followed her during
admission. It was recommended that she take antipsychotics but
she refused. Patient excpressed suicidal ideation during
admission. Sitter in room at all times. After gaurdianship was
resolved, she was given a dose of 5mg zyprexa on [**2178-8-20**].
Social - Given concerns that patient was not capable of making
appropriate medical decisions, process was initiated to obtain
guardianship. This was accomplished on [**8-19**].
FEN/GI - Normal po intake durign admission. Refused blood tests
to assess electrolytes.
CV/Resp - Stable throughout.
Medications on Admission:
Carbamazepine 200 mg TID
Discharge Disposition:
Extended Care
Discharge Diagnosis:
epilespy
Discharge Condition:
stable
Discharge Instructions:
You were admitted with an increase in seizure frequency, having
[**1-27**] seizures per hour on EEG. You had been on tegretol only, but
once admitted you were started on dilantin and phenobarbital
which helped suppress your seizure frequency. You were appointed
a guardian and had arranged transfer to a fcililty that can
better manage your combination of seizures and psychiatric
disease.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 1217**], MD Phone:[**Telephone/Fax (1) 2928**]
Date/Time:[**2178-10-9**] 11:00
|
[
"345.41",
"297.9",
"301.83",
"V62.84",
"309.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.19"
] |
icd9pcs
|
[
[
[]
]
] |
13343, 13358
|
10749, 13268
|
343, 350
|
13411, 13420
|
5744, 10726
|
13858, 14018
|
3114, 3262
|
13379, 13390
|
13294, 13320
|
13444, 13835
|
3277, 3707
|
2524, 2763
|
276, 305
|
378, 2505
|
4581, 5725
|
3746, 4565
|
3731, 3731
|
2785, 2875
|
2891, 3098
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,048
| 149,767
|
54888
|
Discharge summary
|
report
|
Admission Date: [**2167-10-2**] Discharge Date: [**2167-10-9**]
Date of Birth: [**2117-5-29**] Sex: F
Service: MEDICINE
Allergies:
doxycycline / Ace Inhibitors
Attending:[**First Name3 (LF) 13891**]
Chief Complaint:
low back pain
Major Surgical or Invasive Procedure:
PICC placement
History of Present Illness:
This is a 50 year-old Female with a PMH significant for
hypertension, depression and anxiety, obesity, prior back injury
(12 years prior from MVA) who initially presented to the [**Hospital 39437**] ER on [**2167-9-24**] with worsening low back pain with radiation
to the left groin and distally below the knee; with some
potential left-sided lower extremity weakness. She was diagnosed
with left limb sciatica and received Percocet for pain control
and was discharged home.
.
The patient's pain continued to complain of pain with increased
activity. She returned to the ED on [**2167-9-27**] and was given
Demerol, Vistaril and Toradol which improved her pain and she
was again discharged home. She notes that with increasing doses
of Ibuprofen, Diazepam and Percocet, her pain was controlled.
There was also a brief course of Prednisone prescribed by her
PCP without symptomatic improvement. She had no recent fevers or
chills. She denies mechanism of injury or trauma. She has been
doing heavy lifting with heavy suitcases lately, which may be a
triggering event. She denies bladder or bowel incontinence or
other evidence of focal neurologic deficits. She has no history
of spinal surgeries or manipulations.
.
She again returned to [**Hospital3 26615**] on [**2167-10-1**] with intractable
low back pain without further neurologic concerns, but she was
noted to have a fever to 100.0F. Radiographs of her L-spine and
left hip revealed degenerative changes in the lower lumbar spine
as well as a 2-cm calcified density over the proximal right 12th
rib and kidney whcih was concerning for a nephrolith. She was
admitted to Medicine with Orthopedic surgery consultation at
that point for further work-up. A CXR on [**2167-10-1**] demonstrated a
patchy opacity over the right base with mild pulmonary vascular
prominence. CT of the abdomen and pelvis on [**2167-10-2**] demonstrated
no intra-abdominal fluid collection or psoas abscess, diffuse
fatty infiltration of the liver and partial compression fracture
at T12 (age indeterminate). Orthopedic surgery recommended MR
imaging of the lumbar spine to evaluate for an epidural abscess
but she was unable to tolerate this procedure due to
claustrophobia. During her hospitalization she continued to
spike to 103.0F and received IV Vancomycin, Ceftriaxone and
Azithromycin. Blood cultures (from [**2167-10-1**]) speciated
Staphylococcus aureus from 2 bottles.
.
Laboratory data at [**Hospital3 26615**] Hospital were notable for a WBC
15.1 (12.9 on repeat) with 88% neutrophilia and no bands.
Hematocrit was 33.4-36% and platelets were 170. Serum sodium was
134, glucose 149, creatinine 0.8. INR 1.4. LFTs: AST 42 and ALT
76 with lipase 30. T-bili 1.4 and direct bili 0.9. Urinalysis
([**10-1**]) notable for WBC [**2-11**], [**12-3**] RBCs, trace bacteria, moderate
blood and no leukocyte or nitrites.
.
The pateint reportedly developed some acute hypoxic respiratory
concerns with an ABG noting 7.42/37/96. She was continued on
Ceftriaxone and Azithromycin for a presumed pulmonary source
given the right opacification on her CXR. She required ICU
transfer at the OSH given an increasing oxygen requirement (on
6L NC prior to transfer), despite hemodynamic stability. She was
empirically anticoagulated with therapeutic Lovenox for presumed
pulmonary embolus, but CTA imaging was deferred. She was
transferred to [**Hospital1 18**] for further evaluation and management.
.
On arrival to the Medicine floor at [**Hospital1 18**] she was noted to be
hemodynamically stable but had evidence of acute hypoxemia with
an increasing oxygen requirement and labored breathing (ABG
7.46/41/52). She recieved 500 cc normal saline bolus, Lasix 20
mg IV x 1 without improvement and thus she was transferred to
the MICU on a non-rebreather with saturations in the 94-96%
range.
Past Medical History:
1. Hypertension
2. Depression
3. Anxiety
4. Lower back injury (in the setting of an MVA, 12 years prior)
5. s/p D & C (x 4) for several spontaneous abortions and
miscarriages
Social History:
Patient lives at home with her partner, [**Name (NI) **]. Denies tobacco
use and notes ocassional social alcohol use; no recreational
substance use and no history of IVDU. Patient is independent in
ADLs and ambulates unassisted.
Family History:
Father with coronary artery disease, but denies significant
family history of early MI, arrhythmia or sudden cardiac death.
Denies family history of malignancy.
Physical Exam:
ADMISSION EXAM:
GENERAL: Appears in no acute distress. Alert and interactive.
Well nourished appearing. Obese female. Mild diaphoresis.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. JVD difficult to assess
given habitus. Thyroid barely palpable.
CVS: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal.
RESP: Decreased breath sounds bilaterally with dry crackles at
bases right sided greater than left. No wheezing, rhonchi.
Stable inspiratory effort.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses;
right knee with 1-2 cm area of mild blanching erythema overlying
the supra-patellar region with pain with active ROM, not passive
flexion. No significant effusion noted.
NEURO: CN II-XII intact throughout. Alert and oriented x 3. DTRs
2+ throughout, strength 5/5 bilaterally in both lower
extremities, sensation grossly intact. Difficulty raising right
leg off the bed dur to pain limitations. Gait deferred. Normal
rectal tone. No spinal point tenderness.
DERM: No skin lesions or rashes.
Discharge exam:
VS: 98.5 158/92, 86, 98/RA
General: NAD
Lungs: CTAB
CV: RRR, no m/r/g
Abd: +BS, soft, NT/ND
Ext: WWP, no c/c/e; small bruise over the right knee. Right
shoulder with some decreased range of motion on abduction,
flexion, minor tenderness of anterior shoulder to palpation.
Left hip not tender to palpation.
Pertinent Results:
ADMISSION LABS:
[**2167-10-3**] 02:58AM BLOOD WBC-11.9* RBC-4.24 Hgb-11.1* Hct-34.2*
MCV-81* MCH-26.2* MCHC-32.5 RDW-15.2 Plt Ct-167
[**2167-10-3**] 02:58AM BLOOD Neuts-83.8* Lymphs-10.2* Monos-4.8
Eos-0.9 Baso-0.3
[**2167-10-3**] 02:58AM BLOOD PT-13.9* PTT-35.0 INR(PT)-1.3*
[**2167-10-3**] 02:58AM BLOOD Glucose-124* UreaN-12 Creat-0.8 Na-138
K-3.1* Cl-100 HCO3-30 AnGap-11
[**2167-10-4**] 05:33AM BLOOD ALT-44* AST-30 AlkPhos-226* TotBili-0.9
[**2167-10-3**] 02:58AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.3
[**2167-10-3**] 08:25AM BLOOD Vanco-8.1*
[**2167-10-3**] 06:04AM BLOOD Type-ART pO2-52* pCO2-41 pH-7.46*
calTCO2-30 Base XS-4
Discharge labs:
[**2167-10-9**] 07:10AM BLOOD WBC-14.9* RBC-4.23 Hgb-10.9* Hct-33.6*
MCV-79* MCH-25.8* MCHC-32.5 RDW-16.5* Plt Ct-463*
[**2167-10-8**] 06:15AM BLOOD Neuts-77* Bands-4 Lymphs-9* Monos-5 Eos-1
Baso-1 Atyps-1* Metas-1* Myelos-1*
[**2167-10-9**] 07:10AM BLOOD Glucose-106* UreaN-11 Creat-0.8 Na-137
K-4.9 Cl-101 HCO3-27 AnGap-14
[**2167-10-9**] 07:10AM BLOOD ALT-45* AST-41* AlkPhos-150* TotBili-0.6
[**2167-10-9**] 07:10AM BLOOD Calcium-8.5 Phos-4.6* Mg-2.4
Imaging:
CXR [**2167-10-3**]
FINDINGS: No previous images. Cardiac silhouette is enlarged,
and there are
bilateral pulmonary opacifications most consistent with
pulmonary edema. In
the appropriate clinical setting, superimposed pneumonia would
have to be
considered. Costophrenic angles are clear, and there is no
large pleural
effusion.
MRI Thoracic and Lumbar Spine [**2167-10-3**]
FINDINGS: There is no malalignment or loss of vertebral body
height. No
suspect marrow signal is seen. There is no cord compression.
The cord is
normal in signal intensity and morphology. There is mild disc
bulge at L5-S1.
Schmorl's nodes are noted in the thoracic spine. There is no
pathologic
enhancement. Bilateral pulmonary opacification is seen.
IMPRESSION:
No significant abnormality is seen.
CTA Chest [**2167-10-3**]
FINDINGS: Contrast is seen opacifying the segmental and
subsegmental arteries
and pulmonary vasculature, without filling defect to suggest
underlying
pulmonary embolus. There is a normal three-vessel aortic arch
and the heart
size is normal. There is no pericardial effusion. There are
enlarged lymph
nodes in right hilus, AP window and subcarinal location. Other
mediastinal
lymph nodes are prominent but do not meet CT size criteria for
lymphadenopathy. The imaged portion of thyroid is unremarkable.
The airways
are patent to the subsegmental level.
There are diffuse, bilateral ground-glass opacities, concerning
for multifocal
pneumonia. When compared to prior CT, these appear more
confluent and diffuse
than prior. A 5 mm right lower lobe nodular density just
adjacent to the
diaphragm, (2:31) is unchanged. No pleural effusion or
pneumothorax.
Although this study was not tailored to evaluate the
subdiaphragmatic
contents, the liver, spleen and left adrenal gland are normal.
Calcified
right adrenal gland is unchanged.
BONES: There are no suspicious osseous lesions.
IMPRESSION:
1. No pulmonary embolus.
2. Multifocal pneumonia. Recommend repeat chest CT following
completion of
treatment to ensure resolution of findings.
3. Mediastinal lymphadenopathy may be reactive in the setting
of diffuse
pneumonia, and attention to resolution at follow up imaging is
recommended.
CXR [**2167-10-4**]
Cardiac size is top normal. Multifocal ill-defined
consolidations, larger in
the right upper lobe and lower lobes, right greater than left,
are consistent
with multifocal pneumonia better seen in prior CT from [**10-3**]. There is no
pneumothorax or pleural effusion. Mediastinal lymphadenopathy
is also better
seen in prior CT.
RUQ Ultrasound [**2167-10-5**]
FINDINGS: Evaluation of the liver is limited by acoustic
penetration and
window. The liver is diffusely echogenic consistent with fatty
infiltration.
There are no focal liver lesions. There is no intrahepatic
biliary duct
dilatation with a normal-caliber common bile duct measuring 4 mm
in diameter.
The portal vein is patent with hepatopetal flow. There is a
1-cm gallstone
and sludge within the gallbladder without evidence of
cholecystitis. The
pancreas is not well visualized due to overlying bowel gas.
Both right and
left kidneys are unremarkable with no hydronephrosis or stones.
The right
kidney measures 12.5 cm and the left kidney measures 11.9 cm.
The spleen is
enlarged measuring 15.4 cm. There is no intra-abdominal
ascites.
IMPRESSION:
1. Echogenic liver consistent with fatty infiltration. Other
forms of liver
diseases and more advanced liver disease including significant
hepatic
fibrosis or cirrhosis cannot be excluded on the basis of this
study.
2. Approximately 1-cm gallstone and sludge within the
gallbladder.
3. Splenomegaly
Echocardiogram [**2167-10-6**]
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size is normal. with borderline normal free
wall function. 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. Physiologic mitral regurgitation is seen (within
normal limits). There is a very small pericardial effusion.
There are no echocardiographic signs of tamponade.
No vegetation seen (cannot definitively exclude).
CXR [**2167-10-8**]
Left PICC tip is in the lower SVC. Cardiac size is normal. The
lungs are
grossly clear. Diffuse lung opacities previously seen are
either resolved or
below the resolution of this radiograph. Widened mediastinum is
again seen
due to increase in the mediastinal fat and mediastinal
lymphadenopathy.
Microbiology:
[**2167-10-3**] 8:25 am BLOOD CULTURE SET#2.
**FINAL REPORT [**2167-10-9**]**
Blood Culture, Routine (Final [**2167-10-9**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
Susceptibility testing requested by DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 4174**] #[**Numeric Identifier **]
[**2167-10-5**].
FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ 1 S
Aerobic Bottle Gram Stain (Final [**2167-10-4**]):
GRAM POSITIVE COCCI IN CLUSTERS.
Brief Hospital Course:
50F with a PMH significant for hypertension, depression and
anxiety, obesity, prior back injury (12 years prior from MVA)
who has had ongoing intractable lumbar back pain recently
admitted to [**Hospital3 26615**] Hospital with fevers found to have
Staphylococcus bacteremia complicated by acute hypoxemic
respiratory failure.
# MSSA BACETERMIA - The patient was transferred from [**Hospital3 26615**]
with documented MSSA bacteremia on IV vancomycin. No history of
diabetes, skin compromise or open wounds; no recent trauma or
injury. Patient is reportedly immune competent and has no IV
drug use history. On admission, the patient underwent MRI
thoracic and lumbar spine that showed no evidence of epidural
abscess or psoas abscess. She was found to have a possible
community acquired pneumonia. No new cardiac murmur or stigmata
of endocarditis, although this would a potential concern.
Similarly, she had shoulder and hip pain that could be potential
sources of seeding from her bacteremia. The patient was
evaluated by infectious disease, and antibiotics were narrowed
to nafcillin. A TTE was performed which showed no signs of
endocarditis. Patient chose not to have a TEE to definitively
rule out endocarditis. Daily surveillance blood cultures grew
coagulase negative staph [**2167-10-3**] which was thought to be a
contaminant. Blood cultures were negative from [**2167-10-4**] on. The
patient was discharged with a PICC on IV nafcillin to complete
at 4 week course. She will follow up in the outpatient [**Hospital **]
clinic.
# ACUTE HYPOXEMIC RESPIRATORY FAILURE - Patient has no
underlying cardiac or pulmonary disease and is immunocompetent
per her medical history. Over several days, she developed acute
hypoxemia and respiratory failure requiring a non-rebreather for
supplemental oxygen. She was found to have a right lobe
opacification, fevers and hypoxemia supporting likely community
acquired pneumonia. She was started on a 7-day course of
levofloxacin (last day [**2167-10-7**]). She was briefly started on
lovenox for Well's score of 3. However, PE ruled out by CTA.
Her respiratory status improved over 2-3 days and she is now
saturating well on room air. She completed a 7 day course of
levofloxacin. A PICC was placed, and she was discharged on IV
nafcillin to complete a 4 week course for MSSA bacteremia as
above. She will need a follow up chest x-ray to evaluated for
resolution of her pneumonia.
# INTRACTABLE LUMBAR BACK PAIN/JOINT PAIN - Recent history of
intractable back pain in the lumbar region radiating to the
groin and above the knee without inciting factor other than
heavy lifting. The patient remained without spinal point
tenderness, concerning neurologic manifestations, compromise of
rectal tone or saddle anesthesia to suggest acute cord
impingement. The patient also complained of right shoulder pain
and left hip pain. During admission, the patient was ruled out
for epidural and psoas abscess by MRI. She was not found to have
any joint effusions. Pain was managed with lidocaine patch,
NSAIDs, tylenol with breakthrough oxycodone. Her pain improved
significantly prior to discharge.
# HYPERTENSION - Blood pressure was stable without evidence of
hypotension despite concerns for infection. Home regimen
includes: CCB and beta-blocker with good control. However,
patient with SBPs in the 150s off and on throughout
hospitalization. She was continued on her home dose of Atenolol
50 mg PO BID and Amlodipine 10 mg PO daily
.
# TRANSAMINITIS: Patient with elevated ALT, AST, Alk Phos,
trending up from [**Date range (1) 49941**], then stable from [**10-5**]-discharge. No
tenderness on exam, and RUQ US showed sludge, 1cm gallstone, no
cholecystits, fatty liver. The patient reports having single
gallstone chronically. Most likely etiology is
medication-induced vs. fatty liver. Further work up was deferred
in the setting of her acute illness.
# DEPRESSION, ANXIETY - Mood appears stable. Will continue
Fluoxetine 20 mg PO daily. Conside low-dose Alprazolam as needed
for anxiety, but judicious use given sedation concerns
Transitional issues:
- patient will need to follow up with Infectious Disease
- while on antibiotics, will need weekly CBC, LFTs, chem 10
faxed to infectious disease nurses
- Monitor CBC, as patient with leukocytosis (trending downward)
on discharge
- Monitor LFTs for resolution of elevation
- Monitor BP, titrate medications if continues to be elevated
- Will need follow up chest x-ray to asses for resolution of
pneumonia
- Outpatient physical therapy for shoulder and hip
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from Patient
outside records.
1. ALPRAZolam 0.5 mg PO TID:PRN anxiety
2. Fluoxetine 20 mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. Zolpidem Tartrate Dose is Unknown PO Frequency is Unknown
5. Atenolol 50 mg PO BID
6. Oxycodone-Acetaminophen (5mg-325mg) Dose is Unknown PO
Frequency is Unknown
7. Ibuprofen 600 mg PO Q8H:PRN pain
8. PredniSONE Dose is Unknown PO DAILY
9. Diazepam 5 mg PO Q6H:PRN muscle spasm
Discharge Medications:
1. ALPRAZolam 0.5 mg PO TID:PRN anxiety
2. Amlodipine 10 mg PO DAILY
3. Atenolol 50 mg PO BID
4. Diazepam 5 mg PO Q6H:PRN muscle spasm
5. Fluoxetine 20 mg PO DAILY
6. Ibuprofen 800 mg PO Q8H:PRN pain
RX *ibuprofen 800 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*60 Tablet Refills:*0
7. Zolpidem Tartrate 5-10 mg PO HS:PRN insomnia
8. Lidocaine 5% Patch 1 PTCH TD DAILY
RX *lidocaine 5 % (700 mg/patch) apply 1 patch to hip and 1
patch to shoulder daily Disp #*30 Transdermal Patch Refills:*0
9. Miconazole Powder 2% 1 Appl TP [**Hospital1 **]
RX *miconazole nitrate [Anti-Fungal] 2 % apply to rash twice a
day Disp #*1 Unit Refills:*0
10. Nafcillin 2 g IV Q4H
RX *nafcillin in D2.4W 2 gram/100 mL 2g IV every four (4) hours
Disp #*138 Vial Refills:*0
11. Outpatient Lab Work
Weekly CBC, LFTs, Chem 10 for 3 weeks following discharge. All
laboratory results should be faxed to the Infectious Disease
R.N.s at ([**Telephone/Fax (1) 4591**]. All questions regarding outpatient
parenteral antibiotics should be directed to the Infectious
Disease R.N.s at ([**Telephone/Fax (1) 21403**] or to the on-call ID fellow when
the clinic is closed.
12. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
hold for RR < 12
RX *oxycodone 5 mg 1 capsule(s) by mouth every six (6) hours
Disp #*10 Capsule Refills:*0
13. Acetaminophen 650 mg PO Q6H:PRN pain or fever
please notify HO if giving for fever
14. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
RX *sodium chloride 0.9 % 0.9 % Flush with 10 mL Normal Saline
daily and PRN per lumen daily and PRN Disp #*28 Unit Refills:*0
15. Outpatient Physical Therapy
Evaluate and treat left hip and right shoulder pain
Discharge Disposition:
Home With Service
Facility:
Home Solutions
Discharge Diagnosis:
MSSA bacteremia
Community-acquired pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were initially admitted to the hospital with severe hip
pain, and were transferred to [**Hospital1 1170**] after developing fevers and difficulty breathing. You
were found to have bacteria in your blood, and also to have
pneumonia. You were treated with antibiotics and your symptoms
improved. An echocardiogram was done which was normal. You were
seen by the Infectious Disease specialists, who recommended that
you be discharged on IV antibiotics, which will end [**2167-10-31**]. You
will need to follow up with the infectious disease clinic. You
should also have a repeat chest X-ray in [**4-12**] weeks. You will
also have weekly lab tests (CBC, LFTs and Chem 10) drawn while
you are on antibiotics.
Changes to your home medications include:
-Nafcillin 2g by IV every 4 hours, last day will be [**10-31**]
-For pain: Lidocaine 5% patch daily, ibuprofen, acetaminophen
-For rash: Miconazole powder (apply to rash twice daily as
needed)
It was a pleasure taking care of you during your hospitalization
and we wish you the best going forward.
Followup Instructions:
Department: INFECTIOUS DISEASE
When: TUESDAY [**2167-11-3**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 3049**] [**Last Name (NamePattern4) 14666**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Last Name (LF) **],[**First Name3 (LF) 278**] C.
Location: HOLISTIC FAMILY PRACTICE
Address: 65 [**Location (un) **] TURNPIKE, [**Location (un) **],[**Numeric Identifier 112124**]
Phone: [**Telephone/Fax (1) 34088**]
***The office is working on an appt for you and will call on
Tuesday with the appt. If you dont hear from them by Tuesday
afternoon, please call them directly to book.
[**Name6 (MD) 3130**] JUPITER MD [**MD Number(2) 13893**]
Completed by:[**2167-10-11**]
|
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,637
| 154,504
|
638
|
Discharge summary
|
report
|
Admission Date: [**2143-1-21**] Discharge Date: [**2143-2-5**]
Date of Birth: [**2090-5-26**] Sex: M
Service: MEDICINE
Allergies:
Nafcillin / cefazolin
Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
acute epidural abscess, MSSA bacteremia
Major Surgical or Invasive Procedure:
1. Total laminectomy of L1, L2, L3, L4, and L5.
2. Incision and drainage.
3. Debridement.
History of Present Illness:
Mr. [**Known lastname **] is a 52-year-old male with medical history
significant for gout involving the left ankle for 8 years,
atrial fibrillation on warfarin, Hypertension, Hyperlipidemia,
and gout, who presented in atrial fibrillation with rapid
ventricular response on [**2143-1-18**], and was later found to have
MSSA bacteremia. During the admission, he required Medical ICU
monitoring for neurochecks and further evaluation of epidural
abscess.
Pt initially presented to his PCP with an erythematous, painful
left ankle, with concern for gout flare. When seen by his PCP,
[**Name10 (NameIs) **] was SOB and found to be in afib with rapid ventricular
response. He was transferred to the [**Hospital3 2568**] ED, where the
patient was evaluated by orthopedics who felt that the patient
had a painful left ankle with somewhat preserved passive range
of motion, and that his exam could be consistent with cellulitis
of the lateral aspect of the ankle. Initial labs showed INR of
7.4, Lactic acid of 1, WBC 18, BUN and creatinine of 44 and 0.8,
AST and ALT of 108 and 127, respectively, Alkaline Phos 297, and
C-reactive of 348. He was started on Ampicillin/sulbactam for
antimicrobial coverage for possible cellulitis overlying gout.
However, on the night of [**1-18**], he spiked to 102.3 and prelim
cultures grew GPC's and Vancomycin was added. He had x-rays of
the left ankle that showed no acute fracture, and LENI was
negative for DVT. CTA was done at that time which showed no PE,
but showed pulmonary nodules.
Subsequently, blood cultures in [**12-29**] bottles grew out MSSA
bacteria, and she was switched to oxacillin 2g IV q4hrs. TTE was
done, which was poor quality, but showed no vegetations. For his
Afib, he was treated with IV diltiazem, and subsequently
switched to IV and then po dilt. Imaging done at that time was
concerning for an epidural collection and possibly abcess in the
L2 , L3 and L4 level. The provisional report was reported by Dr.
[**Last Name (STitle) 4892**], radiologist at [**Hospital1 18**]. The patient was evaluated by the
Neurosurgeon Dr. [**First Name (STitle) **] [**Name (STitle) 3704**], who recommended that the
patient be transfered the patient to [**Hospital1 18**] as the patient
requires more MRI of the Spine (Thoracic and Cervical) and a MRI
brain to rule out any more extensive pathology.
On arrival to the MICU, the patient was somnolent but
arousable. He has diffuse wheezing bilaterally. He endorses back
pain and neck pain. His vital signs are HR 111 BP 103/72 O2 96%
2L.
The patient was subsequently stabilized in the medical ICU and
later transferred to the hospital medicine service.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath, or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency.
Past Medical History:
-Coronary artery disease with a negative stress in [**2140-12-26**]
-atrial fibrillation
-hypertension
-hypercholesterolemia
-gout
-depression
-recent colonoscopy in [**2142-3-25**]
-Bilateral knee arthroscopy
Social History:
- Tobacco: 70 year pack hx (smoked 2ppd for 35y, quit 16 years
ago)
- Alcohol: 5 bottles of wine/week
- Illicits: used cocaine 30 years ago, denies recent drug use.
Denies IVDA.
Family History:
Father died of an MI at 72. Mother died of an MI at 68.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98.1 BP: 103/72 P:110 R: 14 O2: 96% 2L NC
General: somnolent but redirectable, oriented, no acute distress
HEENT: Sclera anicteric, MMM, PERRL
Neck: thick neck girth
CV: irregular rate, tachycardia, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: diffuse, generalized wheezes, tight air movement
bilaterally
Abdomen: soft, non-tender, distended, bowel sounds present, RUQ
with incr girth than remainder of abdomen
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing. Bilateral LE
pitting edema 3+. Area of external malleolus is erythematous and
outlined but erythema extends beyond borders of outline.
Neuro: CNII-XII intact, 5/5 strength upper extremities, [**1-28**]
strength lower extremities, able to move bilateral LE off the
bed but not able to resist even minimally. grossly normal
sensation, gait deferred. Range of motion of R ankle is normal.
Range of motion of R ankle- active is none. Range of motion of L
ankle passive motion is limited by pain
DISCHARGE PHYSICAL EXAM:
Vitals:
General: Alert and oriented in no acute distress
HEENT: Sclera anicteric, MMM, PERRL
Neck: thick neck girth
CV: irregular rate, normal S1 + S2, no murmurs, rubs, gallops
Lungs: clear to auscultation bilaterally
Abdomen: obese, soft, non-tender, bowel sounds present,
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing. Bilateral LE
pitting edema 2+. Left ankle swelling greater than right. Mild
pain with active and passive range of motion of the left and
right ankle L>R. DP/PT pulses bilaterally
Neuro: CNII-XII intact, 5/5 strength upper extremities, [**3-30**]
strength lower extremities with encouragement, lower ext sensory
intact
Pertinent Results:
ADMISSION LABS
[**2143-1-21**] 02:35AM BLOOD WBC-19.3* RBC-3.30* Hgb-10.2* Hct-29.9*
MCV-91 MCH-31.0 MCHC-34.2 RDW-14.9 Plt Ct-419
[**2143-1-21**] 02:35AM BLOOD Neuts-88.9* Lymphs-8.0* Monos-1.3*
Eos-1.5 Baso-0.2
[**2143-1-21**] 02:35AM BLOOD PT-28.6* PTT-47.0* INR(PT)-2.8*
[**2143-1-21**] 02:35AM BLOOD ESR-131*
[**2143-1-21**] 02:35AM BLOOD Glucose-131* UreaN-43* Creat-1.2 Na-134
K-4.3 Cl-100 HCO3-21* AnGap-17
[**2143-1-21**] 02:35AM BLOOD ALT-91* AST-102* LD(LDH)-314*
AlkPhos-158* TotBili-1.5
[**2143-1-21**] 02:35AM BLOOD Calcium-9.2 Phos-5.0* Mg-2.3
[**2143-1-21**] 02:48AM BLOOD Lactate-1.2
[**2143-1-21**] 02:48AM BLOOD freeCa-1.20
PERTINENT INTERVAL LABS:
[**2143-2-4**] 05:24AM BLOOD WBC-9.7 RBC-2.40* Hgb-7.4* Hct-22.3*
MCV-93 MCH-31.0 MCHC-33.4 RDW-16.2* Plt Ct-415
[**2143-2-3**] 07:19AM BLOOD WBC-9.3 RBC-2.42* Hgb-7.3* Hct-22.5*
MCV-93 MCH-30.2 MCHC-32.6 RDW-15.4 Plt Ct-416
[**2143-2-4**] 05:24AM BLOOD Neuts-74.5* Lymphs-20.6 Monos-3.6 Eos-0.9
Baso-0.4
[**2143-2-5**] 06:06AM BLOOD PT-16.7* PTT-95.6* INR(PT)-1.6*
[**2143-2-4**] 05:24AM BLOOD PT-18.1* PTT-71.6* INR(PT)-1.7*
[**2143-2-1**] 07:01AM BLOOD ESR-146*
[**2143-2-4**] 05:24AM BLOOD Glucose-94 UreaN-33* Creat-1.5* Na-143
K-4.0 Cl-106 HCO3-25 AnGap-16
[**2143-2-3**] 07:19AM BLOOD Glucose-95 UreaN-34* Creat-1.3* Na-142
K-4.2 Cl-107 HCO3-27 AnGap-12
[**2143-1-30**] 05:44AM BLOOD LD(LDH)-314* TotBili-0.7
[**2143-1-28**] 06:55AM BLOOD ALT-38 AST-60* LD(LDH)-295* AlkPhos-97
TotBili-0.8
[**2143-1-26**] 03:40AM BLOOD ALT-32 AST-42* LD(LDH)-232 CK(CPK)-487*
AlkPhos-79 TotBili-1.3
[**2143-1-30**] 05:44AM BLOOD Hapto-559*
[**2143-1-27**] 04:52AM BLOOD Ferritn-2934*
[**2143-2-1**] 07:01AM BLOOD CRP-108.0*
[**2143-1-21**] 02:35AM BLOOD CRP-> 300
[**2143-1-29**] 07:07PM BLOOD Vanco-23.1*
IMAGING:
[**Hospital3 **] RECORDS:
X-ray spine [**2143-1-19**]:
Findings:
Lumbar vertebral heights are preserved. Normal lumbar
vertebral alignment is maintained. Minimal decrease in
intervertebral disc spaces noted, predominantly at the L1-L9,
[**12-28**] levels with anterior osteophytosis. Posterior elements
and soft tissues appear unremarkable.
Impression:
Lumbar spondylosis.
Ankle x-ray [**2143-1-18**]:
Impression: Overlying cast obscures bony details. Sclerotic
line of the medial malleolus may represent a nondisplaced
fracture if there is a history of trauma. Slight widening of
the medial tibial talar joint space. Soft tissue swelling.
Results were discussed with Dr. [**Last Name (STitle) 1137**] in the ER.
CXR [**2143-1-18**]:
Impression: Low lung volumes. No focal airspace disease, or
pulmonary vascular congestion. No pneumothorax.
CTA [**2143-1-18**]:
Findings: There are no filling defects within the pulmonary
arteries and their segmental branches to suggest pulmonary
embolism. There is suboptimal evaluation of the subsegmental
branches.
There are ill-defined densities in both lung apices, which may
reflect post-inflammatory or infectious changes. There is a 4 mm
nodule in the left upper lobe (image 56 of series 3), a 6 mm
ground glass nodule in the right upper lobe (image 45 of series
3), and a 5 mm nodule in the right lower lobe (image 35 of
series 3). There is no pleural effusion. The heart is normal in
size without a pericardial effusion. There is no axillary,
mediastinal, or perihilar lymphadenopathy. The aorta is of
normal caliber. Incidental note is made of a left vertebral
artery that arises from the aortic arch. There are no thyroid
nodules.
The visualized stomach, liver, and spleen are unremarkable.
The bony thorax is unremarkable.
Impression:
1. No pulmonary embolism in the main and segmental pulmonary
arteries.
2. Ill-defined densities in both lung apices, which may reflect
post-inflammatory or infectious changes.
3. Multiple 4 to 6 mm pulmonary nodules.
LENI [**2143-1-18**]: Impression: No deep vein thrombosis.
Abdominal u/s [**2143-1-18**]:
Findings: The liver and spleen are normal in size. Diffuse
increase echogenicity of the liver is seen concerning for
hepatic cellular steatosis. The gallbladder appears
unremarkable. Limited evaluation of the common bile duct which
measures 6mm.
The pancreas is not visualized due to rule bowel gas and patient
habitus No mass of the pancreas is seen. No hydronephrosis or
mass of either kidney is noted. The right kidney measures
13.9cm and the left, 15.7 cm. The IVC and Aorta are not
visualized
Impression: Hepatic cellular steatosis. Limited evaluation as
described above.
TTE [**2143-1-19**]:
This was a technically difficult study secondary to poor
penetration. Moderate left atrial enlargement. Other chamber
sizes are within normal limits. Left ventricular wall thickness
and systolic function overall preserved estimated at 60-65%.
There are no regional wall motion abnormalities seen. Trace
mitral and tricuspid regurgitation are noted. There is no
evidence of a significant pericardial effusion or an
intracardiac mass. Given the technical limitations of the
study, a vegetation cannot be excluded.
EKG: [**1-19**] from [**Hospital3 **] EKG read (no EKG present) Atrial
fibrillation with rapid ventricular response
Possible Inferior infarct (cited on or before [**0-0-0**])
Abnormal ECG When compared with ECG of [**0-0-0**] 07:42,
Atrial fibrillation has replaced Sinus rhythm
Vent. rate has increased BY 43 BPM
Left posterior fascicular block is no longer Present
ST now depressed in Anterior leads
Nonspecific T wave abnormality, worse in Inferior leads
T wave inversion no longer evident in Lateral leads
[**Hospital1 18**] IMAGES:
L ankle film ([**1-21**]):
FINDINGS: No previous images. There is diffuse soft tissue
prominence about the ankle joint. There is substantial narrowing
of the tibiotalar articulation, though no definite erosions are
appreciated. If there is a serious clinical concern for
infection, MRI would be the next imaging procedure.
MR [**Name13 (STitle) 2853**] w/ and w/out contrast ([**1-21**]):
IMPRESSION: Extremely limited study with motion; although there
is no large epidural abscess seen or prevertebral abscess
identified or obvious evidence of discitis or osteomyelitis
seen. Subtle changes within the spinal canal could not be
excluded. If there is continued clinical concern, a repeat study
preferably with sedation can help.
MR T- and L-spine w/ and e/out contrast ([**1-20**]):
IMPRESSION: Heterogeneous pattern of enhancement identified in
the lumbar spine posteriorly, likely consistent with an early
epidural phlegmon or epidural abscess formation, extending from
L2/L3 through L4/L5 levels, causing significant narrowing of the
thecal sac posteriorly. There is also evidence of fat stranding
and edema in the paravertebral soft tissues at L3, L4 and L5
levels as described above with loss of the muscular plane and
fat on the left at L4 level. The examination is limited due to
the patient habitus and epidural lipomatosis, grossly in the
thoracic spine, there is no evidence of
spinal cord compression or intrinsic signal changes within the
thoracic spinal cord.
CXR ([**1-21**]):
IMPRESSION: AP chest reviewed in the absence of prior chest
imaging:
Extremely low lung volumes are responsible for considerable
anatomic
distortions, including crowding of pulmonary vasculature and
widening of the cardiomediastinal silhouette. Nevertheless,
there could be a mediastinal adenopathy though there is also
undoubtedly a contribution of fat deposition. There is no focal
pulmonary consolidation, but there could be mild generalized
interstitial abnormality. Pleural effusions are small, if any. I
would strongly urge conventional chest radiographs and if
serious questions of
abnormality remain clarification by a chest CT scan, if that is
justified clinically. No pneumothorax.
TTE ECHO ([**1-21**]):
IMPRESSION: Very suboptimal image quality. Normal biventricular
cavity sizes with preserved global biventricular systolic
function. No definite valvular pathology or pathologic flow
identified.
If the clinical suspicion for endocarditis is moderate or high,
a TEE is suggested to assess the valves.
MICRO:
[**2143-1-29**] 7:01 pm JOINT FLUID Source: left ankle.
**FINAL REPORT [**2143-2-1**]**
GRAM STAIN (Final [**2143-1-29**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2143-2-1**]): NO GROWTH.
-----------
[**2143-1-22**] 4:30 pm TISSUE
SUPERFICIAL POSTERIOR PARASPINAL MUSCLE ADDON PER MCU [**First Name8 (NamePattern2) **]
[**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] [**2143-1-22**] @630PM.
**FINAL REPORT [**2143-2-8**]**
GRAM STAIN (Final [**2143-1-22**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND SINGLY.
Reported to and read back by [**Female First Name (un) 3567**] [**Doctor Last Name 3566**] # [**Numeric Identifier 4893**]
[**2143-1-22**] [**2065**].
TISSUE (Final [**2143-1-25**]):
STAPH AUREUS COAG +. SPARSE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final [**2143-1-26**]): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Final [**2143-2-8**]): NO FUNGUS ISOLATED.
Brief Hospital Course:
The patient is a 52 yo man with h/o CAD, HTN, A-FIB (Coumadin)
who presented with back pain, found to have MSSA bacteremia and
epidural abscess s/p drainage, with a hospital course
complicated by Acute Renal Failure and hospital-acquired
pneumonia, which both improved prior to discharge.
# Sepsis seconary to MSSA epidural abscess: The patient
initially presented to his internist's office and was referred
to an outside hospital, prior to the diagnosis with Staph
bacteremia and was later with an epidural collection consistent
with abcess. MRI at OSH and at [**Hospital1 18**] was consistent with
epidural abscess L2-L4/5. Patient underwent OR drainage of the
abcess by ortho spine. Cultures subsequently grew MSSA,
prompting the initial use of nafcillin. At the time of
diagnosis with hospital-acquired pneumonia, the patient was
transitioned to Vancomycin and Cefepime, but was transitioned
back to nafcillin and later cefazolin for ongoing treatment of
his epidural space infection.
The patient initially required q4h neuro checks given risk of
epidural hematoma formation, and required medical ICU coverage
earlier in his hospital course. After transfer to the hospital
medicine service, the patient remained hemodynamically stable
without any signs of sepsis. The patient remained afebrile.
After he completed his course of IV vancomycin and cefepime the
patient was transitioned back to nafcillin. Patient subsequently
developed a drug rash lattributed most likely to the nafcillin,
at which point he was switched to cefazolin. The rash stabilized
and slowed in its progression prior to his discharge. The
patient will be discharged on a protracted course of cefazolin.
He is being followed with the infectious disease specialists and
they will monitor him for the length of his antibiotic coverage.
# MSSA septicemia: The patient initially presented with evidence
of sepsis with tachycardia, to the outside hospital, in the
setting of positive blood cultures with MSSA. Once the blood
cultures were noted to be positive at OSH for MSSA, the patient
was started on nafcillin. He was subsequently treated with
vancomycin/cefepime before thansitioning to nafcillin again and
then to cefazolin as noted above. TTE was without signs of
endocarditis. Blood cultures from [**Hospital1 18**] did reveal MSSA, but
later in his course, serial surveillance cultures did not show
bacterial growth. Arthrocentesis did not reveal clear evidence
of joint space involvement. Per ID, the patient will require a
[**5-3**] week course of antibiotics. Although there is no
identifiable source for his bacteremia it is likely secondary to
skin breakdown. Patient has no history recently of IV drug
abuse.
# Left leg gout: LLE edema > R and erythema and tenderness. No
evidence of DVT on LENIs. No evidence of bacteria on gram stain
of joint tap, but many negative biorefringent crystals consitent
with a gout flare. Colchicine was held given worsening renal
function. After transfer to the medicine floor the patient had
worsening left ankle pain and swelling. He also complained of
right ankle and left elbow pain. Presentation is consistent with
polyarticular gout. Patient was transitioned from 20 mg of p.o.
prednisone 60 mg of p.o. prednisone. Dermatology was consulted
and recommended this dose change. The patient will be sent out
on prednisone with a taper until his symptoms improve. A second
arthrocentesis performed the left ankle to insure that he did
not have a septic arthritis as he was at risk to do his
bacteremia and previous arthrocentesis. The cultures remained
negative after the second arthrocentesis.
# Afib with RVR: Started on po dilt at OSH after initiation of
dilt gtt for afib w/ RVR. Once on the medicine floor pt
triggered for A fib with RVR to the 150's. Once in the MICU he
was initiated on a dilt gtt. His dilt gtt was increased to 20
mcg/hr without adequate control of his heart rate. Amiodarone
was briefly started, but was discontinued as it was felt that
concerting the pt to sinus rhythm would produce an increased
risk of thromboembolism. Amiodarone was then stopped,
metoprolol boluses were initiated and dilt gtt was weaned. On
transfer to the floor pt was well controlled on metoprolol 10 mg
q6h IV. The patient was transitioned to 25 mg every 6 hours. He
remained stable on the floor and had no episodes of rapid
ventricular response. The patient was continued on a heparin
drip as her main subtherapeutic from his warfarin. The patient
will be sent to his rehabilitation facility with a heparin drip
as he is transitioned to a therapeutic level on his current
warfarin dosing.
#ARF: Pt's creatinine increased to 4.3 from a baseline of 1.0.
This was thought to be from a pre-renal etiology as the pt was
diuresed with IV lasix upon presentation to the MICU. In
addition, he had nearly a 5-6 L NG tube output once an NGT was
placed. A few muddy brown casts were seen on urinalysis.
Creatinine has begun to downtrend on transfer from the MICU. On
for the patient's urine output remained stable and his
creatinine returned to almost baseline and was 1.6 and his day
of discharge.
#Drug rash: Prior to his discharge patient developed a rash on
his extremities consistent with a drug rash. The development
conincided with the reinitiation of the nafcillin. The nafcillin
was discontinued and he was transitioned to cefazolin. The rash
improved prior to his discharge to rehab. While there was
concern for the potentialcross-reactivity with the cefazolin,
the type of hypersensitivity reaction, as well as the desire to
maintain a bacteriacidal [**Doctor Last Name 360**] led the team to continue with
cefazolin with planned careful monitoring. The ID team planned
close follow-up as well, in the event that a change in gents was
required, given the expected duration of antibiotics.
#Ileus: Pt developed a post-op ileus following episdural
abscess surgery. An NGT was placed and 5-6 L of output was
immediately seen. Pt was kept NPO until he was able to pass
flatus and have BM. On the day prior to transfer to the
medicine floor he had three large BM's and had a significant
decrease in his abdominal pain. On the floor the patient had no
nausea or vomiting had regular bowel movements and tolerated a
regular diet.
#Healthcare associated pneumonia: After the patient's surgical
intervention he began to have increased harsh requirements and
hypoxia as well shortness of breath and fever. The patient's
chest x-ray was consistent with pneumonia. The patient initiated
a course of IV vancomycin and cefepime for total 7 days. The
patient's oxygen requirements were weaned quickly and at the
time of his transfer to the medicine floor from the MICU the
patient no longer required supplemental oxygen.
#Anemia: Postoperatively the patient received 2 units of packed
red blood cells. After that time the patient's hematocrit is
Foley downtrend on the medical floor. He had a negative
hemolysis labwork. He had guaiac negative stools. The patient
was transfused and additional unit of packed red blood cells.
His hematocrit stabilized around 23%. There is no clear cause
for his anemia but he remained stable multiple days prior to his
discharge. We are recommending that the patient has surveillance
hematocrits drawn while at rehabilitation to monitor for need
for transfusion if his hematocrit just below 21%.
#Delirium: Patient had an episode of delirium on the medical ICU
and required intramuscular Haldol. He responded well. On the
floor the patient was noted to be somewhat confused at times.
His opiate analgesics were weaned and the patient's sensorium
cleared. The patient is alert and oriented times discharge.
=================================================
TRANSITIONAL ISSUES
=================================================
# Pulmonary nodules: monitor as outpatient, follow up --> to
ensure resolution
# Drug rash: Need to monitor for worsening or new rash. If so
consider cefazolin as the source.
Medications on Admission:
Medications at home: per [**Hospital3 **] records
-indomethacin 50 t.i.d. x5 days
-prednisone 20 a day x7days
-Coumadin 2.5mg daily
-Crestor 40 daily
-Lotrel 10/40
-citalopram 40
-amlodipine
-Arthrotec 75/200 [**Hospital1 **]
-carvedilol 3.125 mg b.i.d.
-fenofibrate 160 once a day
-Lexapro 20 daily
-colchicine 0.6mg [**Hospital1 **]
-probenecid 500mg daily
.
[**Hospital3 **] Transfer Meds:
COLCHICINE TABLET 0.6 MG daily
IBUPROFEN TABLET 600 MG q6hrs prn pain
ESCITALOPRAM OXALATE TABLET 20 MG daily
CYCLOBENZAPRINE TABLET 10mg [**Hospital1 **]
ACETAMINOPHEN TABLET 650 MG Every 4 Hours prn pain/fever
DILTIAZEM TABLET 60 MG QID
HYDROmorphone VIAL 2 MG Every 3 hours IV prn pain
OXACILLIN SODIUM VIAL 2gram Every 4 Hours IV
ALBUTEROL 0.083% NEB [**Male First Name (un) **] 1 NEB Every 6 Hours neb
Discharge Medications:
1. prednisone 10 mg Tablet Sig: Six (6) Tablet PO once a day:
60mg for 5 days then 40mg for 3 days then 20mg for 3 days then
10mg for 3 days then 5mg for 4 days.
2. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
3. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. Lotrel 10-40 mg Capsule Sig: One (1) Capsule PO once a day.
5. escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
7. oxycodone 5 mg Capsule Sig: [**11-26**] Capsules PO every four (4)
hours as needed for pain.
Disp:*60 Capsule(s)* Refills:*0*
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily): hold for loose stools.
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): hold for loose stools.
12. cefazolin 10 gram Recon Soln Sig: Two (2) grams Injection
Q8H (every 8 hours).
13. heparin (porcine)-0.45% NaCl 12,500 unit/250 mL Parenteral
Solution Sig: 2200 (2200) units Intravenous per hour: goal PTT
60-100 seconds; check PTT [**Hospital1 **] and adjust drip as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Severe sepsis secondary to epidural abscess
Acute renal failure
[**Hospital **]
Health care associated pneumonia
Atrial fibrillation
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:
Mr. [**Known lastname **],
You were hospitalized for a severe infection in the epidural
space in your back. You required surgical intervention. During
your stay you developed a pneumonia and acute renal failure. You
were treated with antibiotics for the back infection and
pneumonia. You are being sent to the rehab with plans for
multiple weeks of IV antibiotics. The infectious diease doctors
[**Name5 (PTitle) **] be managing the antibiotics. You also required blood
transfusion during your stay. You received a total of 3 units of
packed red blood cells. Your blood level stabilized. You were
also found to have an abnormal heart rhythm called atrial
fibrillation. We are treating you with medication to prevent
blood clots. This will be managed by the rehab that you go to.
Medication changes:
STOP probenecid
STOP colchicine
Add prednisone
Stop indomethacin
ADD metoprolol 25mg by mouth every 6 hours
ADD cefazolin 2 grams IV every 8 hours
Followup Instructions:
Name: [**Last Name (LF) 363**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 **]/ORTHOPEDICS
Address: [**Last Name (LF) **], [**First Name3 (LF) **] BLDG. RM 239, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3573**]
When: Friday, [**2141-2-21**]:00 AM
Department: INFECTIOUS DISEASE
When: TUESDAY [**2143-2-12**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4593**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
You should also follow up in the rheumatology clinic in 5 weeks.
You can call [**Telephone/Fax (1) 2226**] to make an appointment with Dr.
[**Last Name (STitle) 4894**].
|
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48,145
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44798
|
Discharge summary
|
report
|
Admission Date: [**2135-6-13**] Discharge Date: [**2135-6-23**]
Date of Birth: [**2050-1-6**] Sex: F
Service: MEDICINE
Allergies:
Latex / Lasix / Sulfa (Sulfonamide Antibiotics) / Ciprofloxacin
/ Clindamycin / IV Dye, Iodine Containing Contrast Media
Attending:[**First Name3 (LF) 7299**]
Chief Complaint:
Dyspnea, hyponatremia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
85-year-old woman recently discharged from [**Hospital1 18**] on [**2135-6-1**] for
CHF exacerbation who presents with hyponatremia and shortness of
breath. The patient had been started on several new medications
during her previous admission, including torsemide. Since her
previous discharge, the patient continues to have a cough that
is mildly productive of clear sputum. She does not use oxygen at
home and denies feeling short of breath there. She has been
feeling somewhat more fatigued. The patient reports that her
symptoms are similar to those during her previous admission.
She denies any fever or chills. She further denies any dysuria,
but does complain of constipation. The patient was brought to
the Emergency Department because her sodium had been dropping
over the last week on outpatient labs. She denies any confusion
or seizures.
In the ED, initial vital signs were 97.6 87 130/63 16 90% RA.
The patient became progressively short of breath. She was
started on bipap and saturations returned to the high 90's. She
was started on Zosyn for UTI following recent hospitalization.
For concern of HCAP, vancomycin also started.
Past Medical History:
HTN
hiatial hernia
acid reflux
rheumatoid arthritis
hysterectomy
breast cancer
Social History:
Patient lives alone. Supportive children. Denies any tobacco
use, drinks alcohol rarely. She uses a cane, does not need a
walker.
Family History:
non-contributory
Physical Exam:
Admission Physical Exam:
Vitals: BP: 108/54 P: 62 R:22 O2: 95% 10L nasal cannula with
shovel mask
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP mildly elevated, no LAD
Lungs: Crackles in left lower base and decreased breath sounds
in right base
CV: S1, S2, irregularly irregular rhythm, no murmurs
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding.
Ext: Warm, well perfused, [**11-28**]+ pitting edema to calves in lower
extremities.
.
Discharge Physical Exam:
Vital Signs T: 97.6 BP: 138/71 P: 89 RR: 20 O2: 92%3L
Gen: Sitting comfortably in bed, NAD
HEENT: mucous membranes and lips dry; bite mark on left buccal
mucosa; oropharynx clear; JVP mildly elevated; no LAD
Card: Irregularly irregular S1, S2, no murmurs, rubs or gallops
Respiratory: mild dry bibasilar crackles
Abdomen: soft, non-tender, non distended; bowel sounds
present, no rebound or guarding
Ext: Warm, well perfused; 2+ pitting edema to calves and
dependent areas; TEDS in place (mildly improved from admission)
Pertinent Results:
- OSH chest CT w/o contrast ([**2135-4-1**] @ [**Hospital6 **]):
There are bilateral thyroid nodules. There is no pneumothorax.
There are predominantly bibasilar subpleural reticular
abnormality with small cystic spaces which are probably due to
senescent lung changes and/or mild fibrotic changes. There is no
pleural effusion. No lung mass or consolidation is seen. The
heart is globally enlarged. There is coronary artery
calcification.
Admission Labs:
[**2135-6-13**] 08:35PM BLOOD WBC-7.7 RBC-4.35 Hgb-13.9 Hct-40.1 MCV-92
MCH-31.9 MCHC-34.6 RDW-14.5 Plt Ct-298#
[**2135-6-13**] 08:35PM BLOOD Neuts-75.5* Lymphs-15.5* Monos-5.7
Eos-2.8 Baso-0.5
[**2135-6-13**] 08:35PM BLOOD PT-26.1* PTT-29.3 INR(PT)-2.5*
[**2135-6-13**] 08:35PM BLOOD Plt Ct-298#
[**2135-6-13**] 08:35PM BLOOD Glucose-105* UreaN-21* Creat-0.7 Na-120*
K-5.0 Cl-87* HCO3-27 AnGap-11
[**2135-6-13**] 08:35PM BLOOD proBNP-1429*
[**2135-6-13**] 08:35PM BLOOD cTropnT-<0.01
[**2135-6-13**] 08:35PM BLOOD Osmolal-259*
Discharge Labs:
[**2135-6-23**] 07:23AM BLOOD WBC-8.0 RBC-4.29 Hgb-13.6 Hct-40.4 MCV-94
MCH-31.6 MCHC-33.6 RDW-14.6 Plt Ct-211
[**2135-6-23**] 07:23AM BLOOD Glucose-96 UreaN-15 Creat-0.5 Na-134
K-4.2 Cl-96 HCO3-32 AnGap-10
[**2135-6-22**] 01:31PM BLOOD Type-ART pO2-66* pCO2-46* pH-7.45
calTCO2-33* Base XS-6 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**]
.
LE U/s IMPRESSION: No evidence of DVT in both lower extremities.
Brief Hospital Course:
Ms. [**Known lastname **] is an 85-year-old woman with a history of diastolic
heart failure presenting with dyspnea and hyponatremia.
.
# Respiratory distress- On admission, patient was found to be
90% on room air. She was placed on BIPAP and admitted to the
MICU. She was ruled out for MI. There was a concern for
pulmonary edema from CHF, given crackles on exam, pitting edema,
and CXR suggestive of pulmonary edema, but diuretics initially
held given hyponatremia. Shortly after admission to the MICU,
BIPAP was discontinued and the patient's respiratory status was
stable on 4L NC and face mask of 50% FiO2. With improvement of
hyponatremia, IV torsemide 5mg [**Hospital1 **] was given with a good
response and patient was weaned to 3-4L O2 NC. She was
transferred to the medical floor. On the floor, the patient
continued to be diuresed with IV torsemide. However, she
remained hypoxemic with a 2-3L O2 requirement. She was
discharged to a long-term care facility for continued diuresis.
The patient should have electrolytes checked every other day
with continued aggressive diuresis. Patient continues to be
4lbs above her dry weight. At baseline, did not require
supplemental oxygen prior to admission. The patient should
follow-up with outpatient pulmonology for evaluation of fibrotic
changes seen on chest CT.
.
# Hyponatremia- The patient was admitted with a sodium of 120.
Hyponatremia was likely secondary to excess water intake in
presence of diuretics following past hospital discharge. TSH,
T4, and random cortisol on admission were are normal, excluding
endocrine abnormality as a cause of hyponatremia. The patient
was water-restricted to 1L/day, and hyponatremia began to
improve. She was given protein shakes TID and was discharged to
a LTAC on a water restriction of 1.5L/day. On day of discharge,
her sodium was 134. Please check electrolytes every other day
with continued aggressive diuresis given history of
hyponatremia.
.
# Urinary tract infection-Urinalysis on admission was strongly
suggestive of continued urinary tract infection. The patient
was given 1 dose of Zosyn in the ED, and 1 dose of macrobid in
the MICU before switching to IV ceftriaxone. She took seven
days of ceftriaxone. Urine culture then returned positive for
coagulase negative staph. The patient received PO
Nitrofurantoin x 3 days.
.
# Atrial fibrillation-The patient was continued on her home rate
control medication of diltiazem. However, due to issues of
tachycardia, diltiazem was changed from 240 mg ER daily to 60mg
PO QID. Home atenolol dose was converted to metoprolol tartrate
for tighter control. The patient was continued on her home
warfarin in house. Once transferred to the floor, INR became
sub-therapeutic. Patient's warfarin dose was doubled to 4mg
daily. On discharge, INR should be tightly monitored. If the
patient becomes supratherapeutic, she should be changed back to
her home dose of 2mg daily at 4pm.
.
# Hypertension: Stable. The patient was continued on diltiazem.
Extended release formulation was converted to short acting
formulation, as above. Atenolol was converted to metoprolol
tartrate.
.
# Osteoporosis: Continued calcium and vitamin D throughout
admission. Patient should resume alendronate as an outpatient.
.
# Constipation - Patient continued on senna, colace, miralax.
PRN bisacodyl was started for constipation.
.
#Transitional issues:
Prior to discharge, the patient's INR was 1.5. Her warfarin
dose was doubled to 4mg daily. On discharge, INR should be
tightly monitored. If the patient becomes supratherapeutic, she
should be changed back to her home dose of 2mg daily at 4pm.
Please check electrolytes every other day, as patient is on
aggressive diuresis with a history of hyponatremia. The patient
should follow-up with outpatient pulmonology for evaluation of
fibrotic changes seen on OSH chest CT.
Medications on Admission:
1. atenolol 50 mg Tablet Sig: One Tablet PO daily.
2. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
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. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
8. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
9. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
10. warfarin 2 mg Tablet Sig: One Tablet PO Once Daily at 4 PM
11. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
12. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for ingestion.
13. diltiazem HCl 240 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
14. quinapril 40 mg Tablet Sig: One (1) Tablet PO twice a day.
15. torsemide 20 mg Tablet Sig: One (1) Tablet PO daily
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day). Tablet(s)
2. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
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. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
8. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
9. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
10. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM: Home dose 2mg daily. However, INR 1.5. Continue to monitor
INR. .
11. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constpation.
13. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for ingestion.
14. quinapril 40 mg Tablet Sig: One (1) Tablet PO twice a day.
15. torsemide 20 mg/2 mL (10 mg/mL) Solution Sig: Five (5) mg
Intravenous twice a day.
16. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
17. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Discharge Disposition:
Extended Care
Facility:
Radius [**Hospital1 392**]
Discharge Diagnosis:
Primary: diastolic CHF, hyponatremia
Secondary: HTN, hiatial hernia, acid reflux, rheumatoid
arthritis
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 **],
You were admitted to [**Hospital1 69**] for
low sodium and shortness of breath. Because of your level of
weakness, you were admitted to the ICU. You were found to have
an exacerbation of your heart failure. We gave you medications
to help you get rid of extra fluid in your body. We also
restricted the amount of fluid you could take in daily to help
your sodium improve. Your sodium level corrected. You were
transferred to the general medical floor. Although the extra
fluid in your body decreased quite a bit over admission, you
continued to require oxygen.
.
During your hospital stay, you were seen by physical therapy who
recommended discharge to rehabilitation. For continued fluid
management, you were discharged to a long-term care facility.
Medication changes made this admission:
START bisacodyl PRN constipation
START metoprolol
STOP atenolol
CHANGE torsemide (from home PO to IV)
CHANGE diltiazem from 240mg ER PO daily to 60 mg PO QID
CHANGE warfarin from 2mg daily to 4mg daily
Followup Instructions:
You are being discharged to a long-term care facility. You will
need to follow up with your primary care physician. [**Name10 (NameIs) **] should
also follow up with a pulmonologist for your lungs. An
appointment will be made for you by the long-term care facility.
|
[
"V58.61",
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"V10.3",
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"515",
"276.1",
"401.9",
"799.02",
"733.00",
"564.00",
"041.19",
"599.0",
"553.3",
"427.31",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11261, 11314
|
4462, 7844
|
403, 409
|
11463, 11463
|
3018, 3459
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12700, 12973
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1855, 1873
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11335, 11442
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8368, 9637
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11646, 12677
|
4020, 4439
|
1913, 2435
|
7865, 8342
|
341, 365
|
437, 1585
|
3475, 4004
|
11478, 11622
|
1607, 1688
|
1704, 1839
|
2460, 2999
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,486
| 193,274
|
3294
|
Discharge summary
|
report
|
Admission Date: [**2201-3-22**] Discharge Date: [**2201-5-13**]
Date of Birth: [**2145-9-6**] Sex: F
Service: SURGERY
Allergies:
Heparin Agents
Attending:[**Last Name (NamePattern1) 15344**]
Chief Complaint:
sepsis, perforated diverticulitis, open abdomen
Major Surgical or Invasive Procedure:
1) Exploratory laparotomy, abdominal washout, and
Dexon mesh abdominal closure. [**2201-4-3**]
2) Exploratory laparotomy, abdominal wash-out,attempt at
abdominal closure. [**2201-3-31**]
3) Exploratory laparotomy, abdominal wash-out, attempt at
abdominal closure. [**2201-3-27**]
4) Exploratory laparotomy, extensive lysis ofadhesions, anterior
resection of the rectosigmoid, small bowel resection. [**2201-3-24**]
5) PICC line placement
6) Tracheostomy [**4-14**]
7) Split thickness skin graft [**4-29**]
History of Present Illness:
55F with acute abdominal pain, fevers, mental status changes,
perforated diverticulitis
Past Medical History:
HTN
hypercholesterolemia
h/o breat abscess
depression
Social History:
noncontributory
Family History:
noncontributory
Physical Exam:
Septic
Pertinent Results:
[**3-22**] WBC 11.9 (17% bands), lactate 9, CK 1013 (MB 5), TnT 0.26
[**3-22**] CT shows ischemic colitis
[**3-25**] heparin dependent antibodies: positive
[**3-30**] RUQ US: portal vein thrombosis
[**4-17**] EEG: A slow background was seen consistent with a moderate
to severe encephalopathy. No evidence for ongoing seizures was
seen.
[**4-19**] CT A/P: There is no evidence of intraabdominal hemorrhage
or collections. Stable appearance of thrombus in the portal
veins.
[**4-19**] LP: negative
[**4-24**] ECHO: 1. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). 2. There are
simple atheroma in the descending thoracic aorta. 3. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. 4. No echocardiographic evidence of endocarditis.
[**4-28**] MRI c/t/l-spine no evidence of abscess/discitis
[**2201-5-13**] 06:10AM BLOOD WBC-11.0 RBC-2.78* Hgb-8.1* Hct-24.7*
MCV-89 MCH-29.0 MCHC-32.7 RDW-15.8* Plt Ct-454*
[**2201-5-13**] 06:10AM BLOOD Plt Ct-454*
[**2201-5-13**] 06:10AM BLOOD PT-15.5* PTT-36.8* INR(PT)-1.6
[**2201-5-13**] 06:10AM BLOOD Glucose-130* UreaN-14 Creat-0.5 Na-139
K-3.7 Cl-102 HCO3-28 AnGap-13
[**2201-5-5**] 03:36AM BLOOD ALT-61* AST-28 CK(CPK)-53 AlkPhos-450*
TotBili-0.9
[**2201-4-28**] 04:02AM BLOOD Lipase-76*
[**2201-5-13**] 06:10AM BLOOD Calcium-10.5* Phos-3.9 Mg-1.9
Brief Hospital Course:
NEURO: Pain controlled with methadone, oxycodone & fentanyl.
Lethargic & nonreponsive postop. Neurology consult obtained.
Negative EEG, CT, LP, MRI head/spine. Most recently, much
improved, alert and oriented. Pain medications weaned off.
Restlessness controlled on Ativan 2mg qid. Restarted on psych
medications (venlafaxine, olanzapine). Psychiatry service
following.
CV: HTN controlled with lopressor & diltiazem. Echo WNL.
RESP: Prolonged respiratory failure, percutaenous tracheostomy
[**4-14**]. Then weaned fairly rapidly off the vent to trach collar.
Most recently with Portex 9 tracheostomy, and Passy-Muir valve.
FEN: Postoperatively fluid overloaded, diuresed with lasix &
diamox, now approaching admission weight and euvolemic. TPN
postoperatively but quickly changed to enteral feedings.
Currently with postpyloric feeding tube and tube feedings
promote with fiber 3/4 strength plus 2 scoops promod daily at
100cc/hr. Speech and swallow service consult ([**5-13**]) recommends
starting po trials.
GI: High LFT's secondary to PV clot seen by U/S. Started on
anticoagulation. Subsequently, LFTs normalized. Ostomy vital but
retracted on medial edge.
RENAL: Normal renal function.
HEME: Found to be HIT+ on POD2, started on lepirudin drip.
Started coumadin after trach on [**4-14**], but developed blood loss
anemia requiring transfusion on [**4-19**]. Guaiac positive, but hct
responded to transfusion & NG lavage was negative for blood or
coffee grounds. Lepirudin & coumadin restarted. Coumadin
switched to 10mg per rectum daily as enteral absorbtion was
questionable. Most recently, lepirudin off, started on
Fondaparinux 7.5mg daily as well as pr coumadin. INR 1.6 on
[**5-13**].
ID: Developed severe septic shock with multiple blood borne
organisms in the 1st postop week (strep milleri, proteus,
providencia & b fragilis). Followed by ID & had persistent
fevers (up to 104, but between 101 & 102 daily) throughout
hospital course. She had several courses of broad spectrum
antibiotics. Most recently, she was diagnosed with Picc line
infection ([**5-3**], MRSA) and is being treated with Vancomycin.
ENDO: Initially insulin drip, no adrenal insufficiency,
recently, BS well controlled on minor insulin sliding scale.
WOUND: Left open postop to prevent compartment syndrome & allow
access for additional procedures. Mesh onlay placed with
overlying VAC on [**4-3**]. Skin transplant [**4-29**] with good take.
Medications on Admission:
atenolol
ativan
buspar
zestril
clonazepam
Discharge Medications:
1. Fondaparinux Sodium 5 mg/0.4 mL Syringe Sig: 7.5 mg
Subcutaneous once a day. mg
2. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mg PO Q4-6H (every
4 to 6 hours) as needed for pain: via J Tube. mg
3. Acetaminophen 160 mg/5 mL Elixir Sig: Six [**Age over 90 1230**]y (650)
mg PO Q4-6H (every 4 to 6 hours) as needed for [**Age over 90 **].
4. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. Insulin Regular Human Injection
7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig:
Thirty (30) mg PO DAILY (Daily): via NG daily.
11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed: Please use carefully as patient has a
rectal stump with a suture line.
12. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours).
13. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Venlafaxine 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: 1000 (1000)
mg Intravenous Q 12H (Every 12 Hours) for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
perforated sigmoid colon
open abdominal wound
methicillin resistant staph epidermis and enterococcus bactermia
and line infection
hypertension
portal vein thrombosis
depression
hypercholesterolemia
Discharge Condition:
good
Discharge Instructions:
Please call doctor [**First Name (Titles) **] [**Last Name (Titles) **] greater than 101, nausea/vomiting,
inability to eat, wound redness/warmth/swelling/foul smelling
drainage, abdominal pain not controlled by pain medications or
any other concerns.
Please take all medications as prescribed.
Please follow-up as directed.
Please continue tube feeds via dobhoff tube as directed.
Please continue routine ostomy care.
Please use passy-muir valve as directed: always deflate cuff
prior to placing valve, monitor sats while valve is in place, do
not allow paitent to sleep with vlave in place.
Please leave skin graft donor site on right thigh alone,
xeroform dressing to be left in place and will peel off on its
own. For abdominal wound, xeroform direct over wound covered
with dsd and then held in place with abdominal binder.
Followup Instructions:
1) Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) 4952**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 15345**] Follow-up
appointment should be in 2 weeks.
2) Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9052**], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2201-6-2**] 3:00
3) Please follow-up with PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 15346**] in two weeks
[**Telephone/Fax (1) 15347**].
4) Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of plastic surgery in
two weeks to evaluate skin graft. Call ([**Telephone/Fax (1) 15348**] for
appointment and directions.
5) Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of neurology, call
[**Telephone/Fax (1) **] for appointment and dircetions.
Completed by:[**2201-5-13**]
|
[
"E934.2",
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"287.4",
"285.1",
"038.8",
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"584.9",
"572.1",
"518.5",
"568.0",
"996.62",
"289.59",
"562.11",
"305.1",
"557.0",
"278.01",
"428.0",
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] |
icd9cm
|
[
[
[]
]
] |
[
"46.11",
"00.17",
"88.72",
"45.76",
"99.15",
"45.62",
"93.59",
"54.25",
"03.31",
"96.6",
"45.91",
"00.14",
"54.63",
"54.59",
"86.69",
"31.1",
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] |
icd9pcs
|
[
[
[]
]
] |
6547, 6617
|
2653, 5089
|
330, 837
|
6859, 6865
|
1139, 2630
|
7750, 8733
|
1080, 1097
|
5181, 6524
|
6638, 6838
|
5115, 5158
|
6889, 7727
|
1112, 1120
|
243, 292
|
865, 954
|
976, 1031
|
1047, 1064
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,191
| 130,885
|
33950
|
Discharge summary
|
report
|
Admission Date: [**2183-6-9**] Discharge Date: [**2183-6-27**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Large Left cerebellar hemorrhage
Major Surgical or Invasive Procedure:
[**6-9**]: Suboccipital craniotomy for hematoma evacuation and
placement of EVD
History of Present Illness:
84F who presented to OSH after a two day history of nausea
and vomiting. She went to the ED earlier this evening for
ongoing nausea and vomiting and increased drowsiness, with an
"inability" to get OOB. Of note patient takes Coumadin 2.5mg
daily for an unknown condition.
Past Medical History:
1. Unknown cardiac condition requiring anticoaguation
2. Insomnia
3. Hypertension
4. s/p CVA
5. s/p THR
Social History:
non-contributory
Family History:
non-contributory
Physical Exam:
On Admission:
O: T: afebrile BP:207/122 HR: 85 RR:18 O2Sats: 97%
ventilated
Gen: intubated.
HEENT: normocephalic, atraumatic
Pupils: equal bilaterally, minimally reactive to light.
EOMs: unable to assess
Extrem: Warm and well-perfused.
Neuro:
Mental status: Spontaneously moving all four extremities,
briskly
withdrawing LE to noxious>upper extremities. Brisk corneals,
+gag to deep suction with associated facial grimacing.
Cranial Nerves:
I: Not tested
II: Pupils equally round and minimally reactive to light,2mm
bilaterally.
III, IV, VI-XII: unable to assess
Toes downgoing bilaterally
Pertinent Results:
CT Scan([**6-8**]) Pre-operative:
IMPRESSION:
1. Large intraparenchymal hemorrhage centered within the left
cerebellar hemisphere with associated effacement of the fourth
ventricle and quadrigeminal plate cistern.
2. Hydrocephalus.
3. Encephalomalacia within the left frontal lobe.
RADIOLOGY Final Report
MR HEAD W/O CONTRAST [**2183-6-25**] 3:29 PM
MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST
Reason: ? evidence for embolic stroke.
[**Hospital 93**] MEDICAL CONDITION:
84 year old woman with possible history of PFO/embolic stroke,
previously on coumadin admitted with left cerebellar hemorrhage,
s/p evacuation. Now with new AMS, aphasia.
REASON FOR THIS EXAMINATION:
? evidence for embolic stroke.
CONTRAINDICATIONS for IV CONTRAST: None.
MRI OF THE BRAIN WITHOUT GADOLINIUM. MRA OF THE BRAIN USING 3D
TIME-OF-FLIGHT TECHNIQUE.
HISTORY: History of embolic stroke on Coumadin, left cerebellar
hemorrhage status post evacuation and change in mental status.
Comparison is made with CT from the same day.
There are encephalomalacic and gliotic changes in the left
cerebellum with blood products relating to a hematoma
evacuation. There is no significant mass effect on the fourth
ventricle. Old infarction in the left frontal lobe is again
noted. There is a focus of restricted diffusion in the right
thalamus, which is probably related to old hemorrhage in this
site. There is an apparent focus of restricted diffusion in the
right frontal lobe, which is quite small. This could represent a
focus of subacute ischemia. There is no significant associated
mass effect. There is no midline shift. There is evidence for
prior hemorrhage or blood products in the right putamen, caudate
and to a lesser extent, the left basal ganglia.
Intracranial flow voids are maintained.
Ventricles and sulci are unchanged in size and configuration.
There is bilateral mastoid opacification.
MRA of the circle of [**Location (un) 431**] demonstrates there is irregularity
of the right distal MCA extending to M2 branches. There is also
narrowing in the left interior M2 branch. These are likely
related to atherosclerotic disease. Bilateral distal PCA
irregularity and narrowing is also noted.
IMPRESSION:
Moderate small vessel ischemic sequela.
Small focus of restricted diffusion in the right frontal white
matter, which could represent a subacute infarction. There is no
associated mass effect or midline shift.
Atherosclerotic narrowing in the circle of [**Location (un) 431**], which does
not appear to be hemodynamically significant.
RADIOLOGY Preliminary Report
VIDEO OROPHARYNGEAL SWALLOW [**2183-6-26**] 1:54 PM
VIDEO OROPHARYNGEAL SWALLOW
Reason: ? aspiration, ? can advance diet.
[**Hospital 93**] MEDICAL CONDITION:
84 year old woman with ICH, AVNRT, AMS with histor of dysphagia,
silent aspiration.
REASON FOR THIS EXAMINATION:
? aspiration, ? can advance diet.
VIDEO OROPHARYNGEAL SWALLOW
INDICATION: 84-year-old woman with intracranial hemorrhage,
presenting with aspiration.
COMPARISON: [**2183-6-20**].
FINDINGS: Oral and pharyngeal swallowing videofluoroscopy was
performed today in collaboration with speech and language
pathology. Various consistencies of barium were administered.
ORAL PHASE: There is moderate impairment of bolus formation and
prolongation of the mastication. The remainder of the oral phase
was within functional limits. There is mild coating of residue
after the _____ solids.
PHARYNGEAL PHASE: There is mild delay in swallow initiation and
mild reduction in laryngeal valve closure. The remainder of the
pharyngeal phase was within functional limits. Mild coating
remains in the valleculae after solid food and purees.
ASPIRATION/PENETRATION: There is intermittent penetration before
the swallow with thin liquids, no aspiration was seen today.
IMPRESSION: Mild-to-moderate oropharyngeal dysphagia but
improved from previous video swallow, resulting in intermittent
penetration with thin liquids, no aspiration was seen today.
EEG:
FINDINGS:
ABNORMALITY #1: Throughout the recording there were frequent
bursts of
mixed frequency generalized slowing.
ABNORMALITY #2: There were also bursts of mixed frequency
slowing seen
bilaterally and independently in temporal areas or a bit more
broadly,
with a mild rightsided emphasis.
BACKGROUND: Was somewhat disorganized but reached an 8 Hz alpha
frequency at times.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Produced symmetric driving.
SLEEP: The patient progressed from wakefulness to drowsiness but
did
not appear to enter stage II of sleep during this recording.
CARDIAC MONITOR: Showed a generally regular rhythm with frequent
PVCs.
IMPRESSION: Abnormal EEG due to the multifocal slowing described
above.
This suggests multifocal subcortical dysfunction. Vascular
disease is
the most common cause at this age. Nevertheless, there were no
areas of
very prominent and fixed focal slowing. There were no
epileptiform
features.
[**6-10**] TTE:
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
The estimated cardiac index is high (>4.0L/min/m2). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. The aortic root is mildly dilated at the
sinus level. The ascending aorta is markedly dilated The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild to moderate ([**1-15**]+)
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 an anterior space which most likely
represents a fat pad.
IMPRESSION: Moderate symmetric left ventricular hypertrophy with
normal systolic function. Mild aortic regurgitation, mild to
moderate mitral regurgitation. Moderate pulmonary hypertension.
Markedly dilated ascending aorta.
Brief Hospital Course:
84F with h/o stroke and temporal arteritis admitted with
cerebellar hemorrhage, s/p evacuation, transferred to MICU after
code blue in setting of AVNRT, required intubation for airway
protection, rapidly extubated. After transfer to general
medical floor she had a recurrent episode of AVNRT prompting
transfer to the cardiology service.
# S/p cerebellar hemorrhage: s/p evacuation on [**6-9**]. Has been
stable, on head CT [**6-25**], no evidence of recurrent bleed or
hydrocephalus. No contraindication to future anticoagulation
per neurosurgical team. Pt will need a repeat MRI in one month
and should follow up with neurosurgery after as an outpatient.
# SVT: likely common AVNRT. Breaks with adenosine. She had three
episodes on [**6-22**] which were responsive to adenosine. Amiodarone
was started, but discontinued after 3 days due to concerns for
mental status changes. Her nodal agents were also titrated up
for improved rate control. There have been no further episodes
of AVNRT this hospitalization. The patient should follow up
with her cardiologist as an outpatient.
# AMS. Geriatrics consulted [**6-24**] for altered MS. Concerned that
she seemed less responsive that she had been on medical floor.
Recommended d/c amiodarone, dilaudid, famotidine and trazodone,
check TSH, B12, folate, UA, CXR. CXR unremarkable, UA negative.
Nl B12/folate.
-Head CT negative for bleed or hydrocephalus. Per son pt had an
embolic stroke ~ 10 years ago and was on coumadin for a possible
"hole in her heart." No PFO seen on in house TTE although no
bubble study was performed. Per neurosurgery coumadin not
contraindicated if deemed necessary. Pt should follow up with
her outpatient cardiologist to discuss whether coumadin is
indicated.
-Neurology consult appreciated. Acute infarct unlikely giving
lack of focality of symptoms and waxing/[**Doctor Last Name 688**] of MS, MRI shows
no evidence of acute infarct. No seizure seen on EEG, findings
more consistent with multifocal cortical dysfunction likely
attributable to vascular disease. Pt to follow up with Dr.
[**Last Name (STitle) **].
-off amiodarone, dilaudid, trazodone, famotidine.
- TSH slightly elevated, FT4 WNL, c/w subclinical
hypothyroidism, to follow up as outpatient and consider possible
initiation of replacement therapy
-no evidence of ongoing infection on CXR or repeat UA.
# HTN: Blood pressure well controlled on new regimen of
lisinopril at 40 mg qday, toprol, verapamil SR
# UTI: Completed 7 day course of cefpodixime for cipro resistant
catheter associated e.coli UTI.
# Respiratory failure: resolved, now extubated. Originally
intubated for treatement of SVT and airway protection. . Chest
CT was negative for PE. Concerning for COPD/reactive airway
disease. Sputum gram stain c/w oropharyngeal flora
- Pt on high dose steroids for presumed COPD exacerbation, has
completed taper and is back to home dose of 5mg maintenance.
- Nebs prn
- has completed 5 days of azithromycin for possible COPD
exacerbation.
# FEN/Lytes: cleared on video swallow for purees softs. NGT
removed [**6-23**]. Was refusing diet and crushed meds as she did not
like taste/texture. Doboff placed for meds/TF. Had repeat video
swallow on [**6-26**], diet advanced to thin liquids/ground solids.
Pt taking more [**Last Name (LF) **], [**First Name3 (LF) **] leave doboff in place for supplemental
feeds, would remove after calorie counts if taking adequate PO,
otherwise may need G-tube.
# Communication: HCP [**Name (NI) 14492**] [**Telephone/Fax (3) 78428**], daughter.
# Prophylaxis: Heparin SC 5000 TID
# Code status: FULL CODE
The patient will be discharged to rehab with outpatient follow
up with neurology, cardiology, neurosurgery and her primary care
physician.
Medications on Admission:
1. Prednisone 5mg daily
2. Warfarin 2.5mg daily
3. Lunesta 2mg QHS
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
10. Verapamil 240 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO Q24H (every 24 hours).
11. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
- Cerebellar intracerebral hemorrhage
- Atrioventricular nodal reentrant tachycardia (AVNRT)
- E. coli UTI
- Dysphagia
- Delirium
Secondary:
- Left frontal CVA [**2163**] (? Paradoxical embolism)
- Temporal arteritis
- Chronic obstructive pulmonary disease
- Hypertension
- Right total hip replacement
- Osteoporosis
Procedures:
- Endotracheal intubation
- Insertion of right frontal ventricular catheter, left
suboccipital craniectomy and evacuation of a cerebellar
intracerebral hemorrhage.
Discharge Condition:
Hemodynamically stable bradycardia, oxygenating well. Pain
free. Oriented to 'hospital', name and date.
Discharge Instructions:
General Neurosurgical Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Patient discharge instructionsL\:
You were admitted with an intracranial hemorrage and underwent
an evacuation operation to treat this. Please see above
instructions and follow up for MRI and neurosurgical follow up 1
month after discharge
Your hospital course was complicated by a rapid heart rate
treated with two medications, Toprol and Verapamil. Please
follow up with your cardiologist after discharge.
Please take all medications as prescribed, please attend all
scheduled follow up appointments.
Some of your medications have been changed:
Your warfarin has been stopped, please discuss whether to
restart this with your cardiologist
You have been started on the following medications
-Toprol XL 200mg daily
-Aspirin 81mg daily
-Verapamil 240mg daily
-Lisinopril 40mg daily
-Vitamin D
-Multivitamin
Please call your doctor or return to the emergency room if you
develop any change in your sensation, strength, speech or
vision, or if you have palpitations, shortness of breath,
lightheadedness, loss of consiousness or fever or for any other
concerning symptom.
Followup Instructions:
Please contact your primary care provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) 11907**] for a
follow up appointment [**Telephone/Fax (1) 56152**].
Please contact Dr. [**Last Name (STitle) **] for a follow up cardiology
appointment ([**Telephone/Fax (1) 5862**]
Neurosurgery Follow-Up Appointment 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 in one
month, please call radiology to schedule: ([**Telephone/Fax (1) 6713**].
|
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"293.0",
"041.4",
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"599.0",
"331.4",
"V43.64",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.77",
"96.6",
"96.04",
"02.2",
"96.71",
"96.72",
"01.39"
] |
icd9pcs
|
[
[
[]
]
] |
12753, 12832
|
7738, 11487
|
292, 374
|
13384, 13492
|
1509, 1949
|
16093, 16699
|
853, 871
|
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|
4234, 4318
|
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|
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220, 254
|
4347, 7715
|
402, 676
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1338, 1490
|
900, 1138
|
1153, 1322
|
698, 803
|
819, 837
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,852
| 120,524
|
29554+57644
|
Discharge summary
|
report+addendum
|
Admission Date: [**2149-12-26**] Discharge Date: [**2150-1-1**]
Date of Birth: [**2069-8-20**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Tape
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
transferred from outside hospital for evaluation of possible
aortic dissection
Major Surgical or Invasive Procedure:
R subclavian venous catheter placement complicated by apical
pneumothorax
R chest tube placement
L femoral hemodialysis catheter placement
continuous [**Last Name (un) **]-venous hemodialysis
History of Present Illness:
Mr. [**Known lastname 70876**] is an 80 yo male with h/o DM type II, CRI, Aortic
stenosis (valve area 0.75 cm2), carotid stenosis and h/o CVA who
was transferred from OSH [**2149-12-26**] for evaluation of back and arm
pain concerning for possible aortic dissection.
.
Per pt's daughter the pt started complaining of backpain and had
elevated blood pressures three nights ago. The next morning he
had severe left arm pain, which radiated around to the right
side. He took some advil and was taken to [**Hospital3 **] on
[**12-25**]. Daughter notes there he had transient right arm and leg
weakness. Per OSH notes he was c/o an upper abdominal tearing or
pulling sensation. In the ER BP was 208/58 and he was treated
with labtetolol and nitroprusside. He had a non-contrast CT of
the chest which showed heterogenous attenuation of the
descending aorta and it was difficult to exclude dissection.
Head CT was negative for acute event. There was also some
concern that the patient had weakness in his arms and legs and
that potentially there was a spinal cord infarction from a
dissection at the T8 level. He was sent to [**Hospital1 **] for further
evaluation of dissection.
.
Pt arrived to [**Hospital1 **] and was responsive upon arrival. He was started
on a labetolol gtt. Overnight UOP decreased and he received 2
units of PRBC for hct of 26.2 (down from 33). He was started on
levophed, but in the AM noted to be less responsive. The
vascular surgery team asked for MICU evaluation.
.
Upon MICU evaluation the patient was not responding to questions
and was requiring increasing doses of levophed. His O2 sats
started dropping to the low 90s on nasal cannula O2 and he was
placed on a NRB. He became acutely bradycardic to the 30s and
hypotensive to systolics in the 60s. He was given one amp of
atropine and his HR and blood pressure improved. He was also
given 0.4 mg of naloxone. His breathing appeared slow and
labored so he was intubated at that time.
Past Medical History:
Aortic Stenosis (valve area 0.75 cm2 in [**2146**])
Type 2 Diabetes
Right carotid stenosis
CRI
CVA
hypothyroidism
h/o TB
Laryngeal cancer s/p chemo in [**2133**]
Social History:
Lives alone
Quit drinking and smoking in the early 90s
No drugs
Family History:
Significant for diabetes
Physical Exam:
On arrival to MICU:
VS: T 95.1 BP 102/31 HR 52
AC: 600 x15 FiO2 40% PEEP 5
Gen: elderly gentleman, eyes opening, not responding to voice,
rhythmically moving tongue
HEENT: Pinpoint pupils, minimally reactive to light, dry MM
intubated
Neck: supple
Pulm: rhonchi and wheezes bilaterally
Cardio: RRR, 3/6 systolic murmur loudest LLSB
Abd: soft, NT, ND, hypoactive BS
Ext: no peripheral edema, palpable pulses
Neuro: Pt's eyes open, looks around room, does not respond to
voice or commands
Upper extremities flacid
Moving toes in left foot
Upgoing Babinski's bilaterally
Pertinent Results:
[**2149-12-26**] 04:04PM WBC-12.0* RBC-5.35 HGB-10.7* HCT-33.0*
MCV-62* MCH-20.0* MCHC-32.4 RDW-17.5*
[**2149-12-26**] 04:04PM PLT COUNT-264
[**2149-12-26**] 04:04PM PT-12.5 PTT-36.0* INR(PT)-1.1
[**2149-12-26**] 04:04PM TSH-1.4
[**2149-12-26**] 04:04PM ALBUMIN-3.9 CALCIUM-9.2 PHOSPHATE-3.8
MAGNESIUM-2.2
[**2149-12-26**] 04:04PM CK-MB-6 cTropnT-0.03*
[**2149-12-26**] 04:04PM LIPASE-41
[**2149-12-26**] 04:04PM ALT(SGPT)-10 AST(SGOT)-13 LD(LDH)-159
CK(CPK)-225* ALK PHOS-89 AMYLASE-62 TOT BILI-0.4
[**2149-12-26**] 04:04PM GLUCOSE-330* UREA N-53* CREAT-3.7* SODIUM-137
POTASSIUM-5.2* CHLORIDE-105 TOTAL CO2-19* ANION GAP-18
[**2149-12-26**] 06:01PM URINE WBCCLUMP-MANY
[**2149-12-26**] 06:01PM URINE RBC-686* WBC-929* BACTERIA-NONE
YEAST-NONE EPI-0
[**2149-12-26**] 06:01PM URINE BLOOD-LGE NITRITE-POS PROTEIN-100
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-MOD
[**2149-12-26**] 06:01PM URINE COLOR-[**Location (un) **] APPEAR-Cloudy SP [**Last Name (un) 155**]-1.010
[**2149-12-26**] 11:49PM CK-MB-5 cTropnT-0.03*
[**2149-12-26**] 11:49PM CK(CPK)-181*
[**2149-12-26**] 11:49PM GLUCOSE-230* UREA N-59* CREAT-4.5* SODIUM-139
POTASSIUM-4.8 CHLORIDE-109* TOTAL CO2-16* ANION GAP-19
[**2149-12-26**] 11:59PM freeCa-1.27
[**2149-12-26**] 11:59PM GLUCOSE-215* LACTATE-2.9* K+-4.8
[**2149-12-26**] 11:59PM TYPE-ART PO2-91 PCO2-37 PH-7.31* TOTAL
CO2-20* BASE XS--6
.
Diagnostics:
OSH:
Cartotid duplex
right carotid: 90% stenosis of proximal common carotid, internal
carotid artery 75% stenosis
left carotid: 60-69% stenosis in the internal carotid artery
.
ECHO [**12-25**]: EF 50%, moderate LVH, severec calcification of aortic
valve with mean gradient 35 mm hg
mitral annular calcification, MR, TR
.
CT head: large chronic cystic lesions in posterior fossa,
bifrontal atrophy, multiple lacunar infarcts with apparent
lesions in the external capsule bilaterally as well as the right
internal capsule
.
[**Hospital1 **] diagnostics:
CXR [**12-27**]: Right subclavian vascular catheter terminates in the
lower superior vena cava. Cardiac silhouette is upper limits of
normal in size. The aorta is tortuous and calcified. Patchy
right basilar atelectasis is present, and there is a
questionable small right pleural effusion.
.
MRI/MRA of chest and abdomen: no aortic dissection, intramural
thrombus, or penetrating ulcer. Large atherosclerotic plaque in
the descending aorta with associated intraluminal thrombus.
.
MRI/MRA Head, Neck C-Spine:
-multiple areas in cerebellar hemispheres, cortex, basal
ganglia, brainstem, C-spine concerning for embolic infarcts
-abnl vertebral signal bilaterally concerning for occlusion vs
dissection
-Diffusely abnormal T2 hyperintense signal involving the
medulla, cervical medullary junction and almost entire aspect of
the cervical cord, involving the lateral and posterior columns,
most likely consistent with a cord edema and possible cord
infarction.
Brief Hospital Course:
A/P: 80 yo male with h/o DM type II, CRI, Aortic stenosis (valve
area 0.75 cm2), carotid stenosis and h/o CVA who was transferred
yesterday for possible aortic dissection now with decreased
responsiveness, oliguria, hypotension and likely sepsis.
.
*Shock: Patient with hypothermia, hypotension, oliguria and
known source of infection in the urine, so likely had urosepsis.
Other sources for sepsis could be line infection, PNA or
endocarditis. Hypotension most likely [**1-23**] to sepsis but could
represent cardiogenic shock possible [**1-23**] to AMI. AS likely
further contributing to patient's inability to maintain
appropriate cardiac output. He was initially maintained on
Levophed, now off since 0200 on [**12-29**]. A cosyntropin stim test
showed minimal response, 30.5-> 29.7-> 32.9, so hydrocortisone
50 mg q6 started [**2149-12-28**]. Urine with CNS > 100,000 colonies of
SA, sensitive to oxacillin, but continuing Vanc/Zosyn until
other cultures have incubated at least 72 hrs before narrowing
coverage. Echo done to rule out dissection shows no evidence of
aortic valve vegetation; would consider TEE if bacteremic given
severe AS. Required volume and intermittent norepinephrine to
maintain MAP >65.
.
*Mental Status changes/weakness: Patient's MS appears to have
acutely declined overnight after hospital admission. Patient was
conversing with family members day of admissioon and was no
longer responding to voice on MICU transfer. Also had bilateral
upper and lower extremity weakness. There was some concern for
spinal artery infarction at the OSH. MS changes could be [**1-23**] to
encephalopathy from sepsis, renal failure. Could also be [**1-23**] to
acute stroke, cord infarct, or cord compression. No evidence of
seizure activity. Neuro was consulted and MRI/MRA head, Cspine,
Tspine showed stroke, likely embolic, in cerebellum, cortex,
brainstem, Cspine, Tspine.
.
*Hypoxia: Patient's O2 sats had been stable on NC O2. This AM
sats dropped to the low 90s on 6L NC and patient was initially
transitioned to NRB. Lungs sounded rhonchorous bilaterally and
it was thought this was [**1-23**] to volume overload or infectious
process. Patient then became bradycardic and respirations
appeared labored, so he was intubated. Source likely pulmonary
edema in the setting of renal failure and AS. Right-side
pneumothorax detected on CXR; thoracic surgery placed chest tube
to suction. CXR with small R PTX, likely aspiration infiltrate
in LLL. Although he woke up enough to open eyes and move his
tongue, he did not breath over the vent when sedation was
lightened.
.
*Renal Failure: Patient's UOP dropped acutely following
presentation in the setting of hypotension. Pt has chronic renal
insufficiency, but urine lytes c/w pre-renal etiology of ARF. Cr
elevated to 5 and UOP continued to be low. CVVH dialysis
catheter placed in right femoral vein by Transplant Surgery and
CVVHD initiated on [**6-27**]. Renally dose meds. Started aluminum
hydroxide 30 ml TID for hyerphosphatemia. Received CVVH x24 hrs;
after discontinuing, his creatinine immediately trended up; in
the abscence of emergent indication for hemodialysis, repeat
hemodialysis was postponed until a family meeting.
.
*Bradycardia: Patient became acutely bradycardic to the 30's
following transfer and had worsening hypotension. Bradycardia
resolved with atropine. Etiology unclear. Electrolytes were
stable at the time. Could be [**1-23**] to CNS dysfunction, AMI or
medications, as pt had recently been on labetalol gtt.
.
*? aortic Dissection: patient was transferred here for possible
aortic dissection. Per report, the MRI/MRA of the abd was
reviewed by both cardiac surgery and vascular and it appears
there is no dissection, and possibly an old intramural thrombus.
A decision was made not to pursue surgery.
.
*Aortic stenosis: Patient has known critical aortic stenosis.
-hold ACEI in setting of hypotension and renal dysfunction
-High suspicion for endocarditis if bacteremic; would consider
TEE of positive blood cultures
.
* Anemia: Patient has known microcytosis at baseline. Hct at OSH
was 37 and 33 upon arrival here. Hct dropped to 26 yesterday,
without a clear etiology. Bumped to 31 s/p 2 units PRBCs. NOw
33.1.
.
*DM: Maintained on insulin gtt.
.
*Hypothyroidism: cont levothyroxine; adjusted dose for IV
administration.
.
*PPX: heparin, bowel regimen, ppi
.
*FEN: NPO [**1-23**] to aspiration. OG tube placed for TF per nutrition
recs.
.
*Access: R subclavian, right femoral dialysis catheter
.
*Communcation: Daughter, grandson. Family meeting scheduled for
[**12-31**].
Medications on Admission:
Medications at home:
Lisinopril 5 mg qd
Toprol XL 50 mg qd
Tramadol 50 mg po QID
Aggrenox [**Hospital1 **]
Levothyroxine 50 mcg qd
ASA 81 mg qd
Lipitor 40 mg qd
Humalog 2 untis prn
lantus 24 units q AM
colace 200 mg qd
Lasix 20 mg qd
calcitriol 0.25 mcg qd
phoslo 667 [**Hospital1 **]
.
Medications on Transfer:
Morphine prn
ASA 325 mg qd
Calcitriol 0.25 mg qd
Atorvastatin 40 mg qd
Calcium acetate 667 mg PO BID
Insulin gtt
Levophed gtt
Protonix 40 mg IV qd
Discharge Medications:
None.
Discharge Disposition:
Expired
Discharge Diagnosis:
1. multiple cerebrovascular accidents involving the upper
cervical cord, the brainstem, both cerebellar hemispheres, left
frontal
subcortical white matter and basal ganglia including the
cerebral
periventricular white matter
2. Septic shock secondary to urinary tract infection
3. Acute renal failure
Discharge Condition:
Deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
Name: [**Known lastname 11953**],[**Known firstname **] Unit No: [**Numeric Identifier 11954**]
Admission Date: [**2149-12-26**] Discharge Date: [**2150-1-1**]
Date of Birth: [**2069-8-20**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Tape
Attending:[**First Name3 (LF) 1015**]
Addendum:
At a family meeting on [**2149-12-31**], the family, after consultation
with the neurology and nephrology teams as well as the MICU
team, decided that the appropriate goal of care for Mr [**Known lastname **]
was comfort, given the poor prognosis of his neurologic injuries
as well as his sepsis complicated by renal failure. The family
requested that he remain intubated with medical supportive
measures until his extended family could travel to the bedside
from [**Country 11955**]. However, on the morning of [**2150-1-1**] his blood
pressure began to drop precipitiously and his immediate family
was called to the bedside. He expired on the afternoon of
[**2150-1-1**] with family members present.
Discharge Disposition:
Expired
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1016**] MD [**MD Number(2) 1017**]
Completed by:[**2150-1-1**]
|
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"434.91",
"285.9",
"443.24",
"785.52",
"512.1",
"585.9",
"336.1",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"99.04",
"38.93",
"96.6",
"38.95",
"39.95",
"96.72",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
13055, 13220
|
6427, 11005
|
367, 560
|
11898, 11908
|
3464, 5214
|
11960, 13032
|
2834, 2860
|
11515, 11522
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11575, 11877
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|
249, 329
|
588, 2550
|
5223, 6404
|
11343, 11492
|
2572, 2736
|
2752, 2818
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,618
| 101,145
|
40193
|
Discharge summary
|
report
|
Admission Date: [**2102-1-20**] Discharge Date: [**2102-1-25**]
Date of Birth: [**2027-9-3**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 2080**]
Chief Complaint:
weakness, shortness of breath
Major Surgical or Invasive Procedure:
None
(Note: patient had right sided chest tube removed that had been
placed at outside hospital)
History of Present Illness:
In summary, Mr. [**Known lastname **] is a 74 year old male with past medical
history significant for COPD on home O2, HTN, paroxysmal atrial
fibrillation, (not on coumadin; compliance issues), diastolic
CHF, and OA who presented initially to OSH at [**Hospital1 18**] [**Location (un) 620**] on
[**1-14**] with worse shortness of breath from baseline, poor PO
intake. Notable leukocytosis to 22k range and concern for
underlying PNA. Additional imaging with chest CT revealed
loculated right pleural effusion with pleural thickening
suggestive of an empyema as well as smaller left sided effusion.
Zosyn was initiated on [**1-20**] and chest tube was placed at OSH
with failure to obtain any pleural fluid. Outside hospital labs
were significant for leukocytosis 22.2 ([**1-19**]: 10.7); HCT 43;
Na: 135; Co2: 32.7; Creatinine 1.7 (prior 0.9); U tox negative.
.
He was transferred to [**Hospital1 18**] [**Location (un) 86**] SICU for additional thoracics
evaluation for potential VATS/pigtail placement vs.
decortication but thoracics team did not feel imaging or
clinical picture suggestive of true empyema and feels this is a
chronic effusion that does not need to be drained. SICU vitals
on arrival to [**Hospital1 18**] [**Location (un) 86**] on [**1-20**] were: HR 93, BP 107/55, RR
24 and O2 sat 97% 3L. Thoracic service had chest tube removed
[**1-21**], this morning. Per SICU team, patient's leukocytosis felt
to be secondary to possible PNA vs. UTI given that recent urine
studies growing coag negative staph. Patient was started on
Vanco/Zosyn at [**Location (un) 620**] which was continued here over past day.
.
In addition, at OSH patient went into afib with RVR to 120s and
was managed on a combination of digoxin and diltiazem gtt prior
to transitioning back to oral beta blocker therapy with fair
resolution and HR control (HRs 70-80s).
.
Also developed ARF over last week as his creatinine on admission
to [**Hospital1 **] [**Location (un) 620**] was 0.8 on [**1-14**] and now up to low 2 range. He had
exposure to contrast for CT imaging studies and he was also
given lasix for question of CHF exacerbation at OSH which may
have been contributing factors. Lasix held here since admission.
.
Lower extremity doppler done here after transfer for mild LE
edema and picked up a right LE DVT with thrombus within the
right superficial femoral vein and within the right popliteal
vein. At time of transfer now patient has yet to be started on
anticoagulation for DVT.
.
Lastly, patient also complained of some vague abdominal pains
and per reports he had question of obstruction at OSH so KUB
performed with with nonspecific bowel gas pattern. Here in SICU
patient has had healthy bowel sounds but mild LLQ tenderness. No
BM since transferred at 10pm last night, no nausea, no vomiting.
Of note, history of diverticulosis.
.
At time of transfer to general medicine service on [**1-21**] patient
appeared to be in no apparent distress but seems confused which
is near typical baseline per family. Vitals signs at time of
transfer: T98.3, BP 110/67, HR 89, RR 16 and 02 Saturation 97%
3L.
.
Review of systems:
Patient unable to cooperate so ROS limited. Denies fever,
chills, night sweats, recent weight loss or gain. Denies
headaches.
Past Medical History:
Past Medical/Surgical History:
-Asthma
-Hypertension
-COPD on home oxygen
-history of atrial fibrillation
-osteoarthritis
-seborrheic dermatitis
-diverticulosis
-RT inguinal hernia
-cataract surgery
Social History:
Social History: Patient states he was living with his son prior
to recent hospitalization. Smoking hx of 1PPD x 30 years (quit
age 50). Distant ETOH use and per prior OMR notes also history
of heroin abuse in the past but quit >20 years ago. Confused at
baseline per family.
.
Family History:
Non contributory
Physical Exam:
Physical Exam at transfer to medicine:
Vitals: T98.3, BP 110/67, HR 89, RR 16 and 02 Saturation 97% 3L.
General: Alert and oriented x2, mildly agitated, no acute
distress
HEENT: Sclera anicteric, MMM, PERRL, + Arcus senilis, oropharynx
clear
Neck: supple, JVP not elevated, no LAD
Lungs: Bilateral basilar crackles (Right >Left). No wheezes. No
dullness to percussion. Prior CT site appears c/d/i with no
bleeding, covered with dressing.
CV: irregular rhythm noted, normal S1 + S2, no murmurs, rubs,
gallops or clicks noted
Abdomen: soft and obese, ventral hernia (mild), mild TTP over
left abdomen but no rebound, non-distended, bowel sounds
present, no guarding, no organomegaly
Ext: Warm and increased erythema below mid calf bilaterally, 2+
pulses, [**1-29**]+ edema over RLE, no clubbing, cyanosis
Access: 22g PIV and groin/femoral CVL in place
Pertinent Results:
ADMISSION LABS:
[**2102-1-20**] 09:20PM GLUCOSE-151* UREA N-25* CREAT-2.1* SODIUM-134
POTASSIUM-3.9 CHLORIDE-89* TOTAL CO2-33* ANION GAP-16
[**2102-1-20**] 09:20PM ALT(SGPT)-15 AST(SGOT)-18 ALK PHOS-85 TOT
BILI-1.8*
[**2102-1-20**] 09:20PM CALCIUM-8.3* PHOSPHATE-3.4 MAGNESIUM-1.9
[**2102-1-20**] 09:20PM WBC-18.9* RBC-4.88 HGB-14.9 HCT-44.0 MCV-90
MCH-30.5 MCHC-33.8 RDW-15.0, PLT COUNT-336
[**2102-1-20**] 09:20PM PT-15.6* PTT-38.9* INR(PT)-1.4*
.
Interval significant labs:
[**2102-1-18**] TSH 2.2
[**2102-1-24**] INR 2.3
[**2102-1-24**] vanco trough 34.7
.
Discharge labs:
[**2102-1-25**] GLUCOSE-85 UREA N-7 CREAT-0.9 SODIUM-136 POTASSIUM-3.4
CHLORIDE-96 TOTAL CO2-33* ANION
[**2102-1-25**] CALCIUM-7.6 PHOSPHATE-2.4 MAGNESIUM-1.7
[**2102-1-25**] WBC-8.5 HCT-36.9 (stable x2 days) PLT COUNT-380
[**2102-1-25**] INR 5.1
[**2102-1-25**] Vanco trough 19.8
.
URINE STUDIES:
[**2102-1-20**] 09:20PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.033
[**2102-1-20**] 09:20PM URINE BLOOD-LG NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2102-1-20**] 09:20PM URINE RBC-0-2 WBC-0-2 BACTERIA-MOD YEAST-NONE
EPI-[**4-1**]
.
IMAGING:
.
[**1-22**] CXR:
The examination is compared to [**2102-1-21**]. In the
interval, the
patient has received a right-sided PICC line. The tip of the
line projects
over the lower SVC. There is no evidence of complications,
notably no
pneumothorax.
Otherwise, the radiograph is unchanged.
[**1-21**] CXR - FINDINGS: As compared to the previous radiograph,
the right-sided chest tube has been removed. Minimal right
pleural thickening, minimal left pleural effusion. No evidence
of pneumothorax.
.
[**1-20**] CXR - FINDINGS: Small lung volumes. Borderline size of the
cardiac silhouette, small left pleural effusion, small platelike
right atelectasis. On the right, the patient has a chest tube.
The sidehole of the tube is outside the pleural cavity and
projects over the soft tissues. There is no evidence of
pneumothorax.
.
[**1-20**] RLE Ultrasound:
Thrombus within the right superficial femoral vein, with total
occlusion seen in the mid portion and partial occlusion seen in
the proximal portion. The distal portion is patent. Patent right
common femoral vein, which contains a catheter. Small isolated
nonocclusive thrombus within the right popliteal vein.
Non-compressible thrombus demonstrated in at least one right
deep calf vein. No DVT detected within the left lower extremity.
The left peroneal veins were not assessed as the patient refused
further evaluation. 6. 3.0 x 2.1 x 2.7 cm right groin hematoma,
without internal flow.
.
OUTSIDE HOSPITAL IMAGES:
[**1-19**]: Chest CT: MDCT of the chest was done with intravenous
infusion of 100 cc Omnipaque 300. Sagittal and coronal
reformatted images were obtained. There is a moderate posterior
right pleural effusion. Suggestion of thickening and enhancement
of the surrounding pleural surfaces. There is minimal swelling
of the overlying soft tissue as well. There is a minimal
posterior left pleural effusion. There is anterior pericardial
thickening or a small loculated anterior pericardial effusion.
Streaky pulmonary parenchymal densities bilaterally, consistent
with subsegmental atelectasis and/or scarring. There is
scattered atherosclerotic calcification. The heart and
mediastinal structures are otherwise unremarkable. No
lymphadenopathy is identified. There is no significant chest
wall abnormality. IMPRESSION: POSTERIOR RIGHT PLEURAL EFFUSION.
EVIDENCE FOR SURROUNDING PLEURAL THICKENING AND ENHANCEMENT
SUGGESTS THE POSSIBILITY OF EMPYEMA; VERY SMALL POSTERIOR LEFT
PLEURAL EFFUSION. MINIMAL PERICARDIAL THICKENING OR LOCULATED
PERICARDIAL EFFUSION.
.
TTE OSH: Ejection fraction is 55%. He has mild aortic stenosis,
normal tricuspid valve, normal pulmonary valve, no pulmonary
hypertension. Overall findings of his echocardiogram similar to
one from
[**2099**].
.
[**1-15**] OSH: RLE ULtrasound: NONCOMPRESSIBILITY OF THE RIGHT
SUPERFICIAL FEMORAL TO POPLITEAL VEIN BUT WITH NORMAL COLOR FLOW
ON DOPPLER STUDIES. AUGMENTATION STUDIES OF THESE SEGMENTS WERE
NOT PERFORMED. FINDINGS ARE SUGGESTIVE OF CHRONIC DVT. NO DVT
WAS SEEN IN THE OTHER LEG, THE LEFT LOWER EXTREMITY
.
CARDIAC:
EKG on [**1-18**]: afib with RVR in low 100s range
.
MICROBIOLOGY:
[**1-20**] Blood cx - pending
[**1-20**] Urine cx - no growth
.
OSH Urine studies [**1-16**]--> Urine tox was positive for opiates,
positive for trace blood, trace ketones, no white blood count.
Micro urine: Coag-negative staph, 25-50, organisms per mL.
Blood
culture is negative.
Brief Hospital Course:
In summary, Mr. [**Known lastname **] is a 74 year old male with longstanding
COPD on home O2, dCHF, atrial fibrillation, admission for
PNA/dyspnea now s/p chest tube placement (then removal) for
questionable empyema who continues to recuperate on IV
antibiotics without any additional thoracic procedures. Please
see below for more detailed hospitalization summary:
.
#Shortness of breath /effusions, healthcare associated PNA: Mr.
[**Known lastname **] has longstanding COPD at baseline and requires home O2
2.5L nasal cannula. He arrived to OSH with notable dyspnea worse
from typical baseline. This was initially attributed to possible
diastolic CHF exacerbation in setting of poorly controlled
atrial fibrillation. He was given generous amounts of IV lasix
at [**Hospital1 18**] [**Location (un) 620**] but continued to have some worse shortness of
breath. CXR showed bilateral effusions. However, review of older
images shows these are chronic, fairly stable effusions and seem
a less likely cause for acute worsened dyspnea. Given elevated
WBC to peak 22k, recent malaise, poor PO intake and shortness of
breath there was clinical suspicion for underlying PNA with
worse local inflammatory/irritation and COPD flare up as patient
with very poor pulmonary reserve. The differential also includes
possible underlying malignancy given his declining state x
months, prominent smoking history and and note of pleural
thickening on recent CT chest. In terms of CHF, recent BNP in
1000s range, h/o mainly diastolic CHF with EF 55% on TTE just
days ago. After concern for possible underlying complicated
loculated effusion with CT chest questioning empyema, patient
underwent right sided chest tube placement at outside hospital
but no pleural fluid able to be collected. He was then
transferred to [**Hospital1 18**] [**Location (un) 86**] Surgical ICU service with urgent
thoracic surgery consult. Thoracic surgery team felt patient had
very minimal effusions on imaging and did not feel CT chest
imaging constituted a true empyema picture. Thus, thoracic
surgery felt a repeat attempt at thoracentesis or any other
invasive procedures like IR guided pigtail drain placement or
VATS/decortication would only be of minimal or no benefit given
very small amount of pleural fluid which was felt to be chronic
as patient has had similar fluid at lung bases in previous
imaging. Chest tube was removed in SICU and patient transferred
to medical service where he was continued on plan for 8 days
continued broad coverage for hospital acquired PNA with IV
Vancomycin and Zosyn. Blood cultures with no growth. Also
continued patient on PRN nebulizers, Advair inhaler, Spiriva,
chest physical therapy routine and he was eventually weaned down
to usual home 2L O2 nasal cannula. At time of discharge he had
no fevers, WBCs in normal range, and no complaints of cough or
shortness of breath.
.
#Leukocytosis: Trend with initial rise from [**1-14**] admission and
then resolved after 2-3 days of being on IV Vancomycin/Zosyn
therapy. WBC trend 10-> 22-> 19-->10--> 8 prior to discharge.
Remained afebrile after his transfer to medicine service on
[**1-21**]. Most probable source was underlying PNA. Although there
was some initial concern for UTI as his urine grew out coag
negative staphylococcus (25-50 only) at OSH. However, a repeat
urinalysis and urine culture collected [**1-20**] showed no
significant evidence for any UTI. Moreover, patient had no
complaints of dysuria, urgency, or frequency. He had some mild
tenderness over his abdominal midline and left side but he
stated this was chronic and due to history of ventral hernia. He
had no concerning abdominal cramps, nausea or emesis prior to
discharge. He did have a few loose stools which were felt to be
a side effect of his antibiotics.
As above, plan is to continue broad IV Abx with Zosyn/Vancomycin
for HAP up until [**1-27**] for full 8 day course.
.
#Right LE DVT: Mild edema was noted on the right lower
extremity. Imaging with ultrasound demonstrated a mixed picture
of possible mixture of both some newer/older thrombi. Patient
very immobile at baseline which increases his risk. He was
started on weight based IV heparin gtt with close PTT monitoring
and started on daily oral Coumadin with plan for at least 3
months of therapy. His heparin was stopped on [**1-24**] when his
INR rose to 2.3 (on 4mg of coumadin) on the evening of [**1-24**] he
got 2mg of coumadin. His INR the morning of discharge was 5.1
(goal INR [**3-2**]) and his coumadin is being held. His INR should be
followed daily and coumadin restarted at 1 mg once his INR is
<3. He will need 3 months of coumadin treatment for his DVT. He
should discuss with his PCP whether he needs to stay on coumadin
longer for his A fib. He has no significant GI bleeding in past
but he is a slight fall risk at this time which makes longer
term anticoagulation decision making more challenging as
risks/benefits need to be discussed further.
.
#Atrial fibrillation: Currently rate controlled with HRs 80s-low
100s range. At home had been on PO diltiazem regimen and needed
placement on dilt drip, digoxin, and additional metoprolol while
at [**Hospital1 18**] [**Location (un) 620**]. He was transitioned to once daily Toprol XL
150 mg the morning of discharge. ******He did have one episode
of emesis and a single dose of metoprolol tartrate 25mg was
given as it is unclear whether he vomited his AM [**Name (NI) 8864**]
dose.********* His metoprolol dose will likely need to be
further uptitrated for tighter HR control. He had a CHADS score
of 3 and a concomitant diagnosis of RLE DVT and is on coumadin
(currently with supratherapeutic INR as above). His worsing a
fib could have been due to hypovolemia volume shifts vs.
infection as outlined above. He was ruled out for acute cardiac
syndromes with biomarkers at OSH. Digoxin was stopped early on
in his admission and no additional diltiazem was used as he did
very well on metoprolol po TID which was transitioned to toprol
XL as above
.
#ARF: Baseline is near 0.9-1.0 range and peaked up to Cr 2.1
range on [**1-20**]. His creatinine was 0.9 on the day pf discharge.
Causes include recent contrast exposure with CT studies,
pre-renal causes in setting of OSH lasix dosing. FeUrea <35% and
urine electrolyte profile favored pre-renal causes. Renal
dysfunction from antibiotics/AIN was also considered but he only
had a very scant amount of eosinophils in urine making this less
probable. Vancomycin was renally dosed and troughs monitored.
His vanco trough was 34.7 on [**1-24**] and 19.8 on [**1-25**]. His
vancomycin dosing was decreased to 1 gram q24 hrs and a dose was
given the morning of [**1-25**]. Gentle IVFs given to patient and his
Lasix was held for several days and his creatinine improved back
to his baseline.
.
#Hypertension, benign: Well controlled and normotensive during
hospital course. Continued on beta blocker as above with no need
to add other agents. His home diltiazem was discontinued.
.
#COPD, chronic: At baseline on home oxygen at 2.5L by time of
discharge. Currently has O2 saturations in the mid 90s range and
has no complaints of worse wheeze or shortness of breath. His
cough has now resolved. As above, continued home Advair and
tiatropium inhaler medications, gave nebulizers PRN, chest
physical therapy and treated PNA with broad antibiotics.
.
#Chronic diastolic CHF: History of noted diastolic CHF. Recent
notes [**First Name8 (NamePattern2) **] [**Location (un) 620**] with last TTE EF%55, mild aortic stenosis,
normal tricuspid valve, normal pulmonary valve, no pulmonary
hypertension. TTE findings similar to that from [**2099**]. Initially
appears intravascularly hypovolemic to euvolemic on exam with no
JVP despite mild overloaded picture on CXR. Very minimal LE
edema (R>L ; DVT RLE). Continued patient on strict I/O checks,
Na restriction diet. Held lasix briefly while ARF resolved and
restarted home Lasix 20mg daily (restarted on [**1-24**]).
.
# Code Status: full code; confirmed with patient
.
#. HCP is daughter [**Name (NI) 16883**] [**Name (NI) **] cell: [**Telephone/Fax (1) 88245**], home
[**Telephone/Fax (1) 88246**]
Medications on Admission:
.
Medications at Home :
-Albuterol INH prn
-Advair 200/50 [**Hospital1 **]
-Diltiazem 120 [**Hospital1 **]
-Spiriva 18mcg daily INH
-Lasix 20 mg daily
.
Medications at Transfer from SICU:
-Potassium Chloride IV Sliding Scale
-Piperacillin-Tazobactam 2.25 g IV Q6H
-Digoxin 0.125 mg PO/NG EVERY OTHER DAY
-OxycoDONE (Immediate Release) 5 mg PO/NG Q6H:PRN pain
-Magnesium Sulfate IV Sliding Scale
-Vancomycin 1000 mg IV Q 12H
-Metoprolol Tartrate 50 mg PO/NG TID
-Metoprolol Tartrate 2.5 mg IV Q6H:PRN tachycardia
-Tiotropium Bromide 1 CAP IH DAILY
-Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
-Heparin 5000 UNIT SC TID
-Aspirin 325 mg PO/NG DAILY
-Ondansetron 4 mg IV Q8H:PRN nausea
-Bisacodyl 10 mg PO DAILY
-Mirtazapine 15 mg PO/NG HS
.
Allergies: NKDA
.
Discharge Medications:
1. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO every eight (8)
hours as needed for pain, arthralgias for 1 weeks: hold for
sedation or RR<12 and re-eval if still needs in 2 wks. Tablet(s)
3. piperacillin-tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous Q6H (every 6 hours) for 2 days: TO END ON
[**2102-1-27**].
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**1-29**] Inhalation AS NEEDED as needed for shortness of breath or
wheezing.
7. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
8. Vancomycin
Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 24 hrs. Got dose morning of [**1-25**] (prior has
supratherapuetic level). Next dose due 10 am on [**1-26**]. Last
dose due [**1-27**].
9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO once a day.
11. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
13. 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.
14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
16. INR, potaasium, calcium, mag, phos check daily.
INR 5.1 on [**2102-1-25**]. Goal [**3-2**] until on stable regimen after
antibiotics are completed.
17. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day for 3
months: PLEASE START ONCE INR <3, WAS 5.1 at DISCHARGE and then
monitor daily given pt on antibiotics. goal INR [**3-2**]. Re-evaluate
if pt should continue after 3 months for his A fib. Currently on
for both DVT and A fib.
18. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
-Pneumonia
-Atrial fibrillation
-Right lower extremity Deep Vein Thrombosis
-Acute Renal Failure
Discharge Condition:
Mental Status: Oriented to self, knew he was at hospital but not
which one, knew date and month but not year. Does not appear
confused.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
HCP is daughter [**Name (NI) 16883**] [**Name (NI) **] cell: [**Telephone/Fax (1) 88245**], home:
[**Telephone/Fax (1) 88246**]
Discharge Instructions:
It was a pleasure taking care of you here at [**Hospital1 771**]. You were admitted to outside hospital
with shortness of breath, poor appetite, and fatigue. You were
then transferred from [**Hospital1 18**] [**Location (un) 620**] after imaging of your chest
with plain x-rays and chest CT revealed concern for possible
complicated pneumonia and worse pleural effusions or fluid on
the lungs. You had a chest tube at outside hospital to attempt
to drain this fluid but because it was a very small amount it
was unable to be successfully drained.
.
You were sent to [**Hospital1 18**] [**Location (un) 86**] for additional management of a
suspected complicated pneumonia and for further evaluation with
the thoracic surgical team. The thoracic surgery specialists did
not feel you needed any further procedures or surgeries. Your
pneumonia was managed with IV antibiotics, increased
supplemental oxygen and nebulizer treatments to help with
shortness of breath. You had no additional fevers and your
breathing was back to your usual baseline on 2.5L oxygen via
nasal cannula by time of discharge. Please continue the
remainder of your antibiotics as prescribed while your pneumonia
continues to resolve. You will need a repeat chest x-ray with
your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] in about 4-6 weeks time.
.
You also had recurrence of your known abnormal heart rhythm
called atrial fibrillation. Your rapid heart rate was eventually
controlled on higher doses of metoprolol which should be
continued as an outpatient. The medical team diagnosed you with
acute kidney injury as well which was attributed to dehydration
and effects from a diuretic medication (for your diastolic
congestive heart failure treatment) called Lasix. After getting
gentle IV fluids and holding your lasix for several days your
kidney function returned to [**Location 213**].
.
After notice of right lower extremity swelling you had an
ultrasound study which revealed a blood clot in your leg called
a deep vein thrombosis (DVT). Therefore you were started on
blood thinning medications called heparin (IV given) and
Coumadin. You will need to continue your outpatient Coumadin
therapy for at least 3 months, perhaps longer. Total length of
therapy needs to be discussed with Dr. [**First Name (STitle) **], your PCP.
.
Please see below for all of your outpatient follow-up
appointment instructions.
.
MEDICATION CHANGES/INSTRUCTIONS:
The following new medications were started:
1. Coumadin daily therapy for your right lower leg blood clot
and atrial fibrillation (prevents strokes). INR level needs lab
monitoring closely on this medicine (INR goal [**3-2**])
2. Toprol XL 150mg daily for heart rate control
3. IV Vancomycin and IV Zosyn until [**1-27**].
4. oxycodone 2.5mg q8hrs as needed for low back pain
5. bisacodyl, senna, and colace as needed for constipation
6. Mirtazepine 15mg before bed for appetite stimulation and
improved mood effects
7. Aspirin 325mg daily
8. Zofran 4mg as needed for nausea
The following medications were discontinued:
-diltiazem
The following medications were continued at their previous dose:
1. Lasix 20mg PO daily
2. albuterol inhaler as needed for shortness of breath or wheeze
3. Advair inhaler twice a day
4. Spiriva inhaler daily
Followup Instructions:
Please make a follow-up appointment with Dr. [**First Name8 (NamePattern2) 429**] [**Last Name (NamePattern1) **] at
#[**Telephone/Fax (1) 16171**] after you are discharged from rehab
Completed by:[**2102-1-25**]
|
[
"496",
"453.41",
"486",
"427.31",
"428.32",
"428.0",
"389.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
21197, 21269
|
9790, 17948
|
334, 432
|
21419, 21419
|
5155, 5155
|
25134, 25349
|
4250, 4268
|
18780, 21174
|
21290, 21398
|
17974, 18757
|
21824, 25111
|
5742, 9767
|
4283, 5136
|
3588, 3716
|
265, 296
|
460, 3569
|
5171, 5726
|
21434, 21800
|
3738, 3939
|
3971, 4234
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,163
| 160,363
|
50059
|
Discharge summary
|
report
|
Admission Date: [**2197-9-9**] Discharge Date: [**2197-9-12**]
Date of Birth: [**2139-5-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
left-sided consolidation
Major Surgical or Invasive Procedure:
none
History of Present Illness:
58 yo male with a past medical history of chronic kidney
disease, atrial fibrillation, and pulmonary hypertension
transferred from an OSH with left lower/upper lobe consolidation
is being admitted from the floor for increasing oxygen
requirement.
.
Patient was started on coumadin in [**12-4**] and has intermittently
had episodes of epistaxis relieved by cauterization. Typically
he stops or decreases his coumadin dose with improvement in his
symptoms. Six days prior to admission, patient developed
epistaxis again but did not decrease his coumadin. Then on the
day of admission, patient developed epistaxis, hemoptysis with
cough productive of sputum and blood, and difficulty breathing.
He presented to an OSH where his Hct was 35.8, Cr 1.8, WBC 14.3,
and INR 2.3. Initial CXR demonstrated left-sided consolidation.
He received 500mg levofloxacin and was transferred to [**Hospital1 18**]
because his [**Hospital1 3390**] admits to [**Hospital1 18**]. Upon arrival in the ED, temp
100.4, HR 107, BP 140/69, RR 19, and pulse ox 96% on 6L NC. Labs
were notable for elevated WBC to 16.3, INR 2.6, and creatinine
1.8. He received zosyn 2.25g x 1. His pulse ox improved to 100%
on 2L and he was initially admitted to the medicine floor.
Shortly after arrival, the patient triggered for hypoxia and he
was transferred to the MICU.
Past Medical History:
Stage III chronic kidney disease (baseline creatinine 2.1)
Cystinuria with a history of heavy stone burden (on longstanding
penicillamine until 3 yrs ago)
Cutis laxa secondary to penicillamine
[**Last Name (un) 4584**] [**Location (un) **] Syndrome (thought to be secondary to
penicillamine)
Restrictive cardiomyopathy (diastolic CHF)
Pulmonary hypertension
Atrial flutter s/p AV node ablation (with postprocedure complete
heart block requiring pacemaker placement)
Pancreatic low grade, benign mucinous cystic neoplasm (LGBMC)
Large bilateral renal cysts
Small AAA
Popliteal aneurysm
hyperuricosuria
restless leg syndrome
GERD
Social History:
Works as a software engineer. Is married with no children.
Denies any smoking or drug history; uses rare alcohol.
Family History:
Several second-degree relatives with DM2.
Physical Exam:
T 100.8 / HR 92 / BP 111/50 / RR 13 / 96% on NRB
Gen: resting comfortable in bed, NAD, speaking in full sentences
without difficulty
HEENT: Clear OP, MMM, no evidence of mucosal bleeding
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: scattered crackles throughout in the left lung field and
clear to auscultation on the left; no dullness to percussion
ABD: Soft, NT, ND. NL BS. No HSM
EXT: No edema. 2+ DP pulses BL
SKIN: No lesions
NEURO: A&Ox3. Appropriate. CN 2-12 intact. 5/5 strength
throughout. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2197-9-9**] 09:19PM HCT-30.6*
[**2197-9-9**] 05:42PM TYPE-ART PO2-102 PCO2-39 PH-7.54* TOTAL
CO2-34* BASE XS-10 COMMENTS-NON-REBREA
[**2197-9-9**] 01:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2197-9-9**] 01:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2197-9-9**] 01:04PM LACTATE-2.1*
[**2197-9-9**] 12:45PM GLUCOSE-114* UREA N-38* CREAT-1.9* SODIUM-142
POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-28 ANION GAP-17
[**2197-9-9**] 12:45PM estGFR-Using this
[**2197-9-9**] 12:45PM CALCIUM-9.5 PHOSPHATE-2.3* MAGNESIUM-2.2
[**2197-9-9**] 12:45PM WBC-16.8*# RBC-3.82* HGB-12.1* HCT-35.6*
MCV-93 MCH-31.7 MCHC-34.0 RDW-16.2*
[**2197-9-9**] 12:45PM NEUTS-94.6* BANDS-0 LYMPHS-2.4* MONOS-2.4
EOS-0.4 BASOS-0.1
[**2197-9-9**] 12:45PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL
OVALOCYT-OCCASIONAL
[**2197-9-9**] 12:45PM PLT SMR-NORMAL PLT COUNT-293
[**2197-9-9**] 12:45PM PT-25.8* PTT-31.6 INR(PT)-2.6*
CXR [**9-9**]
Increased airspace opacity involving the left lung, unchanged.
Diagnostic considerations again include pneumonia.
Small left-sided pleural effusion
.
CXR [**9-9**]
Pneumonia involving the left upper and lower lobe
.
CXR [**9-10**]
ersistent left lung opacity, unchanged. Diagnostic
considerations again include pneumonia.
.
CXR [**9-11**]
Additional interval improvement in left lung opacities.
Brief Hospital Course:
ASSESSMENT:
58 yo male with past medical history of chronic kidney disease,
GERD, and CHF was admitted with left-sided infiltrates
concerning for pneumonia and/or aspiration.
.
PLAN:
1. Left upper and lower lobe consolidation
Patient presented with left-sided consolidations. Differential
diagnosis includes the following: pneumonia, aspiration given
patient's persistent epistaxis and sleeping on his left side, or
diffuse alveolar hemorrhage. CHF appears unlikely given
unilateral findings on CXR and no additional findings of
overload. PE also appears less likely in the setting of
therapeutic INR, significant infiltrate on exam. Patient still
with significant O2 requirement in the MICU, although difficult
to interpret given patient's significant baseline nocturnal O2
requirement of 7 liters due to sleep apnea. Levo flagyl was
continued, sputum cultures were negative. His hematocrit was
monitored [**Hospital1 **] and was stable, humidified air was used, and
coumadin and aspirin were held. He improved and when his O2
requirement was gone he was transferred to the medical floor
where he was stable and was discharged the following day.
.
2. Epistaxis
Patient with a history of epistaxis requiring cauterization in
the past. Currently stable without persistent epistaxis although
at high risk for rebleeding. Significant risks for epistaxis
including high flow O2 by nasal canula at night. He did not
re-bleed. ENT was aware of this patient should he start
bleeding. He will follow up with ENT upon discharge.
.
3. Chronic kidney disease (baseline creatinine 1.8-2.1)
Patient still within baseline, although creatinine increased
from 1.8 to 2.1 since admisison. His creatinine stblized, lasix
was decreased to 80mh po daily. Cacitriol and ferrous sulfate
were continued.
.
4. Atrial Fibrillation
Stable. His coumadin and aspirin were held, and he was
instructed to discuss anti-coagulation with his [**Hospital1 3390**] upon
discharge.
.
5. GERD
Stable, continued PPI
.
6. Restrictive cardiomyopathy (diastolic CHF)
Appeared euvolemic on exam, continued [**Hospital1 8213**] - captopril 25mg PO
qid, aspirin, aldosterone antagonist - eplerenone, and lasix
It was unclear why patient is not on a beta blocker, and we
recommended outpatient follow-up
.
7. Hyperuricosuria
Stable, continued outpatient management with allopurinol 100mg
PO daily
.
8. Pancreatic Mass
Stable, continue outpatient monitoring
.
9. Cystinuria - Stable, continued captopril, consider decreasing
dose if creatinine continues to worsen but as it did not,
captopril dose remained the same
.
10. Restless Legs Syndrome - Stable, continued requip,
oxycontin, oxycodone, and gabapentin
pt's current dose of gabapentin appears quite high in the
setting of chronic renal insufficiency, recommended further
follow-up with outpatient [**Hospital1 3390**] regarding dosage
.
# FEN:
He was on a regular diet, we continued ascorbic acid,
multivitamin per home regimen
and repleted lytes prn
# PPx: pneumoboots, PPI, bowel regimen
# CODE: FULL CODE
# COMM: [**Name (NI) **], Wife [**Name (NI) 553**] [**Name (NI) 1537**] [**Telephone/Fax (1) 104524**], [**Telephone/Fax (1) 104525**]
Medications on Admission:
1. Allopurinol 100mg PO daily
2. Ascorbic Acid 250mg qMWF
3. Aspirin 81mg PO daily
4. Calcitriol .25mcg PO daily
5. Captopril 25mg PO tid
6. Eplerenone (Inspra) 25mg PO daily
7. Ferrous Sulfate 325mg PO qMWF
8. Lasix 120mg PO daily
9. Gabapentin 600mg PO tid
10. Magnesium Chloride 128mg PO daily
11. Multivitamin daily
12. Oxycontin 10mg PO qhs
13. Oxycodone 5-10mg PO qhs prn
14. Rabeprazole (Aciphex) 20mg PO bid
15. Ropinrole = Requip 1mg PO bid
16. Coumadin 2.5mg PO qhs
17. Restasis drops [**Hospital1 **]
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Eplerenone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Ropinirole 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
9. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
10. Ascorbic Acid 500 mg Tablet Sig: 0.5 Tablet PO MWF
(Monday-Wednesday-Friday).
11. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Captopril 12.5 mg Tablet Sig: Two (2) Tablet PO QID (4 times
a day).
15. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
16. Oxymetazoline 0.05 % Aerosol, Spray Sig: One (1) Spray Nasal
[**Hospital1 **] (2 times a day) as needed for 3 days.
17. Levofloxacin 500 mg Tablet Sig: 1.5 Tablets PO Q48H (every
48 hours) for 6 days.
Disp:*10 Tablet(s)* Refills:*0*
18. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*18 Tablet(s)* Refills:*0*
19. Furosemide 80 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
20. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
Discharge Disposition:
Home
Discharge Diagnosis:
aspiration pneumonia secondary to epistaxis
Chronic kidney disease (baseline creatinine 1.8-2.1)
Cystinuria with a history of urolithiasis(on longstanding
penicillamine until 3 yrs ago)
Cutis laxa secondary to penicillamine
[**Last Name (un) 4584**] [**Location (un) **] Syndrome (thought to be secondary to
penicillamine)
Restrictive cardiomyopathy (diastolic CHF)
Pulmonary hypertension
Atrial flutter s/p AV node ablation (with postprocedure complete
heart block requiring pacemaker placement)
Pancreatic low grade, benign mucinous cystic neoplasm (LGBMC)
Large bilateral renal cysts
Hyperuricosuria
restless leg syndrome
GERD
Paroxysmal Atrial Fibrillation - on coumadin but complicated by
epistaxis
Sleep Apnea - on 7 liters of O2 at night - does not tolerate
CPAP mask
Discharge Condition:
stable, afebrile, satting well on room air, good po intake
Discharge Instructions:
You were admitted with nosebleed, and hemoptysis(cough
productive of blood), you were transferred to the MICU due tolow
oxygen saturation. You were treated with oxygen, antibiotics
and you improved. You are felt to have aspiration pneumonitis,
an irritation of your lungs secondary to aspiration. You were
taken off your coumadin.
You should continue to take your medications as prescribed.
Please follow up as outlined below.
Call your doctor for any chest pain, increased cough, shortness
of breath, headache, or any other symptoms.
Followup Instructions:
-Dr. [**First Name (STitle) **], 1244 [**Location (un) **], [**9-18**] 2:45 (ENT)
-please call Dr. [**Last Name (STitle) **] and schedule an appointment within the
next two weeks
-Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **]/DR. [**First Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2197-9-15**] 10:30
-Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2197-9-27**] 11:30
Completed by:[**2197-9-22**]
|
[
"416.8",
"585.9",
"507.0",
"786.3",
"428.30",
"333.94",
"270.0",
"425.4",
"211.6",
"784.7",
"530.81",
"799.02",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10152, 10158
|
4739, 7906
|
337, 344
|
10979, 11040
|
3239, 4716
|
11627, 12186
|
2503, 2546
|
8468, 10129
|
10179, 10958
|
7932, 8445
|
11064, 11604
|
2561, 3220
|
273, 299
|
372, 1703
|
1725, 2354
|
2370, 2487
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,228
| 189,630
|
6729
|
Discharge summary
|
report
|
Admission Date: [**2159-6-19**] Discharge Date: [**2159-6-24**]
Date of Birth: [**2101-9-10**] Sex: M
Service: Cardiac Surgery
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 3142**] is a 57-year-old
man who presents with known carotid disease and symptoms of
worsening chest pain over the last several months. He had
his first episode of chest pain this past winter when he was
laying in bed, had a pressure in the center of his chest that
lasted approximately for 15 minutes before resolving on its
own. He had a second episode approximately a week later that
again occurred while he was at rest, however, in the interval
he was able to tolerate exercise including golfing. He had a
stress test done at [**Hospital1 69**] in
[**Month (only) 116**] in which he exercised for 7 minutes and achieved a peak
heart rate of 123 beats per minute. His EKG showed an
exercise induced left bundle branch block and when this
resolved he was found to have inferolateral ST segment
depressions. He was found to have on echo, new regional wall
motion abnormalities with severe hypokinesis of the
anterolateral inferior and apical walls and a cardiac
catheterization done on [**2159-6-14**] showed three vessel coronary
disease with a 90% osteal LAD lesion, a left circumflex
occlusion after OM1 which had a 50% stenosis and an RCA
proximal occlusion. His EF was found to be 44% and based on
this finding, he was scheduled to have coronary artery bypass
surgery. Of note, he has also been known to have carotid
disease for years, his most recent carotid ultrasound shows
greater than 90% stenosis bilaterally. He has never had any
symptoms but he is now scheduled for carotid stenting with
Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **]. He denies having any claudication,
orthopnea, edema, paroxysmal nocturnal dyspnea or
lightheadedness.
PAST MEDICAL HISTORY: Notable for hypertension,
hyperlipidemia, carotid disease.
MEDICATIONS: On admission, Aspirin 325 mg po q day, Atenolol
100 mg po q day, Lipitor 40 mg po q day.
LABORATORY DATA: Hematocrit 43, white count 8, BUN and
creatinine 12 and 1.1, INR 0.9.
HOSPITAL COURSE: The patient was admitted to the cardiology
service. He was taken to the catheterization laboratory
where he had a left internal carotid artery stent placed.
Postoperatively he was kept on Integrilin for approximately 6
hours. He was then converted to a Heparin drip and a plan to
start Plavix after his bypass surgery was initiated.
On[**2159-6-21**] the patient was taken to the operating room
where he had a coronary artery bypass graft times four. His
grafts were LIMA to LAD, saphenous vein graft to put RM(?)
ramus intermedius vs RCA ?, saphenous vein graft to OM1,
saphenous vein graft to PDA. His cardiopulmonary bypass time
was 91 minutes, his cross clamp time was 55 minutes.
Postoperatively the patient was taken intubated to the
cardiac surgery Intensive Care Unit. He was extubated on the
evening of his operation and had no acute events through the
night. His Plavix was started postoperatively in addition to
his other post cardiac surgery medications. His
postoperative course was extremely unremarkable and he made
rapid progress. His chest tube and pacing wires were
discontinued on the second postoperative day. The patient
ambulated with physical therapy, making excellent progress
and by the third postoperative day looked well enough to be
discharged home on [**2159-6-24**]. The patient was discharged home
in stable condition in the care of his family. He was
instructed to follow-up with his primary care physician in
two weeks and to see Dr. [**Last Name (Prefixes) **] in four weeks. The
patient was discharged home on the following medications.
DISCHARGE MEDICATIONS: Plavix 75 mg po q day, enteric coated
Aspirin 325 mg po q day, Lopressor 25 mg po bid, Lipitor 40
mg po q day, Colace 100 mg po bid, Percocet 5/325 [**1-17**] po q
4-6 hours prn. Of note, the patient was 3 kg below his
pre-op weight at the time of discharge and it was not
believed that he needed to go home on either Lasix or
potassium.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease, now status post coronary artery
bypass graft.
2. Bilateral carotid disease, status post left internal
carotid artery stent.
3. Hypertension, controlled.
4. Hyperlipidemia, treated.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 9638**]
MEDQUIST36
D: [**2159-6-24**] 12:45
T: [**2159-6-26**] 21:27
JOB#: [**Job Number 24479**]
|
[
"305.1",
"E879.8",
"411.1",
"414.01",
"433.30",
"272.4",
"401.9",
"458.2",
"998.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"88.41",
"39.90",
"39.61",
"36.15",
"99.20",
"88.72",
"39.50"
] |
icd9pcs
|
[
[
[]
]
] |
3818, 4158
|
4179, 4656
|
2208, 3794
|
162, 175
|
204, 1914
|
1937, 2190
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,203
| 172,951
|
13497+56467
|
Discharge summary
|
report+addendum
|
Admission Date: [**2184-3-24**] Discharge Date: [**2184-3-29**]
Date of Birth: [**2130-2-9**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / Morphine / Fentanyl
Attending:[**First Name3 (LF) 38982**]
Chief Complaint:
"heavy" left arm
Major Surgical or Invasive Procedure:
Craniotomy with resection metastatic lesion
History of Present Illness:
54yo F w/ h/o renal cell carcinoma diagnosed [**3-/2181**] s/p left
nephrectomy [**4-10**], right wedge resection [**8-12**]. Body Ct post op
was negative and brain MRI showed question of tiny focus right
frontal region. Two episodes of tongue biting in [**2183-7-10**].
Recommended continued follow up with MRI in 3 months. Presents
today with c/o "heavy" left arm - difficulty with using keyboard
left hand and noticed drifting to left in car. No headache or
visual changes.
Past Medical History:
Hypertension, H. Pylori positive ulcer
disease, open appendectomy, renal cell ca. s/p nephrectomy
Social History:
Pediatric physician denies excessive alcohol.
Family History:
Father had a stroke.
Sister and uncle had thyroid cancer.
Physical Exam:
T 97.9, 156/80,86,16, 100%
WDWN, NAD, [**Last Name (un) 12718**] supple, heart RRR no murmer, abd soft,
extremities good pulses. Alert,orientedx3, PERRLA, EOM full,
clear discs, no facial droop, tongue midline, full shoulder
shrug, motor shows increased tone left leg, left pronator drift,
DTR 3+ in left UE, sensation intact, less coordination left arm
with finger to nose, normal tandem gait, negative Rhomberg
Pertinent Results:
[**2184-3-23**] 06:25PM BLOOD WBC-6.7 RBC-4.25 Hgb-12.6 Hct-37.3 MCV-88
MCH-29.5 MCHC-33.7 RDW-12.9 Plt Ct-290
[**2184-3-23**] 06:25PM BLOOD Neuts-63.6 Lymphs-26.3 Monos-3.4 Eos-6.2*
Baso-0.6
[**2184-3-23**] 06:25PM BLOOD PT-12.1 PTT-28.8 INR(PT)-0.9
[**2184-3-23**] 06:25PM BLOOD Glucose-83 UreaN-23* Creat-1.0 Na-145
K-4.2 Cl-107 HCO3-30* AnGap-12
[**2184-3-23**] 06:25PM BLOOD cTropnT-<0.01
[**2184-3-23**] 06:25PM BLOOD Albumin-4.7 Calcium-9.6 Phos-3.8 Mg-2.2
Brief Hospital Course:
Admitted to ICU for q1hour neurological monitoring. Head Ct
showed two lesions in right frontal lobe with vasogenic edema.
Started on decadron. Dr. [**First Name (STitle) **] discussed options for treatment to
patient, who ultimately decided on surgery. Pre-operative work
up done, including consult with neuroncologist and pt brought to
OR [**2184-3-26**] where under general anesthesia right frontal
craniotomy with removal of metastatic lesions was performed.
Stayed in PACU overnight for close monitoring. Post op meds
included dilantin and decadron. Had some decreased movement left
arm and leg post-op.Was transferred to ICU on post op day #1 and
to floor by day#2. Activity and diet increased, decadron was
tapered.Seen by PT who recommended outpatient PT for one
week.Post-op MRI showed good resection of lesions.
Medications on Admission:
lisinopril 20mg
asa 81mg
hctz 12.5mg
nexium
Discharge Medications:
1. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Captopril 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
4. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*2*
5. Famotidine 10 mg Tablet Sig: One (1) Tablet PO twice a day:
take while on steroids.
Disp:*60 Tablet(s)* Refills:*2*
6. Dexamethasone 2 mg Tablet Sig: Two (2) Tablet PO three times
a day for 3 days: then 1 TID x 3 days then 1 [**Hospital1 **].
Disp:*60 Tablet(s)* Refills:*1*
7. Outpatient Physical Therapy
Education/strengthening/mobility and balance training
[**1-11**] x per week x 1 week
Discharge Disposition:
Home
Discharge Diagnosis:
Brain tumor - metastatic renal CA
Discharge Condition:
Neurologically stable
Discharge Instructions:
Keep staples dry. Call for any problems.
Followup Instructions:
Follow up in Brain [**Hospital 341**] Clinic([**Hospital Ward Name 40844**] [**4-16**],[**2184**] at 9:30am.
Follow up for staple remaoval in Dr.[**Name (NI) 14510**] office 7 to 10 days
post-op, call [**Telephone/Fax (1) 2731**] for appt.
Completed by:[**2184-3-29**] Name: [**Known lastname 7394**],[**Known firstname 7395**] DR [**Last Name (STitle) 4221**] [**Name (STitle) **]: [**Numeric Identifier 7396**]
Admission Date: [**2184-3-24**] Discharge Date: [**2184-3-29**]
Date of Birth: [**2130-2-9**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / Morphine / Fentanyl / Keppra
Attending:[**First Name3 (LF) 7397**]
Addendum:
appt made for staple removal
Major Surgical or Invasive Procedure:
Craniotomy with resection metastatic lesion
Discharge Disposition:
Home
Followup Instructions:
Follow up for staple remaoval in Dr.[**Name (NI) 7398**] office
([**Telephone/Fax (1) 7399**] [**4-2**] at 11am. PET scan [**4-2**] 12:10 pm -
[**Hospital Ward Name **]
[**First Name11 (Name Pattern1) 919**] [**Last Name (NamePattern4) 920**] MD [**MD Number(1) 921**]
Completed by:[**2187-6-1**]
|
[
"272.0",
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icd9cm
|
[
[
[]
]
] |
[
"01.59",
"00.39"
] |
icd9pcs
|
[
[
[]
]
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4831, 4837
|
2064, 2887
|
4762, 4808
|
3884, 3907
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,374
| 121,730
|
18917
|
Discharge summary
|
report
|
Admission Date: [**2184-9-14**] Discharge Date: [**2184-9-24**]
Date of Birth: Sex:
Service: NEUROLOGY
HPI:
Mr. [**Known lastname **] a 63-year-old right handed man with history of
uncontrolled hypertension for many years presented to [**Hospital3 15516**] Hospital after an event of seizure at home. According to
the patient and his wife, Mr. [**Known lastname **] was sitting in a chair and
watching television when he all of a sudden started gurgling
incomprehensible language and once the patient's wife
observed him, his eyes were rolled back and he did not
respond to her questions. This lasted about one to two
minutes and the patient was fatigued. 911 was dialed and the
patient was brought to the local emergency department where a
CT of the head showed left temporal hemorrhage. The
patient's blood pressure at that time was 221/129. They
started him on Nipride drip and he was transferred to [**Hospital1 1444**] for further evaluation. Upon
arrival to our emergency department he was witnessed to have
brief seizure by the emergency department staff. He was
loaded on Dilantin and our service was consulted for further
evaluation.
PAST MEDICAL HISTORY: Hypertension on no medication.
Unclear what the baseline blood pressure has been.
ADHD in childhood, no treatment until about seven years ago
when the patient's primary care giver started him on Ritalin
100 mg q day. The indication for this treatment is unclear.
According to the patient and his wife, he noticed clumsiness
and agitation as well as signs of forgetfulness all of which
were attributed to his probably ADHD by his primary care
giver and thus the high dose of Ritalin.
MEDICATIONS:
1. Ritalin 100 mg q day before admission.
ALLERGIES: None.
SOCIAL HISTORY: Married, lives with wife, is currently
building a house on [**Hospital3 **]. Was retired firefighter,
occasional beers. Was a heavy smoker until five years ago. .
PHYSICAL EXAMINATION: Temperature 98.3, pulse 89 and
regular, blood pressure 188/108. Respirations 98% on two
liters.
The patient was awake and alert in no acute distress. His
neck was supple. No carotid bruits. Lungs, heart, abdomen
and extremities were examined with normal findings.
Neurological: The patient was oriented to person, place and
time. Language was fluent upon admission except for
occasional semantic errors. Normal naming, repetition and
mild incomprehension. He had difficulty repeating long
sentences.
Cranial nerves exam was unremarkable.
Motor exam shows normal function.
Sensory exam was intact in all extremities.
Deep tendon reflexes were symmetric and toes were downgoing.
Coordination was without dysmetria. Rapid alternating
movements were normal.
Gait was examined upon arrival.
LABORATORY: On admission CBC, electrolytes, urinalysis were
all normal upon admission. Magnetic resonance scan on
admission showed no evidence of acute infarction. Diffusion
weighted images demonstrate an area of hypodensity in the
right posterior frontal lobe, corresponding to an area of
encephalomalacia and hemorrhage noted on the long TR and
flare images. There was also a left temporal lobe acute
hematoma. Chronic small vessel ischemia was also seen in the
periventricular white matter. Similar findings were present
in the pons as well. No evidence of aneurysm on the
arteriogram. MRA suggested a focal stenosis in the left
posterior cerebral artery with narrowing of the mid-basilar
artery most likely on the basis of atheromatous disease.
Magnetic resonance scan with contrast on [**2184-9-16**] did not show
enhancement of the lesion in the left temporal lobe.
HOSPITAL COURSE:
1. Brain hemorrhage: Imaging studies revealed some old and
one new bleed in Mr. [**Known lastname 51723**] brain. The new bleed was located
in the temporal lobe as noted above, follow-up magnetic
resonance scan with contrast did not show any enhancement of
the lesion suggesting a less likelihood for tumor. However,
in order to rule out neoplastic origin for the lesion, the
patient underwent a CT torso which was negative for any
malignancy in the chest or abdomen. However, it has to be
noted that a CT scan showed a large cyst on the right kidney
without any contrast enhancement. Imaging was repeated with
CT on [**2184-9-22**] that showed no clear progression of prior
hemorrhage. The etiology of the bleed is unclear at this
time. However, given the patient's problem with
forgetfulness and other cognitive tests it is not impossible
that the patient might suffered from amyloid angiopathic
hemorrhage. We hope that the future neurological assessment
in [**Month (only) 359**] will elucidate whether or not the patient has
dementia. If it turns out that the patient suffers from
dementia or preliminary hypothesis about amyloid angiopathy
and bleeding because of angiopathic etiology will be more
likely. At this point we have ruled out tumor, or any
vascular malformations. The location of the bleed is
unlikely to be related to his uncontrolled hypertension.
2. Seizures: Given the absence of any seizures in the past
we believe that the seizure was associated with the bleeding
in the left temporal lobe. The patient was loaded on
anti-epileptic medications and his Dilantin level was over
the threshold of 10. Interestingly, the patient was about to
be discharged on [**2184-9-21**]. About 12:30 PM, we were talking to
the patient when he developed partial complex seizures and
lost consciousness for about a minute. This repeated itself
three times before the patient was given Ativan and was
loaded with Dilantin. He was pan cultured at that time and
as described below, it was found to be related to urosepsis.
Therefore, the patient stayed in the hospital for another two
days. We increased his Dilantin dose from 300 mg q day to
400 mg q day for this reason.
3. Urosepsis. As noted above, urine culture from [**9-22**]
showed between 10,000 and 100,000 E. coli and over 1000 mg
per milliter of proteus mirabilis. Susceptibility tests
showed positive susceptibility to Levofloxacin and many other
medications. The patient was treated with Ceftriaxone
intravenous for two days before going over to Levofloxacin
p.o. Infectious Disease team helped us with the management
of his urosepsis. Based on their suggestion, the patient
needs to continue on Levofloxacin for about ten more days.
4. Elevation of liver enzymes. About one week after the
patient had started on Dilantin his liver enzymes showed
slight elevation. His ALT went up from 35 to 61, 79, and
later came down to 47. His AST was normal at the time of
discharge. His alk phos, amylase, total bilirubin were all
normal. We believe this was reactive hepatotoxicity at a
very mild level due to Dilantin treatment. His liver enzymes
will be hopefully watched by the patient's primary doctor
when he is seen at outpatient setting after discharge.
The patient was discharged to home in good condition.
Follow-up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 51724**], Behavioral
Neurology 9 AM on [**2184-11-4**] and appointment with Dr. [**Last Name (STitle) 51725**]
and Dr. [**Last Name (STitle) **] at [**Hospital 4038**] Clinic on [**2184-10-12**] at 3:30 PM. The
patient will also see his primary doctor in the first week of
dismissal.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 12114**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2184-9-27**] 17:09
T: [**2184-9-27**] 19:38
JOB#: [**Job Number 51726**]
|
[
"041.4",
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"784.3",
"431",
"277.3",
"780.39",
"314.01"
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icd9cm
|
[
[
[]
]
] |
[
"88.41"
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icd9pcs
|
[
[
[]
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] |
3672, 7594
|
1972, 3655
|
1204, 1766
|
1783, 1949
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,337
| 121,846
|
35393
|
Discharge summary
|
report
|
Admission Date: [**2112-1-18**] Discharge Date: [**2112-3-7**]
Date of Birth: [**2036-11-14**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Ciprofloxacin / Oxycodone
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
tachycardia
Major Surgical or Invasive Procedure:
1. Right central line placement
2. Mechanical Ventilation.
3. Left PICC line placement
4. Lumbar puncture x 2
History of Present Illness:
75-year-old woman with history of hypertension and multiple
myeloma, presents to ICU with tachycardia to 180s this AM in
setting of multiple refractory episodes of atrial fibrillation
with RVR earlier in hospital course.
.
Concerning her tachycardia, patient had no known history of
atrial fibrillation prior to this hospitalization, though has
been having episodes of atrial fibrillation with RVR starting on
Friday [**2112-1-22**]. Cardiology consult was obtained on [**2112-1-27**]
due to ongoing paroxysms of RVR through the weekend that were
becoming difficult to control in setting of patient's mucositis.
Cardiology recommended increased frequency of IV metoprolol as
well as a TTE. Presumed atrial fibrillation with RVR to 180s
this morning which responded well to a push of 10 mg IV
diltiazem. Unfortunately, there is no telemetry record of this
event and no EKG was obtained. BMT team is reporting that
patient is becoming symptomatic during the tachycardia with
complaints of dyspnea. They additionally are concerned that her
mental status changes may be related to her tachycardia;
however, she has no documented hypotension.
.
Patient's original reason for admission to hospital was multiple
myeloma. Her MM was initially treated with Revlimid, stopped due
to question of some worsening of renal dysfunction. She was then
treated with Velcade and Decadron and had significant drop in
her paraprotein. Bone marrow on [**2111-11-30**] showed 60-70%
involvement and a follow-up marrow shows 3-5% marrow involvement
representing an excellent partial response. She presented to BMT
service on [**2112-1-18**] for autologous stem cell transplant and is
currently SCT day +6. her course in regards to her MM has been
complicated by a febrile neutropenia with urine culture positive
for VRE on [**2112-1-23**]. Patient being treated with daptomycin
given concern for linezolid causing cytopenias. Sensitivities to
daptomycin were requested on [**2112-1-26**] and are pending at this
time.
.
Patient has limited interaction with examiner, though denies
chest pain or pressure. Denies dyspnea. Notes mouth pain,
headache.
.
REVIEW OF SYSTEMS:
*limited due to limited patient participation in history*
(+)ve: cough, mouth pain, headache
(-)ve: chest pain, palpitations, rhinorrhea, nasal congestion,
sputum production, hemoptysis, dyspnea, orthopnea, paroxysmal
nocturnal dyspnea, nausea, vomiting, diarrhea, constipation,
hematochezia, melena, dysuria, urinary frequency, urinary
urgency, focal numbness, focal weakness, myalgias, arthralgias
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR note [**2111-5-11**], updated [**2111-12-18**]
based on OMR notes and history from pt):
Pt has history of multiple myeloma referred to [**Hospital1 18**] for an
opinion regarding myeloma therapy in the setting of renal
dysfunction by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4223**]. The patient states that she
has been told that she has been anemic over the last several
years. In [**11/2110**], she was noted to have further decrement of
her hemoglobin down to 9.7. Her CBC otherwise showed a white
count of 4.3 and platelet count of 238,000. At that time, her
creatinine was between 1.3 and 1.4. She was ultimately referred
for further evaluation to hematology and was found to have an
elevated immunoglobulin level with an IgG of 2638 and depression
of the IgA at 16 and IgM of less than 4. A bone marrow biopsy
was performed which showed 50% infiltration with IgG kappa
restricted plasma cells. UPEP showed modest amount of urine M
protein. Skeletal survey showed osteopenia without evidence of
focal lytic lesions and a kappa lambda ratio of free chain assay
was 22. The patient was started on Revlimid and Decadron. She
has had one and a half cycles. This was complicated by
escalation in her creatinine to 3.5. The patient ultimately
underwent a kidney biopsy that was suggestive of myeloma kidney
with evidence of light chain cast nephropathy and tubular
damage, some of which was felt to be subacute. The patient was
changed to a Velcade based regimen initially with her first
cycle receiving 75% of the dose in the setting of her renal
dysfunction along with dexamethasone. Although she is older than
typical transplant candidate, she received high cytoxan [**2111-12-18**]
in preparation for autogenic stem cell transplant.
1) Multiple myeloma, diagnosed [**11/2110**]
- s/p Revlamid, d/c due to renal dysfunction
- s/p Velcade and decadron with excellent partial response
- s/p High dose cytoxan [**2111-12-18**] in prep for stem cell harvest
- s/p SCT on [**2112-1-22**]
2) Hypertension
3) Hyperlipidemia
4) GERD
5) s/p Hysterectomy
6) s/p Ventral hernia repair
7) h/o Diverticulitis w/partial colectomy 15-20y ago
8) s/p Basal cell carcinoma excision
Social History:
Lives/works: Lives in [**Location 38**] with her husband of 50 years
(50th anniv [**2111-6-14**]). She has three sons and one daughter. She
continues to work as a bookkeeper in a small office part time.
Tobacco: None
EtOH: occassional wine
Illicits: Denies
Family History:
She had one brother who died of [**Name (NI) 27287**] illness and one
sister with a history of a blood disorder. She has another
brother who died of a [**Name (NI) 80666**] event.
Physical Exam:
VS: T 99.9, HR 116, BP 136/57, RR 27, O2Sat 93% 3L NC
GEN: Appears comfortable
HEENT: PERRL, limited compliance with EOM exam, patient can only
minimally open her mouth so oral mucosa and oropharynx difficult
to examine
NECK: Supple, no [**Doctor First Name **], JVP elevated to ear lobe with flutter
waves evident
PULM: Anterior exam significant for expiratory upper airway
coarse sounds, decreased BS at bases, basilar crackles
CARD: Irregular tachycardia, nl S1, nl S2, no M/R/G
ABD: soft,BS+, voluntary guarding, non-tender, non-distended,
non-tympantic
EXT: 1+ pitting BLE edema
SKIN: No rashes apparent
NEURO: limited partcipation in exam, able to move all
extremities and squeeze hands bilaterally on command, though
follow few additional commands, answers yes/no questions
appropriately
PSYCH: Restricted affect, minimal verbalizations
Pertinent Results:
CXR [**2112-1-23**]: The central venous line inserted through the right
subclavian vein terminates at the mid SVC. There is interval
development of left basal opacity most likely consistent with
atelectasis with potentially present small amount of pleural
effusion. No focal consolidation is demonstrated to suggest
infectious process, although close monitoring of this area is
recommended. There is no evidence of volume overload. There is
no pneumothorax. There is no appreciable right pleural effusion
noted.
.
CT chest w/out Contrast [**2112-1-25**]:
1. Findings compatible with pulmonary edema likely related to
recent stem
cell transplant are new since prior exam. No definite evidence
of infection.
2. Multiple pulmonary nodules, some of which are new.
.
Upper extremity U/S [**2112-1-26**]: No evidence of DVT
.
CT AB/PELVIS [**2112-1-30**]
1. Moderate right, and small left layering pleural effusions,
increased since the prior chest CT.
2. Relatively symmetric bilateral airspace opacities, perihilar
predominant, which may reflect infection or pulmonary edema,
worse since the prior study. Interlobular septal thickening at
the lung apices indicates pulmonary edema.
3. Small pericardial effusion.
4. Nonspecific mesenteric and perinephric stranding. While this
could relate to an infectious process such as pyelonephritis, or
pancreatitis, this may be related to a generalized anasarca.
Clinical correltion with urine analysis and pancreatic enzymes
is recommended.
5. Unchanged bony findings.
.
MRI [**1-29**]
Multiple small areas of elevated T2 signal within the white
matter of both cerebral hemispheres and left temporal cortex. In
a patient of this age, these findings could represent prior
small vessel infarcts. However, in view of the history of
immunocompromised patient status, an underlying opportunistic
infectious condition cannot be excluded. If a gadolinium-
enhanced examination is undertaken (provided there are no
contraindications to its performance) the absence of contrast
enhancement would favor infarction over infection. However, this
distinction cannot be absolutely rendered on the basis of
contrast enhancement characteristics. See above report re: sinus
findings.
.
MRI with gad [**2112-2-3**]
No change since the study of [**2112-1-30**]. Findings suggesting
chronic ischemia with no findings to suggest recent infarction.
No evidence
of infection.
.
CT C/A/P with contrast [**2112-2-5**]
1. No evidence of acute PE with limitations of study.
2. Moderate bilateral simple fluid pleural effusions not
significantly
changed from prior, with associated atelectasis and/or.
3. Segmental jejunal wall thickening in the left upper quadrant.
Differential diagnosis includes infection or graft versus host
disease. If
there has been an episode of hypotension, ischemia should be
considered.
.
TTE [**2112-2-18**]
Left ventricular hypertrophy with small cavity size and
hyperdynamic systolic function. Mild LV outflow tract
obstruction. Mild mitral regurgitation. Mild pulmonary
hypertension. Large bilateral pleural effusions and a very small
pericardial effusion.
.
[**2112-1-18**] 03:30PM BLOOD WBC-4.2 RBC-2.63* Hgb-8.3* Hct-24.8*
MCV-94 MCH-31.6 MCHC-33.5 RDW-14.7 Plt Ct-167
[**2112-1-28**] 12:00AM BLOOD WBC-0.1* RBC-2.88* Hgb-9.1* Hct-25.9*
MCV-90 MCH-31.5 MCHC-34.9 RDW-14.9 Plt Ct-12*
[**2112-1-18**] 03:30PM BLOOD Neuts-53.4 Lymphs-34.3 Monos-6.4 Eos-5.5*
Baso-0.4
[**2112-1-28**] 12:00AM BLOOD Neuts-9* Bands-0 Lymphs-82* Monos-0
Eos-9* Baso-0 Atyps-0 Metas-0 Myelos-0
[**2112-1-18**] 03:30PM BLOOD PT-12.7 PTT-28.0 INR(PT)-1.1
[**2112-1-28**] 12:00AM BLOOD PT-13.9* PTT-32.1 INR(PT)-1.2*
[**2112-1-18**] 03:30PM BLOOD Glucose-86 UreaN-16 Creat-1.1 Na-144
K-3.7 Cl-109* HCO3-26 AnGap-13
[**2112-1-28**] 12:00AM BLOOD Glucose-126* UreaN-23* Creat-0.9 Na-140
K-3.7 Cl-109* HCO3-20* AnGap-15
[**2112-1-18**] 03:30PM BLOOD ALT-14 AST-18 LD(LDH)-193 AlkPhos-41
TotBili-0.3
[**2112-1-28**] 12:00AM BLOOD ALT-10 AST-21 LD(LDH)-266* AlkPhos-44
TotBili-0.3
[**2112-1-23**] 10:00PM BLOOD CK-MB-3 cTropnT-0.03*
[**2112-1-24**] 08:13AM BLOOD CK-MB-3 cTropnT-0.04*
[**2112-1-24**] 02:45PM BLOOD CK-MB-2 cTropnT-0.04*
[**2112-1-18**] 03:30PM BLOOD Albumin-3.8 Calcium-9.1 Phos-3.3 Mg-1.7
[**2112-1-28**] 12:00AM BLOOD Albumin-3.1* Calcium-7.5* Phos-2.3*
Mg-1.7
Brief Hospital Course:
7Summary: 75 yo female with hypertension, diastolic heart
failure who presented to the hospital for high dose chemotherapy
with stem cell rescue for multiple myeloma with a hospital
course complicated by atrial fibrillation with RVR, hypoxia
secondary to pulmonary edema, and delirium which required an ICU
admission and intubation with mechanical ventilation.
.
#. Atrial fibrillation with rapid ventricular [**Last Name (un) **]: Patient had
both atrial flutter and fibrillation on telemetry. Underlying
etiology was volume overload, with worsened RVR in setting of
agitation, fever, and suspected infection over course of weeks.
Cardiology was consulted. TTE showed mild atrial enlargement and
small LV size, likely stiff and contributing to poor forward
flow and volume overload. Patient was controlled on dilt drip
and loaded with digoxin initially. Over her long ICU course, she
was trialed on metoprolol, PO diltiazem. She was transferred out
of ICU on digoxin and metoprolol 75 TID, which was titrated to
optimal rate control. She was diuresed aggresively with lasix
drip, and was negative 6.5 for length of stay in ICU. She
spontaneously converted to normal sinus rhythm on [**2112-2-20**]. The
patient was transferred to the oncology floors in normal sinus
rhythm. Her digoxin was stopped because the patient had altered
mental status. One day after her digoxin was stopped, the
patient went into atrial fibrillation with rapid ventricular
rate during a period of agitation. Metoprolol 5 mg IV x 2 and
loading the patient with Metoprolol 100 mg TID brought the
patient's rate down, however, her periods of agitation caused
her heart rate to increase to 150s again. Cardiology was
consulted and recommended continuing metoprolol and adding
amiodarone, diltiazem and a heparin drip. In addition, the
patient's agitation was controlled. Within a day of adding
amiodarone, the patient converted into normal sinus rhythm. She
was continued on metoprolol tartrate 100 mg TID, diltiazem, and
amiodarone with maintenance of sinus rhythm. In terms of
anticoagulation, cardiology felt that she would benefit from
coumadin since her CHADS 2 score is 4, however, since the
patient is a fall risk, she was not anticoagulated with
coumadin. The heparin gtt was stopped and the patient was given
full-dose aspirin.
**Will need periodic QTc monitoring while on amiodarone and
haldol**
.
#. Altered mental status: With increasing respiratory distress,
the patient became very agitated. On initial presentation to
ICU, patient was agitated and she became increased agitated and
delirious, to the extent that intubation was required to proceed
with testing. Ddx included infectious etiology since pt was
neutropenic and febrile, medication related delirium, cerebral
hemorrhage. Head CT was negative for bleed and follow up MRI's
showed small vessel infarcts but no acute process or infectious
process. LP was unremarkable and HSV PCR negative. Mental status
remained worsened from prior baseline. Patient required zyprexa
and haldol intermittently with attempts to wean sedation. When
extubated, patient remained altered, although improved, and this
was eventually attributed to ICU delirium. The patient was
transferred back to the oncology floors with altered mental
status and agitation. She did not sleep throughout the night.
Efforts were made to orient the patient. Another lumbar puncture
showed no focus of infection. An EEG showed toxic metabolic
encephalopathy. Neurology and psychiatry were consulted.
Psychiatry recommended Haldol at night in order to induce a
normal sleep/wake cycle. Neurology felt that the patient could
have suffered an anoxic brain injury. Within time, the patient
started to sleep more during the night and became A&O x 3. She
was not agitated. Her delirium was likely multifactorial:
drug-induced, ICU induced and possibly anoxic brain injury.
.
#. Fevers and febrile neutropenia: Patient presented with
febrile neutropenia. She was being treated with daptomycin for
VRE UTI, and this was continued. She underwent an LP and BAL.
She received cefepime then meropenem, micafungin, acyclovir,
azithromycin for febrile neutropenia. All cx were negative.
B-glucan/galactomannan were negative. CSF did not appear
infected and HSV PCR was negative. MRI did not show infectious
process. Abx were D/Ced as counts came up and fevers resolved.
.
#. Hypoxia: Patient with new oxygen requirement upon admission.
She required intubation on [**1-29**] for hypoxia and worsened mental
status. Patient had bilateral pleural effusions, likely due to
severe diastolic dysfunction in setting of small and stiff left
ventricle and volume overload. Pt was diuresed and underwent
thoracentesis. She was extubated [**2112-2-7**], but had to be
re-intubated [**2112-2-9**] due to increased A-a gradient, tachypnea,
and failure to improve mental status. Pt continued to fail PSV
trials, likely due to AF with RVR, volume overload with pleural
effusions, and poor mental status. PE was ruled out with CTA.
Patient was aggressively diuresed with Lasix gtt, which did
improve hemodynamics and respiratory status. pt was extubated
[**2-20**] successfully.
.
#. Acute exacerbation of diastolic dysfunction and hemodynamics:
Patient had LVH on EKG and h/o hypertension. She presented with
AF with RVR. TTE showed small LV. Given difficulty assessing
volume status and cardiac function, Swan-ganz catheter was
placed. PCWP 14, CI 2, SVR 900, Sv02 50. Hypothesis is that
patient's small and stiff LV created a tenuous balance between
underfilling and overload. Patient did better with diuresis and
rate control.
.
#. Multiple Myeloma s/p autologous stem cell transplant: the
patient underwent high dose chemotherapy with autologous stem
cell rescue. With the exceptions above, the patient tolerated
the procedure well. Her ANC recovered while in the hospital.
.
# Hypertension: The patient has LVH on EKG. She also had
hypertension which was well controlled on diltiazem and
metoprolol.
.
# Diarrhea: The patient developed diarrhea while in the ICU.
Fecal cultures and numerous C. diff tests were negative. The
patient continued to have diarrhea until discharge, though in
smaller amounts.
Medications on Admission:
-Docusate Sodium 100mg [**Hospital1 **]: PRN constipation
-Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]
[**Name (STitle) 80670**] Succinate XL 25mg daily
-Multivitamin daily
-vitamin B6 50mg [**Hospital1 **]
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1263**] Hospital Inpt
Discharge Diagnosis:
Primary:
-Multiple myeloma
-atrial fibrillation
-delirium
-respiratory distress
.
Secondary
-hypertension
-urinary tract infection
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 827**]. You were admitted for high dose chemotherapy and
an autologous stem cell transplant. Your transplant went well,
but you had complications of a fast heartbeat, respiratory
distress, infection, and delirium. You had a fast irregular
heartbeat (atrial fibrillation) which caused water to build up
in your lungs. The water accumulated in your lungs and you were
not able to breath well. You had to be transferred to the
intensive care unit for mechanical ventilation. You developed a
urinary tract infection during that time treated with
daptomycin. You were weaned off the ventilator and you were
found to be delirious--you did not remember where you were. An
EEG (test of your brain activity) showed that you were not
having seizures. You were transferred to the oncology floor and
you started to sleep more. As you slept more, your thoughts
became clearer. While on the oncology floor, you developed
atrial fibrillation again. You were converted to a regular
rhythm using a drug called amiodarone.
.
Your medications have changed:
-START metoprolol (for your heart rate)
-START amiodarone (for your heart rhythm)
-START diltiazem (for your heart rate)
-START aspirin (to prevent clots in your heart)
-START lovenox 40mg daily for 2 weeks
-START haldol 5mg at night (to help you sleep)
Followup Instructions:
You should followup with Dr. [**Last Name (STitle) **] in the neurology clinic in
[**2-6**] months. Call ([**Telephone/Fax (1) 2528**] to make an appointment.
.
You will also need to follow up wiht Dr. [**Last Name (STitle) **], we made an
appointment for you on:
[**3-14**] at 1:30pm
|
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"203.00",
"287.4",
"348.1",
"428.0",
"584.5",
"272.4",
"427.32",
"528.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"03.31",
"99.25",
"41.04",
"89.64",
"34.91",
"38.93",
"96.04",
"33.24",
"99.15",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
17385, 17445
|
10914, 13308
|
309, 420
|
17620, 17620
|
6598, 10891
|
19168, 19456
|
5537, 5718
|
17466, 17599
|
17127, 17362
|
17799, 19145
|
5733, 6579
|
2594, 2996
|
258, 271
|
448, 2575
|
17634, 17775
|
3018, 5246
|
5262, 5521
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,426
| 153,325
|
1453
|
Discharge summary
|
report
|
Admission Date: [**2123-12-28**] Discharge Date: [**2124-1-17**]
Date of Birth: [**2075-10-6**] Sex: M
Service: MEDICINE
Allergies:
Amitriptyline / Benzodiazepines / Morphine / Valium / Fluoxetine
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Transfer from [**Hospital 8641**] Hospital with respiratory failure due to
pneumonia and myocardial infarction.
Major Surgical or Invasive Procedure:
Broncheoalveolar lavage ([**2124-1-2**])
Endotracheal extubation
Central venous line placement
History of Present Illness:
48 year-old man with HIV/AIDS (CD4 28, VL 65 [**2123-11-4**]; compliant
with HAART), CAD, chronic systolic and diastolic CHF (EF 30%)
who presented to [**Hospital 8641**] Hospital with respiratory failure and
NSTEMI. He presented to the office of his PCP [**12-17**] for a
three-week history of productive cough and was started on
levofloxacin 750 mg without improvement. He was admitted to
[**Hospital 8641**] Hospital [**2123-12-27**] with dyspnea and was intubated in the
ED. Partner states he was febrile to 102 the day of admission.
Chest x-ray with pulmonary edema but no significant
consolidation. He was started on vancomycin/zosyn and continued
on levofloxacin for broad coverage of pneumonia. Afebrile
without leukocytosis during admission.
.
BNP 1041. EKG showed lateral TWI. Cardiac enzymes: [**12-28**] 02:30
CK 348, MB 15.8, troponin I 2.77 -> [**12-28**] 08:00 CK 1514, MB
116.6, troponin I 39.19. He was started on heparin gtt and
integrillin gtt immediately prior to transfer in addition to
home aspirin 325 mg and plavix 75 mg. He was given lasix 40 mg
IV Q8H, however, urine output is not noted.
.
On arrival, the patient had respiratory distress on SIMV with
accesory muscle use, increased expiratory phase, and diffuse
wheezing.
Review of Systems: Unable to obtain.
Past Medical History:
- HIV/AIDS, diagnosed [**2111**]; genotyping in [**10/2116**] showed
high-grade NNRTI resistance, suspected to have PI-resistance as
well; no history of OIs
- Two-vessel CAD; inferior STEMI in [**2114**] (totally-occluded RCA,
two mid-LAD lesions; all of them stented); BMS to RPLB in [**3-/2118**]
(in the setting of positive stress and angina); DES to mid-LAD
(in-stent restenosis; in the setting of worsening fatigue and
exertional dyspnea)
- Diastolic and systolic congestive heart failure (LVEF 37-50%,
depending on study; 30% last TTE [**12/2122**])
- Hypertension
- Dyslipidemia
- Hypertriglyceridemia
- Severe peripheral neuropathy, thought secondary to stavudine;
on very large narcotic regimen
- C5-C6 diskectomy and fusion in [**2110**]
- Emphysema
- Depression
Social History:
The patient lives in [**Location (un) 3844**] with his long-term partner.
[**Name (NI) **] has smoked [**Date range (1) 8642**] ppd for the past 30 years. He does not
drink alcohol and has no history of drug use including IV drug
use.
Family History:
He denies any family history of cancer or lung disease. His
mother has diabetes and coronary artery disease. He reports
that multiple family members have had MIs at early ages.
Physical Exam:
General: Thin, middle-aged man , intubated
HEENT: No scleral icterus or conjunctival erythema, pupils equal
round and reactive to light, ET tube in place
Neck: No cervical or clavicular lymphadenopathy, no JVD
Chest: Scattered faint expiratory wheezing with mild bibasilar
rales; moderately-restricted air movement; no egophony; no
dullness to percussion
Cardiovascular: Borderline tachycardic, regular; normal s1s2; no
murmurs or rubs; nondisplaced PMI
Abdomen: Moderately distended; nontender; normal bowel sounds;
no hepatosplenomegaly
Extremities: 2+ pitting edema bilaterally to the lower shins; 2+
PT pulses; warm, well-perfused; no cyanosis or clubbing
Skin: No lesions, no jaundice
Neuro: Sedated, moving all extremities well
Pertinent Results:
Admit labs:
134 96 23
---------------< 89
3.9 29 1.6
CK: 1661 MB: 74 MBI: 4.5 Trop-T: 3.33
Ca: 8.5 Mg: 1.9 P: 5.8 D
ALT: 33 AP: 93 Tbili: 0.8 Alb:
AST: 153 LDH: Dbili: TProt:
proBNP: 7322
.
WBC: 4.4
HCT: 30
PLT: 147
.
[**12-29**] CT abd:
1. No evidence of hemorrhage in the chest, abdomen or pelvis.
2. Bilateral pleural effusions and consolidations, concerning
for infection.
3. Compression changes in the thoracolumbar spine as detailed
above.
.
[**12-29**] Echo:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated. No masses or thrombi are seen in the left
ventricle. Overall left ventricular systolic function is
severely depressed (LVEF= 20-25 %) with global hypokinesis and
regioanl akinesis of the mid to distal anterior wall, septum,
apex and the entire inferior wall. There is no ventricular
septal defect. The right ventricular cavity is mildly dilated
with borderline normal free wall function. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are mildly thickened. At least moderate (2+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
.
[**1-10**] Echo:
The left atrium is dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated. There is an inferobasal left ventricular
aneurysm. A left ventricular mass/thrombus cannot be excluded.
Overall left ventricular systolic function is severely depressed
with thinning and akinesis/aneurysm of the inferolateral wall
and akinesis of the mid to distal anterior septum, anterior wall
and apex. (LVEF= 20-25 %). Right ventricular chamber size and
free wall motion are normal. The aortic root is mildly dilated
at the sinus level. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Moderate (2+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: RV size and function appear normal. Severely reduced
LV systolic function with akinetic/aneurysmal inferolateral wall
and akinesis of the mid-LAD territory. There may be a thrombus
in the LV apex but this appearance may be due to near-field
artifact. IV echo contrast could not be used due to the
[**Hospital 228**] medical issues. A cardiac MR may help to clarify. At
least moderate mitral regurgitation, probably due to tethering
of the posterior mitral valve leaflet.
.
[**1-15**] MR [**Name13 (STitle) 2853**]:
The study is motion degraded. There is apparent fusion at C5-C6,
which is
likely post-surgical. No malalignment is noted. There is
increased signal
within the C6 vertebral body on both T1- and T2-weighted images,
which may
represent post-fusion sequela. There is no marrow edema on the
STIR images.
Axial images are markedly motion degraded.
At C4-C5, there appears to be a disc osteophyte complex with
mild central
stenosis and mild right and moderate left foraminal narrowing.
At C5-C6, there is mild bilateral foraminal narrowing, but no
significant
central stenosis.
At C6-C7, there is a disc osteophyte complex with mild central
stenosis and an indentation of the anterior thecal sac. There is
moderately severe left and moderate right foraminal narrowing.
At C7-T1, evaluation is limited.
IMPRESSION: Post-surgical changes as described. Additionally,
there are
spondylotic changes at C4-C5 and C6-C7 as detailed above.
Brief Hospital Course:
A 47 year-old man with advanced AIDS, CAD, [**Hospital 1902**] transferred from
OSH with respiratory failure, acute coronary syndrome. Hospital
course by problem:
.
1. Respiratory distress/VAP/pulmonary embolism: Patient
transferred from outside hospital intubated due to respiratory
distress. Severe COPD on imaging and ventilator mechanics
continue to be consistent with obstructive disease. Patient
with trachobronchialmalacia on bronchoscopy. Patient treated
with solumedrol then prednisone [**1-1**] for COPD flare. Patient
given presumptive diagnosis of ventilator associated pneumonia
after developed infiltrate, increased secretions ?????? s/p BAL
[**1-2**], completed course vanc/cipro/zosyn. Diuresed [**2034-1-2**]
given evidence of increased volume by CXR and secretions, but
did not improve oxygenation. PE seen on CT [**1-6**]; relatively
small but given patient's lack of pulmonary and cardiac reserve
this was treated with heparin, switched to Lovenox with bridge
to coumadin at time of discharge. He was extubated on [**1-11**] and
transferred to floor on [**1-12**]. He will have follow-up INR two
days post-discharge faxed to his primary physician's office.
.
2. Acute coronary syndrome: NSTEMI. Patient intially on heparin
and integrillin on presentation, but these were stopped on
recommendation of cardiology once his enzymes were trending
downward as they felt he had a completed infarct ?????? likely
mid-LAD stenosis. ECHO revealed new systolic dysfunction with EF
25%. As soon as able patient placed on aspirin, plavix, toprol,
lisinopril. Statin was discontinued as outpatient due to
interaction with HAART regimen. Cardiology recommended
outpatient stress test once patient recovered from this acute
illness. LV thrombus was noted and pt was anticoagulated on
heparin IV.
.
3. BRBPR: Had BRBPR in setting of initiating heparin and
integrillin gtt [**12-29**], transfused 2 units PRBCS. They were
initially held and then heparin IV was restarted once BRBPR
resolved. No further episodes and HCT was stable w/o need for
repeat transfusion.
.
4. HIV/AIDS: CD4 count 28 with viral load 65. Known to have
virus with NNRTI resistance. On integrase inhibitor as part of
his HAART. We continued home HAART regimen; continued
fluconazole for fungal prophylaxis; and continued Bactrim and
[**Doctor First Name **] prophylaxis.
.
5. Peripheral neuropathy and recent T8 compression fracture:
Neuropathy presumed due to stavudine toxicity, per old notes in
OMR; on a very large home narcotic requirement. Compression
fracture noted on outpatient chest x-ray ?????? chronic on imaging
here. Initially, methadone IV was given to substitute for his
outpatient oxycontin. On [**1-12**] oxycontin and oxycodone prn were
restarted at significantly lower dose than patient was
documented to take outpt. These were uptitrated rapidly as he
appeared to be withdrawing from home doses. He tolerated up to
oxycontin 120 QID without adverse SE.
.
6. Hyperlipidemia: fibrate initially held, restarted [**1-12**].
.
7. Pyramidal symptoms: per patient's partner, hyperreflexia and
psychomotor agitation occurred after previous prolonged
intubation in [**2122**]. This was noted on [**1-15**]. Given concern for
hypersensitivity to SSRIs (per partner's account), fluoxetine
was discontinued and put as an allergy. Given that patient has
hx of C5-C6 fusion and that he had bilateral pyramidal signs, an
MRI C-spine was ordered which showed an osteophyte complex with
mild central stenosis at C6-7. Neurosurgery/spine service was
consulted and did not feel there was emergent need for
intervention. His bilateral upper extremity tremor was felt
more likely to be due to SSRI hypersensitivity as he had had
this identical presentation previously after restarting
fluoxetine. His fluoxetine has been stopped. He will follow-up
in spine clinic with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in 6 weeks.
.
Contact: Partner and HCP is [**Name (NI) 892**] [**Telephone/Fax (1) 8643**]. No other family
members can be told any medical issues.
Medications on Admission:
Medications on Transfer
Propofol gtt
Fentanyl gtt
Acyclovir 400 mg Q8H
Zosyn 3.375 gm IV Q6H
Vancomycin 1000 mg IV Q12H
Aspirin 325 mg PO daily
Diflucan 100 mg PO daily
Lasix 40 mg IV Q8H
Levaquin 750 mg PO daily
Lovenox 40 mg daily
Plavix 75 mg PO daily
Insulin sliding scale
Protonix 40 mg PO daily
Albuterol neb PRN
Heparin gtt
Integrillin gtt
.
Home Medications:
ACYCLOVIR - 400 mg Tablet - one Tablet(s) by mouth three times a
day
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler -
[**1-20**]
puffs(s) inhaled q 3-6 hrs prn
AZITHROMYCIN - 250 mg Tablet - 4 Tablet(s) by mouth weekly
CLOPIDOGREL [PLAVIX] - 75 mg Tablet - one Tablet(s) by mouth
once
a day
DARUNAVIR [PREZISTA] - 300 mg Tablet - 2 Tablet(s) by mouth [**Hospital1 **]
with ritonavir
EMTRICITABINE-TENOFOVIR [TRUVADA] - 200 mg-300 mg Tablet - 1
Tablet(s) by mouth once a day
ETRAVIRINE [INTELENCE] - 100 mg Tablet - 2 Tablet(s) by mouth
[**Hospital1 **]
with food
FENOFIBRATE NANOCRYSTALLIZED [TRICOR] - 48 mg Tablet - one
Tablet(s) by mouth once a day
FLUCONAZOLE - 100 mg Tablet - one Tablet(s) by mouth once a day
FLUOXETINE - 40 mg Capsule - one Capsule(s) by mouth qd - note
new size
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk
with Device - one puff inhaled twice a day
FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily)
LEVOFLOXACIN [LEVAQUIN] - 500 mg Tablet - one Tablet(s) by mouth
once a day
METOPROLOL TARTRATE - 50 mg Tablet - one Tablet(s) by mouth
twice
a day
NITROGLYCERIN - 0.4 mg Tablet, Sublingual - one Tablet(s)
sublingually every 5 mins x 3 for chest pain
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - one
Capsule(s) by mouth once a day
OXYCODONE - 30 mg Tablet - 0.5 - 2 Tablet(s) by mouth tid prn
OXYCODONE [OXYCONTIN] - 80 mg Tablet Sustained Release 12 hr - 1
Tablet Sustained Release 12 hr(s) by mouth five times per day -
20 day supply
OXYCODONE [OXYCONTIN] - 40 mg Tablet Sustained Release 12 hr - 1
Tablet Sustained Release 12 hr(s) by mouth five times per day
with 80 mg dose - 20 day supply
RALTEGRAVIR [ISENTRESS] - 400 mg Tablet - one Tablet(s) by mouth
twice a day
RITONAVIR [NORVIR] - 100 mg Capsule - 1 Capsule(s) by mouth [**Hospital1 **]
with Darunavir
TRIMETHOPRIM-SULFAMETHOXAZOLE [BACTRIM DS] - 800 mg-160 mg
Tablet
- one Tablet(s) by mouth qd or [**Hospital1 **]
Medications - OTC
ASPIRIN - (OTC) - 325 mg Tablet - one Tablet(s) by mouth once a
day
Discharge Medications:
1. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 4 days.
Disp:*8 qs* Refills:*0*
2. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**1-20**] Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
4. Azithromycin 250 mg Tablet Sig: Four (4) Tablet PO 1X/WEEK
([**Doctor First Name **]).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Darunavir 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
8. Etravirine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
9. Fenofibrate Micronized 48 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
13. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
14. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual Take every 5 minutes, up to three tabs as needed for
chest pain.
15. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
16. OxyContin 80 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO five times a day for 20 days:
Please do not drive after taking this medication. This medicine
will make you drowsy and impair your concentration.
Disp:*100 Tablet Sustained Release 12 hr(s)* Refills:*0*
17. Oxycodone 30 mg Tablet Sig: 0.5-2 Tablets PO three times a
day as needed for pain for 100 doses: Please do not drive after
taking this medication. This medicine will make you drowsy and
impair your concentration.
Disp:*100 Tablet(s)* Refills:*0*
18. OxyContin 40 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO five times a day for 20 days:
1 tablet five times per day with 80 mg dose. Please do not
drive after taking this medication. This medicine will make you
drowsy and impair your concentration.
Disp:*100 Tablet Sustained Release 12 hr(s)* Refills:*0*
19. Raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
20. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
21. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
22. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
23. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
24. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QDAY ().
Disp:*10 Adhesive Patch, Medicated(s)* Refills:*2*
25. Outpatient Lab Work
Please have blood drawn on Wednesday [**1-19**] for INR check.
Please have results phoned to Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 3346**]. Fax
number is ([**Telephone/Fax (1) 8644**].
26. Warfarin 5 mg Tablet Sig: 1.5 Tablets PO once a day.
Disp:*45 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Primary Diagnoses
Non ST-elevation myocardial infarction
Ventilator associated pneumonia
Acute on chronic bronchitis
Pulmonary embolism
.
Secondary Diagnoses
HIV/AIDS
Coronary artery disease
Congestive heart failure
Hypertension
Dyslipidemia
Severe peripheral neuropathy
Chronic obstructive pulmonary disease
Depression
Discharge Condition:
Vital signs stable. Oxygen saturations in mid to high 90s on
room air.
Discharge Instructions:
You were hospitalized for treatment of heart attack, worsening
of chronic bronchitis, and pneumonia. You were treated with
antibiotics and prednisone, and your symptoms improved. Your
cardiovascular medicines were also changed.
.
Please note the following changes to your medicines:
1. Fluoxetine was stopped.
2. Levofloxacin was stopped.
3. Metoprolol was decreased to 25 mg XL once daily.
4. Warfarin was added to help treat the blood clot in the
lungs.
5. Lovenox was added; this should be taken until warfarin
levels are therapeutic.
6. Lisinopril was added to help treat heart disease and blood
pressure.
7. Lidocaine patch was added to be taken as needed for back
pain.
.
Please note your follow-up appointments below. You will have a
visiting nurse come to draw the blood to check warfarin levels
on Wednesday [**1-19**].
.
Please call your doctor or return to the emergency room if you
have any fever, chest pain, bleeding or any other symptoms that
are concerning to you.
Followup Instructions:
1. 4-5 mm right lower lobe nodule, chronicity uncertain;
follow-up in six months by chest CT is recommended.
.
2. [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 8645**] Date/Time:[**2124-2-10**]
1:00
.
3. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**2-23**] at 2 o'clock. [**Hospital **] Medical
Building, [**Hospital Unit Name **]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8364**], MD Phone:[**Telephone/Fax (1) 1669**]
Date/Time:[**2124-2-24**] 2:00.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
Completed by:[**2124-1-17**]
|
[
"285.29",
"585.9",
"355.8",
"042",
"428.0",
"415.19",
"518.81",
"733.13",
"491.22",
"707.21",
"707.05",
"410.71",
"311",
"428.42",
"997.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.07",
"33.24",
"88.72",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
17652, 17735
|
7789, 11870
|
437, 534
|
18099, 18173
|
3865, 7766
|
19212, 19937
|
2915, 3095
|
14342, 17629
|
17756, 18078
|
11896, 12245
|
18197, 19189
|
3110, 3846
|
12263, 14319
|
1832, 1851
|
1366, 1813
|
286, 399
|
562, 1349
|
1873, 2647
|
2663, 2899
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,005
| 130,120
|
28576
|
Discharge summary
|
report
|
Admission Date: [**2153-12-5**] Discharge Date: [**2153-12-13**]
Date of Birth: [**2092-11-6**] Sex: M
Service: NEUROLOGY
Allergies:
Codeine
Attending:[**First Name3 (LF) 5341**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
whole brain radiation
History of Present Illness:
61yo man with metastatic melanoma, metastases to brain, and
seizures related to this disorder presents with seizures at
home. The history regarding his melanoma and seizures is listed
below. Per the patient's family, he has had decline over past
week - he has been talking less and less, when he does talk his
voice is very soft and hoarse. He has had trouble swallowing his
pills, and coughing when he drinks. He has persistent L arm and
face weakness that has slowly worsened over time, though he can
still walk around by himself (was walking the morning of
admission). He had been having OCD-like symptoms on Keppra,
which had been started for further seizure control as PHT had
not been controlling the seizures. He saw Dr. [**Last Name (STitle) 4253**] the day
prior to admission, where Lamictal was started and keppra was
discontinued. The morning of admission, the pt woke up "very
groggy." He took the first dose of Lamictal 25 mg and his other
morning meds. At 1:30pm, his wife witnessed a prolonged
seizure-like episode lasting 20-25 minutes - with R hand shaking
and L leg shaking. After the event, he vomited and was very
sleepy. His wife called EMS; it is unclear if benzos were given.
He was taken to [**Hospital6 302**] where a head CT showed some
"slightly" increased edema and hemorrhage at the site of a known
hemorrhagic met in the R frontal [**Last Name (LF) 3630**], [**First Name3 (LF) **] he was transferred
here.
He has been sleepy and not saying much since the event; he has
persistent L arm and face weakness. On ROS, his wife and sister
do not think he has had fever; he has had HAs recently but did
not think he had HA today; no coughing, no GI/GU complaints, no
respiratory complaints except coughing when he eats or drinks
sometimes.
Past Medical History:
-Melanoma Hx:
-- had moles removed few years ago, stage II melanoma, s/p
resection with "clean margins" thought cured, no chemo
-- presented this year with slight L facial droop, diagnosed
with
metastatic melanoma, mets to brain discovered
-- s/p craniotomy with resection R frontal lesion, still had
deeper, contralat lesions
-- s/p gamma knife at RIH/Dr. [**Last Name (STitle) 39706**] for other lesions
-- Hemorrhage in met [**8-27**] had p/w difficulty talking;
hospitalized, had PNA and DVTs (wife denies PE, but Dr.[**Name (NI) 23016**] notes detail that he did have PE); s/p filter in
each
leg (one clotted off)
-- Mesenteric mass [**10-19**] with bx consistent with melanoma
-- Seizures started [**10-3**] - GTC 3-5 minutes, on PHT; subsequent
sz
associated with low PHT levels, several hospitalizations at [**Hospital3 15433**] for this; had been started on Keppra
-- On decadron since [**11-27**] again after another seizure
-- Was taken off Keppra [**11-2**] after obsessive-compulsive sx noted
by family, saw Dr. [**Last Name (STitle) 4253**] for first time, Lamictal started
Other PMH:
-HTN
-Anemia
-Depression
-High cholesterol (recently off meds for this)
-kidney stones
Social History:
Lives with wife, taking medical leave from work - respiratory
therapist at [**Hospital6 302**]. Quit tobacco this year,
formerly smoked "whole life." No etoh, no drugs. Pt has no
living will/advanced directive, has discussed with wife that he
would not want to be on vent for long period of time, but is
full code for now.
Family History:
Mother had [**Name2 (NI) 499**] ca; no other ca, no seizures, no neuro d/o's;
father had MI.
Physical Exam:
Admission exam:
T 99.9 HR 100 BP 119/75 RR 22 100%RA
General appearance: lethargic, sweaty, white male
HEENT: mildly dry mucus membranes
Neck: supple, no bruits
Heart: regular rate and rhythm, no obvious murmurs
Lungs: diminished to auscultation bilaterally
Abdomen: soft, nontender +bs
Extremities: warm, well-perfused
Mental Status: The patient keeps eyes closed for most of exam,
opens eyes spontaneously at end of interview - says "I have to
use the bathroom" - voice very soft and slightly hoarse.
Appears very lethargic, and while examiner is talking to his
wife and sister, pt falls asleep, starts snoring. Easily
arousable from sleep state. O/w no speech heard for entirity of
exam; follows commands to provide resistance, squeeze hands, but
does not follow all commands, and at times seems less attentive,
have to ask pt questions several times before he performs task.
Cranial Nerves: The visual fields are full. The optic discs
could not be visualized due to pupil size. Eye movements normal
with OCR, but pt had R gaze preference, eyes usually midline to
R, no nystagmus. Pupils react equally to light, both directly
and consensually. Bilaterally brisk corneals. Facial movements
are significant for L facial droop (UMN). Hearing is intact to
voice. Tongue and palate appear midline.
Motor System: There is nl tone throughout, nl bulk. Pt
participates on command with most of strength exam as follows:
RUE: [**6-1**] at delt, [**Hospital1 **], tri, wrist and finger ext, and finger flex
RLE: [**6-1**] at IP, ham, quad, foot plantarflex, dorsiflex. LUE:
antigravity with some resistance at delt and [**Hospital1 **] (?4-/5), [**4-1**]
finger flexors, trace mvmt ([**3-4**]) of triceps and finger ext. LLE:
[**5-2**] at IP, full at quad, full plantarflex, did not participate
further.
No tremor, could not assess drift due to pt's participation.
Reflexes: The tendon reflexes are brisk and symmetric
throughout, with no clonus or crossed adductors; both toes are
upgoing.
Sensory: withdraws more vigorously on R side than left side, but
cannot assess sensation more fully at this time due to pt's
fatigue.
Coordination and Gait: Could not be assessed.
Pertinent Results:
Labs:
144 | 104 | 24 / 158 AGap=13
3.1 | 30 |0.9 \
Ca: 8.7 Mg: 1.5 P: 4.2
Phenytoin: 20.1
19.6 \ 11.4 / 218
/ 34.0 \
PT: 14.8 PTT: 20.3 INR: 1.3
Imaging
CT [**12-4**]:
3x3.5 cm right frontal metastasis surrounded by vasogenic edema,
more extensive when compared with [**Month/Day (4) 4338**] [**11-2**]. 2mm shift. Multiple
other mets as noted on previous scans.
.
[**12-7**] - video s/s eval - IMPRESSION: Aspiration of thin
consistency. For further recommendations, please consult the
speech pathology note available on CareWeb.
.
[**12-7**] CT abd/pelvis -
1. Large mass arising from the body of the pancreas with atrophy
of the pancreatic tail. There is an adjacent large lobulated
mass, which likely represents consolidative lymphadenopathy.
These findings are most consistent with metastatic melanoma. A
primary pancreatic neoplasm is less likely.
2. Cholelithiasis without evidence of cholecystitis.
.
[**12-6**] - CXR -IMPRESSION: Bibasilar atelectasis. No evidence of
pneumonia.
Brief Hospital Course:
61yo man with metastatic melanoma with metastases to brain,
presented with likely seizure and was transferred here when OSH
scan showed slight increase in edema and hemorrhage right
frontal known lesion, and new left insular lesion. On exam, he
was very lethargic, with otherwise worsening of baseline
deficits (weakness on L, relative aphasia) which could be
persistent postictal state versus mental status changes from
increased edema associated with metastasis, versus underlying
infection.
Hospital course is reviewed below by problem:
1. seizure: likely secondary to his metastasis and increasing
edema/hemorrhage. He was continued on dilantin with goal level >
20. Lamictal was also continued at his home dose (recently
started). He was started on a low dose of ativan three times a
day. And treated for infection (see below). Patient remained
seizure free thereafter. He was continued on dilantin 300 mg,
300 mg, 200 mg. Lamictal 50 [**Hospital1 **]. increasing dose qmonday,
should be monitored for drug rash. Continue ativan 0.5mg tid.
2. brain metastasis w/ edema: Given the increase in edema, he
was put on a higher dose of decadron. He was initially admitted
to the ICU, and transferred out of the unit when he remained
stable. He was then transferred to the neurooncology service and
underwent whole brain XRT. Neurosurgery saw him prior to the XRT
and determined that he did not need surgical intervention prior
to the radiation. He received XRT, total 5 treatments and was
monitored on a medicine floor during this time and his mental
status continued to improve. He will continue decadron with a
taper and bactrim prophy while on decardron.
3. Melanoma - per [**First Name8 (NamePattern2) **] [**Doctor Last Name **] no planned chemo for atleast 1
month after radiation.
4. ID: Patient febrile and had leucocytosis with bandemia on
admission so in setting
of seizures was started on zosyn. 2/2 blood cx. positive for
pseudomonas, pan sensitive. source unclear, as urine cx., CXR
negative. switched to levofloxacin [**12-7**], afebrile since.
Follow up surveillance cx. negative. Continue levoflox for 14
day course (started [**2153-12-5**]).
5. Elevated amylase, lipase: nl on admit, no abdominal pain,
with elevated amylase after radiation, quickly trended down. ?
acute parotitis with hyperamylesemia following WBXRT. Abd. CT
with pancreatic mass, GI consulted and felt that as has nl.
clinical exam unlikely acute pancreatitis. Continued artificial
saliva PRN.
6. HTN: cont metoprolol, hctz, lasix
7. FEN: He was evaluated by speech and swallow, who were
concerned for silent aspiration; they recommended - reg, HH,
soft diet with nectar-thickened liquids
8. code: DNR/DNI
Medications on Admission:
Toprol XL 12.5 mg qd
HCTZ 25 mg qd
Lasix 20 mg qam
Iron 325 mg tid
KCl 80 mEq [**Hospital1 **]
Zoloft 150 mg qam
Dilantin 300/200/300
OFF Keppra since last night (last dose)
Lamictal 25 mg [**Hospital1 **] (FIRST DOSE THIS AM), with plans to incr over
4 wks
Oxycontin 20 mg [**Hospital1 **]
Colace
Protonix ?40 mg [**Hospital1 **]
Metoclopham 10 mg 4xd
Procrit "prn"
Miralax prn
Decadron 6 mg tid
Ativan 0.5 mg prn sz (took one dose this PM)
Discharge Medications:
1. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q4-6H (every 4 to 6 hours) as needed.
2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
4. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
6. Nystatin 500,000 unit Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours).
7. Artificial Saliva 0.15-0.15 % Solution Sig: One (1) ML Mucous
membrane PRN (as needed) as needed for mouth dryness.
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours): Start date [**12-5**] for total 14 day course. . Tablet(s)
10. Lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
15. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
16. Dexamethasone 8 mg IV Q8H
17. Metoclopramide 10 mg IV Q6H:PRN
18. Lorazepam 0.5-2 mg IV Q4H:PRN
PRN Seizure>3 minutes or >3 seizures in one hour; please call HO
when giving
19. Morphine Sulfate 2-4 mg IV Q4H:PRN Pain
20. Phenytoin 300 mg IV QAM
21. Phenytoin 300 mg IV QPM
22. Phenytoin 200 mg IV QHS
give this dose qPM
23. Heparin Flush Port (10units/ml) 5 ml IV DAILY:PRN
10 ml NS followed by 5 ml of 10 Units/ml heparin (50 units
heparin) each lumen Daily and PRN. Inspect site every shift.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] Rehab
Discharge Diagnosis:
Seizure
Metastatic Melanoma
Bacteremia
Hypertension
Discharge Condition:
Good, afebrile
Discharge Instructions:
Please continue to take all your medications and follow up with
your appointments below.
If you have further seizures, fevers, or chills or other
concerning symptoms please contact your oncologist or return to
the emergency room.
Followup Instructions:
Provider: [**Name10 (NameIs) 4338**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2154-1-14**] 12:00
Provider: [**Name10 (NameIs) 5005**] [**Last Name (NamePattern4) 5342**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2154-1-14**] 3:00
.
Please call [**0-0-**] to setup a follow up appointment with
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1729**] in 1 month.
Completed by:[**2153-12-14**]
|
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"285.9",
"401.9",
"112.0",
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"780.39",
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"197.8",
"V13.01",
"198.3",
"438.11",
"431",
"V10.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.29"
] |
icd9pcs
|
[
[
[]
]
] |
12099, 12151
|
6994, 9705
|
278, 301
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12247, 12264
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5968, 6971
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3770, 4095
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231, 240
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329, 2094
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4674, 5949
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4110, 4658
|
2116, 3304
|
3320, 3645
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,215
| 124,183
|
37990
|
Discharge summary
|
report
|
Admission Date: [**2143-10-21**] Discharge Date: [**2143-10-24**]
Date of Birth: [**2089-10-13**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Prednisone
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
S/P Fall, PNA, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
54 YO M CAD, chronic, likely diastolic CHF who presented 3 days
after being pushed down several stairs with left wrist and ankle
pain as well as hypotension and acute renal failure. The patient
was pushed down several stairs 3 days PTA and land on his left
side injuring his left ankle, wrist and ribs. He denies any LOC
or trauma to his head. For the next 3 days he stayed in bed for
12-14 hours at a time. He was however, able to take his home
meds each day. He was experiencing chills and nightsweats. He
got up and almost fell [**1-14**] generalized weakness. Shortly after
this incident, he decided to present to the ED. In the ED, his
SBP was 90/60 so a LIJ was placed and he received 3L NS. Labs
were notable for creatinine 2.1 from 1.2 in [**8-21**]. A CXR was c/f
possible PNA so he was also given vanc/zosyn and transferred to
the MICU. In the MICU, he was given an additional 2L fluid,
continued vanc/levo. His home anti-hypertensives as well as
diuretics were held. Given his generalized malaise and NS, he
was placed on droplet precautions for r/o flu.
.
At the time of transfer, he is c/o severe left ankle pain but
has no other specific complaints. He also tells me that he was
taking naprosyn 1-2 times daily for at least 1 week. He was
given this at his rest home/residence. He did not realize he was
getting it until recently and asked that they stop giving it as
he was told never to take NSAIDs when was hospitalized with ARF
in the past.
.
Review of sytems:
(+) Per HPI, slight cough productive of green phlegm
(-) Denies fever, recent weight loss or gain. Denies headache,
sinus tenderness, rhinorrhea or congestion. Denied shortness of
breath. Denied chest pain or tightness, palpitations. Denied
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias.
Past Medical History:
1) HTN
2) DM - diet controlled, with neuropathy
3) CAD s/p MI [**2138**] s/p CABG in [**2142-10-13**] with multiple CHF
hospitalizations since then.
4) CHF
5) etoh abuse
6) Gout
7) CRI, baseline Cr 1.2; per patient [**1-14**] longterm NSAID use
Social History:
Lives at a rest home. Denies ongoing alcohol use, smoking or
active drug use. Has used both cocaine and marijuana in the past
and was a heavy drinker in the past.
Family History:
Significant for grandmother with CHF.
Physical Exam:
Vitals: T: 97.4 BP: 93/41 P: 63 R: 26 O2: 98%
General: Alert, oriented, no acute distress, diaphoretic
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi; large lung volumes
CV: Regular rate and rhythm, normal S1 + S2, very distant heart
sounds, 2/6 systolic murmur heard at LUSB
Abdomen: obese, 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; left wrist and ankle with significant swelling, with
limited ROM [**1-14**] pain, no obvious deformities
Pertinent Results:
Admission labs [**10-21**]:
WBC-6.9 RBC-3.75* Hgb-10.8* Hct-31.8* MCV-85 MCH-28.9 MCHC-34.1
RDW-14.4 Plt Ct-206
Glucose-106* UreaN-32* Creat-2.1* Na-137 K-4.2 Cl-97 HCO3-27
AnGap-17
ALT-19 AST-26 LD(LDH)-410* CK(CPK)-65 AlkPhos-176* TotBili-1.2
Lactate-2.3*
Osmolal-290
Discharge labs [**10-24**]:
WBC-4.8 RBC-3.49* Hgb-10.2* Hct-29.4* MCV-84 Plt Ct-162
Glucose- 112* UreaN-17 Creat-1.4* Na-137 K-3.9 Cl-100 HCO3-28
AnGap-13
ALT-15 AST-14 LD(LDH)-329* AlkPhos-196* TotBili-0.9
Microbiology:
[**10-21**] [**Month/Day (4) **] cultures- pending
[**10-21**] MRSA screen- pending
[**10-21**] Urine culture- negative
[**10-22**] Influenza A and B DFA- negative
[**10-23**] Urine cx- pending
[**10-23**] [**Month/Year (2) **] cx- pending
[**10-23**] sputum cx-
GRAM STAIN (Final [**2143-10-23**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN CHAINS.
RESPIRATORY CULTURE (Preliminary):
Imaging:
[**10-21**] EKG: Rhythm may be sinus but consider also ectopic atrial
rhythm. Probable left atrial abnormality. Left axis deviation
may be due to left anterior fascicular block and consider also
possible prior inferior myocardial infarction. Anterolateral
lead ST-T wave changes are non-specific but cannot exclude
myocardial ischemia. Clinical correlation is suggested. Since
the previous tracing of [**2143-8-15**] there is no significant change.
[**10-21**] CXR:
Findings suggestive of mild congestion with left basilar opacity
reflecting either atelectasis or pneumonia/aspiration. If there
is strong
clinical concern for rib fracture, consider dedicated rib series
with skin
marker indicating the site of pain.
[**10-21**] Left hand/wrist x-ray:
No acute fracture or dislocation. Likely chronic triquetral
fracture, soft tissue swelling, osteoarthritis at the
radiocarpal joint.
[**10-21**] Left foot/ankle x-ray:
Bones are slightly demineralized. Mild degenerative disease is
seen at the
first MTP joint with adjacent areas of calcification, likely
chronic.
Retrocalcaneal spur is noted. Mild dorsal spurring along the mid
foot is seen on the lateral view of the foot. The ankle mortise
is symmetric and talar dome is smooth. No soft tissue
abnormalities are seen. No acute fracture or dislocation is
seen.
IMPRESSION: No acute findings.
[**10-23**] CXR:
There has been prior median sternotomy and coronary bypass
surgery.
Heart is upper limits of normal in size and there is a slight
upper zone
vascular re-distribution. Right-sided perihilar haziness,
peribronchial
cuffing are again demonstrated as well as a small amount of
fluid within the fissures. Within the left base, there is a
slightly improved appearance of streaky peribronchiolar
opacities with a predominantly linear orientation accompanied by
some bronchial wall thickening. This may be due to airways
related infection.
Brief Hospital Course:
54 YO M w CAD, CHF, CRI being called out from short stay in MICU
for hypotension, bradycardia and hypothermia who likely has
pneumonia after s/p fall 3 days prior to admission.
# Hypotension: Resolved. Patient presented to ED with SBP in 90s
and was briefly in the MICU for possible sepsis picture without
requirement of pressors. He was not thought to be septic given
good urine output and clinical appearance and transferred to the
floor for management. He did receive 5L of IVF while in the ED
and MICU. His hypotension was likely hypovolemia from poor PO
intake, insensible losses in the setting of chills and
nightsweats, and continued lasix and other anti-hypertensive
usage while at home. His carvedilol was restarted and decreased
to a dose of 12.5mg [**Hospital1 **]. His lisinopril was held during
admission and should not be restarted until he meets with his
PCP. [**Name10 (NameIs) **] cultures are still pending but urine culture from
admission was negative. HIV test was also pending at time of
transfer to rehab. Patient will be called and notified of
result.
# Pneumonia: Patient complained of subjective fever and chills
with night sweats at home as well as productive cough prior to
admission. His CXR on admission showed questionable left lower
lobe pneumonia which may have been from aspiration surrounding
fall or post viral. Flu was ruled out with negative DFA. He was
stable on room air. Repeat CXR showed mild fluid overload (in
setting of holding his lasix) and questionable airways related
infection in LLL. Treatment was started with [**Name10 (NameIs) 1378**] and
vancomycin which was switched to flagyl. He was discharged on
[**Name10 (NameIs) 1378**] and flagyl to complete a 7 day course.
# Likely acute on chronic diastolic CHF: Previous EF noted to be
50% in [**7-21**] echo completed at OSH but scanned into our computer
system. There were no clnical signs of failure but some fluid
overload was seen on CXR. His home lasix was initially held in
setting of acute renal failure but restarted once his renal
function improved. He had a negative set of enzymes and no EKG
changes to suggest ischemia. As previously mentioned, he was
resumed on a decreased dose of carvedilol, home dose of lasix
and lisinopril was held. He will need to discuss restarting his
lisinopril with his PCP.
# Acute on Chronic renal failure: Creatinine was elevated to 2.1
on admission with a FeNa of 0.3. This trended down to 1.4 with
baseline of 1.2 in [**8-21**] after 5L IVFs. Thus, his acute on
chronic picture was likely prerenal from poor PO intake or use
of naproxen/NSAIDs at home. His colchicine was initially held
and restarted at discharge when his renal failure improved.
Lisinopril still held.
# Left hand, foot, rib pain: No bony injury per x-rays, his pain
was controlled with standing tylenol, lidoderm, and PRN
oxycodone. Suspect this was the cause of his elevated LDH and
AP. Physical therapy worked with the patient and suggested that
he go to a rehab facility for continued physical therapy. He
was given an ankle supporting device.
# Anemia: His hematocrit has been stable. Normocytic with
elevated ferritin (pt takes Fe supplements) as he has a history
of poor nutrition. Also on folate and thiamine supplementation.
# Gout: Patient has a history of gout and takes cholchicine at
home. This medication was initially held given his acute renal
failure but restarted at time of discharge.
# Depression: His Citalopram was continued and home clonazepam
was initially held.
Medications on Admission:
Aspirin 325 mg PO Daily
Citalopram 20mg PO daily
Carvedilol 25mg PO BID
Omperazole 40mg PO daily
Simvastatin 80mg PO Daily
Clonzaepam 1mg PO TID
Trazodone 100mg PO QHS PRN
Colchicine 0.6mg PO Daily PRN Gout
Lisinopril 40mg PO Daily
Lasix 80mg PO daily
Ferrous Sulfate 325mg PO daily
NTG 0.3mg SL PRN
MVI 1 Tab PO Daily
Thiamine 100mg PO Daily
Folate 1mg PO Daily
Acet 325mg PO Q6 PRN Pain
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual asdir as needed for chest pain.
11. Clonazepam 0.5 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for anxiety.
12. Trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
13. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Oxycodone 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain: This not a long term medication and
should be discontinued as soon as possible.
15. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) patch Topical once a day: Apply to left ankle for 12
hours on and 12 hours off to control pain.
16. [**Date Range **] 750 mg Tablet Sig: One (1) Tablet PO once a day for
3 days.
17. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO three
times a day for 3 days.
18. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] rehab
Discharge Diagnosis:
Primary:
1. Acute on chronic renal failure
2. Pneumonia
Secondary:
1. Likely acute on chronic diastolic congestive heart failure
2. Gout
Discharge Condition:
Stable, renal failure improved, breathing well on room air
Discharge Instructions:
You were admitted to the hospital after falling down some stairs
and were found to have a low [**Hospital **] pressure and acute renal
failure. After your fall, you landed on your left side and
injured on your ankle and wrist. You had x-rays of these areas
which were negative for new fracture. Your [**Hospital **] pressure and
kidney function improved with IV fluids. You were also found to
have pneumonia which was treated with antibiotics and should be
continued for the next 3 days. You are being transferred to
rehab to continue working with physical therapy.
The following medications were added to your list:
1. [**Last Name (LF) **], [**First Name3 (LF) **] antibiotic, for pneumonia
2. Flagyl, an antibiotic, for pneumonia
3. Lidoderm for pain control
4. Carvedilol dose was decreased to 12.5mg [**Hospital1 **]
5. Please stop your lisinopril until you follow-up with your PCP
6. Oxycodone for pain control. This is a medication you will
only take for pain that is not controlled by tylenol and the
lidoderm patch. It is not for long term use. Do not drink or
drive while taking this medication. It may cause constipation.
If you experience worsening fevers or chills, chest pain,
difficulty breathing or worsening leg swelling, please call your
doctor or come to the ED.
Followup Instructions:
Please make an appointment with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 66235**] by calling
[**Telephone/Fax (1) 22331**].
|
[
"V45.81",
"428.0",
"403.90",
"285.9",
"311",
"458.9",
"274.9",
"250.60",
"357.2",
"584.9",
"486",
"585.9",
"719.47",
"729.5",
"428.33",
"786.50",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12148, 12196
|
6578, 10107
|
315, 322
|
12378, 12439
|
3443, 4608
|
13780, 13930
|
2686, 2725
|
10547, 12125
|
12217, 12357
|
10133, 10524
|
12463, 13757
|
2740, 3424
|
4644, 6555
|
249, 277
|
1829, 2221
|
350, 1811
|
2243, 2490
|
2506, 2670
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,254
| 196,317
|
41285
|
Discharge summary
|
report
|
Admission Date: [**2125-3-19**] Discharge Date: [**2125-3-22**]
Date of Birth: [**2074-2-4**] Sex: M
Service: MEDICINE
Allergies:
atenolol
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Weight loss, thirst, and increased urination
Major Surgical or Invasive Procedure:
None
History of Present Illness:
51 yo M with history of primary hyperaldosteronism and related
hypertension, presented to PCP today with complaint of weight
loss and increased urination. Was found to have a critically
high fingerstick bloodsugar and was referred to the ED. Patient
further elaborates upon story by noting that approximately 2
weeks prior to presentation he began to have nasal congestion
and cough, for which he took OTC cold medicine. He then began to
have increased urination as well as worsening of his vision. He
noted a near 20 pound weight loss. He was thirsty and was
continuously drinking [**Location (un) 2452**] juice and other fruit juices in the
few days leading up to presentation to PCP's office on
[**2125-3-19**].
.
Upon arrival to the ED vitals were: T 100.4, HR 107, BP 130/96,
RR 18, O2Sat 96% RA. Labs notable for hyponatremia to 118 upon
presentation, hyperglycemia to 983 and hyperkalemia to 6.7.
Patient was given two liters NS, 10 IV and subcut insulin,
kayexylate, and repeat labs with sodium 131, glucose 719,
potassium 4.8. Patient reported cough productive of green
sputum, though CXR unremarkable. UA also unremarkable. Vitals
prior to transfer to the MICU were: T 99.2, HR 100, BP 144/86,
O2Sat 96% RA.
Past Medical History:
1) Hyperaldosteronism s/p unilateral adrenalectomy
2) Secondary hypertension
3) Chronic kidney disease (baseline Cr 1.4 to 1.6)
4) Gout
5) Obesity
6) [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] disease
7) Sexual dysfunction
Social History:
Patient works as an engineering manager.
TOBACCO: Denies
ETOH: Rare on holidays
ILLICITS: Denies
Family History:
Extended family history of single person with diabetes and
single person with cancer. No immediate family history of heart
disease, cancer, diabetes.
Physical Exam:
On Admission:
VS: T 99.4, HR 101, BP 120/81, RR 16, 95% RA
GEN: NAD
HEENT: PERRL, EOMI, sclera anicteric, oral mucosa dry
NECK: Supple, no JVP elevation
PULM: CTAB
CARD: RR, nl S1, nl S2, III/VI systolic murmur at RUSB, S4
present
ABD: BS+, soft, NT, ND
EXT: no C/C/E
SKIN: Dry, no rashes
NEURO: Oriented x 3, CN II-XII intact, upper extremity extensor
muscle groups at full strength
PSYCH: Mood and affect appropriate
On Discharge:
VS: Tc 96.8, Tm 99, HR 79, BP 145/100, RR 18, O2 Sat 100% on RA
GEN: NAD
HEENT: PERRL, EOMI, moist mucus membranes
NECK: Supple, no JVP elevation
PULM: CTAB
CARD: RR, nl S1, nl S2, II/VI systolic murmur at RUSB
ABD: BS+, soft, NT, ND
EXT: no C/C/E
SKIN: Dry, no rashes
NEURO: Oriented x 3, CN II-XII intact
PSYCH: Mood and affect appropriate
Pertinent Results:
Admission labs:
CBC: WBC-6.3 RBC-5.08 Hgb-15.7 Hct-46.2 MCV-91 MCH-31.0
MCHC-34.1 RDW-12.1 Plt Ct-464*
Chemistry: Glucose-983* UreaN-37* Creat-2.0* Na-118* K-6.7*
Cl-76* HCO3-29 AnGap-20, Calcium-10.2 Phos-3.8 Mg-2.9*
Osmolal-311*
Blood gas: FiO2-20 pO2-46* pCO2-55* pH-7.37 calTCO2-33* Base
XS-4
Discharge labs:
CBC: WBC-8.2 RBC-4.00* Hgb-12.7* Hct-35.6* MCV-89 MCH-31.6
MCHC-35.5* RDW-11.7 Plt Ct-427
Chemistry: Glucose-126* UreaN-18 Creat-1.1 Na-139 K-3.8 Cl-102
HCO3-27 AnGap-14, Calcium-8.9 Phos-3.0 Mg-2.0
Other pertinent labs:
TSH-0.60
%HbA1c-13.3* eAG-335*
PA and lateral CXR:
FINDINGS: The heart size is at the upper limits of normal. The
mediastinal
contours demonstrate mildly tortuous aorta. The lungs are clear.
There is no
pleural effusion or pneumothorax. The osseous structures are
intact.
IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
Mr. [**Known lastname 89901**] is a 51 year-old man with history of primary
hyperaldosteronism and related hypertension, who presented to
PCP today with complaint of weight loss and increased urination
and was found to have fingerstick elevated to a critical level.
1. Hyperglycemia / Diabetes: Upon presentation to the ED,
glucose was 983. This represents a new diagnosis of diabetes in
the patient. In classifying his presentation he is neither DKA
nor HHS given lack of an anion gap and the relatively small
increase in serum osms overall. Despite this not clinically
being HHS or DKA, the patient was be treated along HHS pathway
given that clinically he is profoundly hypovolemic. Patient was
admitted from the ED to the MICU. In the MICU, an insulin drip
was started the evening of admission. The second day of
admission, the insulin drip was stopped. The patient was then
given NPH 10 units with lunch. However, his sugar was 500 and
[**Last Name (un) **] was consulted and recommended humalog 20units, lantus 40.
However, given but his sugar remained high, he went back on the
insulin gtt. The patient was weaned off insulin gtt on day [**3-21**]
and was now on lantus 40 and humalog sliding scale.
The patient was called out to the floor and was continued on
lantus 40 units with dinner and humalog sliding scale. The
patient's fasting glucose was in the 130s. He was discharged
home on the same regimen. He was given insulin education from
the RN. He will follow-up at [**Last Name (un) **] in one week. He was given
a glucometer and instructed to bring it to his [**Last Name (un) **]
appointment.
Of note, his HgbA1c was 13.3.
2. Gout: Pt with history of gout in the past, usually in his
right foot. He usually takes Alleve for pain control. During
admission, patient complained of pain on the plantar aspect of
his R foot. NSAIDs were avoided due to renal insufficiency (see
below) and steroids were avoided due to hyperglycemia. The
patient received one dose of colchicine, but did not tolerate
further doses secondary to diarrhea. Tylenol and oxycodone were
used for pain control. At discharge patient's pain had improved
and he did not require further oxycodone for pain control.
3. Hyponatremia: At presentation to ED corrected Na was 132 and
then climbed to 141 in 3 hours after administration of insulin
and 2L NS. Predominant cause of hyponatremia at presentation was
most likely net sodium losses from osmotic diuresis in setting
of glucosuria in last two weeks. Sodium was followed closely
during rehydration. Hyponatremia resolved during admission and
at discharge, sodium was 139.
4. Acute on chronic renal insufficiency: Patient with baseline
Cr in range of 1.4 to 1.6. His creatinine was 2.0 at
presentation, most likely caused by pre-renal azotemia given
profound osmotic diuresis from glucosuria. Patient was volume
resuscitated and at discharge creatinine was 1.1.
5. Hypertension: Patient with secondary hypertension requiring 3
home meds. Initially all anti-hypertensive medications were
held. Amlodipine was added back on the second day of admission.
Lisinopril was held until creatinine returned to baseline.
Lasix was held throughout admission given severe volume
depletion. Please consider restarting medication on outpatient
basis.
Medications on Admission:
1) Aspirin 81 mg daily
2) Amlodipine 10 mg daily
3) Lisinopril 40 mg daily
4) Furosemide 80 mg PO daily
5) Cholecalciferol 1000 units daily
6) Colchicine 0.6 mg PRN gout flare
7) Sildenafil 50 mg PRN
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
4. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
5. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID:PRN as
needed for Gout flare.
6. sildenafil 50 mg Tablet Sig: One (1) Tablet PO PRN as needed.
7. lancets Misc Sig: One (1) lancet Miscellaneous four times
a day.
Disp:*QS 1 month box* Refills:*2*
8. FreeStyle Lite Strips Strip Sig: One (1) strip
Miscellaneous four times a day.
Disp:*QS 1 month Box* Refills:*2*
9. Lantus 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous at bedtime.
Disp:*QS 1 month mL* Refills:*2*
10. Humalog 100 unit/mL Solution Sig: As directed units
Subcutaneous QACHS.
Disp:*QS 1 month mL* Refills:*2*
11. syringe with needle (disp) Syringe Sig: One (1) syringe
Miscellaneous QACHS.
Disp:*QS 1 month syringe* Refills:*2*
12. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every six (6)
hours as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: Type 2 Diabetes Mellitus, Hyperglycemia, Hyponatremia,
Acute on chronic renal insufficiency, gout
SECONDARY: Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to participate in your care Mr. [**Known lastname 89901**]. You
were admitted to the hospital with high blood sugar caused by
diabetes. You were initially admitted to the intensive care
unit for an insulin drip. Your blood sugars improved and we
have been controlling your sugar with insulin injections. You
will need to check your blood sugar and continue the insulin at
home.
Please make the following changes to your medications:
1. Add insulin lantus, 40 units, subcutaneously before bed
2. Add insulin humalog sliding scale
3. Add tylenol 650 mg every six hours as needed for foot pain -
do not take more than 4000 mg per day
Please see below for your follow-up appointments.
Followup Instructions:
[**Last Name (LF) 3510**], [**First Name7 (NamePattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Wednesday, [**2125-3-28**]
12:00 pm
[**Hospital1 641**]
[**Location (un) **], [**Location (un) **],[**Telephone/Fax (1) 89902**]
[**Hospital **] [**Hospital 982**] Clinic
([**Telephone/Fax (1) 28500**]
Thursday [**2125-3-29**]
7:30 AM Registration
8:00 AM Eye Imaging
8:30 AM Appointment with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **]
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"276.1",
"274.9",
"286.4",
"276.52",
"250.02",
"585.9",
"584.9",
"403.90",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8465, 8471
|
3808, 7104
|
312, 319
|
8646, 8646
|
2928, 2928
|
9525, 10106
|
1965, 2117
|
7354, 8442
|
8492, 8625
|
7130, 7331
|
8797, 9223
|
3242, 3442
|
2132, 2132
|
2566, 2909
|
9252, 9502
|
228, 274
|
347, 1566
|
2944, 3226
|
3464, 3785
|
2146, 2552
|
8661, 8773
|
1588, 1835
|
1851, 1949
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,919
| 120,128
|
28950
|
Discharge summary
|
report
|
Admission Date: [**2179-8-1**] Discharge Date: [**2179-8-9**]
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 7575**]
Chief Complaint:
found unresponsive after convulsions at rehab
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr [**Known lastname **] is a [**Age over 90 **]yo male with history of colon ca and bleeding
disorder who was found seizing in bed at [**Hospital 582**] rehab around
2200 on [**7-31**]. He was reportedly moving limbs, opening and
closing mouth and blinking with the seizure. His wife is not
sure
if there was lateralizing signs. He was unresponsive and
non-verbal by the time EMS arrived but was noted to be moving
his
right side. He was taken to OSH [**Hospital3 **] where a head CT
showed a large right Subdural Hemorrhage with midline shift.
According to the patient's wife, he had a fall 9 days ago at
home
that was not witnessed. He hit the back of his head on the door
jam and did not lose consciousness. He was able to call for
help
with his lifeline. When his wife arrived, she found him smiling
and oriented, insisting that he was ok. He went to an OSH where
staples were placed in his head and where he spent 1 night in
ICU
and 6 days total being followed for question of bleed in the
brain. The wife was told that the blood they saw was old and he
was sent to rehab.
The wife says that the patient complained of no HA, dizziness or
visual changes, but that he did complain of excessive
sleepiness.
She also notes that in the 48 hrs preceding today's event, he
had
periods of slurred speech and lethargy to the extent where he
would fall asleep mid conversation. He also had difficulty
bearing weight 1 day prior.
Past Medical History:
colon ca, AAA, spinal stenosis, nose bleeds requiring
transfusion, TURP requiring 4 units blood.
Social History:
lives at home with wife but coming from rehab. he is
a retired professor.
Family History:
n/c
Physical Exam:
BP:108/60 HR:58 R:14 O2Sats 100%, intubated
Gen: intubated.
HEENT: Pupils:2mm PERRL
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: intubated and unconsciuos. Eyes dont open to
pain, all extremities withdraw from pain except right arm.
Cranial Nerves:
Pupils equally round and reactive to light, to 2
mm bilaterally. Corneals present bilaterally. No Doll's eyes.
No response to nasal tickle. No blink to threat.
Motor: Normal bulk and tone bilaterally. otherwise unable to
assess.
Sensation: unable to assess
Toes upgoing bilaterally
Coordination: unable to assess
Pertinent Results:
[**2179-8-1**] 02:20AM GLUCOSE-224* UREA N-27* CREAT-1.3* SODIUM-133
POTASSIUM-4.2 CHLORIDE-96 TOTAL CO2-24 ANION GAP-17
[**2179-8-1**] 02:20AM CALCIUM-8.6 PHOSPHATE-4.6* MAGNESIUM-2.2
[**2179-8-1**] 02:20AM WBC-13.1* RBC-3.81* HGB-11.5* HCT-35.2*
MCV-92 MCH-30.2 MCHC-32.7 RDW-14.4
[**2179-8-1**] 02:20AM NEUTS-91.7* BANDS-0 LYMPHS-3.1* MONOS-4.8
EOS-0.1 BASOS-0.2
[**2179-8-1**] 02:20AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-2+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
BURR-1+ TEARDROP-OCCASIONAL
[**2179-8-1**] 02:20AM PLT COUNT-231
[**2179-8-1**] 02:20AM PT-13.1 PTT-26.7 INR(PT)-1.1
CT Head ([**8-1**])
1. Acute on chronic large right-sided subdural hematoma.
Maximum thickness
2.2 cm.
2. Subfalcine herniation with contralateral midline shift of
1.8 cm.
3. No fractures are seen. Surgical staples over posterior
scalp.
CT Head ([**8-5**])
Again seen is a large right subdural extraaxial fluid
collection,
which has the appearance consistent with acute superimposed on
chronic
hemorrhage. In comparison to the most recent study from [**2179-8-1**],
this has
increased in caliber. There is interval increase in the degree
of midline
shift and subfalcine herniation. Additionally, effacement of
the suprasellar
and ambient cisterns is concerning for right uncal herniation.
Brief Hospital Course:
Not a candidate for neurosurgical intervention. See neurosurgery
note for further details.
Patient was intubated for airway protection. After discussions
with family, decision was made to extubate patient which he
tolerated well. He was transferred to the floor where
neurological status initially improved. Was able to follow some
commands and communicate poorly, but was compromised throughout
stay.
Began to have increased edema as evidenced on CT. Exam worsened
and family decided that patient would not want aggressive
measures taken. Was made care measures only and followed by
palliative care.
Patient expired at 3:20am; was CMO at the time. His wife was
notified and declined autopsy. Cause of death was respiratory
arrest secondary to subdural hematoma.
Medications on Admission:
tylenol, amiodarone, lexapro
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
expired; respiratory arrest secondary to subdural hematoma
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"427.31",
"348.4",
"V66.7",
"852.20",
"780.39",
"780.6",
"V10.05",
"E888.9",
"287.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
4903, 4912
|
4020, 4794
|
273, 279
|
5014, 5023
|
2671, 3997
|
5079, 5089
|
1975, 1980
|
4874, 4880
|
4933, 4993
|
4820, 4851
|
5047, 5056
|
1995, 2194
|
188, 235
|
307, 1745
|
2331, 2652
|
2209, 2315
|
1767, 1866
|
1882, 1959
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,014
| 108,365
|
43776
|
Discharge summary
|
report
|
Admission Date: [**2172-10-15**] Discharge Date: [**2172-10-23**]
Date of Birth: [**2135-11-15**] Sex: F
Service: MEDICINE
Allergies:
Prochlorperazine
Attending:[**First Name3 (LF) 3918**]
Chief Complaint:
SOB, CP, n/v
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Ms. [**Known lastname **] is a 36 year old female with history of recently
diagnosed ALL, who came to the oncology clinic to receive her
chemothrapy and complained of worsening shortness of breath and
chest pain for a few days, and was referred to ED for further
evaluation and treatment. Per patient, she has been experiencing
worsening dyspnea for the past week when she had to increase the
number of pillows from 2 to 4 due to shortness of breath when
she slept. States a [**6-14**] midsternal chest pain that radiates
circumferentialy around the ribs to the back that started a few
days ago. Pain is gradual and constant and worse with
inspiration, gets better when she is sits up. Has a productive
cough with white/clear phelegm. Denies any fevers/chills/night
sweats.
.
She has also been experiencing severe nausea and vomiting for
the past week where she has been unable to hold any food down.
Her weight has been fluctuating but no big weight loss recently.
She does endorse dizziness since yesterday when she stands up,
relieved when she sits or lies down.
.
With her hx of asthma, she only uses her inhalers. Has not been
to the ED for any exacerbations. States an increased frequency
of use of her inhalers in the past few weeks.
.
Of note, patient recently presented to ED on [**2172-8-11**] with some
RUE weaknesa and parethesia, and was found to have a WBC of
140K, and emergently leukopheresed, and was diagnosed with ALL.
She was discharged on [**2172-9-22**], and has been receiving
chemotherapy regularly. Today is her phase II day 25 therapy.
.
In the ED, patient's initial vitals were: Afebrile, T98.2 BP
154/120 HR 138 RR 18 SPO297% on R/A. Sat's: off oxygen 93%, 97%
on 4L (depends on position). She was slightly tachypneic, RR
25-30s, and it hurts for her to breath in. She underwent CTA to
rule out PE. Her scan demonstrated large bilateral pleural
effusions and a small pericardial effusion. bedside US showed no
tamponade, and small effusion. She was given 1 gram of Cefepime,
500-1000cc of normal saline, had 200cc urine (no foley). No
change in HR was seen after receiving morphine or IVF. The
oncology fellow was notified of the patient's planned admission
and course. per onc fellow, no urgent need to tap, but may need
to tap overnight if pt is very symptomatic from the pleural
effusion.
.
She was transferred to the [**Hospital Unit Name 153**] for further management.
.
On the floor, she continued to complain of shortness of breath
while lying down, and is sitting up while talking. She continued
to complain of nausea.
.
Review of sytems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied any palpitations. Denied diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria.
Past Medical History:
PAST MEDICAL HISTORY:
- ALL
- Asthma: uses inhalers
- HTN
- Cervical Intraepithelial neoplasia
Social History:
SOCIAL HISTORY: Lives at home with aunt and sister. [**Name (NI) **] 2
children (7, 17). Denies alcohol, tobacco, illicit drugs. Was
previously employed at [**Company 59330**], hasn't been working since being
diagnosed with ALL in [**Month (only) 205**]. She hopes to go back to work. Denies
any recent travel. Her son has been sick with a cold, but hasn't
been with her since he got sick.
Family History:
FAMILY HISTORY:
No family h/o leukemia and lymphoma
Physical Exam:
PHYSICAL EXAMINATION:
VS: T: 98.7 HR: 131 BP 158/122 RR 30 Sat 100% on 4L
Pulsus paradoxus was 5.
GENERAL: No acute distress. She is alert and oriented x3 in good
mood and affect.
HEENT: Pupils are equal and reactive to light. Conjunctivae are
pink. Oropharynx is dry. There are no specific lesions on lips,
teeth, or gums.
NECK: Supple, with no thyromegaly, and no palpable mass.
JVP=10cm
LYMPH NODES: There is no palpable lower cervical,
supraclavicular, axillary, or groin lymphadenopathy.
LUNGS: Decreased breath sounds bilaterally. Poor airway entry.
Diffuse crackles and wheezes
ABDOMEN: Soft, nontender, nondistended with no
hepatosplenomegaly and no masses.
EXTREMITIES: There is no lower extremity edema.
SKIN: There are no rashes and no palpable lesions.
Pertinent Results:
LABORATORIES:
WBC 0.5 Hgb 8.9 Hct 26.3, plt 16 MCV 85 N:23.0 L:74.7 M:1.4
E:0.7 Bas:0.2
Gran-Ct: 161 , repeat 80 --> by discharge the ANC was 1580
On discharge, the pt's WBC's were 4.9, h/h 8.2/24.7 and plts 9
142 105 10
-------------123
3.6 27 0.7
Chems were normal through admission, normal renal function,
except for phosphorous which had the tendency to run high, was
4.8 on d/c.
CK's normal through admission.
Tbili 1.7 (1.3 indirect and 0.4 direct) on admission, trended
down to 1.0 on d/c.
ALT/AST 44/27 on admit, 43/24 on d/c.
LDH 273 on admit and 265 on d/c.
AlkP normal through admission
Alb 3.7
CK MB was normal through admission [**7-12**]
TropT slightly elevated at 0.09-0.11 then trended slightly more
to 0.14-0.17, however not thought to be due to ACS
BNP 5007 on admission
PT: 14.1 PTT: 24.3 INR: 1.2
UA: neg
BCx negative x2
IMAGING:
- CXR ([**2172-10-15**])
IMPRESSION: New interstitial edema and moderate bilateral
pleural effusions with adjacent atelectasis.
.
- TTE [**2172-10-16**]:
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is severe global
left ventricular hypokinesis (LVEF = XX %). No masses or thrombi
are seen in the left ventricle. There is no ventricular septal
defect. Right ventricular chamber size is normal. with severe
global free wall hypokinesis. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests a restrictive filling abnormality, with elevated left
atrial pressure. There is mild pulmonary artery systolic
hypertension. There is a small pericardial effusion. There are
no echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2172-8-12**],
global biventricular systolic dysfunction is new. The
pericardial effusion is new.
.
- CTA report [**2172-10-15**]: FINDINGS: There is no evidence of
pulmonary embolism, aortic dissection, or
pneumothorax. The thoracic aorta is normal in caliber.
There are bilateral moderate new pleural effusions with adjacent
atelectasis
in the lower lobes bilaterally. There are scattered noncalcified
pulmonary
nodules, which are new compared to the recent prior study of
[**9-19**]. Small-
to-moderate pericardial effusion is present. There is diffuse
interstitial
septal thickening, compatible with edema. The airways are patent
to the
subsegmental levels bilaterally. There is no hilar, mediastinal
or axillary adenopathy.
This study is not optimized for subdiaphragmatic evaluation.
Known liver mass in segment VI is not imaged on this study.
IMPRESSION:
1. New large bilateral pleural effusions, small-to-moderate
pericardial
effusion, and interstitial septal thickening, compatible with
edema.
2. Bilateral noncalcified pulmonary nodules. Short interval
development
since the prior study favors infectious/inflammatory etiology,
progression of
the disease less likely.
.
EKG on admission ([**2172-10-15**]):
rate 127, sinus rhythm. normal axis. pr, qrs and qt intervals
within normal range. low amplitude qrs in limb leads. t wave
flattening in limb leads. less than 0.5mm ST depression in V5,
V6.
.
ECHO [**2172-10-16**]
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is severe global
left ventricular hypokinesis (LVEF = XX %). No masses or thrombi
are seen in the left ventricle. There is no ventricular septal
defect. Right ventricular chamber size is normal. with severe
global free wall hypokinesis. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests a restrictive filling abnormality, with elevated left
atrial pressure. There is mild pulmonary artery systolic
hypertension. There is a small pericardial effusion. There are
no echocardiographic signs of tamponade.
.
Compared with the prior study (images reviewed) of [**2172-8-12**],
global biventricular systolic dysfunction is new. The
pericardial effusion is new.
.
EKG [**2172-10-16**]
Sinus tachycardia with slowing of the rate compared to the
previous tracing
of [**2172-10-15**]. The T waves are biphasic in leads I, II aVL, aVF and
V3-V6, similar
to that recorded on [**2172-9-19**] though not as prominent. Followup
and clinical
correlation are suggested.
.
CXR [**2172-10-16**]
FINDINGS: Cardiomediastinal silhouette appears unchanged from
previous study.
Bilateral pleural effusions are seen with bibasilar atelectasis
and mild
pulmonary edema. There is no pneumothorax.
.
ECHO [**2172-10-20**]
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is moderate global
left ventricular hypokinesis (LVEF = 30%). There is no
ventricular septal defect. The right ventricular cavity is
mildly dilated with focal hypokinesis of the apical free wall.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve leaflets are structurally normal. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. There is mild
pulmonary artery systolic hypertension. There is a small
pericardial effusion. The effusion appears circumferential.
IMPRESSION: Moderate global left ventricular systolic
dysfunction. Mild regional right ventricular systolic
dysfunction. Mild mitral regurgitation. Mild pulmonary
hypertension. Small pericardial effusion.
Compared with the prior study (images reviewed) of [**2172-10-16**],
right ventricular cavity is slightly larger, although both RV
and LV overall systolic function has improved. Pericardial
effusion size and other findings are similar.
CXR [**2172-10-21**]
Lung volumes have improved, possibly because of deeper
inspiration. Moderate
bilateral pleural effusions persist. Bibasilar atelectasis is
improved.
Upper lungs clear. Moderate enlargement of the cardiac
silhouette is
unchanged. There is no distention of mediastinal veins to
suggest particular
elevation of central venous pressure.
Brief Hospital Course:
36yo newly Dx'd ALL in [**8-13**], currently getting E2993 Tx, phase
II day+26 admitted for SOB, orthopnea, n/v found to have heart
failure with EF 15-20% with bilateral pleural effusions and
small pericardial effusion, pancytopenic.
.
1. Heart [**Name (NI) 94059**] pt was admitted to the ICU and Dx'd with
acute heart failure, which was thought to be due to Daunorubicin
therapy in the past several months VS myocarditis/pericarditis.
She was tachycardic and HTN, had a CTA without PE or dissection
and had a TTE showing EF of 15-20%, global hypokinesis of LV,
hypokinesis of free wall of RV, and small pericardial effusion.
Given IV Lasix diuresis with good response, hemodynamically
stabilized and called out to the floor where she was continued
on IV Lasix diuresis, then switched to PO diuresis. Cards was
consulted and recommended a heart failure regimen of Lasix 40mg
PO qday, Metoprolol 25mg PO bid, Lisinopril 5mg POqd, and
Aldactone 25mg PO qday, which the pt was started on and
tolerated well. The pt then had a repeat echo the day after she
developed some acute CP (see below) which showed an improvement
in her EF to 30%, improvement in systolic fxn of both
ventricles, no increase in pericardial effusion. By the time of
discharge, the pt's vitals had stabilized and bp's were in the
low 100's-110's and pulse 80's-90's, and her weight had
decreased down to pre-admission weight. The pt will be d/c'd on
her current HF regimen and will need to be reassessed, including
her heart failure meds and repeat echo in the future.
.
2. Chest pain--Pt c/o substernal pleuritic type pain on
admission, and had one acute episode of SOB and substernal chest
pain on the floor, pleuritic in nature, for which an EKG was
obtained which was significant for small voltage QRS complexes
in V3-V6 (no ST changes), a CXR was obtained which showed
continued pleural effusions, and cardiac enzymes were drawn. The
pt received a dose of 40mg IV Lasix and had good UOP overnight,
and the CP/SOB resolved uneventfully. Pt was not given any ASA
during the admission due to low platelet count.
.
Several EKG's were recorded through her admission, all without
ST changes, and CE's were trended through admission. CKMB's
where flat, however there was a small increase in her Troponins
ranging from 0.09 to 0.17. This small increase was thought to be
due to either demand ischemia or to a possible myo/pericarditis
picture, for which Cards recommended doing an oupt cardiac MR in
the future is still clinically warranted.
.
3. [**Name (NI) 94060**] pt had crackles on PE, was requiring O2 via NC, and
had CXR showing pleural effusions. She was started on her home
asthma regimen and occasionally given prn Xopenx nebs, Alubterol
being avoided due to tachycardia at the time. She was weaned off
the O2 as her HF resolved and by time of d/c was satting well on
room air, not tachypneic, not having difficulty breathing.
.
4. [**Name (NI) 94061**] pt was neutropenic on admission and started
on empiric Cefipime, despite being afebrile. The pt never spiked
a fever through admission and Cefipime was discontinued. All
cultures were negative through admission. The pt was started on
Neupogen with appropriate response, which was then d/c'd. The pt
will be discharged on her home regimen of prophylactic ABx
including Atovaquone and Acyclovir.
.
5. [**Name (NI) 94062**] pt was anemic but felt to be at baseline. Did
receive 1U PRBC's through admission but Hct remained stable
through rest of admission.
.
6. [**Name (NI) 94063**] pt was thrombocytopenic with plts 21 on
admission and received 5U plts during admission, with minimal
response. It was felt that the pt had many platelet antibodies
as a result of a long platelet transfusion history and
considering that she was being followed for future
transplantation, that further platelet transfusions would
increase her antibodies and make transplantation more difficult.
Therefore, a lower platelet count was tolerated and aggressive
transfusion was not pursued. She had no clinical evidence of
bleeding, her Hct remained stable, and her tachycardia trended
down as her volume overload and heart failure resolved.
.
7. Pericardial effusion--There was some concern for a
hemorrhagic pericarditis, with a small pericardial effusion seen
on echo and her platelets being low and low voltage QRS
complexes seen on an EKG once. She did not have a rub or pulsus
paradoxus on PE. She received a follow up echo showing that the
pericardial effusion had not increased in size.
.
8. [**Name (NI) 94064**] pt was complaining of a headache on admission
that she said was consistent with what she described as a
history of migraines, however she did not have phonophobia,
photophobia, or an aura. She did however appear to be in pain.
She was started on her home dose of Ultram and she refused any
narcotic pain meds. She occasionally c/o this h/a during
admission but they spontaneously resolved without any
complications with conservative Ultram management.
Medications on Admission:
Medications: (confirmed by [**2172-10-15**] hem/onc note)
ACYCLOVIR - 200 mg Capsule - 2 Capsule(s) by mouth three times a
day
AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth daily
ATOVAQUONE [MEPRON] - 750 mg/5 mL Suspension - 10 mL by mouth
once a day
CIPROFLOXACIN - 250 mg Tablet - 1 Tablet(s) by mouth twice a
daily
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs
inhaled twice a day
IPRATROPIUM BROMIDE [ATROVENT HFA] - 17 mcg/Actuation Aerosol -
2
puffs po four times a day as needed for prn
LORAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth every 6 hours as
needed for Nausea
MERCAPTOPURINE - 50 mg Tablet - 2 Tablet(s) by mouth once daily.
Bring to appointment on Monday [**2172-9-21**].
METOCLOPRAMIDE - 5 mg Tablet - [**2-7**] Tablet(s) by mouth every 8
hours as needed for Nausea
OLANZAPINE [ZYPREXA] - 2.5 mg Tablet - 1 Tablet(s) by mouth
twice
a day
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth daily
ONDANSETRON HCL - 8 mg Tablet - one Tablet(s) by mouth every 8
hours as needed for Nausea
OXYCODONE - (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth every 6 hours as needed for Pain
TRAMADOL - 50 mg Tablet - [**2-7**] Tablet(s) by mouth every six (6)
hours as needed for headache
Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*3*
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*3*
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO ONCE (Once).
Disp:*30 Tablet(s)* Refills:*3*
4. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*3*
5. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
6. Atovaquone 750 mg/5 mL Suspension Sig: One (1) PO BID (2
times a day).
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
8. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) as needed for nausea.
9. Olanzapine 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO three times a day as needed for nausea.
12. Tramadol 50 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for pain.
13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
puffs Inhalation twice a day as needed for shortness of breath
or wheezing.
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
1. ALL
2. Heart failure
Discharge Condition:
By the time of discharge, the pt's volume overload was much
improved, heart function had slightly improved as seen by heart
ultrasound, had good oxygen saturation on room air and vital
signs were stable, had been stabilized on a medicine regimen,
and was medically clear for discharge.
Discharge Instructions:
You were admitted to [**Hospital1 18**] and found to be in heart failure. You
were stabilized in the intensive care unit and given medicines
to draw off extra fluids from your body. Cardiology was
consulted and recommended a regimen to treat your heart failure.
You had a repeat ultrasound of your heart which showed some
improvement.
You were started on 4 new medicines which will be very important
to continue after discharge: Lasix, Metoprolol, Lisinopril, and
Aldactone. You will need to follow up with your physician to
assess your heart function and the necessity of continuing these
medicines. It is very important to take these medicines as
prescribed as your heart is still not up to its full strength.
Please return to the hospital or to a health care provider if
you experience fevers, chills, or night sweats, continued
shortness of breath, difficulty breathing, swelling of your
legs, chest pain, or any other concern.
Followup Instructions:
Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4613**] on Monday [**2172-10-26**] at 2pm on [**Hospital Ward Name 23**] [**Location (un) 436**].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]
Completed by:[**2172-10-27**]
|
[
"787.01",
"204.00",
"401.9",
"518.81",
"287.4",
"285.9",
"530.81",
"428.41",
"428.0",
"288.00",
"E933.1",
"786.50",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
18684, 18736
|
11055, 16037
|
293, 300
|
18804, 19092
|
4559, 11032
|
20074, 20384
|
3706, 3744
|
17380, 18661
|
18757, 18783
|
16063, 17357
|
19116, 20051
|
3759, 3759
|
3781, 4540
|
241, 255
|
2935, 3145
|
356, 2917
|
3189, 3263
|
3295, 3674
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,728
| 142,693
|
36288
|
Discharge summary
|
report
|
Admission Date: [**2127-12-2**] Discharge Date: [**2127-12-10**]
Date of Birth: [**2062-4-30**] Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3645**]
Chief Complaint:
abnormal gait and numbness on his b/l his lower extremities for
two days
Major Surgical or Invasive Procedure:
1. Revision T2, T3, T4, T5, T6 bilateral laminectomy,
medial facetectomy, foraminotomies for removal of
intraspinal extradural mass, most likely renal cell
carcinoma.
2. Removal of posterolateral instrumentation and re-
instrumentation T2 to T7.
3. Primary T7 bilateral laminectomy, medial facetectomy and
foraminotomy for removal of intraspinal extradural mass,
most likely renal cell carcinoma.
4. Application of local autograft as well as allograft.
History of Present Illness:
A 65-year-old gentleman with a history of metastatic renal cell
carcinoma to spine presented with abnormal gait and numbness on
his lower extremities for two days. Because of the metastasis
in the spine, the pt underwent T2-T6 bilateral laminectomy in
[**Month (only) **], he initially felt fine. However, in the morning of
yesterday, he suddenly had difficulty in walking, which
progressively worse over the past 24 hours. He denied weakness,
but he had numbness on his B/L lower extremities. He denied
urine or fecal incontinence although he had constipation that he
attributed to pain medications. He denied fever, chill, but he
still had back pain around his surgical site, which had not
gotten worse.
In the ED, Orthopedics did consult and recommended " NPO after
midnight, NO ANTICOAGULATION, consider IV dexamethasone. Needs
discussion between radiation vs. surgery in AM"
In an OSH [**Name (NI) **], pt had already received one dose of dexamethasone
at 10 mg.
Review of Systems:
(+) Per HPI.
(-) Denies fever, chills, night sweats. Denies blurry vision,
diplopia, loss of vision, photophobia. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies chest pain or
tightness, palpitations, lower extremity edema. Denies cough,
shortness of breath, or wheezes. Denies nausea, vomiting,
diarrhea, abdominal pain, melena, hematemesis, hematochezia.
Denies dysuria, stool or urine incontinence. Denies arthralgias
or myalgias. Denies rashes or skin breakdown. All other systems
negative.
Past Medical History:
Oncology history:
ONCOLOGIC HISTORY:
[**2-24**] : lower back pain and hematuria &#[**Numeric Identifier 25684**]; CT: 8-cm mass from
the upper pole of the right kidney and compressing the IVC.
[**5-27**]: right radical nephrectomy&#[**Numeric Identifier 25684**];RCC, grade [**1-23**],
clear-cell type with clean margins and no lymphatic invasion.
(stage T2N0M0)
[**9-26**] and [**12-28**]: CT scan: 4-cm right lower lobe nodule
suspicious for metastatic disease. Bronchoscopy and biopsy :
nondiagnostic.
[**1-28**] PET : nodule was intensely FDG avid&#[**Numeric Identifier 25684**]; open
thoracotomy and wedge resection of the lung nodule
surveillance CT scan in [**2-26**]: 2.6 x 1.5-cm right paratracheal
lymphadenopathy. Bronchoscopy and EBUS-guided biopsy: renal cell
carcinoma.
[**2125-4-26**]: VATS-assisted mediastinal lymph node dissection by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital3 2358**].
[**2125-11-30**] CT: progression of disease located in the mediastinum,
right hilum, and in the lung parenchyma bilaterally. A small
pericardial effusion was also noted on this report.
[**2125-12-21**]- [**2126-4-20**]:completed IL2 therapy
[**2126-7-10**]: Torso CT: decrease in size of mediastinal and hilar
lymphadenopathy. Increase in size of right upper lobe pulmonary
nodule compared to prior.
[**1-/2127**]:new stable adrenal lesion, likely metastatic
[**8-/2127**]: Left laparoscopic adrenalectomy
[**10-31**] - present with back pain - thoracic spinal met, resection
at [**Hospital1 18**]
Other PMH:
Hyperlipidemia
Recent hypothyroid after IL2
PSH;
T3 to T5 laminectomy and posterior fusion from T2 to T7 on
[**2127-10-18**]
Left laparoscopic adrenalectomy on [**2127-9-2**]
Social History:
Lives with his wife and 3 children in [**Location (un) 82229**], [**State 1727**]. His
children are 18, 20 and 21 years of age. He never smoked and
drank alcohol only occasionally.
Family History:
non-contributory
Physical Exam:
Vitals - T:97 74 118/75 18 99% RA
GENERAL: NAD, lying comfortably on bed
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: AT/NC, EOMI, anicteric sclera, pale conjunctiva, patent
nares, MMM, nontender supple neck, no LAD, no JVD.
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: he was able all extremities, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: 4/5 strength bilaterally throughout. Sensation intact and
symmetric throughout. EOMI. The reflex was hyperactive in the
b/l lower extremities . Loss of proprioception in BLE.
.
Pertinent Results:
[**2127-12-2**] 04:33PM LACTATE-1.4
[**2127-12-2**] 04:20PM GLUCOSE-134* UREA N-22* CREAT-1.0 SODIUM-134
POTASSIUM-4.7 CHLORIDE-99 TOTAL CO2-24 ANION GAP-16
[**2127-12-2**] 04:20PM WBC-7.8 RBC-4.67 HGB-12.6* HCT-39.1* MCV-84
MCH-27.0 MCHC-32.3 RDW-13.3
[**2127-12-2**] 04:20PM NEUTS-94.1* LYMPHS-4.9* MONOS-0.5* EOS-0.3
BASOS-0.1
[**2127-12-2**] 04:20PM PLT COUNT-318
MRI of the spine:
T2-T7 posterior fusion with postop artifact in spinal canal
which obscures
evaluation.
Within surgical bed, there is heterogeneous appearnce within
spinal canal
which may represent susceptilibity +/- residual/recurrent tumor
or
postsurgical fibrosis.
Canal and foramina patent in lower T- and L/S-spine. Cord has
normal signal at these levels.
Brief Hospital Course:
Patient was transferred from OMED to the [**Hospital1 18**] Spine Surgery
Service and taken to the Operating Room for the above procedure.
Refer to the dictated operative note for further details. The
surgery was without complication and the patient was transferred
to the PACU in a stable condition. TEDs/pnemoboots were used
for postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. Foley was removed on POD#2. Physical
therapy was consulted for mobilization OOB to ambulate with
support. Hospital course was otherwise unremarkable. On the
day of discharge the patient was afebrile with stable vital
signs, comfortable on oral pain control and tolerating a regular
diet. Patient will require rehabilitation considering his
neurological status. He will also need adjuvant therapy for
control of local recurrence in the future.
Medications on Admission:
Lipitor 10 mg Tab
1 Tablet(s) by mouth daily
Sutent 50 mg Cap
1 Capsule(s) by mouth once per day for 28 days, then 14 days off
fludrocortisone 0.1 mg Tab
1 tablet by mouth daily
prednisone 2.5 mg Tab
3 tablets by mouth daily and increase if sick or surgery
oxycodone-acetaminophen 5 mg-325 mg Tab
[**12-22**] Tablet(s) by mouth every four (4) hours as needed for pain
levothyroxine 75 mcg Tab
1 Tablet(s) by mouth daily
Discharge Medications:
1. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
4. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for indigestion.
11. Heparin 5000sc tid
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 12564**] hospital
Discharge Diagnosis:
1. Recurrent intraspinal extradural tumor, most likely
renal cell carcinoma, T2 to C7.
2. Thoracic stenosis.
3. Recurrent thoracic myelopathy.
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:
Immediately after the operation:
- Activity: As tolerated
- Rehabilitation/ Physical Therapy:
You can walk as much as you can tolerate. Limit any kind of
lifting.
- Diet: Eat a normal healthy diet. You may have some
constipation after surgery. You have been given medication to
help with this issue.
- Wound Care: Remove the dressing in 2 days. If the
incision is draining cover it with a new sterile dressing. If
it is dry then you can leave the incision open to the air. Once
the incision is completely dry (usually 2-3 days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing and call the office.
- You should resume taking your normal home medications.
- You have also been given Additional Medications to
control your pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
- Follow up:
o Please Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
o At the 2-week visit we will check your incision, take
baseline X-rays and answer any questions. We may at that time
start physical therapy.
o We will then see you at 6 weeks from the day of the
operation and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
see discharge instructions. Activity as tolerated. No
restrictions except for bending forward, and lifting.
Treatments Frequency:
see discharge instructions
Followup Instructions:
You follow up visit at the spine center is scheduled for the [**2127-12-23**] at 1 pm with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]. Please call Spine center
to confirm appointment.
Also please schedule an appointment with Dr [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] for
radiation in the first week of [**Month (only) 404**] (after the Spine center
appointment on 3rd). Dr[**Name (NI) 82230**] office number is [**Numeric Identifier 82231**]
Please schedule an appointment with Dr [**Last Name (STitle) **] 4 weeks from
the day of the surgery for systemic therapy.
|
[
"285.9",
"272.4",
"724.01",
"V10.52",
"781.2",
"336.3",
"198.3",
"244.3",
"E933.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.05",
"03.4",
"81.63"
] |
icd9pcs
|
[
[
[]
]
] |
8487, 8544
|
5900, 6952
|
382, 861
|
8735, 8735
|
5135, 5877
|
10980, 11603
|
4380, 4398
|
7434, 8464
|
8565, 8714
|
6978, 7411
|
8918, 8918
|
4413, 5116
|
10799, 10907
|
10929, 10957
|
10292, 10781
|
8952, 9010
|
1885, 2403
|
270, 344
|
9266, 10281
|
889, 1866
|
8750, 8894
|
2425, 4165
|
4181, 4364
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,444
| 114,251
|
16438+56764
|
Discharge summary
|
report+addendum
|
Admission Date: [**2187-10-27**] Discharge Date: [**2187-10-31**]
Date of Birth: [**2143-1-6**] Sex: F
Service: CCU
CHIEF COMPLAINT: Inferior myocardial infarction, status post
cardiac arrest.
HISTORY OF PRESENT ILLNESS: The patient is a 44 year old
female with a history of insulin dependent diabetes mellitus,
asthma and seizure disorder, who presented to an outside
hospital with complaints of shortness of breath, difficulty
breathing which began the night prior to admission. The
patient did not have a cough, no chest pain, no
light-headedness and no weakness. The patient was given
Combivent in the ambulance with improvement. She had run out
of her medications a couple days prior to admission.
In the Emergency Department, she had an asystolic arrest and
was given Atropine multiple times which converted her to
ventricular fibrillation arrest and then to ventricular
tachycardia. At this time, the patient was intubated and put
on a ventilator. The patient also received Epinephrine,
Amiodarone, and Morphine. She became hypotensive and was
started on Dopamine subsequently. There was a question of
whether the patient had had a seizure prior to her cardiac
arrest.
PAST MEDICAL HISTORY:
1. Insulin dependent diabetes mellitus.
2. Asthma.
3. Seizure disorder.
4. Irregular heart rate.
5. Bronchitis.
MEDICATIONS:
1. Insulin.
2. Tegretol.
3. Zocor.
4. Combivent.
5. Theophylline.
6. Avandia.
7. Zantac.
ALLERGIES: Aspirin and Penicillin.
SOCIAL HISTORY: The patient is a two pack per day smoker.
PHYSICAL EXAMINATION: Vital signs on admission were 99.2
temperature, blood pressure 90/50, heart rate 80s with normal
sinus rhythm, respiratory rate approximately 25 on an assist
control ventilator with FIO2 of 0.6, tidal volume 600 and
PEEP 5 with pressure support 22. In general, the patient was
intubated and on the ventilator. Head, eyes, ears, nose and
throat examination - Multiple freckles, skin discoloration on
eyelids. The pupils are equal, round, and reactive to light
and accommodation. Eyes midline when open. Neck - jugular
venous distention not appreciated, no lymphadenopathy. No
carotid bruits. Cardiovascular - regular rate and rhythm, no
murmurs, rubs or gallops. Pulmonary - good breath sounds
with ventilation, decreased breath sounds at the bases
bilaterally. Abdomen reveals positive bowel sounds, soft,
obese. Extremities - no cyanosis, clubbing or edema. Good
pulses bilaterally. Bilateral groin lines. No bleeding,
hematomas or bruits.
LABORATORY DATA: On admission, laboratories were significant
for a white blood cell count of 22.3, hemoglobin 10.8,
hematocrit 36.4 and platelet count 296,000. Coagulation
studies showed partial thromboplastin time of 26.5 and INR of
1.0. Potassium 4.6, blood urea nitrogen 14, creatinine 0.9.
Tegretol level was subtherapeutic at 1.9 and Theophylline
level was less than 0.8. The patient's cardiac enzymes,
haptoglobin and lipid panel were pending.
Cardiac catheterization showed right dominant system with
normal left main coronary artery, normal left anterior
descending, normal left circumflex. Her right coronary
artery was occluded and was stented. The electrocardiogram
was consistent with this and showed left axis deviation,
possible left bundle branch block, ST elevations in leads II,
III and aVF, reciprocal depressions in I, aVL and V1 through
V6.
CT of the head at the outside hospital was negative per
report.
HOSPITAL COURSE: The patient was admitted to the CCU service
and was slowly weaned off Dopamine and weaned off the
ventilator.
The remainder of her hospital course is to be addended.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15176**], M.D. [**MD Number(1) 15177**]
Dictated By:[**Name8 (MD) 10249**]
MEDQUIST36
D: [**2187-10-31**] 17:11
T: [**2187-10-31**] 18:34
JOB#: [**Job Number 46758**]
Name: [**Known lastname **], IVADEAN Unit No: [**Numeric Identifier 8618**]
Admission Date: [**2187-10-27**] Discharge Date: [**2187-11-2**]
Date of Birth: [**2143-1-6**] Sex: F
Service:
Please change initial portion of the dictation summary to
discharge date [**2187-11-2**]. This is a stat dictation
addendum.
HOSPITAL COURSE BY SYSTEMS:
1. Cardiovascular: The patient was transferred from an
outside hospital intubated and sent for emergent cardiac
catheterization. On catheterization, the patient was found
to have total occlusion of the mid portion of the right
coronary artery. The patient underwent angioplasty and stent
placement with no residual stenosis. The hemodynamics on
catheterization demonstrated a right atrial pressure of 15,
pulmonary capillary wedge pressure is 23, cardiac output of
5.57, and cardiac index of 2.91.
Post catheterization, the patient became hypotensive and
required dopamine for blood pressure support. The patient
was subsequently transferred to the Cardiac Intensive Care
Unit. The patient received 18 hours of Integrilin and was
started on Plavix 75 mg p.o. q.day for a 30 day course. The
patient ruled in for a ST elevation inferior wall myocardial
infarction with a peak creatinine kinase of 3,219 and
creatinine kinase MB of 258.
The patient remained hemodynamically stable and the dopamine
was weaned off on hospital day #2. The patient continued
without further chest pain or EKG changes throughout the
remainder of the hospitalization.
A post myocardial infarction transthoracic echocardiogram
demonstrated decreased left ventricular systolic function
with an ejection fraction of 40 to 50% secondary to moderate
hypokinetic basal and mid ventricular segments of the
inferior and posterior free wall of the left ventricle. The
echocardiogram also demonstrated 1+ mitral regurgitation,
normal left ventricular size and wall thickness, and normal
right ventricular size and function. The post myocardial
infarction Telemetry demonstrated consistent normal sinus
rhythm with occasional premature ventricular contractions.
The patient had a lipid panel which demonstrated
hypertriglyceridemia with a normal low density lipoprotein on
Zocor. The patient continued on Zocor and was started on
Lopid with a goal to increase the patient's high density
lipoprotein. The patient continued with low systolic blood
pressures from ranging in the 90's to 100's, however, was
able to tolerate a low dose beta blocker for post myocardial
infarction protection. The patient continues on aspirin and
Plavix on discharge.
2. Pulmonary: The patient was transferred intubated and was
initially maintained on assist control ventilation with
adequate oxygenation and ventilation. The patient completed
a CPAP wean and was extubated on hospital day #2. The
patient has a known history of asthma and required minimal
nebulizer treatments throughout the admission. The patient
was maintained on adequate oxygenation saturation post
extubation without supplemental oxygen.
3. Hematology: The patient has no known history of gastric
or duodenal ulcer disease. However, on hospital day #2 the
patient had coffee ground emesis from the gastric tube. The
patient was lavaged one liter of normal saline with clearing.
The patient's hematocrit at the time was 34.1 and the
hematocrit subsequently trended down to 27.4 on hospital day
#6. There was no obvious source of bleeding, however, the GI
tract was suspected. The patient was transfused one unit of
packed red blood cells on hospital day #6 for a goal
hematocrit greater than 28.0. The repeat hematocrit is
pending at time of this dictation. Iron studies are also
pending at time of this dictation.
4. GI: The patient developed an upper GI bleed with one
episode of coffee ground emesis on hospital day #2. The
patient was subsequently started on high dose Protonix with
no further evidence of GI bleed. Stool guaiacs are negative
to date.
5. Endocrine: The patient was found on admission to have
hyperglycemia (blood glucose in the 400's), ketonuria, and
metabolic acidosis with a pH at the outside hospital of 6.98,
consistent with diabetic ketoacidosis. The patient was
started on an insulin drip with a maximum rate of 10 units
per hour. The insulin drip was discontinued on hospital day
#2 with continued one to two hour fingerstick glucose checks
and sliding scale insulin.
The patient had a hemoglobin A1c of 9.0 measured on
admission. The patient's blood glucose remained poorly
controlled during the hospitalization on sliding scale
insulin with blood glucoses ranging in the 200's to 300's.
The patient was started on standing NPH and regular insulin
and [**Last Name (un) 616**] consult was requested. The consult
recommendations are pending at time of this dictation.
6. Neuro: Status post extubation, the patient demonstrated
new mental status changes with inattentiveness and poor short
term memory. The patient has a known seizure disorder,
however, there was no evidence of seizure activity during the
hospitalization. The patient was maintained on Tegretol as
per outpatient regimen. Neurology was consulted on hospital
day #4 for a persistent change in mental status. Per
Neurology recommendations, a head MRI / MRA as well as EEG
were obtained. The head MRI / MRA was without evidence of
infarction, mass, or flow abnormality. The EEG is pending at
time of this dictation. Pending a normal EEG, the most
likely cause of the patient's change in mental status is
anoxic encephalopathy.
7. Renal: The patient maintained adequate urine output
throughout the admission with normal renal function.
SUMMARY: The patient is a 44 year-old female with a history
of insulin dependent diabetes mellitus, hypercholesterolemia,
asthma, and seizure disorder who presented from an outside
hospital status post asystolic arrest in the setting of an
inferior wall myocardial infarction. The patient underwent
cardiac catheterization with total occlusion of the right
coronary artery and is now status post stent angioplasty and
stent placement. The patient is now five days status post
asystolic arrest with myocardial infarction and demonstrates
persistent mental status changes likely consistent with
anoxic brain injury.
CONDITION AT DISCHARGE: Good.
MEDICATIONS ON DISCHARGE:
1. Lopid 600 mg p.o. b.i.d.
2. Aspirin 325 milligrams p.o. q. day.
3. Plavix 75 mg p.o. q. day.
4. Protonix 40 mg p.o. b.i.d.
5. Tegretol 200 mg p.o. t.i.d.
6. Metoprolol 12.5 mg p.o. b.i.d.
7. Albuterol 1 to 2 puffs inhaler, q. 4 hours p.r.n.
8. Atrovent 2 puffs inhaler, q. 4 to 6 hours p.r.n.
9. Nicotine 14 mg patch transdermal q. day.
10. Simvastatin 20 mg p.o. q. day.
11. Insulin regular 3 units q. AM, 3 units q. PM
NPH 6 units q. AM, 3 units q. PM.
12. Sliding scale insulin.
DIAGNOSES ON DISCHARGE:
1. Asystolic arrest status post inferior wall myocardial
infarction.
2. Diabetic ketoacidosis.
3. Insulin dependent diabetes mellitus.
4. Seizure disorder.
5. Hypertension.
6. Hypercholesterolemia.
7. Asthma.
8. Coronary artery disease status post right coronary artery
stent placement on [**10-27**].
9. Anemia.
10. Upper GI bleed.
DISCHARGE INSTRUCTIONS:
1. The patient is to be discharged to rehab for physical
therapy, occupational therapy, and neuro / psych therapy.
2. The patient was instructed to follow up with a new primary
care physician, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at the [**Hospital 112**] Clinic on [**11-26**]
at 1:30.
3. The patient was also scheduled to follow up with
Neurology, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**12-3**] at 9:30 AM.
4. Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8619**] at the [**Hospital 616**] Clinic for
diabetes management at 10 AM.
[**First Name8 (NamePattern2) 77**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 715**]
Dictated By:[**Name8 (MD) 2285**]
MEDQUIST36
D: [**2187-11-1**] 17:12
T: [**2187-11-7**] 09:15
JOB#: [**Job Number 8620**]
|
[
"250.00",
"276.2",
"410.11",
"578.0",
"780.39",
"785.51",
"790.01",
"458.2",
"348.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.20",
"96.71",
"37.23",
"88.56",
"36.01",
"96.34",
"36.06"
] |
icd9pcs
|
[
[
[]
]
] |
10281, 10790
|
3484, 4276
|
11171, 12062
|
4304, 10233
|
1577, 3466
|
10248, 10255
|
10804, 11147
|
155, 216
|
245, 1209
|
1231, 1495
|
1512, 1555
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,282
| 119,512
|
49336
|
Discharge summary
|
report
|
Admission Date: [**2160-5-6**] Discharge Date: [**2160-5-12**]
Date of Birth: [**2098-2-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
s/p cardiac arrest
Major Surgical or Invasive Procedure:
endotracheal intubation
cardiac catheterization
arterial line
intra-aortic balloon pump
bronchoscopy
History of Present Illness:
Mr. [**Known lastname 103353**] is a 62 yo man with h/o CAD s/p early MI,
hypertension, hypercholesterolemia, diabetes, smoking who [**Last Name (un) **]
at 11:45 he was walking with his sisters after getting a cup of
coffe and he collapsed on his face approximately at 11:50 (wife
spoke with patient at 11:45 on cell phone). 911 was called; per
the family approximately 5-10 minutes elapsed prior to the
arrival of 1st responders and initiation of CPR. EMS arrived
shortly thereafter and he was found to be in VT. First EMS
strip is 11:54 and appears to be sinus bradycardia with very
wide QRS and PR. Subsequent strips by EMS show VT at 12:01,
12:04, 12:05, 12:06. Multiple VT morphologies and cycle
lengths. He was shocked 4 times; "post shock" rythm shows
resoration of sinus rhythma with very prolonged intervals.
There are numerous rhythm strips showing VT at variable cycle
lengths and morphologies. He also received 3mg epi, 2mg
atropine, and lidocaine.
.
Upon further history taking, he was in his usual state of health
until a few days ago when he began complaining of feeling
generally unwell. As per wife, no specific complaints of chest
pain, palpitations, dyspnea. Speaking with his primary care
year. He was seen mid-[**Month (only) **] where his Hgb A1c was found to be
10, his Cr 2.4, and K 5.9 on lisinopril 5mg po daily. His
hyperkalemia was managed by holding his ACE inhibitor. He was
seen in clinic on [**4-25**] and he was started on lisinopril 10mg
po daily + lasix 40mg po daily without repeating a potassium
measurement.
.
At [**Hospital1 18**] ED he was found to be in VT again, received 2 shocks
and 300mg amiodarone bolus, heparin bolus, 1mg epi x 2, 1mg
atropine, aspirin, versed, and dopamine drip. In the cath lab
he was found to have what appeared to be chronic occlusions of
his LAD and RCA. He had no PCI but did have an IABP placed. In
the cath lab he had inumerable episodes of VT and was probably
shocked 30 times. He received 2g calcium chloride, 4mg
atropine, amiodarone 1mg drip, epinephrine 4mg bolus and
epinephrine 3mcg/min bolus, levophed drip at 1mg/min, lidocaine
200mg bolus, 2g magnesium, 150mEq bicarbonate, 2mg versed,
insulin + bicarbonate. Peri-code it was discovered that his K
was 6.9; the VT appeared to respond most favorably to
insulin/dextrose & bicarbonate. Upon arriving to the CCU he
immediately went into VT again and was coded for about 15
minutes with numerous shocks, several rounds of epi/atropine,
amio bolus. He returned to NSR.
.
Around 5pm he was noted to have rhythmic tongue twitching.
slightly decreased with ativan.
Past Medical History:
as per PCP, [**Name10 (NameIs) 85546**] has been poorly controlled.
CAD s/p IMI in [**2138**]
Diabetes; last A1c 10.1
Hypertension
Hypercholesterolemia
Smoking
CKD Cr 2.4 in [**Month (only) **]; + proteinuria
(hyper K 5.[**2078-3-16**]) lisinopril held. restarted last week at
higher dose 10mg with lasix 40mg po daily last week.
Social History:
Works in sales. + tobacco. No EtOH. Married with 2 children.
Family History:
sudden death (?MI vs arrhythmia) at age 55. Father died later
in life after having AAA repair, ESRD on HD. Sister with
valvular heart disease.
.
Physical Exam:
T AF HR 75 BP 137/76 RR 30 SaO2 98%
Vent: AC 650 x 30, PEEP 10, 100%
on dopamine at 15, epi at 2, norepi at 0.2
.
General: critically ill, intubated, sedated
Cardiovascular: RRR no m/r/g
Pulmonary: roncherous anteriorly
Abdomen: obsese, nd, nt
Extremity: no c/e/c. palpable pulses
Neurologic: pupils fixed and dilated; oculocephalic reflex NOT
intact. Does not open eyes to command or noxious stimuli. +
Babinski. Triple flexor LE response to noxious stimuli.
Decerebrate posturing to noxious UE stim
Pertinent Results:
[**2160-5-6**] 12:45PM WBC-14.6* RBC-4.23* HGB-12.3* HCT-38.3*
MCV-91 MCH-29.0 MCHC-32.1 RDW-14.4
[**2160-5-6**] 12:45PM NEUTS-74.7* LYMPHS-20.9 MONOS-2.5 EOS-1.3
BASOS-0.6
[**2160-5-6**] 12:45PM PT-13.0 PTT-82.4* INR(PT)-1.1
[**2160-5-6**] 12:45PM PLT COUNT-202
[**2160-5-6**] 12:45PM GLUCOSE-298* UREA N-90* CREAT-4.4*
SODIUM-132* POTASSIUM-6.5* CHLORIDE-101 TOTAL CO2-12* ANION
GAP-26*
[**2160-5-6**] 12:45PM ALT(SGPT)-593* AST(SGOT)-548* CK(CPK)-139 TOT
BILI-0.4
Cardiac Enzymes:
[**2160-5-6**] 02:15PM CK-MB-4 cTropnT-0.07*
[**2160-5-6**] 02:15PM CK(CPK)-167
[**2160-5-7**] 06:00AM BLOOD CK(CPK)-1194*
[**2160-5-7**] 06:00AM BLOOD CK-MB-13* MB Indx-1.1
[**2160-5-6**] 10:03PM BLOOD CK-MB-24* MB Indx-2.5
[**2160-5-6**] 10:03PM BLOOD CK(CPK)-978*
[**2160-5-6**] 12:45PM BLOOD %HbA1c-10.0*
.
.
STUDIES:
ECHOCARDIOGRAM: [**2160-5-6**]
The left ventricular cavity is dilated. There is severe global
left ventricular hypokinesis (LVEF = 20 %) with some relatively
improved contractility in the basal inferior and anteroseptal
walls. The right ventricular cavity is mildly dilated with
severe global free wall hypokinesis. The aortic valve is not
well seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Trivial mitral regurgitation is
seen. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Severe biventricular
systolic dysfunction.
.
C CATH [**2160-5-6**]: report pending.
.
EEG [**2160-5-7**]: IMPRESSION: This is an abnormal routine EEG due to
a slow and
disorganized background indicative of a moderate encephalopathy.
Medications, metabolic disturbances, and infection are among the
most
common causes. Anoxia is another possibility. There are no areas
of
focal slowing although encephalopathies can obscure focal
findings.
There were no epileptiform features noted.
.
CT HEAD: [**2160-5-7**]
1. No evidence of acute intracranial hemorrhage or major
territorial infarct is apparent. Of note, MRI with
diffusion-weighted sequences are more sensitive for evaluation
of acute ischemia.
2. Extensive sinus disease.
.
CT CHEST: [**2160-5-7**]
1. Complete collapse of the left lower lobe and partial collapse
of the right lower lobe, likely secondary to secretions. Small
bilateral pleural
effusions.
2. Diffuse stranding around the body and tail of the pancreas
which is
concerning for pancreatitis. Clinical correlation is
recommended. If there
is clinical concern for pancreatitis, a CT of the abdomen may be
obtained for further characterization.
3. Bilateral indeterminate low-density lesions within the
kidneys bilaterally
which statistically most likely represent renal cysts. An
ultrasound may be obtained for further characterization.
4. Multiple right-sided rib fractures involving ribs one through
five
anteriorly and possible fracture of rib nine posteriorly which
are attributed to recent CPR.
.
LENI: [**2160-5-8**]: Negative for DVT bilaterally.
Brief Hospital Course:
Mr. [**Name13 (STitle) 67006**] is a 62 yo man with CAD, CKD, DM who presented
with cardiac arrest and fall.
.
# Cardiac arrest: After further history and evaluation it was
felt that his cardiac arrest was most likely a primary
arrhythmic event from metabolic derangement (most likely
hyperkalemia) given the numerous morphologies of his VT from the
EMS & the wide intervals of his sinus rhythm EKG. However,
given that the patient's first set of labs were drawn after
several cycles of CPR, it is impossible to know whether his
hyperkalemia on admission was the primary problem or secondary.
He was taken to the cath lab and found to have multiple chronic
appearing occulsions of the coronary arteries with good
colateral circulation. There was no evidence of an acute
coronary occulsion. During the next few hours, the patient
continued to have VT/VF which was refractory to aggressive
therapy. He was shocked over 30 times on the day of admission
and he received repeated cycles CPR, his electrolyte abnormaties
were corrected, and anti-arrhythmic medications were
administered, including lidocaine and amiodarone. The patient
was hypotensive and placed on 3 pressors. The patient also had
IABP and pacer wires placed in the cath lab. Eventually, the
patient settled into NSR. The patient was weaned off lidocaine
and given a loading dose of amiodarone. He had several days
without recurrance of his VT; however, on hospital day 6, he had
recurrance of treatment refractory VT and despite multiple
resuscitation efforts, the patient passed away on [**2160-5-12**] at
1700.
# Anoxic brain injury: It was estimated that the patient had
5-10 minutes without a perfusing cardiac rhythm prior to EMS
arriving on the scene. He did not get any CPR during this time.
The patient had signs of severe CNS injury with a bleak
prognosis (decerebrate posturing; babinski, dilated pupils that
were minimally reactive, oculocephalics not intact) most likely
anoxic brain injury. He was not felt to be a good candidate for
cooling as it is a pro-arrhythmogenic and the patient presented
with refractory VT. Head CT was negative for an acute
intracranial bleed. The patient was noted to have tongue
twitching which at first was concerning for seizures; however,
neurology felt it was most consistent with myoclonic jerks from
anoxic brain injury. EEG showed an encephalopathy without
seizure activity. Neurology was planning to reevaluate the
patient's neurologic status and further discuss prognosis on
hospital day 7; however, the patient passed away prior to that
re-evaluation.
.
# Cardiogenic shock: It was felt that his cardiogenic shock was
most likely secondary to an arrhythomia. He was treated with
IVF, pressors and an IABP. Eventually, the patient was weaned
off pressors; however, he intermittently required dopamine for
blood pressure support while getting propofol for sedation to
syncronize the patient with the ventilator. His IABP was d/c'ed
on hospital day 2. An echocardiogram showed severely depressed
LVEF at 20%. The patient had LV and apical akinesis and was
initiated on a heparin gtt for prophylaxis against a ventricular
thrombus.
.
# Respiratory Failure/Ventilator Associated Pneumonia: The
patient was intubated and difficult to oxygenate initially. He
was found on chest CT scan to have collapse of his Left lower
lobe. He most likely had an aspiration event during his arrest.
He spiked a fever and had copious repiratory secretions that
were positive for bacterial pneumonia. His sputum cultures grew
pseudomonas. He was initially treated with broad spectrum
antibiotics but they were narrowed as culture data returned.
The possiblitiy of PE was considered, however, CTA was not
obtained because of the patient's renal function. PE was felt
to be less likely as the patient's hypoxia improved with
aggressive suctioning and treatment of his pneumonia.
Furthermore, he was anticoagulated for his apical akinesis and
therefore was receiving treatment for PE.
.
# Acute renal failure: The patient most likely had worsening of
his chronic kidney disease from lasix and ace inhibitor prior to
admission. This may have caused his hyperkalemia. After the
patient's cardiac arrest, he developed ATN and required CVVH to
manage his uremia.
.
# Shock liver and pancreatitis: The patient had evidence of
injury to mulitple organ systems including his liver and
pancreas secondary to cardiogenic shock.
.
# Diabetes: The patient's diabetes was managed with an insulin
gtt initially and then an insulin sliding scale.
Medications on Admission:
glyburide 5mg [**Hospital1 **]
metformin 1000mg [**Hospital1 **]
lipitor 80mg daily
tricor 145
lisinopril 5mg daily changed to 10mg po daily last week
hctz 25mg daily
coreg 12.5 [**Hospital1 **]
lasix 40mg po daily
.
Discharge Medications:
none. Patient deceased.
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiac arrest secondary to recurrent Vetricular Tachycardia
likely secondary hyperkalemia.
Respiratory failure, hypoxic
Ventilator associated pneumonia
Coronary artery disease
Diabetes
Hypertension
Hypercholesterolemia
Acute on chronic kidney disease
shock liver
pancreatitis
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
none
Completed by:[**2160-5-13**]
|
[
"403.90",
"250.00",
"997.31",
"427.41",
"518.81",
"577.0",
"585.9",
"428.0",
"272.0",
"348.1",
"570",
"428.21",
"416.0",
"785.51",
"584.9",
"414.01",
"276.7",
"427.1",
"041.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.61",
"96.72",
"39.95",
"37.23",
"33.23",
"88.56",
"96.04",
"38.91",
"37.78"
] |
icd9pcs
|
[
[
[]
]
] |
12045, 12054
|
7177, 11730
|
332, 434
|
12374, 12384
|
4214, 4694
|
12437, 12472
|
3525, 3673
|
11997, 12022
|
12075, 12353
|
11756, 11974
|
12408, 12414
|
3688, 4195
|
4711, 6066
|
274, 294
|
462, 3074
|
6075, 7154
|
3096, 3429
|
3445, 3509
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,988
| 164,067
|
47192
|
Discharge summary
|
report
|
Admission Date: [**2194-9-28**] Discharge Date: [**2194-10-6**]
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
hemoptysis, shortness of breath, CXRAY reveals medistinal mass
Major Surgical or Invasive Procedure:
mediastinoscopy, bronchoscopy, evacuation of mediastinal
hematoma.
History of Present Illness:
84-year-old gentleman with
mechanical mitral valve replacement who is a nonsmoker. He
does have asbestos exposure, having worked in a shipyard. He
had an episode of hemoptysis as well as mild shortness of
breath prompting a chest x-ray and a subsequent CT scan which
confirmed a large subcarinal mass. A PET scan showed intense
FDG uptake in the subcarinal mass with an SUV greater than
20. The transbronchial biopsy was nondiagnostic. We
recommended mediastinoscopy. This required admission for
conversion of Coumadin the heparin and with his heparin
discontinued for several hours he was brought to the
operating room for the procedure.
Past Medical History:
PMHx:
1. Mitral valve disease (bacterial endocarditis) s/p replacement
with mechanical valve in '[**85**]
2. Atrial fibrillation
3. LV dysfunction on ECHO([**2193-2-7**]): EF 35%, AR 1+, TR 2+\
4. Hiatal hernia s/p repair
5. GERD
6. s/p fatty tumor removal from stomach, s/p tonsilectomy
7. s/p TERP
Social History:
Worked in the shipyards with lots of asbestos exposure, widowed,
lives alone with family in the area, non-smoker, non-drinker
Family History:
NC
Physical Exam:
General- Elderly male in NAD, cooperative, A&Ox3
HEENT- PERRLA, oralpharynx clear, no cervical adenopathy
REsp-CTA bilat, no crackles or wheezes
Cor-irreg, irreg, mechanical S1
Abd-+ BS, NT, ND, soft; midline scar
Ext-trace edema
Neuro-grossly intact
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2194-10-6**] 06:45AM 6.1 3.22* 9.5* 28.3* 88 29.6 33.7 15.3
209
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2194-10-6**] 06:45AM 209
[**2194-10-6**] 06:45AM 18.9* 36.9* 2.5
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2194-10-6**] 06:45AM 99 20 1.2 135 4.7 100 281 12
RADIOLOGY Preliminary Report
CHEST (PA & LAT) [**2194-10-4**] 7:17 PM
CHEST (PA & LAT)
Reason: Wheezing, slight dyspnea
[**Hospital 93**] MEDICAL CONDITION:
84 year old man with bloody sputum
REASON FOR THIS EXAMINATION:
Wheezing, slight dyspnea
HISTORY: Body sputum, wheezing, dyspnea.
CHEST, TWO VIEWS.
The patient is status post sternotomy, with mitral valve.
There is extensive calcification overlying both lungs related to
calcified asbestos plaques. Prominence of the cardiomediastinal
silhouette is noted in this patient with a known hematoma. The
trachea above the carina is poorly defined. A right subclavian
central line is present, tip overlying uppermost right atrium. I
doubt the presence of a superimposed infiltrate. I doubt the
presence of CHF. No effusion is identified.
IMPRESSION: No significant change detected compared with
[**2194-10-2**].
Brief Hospital Course:
Patient admitted [**2194-9-28**] for reversal of anticoagulation therapy
pre-op for medistinoscopy for evalutation of subcarinal mass on
[**2194-9-30**].
The patient tolerated the procedure well and was extubated in
the operating room and taken to the recovery area in
satisfactory condition. PACU course significant for increased
neck pain 1.5 hours post-op- pain med changed from MSo4 to
Dilaudid w/ good effect, nausea- treated w/ rx. Just prior to
transfer to floor, pt c/o increasing SOB, wheezes, neb given w/o
improvement> pt desaturated, unresponsive and bradycardic. Pulse
temporarily lost/PEA, FULL ACLS initiated, including brief CPR,
pt intubated,epinephrine given, spontaneous return of VS. TEE
done. Pt transfer to ICU.
Mechanical ventilation difficult, w/ desaturation. Bronch >
distal tracheal collapse w/ peripheral vascular clamping.
Mediastinal incision opened, digitally explored w/ no sig
finding. Central line, PA line placed.CT- Chest revealed
medistinal hematoma; evacuated in OR same day.Clindamycin IV for
7 days started.
POD#1--[**2194-10-1**]- Pt stable, mech vent weaned and successfully
extubated, nebs/ CPT done for airway clearance, lasix IVP given
w/ good effect; neogtt weaned to MAP 60/;lopressor 5mg iv q6hr
w/ HR 100-120 irreg; anticoagulation Hep gtt @ 700u/hr restarted
@10am. Pt stabilizing over course of day.Transfused 1U
PRBC;Lasix 20mg am+40 mg pm post transfusion. Coumadin 3mg qd
restarted.
POD#2-Overnight- pulmonary toilet done; penrose drain to med
incision draining minimal amounts and d/c'd.Neo weaned to off.
OOB - ambulation w/ PT assist tol well. PA line changed over
wire to 2 lumen. Pt transferred to floor. Hep increased to
800u/hr w/ tx ptt68. taking po liquids and soft solids well.
Coumadin 3mg given.
POD#3- VSS - temp97-98.pulm toilet; telemetry; Hep 900u/hr, w/
INR1.3 on Coumadin 3mg. Activity increased. Med inc dsg wet >
dry [**Hospital1 **] cont.
POD#4- INR2.2, Heparin gtt d/c; Wound clean. Planning for d/c to
rehab, [**Hospital1 **], home [**10-6**] pending pt status. Activity cont- pt
states weak, requesting assisted facility. Lasix 20 mg IV prn +
lasix 20mg PO qd.
POD#5- Eval by [**Name (NI) **] pt funcitoning slightly below baseline. Will
d/c to [**Hospital1 1501**] to maximize funcitonal level. Pt screened and
accepted by [**Hospital1 1501**] local to pt home. Pt discharged in stable
condition. Ambulatory w/ some assist.O2 Sat 95-96% RA w/
activity.
Medications on Admission:
Lipitor 10', Lopressor 100", Coumadin 3', Lasix 20', Avapro
300', Protonix 40', MVI
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: as directed
units Injection ASDIR (AS DIRECTED): sliding scale.
2. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours) as needed.
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
4. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 5481**] TCU
Discharge Diagnosis:
mitral valve replacement, atrial fibrillation, congestive heart
failure, gastric esophogeal reflux disease, s/p hiatal hernia
repair, s/p turp, benign prostatic hypertrophy.subcarinal
mass.s/p respiratory failure.
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office for any post-surgical issues.
[**Telephone/Fax (1) 170**]
Followup Instructions:
Call for follow-up appointment in 2 weeks w/ Dr.
[**Last Name (STitle) **].[**Telephone/Fax (1) 170**]
Completed by:[**2194-10-6**]
|
[
"427.5",
"200.02",
"427.31",
"530.81",
"501",
"998.12",
"V58.61",
"997.1",
"426.89",
"V58.83",
"V43.3",
"518.5",
"428.0",
"600.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.60",
"99.04",
"88.72",
"42.23",
"40.11",
"38.91",
"96.04",
"33.23",
"38.93",
"96.71",
"34.22",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
6726, 6781
|
3108, 5544
|
288, 357
|
7039, 7046
|
1799, 2337
|
7195, 7329
|
1509, 1513
|
5678, 6703
|
2374, 2409
|
6802, 7018
|
5570, 5655
|
7070, 7172
|
1528, 1780
|
186, 250
|
2438, 3085
|
385, 1025
|
1047, 1349
|
1365, 1493
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,301
| 189,612
|
8604
|
Discharge summary
|
report
|
Admission Date: [**2201-1-27**] Discharge Date: [**2201-2-2**]
Date of Birth: [**2141-9-5**] Sex: F
Service: [**Hospital Unit Name 196**]
HISTORY OF PRESENT ILLNESS: The patient is a 59 year-old
female with a history of hypertension, hyperlipidemia,
insulin dependent diabetes mellitus and mental retardation
who was admitted on [**2201-1-24**] to the [**Hospital6 10353**] for
an episode of retrosternal chest pain that was poorly
described due to the patient's baseline verbal communication
ability. While at [**Hospital6 10353**] she was ruled out by
enzymes for an acute coronary syndrome (troponin I less then
.15 three times, CK 103, 92, 80).
Electrocardiogram showed right axis deviation with first
degree AV block. No ischemic changes were noted. Nuclear
stress test was performed, which showed a moderate to large
fixed defect with a smaller reversible effect in the
inferolateral and inferoapical walls. Echocardiogram done at
that time noted a normal ejection fraction of 54%. The
patient was then referred for catheterization to [**Hospital1 346**].
On presentation at [**Hospital1 69**] the
patient denied any chest pain and did not recall the details
of her episode of chest pain. She does note that she had
some chest pain after vomiting.
PAST MEDICAL HISTORY:
1. Congestive heart failure.
2. Chronic renal insufficiency.
3. Insulin dependent diabetes mellitus.
4. Hypertension.
5. Hyperlipidemia.
6. Mental retardation.
7. Depression.
8. Recent Emergency Room visit at [**2201-1-23**] at [**Hospital1 346**] for nausea and vomiting.
9. Hysterectomy.
10. Sleep apnea.
11. Myoclonic twitches.
MEDICATIONS: Carvedilol 3.125 mg po q day, Lasix 80 mg po
q.d., Zestril 5 mg po q day, Lipitor 10 mg po q day,
Risperdal 2 mg po q day, insulin NPH 10 units in the morning
and 5 units in the evening, Fosamax, Premarin 0.625 mg once a
day, Celexa 20 mg once a day, Pepcid 20 mg once a day,
regular insulin sliding scale, nitropaste prn, Kayexalate
prn, heparin drip.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She lives in a group home where she is
visited by visiting nurses at least twice a day for insulin
injection and finger stick blood glucose.
PHYSICAL EXAMINATION: Temperature 95.9. Blood pressure
120/70. Heart rate 84. Respiratory rate 12. Sating 94% on
room air. General, thin small woman lying in bed. HEENT
oropharynx is clear. Mucous membranes are moist. JVD
approximately 7 cm above the angle of the sternum. Lungs had
fine crackles approximately two thirds of the way up
posteriorly as well as coarse rhonchi throughout both lung
fields. Cardiovascular heart sounds were distant. There
were no murmurs, rubs or gallops. Abdomen was soft,
nontender and mildly distended with no rebound or guarding.
Extremities smooth shiny skin especially over the digits, no
peripheral edema in the lower extremities. Neurological
examination she was slightly confused and perseverating, she
is able to follow commands bilaterally, ambulate with
assistance and move all four extremities symmetrically.
LABORATORY EXAMINATION: Chest x-ray showed bilateral small
pleural effusions, potassium 5.5.
HOSPITAL COURSE: The patient was initially hydrated and
treated with Mucomyst in anticipation of cardiac
catheterization. In the meantime the reports were obtained
from [**Hospital6 10353**] of the nuclear stress test. The
patient was placed on a regular insulin sliding scale for
blood sugars that were greater then 300. It was noted on the
first night of admission the patient's blood sugar fell to
19. At this point one amp of glucose was given and the
patient's mental status improved from somnolent to arousable
and oriented. She was able to move all four extremities and
follow commands at that time. Electrocardiogram was
unchanged at the time.
Following that an endocrine consult was obtained, and a more
gentle insulin sliding scale was devised to take into account
the patient's renal failure as well as her extreme
sensitivity to regular insulin. At that point it was noted
that she could be treated with NPH insulin once a day in the
morning of approximately 16 units.
The patient remained chest pain free while she was in the
hospital and after discussions with her family in particular
her brother, it was decided that catheterization along with
its risks in a perpetually moving and somewhat physically
uncooperative patient outweigh the potential benefits. It
was decided that medical management would be pursued until
such time as her cardiac symtpoms presented themselves in a
more easily identifiable manner.
She was kept on beta blocker, heparin and aspirin as well as
a statin and ace inhibitor. She continued to have problems
with sleep apnea while she was in the hospital.
On [**2201-1-30**] she had an acute desaturation during the night to
52%, which was presumed to be an episode of obstructive sleep
apnea. The patient was initially found to be tachycardic in
the low 120s and hypotensive. Her hypotension was treated
quickly and her clinical picture rapidly began to suggest she
had an element of pulmonary edema. She was treated with
intravenous Lasix and a nitroglycerin drip with improvement
of her saturations.
After this the patient was noted to be more in congestive
heart failure and was placed in a Nesiritide drip as well as
daily Bumex. This resulted in some diuresis and by the end
of her stay she had oxygen saturations in the 90s on room air
while ambulating. Her rales had improved and her JVD had
improved somewhat.
While she was in the hospital she had a brief trial of CPAP
for her obstructive sleep apnea at the suggestion of a
pulmonary consult. She was moved to the Intensive Care Unit
for this trial. She did not tolerate the mask at all and it
was obvious that she had failed CPAP as a therapy for her
obstructive sleep apnea. Her oxygens saturations, though
with her diuresis improved significantly and she seemed to be
sleeping better and more comfortable.
After her episode of pulmonary edema it was noted that her
creatinine had increased from 2.0 to 2.8. This decreased to
2.6 with Nesiritide and it was felt that her kidney function
was improving with diuresis. Her finger stick blood glucoses
remained under better control with a daily regimen of 16
units of NPH with a very light regular insulin sliding scale
to cover her between doses of NPH. She was seen by physical
therapy who felt that she could safely be discharged home to
her group home with visiting nursing for both physical
therapy, range of motion, independence and ambulation as well
as for diabetic care.
On [**2201-2-2**] it was noted that her potassium was 5.8. This was
the second time that her potassium had been elevated during
her hospital stay and she was given Kayexalate 30 grams po.
She responded well to this and her potassium decreased to 5.4
within two hours. The patient also had a repeat x-ray, which
showed slight improvement in her bilateral pleural effusion.
She had no evidence of focal infiltrate visible.
On [**2-2**] she was discharged to her group home with visiting
nursing services to arrange blood draws as well as to perform
physical therapy. She was given follow up clinic
appointments with Dr. [**Last Name (STitle) 5762**], her primary care physician [**Last Name (NamePattern4) **].
[**Last Name (STitle) **], in the heart failure clinic and with Dr. [**Last Name (STitle) **] of
the [**Hospital **] Clinic.
DISCHARGE MEDICATIONS:
1. Carvedilol 3.125 mg po, which was reduced to 1.57 once a
day in an addendum to the visiting nurses services.
2. Lisinopril 5 mg po q.d.
3. Lipitor 10 mg po q day.
4. Celexa 20 mg po q day.
5. Colace 100 mg po b.i.d.
6. Dulcolax suppositories prn.
7. Zantac 150 mg po b.i.d.
8. Risperdal 0.5 mg po q.h.s.
9. Insulin NPH 14 units subQ q.a.m.
10. Regular insulin sliding scale with no coverage from 60
to 250 and 1 unit for 251 to 300, 301 to 350 2 units, 351 to
400 3 units.
11. Iron sulfate one twice a day.
12. Lasix 60 mg po q day.
13. Procrit 40,000 units subQ q week.
14. Premarin 0.625 mg po q day.
15. Fosamax 5 mg po q day.
She was also scheduled for physical therapy as well as finger
sticks four times a day as well as blood draws for serum
chemistry and hematocrit on [**2-3**] and [**2-5**] to be followed up
by Dr. [**Last Name (STitle) 5762**].
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 2139**]
Dictated By:[**Last Name (NamePattern1) 214**]
MEDQUIST36
D: [**2201-2-2**] 10:13
T: [**2201-2-3**] 07:01
JOB#: [**Job Number 30172**]
|
[
"593.9",
"780.57",
"458.9",
"250.80",
"428.0",
"478.29",
"428.30",
"319",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"00.13"
] |
icd9pcs
|
[
[
[]
]
] |
7488, 8636
|
3187, 7465
|
2231, 3169
|
184, 1280
|
1302, 2049
|
2066, 2208
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,107
| 198,124
|
35647
|
Discharge summary
|
report
|
Admission Date: [**2141-1-10**] Discharge Date: [**2141-1-23**]
Date of Birth: [**2057-8-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2167**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
Mechanical Ventilation
PEG Tube Placement
PICC
History of Present Illness:
83 year-old man with a PMH of HTN and HLD who developed abrupt
onset L sided weakness and was taken to an OSH and given tPA and
then transfered to [**Hospital1 18**]. In the ED he has a persistent dense L
hemiplegia as well as significant dysarthria. Repeat imaging
showed no bleeding or vessel obstruction, therefore no arterial
interventions are available. He continued to have L
hemiplegia. He did not pass a speech and swallow evaluation and
continued to have slurred speech. He was started on tube feeds
via NGT. Per his family, he did not speak, but was
communicating with them up to 1 day prior to his ICU transfer.
On the day prior to transfer, he was less communicative.
On morning of [**1-15**] he developed hypoxia with saturation of 79%
on room air. He was suctioned with return of tube feedings. He
was placed on NRB with oxygen saturation of 90-95% on the NRB.
An ABG was drawn with the following numbers 7.44/35/67 and he
was subsequently transferred to the MICU.
Upon arrival to the MICU patient was on NRB with oxygen
saturation of 95%, RR 40s, increased work of breathing,
tachycardic 110-130s. Decision was made to intubate patient.
Past Medical History:
Hypertension
Gout
Gored by bull x 2
OA
BPH
Social History:
unable to obtain
Family History:
NC
Physical Exam:
Vitals: 98.3 160/80 75 40 88RA (-> 98RA)
General: Alert, speech dysarthric, oriented to [**Hospital1 112**], unable to
express date, tachypneic
HEENT: Sclerae anicteric
Lungs: Diminished with rales at left base, remainder CTA
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: NABS, soft, ND/NT.
Ext: Warm, well perfused. 2+ pitting edema in all ext, UE>LE.
Wiggles right fingers/toes, no movement on left extremities.
Pertinent Results:
MICRO:
Positve Sputum Cultures from [**1-15**], [**1-16**], [**1-17**], [**1-18**], [**1-20**]:
GRAM STAIN (Final [**2141-1-15**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2141-1-18**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
Please contact the Microbiology Laboratory ([**6-/2438**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
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
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
[**2141-1-18**] 12:05 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2141-1-18**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2141-1-21**]):
OROPHARYNGEAL FLORA ABSENT.
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Please contact the Microbiology Laboratory ([**6-/2438**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
[**2141-1-22**] 3:44 am STOOL CONSISTENCY: LOOSE Source: Stool.
**FINAL REPORT [**2141-1-22**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2141-1-22**]):
Feces negative for C.difficile toxin A & B by EIA.
Blood Cultures:
[**1-12**], [**1-12**], [**1-15**], [**1-16**], [**1-16**], [**1-16**], [**1-16**], [**1-17**], [**1-17**], [**1-18**],
[**1-20**], [**1-20**]
Cardiology Report ECG Study Date of [**2141-1-10**] 8:12:38 PM
Sinus bradycardia with 1st degree A-V block
Left axis deviation
RBBB with left anterior fascicular block
No previous tracing available for comparison
CT Head [**1-10**]
IMPRESSION:
1. Known acute right hemipontine infarction is not
well-visualized on the CT.
The perfusion of the MCA vascular territory is normal.
2. At least 75% diameter stenosis of the proximal portion of the
right
internal carotid artery, just distal to the bifurcation; this
could be
characterized further by focused son[**Name (NI) 867**].
3. Retropharyngeal course of the more distal cervical right ICA,
a normal
variant.
4. Mural irregularities involving both vertebral arteries with
calcification
at the origin of the right vertebral artery.
5. Left frontal encephalomalacia, most likely related to old
infarct.
MRI Head [**1-11**]
IMPRESSION:
1. Acute infarction of much of the right hemipons, likely on the
basis of
pontine perforating vessel occlusion.
2. Old left frontal and chronic microvascular infarction, with
significant
central atrophy.
3. Normal MR angiogram of the cranial vessels.
CT Head [**1-12**]
IMPRESSION: Evolution of right pontine infarction. No
intracranial
hemorrhage.
CT Chest/Abd/Pelvis: [**1-19**]
1. No PE or aortic dissection although evaluation for
subsegmental PE is
limited due to motion.
2. Significant left lower lobe collapse, bilateral effusions.
3. Traumatic inflation of Foley catheter balloon in the penile
urethra.
4. Hypoattenuating collection in the bladder likely related to
hematoma.
5. Appearance of gastrostomy tube is suspicious for traversing a
loop of
transverse colon prior to entering the stomach.
Abd X-ray [**1-19**]
IMPRESSION: No evidence of contrast extravasation or free air.
TTE [**1-11**]
The left atrium is elongated. No thrombus/mass is seen in the
body of the left atrium. No atrial septal defect is seen by 2D
or color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) are mildly 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. Trivial mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
CXR [**1-22**]
A single portable radiograph of the chest demonstrates a
small-to-moderate
left-sided effusion. There is bibasilar atelectasis. Assessment
is limited
by respiratory motion. Appearance of the heart and lungs is
similar to that
seen on the chest radiograph obtained 10 hours prior.
Right-sided PICC is
unchanged as well.
Brief Hospital Course:
This is an 83 yom with recent right pontine stroke who was
initially in the Neuro ICU who was transferred for aspiration.
Now s/p PEG placement course complicated by aspiration
pneumonia, now with new foley trauma, acute renal failure, and
peg misplacement leading to respiratory distress and relative
hypotension now extubated and clinically improving.
# Right Hemi-Pontine Infarction: 83 year-old man presented to
OSH with abrupt onset L sided weakness and dysarthria, given tPA
and transfered to [**Hospital1 18**], where he was found to have a large R
pontine CVA. In the ED he had a persistent dense L hemiplegia
as well as significant dysarthria. Repeat imaging showed no
bleeding or vessel obstruction, therefore no arterial
interventions were available. He continued to have L hemiplegia.
He did not pass a speech and swallow evaluation and continued to
have slurred speech. His course was complicated by aspiration
pneumonia, hematuria secondary to foley trauma. He should be
continued on ASA, statin and BP control with metoprolol (goal
SBP 120-160). The patient remains a high aspiration risk given
his stroke.
# Aspiration Pneumonia/respiratory failure: After large R
pontine CVA patient had persistent dense L hemiplegia as well as
significant dysarthria. He did not pass a speech and swallow
evaluation and continued to have slurred speech. He was started
on tube feeds via NGT. On morning of [**1-15**] he developed hypoxia
with saturation of 79% on room air. He was suctioned with return
of tube feedings. He was placed on NRB with oxygen saturation of
90-95% on the NRB. An ABG was drawn with the following numbers
7.44/35/67 and he was subsequently transferred to the MICU. Upon
arrival to the MICU patient was on NRB with oxygen saturation of
95%, RR 40s, increased work of breathing, tachycardic 110-130s.
Decision was made to intubate patient. He was started on
vancomycin [**1-15**] and cipro/flagyl [**1-20**]. CXR initially c/w
pneumonitis that cleared, however then developed new infiltrate
c/w asp pna. The patient susequently grew MRSA from his sputum
and was continued on Vancomycin for a 10 day course. The
patient improved and was extubated on [**1-21**] am. He weaned to 1 L
NC with resp alkalosis and intermittent tachypnea with central
etiology. The patient remains tachypenic in the 30-40. His CXR
from [**1-22**] showed small-to-moderate left-sided effusion. There is
bibasilar atelectasis. The patient will be continued on
Vancomycin for a 10 day course ending [**2141-1-24**]. The patient
continues to be a high risk for aspiration given his stroke.
# PEG placement ?????? The PEG was placed on [**1-17**]. It was
incidentally found to traverse through transverse colon and then
to enter the stomach on CT obtained to eval pelvis for hematuria
on [**1-19**]. Surgery was made a aware and nothing to do at this
time. There was no evidence of extravasation of contrast on xray
or CT. Given the patient had recurrent fevers and PEG placement
the pt was started on cipro/flagyl for course planned to end on
[**1-25**].
# Persistent Fevers: Sputum persistenly growing MRSA, on
Vancomycin, however fevers also occurred in setting of
significant acute gouty flare, improving on colchicine. Fever
trending down. Cont abx as above
#. Hematuria: Patient developed hematuria with clots and
urology consulted on [**1-19**]. The patient was given 3 units pRBCs.
He was found to have hematoma in bladder from foley trauma and
a cystocopy revealed prostatic trauma. The patient was started
on CBI and continued until [**1-23**]. If the patient continues to
have hematuria he can be restarted on CBI. Plan at discharge is
for discontinuation of the foley followed by foley trial once
patient has clear urine for 48 hours.
# Coffee Grounds from OG tube: The patient was noted to have one
episode of coffee ground from his OG tube. He was started on IV
ppi [**Hospital1 **]. This is likely secondary to stress ulceration. He as
not had any subsequent episodes and his Hct has remained stable.
PPI was changed to once daily.
# Code Status: During the patient's hospitalization he was made
DNR/DNI.
Medications on Admission:
- allopurinol 100mg PO BID
- atenolol 50mg PO QD
- colchicine 0.6mg PO QD
- (?) detrol LA 2mg PO QD
- (?) Gemfibrozil 600mg PO BID
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
3. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical QID
(4 times a day) as needed.
4. Simvastatin 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
5. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
6. Oxybutynin Chloride 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3
times a day).
7. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: as directed
Injection ASDIR (AS DIRECTED).
8. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
2-4 Puffs Inhalation Q6H (every 6 hours) as needed.
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as
needed.
10. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours) as needed.
11. Allopurinol 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
12. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: Six (6) PO Q6H
(every 6 hours).
13. Ciprofloxacin 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H
(every 12 hours) for 3 days: per PEG.
14. Metronidazole 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q8H
(every 8 hours) for 3 days: per PEG.
15. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
16. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
17. Vancomycin 1,000 mg Recon Soln [**Last Name (STitle) **]: 1250 (1250) mg
Intravenous every twelve (12) hours for 10 days: end date [**1-24**].
18. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr
[**Month/Day (4) **]: One (1) Tablet Sustained Release 24 hr PO once a day.
19. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
[**Month/Day (4) **]: One (1) Tablet Sustained Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] Rehab Hospital
Discharge Diagnosis:
Primary:
Right pontine stroke with left hemiparesis
Respiratory failure
Aspiration pneumonia
Traumatic hematuria
Anemia
.
Secondary:
Hypertension
Gout
OA
BPH
Discharge Condition:
stable, tachypneic with RR 30-40, normotensive, left sided
weakness and dysarthria
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital. You were admitted to [**Hospital1 18**] because of a large stroke.
You were treated at an outside hospital and transferred here.
Your course was complicated by an aspiration pneumonia that you
received antibiotics for. You also had bleeding from your
bladder after a catheter was placed. You received blood
transfusions and your blood level remained stable. You also had
a PEG tube placed for feeding that was found to have gone
through your transverese colon then to your stomach. A X-ray
and CT scan showed that there was no leakage. You were treated
with antibiotics to prevent infection.
Please follow the medications prescribed below.
Please follow up with the appointments below.
Please call your PCP or go to the ED if you experience chest
pain, palpitations, shortness of breath, nausea, vomiting,
fevers, chills, or other concerning symptoms.
Followup Instructions:
It is recommended that you follow-up with your PCP [**Last Name (NamePattern4) **] [**12-23**] weeks
following discharge from rehab.
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 9674**]
|
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"599.0",
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icd9cm
|
[
[
[]
]
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[
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icd9pcs
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322, 370
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15292, 15377
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2165, 4888
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275, 284
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398, 1560
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1582, 1627
|
1643, 1661
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,013
| 160,137
|
54589
|
Discharge summary
|
report
|
Admission Date: [**2109-2-26**] Discharge Date: [**2109-3-5**]
Date of Birth: [**2047-11-5**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
right lung sarcoma
Major Surgical or Invasive Procedure:
1. right pneumonectomy
2. chest wall resection (ribs [**1-17**]) and reconstruction with
[**Doctor Last Name 4726**]-Tex
3. buttressing of bronchial stump with thymic fat pad and pleura
History of Present Illness:
61yo female with metastatic sarcoma to both lungs. She is s/p
left thoractomy with 20 nodular resections by Dr. [**First Name (STitle) **] on
[**2109-1-25**], revealing metastatic sarcoma on pathology. She returns
for right pneumonectomy.
Past Medical History:
PMH: breast cancer felt to be due to a variant BRCA2 mutation,
HTN, endometriosis, depression
PSH: b/l oophorectomy, lumpectomy x3, b/l mastectomy
Social History:
The patient is married and lives with her husband in [**Name (NI) 4047**].
She works as a bookkeeper for a construction company, but is not
currently working due to her illness. She smoked tobacco
socially in the past, but has not smoked
regularly. She has two daughters. She drinks alcohol socially.
Family History:
The patient has no Ashkenazi [**Hospital1 **] heritage in her family. Her
mother had pancreatic cancer in her 60s. Her first cousin, her
maternal uncle's daughter, had breast cancer in her 60s and died
of an MI at 67. The patient's paternal
grandmother had breast cancer in her 70s.
Physical Exam:
VS: T afebrile HR: 90 SR BP 120/80 Sats: 85-89% on RA
w/ambulation, 93% RA
General: 61 year-old anxious female
HEENT: normocephalic, mucus membranes moist
Neck: supple, no lymphadenopathy
Card: RRR normal S1,S2 no murmur
Resp: absent breath sounds on right otherwise clear
GI: benign
Extr: warm, trace bilateral pedal edema
Incision: right thoracotomy site clean, margins well
approximated no erythema
Neuro: awake, alert, oriented
Pertinent Results:
[**2109-3-5**] WBC-9.3 RBC-3.44* Hgb-8.5* Hct-28.4 Plt Ct-1048*
[**2109-3-4**] WBC-9.1 RBC-3.50* Hgb-8.5* Hct-29.2 Plt Ct-1052*
[**2109-2-26**] WBC-26.9*# RBC-4.51 Hgb-11.0* Hct-35.3 Plt Ct-884*
[**2109-3-5**] Glucose-100 UreaN-10 Creat-0.4 Na-141 K-4.7 Cl-100
HCO3-31
[**2109-2-26**] Glucose-153* UreaN-11 Creat-0.6 Na-135 K-4.9 Cl-100
HCO3-25
[**2109-3-5**] Calcium-8.4 Phos-3.3 Mg-2.1
CXR:
[**2109-3-5**] The air component of the right hydropneumothorax has
decreased. The fluid component has minimally increased. The
loculations in the right chest wall and the fluid contents in
the right hemithorax have decreased. The leftlung is clear.
Surgical clips present in the left hemithorax and in the right
upper hemithorax. The cardiomediastinal silhouette is unchanged.
[**2109-3-3**]: Patient has had right pneumonectomy and upper rib
resections. The volume of fluid largely dependent in the right
pneumonectomy space stable or only minimally increased over 24
hours. Loculations of air in the right lower hemithorax and
smaller locules in the soft tissues of the right chest outside
the costal plane are all unchanged. Left lung is grossly clear.
The leftward shift of the lower mediastinum which developed
between [**2-28**] and 16 is unchanged.
Chest CT
[**2109-3-2**]: No evidence of pulmonary embolism.
2. Patient status post right pneumonectomy. Large right-sided
effusion with a large air-fluid level with smaller air bubbles
within. Post-right
thoracotomy changes.
3. Stable nodule or pleural thickening along the left pleura,
likely due to prior left thoracotomy.
Right upper extremity Doppler
[**2109-2-28**]: No evidence of right upper extremity DVT.
Brief Hospital Course:
The patient was admitted to the Thoracic Surgery Service on
[**2109-2-26**], the patient underwent a right pneumonectomy,
resection of chest wall (ribs 3 and 4) and reconstruction with
[**Doctor Last Name 4726**]-Tex, and buttressing of bronchial stump with thymic fat pad
and pleura on the same day which went well without complication
(please refer to the Operative Note for details).
Post-operatively, the patient was transferred to the surgical
intensive care unit for monitoring.
Neuro: The patient initially received an epidural with good
effect and adequate pain control. When tolerating oral intake,
the patient was transitioned to oral pain medications. Her
anxiety level was high and required ativan PRN with reassurance.
CV: She was tachycardiac and her beta-blockers were restarted.
ACE was resumed once her blood pressure tolerated otherwise she
remained hemodynamically stable.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization. She required
supplemental oxygen and mucolytic nebs. She was followed with
serial chest film which showed slow filling of right lung space.
Chest CT: Tachycardic & Tachypnic on [**2109-3-2**], Chest CT revealed
no pulmonary embolism.
GI/GU/FEN: Post-operatively, the patient had self-discontinued
the NG tube upon extubation and was kept NPO with IV fluids the
overnight of POD0. Diet was advanced to clears on POD1, which
was well tolerated and subsequently advanced. Patient's intake
and output were closely monitored, and IV fluid was adjusted
when necessary.
Renal: her renal function remained normal. She was gently
diuresed. Electrolytes were routinely followed, and repleted
when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Extremities: Right upper arm swelling Duplex on [**2109-2-28**] revealed
no DVT.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Disposition: Home with [**Name (NI) 269**], PT, OT and supplemental oxygen and
nebulizers.
Medications on Admission:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): hold if you are dizzy, HR <60 or SBP <100. space
away from lisinopril.
4. Tylenol Extra Strength 500 mg Tablet Sig: Two (2) Tablet PO
every eight (8) hours.
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
9. oxycodone 5-10mg po q 4-6 hrs for breakthrough pain,
10. morphine SR 15mg po bid
Discharge Medications:
1. Home Oxygen
1 Liter continuous pulse dosed for portability.
2. Nebulizer Machine
use as directed
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for anxiety .
Disp:*30 Tablet(s)* Refills:*0*
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*70 Tablet(s)* Refills:*0*
6. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q8H (every 8 hours).
Disp:*90 Tablet Sustained Release(s)* Refills:*0*
7. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
Disp:*90 Capsule(s)* Refills:*2*
9. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) mL Inhalation Q6H (every 6 hours) as
needed for if Mucomyst given.
Disp:*90 mL* Refills:*0*
11. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Three (3) ML
Miscellaneous every twelve (12) hours as needed for if unable to
clear secretions: mix with 3 mL albuterol to prevent
bronchospasm.
Disp:*30 ML(s)* Refills:*0*
12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): on 12
hrs off 12 hrs.
Disp:*10 Adhesive Patch, Medicated(s)* Refills:*2*
13. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
scoop PO once a day.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
16. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for secretions.
17. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
18. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain. Tablet(s)
Discharge Disposition:
Home With Service
Facility:
[**Name (NI) 269**] Caregroup Network
Discharge Diagnosis:
right lung sarcoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers greater than 101, chills, or shakes
-Increased shortness of breath, cough or sputum production
-Chest pain
-Difficulty or painful swallowing, nausea, vomiting
-You may shower. No tub bathing or swimming for 4 weeks
-Incision develops drainage: staples remain until seen by Dr.
[**First Name (STitle) **]
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**]
Date/Time:[**2109-3-14**] 10:00 on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical
Center [**Location (un) 24**]
Chest X-Ray [**Location (un) 861**] Radiology 30 minutes before your
appointment
Completed by:[**2109-3-5**]
|
[
"V45.71",
"300.00",
"V10.3",
"338.12",
"458.29",
"401.9",
"171.4",
"V10.89",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.4",
"34.79",
"32.59"
] |
icd9pcs
|
[
[
[]
]
] |
9615, 9683
|
3760, 6566
|
339, 527
|
9746, 9746
|
2067, 3737
|
10318, 10667
|
1305, 1593
|
7339, 9592
|
9704, 9725
|
6592, 7316
|
9897, 10295
|
1608, 2048
|
281, 301
|
555, 795
|
9761, 9873
|
817, 967
|
983, 1289
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,520
| 101,785
|
52997
|
Discharge summary
|
report
|
Admission Date: [**2199-2-10**] Discharge Date: [**2199-2-13**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
[**Age over 90 **] y/o F extensive PMH including CHF, A Fib on coumadin, chronic
thromboembolic PHTN who presents with hematemesis. Patient's
caretaker noticed her coughing up bright red blood (quarter size
clots) today and consequently brought her to the ED for
evaluation. Vitals on presentation were 97.5 88 99/62 18 85. On
evaluation patient produced large amounts of hematemesis and
required intubation for desaturation and airway protection. She
was given 40 mg protonix, 10 mg IV vitamin K and 2 L of NS. Her
labs were significant for HCT of 20 and creatinine 5.3. BP
ranged from 87-114/54-64. She was transferred to the MICU for
management of upper GI bleed.
.
Patient was recently discharged [**2199-2-8**] from the [**Hospital1 1516**] service
home with hospice following a complicated hospital course.
Patient presented with shortness of breath secondary to CHF
exacerbation, was aggressively diuresised but developed
hematemesis and worsening renal failure. Her renal failure did
not improve and her bleeding source was never found. During the
admission bloody material came from her mouth, but it was not
clear whether it was emesis or cough. There was concern for
malignancy based on prior CT showing thyroid mass and LAD, but a
follow-up non-contrast chest CT did not suggest new pathology.
ENT did not visualize any bleeding source down to the glottis
level. GI was consulted but GI and primary team agreed that
risks of EGD outweighed benefits unless Hct unstable. Prior to
discharge she did have grossly apparent dark red blood in her
bowel movements suggestive of GI etiology. Patient was also
treated for kleibsella UTI during the admission. Due to her
increasingly difficult-to-manage systolic and diastolic CHF,
combined with increasingly severe renal failure and unknown
source of bleed decision was made for comfort focus and she was
discharged home with hospice.
Past Medical History:
Risk factors: no HTN, DM, HL
no prior CABG or PCI
Probable CAD (focal wall motion abnormality & fixed
perfusion defect)
Congestive heart failure, systolic and diastolic, chronic
Atrial fibrillation on coumadin
Valvular disease: 2+ MR & 4+ TR
.
Chronic thromboembolic PHTN with RV failure, s/p IVC filter [**2185**]
CKD (cr 2-2.6)
pancytopenia
Peripheral vascular disease
h/o ischemic colitis
h/o LGIB
Gout/pseudogout: followed by rheum Dr. [**Last Name (STitle) **].
h/o h. pylori positive gastritis
s/p TAH/BSO
OA vs rheumatoid arthritis
Social History:
Lives in her own home with a 24hr home health aide, [**Last Name (STitle) 802**] [**Name (NI) **]
involved and lives nearby. She has a remote history of smoking.
Denies ETOH.
Family History:
Denies significant family history.
Physical Exam:
Initial PE:
General Appearance: Well nourished, No acute distress,
Overweight / Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic
Head, Ears, Nose, Throat: Normocephalic, No(t) Endotracheal
tube, No(t) NG tube, No(t) OG tube
Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal,
No(t) Absent), (S2: No(t) Normal, Distant, No(t) Loud, No(t)
Widely split , No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub,
(Murmur: No(t) Systolic, No(t) Diastolic), Distant heart sounds
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),
(Breath Sounds: No(t) Clear : , Crackles : Few, No(t) Bronchial:
, No(t) Wheezes : , Diminished: , No(t) Absent : , No(t)
Rhonchorous: ), Periodic breaething
Abdominal: Soft, Non-tender, Bowel sounds present, No(t)
Distended, No(t) Tender: , Obese
Extremities: Right lower extremity edema: 1+ edema, Left lower
extremity edema: 1+, No(t) Cyanosis, No(t) Clubbing
Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand
Skin: Warm, No(t) Rash: , No(t) Jaundice
Neurologic: No(t) Attentive, No(t) Follows simple commands,
Responds to: Tactile stimuli, No(t) Oriented (to): , Movement:
Non -purposeful, No(t) Sedated, No(t) Paralyzed, Tone: Not
assessed
Pertinent Results:
[**2199-2-10**] 11:02AM HCT-24.2*
[**2199-2-10**] 03:30AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.010
[**2199-2-10**] 03:30AM URINE BLOOD-LGE NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2199-2-10**] 03:30AM URINE RBC-[**10-26**]* WBC-21-50* BACTERIA-FEW
YEAST-RARE EPI-[**2-8**]
[**2199-2-10**] 03:22AM TYPE-ART RATES-18/ TIDAL VOL-400 PEEP-5
O2-100 PO2-37* PCO2-49* PH-7.32* TOTAL CO2-26 BASE XS--1
AADO2-644 REQ O2-100 -ASSIST/CON INTUBATED-INTUBATED
[**2199-2-10**] 02:09AM COMMENTS-GREEN TOP
[**2199-2-10**] 02:09AM LACTATE-3.4* K+-3.9
[**2199-2-10**] 02:09AM HGB-6.7* calcHCT-20 O2 SAT-62
[**2199-2-10**] 02:00AM PT-18.6* PTT-36.9* INR(PT)-1.7*
[**2199-2-10**] 01:50AM GLUCOSE-177* UREA N-138* CREAT-5.3*
SODIUM-134 POTASSIUM-4.1 CHLORIDE-93* TOTAL CO2-27 ANION GAP-18
[**2199-2-10**] 01:50AM estGFR-Using this
[**2199-2-10**] 01:50AM WBC-5.2 RBC-2.31* HGB-6.3* HCT-20.0* MCV-86
MCH-27.0 MCHC-31.3 RDW-19.2*
[**2199-2-10**] 01:50AM NEUTS-67.3 LYMPHS-25.1 MONOS-5.6 EOS-1.8
BASOS-0.2
[**2199-2-10**] 01:50AM PLT COUNT-151
CXR [**2199-2-10**]
Comparison is made to the prior study from [**2199-2-10**].
Endotracheal tube
terminates 21 mm above the carina which is acceptable.
Nasogastric tube
courses below the diaphragm but the tip is not seen, presumed in
the stomach.
The heart is markedly enlarged. There is patchy consolidation at
both lung
bases as well as in the perihilar region. There may be
superimposed
congestive failure. There are small bilateral pleural effusions.
Brief Hospital Course:
[**Age over 90 **] y/o F CHF, A Fib on coumadin, chronic thromboembolic PHTN who
presents with hematemesis. Patient recently discharged home with
hospice [**2199-2-8**] from [**Hospital1 1516**] service following complicated admission
with CHF exacerbation, renal failure and hematemesis.
.
# Hematemesis: Significant upper GI bleed with hematocrit drop
20 from most recent HCT of 25. Etiology most likely esophagitis,
gastritis versus peptic ulcer disease. Prior EGD [**2193**]
demonstrates gastritis (history of h. pylori). Patient given 10
mg IV vitamin K in ED. Patient home hospice/DNR/DNI prior to
admission, unfortunately unable to reach HCP at time of
presentation and thus she was intubated in the emergency
department. HCP was out of the country. Her [**Last Name (LF) 802**], [**Name (NI) **] was
the only family available by phone. Based on extensive
documention in OMR no central line, pressors or extreme
aggressive measures. We spoke with the hospice nurse involved
in the case as well as available family and decision was made
not to initiate any further invasive procedures.
.
# Positive Ua: Patient oliguric with multiple prior positive
cultures for KLEBSIELLA and is most likely colonized. Patient
treated last admission for Klebsiella with ceftriaxone. Abx
were held as most likely is colonized. Patient hypotensive
secondary to hypovolemia/blood loss and unlikely sepsis.
.
# CHF: Severe diastolic dysfunction and TR. Recent admission
with aggressive diuresis. This was monitored.
# Atrial fibrillation: Currently irregular rate. Patient is not
anticoagulated based on goals of care.
.
# CKD: Baseline renal insufficiency worsened last admission,
continues to climb. Lytes within normal limits. No further labs
were drawn after it was decided not to pursue further
monitoring.
.
# Goals of care: Patient recently discharged home with hospice
however was brought into ED for evaluation. Most likely
caretaker felt overwhelmed at home. Unfortunately, we are unable
to reach patient's HCP for further direction. Touched base with
primary providers, hospice nurse, and available family.
Confirmed that pt and HCP had decided on DNR/DNI, no furthe
treatment was initiated.
- DNR, no aggressive measures such as central access, pressors
.
# FEN: pRBC, replete electrolytes, NPO
# Prophylaxis: pneumoboots
# Access: peripherals X 2
# Communication: Patient
# Code: DNR
# Disposition: ICU pending goals of care discussion
.
Contact: [**Name (NI) **] (not HCP) ([**Telephone/Fax (1) 109254**])
[**Hospital 269**] Hospice [**Telephone/Fax (1) 32042**] [**First Name8 (NamePattern2) 717**] [**Last Name (NamePattern1) **]
*** On [**2199-2-13**], after BPs falling over prior 48 hours, pt. went
into intermittent asystole. Pupils were fixed, no heart or
breath sounds. Once asystolic, ventilator was turned off.
Physical exam repeated without change. Time of death was 04:45.
Her [**Last Name (LF) 802**], [**Name (NI) **] was notified and the family did not choose to
pursue autopsy.
Medications on Admission:
1. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*30 Capsule(s)* Refills:*2*
2. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for indigestion.
Disp:*500 ML(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
Disp:*60 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
5. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
Disp:*2 inhalers* Refills:*3*
6. Home oxygen
Home oxygen, at 1-6L/min, pulse dose for portability
7. Morphine 10 mg/5 mL Solution Sig: One (1) mL PO every [**3-12**]
hours as needed for pain and/or respiratory distress.
Disp:*100 mL* Refills:*0*
8. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
9. Compazine 5 mg Tablet Sig: 1-2 Tablets PO three times a day
as needed for nausea.
Disp:*60 Tablet(s)* Refills:*2*
10. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
Disp:*500 mL* Refills:*2*
11. 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 Medications:
Pt. expired
Discharge Disposition:
Expired
Discharge Diagnosis:
1. GI Bleed
2. Hypotension/Hypovolemia
Discharge Condition:
Pt. expired
Discharge Instructions:
Pt. expired
Followup Instructions:
Pt. expired
|
[
"443.9",
"276.52",
"562.10",
"290.40",
"274.9",
"493.90",
"275.49",
"788.5",
"285.1",
"424.0",
"428.0",
"416.8",
"712.30",
"584.9",
"585.9",
"V12.51",
"284.1",
"437.0",
"428.42",
"424.2",
"V58.61",
"578.9",
"V02.9",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.07",
"99.04",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10587, 10596
|
6012, 9021
|
274, 286
|
10681, 10695
|
4408, 5989
|
10755, 10770
|
2977, 3013
|
10551, 10564
|
10617, 10660
|
9047, 10528
|
10719, 10732
|
3028, 4389
|
223, 236
|
314, 2204
|
2226, 2766
|
2782, 2961
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,156
| 167,702
|
52413
|
Discharge summary
|
report
|
Admission Date: [**2171-11-13**] Discharge Date: [**2171-11-15**]
Date of Birth: [**2098-3-27**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Betalactams / Iodine-Iodine Containing / Meropenem
Attending:[**First Name3 (LF) 4611**]
Chief Complaint:
dizziness, hypoglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
73F w/PMHx CLL and ITP, DM tx from [**Hospital 4199**] hospital due to
persistent weakness and dizziness x 2d. Pt found to have
persistent hypoglycemia while in [**Last Name (un) **] ED. Pt presently on
actos, sulfonylurea, had 3 blood sugars in 50s while @ [**Last Name (un) **],
then BS in 200s after multiple doses of D50. Pt reports that she
has continued to have dull left sided abdominal pain; pt has had
a distended abdomen due to established adenopathy, and states
that there has been no change in abdominal girth. She reports
that she has had a mild decrease in appetite without significant
nausea, having only had a cup of coffee today. Reports
occasional chest pain that is non-radiating and non-exertional.
.
Vitals in the ER: 97.2 78 162/50 16 99% RA. She was given
Calcium Gluconate 2g IV for K 7.4 (5.4 at [**Last Name (un) 4199**] previously)
and Kayexylate 30g PO x1.
.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies blurry vision, diplopia, loss of vision,
photophobia. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations, lower
extremity edema. Denies cough, shortness of breath, or wheezes.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
melena, hematemesis, hematochezia. Denies dysuria, stool or
urine incontinence. Denies arthralgias or myalgias. Denies
rashes or skin breakdown. No numbness/tingling in extremities.
All other systems negative.
Past Medical History:
PAST ONCOLOGIC HISTORY:
On [**2164-1-24**], received fludarabine and rituximab. She went on
to receive 2 cycles of fludarabine and then received Rituxan
alone with four weeks of consolidation. She developed febrile
neutropenia with this regimen.
From [**2164-10-10**] to [**2164-11-2**], she received weekly Rituxan for
thrombocytopenia that was refractory to steroids and IVIG.
In [**4-/2165**], she started maintenance rituximab.
From [**2166-2-24**] until [**2166-4-3**], she was treated with
chlorambucil for painful adenopathy and IVC compression. Her
chlorambucil therapy was interrupted due to thrombocytopenia.
Ultimately chlorambucil was stopped on [**2166-10-2**].
Hospitalization from [**2167-1-8**] to [**2167-2-2**] because of airway
compromise from her lymphadenopathy that required intubation and
radiation therapy.
On [**2169-1-18**], she began cyclophosphamide for
progression of her CLL in the form of a rising white blood cell
count as well as Coombs positive hemolytic anemia and probable
autoimmune thrombocytopenia. Rituximab was held from the 1st
cycle, but she then went on to receive 5 cycles of RCD
(rituximab, cyclophosphamide, and dexamethasone). She received
Neulasta throughout this course of therapy.
On [**2169-10-31**], she began IVIG for hypogammaglobulinemia. She
had
another treatment with IVIG on [**2169-11-28**].
On [**2169-12-20**], she had further progression of her CLL in the
form
of increased adenopathy within the peritoneum, retroperitoneum,
and pelvis. She was subsequently started on rituximab and
dexamethasone on [**2169-12-20**], as well as on [**2169-12-21**].
On [**2169-12-26**], she began pentostatin and rituximab with the
pentostatin given at a dose of 2 mg/m2 once every three weeks.
She received 2 cycles of this chemotherapy with Neulasta
support.
On [**2170-2-6**], she presented with increased abdominal pain and
abdominal distention, and because of this pain she required
inpatient admission.
She received cycle 1 of bendamustine on [**2170-2-7**] and
[**2170-2-8**] at a dose of 50 mg/m2 for relapsed CLL with bulky
disease. The bendamustine was dose reduced by 50% considering
her renal function and tendency for cytopenias.
[**2170-3-7**] - [**2170-3-12**]: hospitalized for neutropenic fever.
[**2170-3-20**] - [**2170-3-28**]: hospitalized for neutropenic fever, right foot
swelling and treated for right leg/foot cellulitis and gout.
[**2170-6-13**]: Cycle 2 Bendamustine 50 mg/m2 (dose reduced)/Rituximab
375 mg/m2
[**2170-7-18**]: Cycle 3 Bendamustine 50 mg/m2/Rituximab 375 mg/m2
[**2170-8-22**]: Cycle 4 dose reduced [**Last Name (un) 106229**] 50 mg/m2/Rituxan 375
mg/m2.
This cycle was complicated by an acute febrile illness -
pneumonia vs. UTI.
[**2170-12-11**]: Patient admitted with fever, likely UTI, and
thrombocytopenia with vaginal bleeding.
.
[**2171-6-15**] - [**2171-6-26**]: Admitted with UTI and pneumonia; had a gout
flare
.
[**8-15**] - [**2171-8-18**] R upper maxillary dental infection, right
maxillary sinusitis treated with Clindamycin and tooth
extractions
.
PAST MEDICAL HISTORY:
- Chronic ITP
- CAD s/p stent to mid-proximal LAD in [**2163**]
- Diastolic dysfunction, last EF 65%, [**7-/2169**]
- h/o hypertensive cardiomyopathy, now resolved
- AF
- CKD [**2-14**] hypertensive nephrosclerosis, baseline Cr 1.8
- DM, Type II
- GERD
- Gout
- Hypothyroidism
- Hypertension
- Dyslipidemia
- Secondary hyperparathyroidism
Social History:
Living in [**Location (un) 3146**] for the past 6 months with her husband.
- Originally from [**Male First Name (un) 1056**]
- She has two daughters who live nearby & are involved in her
care.
- Tobacco: None
- EtOH: None
- Illicits: None
- She has a home health aide that comes for 4 hours/day.
Family History:
- The patient notes a mother with a myocardial infarction at the
age of 71.
- A sister with a myocardial infarction at the age of 47.
- Otherwise, denies any further family history.
Physical Exam:
ADMISSION
VS:98.2, 75, 149, 51, 97% RA
GEN: Elderly man in NAD, awake, alert
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and
without lesion
NECK: Supple
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, NT, ND, bowel sounds present
MSK: normal muscle tone and bulk
EXT: No c/c, normal perfusion
SKIN: No rash, warm skin
NEURO: oriented x 3, normal attention, no focal deficits, intact
sensation to light touch
PSYCH: appropriate
DISCHARGE
Vitals: T98.5 HR 68 BP 151/93 (120s150s/40s-90s) RR20 O2 sat 98%
RA
General: Alert, orientedx3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, scattered cervical LAD (tender
in L anterior cervical chain/superclavicular matted
lymphadenopathy
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic murmur
in the LUSB, no rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, mild tenderness to the left side abdomen,
distended, bowel sounds present
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, gait deferred; no vertiginous symptoms
with head turning.
Pertinent Results:
ADMISSION
[**2171-11-13**] 04:50AM GLUCOSE-317* UREA N-54* CREAT-2.0* SODIUM-134
POTASSIUM-7.3* CHLORIDE-103 TOTAL CO2-19* ANION GAP-19
[**2171-11-13**] 04:50AM ALT(SGPT)-14 AST(SGOT)-21 ALK PHOS-70 TOT
BILI-0.3
[**2171-11-13**] 04:50AM LIPASE-34
[**2171-11-13**] 04:50AM ALBUMIN-4.8
[**2171-11-13**] 04:50AM WBC-164.1* RBC-2.81* HGB-9.7* HCT-29.2*
MCV-104* MCH-34.4* MCHC-33.1 RDW-17.3*
[**2171-11-13**] 04:50AM PLT COUNT-29*
[**2171-11-13**] 07:31AM BLOOD %HbA1c-5.5 eAG-111
[**2171-11-13**] 04:50AM BLOOD ALT-14 AST-21 AlkPhos-70 TotBili-0.3
[**2171-11-13**] 07:31AM BLOOD cTropnT-<0.01
DISCHARGE
[**2171-11-15**] 08:30AM BLOOD WBC-147.9* RBC-2.65* Hgb-9.3* Hct-26.6*
MCV-100* MCH-35.2* MCHC-35.1* RDW-16.8* Plt Ct-34*
[**2171-11-15**] 08:30AM BLOOD Plt Smr-VERY LOW Plt Ct-34*
[**2171-11-15**] 08:30AM BLOOD Glucose-100 UreaN-40* Creat-1.8* Na-146*
K-4.8 Cl-110* HCO3-23 AnGap-18
[**2171-11-15**] 08:30AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.2
PORTABLE CXR [**11-13**]:
IMPRESSION: Mild cardiomegaly. No acute intrathoracic process.
ECG Study Date of [**2171-11-13**] 4:53:10 AM
Artifact is present. Sinus rhythm. Atrial ectopy. The P-R
interval is
prolonged. Non-specific ST-T wave changes. Compared to the
previous tracing of [**2171-8-20**] there is no significant change.
Brief Hospital Course:
73 yo Spanish speaking female with h/o relapsed CLL, chronic
ITP, DM, and CKD (baseline Cr 1.9-2.1) transferred from [**Hospital 4199**]
Hospital for persistent weakness and dizziness for 2 days, found
to have hyperkalemia and hypoglycemia initially, transferred to
[**Hospital1 18**] and found to be hyperglycemic and hyperkalemic. Was
treated for her electrolyte abnormalities and was D/C on her
diabetes medications and lisinopril with outpatient followup.
ACTIVE ISSUES
# Diabetes Mellitus type 2, with Hyperglycemia after 2 days of
hypoglycemia at outside hospital from probable Sulfonurea
overdose - Patient was treated with insulin initially and her
blood sugars stabilized. Pioglitazone and Glipizide were stopped
and she was diet controleld. Fingerstick glucoses day before/of
discharge ranges from 119-141. Was not requiring sliding scale
insulin. Advised her to followup with PCP before restarting any
of her DM medications.
# Hyperkalemia - Likely related to elevated glucose levels.
Patient received regular insulin 10 unit IVx1 and 10 units SC
x1, calcium gluconate 1 g x 2, dextrose 50% x 1, and Kayexalate
60 g. Potassium levels normalized upon correction of glucose
levels. Lisinopril was discontinued pending PCP [**Name Initial (PRE) 4939**].
CHRONIC ISSUES
# CLL - relapsed with worsening lymphadenopathy and
lymphocytosis. Cycle 4 of bendamustine (dose-reduced)/Rituximab
in [**8-24**]. Patient to follow up with Dr. [**Last Name (STitle) **] of Heme/Onc as
outpatient.
# CKD Stage III: Baseline Cr 1.9-2. Lisinopril was held at time
of discharge (as above)
# Chronic ITP: Platelets at baseline of high 20s, low 30s.
.
# Chronic diastolic CHF: Patient euvolemic during admission.
Continued home Imdur, Coreg. Held lisinopril for hyperkalemia.
# Hyperlipidemia: Continued home simvastatin
.
# HTN: Continued home amlodipine
# Hypothyroidism: continued home levothyroxine
# H/o gout: continued allopurinol
TRANSITIONAL ISSUES
1) Hypertension - Stopped Lisinopril due to hyperkalemia, and
patient was hypertensive during this admission. [**Month (only) 116**] need to
uptitrate or adjust regimen if Lisinopril continues to be held.
Carvedilol was not an option due to PR interval prolongation as
well as borderline bradycardia at times on telemetry.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. Allopurinol 100 mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. Bisacodyl 5 mg PO DAILY:PRN constipation
5. Carvedilol 12.5 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. Doxepin HCl 50 mg PO HS
8. Fluoxetine 20 mg PO DAILY
9. Fluticasone Propionate 110mcg 1 PUFF IH DAILY
10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
11. Levothyroxine Sodium 137 mcg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
15. Senna 2 TAB PO DAILY:PRN constipation
16. Simvastatin 40 mg PO DAILY
17. traZODONE 50 mg PO HS:PRN insomnia
18. GlipiZIDE XL 5 mg PO DAILY
19. Lisinopril 30 mg PO DAILY
20. Pioglitazone 15 mg PO DAILY
21. Torsemide 10 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. Allopurinol 100 mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. Carvedilol 12.5 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Doxepin HCl 50 mg PO HS
7. Fluoxetine 20 mg PO DAILY
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
9. Levothyroxine Sodium 137 mcg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Senna 2 TAB PO DAILY:PRN constipation
13. Torsemide 10 mg PO DAILY
14. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
15. traZODONE 50 mg PO HS:PRN insomnia
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary: Hypoglycemia/Hyperglycemia, Hyperkalemia
Secondary: Chronic Lymphocytic Leukemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure caring for you at [**Hospital1 827**]. You were admitted because you were feeling
weakness and dizziness. We determined that you had very large
changes in your blood sugars, as well as high potassium levels.
We treated you with medications to correct these issues. Please
follow up with your doctors [**Name5 (PTitle) **] to ensure you continue to feel
well.
You should STOP your diabetes medications until you follow up
with your doctor. You should also STOP Lisinopril until you see
Dr. [**Last Name (STitle) **], and have him decide whether you can restart it.
Please review the attached medication list for the full details
of the medications you should take.
Followup Instructions:
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 30755**], MD
Specialty: Primary Care
When: Tuesday [**2171-11-19**] - Please walk into the clinic in
the morning of [**11-19**] to be seen.
Address: [**Apartment Address(1) 14920**], [**Location (un) **],[**Numeric Identifier 6809**]
Phone: [**Telephone/Fax (1) 14918**]
Department: HEMATOLOGY/ONCOLOGY
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD [**Telephone/Fax (1) 9645**]
When: WEDNESDAY [**2171-11-27**] at 9:00 AM
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
We are working on a follow up appointment with Dr. [**Last Name (STitle) **] . You
will be called at home with the appointment. If you have not
heard within 2 business days or have questions, please call
[**Telephone/Fax (1) 9645**].
Department: EYE UNIT
When: WEDNESDAY [**2171-11-27**] at 9:00 AM
With: OPTOMETRY [**Telephone/Fax (1) 253**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RADIOLOGY
When: WEDNESDAY [**2171-12-4**] at 4:15 PM
With: RADIOLOGY [**Telephone/Fax (1) 590**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2171-12-10**] at 8:45 AM
With: CHECKIN HEM ONC CC9 [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2171-11-15**]
|
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83,228
| 165,109
|
36987
|
Discharge summary
|
report
|
Admission Date: [**2159-7-9**] Discharge Date: [**2159-7-13**]
Date of Birth: [**2083-9-14**] Sex: F
Service: MEDICINE
Allergies:
metal
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
mechanical fall, hypoxia
Major Surgical or Invasive Procedure:
[**2159-7-9**] - Open reduction and internal fixation left distal
radius fracture 2 or more fragments. Open reduction and internal
fixation left ulnar fracture. Open carpal tunnel release left
arm.
History of Present Illness:
This is a 75 year-old Female with a PMH significant for COPD
(baseline 90-92% without home oxygen), RA (treated with
methotrexate, prednisone) who is s/p mechanical fall with
contact to the left wrist at her rehabilitation facility
(treated for pneumonia recently) this morning. Her fall was
witnessed, without LOC, and she was noted to have evidence of
deformity on left wrist examination. She denies neck pain or
head injury. She was transfered from [**Hospital3 **] [**2159-7-9**],
the morning of admission, for orthopaedic surgery evaluation
given she had radiographic evidence of a 1 to 2-cm displaced,
left distal radius and ulna fracture with parathesias, which was
concerning for median nerve impingement.
.
In the ED, VS 97.6 83 136/70 18 86% 4L. She was triggered for
hypoxia given that her oxygen saturations dropped to the 70%
range on room air, this responded to supplemental oxygen. She
was not tolerating BiPAP in the ED. EKG demonstrated multifocal
atrial tachycardia. She was given albuterol-ipratropium nebs,
methylprednisolone 125 mg IV x 1 given concern for COPD
exacerbation. She was empirically given Azithromycin 500 mg IV,
Levofloxacin 750 mg IV, and Vancomycin 1 g IV x 1. The patient
also received Ativan 2 mg IV once. A CXR showed evidence of
hyperinflation consistent with her known COPD-emphysema, with
opacification in the LLL concerning for PNA with L > R bilateral
pleural effusions. She was seen by Orthopaedic surgery who felt
there was concern for median nerve impingement, opted for closed
reduction with splinting in the ED with plans to bring her to
the OR. She underwent medical optimization in the ED in
preparation for her procedure.
.
Currently, she is without complaints and is preparing to
transport to pre-op holding. She denies dyspnea or productive
cough. She is reclined flat without trouble breathing. She
denies fevers or chills.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
1. COPD (recent diagnosis, not requiring home oxygen and
maintains 90-92% O2 saturations on room air)
2. Rheumatoid arthritis (controlled with methotrexate,
prednisone)
3. Anxiety
Social History:
Previously has lived independently, was recently at rehab with
intentions to transition to an assisted-living facility; denies
recent smoking (quit 12 years prior), denies alcohol use or
recreational substance use.
Family History:
non-contributory
Physical Exam:
ON ADMISSION:
VITALS: 99.4/99.4 94 106/67 20 96% 3L NC
GENERAL: Alert, interactive. No acute distress.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes dry. Neck supple without lymphadenopathy. JVD
8-cm
CVS: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2.
RESP: decreased breath sounds at bases L > R, with crackles at
left lung base to 5th intercostal space. No wheezing or rhonchi.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No masses or peritoneal signs.
EXTR: no cyanosis, clubbing; trace edema B/L, 2+ peripheral
pulses
NEURO: CN II-XII intact, sensation grossly intact throughout;
DTRs 2+ with strength 4/5 in extremities throughout; gait -
deferred - left upper extremity distally sensation intact with
limited ROM due to injury, volar splint in place
.
ON DISCHARGE:
VITALS: 96.8/96.8 82 155/91 20 99% 2L NC I/O: Foley
GENERAL: Alert, interactive. No acute distress.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist. Neck supple without lymphadenopathy. JVD
8-9 cm
CVS: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 (very diminished heart sounds).
RESP: decreased breath sounds at bases L > R, with no crackles,
but mild inspiratory / expiratory wheezes noted. No rhonchi.
Poor inspiratory effort and very diminished breath sounds.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No masses or peritoneal signs.
EXTR: no cyanosis, clubbing; [**12-17**]+ pitting edema B/L, 2+
peripheral pulses
NEURO: CN II-XII intact, sensation grossly intact throughout;
DTRs 2+ with strength 4/5 in extremities throughout; gait -
deferred - left upper extremity distally sensation intact with
limited ROM due to injury, volar splint in place.
Pertinent Results:
[**2159-7-10**] 08:55AM BLOOD WBC-8.5 RBC-3.10* Hgb-8.9* Hct-29.0*
MCV-94 MCH-28.9 MCHC-30.8* RDW-17.8* Plt Ct-551*
[**2159-7-9**] 06:50AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-2+ Polychr-2+ Ovalocy-1+
[**2159-7-9**] 06:50AM BLOOD PT-11.5 PTT-19.8* INR(PT)-1.0
[**2159-7-10**] 08:55AM BLOOD Glucose-150* UreaN-12 Creat-0.6 Na-140
K-4.9 Cl-100 HCO3-30 AnGap-15
[**2159-7-9**] 06:50AM BLOOD cTropnT-<0.01
[**2159-7-9**] 06:50AM BLOOD proBNP-685*
[**2159-7-10**] 08:55AM BLOOD Calcium-8.8 Phos-2.7 Mg-2.2
[**2159-7-9**] 06:59AM BLOOD Lactate-1.1
.
MICROBIOLOGY:
[**2159-7-9**] Blood culture - pending
[**2159-7-11**] Legionella urine antigen - negative
[**2159-7-13**] C.diff toxin - pending
.
IMAGING:
[**2159-7-9**] WRIST(3 + VIEWS) LEFT - post-reduction film - fractures
involving the distal radius and ulna with persistent
displacement. Distal radial fracture fragment abuts the lunate
and displaces
the scaphoid, thereby distorting the proximal carpal row.
.
[**2159-7-9**] CHEST (PORTABLE AP) - Hyperinflation reflects
obstructive lung disease, probably emphysema. Dense
opacification in the left lower lobe, obscuring the left
hemidiaphragm is pneumonia or, less likely atelectasis. Small
bilateral pleural effusion is greater on the left. There is no
pneumothorax.
.
[**2159-7-11**] CTA CHEST W&W/O C&RECONS, NON - No evidence of pulmonary
embolism. Bilateral left more than right small-to-moderate
pleural effusion. Lingular atelectasis most likely due to
secretions and unlikely to represent infectious process. Minimal
bibasilar atelectasis. Endobronchial secretions in particular in
the lower lobes. Coronary calcifications, hemodynamical
significance is unclear. [**Name2 (NI) **] rib fractures. Compression fracture
of the mid thoracic vertebral body, chronicity undetermined.
They are better appreciated on the sagittal reformats as
compared to chest radiograph. Severe emphysema. Minimal
outpouching of the left ventricular apex might be consistent
with small apical aneurysm, please correlate with prior history
of myocardial infarction.
Brief Hospital Course:
This is a 75 year-old Female with a PMH significant for COPD
(baseline 90-92% without home oxygen), RA (treated with
methotrexate, prednisone) who is s/p mechanical fall with
contact to the left wrist at her rehabilitation facility
(treated for pneumonia recently) this morning. Her fall was
witnessed, without LOC, and she was noted to have evidence of
deformity on left wrist examination. She denies neck pain or
head injury. She was transfered from [**Hospital3 **] [**2159-7-9**],
the morning of admission, for orthopaedic surgery evaluation
given she had radiographic evidence of a 1 to 2-cm displaced,
left distal radius and ulna fracture with parathesias, which was
concerning for median nerve impingement.
.
In the ED, VS 97.6 83 136/70 18 86% 4L. She was triggered for
hypoxia given that her oxygen saturations dropped to the 70%
range on room air, this responded to supplemental oxygen. She
was not tolerating BiPAP in the ED. EKG demonstrated multifocal
atrial tachycardia. She was given albuterol-ipratropium nebs,
methylprednisolone 125 mg IV x 1 given concern for COPD
exacerbation. She was empirically given Azithromycin 500 mg IV,
Levofloxacin 750 mg IV, and Vancomycin 1 g IV x 1. The patient
also received Ativan 2 mg IV once. A CXR showed evidence of
hyperinflation consistent with her known COPD-emphysema, with
opacification in the LLL concerning for PNA with L > R bilateral
pleural effusions. She was seen by Orthopaedic surgery who felt
there was concern for median nerve impingement, opted for closed
reduction with splinting in the ED with plans to bring her to
the OR. She underwent medical optimization in the ED in
preparation for her procedure.
.
She was medically optimized and taken to the OR on [**2159-7-9**] with
Orthopedic surgery and is s/p Left ORIF distal radius/ulnar
fracture with carpal tunnnel release; she tolerated the
procedure well. Upon admission to the floor from PACU on
[**2159-7-9**], she was managed with IV Vanc, Levquin PO and IV Zosyn
for HCAP coverage with CXR findings noting bilateral R > L
infiltrates and pleural effusions, although she remained
afebrile and without cough. She was given Prednisone 40 mg PO
daily for COPD exacerbation. She was treated with frequent
nebulizers and her HR and multifocal atrial tachycardia was rate
controlled with Verapamil PO.
.
The morning of [**2159-7-11**] she was noted to have increasing oxygen
requirements, specifically she was 90-94% 4L NC, requiring
frequent nebulizers (Xopenex and iptratropium) and was utilizing
accessory muscles for respiration with wheezing noted on exam
(RR 30-40s) and evidence of volume overload. Her HR escalated to
140-160s, EKG and telemetry findings suggestive of MAT. She
remained HD stable nonetheless with SBPs 110-120s. She was given
Lasix 10 mg IV x 2 with UOP 800 cc on Foley placement, CXR was
stable, Verapamil 5 mg IV x 1 was pushed with minimal HR effect
and frequent nebs were administered. ABG - 7.44/51/85/36. Given
her clinical decline, she was transferred to the MICU for
further management.
.
In the MICU, she was initially treated with NIPPV with good
effect given her respiratory status, a CTA chest demonstrated
bilateral left more than right small-to-moderate pleural
effusion and atelectasis with severe emphysema and no evidence
of PE. She did not require intubation and serial cardiac enzymes
were negative. Her IV antibiotics were continued for HCAP
coverage. Her HR was controlled with Metoprolol 12.5 mg PO Q6H
rather than Verapamil, with trend down into the 100s. Her oral
prednisone was continued. She received 2 units of pRBCs.
# PNEUMONIA - Given the likelihood of HCAP pneumonia, we
empirically treated for a total of 8-days with IV Vancomycin, IV
Zosyn and Levofloxacin PO. She tolerated the regimen well and
will continue 3 more days at rehab. She remained afebrile and
was provided supplemental oxygen. She was weaned to 2L nasal
cannula prior to discharge. The chest CTA confirmed pleural
effusions but only atelectasis without infiltrate was noted. We
also continued her albuterol-ipratropium nebs with mucolytics -
we switched her to Xopenex treatments in the setting of her
tachycardia. We sparingly utilized IV Lasix to diurese her. The
patient did well with diuresis. A sputum culture was not
obtained, because she had no productive cough. She remained
afebrile this admission and showed marked improvement.
.
# COPD EXACERBATION - underlying COPD diagnosis, with recent
initiation of treatment; currently on ProAir, Spiriva INH with
previous smoking history - currently not on home oxygen (90-92%
oxygen saturations at home, on room air). Given the above
course, we continued her supplemental oxgyen, goal > 90-92% RA,
requiring 2L nasal cannula on discharge. She received
albuterol-ipratropium nebs Q4-6H PRN with transition to Xopenex
to avoid tachycardia; she received a one time dose of
Methylprednisolone 125 mg IV x 1 in ED with clinical improvement
and was continued on Prednisone 40 mg PO x 7 days (end date
[**2159-7-17**]) for COPD exacerbation. We recommend tapering her dose
back to her home regimen of Prednisone 4 mg PO BID for her
rheumatoid arthritis. She will need close outpatient follow-up
with pulmonology and with PFT testing.
.
# TACHYCARDIA - EKG consistent with multifocal atrial
tachycardia given underlying COPD exacerbation - plan to treat
underlying cause - was continued on home Verapamil but required
transition to Metoprolol for better control and more frequent
dosing. We will continue this as an outpatient with plan to
titrate back to home Verapamil without beta-blockade. She
remained asymptomatic, with no chest pain. Serial EKGs were
stable and we monitored her with telemetry. We optimized
magensium and potassium and cardiac enzymes were reassuring.
.
# LEFT RADIAL/ULNAR FRACTURE - displaced left radial/ulnar
fracture which underwent closed reduction in the ED by
Orthopaedic surgery; She is s/p closed reduction and volar
splinting in the ED and then s/p OR [**7-9**] for ORIF radial-ulnar
fracture with carpal tunnel release (risk stritification took
place in ED prior to OR, by Medicine c/s) - She was continued on
oxycodone 2.5 mg PO Q4-6 PRN, Tylenol 1000 mg PO TID for pain
control with Morphine IV for breakthrough. She has follow-up
with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP [**Telephone/Fax (1) 1228**] on Thursday [**2159-7-19**] with
Orthopaedics, keep splint in place until f/u appointment.
.
# RHEUMATOID ARTHRITIS - stable disease; being treated with
Methotrexate and Prednisone; we continued her home dosing of
Methotrexate and Leflunomide. We recommend tapering her COPD
steroid flare dose to her home regimen. We continued with her
pain control. If infection persists, would consider altering
DMARD regimen, possible discussion with Rheumatology. We also
recommend considering GI prophylaxis for chronic steroids,
consider Bactrim for PJP ppx in the setting of chronic steroid
use.
.
# ANXIETY - diagnosis included in records, no anti-anxiety
medication reported, started at rehab; received Ativan 2 mg IV
in the ED - will con't PO Ativan 0.5 to 1 mg PO Q4-6H PRN
anxiety
.
TRANSITION OF CARE ISSUES:
1. outpatient follow-up with Podiatry, occupational therapy and
PCP
2. Continue IV Vanc, Zosyn and oral Levaquin until [**2159-7-16**]
3. Continue oral steroid dose at Prednisone 40 mg PO daily until
[**2159-7-17**] for COPD exacerbation, then taper to Prednisone 4 mg PO
BID for her RA management, at the discretion of Rheum and her
PCP
4. Transition from Metoprolol tartrate back to Verapamil home
dosing, as the discretion of her PCP
5. C.diff stool toxin pending on discharge, low suspicion
6. wean oxygen from 2 liters nasal cannula to room air, as
tolerated
Medications on Admission:
HOME MEDICATIONS (confirmed with rehab):
1. Prednisone 4 mg PO BID
2. Methotrexate 7.5 mg PO Q weekly
3. Verapamil SR 180 mg PO daily
4. Folic acid 1 mg PO daily
5. Magnesium oxide 400 mg PO BID
6. Mucinex 600 mg PO BID
7. Proair (albuterol) 90 mcg INH [**Hospital1 **]
8. Ultram 50 mg [**12-17**] tbs PO Q4-6H PRN pain
9. Multivitamin 1 tb PO daily
10. Tylenol 650 mg PO Q4-6H PRN
11. Ambien 5 mg PO QHS
12. Doxycyline 100 mg PO BID (until [**2159-7-11**])
13. Spiriva 18 mcg INH daily
14. Milk of magnesia 30 mL PO daily PRN constipation
15. Ativan 0.5 mg PO Q4-6H PRN anxiety
16. Leflunomide 10 mg QAM
Discharge Medications:
1. methotrexate sodium 2.5 mg Tablet Sig: Three (3) Tablet PO
1X/WEEK (WE).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. leflunomide 10 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
7. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 3 days: Following this regimen (total of 7 days) then return
back to your 4 mg PO twice a day regimen.
Disp:*6 Tablet(s)* Refills:*0*
10. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
11. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO Q6H
(every 6 hours): Hold for SBP < 100 or HR < 55.
12. Mucinex 600 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO twice a day.
13. Xopenex 0.63 mg/3 mL Solution for Nebulization Sig: One (1)
neb Inhalation every 4-6 hours as needed for shortness of breath
or wheezing.
14. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for fever or pain.
15. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) capsule Inhalation once a day.
16. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) mL
PO once a day as needed for constipation.
17. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 3 days: end date [**2159-7-16**] (total of 8-days).
Disp:*3 Tablet(s)* Refills:*0*
18. vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous
every twelve (12) hours for 3 days: start [**2159-7-9**] - end date
[**2159-7-16**].
19. Zosyn 4.5 gram Recon Soln Sig: 4.5 grams Intravenous every
six (6) hours for 3 days: start date [**2159-7-9**] - end date [**2159-7-16**] .
20. Ultram 50 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for pain.
21. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care - [**Hospital1 **]
Discharge Diagnosis:
Primary Diagnoses:
1. COPD exacerbation
2. dyspnea, shortness of breath
3. Healthcare-associated vs. Hospital-acquired pneumonia
.
Secondary Diagnoses:
1. Rheumatoid arthritis
2. Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the Internal Medicine service at [**Hospital1 1535**] on CC7 regarding management of
your COPD exacerbation and shortness of breath with findings of
pneumonia. You were treated with IV steroids tranitioned to oral
steroids, antibiotics for pneumonia and your nebulizers were
continued. You required a brief visit to the ICU for management
when your oxygen status was poor; once we removed fluid from
your lungs and continued your steroids with antibiotics, you
improved. You were then transfered back to the medicine floor. A
CT scan of your lungs was reassuring and showed evidence of
fluid only. Your symptoms improved with the above treatments.
.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
* Your Prednisone dose was increased and will continue at the
higher, once daily dosing until [**2159-7-16**].
* You will continue IV Vancomycin, Levaquin PO and IV Zosyn
until [**2159-7-17**] (completing an 8-day course).
* Your Verapamil was discontinued and you were started on
short-acting Metoprolol for beta-blockade. This will continue
for now and you can be transitioned back to your calcium channel
blocker (Verapamil) as an outpatient, per your PCP.
* We discontinued your Albuterol nebulizer and replaced this
with Xopenex to avoid tachycardia.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.
Followup Instructions:
Department: OCCUPATIONAL HEALTH
When: TUESDAY [**2159-7-17**] at 1:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 83423**], MD [**Telephone/Fax (1) 31189**]
Building: [**Street Address(2) 32216**] ([**Hospital1 **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: None
.
You have follow-up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 69591**] on
Thursday [**2159-7-19**] with Orthopedic Surgery clinic, keep splint in
place on the left arm until that time.
|
[
"714.0",
"V58.65",
"E849.7",
"785.0",
"491.21",
"E888.9",
"354.0",
"300.00",
"511.9",
"486",
"813.44"
] |
icd9cm
|
[
[
[]
]
] |
[
"04.43",
"79.32"
] |
icd9pcs
|
[
[
[]
]
] |
17450, 17523
|
6845, 14579
|
290, 490
|
17754, 17754
|
4742, 6822
|
20250, 20805
|
2885, 2904
|
15235, 17427
|
17544, 17675
|
14605, 15212
|
17937, 20227
|
2919, 2919
|
17696, 17733
|
3777, 4723
|
225, 252
|
518, 2399
|
2934, 3762
|
17769, 17913
|
2421, 2636
|
2652, 2869
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,442
| 134,940
|
30171+57678
|
Discharge summary
|
report+addendum
|
Admission Date: [**2139-4-19**] Discharge Date: [**2139-5-8**]
Date of Birth: [**2064-3-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Transfer for evaluation for CABG versus high-risk PCI.
angina for 4-6 weeks
Major Surgical or Invasive Procedure:
OPCABG x3 [**2139-4-29**] (LIMA to LAD, SVG to OM to PDA)
History of Present Illness:
74 y/o with hx. DM2 on insulin, morbid obesity (380 lbs), PVD
s/p Rt. [**Name (NI) 6024**], CRI (unclear baseline but renal consultant at
[**Hospital 1514**] Hospital felt that her baseline was likely around 1.8
but Cr. now approx 2.4 down from peak of approx 3.6), emphysema,
who presented to [**Location (un) 11248**] [**Hospital3 **] on [**3-10**]
complaining of [**5-1**] weeks of exertional chest pain. She was found
to have bilateral DVT's and bilateral pulmonary emboli at that
time. She was heparinized. Her Troponin T was 0.11 at this time,
but rose to 0.91 - she was then noted to have recurrent chest
pain and inferior ST elevations with antrolateral reciprocal
changes. She was then given integrelin in addition to the
heparin and aspirin. She was transferred to [**Hospital 1514**] Hospital for
cath.
.
Cath [**2139-3-12**]: Lt. main: clean; Lt. Circ: 40-50% stenosis near
branch of OM2; LAD: subtotal occlusion near take-off of a diag
branch; RCA (dominant) focal 95% senosis at mid-vessel. POBA
completed with "moderate success" - 40% residual.
.
She subsequently demonstrated peak CK of [**2132**], and peak Troponin
of 234.
.
She was discharged to [**Hospital3 245**] Rehab from there [**3-26**]. She
continued to have difficulty with fluid management, and with
dyspnea. On the night of [**4-2**], she had recurrent CP alleviated
with SL NTG times two, she also complained of SOB, so she was
transfered back to [**Hospital 1514**] Hospital. She was felt to be in
congestive heart failure. Warfarin was held and she was given
heparin and integrelin again to "temporize" until transfer could
be arranged to tertiary care - she was also started on IABP on
[**2139-4-11**] due to hct drop to 24 (guaiac pos, felt to be due to
GIB associated with anticoagulation), relative hypotension and
decreased urine output; amiodarone gtt was also started because
of runs of atrial fibrillation and ventricular ectopy which made
synchronization with the IABP difficult.
.
Repeat c. cath was undertaken on [**2139-4-17**]: RCA site of
intervention appeared patent with a slight dissection at the
proximal portion of where angioplasty had been completed, but
this was not flow limiting at all. There was a tight, sub-total
occlusion of the mid LAD seen. It could not be crossed with
multiple attempts and wires. Her hct. rebounded to approx. 30
with transfusion, and at the time of transfer, her GIB seemed to
have resolved. She was additionally started on Dopamine for
"renal perfusion".
.
Prior to transfer the Heparin gtt was stopped due to falling
platelets and concern for heparin-induced thrombocytopenia, and
lepirudin was started instead. Her platelets were approx 100 at
the time of transfer.
.
Cardiac review of systems is notable for absence of chest pain;
she endorses dyspnea on exertion, ankle edema.
.
On review of symptoms, he denies any prior history of stroke,
TIA; she has the hx. of deep venous thrombosis and pulmonary
embolism, bleeding at the time of surgery, myalgias, joint
pains, cough, hemoptysis, black stools or red stools. He denies
recent fevers, chills or rigors. He denies exertional buttock or
calf pain. All of the other review of systems were negative.
Past Medical History:
STEMI as above with inf and ant. HK and EF 35%
PE's bilaterally as above
Morbid Obesity
PVD s/p Rt. [**Year (4 digits) 6024**]
Emphysema
CKD
elev. chol.
HTN
Social History:
Social history is significant for the absence of current tobacco
use, although she has hx. of this and resultant emphysema. There
is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Blood pressure was 163/90 mm Hg while supine. Pulse was 73
beats/min and regular, respiratory rate was 14 breaths/min.
Generally the patient was obese and in no acute distress. The
patient was oriented to person, place and time. The patient's
mood and affect were appropriate.
There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. The neck was supple;
there was no JVD cm. The carotid waveform was normal. There was
no thyromegaly. The were no chest wall deformities, scoliosis or
kyphosis. The respirations were not labored and there were no
use of accessory muscles. The lungs were clear to ascultation
bilaterally with normal breath sounds and no adventitial sounds
or rubs.
Palpation of the heart revealed the PMI to be located in the 5th
intercostal space, mid clavicular line. There were no thrills,
lifts or palpable S3 or S4. The heart sounds revealed a normal
S1 and the S2 was normal. There were no rubs, murmurs, clicks or
gallops.
The abdominal aorta was not enlarged by palpation. There was no
hepatosplenomegaly or tenderness. The abdomen was soft and
diffusely tender and slightly distended. The extremities had no
pallor, cyanosis, clubbing or edema. There were no abdominal,
femoral or carotid bruits. Inspection and/or palpation of skin
and subcutaneous tissue showed no stasis dermatitis, ulcers,
scars, or xanthomas.
Pulses:
Right: Carotid 2+ Femoral- did not palpate due to IABP site
Left: Carotid 2+ Femoral 1+ Popliteal 1+ DP 1+ PT 1+
283# 67"
Pertinent Results:
[**2139-5-6**] 06:30AM BLOOD WBC-8.6 RBC-3.02* Hgb-9.4* Hct-29.0*
MCV-96 MCH-31.3 MCHC-32.5 RDW-18.1* Plt Ct-331
[**2139-5-6**] 06:30AM BLOOD PT-22.6* PTT-63.3* INR(PT)-2.2*
[**2139-5-6**] 06:30AM BLOOD Plt Ct-331
[**2139-5-6**] 06:30AM BLOOD Glucose-135* UreaN-33* Creat-1.3* Na-144
K-4.2 Cl-104 HCO3-33* AnGap-11
[**2139-4-20**] 01:58AM BLOOD CK-MB-NotDone cTropnT-0.19*
Cardiology Report ECHO Study Date of [**2139-4-29**]
PATIENT/TEST INFORMATION:
Indication: Congestive heart failure. Coronary artery disease.
Hypertension. Shortness of breath. Intraoperative TEE for off
pump CABG procedure
Height: (in) 67
Weight (lb): 282
BSA (m2): 2.34 m2
BP (mm Hg): 138/58
HR (bpm): 90
Status: Inpatient
Date/Time: [**2139-4-29**] at 12:34
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW000-0:00
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Name (STitle) **]
MEASUREMENTS:
Left Ventricle - Ejection Fraction: 30% (nl >=55%)
Aorta - Ascending: 3.3 cm (nl <= 3.4 cm)
Aorta - Arch: 2.3 cm (nl <= 3.0 cm)
Aortic Valve - Peak Velocity: 1.0 m/sec (nl <= 2.0 m/sec)
Aortic Valve - LVOT Diam: 2.1 cm
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A Ratio: 1.33
Mitral Valve - E Wave Deceleration Time: 240 msec
INTERPRETATION:
Findings:
LEFT ATRIUM: No spontaneous echo contrast in the body of the [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **] LAA. Good
(>20 cm/s) LAA ejection velocity. No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA.
No ASD by 2D or color Doppler.
LEFT VENTRICLE: Severe regional LV systolic dysfunction.
Severely depressed
LVEF. No resting LVOT gradient.
LV WALL MOTION: Regional LV wall motion abnormalities include:
basal anterior
- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid
anteroseptal -
hypo; mid inferior - normal; mid inferolateral - hypo; mid
anterolateral -
hypo; anterior apex - akinetic; inferior apex - hypo; lateral
apex - hypo;
apex - akinetic;
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 ascending aorta. Normal aortic arch
diameter.
Simple atheroma in aortic arch. Normal descending aorta
diameter. Simple
atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Moderate mitral
annular calcification. No MS. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure. The patient appears to be in sinus rhythm. Results
were personally
Conclusions:
1. No spontaneous echo contrast is seen in the body of the left
atrium or left
atrial appendage. No thrombus is seen in the left atrial
appendage. No atrial
septal defect is seen by 2D or color Doppler.
2. There is severe regional left ventricular systolic
dysfunction with
hypokinesia of the mid portions of the anterior wall, anterior
septum ,
inferior septum and septal walls. The apex is akinetic. Overall
left
ventricular systolic function is severely depressed.
3. Right ventricular chamber size and free wall motion are
normal.
4.There are simple atheroma in the ascending aorta. There are
simple atheroma
in the aortic arch. There are simple atheroma in the descending
thoracic
aorta.
5. The aortic valve leaflets (3) are mildly thickened. There is
no aortic
valve stenosis. No aortic regurgitation is seen.
6. The mitral valve leaflets are moderately thickened. Mild (1+)
mitral
regurgitation is seen.
7.There is no pericardial effusion.
8. Post revascularization LV function is unchanged. Mild mitral
regurgitation
persists.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD on [**2139-4-29**] 16:28.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2139-5-7**] 5:01 PM
CHEST (PORTABLE AP)
Reason: evaluate pleural effusions
[**Hospital 93**] MEDICAL CONDITION:
75 year old woman s/p CABG
REASON FOR THIS EXAMINATION:
evaluate pleural effusions
INDICATION: Follow up pleural effusions.
FINDINGS: Single portable AP upright chest radiograph is
reviewed and compared to multiple prior chest x-rays dating back
to [**2139-4-30**]. Limited examination due to patient body habitus.
Patient is status post median sternotomy and CABG. Postoperative
cardiomediastinal contour is unchanged. Perihilar haziness,
upper lobe vascular redistribution, and moderate bilateral
pleural effusions are unchanged. Allowing for differences in
technique, the visualized lung parenchyma is unchanged.
Bibasilar opacities most likely represent atelectasis, but
consolidation, particularly medially, cannot be excluded.
IMPRESSION: Unchanged mild pulmonary edema, with moderate
bilateral pleural effusions and probable bibasilar atelectasis.
Superimposed consolidation cannot be excluded.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5718**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**]
Brief Hospital Course:
75 year old woman with CAD s/p STEMI, DM2 with PVD s/p Rt. [**Last Name (NamePattern4) 6024**],
CKD, Emphysema, morbid obesity, who had STEMI [**3-4**] now s/p
transfer from OSH with sub-total LAD occlusion, ARF, on dopamine
and IABP, for further evaluation for revascularization options
(CABG vs. PCI). The pt. was admitted to the CCU with an IABP on
low dose Dopa. She was not a candidate for PCI and cardiac
surgery was consulted. She had transient renal failure and
eventually her creatinine recovered at 1.5.
On [**4-29**] she underwent OPCABG x3(LIMA->LAD, SVG->OM, PDA). She
tolerated the procedure well and was transferred to the CSRU in
stable condition on epinephrine, insulin and propofol drips. She
had acidosis and required continued intubation, and extubated on
POD #2. SQ heparin started for DVT prophylaxis. Gentle diuresis
continued as drips were weaned. Chest tubes and pacing wires
removed and insulin drip required further stay in the CSRU. She
had some SVT and went in and out of A fib and was started on
heparin as well as coumadin and amiodarone. She transferred to
the floor on POD #6 to begin increasing her activity level and
rehab screening. She continued to progress and was discharged to
rehab in stable condition on POD#9.
Medications on Admission:
Heparin, integrelin, ASA 81 mg daily, Lipitor 40 mg daily,
Plavix 75 mg daily ( last dose 3/23), lantus Insulin 95 units
QHS, Lasix 60 mg IV BID, Metoprolol 25 mg [**Hospital1 **], singulaire,
protonix, Valsartan, Ambien ,albuterol, zithromax 250 mg daily,
cipro 400 mg IV daily, hydralazine 25 mg TID, humalog SS,
zaroxolyn 5 mg daily, oxycodone prn, NTG paste 2" q 6hrs
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day). Tablet(s)
2. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 1 weeks: until [**5-12**], then 400 mg daily for 7 days,
then 200 mg daily ongoing.
7. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q4H (every 4 hours) as needed.
8. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Atorvastatin 40 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).
13. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 days: last dose PM [**5-7**].
15. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed.
16. Insulin Glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous once a day.
17. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1)
Subcutaneous four times a day: Follow insulin SS. Check glucose
QID.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 19504**] of [**Location (un) 1514**] - [**Location (un) 1514**], NH
Discharge Diagnosis:
CAD s/p OPCABG x3
morbid obesity
IDDM
PVD s/p right [**Location (un) 6024**]
CRI
COPD
bilat. DVTs
PE
C. diff.
STEMI
HTN
elev. chol.
SVT
A fib
Discharge Condition:
stable
Discharge Instructions:
no lotions, creams or powders on any incision
may shower over incisions and pat dry
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100.5, redness, or drainage
no driving for one month
Followup Instructions:
see Dr. [**Last Name (STitle) **] in [**1-27**] weeks
see Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
get referral for a local cardiologist from Dr. [**Last Name (STitle) **] and be
seen in [**2-28**] weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2139-5-8**] Name: [**Known lastname 12034**],[**Known firstname 12035**] Unit No: [**Numeric Identifier 12036**]
Admission Date: [**2139-4-19**] Discharge Date: [**2139-5-8**]
Date of Birth: [**2064-3-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 265**]
Addendum:
Pt. is on coumadin for AF and her INR on [**5-8**] is 3.6 and she
should receive 1 mg. of coumadin tonight. She needs daily coags
until stabilized and her INR goal is 2-2.5.
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day). Tablet(s)
2. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 1 weeks: until [**5-12**], then 400 mg daily for 7 days,
then 200 mg daily ongoing.
7. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q4H (every 4 hours) as needed.
8. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Atorvastatin 40 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).
13. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 days: last dose PM [**5-7**].
15. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed.
16. Insulin Glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous once a day.
17. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1)
Subcutaneous four times a day: Follow insulin SS. Check glucose
QID.
18. Coumadin: One (1) mg PO tonight ([**5-8**]) and dose daily for an
INR goal of [**2-27**].5
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 9368**] of [**Location (un) **] - [**Location (un) **], NH
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2139-5-8**]
|
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"414.01",
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icd9cm
|
[
[
[]
]
] |
[
"36.12",
"00.17",
"36.15",
"88.72",
"97.44"
] |
icd9pcs
|
[
[
[]
]
] |
17874, 18091
|
11280, 12537
|
375, 437
|
14918, 14927
|
5660, 6088
|
15187, 16092
|
4030, 4112
|
16115, 17851
|
10093, 10120
|
14752, 14897
|
12563, 12936
|
14951, 15164
|
6114, 10056
|
4127, 5641
|
260, 337
|
10149, 11257
|
465, 3655
|
3677, 3835
|
3851, 4014
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,153
| 103,872
|
47756
|
Discharge summary
|
report
|
Admission Date: [**2174-6-21**] Discharge Date: [**2174-6-29**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Failure to thrive, fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 75001**] is an 87M with a history of CVAs, HTN, CKD and
hypothyroidism who was brought in by his daughter on [**6-21**] for
failure to thrive and difficulty taking care of him at home.
This is all occurring in the setting of a recent disruption in
home VNA and PT services. Since these services stopped, the
patient has been needing 24/7 help with all ADLs. On the
morning of admission the patient was found down presumably after
falling off of the couch. There was no loss of consciousness or
head trauma. His ROS is only notable for decreased PO intake at
home with minimal weight loss. He has not had any other
symptoms at home, she denies any fevers, cough, SOB, abdominal
pain, nausea, vomiting or diarrhea.
.
In the emergency department he had a fever to 102F rectally, and
elevated CK to 2100 with a troponin of 0.17. Otherwise his
vital signs were stable. An EKG was difficult to interperet in
the setting of a LBBB and a V-paced rhythm. CT head and C-spine
were negative. A UA was negative. He was given Vancomycin,
levofloxacin and IVF; and sent to the ICU.
.
In the ICU, a cardiology consult did not feel the patient had an
acute MI. An infectious work-up revealed blood cultures 4/4
bottles positive for GPC's in pairs, clusters, and chains. A CT
of the chest showed multiple bronchial, calcified and
noncalcified pulmonary nodules associated with bronchiectasis
and bronchial impaction concentrated in the upper lobes,
suggesting nonacute nontuberculous mycobacterial infection or
[**Doctor First Name **]. The patient was placed on vancomycin and on respiratory
isolation. The team was unable to obtain sputum for AFB smear.
He was transferred to the floor for further work up.
Past Medical History:
1. Recent temporal lobe CVA [**9-18**]
2. h/o right PICA stroke
3. h/o TIA in [**5-15**] (left weakness, slurred speech)
4. Hypertension
5. Hyperlipidemia (LDL 58, HDL 100 [**3-18**])
6. Hypothyroidism: h/o [**Doctor Last Name 933**], now hypothyroid
7. Chronic kindey disease (baseline mid 2s)
8. Anemia (baseline mid-high 30s): Normal iron studies in [**3-18**]
9. Diverticulosis and internal hemorrhoids
Social History:
Previously took care of his wife, who is severely demented. No
history of tobacco, alcohol or drug use.
Family History:
Non-contributory.
Physical Exam:
Tmax: 96.4 Tcurrent: 95 BP: 97-127/54-77... HR:65-89...
96-100% RA
UOP: 25-40cc/hr
GENERAL: This is a cachectic elderly caucasian male, responsive
to verbal stimuli, minimally responsive to sternal rub
CARDIAC: rrr no murmurs
LUNGS: decreased breath sounds diffusely, RR ~10
ABDOMEN: Scaphoid, NABS, NTTP, soft
HEENT: NC, erythmatous area over righ eyebrow with a small
scrape. No bleeding or oozing.
NEURO: limited, will respond to verbal stimuli but will not
follow commands such as "open your eyes", seems to be refusing
to respond, not unresponsive. Bilateral ankle clonus. Upgoing
toe on the right, down going on the left. able to squeeze
fingers bilaterally, weak, [**3-16**]. Unable to move upper or lower
extremities on command. Pupils are reactive bilaterally.
Pertinent Results:
CT CHEST
1. No acute pulmonary process. Multiple bronchial, calcified,
noncalcified pulmonary nodules associated with bronchiectasis
and bronchial impaction concentrated in the upper lobes suggest
nonacute nontuberculous mycobacterial infection or [**Doctor First Name **]. If
clinically indicated, a followup can be performed in one year.
2. Extensive coronary artery calcifications.
.
CT spine
1. No acute fractures or alignment abnormalities.
.
CT head
1. No acute intracranial process.
2. Left temporal lobe encephalomalacia, likely sequela of an old
infarct.
.
US abdomen
1. Trace amount of pericholecystic fluid with gallbladder
"sludge ball."
2. Large right and small left pleural effusions with trace
amount of free
fluid in the right lower quadrant.
3. 6-mm saccular outpouching from the posterior aspect of the
infrarenal
abdominal aorta which may represent a small saccular aneurysm;
in the setting of known enterococcal bacteremia, endovascular
infection with mycotic aneurysm cannot be excluded.
4. Left hydroureteronephrosis with increased echogenicity of
bilateral renal cortex, suggesting chronic "medical renal
disease" consistent with patient's renal insufficiency.
.
Echocardiogram
Probable small aortic valve vegetation. Mild aortic
regurgitation. Severe global left ventricular systolic
dysfunction. Compared with the prior study (images reviewed) of
[**2173-9-2**], aortic valve abnormality is new. Left ventricular
systolic function has significantly deteriorated.
Brief Hospital Course:
HOSPITAL COURSE BY PROBLEM
.
1. Bacteremia: The patient was found to have persistent
Enterococcal and staphylococcal bacteremia despite broad
spectrum coverage with vancomycin. Abdominal ultrasound was
obtained on [**6-23**] which showed a saccular aneurysm on the
infrarenal aorta, which is concerning for a mycotic aneurysm as
a possible source. Echocardiogram obtained on [**6-24**] showed a
vegetation on the aortic valve. The patient was not likely to
be a good candidate for vascular surgery, given his poor
prognosis and functional capacity. He continued to be
hypothermic and bacteremic on surveillance cultures despite
broad spectrum coverage. The desicion was made by the family to
make him CMO.
.
2. Altered mental status: Likely a result of high grade
bacteremia, we were unable to image with MRI or CT with contrast
as the patient has a pacer and CKD
.
3. Findings on CT chest: The patient was ruled out for pulmonary
TB with three negative AFB smears and taken off of precautions.
.
4. Aspiration risk: The patient was evaluated by speech and
swallow as we had high suspicion for aspiration risk. They
deemed him a high risk and the patient was NPO for several days.
An attempt at an NG tube was unsuccessful, as the patient
refused it and pulled it out. The family was presented with the
options of a percutaneous feeding tube, as TPN was not an option
in the setting of high grade bacteremia. They did not feel that
this was a good option given his prognosis and decided to make
him CMO
Medications on Admission:
ASA 81 mg daily
Levothyroxine 150 mcg daily
Zydis 5 mg [**Hospital1 **]
Acetaminophen 325 mg q4h prn
Simvastatin 20 mg daily
Discharge Medications:
1. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
3. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO Q1H
(every hour) as needed for pain.
4. Lorazepam 0.5 mg IV Q4H:PRN agitation
5. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) patch
Transdermal every seventy-two (72) hours.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 9475**] Care Center - [**Location (un) 3146**]
Discharge Diagnosis:
Enterococcal and staphylococcal bacteremia
Endocarditis
Aneurysm (possibly mycotic)
Failure to thrive
Discharge Condition:
Comfort measures only
Discharge Instructions:
You were admitted with fevers and confusion, and we found you to
have a very severe bloodstream infection. We held a family
meeting to discuss the likelihood of recovery, and the decision
was made to maximize your comfort only, and stop invasive
measures. You will transferred to a facility that focuses on
comfort measures.
Followup Instructions:
None
|
[
"244.9",
"041.19",
"434.90",
"285.21",
"790.7",
"272.4",
"041.04",
"V45.01",
"403.90",
"426.3",
"585.9",
"421.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7059, 7145
|
4926, 5649
|
244, 251
|
7291, 7315
|
3412, 4903
|
7690, 7698
|
2579, 2598
|
6614, 7036
|
7166, 7270
|
6464, 6591
|
7339, 7667
|
2613, 3393
|
179, 206
|
279, 2010
|
5664, 6438
|
2032, 2441
|
2457, 2563
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,890
| 119,241
|
36415+58081
|
Discharge summary
|
report+addendum
|
Admission Date: [**2117-6-8**] Discharge Date: [**2117-6-15**]
Date of Birth: [**2052-8-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
positive exercise tolerance test
Major Surgical or Invasive Procedure:
[**2117-6-10**]:
1. Mitral valve repair with 28 mm 3D annuloplasty [**Company 1543**]
ring.
2. Coronary artery bypass grafting x2 with left internal
mammary artery graft to left anterior descending,
reverse saphenous vein graft to the posterolateral
ventricular branch.
History of Present Illness:
This 64 year old white male has a history of hypertension and
hypercholesteremia and had a myocardial infarction in [**2092**]. He
has been asymptomatic since that time and had a positive nuclear
stress test on [**2117-6-3**] and had ventricular fibrillation in the
recovery phase of the test. He was cardioverted and started on
Lidocaine. He ruled out for a myocardial infarction and
underwent cardiac cath which revealed a 90% right coronary
artery stenosis and a significant left coronary artery lesion.
His left ventricular ejection fraction was 40-45% and he was
transferred for coronary artery bypass grafting.
Past Medical History:
hypertension
coronary artery disease
hypercholesterolemia
status post myocardial infarction
rosacea
ventricular ectopy
status post herniorrophy
Social History:
The patient lives with his wife and works as a computer
programmer. He stopped smoking in [**2092**] and drinks one case of
beer per week.
Family History:
He has two brothers who had myocardial infarctions in their
fifties and his mother died of a myocardial infarction at the
age of 71.
Physical Exam:
General: well developed, well nourished white male in no
apparent distress.
HEENT: normocephalic, atraumatic, pupil equal and reactive to
light, ororpharynx benign
Neck: full range of motion, no thyromegaly, carotids 2+ and
equal without bruits.
Lungs: Clear to auscultation and percussion.
Cardiovascular: regular rate and rhythm, no rubs, gallops or
murmurs
Abdomen: positive bowel sounds, no masses or tenderness, soft
Extremities: no clubbing, cyanosis, or edema, right femoral
artery site intact
Pulses: 2+ and equal bilaterally
Neuro: nonfocal
Pertinent Results:
[**2117-6-15**] 06:30AM BLOOD WBC-7.7 RBC-3.20* Hgb-9.1* Hct-27.3*
MCV-86 MCH-28.4 MCHC-33.3 RDW-13.9 Plt Ct-317#
[**2117-6-10**] 02:04PM BLOOD PT-15.1* PTT-31.8 INR(PT)-1.3*
[**2117-6-14**] 06:00AM BLOOD Glucose-113* UreaN-21* Creat-0.7 Na-135
K-4.1 Cl-100 HCO3-24 AnGap-15
Chest xray:
Final Report
REASON FOR EXAMINATION: Followup of a patient after removal of
the chest tube
after cardiac surgery.
Portable AP chest radiograph was compared to [**2117-6-14**].
The supporting devices have been removed. The cardiomediastinal
silhouette is
unremarkable. Bilateral pleural effusion and bibasilar
atelectasis have
increased slightly, which might be related to termination of
mechanical
ventilation. Small left apical pneumothorax is present. There is
no evidence
of failure.
Findings were discussed with [**First Name8 (NamePattern2) 5627**] [**Last Name (NamePattern1) 4129**] over the phone by Dr.
[**Last Name (STitle) **] at
the time of dictation.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: SAT [**2117-6-12**] 5:29 PM
[**Known lastname **], [**Known firstname 1112**] [**Hospital1 18**] [**Numeric Identifier 82498**]Portable TTE
(Complete) Done [**2117-6-12**] at 11:36:46 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2052-8-3**]
Age (years): 64 M Hgt (in): 69
BP (mm Hg): 93/ Wgt (lb): 217
HR (bpm): 78 BSA (m2): 2.14 m2
Indication: Coronary artery disease. S/p CABG with MV repair.
ICD-9 Codes: 414.8, 424.0
Test Information
Date/Time: [**2117-6-12**] at 11:36 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) 4082**], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**Name2 (NI) 8154**] Bzymek,
RDCS
Doppler: Full Doppler and color Doppler Test Location: [**Location 13333**]/[**Hospital Ward Name 121**] 6
Contrast: None Tech Quality: Suboptimal
Tape #: 2009W013-0:21 Machine: Vivid [**7-26**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 4.0 cm <= 4.0 cm
Left Ventricle - Ejection Fraction: >= 40% >= 55%
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aorta - Arch: 3.0 cm <= 3.0 cm
Aortic Valve - Peak Velocity: 1.6 m/sec <= 2.0 m/sec
Mitral Valve - Peak Velocity: 1.9 m/sec
Mitral Valve - Mean Gradient: 7 mm Hg
Mitral Valve - E Wave: 1.9 m/sec
TR Gradient (+ RA = PASP): *29 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Normal LA size.
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild
regional LV systolic dysfunction. No resting LVOT gradient.
RIGHT VENTRICLE: RV not well seen. Paradoxic septal motion
consistent with prior cardiac surgery.
AORTA: Normal ascending aorta diameter. Normal aortic arch
diameter.
AORTIC VALVE: Aortic valve not well seen. No AS. No AR.
MITRAL VALVE: Mitral valve annuloplasty ring. Increased
transmitral gradient. No MR. [Due to acoustic shadowing, the
severity of MR may be significantly UNDERestimated.]
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Mild PA systolic hypertension.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality - bandages, defibrillator pads or
electrodes.
Conclusions
Technically suboptimal study.
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with hypokinesis of the
basal inferior and basal half of the inferolateral walls. The
remaining segments contract normally (LVEF >40 %).There is no
aortic valve stenosis. No aortic regurgitation is seen. A mitral
valve annuloplasty ring is present with slightly increased
gradient (mean 7mmHg). No mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2117-6-9**], the
severity of mitral regurgitation is reduced. Left ventricular
systolic function is similar.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2117-6-12**] 14:02
Brief Hospital Course:
This 64 year old white male was transferred from [**Hospital1 **] on [**2117-6-8**] and on [**2117-6-10**] he underwent Mitral
valve repair with 28 mm 3D annuloplasty [**Company 1543**]
ring/Coronary artery bypass grafting x2 with left internal
mammary artery graft to left anterior descending,reverse
saphenous vein graft to the posterolateral ventricular branch.
The cross clamp time was 72 minutes and total bypass time was
101 minutes. He tolerated the procedure well and was
transferred to the CVICU in stable condition on propofol,
amiodorone, and epinephrine. He was extubated on the post op
night and was transferred to the floor on post operative day
one. He was seen by EP and who recommended that now that the
patient is revascularized he should have his left ventricular
function reassessed in one month and if it is less that 30% he
should have an AICD placed. His chest tubes were discontinued on
postoperative day 2. He went into atrial fibrillation on postop
day 3 and was restarted on Lopressor. He converted to sinus
rhythm on postop day 4 and had a slight amount of serosanguinous
sternal drainage and was started on Keflex. He continued to
progress and had his sternal wires discontinued on postop day 5.
He went back into a controlled atrial fibrillation on postop
day 5 and his Lopressor was increased and he was started on
coumadin. He was discharged to home on postop day 5 and will
have his coumadin followed by Dr. [**Last Name (STitle) 37063**].
Medications on Admission:
Propanolol 80 mg PO daily
Lipitor 20 mg PO daily
Aspirin 81 mg PO daily
Minocin 50 mg PO daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
9. 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.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
10. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day for
2 days: Take as directed by Dr. [**Last Name (STitle) 37063**] for INR goal of [**2-22**].5.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
hypertension
hypercholesterolemia
ventricular ectopy
post operative atrial fibrillation
coronary artery disease
mitral regurgitation
status post myocardial infarction
Discharge Condition:
Good.
Discharge Instructions:
Take medications as directed.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 10 weeks.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use creams, powders, or lotions on wounds.
Call our office for temperature<101.5, sternal wound drainage or
redness.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 37063**] for 1-2 weeks.
Make an appointment with Dr. [**First Name (STitle) **] for 3 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.
Completed by:[**2117-6-15**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 13191**]
Admission Date: [**2117-6-8**] Discharge Date: [**2117-6-15**]
Date of Birth: [**2052-8-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 741**]
Addendum:
Lopressor decreased back to 12.5 mg PO BID as patient had a
history of post op heart block.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2057**] Hospice and VNA
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2117-6-15**]
|
[
"427.31",
"412",
"414.01",
"272.0",
"427.69",
"E878.2",
"424.0",
"512.1",
"997.1",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"35.33",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
11190, 11379
|
6841, 8323
|
352, 640
|
10100, 10108
|
2348, 6818
|
10444, 11167
|
1629, 1763
|
8468, 9804
|
9910, 10079
|
8349, 8445
|
10132, 10421
|
1778, 2329
|
280, 314
|
668, 1289
|
1311, 1456
|
1472, 1613
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,682
| 121,179
|
13125
|
Discharge summary
|
report
|
Admission Date: [**2116-9-20**] Discharge Date: [**2116-10-3**]
Date of Birth: [**2096-8-1**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
headache. hypertensive emergency
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
Ms. [**Known lastname **] is a 20 y/o woman with PMH of ESRD on HD (last
dialyzed on Friday [**9-18**]) who presents with bilateral frontal
headache since last Tuesday. The patient tells us that the she
was discharged from an OSH in [**Hospital1 789**], RI last Tuesday; her
headache developed upon discharge. She cannot tell me the exact
moment that the headache came on just states that it "started."
She says the headache did not come on gradually and that it
waxes and wanes in severity. She reports photophobia without
scotomata. She denies any neurologic symptoms including
numbness/tingling of arms or legs, slurring of speech, or facial
asymmetry. She also denies fever, nausea, and vomiting. She has
never had a headache like this before. She does report some neck
stiffness; she has been unsteady on her feet due to her "feet
hurting." She has not missed any of her medications per her
report.
.
In the ED, she was initially started on a nipride gtt for BP
190/103. Her blood pressure decreased to 150s-160s systolic. CT
head was performed and did not demonstrate any acute
intracranial hemorrhage. She was then switched to nitroglycerin
gtt with resultant BPs 140s-150s. Labs in the ED demonstrated
initial K of 6.3 and the patient was given insulin, D50,
kayexalate, and calcium gluconate. Repeat K was 5.9. Cardiac
enzymes were sent due to mild lateral ST segment depressions; CK
was 30 with troponin 0.25 (no prior in our system). She received
morphine 2 mg X 2 for pain as well as aspirin 325 mg X 1.
.
The renal team was contact[**Name (NI) **] with plan to dialyze the patient in
the morning. She was maintained on nitroglycerin gtt and
transferred to the [**Hospital Unit Name 153**] for further management.
.
On arrival to the [**Hospital Unit Name 153**], the patient is complaining of [**6-14**]
fonrtal headache. She denies nausea or vomiting.
.
ROS: She reports recent diarrhea and right upper quadrant
abdominal pain. She says that her recent hospitalization for
shortness of breath was complicated by constipation for one
week. She has had loose bowel movements since being home. She
has also had intermittent right upper quadrant pain without an
obvious trigger. Her feet feel "puffy" but her breathing is
comfortable. She denies any chest pain or palpitations. She
denies dysuria and hematuria.
Past Medical History:
* Type I DM - since [**2098**]
* ESRD on HD (MWF in [**Hospital1 789**])
* Pulmonary embolism on coumadin (diagnosed 1 month prior per
patient)
* Hypertension
* Hyperlipidemia
* Retinal detachment L eye
* bilateral cataracts
Social History:
The patient lives at home with her parents and younger sister.
She denies any alcohol or tobacco use.
Family History:
No history of headaches or migraines. Father and grandparents
with hypertension. Two grandparents are diabetic.
Physical Exam:
PE: T: 97 BP: 148/103 HR: 91 RR: 17 O2 98% on 2L NC
Gen: Pleasant, young female in no acute distress
HEENT: PERRL on right, L eye opacified. + photophobia. EOMI on
right. No scleral icterus or conjunctival pallor. MMM, tongue
midline, OP clear. NECK: Supple, No LAD, JVD < 10 cm. No
thyromegaly. Difficulty with flexion of the neck, reports pain
in left ribcage and cannot touch chin to chest even with passive
flexion.
Chest: HD tunnelled catheter in place over the right chest,
nontender to palpation of tunnelled portion.
CV: RRR. nl S1, S2. Soft systolic murmur at the LLSB.
LUNGS: crackles which clear with cough at the bilateral bases.
no wheezing.
ABD: Soft, no organomegaly. normoactive bowel sounds. +
tenderness to palpation in right upper quadrant, negative
[**Doctor Last Name **] sign. Also reports tenderness to palpation in
epigastrium.
EXT: no peripheral edema, warm & well perfused throughout.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 intact. Preserved sensation
throughout. 5/5 strength in bilateral hand grip, biceps,
triceps, knee flexion and extension, ankle dorsi- and
plantarflexion, and hip flexion. Finger to nose testing intact
on the right and left. [**1-7**]+ reflexes, equal BL. Gait not
assessed.
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
ADMISSION LABS:
WBC 10.2 (75% neutrophils, 17% lymphs, 5% eos), Hct 32.7, Plt
477
.
K 6.3 --> 5.9
sodium 134, chloride 93, bicarb 26 (AG 15)
BUN 62, creatinine 9.4, glucose 100
.
CK 30, troponin 0.25
.
INR 3.2, PT 30.2, PTT 34.9
.
lactate 1.5 --> 2.2
.
UA > 50 WBCs, 0-2 RBCs, [**11-24**] epis, 500 protein, 100 glucose
.
OTHER LABS:
LUMBAR PUNCTURE:
TUBE 4: WBC-0 RBC-0 Polys-0 Lymphs-50 Monos-50
CHEMISTRIES: TotProt-21 Glucose-117
.
STUDIES:
CT head [**2116-9-20**]: 1. No evidence of intracranial hemorrhage or
edema.
2. Chronic small vessel ischemic changes and cerebral atrophy.
3. Phthisis bulbi of the left globe.
4. Near complete opacification of mastoid air cells bilaterally.
.
CT HEAD [**2116-9-22**]:
No change from prior study. No acute hemorrhage.
.
PARATHYROID ULTRASOUND [**2116-9-24**]:
No enlarged parathyroid gland identified. If high clinical
suspicion can correlate with Sestamibi nuclear scintigraphy.
.
PARATHYROID SCAN:
Following the intravenous injection of tracer, images of the
neck including anterior, pinhole and marker views were obtained
at 20 minutes. At 2 hours pinhole views of the neck and
SPECT/CT of the neck and chest were obtained.
Initial images show tracer uptake in the thyroid and another
focus in the
mediastinum. 2 hour delayed pinhole image shows washout of
activity from the thyroid with no persistent focus in the neck.
SPECT/CT images show a persistent focus in the anterior
mediastinal, anterior to the superior vena cava. Sestamibi
uptake indicates tissue with high blood flow. In light of the
clinical scenario this would most likely represent a mediastinal
parathyroid adenoma.
Incidental note is made of right maxillary sinus polyp and
scoliosis.
IMPRESSION: Findings compatible with an anterior mediastinal
parathyroid
adenoma. No persistent uptake identified in the neck.
.
CXR:
A right PIC catheter terminates within the
distal SVC. A right subclavian hemodialysis catheter terminates
in the right atrium. The cardiomediastinal silhouette and hilar
contours are within normal limits. Hilar fullness is
significantly decreased from prior exam. The pulmonary
vasculature remains minimally prominent, but is significantly
improved. A small left pleural effusion is stable in size.
IMPRESSION: Resolving pulmonary edema. Stable, small left
pleural effusion.
Brief Hospital Course:
A/P: This is a 20 y/o F with ESRD secondary to type I DM on HD
here with headache X 6 days.
.
# Hypertensive emergency: The patient presented to ED with BP
of 190s/100s and was initially started on a nitroprusside drip.
This was switched to a nitroglyercin drip in the ED due to her
renal failure and concern for cyanide toxicity. This was
switched to labetolol on hospital day two and she was placed
back on her home antihypertensive regimen of losartan and
metoprolol on [**9-21**] and weaned off of the labetolol drip by [**9-22**]
with blood pressures in the 140s to 150s systolic. Given that
her blood pressures appeared to be better controlled on
labetalol her metoprolol was switched to labetalol at equal
conversion. She was discharged on labetalol, losartan, and
nifedipine with good control of her blood pressure.
.
# Headache: The patient presented with a severe [**10-14**] headache,
neck stiffness, nausea and photophobia. She received two
non-contrast head CTs which were negative for acute hemmorhage.
On presentation she was anticoagulated for pulmonary embolism
with coumadin and her INR was elevated. She received multiple
units of FFP with difficulty in normalizing her INR. A lumbar
puncture was performed on [**9-23**] by neurology. There was no blood
found in the CSF and preliminary cultures have been negative.
She is unable to describe the quality of location of the
headache. She received zofran and compazine for nausea with good
improvement. Upon discharge, her headache had completely
resolved.
.
# Type I Diabetes Mellitus. Patient has long standing type I
diabetes. On presentation her blood sugars were fluctuating and
she was unable to take POs secondary to nausea. Her lantus was
decreased given concern for hypoglycemia initially but was
quickly increased back to her usual dose. She currently is
taking lantus 14 in the AM and 10 in the PM (normal dose is 18
in AM and 8 in PM) with a humalog sliding scale. She is
followed by a diabetologist in [**Hospital1 789**]. Last hemoglobin A1C
was 6.2 on admission. She has diabetic nephropathy and
retinopathy. She may well have a component of diabetic
gastroparesis as well given her persistent nausea with PO
intake.
.
# Anemia: On presentation the patient's hematocrit was 32.7.
This decreased to 21.0 on hospital day two. This was intitially
thought to be secondary to dilution as all cell lines were
decreased. Her hematocrit remained stable in the low 20s for
the remainder of her MICU course. She did not require
transfusion. Iron studies were consistent with an anemia of
chronic inflammation. There were no obvious sources of
bleeding. Hemolysis labs were negative. The patient has not
been getting erythropoetin at her dialysis sessions because of
her hypertension. This will need to be readdressed. This will
likely need to be resumed as an outpatient, given good blood
pressure control.
.
# Fever. Patient has low grade temperatures with hemodialysis
on two occasions with the highest being 101.6. No source of
infection was found on blood cultures or on chest X-ray. This
should be followed closely the next time she goes for
hemodialysis with obvious concern for a line infection.
.
# Hypercalcemia. Patient has had hypercalcemia. Her PTH is
elevated, suggesting primary or tertiary hyperparathyroidism.
SPEP normal. She received calcitonin initially for her
hypercalcemia. Her dose of cinacalcet was increased. She
underwent a nuclear medicine scan which showed an affected area
in her mediastinal region suggesting a single mediastinal
parathyroid adenoma. She was given the contact information to
see endocrine surgery here at [**Hospital1 18**] for evaluation.
.
# Nausea/vomiting. Patient has nausea and vomiting for past
day. [**Month (only) 116**] be related to headache and hypertension. [**Month (only) 116**] be
related to gastroparesis, although she does not carry this
diagnosis. The patient was started on reglan PRN for
nausea/vomiting, and nausea was subsequently controlled with no
further need for antiemetics. She was provided with a
prescription for campazine as needed for nausea.
.
# ESRD secondary to type I DM. Patient requires dialysis MWF at
home. Patient has gotten HD every day during her hospital
stay.
.
# Hyperkalemia. Hyperkalemia improved with dialysis.
.
# History of pulmonary embolism. The patient was continued on
Coumadin but held on occasion due to supratherapeutic INR. This
level should be followed at hemodialysis and Coumadin dose
adjusted accordingly.
# FEN: She was maintained on a renal/diabetic diet during her
hospitalization
Medications on Admission:
albuterol PRN
cinacalcet 30 daily
Humalog 5 U TID with meals
Humalog SS
Lantus 18U QAM, 8U QHS
Toprol XL 200 daily
Losartan 100 daily
sevelamer 800 TID
coumadin 5 mg/2.5 mg
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*1*
2. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic DAILY (Daily).
3. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic DAILY (Daily).
4. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily).
5. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO every eight (8) hours as needed for headache for
10 doses.
Disp:*10 Tablet(s)* Refills:*0*
6. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times
a day).
Disp:*360 Tablet(s)* Refills:*1*
7. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours as needed for nausea for 10 doses.
Disp:*10 Tablet(s)* Refills:*0*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours):
Take on an empty stomach, then may eat 1/2 hour after taking.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
9. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
Disp:*180 Tablet(s)* Refills:*1*
10. Warfarin 2.5 mg Tablet Sig: 1-2 Tablets PO at bedtime: Take
2 tablets (5mg)4x/week on Mon, Wed, Fri, Sat - and take 1 tablet
(2.5mg) 3x/week on Tues, Thurs, Sun.
Disp:*50 Tablet(s)* Refills:*2*
11. Insulin Glargine 100 unit/mL Solution Sig: 10 - 12 units
Subcutaneous twice a day: Take 10 units with breakfast, and 12
units at bedtime or as instructed.
12. Humalog 100 unit/mL Solution Sig: One (1) injection
Subcutaneous four times a day: as directed by insulin sliding
scale.
13. Cinacalcet 90 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
14. Losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
15. Nifedipine 20 mg Capsule Sig: One (1) Capsule PO every eight
(8) hours.
Disp:*90 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
vna of care [**Location (un) **]
Discharge Diagnosis:
Primary: Hypertensive urgency, headache
Secondary: DM type I, End Stage Renal Disease on hemodialysis,
hyperparathyroidism - parathyroid adenoma, hypercalcemia,
Pulmonary embolism on coumadin, hyperlipidemia, Retinal
detachment L eye, bilateral cataracts
Discharge Condition:
Hemodynamically stable, afebrile and tolerating oral medication
and nutrition.
Discharge Instructions:
You have been hospitalized for severe headache and uncontrolled
hypertension associated with nausea and vomiting. You have been
evaluated with imaging of your head that did not reveal any
abnormalities and lab tests to monitor your electrolytes and
check for infection. Your symptoms have been controlled with
blood pressure medications, anti-nausea medication and continued
hemodialysis.
.
While you were in the hospital you were found to have a brief
fever on two episodes after hemodialysis. When you go for
hemodialysis on Monday you should let your center know about
these fevers so they can monitor your closely for your next few
hemodialysis sessions.
.
You had an elevated INR (or Coumadin level) while you were in
the hospital. Your dose of Coumadin was changed as instructed
below. You should not take any Coumadin tonight ([**10-3**]), and
start your new prescription for Coumadin tomorrow. You should
get your INR checked again soon - this should be done at
dialysis on Monday and checked 2-3 times per week until you are
in good control.
.
Because you had high levels of calcium in your blood, some of
your medications were changed to help lower this level. More
importantly, you had a special X-ray done (or nuclear
medicine/sestimibi scan) which showed that you have what is
likely a benign tumor (called a parathyroid adenoma) in your
neck which is causing this elevated level. You should follow-up
with here at [**Hospital1 18**] with Dr. [**Last Name (STitle) **] (endocrine surgeon) for
evaluation and possible removal of this gland.
.
You should continue to take your insulin as instructed prior to
this hospitalization, including long-acting insulin (Lantus) and
short-acting insulin with meals (Humalog).
.
In addition to your regular medicine, your medications have been
changed in several ways:
THESE MEDICATIONS HAVE CHANGED DOSAGE
Cinacalcet 30mg has increased to 90mg daily
Sevelamer 800mg has increased to 1600mg three times daily with
meals
Coumadin: 5mg 4x/week (Mon, Wed, Fri, Sat), and 2.5 mg 3x/week
(Tues, Thurs, Sunday)
THESE MEDICATIONS HAVE BEEN ADDED:
Labetolol 800mg three times daily
Calcitonin Salmon 250 UNIT Subcutaneous DAILY
Nephrocaps 1 CAP orally DAILY
NIFEdipine 20 mg orally three times daily
Prochlorperazine 10 mg orally three times daily as needed for
nausea
Pantoprazole 40 mg oreally daily
THIS MEDICATION HAS BEEN DISCONTINUED:
Toprol XL 200 mg once daily
Cozaar 100mg daily
You should keep all your regularly scheduled appoinments and
take all medications as prescribed.
You should return to the Emergency Department or contact your
PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) 40069**] should you notice fever, shaking chills,
headache not controlled by medication, or inability to tolerate
adequate oral fluid intake. Or, for any other symptoms for
which you are concerned.
Followup Instructions:
Follow-up with your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) 40069**] in the next 1-2 weeks
to discuss your hospitalization and any current issues.
.
Call to make an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
(endocrine surgery): ([**Telephone/Fax (1) 9011**]. His office is located at
[**Street Address(2) **], [**Location (un) **], MA.
.
Follow-up with your Endocrinologist in the next 1-2 weeks to
discuss further management of your hyperparathyroidism and
hypercalcemia.
.
Continue to follow-up closely with your gynecologist at Women &
Infant's Hospital.
.
Follow-up with your [**Hospital 197**] Clinic 3-5 days post-discharge for
a INR check and dose adjustment.
Completed by:[**2116-10-3**]
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