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17,384
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9394
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Discharge summary
|
report
|
Admission Date: [**2137-9-7**] Discharge Date: [**2137-9-12**]
Date of Birth: [**2099-9-10**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Tetracyclines / Succinylcholine / Clozaril /
Calcium Channel Blocking Agents-Benzothiazepines /
Beta-Adrenergic Blocking Agents
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
MICU admission
Hemodialysis
History of Present Illness:
37 year old female with schizoaffective d/o, depression, seizure
d/o, ESRD from IGA nephropathy, very poor access with
transhepatic HD catheter on coumadin; now admit with UGIB
(melena, hematemesis). Patient denies past history of
hematemesis but noted to have some in last DC summary, no EGD at
that time. States hematemsis started today, melena last night.
STR notes of dark bloody stool x 3 incontinent episodes. SBP
111 at STR. Patient was receiving coumadin for line as detailed
below; also started on fondaparineux 7.5 daily (appears to have
received 3 doses only) for subtherapeutic INR.
Past Medical History:
ESRD [**3-9**] IgA nephropathy
Schizoaffective disorder
Depression
Chronic anemia
GERD
Cardiomyopathy: ECHO [**2137-8-6**] EF >65%, hyperdynamic, LVH, no
valvular disease
Hypothyroidism
GI bleed
RLE DVT
Seizure disorder
tracheal stenosis s/p trach, on TM at 7L/min at rehab
malignant hypothermia
Surgical History:
s/p L upper and lower extremity AV fistulae(failed),
s/p R upper extremity AV fistula (basilic vein
transposition(failed),
s/p R forearm AV graft (failed),
s/p attempted insertion of a peritoneal dialysis catheter
(failed), central venous stenosis,
Innominate venous stenosis,
s/p R brachioarterial->axillary AV graft, nonfunctional,
status post multiple thrombectomies and angioplasties,
s/p tracheostomy,
s/p thrombectomy of AV graft x5,
s/p Transhepatic HD catheter placement
Social History:
Currently living at [**Hospital **] rehab. No tobacco, EtOH, illicit
drug use.
Family History:
Non-contributory
Physical Exam:
Vitals: T98.5, 95/46, 105, 21, 100% on 50% TM
General: Alert, conversant, flat affect, NAD
HEENT: NC/AT, PERRL, MM moist, small dried blood in nares.
Neck: Trach, no adenopathy
Lungs: coarse but clear, somewhat poor effort
Heart: slightly tachy, regular, no murmur appreciated
Abdomen: Soft, NT/ND. R lateral transhepatic HD line.
Extrem: Warm, no edema, L femoral line in place.
Neuro: Alert and oriented to place
Pertinent Results:
[**2137-9-7**] 10:07PM HCT-17.8*
[**2137-9-7**] 10:07PM PT-16.6* PTT-31.9 INR(PT)-1.5*
[**2137-9-7**] 03:21PM GLUCOSE-108* UREA N-45* CREAT-4.1* SODIUM-139
POTASSIUM-5.4* CHLORIDE-107 TOTAL CO2-24 ANION GAP-13
[**2137-9-7**] 03:21PM ALT(SGPT)-10 AST(SGOT)-13 LD(LDH)-150 ALK
PHOS-80 TOT BILI-0.3
[**2137-9-7**] 03:21PM ALBUMIN-2.7* CALCIUM-7.6* PHOSPHATE-3.0
MAGNESIUM-1.4*
[**2137-9-7**] 03:21PM VANCO-16.6
[**2137-9-7**] 03:21PM WBC-8.3 RBC-2.16* HGB-6.9* HCT-20.3* MCV-94
MCH-31.8 MCHC-33.7 RDW-17.2*
[**2137-9-7**] 03:21PM PLT COUNT-333
[**2137-9-7**] 11:15AM cTropnT-0.10*
[**2137-9-7**] 11:15AM CK(CPK)-15*
Brief Hospital Course:
#UGIB. The patient has had a history of GIB, with last EGD in
[**2134**]. During her last admission previous to this, she again had
a small amount of bleeding but was not scoped. This admission,
the patient again complained of hematemesis in the setting of
anticoagulation with fondaparinaux (however, normal INR due to
prophlactic doses of 1mg Coumadin daily to keep her transhepatic
vein patent) Given her ESRD and recent fondaparinux doses which
is renally cleared, the patient was at particulary high risk of
bleeding. A discussion with heme-path was had and it was
confirmed that there was no specific antidote for fondaparinux.
Therefore, the patient was monitored closely in the ICU due to
her GIB and on [**9-8**] the patient underwent an EGD. At that time,
a bleeding vessel was identified, possibly arterial in source,
and the vessel was clipped and injected with epinephrine.
Following the EGD, the patient had no clinical signs of active
rebleeding and no further investigative radionuclear scans were
needed. Of note, the patient recieved a large amount of FFP and
also recieved ~15 units PRBC this admission. The patient was
maintained on an IV PPI during this admission, which was
switched to sucralfate after several days, and now is being
considered for transfer back to [**Hospital **] rehab after several
days of no hematemesis and stable Hct.
.
# Hypotension. At baseline, pt has a low blood pressure with
SBP's running in the 80's - 100's. During this admission, the
patient had episodes of hypotension below her baseline that were
likely related to hypovolemia/blood loss from her large GIB. BP
was maintained with aggresive therapy with blood products.
Underlying infection/sepsis was considered but there was no
evidence of active infection or this admission. The patient
had two blood cultures on [**9-7**] that were drawn from a left
femoral line, and one of the two bottles showed gram negative
and gram positive rods. The patient had been in the ICU for
several days when these results were received, and was improving
clinically, without an elevated white count, so after discussion
with the team, it was thought that this was most likely a
contaminant. Blood cultures redrawn [**9-11**] are pending. The
patient was continued on treatment with Vancomycin that had been
started during a previous admission for a MRSA bactermia in the
past, with the plan to continue it with dialysis until [**9-15**]. will tolerate SBP in the 80s-use HR as indicator for
volume status as pt was tachycardic originally w acute bleed and
has not been since. In addition, Midodrine was stopped (had
been on 5 mg TID prn for SBP < 90), can consider restarting in
future.
.
# Thrombocytopenia: New development this admission, platelets
have continued to decrease but stabilized and recovered to the
130K range, 104 on discharge. Effect was suspected to be
medication related as fondaparineaux not usually associtaed with
thrombocytopenia, and PPI was switched to Carafate after which,
an improvement in the patient's thrombocytopenia was noted.
.
# ESRD on HD. HD M/W/F. History of extremely difficult access;
currently accessed via transhepatic catheter. On low dose
Coumadin 1mg daily for this with NO GOAL INR.
Pt was dialyzed during this admission without complication.
.
# History of line sepsis. Pt continued to recieve Vanco with HD
while here and recieved an extra 500mg dose early during the
admission secondary to her large volume blood loss and low
Vancomycin levels at that time. The course of Vancomycin
therapy was confirmed with ID and the patient is to continue
Vancomycin with HD through [**2137-9-15**].
.
# History of respiratory failure s/p trach. The patient's
respiratory status was stable during this admission, she was
continued on her trach mask at 40-50% FiO2 with no issues while
in the ICU.
.
# Hypothroidism. Patient was continued on her Synthroid.
.
# Schizoaffective disorder/depression: Patient was continued on
her fluphenazine.
.
# GERD: on Sucralfate, now off PPI/H2 blockers.
.
Medications on Admission:
Albuterol MDI 2 puffs QID
Calcium Acetate 667 mg TID with meals
Cinacalcet 90 mg daily
Fluphenazine 2.5 mg [**Hospital1 **], and 10 mg HS
Fondaparinux 7.5 mg daily (started [**9-4**])
Levothyroxine 100 mcg daily
Midodrine 5 mg TID for SBP <90
Pantoprazole 40 [**Hospital1 **]
Vancomycin 1 gram with HD (reportedly complete on [**9-6**])
Warfarin 3 mg daily
APAP prn
Miconazole prn
Alteplase prn to HD cath
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Fluphenazine HCl 2.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Fluphenazine HCl 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed for wheeze.
7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
8. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
9. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Vancomycin 1000 mg IV HD PROTOCOL
Give one dose after hemodialysis session
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Upper Gastro-intestinal Bleed secondary to bleeding esophageal
vessel and esophagitis
Discharge Condition:
Stable, trach in place
Discharge Instructions:
You were admitted to the hospital with a concern for bleeding.
You underwent a procedure called an EGD to control the bleeding.
You also received blood transfusions to keep your blood level
stable.
.
There were changes made to your medications. You will only
take coumadin 1mg daily and not adjust this for your INR. In
addition, you were started on Sucralfate 1 g four times per day.
This is to help protect your stomach given the recent bleed.
Your Fondaparineux was stopped.
.
If you have any further bleeding, coughing up of blood,
abdominal pain, shortness of breath, or other concerning
symptoms, please return to the ER.
.
You should follow up with your primary care doctor in the next
2-3 weeks.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2137-9-19**]
9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13447**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2137-9-24**] 9:00
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
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420, 449
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8673, 8698
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2009, 2027
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,923
| 151,318
|
39033
|
Discharge summary
|
report
|
Admission Date: [**2196-3-30**] Discharge Date: [**2196-4-14**]
Date of Birth: [**2146-11-10**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Trauma/unresponsiveness
Major Surgical or Invasive Procedure:
[**2196-3-30**]: Left craniectomy, right craniotomy, partial left
temporal lobectomy
[**2196-3-30**]: Right canthotomy
History of Present Illness:
49yM found unresponsive in a parking lot, unclear mechanism of
injury. Brought to the hospital and became combative with
obvious facial and head injuries. He had a genralized
convulsion with noticebale blood [**Last Name (un) **] nares and mouth and he was
intubated for airway protection and deteriorating mental status.
CT head showed EDH/SDH.
Past Medical History:
HTN, EtOH
Social History:
This patient has been involved in a highly contentious divorce
with his current
wife, [**Name (NI) **] [**Name (NI) 86550**] [**Telephone/Fax (1) 86551**]. She reports they are still
legally married, but in the process of divorce. She reports
they
have three children together, and that pt's oldest son [**Name (NI) **]
[**Known lastname 86552**] (19yo) is pt's "best friend."
Per family report, he lives alone, functions independently and
works full-time in the pharmaceutical industry. Per wife and
pt's mother report, pt has
a 20+ year long hx of ETOH abuse.
He is estranged from 16 yo son with active restraining order,
and sister [**Name (NI) **]
is active in pt's life but also somewhat distant due to recent
separation with wife and pt's conflict with younger son.
Family History:
NC
Physical Exam:
Upon Admission
Vital signs stable
Gen: intubated, sedated
HEENT: pupils equal but non-responsive, pinpoint. Copious
bleeding from nares and mouth. Large periorbital hematoma and
proptosis of the right eye
CV: tachycardiac
Pulm: equal breath sounds bilaterally
Abd: soft, nondistended
Ext: no obvious deformities, decorticate posturing
Upon Discharge:
[**4-14**]: He is awake and alert and oriented to person, date/year
and hospital/state. He at times has difficuly with hospital
name. He exhibits tangental thinking. He makes paraphasic errors
and has expressive dysphasia. He has a right conjunctival
hemorrhage. Scalp edema is still present. Incision sites are
clean and dry. EOMi, PERLLA, no facial palsy. No midline drift.
MAE well.
Pertinent Results:
[**3-30**] CT HEAD:
IMPRESSION:
1. Multifocal, multicompartmental intracranial hemorrhage, as
above,
including subdural, epidural, intraparenchymal, and subarachnoid
hemorrhage as
desribed above with rightward subfalcine herniation.
2. Comminuted, minimally displaced fractures of the squamous
portion of the right temporal bone, right greater sphenoid [**Doctor First Name 362**],
orbital process of the right zygomatic bone (lateral right
orbital wall), right nasal bone. Minimally displaced fracture of
the nasal spine of the maxilla.
3. Question of retained foreign body in right temporal epidural
hematoma.
4. Right supraorbital, extraconal hemtaoma with subsequent right
globe
proptosis.
.
CT CSPINE: no fractures
.
CT TORSO
IMPRESSION:
1. Right lower lobe consolidation could represent atelectasis,
aspiration,
pneumonia, and/or pulmonary contusion.
2. Elevation of the right hemidiaphragm. While discrete
discontinuity of the diaphragm is not seen and findings could be
due to volume loss in the right lower lobe, a diaphragmatic
injury is not excluded. This finding was
discussed with Dr. [**Last Name (STitle) **]. [**Doctor Last Name 2319**] on [**2196-3-30**] at 3:15 PM.
3. T12 compression fracture, as above.
4. No evidence of acute visceral injury in the abdomen or
pelvis.
.
CT FACE:
IMPRESSION:
1. Comminuted, minimally displaced fractures of the squamous
portion of the right temporal bone, right greater sphenoid [**Doctor First Name 362**],
right orbital process of the zygomatic bone (lateral right
orbital wall), and right nasal bone. Minimally displaced
fracture of the nasal spine of the maxilla.
2. Right supra-orbital, extraconal hemorrhage with subsequent
right globe
proptosis.
3. Hemosinus and retained secretions post intubation.
Ct T-spine [**2196-3-31**]
Mild acute compression deformity of T12. No other thoracic
vertebral fracture identified
CT head [**2196-4-3**]
Status post left craniotomy/partial temporal lobectomy and right
craniotomy. Slight decrease in the amount of pneumocephalus and
mass effect on the left cerebral hemisphere. Persistent
low-density bifrontal extra-axial collections. No new
intracranial hemorrhage or shift of midline structures.
CXR [**2196-4-7**]
1. Improving basilar predominant opacities which may be due to
atelectasis or improving infectious pneumonia.
2. New linear focus of atelectasis in the right perihilar
region.
Bilateral LENIS [**2196-4-7**]:
No evidence of deep vein thrombosis in either leg
CT Abdomen/pelvis [**2196-4-7**]:
1. Small bilateral pleural effusions with bibasilar
consolidations.
2. No CT findings of acute cholecystitis.
3. Appendix appears normal distally and again measures 8 mm.
However,
minimal stranding along its portion of the appendix is noted;
early
appendicitis not excluded. Serial abdominal exam is recommended.
4. Tiny bubble of gas in the urinary bladder is decreased from
before, with interval removal of Foley catheter.
5. Unchanged T12 superior endplate compression fracture. Also
unchanged
elevation of right hemidiaphragm, without discrete
discontinuity.
Chest X-ray [**2196-4-10**]:
FINDINGS: As compared to the previous radiograph, the band like
right
atelectasis is unchanged. On the left, the pre-existing areas of
parenchymal opacities show a further decrease in extent. On the
lateral radiograph, however, remnant opacities reflecting
healing pneumonia are still visible.
No newly appeared parenchymal opacities. No pleural effusions.
No pulmonary
edema. Normal size of the cardiac silhouette. Mild tortuosity of
the
thoracic aorta.
LENIS [**2196-4-11**]:
No evidence of bilateral lower extremity DVT.
Brief Hospital Course:
Patient was intubated in the ER. After initial primary
assessment he was taken to the CT scanner and found to have
extensive intracranial bleeding. STAT neurosurgery consult
obtained and he was quickly taken to the OR for decompressive
craniectomy. Prior going to the OR he had an epistat device
placed intranasally to control moderate to severe epistaxis. A
lateral canthotomy was also performed urgently in the ED. He
then underwent right craniotomy, left craniectomy, and partial
left temporal lobectomy. He was transferred to the TSICU. Over
the next 24 hours his hemodynamics stabilized and he was taken
off of pressors. He spiked a fever the following day and workup
revealed a likely aspiration PNA, BAL grew out GNRs and GPC
initially. He was started empirically on Vancomycin and CTX.
He was then weaned to extubation and tolerated that well. After
extubation he was AAOx3, moving all extremities, and able to eat
and drink. His Hct did drop from 30 to 20 over 24 hrs, however
he had no new source of bleeding, was HD stable, and was
presumed to be secondary to fluid mobilization and equilibration
from prior blood loss. His Hct was followed, and he was not
initially transfused. He was then transferred to the
Neurosurgery team for continued management on the step down
unit.
His other issues included:
1.) T12 fracture: a dedicated Thoracic spine CT was obtained
which demonstrated only a mild compression fracture of T12.
This was followed by Ortho spine who recommended he did not need
a brace and could come off of logroll precautions.
2.) C-spine: cleared by trauma team as his CT c-spine was
negative
3.) Facial fractures: deemed non-operative by plastic surgery
4.) Epistaxis: balloon epistat was removed prior to extubation,
there was no further bleeding
On [**4-5**] his antibiotic regimen was tailored to Ceftriaxone 1g
Q24 hrs. C.Diff was negative. ID was actively following the
patient and made recommendations for PO antibiotics. This change
was made on [**4-7**]. He continued to get prn Ativan for
intermittent agitation which seems to mainly involve attempts to
leave the building to smoke. Seroquel was added and he did not
need restraints on the night of [**4-7**]. ID eval on this day
revealed some RLQ pain and tenderness. The patient had never
complained of this in the past. His fevers returned and his
temperature was 102. Imaging of head/sinus/lower
extremities/chest showed no new source of fever. Urine and blood
cultures were pending. Abdominal CT showed some stranding at the
appendix suggestive of early appendicitis.
On [**4-8**] interrogations regarding abdominal pain produced
inconsistent responses. He was seen by general surgery and he
denied any abdominal pain and had no tenderness on palpation.
They felt that he may have a partially treated non acute
appendicitis and suggested that broadening his antibiotic
coverage may be beneficial but further work-up revealed no
appendicitis. ID felt no antibiotics was needed and that the
fevers were more central based. On [**4-10**] (midnight temp) was
101.5 and fever work up was done: CXR showed improvement, Urine
culture was negative, and earlier blood cultures were negative.
Psych was consulted on his fantasies about kidnapping and
tangential thinking- they thought this was more organic disease
vs. psychiatric in nature. Infectious Disease also made
recommendations to discontinue his Pepcid as maybe a source of
fevers. On [**4-11**], he remained afebrile. He did complain of calf
and knee pain bilaterally- LENIS were repeated and were
negative. Infectious Disease made final recommendations that Mr.
[**Known lastname 86553**] fevers were not secondary to infectious process but
neurogenic secondary to his bleed. They feel we should monitor
for symptomology and re-work him up if signs of infection
present. ID has cleared patient for rehab as of [**4-11**].
CM continued to screen him for rehab. He was transferred to
rehab on [**2196-4-14**].
Medications on Admission:
atenolol, Ibuprofen, imitrex
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Bacitracin 500 unit/g Ointment Sig: One (1) Appl Ophthalmic
Q4H (every 4 hours).
5. Sodium Chloride 0.65 % Aerosol, Spray Sig: Two (2) Spray
Nasal TID (3 times a day) as needed for dry mucus membrane.
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Fever: Max apap 4g/24hrs.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
13. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
14. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours): end [**4-8**] or [**4-11**].
15. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours) as needed for SBP > 160.
16. Lorazepam 2 mg/mL Syringe Sig: 0.5-1 mg Injection Q4H (every
4 hours) as needed for agitation.
17. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
18. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for agitation.
19. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Give at 1700.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Right Epidural Hematoma
Left Subdural Hematoma
Left IPH
Right lung consolidation
T12 compression fracture
Comminuted, minimally displaced fractures of the squamous
portion of the right temporal bone
Right greater sphenoid [**Doctor First Name 362**] fracture
Right orbital process of the zygomatic bone (lateral right
orbital wall)fracture
Right nasal bone fracture
Minimally displaced fracture of the nasal spine of the maxilla.
Right supra-orbital, extraconal hemorrhage with subsequent
right globe proptosis
Hemosinus
Epistaxis
Neurogenic fever
Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
***** PLEASE WEAR YOUR HELMET WHEN OUT OF BED AT ALL TIME *****
?????? 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 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.
?????? You have been prescribed Keppra (Levetiracetam) for
anti-seizure medicine, take it as prescribed.
?????? 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.
PER ENT:
- do not place anything inside nose except medicine as advised
(no fingers, tissues, q-tips etc.)
- use a humidification
- nasal saline gel (or mist if not available) - 2 spray each
nostril three times daily and as needed
- if you begin to bleed, spray 3 sprays of afrin in each
nostril,
then hold pressure by holding your nostrils closed at the bottom
of the nose and lean with the head tilted forward for 15 minutes
without letting go. If the nosebleed does not stop after this,
please seek medical attention in the [**Hospital1 18**] ED or local ED.
You have had elevated platelet counts while in the hospital. The
ID physicians felt that this elevation was resulting from your
trauma. If the platelet counts remain elevated over the course
of the next 2-3 weeks, you will need to see a hematologist as an
outpatient.
Followup Instructions:
Dr. [**Last Name (STitle) 739**], Neurosurgery: You will need to follow-up with
4 weeks from discharge with a Head CT scan without contrast.
Please call Paresa to make this appointment [**Telephone/Fax (1) 1272**].
Dr. [**Last Name (STitle) 66323**], ENT: you will need to follow up in [**3-24**] weeks.
Please call ([**Telephone/Fax (1) 6213**] for appt.
Dr. [**First Name (STitle) **], Opthomology: you will need to follow up in [**6-28**]
weeks. Please call ([**Telephone/Fax (1) 5120**] for appointment.
You need to follow up with your PCP [**Last Name (NamePattern4) **] [**7-2**] months for a right
lung consolidation.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2196-4-14**]
|
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icd9cm
|
[
[
[]
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] |
[
"33.24",
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"96.71",
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"96.04",
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icd9pcs
|
[
[
[]
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] |
11845, 11915
|
6118, 10084
|
344, 465
|
12507, 12507
|
2463, 2474
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|
1683, 1687
|
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11936, 12486
|
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1702, 2040
|
281, 306
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2056, 2444
|
493, 842
|
2483, 6095
|
12522, 12665
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864, 875
|
891, 1667
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,127
| 106,522
|
8516
|
Discharge summary
|
report
|
Admission Date: [**2133-7-12**] Discharge Date: [**2133-7-15**]
Service: CCU
CHIEF COMPLAINT: Fall, question of stroke.
HISTORY OF PRESENT ILLNESS: This 82 year old female is a
resident of [**Hospital3 24509**] Home with a history of
paroxysmal supraventricular tachycardia and diabetes who was
found down in a puddle of urine the morning of admission.
There was no evidence of trauma and the patient was alert and
oriented at least according to her baseline mental status. A
few hours later she was noticed to have a left facial droop,
dysarthria and left-sided weakness as well as diaphoresis and
being cold to touch. She had a glucose of 404 for which she
received 4 units of insulin with no improvement and was
brought to the [**Hospital6 256**] Emergency
Room for a concern of possible cerebrovascular accident. The
stroke fellow saw her in the Emergency Room and found her
examination showing no evidence of cerebrovascular accident
but noticed bradycardia with pauses of up to 4 seconds. The
Coronary Care Unit Team was called to see her and she was
brought to the Coronary Care Unit for urgent transvenous
pacer placement with a [**Hospital1 1516**] pad placed prophylactically on
her chest. A transvenous pacemaker was introduced through a
right IJ Cordis with good capture with a rate of 70. Post
procedure the patient denied chest pain, shortness of breath,
reported mild nausea but no diarrhea, constipation, abdominal
pain, cough or fevers or chills, but she does not remember
her fall. She has mild pain at the transvenous pacer
insertion site.
PAST MEDICAL HISTORY:
1. Dementia of vascular type also with history of
Alzheimer's type although it is not clear how the latter can
be confirmed given the former.
2. Diabetes Type 2 on Glyburide
3. Degenerative joint disease
4. Anemia
5. Status post hysterectomy
6. History of alcohol abuse, sober times 30 years
7. History of paroxysmal atrial tachycardia/paroxysmal
supraventricular tachycardia for which she takes atenolol and
digoxin.
8. Low back pain with spinal decompression in [**2128**] and
epidural steroid injections.
9. Per nursing home a history of personality disorder.
SOCIAL HISTORY: The patient was at [**Hospital3 24509**]
Home and smokes no tobacco and has a history of distant
history of alcohol abuse. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] is her daughter.
She has power of attorney. Phone #s include [**Telephone/Fax (1) 29986**] and
[**Telephone/Fax (1) 29987**] on her cell phone. The patient is
Do-Not-Resuscitate, Do-Not-Intubate but other intervention
including pressors are okay.
FAMILY HISTORY: The patient denies and she may be an
unreliable historian in this regard.
ALLERGIES: Aspirin and codeine, unknown reactions.
MEDICATIONS:
1. Digoxin 0.125 mg q.d.
2. Prn Trazodone
3. Zyprexa 15 mg q.h.s.
4. Glyburide 10 mg q.d.
5. TUMS 500 mg b.i.d.
6. Colace 100 mg b.i.d.
7. Tylenol 650 mg b.i.d.
8. Aricept 10 mg q.h.s.
9. Neurontin 400 mg t.i.d.
10. Atenolol 25 mg q.d.
11. Effexor 37.5 mg q.d.
12. Multivitamin
13. Zestril 20 mg q.d.
PHYSICAL EXAMINATION: Temperature 98.3, pulse 70, blood
pressure 105/37, respiratory rate 19, sating 96% on 3 liters.
Head, eyes, ears, nose and throat reveals oropharynx clear,
mucous membranes dry and the patient was edentulous. Could
not assess jugulovenous distension secondary to pacer
insertion. In general the patient was in no acute distress
and answered questions intermittently, was insulting to staff
with occasional inappropriate comments, otherwise was an
elderly well developed, well nourished female.
Cardiovascular, the patient was in a regular rate and rhythm
with a normal S1 and S2 without murmurs, rubs or gallops.
Pulmonary, crackles at the bases, left greater than right.
Extremities, 1+ edema, nonpitting, no cyanosis or clubbing.
Neurological, alert and oriented times one. Sensation was
intact. Strength 5/5 bilaterally. Cranial nerves II through
XII were intact.
LABORATORY DATA: White count 39.7, hemoglobin 10.6,
hematocrit 31, platelets 576. Differential, 87 PMNs, 9
bands, 4 lymphs, INR 1.2, PTT 27.7. Arterial blood gases
7.42/37/89/25. Sodium 139, potassium 4.8, chloride 100,
bicarbonate 20, BUN 21, creatinine 1.5, glucose 392, calcium
9.1, magnesium 1.6, phosphate 4.1, Digoxin 1.2, CK 554, MB
fraction 8. Troponin mildly positive at .8. Chest x-ray
showed right middle lobe, +/- right lower lobe, pneumonia
consistent with aspiration. The patient was status post
transvenous pacemaker placement with no pneumothorax or
complication. Electrocardiogram, sinus arrest with asystole,
poor junctional escape without ischemia, however, with 3 to 4
second pauses, long QT. After pacemaker was placed,
electrocardiogram showed V-paced rhythm at 70, left axis
deviation, wide QRS with reciprocal changes and a left bundle
branch pattern.
HOSPITAL COURSE: Cardiology, electricity, for the patient's
initial intermittent sinus arrest with long pauses and
unreliable junctional escape she was admitted to the Coronary
Care Unit and had an urgent transvenous pacemaker placed
[**7-12**] with recapture. There was no clear etiology.
Digoxin level was normal and there was no evidence of
ischemia. The next morning she was noticed to be
intermittently pacer independent but still having long pauses
at times requiring pacer function. Further although her
Digoxin and atenolol were held, since the pacemaker could
have ceased functioning and her nodal blockers would have
produced an intrinsic rate, she was going to need these for
the history of paroxysmal supraventricular tachycardia and
paroxysmal atrial tachycardia, therefore permanent pacemaker
was placed [**2133-7-14**] when her pneumonia was under good
control. This continued to function well throughout her
stay. The type was [**Company 1543**] Stigma SVR 303, Mode DDD, rate
set 60 to 100, serial #[**Serial Number 29988**]. On [**7-15**], the patient
did have several runs of nonsustained ventricular tachycardia
but the significance of this without known coronary artery
disease and reduced ejection fraction is unknown. Further
the patient is not an implantable cardioverter defibrillator
candidate as she is Do-Not-Resuscitate. She also had [**7-15**], AM a run of paroxysmal supraventricular tachycardia with a
rate of 100 to 120s which self-terminated and as a result the
team increased her atenolol her 50 mg. This medication was
reintroduced after the permanent pacemaker was in place. She
also needed further blood pressure control with systolic
blood pressures in the 140s to 160s that day. This will
require follow up as an outpatient. She currently remains on
atenolol 50 and Zestril. Atenolol rather than digoxin is
being used for rate control.
Coronaries and pump - No known issues. The patient tolerated
rehydration without desaturation. CKs dropped with time, MB
fractions were never positive and CKs were assumed to be from
a long lie and not from a coronary source.
Pulmonary - The patient was felt to have pneumonia, right
middle lobe and right lower lobe, possibly secondary to
aspiration, see infectious disease for details. Oxygen was
weaned off with good saturations on room air and no shortness
of breath, also with resolution of infiltrates, at least
partially on post pacemaker films which may indicate a
resolving pneumonitis rather than an actual pneumonia.
Renal - Initially high creatinine to 1.5 normalized to .7
with rehydration. She is on an ACE inhibitor which will help
control a decline in function of her diabetes mellitus.
Diabetes control will assist with this as well.
Infectious disease - Given Levofloxacin and Flagyl in the
Emergency Room for aspiration pneumonia this was renally
dosed and then doses were increased after her creatinine was
normalized. Flagyl was not continued because of the very low
incidents of anaerobic infections and aspiration pneumonia
and her good pulmonary function. White blood cell count fell
from 40 to 20 then to 10 and then to 7.5 at the time of
discharge. Levofloxacin was to be continued for two doses
for a total of five day course given her good room air
status, decrease in abnormal chest x-ray and lack of
shortness of breath or fever at any point. The patient was
given a heart-healthy diabetic diet. For low urine output
and concentrated urine, initially she was rehydrated with
result of increased clear urine output and normalization of
creatinine.
Endocrine - The patient's diabetes Type 2 was managed with
q.i.d. fingersticks and regular insulin, sliding scale with
good control. Glyburide was stopped given the long QT on her
initial electrocardiogram. TSH was checked secondary to
elevated CK but the CKs normalized as expected as they would
from a long lie at the nursing home and TSH was normal at
1.6. Metformin may be initiated if replacement for Glyburide
is required.
Psyche - The patient was kept on her home Aricept, Effexor
and after the first day her Zyprexa. She required a sitter
at points while she had the transvenous pacer and restraints
to keep this device in but otherwise was cooperative. The
patient's daughter has the power of attorney and confirmed
the patient's Do-Not-Resuscitate, Do-Not-Intubate status and
signed a consent for pacemaker placement.
Neurology - The patient had no facial asymmetry or weakness
detected throughout her hospital stay and therefore no head
computerized tomography scan was obtained. The patient
presumably had a transient ischemic attack representing acute
illness bringing out chronic cerebrovascular disease. Her
multi-infarct dementia would best be preventively managed
with aspirin if her presumed allergy is not significant and
blood pressure and glucose control and an ACE inhibitor which
she is already on.
Musculoskeletal - The patient remained immobile in bed
throughout her stay but had no decubiti ulcers. Mild sacral
edema was noted the day of discharge. Mobility is a primary
goal at the nursing home post discharge but she is a
recurrent [**Last Name (un) 29989**].
DISCHARGE MEDICATIONS:
1. Atenolol 50 mg q.d. which may be increased for blood
pressure control as well as control of her paroxysmal
supraventricular tachycardia.
2. Zyprexa 50 mg q.h.s.
3. TUMS 500 mg b.i.d.
4. Colace 100 mg b.i.d.
5. Aricept 10 mg q.h.s.
6. Zestril 20 mg q.d. which is to be increased if she is
hypertensive on a good dose of Atenolol
7. Effexor XR 37.5 mg q.d.
8. Neurontin 400 mg t.i.d.
9. Multivitamin q.d.
10. Milk of magnesia 30 cc q. 4 to 6 hours prn constipation
11. Levofloxacin 500 mg q.d. for two to three more days after
[**2133-7-15**]
12. Sliding scale insulin prn
13. Vancomycin 1 gm 10 AM given on [**2133-7-16**] only to
complete a perioperative course
FOLLOW UP: Follow up is with the Device Clinic in one week,
so the patient is to call for appointment and is given the
number. She is to resume care under her prior primary
medical doctor.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Do-Not-Resuscitate, Do-Not-Intubate and
the daughter has power of attorney.
DISCHARGE DIAGNOSIS: (As admission plus)
1. Status post DDD pacemaker for intermittent sinus arrest
and bradycardia
2. Pneumonia versus aspiration pneumonitis
[**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) 12203**], MD [**MD Number(1) 12204**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2133-8-20**] 17:26
T: [**2133-8-25**] 16:26
JOB#: [**Job Number 29990**]
|
[
"V11.3",
"427.0",
"250.00",
"290.40",
"426.89",
"401.9",
"288.8",
"507.0",
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] |
icd9cm
|
[
[
[]
]
] |
[
"37.83",
"37.78",
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] |
icd9pcs
|
[
[
[]
]
] |
10978, 11083
|
2649, 3101
|
10089, 10764
|
11105, 11522
|
4902, 10066
|
10776, 10956
|
3124, 4884
|
105, 132
|
161, 1580
|
1602, 2175
|
2192, 2632
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,798
| 108,490
|
27464
|
Discharge summary
|
report
|
Admission Date: [**2154-11-5**] Discharge Date: [**2154-11-15**]
Date of Birth: [**2110-2-8**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Percocet / Vicodin / Codeine
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
Direct laryngoscopy with gelfoam injection for vocal cord
medialization.
History of Present Illness:
The patient is a 44 year old woman with hx of IVDU, and COPD
with a recent hospitalization (for tricuspid and mitral valve
MRSA endocarditis complicated by hypoxic respiratory failure,
VAP, c dif colitis, failed swallowing eval who presents fevers
and shortness of breath. She was first evaluated at [**Hospital1 **] in the rehab center where last night she had a fever
101.2, WBC 27k, and had 1 episode of hemoptysis. She has had
greenish sputum x 2 weeks. An ABG at [**Hospital1 392**] was 7.51/41/61 on
4LNC. She had a UA that was positive for [**9-16**] WBC and 40-50 RBC
and culture was pending. She states that today she has been
feeling well. Her breathing is at her baseline. She has chronic
abdominal pain in LLQ but this is unchanged for several weeks.
She has a foley catheter and has no dysuria. She states that her
foley catheter was placed before she left [**Hospital1 18**]. Her PICC line
was placed on [**2154-10-14**].
.
In the ED she was found to have the following vitals 97.7 126/83
16 93%4L. She was given 1 dose of ceftriaxone and zosyn then
transitioned to the ICU.
.
ROS on presentation: denies CP/HA/runny nos/congestion/sore
throat/diarrhea/ hematuria/new rashes/joint pain
.
Past Medical History:
Tricuspid and Mitral valve endocarditis (MRSA) complicated by
both brain and pulmonary emboli
clostridium dificile colitis
funguria
VAP
Chronic kidney disease: Cr baseline 1.4
IVDU
COPD
s/p appy
interstial lung disease.
s/p G-tube placement
Anemia of Chronic disease (hct 23-27)
PICC line placed ([**2154-10-14**])
Social History:
She lives with her mother outside [**Name (NI) 86**] and does have long
history of IVDU. She has a daughter 21 years old in school in
[**Hospital1 789**]. +tobacco use. estranged husband. mother recently
appointed emergency guardian which is active until [**Month (only) 956**]
[**2154**].
Family History:
NC
Physical Exam:
Vitals: 96.6 90 105/63 20 98%4L
Gen: cachetic. chronically ill appearing. hoarse voice
HEENT: thin. MMM. PERRL (5->3mm bilat) EOMI. poor dentition
Neck: IJ to mid-thyroid cart
Chest: early inspiratory crackles
CV: RRR III/VI holosystolic murmur at LLSB
Abd: G-tube in place. flat. minimal tenderness to LLQ w/o
rebound or guarding
Ext: ankle contractures. thin, waisted hand muscles. 2+DP, no
edema
Skin: no rash, no splinters
Neuro:
-MS: alert and oriented x 3. coherent responses to interview
-CN: II-XII intact
-Motor: moving all 4 extremities
-[**Last Name (un) **]: light touch intact to face/hands/ankles
Pertinent Results:
Admission Labs:
[**2154-11-5**] 06:49PM GLUCOSE-77 UREA N-14 CREAT-1.2* SODIUM-134
POTASSIUM-4.0 CHLORIDE-97 TOTAL CO2-24 ANION GAP-17
[**2154-11-5**] 06:49PM ALT(SGPT)-11 AST(SGOT)-14 LD(LDH)-217 ALK
PHOS-125* TOT BILI-0.4
[**2154-11-5**] 06:49PM ALBUMIN-3.3* CALCIUM-9.0 PHOSPHATE-4.6*
MAGNESIUM-1.8
[**2154-11-5**] 06:49PM VANCO-9.0*
[**2154-11-5**] 06:49PM WBC-12.7* RBC-2.77* HGB-8.6* HCT-25.3* MCV-91
MCH-31.1 MCHC-34.1 RDW-16.8*
[**2154-11-5**] 06:49PM NEUTS-74.4* LYMPHS-19.5 MONOS-2.3 EOS-3.7
BASOS-0.1
[**2154-11-5**] 06:49PM PT-14.1* PTT-26.1 INR(PT)-1.2*
[**2154-11-5**] 06:49PM PLT COUNT-358
[**2154-11-5**] 06:45PM LACTATE-0.9
[**2154-11-5**] 06:23PM URINE COLOR-Yellow APPEAR-SlHazy SP [**Last Name (un) 155**]-1.007
[**2154-11-5**] 06:23PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-SM
[**2154-11-5**] 06:23PM URINE RBC-162* WBC-8* BACTERIA-MOD YEAST-NONE
EPI-0
[**2154-11-5**] 03:00PM GLUCOSE-90 UREA N-16 CREAT-1.2* SODIUM-133
POTASSIUM-3.1* CHLORIDE-92* TOTAL CO2-27 ANION GAP-17
[**2154-11-5**] 03:00PM estGFR-Using this
[**2154-11-5**] 03:00PM ALT(SGPT)-11 AST(SGOT)-13 LD(LDH)-205 ALK
PHOS-143* AMYLASE-47 TOT BILI-0.5
[**2154-11-5**] 03:00PM LIPASE-16
[**2154-11-5**] 03:00PM CK-MB-3 cTropnT-0.02*
[**2154-11-5**] 03:00PM ALBUMIN-3.5
[**2154-11-5**] 03:00PM WBC-15.1* RBC-2.79* HGB-8.7* HCT-25.7* MCV-92
MCH-31.4 MCHC-34.0 RDW-16.7*
[**2154-11-5**] 03:00PM NEUTS-81.1* LYMPHS-13.8* MONOS-3.0 EOS-1.6
BASOS-0.5
[**2154-11-5**] 03:00PM PLT COUNT-400
Pertinent Labs:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2154-11-15**] 09:36AM 9.8 2.81* 8.9* 26.7* 95 31.6 33.3 16.8*
514*
VANCO TROUGH (6-8AM)
[**2154-11-14**] 05:46AM 6.8 2.45* 7.9* 22.7* 93 32.1* 34.7 16.9*
385
Source: Line-picc
[**2154-11-13**] 05:45AM 7.3 2.51* 8.1* 23.6* 94 32.3* 34.2 16.8*
471*
Source: Line-picc line
[**2154-11-12**] 05:36AM 10.5 2.64* 8.2* 25.0* 95 31.1 32.8 16.7*
363
Source: Line-picc
[**2154-11-11**] 05:14AM 9.9 2.62* 8.1* 24.2* 92 30.9 33.4 16.6*
400
Source: Line-picc
[**2154-11-10**] 06:08AM 9.4 2.79* 8.8* 25.8* 92 31.6 34.3 16.6*
396
Source: Line-PICC
[**2154-11-9**] 05:40AM 7.4 2.70* 8.4* 25.2* 93 31.0 33.3 16.7*
343
Source: Line-PICC
[**2154-11-8**] 07:18AM 8.7 2.65* 8.3* 24.9* 94 31.5 33.4 16.9*
417
Source: Line-picc
[**2154-11-7**] 05:08AM 8.2 2.55* 8.1* 23.2* 91 31.6 34.8 16.7*
344
Source: Line-picc
[**2154-11-5**] 06:49PM 12.7* 2.77* 8.6* 25.3* 91 31.1 34.1 16.8*
358
SPECIMEN COLLECTED AT 2:00 A.M. [**2154-11-6**]
[**2154-11-5**] 03:00PM 15.1* 2.79* 8.7* 25.7* 92 31.4 34.0 16.7*
400
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2154-11-15**] 09:36AM 137* 15 1.2* 136 3.7 95* 29 16
VANCO TROUGH (6-8AM)
[**2154-11-14**] 05:46AM 110* 17 1.3* 136 3.5 94* 31 15
Source: Line-picc
[**2154-11-13**] 05:45AM 100 16 1.3* 136 3.6 95* 32 13
Source: Line-picc line
[**2154-11-12**] 05:36AM 93 17 1.3* 137 3.6 95* 31 15
Source: Line-picc; TROUGH
[**2154-11-11**] 05:14AM 101 17 1.2* 134 3.6 93* 31 14
Source: Line-picc
[**2154-11-10**] 06:08AM 89 14 1.1 137 4.1 94* 32 15
Source: Line-PICC
[**2154-11-9**] 05:40AM 119* 13 1.1 136 3.2* 94* 34* 11
TROUGH
[**2154-11-8**] 07:18AM 112* 12 1.0 140 3.3 95* 34* 14
Source: Line-picc
[**2154-11-7**] 05:08AM 92 11 1.1 136 3.3 93* 33* 13
Source: Line-picc
[**2154-11-5**] 06:49PM 77 14 1.2* 134 4.0 97 24 17
SPECIMEN COLLECTED AT 2:00 A.M. [**2154-11-6**]
[**2154-11-5**] 03:00PM 90 16 1.2* 133 3.1* 92* 27 17
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili
[**2154-11-5**] 06:49PM 11 14 217 125* 0.4
SPECIMEN COLLECTED AT 2:00 A.M. [**2154-11-6**]
[**2154-11-5**] 03:00PM 11 13 205 143* 47 0.5
CHEMISTRY Alb Calcium Phos Mg
[**2154-11-10**] 06:08AM 10.0 4.8* 1.9
Source: Line-PICC
[**2154-11-9**] 05:40AM 9.4 5.5* 1.9
TROUGH
[**2154-11-7**] 05:08AM 8.9 5.2* 2.1
Source: Line-picc
[**2154-11-5**] 06:49PM 3.3 9.0 4.6* 1.8
HIV SEROLOGY HIV Ab
[**2154-11-8**] 11:15AM NEGATIVE
ANTIBIOTICS Vanco
[**2154-11-15**] 09:36AM 15.51
VANCO TROUGH (6-8AM)
1 UPDATED REFERENCE RANGE AS OF [**2153-8-1**] == REPRESENTS
THERAPEUTIC TROUGH
[**2154-11-14**] 05:46AM 25.7*1
TROUGH
1 UPDATED REFERENCE RANGE AS OF [**2153-8-1**] == REPRESENTS
THERAPEUTIC TROUGH
[**2154-11-13**] 05:45AM 24.7*1
Source: Line-picc line
1 UPDATED REFERENCE RANGE AS OF [**2153-8-1**] == REPRESENTS
THERAPEUTIC TROUGH
[**2154-11-12**] 05:36AM 23.5*1
Source: Line-picc; TROUGH
1 UPDATED REFERENCE RANGE AS OF [**2153-8-1**] == REPRESENTS
THERAPEUTIC TROUGH
[**2154-11-11**] 05:14AM 24.0*1
Source: Line-picc
1 UPDATED REFERENCE RANGE AS OF [**2153-8-1**] == REPRESENTS
THERAPEUTIC TROUGH
[**2154-11-9**] 05:40AM 19.21
TROUGH
1 UPDATED REFERENCE RANGE AS OF [**2153-8-1**] == REPRESENTS
THERAPEUTIC TROUGH
[**2154-11-8**] 07:18AM 17.11
Source: Line-picc
1 UPDATED REFERENCE RANGE AS OF [**2153-8-1**] == REPRESENTS
THERAPEUTIC TROUGH
[**2154-11-5**] 06:49PM 9.0*1
Pertinent Imaging:
.
[**2154-11-5**]: CXR - Interval replacement of Dobbhoff tube with
gastrostomy. Diffuse interstitial air space opacities with areas
of nodularity again noted. Interval resolution of left greater
than right small pleural effusions.
.
EKG ([**2154-11-5**]) - sinus @95. nl axis and intervals. TWI V2-5 (no
change from [**2154-10-24**])
.
Micro: blood culture x3 NGTD
CT of Thorax, Abdoman, Pelvis ([**2154-11-6**]):
CT OF THE CHEST WITH IV CONTRAST: The heart and great vessels
are unremarkable. There is no pericardial effusion. A large
prevascular lymph node measures 3.1 x 1.1 cm (2:19). This lymph
node is probably stable in size compared to the non-contrast CT
examination of [**2154-10-16**]. A right hilar lymph node is enlarged
measuring 1.4 cm in diameter (2:23). No other pathologically
enlarged mediastinal, hilar or axillary lymph nodes are noted.
There are diffuse cystic changes, most notably at the lung
apices, which are overall slightly worse in appearance compared
to the examination of three weeks prior. Cavitary lesions noted
at the left and right lung apex are largely unchanged. Numerous
scattered opacities throughout both lungs are overall smaller in
size compared to the previous examination. For example, a
nodular opacity located in the left lower lobe, superior
segment, now measures 1.3 cm in diameter compared to the
previous measurements of 1.7 cm (2:26). However, there are
several low-attenuation lesions located in the right lower and
right middle lobes with hyperdense rims consistent [**Last Name (un) **]
appearance with small abscesses. A more inferiorly located
lesion measures 1.5 x 1.0 cm (2:39). A lesion located in the
right middle lobe measures 1.3 x 0.7 cm (2:42). The liver,
gallbladder, spleen, adrenal glands, pancreas, and kidneys are
unremarkable. The patient is status post gastrostomy tube
placement. The abdominal portions of large and small bowel
appear grossly unremarkable. A small amount of perihepatic free
fluid is noted. No pathologically enlarged mesenteric or
retroperitoneal lymph nodes are noted.
CT OF THE PELVIS WITH IV CONTRAST: A small amount of free fluid
is present within the pelvis. The rectum, sigmoid colon,
intrapelvic loops of small bowel, uterus and adnexa appear
unremarkable. A Foley balloon is present within the decompressed
bladder.
OSSEOUS STRUCTURES: Compared to the examination of [**2154-10-16**],
there has been new interval destruction of the endplates between
the T7 and T8 vertebral bodies (series 301B:Image 33). A mixed
lytic/sclerotic lesion of the right femur is stable.
IMPRESSION:
1. Endplate destruction at the T7-8 level highly worriesome for
discitis and osteomyelitis in this clinical setting. Correlation
with MR examination of the thoracic spine is recommended.
2. At least 3, approximately 1 cm foci at the right lung base
consistent in CT appearance with abscesses versus early septic
emboli. Whether these lesions are new compared to the previous
examination cannot be definitively commented upon given the
previous lack of intravenous contrast administration. Interval
decrease in size of several nodular opacities in the left lung.
Persistent cavitary lesions involving the lung apices.
3. Prominent, parenchymal pulmonary cystic disease, most notable
in the lung apices in the setting of bibasilar ground glass
opacities. This appearance of the lungs once again raises the
possibility of several etiologies including
lymphangioleiomyomatosis, although the cysts would be more even
and round than in this case; langerhans cell granulomatosis; PCP
is again [**Name Initial (PRE) **] diagnostic possibility given the ground glass
appearance of the lung bases; and if there is a history of HIV
infection, both lymphocytic interstitial pneumonia and an
accelerated, advanced form of emphysema could also appear like
this radiographically.
TTE ([**2154-11-6**])
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 mild hypokinesis of
the anterior septum. Right ventricular chamber size and free
wall motion are normal. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is a
moderate-sized vegetation on the mitral valve. Moderate (2+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is a large vegetation on the tricuspid
valve. Moderate to severe [3+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
IMPRESSION: Moderate (1 x 1.1 cm) vegetation on the posterior
leaflet of the mitral valve. Large (1 x 1.5cm) vegetation that
appears attached to the annulus near the septal leaflet of the
tricuspid valve.
Compared with the prior study (images reviewed) of [**2154-10-16**],
the size and position of the vegetations appear similar. The
degree of tricuspid regurgitation may be slightly worse.
Moderate pulmonary artery systolic hypertension is seen (not
determined on the prior study).
Panorex ([**2154-11-8**])
INDICATION: Endocarditis with osteomyelitis.
FINDINGS: Multiple dental fillings. Teeth #7 in the left upper
jaw shows a subtle periradicular increase of transparency that
could correspond to a periradicular inflammatory granuloma. The
other teeth are unremarkable.
IMPRESSION: Potentially inflammatory granuloma in periradicular
location in the seventh tooth of the left upper jaw.
KUB ([**2154-11-9**])
Application of contrast material over pre-positioned stomatic
stump. Even distribution of contrast material through the colon,
contrast marking of the rectum.
MRI-T-Spine ([**2154-11-10**])
There is abnormal T1 hypointensity and T2 hyperintensity of the
inferior endplate of the T7 vertebral body and superior endplate
of the T8 vertebral body demonstrated. There is abnormal T1 and
T2 hyperintensity of the intervening disc space of the T7-T8
intervertebral disc visualized. These regions enhance with
gadolinium administration. There is questionable anterior
epidural enhancement at the level of T7 and T8 levels
appreciated on the sagittal post-contrast sequence only. There
is thickening and enhancement of the anterior paravertebral soft
tissues.
The remaining of the thoracic spine appears normal. The thoracic
cord demonstrates normal signal intensity. The posterior
elements at all levels appear normal. The neural foramina and
lateral recesses at all levels appear normal.
IMPRESSION:
Discitis and osteomyelitis with anterior paraspinal soft tissue
infection at the level of T7-T8. There is questionable anterior
epidural extension at this level. The thoracic cord appears
normal.MRI-Brain ([**2154-11-10**])
MRI OF THE BRAIN ([**11-11**]):
The [**Doctor Last Name 352**]-white matter differentiation of the brain is well
preserved. There are two new tiny foci of acute infarcts
visualized in the left periventricular deep white matter, which
enhances on contrast administration, suspicious for septic
emboli. There is no evidence of intracranial hemorrhage, edema,
mass effect, shift of normally midline structures, or
hydrocephalus. The ventricles and extra-axial CSF spaces appear
normal. There is no abnormal pachy or leptomeningeal
enhancement. The visualized orbits and paranasal sinuses appear
normal.
MRA OF THE BRAIN: The anterior circulation including the
intracranial internal carotid artery, anterior and middle
cerebral arteries bilaterally appear normal. The posterior
circulation including the vertebrobasilar system and bilateral
posterior cerebral arteries appear normal. There is no evidence
of filling defect, stenosis or aneurysm (greater than 3 mm)
IMPRESSION:
1. Acute infarcts with enhancement in the left periventricular
deep white matter suspicious for septic emboli.
2. Normal MRA study of the brain.
LENI ([**2154-11-13**])
This study was originally booked as a right lower extremity
non-invasive study, but clinical information indicated left calf
pain and this was confirmed by the patient and therefore a left
lower extremity non-invasive study was performed. All of the
deep veins in the left lower extremity show normal
compressibility, normal pulse Doppler waveforms and wall-to-wall
flow on color flow imaging. Numerous patent vessels were
identified in the calf, again with no signs of thrombosis.
CONCLUSION: No evidence of DVT in the left lower extremity
Video Swallow ([**2154-11-15**])
Summary: Ms. [**Name13 (STitle) **] has improved vocal cord closure and improved
oral and pharyngeal strength but conitnues to aspirate during
the swallow with thin and nectar thick liquids. Hoever, she can
begin small trials of nectar thick liquids and pureed solids
with the strategies below when with an SLP or trained staff
member to help cue her. She can identify wet vocal quality and
her cough is effective at clearing her secretions and the
intermitten trace aspiration what wil occur on the above diet.
She will also benefit from voice therary as able and f/u with
ENT to evaluate cord closure with question of additioanl
intervention.
Recommendations:
1) Continue with tube feedings for primary means of nutrition.
2) Trials of nectar thick liquids and pureed solids 1-2x's daily
with SLP and/or trainedstaff with the floowing aspiration
precautions.
a) Nectar thick liquids by tsp only no larger sips
b) when drinking, swallow, cough /clear throat and then swallow
again.
c_ tsp size bites of puree, tuckiung your chin to your chest and
swallow hard.
d) Follow each bite of puree with a sip of nectar think liquid.
e) clear your throat of you hear your vocal quality change.
f) Sit upright for approximately 30 minutes after each meal.
3)All mediations via the PEG tube
4) Consider follow-up with ENT
5) Patient will need repeat video swallow before she can be
safely advanced.
Brief Hospital Course:
In summary, this is a 44 yo F with MRSA endocarditis complicated
by septic emboli to brain, lung, kidneys, history of c. diff
colitis, that re-presents from rehab with fever, increased WBC,
subacute cough and sub-therapeutic vancomycin levels.
.
MICU:
The patient was admitted to the MICU for observation, though the
patient was hemodynamically stable. Her vancomycin trough was
sub-therapeutic and her vancomycin dose was increased to 1gm
Q24h per ID recommendation. The source of her fever at rehab
was thus likely [**1-4**] persistent endocarditis infection on
sub-therapeutic antibiotics. Other potential sources included
the lung given her history of septic emboli and a CT scan was
ordered to evaluate for change. CXR showed no clear changes.
Her PICC line was also a possible source of infections, thus
cultures were sent but PICC was not removed given endocarditis
as more probable source. Pt denied diarrhea and recurrent C Diff
was unlikely. Her u/a showed signs of possible UTI but no new
antibiotics were started pending cultures.
.
HOSPITAL COURSE BY PROBLEM:
.
# Fever and Increased WBC:
Outside hospital records indicate that the patient originally
presented with a WBC of 27K. Upon admission to the [**Hospital1 **] her WBC
was 15.1 and subsequently decreased to normal levels. The
patients Vancomycin trough levels were found to be
sub-therapeutic (9) and thus were increased from 750 mg PO daily
to 1 gram daily. Blood Cultures showed no growth to date. Repeat
echo showed no change in terms of her endocarditis and her
vegetations appeared the same. She also had a CT of the abdomen
showing ?osteomyelitis. MRI confirmed osteomyelitis at the T7-8
level. This was thought to be new radiographic evidence of her
previous bacteremia. CT surgery was reconsulted and did not
think she needed surgery. ID and Neurology followed the patient
throughout her course. Throughout her hospital course the
patient remained afebrile and her WBC stabilized. The patient's
U/A was unrevealing and urine cultures were negative to date.
Patient also had some cough that was initially productive.
Sputum was contaminated. Her cough resolved. CT chest did not
show any infiltrates but did show stable bullous disease. She
remained initially on 4L of O2 by NC but this has improved to
1-2L. The patient agreed to HIV testing was serology was
subsequently negative.
# Endocarditis:
Upon presentation the patient was hemodynamically stable with
stable PR interval on EKG. [**Hospital1 **] Disease was consulted and
her Vancomycin dose was increased from 750 mg per day to 1,000
mg per day due to sub-therapeutic trough levels. TTE was
performed on [**11-7**] revealing a stable moderate (1 x 1.1 cm)
vegetation on the posterior leaflet of the mitral valve. Large
(1 x 1.5cm) vegetation that appears attached to the annulus near
the septal leaflet of the tricuspid valve. CT surgery evaluated
the patient at that time and believed that she was not a
surgical candidate due to her new diagnosis of osteomyelitis and
due to her stable echo findings and stable valvular
abnormalities. Throughout her hospital course the patients blood
cultures showed no growth to date. Patient is to continue on a
current regimen of Vancomycin 850 mg q 24 hrs with ID follow up
scheduled. She will need repeat MRI in the future (not yet
ordered and to be arranged by ID). She needs a vanco trough
level 3 days prior to her ID appointment.
.
# Osteomyelitis/Septic Emboli
The patient also underwent a CT with contrast of the thorax to
assess her previously identified septic emboli to the lungs.
Review of the Ct revealed newly identified destruction of the
end plates between the T7 and T8 vertebral bodies. A mixed
lytic/sclerotic lesion of the right femur is stable. This test
was subsequently followed up with a thoracic MRI that revealed a
discitis and osteomyelitis with anterior paraspinal soft tissue
infection at the level of T7-T8. The patient reports no
increases in back pain nor was any back pain or paraesthesia
elicited on during exam. rectal exam revealed normal tone with
normal sacral sensations. On [**11-11**] the patient had a repeat MRI
of her brain that had questionable new acute finding showing
infarcts within very close proximity of previous septic emboli
to the brain. These results were reviewed with Neuroradiology on
two occasions and these lesions were determined to be very small
and of questionable significance. It is also not entirely clear
if these represent new lesions within the same territory. Final
consensus from radiology was that they may be small adjacent new
lesions. Neurology did not feel that she required any change in
treatment. ID also agreed. CT surgery was reconsulted and again
did not feel this would change her management and did not think
surgery was warranted given that infection of a replaced valve
would be devastating in the setting or active osteomyelitis.
.
# Cranial Nerve Deficits: The patient had new complaints of
right heading loss. In addition the patient complained of a
hoarse voice. The patient had a PEG placed on previous admission
as she had a history of failed swallowing evaluations. Upon
transfer to the floor the patient failed both bedside swallowing
evaluation as well as a video oropharyngeal swallow that found
right vocal cord paralysis. ENT was subsequently consulted and
found additional CN XII findings with right tongue deviation.
Thus, given her cranial nerve findings (deficits of 8, 9, 10,
12) they possibility of a central process was entertained. A
brain MRI was performed to investigate potential centrally
located medulla or pons lesions, however were found to be
negative for septic emboli or infarction. The patient underwent
vocal cord Gelfoam injection for improved speech on ([**11-12**]) with
questionable benefit. She requires ongoing speech therapy and
remained NPO after again failing her swallow evaluation prior to
discharge. Neurology was consulted and suggested further
audiometry testing for her right hearing loss which is scheduled
as an outpatient. Neurology also agreed with the cranial nerve
findings, however they believed that these finding may be
independent and peripheral in nature. They recommend follow-up
as outpatient and she has scheduled follow up. A repeat video
swallowing evaluation was performed on her final day and he diet
was advanced (see last video swallow report).
# Hypoxia: Upon re-admission the patient was requiring
supplemental O2 requirement most likely due to her history of
septic pulmonary emboli from endocarditis, emphysema secondary
to tobacco abuse as well as a recent history of ventilator
associated pneumonia. The patient denied shortness of breath on
re-admission. CT scan showed severe emphysema (unchanged from
prior). From the time of admission the patients pulmonary
symptoms slowly improved clinically with decreased sputum
production and the patient was weaned from 4L NC down to 2L NC.
She was continued on nebulizer treatments. The patient had one
report of left calf tenderness during her admission, however
LENI were negative for DVT and she remained on heparin SC
injections for prophylaxis.
.
# History of C Diff colitis: The patient had recently completed
course of PO vancomycin prior to admission. The patient had no
complaints of diarrhea, however reported persistent lower
quadrants abdominal pain. KUB revealed moderate stool and thus
the patient was given lactulose for constipation. The patients
stool frequency increased dramatically with slight improvement
in her abdominal pain symptoms. C. Diff assays were resent and
were negative. She remains on a bowel regimen given she is on
narcotics for chronic pain.
# Anemia: The patient presented with a HCT in the low to mid
20s, this was stable and at her baseline. Over her hospital
course her Hct remained above a goal of 21. Iron studies from
late [**Month (only) 359**] were consistent with anemia of chronic disease. The
patient had no signs of active bleeding. Prior to discharge the
patient was started on iron supplementation.
# Renal failure: The patient had a baseline Cr of 0.8 upon
admission in [**2154-9-2**]. Upon discharge in late [**Month (only) **]
her Cr increased to 1.2 although it had been as high as 1.6.
Since re-admission the patients Cr has ranged between 1.0 and
1.3.
Patient was discharged in good condition, improved O2
requirements, afebrile, improved functional capacity. Her voice
remains hoarse and she still cannot swallow normally. She is to
remain NPO and requires ongoing treatment of her
endocarditis/osteomyelitis. She has scheduled follow up with a
new primary care physician, [**Name10 (NameIs) 1083**] disease, neurology and
audiology which are all very important for her ongoing care and
management.
Medications on Admission:
Bisacodyl 10 mg HS:prn
Senna 8.6 mg [**Hospital1 **]
Docusate Sodium 100 mg [**Hospital1 **]
Olanzapine 5 mg TID:prn
Vancomycin 250 mg Q6H (completed [**2154-11-3**])
Pepcid 20 mg [**Hospital1 **]
Folic Acid 1 mg DAILY
Thiamine HCl 100 mg DAILY
Acetaminophen 325-650 mg PO Q6H:prn
DuoNeb q4:prn
Nicotine patch 7 mg/24 hr DAILY
Methadone 30 mg TID
Fentanyl 50 mcg/hr Patch Q72H
Heparin 5,000 unit TID
Heparin Flush PICC
Ondansetron 4 mg IV Q8H:PRN
Vancomycin 750 mg q24H (until [**2154-11-28**])
Metoclopramide 10 mg PO TID
Robitussin [**4-11**] mL q6
Cephulac 30 mL TID
Dilaudid 2 mg po q4:prn
Klonopin 0.5 mg [**Hospital1 **]
Lidoderm patch
Protonix 40 mg daily
Ventolin q6:prn
Discharge Medications:
1. Outpatient Lab Work
[**2154-11-19**] Chem 7 with Bun/Cr, CBC, Vanco trough [**5-10**] am and sent
to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] at [**Hospital1 **] at fax [**Telephone/Fax (1) 1419**]
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO HS (at bedtime) as needed.
3. Nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
4. Vancomycin 850 mg IV Q 24H Start: In am
hold dose 12/13
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
7. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: [**12-4**]
Inhalation Q4H (every 4 hours) as needed.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed.
11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
14. Methadone 10 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
15. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO TID (3 times a day).
16. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day) as needed.
17. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
18. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
19. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
20. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
21. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-4**] Sprays Nasal
QID (4 times a day) as needed.
22. Ondansetron 4 mg IV Q8H:PRN
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital
Discharge Diagnosis:
1. MRSA Endocarditis - Mitral and Tricuspid
2. Osteomyelitis T7-8
3. Right sided Hearing loss
Secondary:
- Clostridium dificile colitis s/p rx
- h/o VAP
- Chronic kidney disease: Cr baseline 1.4
- h/o IVDU
- COPD --severe bullous disease on CT on 4L NC O2
- s/p G-tube placement for vocal cord dysfunction, cannot eat
(failed S&S and video swallow, s/p ENT gelfoam injection)
- Anemia of Chronic disease (baseline hct 23-27)
- PICC line placed ([**2154-10-14**])
Discharge Condition:
Good - afebrile, therapeutic vancomycin levels, improved
functional capacity, improved oxygentation
Discharge Instructions:
You were admitted with Endocarditis (infection of the heart
valves)and Osteomylitis (infection of the spine). You were
treated with and increased dose of IV antibiotics.
Please take all of your medications as directed.
Please ensure that you follow up with the appointments listed
below.
Please return to the emergency room with any fevers, chills,
back pain, shortness of breath, chest pain, abdominal pain,
diarrhea, incontinence or any other problems.
Followup Instructions:
You have the following appointments scheduled:
[**Month/Day/Year **] Disease:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2154-12-13**]
10:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2154-11-22**]
9:30
.
Neurology:
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 43**] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2154-12-12**] 4:00
.
Audiology:
Provider: [**Name10 (NameIs) 6410**] [**Name Initial (NameIs) **] [**Last Name (NamePattern4) **], AU.D. Phone:[**Telephone/Fax (1) 6411**]
Date/Time:[**2154-11-20**] 1:00
.
New Primary Care Doctor:
[**2155-1-15**] 03:30p [**Last Name (LF) **],[**First Name3 (LF) **]
[**Hospital6 29**], [**Location (un) **]
[**Hospital 191**] MEDICAL UNIT
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
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"515",
"285.29",
"V44.1",
"799.4",
"584.5",
"041.11",
"304.01",
"421.0",
"585.9",
"722.92",
"707.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"31.0"
] |
icd9pcs
|
[
[
[]
]
] |
29484, 29558
|
17916, 18967
|
314, 389
|
30066, 30168
|
2934, 2934
|
30674, 31625
|
2283, 2287
|
27400, 29461
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29579, 30045
|
26696, 27377
|
30192, 30651
|
2302, 2915
|
269, 276
|
18995, 26670
|
417, 1620
|
2950, 4504
|
4523, 17893
|
1642, 1959
|
1975, 2267
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,736
| 100,210
|
42926
|
Discharge summary
|
report
|
Admission Date: [**2159-5-24**] Discharge Date: [**2159-6-11**]
Date of Birth: [**2106-10-6**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Lovastatin
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
STEMI, motorcycle accident
Major Surgical or Invasive Procedure:
Cardiac catheterization
IABP placement
Mechanical ventilation
Central venous line placement
History of Present Illness:
52yo male presented to [**Hospital 19135**] Hospital s/p motorcycle vs car
collision. The pt was traveling at a high rate of speed, swerved
and fell. + LOC. He and his motorcycle were found in the middle
[**Male First Name (un) **] of the road. He was wearing a helmet. At [**Hospital1 **], he was
alert and oriented x 2. Multiple facial lacerations were noted
and a tetanus shot was given. Vitals upon presentation to
[**Hospital1 **] were BP 174/101, HR 80, RR 20, 100% on RA. Pelvis,
chest, and C-spine [**Last Name (un) 22942**] were unremarkable. He was transfered to
[**Hospital1 18**] for further care. Prior to transfer an ECG had been
obtained which showed inferior ST elevations. He was taken to
the cath lab. He was intubated using laryngoscopy due to airway
swelling. Cath showed thrombotic mid-distal RCA lesion which was
stented with BMS x 2. He was then transfered to the CCU. U tox
came back + for cocaine. Plastic surgery evaluated and sutured
facial lacs. Trauma surgery is folllowing the patient along with
CCU team.
.
Unable to obtain ROS [**12-19**] mental status.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
In the ED here, initial vitals were 179/100, HR 84, RR 19, 100%
O2 sat.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia
2. CARDIAC HISTORY: family denies
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY: GERD, multiple orthopedic
procedures (back, shoulder, knee)
Social History:
Tobacco history: former smoker, quit 2 months ago
Family denies EtOH and ilicit drug use, say he's been clean for
22 years.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death per pt's daughter
Physical Exam:
VS: T=99.3 BP=103/65 HR=102 RR= 16 O2 sat= 100%
GENERAL: sedated, intubated
HEENT: Periorbital ecchymosis and swetting. Lips edematous.
Right forehead facial lact covered with dry gauze
THYROID: no goitre, no signs hyperthyroidism
CARDIAC: RR, normal S1, S2. Soft systolic murmur. No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. CTAB,
no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No tenderness. + BS
EXTREMITIES: No edema
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
GAIT: unable to assess
MUSCLE: tone appears normal
Pertinent Results:
Admission Labs:
[**2159-5-24**] 11:00AM BLOOD WBC-15.9* RBC-5.24 Hgb-15.2 Hct-43.0
MCV-82 MCH-28.9 MCHC-35.3* RDW-14.1 Plt Ct-214
[**2159-5-24**] 11:00AM BLOOD PT-11.8 PTT-20.0* INR(PT)-0.9
[**2159-5-24**] 11:00AM BLOOD Fibrino-288.4
[**2159-5-24**] 03:00PM BLOOD Glucose-190* UreaN-16 Creat-0.8 Na-135
K-4.5 Cl-103 HCO3-24 AnGap-13
[**2159-5-24**] 11:00AM BLOOD CK(CPK)-667*
[**2159-5-24**] 11:00AM BLOOD Lipase-20
[**2159-5-24**] 11:00AM BLOOD cTropnT-<0.01
[**2159-5-24**] 03:00PM BLOOD Calcium-8.2* Phos-2.8 Mg-1.9
[**2159-5-24**] 11:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2159-5-24**] 11:17AM BLOOD Glucose-170* Lactate-1.6 Na-141 K-5.1
Cl-103 calHCO3-23
[**2159-5-24**] 11:17AM BLOOD freeCa-1.03*
Cardiac Enzymes:
[**2159-5-24**] 11:00AM BLOOD CK(CPK)-667*
[**2159-5-24**] 04:48PM BLOOD CK(CPK)-1662*
[**2159-5-24**] 10:43PM BLOOD CK(CPK)-1887*
[**2159-5-25**] 04:10AM BLOOD CK(CPK)-2627*
[**2159-5-25**] 10:00AM BLOOD CK(CPK)-4153*
[**2159-5-26**] 03:59AM BLOOD CK(CPK)-4480*
[**2159-5-26**] 02:47PM BLOOD CK(CPK)-3689*
[**2159-5-24**] 11:00AM BLOOD cTropnT-<0.01
[**2159-5-24**] 04:48PM BLOOD CK-MB-137* MB Indx-8.2*
[**2159-5-24**] 10:43PM BLOOD CK-MB-163* MB Indx-8.6* cTropnT-1.50*
[**2159-5-25**] 04:10AM BLOOD CK-MB-259* MB Indx-9.9*
[**2159-5-25**] 10:00AM BLOOD CK-MB-438* MB Indx-10.5*
[**2159-5-25**] 08:27PM BLOOD CK-MB-422* cTropnT-6.60*
Other Notable Labs:
[**2159-6-7**]: HbA1c 6/0
[**2159-6-7**]: ALT 35, AST 44, AlkPhos 55, TBili 0.7, Albumin 2.9
[**2159-5-29**]: TSH 3.0, T4 5.1, Free T4 0.88
Discharge Labs [**2159-6-11**]:
WBC 6.7, HCT 36.1, Plt 428
Na 141, K 4.7, Cl 107, HCO3 26, BUN 15, Cr 0.9, Glucose 110
Ca 8.4, Mag 2.1, Phos 4.3
PT 14.4, PTT 26.3, INR 1.2
Admission ECG [**2159-5-24**]:
Sinus rhythm. Compared to the previous tracing of [**2153-3-20**] there
is ST segment elevation in the inferolateral leads and ST
segment depression in the anteroseptal leads suggesting acute
myocardial infarction of the inferolateral territory.
Repeat ECG [**2159-5-24**]: Acute inferior myocardial infarction.
Probably mid-right coronary lesion with ST segment depression in
lead aVL and aVR being negative. ST segment elevation in lead
III greater than in lead II. A-V dissociation is not present.
There is some irregularity to the rhythm suggesting capture
beats. This may be interference dissociation with a junctional
rhythm that is rapid. Since the previous tracing of [**2159-5-24**]
junctional rhythm is present with interference dissociation.
Admission CXR [**2159-5-24**]: Low inspiratory lung volumes, but
otherwise no acute
cardiopulmonary process.
Cardiac Cath [**2159-5-24**]:
1. Selective coronary angiography in this right dominant system
demonstrated one vessel disease. The LMCA had no
angiographically apparent disease. The LAD had no
angiographically apparent disease. The Cx had no
angiographically apparent disease. The RCA had a proximal 50%
stenosis as well as a distal 70% stenosis that was thrombotic
and ulcerated. The distal RCA stenosis was located proximal to
the PL/PDA bifurcation.
2. Successful PTCA and stenting of distal RCA with a 4.5x28mm
Vision BMS
postdilated to 5.0mm.
3. Successful PCI of proximal PL with 5.0x18 Ultra stent.
4. Airway compromise from trauma requiring fiberoptic intubation
by
anesthesia staff.
5. Unsuccessful PTCA of distal PL cutoff with 2.5mm balloon.
6. Successful rescue PTCA of PDA origin with 2.0x15mm Apex
balloon.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. STEMI
3. Successful PCI distal RCA.
3. Successful PCI proximal PL.
4. Unsuccessful PTCA of distal PL cutoff.
5. Successful rescue PTCA of PDA origin.
6. Successful fiberoptic intubation by anesthesia staff for
airway
protection.
CT Head w/o Contrast [**2159-5-24**]: No acute intracranial abnormality
CT C-spine w/o Contrast [**2159-5-24**]: No evidence of acute fracture or
malalignment of the cervical spine.
CT Sinus/Mandidble/Maxillofacial Non-Contrast [**2159-5-24**]: Multiple
facial fractures are seen involving the bilateral nasal bones,
bilateral maxillary sinuses (anterior, lateral, posterior and
medial walls), the right palatine process of the maxilla and
palatine bone, bilateral
pterygoid plates, bilateral frontal processes of the maxillae,
right lateral orbital wall and right orbital floor. The globes
appear intact. No extraocular muscle herniation is seen. The
bilateral lamina papyracea are intact. Blood is seen throughout
the bilateral maxillary sinuses, ethmoid air cells, sphenoid
sinuses and frontal sinuses. Soft tissue swelling and hematoma
is seen in the frontal scalp along with
subcutaneous emphysema extending to the right periorbital region
and along the right cheek. Subcutaneous emphysema extends to the
masticator space
bilaterally, right greater than left. The globes appear intact.
No
mandibular fracture is seen. IMPRESSION: Multiple bilateral
facial fractures with involvement of the right lateral orbital
wall and floor as described above. The globes appear intact and
no evidence of ocular muscle entrapment is seen.
CT Abdomen and Pelvis with Contrast [**2159-5-24**]: 1. No acute
traumatic injuries seen within the torso. 2. Left adrenal
nodule, which does not meet criteria for an adrenal adenoma on
this exam. Further evaluation with dedicated CT or MRI of the
adrenal glands is recommended. 3. Mild dependent atelectasis in
both lungs.
TTE [**2159-5-25**]: There is mild symmetric left ventricular hypertrophy
with normal cavity size. There is moderate regional left
ventricular systolic dysfunction with inferior, inferolateral
and inferoseptal akinesis. The remaining segments contract
normally (LVEF = 30%). Right ventricular chamber size is normal
with moderate global free wall hypokinesis. The number of aortic
valve leaflets cannot be determined. There is no aortic valve
stenosis. No aortic regurgitation is seen. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion. IMPRESSION:
Moderate regional biventricular systolic dysfunction, c/w
RCA-territory infarction and RV infarction. Mild mitral
regurgitation. Mild pulmonary hypertension.
Cardiac Cath [**2159-5-25**]:
1. Selective coronary angiography of this right dominant system
revealed
one vessel coronary artery disease. The RCA was 100% occluded
proximal
to the prior stent. The LCA was not engaged.
2. Limited resting hemodyanmics revealed severe hypotension with
a
central pressure of 86/53 mmHg on high dose dopamine.
3. Successful placement of 40cc IABP for hemodyanamic support.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease with occluded RCA due to
stent
thrombosis.
2. Severe hypotension on high dose dopamine.
3. Successful placement of IABP for hemodynamic support.
CT Head w/o Contrast [**2159-5-29**]: 1. New small right parafalcine
subdural hematoma. 2. New scalp collections, left greater than
right, likely evolving hematomas. Overlying fascial enhancement
is likely inflammatory, but please correlate clinically to
exclude the possibility of superimposed infection.
CT Sinus with Contrast [**2159-5-29**]: 1. Extensive facial fractures as
described above, overall unchanged in appearance since [**2159-5-24**]. 2. Interval increase in opacification of the paranasal
sinuses, in part due to blood. This is a common finding in
intubated patients. However, acute sinusitis cannot be excluded,
if it is suspected on clinical grounds.
CT Chest/Abdomen/Pelvis with Contrast [**2159-5-29**]: 1. No acute
intra-abdominal pathology or source of infection identified. 2.
Interval development of small pericardial effusion and moderate
bilateral pleural effusions with fissural component on the left.
Compressive atelectasis of left greater than right lower lobes.
3. Fatty deposition in the liver. 4. Interval development of
trace amount of free fluid within the abdomen and pelvic
cavities, as well as interval increase in subcutaneous edema
likely
reflect a slightly fluid overloaded status.
TTE [**2159-6-2**]: Left ventricular wall thicknesses are normal. The
left ventricular cavity is moderately dilated. Overall left
ventricular systolic function is severely depressed (LVEF= 25 %)
secondary to extensive inferior and posterior akinesis with
focal dyskinesis of the midventricular segment of the inferior
free wall. The right ventricular cavity is dilated with
depressed free wall contractility. There is a small pericardial
effusion. The effusion appears circumferential. There are no
echocardiographic signs of tamponade. Compared with the findings
of the prior study (images reviewed) of [**2159-6-1**], focal
dyskinesis of the inferior free wall is now present.
TTE [**2159-6-4**]: No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is severe regional left
ventricular systolic dysfunction with infer-septal, inferioa,
and infero-lateral hypokinesis to akinesis. The apex appears
hypokinetic. No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. The right
ventricular cavity is mildly dilated with mild 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 mildly thickened. Moderate to
severe (3+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. The pulmonary artery systolic
pressure could not be determined. There is a small to moderate
sized pericardial effusion. There are no echocardiographic signs
of tamponade. Compared with the prior study (images reviewed) of
[**2159-6-2**], no change. IMPRESSION: No VSD or pseudoaneurysm
seen.
CT Head w/o Contrast [**2159-6-6**]: 1. No acute intracranial
hemorrhage. Previously seen tiny right parafalcine subdural
hematoma has since resolved. 2. Multiple facial fractures as
before, incompletely assessed on this study. No new fracture is
identified. 3. Resolution of small bilateral scalp hematomas.
ECG [**2159-6-10**]: Supraventricular tachycardia with a ventricular
premature beat. Inferior ST segment elevation with Q waves and T
wave inversions suggesting an myocardial infarction, could be
recent/acute. T wave inversion in leads I, aVL and V5-V6 also
suggest ischemia. Clinical correlation is suggested. Low QRS
voltage in the limb leads.
Brief Hospital Course:
52yo male admitted after motorcycle accident and found to have
inferior STEMI, who underwent emergent cardiac cath with BMS to
distal RCA.
#) STEMI - Patient brought to CCU s/p emergent cardiac cath for
inferior STEMI, which revealed a proximal 50% stenosis of the
RCA as well as a distal 70% stenosis that was thrombotic and
ulcerated. Patient had BMS placed in distal RCA. There was
evidence of right ventricular ischemia/infarction. Of note,
patient had no previously known h/o CAD, but his urine tox
screen was positive for cocaine on presentation. The patient
later denied any recent cocaine use. A TTE obtained the next
day revealed moderate regional biventricular systolic
dysfunction, c/w RCA-territory infarction and RV infarction,
mild mitral regurgitation, and mild pulmonary hypertension. The
patient developed ventricular bradycardia and hypotension, and
Swan that was placed showed elevated pressures in RA, RV, LA/WP
indicating biventricular failure. Repeat cath the following day
showed thrombosis of RCA stent, and a decision was made to
medically manage the patient as at this point microvascular
perfusion was severely impaired by distal embolization and clot
formation.
Post cath he was gravely ill with acute systolic CHF and right
ventricular failure. He had an IABP placed for support, which
was gradually weaned and pulled. His cardiac enzymes peaked on
[**2159-5-26**]: CK 4480, MB: 300, Trop: 6.21. The patient was
aggressively diuresed after developing significant pulmonary
edema, and his fluid balance was closely monitored given his
pre-load dependence in setting of RV infarct. He had several
repeat TTEs during the admission, and most recent echo was on
[**2159-6-4**]. Echo showed severe regional left ventricular systolic
dysfunction with infer-septal, inferioa, and infero-lateral
hypokinesis to akinesis, a hypokinetic apex, mildly dilated RV,
mild global free wall hypokinesis, mod-severe MR, and a small to
moderate pericardial effusion without evidence of tamponade.
#) Supraventricular tachycardia/atrial fibrillation - On night
of initial presentation, s/p PCI, rhythm went from sinus
tachycardia to atrial tachycardia with ventricular bradycardia;
BP 60-70/40s. Arrhythmia thought to be secondary to AV nodal
infarct (RCA branch) causing some degree of heartblock. Per EP,
patient appeared to have 2:1 conduction at higher HRs with good
conduction at lower HRs (~50), and pacemaker was not indicated
at the time. On [**2159-5-28**] patient had several episodes of
sustained monomorphic V tach, lasting up to 2 min at a time with
increasing frequency. Per EP recs, patient started on
amiodarone bolus and drip. He continued to have several runs of
non-sustained V-tach, and was started on metoprolol tartrate for
additional rate control. The amiodarone was later stopped, but
the patient was continued on metoprolol. He began having
several episodes of a fib/flutter on [**2159-6-7**], without
hemodynamic compromise, and his rhythm would spontaneously
convert back to normal sinus rhythm. He had an episode of
symptomatic bradycardia on [**2159-6-10**], with ECG/telemetry showing
retrograde p waves and junctional rhythm, rate 50/min. The
patient was subjectively SOB but not hypoxic, and episode was
brief. No further episodes of symptomatic bradycardia, but
patient should be closely monitored. Of note, patient had
episode of a fib/flutter on [**2159-6-10**] for which he received 2.5mg
metoprolol IV, with resultant drop in BP and requiring 250cc
bolus NS. His CHADS score is 1 and he will receive aspirin for
thromboembolic prophylaxis.
#) Systolic heart failure: Patient has left ventricular
dysfunction likely seconary to his STEMI with an ejection
fraction of 30%. His heart failure regimen includes metoprolol,
lisinopril, and spironolactone. He was initially managed with
lasix but was autodiuresing well, so his lasix was held on
[**2159-6-10**]. This will need to be restarted as an outpatient to
prevent volume overload.
#) Hypotension - On night of presentation s/p cath, patient
developed atrial tachycardia with ventricular bradycardia and BP
60-70/40s. He was started on Dopamine for pressure support, and
would require ongoing support with several pressors to keep MAP
at goal of >65. He was eventually weaned off pressors, however
his SBPs generally remained in the 80s-90s. He had some degree
of orthostatic hypotension, and his anti-hypertensive and
diuretic regimen were adjusted accordingly. Of note, patient's
SBP persistently in 80s-90s in days prior to discharge. Patient
asymptomatic with SBP in 80s.
#) Respiratory Status - Patient sustained multiple facial
fractures in the MVA, and required intubation for significant
airway swelling. During his CCU course, he was gradually weaned
off ventilator support, and he was successfully extubated on
[**2159-6-3**].
#) Sinusitis/Fever - During early hospital course, patient was
persistently febrile and diaphoretic. In setting of multiple
facial fractures, he was started on broad spectrum antibiotic
coverage. Per ID, patient was on regimen of vancomycin,
aztreonam, cipro, and metronidazole (given penicillin allergy).
No clear source of infection was initially identified, although
it was felt that patient may have develoepd sinusitis in setting
of facial trauma. CT sinus revealed opacification of sinuses,
however ENT consult did not feel there was any pus, abscess or
fluid collection ammenable to drainage. The patient's
antibiotic regimen was tailored back to metronidazole and
levofloxacin, for a 14-day course. He had a PICC placed on
[**2159-6-4**]. The patient was also placed on standing Tylenol during
the time of his persistent fevers. Prior to discharge, the
patient was off all antibiotics and remained afebrile. He had
1/4 bottles on blood culture positive for coag negative staph,
which was felt to be a contaminant. Repeat blood cultures were
negative.
#) Facial fractures - Multiple facial fractures noted on CT,
including the bilateral nasal bones, bilateral maxillary sinuses
(anterior, lateral, posterior and medial
walls), the right palatine process of the maxilla and palatine
bone, bilateral
pterygoid plates, bilateral frontal processes of the maxillae,
right lateral
orbital wall and right orbital floor. Blood was present in the
bilateral
maxillary sinuses, ethmoid air cells, sphenoid sinuses and
frontal sinuses. The globes appeared intact with no evidence of
ocular muscle entrapment. He was seen by trauma surgery,
plastic surgery, and ophthomology. Plastic surgery irrigated and
sutured facial lacerations in CCU, and ophtho was consulted for
periorbital swelling and orbital fx on CT. They did not feel
there was evidence of entrapment or intraoccular involvement.
#) Asymmetric Pupils - Left pupil noted to be 1-2mm more
constricted than the right, and neurology was consulted. Both
left and right pupil would constrict to light. Immediate CT scan
could not be obtained secondary to patient's hemodynamic
instability, but CT head once patient medically stable revealed
only a small subdural hematoma. Ophthomology was [**Name (NI) 653**], and
felt it was highly unlikely any intraocular pathology was
contributing to his asymmetric pupils.
#) Delirium/Agitation - Patient developed agitation and delirium
later in his hospital course, thought to be ICU-related
delirium. He was seen by psychiatry, and started on a regimen
of olanazpine and mirtazapine. He also responsed well to
additional olanzapine prn agitation. He had some difficulty
sleeping, and seemed to respond well to trazadone prn insomnia.
Patient will have neuropsych testing in outpatient setting.
#) Hyperglycemia - The patient had no previous diagnosis of
diabetes, but was persistently hyperglycemic during CCU course,
requiring glargine and an insulin sliding scale. HbA1c was 6.0.
He did not tolerate metformin, and was briefly started on
glyburide. However he had some lower blood sugars in the 60s on
glyburide, and this medication was stopped. He will need close
monitoring of his blood sugar levels following discharge.
#) FEN - The patient was started on tube feeds via OG tube while
he was intubated. His diet was advanced following his
extubation, and he was tolerating a cardiac healthy regular diet
at time of discharge.
Medications on Admission:
Glucosamine HCl 1500mg w/MSM 1500ug
B-50 - high energy complex
Prilosec 20mg daily
Omega 3 fish oil
Vitamin E 400 IU
Potassium gluconate 550mg
MVI daily
Simvastatin 20mg daily
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Docusate Sodium 50 mg/5 mL Liquid Sig: [**11-18**] 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. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
9. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
12. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Olanzapine 2.5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
14. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for Dyspepsia.
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for Dyspepsia.
16. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
17. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: Two
(2) Drop Ophthalmic QID (4 times a day) as needed for dry eyes.
18. White Petrolatum-Mineral Oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic HS (at bedtime) as needed for dry eyes.
19. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 56223**]
Discharge Diagnosis:
Acute ST-elevation myocardial infarction
Acute systolic heart failure
Status post motorcycle accident
Facial fractures
Gastroesophageal reflux disease
Discharge Condition:
Good.
Able to ambulate with walker.
Mental status alert and oriented to person, place, and time
Discharge Instructions:
You were admitted because you had a heart attack and motorcycle
accident. You required cardiac catheterization, mechanical
ventilation, and initiation of heart medications to reduce your
risk of having future heart attacks. You were also found to
have heart failure.
Please take all of your medications as prescribed. Please
attend all of your follow-up appointments.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs. Eat a heart-healthy and low sodium diet. This is
important because of your heart failure.
Followup Instructions:
Cardiology:
[**Hospital1 18**]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD
E/SH-446C
[**2159-6-29**] 10:40 AM
([**Telephone/Fax (1) 2037**]
Neuropsychology:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], PHD
Date/Time:[**2159-6-12**] 9:00
[**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **]
Phone:[**Telephone/Fax (1) 1690**]
Ophthalmology:
Plesae call [**Telephone/Fax (1) 24169**] to schedule an appointment at [**Hospital1 18**] or
follow-up with your local opthalmologist
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,313
| 105,980
|
33228
|
Discharge summary
|
report
|
Admission Date: [**2194-12-24**] Discharge Date: [**2195-1-3**]
Date of Birth: [**2133-3-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 530**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
This is a 61 yo M with a past history of afib not on
anticoagulation, stroke, motor seizure and labile hypertension
who was admitted to an OSH with bright red blood per rectum that
occurred while sleeping. The day prior, he had a bloody BM and
became diaphoretic and pale and did not respond to his wife,
making it difficult to tell if he had an expressive aphasia or
vasovagal syncope. He was admitted to the OSH for fluid
resuscitation and received 2 units of pRBC's. The morning after
admission, the nurses were ambulating the patient and noticed
him leaning more towards the left side and that he was unsteady
on his feet. He had been off coumadin for 6 months secondary to
chronic anemia from hemorrhoidal bleeding.
.
He has a history of significant rectal bleeding about 5-6 months
ago at which time he underwent upper and lower endoscopies that
revealed internal hemorrhoids that were considered a potential
source of bleeding. Surgery was consulted (he has a history of
hemorroidectomy 15 years ago) but any surgical intervention was
delayed in light of his other medical issues.
.
His hypertension has historically been labile and difficult to
control and he has been evaluated at both [**Hospital1 **] and [**Hospital1 2025**] for
this. His current regimen included labetalol, doxazosin,
lisinopril/HCTZ, Cartia. He also has a history of afib and had
significant episodes of arrhythmia during his admission,
prompting a cardiology consultation.
.
His stroke history is significant for a history of right lateral
temporal lobe infarct extending to the right parietal lobe, pre
and post central cortex and right middle frontal gyrus. On this
admission, he experienced sudden left sided weakness with falls,
and he was evaluated by neurology.
.
He is transferred to [**Hospital1 18**] for further work up and treatment of
his GI bleeding, as well as for his neurologic and cardiac
co-morbidities.
.
On arrival to the MICU, the patient was found to be in a
polymorphic wide complex tachycardia to the 200s. He was
mentating, had stable blood pressures, putting out 50cc/hr urine
with good peripheral pulses. Pacing pads were placed and an
amiodarone bolus was administered with initiation of an
amiodarone gtt. He also received 2g Mag. His rate slowed with
the amiodarone and his rhythm returned to a narrow complex
irregular tachycardia. At the time of transfer he had finished
his 5th unit of pRBCs.
.
In the MICU the patient received an additional 6 units of blood.
He was also noted to have a wide-complex tachycardia and was
started on dofetilide, amiodarone and esmolol gtt per the EP
team which were then stopped and then transitioned to diltiazem,
labetolol, which he was taking as an outpatient. His HR remains
fast at around 110 bpm. On admission the patient was also noted
to have a significant speech delay. [**12-24**] MRI/A: showed acute
infarct of R ACA without discrete vascular abnormality (no
acute cutoff or discrete stenosis) at R ACA. Severe atheromatous
disease noted in other intracranial arteries as well as the
basilar artery. R ACA infarct was thought to be [**1-17**] emboli v.
pressure drop distal to severe stenosis. Neurology was
consulted and recommended holding anticoagulation given lower GI
bleed and to maintain SBP 140s-160s. Pt has remained
hypertensive to a peak sbp of 185/126 and his diastolic blood
pressures remain high.
.
On questioning, the patient denies any new headache, visual
changes, speech difficulties, new weakness though he does report
chronic UE and some LE weakness ?R > L. He has chronic knee
pain but is ambulatory. He denies orthopnea or PND and can walk
one block w/o SOB. He has difficulty climbing stairs [**1-17**] to
knee pain. The patient denies any recent weight loss or night
sweats, fevers/chills, denies chest pain, palpitations, or a new
cough. Currently he denies dizzyness and has not had BRBPR
since prior to admission. He is feeling close to his baseline.
Past Medical History:
- a-fib, not on anticoagulation [**1-17**] h/o lower GI bleed
- lower GI bleed 4 years ago s/p hemorrhoidectomy; colonoscopy
[**2193-12-25**] showed large grade IV external hemorrhoid, enormous
tortuous internal and external hemorrhoids, medium-sized polyp
s/p removal
- DM II newly started on oral regimen
- Obesity
- Sleep apnea on bipap
Social History:
Lives with his wife [**Name (NI) **], works as a lumber salesman, drinks
3-4beers per night and one [**Doctor Last Name 6654**], denies eye opener or h/o
withdrawal, denies h/o IVDU or other illicits.
Family History:
no h/o GI cancers, mother living with HTN and DM, father died of
lung cancer
Physical Exam:
VS: 98.2/98.6 BP 164/112 (141-185/93-126) HR 110s RR 20 98% RA
I/O: 1440/[**2111**]
GEN'L: very obese male, delayed speech, comfortable, NAD
HEENT: nc/at, OP clear, MMM, conjunctivae slightly pale, sclera
anicertic, EOMI, PERRL
NECK: supple, no [**Last Name (un) **]/poster cervical LN, no
submandib/supraclavic LN
CVS: tachycardic, regular rhythm, nml s1/s2, no m/r/g
PUL: CTAB, no wheezes or crackles
[**Last Name (un) **]: obese, +BS, non-tender, no masses
EXT: R > L hand/arm edema, L > R LE edema 2+pitting to knees,
warm extremities, no cyanosis or clubbing
NEURO: CN II-XII intact, speech delayed, sensation grossly
intact to light touch face and extremities stregth [**3-21**] R and [**2-18**]
L deltoid; [**3-21**] R and 3/5 L bicep/tricep; [**3-21**] R and 3/5 L wrist
flexion/extension; [**3-21**] R and 4/5 L hip flexor, 5/5 L and r ankle
flexion and extension; slightly delayed L finger to nose, nml
finger tap, +Babinski on left; 2+ bracial, wrist reflexes
SKIN: cherry spots and red small papules diffusely over body, no
other rashes
Pertinent Results:
ADMISSION LABS:
OSH:
Hct 23
Cr 1.8
.
143 114 39
=============< 137
4.3 23 1.5
Ca: 7.8 Mg: 2.3 P: 4.0
.
6.9 > 28.5 < 126
N:79.1 L:15.7 M:3.6 E:1.2 Bas:0.5
.
PT: 14.3 PTT: 26.3 INR: 1.2
.
Ca: 7.7 Mg: 29.0 P: 3.7
.
ALT: 12 AP: 33 Tbili: 0.6 Alb: 2.6
AST: 14 LDH: 132 Dbili: TProt:
[**Doctor First Name **]: Lip: 23
.
MRI/MRA brain [**2194-12-24**]:
IMPRESSION: Acute infarct of the right ACA without discrete
vascular
abnormality detected of the right ACA. However, severe
atheromatous disease is noted in other intracranial arteries as
well as the basilar artery.
.
Echo [**2194-12-30**].
IMPRESSION: Limited study. No PFO seen. Grossly-preserved
biventricular function. Dilated thoracic aorta.
.
MRI/MRA head [**2195-1-1**].
IMPRESSION:
1. No evidence of new brain ischemia apart. Stable signal
abnormality corresponding to known subacute right anterior
cerebral artery territory infarct.
2. Extensive atherosclerotic disease involving the intracranial
carotid and vertebral branches as detailed above. Abrupt cut
off of the right A2 segment of the anterior cerebral artery
likely correlates with the territory of infarction.
3. New, marked focal short segment stenosis of left A1 segement
of ACA with patent artery distally.
3. Grossly patent major cervical vessels; MRA of the neck was
significantly limited due to decreased contrast in the arteries
(bolus timing problem) as above.
4. Bilateral maxillary sinus mucosal thickening versus fluid as
well as fluid within the left mastoid air cells.
.
Colonoscopy [**2195-1-2**].
Grade 1 internal hemorrhoids
Slightly abnormal/thickened appearing fold in right colon.
Mucosa appeared abnormal on NBI (biopsy)
Possible rectal varices.
Diverticulosis of the whole colon
.
Carotid u/s OSH:
R >50% external carotid stenosis, L < 50% external carotid
stenosis, no internal carotid stenosis bilat
.
EKG: [**2194-12-24**]
Baseline artifact. The rhythm is irregular with both wide and
narrow
complexes. Probable sinus rhythm with intraventricular
conduction delay and frequent ventricular premature beats or
aberrated supraventricular
complexes. There appears to be organized atrial activity in some
leads but
cannot rule out the possibility that this is atrial fibrillation
or multifocal atrial tachycardia. Clinical correlation and
repeat tracing are suggested. No previous tracing available for
comparison.
.
R UE u/s [**2194-12-26**]:
IMPRESSION: Occlusive thrombus in the right cephalic vein. The
remaining
vessels are clear.
.
Brief Hospital Course:
61M h/o Afib, CVA, and recurrent lower GI bleed [**1-17**] hemorrhoids
admitted [**2194-12-18**] with rectal bleeding and near syncopal episode.
Transferred to [**Hospital1 18**] with persistent BRBPR and L sided weakness.
Patient was found to have right sided ACA stroke identified on
head MRI.
.
GI Bleed. Patient was initially admitted to OSH for GIB.
Patient has history of GI bleeds from hemorrhoidal bleeding, but
there was no evidence of hemorrhoidal bleeding seen on anoscopy
at OSH. Patient had unremarkable EGD at OSH 5 months prior to
admission. Patient was transferred 5 units of PRBCs prior to
arrival to [**Hospital1 18**]. Patient has been transfused more than 6 units
during [**Hospital1 18**] stay. Colonoscopy on [**1-2**] revealed several
possible etiologies of bleed: internal hemorrhoids vs. rectal
varices vs. diverticuli. Most recent episode of melena on [**12-31**]
and patients last transfusion of 1 unit was on [**2195-1-1**]. Patient
will need Hct checked tomorrow, on [**2195-1-4**]. If patient had any
further GI bleeding, he would likely need tagged red blood cell
scan or anoscopy to evaluate the source of bleed.
.
CVA. Patient has a history of CVA and presented with left sided
weakness and slurred speeck in setting of GI bleed. An MRI/MRA
on [**12-24**] revealed an acute infarct of R ACA without discrete
vascular abnormality (no acute cutoff or discrete stenosis) at R
ACA. Severe atheromatous disease noted in other intracranial
arteries as well as the basilar artery. Right ACA infarct was
thought to be due to embolic event versus pressure drop distal
to severe stenosis. Anticoagulation was held due to GI bleed,
but patient was eventually resumed on Aspirin 325. He recovered
much of his function on left side, however in setting of low
blood pressure (SBP < 130), patient had re-expresion of these
symptoms. His blood pressure was therefore maintained between
140s-160s. He will need to follow up with his neurologist in
[**1-18**] weeks and they will ultimately lower is blood pressure goal.
.
Atrial fibrillation. Patient has A. fib with RVR, but went into
A. flutter and wide complex tachycardia during hospital staty.
Patient takes defetilide at home, but this was stopped as
patient was unable to remain in NSR. He was rate controlled on
labetolol and diltiazem, however, his HR remained in 90s. Due
to goal of maintaining a high blood pressure, attempts at
improved rate control were unsuccessful. Patient could not be
anticoagulated on coumadin due to GI bleed. He was given full
dose aspirin.
.
HTN. Antihypertensives were intially held due to GI bled, but
were resumed with blood pressure goal of 140s-160s systolic due
to recent CVA. Patients blood pressure medications were
converted from long acting to short acting for better control of
blood pressure goal. Doxazosin was discontinued. At lower BPs
(SBP <130s), patient had re-expresion of CVA with left sided
weakness and slurred speeh. He was maintained on diltiazem,
labetolol, and captopril. He will ultimately need to have
diltiazem switched to long acting form and labetolol will need
to be switched to [**Hospital1 **] dosing if BP remains stable.
.
Pulmonary edema. Patient developed hypoxia in the setting of
hypertension, thought to be due to flash pulmonary edema. He
was treated in the ICU with a nitroglycerin drip and diuresis
with good response.
.
Hyperlipidemia. Patient was contineud on Simvastatin. LDL was
checked and found to be 25.
.
Type 2 Diabetes. Home metformin and Actos were initially held
and patient was maintained on a Regular insulin sliding scale.
He will need this resumed as an outpatient. His HgA1C was
checked and found to be 5.8.
.
Right upper extremity cephalic DVT. Patient had a PICC
associated DVT. PICC was removed. Patient was not
anticoagulated for thrombus.
.
Communication: wife [**Name (NI) 1743**] [**Name (NI) 5749**] ([**Telephone/Fax (1) 77190**] (c),
[**Telephone/Fax (1) 77191**] (h), son [**Name (NI) **] [**Telephone/Fax (1) 77192**] (c)
Medications on Admission:
Cartia XT 240mg daily
Labetalol 300mg [**Hospital1 **]
Doxazocin 2mg daily
Lisinopril/hctz 20/12.5
KCl 20mEQ [**Hospital1 **]
Simvastatin 20mg daily
Iron daily
Actos 10mg daily
Metformin 1000mg [**Hospital1 **]
Tikosyn 0.25mg [**Hospital1 **]
Discharge Medications:
1. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
6. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
7. Captopril 25 mg Tablet Sig: Four (4) Tablet PO TID (3 times a
day).
8. Isosorbide Dinitrate 10 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
9. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
10. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
11. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
13. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
14. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1970**] - [**Hospital1 1559**]
Discharge Diagnosis:
GI bleed
CVA
.
Diabetes
Hypertension
Hyperlipidemia
Discharge Condition:
Fair. Hct has remained stable for several day. Blood pressure
is well controlled between 140s and 160s systolic. Left sided
weakness is nearly resolved with 4+/5 strength on left side.
Speech is fluent.
Discharge Instructions:
You were admitted for blood in your stools and for a stroke.
You were treated in the intensive care unit.
.
Please take your medications as directed. A number of
medication changes were made during your hospital stay.
.
Please call you physician or come to the emergency department if
you have chest pain, weakness, numbness/tingling, difficulty
walking, blood in stools, black stools, or any other concerning
symptoms.
Followup Instructions:
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 77193**] in [**12-17**] weeks. Ph
[**Telephone/Fax (1) 77194**].
.
Please follow up with your neurologist in [**12-17**] weeks.
|
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12673, 12917
|
14469, 14891
|
5021, 6074
|
275, 304
|
384, 4331
|
6109, 8591
|
4353, 4694
|
4710, 4912
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,310
| 116,996
|
35836
|
Discharge summary
|
report
|
Admission Date: [**2158-12-31**] Discharge Date: [**2159-1-3**]
Date of Birth: [**2089-4-18**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 19817**]
Chief Complaint:
generalized tonic clonic seizure, status epilepticus
Major Surgical or Invasive Procedure:
intubation/extubation
History of Present Illness:
Per admitting resident:
69-year-old right-handed male with a past medical history
significant for complicated forceps delivery at birth from
presumed anoxic injury, mental retardation, and deep venous
thrombosis with PE on Coumadin, who is followed for epilepsy at
[**Hospital1 18**].
Briefly, the patient first developed seizures at age 14. He was
found by his brother to have a generalized convulsion. He had a
second seizure at age 16, two years after his first episode. He
was maintained on Dilantin and phenobarbital. The patient went
50 years without another seizure. This past [**Month (only) 404**] he was
admitted to the ICU at [**Hospital1 18**] for status epilepticus in the
setting of fever of 105. Lumbar puncture was contraindicated
due
to cervical stenosis. He was empirically treated with 14-day
course of antibiotics and antiviral medications for presumed
meningitis. He was started on Keppra during that
hospitalization.
The patient had a recent admission to [**Hospital1 18**] in [**Month (only) 116**] for two
generalized convulsions. He received 10 mg of Valium for his
first convulsion, 80 mg for second convulsion. He was found to
have a sub therapeutic Dilantin level in the outside hospital.
He was started on Neurontin with a plan to wean Dilantin as an
outpatient.
He was seen in the neurology clinic on [**2158-6-26**]. At
that time, he had no activity concerning for seizures. He was
gradually requested to come off of Dilantin over a period of
approximately one month, and his dilantin was stopped on [**12-4**].
Since his last appointment, the patient continues to be
seizure-free till this am.
I called his Group home after I saw him in ED, and obtained
details of present history as follows-
He was last seen yesterday night and was apparently at his
baseline. This am, at 4.30 am the nurse went to see him, and
give
him his meds at 4.30, he was found to be seizing. his all 4
limbs
were jerking and some movement was noted at the elbow, with some
facial twitching and eye fluttering .This was described as non
violent by RN. EMS was called in , who arrived at 4.36 am.Per
EMS, " temp 98.5, BP 123/80, Glc 106, was given O2, and 10 mg
valium with little response. valium repeated again in [**6-4**] mins
(10 mg) with abortion of seizures in his limbs though facial
twitching continues. was taken to [**Hospital3 **], whre he was
intubated following phosphenytoin 1000 mg, veucuronium 1 mg,
succinylcholine 120 mg, veucuronium 9 mg in that order. His labs
there- wbc 7, hct 36, plt 166, K 3.2, glu 147. he was
transported
to ED at [**Hospital1 18**]. after coming to ED , he was given midaz 5 mg,
fentanyl 100 mcg times 2, and was put on propofol drip.
When I saw him, he did not have any clinical seizure activity.
(off propofol, he was moving his limbs and withdrawing)
Past Medical History:
Epilepsy as above, CHF, depression, anxiety, depression, left
hip fracture status post ORIF seven years ago, DJD, GERD, and
anemia.
Social History:
Lives at a nursing home. Family nearby, including brother also
has sister in [**Name (NI) 108**]. At baseline as per NH ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]): he is
alert, oriented to place and time (incomplete to date). Self
propels a wheelchair. Needs 2 to hoist him out of bed, depended
with feeding and self care.
No alcohol, drugs or smoking per family
Family History:
NC
Physical Exam:
Physical Exam at time of transfer:
T- 98.3 BP- 141/86 HR- 77 RR- 16 O2Sat 100% on CMV, 500/5/16/100
Gen: Lying in bed, intubated, NAD
HEENT: NC/AT, moist oral mucosa
Neck: supple
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: air entry equal , no crackles/rhonchi
aBd: +BS soft, nontender
ext: (+) non-pitting edema B/L. LLE had scaly lesions and
bruises
Neurologic examination:
Mental status: Off sedation. Intubated. Non-responsive to verbal
but withdraws to pain, active movements ain all 4 limbs if off
sedation. Eyes closed and no spontaneous eye opening.
Cranial Nerves:
Pupils equally round and reactive to light, 2to 1 mm
bilaterally (min reactive). Eyes set at midline without mvmt. No
BTT B/L. no nystagmus. No gross facial asymmetries. (+)
corneals B/L. (+) cough.
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
Moves all 4 limbs spontaneously and withdraws to pain
Sensation: withdraws to noxious stim in all 4 ext.
Reflexes:
+1 and symmetric at biceps and patellae, 0 elsewhere.
Toes mute on left but upgoing on right.
Examination at time of discharge:
Pertinent Results:
LABS ON ADMISSION:
[**2158-12-31**] 08:20AM BLOOD WBC-9.7 RBC-4.42*# Hgb-12.7* Hct-39.6*#
MCV-90 MCH-28.8 MCHC-32.1 RDW-15.3 Plt Ct-175
[**2158-12-31**] 08:20AM BLOOD Neuts-91.2* Lymphs-6.0* Monos-2.6 Eos-0.1
Baso-0.1
[**2158-12-31**] 08:20AM BLOOD PT-33.0* PTT-36.2* INR(PT)-3.3*
[**2158-12-31**] 08:20AM BLOOD Glucose-132* UreaN-16 Creat-1.0 Na-143
K-3.8 Cl-101
HCO3-30 AnGap-16
[**2158-12-31**] 08:20AM BLOOD Calcium-9.3 Phos-3.2 Mg-1.9
[**2159-1-1**] 02:13AM BLOOD TSH-1.0
[**2158-12-31**] 08:20AM BLOOD Phenyto-12.0
URINE STUDIES: [**2158-12-31**] 08:20AM URINE Blood-TR Nitrite-NEG
Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG
pH-7.0 Leuks-NEG
[**2158-12-31**] 08:20AM URINE RBC-0-2 WBC-0 Bacteri-NONE Yeast-NONE
Epi-0
TOX SCREEN:
[**2158-12-31**] 08:20AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2158-12-31**] 08:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGING:
CT HEAD: IMPRESSION: No intracranial hemorrhage or edema.
HIP XRAY - No definite evidence of acute fracture or
malalignment.
Brief Hospital Course:
69 year old man with history of MR, CHF, DVT/PE (on coumadin),
depression, and seizure d/o (hospitalized in [**2-3**] for status
epilepticus felt to be due to suspected meningitis), presented
to OSH with facial twitching on the right and generalized
shaking in at his NH which required 20 mg valium to cease
seizure activity. Patient was sedated and intubated at the OSH,
loaded with Dilantin and transferred to [**Hospital1 18**] for further care.
He was admitted to NEURO ICU for further care and evaluation
given intubation at time of presentation. Of note, per OMR he
weas felt to have focal epilepsy with secondary generalization,
likely due to anoxic brain injury at
birth, and probably related to the atrophic changes seen on MRI,
particularly in the left temporal lobe.
NEURO. Patient did not have a clear source for lowering seizure
threshold on evaluation of an infectious and toxic etiology (see
pertinent results). HCT did not show an acute abnormality. He
was provided with all of his medications at the nursing home and
no new medications were started. He was recently, [**2158-12-4**]
tapered off Dilantin, and it was felt that perhaps this
medication was necessary to maintain him seizure free. His
gabapentin was transiently increased to 1200 mg TID, however
this was reduced to his home level of 900 mg TID by the time of
discharge. His keppra dose was increased from 1500 mg [**Hospital1 **] to
1750 mg [**Hospital1 **]. The patient had no further events during the
hospital course and was back at his baseline at the time of
discharge. Full EEG reports are pending at the time of
dictation.
CV. Patient has a history of HF with b/l pitting edema 1+ which
was noted on current examination. CXR revealed evidence of
cardiomegaly but no acute infiltrate. He was continued on home
regimen of lasix.
PULM. By HD#1 patient was extubated without complications.
HEME. Pt. is being treated for remote (> 3 years) DVT and PE.
Coumadin was briefly held for supratherapeutic INR, however his
INR was 1.9 on the day of discharge and his home dose was
reinstated and should be routinely followed for goal INR [**2-28**].
Medications on Admission:
Celexa 20 mg daily, furosemide 40 mg daily,
gabapentin 900 mg t.i.d., Keppra 1500 mg b.i.d., metoprolol
tartrate 12.5 mg b.i.d., potassium
chloride 10 mEq daily, Risperdal 0.25 mg daily, simvastatin 40
mg
daily, warfarin 10 mg daily,(confirmed with RN at group home)
aspirin 81 mg daily, Colace 100 mg t.i.d., Pepcid-AC.
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO TID (3
times a day).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
6. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
9. Levetiracetam 500 mg Tablet Sig: 3.5 Tablets PO BID (2 times
a day): 1750 mg [**Hospital1 **].
10. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours).
11. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO DAYS
([**Doctor First Name **],MO,TU,WE,TH,FR,SA). Adjust accordingly for goal INR [**2-28**].
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] at Silver [**Doctor Last Name **] Commons
Discharge Diagnosis:
Primary: Generalized tonic clonic seizure
Secondary: Epiliepsy, Cerebral Palsy
Discharge Condition:
Hemodynamically stable. Patient is nonverbal but smiles and
mimics. He moves all extremities equally and against
resistance.
Discharge Instructions:
You were admitted to the hospital for an episode of generalized
tonic/clonic seizure. You did not have further seizures while
in the hospital. Your keppra was increased to 1750 mg [**Hospital1 **] and
your neurontin remained at your home dose of 900 mg tid.
Should you experience any further seizures, please call your
neurologist immediately. Should you experience any other
concerning symptoms as listed below, please call your doctor or
go to the emergency room.
Followup Instructions:
NEUROLOGY: Provider: [**First Name11 (Name Pattern1) 12562**] [**Last Name (NamePattern4) 47259**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2159-3-26**] 10:30
|
[
"530.81",
"345.11",
"343.9",
"319",
"300.00",
"V12.51",
"715.90",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
9532, 9624
|
6097, 8244
|
370, 393
|
9747, 9876
|
4973, 4978
|
10395, 10566
|
3822, 3826
|
8616, 9509
|
9645, 9726
|
8270, 8593
|
9900, 10372
|
3841, 4204
|
278, 332
|
421, 3244
|
4427, 4954
|
5955, 6074
|
4993, 5945
|
4243, 4411
|
4228, 4228
|
3266, 3400
|
3416, 3806
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,391
| 194,474
|
16956
|
Discharge summary
|
report
|
Admission Date: [**2129-9-6**] Discharge Date: [**2129-9-15**]
Date of Birth: [**2054-9-10**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Latex
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Dyspnea after elective intubation for Port placement
Major Surgical or Invasive Procedure:
Chest Port placement
History of Present Illness:
Mr. [**Known lastname 47716**] is a 74 year-old male with hx of metastatic lung
cancer on 3L home O2 with a recent admission for RUL obstructive
PNA, who presented to [**Known lastname **] for port placement, and could
not lie flat without dyspnea. He was intubated for his
procedure, and subsequently extubated with acute dyspnea and
agitation with an O2 sat of 79%. A CXR demonstrated complete
conslidation of the R lung field. He was intially placed on
BiPAP and admitted to the [**Hospital Unit Name 153**] for respiratory distress.
.
In the PACU, initial vs were: T 97.8 P 110-120 R 15-21 100% O2
sat. After NC the patient was placed on BiPaP and transfered to
the [**Hospital Unit Name 153**]
.
In the [**Hospital Unit Name 153**], he was breathing comfortably on BiPAP with settings
at 8/5 with an FiO2 of 30% 94% sat, and a minute ventilation of
9.3. he was immediately transitioned to NC at 5L and sating at
100%. Per the patient he has had a productive cough, but denies
any hemoptysis, fevers, chills, nausea, emesis, or change in
bowel or bladder habbits. He reported being thirsty, and was in
no pain.
He is DNR/DNI. He explicity expressed not to be treated with
antibiotic therapy for his possible post-obstructive PNA, until
a discussion with his wife took place.
Past Medical History:
NSLC [**11/2128**] - diagnosed after antibiotics failed for a presumed
PNA. CT staging demonstrated invasion of thoracic structures (L
atrium, SVC, and pericardium, right upper lobe bronchus), and a
biopsy from bronchoscopy confirmed the diagnosis.
Chemotherapy was started on [**2129-1-5**].
THERAPY: Cisplatin (50mg/m2, D1 and D8) and etoposide
(50mg/m2,D1-5)with concurrent radiation therapy.
[**2129-1-5**] Cycle 1 D1
[**2129-1-25**] Completion of 3500 cGy radiation therapy
[**2129-1-31**] Cycle 2 D1
[**2129-2-8**] Completion second cycle Cisplatinum and Etoposide
[**2129-3-8**] C1D1 Pemetrexed. Cycle #6 was on [**2129-7-5**]
Other Medical History:
- Moderate celiac artery stenosis
- Erectile dysfunction
- Primary right total knee replacement
- Left knee arthroscopic meniscectomy
Social History:
Married, wife [**Name (NI) 4333**]. [**Name2 (NI) **] children.
-Smoking Hx: History of 50 yrs smoking, has continued until
recently
-Alcohol: Social
-Drugs: None
Family History:
Mother: Leukemia
Father: Peritonitis
Sister Breast CA
Physical Exam:
Vitals: T: BP:129/85 P:116 R:21 O2:100
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear. EMOI
Neck: supple, no cervical LAD appreciated
Lungs: (Did not allow movment with exam to listen to R) No R
lung sounds anteriorly. Inspiratory crackles on the left.
CV: Tachycardic rate, with normal S1 + S2, No S3 or S4
appreciated.
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, 1+ edema on the R, greater
than the left.
Neuro: Motor and sensation grossly intact. Patient is oriented
to self, hospital, and time, but process information logically.
Pertinent Results:
Labs on Admission:
[**2129-9-6**] 11:06PM GLUCOSE-90 UREA N-13 CREAT-0.9 SODIUM-138
POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-30 ANION GAP-13
[**2129-9-6**] 11:06PM CALCIUM-9.2 PHOSPHATE-4.0 MAGNESIUM-1.8
IRON-9*
[**2129-9-6**] 11:06PM calTIBC-208* FERRITIN-583* TRF-160*
[**2129-9-6**] 11:06PM WBC-8.2 RBC-4.49* HGB-8.8* HCT-30.2* MCV-67*
MCH-19.7* MCHC-29.3* RDW-17.6*
[**2129-9-6**] 11:06PM NEUTS-87.4* LYMPHS-4.7* MONOS-6.3 EOS-1.5
BASOS-0.1
[**2129-9-6**] 11:06PM PLT COUNT-444*
[**2129-9-6**] 11:06PM PT-13.8* PTT-27.1 INR(PT)-1.2*
[**2129-9-6**] 06:39PM TYPE-ART PO2-77* PCO2-51* PH-7.37 TOTAL
CO2-31* BASE XS-2 INTUBATED-NOT INTUBA
.
Labs on Transfer:
[**2129-9-7**] 03:40AM BLOOD WBC-7.9 RBC-4.32* Hgb-8.6* Hct-28.9*
MCV-67* MCH-20.0* MCHC-29.8* RDW-17.6* Plt Ct-439
[**2129-9-7**] 03:40AM BLOOD Plt Ct-439
[**2129-9-7**] 03:40AM BLOOD Glucose-83 UreaN-13 Creat-0.8 Na-137
K-4.2 Cl-99 HCO3-30 AnGap-12
[**2129-9-7**] 03:40AM BLOOD Calcium-9.0 Phos-3.7 Mg-1.7
.
Blood cx: NGTD
.
Imaging:
CXR [**2129-9-6**] post Port Placement: FINDINGS: AP single view of the
chest has been obtained with patient in
supine position. Comparison is made with the next preceding
similar study of
[**2129-9-1**]. On the present examination, a complete white
out of the
right hemithorax has now developed. A new right central venous
line has been
placed apparently using the internal jugular approach on the
right side. The
line terminates overlying the lower mediastinum and most likely
has entered
the right atrium. Withdrawal of the line by approximately 5 cm
is
recommended. There is no evidence of pneumothorax in the
right-sided
completely dense hemithorax. Also on the left side no evidence
of
pneumothorax.
Brief Hospital Course:
# Goals of care: Palliative care saw the patient in the [**Hospital Unit Name 153**];
the patient decided to be made CMO; all medications other than
Vicodin and pain regimen were discontinued.
.
# Acute respiratory failure, in setting of metastatic non-small
cell lung cancer: He was admitted with acute respiratory
failure, and finding of right lung consolidation that is likely
secondary to obstructive PNA. Thoracentesis was considered for
a possible effusion radiographically confounded by infilitrate
on CXR but deferred, and overall after discussion with primary
oncology and family, decision was made to pursue comfort
measures, and stop antibiotics. He was transferred out of the
ICU, and enrolled in inpatient hospice. He was seen by
palliative care as well. He was ultimately sent to the [**Hospital **] for ongoing palliative care/hospice. At the time of
discharge, he was feeling well, no dyspnea or pain, and was
tolerating po intake with assistance.
.
#. NSLC with Metastasis: Possible chemotherapy for palliation
according to primary Hem/Onc team considered, then deferred.
Palliative care consulted. Patient remained comfortable during
the remainder of his admission.
.
#. Malignant shoulder Pain: Known metastasis. Continued on home
regimen of Vicodin PRN in conjunction with a bowel regimen.
.
#. Anemia: Stable, but low relative to recent baseline.
Microcytic - raises question of underlying thalessemia.
Continued home Folic Acid.
Medications on Admission:
1. Folic Acid 1 mg Tablet Sig: One Tab daily.
2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
3. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] SKILLED NURSING CENTER
Discharge Diagnosis:
Acute hypoxic respiratory failure
Non small cell lung cancer, metastatic
Chronic anemia
Malignant pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for placement of a port for chemotherapy, but
then developed trouble breathing. Ultimately you and your
doctors decided not to pursue further treatment, and you were
transitioned to a hospice facility.
Followup Instructions:
As needed with your [**Hospital3 3390**]:
[**Name Initial (NameIs) 3390**]: [**Last Name (LF) 7476**],[**First Name3 (LF) **] [**Telephone/Fax (1) 7477**]
Department: ORTHOPEDICS
When: THURSDAY [**2129-11-3**] at 8:00 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: THURSDAY [**2129-11-3**] at 8:20 AM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 14200**], MD [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"338.29",
"724.2",
"276.52",
"285.22",
"486",
"V46.2",
"198.3",
"518.5",
"496",
"V43.65",
"162.8",
"338.3",
"198.5",
"518.0",
"785.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"86.07"
] |
icd9pcs
|
[
[
[]
]
] |
7196, 7262
|
5221, 6681
|
332, 354
|
7409, 7409
|
3482, 3487
|
7837, 8543
|
2685, 2741
|
6859, 7173
|
7283, 7388
|
6707, 6836
|
7592, 7814
|
2756, 3463
|
240, 294
|
382, 1671
|
3502, 5198
|
7424, 7568
|
1693, 2488
|
2504, 2669
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,262
| 104,926
|
54491
|
Discharge summary
|
report
|
Admission Date: [**2186-2-13**] Discharge Date: [**2186-2-21**]
Service: NEUROLOGY
Allergies:
Naprosyn / Vicodin
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
stroke vs. seizures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a 84 year-old right-handed woman with a PMH of HTN,
HLD, afib and recent bilateral parieto-occipital infarcts and
smaller bilateral frontal infarcts. She is known to me from her
last presentation as a code stroke in [**2185-7-19**]. At that time
she presented with the infarcts described above.
.
This morning she was reportedly in her USOH and was then found
at breakfast "not answering questions". Details of this are not
known but she was taken to [**Hospital3 **] hospital where she was
reportedly witnessed to have a R sided seizure, and a question
of L eye deviation. Her BS was reportedly 140 and her BP 160.
She was given 1mg of Ativan and then was reportedly awake but
details of her exam are not known. It appears that she was given
serial NIHSS from 9-11am with scores in the 30's, however it is
not listed if she was awake during this time (or encephalopathic
vs post -ictal). She was then given dilantin 1gm and flumazenil
0.25mg IV. She had a screening CT at the OSH which reportedly
showed new infarct however on review and comparison with her
CT's here, there is no clear change. Screening labs with a
CBC,UA, and chemistry were unremarkable, however her INR was
3.1. She was then intubated "for airway protection prior to med
flight" and transferred here.
Past Medical History:
- paroxysmal afib
- OA
- HTN
- HLD
- depression
- C7 compression fracture
- Schmorl's node
- transient global amnesia
- memory impairments
- macular degeneration
- BSO
- bilateral parieto-occipital infarcts and smaller bilateral
frontal infarcts
- recent syncope in [**12-26**] with w/u of unknown results
Social History:
-lives in [**Hospital3 **]
-former tobacco (remote)
-no EtOH or tobacco
Family History:
mother: died of stroke
Physical Exam:
Vitals: T: 96.6 P: 116/47 R: 15 BP: 116/47 SaO2: 100% vent
General: NAD
HEENT: NC/AT, no scleral icterus noted, ET in place
Neck: Supple, no carotid bruits appreciated
Pulmonary: decreased breath sounds at the bases
Cardiac: regular, nl S1,S2
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: no edema
Skin: no rashes or lesions noted.
.
Neurologic:
-Mental Status: unresponsive to nox stim
.
CN
I: not tested
II,III: pupils 1.5mm sluggishly reactive, unable to visualize
fundi
III,IV,V: no dolls
V: + corneals & nasal tickle
VII: face appears symmetrical
VIII: UA to formally test
IX,X: + gag
[**Doctor First Name 81**]: UA to formally test
XII: UA
.
Motor: increased tone in all extremites with ankles flexed, no
withdrawal to nox stim in any extremity
.
Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 2 2 2 2 0 Extensor
R 2 2 2 2 0 Extensor
-Sensory: no withdrawal to nox stim in any extremity
-Coordination: NA
-Gait: NA
Pertinent Results:
Admission Labs:
[**2186-2-13**] 01:58PM NEUTS-77.5* LYMPHS-17.8* MONOS-3.5 EOS-0.9
BASOS-0.4
[**2186-2-13**] 01:58PM WBC-7.6 RBC-3.80* HGB-11.9* HCT-34.4* MCV-91
MCH-31.2 MCHC-34.5 RDW-12.9 PLT COUNT-277
[**2186-2-13**] 01:58PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2186-2-13**] 01:58PM ALBUMIN-4.0 CALCIUM-8.9 PHOSPHATE-3.4
MAGNESIUM-2.2
[**2186-2-13**] 01:58PM CK-MB-NotDone cTropnT-<0.01
[**2186-2-13**] 01:58PM ALT(SGPT)-27 AST(SGOT)-33 CK(CPK)-81 ALK
PHOS-73 TOT BILI-1.0
[**2186-2-13**] 01:58PM GLUCOSE-111* UREA N-23* CREAT-1.0 SODIUM-140
POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-26 ANION GAP-16
[**2186-2-13**] 02:05PM FIBRINOGE-300
[**2186-2-13**] 02:05PM PT-35.5* PTT-55.0* INR(PT)-3.8*
[**2186-2-13**] 03:44PM URINE RBC-0-2 WBC-[**6-28**]* BACTERIA-OCC
YEAST-NONE EPI-0-2
[**2186-2-13**] 03:44PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-TR
[**2186-2-13**] 03:44PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010
.
MRI/A Head:
FINDINGS: In comparison with the prior examinations, there are
persistent T2 and FLAIR hyperintensity areas consistent with
encephalomalacia from prior ischemic event involving both
parietal lobes. Cortical areas of hyperintensity signal are
demonstrated on T1, possibly consistent with pseudo-laminar
necrosis, multiple T2 and FLAIR hyperintense foci are also
visualized in the subcortical and periventricular white matter
consistent with chronic microvascular ischemic changes. No
diffusion abnormalities are detected, or acute ischemic changes.
After the administration of gadolinium contrast material, mild
gyriform enhancement is identified in the prior ischemic events.
Bilateral patchy mastoid mucosal thickening is identified. The
orbits are unremarkable.
.
IMPRESSION: Sequelae of prior infarctions involving the parietal
lobes, producing encephalomalacia as described above. Multiple
areas of hyperintensity signal are noted in the subcortical and
periventricular white matter consistent with chronic ischemic
changes. No diffusion abnormalities are detected, or acute
ischemic changes. There is no evidence of abnormal enhancement.
.
MRA OF THE HEAD.
FINDINGS: Again there is a small basilar artery, possibly
related with bilateral fetal PCAs . No significant change is
identified since the prior study. The carotid arteries and
vertebral arteries are patent with no evidence of occlusion or
stenosis.
.
IMPRESSION: No significant change since the prior study. The
carotid and vertebral arteries are patent without evidence of
stenosis or occlusion.
.
EEG: Borderline abnormal EEG due to persistant slowing for the
majority of the recording. This could be due to excessive
drowsiness although it may also be due to a mild encephalopathic
state. Nevertheless there were no epileptiform features noted.
Brief Hospital Course:
Patient is a 84 year old RHW here with acute onset of speech
difficulties followed by a witnessed right-side seizure during
her evaluation at OSH. She was treated with Ativan, loaded with
dilantin, sedated, intubated and transferred to [**Hospital1 18**]
for further management. She is well-known to the stroke service
and she wasn't able to provide any history at the time of
admission.
Her initial labs were noted for elevated INR of 3.8. Head CT
showed no ICH
or early signs of ischemia. It only showed old bilateral
parietal infarcts and MRI also showed no new ischemia. The most
likely explanation for her current presentation is a focal
seizure secondary to her known old left parietal infarct.
EEG was obtained which ruled out non-convulsive seizure and also
showed no epileptiform focus. She was successfully extubated
and transferred to neurology floor service where she continued
to make clinical improvements including mental status. Her
Dilantin was switched to Keppra and her Coumadin was titrated
with goal INR 2~3.
She was evaluated per PT/OT who recommeds acute rehab given
deconditioning from the admission including the ICU stay. She
will also require close INR monitoring with Coumadin titration.
She will be following up with Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] as
outpatient.
Medications on Admission:
-lisinopril 10 mg daily
-Protonix 40 mg daily
-metoprolol 100 mg b.i.d.
-Lipitor 10 mg q.h.s.
-Lexapro 5 mg daily
-alendronate 70 mg once per month
-calcium carbonate and vitamin D
-Lasix 20 mg daily
-warfarin 4 mg on Tuesdays, Thursdays and 3 mg all other days
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
7. Outpatient Lab Work
Daily INR with goal INR between 2~3 until Coumadin dosing stable
- may be spaced out further (1~2x/week) once INR therapeutic and
Coumadin dosing stable. Please forward the results to PCP (Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) **]) for instructions.
Discharge Disposition:
Extended Care
Facility:
Cape [**Hospital **] Rehabilitation & Nursing Center - [**Location (un) **]
Discharge Diagnosis:
Seizure disorder
Atrial fibrillation
hx of biparieto-occipital stroke
Discharge Condition:
Stable - oriented to self but fluent speech although frequent
word finding difficulty; ambulatory with assistance.
Discharge Instructions:
You were admitted after a witnessed episode of generalized
tonic-clonic seizure activity and you were initially intubated
for airway protection. You were successfully extubated within
48 hrs and you were transferred out of the ICU to the neurology
floor where you remained stable without further seizure
activity.
You were evaluated further including MRI/A of head which showed
no new infarcts hence your seizure was likely precipitated by
the old stroke. Also, your INR was supratherapeutic (INR 3.5)
on admission hence your Coumadin was held until for 2 days
before restarting and the dose was continually titrated during
this admission. Your INR is 2 on the day of discharge and
current dose is 2mg daily but will need to be continually
monitored and titrated as needed based on INR with goal INR 2~3.
You also had EEG which showed generalized slow background but no
epileptiform activity. However, given that you are at increased
risk factor for recurrent seizure activity from the stroke and
since you already had witnessed event, you need to be continued
on Keppra indefinitely.
Given the deconditioning with this admission which included an
ICU stay, physical and occupational therapy recommends
rehabilitation in an inpatient facility.
Please take your medication as scheduled - your Coumadin dosing
may further change based on your INR (goal INR 2~3). Also,
please follow up with Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (neurology) as
scheduled and please see your PCP [**Name Initial (PRE) 176**] 2~3 weeks of discharge
from rehab for follow-up.
If you have new weakness, numbness, visual problems, speech
problems such as slurring, and/or other concerns, please call
your PCP.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**MD Number(3) 13795**]:[**Telephone/Fax (1) 1690**] Date/Time:[**2186-3-17**]
1:00
Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2186-4-24**] 1:30 - [**Hospital Ward Name 23**] Clinical Center [**Location (un) **]
Completed by:[**2186-2-21**]
|
[
"311",
"362.50",
"E934.2",
"V45.89",
"715.90",
"401.9",
"780.39",
"272.4",
"438.89",
"427.31",
"V58.61",
"722.30",
"790.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8431, 8533
|
5981, 7358
|
255, 261
|
8647, 8764
|
3072, 3072
|
10574, 11021
|
2010, 2034
|
7670, 8408
|
8554, 8626
|
7384, 7647
|
8788, 10551
|
2049, 2446
|
196, 217
|
289, 1575
|
3088, 5958
|
2461, 3053
|
1597, 1905
|
1921, 1994
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,948
| 191,172
|
22174
|
Discharge summary
|
report
|
Admission Date: [**2174-9-26**] Discharge Date: [**2174-10-4**]
Date of Birth: Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is an 83-year-old female
with witnessed fall out of wheelchair, hitting head on a
cabinet. She currently lived in a nursing home at the time
of injury. She was brought to [**Hospital3 **] where a CT
showed a left frontal subarachnoid hemorrhage with contusion.
Daughter was with the patient at the time of the fall and
reports that she has had declining mental status. At
baseline she has right-sided weakness with some speech
difficulty from an old cerebrovascular accident which was
many years prior to admission, however, now worse. She also
was on Coumadin for her cerebrovascular accident. Patient
speaks Portuguese only. The daughter assisted with
translation.
On arrival to the Emergency Room her vital signs blood
pressure was 190 systolic, heart rate in the 90s, 16.
Patient had a collar in place for C-spine precautions. She
also had a sutured wound over her right eye and a stapled
wound in her front scalp. Her eyes opened to voice. She
followed some commands. Pupils were 3 to 2 bilaterally,
sluggish, reactive. EOMs appeared full. Motor strength in
her left upper extremity was antigravity. Left lower
extremity was antigravity. Right upper extremity had no
movement, and right lower extremity she did attempt to lift.
Her deep tendon reflexes were 1 throughout.
ADMITTING MEDICATIONS:
1. Protonix 40.
2. Senna b.i.d.
3. Lasix 80 once daily.
4. MVI.
5. Lactulose 30 cc.
6. Celexa 20.
7. Nitrodisc 0.3 mg an hour.
8. Duragesic.
9. Coumadin 5 mg.
PAST MEDICAL HISTORY: Significant for ascites, coronary
artery disease, hypertension, old cerebrovascular accident.
ALLERGIES: No known drug allergies.
LABORATORY DATA ON ADMISSION: PT was 23, PTT 44, INR 3.3.
White count 8.3, hematocrit 27.4, platelets 153. Sodium 143,
3.7, 101 for chloride, 30 for bicarbonate, BUN was 35/1.7,
and 159 for her glucose.
HOSPITAL COURSE: Mrs. [**Known lastname 37063**] was a Jehovah's Witness and that
made us unable to give her any blood products, such as fresh
frozen plasma. Her increased INR was treated with vitamin K
only. Again, Mrs. [**Known lastname 37063**] was a Jehovah's Witness and we were
unable to give her any blood products. Her INR was covered
only with vitamin K injections.
She had a repeat stat head CT. She was given vitamin K to
decrease her INR. Neuro Medicine saw the patient also and
strict blood pressure parameters. Trauma Surgery also saw
the patient due to her fall, which they cleared her C, L, and
T spines without difficulty and did not have any further
recommendations. She was admitted to the Intensive Care Unit
where her blood pressure was controlled with
antihypertensives and her INR was repressed.
On her second hospital day her INR still remained high at
2.5. Her hematocrit was stable at 27.4. She continued to
have her blood pressure controlled less than 140. Her head
CT on her second hospital day was stable. She was given
nicardipine for blood pressure control. She had a left
subclavian placed. Was noted to have abdominal distention.
She also had questionable pain to her abdomen, and abdominal
CT revealed ascites, which they felt was old, but no acute
pathology was going on. Neurologically, she moved her left
side well, and she followed commands.
On hospital day number 3 there were discussions with the
family, who made sure again that she was a DNR/DNI. Also,
she had some episodes of atrial flutter for which she was
given 15 mg of Lopressor which decreased her rate. Patient
was also a Jehovah's Witness, so no blood products were
allowed to be given. Cardiology was consulted for slow
atrial fibrillation for which they recommended an
echocardiogram and monitoring the patient closely, using
atropine as needed for low heart rate. Vitamin K continued
to be kept in hopes of decreasing her INR.
On [**9-29**] family requested that her collar be removed.
However, because patient was not a reliable source to tell us
if she had neck pain, we were hesitant to remove her C-spine
cervical collar. However, the family insisted and was given
the risks of possibly removing it, such as paralysis of her
spinal cord injury. However, they insisted to have the C-
collar removed.
On [**9-30**] she was found to be awake, following some commands.
Hematocrit dropped to 23 down from 27. The family again did
not want transfusions based on being a Jehovah's Witness.
INR had come down to 1.5 using only vitamin K. Her sodium
had been noted to be at 149. She was taking some p.o. fluids
on her own. She was transferred to the Surgical floor,
noting that she was a DNR/DNI, and the family did not want
aggressive treatment. On [**10-1**] she was awake, alert, had
some internal rotation of her upper extremity, was moving her
left side spontaneously, and followed some commands.
Physical Therapy was consulted to work with her.
On the morning of [**10-3**] the patient was noted to be
tachypneic overnight and was given Lasix 120 mg. Over a
total of 3 hours she put out 575 cc of urine. Her lungs had
bilateral crackles, left greater than right. Her heart rate
was irregular in the 90s and was noted to have a systolic
murmur. Abdomen was distended. Bowel sounds were faint.
She opened her eyes spontaneously. She was afebrile. Blood
pressures were 140s/70s, heart rate 80 to 100, respirations
were 22 to 30, and her O2 sat was 96 to 98 percent on 50
percent face mask. ABG was sent and showed 7.30 for pH, 35
for CO2, 108 for PO2. A chest x-ray was also placed, and the
family was called.
Spoke with her daughter, [**Name (NI) 1787**], who was the healthcare
proxy. It was reiterated that Mrs. [**Known lastname 37063**] did not want to
have any life prolonging procedures, such as intubation, no
tubes, and no further tests such as a CAT scan. They just
wanted to make her as comfortable as possible. So, at that
point we decided to make her comfort measures only. She was
started on some intravenous fluids since she was not
drinking. She was given Lasix to help diurese her and help
decrease her congestive heart failure. On [**10-4**] at 1:20 in
the morning Mrs. [**Known lastname 37063**] passed away. She was given periodic
morphine as needed.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 8632**]
Dictated By:[**Last Name (NamePattern4) 57890**]
MEDQUIST36
D: [**2175-1-5**] 11:32:58
T: [**2175-1-5**] 13:17:14
Job#: [**Job Number 57891**]
|
[
"E884.3",
"428.0",
"427.0",
"518.82",
"873.42",
"873.0",
"298.9",
"851.80",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
2017, 6592
|
155, 1637
|
1824, 1999
|
1660, 1809
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,675
| 147,424
|
9586
|
Discharge summary
|
report
|
Admission Date: [**2201-4-9**] Discharge Date: [**2201-4-14**]
Date of Birth: [**2147-1-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Keflex / Heparin Agents
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
pt sent to ER after routine F/U for UE DVT with vascular
surgery. In ER c/o dyspnea and was noted to have mental status
changes.
Major Surgical or Invasive Procedure:
none this admission
AVR(tissue) [**3-30**]
History of Present Illness:
s/p AVR [**3-30**]. Postop course c/b right upper extremity DVT and
postop Afib. Discharged home [**4-4**] with instructions to f/u in
vascular clinic. Had vascular clinic f/u on day of admission. At
that time had UE duplex which revealed RUE DVT involving
IJ,Axillary,subclav, brachial, and basilic veins. Then referred
to ER for Tx
Past Medical History:
s/p AVR (#27 pericardial)
post-op Afib
HTN
renal calculi
? sleep apnea
seasonal allergies
s/p 2 surgs. for spermatocele
s/p oral surgery
Social History:
lives with partner
professor/ clinical social worker
quit smoking 20 years ago
occasional ETOH
Family History:
non-contributory for premature CAD; father had MI in his 70's
Physical Exam:
admission PE
VS: HR 103 BP 162/69 RR 14 Sat 92%RA
Neuro: MAE, Follows commands, slightly confused
Heent: PERRL/EOMI, no JVD
Resp: CTAB
CV: RRR S1-S2, no murmur. Sternum stable
Abdm: soft NT/ND/NABS
Ext: + distal pulses, no edema
Discharge PE
VS:T99 HR68 BP113/72 RR18 Sat98% RA
Gen:comforable
Neuro:A&Ox3, MAE,Follows Commands
Resp:CTA-bilat
CV:RRR S1-S2, no MRG
Resp:CTA-bilat
Abdm:soft, NT/ND/NABS
Ext:warm well perfused No CCE
Pertinent Results:
[**2201-4-9**] 08:55PM GLUCOSE-193* UREA N-23* CREAT-1.2 SODIUM-138
POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-21* ANION GAP-21*
[**2201-4-9**] 08:55PM CALCIUM-8.8 PHOSPHATE-3.9 MAGNESIUM-2.4
[**2201-4-9**] 08:55PM PT-15.0* PTT-107.1* INR(PT)-1.3*
[**2201-4-9**] 01:25PM WBC-13.3*# RBC-3.45* HGB-10.6* HCT-30.5*
MCV-88 MCH-30.6 MCHC-34.7 RDW-12.7
[**2201-4-13**] 01:40PM BLOOD WBC-12.9* RBC-3.37* Hgb-10.4* Hct-29.4*
MCV-87 MCH-30.8 MCHC-35.3* RDW-13.3 Plt Ct-345
[**2201-4-14**] 11:34AM BLOOD PT-39.1* INR(PT)-4.4*
[**2201-4-10**] 09:00AM BLOOD HEPARIN DEPENDENT ANTIBODIES- positive
Brief Hospital Course:
Pt admitted [**4-9**] from ER after positive RUE DVT finding in
vascular lab. During ER evaluation pt was noted to have some
degree of dyspnea as well as mental status changes, including
loss of short term memory and brief unresponsive period after
one dose of IV Benadry and steroids prior to CT scan. The CT was
negative for CVA but positive for Pulmonary embolism. He was
transferred to CSRU for evaluation. Neurology was consulted and
the pt also had MRI which was negative.
The pt was begun on heparin gtt and was noted to have platelet
drop>50% after infusion began, hepain was d/c'd. Argatroban was
started abd a HIT panel was sent, HIT panel was positive.
Hematology was consulted.
By the following mornig all mental status changes had cleared
and the pt was transferred to the floors for continued care.
Over the next several days the patient was maintained on
Argatrobanwhile coumadin therapy was initiated. On HD#6 the pt
had a therapeudic INR(4.4) off Argatroban and wad discharged
home. He was to have f/u INR check with Dr [**First Name (STitle) **] on [**4-16**].
Additionally the pt should f/u with the hematology clinic.
Medications on Admission:
ASA 81'
Atorvastatin 10'
Lisinopril 5'
Lopressor 50"
Amiodarone 200'
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Warfarin 2 mg Tablet Sig: 1.5 Tablets PO as directed: 3 mg
[**2126-4-13**] and6/1 then as directed by Dr [**First Name (STitle) **].
Disp:*100 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p AVR [**3-30**](tissue)
readmitted [**4-9**] w/pulmonary embolism, RUE DVT, HIT positive
PMH:HTN, Renal calculi, sleep apnea,
Discharge Condition:
good
Discharge Instructions:
keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Follow-up INR to be drawn [**4-17**], by Dr [**First Name (STitle) **] @[**Telephone/Fax (1) 32507**]
Followup Instructions:
Dr [**First Name (STitle) **] in 3 days
Dr [**Last Name (STitle) **] in 3 weeks
[**Hospital **] clinic in [**11-17**] weeks
Completed by:[**2201-4-14**]
|
[
"780.57",
"E934.2",
"415.11",
"287.4",
"V13.01",
"401.9",
"453.8",
"V42.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4175, 4181
|
2261, 3401
|
418, 463
|
4354, 4361
|
1650, 2238
|
4612, 4767
|
1115, 1178
|
3521, 4152
|
4202, 4333
|
3427, 3498
|
4385, 4589
|
1193, 1631
|
250, 380
|
491, 826
|
848, 986
|
1002, 1099
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,692
| 196,707
|
24924
|
Discharge summary
|
report
|
Admission Date: [**2165-11-14**] Discharge Date: [**2165-11-25**]
Date of Birth: [**2109-2-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Myocardial Infarction
Major Surgical or Invasive Procedure:
[**2165-11-19**] - CABGx3
History of Present Illness:
The patient is a 56-year-old gentleman with rheumatoid
arthritis. He presented with congestive heart failure.
Catheterization showed severe three-vessel disease. Ejection
fraction of 40% with mild mitral regurgitation. The
arteries were extremely diffusely diseased but he was felt to be
a candidate for bypass grafting.
Past Medical History:
Hypercholesterolemia
HTN
Psoriasis
COPD
Anxiety
rheumatoid arthritis
Social History:
+ Smoking. Lives alone.
Physical Exam:
GEN: WDWN, NAD, A+Ox3.
HEENT: PERRL, anicteric sclera. EOMI. OP benign
HEART: Nl S1-S2, no murmur, RRR
LUNGS: Clear
ABD: [**1-20**]+ edema. No varicosities.
NEURO: A+Ox3, nonfocal.
Pertinent Results:
[**2165-11-14**] 04:00PM WBC-14.0* RBC-4.31* HGB-14.5 HCT-41.2 MCV-96
MCH-33.7* MCHC-35.3* RDW-12.5
[**2165-11-14**] 04:00PM ALT(SGPT)-85* AST(SGOT)-29 LD(LDH)-176 ALK
PHOS-185* AMYLASE-76 TOT BILI-1.0
[**2165-11-14**] 04:00PM GLUCOSE-122* UREA N-17 CREAT-1.4* SODIUM-131*
POTASSIUM-4.5 CHLORIDE-96 TOTAL CO2-24 ANION GAP-16
[**2165-11-14**] 05:44PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2165-11-14**] 04:00PM PLT COUNT-355
[**2165-11-24**] 05:50AM BLOOD WBC-10.7 RBC-3.35* Hgb-11.3* Hct-32.0*
MCV-96 MCH-33.7* MCHC-35.3* RDW-13.7 Plt Ct-271
[**2165-11-24**] 05:50AM BLOOD Plt Ct-271
[**2165-11-25**] 06:20AM BLOOD UreaN-8 Creat-1.2 K-4.8
[**2165-11-19**] EKG
Sinus rhythm
Left bundle branch block with left axis deviation
No previous tracing available for comparison
[**2165-11-21**] CXR
Since [**11-19**], patient has been extubated and pleural and
midline drains have been removed. Lung volumes are lower, as
expected, with mild bibasilar atelectasis. There is no
pneumothorax or appreciable pleural effusion. A slight increase
in caliber of the postoperative cardiomediastinal silhouette is
also a reflection of lower lung volumes. Tip of the right
jugular line projects over the course of the right internal
jugular vein at the thoracic inlet.
[**2165-11-15**] ECHO
The left atrium is mildly dilated. Left ventricular wall
thicknesses are
normal. The left ventricular cavity is mildly dilated. There is
mild regional left ventricular systolic dysfunction with
hypokinesis of the inferolateral wall and distal septum, The
distal inferior wall is near akinetic. The remaining segments
contract well. No masses or thrombi are seen in the left
ventricle. 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 leaflets are structurally normal. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
There is no pericardial effusion. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
[**2165-11-15**] Carotid Duplex
1. No evidence of significant atherosclerotic changes or
hemodynamically significant stenosis in the carotid arteries
bilaterally.
2. Nonvisualization of the right vertebral artery with normal in
appearance left vertebral artery.
[**2165-11-15**] X-ray
There is degenerative change with anterior osteophytes
throughout the cervical spine. C1 through the superior portion
of C7 are visualized on the lateral view. There is no evidence
of subluxation or malalignment. There is osteopenia and fused
facet joints secondary to rheumatoid arthritis.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2165-11-14**] for further
management of his coronary artery disease. He was worked-up by
the cardiac surgical service in the usual preoperative manner. A
carotid duplex ultrasound was obtained which revealed no
evidence of significant atherosclerotic changes or
hemodynamically significant stenosis in the carotid arteries
bilaterally. The pulmonary service was consulted given his
history of COPD. His PFT's were obtained from [**Hospital3 45967**]
and smoking cessation was recommended. The rheumatology service
was consulted for his severe rheumatoid arthritis. X-rays were
obtained and NSAIDs were continued. On [**2165-11-19**], Mr. [**Known lastname **] was
taken to the operating room where he underwent coronary artery
bypass grafting to three vessels. Postoperatively he was taken
to the cardiac surgical intensive care unit. On postoperative
day one, Mr. [**Known lastname **] [**Last Name (Titles) 5058**] neurologically intact and was
extubated. He was transfused with red blood cells for
postoperative anemia. He slowly weaned from pressors. On
postoperative day three, he was transferred to the step down
unit for further recovery. He was gently diuresed towards his
preoperative weight. The physical therapy service was consulted
for assistance with his postoperative strength and mobility.
Beta blockade and aspirin were resumed. Pacing wires were
removed and he started on plavix.
Mr. [**Known lastname **] continued to make steady progress and was discharged
Mt. [**Location (un) 33316**] on postoperative day 7. He will follow-up with
Dr. [**Last Name (STitle) **], his cardiologist and his primary care physician as
an outpatient.
Medications on Admission:
Atenolol 50mg daily
Lorazepam 1 mg prn
Ibuprofen 600 mg tid
Lisinopril 30 mg daily
Bumex 1mg twice daily
Nicotine patch
Lipitor 10mg daily
Flovent prn
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
3. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal 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. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 10 days.
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 10 days.
9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
mount [**First Name8 (NamePattern2) **] [**Doctor First Name **]
Discharge Diagnosis:
CAD
Hypercholesterolemia
Hypertension
Psoriasis
Rheumatoid Arthritis
COPD
Anxiety
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours.
4) No lotions, creams or powders to wound until it has healed.
5) No heavy lifting or driving.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 4 weeks. ([**Telephone/Fax (1) 1504**]
Follow-up your cardiologist in 2 weeks.
Follow-up with Dr. [**Last Name (STitle) 62667**] in 2 weeks. ([**Telephone/Fax (1) 62668**]
Call all providers for appointments.
Completed by:[**2165-11-27**]
|
[
"427.41",
"714.30",
"411.1",
"300.00",
"428.0",
"272.4",
"305.1",
"414.01",
"496",
"401.9",
"733.90",
"285.9",
"696.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.72",
"36.15",
"99.04",
"99.62",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
6803, 6894
|
3853, 5576
|
345, 373
|
7020, 7027
|
1074, 3830
|
7354, 7643
|
5777, 6780
|
6915, 6999
|
5602, 5754
|
7051, 7331
|
872, 1055
|
284, 307
|
401, 724
|
746, 816
|
832, 857
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,691
| 147,266
|
53613
|
Discharge summary
|
report
|
Admission Date: [**2147-2-25**] Discharge Date: [**2147-3-1**]
Date of Birth: [**2109-9-30**] Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
hearing loss, visual disturbance, basilar thrombosis
Major Surgical or Invasive Procedure:
Cerebral angiogram with mechanical thrombectomy
History of Present Illness:
37-year-old woman with basilar clot, in the
context of no known medical problems (yet known).
She woke with severe headache at 3:20 AM. She was near bottom of
bed. Asked husband for bucket, feeling as would vomit. Only two
drinks last night. She said she can't see and hear (but able to
hear husband). Vision affected on left. By time EMS arrived, was
vomiting, she could barely talk at this time, around 4 AM. She
had been gesturing as if whole head was painful, but husband
thinks may have said at the back of her head. She was still able
to move everything, including fingers and toes, while en route.
She continued to vomit. She was never able to get out of bed and
seems as if she could not walk.
Taken to [**Hospital3 **]. On arrival, deteriorated, becoming
comatose.
Intubated, paralysed (pancuronium) and heparin (bolus 3900
units,
running 800) at around 4:45 AM. CTA performed at [**Hospital3 **] with
occluded left vert and cut of at midpontine basilar and
reconstitution at high pontine/mesencephalic basilar. Concern
for
basilar thrombus in situ, therefore [**Location (un) **] to [**Hospital1 18**] for
further Mx. Labs normal at [**Hospital3 **].
Went to chiropractor two weeks ago - scoliosis - full body
adjustment. No known pregnancy (and test negative). No trauma to
head or neck otherwise. No prior clots.
Past Medical History:
- No medical problems
- Cholecystectomy at 19 years
- Liposuction one year ago
- Vein stripping
Social History:
Lives with husband and 2 children. Works as third grade teacher.
No drugs, smoking, drugs. She runs and does cross-fit (last 9 AM
yesterday). Husband says very fit.
Family History:
Her father died AAA at 71, also PVD. Mother is well. PGM died
71,
was diabetic. PGF cancer. MGM diabetes, heart disease. PGF heart
failure (enlarged, possible rheumatic fever, died 46),
emphysema,
smoker.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Vitals: HR 44-50, BP 110s, CMV 14 x 400 FiO2 0.4, afebrile
On CMV, breathing spontaneously on CPAP after propofol stopped -
regular, possibly apneustic.
General Appearance: Fit and healthy appearance, no stigmata of
chronic disease.
HEENT: NC, intubated.
Neck: Supple.
Lungs: CTA/vent sounds
Cardiac: Regular bradycardic.
Abdominal: Soft
Extremities: Cool. Peripheral pulses 2+.
Neurologic:
Mental status:
Comatose.
Cranial Nerves:
I: Not tested.
II: Fixed pupils, small.
III, IV, VI: No doll's eyes.
V, VII: Corneal sluggish on left, later also sluggish on right.
VIII: Hearing not tested.
IX, X: Gag intact.
[**Doctor First Name 81**]: Not tested.
XII: Not testable.
Tone initially normal in arms, with extensor increase in legs.
Later increased in arm and more in legs, fingers flexed.
Power
Only evaluable as reflexes, pain, shiver - full in those
regards.
Reflexes
Increased throughout.
Toes triple flexion into painful stimuli.
Sensation intact pain.
PHYSICAL EXAM ON DISCHARGE:
General: awake and alert, NAD
HEENT: NCAT, MMM, sclerae anicteric
CV: RRR, no murmurs
Lungs: CTAB
Abdomen: benign
Ext: no edema
Neurologic:
Mental status: Awake and alert, oriented x 3, speech fluent with
moderate dysarthria, follows commands well.
Cranial Nerves:
I: Not tested.
II: Pupils 4mm-->2mm bilaterally
III, IV, VI: EOMI with sustained nystagmus maximal on leftward
gaze, +saccadic intrusions on smooth pursuit
V: Sensation intact bilaterally
VII: R lower facial droop with weakness of R eye closure as well
VIII: Hearing decreased on R
IX, X: Palate elevates symmetrically
[**Doctor First Name 81**]: SCM and trapezius full strength b/l
XII: Tongue midline
Motor:
D B T WE WF FE FAb | IP Q H AT G/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 938**] TF
R 0 0 0 3 2 2 0 | 2 5 1 0 0 0 0
L 5 5 5 5 5 5 5 | 5 5 5 5 5 5 5
Reflexes:
2+ and symmetric throughout. Patellar response flexor on L,
extensor on R.
Sensation:
Intact to light touch and pinprick throughout.
Coordination:
Intact on L, unable to assess on R
Gait:
Deferred
Pertinent Results:
[**2147-2-25**] 11:11PM PTT-76.6*
[**2147-2-25**] 03:51PM PTT-47.7*
[**2147-2-25**] 03:50PM GLUCOSE-114* UREA N-11 CREAT-0.6 SODIUM-141
POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-22 ANION GAP-15
[**2147-2-25**] 03:50PM CALCIUM-8.4 PHOSPHATE-4.1 MAGNESIUM-1.7
[**2147-2-25**] 03:00PM URINE HOURS-RANDOM
[**2147-2-25**] 03:00PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2147-2-25**] 03:00PM URINE COLOR-Yellow APPEAR-Clear SP
[**Last Name (un) 155**]->1.050*
[**2147-2-25**] 03:00PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
[**2147-2-25**] 03:00PM URINE RBC-10* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2147-2-25**] 07:56AM CREAT-0.9
[**2147-2-25**] 07:56AM estGFR-Using this
[**2147-2-25**] 07:47AM GLUCOSE-132* NA+-142 K+-3.6 CL--104 TCO2-26
[**2147-2-25**] 07:40AM UREA N-17
[**2147-2-25**] 07:40AM HCG-<5
[**2147-2-25**] 07:40AM WBC-8.1 RBC-4.45 HGB-13.2 HCT-40.0 MCV-90
MCH-29.6 MCHC-32.9 RDW-12.7
[**2147-2-25**] 07:40AM NEUTS-86.7* LYMPHS-10.4* MONOS-2.0 EOS-0.5
BASOS-0.4
[**2147-2-25**] 07:40AM PLT COUNT-359
[**2147-2-25**] 07:40AM PT-12.2 PTT->150* INR(PT)-1.1
CTA head and neck [**2147-2-25**]:
CONCLUSION: Intraluminal thrombus occluding the basilar artery.
Poor and
then no opacification of the distal left vertebral artery with
its most distal portion apparently filling retrograde from the
basilar. Severe stenosis of the proximal left vertebral artery,
perhaps representing a dissection.
Cerebral angiogram [**2147-2-25**]:
IMPRESSION:
1. Technically successful intra-arterial mechanical thrombectomy
of a mid
basilar clot.
2. Recanalization of the entire basilar segment with a possible
small thrombus in the right PCA which was not flow limiting.
CT head [**2147-2-25**]:
IMPRESSION: New hyperdense material visualized mostly centered
in the pons
involving the inferior mid brain as well as superior medulla.
These findings are suspicious for hemorrhagic conversion at the
site of prior thrombus.
Close clinical followup as well as imaging followup is
recommended.
MRA head and neck [**2147-2-25**]:
CONCLUSION:
Bilateral pontine and cerebellar infarctions.
Severe stenosis of the proximal left vertebral artery, worrisome
for
dissection.
Wall thickening with hyperintense material in the distal
cervical left
vertebral artery, also worrisome for dissection.
No other vascular stenoses are detected.
TTE [**2147-2-27**]:
IMPRESSION: Possible patent foramen ovale.No other structural
heart disease or pathologic flow identified.
If clinically indicated, a TEE with saline contrast/maneurvers
is suggested to better define the interatrial septum
CT head [**2147-2-27**]:
IMPRESSION:
1. Interval resolution of previously seen hyperdensity in the
left paramedian
pons, indicating that this was due to contrast extravasation. No
new
intracranial hemorrhage.
2. Evolving infarcts in bilateral pons, and cerebellar
hemispheres and right cerebellar vermis, better seen in the
prior MRI study of [**2147-2-25**].
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the neurology service on [**2147-2-25**] as a
transfer from an OSH due to concern for basilar artery
thrombosis. On initial exam she was comatose and responding only
to pain with increased tone in her lower extremities and triple
flexion to noxious stimulation. Repeat CTA confirmed basilar
thrombosis with severe stenosis of the proximal left vertebral
artery concerning for dissection as well as distal left
vertebral artery thrombosis. She was taken urgently to the
angiography suite for clot retrieval. The procedure was
successful, with recanalization of the entire basilar segment
with a possible small thrombus in the right PCA which was not
flow limiting. She was monitored closely in the neuro-ICU
following the procedure. Her mental status improved and she was
successfully extubated. On subsequent exam she was awake and
alert, speech was dysarthric but otherwise mental status was
normal, and she had a residual right facial droop and right
hemiparesis. MRI showed left pontine infarct with some extension
to the right along with bilateral cerebellar infarcts. She was
transferred to the neurology floor on [**2147-2-27**].
Neuro:
She was maintained on a heparin drip with a goal PTT of 50-70
and was started on long-term anticoagulation with coumadin to
treat her vertebral artery dissection. She was maintained on IVF
to keep her systolic blood pressure > 110. A TTE was performed
which showed a possible PFO. TEE was deferred as it would not
change management and would require holding her heparin drip.
This should be performed as an outpatient to further evaluate
for possible PFO. She will also have a full hypercoagulability
work-up performed as an outpatient. Lipid panel was at goal and
HbA1c was 5.0%. She was followed by PT, OT, and speech therapy
who recommended rehab placement upon discharge.
Cardiovascular:
She was maintained on telemetry throughout her admission. BP was
monitored closely as above to maintain adequate cerebral
perfusion. Troponin was initially slightly elevated to 0.02;
this was trended and subsequently normalized. TTE showed a
possible PFO as above; she will need a TEE as an outpatient.
Nutrition:
She was seen by speech therapy and cleared for a regular diet
with no restrictions.
Prophylaxis:
She was maintained on a heparin drip and pneumoboots for DVT
prophylaxis. She was maintained on senna and colace for bowel
prophylaxis.
Code status:
She indicated that she would like to be full code on this
admission.
Transitional care issues:
She will need to be maintained on a heparin drip with goal PTT
50-70 (checked Q6 hrs) until INR is therapeutic [**12-23**]. She will
need intensive PT, OT, and speech therapy to regain her prior
level of functioning. She will need a TEE and a
hypercoagulability work-up as an outpatient for further
investigation as to the etiology of her stroke (although at this
point appears to be most likely due to traumatic vertebral
dissection). She has a follow up appointment with Dr. [**Last Name (STitle) **] in
stroke clinic on [**2147-4-25**].
Medications on Admission:
None
Discharge Medications:
1. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
2. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: As directed Intravenous ASDIR (AS DIRECTED):
Initial Infusion Rate: 1150 units/hr
Adjust for target PTT 50-70. Please draw q6h PTT. To be
continued until INR [**12-23**].
3. Artificial Tears Ointment Sig: One (1) Ophthalmic 1
application both eyes as needed for dry eyes.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Basilar thrombosis
Left vertebral artery dissection
Left pontine and bilateral cerebellar strokes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - with assistance.
Neurologic: Dysarthric speech, R lower facial droop, R
hemiparesis with some preserved movement of fingers and
quadriceps
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to the neurology service on [**2147-2-25**]
after experiencing hearing loss, vision problems, and facial
droop. You were found to have a blood clot in your basilar
artery, likely resulting from a left vertebral artery dissection
that may have been related to trauma from intense exercise. You
underwent angiography with clot retrieval and improved
significantly. You were started on a blood thinner called
coumadin and will need to remain on IV heparin until your level
is high enough. You will need intensive rehabilitation to regain
your strength, given your residual right sided weakness and
difficulty speaking.
We made the following changes to your medications:
Started coumadin 5mg daily
Started heparin IV to be continued until your coumadin level is
high enough
It was a pleasure taking care of you during your hospital stay.
We wish you the best in your recovery!
Followup Instructions:
You have the following appointment scheduled to see Dr. [**Last Name (STitle) **]
in our stroke clinic:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2147-4-25**] 3:30
You should also make an appointment to follow up with your
primary care physician [**Name Initial (PRE) 176**] 1-2 weeks.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"433.01",
"443.24",
"745.5",
"780.01",
"438.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"88.41",
"39.74",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
11132, 11229
|
7556, 10068
|
356, 406
|
11371, 11371
|
4474, 7533
|
12599, 13076
|
2081, 2287
|
10690, 11109
|
11250, 11350
|
10661, 10667
|
11649, 12339
|
2302, 2316
|
3326, 3468
|
12368, 12576
|
264, 318
|
10094, 10635
|
434, 1763
|
3594, 4455
|
2330, 2725
|
11386, 11625
|
1785, 1882
|
1898, 2065
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,197
| 129,212
|
13798
|
Discharge summary
|
report
|
Admission Date: [**2162-10-7**] Discharge Date: [**2162-10-27**]
Date of Birth: [**2088-7-15**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Last Name (un) 11974**]
Chief Complaint:
ICD firing
Major Surgical or Invasive Procedure:
Transesophageal echocardiogram
EGD
Colonoscopy
History of Present Illness:
74 yo M with history of cardiomyopathy (EF 45%), atrial
fibrillation, HTN, CKD with ICD for h/o arrhythmia presenting
after 6 episodes of ventricular tachycardia/fibrillation leading
to ICD firing. Patient was on his way to [**Hospital3 4107**] today
for a scheduled colonoscopy when he became drowsy, vomited and
his ICD fired. It fired a total of 3 times before emergency
services arrived. It fired again in the ambulance, and twice in
the ED.
.
Patient reports that over the last several weeks, he has been
feeling "lousy", reporting fatigue, loss of appetite and
weakness. He saw his PCP who ran several tests and recommended
a colonoscopy. Colonoscopy was scheduled for [**7-30**] and patient
prepped the night before. However, he was extremely weak and
could not stop having diarrhea and cancelled the colonoscopy.
The procedure was re-scheduled for [**10-8**] with plan for patient to
be admitted the night before for bowel prep and ?2U blood
transfusion. Patient reports that he had not eaten for >24hrs
as he was concerned he might "get the call" to come in for the
colonoscopy.
.
Patient's ICD was placed in [**2150**] at [**Hospital1 2025**] after he "flat-lined."
He has only been shocked once, which was approximately 1 week
following original ICD placement and reports that it was because
he "didn't have enough sotalol." Of note, patient had a
generator change of his ICD on [**2162-7-14**], and has "not felt right"
since.
.
Patient reports a 31lb weight loss over the past 4 months which
was partly intentional, but he believes he "went overboard,"
losing more than intended. He denies chest pain or palpitations
recently, but does report shortness of breath. He denies
orthopnea or PND. He has noted worsening fluid accumulation in
his lower extremities.
.
Per report of the patient, he had a stool guaiac which was
positive which prompted the colonoscopy. However, patient
denies any melena or hematochezia. In addition, he has not
noted any changes in the caliber of his stool, and denies
abdominal pain, constipation, or diarrhea. He denies dysuria or
hematuria. He does report recent nocturia, urgency and
occasional overflow incontinence.
.
In the ED, patient had two episodes of witnessed Vtach and was
unresponsive and shocked by ICD. 12 lead EKG captured override
pacing of monomorphic VT decompensating into ventricular
fibrillation during the first episode. The precipitating rhythm
was not captured. During the second event, 12 lead EKG captured
a PVC decompensating into VF. Patient was started on a
lidocaine drip. His potassium and magnesium were low and were
repleted. Patient was seen by the EP team who increased his
pacer settings to a rate of 80 and the patient was admitted to
the CCU for further management.
Past Medical History:
Cardiomyopathy, LVEF 35%- last cardiac cath several years ago at
[**Hospital1 2025**], no h/o CAD, ? familial disease
s/p Dual chamber ICD implant ([**2150**]), s/p gen change in [**3-/2154**]
@[**Hospital1 2025**] and again [**2162-7-14**] @ [**Hospital1 18**]
Hypertension
Type II diabetes- no longer on metformin or glipizide due to
recent low blood sugars
Chronic kidney disease- creatinine 1.5-1.7
Atrial fibrillation- on coumadin
Diverticulitis s/p partial colectomy [**2152**]
Right eye cataracts
Gout
Arthritis
Social History:
Patient is married with four children, 2 boys and 2 girls. He
lives with his wife, his son and daughter in law and two
grandchildren in [**Location 8391**]. One daughter lives in the
apartment upstairs and another daughter lives across the street.
He is retired, but used to be a sheet metal worker, and also
used to own the Barking Crab restaurant.
Tobacco: Quit 15 years ago, 90 pack-year history
ETOH: Denies
Illicits: Denies
Family History:
- Mother: died of breast cancer
- Father: h/o cardiomyopathy ("enlarged heart"), kidney disease
Physical Exam:
Admission physical exam:
VS: T=99.2 BP= 134/64 HR= 82 RR= 16 O2 sat= 100% on 3LNC
GENERAL: Elderly male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, left slightly sluggish
compared to right, EOMI. No conjunctival pallor or cyanosis of
the oral mucosa.
NECK: Supple with JVP of 5cm sitting upright
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, normal S1, S2. grade III/VI holosystolic murmur
radiating into axilla. No thrills, lifts. No S3 or S4.
LUNGS: CTAB, faint crackles at bilateral bases 1/3 up thorax.
No wheezes.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Warm and well perfused. 3+ bilateral lower
extremity edema to knees. No cyanosis.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP/PT dopplerable
Left: DP/PT dopplerable
.
Discharge physical exam:
VS: T=99, BP=118/53, HR=80 (V-paced), RR=20, SPO2=97% RA
GENERAL: Elderly male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL. EOMI. No conjunctival
pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP at clavicle sitting upright.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, normal S1, S2. grade III/VI holosystolic murmur
radiating into axilla. No thrills, lifts. No S3 or S4.
LUNGS: CTAB, faint crackles at bilateral bases. No wheezes.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Warm and well perfused. No edema. No cyanosis.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP/PT dopplerable
Left: DP/PT dopplerable
Pertinent Results:
ADMISSION LABS:
WBC 16.8 Hct 27.8 Hgb 9.3 Plts 269
PT 19.7 PTT 29.8 INR 1.8
Na 141 K 3.5 Cl 102 HCO3 26 BUN 37 Cr 1.5 Gluc 123
Trop-T 0.03
.
DISCHARGE LABS:
WBC 20.7 Hct 33.2 Hgb 11.1 Plts 375
PT 16.4 PTT 31.8 INR 1.4
Na 138 K 5.0 Cl 103 HCO3 27 BUN 17 Cr 1.3 Gluc 133 Ca 9.2
Mg 2.2 Phos 3.5
.
EKG: Atrial fibrillation with ventricular pacing at rate of
approximately 45. 1 PVC developing into ventricular
fibrillation.
.
IMAGING:
-CXR ([**2162-10-7**]): Retrocardiac density. In light of lack of
respiratory
symptomology, this likely represents atelectasis, although an
early developing focus of pneumonia or possibly aspiration
cannot be excluded.
.
-CXR ([**2162-10-11**]): Upright PA and lateral views of the chest are
unchanged from prior. Again seen is a retrocardiac density which
could represent atelectasis or pneumonia in the correct clinical
setting. Left pacemaker wires course through the brachiocephalic
and terminate in right atrium and right ventricle. Mild aortic
tortuosity. Cardiac silhouette is enlarged but unchanged without
evidence of pulmonary edema. No definite pleural effusion.
Incidental note is made of pericardial calcifications.
.
-Transthoracic echocardiogram ([**2162-10-8**]): The left atrium is
moderately dilated. The right atrium is moderately dilated.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is moderately dilated. LV systolic function
appears moderately-to-severely depressed (ejection fraction 30
percent) secondary to extensive apical akinesis, hypokinesis of
the interventricular septum, and marked mechanical dyssynchrony
(pacing vs left bundle branch block). The right ventricular free
wall is hypertrophied. The right ventricular cavity is dilated
with depressed free wall contractility (the apical half of the
right ventricular free wall is akinetic and aneurysmally
dilated). There are three aortic valve leaflets. The aortic
valve leaflets are moderately thickened. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. The tricuspid valve leaflets are mildly thickened.
Moderate [2+] tricuspid regurgitation is seen. [Due to acoustic
shadowing, the severity of tricuspid regurgitation may be
significantly UNDERestimated.] There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
.
-CARDIAC PERFUSION REST ([**2162-10-11**]):
The image quality is suboptimal.
The left ventricular cavity size is enlarged.
Gated images show severe apical perfusion defect extending into
the distal
anterior, septal, and inferior walls, as well as a moderate
inferoseptal
defect.
.
-Non-con Head CT ([**2162-10-15**]):
No hemorrhage, edema, mass effect, or evidence for acute
vascular territorial infarction is present. There is no shift of
normally midline structures and [**Doctor Last Name 352**]-white matter
differentiation appears well preserved. There is prominence of
the ventricles and the sulci, compatible with age-related
parenchymal involution. Osseous structures are intact. The
visualized sinuses are clear
.
-CT ABD/PELVIS ([**2162-10-15**]):
1. No definite nidus of intra-abdominal infection identified.
Normal appendix.
2. Heavily calcified ostium of the superior mesenteric artery.
Mesenteric ischemia cannot be excluded on this study.
3. Small left pleural effusion, small pericardial effusion, and
generalized subcutaneous and mesenteric edema suggesting volume
overload.
4. Coarse calcification of the left ventricular apex may
represent prior infarction or calcified apical aneurysm.
.
-CT CHEST ([**2162-10-15**]):
1. No evidence of pneumonia. Retrocardiac opacity seen in prior
CXR likely corresponds to pleural effusion.
2. Cardiomegaly with extensive vascular calcifications as well
as dense calcification of the left ventricle.
3. Mediastinal lymphadenopathy which may be reactive in this
patient with chronic heart disease.
4. Emphysematous changes with bibasilar bronchial wall
thickening, which could indicate chronic bronchitis.
5. Multiple pulmonary nodules measuring up to 4 mm. Followup
examination is recommended in 12 months.
.
-ECHO TTE ([**2162-10-16**]):
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. There is
mild to moderate regional left ventricular systolic dysfunction
with akinesis/aneysm of the distal third of the ventricle. The
remaining segments contract normally(LVEF = 40 %). A left
ventricular mass/thrombus cannot be excluded. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened. There is minimal aortic valve
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Suboptimal image quality. Symmetric left ventricular
hypertrophy with regional systolic dysfunction c/w CAD. Moderate
tricuspid regurgitation. Milld mitral regurgitation. Minimal
aortic valve stenosis. No discrete vegetation seen. Compared
with the prior study (images reviewed) of [**2162-10-8**], left
ventricular cavity size is smaller and and systolic function has
improved of basal segments. Right ventricular free wall function
has improved. Trace aortic regurgitation and mild mitral
regurgitation were present on review of the prior study.
Valvular morphology is grossly similar.
.
-TAGGED WBC SCAN [**2162-10-21**]:
INTERPRETATION: Following the injection of autologous white
blood cells labeled with In-111, images of the whole body were
obtained at 24hours. These images show expected biodistribution
of radiotracer in the spleen and liver, with no focal areas of
radiotracer identified to indicate a nidus for infection. The
above findings are consistent with no source for infection
localized.
.
PROCEDURES:
-COLONOSCOPY [**2162-10-26**]:
Impression: Diverticulosis of the sigmoid colon. Lipoma in the
distal ascending colon and proximal ascending colon. Otherwise
normal colonoscopy to cecum.
.
-ENDOSCOPY [**2162-10-26**]:
Impression: Erythema, congestion, friability and erosion in the
antrum compatible with gastritis (biopsy). Erythema and
friability in the duodenal bulb compatible with duodenitis.
Ulcers in the first part of the duodenum. Otherwise normal EGD
to third part of the duodenum.
Brief Hospital Course:
74 yo male with cardiomyopathy and h/o arrhythmia with ICD
presenting with ventricular tachycardia/ fibrillation s/p 6 ICD
firings.
.
# s/p VT with ICD firing- Patient has a history of ischemic vs
mixed cardiomyopathy. Patient presented with progressively
worsening heart failure over the past several weeks. During a
prep for colonoscopy the patient reported feeling increasingly
drowsy and weak with multiple episodes of loose stools.
Patient's ICD was reported to have fired several times in the
hours priror to admission. Patient was seen by the EP team who
increased his pacer settings to a rate of 80 and initially
treated with iv lidocaine and transitioned to oral mexilitine.
While no exact etiology was found to explain the patient's ICD
firing it was felt it may have been due to stress from high
output bowel preparation. Sotalol and Digoxin were stopped and
the patient was continued on amiodarone 200 mg daily and
mexilitine 150 mg every 8 hours.
.
# CHF- Patient has history of known systolic dysfunction with a
depressed EF. Echocardiogram performed during this admission
showed EF of 30% with regional wall motion abnormalities, right
ventricular failure and LV hypertrophy. Patient was
significantly volume overloaded at the time of admission and was
diuresed. Patient was evaluated for ongoing ischemia with a
persantine stress test. This showed cardiac chamber
enlargement and severe anteroapical and moderate inferoseptal
perfusion defects. Patient was unable to complete the study as
he became acutely aggitated and the study canceled. Patient was
later noticed to be hypotensive and fluid responsive raising
concern for over diuresis. Lasix was held and patient gradually
weaned back on to home antihypertensives. At the time of
transfer patient was on metoprolol 6.25 mg. Lasix was held and
should be restarted at 20 mg and gradually increased to home
dose of 40 mg. Lisinopril will also need to be restarted at 5
mg once BPs are stable.
.
# Guiac Positive Stools- Patient reports that he had positive
stool guaiac with PCP. [**Name10 (NameIs) **] denies melena or hematochezia. He
does have a history of diverticulitis s/p partial colectomy.
His hematocrit dropped during this admission to 26 from his
baseline around 30. He received 2 units of packed red blood
cells and his hematocrit bumped appropriately. His coumadin was
initially held in the setting of guaic positive stools. He
received an EGD and colonoscopy while inpatient which showed
gastritis and duodenitis as well as diverticulosis. Iron studies
were sent as well which showed him to be iron deficient with an
iron level of 8. He was repleted with Ferric Gluconate 125 mg IV
DAILY for severe iron deficiency. Patient was started on
pantoprazole 40 mg [**Hospital1 **]. H Pylori antibody and biopsy stain were
pending at the the time of transfer.
.
# Leukocytosis- White count was elevated at the time of
admission which was initially felt to reflect the ICD firing
that precipitated admission. His counts initially trended down,
but early in the hospital course spiked to 23 associated with an
acute change in mental status, though the patient was afebrile.
A full infectious work up was conducted including negative head,
chest, abdomen and pelvis cat scans, multiple negative blood and
urine cultures, and a negative WBC scan. C diff was negative on
several occasions. Patient was treated with vancomycin,
cefepime, and levofloxacin for a 10 day course for possible HCAP
(last day [**2162-10-19**]). Patient was also evaluated by the hematology
service. A blood smear, lead levels, SPEP/UPEP, and imaging were
all normal, and no bone marrow biopsy was preformed. A BCR-ABL
gene mutation was pending at the time of transfer. The
patient's white cell count was elevated to 18K at the time of
transfer. The exact etiology of his neutrophil predominant
leukocytosis is unknown, but can classified without exception as
non-infectious in etiology.
.
# Hypotension- The patient experienced several episodes of
hypotension which were all fluid responsive. We believe both of
these episodes were related to over-diuresis as well as
secondary to his blood pressure medications. At the time of
discharge he is on metoprolol tartrate 6.25mg twice daily. We
are holding the Lisinopril, Hydralazine, and Furosemide. We
recommend restarting the furosemide at 20mg daily with gradual
uptitration as indicated. The lisinopril and hydralazine can be
restarted as tolerated by his blood pressure.
.
# H/o Atrial fibrillation- The patient is on amiodarone and
metoprolol as noted above. He is anticoagulated with coumadin.
INR has been suptherapeutic and is 1.4 upon discharge. Coumadin
dose was increased from 2mg to 5mg daily on [**2162-10-26**].
.
# Diabetes- The patient has a reported recent history of
hypoglycemia and is thus not on any diabetes medications. He was
monitored via a insulin sliding scale.
.
# Chronic kidney disease- Baseline creatinine appears to be
~1.4-1.5 and is 1.3 upon discharge.
.
# H/o gout- Continued on allopurinol.
.
# Transitional issues
- pulm nodules 4mm on CT chest - needs f/u in 12 months
- BCR-ABL test was pending at the time of transfer
- H Pylori antibody and stain were pending at the time of
transfer
- patient will need lasix and lisinopril restarted as systolic
pressures tolerate.
Medications on Admission:
1. Sotalol 120mg po BID
2. Lisinopril 20mg po BID
3. Digoxin 0.125mg po qAM
4. Carvedilol 25mg po BID
5. Hydralazine 50mg po BID
6. Furosemide 40mg po qAM
7. Warfarin 2mg po daily
8. Aspirin 81mg po daily
9. Simvastatin 40mg po daily
10. Allopurinol 300mg po qAM
11. Colchicine 0.6mg po daily PRN gout flare
12. Omega 3 fatty acids
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
3. metoprolol tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2
times a day).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
6. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. omega-3 fatty acids Oral
9. allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
10. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day
as needed for gout.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 6560**] Care & Rehab Center - [**Location (un) 86**]
Discharge Diagnosis:
Ventricular tachycardia s/p ICD firing
Cardiomyopathy with systolic dysfunction
Hypertension
Atrial fibrillation
Chronic kidney disease
GI bleeding secondary to gastritis, duodenitis, and
diverticulosis
Leukocytosis of unclear etiology
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. [**Known lastname 41479**],
It was a pleasure caring for you. You were admitted after your
ICD fired. We are treating this with two new medications called
Amiodarone and Mexiletine.
.
You were also noted to have an elevated white blood cell count.
We treated you with antibiotics for a possible pneumonia and
performed numerous other blood tests and imaging, however we did
not find any other source of infection.
.
You were noted to have blood in your stool. We did an EGD
(camera down the throat) and colonoscopy (camera into the large
bowel) which revealed an ulcer, some irritation in your stomach
and small bowel, and diverticulosis. We are treating this with a
medication called pantoprazole.
.
You should weigh yourself every morning and call your doctor if
your weight goes up more than 3 lbs. You will need to have an
echo done at your appt with Dr. [**Last Name (STitle) **] (cardiology) on [**2162-11-19**].
.
We made the following changes to your medications:
- START Amiodarone 200mg daily
- START Mexiletine 150mg every 8 hours
- START Metoprolol tartrate 6.25mg twice daily
- START Pantoprazole 40mg twice daily
- STOP Digoxin, Sotalol, and Carvedilol
- HOLD Lisinopril, Hydralazine, and Furosemide until instructed
otherwise by your doctor
- INCREASE Warfarin from 2mg to 5mg daily
- DECREASE Simvastatin from 40mg to 10mg daily
- CONTINUE Aspirin 81mg daily
- CONTINUE Omega 3 fatty acids
- CONTINUE Allopurinol 300mg daily
- CONTINUE Colchicine 0.6mg daily prn gout
Followup Instructions:
Department: CARDIAC SERVICES
When: FRIDAY [**2162-11-19**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST
Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 11975**]
|
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icd9cm
|
[
[
[]
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icd9pcs
|
[
[
[]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,190
| 146,245
|
1964
|
Discharge summary
|
report
|
Admission Date: [**2194-5-8**] Discharge Date: [**2194-5-10**]
Date of Birth: [**2113-3-13**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Planned admission of aspirin desensitization.
Major Surgical or Invasive Procedure:
Right lower extremity angiogram and stent of anterior tibial
artery
History of Present Illness:
81 yo M being admitted to CCU for aspirin desensitization prior
to RLE angiogram scheduled for [**5-9**]. He has been having
worsening RLE pain with ambulation that is partially relieved by
rest. A CT angiogram was performed showing significant arterial
disease. Given his PAD and CAD, it is important for him to be on
aspirin, but he has been resistant to this. He was reportedly
told by his physicians in [**Country 532**] to never again take aspirin,
and this is for unclear reasons. Given his need for
intervention, as well as worsening CAD and PAD, he is electively
admitted to the CCU for aspirin desensitization.
.
On arrival to the floor, patient is feeling well and has no
complaints.
Past Medical History:
# PAD
# Chronic LLE DVT
# Chronic venous insufficiency
# S/P LCFV stenting
# CAD s/p LAD stenting
# Systolic and diastolic heart failure (EF 45-50%)
# HTN
# ICD for VF during stress test
# PAF (on dabigatran)
# Severe COPD
# SDH s/p craniotomy
# BPH
# Chronic LBP with lumbar DJD, s/p multiple injections
# OA
Social History:
Retired grocery store manager. Married, with two children.
Smoked for about a year in the [**2142**]. Drinks alcohol socially.
Family History:
Father - lung cancer
Brother - lung cancer
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission-
GEN: well-appearing male in no acute distress
HEENT: Moist mucus membranes, PERRL
NECK: supple, no JVD
CV: RRR no murmurs, rubs, gallops
LUNGS: clear to auscultation bilaterally
ABD: soft, non tender, multiple palpable masses throught the
upper abdomen, non distended
EXT: no edema, varicose veins present
SKIN: warm and dry
Discharge-
GEN: well-appearing male in no acute distress
HEENT: Moist mucus membranes, PERRL
NECK: supple, no JVD
CV: RRR no murmurs, rubs, gallops
LUNGS: clear to auscultation bilaterally
ABD: soft, non tender, multiple palpable masses throught the
upper abdomen, non distended
EXT: no edema, varicose veins present. Warm feet
SKIN: warm and dry
PULSE: good pedal pulses
Pertinent Results:
Admission-
[**2194-5-8**] 01:04PM BLOOD WBC-10.2 RBC-4.67 Hgb-14.4 Hct-44.6
MCV-96 MCH-30.9 MCHC-32.4# RDW-13.2 Plt Ct-187
[**2194-5-8**] 01:04PM BLOOD Neuts-86.3* Lymphs-9.2* Monos-3.2 Eos-0.8
Baso-0.5
[**2194-5-8**] 06:33PM BLOOD PT-10.8 PTT-23.4* INR(PT)-1.0
[**2194-5-8**] 01:04PM BLOOD Glucose-179* UreaN-16 Creat-1.1 Na-139
K-4.7 Cl-102 HCO3-29 AnGap-13
[**2194-5-8**] 01:04PM BLOOD Calcium-8.6 Phos-2.4*# Mg-2.1
Discharge-
[**2194-5-10**] 06:54AM BLOOD WBC-7.7 RBC-4.48* Hgb-13.7* Hct-41.7
MCV-93 MCH-30.5 MCHC-32.8 RDW-13.0 Plt Ct-195
[**2194-5-10**] 06:54AM BLOOD Glucose-103* UreaN-12 Creat-0.9 Na-142
K-4.2 Cl-104 HCO3-31 AnGap-11
[**2194-5-10**] 06:54AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.0
Brief Hospital Course:
81 yo M with CAD and PAD, admitted electively to the CCU for an
aspirin desensitization prior to RLE angiogram.
# PAD
The patient has been having worsening right leg pain which is
likely multifactorial. He underwent LE angiogram with stent
placement on [**2194-5-9**]. He is to continue on his pradaxa and
begin taking plavix (for 1 month) and aspirin (indefinitely).
He tolerated the procedure well other than some RLE discomfort
prior to discharge. His exam was wnl.
# Aspirin desensitization:
Pt underwent suggessful aspirin desensitization as per protocol
without reaction. He is to continue aspirin daily.
# CAD
Pt is was continued on his home lisinopril and simvastatin (dose
adjusted). Following his desensitization as above, the patient
is to begin taking aspirin daily.
Medications on Admission:
ALBUTEROL SULFATE - (Prescribed by Other Provider) - 90 mcg HFA
Aerosol Inhaler - 1-2 puffs INH Q 6 hours as needed for SOB,
wheezing
ALPRAZOLAM - 0.25 mg Tablet - 1 Tablet(s) by mouth daily
AMITRIPTYLINE - 25 mg Tablet - 1 Tablet(s) by mouth daily at
bedtime
DABIGATRAN ETEXILATE [PRADAXA] - 150 mg Capsule - 1 Capsule(s)
by mouth twice daily
FLUTICASONE-SALMETEROL [ADVAIR HFA] - (Prescribed by Other
Provider: [**Name Initial (NameIs) **]) - 230 mcg-21 mcg/Actuation HFA Aerosol
Inhaler - 2 puffs inhaled twice daily
FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth once a day as
needed for as needed for edema
GABAPENTIN - 300 mg Capsule - [**1-20**] Capsule(s) by mouth three
times daily
LISINOPRIL - (On Hold from [**2194-3-25**] to unknown for pt reports
low BP at home, lisinopril on hold due to this, he will discuss
with cardiology next month) - 2.5 mg Tablet - 1 Tablet(s) by
mouth once a day
MECLIZINE - 12.5 mg Tablet - 1 Tablet(s) by mouth daily
MONTELUKAST [SINGULAIR] - 10 mg Tablet - 1 Tablet(s) by mouth
once a day
NITROGLYCERIN [NITROSTAT] - 0.3 mg Tablet, Sublingual - 1
Tablet(s) sublingually for chest pain, repeat x2 with 5 minute
interval if needed
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 (One)
Capsule(s) by mouth once a day
OXYCODONE - 5 mg Tablet - 1-1.5 Tablet(s) by mouth up to four
times daily as needed for pain ** may cause sedation; 28 day
supply
PREDNISONE - 10 mg Tablet - 1 Tablet(s) by mouth once a day
SIMVASTATIN - 80 mg Tablet - 1 Tablet(s) by mouth daily at
bedtime
TRAZODONE - 50 mg Tablet - 1 Tablet(s) by mouth once a day
B COMPLEX VITAMINS - Capsule - 1 Capsule(s) by mouth daily
DOCUSATE SODIUM - 100 mg Capsule - 3 Capsule(s) by mouth daily
MAGNESIUM OXIDE - 420 mg Tablet - 1 Tablet(s) by mouth daily
SENNOSIDES - 8.6 mg Tablet - [**1-20**] Tablet(s) by mouth daily as
needed for constipation
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for
sob/wheezing.
2. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
3. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
5. fluticasone-salmeterol 230-21 mcg/actuation HFA Aerosol
Inhaler Sig: Two (2) puffs Inhalation twice a day.
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. gabapentin 300 mg Capsule Sig: [**1-20**] Capsules PO TID (3 times a
day).
8. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual once a day as needed for chest pain.
12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
13. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
14. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day.
15. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
16. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
17. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
18. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
19. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
20. magnesium oxide 420 mg Tablet Sig: One (1) Tablet PO once a
day.
21. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*5*
22. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Peripheral Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 10816**],
You were admitted to the hospital to have an angiogram and stent
performed on your right leg. You were also in the Cardiac ICU so
that we could monitor you while you start aspirin. Your leg pain
will hopefully improve over time, but you should take some pain
medications to treat it until it improves.
Medication Changes:
START aspirin 325mg daily
START clopidogrel 75mg daily for one month
START oxycodone 5mg every four hours as needed for pain
Followup Instructions:
Department: [**Hospital3 249**]
When: MONDAY [**2194-5-19**] at 2:20 PM
With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the [**Company 191**] POST [**Hospital 894**] CLINIC Phone:
[**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2194-5-21**] at 11:40 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"428.42",
"440.21",
"V15.82",
"V16.1",
"427.31",
"401.9",
"V45.02",
"428.0",
"414.01",
"V12.51",
"496",
"V45.82",
"459.81",
"600.00",
"721.3",
"V58.61",
"715.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.90",
"88.48",
"00.40",
"88.42",
"39.50",
"00.46"
] |
icd9pcs
|
[
[
[]
]
] |
7850, 7925
|
3264, 4052
|
349, 418
|
7994, 7994
|
2538, 3241
|
8649, 9324
|
1634, 1793
|
5957, 7827
|
7946, 7973
|
4078, 5934
|
8144, 8480
|
1808, 2519
|
8500, 8626
|
264, 311
|
446, 1141
|
8009, 8120
|
1163, 1474
|
1490, 1618
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,860
| 195,382
|
48073
|
Discharge summary
|
report
|
Admission Date: [**2141-6-24**] Discharge Date: [**2141-7-19**]
Date of Birth: [**2070-12-7**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Cisplatin
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
thoracentesis
diagnostic bronchoscopy
interventional bronchoscopy
History of Present Illness:
70 yo F with SCLC, DMII/HTN/Hyperlipidemia, afib on coumadin,
ESRD 2' previous cisplatin therapy, p/w with SOB. She started
having SOB on exertion gradually over past week. She came to get
her Neulasta today and was found to be SOB and so referred to ED
for evaluation. Of note, she also had some chest discomfort with
SOB during HD today.
She has a has large pleural effusion which was planned to be
tapped as outpt yesterday but was deferred [**2-18**] high INR. She
denies any fever/chills, cough, palpitations. She occassionaly
has some phlegm. She uses O2 at home at 2L for COPD (baseline O2
sat 90-95) and this has been stable for her.
.
ED:
- CXR showed effusion/mass
- CTA Chest: no PE, mod R pleural effusion, narrowing of SVC by
mass
- IP was made aware who recommended admission for tapping by
them
Past Medical History:
PMH:
1. Small cell lung cancer T2N2MO(Stage IIIA), diagnosed [**2138**],
s/p surgery, chemo w/ cisplatin & etoposide, & radiation.
2. Insulin dependent DM
3. CRI (Cr ~8), HD on T, Th, Sat
4. HTN
5. Asthma
6. COPD ([**6-22**] FVC 2.2 and FEV1 1.43; FEV1/FVC 91% predicted)
HOME O2 2L NC
7. h/o rheumatic fever
8. Cardiomegaly ([**5-22**] pMibi LVEF 57%)
9. Chronic low back pain
10. Obesity
11. Ureteroscopy and shockwave lithotripsy x3
[**45**]. s/p Cesarean section
13. h/o Hysterectomy
14. Sleep apnea - does not use prescribed CPAP
Social History:
The patient lives in [**Location 1468**]. Widowed, lives with son. She works
in the mailroom at [**University/College 4700**]. She has a history of
smoking one pack of cigarettes daily for approximately 40 years
before quitting in [**2125**]. She drinks alcohol occasionally. She
denies illicit drug use.
Family History:
The patient's aunt has a history of lung cancer, and her cousin
has a history of breast cancer.
Physical Exam:
Temp: 98.9 BP: 112/86 HR: 90, RR: 21 O2 Sat: 97% 2L NC
GEN: no acute distress, resting comfortably.
HEENT: EOMI, Oropharynx clear, no scleral icterus, mild
submandibular fullness
CV: Regular rate, distant heart sounds, no murmurs, rubs or
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, diminshes
breath sounds on right
Abd: Soft, non tender, non distended
Ext: moderate non-pitting upper ext edema
Pertinent Results:
[**2141-6-24**] 01:20PM BLOOD WBC-3.1*# RBC-4.54 Hgb-11.9* Hct-40.2
MCV-89 MCH-26.1* MCHC-29.6* RDW-20.3* Plt Ct-241
[**2141-6-25**] 06:40AM BLOOD WBC-39.4*# RBC-4.06* Hgb-10.4* Hct-37.1
MCV-92 MCH-25.8* MCHC-28.1* RDW-19.3* Plt Ct-251
[**2141-6-24**] 01:20PM BLOOD Neuts-80.8* Lymphs-14.1* Monos-1.6*
Eos-2.1 Baso-1.4
[**2141-6-24**] 01:20PM BLOOD PT-20.3* PTT-34.4 INR(PT)-1.9*
[**2141-6-25**] 06:40AM BLOOD PT-16.7* PTT-31.9 INR(PT)-1.5*
[**2141-6-25**] 06:40AM BLOOD Glucose-154* UreaN-37* Creat-7.3*# Na-141
K-4.2 Cl-94* HCO3-30 AnGap-21*
[**2141-6-24**] 01:20PM BLOOD CK(CPK)-97
[**2141-6-24**] 09:57PM BLOOD CK(CPK)-73
[**2141-6-25**] 06:40AM BLOOD CK(CPK)-53
[**2141-6-24**] 01:20PM BLOOD CK-MB-3 cTropnT-0.07*
[**2141-6-24**] 09:57PM BLOOD CK-MB-3 cTropnT-0.07*
[**2141-6-25**] 06:40AM BLOOD CK-MB-3 cTropnT-0.06*
[**2141-6-25**] 06:40AM BLOOD Calcium-8.1* Phos-5.4* Mg-2.1
.
CT OF THE CHEST WITH IV CONTRAST: Small amount of pericardial
fluid is again seen. Otherwise, pericardium is unremarkable.
There is no evidence of aortic dissection or pulmonary embolism.
Again demonstrated is a right upper lobe mass and associated
consolidation, encasing the right mainstem bronchus, right main
pulmonary artery and right-sided pulmonary veins. There is an
associated moderate- sized pleural effusion, with fluid tracking
medially and into the fissure on occasion. The overall findings
are largely unchanged from [**2141-5-5**]. Mild centrilobular
emphysema is present. The left lung is grossly clear without
pleural effusion. The SVC appears to be mildly narrowed, with
prominent collaterals, similar in appearance to prior study.
Limited views of the upper abdomen reveal a rounded hypodensity
within the mid pole of the left kidney, incompletely
characterized.
OSSEOUS STRUCTURES: There is a stable compression fracture of
the upper thoracic spine. No suspicious lytic or sclerotic
lesions are identified. There is generalized edema within the
subcutaneous tissues, compatible with anasarca. There is a
slightly sclerotic right third rib, similar in appearance to
recent PET-CT.
IMPRESSION:
1. No evidence of aortic dissection or pulmonary embolism.
2. Stable right hilar and upper lobe consolidation/mass.
Moderate-sized pleural effusion on the right, unchanged. Tiny
amount of pericardial fluid. Mildly narrowed SVC, with prominent
collaterals.
.
U/S: No evidence of deep venous thrombosis in the left upper
extremity.
.
CT CHEST WITH CONTRAST: A tunneled dual chamber large bore
dialysis catheter enters the right internal jugular vein and
terminates in the right atrium. Immediately superior to the
confluence of the left brachiocephalic vein in the right
brachiocephalic vein is a segment of marked narrowing/stenosis
of the right brachiocephalic vein at which point there is no
contrast about the catheter and redirection of contrast via
multiple chest wall collaterals including collateralization of
surface hepatic vessels via intramammary veins onsistent with
hemodynamically significant alternation of normal venous flow.
Narrowing of the right subclavian vein at the thoracic outlet is
likely not as contributory. Although there is a significant
conglomerate of tumor, hilar adenopathy, and consolidated lung
that extends from the right hilum into the right apex
obliterating the right upper, markedly compressing the right
middle, and narrowing the right lower lobe bronchi (all of which
unchanged in the short interval), the SVC distends normally and
the stenosis described seems confined to the distal right
brachiocephalic vein. The heart and great vessels of the
mediastinum are otherwise unchanged. The small right effusion
is changed in distribution but not in size and there is no
pericardial effusion. The left lung is clear aside from trace
atelectasis. No suspicious lesions are identified in the spine.
IMPRESSION: Suspected stenosis of the right brachiocephalic vein
immediately superior to the left brachiocephalic confluence, due
to the indwelling catheter, less likely tumor compression as the
SVC itself distends normally. Appearance of the right upper lobe
mass, adenopathy, and consolidation is unchanged.
.
IR guided venogram:
1) venograms demonstrated patent bilateral internal jugular and
brachiocephalic veins.
2) Small filling defects in the superior vena cava (catheter-
related
clot/fibrin sheath). No evidence of SVC stenosis.
3) Successful exchange for a new tunneled 23- cm cuff- to- tip
14 French
double- lumen dialysis catheter, with the tip positioned in the
right atrium. The line is ready for use.
.
CXR [**7-4**]: There is no change in the known right upper lobe
consolidation and atelectasis. No change compared to the prior
studies. There is interval increase in the right pleural
effusion, current to moderate. The left lung is unremarkable
within the limitation of the chest radiograph. The double-lumen
catheter inserted through right subclavian approach terminates
in mid distal SVC. There is no pneumothorax.
.
PORTABLE SUPINE ABDOMEN, ONE VIEW: Retained contrast is seen
throughout the entire colon, which appears unremarkable. There
are no dilated loops of bowel. There is no supine evidence for
free intraperitoneal air or
pneumatosis.
Brief Hospital Course:
# Small cell lung cancer T2N2MO(Stage IIIA), diagnosed [**2138**], s/p
surgery, chemo w/ cisplatin & etoposide, & radiation. Most
recent treatment with VP etoposide cycle 14 [**2141-6-23**] and Neulasta
[**2141-6-24**].
# Upper extremity edema: The patient was admitted for upper
extremity and facial swelling concerning for SVC syndrome. CT
venogram was initially concerning for extrensic compression of
the SVC by her tumor but thrombus around the dialysis catheter
could not be ruled. Rad/onc advised against any repeat
radiation. On further review, it was thought that the area of
narrowing was closer to the brachiocephalic rather than the SVC
itself. To evaluate her blood vessels and the dialysis catheter,
IR performed a venogram which showed no significant
abnormalities, no stensosis, no thrombus and no extrensic
compression. It is unclear why she had upper ext and facial
swelling.
# Shortness of breath: On admission, her shortness of breath was
at baseline. CTA was neg for PE. A thoracentesis was performed
which removed 1.5L. Over the course of her hospitalization, she
became more wheezy and short of breath. She was started on
Vancomycin and Levofloxacin for hospital acquired post
obstructive pneumonia. Review of her CT indicated that she had
severe right upper lobe and lower lobe collapse secondary to
bronchus compression. Intervential pulmonary was consulted. They
took the patient for stenting of her right main stem bronchus
and a second thoracentesis. After which she was intubated for a
few hours, extubated and transfered from the SICU to the [**Hospital Unit Name 153**].
She developed respiratory failure and required reintubation in
the [**Hospital Unit Name 153**]. Due to her lung cancer and bronchus obstruction, the
most likely etiology is post-obstructive PNA. She was treated
with ABX.
# Bowel ischemia: During her stay in the [**Hospital Unit Name 153**], she developed
bowel ischemia and had a substantial metabolic acidosis with a
high lactate. She had a severe systemic inflammatory response.
Surgery was consulted; however, surgery and the family agreed
that she was not a good surgical canidate. She had but she was
eventually made CMO due to her poor overall prognosis.
The patient expired on [**2141-7-19**].
Medications on Admission:
- ALBUTEROL - 90 mcg Aerosol - 2 puffs inhaled Every 4-6 hours
- ALLOPURINOL - 100 mg QD
- B-COMPLEX-VITAMIN C-FOLIC ACID [RENAL CAPS]
- FENTANYL - 100 mcg/hour Patch 72 hr
- FLUTICASONE-SALMETEROL [ADVAIR DISKUS] 500 mcg-50 mcg/Dose 1
[**Hospital1 **]
- FUROSEMIDE [LASIX] 40 mg once a day on dailysis days
- HYDROMORPHONE [DILAUDID] 2mg Q4h:prn
- PANTOPRAZOLE [PROTONIX] - 40 mg
- RISPERIDONE [RISPERDAL] - 0.5 mg HS:PRN
- SEVELAMER HCL [RENAGEL] 800 mg 1 tab TID
- TIOTROPIUM BROMIDE 18 mcg 1 inh QD
- TRAVOPROST (BENZALKONIUM)
- TRAZODONE - 25-50 mg HS PRN
- WARFARIN [COUMADIN] 1 mg Tab [**1-18**] Tablet(s) QD
- INSULIN NPH & REGULAR HUMAN [HUMULIN 70/30] - 100 unit/mL
(70-30)
Suspension - TAke as directed twice a day 15 UNITS IN AM, 10
UNITS IN PM
Discharge Medications:
Patient expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: SIRS, metabolic acidosis, hypercarbic repsiratory
distress, ESRD on HD, suspected postobstructive pneumonia,
suspected C. difficile infection, cecal dilatation with
pseudoobstruction
Secondary: Afib with RVR, COPD, DMt2, gout
Discharge Condition:
expired
Discharge Instructions:
The patient expired.
Followup Instructions:
none
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2141-7-20**]
|
[
"250.00",
"518.0",
"327.23",
"333.2",
"038.9",
"E935.2",
"519.19",
"276.2",
"585.6",
"995.92",
"403.91",
"557.0",
"511.9",
"338.3",
"518.81",
"780.1",
"V58.67",
"784.2",
"V58.61",
"486",
"162.8",
"560.89",
"496",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"96.04",
"96.71",
"38.93",
"33.23",
"34.91",
"38.95",
"96.05",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
10999, 11008
|
7884, 10150
|
307, 374
|
11288, 11298
|
2658, 7861
|
11367, 11539
|
2112, 2209
|
10958, 10976
|
11029, 11267
|
10176, 10935
|
11322, 11344
|
2224, 2639
|
248, 269
|
402, 1214
|
1236, 1773
|
1789, 2096
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,812
| 127,854
|
53370
|
Discharge summary
|
report
|
Admission Date: [**2154-2-6**] Discharge Date: [**2154-2-22**]
Date of Birth: [**2092-1-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Transfer for liver transplant eval
Major Surgical or Invasive Procedure:
Intubation
Thoracentesis
Chest tube removal
Dobhoff placement x2
History of Present Illness:
This is a 62 year-old female with a history of breast cancer,
hemochromatosis, hepatic encephalopathy, s/p TIPS [**2154-1-13**],
hepatic hydrothorax who is transferred for transplant
evaluation.
The patient was recently discharged on [**1-16**] after a prolonged
hospitalization for ascites and pleural effusions. The patient
underwent TIPS proceudre on [**1-13**] and was discharged home.
However, she became very confused secondary to hepatic
encephalopathy and admitted on [**2154-1-19**]. The patient was found
unresponsive for 8 minutes and transferred to the MICU (no
medications and was not intubated). The patient hepatic
encephalopathy was improving, but she had worsening hypoxia
secondary to pleural effusions. She eventually required
intubation and right chest tube was placed. She had good
drainage from her tube and also diuresed via lasix gtt. She was
able to be extubated on [**1-30**]. Her chest tube continues to drain
500cc per day. Additionally, the [**Hospital 228**] hospital course was
complicated by c. diff colitis for which she was treated with a
16 day course of po vancomycin. Additionally, her blood
cultures grew VRE and was treated with linezolid that was
changed to daptomycin that was d/c on [**1-28**]. The patient also
had several episodes of atrial tachycardia that was initially
treated with propanolol, but was stopped secondary to
hypotension. The patient was also found to have an left
axillary DVT and has been on heparin gtt since [**1-31**]. The
patient was transferred for further workup of the hydrothorax
and liver transplant eval.
On arrival the paient had no complaints and doing well. She
denied abdominal pain, fevers, chills, nausea, vomiting, bloody
stools, SOB or other complaints.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
melena, hematochezia, chest pain, shortness of breath,
orthopnea, PND, lower extremity oedema, cough, urinary
frequency, urgency, dysuria, lightheadedness, gait unsteadiness,
focal weakness, vision changes, headache, rash or skin changes.
Past Medical History:
1) Breast Cancer Stage I (Dx [**2148**]) s/p lumpectomy & radiation.
Currently on tamoxifen
2) Hemochromatosis heterozygous type 2A, A/H63D (liver biopsy
[**2153-11-6**])
3) HTN
4) [**Doctor Last Name 15532**] Esophagus
5) Prior admission on [**2154-1-16**] with pleural effusions s/p
thoracentesis (~5L) and paracentesis x2 (5L and 3.5L)
Social History:
Pt is a teacher and widowed for last couple of years. Denied
EtOH, smoking or other drug abuse
Family History:
No family history of hemochromatosis or liver disease. No other
family history
Physical Exam:
Vitals: T 97.6 BP 98/58 P 74 RR 20 O2sat 99% 2LNC
GEN: thin woman, mildly tachypneic, NAD
HEENT: +scleral icterus
CHEST: diminished breath sounds b/l bases, crackles b/l bases
L>R; R chest tube in place to suction, dressing c/d/i
CV: RRR, S1S2, no m/r/g
ABD: soft, mildly distended, nt, +bs
EXT: no edema, +dp pulses
NEURO: AAOx3, strength intact, no asterixis
Pertinent Results:
Admission:
[**2154-2-6**] 07:32PM BLOOD WBC-11.4* RBC-2.89* Hgb-8.8* Hct-26.1*
MCV-90 MCH-30.4 MCHC-33.7 RDW-23.1* Plt Ct-227
[**2154-2-6**] 07:32PM BLOOD Neuts-73.2* Lymphs-15.3* Monos-3.6
Eos-7.5* Baso-0.4
[**2154-2-6**] 07:32PM BLOOD PT-13.9* PTT-55.1* INR(PT)-1.2*
[**2154-2-6**] 07:32PM BLOOD Glucose-95 UreaN-31* Creat-0.8 Na-133
K-4.0 Cl-88* HCO3-38* AnGap-11
[**2154-2-6**] 07:32PM BLOOD ALT-11 AST-48* LD(LDH)-160 AlkPhos-156*
TotBili-3.2*
[**2154-2-7**] 04:35AM BLOOD CK-MB-2 cTropnT-0.02*
[**2154-2-7**] 02:18PM BLOOD CK-MB-NotDone cTropnT-0.01
[**2154-2-7**] 10:40PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2154-2-6**] 07:32PM BLOOD Albumin-4.5 Calcium-10.1 Phos-4.2 Mg-2.4
Iron-76
[**2154-2-6**] 07:32PM BLOOD calTIBC-79* Ferritn-1239* TRF-61*
[**2154-2-7**] 10:43AM BLOOD Cortsol-8.6
[**2154-2-7**] 06:51PM BLOOD Cortsol-13.9
[**2154-2-7**] 07:31PM BLOOD Cortsol-14.8
[**2154-2-7**] 04:38AM BLOOD Type-ART pO2-253* pCO2-54* pH-7.40
calTCO2-35* Base XS-7
[**2154-2-7**] 04:38AM BLOOD Lactate-4.4*
OTHER PERTINENT LABS:
[**2154-2-19**] 05:23AM BLOOD VitB12-611 Folate-11.3
[**2154-2-10**] 04:43AM BLOOD TSH-1.4
[**2154-2-10**] 04:43AM BLOOD Free T4-0.67*
[**2154-2-11**] 04:30AM BLOOD AFP-8.0
MICRO:
[**2154-2-6**] BCx: negative
[**2154-2-6**] UCx: yeast
[**2154-2-7**] Sputum Cx: rare respiratory flora
[**2154-2-7**] Cdiff: negative
[**2154-2-8**] Cath tip Cx: negative
[**2154-2-8**] BCx: negative
[**2154-2-8**] Pleural fluid Cx: negative
[**2154-2-9**] BCx: negative
[**2154-2-11**] Cdiff: negative
[**2154-2-15**] Cdiff: negative
[**2154-2-15**] Pleural fluid Cx: negative
STUDIES:
CXR [**2-6**]
FINDINGS: Bilateral chest tubes, no evidence of right-sided
pleural effusion. Moderate left-sided pleural effusion with
air-fluid level. Moderate cardiomegaly with increased
interstitial markings. Right PICC line in standard position.
Right basal areas of atelectasis. Obviously atelectatic increase
in lung density around the left hilus. Moderate bilateral apical
thickening.
Bronchial washings [**2-7**]
Atypical epithelial cells in a background of pulmonary
macrophages and bronchial cells.
TTE [**2-7**]
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic (EF
70-80%). 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 leaflets are mildly thickened. There is no mitral
valve prolapse. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
RUQ [**2-8**]
1. Patent and appropriate TIPS and portal veins.
2. Small amount of sludge within the gallbladder with some tiny
stones.
Pleural fluid cytology [**2-8**]
NEGATIVE FOR MALIGNANT CELLS.
Rare mesothelial cells.
Lymphocytes and monocytes (see note).
MRI abd/pelvis [**2-10**]
1. Evidence of iron deposition in the liver and pancreas,
consistent with
primary chemochromatosis. No evidence of iron deposition in the
heart on
limited images presented. No imaging stigmata of cirrhosis.
2. No focal liver lesion.
3. Trace ascites.
4. Patchy increased signal at the lung bases, trace right
pleural effusion.
LUE Doppler U/S [**2-14**]
No deep vein thrombosis seen in the left arm.
Pleural fluid cytology [**2-15**]
NEGATIVE FOR MALIGNANT CELLS.
Reactive mesothelial cells and macrophages.
CXR [**2-16**]
There is blunting of both CP angles, but there is no large
effusion
as was present previously. Right-sided PICC line tip is in the
right atrium. Feeding tube tip is off the film. There are areas
of opacity in the left lower lung and right mid lung. The left
lower lung opacity has a rounded configuration and measures 2.6
cm. This has not been visualized on the prior film, some of
which could have been due to technique, volume loss, infiltrate,
and overlying effusion. The mass lesion in this region cannot be
totally excluded and if cross-sectional imaging has been
obtained at an outside institution would be helpful to ensure
that no lesion is present, this could just be a loculated area
of fluid. The heart is upper limits normal in size.
IMPRESSION: Patchy areas of opacity in the left mid lung and the
right mid
lung. It is unclear if these represent focal infiltrates.
Recommend
followup.
Repeat CXR [**2-16**]
Compared to the film from earlier the same day there is a small
right
pneumothorax. This was present on the earlier film but was not
commented
upon. There is volume loss in both lower lungs and a more
confluent
appearance to the opacity previously mentioned in the left mid
lung. There
continues to be hazy right mid lung alveolar infiltrate.
CXR [**2-17**]
There is a small right pneumothorax, unchanged compared with
[**2154-2-16**].
Otherwise no significant change is detected. Proximal left
humeral fracture again noted.
CXR [**2-20**]
1. Increased right basilar opacity likely represents worsening
pleural
effusion, worsening atelectasis or consolidation in the correct
clinical
setting.
2. Increased left basilar and lingula opacities likely reprsent
atelectases. However, pneumonia can't be excluded in the correct
clinical setting.
DISCHARGE LABS:
[**2154-2-21**]
WBC 24.5 HCT 23.6 Plt 183
Na 131 K 4.2 Cl 95 HCO3 32 BUN 30 Cr 0.7 Glc 101
Ca 7.9 Mg 1.8 Ph 3.2
AP 166 Tbili 1.1 Alb 2.3
PT 12.6 PTT 36.7 INR 1.1
Brief Hospital Course:
Ms. [**Known lastname 174**] is a 62 F with history of breast cancer s/p radiation
and chemotherapy, hemochromatosis, hepatic encephalopathy, s/p
TIPS [**2154-1-13**], hepatic hydrothorax who was transferred from an
OSH for transplant evaluation. Had episode of hypoxia and
hypotension in MICU, requiring intubation and pressors. Now
extubated and stable off pressors. Currently on Vanc/Zosyn for
HAP.
# RESPIRATORY FAILURE: On admission the patient's respiratory
status was stable with O2 sats >95% on 2L NC. She had a left
pleural effusion and right sided effusion that was being drained
by a chest tube secondary to sympathetic effusion from ascites.
The patient went into acute respiratory distress on the morning
of [**2-7**] secondary to hypoxia. She was initially placed on a NRB
without resolution and became more hypoxic to the 60-70 and
tachypneic. She was also hypotensive and started on levophed
and given IVF. She was urgently intubated for hypoxemic
respiratory failure. The patient was initially treated broadly
with vanco/cefepime and then changed to
linezolid/cefepime/flagyl given her prior history of VRE and C.
diff. Her CXR did not show evidence of pneumothorax. The
patient underwent bronch on [**2-7**] that showed small airways, but
no evidence of infection or aspiration of foreign body. The
patient had been maintained on a heparin gtt for axillary DVT
prior to the event making PE less likely. The patient
respiratory status improved and was able to be extubated on [**2-8**].
Likely multifactorial in setting of hydrothorax, secretions
placing her at risk for mucous plugging, pre-existing axillary
DVT leading to PE, re-expansion edema, possibly hepatopulmonary
syndrome with orthodeoxia, aspiration etc. Given rapid
improvement however most likely aspiration event and/or
plugging.
On the floor, the patient maintained a stable respiratory
status. She had a L thoracentesis performed on [**2-15**], which
drained 1.5L. Chest tube was pulled on [**2-16**] and there has been
no reaccumulation of fluid. The patient is currently satting 96%
on RA. Bronchial washings were negative for malignant cells. She
is being treated with Vanc/Zosyn/Levaquin for HAP - 14 day
course to end [**2154-3-1**].
# SHOCK: The patient became hypotensive after her acute
respiratory failure requiring initiation of levophed,
vasopressin and neosynephrine. She was also covered with broad
spectrum antibiotics including linezolid given her history of
VRE, flagyl given her history of c. diff and cefepime. Her
initial UA was positive, but cultures grew yeast likely
colonization. Her C. diff was negative. The patient had an
elevated WBC of 27 after her respiratory failure that resolved
the following day. The patient had a cortstim and did not
respond appropriately. She was started on stress dose sterodis.
An ECHO was performed and showed hyperdynamic without clear
constriction from infiltration. She was able to be weaned off
all pressors by [**2-8**] at midnight. She finished a 7 day course of
Linezolid, Cefepime, and Flagyl. She was transitioned from
Hydrcortisone to oral Prednisone and started on a taper. She has
maintained SBP>95 and has not had any lightheadedness, SOB, or
CP.
#. Anemia: Pt with HCT 26 on admission in the setting of
hypotension and shock - was transfused 3 units pRBCs in the ICU.
HCT increased to the mid30s during the hospitalization - likely
hemoconcentrated, as she was being aggressively diuresed. HCT
decreased as diuresis has been titrated down, currently 23.6,
near baseline ~25. No e/o hemolysis. Pt has been asymptomatic.
Had guaiac positive [**Known lastname **] stool x2. EGD [**11-12**] with esophagitis,
colonoscopy [**12-11**] with e/o diverticula in sigmoid. Vitamin B12
and folate WNL.
- continue to monitor HCT
# Leukocytosis: Pt with WBC up to 27 early in admission, likely
[**2-5**] to stress dose steroids in the ICU. Resolved to 7, but the
started to rise slowly. Stable at ~18 for several days,
increased WBC to 28.7, now decreasing to 24.5 on discharge. Pt
on Vanc/Zosyn/Levaquin for HAP. Pt has been afebrile and has
remained hemodynamically stable. Continues to have loose stool,
but Cdiff negative x5 since last treatment at OSH in [**1-13**];
loose stool correlates with tube feeding, added bananas to diet
to help bulk stool. Attempted to obtain induced sputum, but was
not able to retrieve sample. Pt has been on steroids for adrenal
insufficiency, which could also be influencing the increased WBC
count - currently on Hydrocortisone. Pt had repeat UA/UCx and
BCx sent prior to discharge. UA negative. Repeat CXR with
?infiltrate vs atelectasis, but pt is already on
Vanc/zosyn/Levaquin for HAP, end [**2154-3-1**]. Pt had video swallow
eval to r/o aspiration - no overt aspiration, able to tolerate
nectar thickened liquids and regular diet.
# Hemochromatosis: Pt with MELD score of 6. She was diagnosed
with hemochromatosis in [**11-12**] and has been stable. However, her
course has recently been complicated by recurrent ascites,
pleural effusions and hepatic encephalopathy following TIPS
procedure. She has started her liver transplant eval. Currently
no evidence of encephalopathy or asterixis. Pt required blood
transfusions for oncotic pressure support in the ICU and
therefore receiving futher iron load. RUQ was performed that
showed patent TIPS.
- Please start Ciprofloxacin 250mg PO daily (or 500mg PO daily
if she is on continuous tube feeds) for SBP prophylaxis after
she finishes the course of Vanc/Zosyn/Levquin
#. Axially DVT: Pt with axillary DVT at OSH. She was continued
on a heparin gtt and transitioned to Lovenox. Repeat U/S showed
resolution of clot. She is on Heparin SC BID for prophylaxis
(TID dosing resulted in increased PTT).
# FEN: nectar thick liquids, regular solid, low Na diet, TF.
Medications on Admission:
Omeprazole 20mg dailu
Lidocaine/Maalox
Albuterol neb
Ipratropium neb
Losderm patch
docusate 100mg [**Hospital1 **]
Heparin gtt 1400U/hr
Discharge Medications:
1. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg
Intravenous every twelve (12) hours for 7 days.
2. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig:
4.5 g Intravenous Q8H (every 8 hours) for 7 days.
3. 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.
4. Pantoprazole 40 mg IV Q24H
5. Ondansetron 4 mg IV Q8H:PRN nausea
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q24 (): 12 hours on,
12 hours off.
7. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
8. Tamoxifen 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Spironolactone 100 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
13. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
14. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale Injection ASDIR (AS DIRECTED).
15. Promethazine 6.25 mg IV Q6H:PRN nausea
16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for itching.
17. Hydrocortisone 5 mg Tablet Sig: Two (2) Tablet PO QAM (once
a day (in the morning)).
18. Hydrocortisone 5 mg Tablet Sig: One (1) Tablet PO QPM (once
a day (in the evening)).
19. Levofloxacin in D5W 500 mg/100 mL Piggyback Sig: One (1)
Intravenous Q24H (every 24 hours): end [**2154-3-1**].
20. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection [**Hospital1 **] (2 times a day).
21. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Primary Diagnosis:
Hepatic hydrothorax
Pneumonia
Adrenal insufficiency
Anemia
Secondary Diagnosis:
Hemochromatosis
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 174**],
You were admitted to the hospital with fluid in your lungs. You
were intubated and in the process, one of your vocal cords was
paralyzed. You can follow up with ENT for further evaluation of
your vocal cord. You had fluid removed from your left lung, and
the chest tube that was in place on the right has been removed.
You are being treated with intravenous antibiotics for a
pneumonia - you will need to continue these medications for 7
more days.
The rest of your liver transplant evaluation can be completed as
an outpatient. You still need to have a cardiac MRI and
pulmonary function tests.
Followup Instructions:
MD: [**First Name5 (NamePattern1) 449**] [**Last Name (NamePattern1) 109777**]
Specialty: Otolaryngology/ ENT
Date/ Time: Tuesday, [**2154-3-12**]:30am
Location: 2 [**Location (un) **] Center Dr., [**Name (NI) 1456**] MA
Phone number: [**Telephone/Fax (1) 109778**]
Please follow up with the transplant center:
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 3688**] [**Name8 (MD) **], MD
Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2154-3-8**] 2:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK
Date/Time:[**2154-3-8**] 3:00
|
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26,783
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24584
|
Discharge summary
|
report
|
Admission Date: [**2137-2-7**] Discharge Date: [**2137-3-7**]
Date of Birth: [**2090-1-30**] Sex: M
Service: MEDICINE
Allergies:
Fentanyl Citrate / Penicillins / Dilaudid / Morphine
Attending:[**First Name3 (LF) 1493**]
Chief Complaint:
Reason for Transfer - UGIB; subspecialty care
Major Surgical or Invasive Procedure:
EGD on [**2137-2-8**]: Severe portal hypertensive gastropathy
History of Present Illness:
The patient is a 47 yo morbidly obese M with ETOH cirrhosis,
portal hypertension, and GAVE who originally presented to the
OSH on [**2137-1-21**] after being found unresponsive by his wife at
home. Per OSH records, he was intially thought to have a
brainstem stroke. CT Head was negative for overt stroke. At that
time given his poor overall health the patient was made CMO.
Remarkably, 3 days later, the patient became more responsive and
was transferred to an acute rehab facility on [**2137-1-30**]. Code
status at that time was changed to FULL. On [**2138-2-3**] (at rehab)
the patient became increasingly somnolent and was started on
ciprofloxacin for presumed UTI. Over the next 24 hours his
somnolence increased and his hct was noted to have dropped from
32.7 --> 27.5. He began having melena and his hct continued to
drop. He was then transferred to the OSH ICU. He was started on
IV PPI and Octreotide and his hct stabilized at approximately
Hct 25-26. An EGD was performed and showed severe portal
gastropathy with active oozing. 24 hours later a repeat EGD
showed improvement in the bleeding but continued severe portal
hypertensive gastropathy. He was transfused 2 units of PRBC and
2 units of FFP while in the ICU. His encephalopathy improved
with lactulose. Of note, urine cultures eventually returned
negative and his antibiotics were stopped. The plan was to
transfer to [**Hospital1 18**] for further management of his severe portal
gastropathy and for further assessment.
.
Upon arrival here, the patient reports that he is feeling well.
He denies any recent melena. Had brown stool today. Denies chest
pain, shortness of breath, abdominal pain. + Chronic back pain.
AAO x 3. Patient reports that since he was last seen at [**Hospital1 18**]
1.5 years ago, he has gone from 500lbs to 330lbs.
Past Medical History:
-- ESLD [**2-16**] presumed ETOH cirrhosis +/- NASH
-- Chronic GI Bleeding [**2-16**] GAVE
-- H/O GAVE; h/o argon plasma coagulation therapy in [**2134**] at
[**Hospital1 18**]
-- Anemia - [**2-16**] GAVE and chronic disease
-- Morbid Obesity
-- H/O MRSA; recurrent cellulitis of lower extremities
-- GERD
-- OSA
-- Chronic Pain Syndrome
-- Depression
-- Mild asthma diagnosed in [**2132**]
Social History:
He is married for 16 years and has 3 children; they moved to
[**State 1727**] this past year. He has not worked in the past 1.5 years
[**2-16**] his poor health and obesity. Reports that he quit ETOH 1
year ago. Prior to that he drank "a lot". Denies smoking or
drugs.
Family History:
Hereditary hemochromatosis in a cousin and brother. His father
also has diabetes and ischemic heart disease status post
myocardial infarction and CABG.
Physical Exam:
PHYSICAL EXAM:
VS: 98.1 122/88 57 20 99%RA
Gen: obese male, sitting at edge of bed, tearful at times
discussing disease; able to state year, month, date, and place
HEENT: pupils dilated, but reactive
Neck: supple
Lung: CTA B/L with good air movement
Heart: RRR, II/VI SM at base
Abd: obsese, non-tender, no flank dullness
Ext: bilaterally erythematous; does not appear infected;
necrotic ulcer on right heal; 2+ pulses bilaterally
Neuro: CN II-XII intact, UE/LE strength is [**5-20**] and symmetric.
AOx3, intact serial sevens, repetition.
Pertinent Results:
HEMATOLOGY
[**2137-2-8**] 01:30AM BLOOD WBC-5.7 RBC-3.33* Hgb-10.0* Hct-29.8*
MCV-90 MCH-30.1 MCHC-33.6 RDW-18.0* Plt Ct-168#
[**2137-2-8**] 06:50PM BLOOD Hct-31.2*
[**2137-3-2**] 06:20AM BLOOD WBC-2.1* RBC-2.43* Hgb-7.1* Hct-21.2*
MCV-87 MCH-29.3 MCHC-33.5 RDW-17.8* Plt Ct-100*
[**2137-3-2**] 06:05PM BLOOD Hct-25.8*
[**2137-3-3**] 06:20AM BLOOD WBC-2.5* RBC-2.66* Hgb-7.6* Hct-23.7*
MCV-89 MCH-28.7 MCHC-32.2 RDW-16.8* Plt Ct-111*
[**2137-3-5**] 05:25AM BLOOD WBC-2.4* RBC-2.76* Hgb-7.9* Hct-24.9*
MCV-90 MCH-28.7 MCHC-31.8 RDW-16.8* Plt Ct-116*
[**2137-3-7**] 06:08AM BLOOD WBC-3.0* RBC-2.76* Hgb-7.9* Hct-24.2*
MCV-88 MCH-28.7 MCHC-32.8 RDW-17.6* Plt Ct-152
COAGULATION
[**2137-2-8**] 01:30AM BLOOD PT-17.5* PTT-32.9 INR(PT)-1.6*
[**2137-2-9**] 06:05AM BLOOD PT-18.1* PTT-35.6* INR(PT)-1.7*
[**2137-2-10**] 05:55AM BLOOD PT-18.3* PTT-34.4 INR(PT)-1.7*
[**2137-3-6**] 05:15AM BLOOD PT-18.1* PTT-36.3* INR(PT)-1.7*
[**2137-3-7**] 06:08AM BLOOD PT-18.4* PTT-36.5* INR(PT)-1.7*
CHEMISTRY
[**2137-2-8**] 01:30AM BLOOD Glucose-94 UreaN-4* Creat-0.8 Na-135
K-3.7 Cl-104 HCO3-25 AnGap-10
[**2137-2-9**] 06:05AM BLOOD Glucose-84 UreaN-3* Creat-0.7 Na-137
K-3.5 Cl-106 HCO3-25 AnGap-10
[**2137-2-10**] 05:55AM BLOOD Glucose-91 UreaN-3* Creat-0.8 Na-136
K-3.5 Cl-104 HCO3-26 AnGap-10
[**2137-3-5**] 05:25AM BLOOD Glucose-81 UreaN-6 Creat-0.7 Na-141 K-3.6
Cl-113* HCO3-23 AnGap-9
[**2137-3-6**] 05:15AM BLOOD Glucose-85 UreaN-6 Creat-0.7 Na-137 K-3.6
Cl-110* HCO3-22 AnGap-9
[**2137-3-7**] 06:08AM BLOOD Glucose-88 UreaN-6 Creat-0.7 Na-135 K-3.6
Cl-107 HCO3-24 AnGap-8
[**2137-3-5**] 05:25AM BLOOD Calcium-7.5* Phos-3.9 Mg-1.8
[**2137-3-6**] 05:15AM BLOOD Calcium-7.7* Phos-3.7 Mg-1.8
[**2137-3-7**] 06:08AM BLOOD Calcium-7.5* Phos-3.9 Mg-1.8
[**2137-2-26**] 06:20AM BLOOD Albumin-2.1* Calcium-7.5* Phos-3.7 Mg-1.8
Iron-18*
LIVER
[**2137-2-8**] 01:30AM BLOOD ALT-28 AST-69* LD(LDH)-295* AlkPhos-140*
TotBili-2.6*
[**2137-2-12**] 08:09PM BLOOD ALT-20 AST-37 CK(CPK)-35* AlkPhos-113
TotBili-1.8*
[**2137-3-6**] 05:15AM BLOOD ALT-29 AST-56* LD(LDH)-198 AlkPhos-270*
TotBili-1.2
[**2137-3-7**] 06:08AM BLOOD ALT-29 AST-53* LD(LDH)-213 AlkPhos-277*
TotBili-1.4
[**2137-2-8**] 01:30AM BLOOD calTIBC-203* Ferritn-116 TRF-156*
[**2137-2-13**] 08:40AM BLOOD VitB12-1295*
IRON
[**2137-2-26**] 06:20AM BLOOD calTIBC-176* Ferritn-35 TRF-135*
AMMONIA
[**2137-2-12**] 08:09PM BLOOD Ammonia-70*
[**2137-2-14**] 03:23AM BLOOD Ammonia-96*
[**2137-2-22**] 06:25AM BLOOD Ammonia-54*
[**2137-2-23**] 09:29AM BLOOD Ammonia-65*
PITUITARY
[**2137-2-12**] 04:50AM BLOOD Prolact-18*
[**2137-2-13**] 08:40AM BLOOD TSH-0.51
[**2137-2-23**] 09:29AM BLOOD Prolact-32* <-- following seizure
HEPATITIS SEROLOGY
[**2137-2-25**] 07:35AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
HCV NEGATIVE
AFP SCREENING
[**2137-2-12**] 04:50AM BLOOD AFP-1.1
URINALYSIS Blood Nitrite Protein Glucose Ketone Bilirub Urobiln
pH Leuks
[**2137-2-20**] NEG POS NEG NEG NEG NEG NEG
7.0 SM
MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE
RenalEp
[**2137-2-20**] 10:39PM 0-2 [**3-20**] MANY NONE 0
[**2137-2-13**] RPR NEGATIVE
[**Date range (1) 19593**]/08 C DIFF NEGATIVE X2
URINE CULTURE (Final [**2137-2-24**]):
ESCHERICHIA COLI.
>100,000 ORGANISMS/ML. OF THREE COLONIAL MORPHOLOGIES.
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- 32 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
REPORTS AND STUDIES
[**2137-2-8**] EGD
Granularity, friability and mosaic appearance in the whole
stomach compatible with portal hypertensive gastropathy
Otherwise normal EGD to third part of the duodenum
[**2137-2-8**] US
Sequelae of cirrhosis are evident with fatty infiltration of the
liver, splenomegaly and small amount of ascites. No discrete
focal lesions are seen; however, evaluation is markedly limited
in the presence of fatty infiltration/coarsened echotexture.
Gallbladder is free of stones and sludge. There is no intra- or
extra-hepatic biliary dilatation seen.
The main portal vein is patent and hepatopetal. Intrahepatic
vessels are diminutive and not well seen. The left and middle
hepatic veins are visualized with normal flow and phasicity.
IMPRESSION: Patent main portal vein, with limited visualization
of the intrahepatic vasculature. Sequela of cirrhosis as
evidenced by splenomegaly and coarsened hepatic echotexture.
[**2137-2-13**] HEAD CT
This study is limited by motion artifact. There is no evidence
of acute intracranial hemorrhage, shift of normally midline
structures, mass effect, hydrocephalus or acute major vascular
territorial infarction. There are post-surgical changes of the
sinuses. Metallic surgical material is present along the
posterior wall of the right maxillary sinus. Bilateral sinus
surgeries are noted. There is moderate mucosal thickening of the
maxillary and ethmoid sinuses. Frontal sinuses clear. Right
sphenoid sinus air cells opacified. Mastoid air cells and middle
ear cavities remain clear.
IMPRESSION: No intracranial hemorrhage or mass effect.
Post-surgical changes and mucosal thickening of the paranasal
sinuses
[**2137-2-21**] HEAD / NECK CTA
The CT angiography of the head demonstrates bilateral normal
flow within the arteries of anterior and posterior circulation.
No vascular occlusion, stenosis, or an aneurysm greater than 3
mm in size is seen. Normal flow is identified in bilateral
sylvian branches of the middle cerebral arteries. No abnormal
vascular structures seen. Incidentally noted is a small
infundibulum at the origin of left posterior communicating
artery.
IMPRESSION:
1. No acute abnormalities on head CT or change since the
previous study.
2. No significant abnormalities on CTA of the head. No vascular
occlusion or high-grade stenosis seen. Incidental small
infundibulum at the origin of left posterior communicating
artery.
[**2137-2-24**] EEG
This is an abnormal 24-hour video EEG telemetry in the
waking and sleeping states due to the electrographic seizures
noted with
rhythmic [**2-17**] Hz blunted sharp and slow wave discharges seen
particularly
over the bilateral parasagittal regions with occasional
extension into
the left temporal lobe. There were also intermittent spike and
slow
wave discharges, particularly in the bilateral parasagittal
regions.
There was no clear electrographic correlate for these seizures.
This
recording, thus, demonstrates non-convulsive status epilepticus
which is
intermittent throughout the recording. The parasagittal and
occasionally left temporal sharp discharges may suggest either a
generalized abnormality or multiple potential foci of
epileptogenesis.
Brief Hospital Course:
CIRRHOSIS & PORTAL HYPERTENSIVE GASTROPATHY
The patient had a clinical diagnosis of cirrhosis, likely
alcohol and non-alcohol induced steatosis, complicated by portal
gastropathy with a history of transfusion support, no esophageal
varices, no significant ascites, and no former diagnosis of
encephalopathy. He had an upper endoscopy this admission which
confirmed no esophageal varices, and noted portal hypertensive
gastropathy but no GAVE. He continued on nadolol, and strong
acid protection including PPI [**Hospital1 **], H2 blocker, and sucralfate.
The patient was on low dose lasix and aldactone that was
continued.
He had a neurologic event that was not fully characterized at an
outside/referring hospital that considered to be a brainstem
stroke, but when he recovered fully, this was thought to be
related to hepatic encephalopathy. He was continued on rifaximin
and lactulose while in our hospital. He clinically did not
appear to be encephalopathic while in our hospital, never having
the sign of asterixis. At times, he did appear to be speech
arresting and having delayed responsivenes or inappropriate
answers to questions, but it was never classic for hepatic
encephalopathy as he would, in the course of the same
visit/examination, be able to clearly answer orientation
questions and perform adequately on mental status examination.
On acceptance to our hospital, he was evaluated for insertion of
a transjugular intrahepatic portosystemic shunt. However, he had
a clinical seizure the day prior to scheduled TIPS, and the plan
was aborted pending further characterization of his seizure
disorder. At time of discharge, given concern that his seizure
disorder could be an atypical manifestation of hepatic
encephalopathy, TIPS was indefinitely postponed. However, it was
felt that it could be entirely possible that they are completely
unrelated as he had no other signs or symptoms of hepatic
encephalopathy including asterixis or decreased orientation or
confusion when he was not in a post-ictal state.
He was counseled that he may require transfusions on an as
needed basis, and was going to have follow-up care with his
primary care provider in [**Name9 (PRE) 1727**]. He required only one transfusion
of packed red cells (1 unit) this admission. He was started on
iron supplementation 325mg PO TID after his iron studies showed
that he was iron deficient.
SEIZURE DISORDER / EPILEPSY
The patient developed a new seizure disorder while in the
hospital; further review of his history suggests that the
patient's initial chief complaint in [**Month (only) 404**] prior to presenting
to the hospital which ultimately referred him here was a
seizure.
The patient was witnessed to have two generalized tonic clonic
seizures on the hospital floor, each self-limited lasting
approximately one minute, with a [**3-20**] minute post-ictal period.
He was loaded on keppra given his hepatic disease, and
transferred to the intensive care unit for further EEG
monitoring. This initial monitoring revealed no epileptiform
activity, only nonspecific slowing. Head CT at this time was
unrevealing for any mass lesions or old infarctions. MRI was
deferred because the patient had clips that were not confirmed
to be MRI compatable following sinus surgery. His weight/body
habitus was borderline for scanner limits.
One week later, the patient had several "spells" which he
described as his vision "going blurry then black." The patient
had no clear visual field deficit and visual acuity was grossly
normal. Neurology saw the patient, and recommended a stat head
CTA be performed to rule out vertebrobasilar insufficiency,
which was normal. RPR was checked and was negative.
One to two days later, he again developed generalized
tonic-clonic seizure activity that was witnessed by the medical
housestaff team and the neurology attending. The patient
clinically had a left sided focus. EEG at this time did show
epileptiform activity. He was loaded on dilantin and free
dilantin levels were checked, aiming at the lowest dose that
prevented seizures given possible hepatotoxity. Keppra was
continued. He did not have further seizure activity.
ANXIETY
The patient had a history of OCD/generalized anxiety, and this
was unfortunately severely exacerbated by the keppra. He had
episodes of becoming very agitated, tearful, and feeling as if
he were going to die. He described generalized pain. This abated
somewhat with lowering his keppra dose from 2 gm [**Hospital1 **] to 1.5gm
[**Hospital1 **].
He had several psychotropic home medications, but he was
continued on only the active medication(Lexapro) at time of
interhospital transfer.
URINARY TRACT INFECTION/CYSTITIS
The patient developed a UTI while foley catheter was in place.
He grew E. coli and was treated with fluoroquinolone but
switched to bactrim to complete his 7 day course given that
fluoroquinolones can lower the seizure threshold.
ASTHMA
He was continued on PRN albuterol
SLEEP APNEA
The patient intermittently used CPAP. He did not have his home
mask and felt uncomfortable, and unfortunately generally felt
tired throughout the day.
HEALTH CARE MAINTENANCE
The patient should be immunized against Hepatitis B by his
primary care provider.
Medications on Admission:
MEDICATIONS (at time of transfer):
Benadryl PRN for itching
Lexapro 20mg daily
Nexium 40mg IV q12
Lactulose
Miconazole powder
Nadolol 20mg daily
Spironolactone 50mg daily
Ambien 5mg QHS:PRN
Sucralfate 1g QID
Iron 325mg daily
MVI
Octreotide drip
(holding patients cymbalta, erythromycin, wellbutrin, lasix, and
vicodin)
.
ALLERGIES:
Penicillin
Morphine/Percocet --> nausea.
.
Discharge Medications:
1. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
3. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
9. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
10. Rifaximin 200 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
11. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
12. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for abdominal
discomfort or gas pain.
13. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO TID (3 times a day).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
15. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
16. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day).
17. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for 7 days.
18. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
four times a day as needed for shortness of breath or wheezing.
Discharge Disposition:
Home With Service
Facility:
Androskoggin vna
Discharge Diagnosis:
PRIMARY: CIRRHOSIS
- PORTAL HYPERTENSIVE GASTROPATHY
SEIZURE DISORDER, GENERALIZED TONIC CLONIC
SECONDARY:
- Chronic Pain Syndrome
- Anemia, secondary to past GAVE and portal hypertensive
gastropathy
- Depression, Obesessive Compulsive Disorder, Anxiety
- Obstructive Sleep Apnea
- h/o MRSA cellulitis, lower extremity
- Gastroesophageal reflux disorder
- Asthma, mild
Discharge Condition:
stable, ambulating with walker
Discharge Instructions:
You were transferred to [**Hospital1 18**] with advanced liver disease and
concern for the liver being cause of altered concentration and
mental status. You had clinical seizures while hospitalized and
were started on an two anti-seizure drugs called Keppra and
Dilantin while here.
You had an upper endoscopy which showed a slow bleed from the
high pressures in the veins around your stomach. Because of the
seizure disorder, you did not have a TIPS procedure.
You may periodically need blood transfusions. You should have
your bloodwork reviewed closely by your primary care physician.
MEDICATION CHANGES:
You should continue the PANTROPRAZOLE(PROTONIX),
SUCRALFATE(CARAFATE), and RANITIDINE(ZANTAC) for your stomach
bleeding.
For seizures, you should continue the PHENYTOIN(DILANTIN) and
LEVETIRACETAM(KEPPRA).
For Depression and anxiety, you are still on LEXAPRO, but the
other medications were discontinued, including CYMBALTA and
WELLBUTRIN. You can discuss with your outpatient treaters if
these should be restarted.
You should continue taking IRON three times daily for your
anemia.
RETURN to hospital if you develop any signs of altered mental
status/confusion/encephalopathy, fever, chills, or other
concerning symptoms. If you have a seizure lasting more than
five minutes or that results in any injury, return to the
hospital. For seizure lasting less than five minutes, please
call your neurologist to discuss and be seen in clinic.
Followup Instructions:
Please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2855**]
[**Last Name (NamePattern1) 1968**] in [**State 1727**] within the next 1-2 weeks.
Please call to schedule a follow-up appointment with a
gastroenterologist or hepatologist in [**State 1727**].
If you need a Hepatologist, you can schedule an appointment in
the [**Hospital1 18**] liver center at [**Telephone/Fax (1) 24157**]
Please schedule an appointment to be seen by a Neurologist or
Epilepsy specialist. If you do not have a neurologist in [**State 1727**],
you can be seen in the [**Hospital 875**] clinic at ([**Telephone/Fax (1) 58666**]
|
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83,204
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44326
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Discharge summary
|
report
|
Admission Date: [**2175-12-9**] Discharge Date: [**2175-12-12**]
Date of Birth: [**2137-10-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5119**]
Chief Complaint:
Hematemesis and "dark" stool
Major Surgical or Invasive Procedure:
1.EGD (Esophagogastroduodenoscopy)
2.Colonoscopy
3.Pass through capsule endoscopy study
History of Present Illness:
The patient is a 38yo male with known who Cirrhosis presents
after coughing about a half a cup of blood on Friday night
followed by "dark" and tarry looking stool on Saturday morning.
On friday night ([**2175-12-8**]) he did not feel well after vomiting,
but the remainder of the evening was uneventful. Initially he
did not have headaches, dizziness or lightheadedness but on
Saturday morning after having a large episode of melena he
admits to feeling "dizzy" followed by a brief syncopal episode
witnessed by his girlfriend. [**Name (NI) **] denies any associated head
injuries or hitting his head or other extremities. He was
brought to the ED by his girlfriend shortly thereafter. He
reported malaise and general weakness over the week prior to
this presentation.
.
On additional ROS he had a dry cough last week and 2-3 episodes
of diarrhea. He also reports a subjective fever and night
sweats. He denies any nausea, heartburn symptoms or additional
episodes of emesis. He initially had some mild, diffuse pain is
his lower abdomen upon waking Saturday morning but denies any
additional abdominal pain, nausea or vomiting since his
admission. He denies any sick contacts. [**Name (NI) **] state that his most
recent alcohol consumption was 6 days ago, when he consumed [**7-16**]
beers at a football game. On arrival to the [**Hospital1 18**] ED his
temperature was 98.4F, HR 85, BP 132/71, RR 18, SpO2 100% on
room air. Tmax 99.5 (oral)in ED. He received Octreotide bolus,
IV Pantoprazole, Ciprofloxacin and 3L normal saline IVFs along
with 1 unit PRBC blood transfusion.
.
He states he had previously been a "very heavy" drinker and was
diagnosed with cirrhosis in the [**Country 13622**] Republic in [**2170**] after
an acute presentation for a perforated duodenal ulcer which
required surgery. Per patient, he had a liver biopsy at that
time but efforts to obtain official records have been
unsuccessful to date. He was initially admitted to the MICU for
stabilization where he received an additional unit of blood and
he underwent an EGD which was unremarkable. The patient had some
additional melena in the MICU but no abdominal pain, nausea,
vomiting or chest pain/palpitations. He had two PIVs (18 gauge)
set up for access and Ciprofloxacin was continued in the setting
of his GI bleed. He had a climbing Hct to the 26-27 range, up
from nadir of 24.6 on presentation. He was hemodynamically
stable upon admission to the general medical service. Of note,
the patient's cocaine screen returned as positive soon after
transfer from the MICU.
Past Medical History:
Cirrhosis
Gastric varices
h/o alcohol abuse
Duodenal ulcer, status post Billroth I performed in DR [**Last Name (STitle) **] [**2170**]
Social History:
Lives with girlfriend. [**Name (NI) 1403**] as a stone [**Doctor Last Name 3456**]. He has a prior
history of heavy ETOH use, usually beer, stopped briefly after
duodenal ulcer/surgery in [**Country 13622**] Republic in [**2170**] but
continued to struggle with ETOH-ism. Currently, he reports
occasional beer ([**4-11**] /week) or wine with dinner, but consumed 8
beers at a football game the week prior to admission. No history
of DTs, hallucinations or seizures. Attended AA for a period of
but last meeting about 6 months ago. Patient admits to
intermittent intranasal cocaine use. Denies IVDU. He has never
used tobacco.
Family History:
Noncontributory. Denies any known ETOH-ism in other siblings or
close family members. [**Name (NI) **] known liver or GI diseases in family
per patient.
Physical Exam:
Tc 98.3, Tm 99.3, RR 16-18, HR60-70s, BP 110/80 , 100%RA
GENERAL: No acute distress. Oriented to person, place and time,
affect appropriate.
HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No active
bleeding.
NECK: Supple with JVP of [**5-13**] cm. No lymphadenopathy noted. No
thyromegaly.
CARDIAC: RRR, S1/S2 appreciated, no murmurs/rubs/gallops. No
S3/S4.
LUNGS: No chest wall deformities. CTA bilaterally. No crackles,
wheezes or rhonchi.
ABDOMEN: large vertical scar at midline (10") and ventral
herniation noted, Soft, NT/ND, liver edge palpable at costal
margin. No abdominial bruits. No splenomegaly.
EXTREMITIES: 1+ peripheral LE edema, 2+ pedal pulses bilaterally
SKIN: No rashes, telangiectasias, stasis dermatitis, ulcers or
lesions
NEURO: CNs [**3-21**] grossly intact, no focal sensory or motor
deficits, gait assessment deferred
.
Pertinent Results:
MICROBIOLOGY:
[**2175-12-9**] Blood Cultures x 2 - Negative/No growth
.
OTHER STUDIES/IMAGING:
.
CXR [**2175-12-9**]: The lungs are clear without consolidation or edema.
The
mediastinum is unremarkable. The cardiac silhouette is within
normal limits
for size. No effusion or pneumothorax is noted. The visualized
osseous
structures are unremarkable.
.
EKG [**2175-12-9**] : Rate 80s, NSR, occasional T wave
flattening,compared to the previous tracing [**2174-6-23**] there is a
decrease in voltage in the inferior leads.
.
RIGHT FOOT XRAY [**2175-12-9**]: No significant underlying degenerative
joint disease is noted. No fracture is seen throughout the foot.
The regional soft tissues are unremarkable.
.
EGD: No clear source of bleeding found
.
COLONOSCOPY:Colonoscopy revealed some diverticulitis of the
sigmoid colon, but no source of bleeding
.
CAPSULE ENDOSCOPY: The capsule remained in the stomach for 2h 39
min -
suggestive of gastroparesis 2. No definitive site of gi bleeding
or cause of anemia was identified
.
EGD of [**2175-7-13**]: Normal mucosa in the esophagus 3 cords of
non-bleeding varices at the fundus Granularity, friability,
congestion and erythema in the whole stomach compatible with
portal hypertensive gastropathy Normal mucosa in the duodenum
Otherwise normal EGD to third part of the duodenum Ultrasound of
liver and abdomen of [**2175-7-13**]: Cirrhosis, no ascites,
splenomegaly (constant) of 14.9 cm. Otherwise normal.
.
OTHER ADMISSION LABS:
.
[**2175-12-9**] 04:43PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-POS amphetm-NEG mthdone-NEG
[**2175-12-9**] 04:40PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-4* pH-7.0 Leuks-NEG
[**2175-12-11**] 12:20PM BLOOD Hct-27.7*
[**2175-12-9**] 02:45PM BLOOD Glucose-117* UreaN-14 Creat-0.8 Na-137
K-4.0 Cl-102 HCO3-24 AnGap-15
[**2175-12-9**] 02:45PM BLOOD ALT-46* AST-69* LD(LDH)-173 AlkPhos-106
TotBili-0.7
[**2175-12-11**] 12:20PM BLOOD Hct-27.7*
[**2175-12-10**] 03:42AM BLOOD WBC-4.3 RBC-2.85* Hgb-8.0* Hct-24.6*
MCV-86 MCH-28.0 MCHC-32.4 RDW-14.9 Plt Ct-125*
[**2175-12-9**] 08:05PM BLOOD Hct-26.4*
.
DISCHARGE LABS:
[**2175-12-12**] 07:00AM BLOOD WBC-3.8* RBC-3.06* Hgb-8.5* Hct-26.3*
MCV-86 MCH-27.9 MCHC-32.5 RDW-15.4 Plt Ct-136*
[**2175-12-12**] 07:00AM BLOOD Plt Ct-136*
[**2175-12-12**] 07:00AM BLOOD Glucose-108* UreaN-9 Creat-0.8 Na-135
K-4.0 Cl-102 HCO3-25 AnGap-12
[**2175-12-11**] 06:55AM BLOOD Albumin-3.7 Mg-2.2
Brief Hospital Course:
In summary, Mr. [**Known lastname 77244**] is a 38 yo male with alcoholic
cirrhosis who presented after an episode of hematemasis followed
by melena and then a brief witnessed syncopal episode at home.
He presented to the [**Hospital1 18**] ED and he was immediately admitted to
the medical ICU for close monitoring. On admission, he had a
marked hematocrit drop from the low 30s down to 24 and he
required 2 Units of transfused blood. Fortunately, he appeared
to stabilize thereafter. Additional details outlined below:
.
GI bleed: Mr. [**Known lastname 77244**] has a previous history of bleeding
from a ruptured duodenal ulcer and a history of gastric varices
noted on prior EGD, but emergent EGD on this admission revealed
no bleeding source all the way to the jejunum. Therefore his
initial octreotide was discontinued. The team decided to
continue with his daily Protonix for GI protection and was
started on a 1 week regimen of Ciprofloxacin 500mg [**Hospital1 **] for
infection prophylaxis. Serial Hcts were monitored and his diet
was advanced very slowly from NPO to clears and then regular. On
[**2175-12-11**] after he stabilized further he underwent a colonoscopy
which revealed some diverticulitis of the sigmoid colon, but no
obvious source of bleeding. Thus, it was recommended per the
[**Hospital1 18**] GI team that he proceed to a capsule endoscopy. The
capsule study showed that the capsule remained in the stomach
for about 2 hours and 39 minutes which was suggestive of
gastroparesis, otherwise there were no definitive sites of GI
bleeding identified to explain the cause of Mr. [**Known lastname 95046**]
anemia. Ultimately, a specific source was not identified despite
three thorough GI scoping methods (EGD, colonoscopy and capsule
study). Fortunately, he had no additional bouts of concerning
active bleeding during his hospital stay, with the exception of
a small amount of melena on hospital day #1 in the MICU, and his
hematocrit continued to stabilize while he recovered. At time of
discharge his Hct was in the 26 range and repeat labs done
[**2175-12-13**] showed Hct 27.6. He will plan to follow-up in the
GI/Liver Clinic soon after discharge with weekly Hct checks,
additional studies and management for his cirrhosis.
.
Substance Abuse: Mr. [**Known lastname 77244**] had a prior history of alcohol
abuse which dates back to his twenties and early thirties. He
admits to prior binge drinking and having as many as 15 drinks a
day. Now, he states that he has cut back and drinks 3-4
drinks/week, though he recently had 8 beers one week ago at a
[**Company **] Game. From this history it was felt that ETOH
withdrawal was unlikely but he was nonetheless monitored closely
and placed on a CIWA scale with PRN Valium ordered. He also
admitted to intermittent cocaine use after his urine toxicology
screen tested positive. He was reminded that cocaine use can
also be very addictive any can have serious health consequences
such as acute heart attacks and strokes. He was seen by a social
worker/addictions counselor during his hospital stay. Mr.
[**Known lastname 77244**] expressed some interest in attending AA meetings to
use them for a "crutch" in helping him decrease his drinking. He
explained that he has several sober friends who have offered to
take him to meetings and he is aware of where/when they are (and
plans to look at schedule on line at home). He declined any
offers for professional addictions support or formal therapy. At
time of discharge he appeared to be coping well and he was
reminded to utilize the resources which were discussed to help
him cut back on his drinking and avoid cocaine use. He was asked
to take a daily multivitamin, thiamine, & folate supplements.
.
Syncope: The patient's syncope event was attributed to
orthostasis in the setting of acute acute blood loss. Blood loss
was fairly substantial as it dropped his Hct close to 10 points
from the low 30s to 24 range. The patient's girlfriend witnessed
the syncope and confirmed no head injuries or other injuries.
Throughout his hospital stay orthostatics were assessed and he
had stable supine and standing blood pressures by time of
discharge and he denied palpitations, dizziness, lightheadedness
or nausea.
.
Cirrhosis: Although there is no logged biopsy or tissue evidence
to date the patient reports that he had a liver biopsy done in
[**2170**] in the [**Country 13622**] Republic and was told that he had
cirrhosis at that time. Given his history, this is likely
alcohol related. Per reports, previous work-up has included
normal hepatitis A, B and C serologies. HIV ab, AMA, [**Doctor First Name **], SMA,
IgG level, alpha-1 antitrypsin and ceruloplasmin have also all
been normal. During this hospital stay he had evidence of mild
dysfunction with elevated INR 1.3, high PT levels, and elevated
LFTs (ALT 85, AST 157). Otherwise, no prominent HSM, jaundice or
other stigmata of alcoholic cirrhosis was noted. The patient
will continue his Nadolol and will plan to follow-up at [**Hospital1 18**]
Liver Center with Dr. [**Last Name (STitle) **].
.
Foot/Ankle Pain: The patient complained of right sided foot and
ankle pain and swelling for the past 1 1/2-2 weeks. He denied
any injury to the area during his recent fall with his syncopal
event. A set of plain films were performed and revealed no
fractures or abnormalities. He was given additional pillows, ice
packs and offered a small amount of Tylenol PRN for his joint
pain. He will plan to follow-up on this complaint more
thoroughly on an outpatient basis.
.
Fluids, Electrolytes, Nutrition: The patient was switched from
NPO to clears and then to a regular diet which he tolerated very
well with no evidence of nausea, vomiting or additional UGI/LGI
bleeding. As noted, thiamine and folate were supplemented and
his electrolytes were monitored daily and repleted as needed.
.
Prophylaxis: He was encouraged to ambulate and get up and out of
bed for DVT prophylaxis and Pneumatic boots were also ordered.
Protonix was given for ongoing GI protection.
.
The patient was maintained as a full code status for the
entirety of his hospital stay and communication occurred
directly with the patient on a daily basis regarding his health
care plans and status.
Medications on Admission:
Nadolol 20 mg daily
Multivitamin
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days: take every 12 hours and complete on
[**2175-12-15**] .
Disp:*6 Tablet(s)* Refills:*0*
5. Nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
1 months.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Outpatient Lab Work
Please have weekly blood lab checks (Hematocrit)faxed to Dr.
[**Last Name (STitle) **] at the Liver Center at [**Hospital1 18**] up until your appointment
with him on [**1-17**].
(Fax #[**Telephone/Fax (1) 4400**]). You can go to the [**Company 191**] Atrium Suite between
8:30am and 4pm (phone [**Telephone/Fax (1) 250**]) Monday through Friday to
have labs drawn.
Discharge Disposition:
Home
Discharge Diagnosis:
Cirrhosis
Acute Gastrointestinal Bleed
Alcoholism
Discharge Condition:
Stable. At the time of discharge the patient had stable vital
signs and he appeared to be in no distress. He had no abdominal
pain or complaints of nausea, vomiting or bloody bowel
movements. The patient's hematocrit had greatly improved and
remained stable.
Discharge Instructions:
It was a pleasure taking care of you during your stay here at
[**Hospital1 69**].
You were admitted to the hospital after complaints of bloody
vomit, bloody stool, and an episode of syncope/fainting. You
were initially treated in the intensive care unit and received a
blood transfusion and IV fluids to help stabilize you and then
you were transferred to the regular medical floor.
Gastroenterology (GI) specialists were consulted and you
underwent an EGD or upper GI endoscopy, a colonoscopy and
lastly, a capsule endoscopy study. The results of these tests
will be reviewed further at your follow-up visit to the [**Hospital1 18**]
Liver Center.
Your upper gastrointestinal bleeding and lower gastrointestinal
bleeding are likely related to your alcoholic liver disease. You
should avoid alcohol use as it may worsen your liver disease and
increase your risks for serious, harmful bleeding.
.
Medication instructions:
Please take your daily Nadolol as previously prescribed for
blood pressure control and to help prevent variceal/GI bleeding.
Please continue your daily multivitamins.
Begin taking the following new medications :
Daily thiamine and folic acid supplements as prescribed. Please
complete your antibiotic course with Ciprofloxacin for a total
of 7 days for prevention of bacterial infections which can
spread from your gastrointestinal tract to your bloodstream. You
have already completed the first 4 days of Ciprofloxacin
therapy, so please finish the remainder as instructed until
[**2175-12-15**].
Also, you can continue taking Protonix for anti-acid protection
after discharge.
Additional instruction: You will need to have weekly blood lab
checks (Hematocrit)faxed to Dr. [**Last Name (STitle) **] at the Liver Center at
[**Hospital1 18**] up until your appointment with him on [**1-17**]. (Fax
#[**Telephone/Fax (1) 4400**])
.
Call your primary care doctor or go to them emergency room if
you have any additional bloody vomit, lightheadedness,
dizziness, shortness of breath, fainting, bloody stools,
worsening abdominal pain, fevers, chills or any other concerning
symptoms.
Followup Instructions:
1. Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Wednesday [**12-13**] at 9:50am in the Atrium Suite on the [**Location (un) 448**] of the
[**Hospital Ward Name 23**] Building/[**Hospital Ward Name 516**] [**Hospital1 18**] (phone #[**Telephone/Fax (1) 250**]). You
will still keep your new primary care appointment with Dr. [**Last Name (STitle) **]
on [**2-14**]. [**2176**].
.
2.Please follow-up with the [**Hospital1 18**] Liver Center with Dr. [**Last Name (STitle) **]
in the [**Hospital Unit Name **], [**Location (un) **]. On [**1-17**] at 3:30pm .
Phone #[**Telephone/Fax (1) 2422**]
.
3.You will need to have weekly blood lab checks
(Hematocrit)faxed to Dr. [**Last Name (STitle) **] at the Liver Center at [**Hospital1 18**]
up until your appointment with him on [**1-17**]. (Fax
#[**Telephone/Fax (1) 4400**]). Please go to the Atrium Suite blood lab on the
[**Location (un) 448**] of the [**Hospital Ward Name 23**] Building/[**Hospital Ward Name 516**] [**Hospital1 18**] (phone
#[**Telephone/Fax (1) 250**]between 8:30am and 4:00pm.
.
4.Please call your health insurance company/provider to let them
know of the above appointments prior to your visit.
.
5. Please consider follow up with Alcoholics Anonymous
([**URL 95047**])
.
[**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**]
Completed by:[**2175-12-17**]
|
[
"578.1",
"578.0",
"285.1",
"276.52",
"303.91",
"V45.75",
"456.21",
"780.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
14874, 14880
|
7407, 13658
|
346, 435
|
14974, 15235
|
4933, 6393
|
17390, 18856
|
3836, 3990
|
13741, 14851
|
14901, 14953
|
13684, 13718
|
15259, 16157
|
7075, 7384
|
4005, 4914
|
278, 308
|
463, 3017
|
6409, 7059
|
16182, 17367
|
3039, 3176
|
3192, 3819
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,465
| 119,095
|
39137
|
Discharge summary
|
report
|
Admission Date: [**2117-12-7**] Discharge Date: [**2117-12-17**]
Date of Birth: [**2041-7-19**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
right lung mass
Major Surgical or Invasive Procedure:
Intubation
Bronchoscopy with lymph node biopsies
Laryngoscopy with vocal cord biopsy
History of Present Illness:
76F with little PMH, lifelong smoker, admitted to OSH with chest
pain, shortness of breath, and nausea; now transferred to [**Hospital1 18**]
for further management of R lung and vocal cord masses.
.
She presented to [**Hospital1 392**] on [**12-6**] with the above complaints. Per
her husband, she urgently woke him up with complaints of not
being able to breathe. Also reported chest pain. Her husband
reports that though she has not specifically been complaining of
shortness of breath prior, but for at least a month prior he had
been noting that she might be dyspneic. At baseline able to
ascend a flight of stairs without clear dyspnea, though does so
slowly. He does note that she often bent her neck forward when
struggling to breath. Family has noted raspy voice for several
years without much recent change. Note frequent coughs/cold,
which she attributed to pet allergies. ROS also notable for 30#
weight loss over last 6 months despite good PO intake; also with
intermittent L leg swelling x months.
.
At OSH she received lasix, NTG, and aspirin as well as Reglan
and zofran for nausea. Her husband described that she complained
of a gagging and choking sensation that caused her to feel like
she need to throw up. She had a chest CT without PE but this did
show RLL mass. She therefore had bronchoscopy today; during the
procedure was found to have large vocal cord mass. Intubated
with 7.0 tube. Her vocal cord and endobronchial masses were both
biopsied. RIJ was also placed. Ceftriaxone and azithromycin were
given for ?CAP.
.
In the MICU, the patient's antibiotics were changed to clinda
and CTX to cover necrotizing pneumonia since CT showed gas in
collapsed RLL. IP and ENT were consulted initially. Both
recommended steroids for airway edema and taking to OR for
biopsies. Patient went to OR on [**12-10**] and had biopsies of
subcarinal and mediastinal LNs. Airway edema persisted so she
was maintained on steroids. She was extubated on [**12-11**] without
difficulty. On [**12-12**] she did have some agonal breathing while
sleeping but this resolved upon awakening. ENT plans to perform
laryngoscopy to biopsy mass and assess airway edema.
.
On presentation to the floor patient had no complaints. Was
feeling well but a little sleepy (it was 11pm).
.
Review of systems:
(+) Per HPI
(-) Per family, no fever, chills, night sweats, headache, recent
chest pain, palpitations, or weakness. No diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes.
Past Medical History:
- Tobacco abuse - 50-60 pack year history. Denies prior
diagnosis of COPD or asthma.
- h/o herpes zoster - involving face on right side several years
ago.
- s/p cholecystectomy
- s/p appy
- s/p hernia repair
Social History:
Lives with husband. [**Name (NI) **] children closely involved and
supportive. Worked many years ago in bookkeeping, nothing
recent. No asbestos or occupational exposures.
- Tobacco: 50-60 pack year history (1 PPD x 50-60 years).
- Alcohol: Rare use. No excessive/binge drinking.
- Illicits: None.
Family History:
Brother had some type of primary pulmonary issue (details
unclear). Sister with [**Name2 (NI) 499**] ca (and mets to lung), other sister
with breast ca. Mother lived to age [**Age over 90 **].
Physical Exam:
Vitals: T: 97.4 BP: 132/66 P: 65 R: 20 O2: 96% 3L NC
General: sleeping, NAD
HEENT: Sclera anicteric, PERRL, EOMI, MMM, oropharynx without
lesions
Neck: supple, JVP not elevated, no LAD. RIJ in place and appears
benign.
Lungs: Clear to auscultation bilaterally with some decreased air
entry at R base and occ inspiratory rhonchi posteriorly, no
accessory muscle usage
CV: Regular rhythm, normal rate, normal S1 + S2, soft SM at LUSB
without radiation.
Abdomen: soft, obese, non-tender, non-distended, bowel sounds,
without masses, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII grossly intact, no focal deficits appreciated
Pertinent Results:
[**2117-12-7**] 08:15PM WBC-13.1* RBC-3.13* HGB-7.9* HCT-26.8* MCV-86
MCH-25.4* MCHC-29.6* RDW-14.9
[**2117-12-7**] 08:15PM NEUTS-84.1* LYMPHS-7.7* MONOS-8.0 EOS-0
BASOS-0.2
[**2117-12-7**] 08:15PM GLUCOSE-113* UREA N-15 CREAT-0.6 SODIUM-139
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-32 ANION GAP-6
[**2117-12-7**] 08:15PM CALCIUM-7.9* PHOSPHATE-1.9* MAGNESIUM-1.6
IRON-13*
[**2117-12-7**] 08:15PM ALT(SGPT)-5 AST(SGOT)-14 LD(LDH)-69*
CK(CPK)-12* ALK PHOS-66 TOT BILI-0.2
[**2117-12-7**] 08:15PM calTIBC-140* VIT B12-328 FOLATE-4.9
FERRITIN-346* TRF-108*
[**2117-12-7**] EKG: Sinus rhythm. Low QRS voltage is non-specific.
[**2117-12-7**] CXR: No previous images. Endotracheal tube tip lies
approximately 3 cm above the carina. Nasogastric tube extends
well into the stomach. Right IJ catheter extends to the mid to
lower portion of the SVC. No evidence of pneumothorax. There is
some indistinctness of pulmonary vessels that could reflect
elevated pulmonary venous pressure. The left lung is clear.
There is increased opacification at the right base, most likely
consistent with effusion and atelectasis.
[**2117-12-8**] TTE: The left atrium is normal in size. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). There is a mild resting left ventricular outflow
tract obstruction. Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. 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). The pulmonary
artery systolic pressure could not be determined. There is a
trivial/physiologic pericardial effusion.
[**2117-12-8**] LENIs: No evidence of left lower extremity DVT.
[**2117-12-9**] CT neck: 1. The subglottic lesion is not seen on this
study, which may relate to presence of the endotracheal
tube.Recommend repeat study after extubation. 2. Right pleural
effusion. 3. Emphysema.
[**2117-12-10**] LN biopsy x2: NEGATIVE FOR MALIGNANT CELLS
[**2117-12-15**] CT Torso: 1. Known heterogeneous 5.3 cm x 5.1 cm cystic
and solid mass predominantly centered within the posterior basal
segment of the right lower lobe. Associated mediastinal and
right hilar lymph nodes as detailed above with the largest being
a subcarinal lymph node measuring up to 12 mm in short axis. 2.
Suspicious rim-enhancing foci in the spleen, the largest of
which measures 13 mm and a second focus which measures 8 mm as
detailed above. No focal liver lesions are identified. 3.
Bilateral small pleural effusions, also with fluid tracking
along the right major fissure.
[**2117-12-16**] MRI head: 1. No evidence for intracranial metastatic
disease. 2. Chronic microvascular white matter ischemic disease
without acute findings. 3. Diffusely hypointense bone marrow
signal is present without focal abnormality. The findings may
relate to anemia versus a variety of other etiologies and should
be correlated with patient's history.
Brief Hospital Course:
76yo F with h/o tobacco use admitted from OSH with vocal cord
lesion - likely benign - and RLL lung mass - concerning for
squamous cell carcinoma.
#. Lung Mass: The patient presented from an outside hospital
with a lesion in her right lower lobe. The patient presented
with dyspnea. A CXR was taken which was significant for a mass
in the RLL. A CT was done which showed a cystic mass. The
patient had biopsies of the mass taken via bronchoscopy at the
OSH. The pathology of these lesions were "very concerning for
malignancy". The patient was transferred to [**Hospital1 18**] for further
management. She presented with a significant oxygen requirement
requiring ICU admission. Interventional pulmonology was
consulted and biopsied two enlarged lymph nodes. These were
negative for malignant cells. Hematology/oncology was consulted
and requested a CT torso and MRI head for further evaluation.
The MRI of the head had no evidence for mets. The CT torso had a
"suspicious lesion" in the spleen. A thoracocentesis was
attempted but failed. Thoracic surgery was consulted to get
tissue for a definitive diagnosis. They will further work her up
as an outpatient. The patient was discharged with an appointment
for thoracic surgery and a primary care physician. [**Name10 (NameIs) **] will need
to have a tissue diagnosis and PET scan prior to hematology
oncology evaluation. She was discharged on 2L oxygen via NC.
#. RLL PNA: The patient presented with a pneumonia, likely
post-obstructive in nature. She was started on clindamycin and
ceftiraxone. She received a total of 9 days of antibiotics
before they were discontinued. She had no signs of fevers and
her oxygen requirement had improved at time of discharged.
#. Vocal Cord mass: The patient also had a mass on her vocal
cords. ENT was consulted. She had a laryngoscopy with biopsy of
the mass. Per ENT the mass looked benign and most likely
represented a polyp. They did notice significant swelling of her
airway. She was started on IV steroids. A repeat laryngoscopy
and stroboscopy showed resolution of the swelling. The patient
was discharged on a steroid taper.
#. Bradycaredia: The patient had asymptomatic bradycardia at
night. She dipped into the 30s while sleeping. Upon awakening
her heart rate would return to normal range. She was maintained
on telemetry.
#. Anemia: Her hematocrit was stable since the outside hospital
course. Likely secondary to malignancy. Further work up should
be considered as an outpatient.
#. Elevated PTT/INR: Possibly secondary to malnutrition.
Improved slightly during hospitalization.
#. Hypertension: Lisinopril daily.
Medications on Admission:
None
Discharge Medications:
1. Home oxygen
2-3 L continuous via pulse dosed for portability.
Diagnosis: Lung cancer
2. Prednisone 5 mg Tablet Sig: as directed Tablet PO once a day
for 6 days: please take 20mg (4 tabs) for 2 days, then take 10mg
(2 tabs) for 2 days, then take 5mg (1 tab) for 2 days then stop
the medication.
Disp:*14 Tablet(s)* Refills:*0*
3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q6H (every 6 hours) as needed for wheeze.
Disp:*1 inhaler* Refills:*0*
4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheeze.
Disp:*1 inhaler* Refills:*0*
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*0*
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnosis:
1. Lung mass
2. Pneumonia
3. Throat swelling
4. Vocal cord polyp
5. Hypoxemia
Secondary Diagnosis:
1. Tobacco abuse
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 from another hospital for evaluation of a lung
mass. You were intubated and had a pneumonia. You were treated
with antibiotics and were extubated without difficulty. You
underwent an ultrasound guided biopsy of lymph nodes in your
chest which were negative. You also had a polyp on your vocal
cord which was biopsied and appears benign. You had an MRI which
was negative for signs of metastatic lesions in your brain. You
had a CT torso which showed a suspicious lesion in your spleen.
You will need a PET/CT scan and pulmonary function tests
(PFTs)as an outpatient which we have set up for you. You will
follow up with interventional pulmonology doctors, the thoracic
surgeons, and the ear-nose-throat doctors. [**First Name (Titles) **] [**Last Name (Titles) 4314**]
are listed below.
The following medications were started:
1. Albuterol inhaler 2 puffs by mouth as needed for shortness of
breath or wheeze
2. Ipratropium bromide MDI 6 puffs inhaled by mouth as needed
every 6 hours for wheeze
3. Lisinopril 5mg by mouth daily
4. Nicotine patch 21mg on your skin daily
5. Prednisone taper by mouth 20mg (4tabs) for 2 days then 10mg
(2tabs) for 2 days then 5 mg (1tab) for 2 days then stop
6. Famotidine 20mg by mouth twice daily
Followup Instructions:
Please call your new Primary Care Physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) **], to
set up an appointment.
[**Hospital1 **] Healthcare - [**Location (un) 1439**]
[**Street Address(2) 19167**]
[**Location (un) 1439**], [**Numeric Identifier 10535**]
Phone: [**Telephone/Fax (1) 9347**]
Fax: [**Telephone/Fax (1) 12540**]
Pulmonary Doctor [**First Name (Titles) **] [**Last Name (Titles) 1092**] Surgeon:
Provider: [**First Name8 (NamePattern2) 828**] [**Name11 (NameIs) 829**], MD Phone:[**0-0-**]
Date/Time:[**2117-12-28**] 1:30 [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**]
Date/Time:[**2117-12-28**] 2:00 [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
Ear Nose and Throat Doctor:
Provider: [**First Name4 (NamePattern1) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 41**]
Date/Time:[**2118-1-14**] 1:00
[**Hospital Ward Name **] BLDG ([**Doctor First Name **]), [**Location (un) **]
The PET/CT scan is on Febuary 5th at 1:45pm. Located in the
[**Hospital Ward Name 23**] building, [**Location (un) **].
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2117-12-28**] 11:00 [**Hospital Ward Name **] BUILDING
(FELBEERG/[**Hospital Ward Name **] COMPLEX), [**Location (un) **]
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
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] |
icd9cm
|
[
[
[]
]
] |
[
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] |
icd9pcs
|
[
[
[]
]
] |
11307, 11364
|
7646, 10271
|
308, 395
|
11544, 11544
|
4478, 7623
|
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253, 270
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11504, 11523
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11404, 11483
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11558, 11697
|
3030, 3240
|
3256, 3556
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,051
| 183,735
|
24203
|
Discharge summary
|
report
|
Admission Date: [**2162-2-8**] Discharge Date: [**2162-2-23**]
Date of Birth: [**2083-5-1**] Sex: M
Service: CSU
Patient is a postoperative admit, being directly admitted to
the operating room for coronary artery bypass grafting.
CHIEF COMPLAINT AND PREADMISSION TESTING: Dyspnea on
exertion.
HISTORY OF PRESENT ILLNESS: Seventy-eight-year-old man with
multiple cardiac risk factors status post multiple stents in
the past. He has had increasing dyspnea on exertion and a
recent exercise tolerance test showed ST depressions.
Catheterization following exercise tolerance test revealed
50% left main with patent stents, and he was referred for
surgical management. Catheterization done [**2161-12-3**]:
50% left main; LAD, circumflex, and RCA stents all patent.
Aortic and mitral valves: Also normal. Echocardiogram data
from [**12-4**] showed an EF of 50-55%.
PAST MEDICAL HISTORY: Significant for CAD, status post
multiple stents including the RCA, LAD, and circumflex. The
RCA done in [**2161-3-15**], the circumflex and LAD done in
[**2161-6-15**]. Hypertension, hypercholesterolemia, GERD,
autoimmune hemolytic anemia, gout, chronic renal
insufficiency, osteoarthritis, and basal cell skin CA.
MEDICATIONS PRIOR TO ADMISSION: Aspirin 325 daily, Toprol XL
25 daily, Nexium 40 daily, Celebrex 200 b.i.d., Neurontin 300
b.i.d., ferrous gluconate 300 daily, Lipitor 10 daily, Plavix
75 daily, lisinopril 5 daily, prednisone 2.5 daily, MultiVite
1 daily, and colchicine 0.6 mg daily. Additionally, the
patient takes Toradol p.r.n. and sublingual nitroglycerin
p.r.n.
ALLERGIES: He has no known drug allergies.
FAMILY HISTORY: Noncontributory.
OCCUPATION: Retired from [**Company 2676**].
SOCIAL HISTORY: Remote tobacco: He quit greater than 30
years ago. One to 2 drinks per day and no IV drug use or
other recreational drug use. He lives alone.
REVIEW OF SYSTEMS: Decreased exercise tolerance due to
dyspnea. Skin: Status post removal of multiple lesions from
face and neck. Somewhat hard of hearing. Does not wear
hearing aids. Does, however, use [**Location (un) 1131**] glasses. No asthma,
COPD, or pneumonia. No cough or sputum production. No
shortness of breath or chest pain. No orthopnea or PND. No
nausea, vomiting, diarrhea, or constipation. Positive GERD.
No dyspepsia. No BPH, no frequency, incontinence. History of
OA with arthritis of the back, the knees, and the hands.
Peripheral vascular: Positive claudication on Neurontin.
Neuro: No CVA or syncope. No TIAs. Heme: No bleeding issues,
but history of autoimmune anemia.
PHYSICAL EXAM: Heart rate 84; blood pressure on the right
136/72; on the left, 124/72; respiratory rate 22; height 5
feet, 8 inches, weight 155 pounds. General: Well-appearing 78-
year-old man in no acute distress. Skin: Without lesions,
warm, and dry. HEENT: Pupils: Equally round and reactive to
light without extraocular movements intact. Neck is supple.
OP is benign; no JVD. Chest is clear to auscultation
bilaterally. Heart: Regular rate and rhythm, S1, S2 with no
murmurs, rubs, or gallops. Abdomen is soft, nontender,
nondistended with normoactive bowel sounds. Extremities are
warm and well perfused with no edema, no varicosities. Neuro:
Is alert and oriented x3. Moves all extremities. Nonfocal
exam. Pulses: Femoral: 2+ bilaterally. Dorsalis pedis: 1+
bilaterally. Posterior tibial: 1+ bilaterally. Radial: 2+
bilaterally. Carotids are without bruits.
Carotid ultrasound done in [**Month (only) 404**] showed 40-60% bilateral
stenoses.
HOSPITAL COURSE: As stated, the patient was admitted
directly to the operating room where he underwent coronary
artery bypass grafting. Please see the OR report for full
details. In summary, he had a LIMA to the LAD and a saphenous
vein graft to the OM. His bypass time was 52 minutes with a
cross-clamp time of 38 minutes. He tolerated the operation
well and was transferred from the operating room to the
cardiothoracic intensive care unit.
At the time of transfer, he was in a sinus rhythm at 90 beats
per minute with mean arterial pressure of 74 and CVP of 14.
He had epinephrine at 0.012 mcg per kilogram per minute, Neo-
Synephrine at 0.5 mcg per kilogram per minute, and propofol
at 30 mcg per kilogram per minute.
Patient did well in the immediate postoperative period. He
was weaned from his epinephrine drip. Initial attempts to
awaken the patient and wean from the ventilator were
discontinued as the patient became increasingly agitated as
the sedation was weaned to off. He, therefore, was resedated
and remained intubated throughout the night on the day of
surgery.
On postoperative day 1, patient was again attempted to be
weaned from his sedation. He, again, became agitated. It was
felt that there was a possibility the patient could be
suffering from alcohol withdrawal. At that time, a neurology
consult was obtained. They had requested a CAT scan to rule
out stroke and that was obtained, and was found to be
negative.
On postoperative day 2, it was again attempted to wean the
patient from sedation and the ventilator. He, again, became
increasingly agitated. However, during that period, the
primary team felt that the patient had decreased movement in
his left upper and lower extremities, and he was therefore
resedated with followup from neurology. Additionally, patient
had episodes of postoperative atrial fibrillation for which
he was started on amiodarone.
Postoperative day 3, the patient's central lines, Swan-Ganz
catheter was removed. His cordis was changed to a triple
lumen catheter. His chest tubes were removed. He was, again,
scheduled for a repeat CAT scan to rule out CVA. For a 2nd
time, the patient's CAT scan was negative. The sedation was
changed to Precedex following which the patient was able to
be successfully weaned from the ventilator and extubated.
Patient remained hemodynamically stable during this period.
However, his pulmonary status was somewhat tenuous and
therefore, he remained in the intensive care unit for several
days following extubation.
On postop day 5, the patient failed swallow evaluation.
Therefore, a Dobbhoff feeding tube was placed and tube feeds
were initiated. Over the next few days, the patient was
diuresed. He received vigorous chest physiotherapy. His tube
feeds were advanced to goal and on postoperative day 9, he
was transferred to the floor for continuing postoperative
course and cardiac rehabilitation.
It should be noted that during the patient's stay in the
intensive care unit, his creatinine which has a baseline of
2.3, had risen to [**Location (un) **] of 3.3 at which point the
nephrology service was consulted. Over the next several days,
the patient's creatinine returned to baseline.
Once on the floor, the patient's activity level was increased
with the assistance of the nursing staff as well as physical
therapy. By postoperative day 13, it was decided that the
patient was stable and ready to be discharged to home.
At the time of this dictation, the patient's physical
condition is as follows: Temperature 98.3, heart rate 72
sinus rhythm, blood pressure 106/57, respiratory rate 18, O2
saturation 95% on room air, weight is 66.3 kilograms; at
admission, it was 70.4 kilograms.
LABORATORY DATA: Potassium 4.3, BUN 50, creatinine 2.3.
White count 11, hematocrit 32.6.
PHYSICAL EXAM: Neuro: Alert, oriented, nonfocal exam.
Pulmonary: Scattered rhonchi. Cardiac: Regular rate and
rhythm, normal S1, S2. Sternum is stable. Incision with Steri-
Strips. No erythema. Abdomen is soft, nontender, nondistended
with normoactive bowel sounds. Extremities are warm and well
perfused with no edema. Left leg incision from endoscopic
vein harvesting with Steri-Strips and a small amount of
ecchymosis.
DISPOSITION: Patient is to be discharged home with visiting
nurses.
DISCHARGE CONDITION: Good.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery
bypass grafting x2 with a left internal mammary artery to
the left anterior descending artery and a saphenous vein
graft to the obtuse marginal.
2. Status post percutaneous coronary intervention with
stents to the left anterior descending artery,
circumflex, and right coronary artery.
3. Chronic renal insufficiency with a baseline creatinine of
2.3.
4. Autoimmune anemia.
5. Hypertension.
6. Gastroesophageal reflux disease.
7. Osteoarthritis.
8. Gout.
FO[**Last Name (STitle) 996**]P: He is to have followup in the wound clinic in 2
weeks. Follow up with Dr. [**Last Name (STitle) **] in [**12-18**] weeks. Follow up
with Dr. [**First Name (STitle) **] in [**1-16**] weeks, and follow up with Dr. [**Last Name (Prefixes) 411**] in 4 weeks.
DISCHARGE MEDICATIONS: Aspirin 81 mg daily, Plavix 75 mg
daily, Colace 100 mg b.i.d., prednisone 2.5 mg daily,
Neurontin 300 mg daily, ciprofloxacin 500 mg daily x7 days,
erythromycin 0.25-0.5 inch q.i.d. p.r.n., metoprolol 25 mg
b.i.d., amiodarone 400 mg daily x7 days, then 200 mg daily,
and Nexium 40 mg daily.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2162-2-23**] 15:50:48
T: [**2162-2-23**] 17:03:38
Job#: [**Job Number 61469**]
|
[
"E879.9",
"414.01",
"274.9",
"585.6",
"403.91",
"238.7",
"E849.7",
"530.81",
"285.9",
"427.31",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"38.93",
"36.11",
"96.6",
"99.04",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7826, 7833
|
1658, 1723
|
7854, 8687
|
8711, 9259
|
3545, 7310
|
7326, 7804
|
1259, 1641
|
1903, 2576
|
346, 886
|
909, 1226
|
1740, 1883
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,357
| 163,534
|
12585
|
Discharge summary
|
report
|
Admission Date: [**2146-3-16**] Discharge Date: [**2146-3-28**]
Date of Birth: [**2086-5-15**] Sex: M
Service: Urology
2)Blood loss anemia from hematuria
3)History of alcohol abuse
4)COPD
5)s/p CVA
7)Postoperative change in mental status
HISTORY OF PRESENT ILLNESS: The patient is a 59 year-old
male status post stroke four or five years ago with right
sided weakness. Approximately four weeks prior to admission
the patient began to notice hematuria and left flank pain and
the patient was initially worked up in an outside hospital.
stone was seen. The MRI showed a questionable left renal
vein thrombosis and the patient was transferred to [**Doctor First Name **]
evaluation.
PAST MEDICAL HISTORY: Significant for:
1. Hypertension.
2. Smoking one half pack for 40 years.
3. COPD.
4. Alcohol abuse.
HOME MEDICATIONS:
1. Restoril 20 milligrams po q day.
2. Elavil 250 milligrams po q day.
3. Aspirin.
HOSPITAL COURSE: The patient was admitted on [**2146-3-16**].
After admission the patient underwent cystoscopy to evaluate
his hematuria. Bladder biopsies and retrograde pyelogram were
performed. The patient had an MRI, which more clearly showed a
lower pole renal mass. The patient was taken to the
operating room on hospital day three for a left
nephroureterectomy.
On postoperative day one the patient was placed in the ICU
and the patient was extubated on postoperative day one. The
patient had a chest tube and Foley catheter. After extubation
the patient was transferred onto the floor without any
incidents. However the patient's course was somewhat
complicated.
On postoperative day two when during the day the patient
developed agitation and desaturation down to 77% after
pulling his chest tube. At that time EKG was obtained and
serial cardiac enzymes were cycled. It appeared his cardiac
enzymes had elevated. The patient appeared to have suffered
a non-Q wave acute myocardial infarction. Cardiology was
consulted. They recommended cardiac echo which done which is
showing the patient to have a ejection fraction of 30% and
some global hypokinesis. Under Cardiology recommendations
Captopril was started and Norvasc and Lopressor were started
for patient's blood pressure control and heart rate control.
On postoperative day four due to patient's labile blood
pressure the patient was transferred into the ICU for another
additional day and on the following day the patient's
condition was stabilized and transferred back on to the
floor. Since then the patient has been stable. Epidural was
discontinued. The patient regained his previous mental
status.
On postoperative day four his cardiac enzymes level has begun
to trend down. Daily serial EKGs showed no change. The
patient began to pass gas and having bowel movements. The
patient was placed on a regular diet. A repeat chest x-ray
showed the left apical pneumothorax as getting smaller.
Chest tube was discontinued on postoperative day six. A
chest x-ray following the chest tube discontinued showed
pneumothorax had resolved. The patient was placed on a
regular diet. Foley catheter was discontinued on
postoperative day six however due to failure to void the
patient's Foley catheter was placed back on postoperative day
seven. At this point the patient is deemed ready for
discharge to a rehabilitation facility.
Prior to discharge the patient was afebrile. Vital signs are
stable. Chest was clear to auscultation bilaterally. Heart
was regular rate and rhythm. The incision was clean, dry and
intact. Staples were in place. The patient was tolerating a
regular diet and has been passing gas. The patient will be
discharged with a Foley catheter due to his difficulty to
void. The patient will be instructed to have Foley catheter
voiding trial again in a few days at the rehabilitation
facility.
DISCHARGE MEDICATIONS:
1. Restoril 20 milligrams po q day.
2. Elavil 250 milligrams po q day.
3. Aspirin 325 milligrams po q day.
4. Lopressor 100 milligrams po bid.
5. Captopril 50 milligrams po tid.
6. Norvasc 5 milligrams po q day.
7. Tylenol #3 one to two tabs po q four to six hours prn.
No narcotics due to patient's profound sedation to narcotic
agents.
DISCHARGE INSTRUCTIONS: The patient is to follow up with Dr.
[**Last Name (STitle) 9125**] in one to two weeks. The patient is to be discharged
with a Foley catheter. The Foley catheter can be removed at
the rehabilitation facility in a few days. The patient can be
on for another voiding trial.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(1) 13269**]
Dictated By:[**Name (STitle) **]
MEDQUIST36
D: [**2146-3-28**] 11:51
T: [**2146-3-28**] 12:03
JOB#: [**Job Number 38936**]
|
[
"512.1",
"189.0",
"496",
"410.91",
"E878.8",
"401.9",
"997.1",
"599.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"87.74",
"57.33",
"55.51",
"56.0"
] |
icd9pcs
|
[
[
[]
]
] |
3903, 4250
|
1004, 3880
|
4275, 4837
|
899, 986
|
336, 753
|
776, 881
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,510
| 153,578
|
30003
|
Discharge summary
|
report
|
Admission Date: [**2137-3-28**] Discharge Date: [**2137-4-3**]
Date of Birth: [**2110-7-1**] Sex: M
Service: MEDICINE
Allergies:
Latex / Oxycodone
Attending:[**First Name3 (LF) 2159**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
bronchoscopy
History of Present Illness:
26 yo M with h/o asthma now admitted for persistent dyspnea. Pt
was recently admitted to hospital in [**State 3914**] with dyspnea which
was thought to be due to asthma exacerbation. However, he did
not improve with standard therapies and a bronchoscopy was
performed which was very difficult but did not show clear
tracheobronchomalacia but did show possible vocal cord
dysfunction. (Of note, pt required extremely heavy doses of
versed and fentanyl to be able to tolerate bronch). He did seem
to improve with Bipap. He was discharged home but has continued
to have severe dyspnea. Per pt he is not able to lie flat and
continues to be tachypneic. On DOA he had an appointment with IP
at [**Hospital1 18**] for a consult given the abnormal bronch findings. He
arrived in the IP suite but was felt to be too tachypneic to
tolerate bronch. Plan is to admit to MICU overnight to start pt
on BiPAP and check ABG with future plans to bronch in next few
days. Of note, per pulmonary fellow once patient was given plan
of being admitted and was asked to wait for MICU bed he appeared
much less tachypneic and seemed comfortable with breathing.
.
Per patient his SOB began about 3 weeks ago whe he was
increasing using his albuterol inhaler. He notes that he has
has asthma all of his life, but never been intubated. He
outpatient doctor started him on prednisone but his SOB was so
bad that he presented to the ED in [**State 3914**]. There is was
hospitalized for and underwent 3 brochcoscopies, and CTA for PE
x2 which were negative per patient. He was discharged from OSH 3
days ago with no improvement as mentioned above.
.
Currently he feels SOB and complains of right sided pain that
radiates to his back with every inspiration. His pain is well
controlled with morphine.
Social History:
Lives in [**State 3914**]. Works as a mechanic. Denies smoking. Has used
chewing tobacco. No other drug use.
Family History:
No history of asthma or other lung problems
Physical Exam:
General: AAOx3, tachypneic, not able to speak in full sentences
with doing nebulizer treatment
Vitals: T 96 BP 132/92 HR 86 RR 40 O2 sats 99% on RA
HEENT: MMM, OP clear, PERRL
Neck: supple, LAD
CV: RR, tachycardic, no m/g/r
Pulm: wheezes, upper airway more than lower, no crackles
Chest: No tenderness on palpation of right sided ribs of CVAT
Abd: + BS, soft, NT/ND
Ext: race edema at ankles, warm, well perfused
Neuro: AAOx3, CN II-XII intact, strength in upper and lower
extremities [**4-27**] and equal
Pertinent Results:
cxr [**2137-3-31**]: FINDINGS: There continues to be subsegmental
atelectasis in the left lower lobe but no focal infiltrate.
There is a small left effusion that is new compared to the prior
study.
.
[**2137-3-29**] bronchoscopy
IMPRESSION:
1. Normal vocal cord motion.
2. No evidence of tracheobronchial malacia.
3. Diffuse erythema of the airways.
.
.
labs on [**Last Name (un) **]
Brief Hospital Course:
26 yo M with h/o asthma now with persistent dyspnea and
tachypnea wheezing and pleuritic right sided chest pain
.
# Dyspnea/Asthma: His dyspnea was related to severe asthma
exacerbation with unclear precipitant. Patient was admitted to
MICU for overnight observation and was put on BiPAP with good
response. He was given solumedrol 120 Q6, advair and albuterol
with good response. He underwent bronchoscopy on [**2137-3-29**] which
showed erythematous mucosa and no tracheobronchomalacia and
normal vocal cords. The patient had no issues in the MICU and
was transferred to medicine. On the floor the patient denied
dyspnea and was doing well on steroids. He was continued on a
steroid taper including IV methylprednisolone 80 mg IV q 6, 40
mg IV q 6 x 1 day, 20 mg IV Q6H x 1 day and then 80 mg PO daily
for discharge (with PO prednisone taper written out at end of
this summary). The patient remained stable on steroids, advair,
albuterol and accolate. Per pulmonary, his work as mechanix may
also exacerbate his asthma as well as GERD. He was taught to use
a peak flow meter and will need to have his RAST and IGE
followed as an outpatient. He will need close follow-up by
pulmonary at discharge. It was recommended that Zolair can be
tried as an outpatient. He was also started on bactrim for PCP
prophylaxis while on high dose steroids. IGE was elevated at 192
(range 0-114) at discharge.
.
# back pain: The patient had paraspinal back pain with no
spinous tenderness. The pain was positional and improved with
heating pad application; he was weaned off morphine and he was
comfortable on NSAIDs, tylenol, and flexeril. No clinical
evidence to suggest nephrolithiasis or more concerning
etiologies. He was continued on tylenol and flexeril for two
more days.
.
# h/o atopy: This could be related to a reaction to some
environmental factor so the patient was advised to have an
outpatient allergy evaluation, and was started on nasal
steroids. Of note, IgE returned elevated, and will require
further follow up. Out patient serum aspergillus preciptins
testing should be pursued, in addition to evaluation for ABPA.
.
# HTN: Pt's BP was between 122-150 systolic and 60 - 89
diastolic, on the day of discharge: 137/72. This could be
related to the intensive treatment with steroids in addition to
pain. However, as pt states, that prior to this exacerbating
event, an elevated BP was measured, so pt was suggested to have
an outpatient HTN evaluation after he is off steroids.
.
# Hyperglycemia:
Pt developed elevated blood sugar levels while on steroid
treatment and recieved ISS. Along with the continuation of
steroid taper on an oral base, pt will need daily FS and in case
blood sugar > 200, pt will require appropriate application of
Insulin SQ. Therefore, pt recieved education concerning FS and
insulin injection. As an underlying glucose intolerance cannot
be ruled out completely, a followup and fasting glucose level is
recommended on an outpatient base after steroid taper has been
stopped.
.
# Elevated ALT:
During stay on [**Hospital1 **], elevated ALT level was noticed (initially,
ALT 81 IU/l finally 69 IU/l), further liver tests were within
the normal range. Re-evalutaion of this parameters can be
considered on an outpatient base after he is off steroids.
.
# Elevated WBC/elevated BUN:
Pt developed increased WBC and slightly elevateed BUN. Both
findings were attributed to the steroid treatment.
.
.
ISSUES for OUTPATIENT FOLLOW-UP
.
1) Steroid Taper: Plan for taper is as follows:
- Prednisone 80 mg QD X 5 days (start [**4-3**]- [**4-7**])
- Prednisone 60 mg QD X 5 days ([**4-8**] - [**4-12**])
- Prednisone 40 mg QD X 5 days ([**4-13**]- [**4-17**])
- Prednisone 20 mg QD X 5 days ([**Date range (1) 71614**])
- Prednisone 10 mg QD X 5 days ([**Date range (1) 71615**])
- Prednisone 5 mg QD X 5 days ([**4-28**] - [**5-2**])
.
2) Hyperglycemia [**1-25**] steroids: Pt will need daily FS checks. If
blood sugar greater than 200, he will need SQ insulin. Teaching
and appropriate scripts were given to patient. PCP should
[**Name9 (PRE) 702**] regarding fasting BS once off steroids.
.
3) Asthma:
- Pulmonary consult recommended checking RAST as outpatient.
- Pt will need referral from PCP regarding local asthma clinic
and continued teaching
.
4) PCP should check LFT's, blood pressure, fasting glucose once
off steroids.
Medications on Admission:
Advair 500/50 [**Hospital1 **]
Duonebs PRN
Albuterol PRN
Prednisone taper
Accolate 20 mg PO BID
Discharge Medications:
1. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day): advair.
Disp:*60 Disk with Device(s)* Refills:*2*
2. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2)
Spray Nasal DAILY (Daily): flonase.
Disp:*1 bottle* Refills:*1*
3. Accolate 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) inhaler
Inhalation twice a day as needed for shortness of breath or
wheezing.
Disp:*1 inhaler* Refills:*5*
6. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for back pain for 2 days.
Disp:*6 Tablet(s)* Refills:*0*
7. Prednisone 20 mg Tablet Sig: as directed Tablet PO DAILY
(Daily): Prednisone 80 mg (4 tablets) QD X 5 days (start [**4-3**]-
[**4-7**]); 60 mg QD X 5 days ([**4-8**] - [**4-12**]); 40 mg QD X 5 days ([**4-13**]-
[**4-17**]); 20 mg QD X 5 days ([**Date range (1) 71614**])
.
Disp:*50 Tablet(s)* Refills:*0*
8. Prednisone 5 mg Tablet Sig: as directed Tablet PO once a day
for 2 weeks: Prednisone 10 mg (2 tablets) ([**Date range (1) 71615**]); then 5 mg
QD X 5 days ([**4-28**] - [**5-2**])
.
Disp:*15 Tablet(s)* Refills:*0*
9. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
10. Insulin Regular Human 100 unit/mL Cartridge Sig: 1-16 units
Injection twice a day: as directed. please see sliding scale.
Disp:*1 bottle* Refills:*2*
11. Insulin Syringe Syringe Sig: One (1) syringe
Miscellaneous twice a day.
Disp:*qs qs* Refills:*2*
12. Insulin Needles (Disposable) Needle Sig: One (1) needle
Miscellaneous twice a day: as directed.
Disp:*qs qs* Refills:*2*
13. Lancets & Blood Glucose Strips Combo Pack Sig: One (1)
Miscellaneous twice a day: please use as directed. .
Disp:*qs qs* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Asthma
2. Steroid induce hyperglycemia
3. musculoskeletal back pain
4. hypertension (steroid induced)
Discharge Condition:
stable, tolerating medications.
Discharge Instructions:
You were admitted for severe asthma exacerbation, and will need
close follow-up. You will continue all home meds, except you
are now on a higher dose of prednisone, flonase and
pantoprazole.
.
You will need to monitor your peak flow at home and need close
follow-up with your pulmonologist, primary care doctor and will
likely need allergy evaluation as well.
.
We have started you on some new medications. Please take all
medications as prescribed:
1) Prednisone Steroid Taper: Plan for taper is as follows:
- Prednisone 80 mg QD X 5 days (start [**4-3**]- [**4-7**])
- Prednisone 60 mg QD X 5 days ([**4-8**] - [**4-12**])
- Prednisone 40 mg QD X 5 days ([**4-13**]- [**4-17**])
- Prednisone 20 mg QD X 5 days ([**Date range (1) 71614**])
- Prednisone 10 mg QD X 5 days ([**Date range (1) 71615**])
- Prednisone 5 mg QD X 5 days ([**4-28**] - [**5-2**])
.
2) Bactrim: an antibiotic while you are high dose steroids
3) Albuterol MDI, Advair, and Montelukast asthma medications.
.
.
Notify your doctor or go the the emergency room if you have any
fevers, chills, chest pain, dizziness, shortness of breath,
wheezing, chest tightness and any worrisome symptoms.
.
Please make all necessary follow-up appointments.
Followup Instructions:
1. Please follow up with your primary doctor in 1 week call
[**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 71616**] for the appointment.
2. Follow-up with your pulmonologist in 1 week.
3. Follow-up with allergy testing as an outpatient.
|
[
"401.9",
"511.9",
"724.5",
"493.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
9840, 9846
|
3245, 7601
|
284, 299
|
9995, 10029
|
2834, 3222
|
11291, 11596
|
2245, 2290
|
7747, 9817
|
9867, 9974
|
7627, 7724
|
10053, 11268
|
2305, 2815
|
237, 246
|
327, 2103
|
2119, 2229
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,499
| 114,114
|
50591
|
Discharge summary
|
report
|
Admission Date: [**2102-3-28**] Discharge Date: [**2102-3-30**]
Date of Birth: [**2041-6-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1646**]
Chief Complaint:
suicide attempt, EtOH withdrawal
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 23815**] is a 60 year old male with a history of depression,
anxiety, substance use, HCV, and prior suicide attempts who
presents with alcohol withdrawal after a suicide attempt earlier
today. He ran out of his psychiatric medications two weeks ago
and has felt increasingly suicidal since. He attempted to hang
himself with a belt from the ceiling and after kicking the chair
out from under himself the ceiling fell and he landed on the
ground. He then called a cab to bring him to the ED. He normally
drinks a quart to a half gallon of liquor. He drank about a
quart this morning. He endorses prior history of DTs and
seizures with alcohol withdrawal.
.
In the ED, initial vs were: Pain 0, T 98.8, HR 97, BP 180/111,
RR 22, O2 sat 98% RA. He was noted to have anisocoria and to be
tremulous. He had no dysphonia or dysphagia. Imaging of the head
and neck showed no fracture, ICH, or arterial abnormalities.
Patient was given valium 10 mg IV x 2 and 5 mg IV x 2. Vital
signs on transfer were: HR 81, BP 154/93, RR 13, 100%RA. He was
admitted to the ICU due to concern for severe alcohol
withdrawal.
.
On arrival to the ICU, the patient was tremulous and stated that
he felt so bad that he wanted to die. Later he denied any desire
to kill himself and stated that he simply wanted help.
.
Review of sytems:
(+) Per HPI. +2/10 chest pain and [**2102-3-30**] abdominal pain. +
chills, + shortness of breath. + pain with urination.
(-) Denies fever, recent weight loss or gain. Denies headache,
sinus tenderness, rhinorrhea or congestion. Denied cough. Denied
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. Denied arthralgias or
myalgias. No intercourse x 7 years.
.
Past Medical History:
1. Reiter's syndrome
2. HCV
3. Hx IVDU, in methadone program, recent relapses
4. Hx Suicidality
5. Depression and anxiety
6. Mitral valve prolapse
7. Osteoarthritis, chronic pain
8. Hypertension
9. Bell's palsy
10. s/p Left lis franc ORIF
Social History:
Lives alone. Former nurse, currently on disability. No tobacco.
[**1-30**] - [**1-28**] gallon EtOH daily. Denies recent ilicit drug use but
has past history of heroin use. States he bought klonopin 2 mg
#15 tabs off the street and took them all this past weekend to
"help me come down".
Family History:
Mother had an alcohol problem until she was 48 and has since
been sober. Mother also had colon cancer. Per OMR, depression in
maternal relatives.
Physical Exam:
Vitals: T: 96.2 BP: 140/101 P: 82 R: 15 O2: 100% RA
General: Middle-aged Caucasian male, tremulous, appears
uncomfortable.
HEENT: Sclera anicteric, MM dry, oropharynx with thick, dry
secretions.
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: +BS, soft, mildly tender periumbilically and in the
epigastrium, no rebound tenderness or guarding
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&O, CNII-XII intact, PERRL (4->2), moves all extremities
Psych: Responds minimally to questions. ??????I feel like I??????m
crawling out of my skin??????. Appears depressed. Endorses SI.
Exam on discharge 97.0 102/68 83 18 95RA
minimal tremulousness, abd soft and NT. awake, alert, and clear
thinking.
Pertinent Results:
[**3-28**] CT C-spine: IMPRESSION: No evidence of acute fracture.
[**3-28**] CT non-contrast head: IMPRESSION:
1. No acute intracranial process.
2. Mild paranasal sinus disease.
[**3-28**] CTA neck: Pending
[**3-28**] CXR: Pending
[**2102-3-28**] 12:53PM BLOOD WBC-7.8 RBC-3.97* Hgb-12.2* Hct-34.9*
MCV-88 MCH-30.7 MCHC-35.0 RDW-14.4 Plt Ct-230
[**2102-3-28**] 12:53PM BLOOD Neuts-78.4* Lymphs-16.3* Monos-3.1
Eos-1.9 Baso-0.2
[**2102-3-28**] 12:53PM BLOOD Glucose-87 UreaN-19 Creat-1.1 Na-141
K-3.6 Cl-106 HCO3-22 AnGap-17
[**2102-3-28**] 12:53PM BLOOD ALT-14 AST-23 CK(CPK)-231 AlkPhos-65
Amylase-53 TotBili-0.4
[**2102-3-28**] 08:56PM BLOOD CK(CPK)-144
[**2102-3-29**] 03:44AM BLOOD CK(CPK)-88
[**2102-3-28**] 12:53PM BLOOD Lipase-20
[**2102-3-28**] 12:53PM BLOOD CK-MB-3 cTropnT-<0.01
[**2102-3-28**] 08:56PM BLOOD CK-MB-3 cTropnT-<0.01
[**2102-3-29**] 03:44AM BLOOD CK-MB-2 cTropnT-<0.01
[**2102-3-29**] 03:44AM BLOOD Calcium-8.1* Phos-4.2 Mg-2.0
[**2102-3-28**] 12:53PM BLOOD ASA-NEG Ethanol-34* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2102-3-28**] 03:35PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-POS
[**2102-3-28**] 03:35PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-5.0 Leuks-NEG
[**2102-3-28**] 03:35PM URINE RBC-0-2 WBC-0 Bacteri-NONE Yeast-NONE
Epi-0
Brief Hospital Course:
This is a 60 year old male with a history of depression,
anxiety, and substance use who presents with alcohol withdrawal
after an attempted suicide by hanging now with chest pain and
abdominal pain.
# Alcohol withdrawal. On arrival to the [**Hospital Unit Name 153**], patient was
uncomfortable, but not tachycardic. He was given valium 10mg
IV, then valium 10mg PO q1hr for CIWA >10. [**Last Name (un) **] received 5 doses
of PO valium for a total of 50 mg o/n. In the morning, he
appears more comforatble and he was normotensive and not
tachycardic. His dose was decreased to 5mg PO q2hr for CIWA >
10. At the time of discharge on valium 5 q6 with q3 prn. Still
no significant s/s of DT's. Only experiencing anxiety. Social
work was consulted.
# Suicidal ideation/depression. Patient s/p suicide attempt. Has
prior history of suicide attempts. This decompensation appears
to be associated with running out of his psych meds. He has no
current prescriber or psychiatric follow-up despite attmpts from
psychiatry to arrange outpatient follow up for him. A 1:1
sitter attended the patient overnight. His bupropion,
venlafaxine, valproate, trazodone and benadryl were held, and he
was given his home risperdone 3mg PO. Psychiatry was consulted
to help advise regarding psych meds. Risperdal was continued,
all other meds held. Transfer to [**Hospital1 **] 4 completed on [**3-30**].
# Chronic pain/methadone use - Patient not endorsing significant
pain currently. He was given his home dose of methdone that was
confirmed with his methadone clinic. Neurontin was held on
admission and it was planned to discuss dosing with psychiatry.
Baycove was called and confirmed his dose of 74mg methadone
daily (can be given in divided doses [**Hospital1 **]).
# Chest pain - EKG unremarkable. Differential included cardiac
vs. GI vs. vascular. Cardiac biomarkers were negative x 3. CXR
was unremarkable. Given EtOH history, it was thought that this
was likely GI related and he was treated with prn maalox with
resolution of his symptoms. He was on a home dose of aspirin of
325 mg. On review of his records I could find no indication for
this. He has never had a stroke, MI, or AF. His simvastatin dose
should remain at 80 mg, but can be held until discharge home.
# Dysuria - There was no evidence of UTI on UA. Patient has not
been sexually active recently. Dysuria could be secondary to
Reiter's syndrome given [**Hospital 228**] medical history.
# Anemia - Patient's Hct was at baseline, stable throughout his
ICU stay. Prior iron/folate/b12 studies were normal.
Code: FULL CODE
DISPO: to [**Hospital1 **] 4
Medications on Admission:
Bupropion HCl SR 150 mg daily
Divalproex 500 mg TID
Gabapentin [Neurontin] 800 mg TID
Ibuprofen 800 mg TID - not taking
Ketoconazole [Nizoral] 2 % Shampoo daily - not using
Methadone 10 mg/mL Concentrate 3.4 mL(s) daily (74 mg daily per
patient)
Omeprazole 40 mg daily
Risperidone 3 mg QHS
Simvastatin 80 mg QHS
Trazodone 100 mg QHS - not taking
Venlafaxine [Effexor XR] 225 mg daily
Aspirin 325 mg daily
Diphenhydramine HCl 25-50 mg QHS - not taking
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Risperidone 2 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
4. Methadone 10 mg Tablet Sig: Seventy Five (75) MG PO DAILY
(Daily): can be given in divided doses.
5. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day:
to be restarted at the time of discharge.
7. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
8. Valium 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours: with taper.
9. Valium 5 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for anxiety, s/s of etoh w/d.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnosis: 291.0 DRUG WITHDRAWAL, ALCOHOL W/ DELERIUM
TREMENS
Secondary Diagnosis: 311 DEPRESSION, NOS
Secondary Diagnosis: V62.84 SUICIDAL IDEATION
Secondary Diagnosis: 789.04 PAIN, ABDOMINAL-LLQ
Secondary Diagnosis: 285.9 ANEMIA, UNSPECIFIED
Secondary Diagnosis: 099.3 REITER'S SYNDROME
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
Patient being discharged to [**Hospital1 **] 4. Home discharge instructions
to be completed at a later date.
Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2102-4-20**] at 1:45 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: MONDAY [**2102-6-5**] at 10:00 AM
With: [**Name6 (MD) 13978**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"789.04",
"285.9",
"291.0",
"099.3",
"E953.0",
"V62.84",
"424.0",
"788.1",
"311",
"338.29",
"304.71",
"715.90",
"070.70"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9050, 9065
|
5144, 7763
|
347, 353
|
9406, 9406
|
3769, 5121
|
9687, 10283
|
2711, 2859
|
8265, 9027
|
9086, 9086
|
7789, 8242
|
9554, 9664
|
2874, 3750
|
275, 309
|
1710, 2127
|
381, 1692
|
9359, 9385
|
9105, 9156
|
9421, 9530
|
2149, 2390
|
2406, 2695
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,245
| 119,348
|
45611
|
Discharge summary
|
report
|
Admission Date: [**2200-11-29**] Discharge Date: [**2200-12-8**]
Date of Birth: [**2132-7-30**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base / Demerol / Ceftriaxone
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Altered mental status and hypertension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 68 year old female with past medical history of
multiple MDR infections/sepsis in multiple sources (VRE, ESBL,
C. glabrata and parapsilosis in urine, blood, joints),
metatstatic ovarian cancer with liver mets s/p XRT and chemo c/b
radiation-induced enteritis and multiple admissions for SBOs as
well as chemotherapy-associated cardiomyopathy (EF of 50% in
[**11-4**]), presents from her rehabilitation center with increased
confusion and hypertensive urgency (BPs 200s/100s). She suffers
from chronic abdominal pain and was given Dilaudid before
becoming somnolent. She was given Narcan 0.4 mg x 2 and
lopressor 5mg x 1 at the rehab and slightly improved. The
patient recently finished a course of Linezolid at the rehab on
[**11-23**] for VRE.
.
In the ED, her initial VS were P 68, BP 192/116, R 12, O2 100%.
She was put on a nitro gtt briefly, with a rapid response of her
BP to 127/74 with a HR of 74. EKG showed NSR, ST dep v3-v5, I.
She was given Narcan 2 mg x 1 with minimal improvement in mental
status. Imaging - CT head was negative, KUB showed dilated loops
of bowel and SBO could not be excluded, but her abdominal pain
improved as she woke up more.
.
The patient was initially admitted to the floor and quickly
transferred to the MICU for an acute worsening of her mental
status and BP of 70/dopplerable. In the MICU, the patient
became progressively oliguric, but renal U/S was negative. Her
blood pressure responded well to fluids and she became
hypertensive, prompting administration of labetalol and
hydralazine for better control with return of urine output, but
transient bradycardia. Further work-up of her hypotension
included a CXR showing multifocal opacities and CT scan with ?
consolidation. Her urine culture grew E.coli once again and she
was started on linezolid and meropenem for suspected ESBL
organisms. She has not had any respiratory issues. Her Hct has
been dropping (13 pts in total from admission), stool guaiac
neg. CT abdomen did not show an RP bleed. She is s/p 1 unit
yesterday and Hct is at baseline in mid 20s and now stable. She
has never been febrile and her mental status has remained
stable.
.
Upon transfer to the floor, vitals are 97.1, 159/76, 84, 19 and
100%RA. She continues to have diffuse abdominal pain and is
experiencing increased RUE swelling, so much so that she cannot
wear her watch anymore. She reports watery diarrhea, worse over
the last 4 days than her chronic diarrhea, as well as 4 days of
burning/frequency on urination. She is alert and oriented, but
tearful about her illnesses. She has lost 60 lbs over the last
2 years due to her chronic diarrhea.
.
Review of systems:
(+) Per HPI
(-) [**Month/Year (2) 4273**] [**Month/Year (2) **], chills, night sweats, recent gain. [**Month/Year (2) 4273**]
headache, sinus tenderness, rhinorrhea or congestion. Denied
cough, shortness of breath. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting. Denied arthralgias or
myalgias.
.
Past Medical History:
*GI
- multiple admissions (reportedly ~ 100) for partial SBO,
usually managed conservatively, most recently [**2200-6-8**] - [**2200-6-15**]
.
*ID
- Recent hip fracture [**1-28**] MSSA osteomyelitis on [**2200-3-31**],
on daptomycin for 6 weeks, recently discharged from
rehabilitation in early [**Month (only) **]
- h/o MRSA bacteremia ([**4-4**]), ([**6-4**]), ([**11-4**]), complicated by
L2-L3 discitis/osteomyelitis, failed 4 month course of
vancomycin, resolved with surgical intervention with L2, L3
partial corpectomy/debridement on [**2199-11-19**] followed by 3 month
course of vancomycin
- C. Glabrata sepsis [**10-5**]
- C.diff colitis [**2200-4-7**], neg C.diff toxin [**2200-6-11**]
- C.parapsilosis line-associated BSI ([**8-/2199**])
- P.vulgaris pyelonephritis w/ bilat hydronephrosis dx [**12/2199**],
treated with meropenem --> ciprofloxacin
.
*Heme/Onc
-Ovarian cancer: Dx in [**2175**], stage IV metastatic to liver, s/p
TAH-BSO, adriamycin and XRT
-Iron deficiency anemia
-h/o RUE brachial thrombus, PICC associated, in [**2199-4-11**]
-h/o LUE DVT
.
*CV
-Chemotherapy-associated cardiomyopathy, last ECHO in
[**11-4**] with EF of 50%
-s/p left MCA CVA (on warfarin) - [**7-/2200**]
-Hyperlipidemia
.
*Other
-Chronic kidney disease (baseline Cr 1.3-1.5)
-Osteoporosis
-Hypothyroidism
-Depression
-tonsillectomy, adenoidectomy
-appendectomy
Social History:
Patient currently in a rehab. Formerly lived with her husband,
has 2 grown sons, and 3 grandchildren. She was a nurse until 6
months ago. She is a remote smoker. No etoh, recreational drug
use. Walks with a walker at baseline secondary to hip pain.
Family History:
Breast cancer in maternal grandmother. Prostate cancer in
maternal grandfather.
Physical Exam:
On transfer to medical floor (from ICU)
.
VS: T 97.1, BP 159/76, HR 84, RR 19 and 100% on RA
GA: AOx3, NAD
HEENT: PERRLA, EOMI, mild proptosis, MMM, oropharynx clear
Neck: no LAD, minimal JVD, +thyromegaly (R lobe > L)
CV: RRR, nl S1/S2, no m/r/g
Pulm: decreased air entry and rales at the bases B/L
Abd: +BS, soft, diffusely tender, no rebound/guarding
Extremities: hands/feet cool, with marked RUE edema and no LE
edema, DPs and radials 2+.
Skin: no rashes/lesions
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
sensation intact to LT in all 4 extremities. cerebellar fxn and
gait not assessed
Pertinent Results:
Labs on admission:
.
[**2200-11-29**] 02:00PM BLOOD WBC-11.7* RBC-4.17* Hgb-12.0 Hct-35.5*
MCV-85 MCH-28.9 MCHC-34.0 RDW-15.0 Plt Ct-394
[**2200-11-29**] 02:00PM BLOOD Neuts-70.4* Lymphs-24.9 Monos-3.6 Eos-0.5
Baso-0.7
.
[**2200-11-29**] 02:00PM BLOOD Glucose-114* UreaN-21* Creat-1.5* Na-130*
K-4.4 Cl-91* HCO3-23 AnGap-20
.
[**2200-11-29**] 02:00PM BLOOD ALT-11 AST-19 AlkPhos-95 TotBili-0.3
.
[**2200-11-29**] 08:16PM BLOOD CK(CPK)-12*
[**2200-11-29**] 02:00PM BLOOD cTropnT-0.01
[**2200-11-29**] 08:16PM BLOOD CK-MB-3 cTropnT-0.02*
[**2200-11-30**] 03:44AM BLOOD CK-MB-3 cTropnT-0.01
.
[**2200-11-29**] 02:00PM BLOOD Calcium-10.4* Phos-2.2* Mg-1.4*
.
Labs on discharge:
.
[**2200-12-6**] 06:34AM BLOOD WBC-10.4 RBC-3.46* Hgb-10.1* Hct-29.8*
MCV-86 MCH-29.0 MCHC-33.8 RDW-15.6* Plt Ct-458*
[**2200-12-6**] 06:34AM BLOOD PT-22.5 --> 19.4*, PTT-38.5*, INR(PT)-
2.1 --> 1.8*
[**2200-12-6**] 06:34AM BLOOD Glucose-87 UreaN-12 Creat-1.4* Na-133
K-4.1 Cl-100 HCO3-25 AnGap-12
[**2200-12-6**] 06:34AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.2*
.
Microbiology:
Urine cx ([**2200-11-29**]): ESCHERICHIA COLI.
SENSITIVITIES: MIC expressed in MCG/ML
________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
Blood cultures and fungal cultures - no growth to date
.
C. diff toxin - negative
.
Imaging:
.
CXR ([**11-29**]):
IMPRESSION: No evidence of acute cardiopulmonary process.
.
CT Head ([**11-29**]):
IMPRESSION: No acute intracranial process.
.
Abdominal XR ([**11-29**]):
IMPRESSION: Mildly dilated loop of small bowel in the left
hemiabdomen with paucity of gas in distal bowel. A small bowel
obstruction is not excluded. Consider CT for further evaluation.
.
Renal U/S ([**11-30**]):
IMPRESSION:
1. No hydronephrosis or stones. There is minimal prominence of
the right
renal pelvis.
2. Normal Doppler arterial and venous waveforms in the bilateral
main renal artery and vein.
.
CT abdomen/pelvic ([**12-1**]):
IMPRESSION:
1. No evidence of hematoma to explain the patient's hematocrit
drop.
2. Small right and trace left pleural effusions with patchy
bibasilar
opacities which may represent atelectasis or
aspiration/pneumonia.
3. Slightly improved anasarca.
4. Moderate dilation of the small bowel with thickening of the
small bowel
folds, which may be due to edema given the patient's anasarca,
though the
differential is broad. Recommend an exam with oral and IV
contrast when
feasible.
.
CXR ([**12-1**]):
There are multiple new opacities seen in the lungs that might be
worrisome for multifocal infection in the right lower lobe and
left lower lobe.
Cardiomediastinal silhouette is unchanged. There is no pleural
effusion or
pneumothorax. The left PICC line tip is at the level of superior
mid SVC.
Brief Hospital Course:
68 year old female with history of multiple MDR
infections/sepsis in multiple sources (VRE, ESBL, C. glabrata
and parapsilosis in urine, blood, joints), radiation-induced
enteritis c/ chemotherapy-associated cardiomyopathy and chronic
diarrhea/malabsorption, presents from her rehabilitation center
with increased confusion and hypertensive urgency (BPs
200s/100s), with development of labile BPs, E.coli UTI, multiple
lung opacities, currently on Meropenem (UTI) / Linezolid (?PNA).
.
** FOR ABBREVIATED MICU COURSE, PLEASE SEE HPI **
.
# ID: Urine culture grew ESBL E. coli, highly sensitive to
meropenem. Patient was started on meropenem in the MICU due to
her presentation of acute change in mental status and she was
continued on meropenem on the floor. On her CXR before leaving
the MICU, right and left lower lobe opacities were concerning
for PNA and ?aspiration. Patient developed cough with
productive sputum and low-grade [**Month/Day (4) **], so linezolid was
continued. Sputum cultures were ordered, but patient was unable
to produce a sputum to send to the lab. Antibiotic regimen of
meropenem/linezolid continued during the hospitalization. She
will continue on meropenem only for 3 more days upon discharge.
All blood cultures, repeat urine cultures, and C. diff toxins
were negative to date.
.
# Labile blood presures: While in the MICU, the patient's blood
pressures were quite labile and highly sensitive to AV nodal
blockers (labetalol) with resulting bradycardia and hypotension.
She was discontinued on all anti-hypertensives upon transfer to
the floor since she became oliguric while hypotensive in the
MICU. Her blood pressures were mostly elevated on the floor and
she was uptitrated slowly on Captopril to 25mg TID for
longer-term BP control without concern for bradycardia. Over
the few days leading to her discharge, she had much fewer
episodes of SBPs to 190s and were mostly between the 120s to
160s, signifying much improved control.
.
#. Abdominal pain and diarrhea: Chronic issue [**1-28**] radiation
enteritis. Previous GI consult recommended continuing course of
opium tincture and lomotil and this was continued on the
hospitalization. Infectious diarrhea quite unlikely, and C.
diff was negative. Her abdominal pain and diarrhea continues on
discharge, with pain controlled with IV dilaudid every 3 hours.
She did not tolerated PO dilaudid.
.
#. Hyponatremia: Stable around low 130s. Patient appeared
euvolemic on exam and was likely not hypovolemic, given her good
PO intake. Uosms = 126 with urine Na of 47 usually indicates
polydipsia, but fluid restriction did not correct serum sodium
levels. It is unlikely to be due to lack of Na+ intake, since
she would be more sodium avid. She continues to remain
asymptomatic, but any future mental status could potentially be
due to a dropping serum sodium and it should be monitored.
.
# Mental status changes: Her initial presentation of mental
status changes were likely secondary to hypoperfusion, opioid
overdose (given her response to Narcan), and possibly UTI. Her
sensorium was clear for the remainder of her hospitalization
Currently clear mental status, on antibiotic course.
.
Medications on Admission:
REHAB MEDICATIONS:
Dronabinol 2.5mg [**Hospital1 **]
Carvedilol 25 mg PO BID
-Heparin Flush (10 units/ml) 2 mL IV PRN line flush
-Levothyroxine Sodium 168 mcg IV DAILY
Zoloft 150 mg daily
-Zolpidem 5 mg PO qhs
-Cyanocobalamin 1,000 mcg tablet qod
-Opium tincture 10 mg/mL Ten (10) Drop PO Q4H prn for diarrhea
-Miconazole nitrate 2 % Powder [**Hospital1 **]
Hydromorphone 4 mg q4h prn for pain
-Omeprazole 40 mg daily
-Warfarin 3 mg daily
-Diphenoxylate-atropine 2.5-0.025 mg 1-2 Tablets q8h prn for
diarrhea
Discharge Medications:
1. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
2. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for itching.
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day.
5. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO EVERY OTHER DAY (Every Other Day).
6. opium tincture 10 mg/mL Tincture Sig: Ten (10) Drop PO Q6H
(every 6 hours) as needed for diarrhea.
7. levothyroxine 200 mcg Recon Soln Sig: One [**Age over 90 881**]y Eight
(168) mcg Injection DAILY (Daily).
8. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
9. Lomotil 2.5-0.025 mg Tablet Sig: 1-2 Tablets PO every eight
(8) hours as needed for diarrhea.
10. meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg
Intravenous Q12H (every 12 hours) for 3 days: Please take until
[**12-11**].
11. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
12. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
13. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4)
Injection every eight (8) hours as needed for nausea.
14. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. captopril 25 mg Tablet Sig: One (1) Tablet PO three times a
day. Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] at [**Hospital1 8**]
Discharge Diagnosis:
Primary diagnosis:
Multiple drug resistant urinary tract infection
Pneumonia
Hypertension
Altered mental status
Radiation-induced enteritis
.
Secondary diagnoses:
Chronic kidney disease
Hypothyroidism
Metastatic ovarian cancer, with chemotherapy and radiation
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 Mrs. [**Known lastname 97260**],
It was a pleasure treating you at the [**Hospital1 827**]. You were initially admitted to the intensive
care unit after you had some confusion and very high blood
pressures at the rehabilitation center. We found that you had a
urinary tract infection and we treated it with antibiotics.
Once your blood pressures were better controlled, you were moved
to the general medicine floor. You continued to have abdominal
pain and diarrhea, but this was mostly unchanged from before.
Once your blood pressures were under control and your condition
continued to improve, we felt comfortable discharging you back
to the rehabilitation center. They will continue physical
therapy with you to get your strength up. Please be careful not
to take too many pain medications, as we think this may have
contributed to your confusion.
.
We have started the following medications, to be administered in
the rehab facility:
START Meropenem 500mg IV twice a day until [**12-11**]
START Captopril 25mg by mouth three times a day
START guaifenesin (cough syrup) 100 mg/5 mL Syrup, 5-10 MLs by
mouth every 6 hours as needed for coughing
START ondansetron 4mg IV every 8 hours as needed for nausea
START taking 1 multivitamin every day
.
STOP Dronabinol
STOP Carvedilol
.
CHANGE Hydromorphone PO 4mg every 4 hours to 2mg every 6 hours
as needed for pain
Followup Instructions:
In the rehabilitation center, you will be seen by the staff
physician. [**Name10 (NameIs) 357**] feel free to schedule an appointment with
your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3649**], whenever it is
convenient for you.
|
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"507.0",
"707.03",
"599.0",
"585.9",
"707.22",
"486",
"E879.2",
"909.2",
"V15.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.14"
] |
icd9pcs
|
[
[
[]
]
] |
14130, 14194
|
8896, 12085
|
355, 362
|
14498, 14498
|
5781, 5786
|
16078, 16389
|
5047, 5129
|
12645, 14107
|
14215, 14215
|
12111, 12622
|
14681, 16055
|
5144, 5762
|
14378, 14477
|
3055, 3377
|
277, 317
|
6455, 8873
|
390, 3036
|
14234, 14357
|
5800, 6436
|
14513, 14657
|
3399, 4765
|
4781, 5031
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,119
| 116,746
|
25784
|
Discharge summary
|
report
|
Admission Date: [**2173-11-21**] Discharge Date: [**2173-12-15**]
Date of Birth: [**2103-8-12**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Atorvastatin
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
MS changes and seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 70 year old woman with a history of hypertension, diabetes,
dementia, CRI (1.8) who was recently discharged from the
neurology service with a large temporo-parietal bleed in the
setting of Lovenox now presenting from nursing home with mental
status changes and possible seizure activity. Believed that ICH
was secondary to amyloid angiopathy and that surgical
intervention would be in vain. Pt transferred to [**Hospital **] rehab
on seizure prohphlaxis, but apparently was seizure free during
initial hospitalization. Pt transitioned from rehab to nursing
home yesterday. Pt unable to provide history and there is no
documentation of event, however, per EMS report they witnessed
tonic-clonic activity.
.
Review of Systems: unobtainable
Past Medical History:
-left temporo-parietal bleed
-amyloid angiopathy
-CKD (1.8)
-diabetes "labile"
-hypertension
-CHF (unknown EF)
-h/o hyperkalemia
-depression
-asthma/copd
-peripheral neuropathy
-dementia
-s/p trach
Social History:
-resident of [**Hospital6 25759**] Home
-no recent history of smoking or alcohol use
Family History:
-unobtainable
Physical Exam:
Physical Exam:
Vitals: 98.9, 68, 160/71, 77, 98% RA
General: Comfortable, NAD, does not respond to voice, shaking or
sternal rub
HEENT: pinpoint pupils, OP wnl
Neck: supple,
Lungs: CTAB anteriorly
CV: regular rate and rhythm, s1/s2, no M/R/G
Abdomen: soft, non-tender, non-distended, NA-bowel sounds
present, GTube in place
Ext: warm/dry, no edema
Neurologic Examination: Patient does not respond to voice,
shaking or sternal rub. Has pinpoint pupils. Patient not able to
cooperate with neuro exam.
Pertinent Results:
[**2173-11-21**] 08:59AM BLOOD WBC-12.5* RBC-3.06* Hgb-9.8* Hct-30.5*
MCV-99* MCH-32.1* MCHC-32.3 RDW-13.4 Plt Ct-230
[**2173-11-22**] 04:15PM BLOOD WBC-7.4 RBC-3.10* Hgb-10.3* Hct-31.2*
MCV-101* MCH-33.2* MCHC-33.0 RDW-13.3 Plt Ct-201
[**2173-11-23**] 04:44AM BLOOD WBC-6.2 RBC-2.73* Hgb-9.0* Hct-27.8*
MCV-102* MCH-32.8* MCHC-32.2 RDW-13.5 Plt Ct-179
[**2173-11-21**] 08:59AM BLOOD Neuts-87.3* Lymphs-8.3* Monos-4.0 Eos-0.2
Baso-0.2
[**2173-11-21**] 08:59AM BLOOD PT-12.8 PTT-28.7 INR(PT)-1.1
[**2173-11-21**] 08:59AM BLOOD Glucose-333* UreaN-73* Creat-2.6*# Na-142
K-5.1 Cl-94* HCO3-42* AnGap-11
[**2173-11-22**] 04:15PM BLOOD Glucose-86 UreaN-55* Creat-1.9* Na-147*
K-4.8 Cl-100 HCO3-41* AnGap-11
[**2173-11-23**] 04:44AM BLOOD Glucose-331* UreaN-50* Creat-1.9* Na-146*
K-4.6 Cl-96 HCO3-43* AnGap-12
[**2173-11-21**] 07:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2173-11-23**] 11:51AM BLOOD Type-ART pO2-86 pCO2-82* pH-7.38
calHCO3-50* Base XS-18
[**2173-11-23**] 11:51AM BLOOD Lactate-2.5*
[**2173-11-21**] 08:00AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2173-11-23**] 08:35AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD
[**2173-11-21**] 08:00AM URINE RBC-0 WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0-2
[**2173-11-23**] 08:35AM URINE RBC-0-2 WBC-[**4-3**] Bacteri-MOD Yeast-NONE
Epi-0
[**2173-11-21**] 08:00AM URINE CastHy-0-2
[**2173-11-21**] 05:48PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
CXR [**11-21**]:
1. No pneumonia.
2. Mild volume overload.
.
head CT [**11-21**]: IMPRESSION: 2.8 x 2.2 cm rounded focus at the
site of prior intraparenchymal hemorrhage. There is surrounding
decreased attenuation, consistent with edema or malacia. While
this could represent resorbing hematoma, this appearance is
concerning for a mass lesion and further evaluation could be
obtained
.
CXR [**11-22**]: Opacity in the right middle lobe, not present on the
previous study. Findings represent aspiration and/or pneumonia
.
ECHO [**11-22**]:
Conclusions:
1. The left atrium is mildly dilated.
2. There is mild symmetric left ventricular hypertrophy with
normal cavity
size and systolic function (LVEF>55%). Regional left ventricular
wall motion
is normal.
3. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**1-31**]+)
mitral regurgitation is seen.
4. Moderate [2+] tricuspid regurgitation is seen. There is
moderate pulmonary
artery systolic hypertension
.
CXR [**11-28**]: IMPRESSION:
1. Slight improvement in patchy right infrahilar opacity, which
may be due to improving asymmetrical edema, focal atelectasis or
pneumonia.
2. Mild congestive heart failure.
.
CXR [**12-8**]: IMPRESSION:
1. Persistent mild congestive heart failure.
2. Right infrahilar opacity is stable and may represent
asymmetric edema or may be due to aspiration.
.
EKG [**12-10**]:
Normal sinus rhythm, rate 70. Left-sided early repolarization.
Compared to the
previous tracing of [**2173-12-8**] probably no significant change.
.
CXR [**12-13**]
IMPRESSION: No evidence of congestive heart failure or
pneumonia.
Brief Hospital Course:
70 year old female w/ h/o HTN, diabetes, dementia, CRI, and
recent temporo-parietal bleed presented with MS changes likely
secondary to seizure, c/b acute renal failure.
.
# Neuro/Resp: Patient was admitted with seizures likely d/t
temporo-parietal ICH with possible mass on CT. Was seen by
neurology in the ER and loaded on dilantin and started on
keppra. Tox-Met workup performed and was negative (negative
serum and urine tox screen, neg. UA). It was felt that the
patient would benefit from additional imaging of mass to
differentiate resolvind hematoma from other mass, but this was
not able to be performed because patient was unable to tolerate
MRI at any point d/t continued agitations [**Hospital 49997**] hospital
stay. Patient was on and off agitated throughout her hospital
course, and a variety of antipsychotics including olanzapine,
risperidone, seroquel, and eventually haldol were used. The
patient required level II restraints for the majority of her
hospitalization, renewed daily. Psychiatry was consulted,
followed the patient, and made recommendations. A FM was used
for a couple of days to maintain O2 saturations, but this was
stopped for fear of decreasing resp drive and an increasing PCO2
(ABG showed pH 7.38/86/80, due to metabolic acidosis with
significant chronic renal compensation). Patient was
transferred to MICU on [**2173-11-25**] for bradycardia, hypotension,
and hypoxia. Cause unclear although there was some concern for
seizure. (Patient had initially had evidence of PNA on CXR and
this was treated with 14 days of abx, but the opacity cleared
after two days and it was unclear if she actually had PNA).
Episode resolved on its own without intervention. Loaded with
dilantin. Thought to be d/t cenrally mediated process. CT of
head unchanged with no new bleed or mass effect. Cardiology
consulted and found no evidence of structural heart disease or
conduction delay. A breast mass was found on exam in MICU,
raising concern for etiology of head mass. Plan was to work
this up further once patient more stable. No pressors required
while in MICU. Transferred to floor. Patient remained agitated
a frequently desaturated to 70's when agitated, but would bump
to 100% with nebs. Etiology thought to be combination of
asthma/COPD, CHF, agitation, and decreased respiratory drive.
On [**2173-12-11**], pt was noted to be more somnolent with ABG
7.16/110/39/51 and was transferred to unit for trial of BIPAP.
Etiology hypercarbic respiratory failure secondary to sedation
and infection (UTI and +blood cultures 1/4) and COPD. While in
the MICU the patient was essentially made comfort care d/t poor
prognosis and no improvement with BIPAP (pt DNR/DNI). She was
transferred to the floor where sshe continued to decline.
Family meeting had and it was decided that her chances of
returning to a meaningful life or even back to near baseline was
minimal, and care was focused on comfort. Antibiotics, FS,
insulin, and diuretics were stopped on [**2173-12-14**] and the patient
passed on [**2173-12-15**], likely d/t respiratory arrest. Permission
to perform autopsy was obtained from health care proxy with
specific interest in identifying the intracranial mass.
.
# ARF: Pt with CKD and baseline Cr 1.8 who presented with acute
worsening (cr 2.6). Thought to be pre-renal process, possibly
secondary to over diuresis. Initially UA did not show any
evidence of UTI, but pt eventually developed klebsiella UTI, for
which she was treated. During second MICU stay there was some
concern for urosepsis, and antibiotic coverage was broadened to
cover this possibility. For part of her hospitalization the Cr
returned to baseline with gentle IVF's, but eventually this
again worsened and while in the MICU the second time she became
anuric.
.
# CHF: Patient had an unknown EF but was on chronic lasix.
Lasix was administered on as needed basis, taking into account
her renal failure and pulmonary edema potentially contributing
to respiratory distress.
.
# DM: Pt initially hypoglycemia (11) in ED after getting 10
units RI for BG ~325 and not receiving tube feeds. Throughout
hospitalization patient alternated between hypoglycemia and
hyperglycemia. [**Last Name (un) **] followed the patient closely but it was
very difficult to control her sugars, especially in setting of
receiving intermittent TF's d/t pulling out PEG and high
residuals.
.
#Hypernatremia: Patient fluctuated between normal and
hypernatremic, likely because she was unable to take free water
d/t agitation and delerium. Free water flushes via PEG were
administered, but high residuals made this difficult.
.
# HTN: Outpatient lopressor continued with moderate control
.
# Dementia: Acute on chronic. Multifactorial. Did not improve
during hospitalization.
.
# DNR/DNI
Medications on Admission:
Lasix 40 mg NG qd z 2 days then 20 mg NG qd
Risperidal 0.5 mg NG qAm and 0.75 mg qhs
Insulin: Lantus 10 units qAM and NPH qPM
RISS
Lopressor 37.5 mg NG TID
Heparin 500 units SC q 12 hrs
Prevacid 30 mg qd
Zantact 150 mg [**Hospital1 **]
MVI
Colace NG 100 mg [**Hospital1 **]
Duonevs q 4 hrs PRN
Lactulose 30 cc NG q12 hours PRn
NaCL 2 gm [**Hospital1 **] with 300 cc H2O
H20 300 cc NG [**Hospital1 **]
Celexa 10 mg NG qd
.
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Hypercarbic hypoventilation
PNA
Urosepsis
COPD/Asthma
Acute renal failure
Dementia
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"038.49",
"507.0",
"584.9",
"438.11",
"250.00",
"491.21",
"294.8",
"584.5",
"518.84",
"996.62",
"277.3",
"780.39",
"V58.67",
"038.0",
"599.0",
"293.0",
"403.91",
"428.0",
"995.92",
"327.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"38.91",
"38.93",
"96.6",
"97.02",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
10512, 10521
|
5210, 10010
|
310, 316
|
10647, 10657
|
1982, 5187
|
10710, 10847
|
1431, 1447
|
10483, 10489
|
10542, 10626
|
10036, 10460
|
10681, 10687
|
1477, 1810
|
1075, 1090
|
248, 272
|
345, 1056
|
1834, 1963
|
1112, 1312
|
1328, 1415
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,793
| 105,718
|
40522
|
Discharge summary
|
report
|
Admission Date: [**2185-5-21**] Discharge Date: [**2185-6-28**]
Date of Birth: [**2155-6-20**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
29M helmeted driver s/p MCC, intubated at site for change in MS,
w/SDH, L frontal epidural hematoma, L zygomatic frx, inf orbital
frx, dens type II frx, now w/pna & [**Doctor First Name **]
Major Surgical or Invasive Procedure:
[**2185-5-27**] Open reduction, internal fixation C2 fracture with a
lag screw.
History of Present Illness:
29M s/p MCC, intubated at site for change in MS, w/SDH, L
frontal epidural hematoma, L zygomatic frx, inf orbital frx,
dens type II frx, now w/pna & [**Doctor First Name **].
Past Medical History:
none
Social History:
non-contributory
Family History:
non-contributory
Physical Exam:
Upon presentation to [**Hospital1 18**]:
T:97 BP: 140/ 90 HR: 91 R:17 O2Sats:100% CMV 100%
FIO2400x18 5 peep
Gen: intubated
HEENT: No corneals, + gag, + cough. No Battle, No raccoon sign,
no otorrhea or rhinorrhea. Pupils:left 5 mm reactive right 2 mm
reactive EOMs: conjugate gaze- otherwise unable to test
Neck: hard cervical collar
Extrem: Warm and well-perfused.
Neuro:
Mental status/Orientation:GCS4T: Eyes-1, Verbal-1T, Motor-3
Recall/Language: unable to test
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, left 5 mm
reactive Right pupil 2 mm reactive
mm bilaterally. Visual fields- unable to test
III, IV, VI: Extraocular movements-unable to test- gaze is
conjugate
V, VII,VIII,IX, XXI,XII:unable to test
Motor: the patient is spontaneously extending bilateral upper
extremities bilaterally. To noxious stimulus the patient is
localizing. moving lower extremities antigravity. Pronator
drift-unable to test
Sensation: unable to test
Toes upgoing
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Pertinent Results:
CT HEAD [**2185-5-21**] 8:44 AM:
Intracranial hemorrhage, most likely representing an epidural
hematoma given the mechanism of injury, with 5-mm thickness from
the inner table of the skull. 2. Skull fracture left frontal
fracture extends inferiorly through the greater [**Doctor First Name 362**] of the
sphenoid, traverses the left carotid canal, the clivus, and
terminates into the foramen magnum, extending through the
carotid
canal.
CTA [**5-21**]:
No evidence of arterial vascular injury, normal neck and
head arterial angiogram; however, there is apparent filling
defect in the left internal jugular vein at the level of the
jugular foramen (2:237). Unchanged left temporal tip epidural
hematoma. Slight interval increase in size of 9 mm of left
frontal subdural hematoma. There is no evidence of midline shift
or new hemorrhage. Unchanged left upper lobe consolidation.
Stable appearance of the skull base fractures, extending through
the left carotid groove and also unchanged odontoid fracture.
MRV of the head [**5-21**]:
There is no evidence of intracranial venous sinus thrombosis.
CT Head [**5-22**]:
1. Stable epidural hematoma along the left frontal convexity and
anterior left temporal lobe.
2. Non-displaced fracture of the left frontal bone, sphenoid
bone, and clivus, involving the left carotid canal and the
foramen magnum, as described previously.
3. Fractures of the left zygomatic arch and the left inferior
orbital wall. Left zygomaticomaxillary complex fracture is
suspected, and left maxillary sinus fracture cannot be excluded.
Further evaluation by a facial bone CT is recommended.
Brief Hospital Course:
He was admitted to the Acute Care team and transferred to the
Trauma ICU.
His ICU course as follows as dictated by PGY-2 resident:
Neuro: He was intubated and sedated at the time of presentation.
Neurosurgery was consulted who recommended Dilantin. Serial head
CT scans were obtained shortly after admission and were
unchanged. Orthopedic Spine surgery was consulted for the C2
dens fracture which was repaired in the OR on [**5-27**]. During his
ICU course he was very slow to awaken despite lightening his
sedation. Neurology was consulted as a result and recommended
MRI to assess for [**Doctor First Name **] and to rule out any focal
process. The MRI did show some focal evidence of [**Doctor First Name **]. Plastics
was consulted for the facial fractures and felt that they were
non operative and deferred follow up as an outpatient. He was
placed on sinus precautions.
Over the course of his ICU stay his mental status did eventually
slowly improve to the point that he was able to be weaned and
extubated.
CV: There were no active issues.
Respiratory: He developed VAP and underwent bronchoscopy - BAL
results showed MSSA pneumonia. He was treated with IV
antibiotics prophylactically pending sensitivities which did
eventually show organism sensitive to Nafcillin.
GI: Early on he was started on tube feeds initially via the OG
tube. Because of his decreased mental status the decision was
made to place a PEG feeding tube.
GU: He required Foley catheter. No other active issues.
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
Once stabilized in the unit he was transferred to the regular
nursing unit. He was noted with intermittent episode of
increased agitation requiring [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] bed. He required treatment
with antipsychotic standing and prn. Trazodone was also started
to help regulate his sleep/wake cycle. His agitation improved
significantly.
He was seen by Physical and Occupational therapy and
recommendations for traumatic brain injury rehab were made.
Because of his brain injury guardianship was sought. Psychiatry
would later become involved to assess his capacity and it was
determined that he did not possess full capacity despite
improvement in his overall mental status. There were issues
surrounding lack of insurance and this process was also
initiated during his stay.
Eventually his PEG was removed as he was tolerating oral solids
without any difficulties.
Over the course of his hospital stay his mental status improved
significantly to the point that he no longer required inpatient
rehab. A family meeting took place on [**6-28**] to discuss the
guardianship process and disposition. The decision was made that
he would be discharged to the intended guardians' home and will
follow up at [**Hospital1 18**] for outpatient Occupational therapy. he was
also provided with information regarding follow up with Dr. [**Last Name (STitle) **]
[**Name (STitle) **], Cognitive Neurology.
He will follow up with Dr. [**Last Name (STitle) 1352**] in about 2 weeks where it
will be determined that his cervical collar can be removed.
Discharge Medications:
1. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
2. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day).
Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*0*
3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Outpatient Occupational Therapy
Dx: s/p Moped crash w/ Traumatic Brain Injury
Sig: OT eval and treatment
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Moped crash
Injuries:
Left frontal epidural
Subdural hematoma
Left frontal bone fracture
Type II Dens fracture
Left forehead laceration
Facial fractures
Pulmonary contusions
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admmitted to the hospital after a moped crash where you
sutained multiple injuries which include a bleeding brain
injury, facial bone fractures and spine fracture that required
an operation to repair. A cervical collar which is a neck brace
needs following surgery to be worn for a total of 8 weeks from
your surgery date of [**2185-5-27**]. At this point you will return to
Dr.[**Hospital 6493**] clinic where another xray of your spine will be
done. it will be determined by him when to take the collar off
permanently.
Return to the Emergency room if you experience worsening
headaches, dizziness, changes in your vision, weakness in your
extremities and/or any loss of function in your extremities.
Followup Instructions:
Follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**], Orthopedics Spine on Tuesday
[**7-12**] at 10:40 a.m. Call [**Telephone/Fax (1) 3736**] if you need to change
the appointment. Location [**Hospital1 18**] [**Hospital Ward Name 516**] in the [**Hospital Ward Name 23**] Bldg,
[**Location (un) **] Spine Center.
Follow up in [**1-13**] weeks with Dr. [**Last Name (STitle) 60707**] [**Name (STitle) **], Cognitive
Neurology; call [**Telephone/Fax (1) 1690**]. Office/clinic is located at [**Hospital1 18**]
[**Hospital Ward Name 516**].
Follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], Neurosurgery on Thursday [**7-14**]; please go to xray on the [**Location (un) 470**] of the [**Hospital Ward Name 517**]
Clinical Center at 1:15 pm at for a repeat head CT scan. You
will then go to Dr. [**Last Name (STitle) **] office located at [**Hospital1 18**] [**Hospital Ward Name 517**],
[**Hospital **] Medical Office Bldg, [**Last Name (NamePattern1) **] (located across from
emergency room) [**Location (un) 470**]; tel # [**Telephone/Fax (1) 1669**].
Completed by:[**2185-7-5**]
|
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[
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,114
| 133,499
|
19865
|
Discharge summary
|
report
|
Admission Date: [**2131-6-29**] Discharge Date: [**2131-7-18**]
Date of Birth: [**2087-4-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Jitteriness
Major Surgical or Invasive Procedure:
Thoracenteses (2 right lung)
Peripherally inserted central catheter (right)
Video assisted thoracoscopy (right)
History of Present Illness:
44 yo F with h/o EtOH abuse and h/o at least one alcohol w/drawl
sz, presents with jitteriness. history obtained from
conversation with ED resident. pt sleepy and unable to answer
questions. last drink last night. had 6-8 beers yesterday. drink
12-18 beers a day. no hard liquor. denies drugs. denies h/o
hallucinations.
In the ED vitals were afeb, Hr 120, 129/85, 20, 96%/RA. she
received total of 45 mg IV ativan. also recd banana bag and
additional thiamne and folate. CXR showed RLL opacity and she
was given levoflox and cefepime for PNA. her O2 req went up in
the ED and she was 95% on 5L O2 by NC. her jitteriness improved
in the ED. etoh level 56 and tricyclics +ve.
Past Medical History:
Alcohol dependence
Withdrawl seizures
Depression and anxiety -- She is followed by Dr. [**First Name (STitle) **] at [**Hospital **]
Hospital and sees [**First Name8 (NamePattern2) 42907**] [**Last Name (NamePattern1) **] for psychotherapy
suicide attempts
Social History:
Ms. [**Known lastname 3234**] was born in [**Male First Name (un) 1056**] and came to [**Location (un) 86**] at age 3.
She has 16 sibilings and currently lives in [**Location 2312**] in public
housing with one of her brothers whom is her only familial
support. She as been dating her boyfriend for 4 years who has
visited her during her stay. She is on disability for her
depression, and supports herself with SSI and regular Masshealth
managed care. She was married for 11 years until 6 years ago
and has 6 children (ages [**9-6**]) whom the youngest are under legal
guardianship via DSS.
Ms. [**Known lastname 3234**] has smoked at least a pack a day since adolescence
and drinks >12 alcoholic drinks almost every day. She has a past
history of crack/cocaine use but denies any iv drug use. She
was tested HIV - 6 months ago and again during her stay here.
(Additional information from psych note in 05.)
-history of sexual abuse at age 6
-she was physically abused during her marriage of 11 years,
which
ended 9 years ago.
-Longstanding history of alcohol dependence. Drinks about 12
beers
a day normally, but reports recent increase in drinking. Last
period of sobriety was 5 years ago when she had a 2 year period
of recovery. She reports tremors if she does not drink in the
morning, but denies a history of DTs. She did have 1 seizure
in the setting of alcohol withdrawal in the past. She has had
multiple prior detoxes for alcohol dependence.
Family History:
Brother: deceased with AIDS/TB
As per psych note: family members with substance dependence,
depression, and anxiety disorders. Both her parents are deceased
from unknown causes.
Physical Exam:
On admission:
100.1 120 130/80 30 96/6l NC
sleepy. waking up to sternal rub. answers questions for a couple
of seconds and then drifts back to sleep
Chest: crackles L side. decr BS R side
Heart: RRR, no m/r/g. nl s1 s2
Extr: no edema
Abd: soft, NT, ND, no HSM, surgical scar +
On discharge:
Tm: 101.8 Tc: 98.9 BP: 120/80 HR: 95 RR: 18
Pt is rousable, pleasant
CVS: regular, no murmur
Lungs: Pleural rub with mildly decreased breath sounds on the
right
Abd: soft, NT, obese, NABS
Ext: no edema, WWP
Pertinent Results:
PERTINENT LABS:
[**2131-6-29**] WBC-4.4 RBC-4.25 HGB-13.7 HCT-39.6 MCV-93 PLT COUNT-399
[**2131-6-29**] NEUTS-64.1 LYMPHS-22.0 MONOS-11.5* EOS-1.6 BASOS-0.8
[**2131-6-29**] GLUCOSE-130* UREA N-6 CREAT-0.8 SODIUM-132*
POTASSIUM-8.1* CHLORIDE-99 TOTAL CO2-21
[**2131-6-29**] 03:30AM ASA-NEG ETHANOL-56* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-POS
[**2131-6-29**] ALT-47* AST-41* LD(LDH)-303* AlkPhos-111 TotBili-0.2
[**2131-6-29**] Amylase-37 Lipase-21
[**2131-6-29**] 06:25AM CK(CPK)-257* CK-MB-3 cTropnT-<0.01 proBNP-347*
[**2131-6-29**] TSH-1.1
[**2131-6-29**] T4-4.8
[**2131-6-29**] Lactate-2.5
MICRO DATA:
[**6-29**] BLOOD CX: no growth
[**6-29**] URINE CX: no growth
[**6-29**] URINARY LEGIONELLA Ag: negative
[**7-1**] BLOOD CX: no growth
[**7-1**] URINE CX: no growth
[**7-2**] BLOOD CX: no growth
[**7-4**] BLOOD CX: no growth to date
[**7-4**] URINE CX: yeast 10,000-100,000 org/ml
[**7-6**] BLOOD/FUNGAL/AFB CX: no growth to date
[**7-7**] BLOOD CX: no growth to date
[**6-29**] PLEURAL FLUID:
GRAM STAIN (Final [**2131-6-29**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2131-7-2**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2131-7-5**]): NO GROWTH.
[**7-3**] PLEURAL FLUID:
GRAM STAIN (Final [**2131-7-3**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2131-7-6**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2131-7-7**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Pending):
.
[**7-6**] SPUTUM:
GRAM STAIN (Final [**2131-7-6**]):
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final [**2131-7-6**]):
TEST CANCELLED, PATIENT CREDITED.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2131-7-7**]): NEGATIVE for Pneumocystis jirvovecii
(carinii).
FUNGAL CULTURE (Preliminary):
ACID FAST SMEAR (Preliminary):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
This is only a PRELIMINARY result. If ruling out
tuberculosis, you
must wait for confirmation by concentrated smear.
ACID FAST CULTURE (Preliminary):
.
[**7-9**] SPUTUM:
ACID FAST SMEAR (Pending):
ACID FAST CULTURE (Pending):
[**7-6**] HIV Ab: negative
[**7-3**] PLEURAL FLUID CYTOLOGY: NEGATIVE for malignant cells
STUDIES:
CXR ([**6-29**]): The heart size is normal. The mediastinal and hilar
contours are unremarkable. The left lung is clear. There is a
moderate-sized right pleural effusion obscuring the right
hemidiaphragm and right heart border with adjacent
consolidation. Osseous structures are unremarkable.
.
TTE ([**6-29**]): The left atrium is mildly dilated. Left ventricular
wall thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is mildly depressed (LVEF= 40%), possibly in
part secondary to tachycardia. Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Moderate to severe (3+)
mitral regurgitation is seen. No vegetation is seen on the
mitral regurgitation. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Moderate-to-severe mitral regurgitation. Mild global
left ventricular systolic dysfunction.
RUQ ULTRASOUND ([**6-30**]): 1. Diffusely echogenic liver consistent
with fatty infiltration. However, other forms of diffuse liver
disease including significant fibrosis/cirrhosis cannot be
excluded on this study.
2. Right pleural effusion, without right upper quadrant ascites.
CTA CHEST ([**7-1**]): There is a small-to-moderate right pleural
effusion with areas of loculation. An area of consolidation is
seen within the left lung base (3, 62). In addition, a rounded
area of increased density (3, 41) is identified near the right
hilum and measures approximately 1.4 x 2.3 cm likely represents
a lymph node. Multiple scattered mediastinal lymph nodes are
identified, none of which meet CT criteria for pathologic
enlargement. There is no axillary lymphadenopathy identified.
There are no definite filling defects within the main pulmonary
arteries or proximal segmental branches. Multiple pulmonary
nodules are identified particularly in the right lobe (3, 33),
(3, 44), and (3, 47). The largest of these measures 7 mm. There
is no pericardial effusion identified. Multiple subpleural blebs
and emphysematous changes are noted.
CT CHEST ([**7-5**]): There has been interval decrease in a
small-to-moderate partially loculated right pleural effusion.
There is no pneumothorax. Consolidation in the left base has
almost completely resolved. From the previously described
noncalcified lung nodules only one is clearly detected on this
examination located in the right middle lobe (4, 133). Small
areas of atelectasis in the right middle lobe and adjacent to
the pleural effusion have decreased. There are no new lung
abnormalities. Cardiac size is normal. There is no pericardial
effusion. The aorta is normal in caliber. There are no axillary
lymph nodes. Mediastinal lymph nodes measure up to 10 mm in the
subcarinal stations. Right hilar lymphadenopathy measures up to
20 mm.
Phrenic lymph node measures 5 mm.
PLEURAL TISSUE
Acute, chronic, and granulomatous inflammation with focal
necrosis. Special stains for microorganisms are pending.
Please also see included paperwork.
Brief Hospital Course:
44 year-old woman with history of EtOH dependence who presented
with EtOH intoxication hypoxic respiratory distress.
#Hypoxic respiratory distress: She initially presented with
hypoxic respiratory failure and a 6L oxygen requirement. This
was felt to be likely multifactorial from pleural effusion,
pulmonary edema, and likely aspiration pneumonia. Her pleural
effusion was tapped and showed an exudative process, likely
parapneumonic effusion from previous pneumonia as bronchiectasis
was seen on CTA chest. CTA chest also showed a LLL
consolidation and no evidence of PE. Pt was initially started
on levofloxacin and Unasyn to empirically cover for aspiration
and community-acquired pneumonia. There was a question of
whether the effusion could be related to CHF. TTE revealed an EF
of 40% with 3+MR, but BNP was unremarkable at 347. She was
diuresed 3L with furosemide in the ICU. Liver US showed fatty
infiltrate and no ascites. The pleural effusion re-accumulated
and she had repeat R-sided [**Female First Name (un) 576**] on [**7-5**] with 800 cc serous
fluid removed, consistent with exudate. ID, Pulmonary, and
Thoracic Surgery were consulted. Discussion with patient at
this time revealed close TB exposure through deceased brother
and positive PPD test within last year without treatment. A
VATS procedure was scheduled both for diagnostic and therapeutic
uses. Patient returned the day after surgery to the medical
floor with a temperature overnight of 104, tachycardia and
hypotension. She became hypotensive that morning and returned
to the MICU for stabilization. During that time, pleural tissue
sample from the VATS procedure showed caseating granulomas. DPH
was contact[**Name (NI) **] about her brother's original case. The file
indicated pan-sensitivities so an oral drug regimen recommended
by ID was started on [**2131-7-15**]. Three concentrated respiratory
sputum samples were negative for acid fast bacilli as of
[**2131-7-17**], however, given her exposure and clinical picture, the
patient was started on empiric weight bases therapy prior to her
discharge from [**Hospital3 **].
# Pleural TB: The patient has presumed pleural tuberculosis, for
which she is currently being treated with multi-drug therapy.
The duration of this therapy will be at the discretion of the
infectious disease physicians at the [**Hospital1 **]. She will have
observed therapy until decided otherwise. The patient had a
baseline ophthalmologic eye exam while in the hospital, which
was normal. She will need to have her eye exam followed while
on the tuberculosis medications. In addition, the patient will
need to have her liver function tests followed weekly.
# Pain control: The patient was in pain secondary to her chest
tubes, the last of which was removed yesterday with no evidence
of pneumothorax on x-ray. She was maintained on Tylenol around
the clock with opioids as adjunct therapy. Titration of her
pain medications has been complicated by somnolence. She has
been fairly alert on the current regimen. When her pain is
better controlled, please consider discontinuing the Tylenol as
well as titrating down the morphine when able.
# Fevers: The patient has had cyclical fevers since admission,
which have been trending down. Her blood cultures have all been
negative to date. Initially she was treated with levofloxacin
and Unasyn to cover for aspiration and community-acquired
pneumonia. Coverage was broadened to vanco/Zosyn on hospital day
3. After completing a week of antibiotics, she remained
persistently febrile. All culture data including pleural fluid,
blood, and urine was negative. ID was consulted. Antibiotics
were held. Sputum was sent for AFB x 3. HIV Antibody was
negative. Fever has improved since induction of TB therapy.
#EtOH abuse/withdrawal: She required significant amounts of
Valium in the ICU (200 mg over the first 24 hours). Her liver
US demonstrated fatty infiltrate but was unable to completely
rule out underlying cirrhosis, no ascites. By transfer to the
medical floor, she was still exhibiting signs of withdrawal
including anxiety, tremulousness, and tachycardia but improving.
CIWA scale was discontinued on [**7-4**]. She was supplemented with
thiamine and folate. SW and Addiction were consulted. The
patient continues to articulate interest in an alcohol treatment
program.
#?Tricyclics OD: Pt did not have EKG changes suggestive of
tricyclic overdose nor anticholinergic side effects like dry
mouth or dilated pupils. Notably the patient was on a home dose
of Doxepin at the time of presentation. It was discontinued
during this admission and the patient was instead started on
citalopram and olanzapine. She was continued on low doses of
lorazepam.
# Acute systolic CHF: ECHO showed EF of 40%, 3+ MR, possibly
[**3-17**] to ETOH cardiomyopathy. She had flashed on [**6-29**] and was
started on nitro gtt for 24 hrs as above. She was diuresed as
well and started on a low dose ACE-I. BB was started given the
cardiomyopathy once the patient was out of the window of acute
withdrawal. On transfer to the medical floor she was felt to be
euvolemic and was not diuresed further. Post-VATS operation, she
likely became hypotensive (to 80's) and most likely from the
inflammatory response to surgery, aggressive post-operative pain
control, and sub-optimal systolic output. Upon re-admission the
the medical floor, the patient has had no crackles or examples
or other indications of volume overload even with fluid
replacement (up to 1 L/day at 100ml/hr) to aid with ARF.
# Sinus tachycardia: This was likely multifactorial, due to
infection, fevers, ETOH withdrawal, and anxiety. CTA chest
showed no PE. Metoprolol was started given her cardiomyopathy.
The patient began having regular rate and rhythm several days
after beginning TB drug therapy and receiving minor fluid
resuscitation. Currently, patient is no longer tachycardic.
# Acute Renal Failure: The patient had a rise in her creatinine
(peak 1.8) on [**7-11**]/3008 when she had episode of hypotension and
was sent back to the MICU. Her labs demonstrated a combination
of pre-renal and ischemic ATN at that time. Her renal function
improved with fluids and time. Please continue to follow her
renal function at least weekly to ensure her creatinine
continues to improve.
# Thrombocytosis: Since admission, the patient's platelet count
rose significantly peaking in high 900,000 range and rose
rapidly around time of VATS surgery. This is most likely a
reactive progress and she was monitored for clinical signs of
thrombosis. She remains asymptomatic.
# Anemia: The patient has an anemia which is likely her
baseline. Her iron studies appear consistent with anemia of
chronic disease/inflammation. Please continue to follow a
weekly CBC to monitor for stability of her hematocrit.
# General Anxiety Disorder: She was initially on a CIWA scale
receiving large quantities of Valium. When this was discontinued
she was transitioned to Ativan 0.5 mg TID prn, which controlled
her anxiety well. SW spoke with her outpatient psychiatrist
about long-term follow-up.
# Pulmonary nodules: This was seen on chest CTA. Pt has a
smoking history. She will need f/u CT scan in 3 months for f/u.
Medications on Admission:
(from psych note in 05. current meds unknown)
Prozac 40mg po daily
Zyprexa 25mg po qHS
Doxepin 40mg po qHS.
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours) as needed.
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
8. Olanzapine 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8 ().
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
13. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY
14. Rifampin 300 mg Capsule Sig: Two (2) Capsule PO Q24H (every
15. Isoniazid 300 mg Tablet Sig: One (1) Tablet PO DAILY
16. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
17. Morphine 15 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4
hours) as needed.
18. Ethambutol 400 mg Tablet Sig: Three (3) Tablet PO DAILY
19. Pyrazinamide 500 mg Tablet Sig: Three (3) Tablet PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
# Alcohol withdrawal
# Pneumonia with parapneumonic effusion
# Urinary tract infection
# Acute renal failure
Secondary:
# Anemia
# Depression/anxiety
# Cardiomyopathy
Discharge Condition:
Patient is 8 days s/p thorascopy. Afebrile. Stable vital signs.
Pain is adequately controlled on her current medication regimen.
Discharge Instructions:
You were admitted to the hospital for alcohol withdrawal,
pneumonia, and fluid in your lungs. You were treated for
alcohol withdrawal with medication and the pneumonia with
antibiotics. You had two thoracentesis where fluid was removed
from your lungs. You spoke with social work and addiction
counseling and the joint decision was made that you would enroll
in an alcohol treatment program pending your medical recovery.
You were found to have a urinary tract infection which was
treated in conjunction with your pneumonia. You had a
thoracoscopy to help treat your pleural effusion and diagnose
it. Two chest tubes were placed for drainage which were later
removed and you were started on medication to manage pain. You
were treated for hypotension and acute renal failure which you
recovered from acutely.
You were diagnosed with tuberculosis in your pleural space. You
are being treated with multiple medications. You were diagnosed
with an anemia which is likely due to your ongoing infection.
You will be transferred to [**Hospital **] Hospital where you can
continue your recovery including getting your pain and
tuberculosis medications.
At the point at which you are fully discharged from medical
care, please come back to the hospital if you have chest pain,
shortness of breath, temperature of > 101 or any new symptom
that is concerning to you.
Followup Instructions:
You are being transferred to [**Hospital **] Hospital for completion of
your medical care specifically to help you take your
tuberculosis medication and manage your pain.
Given your initial presentation with alcohol withdrawal, there
will be effort to follow-up your request and recommendations for
you to join an alcohol treatment program.
Pulmonary nodules were seen on your CT scan on [**2131-7-1**] so we
recommend that you have a repeat CT scan in 3 months from that
date to follow-up.
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
[
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326, 440
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18828, 18960
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275, 288
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468, 1146
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3127, 3391
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5257, 5351
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3654, 5221
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1168, 1427
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1443, 2902
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,342
| 136,006
|
49011
|
Discharge summary
|
report
|
Admission Date: [**2176-6-4**] Discharge Date: [**2176-6-7**]
Date of Birth: [**2130-4-3**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
CC: coffee ground emesis, black diarrhea
Major Surgical or Invasive Procedure:
Upper endoscopy
History of Present Illness:
The patient is a 46 year old woman with EtOH/HCV cirrhosis,
grade 1 varices and portal gastropathy who presents with n/v/d,
abdominal pain and coffee ground emesis since this am. In the
ED, she was initially hemodynamically stable with maintained
Hct. NG lavage revealed red blood that cleared after 750 cc.
She also passed large amounts of melena. In the Ed she was
given 2 units of FFP, vitamin K, levofloxacin 500 mg x 1,
octreotide gtt, and 1 liter of NS.
Upon stabilization she said that her only complaint was RLQ abd
pain which was somewhat worse with movement, it was
non-radiating and intermittent. She has chronic diarrhea for
the past several years, but had not experienced any in the few
days prior to admission. On review of systems she denied
headache, dizziness, chest pain, SOB or cough. She did feel
weak and described having a sore throat. She has no history of
easy bruising or bleeding problems. She denied having any GU
symptoms including hematuria prior to admission.
Past Medical History:
-Heavy ETOH abuse
-HCV
-Elevated portal pressures with varices and portal gastropathy
-Chronic LE neuropathy
-Diastolic CHF
-Asthma
-Depression
-Osteopenia
.
PSH:
-CCY
-TAH for endometrial hyperplasia
Social History:
Lives with husband and 29 y.o son from a previous marriage.
Heavy etoh abuse in the past, last drink 3 months ago. Had
"DTs" in during years of EtOH abuse never admitted for
withdrawal symptoms. Tobacco 1 ppd x 30 years. No IVDU.
Family History:
Father died of MI in 80's. Many alcoholics in family. One
cousin with celiac sprue.
Physical Exam:
On arrival to medical floor:
Vitals: 98.3 92/55 79 20 97%RA
Gen: alert, mildly uncomfortable with movement.
HEENT: L pupil 5->3, R pupil 3->2 (patient reports this is
normal for her). MMM, remnants of blood on teeth, erythematous
oropharynx, no discrete lesions.
Chest: soften breath sounds bilat. good air entry no wheeze or
crackles
CV: RRR no murmur/rub/gallop
Abd: soft, non-distended, mild tenderness to RLQ but diffusely
as well. indirect tenderness across abdomen
Extr: tender on lower extremities [**1-11**] neuropathy
Neuro: a&ox3, pupils as described above.
Pertinent Results:
[**2176-6-4**] 02:25PM WBC-8.9 RBC-3.82* HGB-11.8* HCT-33.3* MCV-87#
MCH-30.8 MCHC-35.4* RDW-14.5
[**2176-6-4**] 02:25PM PT-19.9* PTT-40.1* INR(PT)-1.9*
[**2176-6-4**] 08:55PM WBC-4.9 RBC-3.19* HGB-9.8* HCT-27.9* MCV-87
MCH-30.8 MCHC-35.3* RDW-14.7
[**2176-6-4**] 08:55PM GLUCOSE-70 UREA N-19 CREAT-0.6 SODIUM-135
POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-23 ANION GAP-18
[**2176-6-4**] 08:55PM CK(CPK)-25*
.
[**2176-6-4**]: EGD:
Grade I varices at the lower third of the esophagus
Grade 1 esophagitis in the gastroesophageal junction
Portal gastropathy
Duodenitis in the proximal bulb
Large duodenal varix.
Brief Hospital Course:
The patient is a 46 year old woman with history of alcohol/hep C
cirrhosis, portal hypertension and recent episode of colitis who
presented with an upper GI bleed.
.
1.) Upper GI bleed: The patient presented with a UGIB. She was
volume expanded with normal saline and a total of 9 pRBC units.
She underwent EGD to evaluate the source of her bleeding. There
were no active bleeding vessels visible during the procedure and
none of the lesions detected required intervention. The leading
culprit was thought to be the large duodenal varix. She
continued on the IV PPI twice daily while in the MICU, but this
was decreased upon discharge to once daily oral dosing. Her
hematocrit stablized in the mid 30s but time of discharge and
she exhibited no evidence of re-bleeding. She was discharged in
stable condition, tolerating oral food and medication. She was
referred to follow-up with Dr. [**Last Name (STitle) 497**] in the Liver Center with
the consideration that a TIPS procedure might be therapeutic to
treat her duodenal varix that was the presumptive cause of the
bleeding.
.
2.) Hypotension: In the ED the patient became hypotensive to
sbp ~80s. She was relatively asymptomatic at the time and was
able to mentate well. She was vigorously volume expanded with
saline and blood products and transfered to the MICU for close
observation. Following stabilization and transfer to the
medical floor, she stated that her blood pressure has always run
low and 80s and 90s systolic are not uncommon for her. Her home
diuretics were held during the hospitalization, and only the
furosemide at a low dose was to be re-started at discharge. Her
blood pressure increased by time of discharge and was stable
with systolic [**Location (un) 1131**] in the 110s.
.
3.) Hypoxia: With the history of diastolic CHF the patient
developed mild hypoxia following the vigorous volume expansion
with saline and blood. This was corrected with natural diuresis
and supplemental oxygen. Upon transfer to the medical floor her
oxygen saturation was 97% on room air alone.
.
4.) Thrombocytopenia: The patient has a baseline platelet count
range 110s over the past 4 months. This could be secondary to
hypersplenism. However the level dropped on admission with a
nadir of 48,000. This was thought secondary to octreotide
(which was later stopped) on top of chronic hypersplenism,
however, other possiblities were entertained included secondary
to the PPI, ITP or DIC, and HIT. The smear did not reveal
appreciable shistocytes and the DIC panel including trend did
not support DIC. Heparin was held. There were no thombotic
events to support an immune HIT picture. The platelet level
should be followed as outpatient for return with consideration
for discontinuing the PPI if the platelet count does not
recover.
.
5.) Liver Disease: The patient has a history of alcohol and Hep
C cirrhosis. The last viral load was measured in [**2175-4-9**] with
600-700,000 copies/mL detected. Her INR has slowly increased
over the past year now stabilizing at 1.7 prior to discharge.
The total bilirubin has fluctuated highly over the past year but
during this hospitalization was toward the low of the the range
at 3.4. CT scan demonstrated a increase in her splenic
diameter compared to [**2176-3-9**]. At discharge she was re-started
on low dose nadolol and furosemide and scheduled for Liver
Center follow-up.
.
6.) Hematuria: The patient reported no history of hematuria
prior to admission. However, a large RBC count was measured in
a sample from a foley catheter. This was thought to be
secondary to a traumatic foley placement. A follow-up UA after
the foley was removed showed a decrease in the RBC by more than
half the prior level. Routine UA follow-up is recommended to
confirm the clearance of the urine.
.
7.) Abd pain: The patient described a pain in her RLQ. Upon
examination she was more tender in a diffuse location instead of
a more focal area. Potential diagnoses included a re-lapse of
her pancoltis from [**3-14**], appendicitis, mesenteric adenitis,
constipation, or less likely ovarian cyst. A abdominal CT was
obtained that revealed portal gastropathy and mesenteric
collaterals, resolved colitis, but no obvious source for abd.
pain. Her bowel regimen was changed and she was tolerating food
upon discharge.
.
8.) Chronic Diarrhea/Bloating: This was thought likely
secondary to celiac sprue (+FH, duodenal biopsy + for early
disease, TTG reported as + although no result in OMR). She was
prescribed a gluten free diet and asked to make an appointment
with the dietician whom she had already contact[**Name (NI) **]. A nutrition
consult was made for some inpatient teaching.
.
9.) FEN: tolerating full regular diet.
.
10.) Prophy: on PPI, had pneumoboots while on bedrest but later
was ambulating well.
.
11.) Code Status: the patient remained full code througout her
hospitalization.
.
12.) Dispo: home with Liver Center follow-up.
Medications on Admission:
Pantoprazole 40 mg po daily
Gabapentin 400 mg po 3x/day
Nadolol 20 mg po daily
Spironolactone 25 mg po daily
Furosemide 80 mg po daily
Levothyroxine 50 mcg po daily
Discharge Medications:
1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Name (NI) **]:*30 Tablet(s)* Refills:*2*
2. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
4. Nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day.
[**Name (NI) **]:*30 Tablet(s)* Refills:*2*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Name (NI) **]:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Upper gastro-intestinal bleed
Secondary:
Cirrhosis
Alcoholic hepatitis
Chronic Hepatitis C
Esophageal Varices
Peripheral Neuropathy
Celiac sprue
Discharge Condition:
Good: Hct stable, bp stable at her baseline, no evidence of
re-bleeding.
Discharge Instructions:
Please call your doctor if you begin to vomit blood, she will
likely tell you to call 911 and come to the hospital.
Please attend your follow-up appointments.
Followup Instructions:
Please call your dietician to arrange for an appointment.
Please call Dr.[**Name (NI) 32725**] office to schedule an appoinment in
the next 1-2 weeks. ([**Telephone/Fax (1) 250**])
Please see Dr. [**Last Name (STitle) 497**] in the Liver Center on [**6-17**] at 3:30pm
([**Telephone/Fax (1) 2422**])
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"571.2",
"493.90",
"998.11",
"799.02",
"578.0",
"571.1",
"572.3",
"428.30",
"285.1",
"428.0",
"287.5",
"244.9",
"458.9",
"311",
"733.90",
"456.1",
"E879.6",
"355.8",
"303.90",
"579.0",
"456.8",
"537.9",
"070.70"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"99.04",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
8913, 8919
|
3186, 8160
|
319, 336
|
9118, 9193
|
2549, 3163
|
9401, 9827
|
1854, 1940
|
8375, 8890
|
8940, 9097
|
8186, 8352
|
9217, 9378
|
1955, 2530
|
239, 281
|
364, 1364
|
1386, 1588
|
1604, 1838
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,554
| 181,990
|
1890
|
Discharge summary
|
report
|
Admission Date: [**2191-3-27**] Discharge Date: [**2191-4-20**]
Date of Birth: [**2106-12-8**] Sex: F
Service: MEDICINE
Allergies:
Iodine; Iodine Containing / Quinine / Heparin Agents
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Shortness of breath.
Major Surgical or Invasive Procedure:
Endotracheal intubation.
Bronchoscopy.
Pig-tail catheter placement (R-side) for pneumothorax.
PICC placement.
A-line placement.
History of Present Illness:
Mrs. [**Known firstname 4317**] [**Known lastname **] is a very nice 84 year-old woman with chronic
renal failure, colon cancer s/p resection, hypertension, and
diastolic dysfunction with shortness of breath. She reports one
week of SOB and worsening DOE. Her daughter notes that she has
not been the same as far as her exercise tolerance since
breaking her left ankle 3 months ago though her PT over the past
months has not been limited by pain until now.
.
Note is made that at the end of [**Month (only) 956**], she was admitted with
a pneumonia treated with levofloxacin. She was dischaged to
[**Hospital 38**] Rehab but has been home subsequently. She reports that
she was discharged on oxygen but has been off for approx 2
weeks.
.
Initial VS in the ED: 99.6, 150/59, 85, 19, 79% on NRB. She had
a WBC of 11.4 and a BNP of 8000. Labs were significant for a
lactate of 2.4 and an AG of 21. She had a CXR which showed
pulmonary edema and multiple opacifications. Given Vancomycin 1G
IV, Levofloxacin 750mg IV X1, ASA 325mg X1 EKG SR at 81, LAD,
1st degree HB, ST dep I, avL present from prior, .5-1 mm dep
V4-V6. She was seen by cards who said to give ASA only. She had
LENIs which the prelim were negative for DVT. VS on transfer
were: 6L NC 92-94%, HR 83, 147/64.
.
In the medical floor she was started on treatment for healthcare
acquired pneumonia with Vanc/levofloxacin (day 1 [**3-27**]). Her urine
legionella was negative. Her initial lactate was 2.4 and it
imrpoved to 1.6 after hydration. She received 20 mg of IV lasix.
.
At 7:35 AM she triggered for hypoxia. Her vital signs were HR 78
BPM, BP 120/69 mmHg, RR 22, T 97.3, 85% on 3 L NC. She was
diuresed with 20 mg of IV lasix x1. Her BNP was 8012, CXR [**Last Name (un) **]
bilateral alveolar infiltrates and echocardiogram worsening
diastolic dysfunciton with EF of 55% and moderate MR [**First Name (Titles) **] [**Last Name (Titles) 114**]e TR as well as moderate pulmonary hypertension. She was
ROMI with three sets of CE with peak Trop T of 0.12 and CK 100
with MB of 8. Her creatinine was slightly increased to 2.7 from
her baseline of 2.5. She has continued to have a mild AG
metabolic acidosis. She has received a total of 80 mg of IV
lasix with good response in UOP (1900, 1000 net negative). At
10:37 PM she trigered for lower SpO2 with sats of 86% on NRB.
ABG was 7.53/31/61 at FiO2 of 50% and did not change with higher
SpO2 of 100% in NRB at 7.49/31/61. CXR showed worsening edema.
Pt received Bumetanide 2 mg IV X2 and antibiotics were broadened
to Vanc/Zosyn. She was transfered to ICU.
Past Medical History:
1. Aortic bovine bioprosthetic valve ([**2179**]) mean gradient of 18
mmhg
2. Hypertension
3. Diastolic dysfunction EF 55%
4. Hyperlipidemia
5. Spinal Stenosis
6. h/o Colon Cancer s/p resection and adjuvant chemotherapy
7. Substernal Goiter
8. s/p Cholecystectomy
9. s/p TAH
10. Left Ankle Fracture in [**2191-1-8**], followed by Dr. [**First Name (STitle) **]
11. Stage IV Chronic Renal Failure
12. Moderate MR
13. Moderate TR
14. Moderate pulmonary HTN
15. Hypothyroidism
16. Depresion
Social History:
Home: lives at home with her daughter and grandson.
Occupation: retired, previously worked at [**State 350**] Eye and
Ear Infirmary doing secretarial work
EtOH: Denies
Drugs: Denies
Tobacco: Denies
Family History:
Diabetes
Cancer
Physical Exam:
VITAL SIGNS - Temp F, BP 144/81 mmHg, HR 89 BPM, RR 23 X',
O2-sat 92% 50%
GENERAL - well-appearing woman in NAD, comfortable, appropriate,
notjaundiced (skin, mouth, conjuntiva), with flow mask
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, JVP to the mandible, 20 cm, no
carotid bruits
LUNGS - bibasilary crackles, no wh, decreased air movement, resp
unlabored, no accessory muscle use, no consolidation syndrome
HEART - PMI non-displaced, RRR, SEM [**1-29**] in apex radiating
towards axila, SEM [**1-29**] in tricuspid region, SEM [**1-1**] in RUSB
without radiation, nl S1-S2, S3 present, no hepato-jugular
reflex
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), 3+ edema bilateraly up to the knees
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**3-30**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2191-3-27**] 02:30PM WBC-11.4* RBC-2.62* HGB-8.3* HCT-25.9*
MCV-99* MCH-31.7 MCHC-32.1 RDW-24.8*
[**2191-3-27**] 02:30PM NEUTS-86.3* LYMPHS-8.2* MONOS-4.6 EOS-0.6
BASOS-0.3
[**2191-3-27**] 02:30PM PLT COUNT-142*
[**2191-3-27**] 02:30PM PT-16.1* PTT-36.8* INR(PT)-1.4*
[**2191-3-27**] 02:30PM GLUCOSE-179* UREA N-77* CREAT-3.0* SODIUM-143
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-19* ANION GAP-25*
[**2191-3-27**] 02:30PM cTropnT-0.10*
[**2191-3-27**] 02:30PM proBNP-8012*
[**2191-3-27**] 02:30PM CALCIUM-8.3* PHOSPHATE-4.3 MAGNESIUM-2.3
.
[**2191-4-17**] 03:18AM BLOOD WBC-9.3 RBC-2.37* Hgb-7.1* Hct-22.3*
MCV-94 MCH-30.1 MCHC-31.9 RDW-20.4* Plt Ct-142*
[**2191-4-17**] 09:23PM BLOOD Hct-27.5*
[**2191-4-18**] 05:20AM BLOOD WBC-11.4* RBC-2.88* Hgb-8.5* Hct-25.9*
MCV-90 MCH-29.4 MCHC-32.7 RDW-20.5* Plt Ct-133*
[**2191-4-18**] 07:40PM BLOOD WBC-13.8* RBC-3.00* Hgb-9.2* Hct-27.5*
MCV-92 MCH-30.8 MCHC-33.6 RDW-21.4* Plt Ct-112*
[**2191-4-19**] 03:02AM BLOOD WBC-12.0* RBC-2.90* Hgb-8.8* Hct-26.3*
MCV-91 MCH-30.3 MCHC-33.5 RDW-20.8* Plt Ct-118*
[**2191-4-20**] 02:37AM BLOOD WBC-12.3* RBC-2.88* Hgb-9.0* Hct-26.3*
MCV-91 MCH-31.3 MCHC-34.3 RDW-21.2* Plt Ct-105*
[**2191-4-9**] 02:52AM BLOOD Neuts-94* Bands-3 Lymphs-1* Monos-0 Eos-1
Baso-0 Atyps-0 Metas-1* Myelos-0
[**2191-4-17**] 03:18AM BLOOD Glucose-143* UreaN-41* Creat-2.7* Na-138
K-3.9 Cl-103 HCO3-25 AnGap-14
[**2191-4-18**] 05:20AM BLOOD Glucose-90 UreaN-50* Creat-3.2* Na-139
K-3.6 Cl-102 HCO3-26 AnGap-15
[**2191-4-18**] 07:40PM BLOOD Glucose-118* UreaN-16 Creat-1.7*# Na-142
K-3.7 Cl-104 HCO3-29 AnGap-13
[**2191-4-19**] 03:02AM BLOOD Glucose-95 UreaN-19 Creat-2.0* Na-141
K-3.6 Cl-104 HCO3-27 AnGap-14
[**2191-4-20**] 02:37AM BLOOD Glucose-86 UreaN-33* Creat-3.0* Na-139
K-3.7 Cl-101 HCO3-24 AnGap-18
[**2191-4-18**] 07:40PM BLOOD CK(CPK)-35
[**2191-4-19**] 03:02AM BLOOD CK(CPK)-36
[**2191-4-18**] 07:40PM BLOOD CK-MB-NotDone cTropnT-0.21*
[**2191-4-19**] 03:02AM BLOOD CK-MB-NotDone cTropnT-0.24*
[**2191-4-16**] 04:37AM BLOOD calTIBC-228* Ferritn-723* TRF-175*
.
TTE:
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). Diastolic function
could not be assessed. The right ventricular cavity is mildly
dilated with borderline normal free wall function. [Intrinsic
right ventricular systolic function is likely more depressed
given the severity of tricuspid regurgitation.] The diameters of
aorta at the sinus, ascending and arch levels are normal. A
bioprosthetic aortic valve prosthesis is present. The mitral
valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
.
CT CHEST:
Axial imaging makes it clear that the process is generalized
relatively symmetric from side to side and more severe in the
dependent, i.e., posterior lungs. The morphology of the
abnormality is not uniform:
ground-glass opacification dominates the lung apices, traversed
by mild,
smooth thickening of interlobular septae. The septal thickening
and
intralobular lines are more irregular and thicker in the
dependent areas where there is relatively more peribronchial
infiltration with intervening ground glass opacity. Mild
dilation of segmental and more peripheral bronchi is seen in all
areas, most striking in the lingula.
The simplest explanation for all these findings is cardiogenic
edema, but the absence of any appreciable pleural effusion or
progression of pre-existing moderate cardiomegaly argue against
that (as does the recent clinical history of worsening
respiratory failure despite diuresis).
There is some heterogeneity in the background density of the
lungs on the [**2188**] torso CT, but this could be due to simple air
trapping. But, the conventional chest radiograph performed
[**2191-1-18**] which showed unequivocal right lower lobe
pneumonia also showed a large ground-glass abnormality in the
perihilar left lung and right apex medially which could have
been the early stages of the current process. Differential
diagnosis for that sequence is drug reaction, pulmonary alveolar
proteinosis, and fulminant cryptogenic organizing pneumonia.
If on the other hand, the findings in [**Month (only) 956**] were not a
precursor to the
current condition, one can add to the list any cause of
non-cardiogenic edema (ARDS) including acute intersitial
pneumonia.
Mild central adenopathy is new since [**2188**]: in the prevascular
mediastinal
station for example, 1 characteristic node is 8 mm, another 7
mm, previously 5 and 7 mm respectively, and in the right lower
paratracheal station a node grew from 8 mm to 11.5 mm. There are
no enlarged axillary nodes. New layering non-hemorrhagic left
pleural effusion is minimal and there is no right pleural or
pericardial effusion. Relative low density of cardiac contents
is
explained by anemia.
This study is not designed for subdiaphragmatic diagnosis except
to note
normal sized adrenal glands.
IMPRESSION:
See detailed discussion of differential diagnosis: drug
toxicity, non-cardiac edema (ARDS)including acute interstitial
pneumonia, pulmonary alveolar proteinosis, and cryptogenic
organizing pneumponia.
CXR [**4-16**]:
Since the prior chest x-ray, the endotracheal tube has been
removed. The
position of the central line and PICC line is unchanged. Small
right-sided
chest tube is still present. No pneumothorax is currently
identified.
Interstitial [**Doctor Last Name 5926**] is seen, unchanged on the left side.
IMPRESSION: No pneumothorax.
.
CXR [**4-17**]:
Compared to the study from the prior day, there has been no
significant
interval change.
.
LE ultrasound [**4-18**]:
IMPRESSION: No evidence for DVT in the bilateral lower
extremities.
.
CXR [**4-18**]:
IMPRESSION: AP chest compared to [**4-17**]:
Endotracheal tube ends between 3 and 4 cm above the carina, a
right PIC line tip projects over the region of the superior
cavoatrial junction, and a dual-channel hemodialysis catheter
ends in the upper and mid right atrium, all in standard
placements. No pneumothorax, pleural effusion or mediastinal
widening. Heart size normal. Severe interstitial pulmonary
abnormality could be either severe edema, the residual of
rapidly migratory pulmonary abnormalities solid radiographically
over the past month. Contribution of diffuse pulmonary
hemorrhage or organizing interstitial pneumonitis should not be
discounted. Heart size is top normal.
.
EKG [**4-18**]:
Normal sinus rhythm. Left ventricular hypertrophy. Non-specific
ST-T wave
changes in leads I, aVL and V6. Poor R wave progression.
Consider left atrial abnormality. Compared to the previous
tracing of [**2191-4-11**] the T wave inversions seen in leads V1-V3 are
much less prominent at that time. No other diagnostic interval
change.
Brief Hospital Course:
Mrs. [**Known firstname 4317**] [**Known lastname **] is a very nice 84 year-old woman with chronic
renal failure, colon cancer s/p resection, hypertension, and
diastolic dysfunction with shortness of breath.
.
#. Hypoxic respiratory failure - Patient came to the hospital
with progressive SOB over the last week, orthopnea, weight loss,
no fever or cough. Initial WBC 11.4, 86.3% PMNs and no bands and
a lactate of 2.4. She had bilateral pulmonary infiltrates and
hypoxia that improved with oxygen. It was unclear if she was
having an exacerbation of her diastolic heart failure (mostly
diastolic dysfunction) versus a healthcare acquired pneumonia
([**Known lastname 10540**]). Her NT-proBNP was 8012 while her prior values were in
the [**2180**] range. She was started on lasix 160 mg TID IV and
diuresed 6 L. Furthermore, treatment was started with
Vancomycin/Cefepime/Ciprofloxacin (Day 1 [**3-29**]). Her oxygen
requirements continued to worsen and her SpO2 dropped to mid 80s
on 6 L NC and 75% high-flow. Extensive discussions with
Attending Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4507**], patient, HCP and family took place;
patient did NOT want to be intubated. After extensive discussion
it was decided to intubate her for a bronchoscopy and CT scan
with a maximum of 5 days. Patient was intubated electively.
Bronchoscopy showed normal lungs; BAL showed PMNs, but no
bacteria. CT scan showed non-cardiac ARDS that could be
compatible with drug toxicity, non-cardiac edema (ARDS)including
acute interstitial pneumonia, pulmonary alveolar proteinosis,
and cryptogenic organizing pneumponia. GIven patient had been on
steroids a short [**Doctor Last Name 2949**] of prednisone 60 mg and Bactrim was
started to cover PCP while stains came back. It was stopped
within 24 hours as soon as it came back negative. Once cultures
negative and with no clear picture it was decided to give a
3-day burst of methylprednisolone 125 mg QID and then go down to
slowly to 40 mg, which if she survives she should continue for
2-3 months with a very slow [**Doctor Last Name 2949**] for pneumonitis/AIP. Her
outpatient nephrologist thought there could be a small
contribution of fluid and that diuresis could help with hypoxia,
so recommended CVVH. It did not improve hypoxia at all. Patient
developed progressive hypoxia that responded to increase in PEEP
up to 15. [**Doctor First Name **] and anti-GBM were negative. Pressures dropped and
she developed a R pneumothorax. After extensive discussion, R
pig-tail catheter was placed and pneumothorax resolved. She
continued to be intubated for several days and after with
extensive family discussions. It was decided to continue
high-dose steroids for any possible benefit. Through CVVH and
HD she was made euvolemic. She completed a course of
antibiotics for pna. Her vent was weaned to [**3-30**] for several
days. She developed increased sputum and was restarted on a 7
day course of cefepime/linezolid for possible VAP. On [**2191-4-16**],
she was successfully extubated and remained stable for several
days without ventilation; however, her O2 saturations
continually dropped into the 80s with movement and she required
O2 by NC and by facetent. On [**4-17**], she was reintubated for
hypoxia and unresponsiveness while her HD line was replaced by
IR. LE u/s was negative. CXR showed no new processes. She was
rapidly weaned and extubated the same day. She likely mucous
plugged as she had some thickened secretions though the ET tube
while she was intubated. She remained stable still with
occasionally desaturations but was satting well on 2L O2 on the
day of discharge. A steroid taper was begun with 40mg po
prednison with plans to decrease by 10mg every 5 days. She was
down to 30mg PO prednisone starting on [**2191-4-20**]. She will need
continued pulm toilet, pulm rehab, supplemental O2, and
albuterol prn, and steroid taper (down 10mg every 5 days, last
changed to 30mg on [**4-20**]). It is possible she will need a longer
taper given the length of time she was on high dose steroids.
She was started on DS bactrim daily for PCP prophylaxis while on
high dose steroids.
.
#. Acute on chronic diastolic heart failure - She has chronic
heart failure and reports losing weight. She is NYHA II. Her dry
weight is ~164. She had S3 on exam and increase JVP to the jaw.
Initial diuresis with 160 mg of IV lasix TID and metolazone 5 mg
daily was started and -6 L of fluid were removed without
improvement in the hypoxic respiratory failure. She was run
even. Then, nephrologist suggested CVVH, but she did not improve
further. Her echocardiogram showed preserved EF with diastolic
dysfunction and no WMA. Her CE were negative and there were no
ECG changes. She remained on CVVH/HD and was made and kept
euvolemic with improvement in her respiratory status as above.
.
#. Healthcare acquired pneumonia and ventilator associated
pneumonia - Initially it was unclear if patient had [**Name (NI) 10540**] or CHF
exacerbation. She was treated for both as described above. She
completed an 8-day course of Vanc/Cefepime/Ciprofloxacin (Day 1
[**3-29**]) without improvement. Her CXR did never show clear alveolar
infiltrates and she was too unstable and with too high oxygen
requirements to be taken to the CT scanner. After intubation and
further data it was thought she had a pneumonitis (medication
effect, AIP, etc). As above, she developed thickened secretions
on [**4-13**] and was treated with another 8 days of cefepime and
linezolid (linezolid to also cover her VRE as below).
.
#. VRE bacteremia: grown from BCx on [**4-6**] from 1/2 bottles taken
from her A-line. Her A-line was discontinued. She was started
on daptomycin on [**4-8**] with plans for 2 week course. This was
changed to linezolid to also cover her VAP on [**4-13**]. Her
linezolid should continue with last doses on [**4-22**]. All
subsequent blood cultures (drawn [**4-6**] to [**4-10**]) were negative.
.
#. Hypertension - Initially continued her home diltiazem, but
patient then developed hypotension. She never required pressors.
.
#. Chronic kidney disease - eGFR of 18 ml/min with Stage IV CKD
according to MDRD formula at baseline. Her PTH is 39 with a
target of 70-110. She became anuric, then CVVH was started for
fluid removal and she was transitioned to HD on [**4-9**]. Her
calcitriol was continued. Initially she developed
hyperphosphatemia, but after initiation of CVVH it resolved.
She continued to require HD with CVVH. A tunneled HD catheter
was placed on [**4-17**] and she will continue to require HD for the
forseeable future.
.
#. Anemia - Pt with HCT of 24.3 with borderline normocytic (MCV
99) microcytic anemia with RDW of 25.1. Iron 122, ferritin 249,
TIBC 424, TRF 326 anemia of chronic kidney disease. Furthermore,
she has CKD and probably poor production given low EPo. B12 and
Folate were normal. Repeat iron studies showed iron 81, TIBC
228, and Ferritin 723, though this was in the setting of
previous blood transfusions. She is not currently getting iron
supplementation. She received intermittent blood transfusions
throughout her stay, last on [**4-17**]. It has been stable since
with a HCT around 26. She had guaiac positive brown stools and
may require outpatient colonoscopy or EGD if they continue.
.
#. Hypothyroidism - Last TSH in [**10-4**] 0.36. Her home-dose
thyroid hormone was continued.
.
#. thrombocytopenia - her plts dropped from 140s to 105 after
starting cefepime and linezolid. The cefepime is now
discontinued, but the linezolid is planned for another 2 days.
Her platelets should be checked every few days to ensure
stability and improvement.
.
#. Diarrhea - Pt developed diarrhea upon the first 2 days in the
ICU. She was C diff negative twice.
.
#. Access - PICC was placed on [**3-29**] for access. She has an
tunneled HD catheter. PICC was discontinued on [**4-20**] prior to
transfer.
.
#. Ethical issues - Patient initially did not want to get
intubated and it was more than clear that she would never want
to be trached or have prolonged course of rehab. After many
meetings it was decided in a short intubation for diagnostic
procedures and tailor therapy. Two family members, who are not
HCP, pushed for much more aggressive therapy and medical staff
felt uncomfortable and going against clearly voiced patient
wishes a few days prior. Social work, palliative care and ethics
services were called. Family was bargaining for time and they
were not sure how upset pt would be if she knew she had been
intubated this long. Through continued discussions, the plan
was to extubate if medically ready, and to reintubate if
necessary. She was extubated and reintubated once several days
later for likely mucous plugging as above, then reextubated.
She remains DNR, but can be intubated. The patient documented
her wishes in company of family and staff and has been video
recorded. She was transiently made full code for her transport
to her respiratory rehab, discussed with family. This should
revert to DNR with possiblity for intubation when she arrives at
her rehab. Code is DNR, can intubate.
Medications on Admission:
Omeprazole 20mg daily
Levothyroxine 137 mg daily
Clonazepam 0.5mg prn
Sertraline 100mg daily
Lovastatin 20mg daily
Oxycodone 5mg prn gout
Propoxyphene/Darvocet 100/650 prn pain
Gerrous sulfate 325mg [**Hospital1 **]
Diltiazem ER 120mg daily
Calcitriol .25mg MWF
Allopurinol 100mg daily
Bumex 1mg TID
Tums 2 daily
MVI daily
Discharge Medications:
1. Levothyroxine 137 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
6. insulin
humalog insulin per attached sliding scale
7. lab work
please check platelets every 3 days until stable/improved.
8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebs Inhalation Q6H (every 6 hours) as
needed for sob, wheezing.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO QHD (each hemodialysis).
13. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): 30mg until [**2191-4-24**], then 20mg [**4-25**] to [**4-29**], then 10mg
[**4-30**] to [**5-4**].
14. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 2 days: Through [**4-22**].
on HD days, the dose should be given after dialysis so it is not
dialyzed off right after given.
15. 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: Hypoxic respiratory failure, Acute renal failure on
chronic kidney disease, ventilator associated pneumonia, VRE
bacteremia, decompensated diastolic heart failure
Secondary: Hypothyroidism, history of bioprosthetic aortic valve
replacement
Discharge Condition:
Hemodynamically stable, mental status alert, following commands
and oriented. Full assist to chair with poor pulmonary reserve.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
You were admitted with shortness of breath that required
mechanical ventilation. This is likely due to a variety of
causes including heart failure, volume overload, kidney failure,
infection and lung inflammation. You were extubated on [**2191-4-15**].
You still need extra oxygen and have poor lung reserve. You
will need to have extensive physical therapy, pulmonary
rehabilitation and close monitoring in an extended care
facility. Your hospitalization was also complicated by blood
infection (Vancomycin Resistant Enterococcus) and kidney failure
requiring initiation of dialysis.
Followup Instructions:
Endocrinology Specialist
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10541**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2191-4-26**] 2:30 PM
Kidney Specialist
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2191-5-12**] 11:00 AM
Hematology Specialist
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2191-5-12**] 2:00 PM
Upon discharge from [**Hospital1 1872**] Rehab, please help Ms. [**Known lastname **] [**Last Name (Titles) 10542**]e a follow-up appointment with her primary care provider
[**Name Initial (PRE) 176**] 2 weeks.
Name: [**Last Name (LF) 10543**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES
Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 4474**]
Phone: [**Telephone/Fax (1) 4475**]
|
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13,837
| 138,760
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10872
|
Discharge summary
|
report
|
Admission Date: [**2163-1-10**] Discharge Date: [**2163-1-18**]
Date of Birth: [**2086-7-12**] Sex: F
Service: MEDICINE
Allergies:
Colchicine / Atorvastatin / Cinacalcet
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
PICC line placement ([**1-11**])
Sigmoidoscopy ([**1-14**])
Colonoscopy ([**1-17**])
History of Present Illness:
76 year-old woman with type 2 DM complicated by ESRD on HD,
hypertension/hyperlipidemia CHF (EF 30-40% in [**3-/2162**]),
sarcoidosis who presents with bright red blood per rectum. The
patient was in her usual state of health this morning when she
had two bowel movements ~9:30 am which were soft, slightly loose
and the toilet bowl was filled with blood. The patient denies
chest pain, shortness of breath, lethargy with these two
episodes although she did endorse some mild abdominal crampiness
and lightheadedness. Of note, the patient had a normal
colonoscopy in [**2160-5-13**] when she was also evaluated for BRBPR.
She had been guaiac negative X3 last week, per report.
She was brought from [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] to the ED where her initial
Hct 31.3 (baseline low 30s) and her creatinine slightly elevated
from priors but no significant electrolyte abnormalities. She
reports her last HD session was last Tuesday. Her initial vitals
were T98.2, BP185/72, HR80, RR20 and 99% on RA. The patient had
two more bowel movements in the ED which were maroon colored,
with streaks of blood also on soft stools so she was admitted to
the [**Hospital Unit Name 153**]. She denied any symptoms, including crampy abdominal
pain, with these two bowel movements. She received 2L IVF.
ROS (+) Per HPI
(-) Denies fever, chills. Denies headache, cough, shortness of
breath. Denies chest pain or tightness, palpitations. Denies
nausea, vomiting, diarrhea. Has baseline numbness/tingling of
bilateral lower extremities X1-2 months.
Past Medical History:
* Dyslipidemia/hypertension - coronary artery disease on
aspirin/plavix
* Hypertension
* Complicated proximal humerus fracture ([**6-/2161**]): followed by
orthopedics, currently advised to avoid L arm weight bearing
* Stroke, per family 2, one about 4-5 years prior and one >20
yrs ago family is unsure of deficit
* Post polypectomy bleed admitted on [**4-24**] for BRBPR
* ESRD on HD: Tues, Thurs, Sat at [**Location (un) **].
* CHF: ECHO [**2162-3-25**]: EF 30-40%. LVH (moderate, and diastolic
dysfunction)
* Type 2 DM: diagnosed >40 years ago, complicated by ESRD,
controlled on insulin
* Sarcoidosis with ocular involvement: seen every 3 months for
eye exam - not biopsy proven
* Gout: last flair [**10-18**]; usually occurs in R toes
* Knee surgery s/p fall
* Obstructive sleep apnea: [**2161-8-12**] sleep study shows moderate
obstructive sleep apnea consisting mainly of hypopneas that
produced substantial drops in oxygen saturation.
Social History:
Currently resides at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] long term care. No smoking
history, rare alcohol intake. Denies illicit drugs. Currently
resides at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] after L arm fracture, previously lived
with her daughter. Ambulatory with cane at baseline.
Family History:
Type 2 Diabetes mellitus, hypertension.
Physical Exam:
Admission:
VS: Temp: 98.4 BP:116/59 HR:78 RR:16 O2sat100% on RA
GEN: Pleasant, comfortable, NAD
HEENT: PERRL, EOMI, MMM, oro/nasopharynx clear, no JVD or
hepatojugular reflux currently, neck soft and supple without
lymphadenopathy.
RESP: CTA b/l with good air movement throughout, no
wheezing/rhonchi/rales
CV: RRR, S1 and S2 wnl, no r/g, RUSB --> apex holosystolic
blowing murmur, right sided HD catheter c/d/i w/o TTP or
erythema
ABD: nd, +b/s, soft, nt, no palpable masses
EXT: no c/c/e, RUE AV fistula c/d/i
SKIN: No rashes/lesions
NEURO: AAOx3. CN II-XII intact. Strength and sensation grossly
intact.
RECTAL: Grossly maroon, soft stools, no palpable hemorrhoids
Pertinent Results:
[**2163-1-10**] 01:10PM BLOOD WBC-7.1 RBC-3.21* Hgb-10.0* Hct-31.3*
MCV-97 MCH-31.2 MCHC-32.0 RDW-17.0* Plt Ct-206
[**2163-1-18**] 06:00AM BLOOD WBC-7.6 RBC-2.89* Hgb-8.8* Hct-26.1*
MCV-90 MCH-30.3 MCHC-33.6 RDW-16.5* Plt Ct-197
[**2163-1-10**] 01:10PM BLOOD Glucose-90 UreaN-76* Creat-7.5*# Na-138
K-6.4* Cl-96 HCO3-24 AnGap-24*
[**2163-1-18**] 06:00AM BLOOD Glucose-128* UreaN-31* Creat-7.7*# Na-143
K-4.1 Cl-94* HCO3-35* AnGap-18
[**2163-1-18**] 06:00AM BLOOD Calcium-9.5 Phos-5.7* Mg-2.2
.
EKG ([**1-11**]): Sinus rhythm. Left bundle-branch block. Left
ventricular hypertrophy. Compared to the previous tracing of
[**2162-8-11**] no diagnostic interim change.
.
CXR ([**1-11**]): Left PICC ends at level of mid to low SVC. No
pneumothorax.
.
Sigmoidoscopy ([**1-14**]):
Findings: Contents: Old blood was seen in the rectum, sigmoid
and descending colon, and splenic flexure. Blood was washed off
at multiple sites and normal appearing mucosa was noted beneath.
Mucosa: Normal mucosa was noted in the rectum, sigmoid colon,
descending colon and splenic flexure. Protruding Lesions Two
non-bleeding polyps of benign appearance and ranging in size
from 2 mm to 3 mm were found in the rectum. Excavated Lesions
Multiple non-bleeding diverticula were seen in the sigmoid colon
and descending colon.
Impression: Blood in the rectum, sigmoid colon and descending
colon. Diverticulosis of the sigmoid colon and descending colon.
Polyps in the rectum. Normal mucosa in the rectum, sigmoid
colon, descending colon and splenic flexure. Otherwise normal
sigmoidoscopy to splenic flexure.
Recommendations: Return to hospital floor.
Follow Hcts and transfuse PRN.
Will need full colonoscopy at some point.
If brisk bleeding would proceed to tagged-RBC scan.
.
Colonoscopy ([**1-17**]) Impression: Grade 1 internal hemorrhoids
Diverticulosis of the sigmoid colon
Otherwise normal colonoscopy to cecum
[**Telephone/Fax (1) 682**]. Procedures and appointments can be scheduled by
calling [**Telephone/Fax (1) 682**] or by email [**University/College **]. Likely
resolved diverticuli bleeding.
Brief Hospital Course:
76 year-old woman with ESRD, CHF (EF 30-40%), was initially
admitted with LGIB to [**Hospital Unit Name 153**]. In the ICU she received 3 units of
PRBCs over the course of 3 days. She was transferred to the
floor where she received a 4th unit of PRBC ([**1-14**]). 1st attempt
at bowel prep resulted in pulmonary edema after 1L golytely.
Tried tap water enema instead for flex sig. Flex sig [**1-14**]
showed old blood. Pt still with intermittent blood per rectum,
so a reattempt at bowel prep was made. Slow prep with GoLytely
over 36 hours was successful. She underwent colonoscopy which
showed diverticulosis, but no blood. It was suspected that her
episode of bleeding was likely due to a diverticular bleed. Due
to this episode, it is recommended that patient remain off of
bisacodyl, as it may predispose her to future episodes of
bleeding.
# Anemia [**3-16**] acute blood loss from LGIB: patient recieved 4
units of PRBC transfusion.
# ESRD: patient continued HD, and required dialysis for
management of acute CHF.
# HTN, benign: On Losartan, helding Coreg during GI bleed, but
this was resumed prior to discharge.
# Systolic CHF, EF 30-40%
Pt developed pulmonary edema from Golytely prep during the
admission, for which she received dialysis. On [**1-18**], she felt
somewhat short of breath and had pulmonary rales on exam. She
underwent HD with 1 liter fluid removal, and she now appears
euvolemic. Her Avapro (non-formulary) was replaced with
Losartan during the admission, which she tolerated well. Coreg
was resumed prior to discharge.
# CAD, native vessel:
Her Aspirin and plavix were initially held due to her GI
bleeding. Her HCT appeared stable, without any evidence of
ongoing bleed, so she was resumed on her aspirin 81 mg po q day
on [**1-18**]. Her Plavix remains held for now, and recommend
resuming on [**1-21**].
# Diabetes type II, controlled: continued insulin sliding scale
# Gout, chronic: continued allopurinol
# Sarcoidosis: No active issues.
# Code: Full Code
# Emergency Contact: [**Name (NI) 19267**] [**Telephone/Fax (1) 35116**] (HCP), [**Name (NI) **]
[**Telephone/Fax (1) 35405**]
Medications on Admission:
* Carvedilol 12.5mg twice daily M/W/F/Sun
* Carvedilol 6.25mg twice daily T/Th
* Renvela 1600mg three times daily w/ food, omit noon dose on HD
days
* Senna 8.6mg two tablets three times daily, omit noon dose on
HD days
* Lumigan 0.03% eye drops instill one drop in boths eye qHS
* Novolin sliding scale
* Tylenol 650mg q6h PRN pain
* Bisacodyl 10mg PR qday PRN constipation
* Enulose 30mL by mouth daily PRN constipation
* [**Male First Name (un) **]-tussin 10mLs q4h PRN cough
* Fleets enema PR qday PRN constipation
* Avapro 150mg qHS
* Claritin 10mg daily
* Allopurinol 100mg every other day
* Plavix 75mg daily
* Aspirin 81mg daily
* Omeprazole 20mg daily
* Nephrocaps q5pm
Discharge Medications:
1. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Mon, Wed, Fri.
2. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Tue, Thurs.
3. senna 8.6 mg Tablet Sig: Two (2) Tablet PO three times a day:
omit noon dose on HD days.
4. Lumigan 0.03 % Drops Sig: One (1) gtt Both eyes Ophthalmic at
bedtime.
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
6. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once
a day.
7. Avapro 150 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day:
Please hold until [**1-21**], at which time you may resume.
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
12. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
13. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day.
14. Renvela 800 mg Tablet Sig: Two (2) Tablet PO three times a
day: with meals. Omit noon dose on HD days.
15. insulin regular human 100 unit/mL Solution Sig: as per
sliding scale units Injection QACHS.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Gastrointestinal bleeding
- Anemia from acute blood loss
- Diverticulosis
SECONDARY DIAGNOSES:
- End stage kidney disease on hemodialysis
- Hypertension
- Coronary artery disease
- Systolic heart failure
- Gout
- Sarcoidosis
- Diabetes mellitus, type II
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital for evaluation of bleeding
from the gastrointestinal tract. Multiple units of red blood
cells were transfused as needed to keep your blood count
adequate. You underwent both a sigmoidoscopy and a colonoscopy
to evaluate for a source of bleeding. You were found to have
diverticulosis, which was the likely source of bleed.
Followup Instructions:
Department: RADIOLOGY
When: FRIDAY [**2163-2-18**] at 10:30 AM
With: ULTRASOUND [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE
Department: MEDICAL SPECIALTIES
When: FRIDAY [**2163-2-25**] at 11:00 AM
With: MALA [**Last Name (NamePattern4) 16956**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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"135",
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icd9cm
|
[
[
[]
]
] |
[
"48.23",
"38.97",
"45.23",
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icd9pcs
|
[
[
[]
]
] |
10419, 10541
|
6214, 8356
|
327, 414
|
10861, 10861
|
4109, 6191
|
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|
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|
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|
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|
442, 2012
|
10876, 11020
|
2034, 2979
|
2995, 3349
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,413
| 166,395
|
45366
|
Discharge summary
|
report
|
Admission Date: [**2172-4-20**] Discharge Date: [**2172-4-24**]
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
84 y.o. man with h/o CAD, AFib, ESRD on HD, PVD, severe mitral
regurg, poor historian, who presented last night to the ED via
EMS for increased weakness. Patient says he has been weak for
some time, and on day of presentation had two episdes where he
was unable to rise from a sitting position. The first time he
was unable to rise from a toilet. His wife called EMS but pt
refused transport. Later in the day, patient was unable to rise
from a chair and agreed to be taken to the ED. The paramedics
noted a SBP in the 70's which responded to IVF.
.
In the ED, blood and urine cultures were sent and the patient
received vanco, levo, and Flagyl, ASA 325 and tylenol x 1. His
rectal temp was noted to be 102.6 and he was again hypotensive
to the 70's. He was given IVF, vanco, levo, and flagyl and his
blood pressure improved and have stable since that time.
.
Patient says he last felt well about a week ago. [**First Name3 (LF) 4273**] any
specific symptoms of illness - no cough or cold symptoms, no abd
pain, diarrhea, constipation, vomiting, dysuria. Says his
appetite has been normal. However, as noted patient is a poor
historian.
Past Medical History:
1)CHF: ischemic cardiomyopathy w/severe LV systolic dysfunction
with
EF of 30%
2)CAD
3)severe mitral regurgitation
4)Atrial fibrillation, s/p ICD-not anticoagulated, on amio
5)Peripheral [**First Name3 (LF) 1106**] disease, s/p bypass leg surgery
6)ESRD on HD with R tunneled line
7)Anemia on Procrit and iron supplementation
8)? CVA [**90**] years ago with left facial numbness
9)Hypothyroidism
10) s/p right above the knee popliteal bypass graft in [**2160**] and
a left femoral popliteal artery bypass graft with revision that
included the left femoral to anterior tibial artery jump graft
in [**2167**]
11) BRBPR: hospitalized [**4-1**], EGD showed severe gastritis and
colonoscopy showed numerous diverticuli and adenomatous polyps,
tagged RBC scan negative
12) Cdiff [**2172-3-29**]
13) L foot hematoma requiring I and D hospitalization
Social History:
Smoked 1 ppd x 50 yrs, quit [**2163**]. Reported heavy EtOH use in
past, none currently. currently at [**Hospital1 **]. Lives with his
wife in [**Name (NI) **]. 2 children living in [**State 8449**].Retired
maintenance worker at [**Hospital3 **].
Family History:
NC
Physical Exam:
VS: 97.9 125/59 82 RR: 11 98% on 2L
Gen: elderly man lying in bed, dozing, in no apparent distress
HEENT: PERRLA, neck supple
Cardiac: irregular, [**3-3**] murmur
Pulm: scattered wheezes in all lungs fields
Abd: soft, NT, ND, +BS
Ext: + 2 edema, + 2 DP pulses
Neuro: alert, oriented, variably cooperative with exam, CN 2-12
intact, strength 3-4/5 in BL upper and R lower extremity,
(inconsistant) LLE seems to be 1-2/5, cerbellar exam wnl,
reflexes
+3 in RLE, and +2 elsewhere. Sensation diminished in lower
extremities to shins BL.
Pertinent Results:
CT abd/pelvis: 1. Ultrasound and CT findings are consistent with
adenomyomatosis of the gallbladder. There is also a gallstone
present.
2. Mass lesion within the lower lobe of the left lung, measuring
up to 2.7 cm in diameter. Correlation with outside imaging
studies would be helpful.
3. Small bilateral pleural effusions.
4. Massive splenomegaly, with a wedge shaped peripheral
hypodensity
concerning for infarct.
5. Atherosclerotic disease of the abdominal aorta with
aortobifemoral bypass.
6. Tiny hypodensities of the liver and kidneys, too small to
characterize.
7. Sigmoid diverticulosis, without evidence of diverticulitis.
.
RUQ US: 1. Collapsed gallbladder with calcifications of the
wall, which is thickened. There is no ultrasound evidence of
acute cholecystitis.
2. Hemangioma of the left lobe of the liver.
3. No intra- or extrahepatic biliary ductal dilatation.
.
CXR: No evidence of acute cardiopulmonary process.
Brief Hospital Course:
84 y.o. man with h/o CAD, AFib, ESRD on HD, PVD, severe mitral
regurg, poor historian, who presented to the ED via EMS with
increased weakness and hypotension.
.
#weakness: Neuro exam essentially normal although strength is
difficult to assess [**2-28**] variable patient effort. Ddx includes
deconditioning, infection, inadequately repleted hypothyroidism,
hypoadrenalism. Per patient's wife he has declined recently and
he has not had a good quality of life. In the MICU he continued
to spike fevers and although BP was stable, his mental status
was poor. The family decided that he would not have wanted such
aggressive measures given his poor state of functioning and he
was made CMO. The patient was put on morphine gtt and died on
[**2172-4-24**].
Medications on Admission:
hydralazine 50 mg q6h
amiodarone 200 mg daily
toprol 100 mg daily
neurontin 100 mg [**Hospital1 **]
imdur 30 mg daily
renagel 400 TID
protonix 40 QD
levoxyl 137 QD
valsartan 80 mg daily
MVI
lasix
allopurinol 100 QD
glyburide 1.25 QD
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"285.21",
"599.0",
"585.6",
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"287.5",
"424.0",
"458.9",
"892.0",
"443.9",
"412",
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"427.31",
"403.91",
"440.0",
"428.0",
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"995.91",
"276.50",
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"518.89",
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"562.10"
] |
icd9cm
|
[
[
[]
]
] |
[
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] |
icd9pcs
|
[
[
[]
]
] |
5161, 5170
|
4092, 4848
|
230, 236
|
5221, 5230
|
3137, 4069
|
5283, 5384
|
2563, 2567
|
5132, 5138
|
5191, 5200
|
4874, 5109
|
5254, 5260
|
2582, 3118
|
182, 192
|
264, 1412
|
1434, 2281
|
2297, 2547
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,849
| 195,254
|
47509
|
Discharge summary
|
report
|
Admission Date: [**2137-9-15**] Discharge Date: [**2137-10-11**]
Date of Birth: [**2077-8-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Heparin Agents
Attending:[**Last Name (NamePattern1) 2499**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
#. Tracheotomy
#. Flexible Bronchoscopy
#. Thoracostomy with placement of chest tube
#. Left VATs with pericardial window
#. Pleural Biopsy
#. Pericardiocentesis
History of Present Illness:
Patient is a 60F with ER negative, Her-2/neu positive breast
cancer with mets to lymph node, pericardium, spleen, and bone
who was recently receiving chemoradiation at which time she
became short of breath and was found to have laryngeal edema and
vocal cord paralysis. She was admitted to the ICU where she had
a trach placed, a chest tube placed for a large Left pleural
efusion and a pericardial window for malignant pericardial
effusion with a pulsus paradoxus of 15 to 20 prior to
pericardiocentesis and window. After resolution of these
problems (see hospital course) , due to the progressive nature
of her disease despite recent therapy with radiation to her left
brachial plexus and xeloda and herceptin, she was transferred to
the oncology service for additional chemotherapy with Adriamycin
and Cytoxan. On arrival to the floor, the patient had a pulsus
of 10.
.
Allergies:
PCN - ? hives
HIT positive, heparin listed as allergy
Past Medical History:
1. Initially diagnosed as a stage I (T1b, No, M0) infiltrating
ductal, ER negative breast cancer of the upper outer quadrant of
the right breast in [**2120**] treated with lumpectomy and axillary
lymph node dissection. Now s/p several chemotherapy regimens and
radiation to left brachial plexus. Patient now with known Stage
IV metastatic to nodes, spleen, bone. On chemo/XRT.
- Zeloda treatment began [**9-13**] but the patient has been treated
with Herceptin, Navilbine in past.
- s/p sinus surgery [**2127**].
Social History:
Patient is single, but has been married two times in the past
for a short period of time. She has no children. She lives in
[**Location 32775**] and works part time at a bank in the [**Location (un) 5110**] area. She
reports smoking half a pack of cigarettes a day for 40 years
without any other known toxic exposures. She reports her family
is small, both parents deceased and has one brother. She has a
cousin she is close with in the [**Name (NI) 5110**] area ([**Telephone/Fax (1) 100452**])
Family History:
No family history breast cancer. [**Name (NI) **] mother was diagnosed
with ovarian cancer at the age of 67 and died the following
year. Patient's paternal aunt was diagnosed with ovarian cancer,
age unclear. [**Name2 (NI) **] father was diagnosed with colon cancer at age
77. [**Name (NI) **] brother had asthma and died of cardiac arrest in
his 40's. Patient has not undergone genetic testing for BRCA 1
or BRCA 2, but has met with genetic counselors.
Physical Exam:
GEN: NAD, appearing older than stated age
HEENT: PERRLA, EOMI, supraclavicular LAD, anterior cervical,
submental LAD.
PULM: CTAB anteriorly, diffuses rhonchi posteriorly; crackles
half way up
CV: RRR, S1/S2, no murmurs/rubs/gallops; pulsus paradoxes 20
ABD: +BS, NTND
EXT: WWP, no edema
Neuro: A&O x 3; follow commands
Pertinent Results:
Admission Labs:
[**2137-9-15**] 12:46PM PLEURAL TOT PROT-2.3 GLUCOSE-188 LD(LDH)-1218
[**2137-9-15**] 12:46PM PLEURAL WBC-2900* RBC-[**Numeric Identifier 100453**]* POLYS-72*
BANDS-1* LYMPHS-27* MONOS-0
[**2137-9-15**] 08:20AM PT-13.2 PTT-24.7 INR(PT)-1.2
[**2137-9-15**] 07:50AM URINE HOURS-RANDOM
[**2137-9-15**] 07:50AM URINE GR HOLD-HOLD
[**2137-9-15**] 07:50AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.030
[**2137-9-15**] 07:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2137-9-15**] 07:50AM URINE RBC-0 WBC-0 BACTERIA-RARE YEAST-RARE
EPI-0
[**2137-9-15**] 07:50AM URINE MUCOUS-MOD
[**2137-9-15**] 06:00AM GLUCOSE-134* UREA N-15 CREAT-0.6 SODIUM-136
POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-21* ANION GAP-19
[**2137-9-15**] 06:00AM LD(LDH)-814*
[**2137-9-15**] 06:00AM TOT PROT-6.3*
[**2137-9-15**] 06:00AM WBC-16.4*# RBC-4.29 HGB-13.2 HCT-39.9 MCV-93
MCH-30.9 MCHC-33.2 RDW-13.8
[**2137-9-15**] 06:00AM NEUTS-91* BANDS-0 LYMPHS-4* MONOS-4 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2137-9-15**] 06:00AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
OVALOCYT-OCCASIONAL BURR-OCCASIONAL
[**2137-9-15**] 06:00AM PLT SMR-NORMAL PLT COUNT-316
Other pertinent labs/studies:
[**2137-10-1**]: UA - WNL, no blood
.
Trending:
CA 27.29: 34 -> 37 -> 68 -> 129 -> 95 ([**2137-9-30**])
[**2137-9-30**]: CEA: 52
.
[**2137-9-22**]: HIT Ab - positive
[**2137-10-3**]: HIT Ab - positive
.
Pleural Fluid: [**2137-9-15**]
WBC-2900 RBC-[**Numeric Identifier 100453**] Polys-72 Bands-1 Lymphs-27 Monos-0
Total Prot-2.3 Glu-188 LDH-1218
.
Pericardial Fluid: [**2137-9-16**]
WBC-201 RBC-6556 Polys-0 Lymphs-10 Monos-0 Other-90
Tot Prot-4.9 Glucose-0 LD(LDH)-2130 Amylase-51 Albumin-3.1
.
Microbiology:
[**2137-9-15**]: Pleural Fluid - No growth, No PMNs
[**2137-9-16**]: Pericardial Fluid - No growth, 2+ PMNs
.
[**9-17**], [**9-19**], [**9-24**]: Sputum cx: rare growth OP Flora
[**2137-10-3**]: Sputum cx: ACINETOBACTER BAUMANNII sensitive to
Gentamycin and Tobramycin
[**2137-10-4**]: Sputum cx: ACINETOBACTER BAUMANNII sensitive to
Gentamycin and Tobramycin
.
[**9-24**] ; [**9-25**] ; [**10-3**]: Stool cx - C. Diff Negative, cultures
negative
[**2137-10-9**]: Stool cx - C. Diff, cultures pending
.
[**2137-9-26**]: Urine cx: No growth
.
No Blood cultures drawn during admission
Cytology:
[**2137-9-16**] - Pericardial Fluid - POSITIVE FOR MALIGNANT CELLS
consistent with metastatic adenocarcinoma.
.
[**2137-9-15**] - Pleural Fluid - Highly atypical cells present -
cannot exclude carcinoma.
Radiology:
[**2137-10-9**]: CT Chest - 1. Improvement to prior multifocal ground
glass opacity and consolidation, but new right perihilar
consolidations. Temporal context and behavior of these findings
are most suggestive of drug reaction, atypical edema, or
pulmonary hemorrhage. Infectious process is felt to be unlikely.
2. Early development of fibrotic changes in the upper lobes,
supportive of drug toxicity scenario. 3. Small pericardial
effusion, increased from prior exam.
.
[**2137-10-3**]: CT Chest - 1. Acute pulmonary embolism in the right
lower lobe pulmonary artery extending into the segmental and
subsegmental branches. There is mild compression of the right
lower lobe pulmonary artery superior to the filling defect
secondary to right hilar lymphadenopathy. As the size of the
filling defect is larger than the narrowed lumen of the artery
proximally, an element of thrombus is also likely present.
Subsegmental pulmonary emboli are also demonstrated within the
right upper lobe and right middle lobe pulmonary arterial
branches.
2. Stable appearance of the lungs with multiple areas of ground
glass opacity and consolidation predominantly in the peripheral
and peribronchial distribution. No new areas of consolidation
are demonstrated. 3. Stable bilateral axillary, hilar, and
mediastinal lymphadenopathy. 4. Unchanged appearance of low
density lesion in the right love of the liver. 5. Stable
appearance of loculated, moderate in size left pleural effusion.
.
[**2137-10-2**]: LE US - IMPRESSION: Bilateral lower extremity deep
vein thromboses, right greater than left, age indeterminate.
.
[**2137-10-1**]: CT Chest without contast: 1) Multifocal areas of
ground glass and consolidation in peripheral and peribronchial
distribution. Rapid progression and development of these
findings favors an inflammatory or infectious etiology such as
cryptogenic organizing pneumonia, eosinophilic pneumonia, or
fungal infection. Less likely considerations include vasculitis
or drug reaction. Rapid progression argues against a neoplastic
process. 2) New porta hepatis and celiac axis lymph nodes, and
mild enlargement of right axillary and mediastinal lymph nodes.
3) Moderate loculated left pleural effusion, reduced in size in
the interval. 4) Resolution of pericardial effusion.
.
[**2137-9-26**]: Portable Chest: Findings suggest improvement in the
appearance of the chest since [**2137-9-25**] with persistent bilateral
opacities.
.
[**2137-9-16**] (s/p pericardiocentesis): Echo: Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There is a trivial/physiologic pericardial effusion.
Compared with the report of the prior study of [**2137-9-15**], the
pericardial effusion has resolved. Overall biventricular
systolic function remains preserved.
.
[**2137-9-16**]: Cardiac Cath: 1. Coronary arteries were not assessed.
2. Normal ventricular function. 3. Severe pericardial tamponade.
.
[**2137-9-13**]: Chest CT: 1. Interval increase in axillary,
mediastinal, and hilar lymphadenopathy. 2. New moderate to large
left pleural effusion with atelectasis. 3. New large pericardial
effusion.
4. Narrowing of the bronchus intermedius and right middle lobe
and lower lobe bronchus by the adjacent enlarged right hilar
node.
5. Stable splenic cyst. 6. Subtle ground-glass opacities and
septal thickening likely secondary to congestive heart failure,
although differential diagnosis includes atypical infection and
drug reaction. 7. 3-mm nodule in the right lower lobe,
follow-up for this is recommended in 3 months.
Discharge Labs:
CBC: WBC-5.0 ; Hct-25.7 (before transfusion 1U PRBCs) ; PLT - 45
Chem: Na-140 ; K-3.7 ; Cl-104 ; HCO3-28 ; BUN-6 ; Cr-0.5
PT-20.8 ; INR-3.1 ; Fibrinogen-495
Brief Hospital Course:
Patient is a 60yo F with metastatic breast cancer who has
received multiple chemotherapy regimens and radiation ([**8-22**])
for left brachial plexus tumor invasion with progression of
disease. On the morning of [**2137-9-15**], the patient presented to the
hospital with acute SOB and was found to have laryngeal
edema/vocal cord paralysis, a large pleural effusion and
pericardial effusion with tamponade physiology.
#. Pericardial effusion/tamponade: The patient initially
presented with hypotension, tachycardia, elevated JVP, and
pulsus paradoxus. Chest CT showed interval rapid accumulation of
pericardial effusion over two weeks. She deteriated
hemodynamically with hypotension, increased HR, and elevated
JVPs. Pericardiocentesis was performed with drainage of 480cc
turbid and bloody fluid, culture was negative and cytology
revealed maligancy. She underwent a left chest VATS, pleural
biopsy, and pericardial window, and a pericardial drain was
placed. Immediately postop, the patient developed flash
pulmonary edema and was diuresed overnight. Her pulsus was
normal on transfer to the OMED service. She was kept on
telemetry and remained in sinus tach for most of admission.
After vigorous diuresis her tachycardia has improved. Currently,
the patient is felt to be euvolemic without repeat epidoses of
hypotension. The patient has had no episodes of chest pain and
had no JVD. A recent CT performed on [**2137-10-9**] for a different
indication (see below) revealed small pericardial effusion which
was not seen on previous CT images. The patient currently does
not have a widened pulsus but has at baseline since her
admission to the floor stable tachycardia (rate 100-115) and
systolic blood pressures ranging from 90-115. Patient has been
working with PT and her exercise tolerance has been improving.
Patient's effusion will be followed with subsequent imaging and
clinical exam by her oncologist on outpatient visits.
.
#. Shortness of breath: Patient's shortness of breath upon
initial presentation was thought to be likely multi-factorial,
with vocal cord paralysis/laryngeal edema as side effect of
radiation, tumor obstruction of endotracheal tree, pleural
effusion, pericardial effusion, pulmonary edema, and PNA. Given
laryngeal edema and vocal cord paralysis, patient had an urgent
trach placed on [**2137-9-15**]. Additionally, as initial CT showed a
large left pleural effusion, a chest tube was placed on
[**2137-9-15**], which drained more than 1.4L of serosanguinous fluid.
As the patient was demonstrating tamponade physiology with
worsening hypotension the patient underwent pericardiocentesis
for immediate relief followed by a left VATS procedure with a
pericardial window. After stabilization and transfer to the
floor for additional chemotherapy given progression of disease,
the patient's trach was noted to continue to put out large
amounts of thick mucous and she was started on levofloxacin and
flagyl empirically for aspiration pneumonia, although the
patient was afebrile. Despite therapy, the patient's secretions
continued and chest film demonstrated worsening opacities
bilaterally without improving oxygen requirements. The patient
was diuresed with rapid improvement in her CXR and O2 sats. By
this time, the patient had completed 6 days of Levo/Flagyl and
antibiotics were held as it was thought that the patient's
clinical improvement was likely secondary to fluid diuresis
rather than an infectious etiology. However, on [**2137-9-30**] A CT
chest was performed which demonstrated multifocal areas of
ground glass and consolidation in peripheral and peribronchial
distribution with differential as discussed by radiology as
possible cryptogenic organizing pneumonia, eosinophilic
pneuomonia, or fungal infection. The chest CT was discussed with
the pulmonary team whose impression was that it more likely
represented a nosocomial pneumonia, although the exact etiology
of this alveolar consolidating process is not currently clear.
Chemo with Adriomycin/Cytoxan was initiated on [**9-30**]. An official
pulmonary consult was requested for help with management of this
patient, with new ground glass appearing infiltrates. The
patient had been afebrile, with stable O2 sats on trach mask and
even RA, but noted to have desaturation into the high 70's to
low 80's with ambulation. Additionally, in the setting of
working up the patient's hypoxia and ground glass infiltrates,
the patient was noted to have new right lower leg edema. A Lower
extremity ultrasound was performed which demonstrated bilateral
DVTs. As the patient is HIT Ab positive, the patient could not
be started on Heparin, but was instead started on an argatroban
drip for anti-coagulation. As the patient had known DVT as well
as hypoxia that was not improving, the patient underwent a CT of
the chest which demonstrated RLL pulmonary artery PE with
extension into the subsegmental arteries as well as additional
smaller subsegmental PEs on the right side. The patient
therefore received 5 days of argatroban and coumadin overlap,
and is currently receiving anticoagulation with coumadin only.
Despite all these events, the patient reports that she feels
better although she is noted to still have ongoing productive
cough. The pulmonary team was consulted to evaluate the patient
given her ongoing sputum production and the above previously
visualized ground glass opacities. The pulmonary team favored
obtaining sputum cultures to see if a causative organsim could
be identified before proceeding to Bronch. Sputum cultures were
performed and were found to be growing Acinetobaceter,
multi-drug resistant, but sensitive to tobramycin and
gentamycin. An infectious disease consult was addiitonally
requested. The impression of the ID team was that given that the
patient looked clinically well, was afebrile with stable oxygen
requirements, they believed that the acinetobacter was likely a
colonizer rather than a pathogenic organism and was therefore
not initially treated. However, the pulmonary team believed this
was not the case and that this organism should be thought to be
a cause of pulmonary infection given the CT findings and the
fact that this is a virulent organism. In the setting of this
decision making process, the patient developed neutropenia
secondary to her recent chemotherapy. Repeat CT was suggested as
well as starting cefepime 2gm q8hr with gentamycin 5mg/kg IV
q24hr for a fever spike given the patient's known acinetobacter.
A repeat CT was performed which demonstrated resolution of
previous ground glass opacities with development of a right
hilar consolidation which was not thought to be infectious, but
possibly representative of a drug effect vs. edema vs. bleed
(per radiology report). Therefore, given that the patient
continued to look well clinically and is now having decreasing
oxygen requirements the decision was made to not treat the
patient's acinetobacter as it is likely only a colonizer. Even
in the setting of neutropenia the patient did not develop fevers
or have worsening pulmonary status. Currently, the patient is no
longer neutropenic, remains afebrile, but still does have stable
amonts of thick yellow sputum production. The patient was
assessed by physical therapy on [**2137-10-9**] and was found to have
O2 sat of 90% on RA, with decrease to 88% when walking, but
recovery with rest. The patient is thought to requre still
additional rehab and will go to an extended care facility for
ongoing rehabilitation and PT.
.
#. Metastatic Breast Ca: The patient was admitted with known
metastatic breast cancer to the LN, bones, and spleen. She
responded poorly to initial chemo regimens. The patient is aware
of her poor prognosis but wishes to try further chemotherapy.
Therefore, on [**2137-9-30**] the patient began treatment with
Adriamycin and cytoxan (A/C) which was tolerated well. The
patient's course was complicated by neutropenia as described
above, but did not develop fever's during her course of
neutropenia. The patient had a pan-cytopenia secondary to
myelosuppression requiring transfusion of 1U of PRBC for Hct of
23.5 with appropriate bump but did not require any platelet
transfusions. The patient was transfused one additional unit of
PRBCs today on the day of discharge, for a Hct of 25.7. She has
guaiac negative stool and is thought to have anemia secondary to
her myelosuppression. The patient will require additional cycles
of A/C. Given the patient's complicated hospital course and
sub-optimal performance status at this time, she likely will
receive cycles of chemotherapy every two to three weeks. She is
planned to follow up with the office of her Oncologist, Dr.
[**Last Name (STitle) **] upon discharge for additional chemotherapy and
management of her cancer. She will need to be seen on [**2137-10-18**]
for additional chemotherapy and has been given instructions to
call Dr.[**Name (NI) 17513**] office to confirm appointment time.
.
#. Diarrhea: Patient developed diarrhea during her hospital
course. She had C. Diff sent x 4, all of which were negative and
the patient has remained afebrile with all stool cultures
negative. Therefore, the etiology of the patient's diarrhea does
not appear to be infectious at this time. The patient previously
was having 3 to 5 loose bowel movements a day, but currently the
frequency and severity of her diarrhea is decreasing.
.
#. Thrombocytopenia: patient was found to be thromocytopenic and
HIT Ab was positive. All heparin containing products were
avoided. In the setting of myelosuppression secondary to
chemotherapy, the patient was noted to develop thrombocytopenia
with a nadir on [**2137-10-9**] of 33 with now increasing counts. The
patient did not require any platelet transfusions and has not
had any adverse bleeding events, even in the setting of
thrombocytopenia and anti-coagulation for her DVT/PE.
.
#. Nutrition: Patient had a video swallowing study and it was
recommendedable that an appropriate diet would be ground solids
and thin liquids originally after multiple procedures. Since
then, the patient has had repeat video swallow which
demonstrated patient was appropriate for house diet with thin
liquids with no need for chin tuck or other such maneuvers.
Medications on Admission:
Xanax
protonix
Xeloda
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q2H (every 2 hours) as needed.
3. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day) as needed.
4. Codeine Sulfate 30 mg Tablet Sig: 0.5 Tablet PO Q4-6H (every
4 to 6 hours) as needed.
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
7. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO DAILY (Daily).
8. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6
hours) as needed.
10. Lorazepam 2 mg/mL Syringe Sig: .25 mg Injection Q4H (every 4
hours) as needed.
11. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
12. Procrit 40,000 unit/mL Solution Sig: One (1) ml Injection
once a week: patient should receive first dose on [**2137-10-12**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] Hospital - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
1. Metastatic Breast Cancer
2. Pericardial effusion with tamponade
3. Pleural effusion
4. Aspiration Pneumonia
5. Pulmonary Edema
6. Bilateral Deep Venous Thrombosis
7. Pulmonary Embolism
8. Larygneal Edema
9. Vocal Cord Paralysis
Discharge Condition:
Fair. Patient is afebrile with persistent mild tachycardia
100-110, with stable blood pressure with systolics ranging from
90-110 without a widened pulsus. Patient has a trach and
requires humidified air or low flow oxygen. Her oxygen
saturation at rest off oxygen is 90%, with decrease to 88% while
walking, but recovery to 90 to 92% with rest.
Discharge Instructions:
1. Please take all medications as prescribed
2. Please keep all outpatient appointments
3. Please return to hospital immediately for any symptoms of
increasing shortness of breath, dizziness, fainting,
fever/chills or any other concerning symptoms
Followup Instructions:
Patient should call the office of Dr. [**Last Name (STitle) **] for follow up
appointment. Patient will need to be seen on Friday [**10-18**] for
additional chemotherapy. Patient should call the office of Dr.
[**Last Name (STitle) **] at ([**2137**] to confirm time of appointment
.
Patient should follow up with Dr. [**Last Name (STitle) **] in [**Hospital **]
clinic. Please call ([**Telephone/Fax (1) 1504**] for appointment.
|
[
"196.3",
"478.30",
"198.89",
"V10.3",
"197.2",
"288.0",
"507.0",
"197.8",
"514",
"E879.2",
"287.4",
"453.42",
"478.6",
"196.1",
"E934.2",
"518.81",
"423.8",
"787.91",
"198.5",
"E930.7",
"415.19",
"E933.1",
"289.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.24",
"99.25",
"99.04",
"34.09",
"37.0",
"31.1",
"37.12",
"33.21"
] |
icd9pcs
|
[
[
[]
]
] |
21242, 21320
|
9821, 20050
|
318, 482
|
21603, 21951
|
3323, 3323
|
22249, 22681
|
2514, 2969
|
20122, 21219
|
21341, 21582
|
20076, 20099
|
21975, 22226
|
9640, 9798
|
2984, 3304
|
259, 280
|
510, 1449
|
3339, 9624
|
1471, 1985
|
2001, 2498
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,814
| 101,008
|
17788
|
Discharge summary
|
report
|
Admission Date: [**2148-1-30**] Discharge Date: [**2148-2-10**]
Service:
HISTORY OF THE PRESENT ILLNESS: The patient is an
82-year-old male with known mitral valve disease and has been
experiencing increased shortness of breath for several months
and initially it was attributed to COPD; however, on repeat
echocardiogram which showed worsening MR and LV dilatation,
scheduled for cardiac catheterization and it showed LAD 80%
occluded, left circumflex 99% occluded, 3+ MR, and elevated
PA pressures.
The patient was initially admitted to the Medicine Service
for stabilization.
PAST MEDICAL HISTORY:
1. COPD.
2. Mitral valve disease.
3. Hypertension.
4. Pulmonary hypertension.
5. Coronary artery disease.
6. Status post MI in [**2120**].
7. GERD.
8. Cataract.
9. Bladder cyst.
HOSPITAL COURSE: The patient was initially admitted to the
Medicine Service and stabilized on the Medicine Service. The
patient was taken by Dr. [**Last Name (STitle) **] to the Operating Room on
[**2148-2-2**] and underwent a CABG times three, mitral
valve repair, and annuloplasty.
On postoperative day number one, the patient was admitted to
the DIC CRSU on an intra-aortic balloon pump and paralyzed
and sedated on Milrinone, Levophed, epinephrine, and
Pitressin. The patient required multiple units of packed red
blood cells and FFP to maintain his cardiac index.
On postoperative day number one, the patient was started on
CVVH given his renal impairment and also given his fluid
overload.
The patient was transferred to the unit. Postoperatively,
the chest was left open because difficulty ventilating the
patient because of COPD intraoperatively and at the time of
operation it was decided to leave the chest open. The
patient was transferred to the CRSU with the chest open. The
chest tube was clotted off postoperatively on postoperative
day number one and stopped draining.
The patient was becoming increasingly difficult to ventilate.
The decision was made to re-explore and evacuate a hematoma
at the bedside on postoperative day number one for which the
procedure was carried out and the patient stabilized. He was
continued on CVVH by the Renal service.
The patient was continued on the .................... stable
state for the next several days without any event. He was on
CVVH on milrinone, epinephrine, Levophed, and was being
paralyzed and sedated for the next several days.
TPN was started on postoperative day number three. On
postoperative day number five, we began to try some trophic
feeds; however, the patient did not tolerate trophic feeds.
On [**2148-2-9**], the patient's cardiac index appeared to be
deteriorating and the decision was made to re-explore the
chest again at the bedside. The procedure was carried out;
1/2 liters of fluid was evacuated from the right pleural
space and some clots were evacuated from the chest tube.
However, since that day on the patient's condition began to
deteriorate rapidly and overnight the patient began to
require several amps of bicarbonate still having a pH of 7.21
on ABG.
Throughout the night of [**2148-2-9**], the patient continued
to require bicarb. He went into A fib and was cardioverted
and went back into A fib again.
Eventually, on the morning of [**2148-2-10**], at approximately
6:30 a.m., the patient went into asystole. Cardioversion was
carried out and several amps of bicarbonate and several amps
of calcium were given. The epinephrine drip was turned up.
Milrinone was turned up to maximum. Pitressin was turned up
to maximum, however, to no avail.
The patient expired on the morning of [**2148-2-10**] at
approximately 6:30 a.m.
DISCHARGE PROCEDURE: Status post coronary artery bypass
graft, MVR and revision.
DISCHARGE DIAGNOSIS:
1. Chronic obstructive pulmonary disease.
2. Mitral valve disease.
3. Hypertension.
4. Pulmonary hypertension.
5. Coronary artery disease.
6. Status post myocardial infarction.
7. Gastroesophageal reflux disease.
8. Cataract.
9. Bladder cyst.
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2148-2-10**] 09:16
T: [**2148-2-10**] 10:44
JOB#: [**Job Number 49401**]
|
[
"427.31",
"996.72",
"038.9",
"998.12",
"286.6",
"424.0",
"997.3",
"492.8",
"276.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"34.03",
"99.15",
"39.61",
"99.61",
"37.61",
"35.12",
"39.95",
"36.12",
"34.79",
"96.6",
"96.72",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
3754, 4142
|
821, 3733
|
615, 803
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,124
| 175,333
|
30750
|
Discharge summary
|
report
|
Admission Date: [**2191-5-15**] Discharge Date: [**2191-6-11**]
Date of Birth: [**2111-10-25**] Sex: F
Service: SURGERY
Allergies:
Codeine / Lopressor
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 79 year old woman who underwent an exploratory
laparotomy with lysis of adhesions in [**3-28**] presented to
[**Hospital6 18346**] with nausea and vomiting. This began
with awaking with acute onset of pain at 2 AM. On [**Hospital1 6687**],
her CT scan demonstrated poor perfusion to the pancreatic head
as well as partial thrombus of the SMV and splenic vein.
Past Medical History:
Hypertension
History of atrial fibrillation
Surgical history:
Ruptured appendix 3 years ago
Small bowel obstruction, lysis of adhesions
Social History:
Ms [**Known lastname 72820**] lives with her [**Age over 90 **] year old husband on [**Name (NI) 6687**] where
she is a real estate [**Doctor Last Name 360**]. She has 3 daughters. One also lives
on [**Hospital1 6687**] and works for the historical society. Ms [**Known lastname 72820**] is
the primary caregiver for her husband. She denies tobacco use,
reports EToH daily, a glass of wine. She denies recreational
drug use.
Family History:
NC
Physical Exam:
T 96.8, P 80, BP 120/60
General: No acute distress
Heart: Regular rate and rhythm
Lungs: Diminished breath sounds at the bases
Abdomen: Soft, nondistended, diffusely tender.
Pertinent Results:
Radiology:
[**5-15**] RUQ U/S: Cholelithiasis without evidence of acute
cholecystitis.
[**5-16**] CTA Abdomen/Pelvis:
1. Acute necrotizing pancreatitis. Nonenhancement consistent
with necrosis involves the body and neck region of the pancreas
with significant peripancreatic stranding and fluid, some of
which extends into the left anterior pararenal space. No gas
within pancreas or and no discrete fluid collections. Thrombus
is present within the SMV distally and near the SMV portal vein
confluence.
2. 3.4 cm heterogeneously enhancing left renal mass, highly
concerning for renal cell carcinoma. Left renal cysts. Probable
tiny right renal cysts.\
3. 1.9 cm right adnexal cyst.
4. Small bilateral pleural effusions
[**5-20**] MRCP:
1) Necrotizing pancreatitis.
2) Near-occlusive thrombosis of the superior mesenteric vein,
progressed since [**2191-5-16**].
3) Left renal mass with appearance consistent with renal cell
carcinoma.
4) Pancreas divisum.
5) Bilateral renal cysts
[**5-26**] CT Abdomen/Pelvis:
1. Evolving pseudocyst(s) in the location of previously
visualized necrosing pancreatitis changes, with interval
increase in superior mesenteric vein thrombus.
2. Persistent enhancing left renal cortical mass, highly
suspicious for renal cell carcinoma.
3. Interval increase in bilateral pleural effusions with
associated lower lobe collapse.
4. New diffuse subcutaneous edema.
5. Redemonstration of an incompletely imaged right adnexal cyst.
[**2191-5-15**] 03:40PM BLOOD WBC-16.1*# RBC-4.68 Hgb-14.3 Hct-40.5
MCV-87 MCH-30.5 MCHC-35.2* RDW-14.4 Plt Ct-345
[**2191-6-11**] 08:05AM BLOOD PT-22.0* PTT-28.6 INR(PT)-2.2*
[**2191-5-15**] 03:40PM BLOOD Glucose-154* UreaN-24* Creat-1.3* Na-139
K-5.0 Cl-105 HCO3-21* AnGap-18
[**2191-5-15**] 03:40PM BLOOD ALT-15 AST-39 AlkPhos-86 Amylase-1460*
TotBili-0.3
[**2191-5-15**] 03:40PM BLOOD Lipase-2144*
Brief Hospital Course:
Ms. [**Known lastname 72820**] was admitted to [**Hospital1 18**] under the care of Dr. [**Last Name (STitle) **]
in the SICU for care for her necrotizing pancreatitis. For her
SMV and splenic vein thromboses, she was placed on a heparin
drip with a goal of 60-80 seconds for PTT. An arterial line was
placed to more accurately follow her blood pressures.
Meropenem therapy was initiated for her necrotizing pancreatitis
on HD3 and a PICC line was placed. TPN was initiated.
Cardiology was consulted for rapid atrial fibrillation on HD4.
She was treated with diltiazem.
On HD9, she was given Coumadin to begin transitioning to a PO
anticoagulation regimen. She required a Neosynephrine drip to
maintain her blood pressure. However, on HD10, she was
intubated for respiratory failure. Her Neosynephrine drip was
weaned to off. Her TPN was stopped, and tube feeding was
initiated via [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-jejunal tube. Neosynephrine was
reinitiated to maintain her blood pressure.
On HD14, she had another bout of atrial fibrillation and was
placed on an Amiodarone drip. On HD 15, her pressors were again
weaned to off. On HD 17, she was extuabed. Her heart rhythm
had converted to sinus on amiodarone and diltiazem. Active
diuresis ensued. On HD18, she passed her speech and swallow
evaluation and began to tolerate PO feeds. On HD19, she was
transferred to the floor.
On the morning of HD21, after missing 2 doses of PO amiodarone,
she was noted to be in atrial fibrillation. She was given IV
diltiazem with no effect. She was then transferred to teh SICU
for an amiodarone bolus and drip. She converted back to siunes
rhythm and was transferred to the floor on HD22. At this time,
she was not therapeutic on Coumadin, and her doses were
adjusted. She tolerated a regular diet and tube feeds were
stopped. On HD24, her Foley catheter was removed. She was
noted to have an INR of 2.0 on HD26.
On HD28, she was deemed ready for discharge home. She is to
follow up with Dr. [**Last Name (STitle) **] in 2 weeks with a CT scan. She
should follow up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 3748**]. She should
follow up with Dr. [**First Name (STitle) 2429**], her PCP, [**Name10 (NameIs) **] [**Name11 (NameIs) 766**] to discuss
management of her coumadin and amiodarone.
Medications on Admission:
Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Medications:
1. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*5 Tablet(s)* Refills:*0*
2. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 1 months.
Disp:*120 Tablet(s)* Refills:*0*
3. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
7. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 18346**]
Discharge Diagnosis:
Necrotizing pancreatitis
Discharge Condition:
Good
Discharge Instructions:
Please call the office or go to the Emergency Room if you
experience:
--Fever above 101.5 F
--Nausea that will not go away
--Worsening abdominal pain
--Bleeding that will not stop
--Any other concerns
You will be taking Coumadin. You should follow up with your PCP
(Dr. [**First Name (STitle) 2429**] on [**First Name (STitle) 766**] to discuss dosing.
Followup Instructions:
Follow up with Dr [**Last Name (STitle) **] in 2 weeks. You should have a CT
scan performed the morning of this appointment. You should call
his office at [**Telephone/Fax (1) 3201**] to arrange this.
At that hospital visit, you should also follow up with Dr.
[**Last Name (STitle) **] ([**Telephone/Fax (1) 1231**]) and Dr. [**Last Name (STitle) 3748**] ([**Telephone/Fax (1) 3752**]).
You should see Dr. [**First Name (STitle) 2429**] on [**First Name (STitle) 766**] for discussions about
Coumadin and Amiodarone.
|
[
"401.9",
"427.31",
"518.81",
"577.2",
"428.0",
"573.4",
"574.20",
"557.0",
"289.59",
"285.9",
"577.0",
"189.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.72",
"99.15",
"99.04",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
6789, 6841
|
3420, 5786
|
295, 302
|
6910, 6917
|
1536, 3397
|
7320, 7844
|
1323, 1327
|
6141, 6766
|
6862, 6889
|
5812, 6118
|
6941, 7297
|
1342, 1517
|
241, 257
|
330, 703
|
725, 864
|
880, 1307
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,528
| 193,134
|
54093
|
Discharge summary
|
report
|
Admission Date: [**2165-6-3**] Discharge Date: [**2165-6-5**]
Date of Birth: [**2095-10-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
69 y.o male with hx notable for CAD s/p PTCA ([**2138**]) and NSTEMI
([**2-/2165**]) on plavix, Ischemic cardiomyopathy with EF of 30% S/P
AICD [**2-2**] (generator change [**9-/2164**]), Liver failure [**2-28**] ETOH
abuse with Thrombocytopenia and PVD s/p iliac stent ([**2158**]) with
a recent hospitalization [**5-6**] - [**5-15**] [**2165**] for recurrent MSSA
endocarditis. His pacing device was removed at that time and he
was placed on long-term nafcillin (5 weeks, last dose 5/23). He
had never been shocked by the device before.
He had an earlier hospitalization to OSH on [**2165-2-27**] for MSSA
endocarditis at which time he had respiratory failure requiring
intubation, at which time he had EKG showed inverted T waves
in leads II, III, avF. TropT became elevated to 13.1. He had a
second admission later in [**Month (only) 956**] to OSH for fevers, requiring
ICU stay and pressors.
He then completed multiple weeks of antibiotics, and quickly
after stopping antibiotics started to have fevers again and was
admitted for the [**Month (only) 547**] [**Hospital1 18**] hospitalization for recurrent MSSA
bacteremia for which he was started on Nafcillin and had his
pacer leads removed.
The patient currently presents from Rehab with hypotension and
general malaise. At OSH, ECG showed wide complex tachycardia
which appeared to be new LBBB. On this ECG, he appeared to have
inferior ST elevations. He was transfered to [**Hospital1 18**] ED, where
EKG demonstrated another morphology of wide-complex, regular
appearing tachycardia, presumed to be VT. He was defibrillated
x2 in ED without rhythm conversion, so he was started on
lidocaine drip and taken to EP lab for EP study.
In the ED, initial vitals were 97.7 118 88/62 26 95% 4L.
Labs and imaging significant for:
134 \ 107 \ 32 \ 118 AGap=17
=================
4.9 \ 15 \ 1.3
estGFR: 55/66 (click for details)
Ca: 8.4 Mg: 1.7 P: 4.6
MCV121
WBC 7.3 Hgb11.9 Plt 178;
Hct 38.8 ;
N:83.3 L:10.3 M:5.8 E:0.2 Bas:0.3
PT: 13.9 PTT: 37.8 INR: 1.3
The patient went to the EP lab, and it was determined that the
patient most likely has at least two different morphologies of
monomorphic ventricular tachycardia, potentially secondary to
ischemia, although etiology unclear; other considerations for
etiology included junctional rhythm, atrial tachycardia with
ischemic changes. In the EP lab, rhythm converted to sinus with
continued lidocaine drip. Temporary pacing leads placed in
coronary sinus and RV for EP study. He then became
hemodynamically unstable with episodes of hypotension, requiring
endotracheal intubation and initiation of pressors, so the EP
study was aborted.
The patient then underwent cardiac catheterization to assess the
coronary anatomy, demonstrating severe proximal and mid-LAD
disease; in addition, he was noted to have severe left
circumflex and RCA disease with good collaterals. The LAD was
calcified, the proximal LAD was dilated and stented with a BMS,
with good result.
A balloon pump was placed in left groin with swan in right
groin. Temp pacing wires in right groin were left in place for
AV sequentially pacing to be coordinated with balloon pump. The
balloon pump was working well after adjusting for pacing. The
patient's blood pressure is augmenting well with balloon pump
and two pressors: norepinephrine and phenylephrine. The R
radial was used for the interventional procedure.
On arrival to the floor, patient is intubated and sedated,
ill-appearing.
Past Medical History:
1. Ischemic cardiomyopathy
2. CAD s/p MI with PTCA ([**2138**]); NSTEMI ([**2-/2165**]) with no stents,
started on plavix
3. DDD pacemaker with defibrillator implantation in [**2160-1-28**],
generator change in [**9-/2164**]
4. CRI
5. Thrombocytopenia
6. CHF
7. PVD s/p grafts
8. HTN
9. Hyperlipidemia
10. Hx of ETOH abuse
11. Tonsillectumy
12. Lumbar discectomy in [**2157-5-28**]
13. RF with rhabdo after a fall in [**2163**]
Social History:
used to work in [**Location (un) **] and [**Location (un) 6482**] as technical manager.
Tob: quit 25 years ago
EtOH: quit 2 years ago at advice of his physician. [**Name10 (NameIs) 17613**] that
he used to drink 2 drinks/day
Drugs: Never
Family History:
Father had heart disease and MI many years ago.
Physical Exam:
PHYSICAL EXAMINATION:
VS: T= BP=109/43 HR= 81 RR= 16 O2 sat= 100% on FiO2 100%,
PEEP5
(Swan-Ganz: PA 50/32)
GENERAL: appears older than stated age, intubated and sedated.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink.
mouth open with mildly dry mm.
NECK: Supple with JVP difficult to assess while supine.
CARDIAC: Reg Rhythm, normal rate, with balloon pump sounds.
Difficult to assess for murmurs with balloon pump.
CHEST: Left upper chest with stitches from device removal, no
signs of infection
LUNGS: clear anteriorly and mild crackles laterally
ABDOMEN: Soft, mildly distended. No HSM or grimace to palpation.
EXTREMITIES: No
SKIN: telangiectasia on forehead, petechiae around inferior
orbits bilaterally ; buttocks with purplish deep tissue injury
bilateral with some skin tears (R>L).
PULSES:
Right: Carotid 2+ Femoral 2+ DP- cannot doppler PT-
dopplerable
Left: Carotid 2+ Femoral 2+ DP- cannot doppler PT-
dopplerable
Pertinent Results:
BRIEF HISTORY:
Mr. [**Known lastname 20889**] is a 69 year old man with known ischemic
cardiomyopathy who
presented with VT. He was brought to the EP lab for mapping and
possible
ablation, but the VT was thought to be ischemic. He was referred
for
emergent cardiac catheterization due to VT and hemodynamic
instability
INDICATIONS FOR CATHETERIZATION:
Ventricular Tachycardia
Hypotension
PROCEDURE:
Intra-aortic balloon counterpulsation: was initiated with an
introducer
sheath using a Cardiac Assist 9 French 30cc wire guided
catheter,
inserted via the left femoral artery.
Percutaneous coronary revascularization was performed using
placement of
bare-metal stent(s).
Peripheral Catheter placement was performed.
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
HEMODYNAMICS RESULTS BODY SURFACE AREA: m2
HEMOGLOBIN: gms %
OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed.
**PTCA RESULTS
LAD
PTCA COMMENTS:
Diagnostic angiography performed from right radial approach and
showed
three vessel coronary artery disease. The patient was
hypotensive
requiring norepinephrine and was intubated and sedated.
Descending
aortography showed patent aorta and patent known left iliac
stent.
Decision made to place IABP via left femoral access which
proceeded
without difficulty. MAP's stabilized and we proceeded with PCI.
Discussion occurred with family who confirmed wishes to proceed
with
aggressive therapy. Initial angiography showed a calcified LAD
with a
hazy, thrombotic appearing lesion in proximal vessel thought to
be
culprit and decision made to proceed with PTCA and stenting of
that
lesion (Lcx and RCA chronic disease). Heparin was continued in
addition
to integrilin. A 6F XBLAD 3.0 guiding catheter (via right
radial)
provided adequate support for the procedure. A Prowater wire
crossed the
lesion with minimal difficulty. We attempted to perform export
thrombectomy however the catheter would not pass the calcified
first
turn in the proximal LAD. We then dilated the proximal LAD with
a
2.5x12mm Apex OTW balloon and inflated to 10 atms for two
inflations
with improved appearance of the thrombus. WE deployed a 3.5x18mm
Integrity bare metal stent in the proximal LAD at 14 atms. The
proximal
segment of the stent was postdilated with a 3.5x12mm NC Quantum
apex Mr
balloon at 22 atms. Final angiography showed no residual
stenosis in
stented segment, an area of non flow limiting haziness
proximally, no
angiographically apparent dissection and TIMI 3 flow. The IABP
was
sutured in place.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = minutes.
Arterial time =
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol 190 ml
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Heparin 5000 units IV
Cardiac Cath Supplies Used:
- [**Company **], MAGIC TORQUE 260CM
- [**Doctor Last Name **], PROWATER 300CM
2.5MM [**Company **], APEX 12/1.5 FLEX
2.5MM [**Company **], APEX 12/1.5 FLEX
6FR CORDIS, XBLAD 3.0
8FR ARROW, IABP ULTRA FIBEROPTIX CATHETER 30CC
- [**Company **], INTEGRITY RX 18/3.5
- [**Company **], EXPORT ASPIRATION CATHETER
- ALLEGIANCE, CUSTOM STERILE PACK
- MERIT, LEFT HEART KIT
- TERUMO, JACKY RADIAL CATHETER
5FR COOK, MICROPUNCTURE INTRODUCER SET
5FR TERUMO, GLIDESHEATH
- [**Doctor Last Name **], PRIORITY PACK 20/30
- TERUMO, TR BAND LARGE
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
three vessel coronary artery disease. The LMCA had no
angiogrphically
apparent disease. The LAD was calcified and had a hazy,
thrombotic
appearing lesion in proximal portion. The LCx had a severe 80%
stenosis
in the proximal portion. The RCA was chronically totally
occluded and
filled via left to right collaterals.
2. Cardiogenic shock requiring pressors and IABP placement prior
to PCI.
3. Ventricular tachycardia requiring lidocaine gtt.
4. Successful PTCA and stenting of proximal LAD with 3.5x18mm
Integrity
bare metal stent postdilated proximally to 3.5mm. Unsuccessful
attempt
to Export (unable to deliver to lesion).
5. Successful hemostasis of right radial arteriotomy with TR
band.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Successful PCI of LAD with BMS.
3. Cardiogenic shock
4. Successful IABP via LFA
5. Ventricular tachycardia
6. Successful RRA TR band.
7. Temporary pacing wires per EPS management.
[**Hospital1 18**] ATTENDING OF RECORD: [**Last Name (LF) **],[**First Name8 (NamePattern2) 251**] [**Doctor Last Name 640**]
REFERRING PHYSICIAN: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) 251**] [**Doctor Last Name 640**]
FELLOW: [**Doctor Last Name 28713**],[**Doctor First Name 28714**]
[**Last Name (LF) **],[**First Name3 (LF) **] B.
INVASIVE ATTENDING STAFF: [**Last Name (LF) **],[**First Name3 (LF) **]
Brief Hospital Course:
Patient was admitted to the CCU following procedure. Over the
course of his stay he was found to have severely worsening
cardiac function and had increasingpressor requirements as well
as worsening renal function. He had a brief period of asystole
the morning of [**2165-6-2**]. He was coded breifly with return of
pulse. A family meeting was held during which a decision was
made to not escalate care. Ont he morning of [**2165-6-3**] another
meetign was held with the patitn's Sister and the CCU team.
After a discussion the decision was made to withdraw care and
Mr. [**Known lastname 20889**] passed away at 1500h [**2165-6-8**]. His family was at his
side.
Medications on Admission:
1. spironolactone 50 mg Tablet Sig: One (1) Tablet PO twice a
day.
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
4. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) ml
PO once a day as needed for constipation.
5. Vitamin B-12 2,000 mcg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO once a day.
6. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Pepto-Bismol 262 mg Tablet Sig: One (1) Tablet PO once a day
as needed for indigestion.
8. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
12. nafcillin 2 gram Recon Soln Sig: Two (2) grams Intravenous
every four (4) hours for 5 weeks: 5 weeks after discharge, last
dose on [**2165-6-19**].
13. heparin Sig: 5000 (5000) units Subcutaneous three times a
day.
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
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5,928
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51244
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Discharge summary
|
report
|
Admission Date: [**2153-9-2**] Discharge Date: [**2153-9-14**]
Date of Birth: [**2102-8-5**] Sex: F
Service: MEDICINE
Allergies:
Depakote / Aricept / Lamictal / eggs / Penicillins
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 106322**] is a 51-year-old woman with a pmhx. of bipolar
disorder and hypothyroidism who is admitted with hypercarbic
respiratory distress in the setting of an asthma exacerbation.
Ms. [**Known lastname 106322**] states that she felt ill a few days prior to
admission with nasal congestion, mild cough, and subjective
chills. She then started wheezing about 48-hours prior to
admission, using her albuterol inhaler frequently. However,
symptoms progressied and she presented to the ED for further
evaluation and treatment.
Ms. [**Known lastname 106322**] has a long history of asthma beginning in
childhood. she has been hospitalized in the ICU 4 times for
asthma exacerbations but has never been intubated. Her typical
trigger is URI, and she states all of her hospitalizations were
for post-viral asthma attacks.
Initial vitals were: afebrile, HR 120, BP 150/88, RR 24, 95% on
NRB. She was able to speak in [**12-29**] word phrases and was using
accessory muscles to breathe. She was placed on a
non-rebreather. She was treated with back-to-back nebulizer
treatments (albuterol-ipratropium-albuterol), methylprednisolone
125mg IV x1, magnesium sulfate 2g x1 with initial success. CXR
showed hyperinflation without effusion or consolidation. She
improved and was able to speak in full sentences and to sit
upright without accessory muscle use. She was weaned to 2-3L
NC. After roughly 90 minutes she began to wheeze and was again
given an albuterol nebulizer with good effect. She remained on
NC on transfer to ICU. VBG: 7.28 / 58 / 75. On arrival to
MICU, patient's VS: 97.5 HR 108 112/73 sat 97% on 6L NC. In
the ICU, patient was continued on prednisone 40mg QD. She was
also started on flovent. Her vitals remained stable aside from
tachycardia, and on day after admission, Ms. [**Known lastname 106322**] was
transferred to the general medicine floor.
A 10-point review of systems is negative aside from what is
described above.
Past Medical History:
1) ASTHMA
Per recent Allergy Note:
-elevated IgE levels being worked up for Job's syndrome
(hyper-IGE)
-hx asthma since childhood
-few significant asthma flares requiring hospitalization
-never intubated & responded to prednisone and antibiotics
-flare in [**2140**] due to overgrowth of aspergillus in her apartment
-under good control on Flovent/Zafirlukast and Albuterol PRN
-history of one sputum culture with pseudomonas, all others oral
flora
Per recent pulm note: Spirometry [**2153-1-25**]:demonstrates an FVC
of 3.97 liters, which is 110% of predicted with an FEV1 of 2.10
liters, which is 77% of predicted, with an FEV1/FVC ratio of 53.
Compared to the last spirometry obtained in [**2152-7-27**],
there has been a significant decrease in her FEV1. This
demonstrates a mild obstructive ventilatory deficit.
2) HYPOTHYROIDISM: on levothyroxine, last TSH 0.36 on [**2153-9-3**]
3) BIPOLAR DISORDER: on seroquel and gabapentin
4) ECZEMA
5) ELEVATED IGE
-elevated IgE levels being worked up for Job's syndrome, however
recent Allergy note states this is unlikely diagnosis
Social History:
The patient lives in [**Location 27256**]. No history of tobacco, EtOH,
or other drugs. Has had dogs for years; has a puppy at home
currently. Used to work as an interior decorator. Curently
unemployed.
Family History:
There is no family history of asthma, atopy, or other pulmonary
disease. No family history of cancer.
Physical Exam:
VS: Afebrile, 100, 128/67, 92% on RA
GENERAL: Anxious, using accessory muscles but breathes
comfortably when distracted, speaks in full sentences
HEENT: Mucous membranes moist
CHEST: Diffuse wheezes bilaterally, but moving air
CARDIAC: Tachycardic, normal S1 and S2
ABDOMEN: +BS, soft, non-tender, non-distended
EXTREMITIES: Thin, in compression boots, no edema bilaterally
Pertinent Results:
ADMISSION LABS
[**2153-9-2**] 08:41PM BLOOD Type-[**Last Name (un) **] pO2-75* pCO2-58* pH-7.28*
calTCO2-28 Base XS-0
[**2153-9-2**] 08:35PM BLOOD WBC-8.5 RBC-4.01* Hgb-12.9 Hct-39.7
MCV-99* MCH-32.3* MCHC-32.6 RDW-12.5 Plt Ct-256
[**2153-9-2**] 08:35PM BLOOD Neuts-60.1 Lymphs-27.1 Monos-4.7 Eos-7.2*
Baso-0.9
[**2153-9-2**] 08:35PM BLOOD Glucose-91 UreaN-14 Creat-1.0 Na-142
K-4.2 Cl-108 HCO3-26 AnGap-12
[**2153-9-3**] 04:01AM BLOOD Type-[**Last Name (un) **] Temp-36.7 pO2-45* pCO2-47*
pH-7.37 calTCO2-28 Base XS-0 Intubat-NOT INTUBA
[**2153-9-3**] 03:39AM BLOOD Glucose-184* UreaN-14 Creat-0.9 Na-144
K-4.3 Cl-109* HCO3-26 AnGap-13
[**2153-9-3**] 03:39AM BLOOD Calcium-9.0 Phos-2.8 Mg-2.5
[**2153-9-3**] 03:39AM BLOOD TSH-0.36
CXR [**2153-9-3**]:
Compared with [**2153-9-2**] at 20:28 p.m., no significant change is
detected. The lungs are hyperinflated. The heart is not
enlarged. The pulmonary hila are unchanged. No CHF, focal
infiltrate, or effusion is detected. Tiny (<1mm) rounded
density adjacent to the left first rib likely represents a
vessel seen on end.
IMPRESSION:
1. Focal ground-glass opacity in the left upper lobe and
scattered
micronodular tree-in-[**Male First Name (un) 239**] opacities with bronchiectasis in the
bilateral lower
lobes is most consistent with [**First Name8 (NamePattern2) **] [**Doctor First Name **] infection, possibly acute
on chronic.
2. Calcified pulmonary nodules, mediastinal lymph nodes, and
splenic nodules
are consistent with prior granulomatous disease.
[**2153-9-11**] 11:01 am BRONCHOALVEOLAR LAVAGE BAL.
GRAM STAIN (Final [**2153-9-11**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
RESPIRATORY CULTURE (Preliminary):
>100,000 ORGANISMS/ML. Commensal Respiratory Flora.
YEAST. ~[**2140**]/ML.
Isolates are considered potential pathogens in amounts
>=10,000
cfu/ml.
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2153-9-14**]):
TESTING REQUESTED BY DR. [**First Name (STitle) **] # [**Numeric Identifier 28457**] [**2153-9-13**] 1542.
NO FUNGAL ELEMENTS SEEN.
This is a low yield procedure based on our in-house
studies.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2153-9-11**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary):
YEAST.
ACID FAST SMEAR (Final [**2153-9-12**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
No Cytomegalovirus (CMV) isolated.
CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final
[**2153-9-14**]):
Negative for Cytomegalovirus early antigen by
immunofluorescence.
Refer to culture results for further information.
Brief Hospital Course:
cc asthma
ros: mild cough improving, no fevers
hpi no events, breathing is better overall, mood is calm, denies
pain
discharge exam
97.5 98/60 (at baseline) 84 18 98% RA
non-toxic, speaking in full sentences breathing is comfortable
substantial improvement in air movement, less wheezey, no
crackles
no peripheral edema
HR is now <100
data:
BAL [**9-11**] with coag positive staph
WBC 12
repeat cxr [**9-14**] no infiltrate suggestive of pneumonia
PLAN
--she is medically stable for discharge home
-->30min spent on d/c activities
--she has PCP f/u next week. PCP emailed re: plan
Ms. [**Known lastname 106322**] is a 51-year-old woman with a history of asthma,
bipolar disorder and hypothyroidism who presents with
hypercarbic respiratory distress secondary to asthma
exacerbation requiring admission to ICU.
# Acute hypoxemic respiratory distress/ASTHMA EXACERBATION:
Secondary to asthma exacerbation with. She received emperic
antibiotics in the MICU with levofloxacin for under 48hrs and IV
steroids initially. On [**9-4**] her steroids were changed to 60mg
PO prednisone, which was reduced to 40mg on [**9-10**]. She will
taper her steroids over the course of the next 9 days until she
is off. Since there was no evidence of pneumonia she has been
off antibiotics without fever during this hospitalization.
Pulmonary evaluated her after a CT chest showed some ground
glass opacities and tree and [**Male First Name (un) 239**] lesions suggestive of possible
[**Doctor First Name **] infection. She had three sputa negative for AFB (2 induced,
1 BAL specimen). She underwent bronch on [**9-11**] without visible
purulence or airway abnormalities and no significant
leukocytosis on cell count and growth of coag positive staph on
culture as of [**9-14**]. I spoke with the pulmonary attending,
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**9-14**] re: this pathogen and we agreed not to treat
it as the patient's pulmonary symptoms were improving and she
has no infiltrate on her CXR. Also, the goal of the bronch was
to assess for smoldering infection with pseudomonas or other
pathogens. New meds include advair and she can continue
albuterol PRN at home. Room air sats >94% with activity prior
to discharge.
# TACHYCARDIA: Likely in the setting of albuterol use and
anxiety. Patient's tachycardia improved as her asthma
exacerbation resolved.
# BIPOLAR DISORDER: Long-standing relationship with
psychiatrist. Continued on seroquel and gabapentin. Patient's
psychiatrist was made aware of her admission and high dose
prednisone.
# HYPOTHYROIDISM: Levothyroxine was continued.
# ECZEMA: no acute issues
PENDING LABS
[]FINAL MICRO STUDIES FROM BAL, INDUCED SPUTA
TRANSITIONAL ISSUES
[]PULMONARY F/U
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. modafinil *NF* 50 mg Oral daily
2. Clobetasol Propionate 0.05% Ointment 1 Appl TP [**Hospital1 **]
apply to affected area twice a day for 2 weeks, then as needed
avoid face, skin folds, and groin
3. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP DAILY:PRN
eczema
once per day to itchy spots on skin for up to 14 days per month
avoid face-folds-genitals
4. olopatadine *NF* 0.1 % OU q6hPRN allergies
5. Gabapentin 1200 mg PO HS
6. Quetiapine Fumarate 400 mg PO QPM
7. Lorazepam 2 mg PO HS
8. zafirlukast *NF* 20 mg Oral [**Hospital1 **]
9. Cetirizine *NF* 10 mg Oral DAILY:PRN allergies
10. albuterol sulfate *NF* 90 mcg/actuation Inhalation q6h:PRN
SOB/wheezing
11. tacrolimus *NF* 0.1 % Topical QOD:PRN lesions
2-3 times per week as needed to face avoid prolonged use
12. Levothyroxine Sodium 50 mcg PO DAILY
Discharge Medications:
1. Gabapentin 1200 mg PO HS
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Lorazepam 1-2 mg PO Q12H:PRN anxiety
Please hold for oversedation or RR <10.
4. Quetiapine Fumarate 400 mg PO QPM
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/Dose 1
puff inh twice a day Disp #*1 Inhaler Refills:*0
6. zafirlukast *NF* 20 mg Oral [**Hospital1 **]
7. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP DAILY:PRN
eczema
once per day to itchy spots on skin for up to 14 days per month
avoid face-folds-genitals
8. Tacrolimus *NF* 0.1 % TOPICAL QOD:PRN lesions
2-3 times per week as needed to face avoid prolonged use
9. olopatadine *NF* 0.1 % OU q6hPRN allergies
10. modafinil *NF* 50 mg Oral daily
11. Clobetasol Propionate 0.05% Ointment 1 Appl TP [**Hospital1 **]
apply to affected area twice a day for 2 weeks, then as needed
avoid face, skin folds, and groin
12. Cetirizine *NF* 10 mg Oral DAILY:PRN allergies
13. albuterol sulfate *NF* 90 mcg/actuation Inhalation q6h:PRN
SOB/wheezing
14. Acetaminophen 325-650 mg PO Q6H:PRN pain
15. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB/wheezes
RX *albuterol sulfate 1.25 mg/3 mL 1 neb inh every six (6) hours
Disp #*1 Bottle Refills:*2
16. Aluminum-Magnesium Hydrox.-Simethicone 15-30 mL PO QID:PRN
indigestion
17. Artificial Tears Preserv. Free 1-2 DROP BOTH EYES PRN dry
eye
18. Docusate Sodium 100 mg PO BID
19. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
20. Polyethylene Glycol 17 g PO DAILY
21. PredniSONE 30 mg PO QD Duration: 3 Days
Tapered dose - DOWN
RX *prednisone 10 mg 3 tablet(s) by mouth once a day Disp #*18
Tablet Refills:*0
22. PredniSONE 20 mg PO QD Duration: 3 Days
Tapered dose - DOWN
23. PredniSONE 10 mg PO QD Duration: 3 Days
Tapered dose - DOWN
24. Protopic *NF* (tacrolimus) 0.03 % TOPICAL DAILY Reason for
Ordering: Wish to maintain preadmission medication while
hospitalized, as there is no acceptable substitute drug product
available on formulary.
25. Senna 1 TAB PO BID:PRN constipation
26. Sodium Chloride Nasal [**11-27**] SPRY NU QID:PRN congestion
Discharge Disposition:
Home
Discharge Diagnosis:
Asthma exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 106322**],
It was a pleasure taking care of you during your admission. You
came to the hospital because of shortness of breath and wheezing
in the setting of an exacerbation of your asthma. You were
initially admitted to the ICU because your breathing was
labored; however, you continued to improve and you were
transferred to the general medicine floor. You responded well
to prednisone and inhalers.
The following changes were made to your medications:
1. Take prednisone 60mg once a day through [**9-11**], take
prednisone 40mg once a day through [**9-14**], take prednisone 20mg
once a day through [**9-16**], take prednisone 10mg once a day
through [**9-18**].
2. Start Advair 250/50 twice a day
3. Albuterol nebulizer every 4-6 hours as needed
Please take all of your medications as prescribed. Please keep
all of your follow-up appointments.
Followup Instructions:
Department: [**State **]When: WEDNESDAY [**2153-9-19**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3747**], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
****The Pulmonology Dept is working on an appt for you and will
call you at home with an appt. If you dont hear from the office
by Tuesday, please call them directly to book at [**Telephone/Fax (1) 612**]
|
[
"296.80",
"300.00",
"244.9",
"493.92",
"692.9",
"518.82",
"494.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
13203, 13209
|
7285, 10042
|
329, 335
|
13272, 13272
|
4209, 6011
|
14331, 14846
|
3690, 3794
|
11013, 13180
|
13230, 13251
|
10068, 10990
|
13422, 14308
|
3809, 4190
|
6957, 7262
|
6809, 6920
|
6052, 6773
|
270, 291
|
363, 2342
|
13287, 13398
|
2364, 3449
|
3465, 3674
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,223
| 124,615
|
24146
|
Discharge summary
|
report
|
Admission Date: [**2188-1-9**] Discharge Date: [**2188-1-16**]
Date of Birth: [**2133-1-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
intubation and mechanical ventilation
History of Present Illness:
Mr. [**Known lastname 61356**] is a 54 year old farmer from [**State 4260**] who has a PMH
significant for CAD and ? COPD who was in his usual state of
health until a day prior to admission when he developed the
onset of a HA, sore throat, chills, myalgias, and arthralgias.
He then boarded an airplane to [**Location (un) 9012**] where he became
increasingly dyspneic. From there, he took a flight to [**Location (un) 86**],
and by the time he got to [**Location (un) 86**], he had to be carried off the
plane. Of note, he reports that he was in contact with his
girlfriend who had the flu several days ago. He came to [**Location (un) 86**]
to pick up a friend's new limosine to drive it back to [**State 4260**].
ROS: + for pleuritic chest and back pain
Past Medical History:
CABG x 4 [**2184**]
CABG x 3 [**2176**]
s/p spinal fusion [**2158**] following trauma
Social History:
farmer, smoker [**1-25**] cigarrettes per day but 40 pack year history,
denies EtOH or other drugs. Lives alone on 200 acre corn/ soy
bean farm.
Family History:
HTN dad, CAD in mom and dad, hypercholesterolemia in dad, CA
(unknown primary) in grandmother and grandfather
Physical Exam:
afebrile HR 75 BP 112/70, RR 19, O2 96% on RA
Gen: pleasant and cooperative, tanned and thin
HEENT: absent some left maxillary teeth, MMM, PERRLA, supple
neck, no cervical lymphadenopathy
Cor: RRR no m/r/g
Pulm: using accessory muscles to breath, coughing, mild wheezes
but most notable for poor air movement bilaterally
Abd: soft, NT ND
Chest: well healed midline surgical incision consistent with s/p
CABG
Back: well healed midline surgical incision consistent with
spinal fusion
Ext: WWP, strength 5/5 bilaterally upper and lower extremities,
[**First Name4 (NamePattern1) 15954**] [**Last Name (NamePattern1) 4610**] tatoo on LUE
Peak flow 150
Pertinent Results:
[**2188-1-9**] 10:30AM URINE HOURS-RANDOM UREA N-762 CREAT-267
SODIUM-31 POTASSIUM-78 CHLORIDE-36
[**2188-1-9**] 10:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-100 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2188-1-9**] 06:00AM GLUCOSE-170* UREA N-31* CREAT-1.6* SODIUM-138
POTASSIUM-4.8 CHLORIDE-106 TOTAL CO2-22 ANION GAP-15
[**2188-1-9**] 06:00AM CALCIUM-8.6 PHOSPHATE-3.0 MAGNESIUM-1.5*
[**2188-1-9**] 06:00AM WBC-9.5 RBC-3.87* HGB-12.1* HCT-35.6* MCV-92
MCH-31.3 MCHC-34.1 RDW-12.6
[**2188-1-9**] 06:00AM PLT COUNT-171
[**2188-1-8**] 11:55PM CK(CPK)-220*
[**2188-1-8**] 11:55PM cTropnT-<0.01
ABG: O2100 CO253* pH7.29*
GRAM STAIN (Final [**2188-1-10**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2188-1-12**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2188-1-14**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
Respiratory Viral Identification (Final [**2188-1-10**]):
Positive for Influenza A viral antigen.
CULTURE CONFIRMATION PENDING.
REPORTED BY PHONE TO MARK WENNECK 1535 [**2188-1-10**]
URINE CULTURE (Final [**2188-1-11**]): <10,000 organisms/ml
CTA:
1) No evidence of acute pulmonary embolism.
2) Multiple right hilar, and subcarinal calcified lymph nodes
consistent with prior granulomatous infection.
3) 5 mm right middle lobe calcified nodule consistent with prior
granulomatous infection. Additionally, two smaller non-specific
nodules as described above.
4) Diffuse atherosclerotic disease.
CXR: The heart size and mediastinal contours are within normal
limits. Sternal suture wires and mediastinal clips consistent
with prior CABG. The pulmonary vasculature appears unremarkable.
At the left base, an area of apparent increased opacity likely
relates to superimposition of vascular and osseous structures at
the crossing of two ribs. No pleural effusion and no
pneumothorax. The osseous structures appear unremarkable.
IMPRESSION: No acute cardiopulmonary abnormality.
Brief Hospital Course:
Mr. [**Known lastname 61356**] is a 54 year old man s/p CABG, who presented with a
COPD flare. He was initially started on azithromycin x 5 days
and a prednisone taper. He was also started on albuterol,
ipratropium nebulizers. He was also found to be positive for
influenza A by nasal aspirate. On his second hospital day, Mr.
[**Known lastname 61356**] had an acute decompensation and was found to be in
respiratory distress. His ABG showed 7.29/53/100 despite
numerous nebulizers. He was transferred to the MICU and
intubated. He was stabilized, started on Tamiflu, and
successfully extubated 3 days later. He was found to be growing
4+ gram positive cocci in his sputum and started a course of
levofloxacin prior to discharge.
In terms of Mr. [**Known lastname 61357**] CAD, he remained stable. He was continued
on ASA, Lipitor, and BB. His ACE I was held initially given mild
acute renal failure. The ACE was restarted at discharge.
Regarding the acute renal failure, this was thought to be a
combination of intravascular depletion (prerenal) and contrast
induced from the CTA obtained to rule out pulmonary embolism.
Mr. [**Known lastname 61356**] was vaccinated against the flu and pneumococcal
pneumonia. He was discharged to a local hotel in excellent
condition and with his sister's company. He had been counselled
to quit smoking and take rests on his car trip home to [**State 4260**].
Medications on Admission:
toprol xl 100, lipitor 10, asa QD, accupril 10 mg QD
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
5. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*QS * Refills:*2*
6. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 9 days.
Disp:*9 Tablet(s)* Refills:*0*
7. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 15 days: Take 40 mg for 3 days, 30 mg for 3 days, 20
mg for 3 days, 10 mg for 3 days, 5 mg for 3 days, off.
Disp:*QS Tablet(s)* Refills:*0*
8. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
9. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. Accupril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Chronic obstructive pulmonary disease
Coronary Artery Disease, s/p CABG [**2176**], [**2184**]
s/p spinal fusion [**2158**]
Discharge Condition:
good
Discharge Instructions:
Continue your regular medications. Quit smoking. See your doctor
withing 2 weeks after you go home. Finish a course of levoquin
and a steroid taper. Use your inhalers. You've gotten the flu
vaccine and pneumococcal vaccine too.
Followup Instructions:
Please see your doctor within two weeks of getting home.
|
[
"584.9",
"V15.82",
"518.81",
"V45.81",
"491.21",
"487.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7140, 7146
|
4556, 5957
|
321, 361
|
7313, 7319
|
2229, 3234
|
7595, 7654
|
1435, 1546
|
6061, 7117
|
7167, 7292
|
5983, 6038
|
7343, 7572
|
1561, 2210
|
3267, 4533
|
274, 283
|
389, 1148
|
1170, 1257
|
1273, 1419
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,057
| 117,651
|
8162
|
Discharge summary
|
report
|
Admission Date: [**2196-2-8**] Discharge Date: [**2196-2-24**]
Date of Birth: [**2144-10-9**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
Trachealbronchialmalcia s/p stent evaluation
Major Surgical or Invasive Procedure:
[**2196-2-9**] Flexible Bronchoscopy
[**2196-2-10**] Rigid and Flexible Bronchoscopy, stent Removal
[**2196-2-11**] Triple lumen central line placement
[**2196-2-18**] Rigid bronchoscopy with remainder stent removal
[**2196-2-22**] Right upper extremity ultrasound
[**2196-2-24**] Bilateral lower extremity ultrasound
[**2196-2-24**] Mammogram and bilateral breast ultrasound
History of Present Illness:
Mrs. [**Known lastname **] is a 51 year-old female with
trachaelbronchialmalacis & tracheal stenosis s/p stent placement
6 years ago now with dislodged/fractured stents She has been
referred from [**State 108**] for flexible bronchoscopy to further
evaluate and management of stents and airway.
Past Medical History:
Tracheal stenosis s/p stent removal
Trachealbronchialmalacia
Asthma
Hypertension
Diabetes Mellitus
CVA
Right axillar and right internal jugular thrombus
Mastitis, bilateral
Social History:
She lives with her family in [**State 108**] and has five children. No
ethanol, no tobacco, no recreational drugs.
Family History:
Non-contributory
Physical Exam:
General: 51 year-old spanishing speaking female in no apparent
distress
HEENT: normocephalic, mucus membranes moist
Neck: thick, no lymphadenopathy
Card: regular, rate & rhythm, normal S1,S2, no murmur/gallop or
rub
Resp: decreased
GI: obese, bowel sounds positive, abdomen soft
Non-tender/non-distended
Extr: warm, Right upper extremity with 2+ edema, left non, lower
extremity no edema
Pulses: (B) brachial, radial 2+
Breast: bilateral erythema, warm & tender
Neuro: non-focal
Pertinent Results:
[**2196-2-8**] WBC-16.4*# RBC-3.75* Hgb-9.1* Hct-30.0 Plt Ct-228
[**2196-2-21**] WBC-7.7 RBC-3.17* Hgb-7.4* Hct-25.7 Plt Ct-340
[**2196-2-24**] PT-14.5* PTT-40.3* INR(PT)-1.3*
[**2196-2-8**] Glucose-278* UreaN-13 Creat-0.8 Na-147* K-3.9 Cl-108
HCO3-22
[**2196-2-21**] Glucose-79 UreaN-6 Creat-0.7 Na-138 K-3.4 Cl-102
HCO3-27
Cultures:
[**2196-2-15**] 8:16 am SWAB Source: Rectal swab. R/O VANCOMYCIN
RESISTANT ENTEROCOCCUS (Final [**2196-2-18**]): No VRE isolated.
[**2196-2-15**] 8:16 am MRSA SCREEN Source: Rectal swab.
MRSA SCREEN (Final [**2196-2-17**]): No MRSA isolated.
[**2196-2-12**] 1:46 am SPUTUM Source: Endotracheal. GRAM STAIN
(Final [**2196-2-12**]): >25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2196-2-14**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
[**2196-2-24**] 12:10 pm TISSUE Site: BREAST
LEFT BREAST ABSCESS DRAINAGE. GRAM STAIN (Pending):
TISSUE CULTURE-TISSUE (Pending):
ANAEROBIC CULTURE (Pending):
CT TRACHEA W/O C W/3D REND [**2196-2-9**]
Secretions are demonstrated within the trachea. The diameter of
the trachea is difficult to assess in the presence of the stent,
although at least the diameter of the new stent which is about
13 mm. The right main bronchus, bronchus intermedius and right
lower lobe bronchus are patent during the inspiration. Narrowing
of the orifice of the right middle lobe bronchus is
demonstrated, although it is patent during inspiration. The left
upper and left lower lobe bronchi are patent during inspiration.
The dynamic expiration series demonstrate significant decrease
of the diameter of the right main bronchus, from 7.7 to less
than 3 mm with right middle lobe and right lower lobe origins
almost collapsed on end-inspiration as a collapsed segmental
bronchi in both lower lobes and right middle lobe with
subsequent significant widespread areas of air trapping, most
likely attributed to this dynamic airway collapse.
The evaluation of the lung parenchima demonstrate multiple
rounded opacities, in the right apex, 7:25, in right upper lobe,
7:33, 7:36, extensive areas of centrilobular ground-glass
opacities and more rounded consolidations in right middle lobe
and right lower lobe as well as in the left lung to a lesser
extent, findings which are consistent with widespread
infection/aspiration. There is no pleural or pericardial
effusion. Several mediastinal lymph nodes do not meet the size
criteria for lymphadenopathy ranging up to 8 mm in right lower
paratracheal, 10 mm in subcarinal and 5 mm in the aortopulmonic
window. The heart size is mildly enlarged, stable compared to
the previous studies.
IMPRESSION:
1. Severe bronchomalacia as described, bilateral. The presence
of the endotracheal stent prevents the evaluation of malacia.
The newest internal stent is most likely broken. Narrow lumen
left in left main bronchus.
2. Extensive areas of rounded consolidations, ground-glass
opacities and centrilobular nodules are consistent with
widespread infection/aspiration. Differential diagnosis might
include parenchymal hemorrhage in the appropriate clinical
setup.
CHEST (PORTABLE AP) [**2196-2-20**] 1:23 PM
FINDINGS: Compared to the film from earlier the same day there
continues to be bilateral lower lobe volume loss with question
infiltrate in the right and left lower lobes. The tracheal and
left mainstem stents are unchanged. The left subclavian line is
unchanged.
UNILAT UP EXT VEINS US RIGHT [**2196-2-23**] 12:37 AM
RIGHT UPPER EXTREMITY VENOUS ULTRASOUND: Grayscale and Doppler
son[**Name (NI) 1417**] of the right internal jugular, subclavian, axillary
veins were performed. The basilic and cephalic veins were not
visualized. There is partially occlusive thrombus within a [**2-21**]
cm segment of the right internal jugular vein. There is an
additional larger partially occlusive thrombus within a 2-3 cm
segment of the right axillary vein.
IMPRESSION: Partially occlusive thrombi within the right
internal jugular and right axillary vein.
BILAT LOWER EXT VEINS [**2196-2-24**] 8:49 AM
IMPRESSION: No evidence of DVT.
Brief Hospital Course:
Mrs. [**Known lastname **] underwent flexible bronchoscopy to evaluate stent
placement and airway. On HD#2 she was taken to the operating
room and underwent flexible and rigid bronchoscopy, foreign body
(stent) removal and bronchoalveolar lavage. She was transferred
to the intensive care unit intubated for airway management. She
was started on intravenous antibiotics for her aspiration
pneumonia. On POD #1 a central line was placed for access and
intravenous antibiotics. She remained stable and on POD#3 was
taken for a flexible bronchoscopy to further evaluate her
airway. She was taken back to the surgical intensive care unit
and was unable to extubate secondary to agitation. On [**2196-2-18**]
she was taken back to the operating room for flexible and rigid
bronchoscopy with silicone stent placement. She tolerated the
procedure well and was extubated on [**2-19**] without difficulty.
She transferred to the floor in stable condition. She was
restarted on her home medications. A clear liquid diet was
started and advanced as tolerated. On [**2-22**] she found to have
right upper arm edema and a right upper extremity ultrasound was
positive for a partially occlusive thrombi within the right
internal jugular and right axillary vein. She was started on
Lovenox and Coumadin. On [**2-23**] she complained of bilateral
breast tenderness and warmth. She was placed on Keflex for
possible mastitis. Given her history of past DVTs a lower
extremity ultrasound was negative for DVT. On [**2-24**] bilateral
breast ultrasound revealed a small left-sided fluid collection
which was drained for 1.5 cc of serous fluid. Cultures were
sent and results are pending.
Medications on Admission:
Prednisone 30 mg once daily
Procardia 60 once daily
Lasix 40 once daily
Percs [**1-20**] prn & morphine 100 mg tid
Albuterol, atrovent;
Xanax 0.5 tid
Zocor 20 qd
Ambien 10 qhs
Asa 325 mg once daily
Nitro prn
insulin 70/30- 25am/15pm
Discharge Medications:
1. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
4. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge
Sig: Twenty Five (25) Units Subcutaneous once a day.
6. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO every twelve (12) hours:
indefinitely for tracheal stents.
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
8. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours) as needed.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
10. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed.
11. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed: take with food and water.
12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
13. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours): until INR > 2.0.
14. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 14 days.
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
16. Coumadin 1 mg Tablet Sig: Take as directed to maintain INR
2.0-3.0 Tablets PO once a day.
17. Regular insulin
per sliding scale finger stick
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **]
Discharge Diagnosis:
Tracheal stenosis s/p stent removal
Trachealbronchialmalacia
Asthma
Hypertension
Diabetes Mellitus
CVA
Right axillar and right internal jugular thrombus
Mastitis, bilateral
Discharge Condition:
Stable
Discharge Instructions:
Call interventional pulmonology [**Telephone/Fax (1) 7769**] as needed
Complete Keflex course for mastitis
Lovenox 80 mg q12h for Right axillar and right internal jugular
thrombus
Coumadin INR Goal 2.0-3.0: Monitor INR and dose coumadin
appropiately
Monitor fingerstick blood surgars before meals and bedtime cover
with sliding scale
Continue albuteral and atrovent nebulizers
Mucinex 1200mg twice daily indefinitely
Monitor CBC, lytes, BUN & Cre
Follow-up on Left breast fluid collection cultures.
Monitor Left breast drain site for signs or symptoms of
infection
Followup Instructions:
Follow-up with your PCP in [**Name9 (PRE) 108**]: for further coumadin
management
Follow-up with interventional pulmonology as needed [**Telephone/Fax (1) 7769**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
Completed by:[**2196-3-1**]
|
[
"493.90",
"453.8",
"412",
"401.9",
"V12.51",
"V45.89",
"611.0",
"438.83",
"996.59",
"519.19",
"E878.1",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"85.91",
"96.6",
"96.05",
"98.15",
"38.91",
"33.24",
"96.72",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
9932, 9979
|
6354, 8041
|
364, 742
|
10196, 10205
|
1946, 6331
|
10819, 11103
|
1413, 1431
|
8324, 9909
|
10000, 10175
|
8067, 8301
|
10229, 10796
|
1446, 1927
|
280, 326
|
770, 1067
|
1089, 1263
|
1279, 1397
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,755
| 167,860
|
21276
|
Discharge summary
|
report
|
Admission Date: [**2181-3-21**] Discharge Date: [**2181-4-3**]
Date of Birth: [**2122-10-27**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Right lower extemity ischemia, rest pain
Major Surgical or Invasive Procedure:
[**3-29**] Right profundaplasty, right superficial femoral artery
endarterectomy with superficial femoral artery patch angioplasty
of common femoral and profunda arteries on the right side. Right
femoral thrombectomy
History of Present Illness:
58 year old f with PVD, s/p RT CFA-AKpop with PTFE in [**5-23**] and
s/p RT ileofem embolectomy with Dacron angioplasty in [**11-26**] now
presents with RLE rest pain, numbness, coolness.
Past Medical History:
PMH: PVD, benign breast tumors, TIAs/R-hemispheric embolic CVA
PSH: R-CFA-akPop w PTFE 6mm ('[**77**]--failed), L-CFA:akPop with
NRGSV ([**2178-6-3**]),s/p R-CIA/EIA stenting on [**2179-11-4**]
Social History:
lives with her husband.works at [**Name (NI) 10936**] Brothers.occasional
EtOH.15 pack years smoking
Family History:
non contribituary
Physical Exam:
99.5, 120/68 75 94%RA
GEN: NAD
CARDS:RRR
ABD: soft, NT +BS
RT groin incision C/D/I
B/L dop DP
Pertinent Results:
[**2181-4-2**] 04:22AM BLOOD WBC-8.8 RBC-3.19* Hgb-8.6* Hct-25.8*
MCV-81* MCH-27.0 MCHC-33.5 RDW-19.5* Plt Ct-221
[**2181-4-1**] 07:59PM BLOOD Hct-26.2*
[**2181-4-3**] 05:55AM BLOOD PT-30.0* PTT-34.9 INR(PT)-3.2*
[**2181-4-2**] 04:22AM BLOOD Glucose-98 UreaN-7 Creat-0.6 Na-138 K-3.5
Cl-105 HCO3-27 AnGap-10
Brief Hospital Course:
Admitted through ED for RLE ischemia. RLE rest pain, coolness
and mild numbness started prior to arrival. Started on Heparin
gtt and angio scheduled.
[**2181-3-22**] No overnight events, Underwent diagnostic angiogram. LT
groin c/d/i, no hematoma. Surgery required. Remained on Heparin
gtt (titrated to maintain ptt 60-80). Pain with ambulation and
RT foot rest pain.
[**2181-3-29**] Underwent Right profundaplasty, right superficial
femoral artery endarterectomy with superficial femoral artery
patch angioplasty of common femoral and profunda arteries on the
right side. Right femoral thrombectomy. Extubated and
transferred to PACU. On Dilaudid gtt for pain.
[**2181-3-30**] VSS HCT 25 Transfused 1uPRBCs, RT DP dopplerable.
Heparin gtt resumed.
[**2181-3-31**] VSS, Dilaudid PCA discontinued. Tolerating diet.
[**Date range (1) 56291**] No events Coumadin restarted, Levo for UTI OOB with
nursing and PT. RT DP dopplerable, LT DP/PT dopplerable. Will
save RT arm veins in case of need for future distal bypass.
patient and husband aware of plan.
[**2181-4-3**]: VSS, no overnight events. OOB ambulating. Pain
decreased. Will follow up with Dr. [**Last Name (STitle) **] next week. VNA and PT
arranged to monitor wound, draw INR and home safety eval/PT. Dr.
[**First Name (STitle) **] will continue anticoagulation monitoring.
Medications on Admission:
ASA 81', Atorvastatin 40', coumadin 5', tramadol 2 in am / 1 pm
(leg pain), neurontin 300"' (leg pain)
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): [**Name6 (MD) **] primary MD [**First Name (Titles) **] [**Last Name (Titles) **]: [**Last Name (LF) **],[**First Name3 (LF) **] D
[**Telephone/Fax (1) 45859**].
Disp:*30 Tablet(s)* Refills:*0*
3. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime):
Continue monitoring by Dr. [**First Name (STitle) **].
4. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Outpatient Lab Work
Labwork: INR/pt 2x per week and prn. Results to Dr. [**First Name (STitle) **],[**First Name3 (LF) **]
D [**Telephone/Fax (1) 45859**]
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
RLE ischemia
PMH: PVD, benign breast tumors, TIAs/R-hemispheric embolic CVA
PSH: R-CFA-akPop w PTFE 6mm ('[**77**]--failed), L-CFA:akPop with
NRGSV ([**2178-6-3**]),s/p R-CIA/EIA stenting on [**2179-11-4**]
[**Last Name (un) 1724**]: ASA 81', Atorvastatin 40', coumadin 5', tramadol 2 in am /
1 pm (leg pain), neurontin 300"' (leg pain)
Discharge Condition:
INR 3.2
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**12-23**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
You have a post op visit scheduled with Dr. [**Last Name (STitle) **] on [**4-10**] at
315pm. Call [**Telephone/Fax (1) 1241**] with any questions.
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2181-5-8**] 1:30
Completed by:[**2181-4-3**]
|
[
"E878.1",
"444.22",
"285.9",
"599.0",
"996.74",
"E849.0",
"440.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"39.49",
"88.48",
"38.18",
"00.40",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
4549, 4604
|
1624, 2956
|
355, 574
|
4986, 4996
|
1292, 1601
|
7833, 8166
|
1144, 1163
|
3111, 4526
|
4625, 4965
|
2983, 3088
|
5020, 7401
|
7427, 7810
|
1178, 1273
|
275, 317
|
602, 791
|
813, 1009
|
1025, 1128
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,734
| 168,128
|
9932
|
Discharge summary
|
report
|
Admission Date: [**2131-9-14**] Discharge Date: [**2131-9-17**]
Date of Birth: [**2063-12-22**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 67-year-old female
with a past medical history of coronary artery disease,
status post coronary artery bypass graft in [**2131-3-29**] who
also has noninsulin dependent diabetes mellitus,
hypertension, right artery stenosis with totally occluded
left renal artery and 40-50% stenosis on the right with
progressively worsening renal insufficiency since coronary
artery bypass graft. Patient had an arterial venous fistula
placed on [**2131-8-31**] with subsequent initiation of
hemodialysis. She has had six dialysis treatments, but now
presents for outpatient revision of AV fistula and placement
of a Permacath. Intraoperatively, the patient became
hypotensive for which she was begun on Neo-Synephrine in the
Operating Room. Postoperatively, the patient failed to wean
off Neo-Synephrine in the Recovery Unit. A Medical consult
was placed and the Medical Intensive Care Unit Team was
called. Postoperative course was also noticeable for 30
seconds of jaw pain, her anginal equivalent which was
transient [**2-7**] in intensity self resolving without other
associated symptoms. The patient is also complaining of
occasional shaking mainly in her lower extremities,
accompanied by chills. However, she denies any fevers,
cough, sore throat, shortness of breath, abdominal pain,
diarrhea, flank pain, suprapubic pain or dysuria.
PAST MEDICAL HISTORY: Coronary artery disease, status post
coronary artery bypass graft in [**2131-3-29**] which involved
four vessels. Also, noninsulin dependent diabetes mellitus,
hypertension, renal artery stenosis by MRI and
[**Year (4 digits) 29817**], chronic renal insufficiency, progressive
since coronary artery bypass graft and now on hemodialysis,
peripheral vascular disease, history of atrial fibrillation,
hyperlipidemia.
OUTPATIENT MEDICATIONS:
1. Lopressor or metoprolol 50 mg po b.i.d.
2. Zantac.
3. Glucoside 5 mg q.d.
4. Regular insulin sliding scale.
5. Isordil 10 mg t.i.d.
6. Erythropoietin 4000 units two times per week, Wednesday
and Saturday.
7. Colace.
8. Aspirin 325 mg q.d.
9. Renagel 1600 mg t.i.d.
10. Lipitor 40 mg po q.d.
FAMILY HISTORY: Father died of myocardial infarction at age
55. Mother lived to age [**Age over 90 **] but she Alzheimer's.
SOCIAL HISTORY: She is married and lives at home with her
husband. She has a remote smoking history of one pack per
day for 20 years but quit 27 years ago. She denies any
alcohol use.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Temperature 96.6. Heart rate 66.
Blood pressure 101/56. Saturating at 97% on room air.
General: She is comfortable in no apparent distress. Head,
eyes, ears, nose and throat: Anicteric. Pupils equal, round
and reactive to light. Moist mucous membranes. No oral
lesions. Neck: Supple, no jugular venous distention, no
lymphadenopathy. Heart regular rate and rhythm S1, S2
normal, 2/6 systolic ejection murmur at right upper sternal
border crescendo-decrescendo. Lungs: Decreased breath
sounds at left base. Abdomen: Obese, soft, nontender,
normal active bowel sounds, no hepatosplenomegaly. Back: No
CVA tenderness. Extremities: No cyanosis, clubbing or edema.
1+ pedal pulses bilaterally.
LABORATORIES: Hematocrit 24.4, pH 7.31, lactate .9, free
calcium 1.14. Sodium 127, potassium 5.0, chloride 94,
bicarbonate 19, BUN 58, creatinine 8.5, glucose 156. CK 38,
CK-MB not done because CK was less than 200. Troponin 0.7.
IMAGING: Portable chest x-ray done on [**9-14**] showed
double lumen catheter tip in distal SVC. Cardiac silhouette
enlarged, stable since birth. Left pleural effusion.
Pulmonary vascularity appears normal. No consolidation, no
pneumothorax.
ASSESSMENT: The patient was a 69-year-old female with a
history of progressive renal insufficiency since her coronary
artery bypass graft. She had an AV fistula placed on [**2131-8-31**] and required a revision of the AV fistula and
placement of Permacath. During the postoperative course, she
was unable to wean off of the Neo-Synephrine which had been
started intraoperatively. She was brought to the Intensive
Care Unit and required handling of her pressor support.
HOSPITAL COURSE: By issues:
1. Cardiac: She had ischemia. She had transient jaw pain
intraoperatively. Jaw pain was concerning because it is her
anginal equivalent. Because of this concern, she was
followed for CK. Her CKs were initially negative. On [**2131-9-15**], she developed further jaw pain with chest heaviness
at 7 p.m. It was associated with shortness of breath. She
had an electrocardiogram which showed no changes. Her blood
pressure at that time was 220/110 with a heart rate of 80 and
02 of 97%. She was started on oxygen, given two sublingual
nitroglycerins, 5 mg of metoprolol with resolution of
symptoms. Her blood pressure decreased to 160/80. It was
thought that the ischemia was secondary to weaning off her
antihypertensive medications and was not having a reflexive
hypertension. That is when she was restarted on her home
medications of Metoprolol 50 mg po b.i.d. and Isordil 10 mg
po t.i.d. CK and troponins were checked and were negative.
She did not have any further episodes of ischemic type pain.
2. Pulmonary: She received an A line in the Intensive Care
Unit. She was found to actually be hypertensive and not as
hypertensive as had been previously thought. In the setting
of her chest pain and jaw pain, she was converted. The
pressors were weaned off completely. Instead, she was
actually given antihypertensive medications and restarting of
her home medications including metoprolol 50 mg po b.i.d.,
Isordil 10 mg b.i.d. There was some controversy over what
her actual blood pressure was. When A line was placed in the
right arm, right radial line, her blood pressure was actually
187/73. In her left leg, it was 98/49. In the Operating
Room, her legs were used for measuring her blood pressure.
There was some concern that she did have a drop in pressure
during the Operating Room and though she was probably not
hypotensive, it was a relative hypotension considering that
it was a drop from her baseline in the Operating Room. The
hypotension in the lower extremities was thought to be due to
her severe peripheral vascular disease. She has risk factors
including diabetes, hypertension and hypercholesterolemia.
The relative hypotension during the Operating Room was
thought possibly due to bacteremia given that the patient did
have rigors and there was catheter manipulation. The blood
pressure was then converted to the right upper extremity.
In the Operating Room, her blood pressure dropped from 120 to
70 systolic. At that time, she was placed on a
Neo-Synephrine drip. She was also found to have increased
cholesterol. Subsequently, she was started on Lipitor. She
was weaned off her pressors and was started on her
antihypertensive medications. Her metoprolol was increased
to 75 mg po b.i.d. She was started on aspirin and Isordil.
In the future, an ACE inhibitor might be employed to control
her blood pressure. Consequently the differential in her
extremities was thought to be due to peripheral vascular
disease and not coarctation in the aortic system. She was
transferred to the floor on [**2131-9-17**] and was actually
discharged on the same day and since there are cardiac
issues, an ACE inhibitor was considered but it was not
started at this time. She presented with a confusing picture
in that she was transferred to the Medical Intensive Care
Unit because she was thought to be hypotensive. However, the
blood pressure in her right upper extremities did not
correspond with her lower extremity. It was thought that the
difference was due to peripheral vascular disease in the
lower extremities. The real pressure was thought to be in
the right upper extremity and she received antihypertensive
medications for it.
2. Infectious Disease: The patient was considered or at
least was on the differential that she may have had a
bacteremic episode including the hypertension in the
Operating Room. The bacteremia may have been caused by
manipulations in the catheter. She also had rigors in the
Operating Room. She was started on antibiotics with the
concern for infection. She had blood cultures and urine
cultures which were negative. She was given vancomycin 1
gram which was also to be followed. Gentamicin was also
started 80 mg to begin after dialysis. Because the cultures
were negative, the antibiotics were discontinued. It was
thought that she probably did have a bacteremic issue, that
it was transitory and had resolved.
3. Vascular: The patient was able to complete the surgery.
The exact nature of what was needed was that she had had a
left-sided AV graft and a left IJ Permacath inserted on
[**2131-8-31**] and she came in for vein mapping on [**2131-9-13**] because of clotting in the left upper extremity. She
was actually admitted for thrombectomy and revision of the
left upper extremity AV fistula. She was also to have a
right IJ Permacath placed as the left one had clotted off.
The procedure was thought to be successful. She was able to
continue with her renal hemodialysis. She appears to have
follow-up appointment with Dr. [**Last Name (STitle) **] in two weeks for staple
removal. The graft was considered not to be functional at
least in the immediate setting. Consequently, the Permacath
was used for hemodialysis.
4. Renal: The patient required hemodialysis through the
admission. She required fluid removal considering her left
pleural effusion. She was continued on her erythropoietin
and Renagel. An extra hemodialysis session was done to
remove fluid.
5. Hematology: The patient was anemic. However, she is
anemic chronically. She did receive a unit in the
postoperative setting because of fear of her blood loss
during her procedure and given her hypotension.
6. Endocrine: She has diabetes and was continued on
capozide. She also received her regular insulin sliding
scale.
FOLLOW-UP: The patient was to follow up with her primary
care physician and with Dr. [**Last Name (STitle) **]. She is to follow up with
her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], in [**Location (un) 1475**],
[**Hospital 33290**] Clinic. The appointment was scheduled for
[**2131-9-24**] at 10:45 a.m.
DISCHARGE MEDICATIONS:
1. Lipitor 40 mg po q.h.s.
2. Erythropoietin 4000 units subcutaneous two times per week
on Saturday and Wednesday.
3. Renagel 1600 mg po t.i.d.
4. Aspirin 325 mg po q.d.
5. Metoprolol 75 mg po t.i.d.
6. Atorvastatin as mentioned previously.
7. Isordil.
8. Dinitrate 10 mg po t.i.d.
9. Glipizide 5 mg po q.d.
DISCHARGE STATUS: Patient was to be discharged home.
CONDITION AT DISCHARGE: Patient was in stable condition.
She did not need any antibiotics because her cultures were
negative.
DISCHARGE DIAGNOSES:
1. Hypotension and hypertension.
2. Left AV fistula thrombosis that underwent thrombectomy.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Name8 (MD) 4523**]
MEDQUIST36
D: [**2132-2-2**] 19:00
T: [**2132-2-2**] 19:00
JOB#: [**Job Number 33291**]
|
[
"V45.1",
"414.01",
"403.91",
"440.1",
"V45.81",
"996.73",
"272.0",
"V45.82",
"250.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.49",
"38.95",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
2288, 2398
|
11051, 11395
|
10529, 10912
|
4328, 10506
|
1967, 2271
|
2647, 4310
|
10927, 11030
|
157, 1504
|
1527, 1943
|
2415, 2624
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,157
| 156,695
|
6114
|
Discharge summary
|
report
|
Admission Date: [**2105-6-22**] Discharge Date: [**2105-7-1**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
left hip fracture
Major Surgical or Invasive Procedure:
Left DHS (hip surgery)
Intubation for surgery
History of Present Illness:
86yoF with DM, HTN, CAD, s/p fall out of bed on [**2105-6-22**]. Patient
was found to have L intertrochanteric fracture and was to under
ORIF on [**6-26**]. However on [**6-23**], pt developed NSTEMI and had a cath
on [**6-24**]. Cath demonstrated severe three vessel disease with
totally occluded RCA and LAD -- all vessels fed by the LCX. Pt
had POBA of the left circumflex. Had Left DHS surgery on [**6-26**]. In
the postop period, she developed AFib which spontaneously
converting to SR. She was hemodynamically stable during this
episode for AFib.
Past Medical History:
DM
Dementia
HTN
CAD s/p MI [**2095**]
endometrial Ca s/p XRT -> strictures -> ileostomy
spinal stenosis, L4-L5
hearing loss
Cataracts
Social History:
Lives with grandaughter. No ETOH/Tobacco abuse
Family History:
not contibutory
Physical Exam:
VS: T 100.0 BP 104/28 HR 83 RR 20 100% on RA
Gen: NAD, resting comfortably in bed.
HEENT: OD with erythematous conjuctiva and crusting, PERRL and
EOM intact.
Neck: no LAD, no JVD, no masses.
Lungs: CTA b/l, no crackles or wheezes.
Heart: RRR, nl s1s2, iii/vi sem at LUSB, i/vi sem at apex.
Abd: ilial conduit for urine RLQ, abd soft, nt/nd, +bs, no
organomegaly.
Extr: wwp, 2+ distal pulses, no cyanosis, no edema; moving all 4
extremities, L leg externally rotated in bed.
Neuro: demented, awake, a&ox0, cn grossly intact.
Pertinent Results:
[**2105-7-1**] 05:50AM BLOOD WBC-7.4 RBC-3.43* Hgb-9.8* Hct-29.3*
MCV-86 MCH-28.5 MCHC-33.3 RDW-15.4 Plt Ct-261
[**2105-6-22**] 04:35PM BLOOD Neuts-84.7* Bands-0 Lymphs-8.6* Monos-4.7
Eos-1.1 Baso-0.8
[**2105-7-1**] 05:50AM BLOOD Plt Ct-261
[**2105-7-1**] 05:50AM BLOOD Glucose-195* UreaN-33* Creat-0.9 Na-137
K-4.5 Cl-102 HCO3-24 AnGap-16
[**2105-6-29**] 06:00AM BLOOD CK-MB-3 cTropnT-0.57*
[**2105-7-1**] 05:50AM BLOOD Calcium-8.0* Phos-2.6* Mg-1.8
[**2105-6-30**] 05:55AM BLOOD Triglyc-140 HDL-27 CHOL/HD-3.3 LDLcalc-33
[**2105-6-29**] 06:00AM BLOOD TSH-1.4
[**2105-6-29**] 06:00AM BLOOD Free T4-1.4
***
HIP UNILAT MIN 2 VIEWS LEFT [**2105-6-22**]
Fracture lines through the left intertrochanteric area, with
bone fragment and displacement of the distal fracture fragment
laterally.
***
BILAT LOWER EXT VEINS [**2105-6-22**]
No evidence of left or right lower extremity deep vein
thrombosis
***
ECHO Study Date of [**2105-6-23**]
The left atrium is normal in size. There is moderate symmetric
left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is
moderately-to-severely depressed (ejection fraction 30 percent)
secondary to severe hypokinesis of all walls except the
posterior wall, with apical akinesis. Tissue velocity imaging
E/e' is elevated (>15) suggesting increased left ventricular
filling pressure (PCWP>18mmHg). Tissue velocity imaging
demonstrates an e' of <0.08m/s c/w an elevated left ventricular
filling pressure (>12mmHg). 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. There
are three aortic valve leaflets. The aortic valve leaflets are
moderately thickened.
There is mild aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. There is no mitral valve prolapse. There is moderate
thickening of the mitral valve chordae. The study is inadequate
to exclude significant mitral valve stenosis. Moderate (2+)
mitral regurgitation is seen. The left ventricular inflow
pattern suggests impaired relaxation. There is no pericardial
effusion.
***
C.CATH Study Date of [**2105-6-24**]
1. Selective coronary angiography showed a right dominant system
with
severe three vessel disease. The LMCA was angiographically
without
disease. The LAD was proximaly occluded and filled in the mid
section
via left-to-left collaterals. The LCX was heravily calcified in
the
proximal segment and filled a small OM1 with and ostial 95%
stenosis
(2.0 mm vessel). There was a very large OM2 with a hazy 80%
stenosis.
The OM2 gave collaterals to the LAD as well as to the RCA. The
RCA was
the dominant vessel which was occluded proximally. The rPDA and
the PL
filled via left-to-right collaterals from the OM2.
2. Successful POBA of the OM2 with a 2.5mm balloon with great
results
(see PTCA comments).
***
HIP UNILAT MIN 2 VIEWS LEFT [**2105-6-26**] 2:16 PM
FINDINGS: Two intraoperative images from the operating room
demonstrates interval placement of a lateral plate and dynamic
hip screw fixating an intertrochanteric fracture of the left
proximal femur. A small displaced lesser trochanter fragment is
noted. Please refer to surgical report for further details
Brief Hospital Course:
A/P: 86yoF with L hip fracture and NSTEMI.
.
# CAD: She developed chest pain with CE leak few days prior to
her hip surgery. CEs positive, consistent with NSTEMI. Cath
([**6-24**]): Selective coronary angiography showed a right dominant
system with severe 3VD. The LMCA was angiographically without
disease. The LAD was proximally occluded and filled in the mid
section via left-to-left collaterals. The LCx was heavily
calcified in the proximal segment and filled a small OM1 with
and ostial 95% stenosis (2.0 mm vessel). There was a very large
OM2 with a hazy 80% stenosis. The OM2 gave collaterals to the
LAD as well as to the RCA. The RCA was the dominant vessel which
was occluded proximally. The rPDA and the PL filled via
left-to-right collaterals from the OM2. s/p POBA to LCx.
Cardiology was following her and was started on ASA, plavix,
statin, BB, ACEI. They recommended outpt follow up for further
discussion about ICD placement. She has an appointment in [**Month (only) 205**]
for this.
.
# Atrial Fibrillation: had one episode in postop period after
which she spontaneously reverted back. After she was transferred
to the floor, she went back into Afib. She was tachy in the 130s
with pressure in 90's. She got 5mg IV lopressor after which her
rate came down to the 80's with pressure in 110's. Her BB was
increased and then she reverted back to sinus rhytm. She
remained in sinus rhythm. She was started on Amiodarone with a
loading dose and also started on Digoxin. Her BB was titrated.
It was decided not to anticoagulate her with coumadin as she is
very high risk for falls. This was done in discussion with the
patient, her family and PCP.
.
# Hip fracture: She had a DHS procedure for her left hip
fracture. She was placed on lovenox for DVT prophylaxis which
was to be continued for total of 14 days after surgery. She was
seen by physical therapy and there was no restriction on her
activity.
.
# UTI: u/a consistent with UTI, cx shows coag + SA, but could be
skin flora contaminant. repeat urine cx NGTD. She completed 5
days of Ciprofloxacin and 3 days of Levofloxacin.
.
# HTN: Her BP remained stable.
.
# CRI: Cr elevated to 1.4 from baseline 0.8-0.9 on admission,
then resolved, likely dehydrated.
.
# DM2: continue fixed humalog and ISS as needed with QID f/s.
Humalog was titrated during this hospital admission.
.
# conjunctivitis: continued to treat with erythromycin drops.
erythema and discharge improved.
Discharge Medications:
1. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4
times a day).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 5 days.
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Please start this after completion of 400 mg [**Hospital1 **] of Amiodarone.
10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Insulin Regimen
Please see the attached sheet (Fixed dose and sliding scale) for
insulin regimen
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Toprol XL 200 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
15. Lasix 20 mg Tablet Sig: One (1) Tablet PO QAM.
16. Lovenox 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
twice a day for 10 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Hip Fracture
MI
Atrial fibrillation
Discharge Condition:
Stable
Discharge Instructions:
Please take all your medication and follow up with all your
appointments. Please report to the ED or to your physician if
you have worsening chest pain, nausea/vomiting, shortness of
breath, sever pain in hip or any other concerns.
Followup Instructions:
Appointments:
1. Dr.[**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**]: on [**7-15**] at 11AM
.
2. Cardiology: Arrythmia service for evaluation of ICD
placement. Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 2934**]
Date/Time:[**2105-7-31**] 10:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
Completed by:[**2105-7-1**]
|
[
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"820.21",
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"401.9",
"599.0",
"410.71",
"585.9",
"372.00",
"427.31",
"414.01",
"369.00",
"V58.67",
"250.00",
"E884.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"00.40",
"99.04",
"79.35",
"00.66",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
8865, 8944
|
5000, 7443
|
236, 284
|
9024, 9033
|
1681, 4977
|
9314, 9862
|
1104, 1121
|
7466, 8842
|
8965, 9003
|
9057, 9291
|
1136, 1662
|
179, 198
|
312, 866
|
888, 1024
|
1040, 1088
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,289
| 106,751
|
2422
|
Discharge summary
|
report
|
Admission Date: [**2110-3-29**] Discharge Date: [**2110-4-8**]
Service: NEUROLOGY
Allergies:
Benadryl
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
84 year-old right-handed man with a history of hypertension,
long-standing diabetes, and atrial fibrillation (not on
anti-coagulation or anti-platelet therapy due to a history of
gastrointestinal bleeding), and chronic kidney disease
(creatinine baseline ~[**1-14**]) who presented earlier today after a
fall with left hip pain; a code stroke was called at 8:13 pm,
after concern for a right MCA infarction on CT of the head.
According to the patient's daughter, with whom I discussed the
case over the phone, the patient was in his usual state of
health until awakening this morning. At that time, he reported
difficulty seeing multiple objects in the kitchen, including a
kettle on the stove as well as a cup. He did not further
describe the character of the vision loss. His daughter thought
that this was unusual in a well-lit room, but attributed the
difficulties from recently awakening, transitioning from the
dark to light. He did not have any clear weakness, difficulty
with speaking or comprehension. He has chronic tingling in his
fingers related to diabetes, though no new sensory changes.
At approximately 2 pm, he tripped over a cord as he walked from
the kitchen, and fell forward. He was able to break his fall
with his hands on a nearby table before landing on the floor of
the study. There was no observed head trauma nor loss of
consciousness. He reported pain in the left hip and was taken
to [**Hospital1 18**] for further evaluation. Once at [**Hospital1 18**], the patient
underwent a trauma evaluation for his fall. He was reporting
pain and given 4 mg of morphine at 5:55 pm for his discomfort,
then 50 mg bendadryl at 6:04 pm for subsequent itchiness. An
attempt to perform CT scan was made around this time (~6 pm),
but the patient was sent back as he was becoming increasingly
confused and unable to sit still. He subsequently received 1 mg
of lorazepam at 6:42 pm, then developed apneic periods for
~10-15 seconds at a time over a period of 20 minutes, by ED
report. He received the CT of the head at 7:45 pm and a code
stroke was called at 8:13 pm after a preliminary read of a right
middle cerebral artery stroke.
Review of Systems:
Unable to obtain at this time due to confusional state.
Past Medical History:
Chronic Systolic CHF - Echo [**3-20**] with EF 25%
Hypertension
Dyslipidemia
Afib not on Coumadin
CKD IV, baseline 2.1-2.5, sees Dr. [**Last Name (STitle) 4883**]
Anemia - likely mixed, CKD and Iron Deficiency, baseline 35-39
DM, on insulin, hgb A1c 9.2 [**3-20**]
Gastritis
- hematemesis [**2109-7-12**]. EGD with antral erosions, small AVM in
duodenum
- colonoscopy [**12/2108**] with single sessile 2 mm polyp of benign
appearance in the proximal transverse colon (not removed [**1-13**]
bleeding risk)
Prior Tobacco use
Osteoarthritis
Prostate Cancer s/p prostatectomy
Urinary incontinence
Social History:
Widowed and lives with his daughter [**Name (NI) 12469**], who is his health
care proxy. Former [**Name2 (NI) 1818**], smoked 1-2 packs daily for ~40 years.
Previously drank one shot of whiskey daily. No known history of
illicit drug use.
Family History:
Non-contributory
Physical Exam:
Vitals: T 98.6 F BP 133/75 P 84 RR 14 SaO2 100 RA
General: Thin, elderly gentleman - mildly deshevelved appearing.
[**Name2 (NI) 4459**]: NC/AT, sclerae anicteric, MMM, no exudates in oropharynx
Lungs: clear to auscultation
CV: irregularly irregular, no MMRG
Abdomen: soft, non-tender, non-distended
Ext: dry, no edema, pedal pulses appreciated
An NIHSS could not be performed due to the patient's confusional
state
Neurologic Examination:
Mental Status:
Alert and oriented to place and self. Mildly dysarthric speech
but fluent. Follows commands.
Cranial Nerves:
Fundi difficult to visualize bilaterally; inconsistent blink to
threat on either side. Pupils equally round and reactive to
light, 3 to 2.5 mm bilaterally. Eyes move to the left and
right, but no gaze deviation. Corneals intact bilaterally, and
face appears grossly symmetric. Tongue midline and palate
elevated evenly.
Sensorimotor:
Normal bulk throughout, though tone is difficult to assess given
active movement. No tremor. He had mild L pronator drift but
full strength otherwise.
Reflexes: B T Br Pa Pl
Right 2 2 2 2 0
Left 2 2 2 2 0
Left toe upgoing, right toe downgoing.
Coordination and gait: Mild dysmetria with FTF more on L likely
reflecting weakness. Ambulatory with minimal assistance.
Pertinent Results:
[**2110-4-8**] 06:00AM BLOOD WBC-5.5 RBC-4.39* Hgb-12.1* Hct-37.6*
MCV-86 MCH-27.5 MCHC-32.1 RDW-17.3* Plt Ct-163
[**2110-4-8**] 06:00AM BLOOD PT-18.3* PTT-36.1* INR(PT)-1.7*
[**2110-4-8**] 06:00AM BLOOD Glucose-107* UreaN-32* Creat-2.2* Na-141
K-3.9 Cl-102 HCO3-26 AnGap-17
[**2110-3-29**] 05:55PM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2110-3-30**] 07:45AM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2110-4-8**] 06:00AM BLOOD Calcium-9.4 Phos-2.6* Mg-2.0
[**2110-3-29**] 05:55PM BLOOD calTIBC-399 Ferritn-55 TRF-307
[**2110-3-30**] 07:45AM BLOOD %HbA1c-9.7*
[**2110-3-30**] 07:45AM BLOOD Triglyc-49 HDL-52 CHOL/HD-2.0 LDLcalc-40
[**2110-4-1**] 04:40AM BLOOD Ammonia-73*
[**2110-3-29**] 05:55PM BLOOD TSH-1.5
[**2110-4-4**] 05:20PM BLOOD PEP-POLYCLONAL IgG-1334 IgA-385 IgM-252*
HEAD CT [**3-29**]:
1. Acute infarct of the distal right MCA (M3) distribution.
Regional sulcal effacement without midline shift. No
intracranial hemorrhage at this time.
2. Left frontal arachnoid cyst, unchanged.
Carotid US [**3-31**]:
No evidence of internal carotid artery stenosis in their
extracranial portion.
Renal US [**3-31**]:
1. No evidence of hydronephrosis.
2. Small amount of ascites.
MRI HEAD [**3-31**]:
1. Right MCA, superior division, acute infarct.
2. Chronic small vessel ischemic disease.
3. No evidence of intracranial hemorrhage.
Echocardiogram [**4-2**]:
The left atrium is elongated. The estimated right atrial
pressure is 10-20mmHg.There is moderate symmetric left
ventricular hypertrophy with normal cavity size and severe
global hypokinesis (LVEF = 20-25 %). No masses or thrombi are
seen in the left ventricle. The right ventricular cavity is
mildly dilated with moderate global free wall hypokinesis. The
ascending and descending thoracic aorta are mildly dilated. 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. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is a trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2109-7-16**],
left ventricular systolic function is less vigorous. In the
absence of a history of marked hypertension, the findings are
suggestive of an infiltrative process (e.g., amyloid, Fabry's
etc.)
Brief Hospital Course:
84 year-old right-handed man with a history of hypertension,
long-standing diabetes, and atrial fibrillation (not on
anti-coagulation or anti-platelet therapy due to a history of
gastrointestinal bleeding), presented to ED after a fall and
left hip pain. Code stroke was called after a head CT
concerning for R MCA infarct and his
examination was limited, given an acute confusional state with
left upgoing toe is the only clear localizing finding at the
time. He was out of the window for intervention and vessel
imaging and contrast studies were risky given his degree of
renal failure.
Patient was admitted to neurology service and he underwent
pelvis study to rule out hip fracture and renal US to rule out
renal obstruction. His left lower back pain most likely spasm
s/p fall since he responded very well to small dose Valium and
analgesics.
Although, he initially was quite confused, he improved
significantly with near full strength on his left side except
for mild left facial, left pronator drift and some dysarthria.
He was evaluted per PT/OT who recommended home PT/OT and VNA
services plus speech recommended regular diet if he has his
dentures.
Given that patient has Afib and this is most likely
cardioembolic stroke given the risk factors, GI was consulted
about his hx of gastritis and possible duodenal AVM. GI
recommended colonoscopy for risk stratification - bowel prep was
extremely difficult. He has hx of several failed colonoscopies
in the past due to poor prep. After several days of clear diet
and several rounds of golytely, he underwent colonoscopy on [**4-7**]
which showed a few polyps but no contra-indication for
anticoagulation hence he was started on Coumadin with [**Month/Year (2) **]
bridging ([**Month/Year (2) **] to be stopped once INR therapeutic between 2~3).
His INR will be followed up per Dr. [**Last Name (STitle) 8499**], PCP.
Also, given his CHF hx and Afib, cardiology was also consulted
who recommended changing Coreg to Metoprolol since it is less
hypotensive and he was instructed to restart low dose ACEI per
PCP as outpatient. He had repeat echocardiogram that showed
even more reduced EF of 20~25% and signs of infiltrative disease
hence SPEP and UPEP were checked that appeared within normal
range. He will be following up with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] at the
heart failure clinic.
Patient was discharged home with home PT/OT and VNA services
plus follow-up appointments with his healthcare providers
including Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] for neurology.
Medications on Admission:
-Lipitor 10 mg daily
-Calcitriol 0.25 mcg daily
-Colchicine 0.6 mg Tablet daily
-Aranesp 40 mcg/0.4 mL Syringe SQ weekly
-Fluticasone 50 mcg spray, 1 puff each nostril daily
-Lasix 120 mg [**Hospital1 **]
-Insulin aspart: Take 8 units when blood sugar over 150 before
supper once a day
-Insulin detemir: Take 50 units SC once a day at supper
-Metalozone 2.5 mg daily in am if weight 165 and over as needed
for for swelling
-Nitroglycerin 0.1 mg/hour Patch 24 hr apply at night, remove
in once daily in am
-Protonix 40 mg daily
-Potassium chloride 20 mEq daily
-Diovan 40 mg daily
-Acetaminophen 325 mg TID as needed for fever, pain
-Ferrous sulfate 325 mg [**Hospital1 **]
-Artificial tears one drop QID, bilaterally
-Senna/colace [**Hospital1 **], as needed for constipation
Discharge Medications:
1. Outpatient Lab Work
Please draw an INR this every Monday, Wednesday and [**Hospital1 2974**] until
told otherwise per Dr. [**Last Name (STitle) 8499**]. Fax results to [**First Name4 (NamePattern1) 122**]
[**Last Name (NamePattern1) 8499**] [**Location **]Health Ctr, [**Hospital1 7977**],
[**Location (un) 686**], [**Numeric Identifier 12477**]
Phone: ([**Telephone/Fax (1) 2535**]
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
6. Nitroglycerin 0.1 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal Q24H (every 24 hours).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
[**Telephone/Fax (1) **]:*60 Capsule(s)* Refills:*2*
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please stop once INR therapeutic (2~3).
[**Telephone/Fax (1) **]:*30 Tablet(s)* Refills:*2*
9. Epoetin Alfa 3,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-[**Telephone/Fax (1) 2974**]).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
[**Telephone/Fax (1) **]:*60 Tablet(s)* Refills:*2*
11. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily) as
needed for hold if SBP < 100 or HR < 55.
[**Telephone/Fax (1) **]:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
12. Insulin Glargine 100 unit/mL Cartridge Sig: One (1)
Subcutaneous at bedtime: Please take 25 units at bedtime.
[**Telephone/Fax (1) **]:*8 cartridge* Refills:*2*
13. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Please adjust the dose per Dr. [**Last Name (STitle) 8499**] with goal INR 2~3 and
please take Coumadin between 4~6pm every day. You will need
frequent INR checks while on Coumadin.
[**Last Name (STitle) **]:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
primary diagnoses:
right middle cerebral artery cardioembolic stroke
uncontrolled diabetes mellitus (A1C 9.7)
systolic congestive heart failure (EF 20-25%)
left lower back strain
secondary diagnoses:
atrial fibrillation
chronic renal insufficiency
mildly elevated ammonia
hypertension
anemia, secondary to iron deficiency and chronic kidney disease
Discharge Condition:
mild left sided neglect with mild left facial droop
Discharge Instructions:
You were admitted with a right middle cerebral artery territory
stroke that was likely cardioembolic. On echocardiogram, you
were found to be in worsened congestive heart failure (EF
20-25%) and were seen by cardiology who recommended that you
follow-up in heart failure clinic as an outpatient. Because of
atrial fibrillation, stroke and heart failutre, you were started
on a blood thinning medication called Warfarin which will need
close blood checks after undergoing colonoscopy to assess for
gastro-intestinal bleeding risk.
You have been evaluated and treated per occupational and
physical therapy during this admission who recommend discharge
to home under the care of your daughter with home PT/OT and VNA
services.
You will need to follow-up with your primary care physician this
coming Tuesday, [**4-8**] at 12:15pm where he will check your INR
(goal [**1-14**]) and adjust your Warfarin dose accordingly. You will
likely need your INR blood level checked at least twice or
thrice weekly until your PCP instructs you otherwise.
Please take medications as prescribed.
Please keep follow-up appointments with all your health care
providers.
Given your heart failure and low ejection fraction, please weigh
yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Also please
adhere to 2 gm sodium diet and fluid restriction: 1.5 liters
Please call your PCP [**Last Name (NamePattern4) **] 911 if you have new weakness/numbness,
visual problems including transient blindness and/or speech
problems including slurring of speech.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2110-4-9**] 3:00 PM
Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**]
Date/Time:[**2110-4-9**] 9:30
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2110-4-15**] 2:00
[**First Name8 (NamePattern2) **] [**Doctor Last Name **] (neurology) [**2110-5-14**] 2:30 PM [**Hospital Ward Name 23**] Clinical Center
[**Location (un) 858**]
[**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] (cardiology - heart failure clinic) [**2110-5-19**] 1:00 PM
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2110-4-13**]
|
[
"781.94",
"211.3",
"428.0",
"585.4",
"348.39",
"434.11",
"E885.9",
"285.21",
"846.9",
"403.90",
"427.31",
"V58.67",
"348.0",
"428.22",
"250.02",
"535.50",
"V10.3",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
12646, 12703
|
7172, 9779
|
221, 234
|
13096, 13149
|
4744, 7149
|
14753, 15659
|
3390, 3408
|
10606, 12623
|
12724, 12904
|
9805, 10583
|
13173, 14730
|
3423, 3851
|
12925, 13075
|
2442, 2499
|
177, 183
|
262, 2423
|
4002, 4725
|
3890, 3986
|
3875, 3875
|
2521, 3116
|
3132, 3374
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,714
| 192,741
|
40111
|
Discharge summary
|
report
|
Admission Date: [**2146-1-17**] Discharge Date: [**2146-1-22**]
Date of Birth: [**2073-9-20**] Sex: M
Service: MEDICINE
Allergies:
scallops
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
72 year old male with past medical history of COPD on 3L home
oxygen, CAD, hypertension, and s/p endovascular repair of
abdominal aortic aneurysm on [**2145-5-19**] and a left femoral
endarterectomy on [**2145-5-22**] complicated by respiratory failure,
myocardial infarction, and left lower extremity ischemia, now
presenting with two day history of shortness of breath without
any new sputum production or other upper respiratory symptoms.
.
He was extremely short of breath per EMS had O2 sats of 73% on 3
L oxygen. He denied fever chills headache or chest pain. He has
been nauseous without vomiting.
Initial vitals in the ED were: 95 111 192/124 24 92% 15L. Labs
notable for WBC of 15.1, ABG of 7.15/114/203 and normal UA. CXR
showed worsening pulmonary edema and blunted costodiaphragmatic
angles. He was intubated for hypercarbic respiratory distress,
after satting 90%s on NRB and dropping his sats to 86% with
increasing nausea preventing tolerance of BiPAP. He was treated
for COPD exacerbation with IV methylprednisone, ceftriaxone and
azithromycin along with magnesium and duonebs x2. He was
started on propofol in setting of intubation, which was
subsequently switched to fentanyl and versed due to hypotension,
but never required levophed (ordered in system). Of note,
increasing respiratory rates on the ventilator seem to cause
hypotension as well. On transfer, vitals were: 60s, 96% O2 on
Fi02 70%, 112/60
.
He was transferred to MICU for evaluation and management of
hypercarbic respiratory failure.
.
On arrival to the MICU, he arrived sedated and ventilated. He
was hypotensive to 74/37, R IJ CVL was placed and he was started
on norepinephrine. His initial ABG in the MICU was
7.08/120/89/38.
.
Review of systems:
Patient intubated, unable to complete review of systems, please
see ED documentation for ROS obtained prior to intubation, will
review with patient once extubated.
Past Medical History:
- COPD- baseline home O2 3LCN
- Morbid Obesity
- HTN
- HL
- AAA
- Pulm. nodule
- Edema
- S/P abd. hernia repair
Social History:
Lives at home with wife, daughter, son-in-law and 3
grandchildren. Used to work as a office equipment repairman.
Tobacco - quit [**2136**], was a lifetime smoker - 1-2ppd for 43 years
EtOH - occasional ethanol
drug use - denies.
Family History:
CAD/PVD - father and mother, died in their 70s
CVA - brother in 60s. Brother diagnosed with alzheimers at age
60.
Physical Exam:
On Admission:
Vitals: T:96.7 BP:119/51(69) P:65 R:22 O2:93% FiO270%
General: Intubated, sedated
HEENT: MMM, oropharynx clear, PERRL
Neck: no obvious JVD, difficulty to assess due to size
CV: Regular rate and rhythm, no m/r/g
Lungs: Mild wheezes bilaterally, no rales, ronchi.
Abdomen: Obese, protuberant, nontender, nondistended
GU: Foley in place
Ext: warm, well perfused, 1+ pulses equal in all extremities,
lower extremity swelling bilaterally RLE > LLE
Prior to discharge:
96.0 124/64 77 20 97% on 3L
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - decreased breath sounds diffusely. no rhonchi, resp
unlabored, no accessory muscle use
HEART - distant heart sounds [**3-10**] body habitus, RRR, no MRG, nl
S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, bilateral lower extremity edema, +1 pitting
2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, moving all 4
extremities
Pertinent Results:
Admission Labs:
[**2146-1-19**] 02:30AM BLOOD WBC-16.3*# RBC-3.75* Hgb-11.0* Hct-36.1*
MCV-96 MCH-29.5 MCHC-30.6* RDW-14.6 Plt Ct-212
[**2146-1-18**] 03:43AM BLOOD WBC-10.1 RBC-3.78* Hgb-11.2* Hct-35.4*
MCV-94 MCH-29.6 MCHC-31.5 RDW-14.5 Plt Ct-206
[**2146-1-17**] 05:07PM BLOOD WBC-9.1 RBC-3.83* Hgb-11.5* Hct-36.9*
MCV-96 MCH-30.0 MCHC-31.2 RDW-14.4 Plt Ct-175
[**2146-1-17**] 08:25AM BLOOD WBC-15.1*# RBC-4.52* Hgb-13.4* Hct-43.2
MCV-96# MCH-29.6 MCHC-30.9* RDW-14.2 Plt Ct-242
[**2146-1-19**] 02:30AM BLOOD Neuts-91.0* Lymphs-4.3* Monos-4.3 Eos-0.4
Baso-0.1
[**2146-1-17**] 05:07PM BLOOD Neuts-95.1* Lymphs-3.8* Monos-0.6*
Eos-0.3 Baso-0.1
[**2146-1-17**] 08:25AM BLOOD Neuts-71.8* Lymphs-21.8 Monos-5.0 Eos-0.9
Baso-0.4
[**2146-1-19**] 02:30AM BLOOD Plt Ct-212
[**2146-1-18**] 08:15AM BLOOD PTT-150*
[**2146-1-18**] 03:43AM BLOOD Plt Ct-206
[**2146-1-18**] 03:43AM BLOOD PT-11.5 PTT-138.3* INR(PT)-1.1
[**2146-1-17**] 05:07PM BLOOD PT-10.8 PTT-44.2* INR(PT)-1.0
[**2146-1-19**] 04:11PM BLOOD Glucose-111* UreaN-31* Creat-1.0 Na-145
K-4.1 Cl-96 HCO3-43* AnGap-10
[**2146-1-19**] 02:30AM BLOOD Glucose-158* UreaN-26* Creat-1.2 Na-143
K-4.2 Cl-98 HCO3-39* AnGap-10
[**2146-1-18**] 05:20PM BLOOD Glucose-148* UreaN-25* Creat-1.2 Na-140
K-5.6* Cl-98 HCO3-36* AnGap-12
[**2146-1-18**] 03:43AM BLOOD Glucose-154* UreaN-22* Creat-1.1 Na-143
K-4.7 Cl-101 HCO3-31 AnGap-16
[**2146-1-17**] 05:07PM BLOOD Glucose-151* UreaN-19 Creat-1.1 Na-142
K-6.8* Cl-105 HCO3-32 AnGap-12
[**2146-1-17**] 08:25AM BLOOD Glucose-162* UreaN-18 Creat-1.1 Na-145
K-4.9 Cl-97 HCO3-40* AnGap-13
[**2146-1-19**] 02:30AM BLOOD ALT-23 AST-40 LD(LDH)-272* AlkPhos-84
TotBili-0.3
[**2146-1-19**] 04:11PM BLOOD Calcium-8.3* Phos-4.0 Mg-2.5
[**2146-1-19**] 02:30AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.4
[**2146-1-18**] 05:20PM BLOOD Calcium-8.1* Phos-3.2 Mg-2.3
[**2146-1-18**] 03:43AM BLOOD Calcium-8.1* Phos-2.4*# Mg-2.2
[**2146-1-17**] 05:07PM BLOOD Albumin-4.0 Calcium-6.9* Phos-4.2 Mg-2.2
[**2146-1-17**] 08:36AM BLOOD Lactate-1.7 Na-144 K-4.6 Cl-89*
calHCO3-42*
[**2146-1-19**] 09:16AM BLOOD freeCa-1.04*
[**2146-1-19**] 02:55AM BLOOD freeCa-1.12
Notable Studies:
CTA chest:
As compared to the previous examination, there is slightly
improved contrast filling, currently no evidence of pulmonary
embolism, but a filling inhomogeneity in the lingular artery.
Bilateral mild-to-moderate pleural effusions, bilateral areas of
dorsal and perifissural atelectasis. No evidence of right heart
strain. No enlarged mediastinal lymph nodes. Saber-sheath
trachea.
[**2146-1-18**] TTE:
Conclusions
The left atrium is elongated. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Right ventricular chamber
size and free wall motion are normal. The number of aortic valve
leaflets cannot be determined. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are not well seen. Physiologic mitral regurgitation is
seen (within normal limits). There is an anterior space which
most likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size and global systolic function.
Compared with the report of the prior study (images unavailable
for review) of [**2145-5-24**], there is no significant tricuspid
regurgitation detected on the current study.
LENIs [**2146-1-17**]:
IMPRESSION: No evidence of DVT.
[**1-20**] CXR: FINDINGS: As compared to the previous radiograph, the
patient has been extubated and the central venous access line
has been removed. Lung volumes are relatively large. There is
evidence of cardiomegaly and mild fluid overload. Unchanged
right basal atelectasis and presence of a small left pleural
effusion with subsequent left retrocardiac atelectasis.
Discharge Labs:
[**2146-1-22**] 07:30AM BLOOD WBC-8.1 RBC-3.87* Hgb-11.2* Hct-35.5*
MCV-92 MCH-29.0 MCHC-31.6 RDW-14.4 Plt Ct-167
[**2146-1-22**] 07:30AM BLOOD Glucose-84 UreaN-31* Creat-1.0 Na-142
K-3.2* Cl-91* HCO3-40* AnGap-14
[**2146-1-19**] 12:53PM BLOOD Type-ART FiO2-50 pO2-112* pCO2-66*
pH-7.41 calTCO2-43* Base XS-14 Intubat-NOT INTUBA Comment-FACE
TENT
Studies Pending at Discharge:
None
Brief Hospital Course:
72M with Chronic Obstructive Pulmonary Disease (on home O2 at
3L), coronary artery disease s/p AMI, hypertension, AAA s/p EVAR
([**2145-5-7**]), peripheral vascular disease s/p left femoral
endarterectomy admitted with hypercarbic respiratory failure due
to severe COPD exacerbation.
.
# Hypercarbic respiratory failure/Severe exacerbation of COPD:
Patient was admitted to the Intensive Care Unit with hypercarbic
respiratory failure requiring intubation. Imaging did not show
evidence of pneumonia and no pulmonary embolism was seen on CTA.
LENIs were negative for DVT. Patient was treated with steroids
and azithromycin for severe exacerbation of COPD. Patient was
extubated, finished course of azithromycin in-house, and was
discharged on 3L of oxygen by nasal canula to complete a two
week course of prednisone taper.
#Acute Diastolic Heart Failure:
While on the ventilator patient was diuresed for volume overload
with improvement in oxygenation. It was felt that stress of COPD
exacerbation had led to mild heart failure exacerbation. TTE
showed a preserved EF.
# Hypotension:
Patient was transiently on vasopressors while intubated.
.
# Lower extremity edema: RLE > LLE, unknown duration of
symptoms, high concern for DVT/PE given clinical presentation.
Bilateral duplex U/S: negative for DVT, initially treated with
heparin drip that was discontinued when evaluation was negative
for DVT and PE.
.
CAD s/p STEMI: Continued ASA, clopidogrel
.
HTN: Placed on home BP medications.
.
HLD: Continued on home statin.
.
Transitional issues:
-2 week prednisone taper
-may benefit from sleep study and night time NIPPV
-nevus on leg was evaluated by dermatology, no concern for
melanoma
Medications on Admission:
albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler
aspirin 325 mg po qdaily
clopidogrel 75 mg po qdaily
iron 325 mg po qdaily
enalapril maleate 5 mg po qdaily
fluticasone 110 mcg/Actuation Aerosol 2 puffs [**Hospital1 **]
furosemide 20 mg po qdaily
metoprolol succinate 100 mg po qdaily
rosuvastatin 20 mg po qdaily
tiotropium bromide 18 mcg po qdaily
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB.
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Iron (ferrous sulfate) 325 mg (65 mg iron) Tablet Sig: One
(1) Tablet PO once a day.
5. enalapril maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
9. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
11. prednisone 20 mg Tablet Sig: as directed below Tablet PO
once a day for 10 days: take 2 tabs for the first 2 days, 1 tab
for the next 4 days, and half a tab for the last 2 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1468**] VNA
Discharge Diagnosis:
COPD exacerbation
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 88137**],
You were admitted to the hospital because you had an
exacerbation of your COPD/emphysema. You were found to be in
respiratory failure and you were intubated in the emergency
department. You were admitted to the intensive care unit and
started on antibiotics and steroids. You were extubated,
improved clinically, and transferred to the floor.
The following medication has been added to your regimen:
Prednisone: Please take 2 pills (40 mg) for the first two days,
1 pill (20 mg) for the next 4 days, and half of a pill (10 mg)
for the last 4 days.
Followup Instructions:
Please be sure to keep all of your followup appointments as
listed below:
Primary Care appointment:
Dr. [**Last Name (STitle) 88138**],CANDAN
** Friday, [**1-28**] at 12:40pm
26 CITY [**Doctor Last Name **] MALL, [**Location (un) **],[**Numeric Identifier 11562**]
Phone: [**Telephone/Fax (1) 31019**]
Fax: [**Telephone/Fax (1) 6808**]
Department: VASCULAR SURGERY
When: FRIDAY [**2146-2-11**] at 10:15 AM
With: VASCULAR LAB [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: VASCULAR SURGERY
When: FRIDAY [**2146-2-11**] at 11:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2146-1-25**]
|
[
"V15.82",
"443.9",
"414.01",
"V45.89",
"785.59",
"518.81",
"216.7",
"272.4",
"428.31",
"278.01",
"E938.3",
"V46.2",
"412",
"288.60",
"493.22",
"276.0",
"458.29",
"401.9",
"428.0",
"518.89",
"V85.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"38.91",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
11361, 11420
|
8155, 9678
|
288, 300
|
11482, 11482
|
3864, 3864
|
12276, 13233
|
2634, 2751
|
10250, 11338
|
11441, 11461
|
9870, 10227
|
11665, 12253
|
7748, 8112
|
2766, 2766
|
8126, 8132
|
9699, 9844
|
2069, 2234
|
229, 250
|
328, 2050
|
3880, 7732
|
2780, 3845
|
11497, 11641
|
2256, 2370
|
2386, 2618
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,899
| 170,986
|
41622
|
Discharge summary
|
report
|
Admission Date: [**2144-11-18**] Discharge Date: [**2144-12-7**]
Date of Birth: [**2086-11-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
pain/fever
Major Surgical or Invasive Procedure:
[**2144-11-30**]
1. Irrigation and debridement of right lower extremity
wound.
2. Partial delayed primary closure.
3. Placement of negative pressure dressing.
[**2144-12-3**]
1. Irrigation and debridement of right lower extremity.
2. Delayed primary closure of the wound.
History of Present Illness:
58yoM s/p Coronary artery bypass grafting times two(Left
interior
mammary artery to left anterior descending, saphenous vein
grafting to obtuse marginal) on [**2144-10-20**] Uneventful post-op
course, discharged to rehab at Blueberry [**Doctor Last Name **] rehab on [**2144-10-24**]
States he was doing well, discharged from rehabilitation last
week, developed leg pain over first few days after discharge
from
rehab presented to [**Hospital6 3105**] on [**11-16**] with pain
and fever. Found to have cellulitic left leg. Placed initially
on
Vanco which was changed to Zosyn for broader coverage. His WBC
was 17.7. He continued to have fevers as high as 102.3, with
worsening pain in leg, he was transferred to [**Hospital1 18**] for further
care.
Past Medical History:
Open lower leg wound s/p CABG
MRSA
PMH:
Coronary Artery Disease s/p CABG [**2144-10-20**]
Left Anterior Descending PCI/stent [**12-24**]
Non-Insulin Dependent Diabetes Mellitus
Dilated cardiomyopathy
Hypertension
Hyperlipidemia
Depression
St. [**Male First Name (un) 923**] AICD [**6-25**] ([**Hospital3 **])
Social History:
Mr. [**Known lastname 90470**] lives with:friend in rooming house. He is an
unemployed beer truck driver. He last smoked a cigarette on
[**10-9**] and reports smoking two packs per day. He smokes crack
cocaine every Tuesday, last on [**10-9**].
Family History:
non-contributory
Physical Exam:
T 102.3
Pulse: 72 SR Resp: 20 O2 sat: 100% RA
B/P Right: 122/72 Left:
General: Flushed-rigors
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] +BS [x]
Extremities: Warm [x],
Right lower leg with escar at EVH site, surrounding erythema
10cm. Very tender to palpation. Limited motor function likely
related to pain
Pulses: 2+ radial/femoral, 1+ DP/PT
Neuro: Grossly intact [x]
Pertinent Results:
[**2144-11-24**] CT RLE
IMPRESSION:
1. Interval increased size of cutaneous tissue defect in
proximal medial calf
in region of prior saphenous vein graft with interval
development of increased
locules and foci of gas in this region and also within the
proximal aspect of
a hypoattenuated collection which is seen predominantly
overlying the medial
head of gastrocnemius musculature extending inferiorly to the
level of the
proximal Achilles tendon with total size measuring approximately
5.4 x 1.5 x
31.7 cm. Examination is slightly limited without the benefit of
intravenous
contrast, however, this could represent postoperative
phlegmonous change or
even early abscess formation. Correlate clinically to exclude
the possibility
of necrotizing fasciitis. This has increased in size in
comparison to prior
examination dated [**2144-11-17**].
2. No periostitis or osseous erosions to suggest osteomyelitis.
3. Extensive subcutaneous soft tissue edematous changes and
thickening
throughout the right lower extremity extending into the dorsum
of the foot,
concerning for cellulitis in the appropriate clinical setting.
4. Calcified atherosclerotic vascular disease involving the
right lower
extremity.
5. Achilles tendinosis.
6. Mild degenerative changes of the first MTP joint.
.
[**2144-11-24**] RLE u/s
ULTRASOUND-GUIDED ASPIRATION: Targeted ultrasound was performed
in the medial
right calf subjacent to an incision for recent bypass surgery,
which underwent
superficial debridement earlier today. The medial right calf is
edematous and
erythematous, with scattered foci of gas and nonencapsulated
trace fluid, to
be expected following recent debridement. There is no focal
discernable fluid
collection for drainage.
IMPRESSION: Right medial calf status post recent debridement
with edematous
soft tissues, but without a discrete underlying fluid collection
for drainage.
.
[**2144-12-7**] 06:07AM BLOOD WBC-6.7 RBC-2.83* Hgb-8.3* Hct-25.6*
MCV-91 MCH-29.5 MCHC-32.6 RDW-14.3 Plt Ct-535*
[**2144-12-4**] 05:06AM BLOOD WBC-7.7 RBC-2.75* Hgb-7.9* Hct-24.9*
MCV-91 MCH-28.9 MCHC-31.9 RDW-14.1 Plt Ct-630*
[**2144-12-3**] 04:23AM BLOOD WBC-9.2 RBC-2.67* Hgb-7.9* Hct-24.3*
MCV-91 MCH-29.7 MCHC-32.7 RDW-14.4 Plt Ct-606*
[**2144-12-7**] 06:07AM BLOOD Glucose-120* UreaN-28* Creat-1.2 Na-139
K-4.6 Cl-101 HCO3-31 AnGap-12
[**2144-12-4**] 05:06AM BLOOD Glucose-269* UreaN-25* Creat-1.0 Na-137
K-4.2 Cl-100 HCO3-30 AnGap-11
Brief Hospital Course:
The patient was admitted for further management of right lower
extremity cellulitis of endoscopic vein harvest site. ID was
consulted and guided antibiotic regimen. The patient was
started on Vancomycin and Ciprofloxacin. Subcutaneous heparin
was initiated for DVT prophylaxis in the setting of decreased
mobility.
The patient developed urinary retention and was started on
Flomax. Culture was sent from leg site which would grow MRSA.
The patient was continued on Vancomycin and Zosyn. Pain became
severe and he was placed on a Morphine PCA. Additionally, he
was diuresed in an effort to alleviate lower extremity edema.
The patient underwent bedside debridement on [**2144-11-24**]. Fibrinous
tissue was removed and the wound was packed wet to dry.
Leukocytosis persisted and CT scan of the leg was repeated.
This revealed evidence of subcutaneous gas. He was taken to the
Operating Room on [**2144-11-25**] where he underwent surgical
debridement with Dr. [**Last Name (STitle) **]. Cultures from this tissue grew
MRSA. Plastic Surgery was consulted regarding wound closure.
He returned to the OR on [**11-30**] with Dr. [**First Name (STitle) 1022**] where the wound was
debrided, irrigated, partially closed and Vac dressing was
placed. Zosyn was discontinued, and the patient remained on
Vancomycin for MRSA.
Amiodarone was discontinued, as the patient had demonstrated
Sinus Rhythm for longer than 1 month. Analgesia was achieved
with oral medication and the PCA was discontinued.
He returned to the OR with PRS on [**2144-12-3**] for right lower
extremity VAC removal and primary incision closure. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
drain was placed and the patient was transferred back to [**Wardname 5010**]
in good condition. The Infectious Disease service continued to
follow, Vancomycin was continued at 750mg IV q12hrs until an end
date of [**2144-12-22**]. The patient is planned to be discharged to
rehabilitation center on [**2144-12-6**] for long-term IV antiobiotic
therapy.
Medications on Admission:
1. sertraline 50 mg DAILY
2. gabapentin 800 mg [**Hospital1 **]
3. docusate sodium 100 mg [**Hospital1 **]
4. ranitidine HCl 150 mg [**Hospital1 **]
5. aspirin 81 mg DAILY
6. oxycodone-acetaminophen 1-2 Tablets Q4H as needed for pain.
7. magnesium hydroxide 400 mg/5 mL: Thirty 30 ML PO HS as needed
for constipation.
8. glipizide 5 mg [**Hospital1 **]
9. trazodone 50 mg HS as needed for insomnia.
10. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): on [**10-31**] decrease to 400mg daily for 7 days then
decrease to 200mg daily.
11. simvastatin 10 mg DAILY
12. metformin 250 mg [**Hospital1 **]
13. carvedilol 3.125 mg [**Hospital1 **]
lasix 40 daily
KCL 20 daily
Discharge Medications:
1. Outpatient Lab Work
weekly:
CBC w diff, chem 7, ESR, CRP, vancomycin trough
fax to ID: [**Telephone/Fax (1) 1419**]
2. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
3. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
11. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. brinzolamide 1 % Drops, Suspension Sig: One (1) Ophthalmic
[**Hospital1 **] ().
13. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
14. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
15. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H
(every 6 hours) as needed for constipation.
16. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED): see attached sliding scale.
17. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
18. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
19. glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
20. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
21. 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.
22. Vancomycin 1000 mg IV Q 12H
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Open lower leg wound s/p CABG
MRSA
PMH:
Coronary Artery Disease s/p CABG [**2144-10-20**]
Left Anterior Descending PCI/stent [**12-24**]
Non-Insulin Dependent Diabetes Mellitus
Dilated cardiomyopathy
Hypertension
Hyperlipidemia
Depression
St. [**Male First Name (un) 923**] AICD [**6-25**] ([**Hospital3 **])
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Right leg - incision c/d/i without erythema or drainage, 1 JP
drain
Discharge Instructions:
Post Surgery Wound Care
If you have steri-strips on your incision (little white paper
tapes), keep them in place until they begin to fall off on their
own. Do not pull the steri-strips off as this could put stress
on the incision line. When the steri-strips start to peel off,
they can be gently washed off.
Please try to keep the incision line clean and dry. You can
shower and gently wash the incision line with soap and water.
Dry the incision area and keep the incision line open to air.
It is not necessary to apply antibiotic ointment, alcohol,
hydrogen peroxide, or a new bandage to the incision line. If
your sutures get caught on your clothing or there is a small
amount of drainage from the incision, you may want to cover it
with small gauze for your own comfort. If so, please use as
little tape as possible to hold the gauze in place as tape can
irritate the skin.
A small amount of drainage from the incision in the first few
days after surgery is not unusual and it will probably resolve
on its own. However, if you should notice bleeding from the
surgical site, apply firm direct pressure for ten minutes. If
the bleeding persists, reapply firm direct pressure for an
additional ten minutes. If the bleeding does not stop after 20
minutes, call our contact phone numbers or go to the nearest
emergency room for assistance.
What to Avoid
Please avoid the following:
Do not submerge the incision line under water for a prolonged
period of time with activities like taking a bath, swimming, or
sitting in a hot tub.
Do not participate in any vigorous activities or exercises that
may put stress on the incision.
Do not apply perfumes or scented lotions to the sutures as this
may cause irritation.
When to Call the Doctor
Please contact us immediately if you develop:
Fevers, chills, or night sweats
Increasing redness, pain, or pus at the incision
Bleeding that does not stop with firm pressure
Followup Care
If your sutures need to be removed, this is usually done [**1-20**]
weeks after surgery. Even if your sutures will dissolve, the
doctor usually likes to examine the incision while it is
healing. Therefore, you should have been scheduled for a
follow-up appointment in clinic at the time of your discharge
from surgery. As this appointment is very important, please
contact the clinic if you do not have one scheduled or you need
to change the date and/or time.
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month 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 cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Plastic surgery: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**] [**Telephone/Fax (1) 4652**] Friday, [**2144-12-18**], 1:30pm, [**Hospital Ward Name 23**] [**Location (un) 470**]
ID: office will call you with appointment
Please call to schedule the following:
Dr. [**Last Name (STitle) 90472**],GIULIA H. M. [**Telephone/Fax (1) 90473**] in [**4-21**] weeks
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]
All questions regarding outpatient antibiotics should be
directed
to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**]
Completed by:[**2144-12-7**]
|
[
"305.1",
"V45.81",
"V45.82",
"041.12",
"E878.2",
"250.02",
"401.9",
"272.4",
"V45.02",
"998.59",
"305.61",
"414.00",
"788.29",
"425.4",
"682.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.22",
"83.45",
"38.93",
"86.04"
] |
icd9pcs
|
[
[
[]
]
] |
9831, 9931
|
5054, 7092
|
324, 603
|
10284, 10508
|
2601, 5031
|
13622, 14272
|
1997, 2015
|
7830, 9808
|
9952, 10263
|
7118, 7807
|
10532, 13599
|
2030, 2582
|
273, 286
|
631, 1382
|
1404, 1715
|
1731, 1981
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,929
| 158,309
|
17928
|
Discharge summary
|
report
|
Admission Date: [**2116-9-10**] Discharge Date: [**2116-9-15**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
Hip surgery
History of Present Illness:
[**Age over 90 **] year old female with COPD presents from senior housing s/p
fall. A care taker who was visiting her knocked on her door and
soon afterward heard a thump. The care taker opened the door
and found the patient on the floor alert and oriented. The
patient reports that she tripped and fell, without hitting her
head or loosing consciousness.
.
At the ED, her initial vitals were 97.4, 85, 170/64, 23, 90%
4LNC. A CT Head was negative. Hip/femur/knee xray showed a
mildly displaced intertrochanteric proximal right femur
fracture. Ortho plans to do a ORIF tomorrow [**9-11**]. In the ED,
her pain was controlled with IV morphine. She got a total of
9mg. Then she destaurated to 68-72% on a non-rebreather. ABG
was 7.39, 50, 63. It was unclear whether she was somnelent or
alert, but her respiratory rate was recorded to be 18-20 on the
flow sheets. Eventually her O2 sat improved and was 89% on
venti-mask. She was transferred to the MICU for closer
observation until she gets surgery tomorrow.
.
Past Medical History:
# Hypertension
# Hypercholesterolemia
# Chronic obstructive pulmonary disease:
# Insomnia
# Depression
# Osteoporosis
# Weight loss
# Memory disorder
# Fracture of the shoulder and pelvis s/p fall in [**4-2**]
.
Social History:
The patient is a former smoker and smoked for about 20 years,
one pack a day. She quit smoking about 20 years ago. She is
widowed. Lives in senior housing close to daughter's home.
Family History:
Positive for hypertension and depression in one daughter who is
unwell and lives in [**Name (NI) **].
Physical Exam:
VITALS: 98.2, 132/67, 76, 18, 88% 2LNC+OFM
GEN: Alert and oriented x 3, pleasant
HEENT: MMM, OP clear
NECK: JVP flat
CV: RRR, no m/g/r
PULM: CTAB, no w/r/r
ABD: Soft, NT, ND, +BS
EXT: no edema, right left in brace, right hip tender to touch
and movement
.
Pertinent Results:
.# CXR [**2116-9-10**]:
An S-shaped scoliosis of thoracolumbar spine is again identified
with degenerative changes. The lungs are clear aside from
linear atelectasis/scarring within the right mid lung. No
pleural effusions are seen. The aorta is unfolded with wall
calcifications. Slight opacification of the right-sided
superior mediastinum is stable, likely indicating tortuous
vessels.
IMPRESSION: No acute cardiopulmonary disease.
.
# R HIP AND KNEE [**2116-9-10**]:
Mildly displaced intertrochanteric proximal right femur fracture
EKG: sinus 74 BPM, NA, borderline long QTc, large P in inferior
lead, no previous EKG to compare; no ST elevations or
depressions, no TWI
.
R hip [**9-13**] (POD#2)
IMPRESSION: Three views of the right hip show an ORIF device
traversing an intratrochanteric fracture of the proximal right
femur. The middle of three screws traversing the distal fragment
is obliquely oriented with respect to the other two. The
fracture maintains up to 5 mm of separation.
.
STUDIES:
# CT HEAD [**2116-9-10**]:
No acute intracranial hemorrhage.
.
[**2116-9-10**] 03:20PM BLOOD WBC-20.8*# RBC-4.25 Hgb-13.6 Hct-39.7
MCV-93 MCH-32.0 MCHC-34.3 RDW-14.1 Plt Ct-314
[**2116-9-11**] 01:34AM BLOOD WBC-16.5* RBC-3.75* Hgb-12.1 Hct-35.0*
MCV-93 MCH-32.3* MCHC-34.6 RDW-14.3 Plt Ct-292
[**2116-9-12**] 03:37AM BLOOD WBC-10.6 RBC-2.69*# Hgb-8.9*# Hct-25.2*#
MCV-94 MCH-33.3* MCHC-35.5* RDW-14.3 Plt Ct-202
[**2116-9-14**] 06:10AM BLOOD WBC-8.0 RBC-2.56* Hgb-8.1* Hct-23.4*
MCV-92 MCH-31.6 MCHC-34.5 RDW-15.0 Plt Ct-239
[**2116-9-14**] 05:34PM BLOOD Hct-25.5*
[**2116-9-15**] 06:20AM BLOOD WBC-7.7 RBC-3.23*# Hgb-10.2*# Hct-28.6*
MCV-89 MCH-31.7 MCHC-35.7* RDW-16.8* Plt Ct-294
[**2116-9-10**] 03:20PM BLOOD PT-10.6 PTT-23.6 INR(PT)-0.9
[**2116-9-14**] 06:10AM BLOOD Ret Aut-2.6
[**2116-9-11**] 01:34AM BLOOD Calcium-9.1 Phos-4.4 Mg-2.3
[**2116-9-12**] 03:37AM BLOOD Calcium-7.9* Phos-2.0*# Mg-2.0
[**2116-9-15**] 06:20AM BLOOD Calcium-8.9 Phos-2.1* Mg-2.3
[**2116-9-14**] 06:10AM BLOOD calTIBC-222* VitB12-749 Folate-GREATER TH
Ferritn-149 TRF-171*
[**2116-9-11**] 08:58AM BLOOD freeCa-1.13
Brief Hospital Course:
# RIGHT FEMUR FRACTURE: The patient is s/p ORIF R femur, with
pain well controlled with standing tylenol, and PRN oxycodone.
Orthopedics followed patient and recommended prophylactic
lovenox for 4 weeks, weight bearing and range of motion as
tolerated, and follow up in two weeks with Dr. [**Last Name (STitle) **].
.
# RESPIRATORY DISTRESS: She chronically lives with O2 sat at
around 88%. She has O2 at home as needed but rarely puts it
on. Her ABG is consistent with her history of COPD since she is
hypercarbic with chronic compensatory met alkolosis. CXR was
without signs of pulm edema or PNA. Her oxygenation was
maintained initially with face mask and was then weaned to nasal
canula. On discharge her O2 sat was 98% on 3L NC. She is on
standing atrovent nebulizers with PRN albuterol.
.
# Acute blood loss anemia
10pt HCT drop (35-25) pre-op to post-op. Stable for one day but
then dropped to 23 with increase in RLE echymosis, swelling and
pain. Transfused with one unit PRBCs with rise in HCT to 28 on
day of discharge.
HCT should be followed up in 2 days.
# HTN: She was on procardia according to recent clinic notes but
her senior home records indicates that she has not been on it.
Currently normotensive without BP meds.
.
# HYPERCHOLESTEROL: continued outpatient pravachol
.
# DEMENTIA: continued outpatient exelon
.
# OSTEOPORISIS: continued outpatient calcium and vitamin d and
fosamax.
Medications on Admission:
# ALBUTEROL 90 mcg/Actuation--1-2 puffs inhaled as needed
# Aspirin Low-Strength 81 mg--1 tablet(s) by mouth once a day
# CELEXA 20 mg--1 tablet(s) by mouth at bedtime
# Calcium + D 600-200 mg-unit--1 tablet(s) by mouth once a day
# EXELON 3 mg--2 capsule(s) by mouth qam, 1 capsule qpm
# FOSAMAX 70 mg--1 tablet(s) by mouth qweek
# Multi-Vitamin --1 tablet(s) by mouth daily
# PRAVACHOL 20 mg--1 tablet(s) by mouth once a day
# PRILOSEC 20 mg--1 capsule(s) by mouth once a day
.
ALLERGIES: NKDA
.
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Rivastigmine 3 mg Capsule Sig: Two (2) Capsule PO QAM (once a
day (in the morning)).
3. Rivastigmine 3 mg Capsule Sig: One (1) Capsule PO QPM (once a
day (in the evening)).
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) syringe
Subcutaneous Q24H (every 24 hours) for 4 weeks: continue for
4wks post-op ([**10-13**]).
10. Pravastatin 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
11. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours): for post-op pain.
12. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain: for post-op pain.
13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
14. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for aggitation: hold for sedation.
15. Docusate Sodium Oral
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
17. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
neb Inhalation Q4H (every 4 hours) as needed.
18. Ipratropium Bromide 0.02 % Solution Sig: One (1) inh
Inhalation Q6H (every 6 hours).
19. Morphine 2 mg/mL Syringe Sig: 1-2 mg Injection Q2H (every 2
hours) as needed for breakthrough pain: hold for sedation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
R femur fracture
emphysema
acute blood loss anemia.
.
Secondary:
dementia
Discharge Condition:
Good, amble to ambulate to bathroom, O2 saturations 98% on 3L
NC, normotensive without medications.
Discharge Instructions:
You were admitted with a fracture of your right femur. This was
repaired by orthopedic surgery.
You have a diagnosis of emphysema and had a low oxygen level.
You were kept on home oxygen, which you have at home already.
You should continue to use home oxygen while at rehab and at
home.
You had bleeding after your surgery, most likely within the leg.
This is common after the procedure you had. We treated your
anemia with a transfusion and the hematocrit rose to 28. this
should be rechecked at rehab in two days.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2116-9-24**] 10:50
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2116-11-26**]
11:00
|
[
"276.2",
"783.21",
"737.30",
"272.0",
"E849.7",
"294.8",
"V46.2",
"285.1",
"401.9",
"E888.9",
"780.52",
"496",
"799.02",
"820.21",
"733.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.35",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8037, 8103
|
4311, 5727
|
267, 280
|
8230, 8332
|
2182, 4288
|
8900, 9194
|
1787, 1890
|
6278, 8014
|
8124, 8209
|
5753, 6255
|
8356, 8877
|
1905, 2163
|
223, 229
|
308, 1333
|
1355, 1569
|
1585, 1771
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,313
| 169,298
|
19065+57014
|
Discharge summary
|
report+addendum
|
Admission Date: [**2139-12-22**] Discharge Date: [**2139-12-25**]
Date of Birth: [**2081-8-23**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
right arm and left leg shaking
Major Surgical or Invasive Procedure:
Carotid artery stent
History of Present Illness:
The patient is a 58 year old right handed man with multiple
stroke risk factors, who presented with transient periods of
loss of control in LUE and LLE concerning for limg shaking TIA.
.
Briefly, the patient has had HTN, HL, DM, MI in [**2136**] followed by
3 cardiac stents, and was recently admitted for CABG a 4 vessel
CABG on [**2139-12-8**]. A day post-op on [**12-10**] he developed altered MS
and difficulty with speech production and understanding (he did
not know his age, would mix up the word cereal with fruit). He
was seen by neurology and their note provides full details. His
work up included MRI showing multiple small bilateral foci
consistent with embolic stroke, but his exam was nonfocal per
neurology consult team. Per US carotids, his carotids were
80-99% stenosed bilaterally. His EEG was normal (done for MS
change). It was decided not to pursue urgent CEA or other tx
at that time.
.
Since going home, the patient has had 3 episodes of concern: 6
days ago he
noted that his LUE was clumsy and hard to control, with
occasional
flexion at the elbow. This lasted 10 seconds and resolved sine
sequelae. Then whilst walking 2 days prior to presentation he
had two episodes
lasting 10 sec each of LLE weakness and clumsiness, which again
resolved completely. This episoded occurred while walking. He
comes in today per PCP [**Name Initial (PRE) **].
PCP also asked him to take a Plavix before coming, in addition
to
his usual ASA 81.
.
ROS: As per HPI. Additionally, pt denied HA, diplopia, blurry
vision, tinnitus, vertigo, dysphagia, dysarthria. No F/C, no
weight loss, no SOB/CP/pressure/palps, no N/V/abd
pain/constipation/diarrhea, no muscle aches/joint pains, no
rash,
no dysuria.
Past Medical History:
HTN
Hyperlipidemia
DM
CAD s/p MI in [**2136**] with 3 stents and 4 vessel CABG on [**2139-12-8**]
Carotid Stenosis
Social History:
Tob: no EtOH: occasional IVDA: no
Family History:
sister with cardiomyopathy and sepsis, died at 51y, and
father with MI, died 57y
Physical Exam:
VS: T: 97 BP: 139/72 P: 88 RR: 18 O2 sat: 100 RA
General: WNWD, NAD
HEENT: Anicteric, MMM without lesions, OP clear; positive
periorbital pulses on the R.
Neck: Supple, no LAD, bilateral carotid bruits, no thyromegaly
CV: RRR s1s2 no m/r/g
Resp: CTAB no r/w/r
Abd: +BS Soft/NT/ND no HSM/masses
Ext: No c/c/e, distal pulses intact
Skin: No rashes, petechiae
.
MS: A&O x 3, interactive, appropriate, following all commands
Spells WORLD backwards, names months of year backwards, makes
change
Memory [**1-22**] immediately & w/o prompting at 5 minutes
Speech fluent w/o paraphasic errors, +naming of wholes & parts,
+repetition, +comprehension
No evidence of neglect with visual or tactile stimulation
No apraxia: able to comb hair, screw in light bulb
CN: I - not tested, II,III - PERRL, VFF by confrontation, optic
discs sharp, visual acuity OD, OS; III,IV,VI - EOMI, no ptosis,
no nystagmus; V- sensation intact to LT/PP, corneal reflex
intact, masseters strong symmetrically; VII - no facial
weakness/asymmetry; VIII - hears finger rub B; IX,X - voice
normal, palate elevates symmetrically, gag intact; [**Doctor First Name 81**] -
SCM/Trapezii [**3-25**] B; XII - tongue protrudes midline, no atrophy
or
fasciculations
Motor: nl bulk and tone, no tremor, rigidity or bradykinesia.
No
pronator drift. No asterixis.
Deltd Bicep Tricp ECR/U ExDig FlDig DorsI OppPB
Axill mscut [**Month/Day (1) 21443**] [**Name6 (MD) 21443**] [**Name8 (MD) 21443**] md/ul ulnar medin
C5 C5-6 C7 C6-7 C7 C8 T1
C8-T1
L 5 5 5 5 5 5 5
5
R 5 5 5 5 5 5 5
5
Ilpso Addct Glmed Glmax Qufem Hamst TibAn
[**First Name9 (NamePattern2) 2778**] [**Last Name (un) 938**]
Femor obtur supgl infgl femor [**First Name9 (NamePattern2) 21444**] [**Last Name (un) 18709**] tibil
dpper
L1-2 L2-3 L4-5 L5-S1 L3-4 L5-S2 L4-5 S1-2
L5
L 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5
DTRs: [**Name2 (NI) **] (C56) BR (C6) Tri (C7) Pa (L34) Ac (S12) Plantar
L 2 2 2 2 2 down
R 2 2 2 2 2 down
Sensory: LT, temperature and joint position intact. Stereognosis
is normal. Vibration decreased from R ankle down and L knee
down.
Coord: finger tap rapid & symm, F'N & FNF intact B. HKS intact
B, foot tap rapid & symm.
Gait: Romberg neg. Tandem gait intact. Posture, stance, stride
and arm-swing normal.
Pertinent Results:
ADMISSION LABS:
[**2139-12-22**] 5:00p
Trop-*T*: 0.02
.
142 105 24 111 AGap=14
4.4 27 1.6
.
CK: 46 MB: Notdone
Ca: 8.9 Mg: 1.8 P: 3.6
ALT: 114 AST: 32 LDH: 213
.
....... 87
9.4 10.5 316 D
.....30.2
N:78.9 L:15.2 M:3.7 E:2.0 Bas:0.2
Poiklo: 1+
.
PT: 14.3 PTT: 31.2 INR: 1.3
.
CT HEAD W/O CONTRAST [**2139-12-22**] 4:28 PM
FINDINGS: This study is compared with recent CT dated [**2139-12-10**];
the overall appearance is unchanged. There is mild prominence of
the frontal extra-axial CSF spaces. There is no intra or
extra-axial hemorrhage, and the mid-line structures are in
normal position. The ventricles and cisterns are symmetric and
unchanged in size and in contour. The [**Doctor Last Name 352**]-white matter
differentiation is maintained, throughout. Evaluation of the
posterior fossa is limited by extensive beam-hardening artifact,
but is grossly unremarkable.
IMPRESSION: No acute intracranial hemorrhage and no significant
change since [**2139-12-10**] study.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7593**]
.
MRA CAROTID/VERTEBRAL W/O CONTRAST MR HEAD W/O CONTRAST [**2139-12-22**]
7:08 PM
FINDINGS: It should be noted that the prior study, performed
only 11 days before the current examination revealed evidence of
"small" acute cortical and subcortical infarcts in the right
frontal lobe and possibly in the left parietal lobe. These
lesions are redemonstrated on the present study, and their
presence on both the T2-weighted and diffusion images is
consistent with a subacute-to-chronic age of this pathology.
Given the history of "vascular risk factors," small vessel
infarction would be a reasonable diagnosis, as opposed to
post-inflammatory or even neoplastic etiologies. There is no new
major vascular territorial infarct, mass effect, or shift of
normally midline structures, nor is there hydrocephalus. There
are no areas of abnormal susceptibility seen within the brain
parenchyma. The principal vascular flow patterns are identified.
There is mild mucosal thickening within the ethmoid sinuses
bilaterally. This finding likely indicates an allergic or some
other type of inflammatory process.
CONCLUSION: No new infarct seen compared to the prior study.
.
MR ANGIOGRAPHY OF THE CIRCLE OF [**Location (un) **] AND ITS TRIBUTARIES
FINDINGS: There is no change in the patency of the major
vascular tributaries of the circle of [**Location (un) 431**], compared with the
prior study. There is no new overt vascular stenosis or
occlusive process seen.
.
MR ANGIOGRAPHY OF THE NECK ARTERIAL VASCULATURE
FINDINGS: The 2-dimensional study suggests bilateral high-grade
stenoses of the origins of the internal carotid arteries, with
the right-sided lesion being approximately 5 mm in length and
the left-sided lesion probably close to a cm in length, although
precise measurements based on 2-D images are difficult, due to
the susceptibility of this technique to exaggeration of the
"flow gap" due to turbulent flow through a stenotic segment.
No other vascular pathology is seen. Apparently, these stenoses
were documented on a carotid son[**Name (NI) **] dated [**2139-12-11**].
.
EEG: preliminary read: normal
.
CTA neck: pending
Brief Hospital Course:
The patient is a 58 year old man with DM, HTN,
hypercholesterolemia, CAD (s/p MI x2, stents x3; s/p CABG [**12-8**]),
bilateral carotid stenosis (80-99%), recent R-frontal and
L-parietal strokes, now presenting after episode of L-arm
shaking (x1) and L-leg shaking (x2). No LOC. No accompanying
symptoms. He had small, R-frontal and L-parietal subcortical
strokes following the CABG. At that point the bilateral carotid
stenosis was noted. He has had a low grade fever since a week
prior to presentation (on Keflex).
Exam shows extinction to DSS on L-leg; decreased sense to
vibration and cold in both legs. His memory is poor ([**11-24**] and [**12-25**]
on recall) and he made an phonemic mistake on naming. The
episode could represent shaking limb TIA or a seizure with as
focus either the old R-frontal stroke or a new embolic stroke.
The patient was admitted ot the stroke service for further
workup and management.
.
Neuro:
No further episodes occurred during the admission. A CT head was
negative for a hemorrhage or mass. An MRI/MRA head and neck
showed t2 lesions at right frontal and left parietal subcortical
(representing the recent strokes). No new lesions were seen. An
eeg was normal. MRA and CTA of the neck indicated bilateral
severe internal carotid stenosis, right>left.
Blood cultures to rule out endocarditis were negative. The
following labs were obtained: HbA1C 6.6; lipid panel: 78, 84,
23, 3.4, 38; fibrinogen: 564. ASA 325mg and lipitor 40mg were
continued and fish oil was started. He also received Plavix x2.
For further management and intervention (for symptomatic ICA
stenosis), vascular surgery was consulted. They proceded with
stenting of the right ICA. In preparation of this procedure he
was started on iv heparin.
.
CV:
The patient ruled out for MI per serial cradiac enzymes. All
antihypertensives were held to increase blood flow to the brain.
.
Inf:
The patient had had a low grade fever since a week. Bcx were
negative. Keflex was continued as prior to presentation.
.
Endo:
DM: To control DM, the patient was started [**Female First Name (un) **] ISS, with FSBS.
He was continued on glyburide, which was held while NPO for the
stenting procedure.
.
Vascular: see neuro for details - pt underwent a carotid
stenting without incidence.
.
FEN:
-cardiac, diabetic diet
-IVF for gentle hydration; mucomyst for renal protection prior
to CTA
.
Proph:
-VD boots; OOB
Medications on Admission:
ASA 81 QD, Keflex, Glyburide, Lipitor
ALL: nkda
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 3 days.
Disp:*12 Capsule(s)* Refills:*0*
4. Omega-3 Fatty Acids 120-180-1.8 mg-mg-unit Capsule Sig: One
(1) Capsule PO BID (2 times a day).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*6*
6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. Iron 325 (65) mg Tablet Sig: One (1) Tablet PO once a day for
30 days.
Disp:*30 Tablet(s)* Refills:*0*
8. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 6138**] VNA
Discharge Diagnosis:
1. limb shaking TIA
2. critical stenosis R internal carotid artery
Discharge Condition:
Stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOLLOWING CAROTID STENT PLACEMENT
.
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 other than no
lifting an object heavier than twenty-five (25) pounds for the
first week. Gradually increase your level of activity back to
normal depending on how you feel. Fatigue is normal, especially
for the first couple of days post procedure. Resume driving when
you feel strong enough and comfortable enough.
.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
.
Weakness, numbness, tingling involving your arm, leg or face .
.
Loss of vision .
.
Difficulty speaking .
.
Severe headache (mild headache is common) .
.
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.
.
Check the puncture site daily.
.
Report any unusual pain, swelling, bright red bleeding, (a small
bruise is not unusual at the insertion site).
.
EXERCISE:
.
Limit strenuous activity for 3-5 days.
.
Do not drive a car for 48 hours.
.
No heavy lifting greater than 25 pounds for the next 3 days.
.
Avoid excessive bending at the hips and stooping for the next 3
days.
.
MEDICATIONS:
.
You may resume taking medication you were on prior to your
surgery unless specifically instructed otherwise by your
physician [**Name9 (PRE) **] will be given a new prescription for pain
medication, which should be taken every three (3) to four (4)
hours only 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.
.
No strenuous activity for 4-6 weeks after surgery. .
.
WOUND CARE:
.
You may remove your bandage in the morning after discharge.
.
Keep the site clean and dry.
.
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 vascular 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 :
.
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!
.
Please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are 8:30-5:30 Monday
through Friday.
.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE.
.
Followup Instructions:
Please follow up at the [**Hospital 4038**] Clinic with Dr. [**Last Name (STitle) 1693**]. Please
call [**Telephone/Fax (1) 52052**] to update your demograpics, make the
appointment and receive directions.
Call Dr[**Name (NI) 1720**] office at [**Telephone/Fax (1) 1241**]. Schedule an appointment
for your follow-up stent.
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 7045**], MD Date/Time:[**2140-1-19**] 1:00
Completed by:[**2139-12-25**] Name: [**Known lastname 9682**],[**Known firstname **] Unit No: [**Numeric Identifier 9683**]
Admission Date: [**2139-12-22**] Discharge Date: [**2139-12-25**]
Date of Birth: [**2081-8-23**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 270**]
Addendum:
Pt with 8 beat run SVT
Cardiology consulted
recommendation lopressor 50 [**Hospital1 **]
Holter moniter 48 hrs
F/U with PCP [**Name Initial (PRE) **] [**Name10 (NameIs) **] will be sent the report
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 9684**] VNA
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 272**] MD [**MD Number(1) 273**]
Completed by:[**2139-12-25**]
|
[
"435.9",
"V45.82",
"250.00",
"412",
"427.32",
"272.4",
"401.9",
"427.89",
"V45.81",
"433.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.61",
"00.63",
"00.45",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
17707, 17922
|
8271, 10673
|
348, 370
|
11639, 11647
|
5026, 5026
|
16643, 17684
|
2322, 2404
|
10773, 11447
|
11550, 11618
|
10699, 10750
|
11671, 14447
|
2419, 5007
|
277, 310
|
14462, 16620
|
398, 2115
|
5042, 8248
|
2137, 2253
|
2269, 2306
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,108
| 161,316
|
4114
|
Discharge summary
|
report
|
Admission Date: [**2166-2-20**] Discharge Date: [**2166-3-13**]
Date of Birth: [**2091-3-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11495**]
Chief Complaint:
SOB, loss of appetite, fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
74 yo M with 3VD (inoperable), ischemic CM, CHF (EF 15-25%),
severe MR, s/p VT ablation and ICD, CRI, PVD, CVA who presents
with several week h/o dyspnea and decreased PO intake. The
dyspnea is not exacerbated with exertion. He denies fever,
chills, though has occasional dry cough. He has had no recent
known sick contacts and did receive his flu shot this year. No
chest discomfort. No palpitations. Dyspnea has been
accompanied by generalized weakness and decreased PO intake,
with 5-6 pound weight loss over the past week. He has had
difficulty sleeping for the past two nights, though denies PND.
No LE edema.
Mr. [**Known lastname 18034**] was recently hospitalized [**1-2**] -> [**1-11**] with
frequent episodes of VT. Underwent VT ablation, and amiodarone
was restarted at 400mg. Also noted to have ARF, which was
attributed to hypotension, and improved.
Recent clinic notes from Dr. [**Last Name (STitle) **] detail similar
presentation of weakness. He has had several medication changes
recently, including his amiodarone and digoxin dosing. His
amiodarone was originally discontinued following recent VT
ablation,though was subsequently restarted at 800 mg daily.
Following reinitation, he noted weakness and blurred vision.
His amiodarone was again d/c'd [**2166-2-12**]. In addition, his
digoxin was d/c'd at 12/29, to see whether his symptoms improved
without it. Per the patient's daughter, his symptoms initially
improved somewhat, though overall have not changed
significantly.
Per family members, he has been intermittently confused, and has
had bowel incontinence on several occasions.
ROS negative for HA, melena, BRBPR, abdominal pain. Has had
intermittent nausea.
Past Medical History:
CAD s/p cath [**12/2161**]: 3VD: 100% occlusion in prox RCA, 100% mid
LAD and 100% intermedieus disease
MI [**4-18**] (markedly elevated TnT, negative CK)
profound ischemic cardiomyopathy with an EF of 15-25%
chronic atrial fibrillation
s/p ICD, Biventricular PPM [**2163**]
h/o monomorphic VT [**2165**], s/p successful ablation of three VT
circuits
CHF
CRI - baseline 1.3-1.9.
4+MR, 2+TR
HTN
hyperlipidemia
PVD
CVA x 2 12 years ago, 6 years ago. Residual L-sided weakness
He had a nephrectomy in [**2153**] secondary to complication of
nephrolithiasis.
pulm HTN (TR grad 72 [**12-19**]).
He had a LV thrombus documented in [**2161**] by echocardiogram
Depression
LBP
BPH
Social History:
Married, lives with wife. Former tobacco and EtoH use.
Family History:
NC
Physical Exam:
PE: T 95.9 BP 111/47 P 50 RR 16 97% RA
patient found lying flat in bed, in NAD
anicteric, conj uninjected, MMM. No sores in OP
JVP ~[**7-22**], no LAD
Regular bradycardic rhythm, III/VI HSM at apex
abd soft, NT/ND, +BS
no peripheral edema, no calf tenderness
follicular rash on chest
awake, alert, answers questions (limited by language barrier,
able to communicate with daughter). CN II - XII in tact.
strength 5+ RUE/RLE, 5+ LUE/LLE (though mildly weaker than R
diffusely).
Pertinent Results:
Spirometry [**1-18**]:
Actual Pred %Pred Actual %Pred %chg
FVC 3.07 3.16 97
FEV1 2.25 2.11 107
MMF 1.59 2.11 75
FEV1/FVC 73 67 110
Impression: Isolated reduction on diffusing capacity suggests
perfusion limitation.
-
ECHO [**12-19**]: EF25%, Left ventricular cavity enlargement with
global and regional systolic dysfunction c/w multivessel CAD or
other diffuse process. 4+ mitral regurgitation. Severe pulmonary
artery systolic hypertension. Right ventricular hypokinesis.
-
P/A LAT: no acute cardiopulmonary placement. stable
cardiomegaly.
ECG: paced rhythm, 50bpm, wide complex (Qtc ~500), LAD, LBB
pattern.
Brief Hospital Course:
A/P 74 yo M with ischemic CM, CHF with biV ppm, PVD, admitted
with dyspnea, weakness, decreased PO intake and ARF on CRI.
The pt was felt to be dehydrated d/t decreased po intake on
initial admission, which improved gradually. He was laced on
nesiritide and lasix per cardiolgoy given his CHF. The pt had a
history of afib, mural thrombus, and frequent Vtach. Coumadin
was held on admission given a high INR. Pacemarker was
interoogated showing intermittent complete heart block and high
grade AV block, changes attributed to amiodarone toxicity. His
pacemaker setting were changed. For his h/o CAD, continued
aspirin, b-blocker, statin. The pt had elevated LFT's and had a
RUQ US which showed no e/o liver or gallbladder pathology.
On [**2166-2-27**], the pt underwent cardiac arrest, whcih appeared to
be a PEA to asystole arrest due to failure of pacing capture.
Code labs revealed marked acidosis with elevated K. Hypotheses
included ischemic bowel from severe CHF, leading to lactic
acidosis, leading to pacer firing but not capturing. The pt was
hypotensive and was transiently on dobutamine and levophed. His
renal function worsened, felt secondary to shock. The pt's MS
was affected after the first code although he was noted to have
a lack of movement in his LUE; however, this might have been
from reexpression of previous strokes. EEG showed moderate
encephalopathy.
The pt was extubated on [**2166-3-2**]. He developed septic physiology
and was treated for an enterococcal UTI and for group B strep in
the blood with broad spectrum abx. His renal failure continued
to worsen. He was placed on milrinone with improvement in
cardiac index. He then had UGIB with episodes of melena and was
transfused. His LFT's rose significantly, felt to be c/w shock
liver. RUQ US showed no evidence of cholestasis. The pt's skin
was bright yellow/[**Location (un) 2452**], and was biopsied by dermatology (his
TBili was in the high 20's). The pt also had a coagulopathy from
unclear source, resolving with Vitamin K. The pt's MS began to
worsen, felt to be infectious/metabolic in origin. He then
developed a thrombocytopenia of unclear etiology.
The pt was medically stable but his MS did not return. He was
transferred to the cards floor. On [**2166-3-12**], the pt went into
respiratory arrest s/p possible aspiration event. He was
reintubated. His BP went to the 50's despite max doses of
levophed, dopamine, and milrinone. Epinephrine was started.
Code status was discussed at length with the pt's family
throughout the hospitalization. At this time, they agreed to
withdraw medical support and the patient passed away.
Medications on Admission:
ASA 81 mg qd, Coumadin 1mg QD (2mg [**Last Name (LF) **], [**First Name3 (LF) **]), Coreg 12.5 mg
[**Hospital1 **], Bumex 1 mg qd, digoxin 0.125 mg qd (held for past week),
amiodarone 800 mg qd (held for past week), Lipitor 80 mg qd,
Flomax .4, and Detrol 2.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
COPD, CHF
Discharge Condition:
Deceased
|
[
"557.1",
"570",
"578.9",
"783.7",
"286.9",
"403.91",
"996.72",
"427.31",
"427.5",
"E942.0",
"276.7",
"584.5",
"486",
"287.5",
"426.0",
"276.5",
"599.0",
"428.0",
"782.1",
"276.2",
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] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
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"96.04",
"99.04",
"99.60",
"00.17",
"99.07",
"86.11",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
7082, 7097
|
4145, 6772
|
347, 353
|
7151, 7162
|
3392, 4122
|
2874, 2878
|
7118, 7130
|
6798, 7059
|
2893, 3373
|
277, 309
|
381, 2087
|
2109, 2785
|
2801, 2858
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,132
| 144,530
|
28324
|
Discharge summary
|
report
|
Admission Date: [**2144-7-7**] Discharge Date: [**2144-7-12**]
Date of Birth: [**2096-2-16**] Sex: M
Service: SURGERY
Allergies:
Tetracycline / Nsaids
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
1. Incisional hernias, abdomen.
2. Excess skin.
3. Panniculitis left wall.
Major Surgical or Invasive Procedure:
Repair of incissional hernia and abdominoplasty
1. Repair of incisional hernia x 2 with a single mesh,
abdomen.
2. Abdominoplasty.
Past Medical History:
Hypertension
GERD
Dyslipidemia
Chronic low back pain
Osteoarthritis of knee joints and ankles.
Social History:
He has no known food or drug allergies. He denied tobacco or
recreational drug usage, had bourbon daily for 8 years and
quitin [**2131**],and drinks 12 ounce diet cola 4 times a day but has
stopped. He is employed as a production supervisor and is
divorced with 2 daughters ages 14 and 18.
Family History:
Father: [**Name (NI) **], age 71 with cardiac disease s/p CABG x 3 and h/o
of cancer of prostate;
Mother: [**Name (NI) **] age 74 with rheumatoid arthritis and h/o colon CA
on maternal side
Daughter: age 17 with asthma
Physical Exam:
Vitals:Temp:97.4,Hr:74,BP:116/90,RR:16,Sat 94%RA
Gen:A+Ox3
HEENT:PERRL,EOMI
Chest:clear,B/L breath sounds N
CVS:N S1 S2.No M/R/G
Abdomen: soft and non-tender, non-distended with normal bowel
sound.
Wound:Incissional site C/D/I.
Extremities: No edema. B/l DP pulse present.
CNS:There were no focal neurological deficits and her gait was
normal.
Pertinent Results:
[**2144-7-7**] GLUCOSE-115* LACTATE-1.9 NA+-137 K+-4.0 CL--103 TCO2-26
HGB-13.0* calcHCT-39 freeCa-1.07*
Brief Hospital Course:
Mr [**Known lastname 68756**] was admitted to the hospital and taken to the
Operating Room where he underwent a gastric bypass.He tolerated
the procedure well and returned to the PACU in stable condition.
His hemodynamics remained stable and her pain was controlled
with a PCA.
Following transfer to the Surgical floor he continued to make
good progress.His epidural was removed on post op day 2.His pain
medication was changed to Roxicet and was very effective.
Subsequently his foley was removed but he failed his trial of
void and the foley was removed. His diet was gradually advanced
from sips to clears and he tolerated it well without any
fullness or nausea. After failing a second voiding trial, his
foley kept in with the plan to discharge him home with a
catheter and leg bag, with instructions to follow up with a
urologist as an outpatient.
From a respiratory standpoint he used his incentive spirometer
during the day. He was up and walking independently and his
oxygen was gradually weaned off.
His abdominal wound was healing and his left JP drain was
removed prior to discharge.
After an uneventful post op course he was discharged to home and
will follow up with Dr. [**Last Name (STitle) **].
Medications on Admission:
CYCLOBENZAPRINE [FLEXERIL] 10mg Tablet -po
DIAZEPAM [VALIUM] 5 mg Tablet po prn for muscle spasms
LANSOPRAZOLE [PREVACID SOLUTAB]
CALCIUM CITRATE -VITAMIN D3 500 mg-200 unit Tab po bid,
CYANOCOBALAMIN [VITAMIN B-12] 1,000 mcg Tab po qid
MULTIVITAMIN 2 Tab po qid
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 MLs
PO Q6H (every 6 hours) as needed for pain.
Disp:*250 ML(s)* Refills:*0*
2. Cyclobenzaprine 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3
times a day) as needed for muscle spasms. Tablet(s)
3. Diazepam 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6
hours) as needed for muscle spasm and pain.
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
5. Cyanocobalamin 500 mcg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
6. Multivitamin Tablet [**Last Name (STitle) **]: 1-2 Tablets PO DAILY (Daily).
7. Calcet Creamy Bites 500 mg(calcium) -400 unit Tablet,
Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable PO bid ().
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
PREOPERATIVE DIAGNOSIS:
1. Incisional hernias, abdomen.
2. Excess skin.
3. Panniculitis left wall.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions: Please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.
Medication Instructions:
Resume your home medications.
You will be starting some new medications:
1. You are being discharged on medications to treat the pain
from your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
2. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
Activity:
No heavy lifting of items [**9-25**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2144-7-22**] 3:15
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18800**], RD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2144-7-13**] 10:30
Please contact your primary care provider to receive referral
for a urology followup with a local urologist this week.
|
[
"553.21",
"530.81",
"729.39",
"401.9",
"701.9",
"327.23",
"724.2",
"272.4",
"715.97",
"V45.86",
"715.96"
] |
icd9cm
|
[
[
[]
]
] |
[
"57.95",
"53.61",
"03.90",
"86.83"
] |
icd9pcs
|
[
[
[]
]
] |
4082, 4137
|
1665, 2883
|
355, 493
|
4280, 4280
|
1536, 1642
|
5795, 6251
|
935, 1155
|
3198, 4059
|
4158, 4259
|
2909, 3175
|
4455, 4890
|
1170, 1517
|
240, 317
|
5544, 5772
|
4915, 5532
|
4295, 4407
|
515, 611
|
627, 919
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,412
| 138,885
|
7945
|
Discharge summary
|
report
|
Admission Date: [**2117-1-26**] Discharge Date: [**2117-2-2**]
Date of Birth: [**2050-7-29**] Sex: M
Service: Vascular Surgery
CHIEF COMPLAINT: Ischemic left heel ulcer.
HISTORY OF PRESENT ILLNESS: This is a 56-year-old white male
with diabetes, hypertension, hepatitis C, and a history of
intravenous drug abuse who has been followed by Dr. [**Last Name (STitle) **]
of Podiatry for a left heel ulcer which developed several
weeks prior to admission. The patient was referred to Dr.
[**Last Name (STitle) **] for further evaluation and treatment.
PAST MEDICAL HISTORY:
1. Diabetes.
2. Hypertension.
3. Hepatitis C.
4. History of intravenous drug abuse.
PAST SURGICAL HISTORY:
1. Cholecystectomy.
2. Bilateral fifth toe amputation.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. NPH insulin 12 units subcutaneously q.a.m.
2. NPH insulin 4 units subcutaneously at supper.
3. Methadone 40 mg p.o. q.d.
4. Cardizem-CD 240 mg p.o. q.d.
5. Lasix 40 mg p.o. q.d.
6. Tylenol p.o. as needed.
7. Oxygen via nasal cannula as needed.
FAMILY HISTORY: Family history was noncontributory.
SOCIAL HISTORY: The patient lives at the Greenery in [**Location (un) 9101**]
for the previous seven years. He is a cigarette smoker. He
does not drink alcohol. He has a history of intravenous drug
abuse. He has been using a cane and/or wheelchair for
mobility.
PHYSICAL EXAMINATION ON PRESENTATION: General physical
examination revealed an alert and cooperative white male in
no acute distress. Heart examination revealed a regular rate
and rhythm without murmurs. The lungs were clear
bilaterally. The abdomen was soft and nontender.
Extremities revealed left heel ulceration was present. Pulse
examination revealed femoral pulse was palpable bilaterally.
Neurologic examination was nonfocal. Pulses had dopplerable
signals bilaterally. Neurologic examination was nonfocal.
PERTINENT LABORATORY VALUES ON PRESENTATION: Admission
laboratories from [**2117-1-26**] revealed white blood cell
count was 14.9, hemoglobin was 10.2, hematocrit was 33.4, and
platelets were 324,000. Sodium was 138, potassium was 5.1,
chloride was 106, bicarbonate was 24, blood urea nitrogen was
29, creatinine was 1.6, and blood glucose was 106.
Urinalysis on [**2117-1-27**] was negative. A culture of the
left heel ulcer from [**2117-1-19**] showed
methicillin-resistant Staphylococcus aureus, moderate growth.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray showed no acute
pulmonary disease.
Electrocardiogram revealed intermittent sinus rhythm at a
rate of 46, ectopic atrial focus was present.
HOSPITAL COURSE: The patient was admitted to the hospital
on [**2117-1-26**]. He was placed on the Mucomyst protocol and
hydrated prior to angiogram in the cardiac catheterization
laboratory on [**2117-1-27**].
The Cardiology Service was consulted for preoperative
clearance. An echocardiogram on [**2117-1-28**] showed normal
left ventricular wall thickness and cavity size. The left
ventricular systolic function was normal with an left
ventricular ejection fraction of greater than 55%. The
patient was cleared for surgery.
Mavik was recommended for better blood pressure control. T
his was started on [**2117-1-28**]. Approximately three hours
after the first dose, the patient's systolic blood pressure
dropped to 80. The patient's only complaint was nausea. The
patient was transferred to Surgical Intensive Care Unit for
close monitoring. A dopamine drip was used to manage his
systolic blood pressure. Cardiac isoenzymes were cycled and
were negative. It was determined that a larger dose of Mavik
was given than recommended. The patient's blood pressure
returned to baseline. The patient was scheduled for surgery.
On [**2117-1-29**], the patient underwent an uneventful left
superficial femoral artery endarterectomy with a Dacron
patch. At the end of surgery, the patient had a dopplerable
left dorsalis pedis and posterior tibialis pulse. He
received 2 units of packed red blood cells intraoperatively.
The patient received several doses of Kefzol perioperatively.
The patient was started on Lopressor; per postoperative beta
blocker protocol.
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], the patient's endocrinologist, followed the
patient for diabetic management.
Physical Therapy evaluated the patient for full weightbearing
ambulation on his left foot using a healing sandal. The
patient will continue to wear a multipoultice splint on his
left leg when he is not ambulating.
At the time of discharge, the patient's left thigh incision
was intact. There was minimal serosanguineous drainage from
the incision. His left heel ulcer is clean and without
erythema. He will continue to have normal saline,
wet-to-dry, dressing changes t.i.d. His incision will be
swabbed with a Betadine stick q.d. The patient had
dopplerable signals at his pedal pulses bilaterally.
The patient was to follow up with Dr. [**Last Name (STitle) **] in the office
for staple removal in 10 days.
MEDICATIONS ON DISCHARGE:
1. Methadone 40 mg p.o. q.d.
2. NPH insulin 12 units subcutaneously q.a.m.
3. NPH insulin 4 units subcutaneously at supper.
4. Regular insulin sliding-scale q.i.d.
5. Cardizem-CD 240 mg p.o. q.d.
6. Lopressor 12.5 mg p.o. b.i.d.
7. Lasix 40 mg p.o. q.d.
8. Ecotrin 325 mg p.o. q.d.
9. Heparin 5000 units subcutaneously b.i.d.
10. Sucralfate 1 g p.o. q.i.d.
11. Reglan 10 mg p.o. a.c. and q.h.s.
12. Ranitidine 150 mg p.o. b.i.d.
13. Calcium carbonate 500 mg p.o. q.i.d. as needed.
14. Percocet one to two tablets p.o. q.4h. as needed.
15. Tylenol 325 mg to 650 mg p.o. q.4h. as needed.
16. Oxygen via nasal cannula (to maintain oxygen saturations
of greater than 92%).
CONDITION AT DISCHARGE: Condition on discharge was
satisfactory.
DISCHARGE STATUS: Return to [**Hospital3 28512**] Home in
[**Location (un) 9101**].
DISCHARGE DIAGNOSES:
1. Ischemic left heel ulcer.
2. Left superficial femoral artery endarterectomy with
Dacron patch on [**2117-1-29**].
SECONDARY DIAGNOSES:
1. Diabetes.
2. Gastroparesis.
3. Hypertension.
4. Hepatitis C.
5. Methicillin-resistant Staphylococcus aureus (left heel).
6. History of intravenous drug abuse.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 19472**]
Dictated By:[**Last Name (NamePattern1) 3954**]
MEDQUIST36
D: [**2117-2-2**] 10:12
T: [**2117-2-2**] 10:23
JOB#: [**Job Number 28513**]
|
[
"458.2",
"536.3",
"357.2",
"401.9",
"707.14",
"304.01",
"070.54",
"440.23",
"250.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.42",
"88.48",
"38.18",
"39.57"
] |
icd9pcs
|
[
[
[]
]
] |
1102, 1139
|
5974, 6094
|
5106, 5810
|
830, 1085
|
2653, 5079
|
708, 804
|
6115, 6563
|
5825, 5953
|
166, 193
|
222, 574
|
596, 685
|
1156, 2634
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,190
| 120,265
|
12926
|
Discharge summary
|
report
|
Admission Date: [**2129-5-14**] Discharge Date: [**2129-5-20**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
ALTERED MENTAL STATUS
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
[**Age over 90 **]M hx of dementia and depression, lower GI bleed with villous
adenoma status post colostomy, PE on coumadin, Afib and DM who
presents from [**Hospital1 1501**] with with AMS and lethargy.
.
In the ED, initial VS were 96.0 68 98/48 18 99%/RA. Labs were
notable for Na 159, K 6.3, Cr 5.2, Gluc 140, WBC 13.2 76.5%N,
INR 3.4, HCT 40.4 and lactate of 2.1. CXR revealed no focal
consolidation. Head CT revealed no acute intracranial process.
Patient received 1 amp D50 and 10 units of insulin in the ED.
Renal fellow was consulted and advised emergent HD.
.
On arrival to the MICU, pt appeared comfortable but was
unarousable and therefore unable to answer questions. [**Hospital1 1501**] staff
reported recent FTT (eats only [**Country **] food brought in by family
who live several hours away). Not aware of any recent fevers,
chills or urinary symptoms.
Past Medical History:
b/l pulmonary emboli
prostate CA
villous adenoma s/p colectomy w/colostomy, with chronically
prolapsed stoma
DM2
anemia of chronic disease
depression
hx of ethanol use
right hip fracture
hypertension
urethral strictures
Social History:
Immigrated from [**Country **] in [**2096**]. Retired, lives in nursing
home. Widowed. 20-30 pack year history of smoking, quit 20
years ago. Past ethanol abuse, none now. No illicits. Daughter
[**First Name8 (NamePattern2) 13409**] [**Last Name (NamePattern1) **] lives in [**Location **], is HCP [**Telephone/Fax (1) 39709**]
(home)[**Telephone/Fax (1) 39710**] (cell). Step-daughter [**Name (NI) **] [**Name (NI) 732**] also aware
but prefers not to be involved in [**Hospital **] medical decision-making.
Family History:
non-contributory
Physical Exam:
ADMISSION EXAM
VS T 98.2 HR 80 BP 117/57 RR 17 O2 98/RA
General: Alert, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: tachycardic to 110, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: good air entry b/l, but prolonged expiration, with
diffuse expiratory wheezes b/l, fine crackles at bases, L>R
Abdomen: firm, non-tender, non-distended, hypoactive bowel
sounds, no tenderness to percussion, no rebound
GU: foley in place, no lesions, no scrotal edema
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, finger-to-nose intact
.
Discharge exam:
Physical Exam:
Vitals: Tm 99.1 97.8 140/80 (132-154/60-80) 93 (70-102) 93-98RA
FSG 136
incontinent of urine
General: alert and interactive this morning, AAO x3
HEENT: Sclera anicteric
Neck: supple, JVP not elevated, no LAD
CV: RRR, S1 S2, ? SEM loudest at USB
Lungs: clear to auscultation b/l, with poor air movement
Abdomen: soft, nontender, nondistended, +BS, + ostomy with about
10 cm of prolapsed intestine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS
[**2129-5-14**] 01:25AM BLOOD WBC-13.2*# RBC-4.37* Hgb-11.9* Hct-40.4
MCV-92 MCH-27.1 MCHC-29.4*# RDW-14.6 Plt Ct-233
[**2129-5-14**] 01:25AM BLOOD Neuts-76.5* Lymphs-13.0* Monos-7.3
Eos-2.9 Baso-0.3
[**2129-5-14**] 01:25AM BLOOD PT-34.5* PTT-50.7* INR(PT)-3.4*
[**2129-5-14**] 01:25AM BLOOD Glucose-140* UreaN-108* Creat-5.2*#
Na-159* K-7.1* Cl-120* HCO3-23
[**2129-5-14**] 01:25AM BLOOD ALT-22 AST-36 AlkPhos-98 TotBili-0.3
[**2129-5-14**] 01:25AM BLOOD Lipase-89*
[**2129-5-14**] 01:25AM BLOOD Albumin-3.8 Calcium-9.8 Phos-6.0*#
Mg-3.1*
[**2129-5-14**] 01:31AM BLOOD Lactate-2.1*
.
URINALYSIS
[**2129-5-14**] 07:54AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.015
[**2129-5-14**] 07:54AM URINE Blood-MOD Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
[**2129-5-14**] 07:54AM URINE RBC-29* WBC-41* Bacteri-MANY Yeast-NONE
Epi-0
[**2129-5-14**] 07:54AM URINE CastHy-111*
.
MICRO
[**2129-5-15**] BLOOD CULTURE -PENDING
[**2129-5-15**] BLOOD CULTURE -PENDING
[**2129-5-14**] MRSA SCREEN {POSITIVE FOR METHICILLIN RESISTANT STAPH
AUREUS}
[**2129-5-14**] URINE CULTURE-FINAL {ESCHERICHIA COLI}
[**5-14**] BLOOD CULTURE - 2/4 BOTTLES
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- <=1 S
Aerobic Bottle Gram Stain (Final [**2129-5-14**]):
Reported to and read back by DR. [**First Name (STitle) **] [**Doctor Last Name **] @ [**2047**],
[**2129-5-14**].
GRAM NEGATIVE ROD(S).
Anaerobic Bottle Gram Stain (Final [**2129-5-14**]): GRAM
NEGATIVE ROD(S).
Discharge labs:
[**2129-5-19**] 06:55AM BLOOD WBC-8.6 RBC-3.47* Hgb-9.3* Hct-30.6*
MCV-88 MCH-26.7* MCHC-30.3* RDW-14.4 Plt Ct-161
[**2129-5-20**] 06:01AM BLOOD WBC-8.2 RBC-3.14* Hgb-8.5* Hct-27.9*
MCV-89 MCH-26.9* MCHC-30.3* RDW-14.9 Plt Ct-144*
[**2129-5-14**] 01:25AM BLOOD Neuts-76.5* Lymphs-13.0* Monos-7.3
Eos-2.9 Baso-0.3
[**2129-5-19**] 06:55AM BLOOD Glucose-183* UreaN-9 Creat-1.1 Na-142
K-3.7 Cl-109* HCO3-25 AnGap-12
[**2129-5-20**] 06:01AM BLOOD Glucose-122* UreaN-7 Creat-0.9 Na-145
K-3.4 Cl-111* HCO3-29 AnGap-8
[**2129-5-19**] 06:55AM BLOOD Calcium-8.0* Phos-2.2* Mg-1.8
[**2129-5-20**] 06:01AM BLOOD Calcium-8.4 Phos-2.4* Mg-1.6
Brief Hospital Course:
[**Age over 90 **]M nursing home resident w/hx colectomy [**2-17**] villous adenoma,
b/l PE, atrial fibrillation, DM2 and recent FTT was send in for
AMS, found to have sepsis from a urinary source, with ARF,
hypernatremia, & hyperkalemia. Clinically improved w/IVF and
antibiotics.
# DELIRIUM
Patient has underlying dementia and recent FTT. However, [**Hospital1 1501**]
staff report that at baseline he is conversational and
appropriate. Now p/w AMS (lethargic, nonverbal, on neuro exam he
did not respond to voice or sternal rub but did withdraw to
pain). Suspect AMS the result of urosepsis (see below) plus
metabolic encephalopathy, as patient was severely dehydrated on
admission (clinically-apparent and reflected in hypernatremia to
159 and hyperkalemia >6 on admission).
After transfer to the general medicine floor, the patient's
mental status improved, as his blood and urine infection was
treated with ertapenum(see below) and his hypernatremia was
corrected (see below).
# SEPSIS FROM URINARY SOURCE
Pt p/w tachycardia, tachypnea, altered mental status,
leukocytosis w/left-shift, and hypotension. Blood cultures and
urine cultures drawn in the ED grew E coli, sensitive to
cefepime. He was started on cefepime on admission. Also received
continuous IVF. WBC count, HR and mental status normalized
within 48h.
The patient's antibiotics were switched from cefepime to
meropenum after discussing with ID, as his urine E. coli was
only intermediately sensitive to the cefepime. Because of the
positive blood cultures, the patient will have to continue 2
weeks of ertapenum since 1st negative blood culture.
# HYPERNATREMIA
Na 159 on admission. Patient has a 3.8L free water deficit.
Initiated IVF therapy w/D51/2NS. Sodium initially corrected very
slow due to access difficulties (limited to one 22gauge IV - CVL
placement attempt failed on HD1). Once access was obtained via
PICC on HD2, pt was given D5W and Na rapidly corrected to 143.
Fluids held overnight - Na jumped to 156. D51/2NS started on the
morning of HD3 - Na corrected steadily thereafter. Pt
transferred from the MICU to the floor when Na dropped to 150.
While on the general medicine floor, the patient's sodium
continued to trend down; he was maintained on D5 half normal
saline, with q6h lyte check. The rates of the IVF were adjusted
as needed to ensure that the patient was not being corrected too
fast. When his sodium was stable and the patient was taking
good PO intake, IVF were discontinued.
# ACUTE-ON-CHRONIC RENAL FAILURE
Patient has history of labile renal function, baseline Cr
1.1-1.3. Cr was 5.2 on admission - thought to be reflective of
severe dehydration as GFR improved rapidly with IVF (1.6 at time
of MICU-to-floor transfer). Renal consult service followed
closely and assisted with electrolyte management.
The patient's creat continued to trend down while on the general
medicine floor while getting IVF. Upon discharge, the patient's
creatinine was 0.9.
# HYPERKALEMIA
Patient was found to be profoundly hyperkalemic to 6.3 on
arrival to the [**Last Name (LF) **], [**First Name3 (LF) **] he was given 10U insulin and an amp of
D50. Renal consulted in the ED for question of dialysis; pt
admitted directly to the ICU for this possible. K quickly
corrected to <5 w/kayexelate and hydration (in addition to
insulin/D50 given in the ED). Home lasix also held in this
setting.
While on the medicine floor, the patient's potassium remained
stable.
# ANTICOAGULATION
Pt has hx multiple PEs & atrial fibrillation. On warfarin - INR
3.4 on admission. Patient was recently admitted in [**3-/2129**] for
GIB from colostomy at which time warfarin was stopped.
Anticoagulation has aparently been resumed as an outpatient & he
was again supratherapeutic on admission. Held coumadin in the
setting of supratheraputic INR.
While on the medicine floor, the patient was restarted on his
home dose coumadin, with goal INR closer to 2, given his history
of GI bleeding in the past. Upon discharge the patient's INR was
elevated, and his coumadin was held.
# HTN
Patient was on lisinopril and metoprolol for HTN at home.
Initially, the patient's lisinopril was held given ARF; his
lisinopril was ultimately held at discharge. This should be
followed up as an outpatient and if needed, it should be
restarted.
#DM2
BS reportedly well-controlled on metformin at baseline. Given
reduced renal function and lactic acidosis, held metformin.
Managed sugars w/ISS.
Transitional Issues:
- The patient was DNR/DNI during this admission; his daughter
[**Name (NI) 39711**] [**Name2 (NI) **] is his HCP and it was decided to make the patient
DNR/DNI. This issue will have to be readdressed as an
outpatient.
- The patient will have to continue Ertapenum for 2 weeks; he
had PICC placed during this admission. STOP date for Ertapenum
[**2129-5-29**].
- Please continue to encourage good PO.
- The patient's lisinopril was held at discharge; his pressures
will have to be followed as an outpatient and if needed,
restarted.
- The patient's INR was 3.0 the day of discharge; given his
history of GIB, target INR should be closer to 2.0. His dose of
coumadin was held the day of discharge; this will have to be
followed up, and INR checked on [**2129-5-21**].
Medications on Admission:
- Metformin 500 mg QAM and 250 mg QPM
- Aspirin 81 mg daily
- Lactulose 30 mL QID:PRN constipation
- Sertraline 25 mg daily
- Brimonidine 0.15 % Drops [**Hospital1 **]
- Lisinopril 20 mg daily
- Mirtazapine 15 mg QHS
- Warfarin 4 mg daily
- Acetaminophen 500 mg [**Hospital1 **]:PRN pain
- Senna 8.6 mg [**Hospital1 **]:PRN constipation
- Colace 100 mg [**Hospital1 **]
- Milk of Magnesia 400 mg/5 mL daily:PRN constipation
- Albuterol sulfate 2.5 mg /3 mL (0.083 %) Q6H:PRN wheezing
- Mucinex 600 mg PRN cough
- Metoprolol succinate 25 mg daily
- Multivitamin daily
Discharge Medications:
1. MetFORMIN (Glucophage) 500 mg PO QAM
2. MetFORMIN (Glucophage) 250 mg PO QPM
3. Aspirin 81 mg PO DAILY
4. Lactulose 30 mL PO Q6H:PRN constipation
5. Sertraline 25 mg PO DAILY
6. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
7. Mirtazapine 15 mg PO HS
8. Acetaminophen 500 mg PO BID:PRN pain
9. Senna 1 TAB PO BID:PRN constipation
10. Docusate Sodium 100 mg PO BID
11. Milk of Magnesia 30 mL PO Q6H:PRN constipation
12. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
13. Mucinex *NF* (guaiFENesin) 600 mg Oral PRN cough
14. Metoprolol Succinate XL 25 mg PO DAILY
please hold for SBP<100, HR<60
15. Multivitamins 1 TAB PO DAILY
16. Warfarin 4 mg PO DAILY16
17. ertapenem *NF* 1 gram Intravenous daily Duration: 10 Days
PLEASE STOP on [**2129-5-29**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) **]
Discharge Diagnosis:
primary diagnosis:
metabolic encephalopathy
hypernatremia
acute renal failure
E. coli septicemia
E. coli urinary tract infection
secondary diagnosis:
dementia
depression
atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Last Name (un) 39712**],
It was a pleasure taking care of you while you were hospitalized
at [**Hospital1 18**]. You were admitted to the hospital because you were
found to be lethargic and confused at your facility. We found
that you had an infection in your blood and urine, which we
treated with antibiotics. The sodium levels in your blood were
also very elevated; we think this is because you have not been
eating or drinking enough. We fixed these sodium levels by
giving you fluid through your veins. It is VERY important that
you continue to eat and drink well at the facility.
We made the following changes to your medications:
START ertapenum 1 gram through your veins daily (STOP DATE
[**2129-5-29**])
STOP Lisinopril 20 mg daily
Followup Instructions:
Please follow up with your primary care doctor within one week
of leaving the hospital.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2129-5-20**]
|
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"294.20",
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icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12817, 12900
|
6144, 10602
|
272, 293
|
13135, 13135
|
3254, 5474
|
14095, 14335
|
1981, 1999
|
12014, 12794
|
12921, 12921
|
11423, 11991
|
13311, 13938
|
5491, 6121
|
2769, 3235
|
2754, 2754
|
10623, 11397
|
13967, 14072
|
211, 234
|
321, 1191
|
13072, 13114
|
12940, 13051
|
13150, 13287
|
1213, 1434
|
1450, 1965
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,180
| 125,541
|
28921+57615
|
Discharge summary
|
report+addendum
|
Admission Date: [**2131-7-30**] Discharge Date: [**2131-8-3**]
Date of Birth: [**2063-2-25**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
off balance, vomiting
Major Surgical or Invasive Procedure:
Arterial line placement
History of Present Illness:
Pt. is a 68 year old with a history of aortic dissection s/p
arch repair and fem-fem bypass, started on coumadin [**7-19**] for
clot in the bypass, who presents with nausea/vomiting, and
feeling off balance since friday (3 days PTA), found to have a
cerebellar hemorrhage on OSH head CT.
Pt. reports that he woke up early friday morning in a sweat. He
tried to get out of bed and he felt like he was "tilting" to the
left. He had no balance on his feet, and had to hold onto
things to keep from falling. He did not have any room spinning
feeling. He had a headache in the morning that was bifrontal and
achy, which resolved by the afternoon. He spent the day in bed
because he felt too unsteady to leave. He threw up once in the
morning, and felt somewhat nauseated for the rest of the day.
The next day he still felt that his balance was off, and that he
had to hold onto the walls to walk, but he was able to get out
of bed. He still felt like he was falling to the left. Sunday
he felt about the same. Today he felt his balance was if
anything somewhat worse, and he threw up after breakfast, so he
decided to present to the hospital.
On ROS he denies (and his family concurs) any facial droop,
diplopia, blurry vision, dysarthria, word finding or
comprehension problems, dysphagia, weakness, numbness, tingling,
headache, or bowel or bladder incontinence.
At OSH Head CT was performed and showed an 18 mm midline
cerebellar hemorrhage. INR was checked and was 3.97, and he was
given Vitamin K 10 mg PO x 1. His BPS were 130s-140s there. On
their exam he had a surgical non-reactive pupil on the L,
reactive on the R, intact strength and sensation, intact FNF
bilaterally, and moderate to severe gait ataxia. He was
transferred here. Here he received Profiline x 2 vials at
14:30. He was evaluated by Neurosurgery, who felt he required no
acute neurosurgical intervention.
Past Medical History:
- aortic dissection with aortic hemiarch repair, aortic root
repair, femoral to femoral bypass, and RLE fasciotomy for
compartment syndrome
- multiple bilateral strokes (right parietal and bilateral
frontal) thought to be embolic from aortic arch repair,
initially
with some residual L facial droop and L hand weakness, now
resolved per family and pt.
- Left ear surgery for decreased hearing
- L vitreous hemorrhage, L retinal detachment s/p surgical
repair
Social History:
Pt is a retired machinist. Lives with his wife. Former [**Name2 (NI) 1818**],
quit. 3 drinks/day for years.
Family History:
No history of stroke. Father with CHF
Physical Exam:
T- 97.6 BP- 166/75 HR- 63 RR- 14 O2Sat- 99% on 2L
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive.
Speech
is fluent with normal comprehension and repetition; naming
intact. No dysarthria. Registers [**2-3**], recalls [**2-3**] in 5 minutes.
No right left confusion. No evidence of apraxia or neglect.
Cranial Nerves:
Pupil surgical, irregular, NR on L, 4 -2 on R. Visual fields are
full to confrontation. Extraocular movements intact bilaterally,
no nystagmus. Sensation intact V1- V3. Facial movement
symmetric. Hearing intact to finger rub bilaterally. Palate
elevation symmetrical. Sternocleidomastoid and trapezius normal
bilaterally. Tongue midline, movements intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
No pronator drift
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch, pinprick, vibration and
proprioception throughout. No extinction to DSS
Reflexes:
+2 and symmetric throughout.
Toes downgoing bilaterally
Coordination: finger-nose-finger normal, heel to shin normal,
RAMs clumsy bilaterally, L > R.
Gait: wide based, very unsteady, sways L and backwards
intermittently
Romberg: sways backwards, stumbles back
Discharge Exam:
Unchanged as above with continued gait ataxia.
Pertinent Results:
CTA HEAD W&W/O C & RECONS [**2131-7-30**] 9:20 PM
NON-CONTRAST HEAD CT: Again demonstrated is a round area of
increased attenuation consistent with hemorrhage which appears
to displace the fourth ventricle to the right and therefore
could be located within the cerebellar vermis. The area of
hemorrhage measures 1.6 x 1.7 cm which is stable to both prior
comparison CT's. No hydrocephalus is seen. Again demonstrated is
almost complete effacement of the fourth ventricle. No other new
areas of intracranial hemorrhage are identified. Re-demonstrated
are stable foci of hypoattenuation in the frontal lobes
bilaterally and in the right parietal lobe consistent with
chronic lacunar infarcts.
Mild mucosal thickening is seen in the right maxillary sinus and
ethmoid air cells. The mastoid air cells are well aerated.
CTA HEAD: There is no evidence of arteriovascular malformation
in the area of hemorrhage or elsewhere in the brain. No
aneurysms and no areas of stenosis are identified . The
visualized vessels are patent. Atherosclerotic calcifications
are noted in the left cavernous internal carotid artery.
IMPRESSION:
1) Stable size of hemorrhage in the posterior fossa, likely
centered within the cerebellar vermis with effacement of the
fourth ventricle. No hydrocephalus.
2) Unremarkable CTA without evidence of arteriovenous
malformation or aneurysms.
CT HEAD W/O CONTRAST [**2131-7-30**] 4:10 PM
CT HEAD WITHOUT IV CONTRAST: There is a round area of
hyperattenuation consistent with hemorrhage (series 2, image 8)
measuring 1.6 x 1.7 cm. This focal hemorrhage appears to have
the shape of the fourth ventricle but appears to displace the
fourth ventricle to the right. The hemorrhage is likely centered
within the region of the left cerebellar vermis. There is no
significant change from the exam six hours earlier, but this
area is new when compared to the previous neck CT. There is no
hydrocephalus, although the fourth ventricle appears nearly
completely effaced. No other intracranial hemorrhage is
identified. There are focal small areas of hypoattenuation
within the frontal lobes bilaterally and in the posterior right
parietal lobe at the level of the centrum semiovale, consistent
with small old infarcts.
The paranasal sinuses are well aerated.
IMPRESSION: 1.6 x 1.7 cm hemorrhage likely centered within the
region of the left cerebellar vermis, which effaces the fourth
ventricle. No significant change from the recently previous head
CT. No definite evidence of intraventricular extension or
hydrocephalus at this time.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2131-7-31**] 8:16 PM
There is minimal atelectasis at the lung bases, there are no
worrisome lung lesions. There is no pericardial or pleural
effusion. There is no significant mediastinal lymphadenopathy.
The patient is status post median sternotomy.
There are multiple calcified granulomas projected over the liver
surface which may be diaphragmatic versus hepatic parenchymal.
The spleen and adrenal glands appear unremarkable.
MUSCULOSKELETAL: Coarse trabecular pattern is seen in the
thoracic vertebral bodies and a hemangioma is seen in the mid
thoracic spine.
CTA OF THE THORACIC AORTA: The patient is status post ascending
aortic repair with ascending aortic graft visualized. The soft
tissue at the level of the aortic root including the aortic
graft measures 59.7 x 57.6 mm, previously 53.6 x 53.9 mm. The
descending thoracic aorta including the true and false lumen at
the level of the left inferior pulmonary vein measures 43.0 x
39.4 mm, previously 38.4 x 34.9 mm. The false lumen at this
level measures 35.9 x 30.5 mm, previously 35.1 x 28.7 mm.
The pseudoaneurysm below the aortic arch at the level of the
aortic root surgery measures 30.5 x 13.7 mm, previously 9.2 x
6.3 mm. The descending thoracic aorta at the level of the celiac
artery measures 34.9 x 31.2 mm, previously 31.7 x 31.6 mm.
The dissection extends from the level of the aortic arch all the
way down into the abdominal aorta, the dissection also extends
into the celiac axis which is a new finding since the prior
examination. The celiac artery fills mostly via the true lumen.
The coronary arteries arise from the normal anatomical location
and have good perfusion. The dissection extends into the left
subclavian artery and there is wide communication between the
false and true lumens at the origin of the dissection flap.
There is slight differential flow within the false lumen. There
is no pulmonary embolism.
CONCLUSION:
1. Aortic dissection from the level of the aortic root with
extension into the left subclavian artery and extension into the
descending thoracic aorta, abdominal aorta and the celiac axis.
2. Overall interval increase in the size of the soft tissue at
the aortic root/site of ascending aortic graft with increased
size of the pseudoaneurysm medial to the site of the
anastomosis.
3. The extension into the celiac artery is a new finding.
CT HEAD W/O CONTRAST [**2131-7-31**] 9:56 AM
CT HEAD W/O CONTRAST
Reason: eval for extension or hemorrhage or evidence of
hydrocephalu
[**Hospital 93**] MEDICAL CONDITION:
68 year old man with midline cerebellar hemorrhage in the
setting of coumadin use
REASON FOR THIS EXAMINATION:
eval for extension or hemorrhage or evidence of hydrocephalus
given mass effect on 4th on OSH CT
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 68-year-old man with midline cerebral hemorrhage in
the setting of Coumadin. Assess for interval change.
Comparison is made to three prior CTs, all acquired on [**7-30**], [**2130**].
CT HEAD WITHOUT CONTRAST: Again demonstrated is a rounded focus
of increased attenuation in the midline of the posterior fossa
between the cerebral hemispheres, consistent with hemorrhage.
The size is stable measuring 1.6 x 1.7 cm. Size of ventricles is
stable. No other foci of intracranial hemorrhage are seen.
Bony structures and surrounding soft tissue structures are
unremarkable. Visualized paranasal sinuses are clear.
IMPRESSION: Stable midline cerebellar hemorrhage, measuring 1.6
x 1.7 cm. No evidence of interval development of hydrocephalus.
PORTABLE ABDOMEN [**2131-8-1**] 1:17 PM
FINDINGS: There is no evidence of free intraperitoneal air.
There are no dilated small bowel loops or air-fluid levels to
suggest small-bowel obstruction. Stool and gas is seen in the
large bowel.
Increased density of kidneys are seen bilaterally, raising
question of persistent nephrogram from contrast administration
on [**7-31**], concerning for renal failure.
Calcifications are seen in the dome of the liver. The thoracic
aorta is increased in diameter, better evaluated on the recent
CT.
IMPRESSION:
1. No evidence of a bowel obstruction.
2. Persistent nephrograms bilaterally, concerning for renal
failure.
Brief Hospital Course:
Mr. [**Known lastname **] is a very pleasant 68 year old gentleman with history
of aortic dissection s/p arch repair and fem-fem bypass,
multiple embolic strokes felt to be due to the surgery, with no
residual deficits per the patient prior to this admission, also
hypertension, hyperlipidemia, who presented with 3 days of
nausea, vomiting, and gait ataxia. He was found to have an 18 mm
hemorrhage in the cerebellar vermis with some mass effect on the
4th ventricle. On exam his mental status testing was intact,
and he was without focal weakness; he was clumsy with rapid
alternating movements bilaterally (L > R), and most
significantly his gait was ataxic. The most likely etiology of
his hemorrhage is due to the recent initiation of Coumadin and
hypertension, however an underlying mass lesion could not be
ruled out. Follow up MRI should take place as detailed below.
1) Cerebellar Hemorrhage-
The patient was symptomatic for 3 days prior to presentation,
and likely had already reached the peak of edema, however there
was evidenc by CT for pressure on the 4th ventricle.
Neurosurgery was consulted on the arrival and followed him
throughout this admission. He did not require surgical
decompression or other surgical intervention. His INR was
reversed with profiline and vitamin K. Given the location in the
posterior fossa and risk of brain stem compression, he was
admitted to the Neuro-ICU for observation and started on
mannitol diuresis. Repeat head CT revealed stable size of
hemorrhage without significant mass effect. His blood pressure
was tightly managed on his home regimen in combination with a
labetalol gtt. Goal MAP < 130. He was later changed to his home
regimen alone with excellent blood pressure regulation. His
neurologic examination remained stable in combination with
stable head CT. His gait ataxia persists necessitating acute
rehab placement. Follow up MRI/MRA +/- gadolinium should take
place in a few weeks to further evaluate the site of hemorrhage
for possible underlying mass lesion. His cochlear implant and
clip for his vitreous hemorrhage will need to be cleared for
this MR examination. The order was placed in [**Last Name (LF) **], [**First Name3 (LF) **] need to
be scheduled by the patient once he is available for the study.
Call ([**Telephone/Fax (1) 6713**] for appointment.
2) Aortic dissection-
Cardiac surgery was consulted for possible widened mediastinum
by admission chest xray. CTA revealed 1cm worsening of
pseudoaneurysm at the junction of the ascending aorta with the
graft. This was considered to be an expected finding with aortic
grafts and no further intervention was warranted. He should
follow up with his cardiac surgeon Dr. [**First Name (STitle) **] in 3 months
following discharge. He was continued on Dyazide, Altace, and
Norvasc and metoprolol TID for tight BP control.
3) Femoral Bypass Graft Thrombus-
Coumadin was held on admission given hemorrhage. Vascular
surgery was consulted. The patient has an appointment to see Dr.
[**Last Name (STitle) **] (vascular surgery) at [**Hospital1 18**] in 2 weeks for further
evaluation. Dr. [**Last Name (STitle) **] would like to be contact[**Name (NI) **] for further
discussion should Dr. [**Last Name (STitle) **] feel coumadin therapy is warranted.
4) Nausea/[**Name (NI) 23788**]
Pt complained of occasional nausea/vomiting after meals. This
resolved with PRN antiemetics. He lacked any abdominal pain or
other signs of bowel ischemia. His abdominal xray was without
signs of bowel obstruction. Aggressive bowel regimen relieved
his symptoms significantly. Further evaluation may continue at
rehab should symptoms persist.
5) Renal-
Stable renal function. Urine osmolality was followed while on
Mannitol. Persistent nephrograms on abdominial xray likely
incidental finding, but could related to altered vascular
anatomy s/p aortic graft. Further follow up to take place with
vascular and cardiac surgery.
Medications on Admission:
Metoprolol 75 TID
ASA 81 mg QD
Colace
Norvasc 10 mg QD
Zocor 40 mg QD
Dyazide 37.5-25 QD
Altace 5 mg QD
Coumadin 2.5 mg QD (started [**7-19**] for clot in bypass)
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, T > 100.4.
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.
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
8. Ramipril 5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily).
9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
11. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
Blueberry [**Doctor Last Name **] Skilled Nursin Facility
Discharge Diagnosis:
Cerebellar hemorrhage
Discharge Condition:
Stable. Persistent cerebellar gait ataxia.
Discharge Instructions:
You were admitted for a cerebellar hemorrhage. This was likely
related to coumadin use. You should have an MRI as an outpatient
to evaluate this area in a few weeks.
Do not take coumadin or aspirin until you are seen by Dr. [**Last Name (STitle) **]
in vascular surgery, if Dr. [**Last Name (STitle) **] would like to start coumadin
he should confer with Dr. [**Last Name (STitle) **] (Neurology) prior to doing so.
Please continue to take all medications only as listed in this
discharge summary.
Call your doctor or 911 for chest pain, shortness of breath,
worsening dizziness, weakness, numbness, tingling or any other
concerning symptoms.
Followup Instructions:
You have a follow up appointment with Dr. [**Last Name (STitle) **] at [**Hospital1 18**]
Neurology on [**9-25**] at 1:30pm. Please obtain a referral
from your primary care doctor. Please call to update your
patient information.
You have an appointment to see your vascular surgeon [**Name6 (MD) **] [**Name8 (MD) 69775**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2131-8-21**] 9:00 in the
[**Hospital Unit Name **] on [**Hospital1 18**] [**Hospital Ward Name **] Suite 5C.
Please call for a follow up appointment to see your cardiac
surgeon Dr. [**First Name (STitle) **] regarding your aortic graft in 3 months.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Name: [**Known lastname 11861**],[**Known firstname **] Unit No: [**Numeric Identifier 11862**]
Admission Date: [**2131-7-30**] Discharge Date: [**2131-8-3**]
Date of Birth: [**2063-2-25**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 608**]
Addendum:
Mr. [**Known lastname 11863**] morning labs were noted to have creatinine elevation
to 1.5 from 1.1. Given the timing of onset this is likely
related to contrast nephropathy in the setting of studies
obtained for purposes of graft evaluation. Intravenous hydration
should be given at rehabilitation with repeat chem 7 monitoring
for normalization of renal function.
Discharge Disposition:
Extended Care
Facility:
Blueberry [**Doctor Last Name **] Skilled Nursin Facility
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 610**]
Completed by:[**2131-8-3**]
|
[
"E934.2",
"431",
"E878.2",
"996.74",
"401.9",
"272.4",
"441.2",
"V58.61",
"V12.51",
"586"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
19055, 19259
|
11601, 15537
|
337, 363
|
16816, 16861
|
4787, 4851
|
17555, 19032
|
2914, 2955
|
15751, 16643
|
9913, 9995
|
16771, 16795
|
15563, 15728
|
16885, 17532
|
2970, 3324
|
4719, 4768
|
275, 299
|
10024, 11578
|
391, 2288
|
3687, 4703
|
4860, 9876
|
3363, 3671
|
3348, 3348
|
2310, 2771
|
2787, 2898
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,243
| 113,736
|
46565+47582
|
Discharge summary
|
report+report
|
Admission Date: [**2184-8-23**] Discharge Date: [**2184-8-28**]
Service: NEUROLOGY
HISTORY OF THE PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
right-handed woman with hypertension, high cholesterol, who
had a large left MCA territory stroke. She was last known to
be in her usual state of health on [**2184-8-22**] at 4:00
p.m. On [**2184-8-23**] at 11:00 a.m. she apparently fell
and then called a family member. The family member then
found her at 1:30 p.m. to be confused with slurred speech.
She was taken to the [**Hospital6 256**]
Emergency Department. Her initial examination at
approximately 5:00 p.m. noted her to be nonfluent with a
right facial droop and a right pronator drift. MRI/MRA was
done and showed decreased flow in the left internal carotid
artery. There was a suggestion of a subacute to chronic
infarct in the right periatrial white matter.
Upon returning from MRI, at approximately 7:30 p.m., she had
the acute onset of global aphasia and left gaze preference
and right hemiplegia. A stat head CT and CTA showed absent
flow in the left internal carotid artery. Her vessel imaging
and examination findings were felt to be consistent with a
large left MCA territory acute stroke. Due to the unclear
onset of her symptoms, she was felt not to be a TPA candidate
after discussion with the family as well. She was admitted
to the Intensive Care Unit.
HOSPITAL COURSE IN THE INTENSIVE CARE UNIT: 1. NEUROLOGY:
A carotid ultrasound was suggestive of distal left ICA
occlusion. A repeat head CT on [**2184-8-24**] showed a
large acute left MCA stroke in the left frontal lobe
extending into the insula as well as the left parietal lobe
with a blurred [**Doctor Last Name 352**]-white junction. She was initially loaded
on Dilantin for concern of seizure but this was then
discontinued.
A transthoracic cardiogram was performed and showed left
ventricular systolic dysfunction consistent with coronary
artery disease. There was no visualized thrombus. She was
started on aspirin for secondary prophylaxis.
2. CARDIOVASCULAR: The patient ruled out for a myocardial
infarction based on enzymes.
3. RESPIRATORY: The patient had chest x-rays performed
which were consistent with mild pulmonary edema. She had
normal saturations on 3 liters nasal cannula.
4. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was
kept n.p.o. with IV fluids running.
5. INFECTIOUS DISEASE: The patient was started on
levofloxacin for pyuria with urine culture pending.
6. CODE STATUS: The patient was made DNR, DNI by the
family. On [**2184-8-24**], the patient was transferred to
the Neurology floor. Her examination at that time showed a
temperature of 97.2, blood pressure 120/58, pulse 61,
respiratory rate 22, oxygen saturation 97% on 3 liters.
General: She is an elderly appearing female with her eyes
closed in no apparent distress. Her neck showed no carotid
bruits. The lungs had bilateral basilar crackles. Her
cardiac examination showed a regular rate and rhythm with a
II/VI systolic murmur at the left sternal border. Her
abdomen was soft. On neurological examination, on mental
status examination, her eyes were closed. She did not open
her eyes to voice or to painful stimuli. She had no speech
production. She was not following commands. Cranial nerve
examination: There was deviation of gaze to the left but she
was able to cross the midline with doll's maneuver. The
pupils were 3 mm bilaterally and reacted to 2 mm. The left
corneal reflex is present. Right corneal reflex is absent.
There is a right facial droop. On motor examination, there
was decreased tone in the right upper and lower extremity.
There was spontaneous movement of the left upper and lower
extremity. There was extensor posturing of the right upper
extremity in response to noxious stimuli. There was triple
flexion response of the right lower extremity in response to
painful stimuli. Reflexes were 1+ and symmetric. Toes were
upgoing bilaterally.
The patient was continued on supportive care with IV fluids,
aspirin prophylaxis, respiratory monitoring, and
levofloxacin. Her urine culture returned with no growth to
date and the levofloxacin was discontinued. Her chest x-ray
showed progressive pulmonary edema and her IV fluids were
decreased.
On [**2184-8-26**], after extensive discussions with the
Neurology Team, her family decided to redirect care towards
comfort measures only. At this point in time, the next step
would have been a PEG tube placement, but the patient had
previously discussed this with the family that she would not
have wanted this invasive measure. Therefore, the patient
was placed on comfort measures only. Her nasogastric tube
was discontinued. Laboratories and chest x-rays were
discontinued. Accu-Cheks were discontinued.
Her neurologic examination showed her to be slightly more
alert with eyes open. However, she did not have any speech
production and was not following any commands. Her right
upper and lower extremity remained hemiplegic. She was seen
by the palliative care service and placed on medications as
needed for comfort, including morphine, Ativan, Scopolamine
and Tylenol. She was screened for hospice care and will
likely be transferred to hospice within the next one to two
days to continue on comfort measures.
CONDITION ON DISCHARGE: Poor.
DISCHARGE STATUS: Hospice.
DISCHARGE DIAGNOSIS: Left middle cerebral artery territory
stroke.
DISCHARGE MEDICATIONS:
1. Morphine 5 to 20 mg sublingually q. four hours p.r.n.
distress.
2. Ativan 0.5 to 1 mg sublingually q. four hours p.r.n.
agitation.
3. Scopolamine 1.5 mg patch transdermally q. 72 hours p.r.n.
secretions.
4. Tylenol 650 mg p.r. q. four hours p.r.n. fever.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 12114**]
Dictated By:[**Name8 (MD) 33494**]
MEDQUIST36
D: [**2184-8-27**] 05:31
T: [**2184-8-27**] 18:43
JOB#: [**Job Number 98869**]
Admission Date: [**2184-8-23**] Discharge Date: [**2184-8-30**]
Service: NEUROLOGY
ADDENDUM TO PREVIOSU DISCHARGE SUMMARY FROM [**2184-8-28**]: Over
this time course the patient became more alert on
examination. However, she still had no movement of the right
arm or leg. She had no speech output. She did not follow
any commands consistently. Discussion with the family were
continued and they were made aware that the patient had
became more alert on examination. However, they continued to
reiterate that the patient's wishes were not to continue with
any invasive care or if she were to have this type of event.
Therefore the patient was continued on comfort measures only.
Her intravenous fluids were discontinued prior to discharge
as the receiving facility and any receiving facility would
require more long term intravenous access. After discussion
with the family it was decided that the discomfort associated
with placing such a line outweighed any potential benefits of
the intravenous fluid. She continued to appear comfortable
and did not require any prn morphine or Ativan while she was
here. She was discharged to hospice on comfort measures only
at this time.
DISCHARGE DIAGNOSIS:
Left middle cerebral artery stroke.
DISCHARGE MEDICATIONS:
1. Morphine 5 to 20 mg sublingual q 4 hours prn distress.
2. Ativan .5 to 1 mg sublingual q 4 hours prn agitation.
3. Scopolamine 1.5 mg patch transdermally q 72 hours prn
secretions.
4. Tylenol 650 mg pr q 4 hours prn fever.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 12114**]
Dictated By:[**Name8 (MD) 100556**]
MEDQUIST36
D: [**2184-8-30**] 12:47
T: [**2184-8-30**] 13:37
JOB#: [**Job Number 100557**]
|
[
"784.3",
"433.11",
"733.00",
"272.0",
"342.91",
"416.0",
"396.3",
"V10.05",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7272, 7738
|
7212, 7249
|
5370, 5406
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,474
| 176,503
|
33332
|
Discharge summary
|
report
|
Admission Date: [**2110-2-26**] Discharge Date: [**2110-3-6**]
Date of Birth: [**2044-10-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catherization and stent placement
History of Present Illness:
This is a 65 yoM w/h/o CAD s/p BMS to LAD and LCS on [**2110-2-17**]
discharged on [**2110-2-19**] home and represents w/SOB and CP this AM.
Pt notes that he had had fatigue but was otherwise feeling well
since his discharge w/o any SOB or CP. However, this AM, after
his shower this AM, he had SOB, nausea, emesis x 2 w/gradual
onset of CP that persisted >1hour. He describes CP as substernal
w/o radiation same as the pain he had on [**2-17**] when he received
his first BMS; this is his first episode since prior
presentation. He took two [**Month/Year (2) **] w/o improvement, his daughter
called EMS and he was brought in to the ED. EMS strips showed ST
elevations in V2-V5.
.
Upon arrival, he was noted to have [**3-6**] cp and V2-V5 ST
elevations no EKG; code stemi was initiated and pt went to cath
lab where he had LAD clot lysis and a stent placed distal to his
original stent.
.
Of note, he and his daughter report that they did not pick up
his new discharge cardiac medications and the only meds he has
been taking is a baby [**Month/Year (2) **], and his psych meds.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. He denies sx of
recent depression/anxiety; no thoughts of harming himself or SI.
All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of prior chest
pain, dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope.
Past Medical History:
anxiety
depression w/prior suicide attempts including on prior admission
[**2110-2-17**]
Hx ETOH abuse-sober x 15 years
NIDDM
Cardiac Risk Factors: + Diabetes, - Dyslipidemia, - Hypertension
Social History:
Social history is significant for the positive for recent
tobacco use 1pack/day, reports that he quit on [**Month/Day/Year 2974**]. There is
a positive history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: T 98, BP 142/69, HR 56, RR 18, O2 100% on 4L
Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple unable to assess JVP lying flat.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: sheath in place, No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
Cardiac cath [**2110-2-26**]
COMMENTS:
1. Selective coronary angiography of the LMCA, LAD and LCX
revealed
totally occluded LAD at mid segment with abundant thrombus
burden
therafter. The LCX had slow flow but otehrwise was patent. The
RCA was
not engaged.
2. Limited resting hemodynamic assessment revealed systemic
arterial
hypertension (143/104 mmHg).
3. Left ventriculography was deferred.
4. Successful PCI/stent to stent thrombosis of mid LAD with a
3.0x12mm
Vision stent deployed to 15atms. The stents were postdilated to
3.25mm
at 14 atms. Excellent result with normal flow down vessel and no
residual stenosis.
TTE [**2110-2-27**]
The left atrium is moderately dilated. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. There is severe regional left ventricular
systolic dysfunction with akinesis of the mid-distal septum,
anterior wall and the entire distal one-third of the left
ventricle, as well as mild hypokinesis of the basal inferior
wall (EF 25-30%), c/w multivessel CAD. No masses or thrombi are
seen in the left ventricle. Tissue Doppler imaging suggests a
normal left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
number of aortic valve leaflets cannot be determined. There is
no aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Severe gional left ventricular systolic dysfunction,
c/w CAD.
Compared with the prior study (images reviewed) of [**2110-2-18**],
regional LV wall motion abnormalities in the distribution of the
LAD are new.
FEMORAL VASCULAR US RIGHT [**2110-3-2**] 9:27 PM
RIGHT GROIN ULTRASOUND: There is a 2.7 x 2.6 x 1.6 cm ovoid
hypoechoic structure adjacent and superficial to the right
common femoral artery, which appears to be connected to the
artery with a short neck. No definite flow is demonstrable
within the structure, although there does appear to be some
arterial flow within the neck. The common femoral arterial
waveform is normal. The common femoral venous waveform is
normal.
IMPRESSION: Findings are most suggestive of a thrombosed
pseudoaneurysm arising from the right common femoral artery.
Flow detectable only within the neck of the pseudoaneurysm.
LABS
[**2110-2-27**] 06:47AM BLOOD WBC-10.9 RBC-4.65 Hgb-14.8 Hct-42.8
MCV-91 MCH-31.8 MCHC-34.9 RDW-13.2 Plt Ct-261
[**2110-2-27**] 06:47AM BLOOD Plt Ct-261
[**2110-2-27**] 03:51PM BLOOD PT-14.4* PTT-67.0* INR(PT)-1.3*
[**2110-2-27**] 06:47AM BLOOD Glucose-197* UreaN-19 Creat-0.6 Na-142
K-4.4 Cl-104 HCO3-22 AnGap-20
[**2110-2-27**] 06:47AM BLOOD ALT-69* AST-216* LD(LDH)-902*
CK(CPK)-2179* AlkPhos-91 TotBili-1.2
[**2110-2-27**] 06:47AM BLOOD Albumin-3.7 Calcium-9.6 Phos-3.1 Mg-1.9
[**2110-2-27**] 06:47AM BLOOD TSH-1.1
LFTS
[**2110-2-27**] 06:47AM BLOOD ALT-69* AST-216* LD(LDH)-902*
CK(CPK)-2179* AlkPhos-91 TotBili-1.2
[**2110-3-1**] 05:58AM BLOOD ALT-35 AST-41* AlkPhos-74 TotBili-0.9
CARDIAC ENZYMES
[**2110-2-26**] 08:39PM BLOOD CK-MB-321* MB Indx-8.3*
[**2110-2-27**] 06:47AM BLOOD CK-MB-118* MB Indx-5.4
[**2110-2-28**] 03:41AM BLOOD CK-MB-17* MB Indx-3.6 cTropnT-3.5*
[**2110-2-26**] 08:39PM POTASSIUM-5.2*
[**2110-2-26**] 08:39PM CK(CPK)-3881*
[**2110-2-26**] 08:39PM CK-MB-321* MB INDX-8.3*
[**2110-2-26**] 08:39PM PLT COUNT-272
[**2110-3-6**] 09:30AM BLOOD WBC-7.2 RBC-4.07* Hgb-12.7* Hct-36.6*
MCV-90 MCH-31.2 MCHC-34.6 RDW-14.0 Plt Ct-222
[**2110-3-6**] 09:30AM BLOOD PT-22.0* PTT-39.1* INR(PT)-2.1*
[**2110-3-6**] 08:00AM BLOOD PT-21.1* PTT-40.7* INR(PT)-2.0*
[**2110-3-6**] 09:30AM BLOOD Glucose-214* UreaN-13 Creat-0.7 Na-140
K-4.1 Cl-105 HCO3-24 AnGap-15
[**2110-3-1**] 05:58AM BLOOD ALT-35 AST-41* AlkPhos-74 TotBili-0.9
[**2110-3-6**] 09:30AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.9
[**2110-3-4**] 07:25AM BLOOD Osmolal-292
[**2110-2-27**] 06:47AM BLOOD TSH-1.1
[**2110-3-4**] 05:56PM URINE Hours-RANDOM Creat-121 Na-25
[**2110-3-4**] 05:56PM URINE Osmolal-447
Brief Hospital Course:
This is a 65 yoM w/h/o CAD s/p BMS to LAD and LCS discharged on
[**2110-2-19**] represents after 1 week off of cardiac medications
w/STEMI now s/p stent distal to initial LAD stent for in-stent
thrombosis off [**Date Range 4532**].
# CAD/Ischemia: Patient had recent admission for placement of
BMS to LAD, LCS who represented w/STEMI after 1 week of not
taking any cardiac medications (including [**Date Range 4532**]) prior to
readmission. He had ST elevations in V2-V5 which resolved after
being taken emergently to cath lab and receiving distal stent to
LAD for in-stent thrombosis off [**Date Range 4532**]. He received integrillin
after the procedure and was optimized on regimen of [**Last Name (LF) 4532**], [**First Name3 (LF) **],
statin, ACEi, and beta blocker. Patient was CP free after the
procedure. The importance of taking [**First Name3 (LF) **] and other cardiac
medications has been reemphasized to the pt multiple times. They
deny financial or social reasons for not picking up the
medications. He has follow-up next week with Dr. [**Last Name (STitle) **]. His
BBlocker was decreased upon discharge for SBP ranging from 90s
to 120s. It should be titrated appropriately. Cath was
complicated by a pseudocyst, which thrombosed spontaneously.
Distal pulses were intact.
# Pump: EF on prior TTE 45% w/inferoapical and lateral akinesis,
he also has diastolic dysfunction noted on prior TTE. Repeat
ECHO on [**2-27**] showed worsened EF of 25-30% and global LV systolic
dysfunction. He was euvolemic and started on ACE inhibitor for
afterload reduction.
# Rhythm: Rhythm: Patient was NSR until AM of [**2-27**] when he had
acute episode of afib with RVR and hypotension to SBP 70s. He
was given IV boluses of metoprolol and started on amiodarone
bolus and gtt. EP was consulted, but intermittent afib thought
to be [**12-28**] recent ischemia and no need for amiodarone unless
recurrent episodes. Patient had question of transaminitis with
amiodarone so PO amiodarone was never started. He was titrated
up on his metoprolol and he had no additional episodes of afib
and maintained NSR with beta blocker. He was started on coumadin
5mg PO daily given high risk of thromboembolic event (both [**12-28**]
afib and severe LV dysfunction). His dose was titrated as high
as 10mg/day to get therapeutic, though his dose was decreased
upon discharge as there would be 4 days until he could get his
INR drawn. He was discharged on coumadin with followup with PCP
and lab draws for INR to follow coumadin dosing with goal INR
[**12-29**]. He has a prescription for lab draws and an appointment to
follow-up with his PCP, [**First Name4 (NamePattern1) 794**] [**Last Name (NamePattern1) 77374**], NP. Phone: [**Telephone/Fax (1) 25350**].
Fax: [**Telephone/Fax (1) 77375**].
# Orthostatic Hypotension: Pt was symptomatic on [**2110-3-4**] with
lightheadedness upon standing. His vitals showed orthostatic
hypotension. He was given a fluid bolus with improvement in
symptoms. Urine lytes FeNA consistent with prerenal. He
continued to be orthostatic by vitals through the rest of his
stay, though he was asymptomatic. He was encouraged to take PO
fluids. His BBlocker was decreased to 100mg Toprol qday upon
discharge and may need to be further titrated down.
# DM: Had been off of diabetes meds prior to admission. covered
w/SSI while in house and he was started on metformin 500mg [**Hospital1 **]
with improved control. His regimen should continue to be
titrated for blood glucose.
# Depression/anxiety: S/P recent suicide attempt. Patient was
continued on venlafaxine and clonazepam. No SI/HI and was seen
by outpatient psychiatrist in hospital.
# Prophylaxis: heparin, PPI, bowel regimen
# Code: Full
Medications on Admission:
*** unclear if patient taking these medications. These were his
discharge medications from last admission
1. Aspirin 325 mg PO daily
2. Clopidogrel 75 mg Tablet PO daily
3. Atorvastatin 80 mg Tablet PO daily
4. Venlafaxine SR 150 mg Capsule, PO daily
5. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
6. Pantoprazole 40 mg PO daily
7. Lisinopril 5 mg Tablet PO daily
Discharge Medications:
1. Outpatient Lab Work
INR check on [**2110-3-10**]. Please fax to [**First Name5 (NamePattern1) 794**] [**Last Name (NamePattern1) 77376**] at
[**Telephone/Fax (1) 77375**]. Phone: [**Telephone/Fax (1) 25350**].
2. 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*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*80 Tablet(s)* Refills:*2*
5. Venlafaxine 150 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
6. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
8. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once
Daily at 16).
Disp:*30 Tablet(s)* Refills:*2*
10. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
11. 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*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
stemi from instent thrombosis
acute on chronic systolic heart failure
.
Secondary:
anxiety
depression w/prior suicide attempts including on prior admission
[**2110-2-17**]
Hx ETOH abuse-sober x 15 years
NIDDM
Discharge Condition:
good
Discharge Instructions:
You were seen at [**Hospital1 18**] for thrombosis in your coronary stents.
It is imperative that you take all of your medications,
especially your aspirin and [**Hospital1 4532**], to avoid future
complications. All of your medications are important.
.
You have been started on a medication called coumadin. The
level of this medication is important to maintain. You will
need close follow-up for this. Please go to [**First Name5 (NamePattern1) 794**] [**Last Name (NamePattern1) 77377**]
office on Monday [**2110-3-10**] (in addition to the appointments below)
to get your blood drawn. You have a prescription for this.
.
You were also lightheaded during your stay, which improved with
fluid. You should stay hydrated by drinking plenty of fluid
daily. You should discuss this lightheadedness with your PCP as
well as further monitoring of your blood pressure, which was
occasionally low especially when standing (orthostasis).
.
Please take your medications as prescribed.
.
Please follow-up as below. You should discuss your blood
pressure, orthostatic symptoms, coumadin, and blood sugar
(titration of metformin or other diabetic medications) with
[**First Name5 (NamePattern1) 794**] [**Last Name (NamePattern1) 77376**].
.
You should call your primary care provider or return to the
emergency department if you experience chest pain, shortness of
breath, lightheadedness, loss of consciousness, lower extremity
swelling, or any other symptoms that concern you.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) 794**] [**Last Name (NamePattern1) 77376**], NP. [**Hospital 86**] Health Center. Wednesday,
[**2110-3-12**] at 1:15pm. Phone: [**Telephone/Fax (1) 25350**]
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 4023**]
Date/Time:[**2110-3-14**] 1:40
|
[
"996.72",
"428.23",
"410.71",
"414.01",
"428.0",
"250.00",
"458.29",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.20",
"88.56",
"00.40",
"00.45",
"36.06",
"00.66"
] |
icd9pcs
|
[
[
[]
]
] |
13215, 13273
|
7598, 11330
|
326, 369
|
13535, 13542
|
3492, 7575
|
15067, 15422
|
2524, 2606
|
11792, 13192
|
13294, 13514
|
11356, 11769
|
13566, 15044
|
2621, 3473
|
276, 288
|
397, 2096
|
2118, 2312
|
2328, 2508
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,636
| 145,069
|
37515
|
Discharge summary
|
report
|
Admission Date: [**2117-3-13**] Discharge Date: [**2117-4-9**]
Date of Birth: [**2049-2-20**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 5606**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
PICC placement
History of Present Illness:
68 year-old man with history of COPD (home O2, only using O2 at
night) and hepatocellular carcinoma who initially present
[**Hospital 6783**] hospital with shortness of breath and cough.
Information was gatherered from patient and OSH notes.
States symptoms began suddenly on [**3-12**] at noon. Had associated
nonproductive cough in the setting of reduced PO intake but
denied any fevers, chills, chest pain or palpitations. Of note
patient was recently admitted and treated for PNA in [**10/2116**] and
states that he has not quite the same ever since. States that he
has been in and out rehab since then, last discharged in
12/[**2116**].
On arrival to OSH, initial VS were BP 169/53 HR 88 RR 32 and
initial ABG revealed respiratory acidosis with PCO2 in 80s.
Dyspnea reportedly improved on BiPAP and bronchodilators. CXR
was suggestive of pneumonia and he was started on Vancomycin and
Ceftazidime there. He was continued on continuous nebs and
started on solumedrol 125mg IV x 1. Also received a full dose
aspirin. Given need for BiPAP, patient was to be admitted to the
ICU. However because there were no available ICU beds, patient
was tranferred to [**Hospital1 18**] for further management. VS prior to
admission were BP 105/47 HR 62 RR 24 SpO2 97% on BiPAP (FiO2
60%).
On arrival to the ICU, patient states that his breathing feels
somewhat improved however continues to have significant
difficulty with breathing. Denied orthopnea or PND.
Review of systems:
(+) Per HPI and recent sick contact with granddaughter who was
diagnosed with mono
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
- Hypertension
- Hyperlipidemia
- Diabetes complicated by neuropathy
- COPD on home O2
- Prior CVA with right-sided residual paraparesis
- Hepatocellular CA diagnosed in [**2114**] (never been treated [**2-25**]
comorbidities)
- Cirrhosis diagnosed at an outside hospital
- Depression
- Seizure Disorder
Social History:
Lives with daughter and her boyfirend at home. Wheelchair bound.
Has significant help with ADLs from grandchildren. Prior police
officer.
- Tobacco: prior use
- Alcohol: denies
- Illicits: denies
Family History:
Not significant to this admission.
Physical Exam:
Admission Physical Exam:
.
Vitals: 128/68 60 24 98% on [**10-29**] BiPAP at 50% FiO2
General: Alert, oriented, moderate respiratory distress off
BiPAP more comfortable on BiPAP, cachetic, appears older than
stated age
HEENT: Sclera anicteric, very dry MM, oropharynx clear,
prominent eyes, poor dentition
Neck: Supple, JVP not elevated, no LAD
Lungs: Prolonged expiratory phase, with inspiratory wheezing
heard prominently anteriorly, diminished breath sounds on left
base posteriorly with scattered rhonchi
CV: Difficult to discern heart sounds from loud breath sounds
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: No foley
Ext: Cool, 2+ radial and femoral pulses, no clubbing, cyanosis
or edema
DISCHARGE EXAM: EXPIRED.
Pertinent Results:
LABS:
[**2117-3-13**] 01:39AM BLOOD WBC-8.3 RBC-4.44* Hgb-13.0* Hct-40.7
MCV-92 MCH-29.3 MCHC-32.0 RDW-14.6 Plt Ct-256
[**2117-3-13**] 01:39AM BLOOD Neuts-87.1* Lymphs-8.3* Monos-3.9 Eos-0
Baso-0.6
[**2117-3-13**] 01:39AM BLOOD PT-13.9* PTT-28.9 INR(PT)-1.3*
[**2117-3-13**] 01:39AM BLOOD Glucose-302* UreaN-30* Creat-0.7 Na-140
K-5.5* Cl-99 HCO3-30 AnGap-17
[**2117-3-13**] 04:11PM BLOOD Calcium-8.8 Phos-2.0* Mg-2.2
[**2117-3-13**] 01:39AM BLOOD Albumin-3.4* Calcium-8.2* Phos-2.3*
Mg-2.2
[**2117-3-13**] 02:18AM BLOOD Lactate-1.8
[**2117-3-13**] 01:39AM BLOOD CK(CPK)-59
[**2117-3-13**] 01:39AM BLOOD CK-MB-3 cTropnT-0.04*
[**2117-3-14**] 04:10AM BLOOD proBNP-3383*
[**2117-3-18**] 03:13PM BLOOD Lactate-3.1*
[**2117-3-19**] 07:02AM BLOOD ALT-20 AST-21 CK(CPK)-10* AlkPhos-100
TotBili-0.3
[**2117-3-19**] 11:29AM BLOOD Ammonia-19
VENOUS BLOOD GAS:
[**2117-3-16**] 11:54AM BLOOD Type-[**Last Name (un) **] pO2-19* pCO2-96* pH-7.38
calTCO2-59* Base XS-24
[**2117-3-21**] 08:30PM BLOOD Type-[**Last Name (un) **] Temp-36.8 O2 Flow-5 pO2-69*
pCO2-63* pH-7.40 calTCO2-40* Base XS-10 Intubat-NOT INTUBA
Comment-NASAL [**Last Name (un) 154**]
EKG [**3-13**]:
Baseline artifact. Sinus tachycardia. Inferior and precordial ST
segment
depressions with T wave abnormalities. Since the previous
tracing of [**2115-4-11**] the rate is faster. ST-T wave abnormalities
are now more prominent.
CXR [**3-13**]:
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Mild generalized interstitial thickening, combined to
mild distention of the pulmonary vessels, likely to be caused by
a combination of COPD and fluid overload. The size of the
cardiac silhouette is at the upper range of normal. No newly
appeared focal parenchymal opacities, no larger pleural
effusions.
CXR [**3-14**]:
1. Cardiac and mediastinal contours are stable. Left subclavian
PICC line
remains in place having its tip in the mid superior vena cava.
There
continues to be a diffuse interstitial abnormality with more
focal changes at the right base which are felt to likely be
post-inflammatory. No pulmonary edema or pneumothorax. No large
pleural effusions. The lungs are somewhat hyperinflated with
flattened diaphragms, which could reflect an underlying
component of emphysema. Clinical correlation is advised.
EKG [**3-16**]:
Sinus rhythm. Since the previous tracing there is more baseline
artifact, the rate is somewhat faster. T wave abnormalities in
lead aVF are less prominent
CXR [**3-16**]:
IMPRESSION: Persistent diffuse interstitial abnormality, most
prominent in
the right lung base demonstrates interval regression from
[**2117-3-14**]. No new
focal consolidation or opacity.
ECHO:
Very suboptimal image quality. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF 70%).
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Right ventricular chamber
size and free wall motion are normal. The aortic valve is not
well seen. There is no aortic valve stenosis. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. Tricuspid regurgitation may be present but cannot be
quantified. The pulmonary artery systolic pressure could not be
determined. There is a trivial/physiologic pericardial effusion.
There is an anterior space which most likely represents a
prominent fat pad.
HEAD CT [**3-18**]:
1. No acute intracranial process.
2. Two small hypodense lesions in the left pons that may
represent old
lacunar infarcts. This is unchanged compared to study on [**5-24**], [**2114**].
3. Sulci and ventricles are mildly prominent consistent with
atrophy.
CTA CHEST [**3-19**]:
1. No evidence of pulmonary embolus.
2.Diffuse bronchial wall thickening, bronchial fluid and/or
mucus plugging involving the bilateral lower lobes, with
intralobular septal thickening and centrilobular ground-glass
nodular densities in right and left lower lobes and lingula.
Findings are suggestive of aspiration and/or superimposed
atypical infection.
3. New nodules in the right upper and superior segment of right
lower lobe
measuring 5 and 7 mm are worrisome for metastases in the setting
of
hepatocellular carcinoma. However, given a possible superimposed
infectious process, short-interval followup is recommended with
CT within three months.
4. Limited imaging of the known treated HCC within the liver.
5. Findings consistent with subacute fractures of the right
seventh and
eighth ribs.
6. Emphysema.
UPPER EXTREMITY U/S [**3-20**]:
No evidence of hematoma in the right upper extremity at the site
of swelling.
CT HEAD NONCONTRAST [**3-21**]:
1. No acute intracranial hemorrhage or fractures.
2. The ventricles and sulci are moderately enlarged, consistent
with moderate involutional changes.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
68M with a PMH significant for oxygen-dependent COPD, alcoholic
cirrhosis with untreated likely metastatic hepatocellular
carcinoma (diagnosed in [**2114**]), prior CVA with right-sided
residual hemiparesis, seizure disorder, diabetes mellitus
(complicated by neuropathy), depression, HTN, HLD who presented
with acute hypoxic respiratory failure with COPD exacerbation
and MRSA pneumonia which was complicated by altered mental
status, [**Last Name (un) **], toxic metabolic encephalopathy requiring
intubation, continuous seizure activity and hypotension
requiring pressor support. On [**4-4**] he was extubated
successfully having already been weaned off a pressors and was
transferred to the medical floor for further treatment of
delerium.
On the day of expiration, the patient was AOx0 (baseline since
transfer from the MICU) but had stable vital signs, was on room
air without respiratory distress, afebrile. He had failed a
speech and swallow the day prior and was found to be continually
aspirating. On [**4-9**] at 2pm he was observed by a nurse to be in
his usual state of health. At 3/16 at 215pm, the nurse again
went into his room and found him pale, warm and pulseless
without spontaneous respirations. The patient was not on
telemetry as the team was trying to avoid tethers as much as
possible to help clear his delerium. In addition, the patient
had no history of significant cardiac disease or arrhythmia.
The HCP had made him DNR/DNI without escalation of care prior to
transfer out of the MICU and was in the process of moving to
CMO.
He was pronounced dead at 220pm [**4-9**] from presumed respiratory
failure from mucous plugging versus fatal arrhythmia (no hx of
this during the admission). The family was notified and
declined autopsy.
Medications on Admission:
mirtazepine 15 mg hs
albuterol 0.83% nebs QID
advair 250 [**Hospital1 **]
folate 1 mg daily
ropinirole 0.25 at bedtime
alendronate 70 mg weekly
glyburide 5 mg daily
keppra 500 mg [**Hospital1 **]
gabapentin 300 mg 2 tab [**Hospital1 **]
paroxetine 20 mg daily
ASA 81 mg daily
Discharge Medications:
expired
Discharge Disposition:
Home with Service
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
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"357.2",
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"E879.8",
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"873.0",
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icd9cm
|
[
[
[]
]
] |
[
"99.15",
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"03.31",
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] |
icd9pcs
|
[
[
[]
]
] |
10601, 10620
|
8471, 10243
|
276, 293
|
10671, 10680
|
3625, 8425
|
10736, 10746
|
2758, 2794
|
10569, 10578
|
10641, 10650
|
10269, 10546
|
10704, 10713
|
2834, 3580
|
3596, 3606
|
1794, 2202
|
229, 238
|
321, 1775
|
2224, 2529
|
2545, 2742
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,637
| 196,177
|
48792
|
Discharge summary
|
report
|
Admission Date: [**2112-7-8**] Discharge Date: [**2112-7-13**]
Date of Birth: [**2039-4-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 832**]
Chief Complaint:
shortness of breath, BRBPR
Major Surgical or Invasive Procedure:
Left sided PICC placed [**7-12**]
History of Present Illness:
73M with multiple medical problems including HIV (CD4 76, VL 48
on [**5-/2112**]) on HAART, atrial fibrillation (not on coumadin),
GERD, distant history of peptic ulcer disease presents with
shortness of breath, coming BRBPR, abdominal pain. Patient has a
history of chronic abdominal pain (eval by Dr. [**Last Name (STitle) 2161**] but no
episodes of bleeding in past. Reports several episodes of bloody
bowel movements starting yesterday when went to urinate. Last
episode earlier today. Denies dizziness, syncope. Also reports
that yesterday started to feel short of breath at rest (at
baseline walks with walker with dyspnea on exertion for several
months) associated with new non-productive cough. Denies fever
but feels colder than usual. Wife says has been in bed most of
the time for past couple of days, minimal PO intake.
.
In the ED, initial vs were: 98.1 110 114/66 24 97. Triggered for
respiratory distress, breathing at 35, put on NRB. Rectal with
gross blood and clots, had large episode BRBPR. Type and cross
for 2 units. Has 2PIV, started protonix GTT with bolus. No NGT
lavage given respiratory status. Plan for CT abdomen given
abdominal pain but unable to lie flat without SOB. CXR notable
for right lower lobar consolidation. He was given vancomycin,
zosyn, and levoquin for PNA. Given insulin, calcium, dextrose
for hyperkalemia. Got 3L of fluid, lactate of 3.3 down to 2.2.
Current vitals: AFIB 113 125/87 20 99% NRB. Access: 2 18G PIV.
Past Medical History:
# HIV disease, dx [**9-15**] likely secondary to heterosexual
transmission. ATRIPLA started [**12-18**]. Self-d/c meds due to side
effects. Last CD4 count last month 76 ([**5-19**]).
# Chronic kidney disease (baseline cr 1.0)
# Atrial fibrillation - off coumadin due to GI bleed
# Prostate cancer - Diagnosed 15 yrs ago, in remission s/p
hormonal and radiation therapy
# COPD, long ex-tobacco history, severe emphysema on radiography
# 2mm LUL lung nodule detected on CT chest [**9-15**]
# GERD
# PUD, Had 'surgery' 40 yrs ago, likely a Billroth
# Anemia
# Lumbar radiculopathy, spinal stenosis
# Left shoulder rotator cuff tear with repair in [**10/2105**]
# Trichomonas
# Gout
# Hx of esophageal candidiasis
# Chronic left-sided abdominal pain, follows with GI here,
extensive negative workup as an outpatient
# Infrarenal abdominal aneurysm, measuring 3.6 cm on [**2111-12-31**]
# pulmonary nodule
Social History:
He lives with his wife in [**Location (un) 686**]. He is retired. He smokes 1
ppd (smoking since age 7). Denies alcohol or drug use. Uses a
walker recently, but using a cane before that.
Family History:
No history of lung disease, cancer or CAD.
Physical Exam:
ADMISSION EXAM:
Vitals: T: 98 103/53 107 99%4L
General: Africal American Male sitting 45 degrees in bed NAD
HEENT: Sclera anicteric, dry membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: unlabored respirations, decreaseed BS left base
CV: S1, S2 irregular rhythm, borderline fast rate
Abdomen: soft, tenderness diffusely most prominent RUQ, no
guarding
GU: foley with straw colored urine
Ext: warm, distal pulses palpable, bruising left leg above ankle
Pertinent Results:
Labs:
[**2112-7-8**] 02:00PM BLOOD WBC-13.3*# RBC-4.30* Hgb-13.4* Hct-40.9
MCV-95 MCH-31.1 MCHC-32.6 RDW-20.3* Plt Ct-204
[**2112-7-13**] 05:19AM BLOOD WBC-7.0 RBC-3.47* Hgb-11.0* Hct-33.8*
MCV-98 MCH-31.7 MCHC-32.5 RDW-19.4* Plt Ct-274
[**2112-7-13**] HCT-31.4
[**2112-7-8**] 02:00PM BLOOD Neuts-91.4* Lymphs-6.4* Monos-1.9* Eos-0
Baso-0.1
[**2112-7-8**] 02:00PM BLOOD PT-14.4* PTT-23.9 INR(PT)-1.2*
[**2112-7-8**] 02:00PM BLOOD Glucose-124* UreaN-55* Creat-3.7*#
Na-132* K-6.0* Cl-95* HCO3-18* AnGap-25*
[**2112-7-13**] 05:19AM BLOOD Glucose-85 UreaN-10 Creat-0.9 Na-137
K-3.5 Cl-107 HCO3-22 AnGap-12
[**2112-7-8**] 02:00PM BLOOD ALT-55* AST-56* AlkPhos-79 TotBili-0.7
[**2112-7-11**] 05:30AM BLOOD ALT-35 AST-49* LD(LDH)-265* AlkPhos-47
TotBili-0.8
[**2112-7-8**] 11:11PM BLOOD Calcium-8.3* Phos-4.8*# Mg-2.1
[**2112-7-13**] 05:19AM BLOOD Calcium-7.9* Phos-2.8 Mg-1.9
[**2112-7-8**] 11:11PM BLOOD Hapto-349*
[**2112-7-8**] 04:35PM URINE Blood-LG Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2112-7-8**] 04:35PM URINE RBC->50 WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-[**2-12**] TransE-0-2
[**2112-7-8**] 04:35PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.012
Imaging:
CT A/P [**2112-7-9**]:
1. No apparent etiology to abdominal pain.
2. New right pulmonary consolidation and extensive ground-glass
opacity with a background of emphysema. These findings suggest
possible pneumonia and should be correlated to clinical
presentation and followed to resolution by imaging.
3. Unchanged thickening of the left adrenal gland. This could be
correlated to serum biochemical markers if clinically indicated.
4. Unchanged abdominal aortic aneurysm.
CXR [**2112-7-8**]:
1. Large area of ground-glass, airspace opacity projecting over
the
mid-to-lower right lung, consistent with consolidation, which
could be
secondary to infectious process, hemorrhage, or infarct.
Clinical correlation advised. 2. Possible trace right pleural
effusion.
LENI LLE [**2112-7-10**]: IMPRESSION: No DVT.
[**7-12**] CHEST PORT LINE PLACEMENT: Dense stable right lower lobe
consolidation and moderate cardiomegaly. Clinical correlation
is suggested as to the cause of this dense consolidation, as
mentioned in a previous report, the differential diagnosis
includes infection, infarction or hemorrhage.
The peripherally inserted central catheter is projected over the
right atrium and should be retracted by approximately 5 cm.
Micro:
[**2112-7-9**] 4:31 am SPUTUM Source: Expectorated.
**FINAL REPORT [**2112-7-11**]**
GRAM STAIN (Final [**2112-7-9**]):
>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 POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2112-7-11**]):
SPARSE GROWTH Commensal Respiratory Flora.
ENTEROBACTER CLOACAE. SPARSE GROWTH.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
`73M with multiple medical problems including HIV (CD4 6, VL 48
on [**5-/2112**]) on HAART, atrial fibrillation (not on Coumadin),
distant history of peptic ulcer disease who presented with
hematochezia, pneumonia, acute renal failure, hyperkalemia.
#Ischemic colitis: Bright red blood per rectum with suspicion
higher that lower GI source was thought to be due to ischemic
colitis (in setting of dehydration). He had no diverticula on
prior colonoscopy. AVM was also in the differential. Also
considered in HIV immune compromised patient was lymphoma, CMV,
or histoplasmosis but these seemed less likely. He was given 2
units of blood and monitored in the ICU. GI was consulted and
the pt refused colonoscopy after speaking with both the floor
attending and GI attending. He was alert and oriented and had
decisional capacity to do so. His bleeding resolved except for a
small amount on [**7-12**] that did not require transfusion. He was
started on a H2 blocker due to PPIs interacting with his HAART
medications. Abdominal CT without contrast did not show a source
of bleeding.
.
#Pneumonia: Found to have a right lower lobe consolidation on
imaging c/w lobar pneumonia. Differential considered in HIV
patient with CD4<50 would be bacterial vs. fungal vs atypical.
He was initially treated with vanco/zosyn/levaquin. Later as pt
improved levo was stopped. Sputum cx grew ENTEROBACTER CLOACAE
sensitive to zosyn. Urine legionella was negative. Pt has a PICC
for abx, and is on day 5 of a 8 day course on discharge, last
day on [**2112-7-16**]. Will have follow up with Dr. [**First Name (STitle) **] from ID.
.
# Acute renal failure: Baseline creatinine of 1.0 with increased
creatinine to 3.7. Most likely due to pre-renal in setting of
decreased renal perfusion in setting of dehydration. ATN
considered although has been hemodynamically stable. Pt was
given aggressive IVF and cr improved to 0.9. Bactrim was
initially held and then restarted for PCP [**Name Initial (PRE) **].
.
#HYPERKALEMIA: Patient with potassium of 6, no EKG changes in
setting of acute renal failure. Resolved with IVF.
#ATRIAL FIBRILLATION: Was controlled on dilt.
.
#HIV: Viral load suppressed on HAART. Continued HAART.
.
#[**Female First Name (un) **] ESOPHAGITIS: On fluconazole for 14 day course (day 1
[**2112-7-2**]). Also on nystatin swish and swallow.
Communication: [**Name (NI) **] (wife) [**Telephone/Fax (1) 102538**]
Pt was discharged to rehab.
Medications on Admission:
-abacavir-lamivudine 600-300mg 1 tablet QHS
-albuterol 2 puff Q4PRN
-atazanavir 400mg QHS
-diltiazem 180mg daily
-fluconazole 100mg daily
-fluoxetine 40mg daily
- mirtazapine 30mg daily
- nystatin 5ml Q6hrs
- oxycodone 10mg Q4PRN
- oxycontin 30mg [**Hospital1 **]
- prochlorperazine maleate 10mg [**Hospital1 **]
- raltegravir 400mg [**Hospital1 **]
- ranitidine 150mg daily
- bactrim 800-160 daily
- tiotropium 1 capsule daily
Discharge Medications:
1. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
2. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours): Please take for 3 more
days from [**7-13**] .
3. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours): Please take for 3 more days
from [**7-13**] .
4. Diltiazem HCl 120 mg Capsule, Sust. Release 24 hr Sig: One
(1) Capsule, Sust. Release 24 hr PO DAILY (Daily): Please start
at 6PM on [**7-13**] .
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
7. Atazanavir 200 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
8. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO QHS (once a day
(at bedtime)).
9. Lamivudine 150 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
10. Raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO once a
day.
12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB.
13. Fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day.
14. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO once a day.
15. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) **]
Discharge Diagnosis:
Ischemic Colitis
Pneumonia
Acute Renal Failure
Hyperkalemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It was a pleasure to care for you as your doctor.
.
You were brought to the hospital because of a intestinal bleed
and pneumonia. We felt like your intestinal bleed was due to
dehydration which caused damage to your intestines. During your
admission your blood level remained stable and we gave you
intravenous fluids. We wanted to do a colonoscopy to possibly
see a origin of your bleeding however you declined this
procedure. For your pneumonia we gave you intravenous
antibiotics and you improved clinically. You would need to
continue these intravenous antibiotics as an outpatient.
.
We made the following changes to your home medication list:
We changed decreased your long acting diltiazem to 120 mg from
180mg which will help control your heart rate.
We added 2 intravenous antibiotics Vancomycina and Zosyn, which
you must keep taking for 3 more days after discharge.
.
Please follow up with the following outpatient appointments
below:
Followup Instructions:
Provider: [**Name10 (NameIs) **] Clinic
DATE: Monday [**7-18**] 4:30PM
Location: LMOB 8E/West
Phone Number: ([**Telephone/Fax (1) 451**]
.
Date: [**2112-7-15**] 11:30a
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 2324**] [**Name12 (NameIs) 2323**]
Telephone Number: ([**Telephone/Fax (1) 4170**]
Location: LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), BASEMENT ID WEST
(SB)
.
Department: PULMONARY FUNCTION LAB
When: FRIDAY [**2112-7-15**] at 10:10 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: PFT
When: FRIDAY [**2112-7-15**] at 10:30 AM
.
Department: MEDICAL SPECIALTIES
When: FRIDAY [**2112-7-15**] at 10:30 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"530.81",
"276.2",
"305.1",
"276.7",
"274.9",
"492.8",
"042",
"585.9",
"584.9",
"486",
"557.9",
"112.84",
"427.31",
"276.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11900, 11983
|
7554, 10000
|
340, 376
|
12087, 12087
|
3572, 7531
|
13235, 14258
|
3014, 3058
|
10479, 11877
|
12004, 12066
|
10026, 10456
|
12265, 13212
|
3073, 3553
|
274, 302
|
404, 1866
|
12102, 12241
|
1888, 2792
|
2808, 2998
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,619
| 191,726
|
40337
|
Discharge summary
|
report
|
Admission Date: [**2149-10-4**] Discharge Date: [**2149-10-10**]
Date of Birth: [**2075-2-1**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
"subjective fevers, diarrhea and dry cough."
Major Surgical or Invasive Procedure:
expired
History of Present Illness:
This is a 74 yo M with PMHx of HTN, HLD, DM-2 and MDS-RAEB-II
s/p 6 cycles of vidaza who presents with 3 days of weakness and
subjective fevers.
The patient was recently d/c from the OMED service on [**2149-9-30**]
after presenting on [**2149-9-25**] with a cc of weakness and bleeding
gums. He was found to be pancytopenic and received multiple
transfusions and was also treated with empiric antibioitcs for
neutropenic fever. A CT thorax showed multifocal parenchymal
nodular opacifications. The patient was discharged on oral
levoquin, acyclovir and fluconazole. He also p/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] with creat
peak to 1.6. There was a concern for a MDS transformation and
BMB was done in house. The final read was pending at the time
of this note but was reported to be carcinoma of unknown
primary.
THe patient reports that he was able to get out of bed with
assistance last Thursday following his discharge. He localizes
his weakness mostly to his rle on the side were he got his BMB.
He has gotten prior BMB and has not had a similar reaction. The
patient denies any known discharge from the puncture from the
BMB. The patient localized his pain to the right side of his
back and rates it as [**7-25**]. He thinks the pain has been
progressively getting worse. The patient denies UE or lle
weakness. Saturday in the AM the patient experienced subjective
fevers and they did not recurr after that. The patient had been
complaint with his antibitoics at home. Denies cough, dysuria
or other localizing signs of infection.
The patient also reports loose BM's X3. They were non-bloody
and the patient normally goes once a day. The increase in BM
started once the patient started abx. He has no accompanying
abdominal pain.
ROS is otherwise normal except per above
Past Medical History:
1) h/o MDS-RAEB II (dx 6-7 months ago) with complex and poor
risk cytogenetics s/p 6 cycles of vidaza most recently on
[**2149-9-1**]
2) HTN
3) HLD
4) DM-2
5) spinal stenosis
6) arthritis
7) gout
8) s/p right hip replacement
Social History:
-h/o smoking, quit 6 months ago, 40 py history
-occasional drinker
-married lives in [**Location 88484**]
-retired for 20 years-was a barber
Family History:
-father died of malignancy, unknown type
-sister has a h/o renal impariment-died of DM
Physical Exam:
Physical Exam on Admission
VS
T-99.3
BP-112/56
HR-93
RR-22
SaO2-100 on RA
General: AAOX3, in NAD, pleasant
HEENT: MMM, CN2-12 grossly intact, no lad or palpable thyroid
nodules
CV: RRR no rmg
Lungs: distant BS but clear to auscultation bilaterally
Abdomen: not TTP, active BS in 4 quadrants, liver and spleen not
palpable
Extremities:
UE
-5/5 strength in bue, sensation intact, pulses 2+ and equal
LE
-[**6-19**] strenght in ble, sensation intact, cool le, pulses 2+ and
equal
.
Physical Exam on Discharge
Expired
Pertinent Results:
[**2149-10-4**] 07:50PM D-DIMER-3108*
[**2149-10-4**] 07:50PM FIBRINOGE-572*
[**2149-10-4**] 06:51PM PT-18.3* PTT-27.4 INR(PT)-1.6*
[**2149-10-4**] 06:15PM URINE HOURS-RANDOM
[**2149-10-4**] 06:15PM URINE GR HOLD-HOLD
[**2149-10-4**] 06:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2149-10-4**] 06:15PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-2* PH-5.0 LEUK-NEG
[**2149-10-4**] 06:15PM URINE RBC-80* WBC-1 BACTERIA-FEW YEAST-NONE
EPI-1
[**2149-10-4**] 06:15PM URINE HYALINE-13*
[**2149-10-4**] 06:15PM URINE MUCOUS-RARE
[**2149-10-4**] 05:12PM LACTATE-2.5*
[**2149-10-4**] 05:10PM GLUCOSE-112* UREA N-36* CREAT-1.3* SODIUM-133
POTASSIUM-3.4 CHLORIDE-97 TOTAL CO2-22 ANION GAP-17
[**2149-10-4**] 05:10PM estGFR-Using this
[**2149-10-4**] 05:10PM ALT(SGPT)-19 AST(SGOT)-34 LD(LDH)-239 ALK
PHOS-88 TOT BILI-1.7*
[**2149-10-4**] 05:10PM LIPASE-14
[**2149-10-4**] 05:10PM HAPTOGLOB-96
[**2149-10-4**] 05:10PM WBC-1.1* RBC-3.21* HGB-9.9* HCT-27.6* MCV-86
MCH-30.9 MCHC-35.9* RDW-14.4
[**2149-10-4**] 05:10PM NEUTS-5* BANDS-0 LYMPHS-91* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2149-10-4**] 05:10PM I-HOS-AVAILABLE
[**2149-10-4**] 05:10PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2149-10-4**] 05:10PM PLT SMR-RARE PLT COUNT-5*#
CT thorax [**2149-9-26**]
1. Multifocal parenchymal nodular opacification as detailed
above concerning
for infection, with atypical infections such as fungal infection
not excluded.
2. Large left pleural effusion with associated atelectasis.
3. Mediastinal lymphadenopathy, likely attributed to the
patient's known
blood dyscrasia.
Brief Hospital Course:
ICU Course:
Patient was transferred to the ICU on [**10-8**] with respiratory
distress and tachycardia in the setting of known MDS and
squamous cell malignancy involving the bone marrow and overall
poor prognosis. He was intubated for hypoxic respiratory
failure. He developed a septic picture. Patient with known
C.dif colitis, so, since no other source of infection was found,
presumed to have fulminant C.dif colitis. Patient was on
Vancomycin PO, IV and PR for C.dif colitis as well as broad
spectrum antibiotics to cover essentially any infectious source.
Despite this, patient's blood pressure continued to decline.
He was started on pressors, and maxxed out on Levophed, Neo,
Vasopressin. Despite agressive treatment, he was unable to
maintain adequate blood pressures and passed away on [**10-10**].
.
This is a 74 yo M with PMHx of HTN, HLD, DM-2 and MDS-RAEB-II
s/p 6 cycles of vidaza who presents with 3 days of lethargy,
subjective fevers and diarrhea.
.
#Clostridium difficile colitis: Pt was admitted with diarrhea
and subjective fevers and fatigue following recent discharge
during which he was treated with vancomycin/cefepime for
neutropenic fevers and sent home with lovenox for CAP and
fluconazole and acyclovir for prophylaxis. On admission he was
found to be febrile with and Cdiff stool toxin assay was
positive so he was started on PO flagyl. He began to describe
pain in his throat making it difficult for him to swallow so his
antibiotics were switched to IV. He then began spiking fevers to
102 despite IV flagyl and was started on IV vanc and cefepime.
He then triggered on [**10-8**] for tachypnea, labored breathing,
tachycardia to the 130's and hypotension as low as the high 80's
systolically. He was treated with bolused fluids and his
pressures improved, he desatted to 88 on RA and was started on
O2 and began satting well but remained tachycardic and continued
to have labored respirations. He was also started on PO
vancomycin. CXR demonstrated worsening of a left pleural
effusion and ABG demonstrated mixed respiratory alkalosis and
non-gap metabolic acidosis which we assessed as a combination of
sepsis and diarrhea. We had mild concern for PE but felt he was
too unstable for CT scanner. Abdominal XR showed no free air and
was not concerning. He was transferred to the [**Hospital Unit Name 153**] overnight.
.
#RLE weakness: Pt was admitted complaining of RLE weakness but
had equivalent strength on exam but continued R hip pain which
has been a chronic issue following a hip replacement ~20 years
ago. He had a bone marrow biopsy at the right pelvis during his
recent admission and had mild tenderness at the site but no
signs or symptoms otherwise concerning for infection. XR of the
R hip was normal and our clinical suspicion wasn't high enough
to perform MRI to look for osteomyelitis. His CRP and ESR were
severely elevated but this was felt to be related to his Cdiff
colitis as above.
.
Worsening Pancytopenia: Pt with poor production from severe MDS
and new diagnosis of invasive squamous carcinoma (presumably
from lung primary but primary unknown) infiltrating his bone
marrow rendering him transfusion dependent over the past several
months. Hemolysis labs negative, reticulocyte index low, iron
studies suggestive of anemia of chronic disease. He was
transfused RBC's and platelets with the threshold of plt >10 and
Hct >21 to maintain perfusion and hemostasis. During blood
transfusion he spiked fevers likely related to his Cdiff or
other underlying infectious processes and blood transfusions
were held pending resolution of fevers. Pt also severely
neutropenic and was maintained on acyclovir and fluconazole
prophylaxis, started on IV Vanc/Cefepime as described above.
.
#[**Last Name (un) **]: Pt admitted in [**Last Name (un) **], likely prerenal from diarrheal losses
and poor PO intake which resolved with IV fluids and blood.
.
#Elevated D-dimer: Pt with elevated D-Dimer on admission,
possibly due to MDS vs. solid carcinoma activity. We also
considered possibility of DVT yet patient did not have si/sx
concerning for DVT or PE by history or exam. During his trigger
on [**10-7**] we had suspicion for possible PE but felt he was
unstable for CT imaging.
.
Hyperbilirubinemia: Likely gradual RBC breakdown. Stable and
down from prior hospitalization.
.
Medications on Admission:
atenolol 100 po qd
HCTZ 25 po qd
xalatan .005 one drop each eye qd
metformin 500 po qd
nifedipine 60 po qd ER
potassium chloride 20 po QD
simvastatin 10 po qd
asa 325 po qd
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2149-10-11**]
|
[
"199.1",
"238.75",
"250.00",
"V15.82",
"276.1",
"038.9",
"401.9",
"995.92",
"785.52",
"276.2",
"486",
"198.5",
"286.6",
"518.81",
"578.0",
"008.45",
"782.4",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.97",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
9619, 9628
|
5033, 9363
|
349, 359
|
9680, 9690
|
3273, 5010
|
9746, 9786
|
2636, 2724
|
9587, 9596
|
9649, 9659
|
9389, 9564
|
9714, 9723
|
2739, 3254
|
265, 311
|
387, 2214
|
2236, 2462
|
2478, 2620
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,340
| 152,780
|
24696+57420
|
Discharge summary
|
report+addendum
|
Admission Date: [**2121-1-7**] Discharge Date: [**2121-1-19**]
Date of Birth: [**2053-2-2**] Sex: M
Service: CSU
CHIEF COMPLAINT: Mr. [**Known lastname **] is a 67-year-old man with known
CAD as well as mitral regurgitation who is scheduled for
postoperative admission following cardiac surgery. His H and
P was done on preadmission testing.
HISTORY OF PRESENT ILLNESS: This is a 67-year-old man with
known CAD, five prior MIs and CABG x3 in the past who
presented to an outside hospital with chest pain and
congestive heart failure and was started on IV Integrilin,
nitroglycerine and Lopressor. The Integrilin was discontinued
because of epistaxis. She also had a run of ventricular
tachycardia during that ER visit. He was transferred to [**Hospital1 18**]
for cardiac catheterization and an echo and was referred to
Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] following catheterization for
evaluation of surgical candidacy.
PAST MEDICAL HISTORY:
1. Significant for CABG x3 in [**2103**] with LIMA to the LAD,
saphenous vein graft to OM, saphenous vein graft to the
PDA.
2. Ischemic cardiomyopathy.
3. Multiple percutaneous interventions.
4. Diabetes.
5. Mitral regurgitation.
6. Renal artery stenosis with stenting.
7. Right bundle branch block.
8. Glaucoma.
9. Hypertension.
10. Carotid disease.
11. Hypercholesterolemia.
12. Hernia repair.
13. Chronic renal insufficiency with a baseline of 1.6.
14. Peripheral vascular disease with bilateral popliteal
stenting.
15. Congestive heart failure.
SOCIAL HISTORY: Retired. Smoked 1 pack per day x25 years but
quit in [**2096**]. No alcohol or recreational drug use.
FAMILY HISTORY: Noncontributory.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Plavix 75 once daily.
2. Enalapril 20 b.i.d.
3. Glyburide 10 b.i.d.
4. Norvasc 10 b.i.d.
5. Lipitor 20 once daily.
6. Coreg 25 b.i.d.
7. Aspirin 81 once daily.
8. Omeprazole 20 once daily.
9. Fish oil 1 gram daily.
10. Betoptic 1 drop both eyes b.i.d.
11. Lantus 14 once daily.
12. Humalog 4 to 8 unit t.i.d.
13. Lasix 40 mg once daily.
14. Nitro patch.
His medications on transfer include:
1. IV heparin
2. Zetia 10 once daily
3. Regular insulin sliding scale.
4. Acetylcysteine 20% 600 mg b.i.d.
5. Lipitor 80 once daily..
6. Carvedilol 25 b.i.d.
7. Nitroglycerin ointment [**2-11**] inch topically q6 hours.
8. Lasix 40 once daily.
9. Plavix 75 once daily.
10. Amlodipine 10 once daily
11. Protonix 40 once daily.
12. Enalapril 20 b.i.d.
13. Aspirin 325 once daily.
14. Betoptic drops.
LABORATORY DATA: White count 6.1, hematocrit 36, platelets
121, PT 13.6, PTT 30.8, INR 1.3, sodium 142, potassium 3.8,
chloride 100, CO2 20, BUN 46, creatinine 2.3, troponin 0.56.
ALT 14, AST 21, alkaline phosphatase 77, total bilirubin 1.2,
albumin 4, amylase 55. The patient had a catheterization done
and it showed saphenous vein graft to the PDA with 95% distal
stenosis, LIMA to the LAD was patent and vein graft to the OM
as 100% occluded. Circumflex was 100% occluded. LAD 100%
occluded and RCA 100% occluded with 95% left main.
Echocardiogram showed 3+ MI with an EF of 30% to 35%,
inferior and posterior basilar akinesis and inferior and
posterolateral hypokinesis.
PHYSICAL EXAMINATION: Heart rate 62, blood pressure 136/71,
respiratory rate 18, oxygen saturations 94% on room air.
Neuro grossly intact, nonfocal examination. Cardiac regular
rate and rhythm S1 and S2 with 2 to 3 out of 6 systolic
ejection murmur. Respiratory clear to auscultation
bilaterally with a well-healed sternotomy incision. Abdomen
soft, nontender, nondistended with normal active bowel
sounds. No CVA tenderness. Extremities, right lower extremity
saphenous site from the ankle to the lower thigh is well
healed. No clubbing, cyanosis or edema. Both extremities are
warm and well perfused. Pulses - radial 2+ bilaterally.
Posterior tibial 2+ bilaterally, dorsalis pedis 1+
bilaterally. Femoral 2+ on the left. The right is covered
with a dressing.
Following much discussion it was decided that the patient
should undergo stenting of his occluded saphenous vein grafts
and then a minimally invasive mitral repair via right
thoracotomy. On [**1-7**], the patient was admitted
directly to the operating room at which time he underwent a
mitral valve repair of the right thoracotomy with No. 28 CE
annuloplasty band. Please see the OR report for full details.
In summary he had minimally invasive right thoracotomy. His
bypass time was 64 minutes with no cross clamp time. He
tolerated the operation and was transferred from the
operating room to the cardiothoracic intensive care unit.
At the time of transfer he had Neo-Synephrine 0.4 mcg per kg
per minute, epinephrine at 0.02 mcg per kg per minute,
milrinone is 0.4 mcg per kg per minute and insulin at 2 units
per hour, and propofol at 20 mcg per kg per minute. The
patient did well in the immediate postoperative period. His
anesthesia was revered and he was weaned from the ventilator
and successfully extubated. During he course of postoperative
day 1, he was weaned from his epinephrine drip, his milrinone
drip initial wean was begun and he was also slowly weaned
from his Neo-Synephrine. Additionally the patient's diuresis
was initiated.
On postoperative day 2, the patient continued to be
hemodynamically stable. His milrinone was weaned off and he
was begun on beta blockade as well as an after load reducing
[**Doctor Last Name 360**] to maintain blood pressure control. During the evening
of postoperative day 2, the patient was noted to have some
atrial fibrillation and he was begun on amiodarone infusion.
He remained hemodynamically stable on postoperative day 3,
however continued to have bursts of atrial fibrillation and
he was begun on anticoagulation at that time. The patient was
additionally seen by the electrophysiology service.
On postoperative day 6, the patient was noted to have
additional arrhythmias with several episodes of ventricular
tachycardia versus aberrantly conducted atrial fibrillation.
This was further evaluated by the electrophysiology service
and it was decided that the patient should undergo AICD
placement prior to discharge from the hospital.
During one of these episodes the patient was cardioverted to
a normal sinus rhythm. On postoperative day 7, the patient
continued to do well and he was transferred from the ICU to
floor 2 for continuing postoperative care. Over the next
several days his activity level was advanced. On
postoperative day 9 an AICD was implanted by the EP service,
dual chamber, [**Company 1543**]. On postoperative day 9 it was
decided that the patient would be stable and ready for
discharge to home on Sunday following the final dose of
vancomycin given to cover his AICD implantation.
PHYSICAL EXAMINATION: At the time of this dictation, the
patient's physical examination is as follows: Temperature 98,
heart rate 67, sinus rhythm, blood pressure 129/70,
respiratory rate 20, oxygen saturations 95% on room air.
Weight is 78 kg. Neuro, alert and oriented. Moves all
extremities and follows commands. Nonfocal examination.
Pulmonary clear to auscultation with somewhat diminished
breath sounds in the right breast. Cardiac regular rate and
rhythm. Left upper shoulder incision is clean and dry. Dry
thoracotomy incision without erythema or drainage. Abdomen
soft, nontender, nondistended with normal active bowel
sounds. Extremities warm and well perfused with no edema. The
patient's condition at the time of discharge is good.
LABORATORY DATA: White count 8.6, hematocrit 29.4, platelet
count 242, sodium 136, potassium 4.6, chloride 106, CO2 18,
BUN 45, creatinine 1.8, glucose 174.
DISCHARGE DIAGNOSES: Status post mitral valve repair with
#28 annuloplasty band. Status post AICD placement.
PAST MEDICAL HISTORY: CABG x 3, ischemic cardiomyopathy,
congestive heart failure, multiple percutaneous
interventions, diabetes mellitus, renal artery stenosis,
chronic renal insufficiency with a baseline of 1.6, right
bundle branch block, glaucoma, hypertension, carotid disease,
hypercholesterolemia, hernia repair, peripheral vascular
disease with bilateral popliteal stents.
He is to be discharged home with visiting nurses. He is to
follow up in the wound clinic in 2 weeks, follow up with Dr.
[**First Name (STitle) **] [**Last Name (Prefixes) **] in 4 weeks, follow up with Dr. [**Last Name (STitle) **],
his cardiologist in 2 to 3 weeks and follow up in the EP
device clinic on [**1-23**] at 11 a.m.
DISCHARGE MEDICATIONS: The patient's discharge medications
include:
1. Plavix 75 mg once daily.
2. Pantoprazole 40 mg once daily.
3. Zetia 10 mg once daily.
4. Glyburide 10 mg b.i.d.
5. Atorvastatin 80 mg once daily.
6. Amlodipine 10 mg q.i.d.
7. Colace 100 mg b.i.d.
8. Aspirin 81 mg once daily.
9. Betaxolol 1 drop both eyes b.i.d.
10. Glargine 14 units once daily.
11. Carvedilol 25 mg b.i.d.
12. Percocet 5/325 1 to 2 tablets q4 to 6 hours p.r.n. as
needed.
13. Lasix 40 mg once daily.
14. Enalapril 10 mg once daily.
15. Humalog. Resume preop sliding scale.
The patient is to have an INR check done by the visiting
nurses on [**1-21**] with the results called to [**Doctor First Name **] in Dr.[**Name (NI) 62306**] office who will then dose the patient's warfarin
accordingly. Additionally the patient will take warfarin on a
daily basis. Doses as determined at the time of discharge.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2121-1-17**] 17:22:12
T: [**2121-1-18**] 04:53:33
Job#: [**Job Number 62307**]
Name: [**Known lastname 11213**],[**Known firstname 389**] J Unit No: [**Numeric Identifier 11214**]
Admission Date: [**2121-1-7**] Discharge Date: [**2121-1-20**]
Date of Birth: [**2053-2-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 674**]
[**Last Name (NamePattern4) **]m:
Mr. [**Known lastname **] remained in house over the weekend to get his INR to a
therapeutic level. He was discharged on [**2121-1-20**] to his home
with a visiting nurse. He will have labs drawn by his visting
nurse (BUN, Creatinine) and the results sent to Dr.[**Name (NI) 11215**]
office. His coumadin will be managed by Dr. [**Last Name (STitle) 11216**] for a target
INR of 2.0-2.5 for atrial fibrillation. He is scheduled to see
Dr. [**Last Name (STitle) 11216**] on [**2121-1-22**] at 1:00PM. The discharge dose of coumadin
will be 3mg to be taken [**2121-1-21**] and then as instructed by Dr.
[**Last Name (STitle) 11216**]. He will follow-up with Dr. [**Last Name (Prefixes) **], his cardiologist,
the electrophysiology service and his primary care physician as
an outpatient.
Major Surgical or Invasive Procedure:
[**2121-1-7**] - MVRepair(#28 Annuloplasty band) via right thoracotomy
[**2121-1-16**] - AICD Implant ([**Company 1331**] Dual chamber Entrust D154ATG)
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 437**] VNA
[**Doctor Last Name **] [**Last Name (Prefixes) **] MD [**MD Number(1) 681**]
Completed by:[**2121-1-20**]
|
[
"427.1",
"443.9",
"250.00",
"412",
"593.9",
"V45.82",
"424.0",
"428.0",
"401.9",
"427.31",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.94",
"88.72",
"39.61",
"35.12",
"93.90",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
11106, 11300
|
10929, 11083
|
1698, 3257
|
7720, 7809
|
8545, 10891
|
6815, 7698
|
152, 365
|
394, 968
|
7832, 8521
|
1578, 1681
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,926
| 185,036
|
50261
|
Discharge summary
|
report
|
Admission Date: [**2197-5-11**] Discharge Date: [**2197-5-24**]
Date of Birth: [**2117-4-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Ace Inhibitors / Hytrin /
Verapamil
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Shortness of breath and chest pain
Major Surgical or Invasive Procedure:
[**2197-5-12**]
1. Epiaortic ultrasound
2. Mitral valve replacement with a 29-mm St. [**Male First Name (un) 923**] Epic tissue
valve model #E100-29M-00, Serial #[**Serial Number 104821**].
3. Tricuspid valve repair with an [**Doctor Last Name **] 28-mm annuloplasty
ring, model #6200, serial #[**Serial Number 104822**].
History of Present Illness:
80 year old female with severe dilated cardiomyopathy, heart
failure, and severe mitral regurgitation. She reports worsening
shortness of breath with talking and associated with chest
tightness and pressure on exertion. She reports occasional
associated palpitations, nausea, and dizziness. Most recent
echocardiogram shows moderately dilated right atrium, moderately
dilated left ventricular cavity with severely depressed LV
systolic function (LVEF 10-15%), 3+ mitral regurgitation, 2+
tricuspid regurgitation, and severe pulmonary artery systolic
hypertension with significant pulmonic regurgitation. She was
referred for right and left heart catheterization and pre-op
evaluation for cardiac surgery for a mitral valve replacement
and tricuspid valve repair. Cath results below. Admitted today
for heparin bridge with plans for MVR/TV repair in AM with Dr.
[**Last Name (STitle) **].
Past Medical History:
Mitral Regurgitation
Paroxysmal atrial fibrillation on warfarin
NSVT s/p [**Company 1543**] dual chamber ICD placement
Cardiomyopathy, EF 15-20%, with asymptomatic hypotension
Congestive heart failure
Hyperlipidemia
Hypertension
Diabetes Mellitus
GERD
Hiatal Hernia
Gait disorder
Low back pain
Lung nodule
Colonic polyps
s/p partial hysterectomy
s/p hemorrhoidectomy
Social History:
Lives with: alone with granddaughter living downstairs
Contact: [**Name (NI) **] (daughter) Phone# [**Telephone/Fax (1) 104823**]
Occupation:retired
Cigarettes: Smoked no [] yes [x] Hx:quit 35 years ago, and
smoked for 35 years
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**2-21**] drinks/week [] >8 drinks/week []
Illicit drug use: Denies
Family History:
Father with MI, mother with [**Name (NI) 10322**], sister with [**Name2 (NI) 32071**] heart
disease, daughter with diabetes and ESRD
Physical Exam:
Pulse: 75 Resp: 18 O2 sat:100% RA
B/P Right: 85/53 Left: 88/58
Height:5'5" Weight:123 lbs
General: NAD
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 2/6 systolic
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 intact [x]
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 1+ Left:1+
PT [**Name (NI) 167**]: 1+ Left:1+
Radial Right: TR band Left:2+
Carotid Bruit no bruits
Pertinent Results:
ECHO [**2197-5-12**]: Pre Bypass: The left atrium is markedly dilated.
The left atrium is elongated. No mass/thrombus is seen in the
left atrium or left atrial appendage. The right atrium is
markedly dilated. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses are normal. The left
ventricular cavity is severely dilated. There is severe global
left ventricular hypokinesis (LVEF = [**5-25**] %). The right
ventricular free wall thickness is normal. The right ventricular
cavity is markedly dilated with mild global free wall
hypokinesis. [Intrinsic right ventricular systolic function is
likely more depressed given the severity of tricuspid
regurgitation.] There are simple atheroma in the aortic root.
There are simple atheroma in the ascending aorta. There are
simple atheroma in the aortic arch. There are complex (>4mm)
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. There is mild aortic valve stenosis (valve area
1.2-1.9cm2). Plainemetry yields 1.8, calcuations yield 1.4 in
the setting of a cardiac index of 1.2-1.4.. Trace aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. There is moderate thickening of the mitral valve
chordae. Moderate to severe (3+) mitral regurgitation is seen.
The tricuspid valve leaflets are moderately thickened. Moderate
to severe [3+] tricuspid regurgitation is seen. Initial TR was
moderate at worst, but was dynamic and became 3+ when pulmonary
artery pressures increased to 60's systolic. There is IVC flow
reversal. There is a trivial/physiologic pericardial effusion.
Post bypass: Patient is a-paced in Epinepherine, Milrinone, and
Phenylepherine infusions. There is a tissue prosthetic mitral
valve in place without MR [**First Name (Titles) **] [**Last Name (Titles) 31820**] leaks. Peak gradient
[**11-28**], mean 5 mm Hg. Note is made of a presistent artifact in
the left atrium which precludes full visualization of other
structures. This could represent artifact from the valve,
suture, a probe problem, or other- discussed with surgeons and
images reviewed with surgeons prior to chest closure. TR is now
trace to mild. Peak gradient 1. LV function is slightly improved
on ionotropes to 10-15%. RV function is now moderately
hypokinetic. Aortic contours intact. Remaining exam is
unchanged. All findings discussed with surgeons at the time of
the exam.
.
Echo [**2197-5-15**]: Marked left ventricular cavity dilation with
severe global hypokinesis c/w diffuse process. Right ventricular
free wall hypokinesis. Moderate pulmonary artery hypertension.
Well seated mitral valve bioprosthesis with normal gradient.
Compared with the prior study (images reviewed) of [**2197-4-26**], the
mitral valve has been replaced with a normal functioning mitral
valve bioprosthesis and right ventricular free wall motion is
improved. The other findings are similar.
.
CXR [**2197-5-22**]: As compared to the previous radiograph, there is a
substantial
decrease of the right pleural effusion after thoracocentesis.
The remaining effusion is limited to the costophrenic sinus.
There is mild opacity at the right lung base, potentially
representing re-expansion edema. The right lung shows no
pneumothorax. Unchanged moderate cardiomegaly with retrocardiac
atelectasis.
.
[**2197-5-11**] 03:45PM BLOOD WBC-5.1 RBC-4.23 Hgb-12.0 Hct-38.0 MCV-90
MCH-28.3 MCHC-31.5 RDW-15.8* Plt Ct-221
[**2197-5-15**] 03:09AM BLOOD WBC-9.9 RBC-3.10* Hgb-9.2* Hct-28.1*
MCV-91 MCH-29.7 MCHC-32.7 RDW-15.2 Plt Ct-58*
[**2197-5-24**] 05:25AM BLOOD WBC-10.5 RBC-3.31* Hgb-9.7* Hct-31.2*
MCV-95 MCH-29.3 MCHC-31.1 RDW-15.7* Plt Ct-302
[**2197-5-11**] 03:45PM BLOOD PT-13.1* PTT-28.5 INR(PT)-1.2*
[**2197-5-24**] 05:25AM BLOOD PT-17.1* INR(PT)-1.6*
[**2197-5-11**] 03:45PM BLOOD Glucose-93 UreaN-30* Creat-1.2* Na-139
K-4.7 Cl-101 HCO3-30 AnGap-13
[**2197-5-15**] 03:09AM BLOOD Glucose-86 UreaN-17 Creat-0.9 Na-133
K-3.8 Cl-101 HCO3-24 AnGap-12
[**2197-5-24**] 05:25AM BLOOD Glucose-97 UreaN-37* Creat-1.1 Na-136
K-4.6 Cl-102 HCO3-25 AnGap-14
[**2197-5-11**] 03:45PM BLOOD ALT-22 AST-26 LD(LDH)-224 AlkPhos-41
Amylase-239* TotBili-0.6
[**2197-5-17**] 03:42AM BLOOD ALT-23 AST-39 LD(LDH)-337* AlkPhos-41
Amylase-247* TotBili-2.3*
[**2197-5-24**] 05:25AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.3
Brief Hospital Course:
Ms. [**Known lastname 104824**] was admitted to the [**Hospital1 18**] on [**2197-5-11**] for surgical
management of her mitral and tricuspid valve disease. She was
placed on heparin as a bridge to surgery and worked-up in the
usual preoperative manner. On [**2197-5-12**], she was taken to the
operating room where she underwent a mitral valve replacement
and tricuspid valve repair. Please see operative note for
details. Postoperatively she was taken to the intensive care
unit for monitoring on epinephrine and milrinone. Initial
post-op chest tube output was high and she received multiple
blood products as well as protamine. She remained
hemodynamically unstable in the initial post-op period,
requiring inotropic and vasopressor support. She remained
intubated. She had several episodes of sustained v-tach to which
her ICD fired. EP was consulted and ICD interrogated x 2. She
was started on amiodarone and lidocaine drips. Chest tubes and
pacing wires were discontinued without complication. Coumadin
was resumed for AFib. She remained in CVICU for several days
while she ultimately weaned off inotropic and vasopressor
support. The swan ganz catheter was discontinued on post
operative day 8 as the patient remained stable being v-paced.
Gentle diuresis was initiated. [**First Name8 (NamePattern2) 6**] [**Last Name (un) **] was reinstated to reduce
afterload. Physical Therapy was consulted for evaluation of her
strength and mobility. on [**2197-5-21**] a PICC line was placed for
intravenous access. On post operative day 9, the patient was
transferred down to the step down unit for further monitoring
and recovery. On post-op day 10 her Foley was removed (initially
had failure to void) and she underwent a right thoracentesis
which drained 1.3 liters. The remainder of her postoperative
course was essentially uneventful. She continued to slowly
progress and on POD 12 she was discharged to [**Hospital1 12004**] in [**Hospital1 8**]. All follow up appointments were
advised.
Medications on Admission:
ALENDRONATE 70 mg mouth once a week/Saturday
ATORVASTATIN 80 mg daily
GLIPIZIDE(Not Taking as Prescribed: Has 2.5 mg tablets at home.
Takes one tablet every morning) 5 mg Tablet - one Tablet(s) by
mouth daily
LOSARTAN (Dose adjustment - no new Rx) (Not Taking as
Prescribed: Bottle at home: 2.5 mg tablets. Pt takes one tablet
daily.) - 25 mg Tablet - one Tablet(s) by mouth once a day
METOPROLOL SUCCINATE 50 mg daily
NITROGLYCERIN Dosage uncertain
ZANTAC 150 mg [**Hospital1 **]
SOTALOL(Not Taking as Prescribed: No dosage amount on bottle at
home. Filled by Caremark) 80 mg Tablet - 1 Tablet [**Hospital1 **]
SPIRONOLACTONE (Not Taking as Prescribed: Takes 25 mg tablet.
one tablet daily. Needs clarification.) 25 mg Tablet - 0.5
Tablet daily
TORSEMIDE 20 mg daily
WARFARIN 2 mg Daily
ASPIRIN 81 mg daily
VITAMIN D3 1,000 unit daily
COD LIVER OIL Dosage uncertain
Discharge Medications:
1. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO DAILY (Daily).
6. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. alendronate 70 mg Tablet Sig: One (1) Tablet PO QSAT (every
Saturday).
8. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezes.
11. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours).
13. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Please give two 200mg tablets twice daily for 3 days.
Then one 200mg tablet twice daily for one week. Finally one
200mg tablet daily until stopped by cardiologist.
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
15. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day:
Titrate for goal INR [**2-17**] and adjust accordingly.
Discharge Disposition:
Extended Care
Facility:
tbd
Discharge Diagnosis:
Mitral Regurgitation s/p Mitral valve replacement
Tricuspid Regurgitation s/p Tricuspid valve repair
Past medical history:
Paroxysmal atrial fibrillation on warfarin
NSVT s/p [**Company 1543**] dual chamber ICD placement
Cardiomyopathy, EF 15-20%, with asymptomatic hypotension
Congestive heart failure
Hyperlipidemia
Hypertension
Diabetes Mellitus
GERD
Hiatal Hernia
Gait disorder
Low back pain
Lung nodule
Colonic polyps
Discharge Condition:
Alert and oriented x 3
Deconditioned
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Edema 1+
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
*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: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2197-6-15**]
1:00
Cardiologist: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2197-5-29**] 11:30
Please call to schedule appointments with your
Primary Care Dr. [**First Name (STitle) **],[**Last Name (un) 3895**] [**Doctor First Name 3896**] [**Telephone/Fax (1) 719**] in [**4-20**] 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:[**2197-5-24**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,770
| 151,199
|
31986+31987
|
Discharge summary
|
report+report
|
Admission Date: [**2153-2-15**] Discharge Date: [**2153-3-7**]
Date of Birth: [**2102-12-17**] Sex: F
Service: NEUROSURGERY
Allergies:
Fluconazole / Dilantin / Penicillins / Ertapenem
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
worsening nausea/vomiting/headache
Major Surgical or Invasive Procedure:
REMOVAL OF VPS
PLACEMENT OF EXTERNAL VENTRICULAR DRAIN
REMOVAL OF EXTERNAL VENTRICULAR DRAIN
History of Present Illness:
HPI: pt was recently discharged from hospital [**2-8**] after
VP shunt insertion for obstructive hydrocephalus. Two days after
D/C she developed nausea and vomiting which has been increasing
in frequency over the last 5-7 days, occurring 5-6 times
yesterday and 3-4 times today. She also has had worsening of her
baseline intermittent headaches over the last 2-3 days. She has
been complaining of [**First Name9 (NamePattern2) 5283**] [**Last Name (un) 103**] pain. No fever, no diarrhea.
Presented to [**Hospital6 3105**] where she had a repeat
NCHCT that showed new blood in ventricular system as well as
intraparenchymal blood along shunt tract. She was given 50 mg iv
Hydrocortisone due to vomiting, as well as Zofran, and she was
transferred to [**Hospital1 18**].
Past Medical History:
Pituitary adenoma s/p resection with right craniotomy [**2152-9-22**]
PE [**10/2152**] s/p IVC filter, on lovenox
Impaired vision: R eye blindness, blurry L eye
Hypertension
SIADH due to adenoma
Hyponatremia
Chronic back and hip pain
Nephrolithiasis
Impaired mental status at baseline
s/p TAH for fibroids
Social History:
Married with 3 children.
Family History:
+HTN in mother
Physical Exam:
PHYSICAL EXAM
T 97.7 HR 80 BP 165/91 RR 18 O2 sat 98%RA
HEENT: mmm, shunt palpable, no tenderness or erythema around
reservoir or around track, staples in place
Neck: supple
Cardiac: RRR, N S1 & S2, no murmur
Chest: CTAB
[**Last Name (un) **]: bowel sounds present, non-distended, mild tenderness to
palpation in [**Last Name (un) 5283**]
Extremities: no edema
NEURO:
MSE: awake, alert, and fully oriented. Speech fluent,
comprehension intact through translation via her daughter who
was
accompanying her today.
CN: R pupil 7 mm and unreactive but preexisting deficit and mild
R ptosis, L pupil 4 to 2, EOMI without nystagmus, complete
[**Last Name (un) **]
loss in the right eye without light detection, only left nasal
field vision in the L eye, facies symmetric, facial sensation is
intact to light touch bilaterally, hearing is intact to finger
rub bilaterally, tongue protrudes midline, palate elevates
midline, sternocleidomastoids and trapezii are strong.
MOTOR: nml bulk and tone, no drift, no adventitious movements,
muscle strength 5/5 throughout
REFLEXES: DTRs in [**Name2 (NI) **] 2+ and symmetric bilaterally, UEs 3+ and
symmetric, plantars downgoing bilat
SENSORY: intact to light touch, no extinction to DSS
COORDINATION: no dysmetria on finger-nose-finger
GAIT: deferred but walking independently and no ataxia according
to daughter
On Discharge:
Neuro/MS: Spanish speaking, with translation pt A/A/Ox3, pupils
left [**5-27**]/brisk right 6NR at baseline with complete [**Month/Day (3) **] loss,
EOMI face symmetric, tongue midline, MAE [**5-28**] with generalized
weakness, no pronator drift.
Pertinent Results:
NCHCT
COMPARISON: [**2153-2-7**].
FINDINGS: There is a right frontal ventriculoperitoneal shunt
coursing through the right frontal lobe with tip terminating in
the region of the foramen of [**Last Name (un) 2044**]. The overall course of this
shunt is unchanged from [**2153-2-7**]. However, there is
interval development of hemorrhage along the course of this
shunt
with associated vasogenic edema. Additionally, there is
new intraventricular hemorrhage with blood layering posteriorly
within the lateral ventricles. Again seen is a small amount of
intraparenchymal hemorrhage within the inferior bifrontal lobes,
left greater than right, similar in appearance to prior study.
The ventricular system is more prominent, suggesting an element
of hydrocephalus.
Otherwise, again seen is a suprasellar mass, with extension to
the level of the clivus, floor of the third ventricle, and
sphenoid and ethmoidal sinuses. This mass is overall unchanged.
There is no shift of normally midline structures. No acute major
vascular territorial infarction is identified.
CT HEAD W/O CONTRAST [**2153-3-4**] 6:00 AM
CT HEAD W/O CONTRAST
Reason: ? vent size, please do if possible at 5 am on [**2153-3-4**]
thank
[**Hospital 93**] MEDICAL CONDITION:
50 year old woman with
REASON FOR THIS EXAMINATION:
? vent size, please do if possible at 5 am on [**2153-3-4**] thank you
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Please reassess size of ventricles.
COMPARISON: CT study from [**2153-2-23**].
TECHNIQUE: Non-contrast head CT.
FINDINGS: Again seen is evidence of prior frontotemporal
craniotomy on the right with a right frontal burr hole. Minimal
amount of hyperdensity along the previous ventricular catheter
tract in the right frontal region remains, although
pneumocephalus has resolved. The ventricular size is unchanged
compared to previous study. Configuration of the large
suprasellar mass is unchanged. Extent of the heterogeneous
inferior left frontal lesion with surrounding edema is also
stable. A small amount of blood in the occipital [**Doctor Last Name 534**] of the
right lateral ventricle may be slightly decreased compared to
the previous study. No new areas of hemorrhage are identified.
Total opacification of the left sphenoid air cell, near total
opacification of the right sphenoid air cell, and opacification
of the posterior left ethmoid air cells are also stable
findings. Soft tissues demonstrate removal of the skin staples
and resolution of the subcutaneous emphysema.
IMPRESSION:
1. No new hemorrhage. Stable ventricular size.
2. Suprasellar and left frontal lesions, unchanged. Small amount
of blood layering in the occipital [**Doctor Last Name 534**] of the right lateral
ventricle, and a small amount of blood along the prior right
frontal ventricular catheter, stable.
MR HEAD W & W/O CONTRAST [**2153-2-27**] 8:21 PM
MR HEAD W & W/O CONTRAST
Reason: assess for brain abscess
[**Hospital 93**] MEDICAL CONDITION:
50 year old woman with pmh obstructive hydrocephalus, recent
removal of VP shunt, now with meningitis
REASON FOR THIS EXAMINATION:
assess for brain abscess
CONTRAINDICATIONS for IV CONTRAST: None.
MR HEAD
HISTORY: A 50-year-old female with sellar tumor status post
partial resection with subsequent hemorrhage recently with
hemorrhage around new ventricular shunt now with meningitis,
assess for brain abscess.
TECHNIQUE: Multiplanar multisequence MR images of the head were
obtained before and after the administration of IV gadolinium.
FINDINGS: Comparison is made to most recent head CT from
[**2153-2-23**] as well as a prior head MR from [**2153-1-8**]. Again
seen is blood within the former right frontal ventricular shunt
tract. There is minimal enhancement along the shunt tract, but
no discrete fluid collections concerning for abscesses are
identified. Surrounding T2 hyperintensity around the shunt tract
is seen consistent with edema. There is minimal pachymeningeal
enhancement underlying the right frontal craniotomy site as
before which likely represents postop change.
Tiny amount of pneumocephalus is seen. Intraventricular blood is
again seen in the occipital horns. The ventricles are dilated,
as before.
Again seen is a large homogenously enhancing mass involving the
sella, clivus, sphenoid sinus, extending into the adjacent basal
cisterns as before. The tumor is encasing the right internal
carotid artery and the MCA artery as before.
Old hematoma in the left inferior frontal lobe is again seen, as
well as surrounding T2 hyperintensity, which likely represent
gliosis.
IMPRESSION:
1. Blood and minimal enhancement along the right frontal shunt
tract with large area of surrounding vasogenic edema.
2. No peripherally enhancing fluid collections concerning for
abscesses.
3. Enlargement of the ventricles with intraventricular blood and
pneumocephalus as seen on the most recent CT scan.
4. No significant change in the large enhancing sellar mass with
invasion of the adjacent structures as described above. No
significant change in an old hematoma and surrounding gliosis of
the left inferior frontal lobe.
CHEST (PORTABLE AP)
Reason: r/o pneumonia
[**Hospital 93**] MEDICAL CONDITION:
50 year old woman with h/o IVH, s/p EVD removal, Fever 101.5
REASON FOR THIS EXAMINATION:
r/o pneumonia
AP CHEST, 10:46 A.M., [**2-23**]
HISTORY: Drain removal. Fever. Rule out pneumonia.
IMPRESSION: AP chest compared to [**2-15**]:
Heart size top normal. Lungs clear. No pleural abnormality. Mild
elevation of the left hemidiaphragm longstanding. No
pneumothorax.
LABS:
WBC 5, Hgb 12, Hct 33.1, plts 392
INR 1.1, PTT 37.4
gluc 115, BUN 13, Creat 0.8, Na 135, K 4.7, Cl 98, HCO3 28
[**2153-3-4**] 11:14AM BLOOD WBC-4.8 RBC-3.52* Hgb-11.4* Hct-31.1*
MCV-88 MCH-32.5* MCHC-36.7* RDW-13.4 Plt Ct-336
[**2153-3-4**] 04:28PM BLOOD ESR-40*
[**2153-3-7**] 04:13AM BLOOD Glucose-77 UreaN-7 Creat-0.6 Na-142 K-3.5
Cl-112* HCO3-23 AnGap-11
[**2153-3-7**] 04:13AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.7
[**2153-3-1**] 02:48PM BLOOD Osmolal-271*
[**2153-3-4**] 04:28PM BLOOD CRP-8.3*
[**2153-3-5**] 05:16AM BLOOD Vanco-20.3*
Brief Hospital Course:
This 50yo female Spanish speaking only patient admitted for
shunt removal.
Pt was previously admitted in mid [**Month (only) 404**] and underwent
laparoscopically assisted right sided VP shunt placement for
hydrocephalus. Two days later, she was seen at [**Hospital3 **] with nausea vomitting and headache and found to have a
bleed along the course of the VP shunt. She transferred to
[**Hospital1 18**] and urgently underwent shunt removal with placement of EVD
drain on [**2153-2-15**].
Due to postoperative fevers and hyponatremia, infectious disease
and endocrinology were consulted.
Perioperatively, she was covered with prophylactic cefazolin
from [**Date range (1) 74943**]; that was
continued while she had her drain in place. She had her drain
removed on [**2-22**] uneventfully, tip not sent for culture. She was
noted to have a leak from the burr hole generated in the course
of placing her EVD and had stitches placed on [**3-13**] overnight.
She developed fevers and then developed neck stiffness on [**2-25**]
and underwent LP at 12:30 AM. She was given vancomycin,
ceftriaxone and acyclovir [**2-25**] at 2 AM. Her coverage was changed
to ceftazidime, vancomycin on [**2-25**] at 6 PM. Pt's abx coverage
further changed to Vanco and Ertapenem, which will end on
[**2153-3-13**].
Additionally, since patient's first surgery for pituitary mass
patient developed panhypopit after surgery and has been on
hydrocortisone and LT4 replacement
Since admission, pt has been on stress dose of hydrocortisone
50mg IV Q8 hours. Levothyroxine was continued at home
dose(100mcg qday). She was found to have hyponatremia since
[**2-17**]: 130 and trended down to 126 despite being on IVF: NS
80cc/hr since admission. Patient placed on Sodium tablets TID
with fluid restriction to 500cc/day. Pt now eating and drinking
regularly on fluid restriction, and has balanced input and
output. Pt is feeling well. Her headache has resolved. She
denies nausea or vomiting.
Pt restarted lovenox [**2153-3-3**]
ID following patient for ESR/CRP trend.
Neurologically pt improving with improved sodium levels,
afebrile and repeat CT showing stable ventricle size, no
hydrocephalous.
Pt consulted by physical therapy and cleared for d/c home
without PT services required.
Pt discharged home on IV abx for 6 remaining days, drug levels
to be tested [**2153-3-8**] and patient instructed with Spanish
interpreter to follow up with Dr.[**Last Name (STitle) **] on [**4-3**] with CT.
Medications on Admission:
MEDs: Lasix 40 Qday
Keppra 1000 [**Hospital1 **]
KCl 20 mEq ER Qday
Ca 500 TID
Enalapril 5 [**Hospital1 **]
Levothyroxine 100 mcg Qday
Lovenox 0.7 cc (70 mg) SQ [**Hospital1 **]
Hydrocortisone 20/12.5 mg
Omeprazole 20 Qday
Percocet 5-325 1-2 tabs Q4hPRN
ALLERGIES: FLUCONAZOLE (RASH), DILANTIN (RASH), AND PENICILLINS
(RASH).
Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
2. Sodium Chloride 1 gram Tablet Sig: Two (2) Tablet PO TID (3
times a day).
Disp:*180 Tablet(s)* Refills:*2*
3. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Hydrocortisone 20 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
Disp:*30 Tablet(s)* Refills:*2*
5. Hydrocortisone 20 mg Tablet Sig: 0.5 Tablet PO QPM (once a
day (in the evening)).
Disp:*30 Tablet(s)* Refills:*2*
6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
10. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
Disp:*60 * Refills:*2*
11. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 6 days.
Disp:*24 * Refills:*0*
12. Saline flush 5-10cc
Flush 5-10cc sash and prn
13. Outpatient Lab Work
vanco trough q week
and serum sodium q weekly
14. heparin flush 100units/ml
please flush 100units/ml 3-5ml sash and prn
15. Outpatient Lab Work
crp/esr weekly
please fax to [**Telephone/Fax (1) 1419**] [**Hospital **] clinic
16. Ertapenem 1 gram Recon Soln Sig: One (1) Intravenous once a
day for 6 days.
Disp:*6 * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
INTRAVENTRICULAR HEMORRHAGE
SHUNT FAILURE
HYPONATREMIA
HYDROCEPHALUS
SIADH
PITUITARY MASS
Discharge Condition:
NEUROLOGICALLY STABLE
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY
?????? Have a family member check your incision daily for signs of
infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] IF YOU NEED TO CANCEL YOUR SCHEDULED
APPOINTMENT WITH DR.[**Last Name (STitle) **] ON [**4-3**].
PLEASE ARRIVE IN THE MORNING FOR A 10:30AM CAT SCAN WITHOUT
CONTRAST, THEN FOLLOW WITH AN 11AM APPOINTMENT WITH DR.[**Last Name (STitle) **].
Follow up with Infectious Disease doctors [**Last Name (NamePattern4) **] 2 weeks With ESR
and CRP BLOOD WORK. Call for an appointment. [**Telephone/Fax (1) **]
Follow up with endocrinology Dr. [**Last Name (STitle) **] in 2 weeks. Call for an
appointment. ([**Telephone/Fax (1) 9072**]
Provider: [**First Name11 (Name Pattern1) 312**] [**Last Name (NamePattern4) 3015**], M.D. Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2153-5-9**] 2:30
Completed by:[**2153-3-7**] Admission Date: [**2153-3-11**] Discharge Date: [**2153-3-16**]
Date of Birth: [**2102-12-17**] Sex: F
Service: MEDICINE
Allergies:
Fluconazole / Dilantin / Penicillins / Ertapenem
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
rash, facial swelling
Major Surgical or Invasive Procedure:
lip biopsy
History of Present Illness:
50 y/o female with a h/o pituitary miroadenoma s/p resection,
HTN, and panhypopituitarism who presented to the ED with oral
pain and rash. The rash start 2 days ago. She does not note oral
pain. She does feel that the rash is painful on the back and the
dorsal hands. She denies pain of the genitals. She and her
daughters state that she has not taken any herbals or any other
oral medications other than what she is precribed.
ED course:
Vitals on presentation:
T 99.5 HR 117 BP 130/69 RR 22 100%RA. She was given benadryl 50
mg IV x 1, solumedrol 125 mg IV x 1, famotidine 20 mg IV x 1,
tylenol 1 g x 1, and IVF (2L). She was seen by dermatology who
was concerned for [**Doctor Last Name **]-[**Location (un) **] syndrome. Skin biopsy was
performed in the ED. ID was also curbsided and recommended
stopping ABx (given that pt is to finish on Tuesday) and
admission to the ICU for close monitoring.
Past Medical History:
1. Pituitary microadenoma
Had symptoms for years, s/p resection in [**8-30**] at [**Hospital3 **], course c/b panhypopituitarism, SIADH, and
hypothyroidism, transferred to rehab in [**9-30**], readmitted in
[**10-30**] with alpha strep bacteremia and candidemia from PICC line,
transferred to ICU [**2-24**] to hypotension and tachycardia, required
pressors, admission c/b acute renal failure and DVT of right
arm, left leg, and PE RML and RLL, transitioned to Lovenox, and
later switched to Arixtra because of suspected heparin-induced
thrombocytopenia, also c/b vision loss
Admitted in [**1-30**] and underwent laparascopically assisted
right-sided VP shunt placement for hydrocephalus, represented to
[**Hospital3 **] 2 days later with N/V and HA, found to have a
bleed along the VP shunt, transferred to [**Hospital1 18**] and underwent
shunt revision/removal with placement of an EVD drain on
[**2153-2-15**], drain was removed on [**2153-2-22**], noted to have a leak from
the burr hole from the EVD drain placement, stiches were placed
overnight on [**2153-2-23**], developed fevers and neck stiffness
on [**2153-2-25**], LP was performed, started on vancomycin, ceftriaxone,
and acyclovir, coverage changed to ceftazidime and vancomycin,
then switched to meropenem and vancomycin, discharged on a
course of ertapenem and vancomycin due to finish on [**2153-3-13**]
2. Hypertension,
3. Chronic back/hip pain
4. Nephrolithiasis
5. Uterine cyst s/p hysterectomy
6. ESBL E.coli - treated with [**Last Name (un) 2830**]/ertapenem [**Date range (1) 74944**]
7. DVT RUE/RLE and PE s/p IVC filter on [**11-4**]
Social History:
Spanish-only speaking. Married with 3 children, lives with
husband and son.
Family History:
Mother with HTN and OA, cousin with breast CA, no h/o
coagulation disorders or anemia
Pertinent Results:
ADMISSION LABS:
CBC:
WBC-3.7* RBC-3.73* Hgb-11.2* Hct-34.0* MCV-91 MCH-30.1
MCHC-33.0# RDW-12.5 Plt Ct-269 Neuts-69.2 Lymphs-21.6 Monos-2.4
Eos-6.4* Baso-0.3
.
PT-12.3 PTT-28.9 INR(PT)-1.0
.
Glucose-95 UreaN-10 Creat-0.9 Na-139 K-3.3 Cl-106 HCO3-23
AnGap-13
Lactate-0.8
.
************MICRO***********
[**3-11**] BCx PND
***********RADIOLOGY
none yet
Pathology:
Skin, left upper outer arm; punch biopsy (A):
Interface dermatitis with prominent single cell dyskeratosis,
focal confluent epidermal necrosis and a superficial
perivascular lymphocytic infiltrate containing sparse
eosinophils (see comment).
Comment: The histologic appearances are consistent with
erythema multiforme. However, as there are areas of more
confluent epidermal necrosis correlation with the clinical
findings is necessary to exclude a more severe interface drug
reaction in evolution. Case findings discussed with Dr. [**First Name (STitle) 916**] at
~ 1700 [**2153-3-13**]. Slides reviewed with concurrence by Dr. [**Last Name (STitle) **].
[**Doctor Last Name **].
Brief Hospital Course:
Erythema Multiforme Reaction to Ertapenem) Patient presented
with diffuse dusky confluent erythematous rash and papules on
face and involvement of upper chest, back and bilateral arms
with erythematous papules and circular plaques. Upper palate
had bright red erythema and desquamative white mucosa. Due to
these findings, initially there was concern for [**First Name8 (NamePattern2) **] [**Location (un) **]
Syndrome and the patient was admitted to the ICU for monitoring
and treated with systemic steroids. After derm bx and further
evaluation, the dermatology service concluded that the patient
did not have a true [**First Name8 (NamePattern2) **] [**Location (un) **] Syndrome but instead had an
atypical erythema multiforme dermatologic reaction believed
secondary to the patient's ertapenem use.
The patient was treated with topical derm treatments and
transferred to the hospitalist service where she was stable and
discharged on daerm topical treatments with derm f/u.
Panhypopituitarism) Outpatient hydrocortisone dose.
Hypothyroid) Levothyroxine.
DVT and PE Hx) Patient discharged on outpatient lovenox.
Seizure disorder) Keppra.
HTN, benign) Enalapril dose increased for better bp control.
Medications on Admission:
Calcium 500 mg PO TID
Enalapril 5 mg PO BId
Hydrocortisone 20 mg PO QAM, 25 mg PO QPM
Levothyroxine 100 mcg PO daily
Levetiracetam 1000 mg PO BID
Pantoprazole 40 mg PO daily
Colace
Lovenox 60 mg SQ [**Hospital1 **]
Vancomycin
Ertapenem
Lasix 40 mg PO daily
K 20 meq PO daily
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Hydrocortisone 20 mg Tablet Sig: One (1) Tablet PO QAM.
4. Hydrocortisone 5 mg Tablet Sig: Five (5) Tablet PO QPM.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
6. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
9. Clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*1 tube* Refills:*6*
10. Desonide 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day) as needed.
Disp:*1 tube* Refills:*5*
11. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
Discharge Disposition:
Home
Discharge Diagnosis:
Atypical Erythema Multiforme reaction to Ertapenem
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
Return to emergency room if having worsening skin rash, fevers,
difficulty breathing, rectal or oral pain/bleeding.
Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2153-4-3**] 3:00
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 9151**], MD Phone:[**Telephone/Fax (1) 1669**]
Date/Time:[**2153-4-3**] 3:45
Provider: [**Name10 (NameIs) 6821**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2153-4-10**]
3:30
|
[
"V12.01",
"431",
"253.6",
"719.45",
"401.9",
"996.2",
"244.9",
"695.1",
"285.9",
"997.09",
"345.90",
"253.2",
"724.5",
"V12.51",
"331.4",
"338.29",
"E930.8",
"322.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.2",
"38.93",
"86.11",
"03.31",
"02.43"
] |
icd9pcs
|
[
[
[]
]
] |
23029, 23035
|
20451, 21665
|
16587, 16599
|
23130, 23151
|
19380, 19380
|
23315, 23683
|
19274, 19361
|
21991, 23006
|
8483, 8544
|
23056, 23109
|
21691, 21968
|
23175, 23292
|
1662, 3013
|
3027, 3276
|
16526, 16549
|
8573, 9397
|
16627, 17530
|
19396, 20428
|
17552, 19165
|
19181, 19258
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,437
| 131,299
|
20433
|
Discharge summary
|
report
|
Admission Date: [**2103-9-20**] Discharge Date: [**2103-11-16**]
Date of Birth: [**2056-6-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lithium / Klonopin
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
Squamous cell cancer of lung.
Major Surgical or Invasive Procedure:
Left upper lobectomy with mediastinal lymph node dissection,
[**2103-9-20**]
Placement of percutaneous tracheostomy tube, [**2103-9-24**]
Placement of percutaneous gastrostomy tube, [**2103-10-14**]
History of Present Illness:
Pt is a 47yo man with a history of Stage III squamous cell
cancer of lung. He underwent chemo/rads treatment, which was
completed in [**5-11**]. He presents for resection of his primary
tumor.
Past Medical History:
1. Stage 3 lung cancer as well as a separate Stage 1 lesion,
status post incomplete round of [**Doctor Last Name **]-Taxol and is currently
undergoing radiation therapy.
2. Interstitial nephritis secondary to Lithium toxicity. His
chronic renal failure is currently stable.
3. Hypertension.
4. History of seizures on Clozaril.
5. Question of hypothyroidism.
6. Head injury in [**2077**] with a loss of consciousness.
Past psychiatric history:
The patient has had multiple past inpatient admissions beginning
during his senior year of high school. His last hospitalization
was at [**Hospital1 **] 4 prior to being transferred to the medical
service for hypotension. Outside records indicate that prior to
that the most recent hospitalization was at the [**Hospital3 13347**] for one and a half months from [**Month (only) 404**] to [**Month (only) 958**] of this
year. He has one past suicide attempt by wrist cutting in [**2065**]
and said that this was because his father died. Outside records
indicate that he also had a suicide attempt by jumping off a
bridge in the remote past (?[**2077**]). He has been on a variety of
antipsychotic and mood-stabilizing agents in the past and has
had at least two sessions of electroconvulsive therapy. He did
extremely well on Clozaril between [**2099**] and [**2102-5-7**] until
it had to be stopped because of seizures.
Substance Abuse history:
Records indicate that pt has a history of drug abuse including
heroin but pt has refused to talk about it further. Pt has a
tobacco history and reports that prior to admission he smoked
one to four cigarettes per day.
Social History:
He has mother and brother who live together with whom he has
close contacts. The patient reports that his father died of a
amyotrophic lateral sclerosis in [**2065**]. Currently he is
unemployed. He did complete some college, his closest supports
are his family and staff members at his group home. Please also
see Dr.[**Name (NI) 54684**] discharge summary of [**2103-5-31**] for more
information. Difficult to elicit specific smoking or alcohol
history
Family History:
Maternal grandfather with alcohol abuse, he denies a family
history of mental illness or suicide. Family history otherwise
non-contrbutory.
Physical Exam:
Physical exam on admission:
VS: 97.7 77 155/92 97%RA
CV: RRR
Pulm: decreased BS on L, otherwise clear
Abd: Soft, non-tender
Ext: WArm, well-perfused.
Pertinent Results:
MRSA positive on [**2103-10-31**]
Brief Hospital Course:
Pt had very long, complicated hospital course. Admitted on
[**2103-9-20**] for left upper lobectomy and mediastinal lymph node
dissection. Tolerated procedure well. Admitted to SICU post-op
for close respiratory monitoring, and close follow of
electrolytes secondary to chronic renal insufficiency from
lithium toxicity.
Neuro: Sedated and ventilated for much of SICU course. As pt was
extubated and gradually weaned off sedation, his psych
comorbidities emerged as a greater problem, and he eventually
needed a 1:1 sitter for behavioral safety. With the assistance
of the psychiatry service, pt was eventually returned to his
home regimen of psychiatric medications with appropriate
behavior and responses.
Resp: Tracheostomy placed [**9-24**] in anticipation of long-term
ventilation, with eventual decannulation as longer-term plan. Pt
frequently had thick, heavy secretions requiring bronchoscopic
cleanout several times. Eventually pt was better able to handle
his own secretions and could maintain near-normal saturations
with only intermittent suctioning by nursing staff.
FEN/GI: Nutritionally maintained through dobhoff feeds with
Promote feed. Eventually a PEG tube was placed as it was
anticipated pt would have poor swallow status, and would need
nutrition to recover appropriately from surgery. Due to his CRI,
his creatinine was closely monitored, and near the end of his
hospital stay he was changed to Nepro formula (from Promote) as
his K and Cr continued to rise. Pt at goal calories. Pt failed 2
video swallow evals, although on the second he showed
considerable improvement. It is likely that, as his mental
status continues to improve, his ability to coordinate swallow
instructions from therapists will further improve his swallow.
ID: Pt found to be MRSA positive by swab culture on [**10-31**], and
maintained on appropriate precautions. Treated with Zosyn on
course suggested by ID.
Medications on Admission:
Seroquel 200mg [**Hospital1 **]
Levoxyl
Labetolol
Verapamil
Protonix
Discharge Medications:
1. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO QD
().
2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-8**]
Puffs Inhalation Q6H (every 6 hours) as needed.
4. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) capsule PO
BID (2 times a day).
5. Valproate Sodium 250 mg/5 mL Syrup Sig: Fifteen (15) ml PO
Q12H (every 12 hours).
6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
7. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed
for constipation.
10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
11. Quetiapine Fumarate 25 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day) as needed for anxiety,insomnia.
12. Perphenazine 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
13. Quetiapine Fumarate 200 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
14. Quetiapine Fumarate 100 mg Tablet Sig: One (1) Tablet PO QAM
(once a day (in the morning)).
15. Methadone HCl 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day): Change to 2.5mg qd for 3 days, then d/c.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Squamous cell cancer of lung, Stage III
Hypertension
Schizophrenia
Pneumonia
Chronic Renal Insufficiency
Seizure disorder NOS
Discharge Condition:
Stable.
Discharge Instructions:
Pt will require physical therapy for ambulation.
Pt will require pulmonary toilet and respiratory rehabilitation,
with eventual decannulation of tracheostomy site.
Pt will require ongoing therapy for speech and swallowing, with
eventual return to po intake.
Followup Instructions:
Please see Dr [**Last Name (STitle) 952**] in clinic in 3 weeks. Please call to
schedule that appointment.
|
[
"593.9",
"482.83",
"E915",
"510.9",
"518.0",
"295.90",
"E879.8",
"458.9",
"581.9",
"V15.81",
"162.8",
"V15.82",
"780.39",
"507.0",
"304.03",
"934.1",
"041.19",
"427.31",
"519.02",
"401.9",
"518.81",
"E939.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"40.3",
"31.1",
"99.10",
"33.23",
"96.04",
"34.04",
"96.72",
"33.21",
"83.82",
"43.11",
"97.23",
"32.4",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6775, 6830
|
3255, 5169
|
324, 525
|
6999, 7008
|
3197, 3232
|
7314, 7424
|
2868, 3009
|
5288, 6752
|
6851, 6978
|
5195, 5265
|
7032, 7291
|
3024, 3038
|
255, 286
|
553, 747
|
3052, 3178
|
769, 2380
|
2396, 2852
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,446
| 177,694
|
45881
|
Discharge summary
|
report
|
Admission Date: [**2206-5-14**] Discharge Date: [**2206-6-6**]
Date of Birth: [**2146-4-3**] Sex: F
Service: MEDICINE
Allergies:
Iodine; Iodine Containing / Lisinopril
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
Dyspnea, hypotension
Major Surgical or Invasive Procedure:
1) Bronchoscopy
2) Transfusion with packed red blood cells
3) Intubation/extubation
4) Central Line placement (L and R)
History of Present Illness:
Ms. [**Known lastname 97713**] is a 60 year old female with past medical
history of CAD status-post CABG, status-post AVR and MVR, and
COPD who presented with dyspnea. History is obtained from ED
sign-out and chart review, per discussion much is from the
daughter.
.
Per report, she has had worsening dyspnea for about one week,
along with dizziness. Reportedly she has not been taking her
medications, and her daughter has found them hidden around the
house. The night before admission, she was more short of breath,
and either coughed or vomited up a small amount of blood. This
morning, she attempted to walk to the bathroom and fell twice,
at which point EMS was called.
.
Upon arrival to the BIMDC ED, her initial vitals were a
temperature of 101, blood pressure of 129/78, heart rate of 136,
respiratory rate of 32, and oxygen saturation of 92% on
non-rebreather. Due to respiratory distress and respiratory rate
of 40, she was intubated with etomade and succ. Prior to
intubation, systolic blood pressure recorded as 160-170.
Post-intubation, on propofol, systolic blood pressure dropped to
70-80. She received 300 cc of IVF with improved to 80's, however
at that point a right IJ central line was placed and neo was
started peripherally. Levophed was initiated after central line
placement.
.
While in the ED, she also received 1 gram of ceftriaxone, 500 mg
of azithromycin, 650 mg of acetaminophen, and 10 mg of IV
decadron.
.
Cardiology was consulted regarding elevated troponin, and given
the bloody ETT secretions, it was recommended that heparin drip
be held for now.
.
Upon arrival to the ICU, she is intubated and sedated,
occasional moving.
Past Medical History:
- CAD s/p CABG '[**95**] and stents in [**2199**].
[**2195**]: non-Q MI s/p CABG in [**2195**] (by Dr. [**Last Name (STitle) 1537**]. LIMA>>LAD,
SVG>>PDA and OM1. [**9-1**] Cardiac cath: 2VD
- Aortic valve replacement in [**2195**]; Mitral valve
ring-annuloplasty [**2204**]
- Diastolic CHF, EF 55%, followed by Dr. [**First Name (STitle) 437**] and [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **].
- HTN
- Hyperlipidemia
- Hypothyroidism [**12-31**] iodine treatment for [**Doctor Last Name 933**] disease- [**2180**]
- Depression with psychosis, bipolar disorder
- Discoid lupus
- PTSD
- H/o carcinoid s/p resection in [**2173**]
- COPD, prior admissions for acute exacerbations [[**8-1**] PFTs FEV1
51%pred, FVC 51%pred, DSB(Hb) 56%pred]
- TAH bilateral SBO
- Hemolytic anemia secondary to AVR
- Migraine
- T9-T10 disk herniation
- Temporal arteritis, followed by Dr. [**Last Name (STitle) **]
- Obstructive sleep apnea, not on CPAP
- Chronic renal disease, baseline creatinine 1.3-1.4
# Coronary artery disease, sp CABG and AVR, with MV
annuloplasty, [**2204**], also s/o cath [**2199**] with multiple stents.
# Diastolic CHF, EF [**2204**] 55%
# Hypertension
# Hyperlipidemia
# Hypothyroidism secondary to RAI for [**Doctor Last Name 933**] Disease
# Depression with psychosis/ bipolar disorder
# Discoid Lupus
# PTSD
# Carcinoid s/p resection in [**2173**]
# COPD w/ admissions for acute exacerbations ([**8-1**] PFTs FEV1
51%pred, FVC 51%pred, DSB(Hb) 56%pred)
# s/p TAH and b/l BOS
# Hemolytic Anemia
# Migraine
# T9/T10 Disc Herniation
# Right hip arthritis
# obstructive sleep apnea (not on CPAP)
Social History:
Per notes, smokes a pack per day, no alcohol or ilicit drug use.
Significant social stressors, including possible pending
eviction. On disability.
Family History:
Per prior notes:
Mother with MI. Hypertension, migraines, breast cancer in other
relatives.
Sister with MI, "enlarged heart" at 42, fatal.
Father still alive at 90.
Physical Exam:
Temperature 101, Heart rate 99, Blood pressure 114/66
Ventilator settings: AC, TV 450, RR 14, FiO2 100%
General: Sedated, though awakens intermittently and responds to
commands
HEENT: NC/AT, MMM, clear oropharynx with ETT and OG in place. No
scleral icterus or pallor.
Neck: Supple, no thyroid tissue palpable. Right IJ in place,
appears c/d/i. Very difficult to assess JVP, but appears
slightly elevated.
Lungs: Diffuse rhonchi, left greater than right,
Cardiac: Regular, tachycardic, possible soft systolic murmur, no
clear rubs or gallops
Abd: Soft, no clear tenderness, +BS but soft
GU: Foley in place with dark amber urine
Extr: Trace bilateral peripheral edema bilaterally to ankles,
cool hands, feet warmer, though still cool. No clubbing or
cyanosis.
Neuro: Awake intermittently, appropriately following commands.
PERRL
Psych: Unable to fully assess
Physical Exam on Discharge:
Lungs: CTAB
MSK: [**3-3**] muscle strength throughout, still weak
GU: No foley or rectal tube in place
Neuro: A&Ox3, responds appropriately, back to baseline
Pertinent Results:
[**2206-5-14**] 10:00AM PT-13.3 PTT-28.0 INR(PT)-1.1
[**2206-5-14**] 10:00AM PLT COUNT-173
[**2206-5-14**] 10:00AM NEUTS-91.0* LYMPHS-5.2* MONOS-3.1 EOS-0.6
BASOS-0.2
[**2206-5-14**] 10:00AM WBC-12.9* RBC-4.06* HGB-11.5* HCT-35.9*
MCV-89 MCH-28.3 MCHC-31.9 RDW-19.0*
[**2206-5-14**] 10:00AM CORTISOL-86.7*
[**2206-5-14**] 10:00AM CK-MB-19* MB INDX-0.2
[**2206-5-14**] 10:00AM cTropnT-0.34*
[**2206-5-14**] 10:00AM CK(CPK)-[**Numeric Identifier 97722**]*
[**2206-5-14**] 10:00AM estGFR-Using this
[**2206-5-14**] 10:00AM GLUCOSE-197* UREA N-18 CREAT-1.7* SODIUM-136
POTASSIUM-2.5* CHLORIDE-96 TOTAL CO2-24 ANION GAP-19
[**2206-5-14**] 11:02AM URINE EOS-NEGATIVE
[**2206-5-14**] 11:02AM URINE MUCOUS-FEW
[**2206-5-14**] 11:02AM URINE GRANULAR-0-2 HYALINE-0-2 WBCCAST-<1
[**2206-5-14**] 11:02AM URINE RBC-[**1-31**]* WBC-[**1-31**] BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2206-5-14**] 11:02AM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2206-5-14**] 11:02AM URINE COLOR-[**Location (un) **] APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2206-5-14**] 11:02AM URINE GR HOLD-HOLD
[**2206-5-14**] 11:02AM URINE HOURS-RANDOM
Labs at Discharge:
[**2206-6-6**] 06:31AM BLOOD WBC-7.9 RBC-3.13* Hgb-9.4* Hct-28.9*
MCV-92 MCH-30.0 MCHC-32.5 RDW-23.0* Plt Ct-240
[**2206-6-6**] 06:31AM BLOOD PT-35.7* PTT-33.5 INR(PT)-3.7*
[**2206-6-6**] 06:31AM BLOOD Glucose-91 UreaN-22* Creat-1.2* Na-139
K-3.9 Cl-104 HCO3-28 AnGap-11
[**2206-6-4**] 06:27AM BLOOD ALT-61* AST-72* LD(LDH)-423* CK(CPK)-56
AlkPhos-111* TotBili-0.6
[**2206-6-6**] 06:31AM BLOOD Calcium-8.3* Phos-2.5* Mg-2.2
Cardiac Enzymes:
[**2206-6-3**] 11:17PM BLOOD CK-MB-5 cTropnT-0.30*
[**2206-6-4**] 06:27AM BLOOD CK-MB-5 cTropnT-0.39*
[**2206-6-4**] 04:10PM BLOOD CK-MB-8 cTropnT-0.29*
Imaging:
[**6-5**] CXR- IMPRESSION: Minimal decrease in left upper lobe
pneumonia from the most recent study but considerable
improvement since [**2206-4-29**]; small left pleural effusion.
Echo [**5-17**] The left atrium is mildly dilated. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
normal (LVEF>55%). Diastolic function could not be assessed. The
right ventricular cavity is dilated with depressed free wall
contractility. There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. A
mechanical aortic valve prosthesis is present. The aortic valve
prosthesis leaflets appear to move normally. The transaortic
gradient is normal for this prosthesis. The mitral valve
leaflets are mildly thickened. A mitral valve annuloplasty ring
is present. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion. Compared with the prior study (images
reviewed) of [**2206-5-14**], the findings are similar.
Brief Hospital Course:
Ms. [**Known lastname 97713**] is a 60 year old female with complicated past
medical history including coronary artery disease, status-post
aortic and mitral valve replacement, COPD, temporal arteritis,
and chronic renal insufficiency who presented with hypoxemic
respiratory failure and hypotension.
#) Hypoxemic respiratory failure: Ms. [**Known lastname 97713**] presented with
significant respiratory distress and was intubated in the
emergency room. Initially the etiology of her respiratory
failure was unclear. She was treated broadly with antibiotics
for hospital-acquired pneumonia, and heparin drip was initiated
for her mechanical heart valves, which also empirically covered
for PE. Upon arrival to the MICU, she was noted to have some
blood-tinged secretions, and underwent bronchoscopy for airway
inspection and broncho-alveolar lavage (BAL). There was no
active bleeding identified, so anti-coagulation for her AVR and
MVR was pursued.
The morning after admission, her urine legionella antigen
returned positive. Her BAL did not grow out any organisms. She
remained on the ventilator until [**2206-5-25**]. During the first
week, there were times when she was difficult to oxygen and
ventilate, and she required paralytics in order to fully be
ventilated. Eventually her respiratory support was able to be
decreased as she was diuresed prior to extubation. She continued
on atrovent and albuterol for her history of COPD.
Broad antibiotic coverage was continued for a two week course,
however eventually narrowed to levofloxacin for the legionella.
Her pneumonia improved and now has no oxygen requirement, O2 Sat
99% on RA and has completed her course of Levofloxacin on
[**2206-6-5**].
#) Shock: Initially Ms. [**Known lastname 97713**] was hypotensive and placed
on pressors. Given that she had cool extremities, her cardiac
history, and a sub-therapeutic INR, cardiogenic etiology was
considered. An echocardiogram completed within hours of MICU
admission did not reveal any significant change, aside from
increased right-sided pressures, which were eventually felt to
be secondary to her very large left-sided pneumonia. Her shock
was felt to be septic in nature, supported by her imaging
findings of pneumonia. She was bolused with intravenous fluids
until her CVP was at goal and she was no longer fluid
responsive. She was on supported with pressors until these were
able to be weaned.
#) Supraventricular tachycardia: During her ICU stay, she
developed a narrow-complex tachycardia intermittently, most
commonly in setting of febrile state, with rates to the 160's.
Intravenous beta-blockers and calcium-channel blockers were
used, and eventually an amiodarone drip was required to control
her heart rate. Cardiology was consulted and followed along.
Eventually she was able to be weaned off the amiodarone drip,
and continued on an oral amiodarone load. Her loading dose of
amiodarone was initiated on [**5-22**] and is 400mg tid.
At follow up with her cardiologist, Dr. [**First Name (STitle) 437**], decision may be
made regarding whether she needs to continue on the amiodarone
and at what dose. Her amiodarone was d/c'd and her metoprolol
was decreased to 25mg. She will follow up with Dr. [**First Name (STitle) 437**] 2 weeks
after discharge.
#) Acute on chronic kidney injury: Patient initially was
olioguric during the initial part of her MICU stay. Her acute
kidney injury was felt to be secondary to hypotension and likely
ATN. Her creatinine peaked at 2.4. Her renal function recovered
and was better than baseline(1.3-1.4) at time of discharge.
#) Leukocytosis and Fevers: Patient had significant leukocytosis
during her admission, with peak WBC of 38.2. Additional work-up
for her fever was undertaken, including urine, blood, and sputum
cultures. CT of her chest/abdomen/pelvis did not reveal any
other pathology to account for her fever. She was not found to
have a large enough pleural effusion to tap. Her central line
was re-sited and cultured. She was covered with broad
antibiotics, including metronidazole for c. difficile, however
these were narrowed to only levofloxacin for her legionella
pneumonia. She had one positive blood culture with coagulase
negative staph, which was likely a contaminant, however she
completed a course of vancomycin.
During her admission, she initially spiked high fevers to
103-104 nearly daily. This was felt to be secondary to her
legionella pneumonia, however search for other potential
etiologies (including drug fever) was completed as noted above.
Prior to discharge, her fever curve had greatly improved and she
was afebrile for 24 hours, though had had some low grade
temperatures (99-100.5) in the preceding days.
At time of discharge, her white blood cell count was 7.9
#) Status-post AVR and MVR: At time of admission, patient's INR
was 1.1. It was unclear if she had been taking her warfarin, as
further history was not able to be obtained from patient. Per
report from family, there were concerns regarding whether she
had been taking her medications recently. After bronchoscopy
which did not reveal any active bleeding source, she was
initiated on a heparin drip. Prior to discharge, her warfarin
was resumed on [**2206-5-27**] and she was bridged on a heparin drip.
Her INR at time of discharge was 3.7. She will need to be
followed by the [**Hospital 191**] [**Hospital **] clinic ([**Telephone/Fax (1) 10844**].
Warfarin was held on the day of discharge due to
supratherapeutic INR of 3.7. Goal is 2.5 to 3.5. INRs will need
to be checked daily at rehab. Would recommend restarting
Coumadin at dose of 2 mg daily on [**2206-6-7**] if INR is not
supratherapeutic.
#) Elevated LFT's: Patient was noted to have rising LFT's during
her admission. It was felt that this was possibly due to
right-sided congestion after fluid rescusitation, medication
effect, or possibly from shock liver. Hepatology consult was
obtained, and a number of test were completed, including iron
studies (Ferritin 1724, TIBC 174, Iron 106), Hepatitis A, B, and
C (all negative), AMA/[**Doctor First Name **] (negative) and HSV 1& 2(IgG positive).
Liver ultrasound was unremarkable. Anti-smooth muscle antibody
was positive.
At time of discharge, her numbers were trending downward, with
ALT 44, AST 72, Alk Phos 189, and Total bilirubin of 1.1.
She should follow up with her PCP, [**Name10 (NameIs) **] which time referral to
hepatology may be considered should her liver function tests
remain elevated.
#) Anemia: Patient had anemia during her admission, which was
felt to be secondary to both serial phebletomy, anemia of
chronic disease, and possibly low level hemolysis secondary to
her AVR. Her HCT remained stable and was at 28 at tiem of
discharge. During her stay, she received a total of four units
of packed red blood cells.
#) COPD: She was treated with albuterol and ipratropium while
intubated, and resumed on her home regimen of albuterol, advair,
and spirvia at time of discharge.
#) Temporal arteritis: Patient was continued on her home dose of
prednisone (7 mg). She required 20mg of stress dose steroids as
her cortisol was low. Her methotrexate was held given liver
abnormalities, and may be re-started after discharge per
instructions from her rheumatologist. She will need to follow up
with rheumatology within 2-3 weeks of discharge.
#) Psychosis: Patient's seroquel was held after extubation due
to her mild somnolence but was resumed before discharge.
#) Depression: Citalopram was continued. Clonazepam was held
given her mental status, and was resumed before discharge.
Lamotrigine was continued.
#) Hypertension: Prior to discharge, an [**First Name9 (NamePattern2) 97723**] [**Last Name (un) **]
(losartan) was resumed. The patients Lasix was d/c'd due to an
episode of hypotension most likely from dehydration. Her
metoprolol was decreased to 25mg.
#) CAD: Patient's clopidogrel was held due to bloody secretions
from her ETT tube and need for anti-coagulation given her
mechanical valves. This was resumed at discharge. Her isosorbide
was also resumed. Her statin was held given her elevated liver
function tests, but resumed prior to discharge as they were
trending downward. She initially had a set of cardiac enzymes
checked that remained flat.
#) Elevated troponin: Troponin was checked on [**2206-6-4**] in the
setting of hypotension. This was elevated to peak 0.39 but
remained flat with negative CK and unchanged EKG. The patient
was evaluated by cardiology, who recommended outpatient
cardiology follow-up.
#) Hypernatremia: The patient developed hypernatremia during her
MICU stay likely secondary to the furosemide drip and tube
feeds. She was repleted with free water throughout her stay.
On the day of transfer from the MICU, her sodium level was 147.
She received 1L of D5W prior to transfer. On day of discharge,
her Na=139.
#) Hypothyroidism: TSH was checked during her admission and
found to be 0.71. Her home dose of levothyroxine was continued.
#) Code status: FULL CODE
Medications on Admission:
- Albuterol nebulizer q4 hours PRN wheezing
- Albuterol inhaler 90 mcg: 2 puffs every 6 hours PRN shortness
of breath
- Atorvastatin 10 mg
- Chlorhexidine mouth wash
- Citalopram 30 mg daily
- Clonazepam 2 mg QAM, 1 mg QHS
- Clopidogrel 75 mg
- Cyclobenzaprine 10 mg [**Hospital1 **]
- Ergocalciferol 50,000 units weekly for 3 months
- Fluticasone-salmeterol 100 mcg/50 mcg [**Hospital1 **]
- Folic acid 1 mg daily
- Furosemide 160 mg
- Isosorbide SR 60 mg daily
- Lamotrigine 75 mg daily
- Levothyroxine 112 mcg daily
- Methotrexate 10 mg weekly
- Metoprolol Succinate 100 mg daily
- Nitroglyercin SL PRN
- Nystatin cream PRN
- Olmesartan 5 mg
- Omeprazole 20 mg
- Oxycodone 5-10 mg [**Hospital1 **]
- Prednisone 7 mg daily
- Quetiapine 100 mg QHS
- Tiotropium 18 mcg daily
- Warfarin 2-4 mg daily as directed by [**Hospital 191**] [**Hospital 197**] Clinic
- Aspirin 81 mg
- Bisacodyl 10 mg PRN constipation
- Docusate 200 mg daily
Discharge Medications:
1. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Lamotrigine 25 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
4. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week.
5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
6-8 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**11-30**] Inhalation Q6H (every 6 hours).
7. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day: Check
LFTs.
8. [**Month/Day (2) **] 75 mg Tablet Sig: One (1) Tablet PO once a day.
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
10. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Was
held on [**6-6**], please start on [**6-7**] and check INR daily. Goal INR
2.5 to 3.5.
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
12. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Inhalation twice a day.
15. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
16. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
17. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO once a day:
Give 3 tablets (15mg) for 3 days, then give 2 tablets (10mg)
daily as her standing dose for her history of temporal arteritis
.
18. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for pain.
19. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times
a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center
Discharge Diagnosis:
Primary: Legionella Pneumonia
Secondary:
-Acute renal failure
-Anemia
-Hypernatremia
-COPD
-Hypertension
-Status-post AVR, MVR on Warfarin
-CAD status-post stent now on [**Hospital **]
-Supraventricular tachycardia
-Hypothyroidism
-Constipation
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:
You were admitted with difficulty breathing, and found to have a
pneumonia and treated with the antibiotic Levofloxacin. You
were placed on a ventilator, and cared for by the medical ICU
team. You were then transferred to the general medicine floor.
Your pneumonia improved and your antibiotic was stopped while
you were still in the hospital. You were delerious and
hallucinated in the beginning but improved and returned to your
normal state of mental health by the time of discharge.
It is IMPERATIVE that you stop smoking.
The following changes have been made to your medications:
1) Metoprolol tartrate is now 25mg twice daily
2) STOP taking your Methotrexate Sodium 10 mg Tablet once a week
until you see your rheumatologist DR. [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**] and he
says that it is okay to re-start it.
3) INCREASE your dose of Prednisone to 15mg once a day for only
3 days, then take 10mg daily. This will be your new Prednisone
dose that you will take for your history of having temporal
arteritis.
.
The following medications were stopped:
-Cyclobenzaprine 10mg [**Hospital1 **]
-Oxycodone 500mg 1-2tab [**Hospital1 **]
-Isosorbide Mononitrate
-Olmesartan
-Lasix
.
Please follow up with your appointments as stated below.
Followup Instructions:
Please go to your appointment with your Primary Care Physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 665**], on WEDNESDAY [**2206-6-11**] at 12:00 PM.
Please go to your appointment with Dr. [**First Name (STitle) 437**] (Cardiology) on
TUESDAY [**2206-7-1**] at 2:00 PM.
Please go to your appointment with your Rheumatologist, Dr.
[**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**] on WEDNESDAY [**2206-6-18**] at 11:30 AM.
Department: [**Hospital3 249**]
When: WEDNESDAY [**2206-6-11**] at 12:00 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: TUESDAY [**2206-7-1**] at 2:00 PM
With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RHEUMATOLOGY
When: WEDNESDAY [**2206-6-18**] at 11:30 AM
With: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital3 249**]
When: [**Hospital3 **] [**2206-7-21**] at 10:20 AM
With: [**Name6 (MD) 10160**] [**Name8 (MD) 10161**], NP [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: WEDNESDAY [**2206-12-3**] at 11:40 AM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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[
[
[]
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[
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icd9pcs
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[
[
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|
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6436, 6861
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2149, 3778
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3794, 3942
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,102
| 140,600
|
39469
|
Discharge summary
|
report
|
Admission Date: [**2145-11-17**] Discharge Date: [**2145-11-21**]
Date of Birth: [**2069-1-18**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Shellfish Derived / Lactose / Nut Flavor / Benicar / Tiazac /
Diovan / Inderal La / Advil / Amoxicillin / Zithromax / Sulfa
(Sulfonamide Antibiotics) / Hydrochlorothiazide / Codeine /
Morphine / Motrin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
dizziness at rest and with exertion
Major Surgical or Invasive Procedure:
Mitral valve replacement with 27-mm St.[**Hospital 923**] Medical Biocor
tissue valve on [**2145-11-17**].
History of Present Illness:
76yo woman with history of mitral valve endocarditis in [**Month (only) 116**]
[**2145**]. Treated with antibiotics but now has moderate to severe
mitral regurgitation. She states her
symptoms of dizziness have increased over past month. Presents
today for pre-admission testing prior to MVR.
Past Medical History:
Hypertension
Hypertrophic obstructive cardiomyopathy(HOCM)
Strep gordonii mitral valve endocarditis [**4-/2145**](Tx Ceftriaxone)
Supraventricular tachycardia
Osteoporosis-Arthritis(hands)
Colon Cancer
B12 deficiency
Hemolytic anemia
Past Surgical History: S/p Hysterectomy, s/p colectomy
Social History:
Race:caucasian
Last Dental Exam:1 month ago(DR [**Last Name (STitle) **] [**Name (STitle) 62514**] [**Telephone/Fax (1) 87192**])
Lives with:husband
Occupation:[**Name2 (NI) 87193**]
Tobacco: none
ETOH: none
Family History:
Father died ALS(57yo), Mother died HTN(76yo),
Physical Exam:
Admission Physical Exam
General: NAD
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: 4/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema: none
Varicosities: mild [x]
Neuro: Grossly intact, non-focal exam
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 1+ Left:1+
Radial Right: 2+ Left:2+
Carotid Bruit radiated murmur
Pertinent Results:
[**2145-11-20**] 11:20AM BLOOD Hct-25.4*
[**2145-11-17**] 06:48PM BLOOD WBC-10.8# RBC-2.61*# Hgb-8.1*# Hct-23.3*#
MCV-89 MCH-31.2 MCHC-34.9 RDW-14.6 Plt Ct-123*
[**2145-11-17**] 07:57PM BLOOD PT-14.9* PTT-41.9* INR(PT)-1.3*
[**2145-11-17**] 06:48PM BLOOD PT-15.9* PTT-41.4* INR(PT)-1.4*
[**2145-11-19**] 04:30AM BLOOD Glucose-142* UreaN-24* Creat-0.9 Na-136
K-4.6 Cl-102 HCO3-27 AnGap-12
[**2145-11-17**] 07:57PM BLOOD UreaN-15 Creat-0.5 Na-141 K-4.4 Cl-114*
HCO3-25 AnGap-6*
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 87194**] (Complete)
Done [**2145-11-17**] at 6:52:18 PM 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: [**2069-1-18**]
Age (years): 76 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: [**Male First Name (un) **]/HOCM FOR MVR/?SEPTAL MYOTOMY
ICD-9 Codes: 786.05, 786.51, 424.0
Test Information
Date/Time: [**2145-11-17**] at 18:52 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2010AW1-: Machine: [**Doctor Last Name 11422**] OR 3
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Peak Resting LVOT gradient: *113 mm Hg <= 10
mm Hg
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no atherosclerotic plaque.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Severely thickened/deformed mitral valve leaflets.
Mild mitral annular calcification. Moderate to severe (3+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
Conclusions
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen.
The mitral valve leaflets are severely thickened/deformed.
Moderate to severe (3+) mitral regurgitation is seen.
There is severe [**Male First Name (un) **] and HOCM.
There is no pericardial effusion.
Post-CPB:
There is a bio-prosthetic mitral valve which is well-seated with
no leak and no MR.
[**First Name (Titles) **] [**Last Name (Titles) 50255**] systolic fxn.
There is no significant LVOT gradient.
No AI. Aorta intact.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2145-11-18**] 09:00
?????? [**2138**] CareGroup IS. All rights reserved.
Brief Hospital Course:
[**2145-11-17**] Ms.[**Known lastname **] was taken to the operating room and underwent
Mitral valve replacement with 27-mm St.[**Hospital 923**] Medical Biocor
tissue valve with Dr.[**Last Name (STitle) **]. Please refer to operative report
for further details. She tolerated the procedure well and was
transferred to the CVICU intubated and sedated in stable but
critical condition. She awoke neurologically intact and was
extubated without difficulty.She was weaned off all drips.
Beta-blocker/ASA and diuresis was initiated. All lines and
drains were discontinued in a timely fashion. POD#1 she was
transferred to the step down unit for further monitoring.
Physical Therapy was consulted for strength and mobility
evaluation. A transient postoperative burst of atrial
fibrillation was controlled with Beta-blocker and her rhythm
converted. The remainder of her hospital course was essentially
uneventful. POD# 4 she was cleared for discharge to home with
VNA. All follow up appointments were advised.
Medications on Admission:
Metoprolol ER 12.5 QHS, Mirtazipine 15', Folic acid 800mcg', B12
qmo, Vit D 1000u'
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
5. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
8. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1
weeks.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
Discharge Disposition:
Home With Service
Facility:
VNACareNetwork
Discharge Diagnosis:
Severe mitral regurgitation, status
post mitral valve endocarditis, and hypertrophic obstructive
cardiomyopathy.
PMH:
Hypertension
Hypertrophic obstructive cardiomyopathy(HOCM)
Strep gordonii mitral valve endocarditis [**4-/2145**](Tx Ceftriaxone)
Supraventricular tachycardia
Osteoporosis-Arthritis(hands)
Colon Cancer
B12 deficiency
Hemolytic anemia
Past Surgical History: S/p Hysterectomy, s/p colectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesic
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema- 1+ bilaterally
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) **] # [**Telephone/Fax (1) 170**] an appointment was arranged
for [**2145-12-9**] at 1:45pm
Cardiologist:Dr. [**First Name8 (NamePattern2) 3924**] [**Last Name (NamePattern1) 20222**] arranged for [**2145-12-27**] at 2:30pm
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **],[**Doctor First Name 57825**] [**Telephone/Fax (1) 87195**] in [**1-30**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2145-11-22**]
|
[
"733.00",
"716.94",
"266.2",
"425.1",
"V10.05",
"427.31",
"424.0",
"401.9",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.23",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
8225, 8270
|
6086, 7092
|
508, 617
|
8721, 8963
|
2144, 6063
|
9887, 10562
|
1496, 1544
|
7226, 8202
|
8291, 8643
|
7118, 7203
|
8987, 9864
|
8666, 8700
|
1559, 2125
|
431, 469
|
645, 940
|
962, 1196
|
1269, 1479
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,334
| 136,777
|
22356
|
Discharge summary
|
report
|
Admission Date: [**2179-10-7**] Discharge Date: [**2179-10-13**]
Date of Birth: [**2157-9-29**] Sex: M
Service: MED
HISTORY OF PRESENT ILLNESS: This is a 22-year-old male who
reportedly rolled down a [**Doctor Last Name **] in a barrel with moving all 4
extremities at the scene. However, became combated and was
intubated and sedated at an outside hospital. CAT scan of
his head showed a left convexity lens-shaped hemorrhage deep
to the skull fracture, which had increased in size from his
outside hospital film. There is subarachnoid and
intraparenchymal hemorrhage surrounding edema of the right
anterior cranial fossa, which was unchanged from his outside
films. There was a third extraaxial hemorrhage located
laterally along the right convexity, which was unchanged from
his outside films. He also had a left occipital fracture at
the base of his skull. A T-spine CAT scan was negative for
any thoracic fractures.
HOSPITAL COURSE: The patient was admitted to the Trauma
Intensive Care Unit where he was monitored with serial CAT
scans, which did not show any additional increase in size of
his hemorrhages. He was placed on Decadron, Dilantin, and
mannitol. He received one dose of mannitol. He was kept
sedated and intubated for the first 24 hours. In the evening
of [**10-7**], he had a repeat CAT scan, which did not show any
increased hemorrhage on his CAT scan. He underwent a
diagnostic cerebral angiogram, which showed no evidence of
carotid or vertebral injury or any problems with his middle
meningeal branch. During angiogram, there was a question of
expanding epidural. He went down for a stat head CT, which
showed again a lens-shaped hemorrhage along the left inner
convexity, which measured 9 mm in its greatest width, which
was not significantly changed compared to the prior study.
He returned back to the Intensive Care Unit where he remained
neurologically intact and he was extubated on the morning of
[**2178-10-7**]. His fluid balance was kept euvolemic to negative.
His pupils were 3 to 2. He was moving all extremities
spontaneously. His blood pressure was kept in the 120 to 130
range. He had a repeat head CT on [**10-8**], which showed no
change in multiple foci of hemorrhage within the brain. On
[**10-9**], he was transferred to the Step Down Surgical Unit
where he was continued with q.1 hour nerve checks and close
monitoring. He remained awake, alert, had difficulty at
times with orientation and sometimes required one-to-one
supervision. On [**10-11**], he was seen by speech therapy, who
found him stage 2, who cleared him for regular diet. He was
then transferred to the surgical floor where he continued to
make good progress. He was seen by physical therapy who felt
that he would need some assistance with mobility and balance
training. However, he ambulated with minimal difficulty. He
was reassessed on [**10-13**], and they felt he was safe to be
discharged home. Also on [**10-13**], he had flexion-extension
films, which showed no cervical or spinal instability.
However, he had complained of some neck pain the 2 days prior
to having these films done and he was out of the 72 hour
window to receive MRI assessment for ligamentous injury. So,
it was recommended that he maintain in a cervical collar for
the next 2 weeks' and follow-up again with flexion-extension
films.
DISCHARGE DIAGNOSES: Closed head injury.
Epidural hematoma.
Multiple cerebral contusions.
Occipital fracture.
DISCHARGE INSTRUCTIONS: Keep his hard collar on at all
times.
Continue on Dilantin.
No heavy lifting greater than 10 pounds.
No driving until he follows up.
He should call Dr.[**Name (NI) 9224**] office if he develops headache
which is not relieved by medication or dizziness. He should
have his Dilantin level checked by his primary care
physician. [**Name10 (NameIs) **] should follow-up with Dr. [**Last Name (STitle) 1132**] on [**10-29**] with
flexion-extension films; those are done at [**Hospital Ward Name 23**] at 11
o'clock in the morning, and then follow-up with a CAT scan at
11:30, and then follow-up with Dr. [**Last Name (STitle) 1132**] at 12:30.
FOLLOWUP MEDICATIONS:
1. Dilantin 200 mg 1 p.o. b.i.d.
2. Tylenol as needed.
3. Percocet 1 to 2 tablets p.o. q. 4 to 6 hours.
On his discharge day of [**10-13**], his Dilantin level was 1.0.
He was loaded with 1 g of Dilantin and his medication was
increased to 200 mg b.i.d., which he should follow-up with a
primary care physician to have his Dilantin level checked.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 8633**]
MEDQUIST36
D: [**2179-10-13**] 15:47:32
T: [**2179-10-14**] 04:38:34
Job#: [**Job Number 58193**]
|
[
"723.1",
"E884.9",
"801.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.91",
"96.6",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
3396, 3489
|
968, 3374
|
3514, 4787
|
166, 950
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,020
| 122,093
|
20466
|
Discharge summary
|
report
|
Admission Date: [**2165-12-18**] Discharge Date: [**2165-12-24**]
Date of Birth: [**2114-7-6**] Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
HCV here for liver transplant
Major Surgical or Invasive Procedure:
[**2165-12-18**] liver transplant
History of Present Illness:
51 y/o male who is originally from the [**Location (un) 3156**] where he believes
he acquired the HCV in [**2137**] when he received a blood
transfusion. The HCV was diagnosed in [**2158**] and he has undergone
multiple interferon-based therapies including interferon
monotherapy, Rebetron, and Peg-Intron and ribavirin without
achieving an EVR or SVR. He was part of the COPILOT maintenance
arm trial in [**2160**] and in Fall of [**2163**] had complete viral
suppression. He has been off of all antiHCV therapies now for
the past 18 months and has had no HCV viremia
on his labwork. He recently underwent surveillance CT which
demonstrated a known lesion had increased slightly to 15mm in
size. The CTs were to be repeated q 3 months. Patient denies
recent illnesses, no chest pain, SOB, N/V/D has occasional right
sided discomfort not decribed as pain
Past Medical History:
HCV / HCC with portal hypertension
Osteomyelitis s/p leg fracture [**2137**]
.
PSH:
Multiple lithotripsies for kidney stones
Social History:
past ETOH use, now quit, no tobacco or IVDU
Lives with wife and has two grown sons
.
Family History:
Mother with [**Name (NI) 2320**], no liver disease
Physical Exam:
VS: 97.3, 93, 124/83, 16, 97%RA
General: appears well, NAD
HEENT: PERRLA, no LAD
Card: RRR, no M/R/G
Lungs: CTA bilaterally
Abd: soft, non distended non-tender, +BS, no surgical scars
Extrem: 2+ bilateral lower extremity edema
Neuro: A+Ox3, no focal deficit
Skin: No rashes
.
Pertinent Results:
[**2165-12-24**] 05:40AM BLOOD WBC-6.7 RBC-2.75* Hgb-9.0* Hct-26.7*
MCV-97 MCH-32.9* MCHC-33.8 RDW-19.1* Plt Ct-67*
[**2165-12-24**] 05:40AM BLOOD PT-13.8* PTT-28.7 INR(PT)-1.2*
[**2165-12-24**] 05:40AM BLOOD Glucose-90 UreaN-21* Creat-0.7 Na-136
K-3.3 Cl-101 HCO3-28 AnGap-10
[**2165-12-18**] 02:25PM BLOOD ALT-23 AST-44* AlkPhos-139* TotBili-3.0*
[**2165-12-24**] 05:40AM BLOOD ALT-215* AST-48* AlkPhos-66 TotBili-0.9
[**2165-12-24**] 05:40AM BLOOD Albumin-2.8* Calcium-8.0* Phos-3.7 Mg-1.6
Brief Hospital Course:
On [**2165-12-18**], he underwent liver transplant. Surgeon as Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]. Induction immunosuppression was administered. Please
refer to operative note for complete details. Two JPs were
placed. During dissection a small defect was made in the
diaphragm. This was closed with a figure-of-eight silk suture
after evacuating the pneumothorax using a red rubber catheter
placed to suction. He did very well and was transferred to the
SICU postop for management. A CXR demonstrated a increased size
of right apical pneumothorax and right upper lobe collapse. A
chest tube was placed with improvement. Chest tube was removed
on [**12-21**]. Postop LFTs initially increased then trended down
daily. He remained hemodynamically stable. JP drains were
non-bilious. Postop, liver duplex showed patent vasculature and
no ductal dilatation.
He was transferred out of the SICU to the med-[**Doctor First Name **] unit where he
made daily progress. Diet was advanced and tolerated. He
required insulin sliding scale for hyperglycemia secondary to
steroids. He became independent with ambulation. JPs were
removed. He did well with immunosuppression teaching. Steroids
were tapered per protocol. Cellcept was well tolerated. Prograf
was initiated on postop day 0. Trough levels were done daily
with dose adjustments. Prograf was increased to 9mg [**Hospital1 **] for a
trough of 5 on [**12-24**].
He experienced intractable hiccoughs as a result of the
diaphragm repair. He did receive a couple low doses of thorazine
with temporary relief.
Due to sulfa allergy, bactrim was not ordered for PCP
[**Name Initial (PRE) 1102**]. He received a Pentamidine inhalation treatment on
[**12-23**]. He also received a Pamidronate treatment on [**12-24**] for
osteopenia.
He was discharged home with instructions to check his blood
sugar prior to breakfast and supper. He will follow up in the
outpatient clinic on [**1-2**]. Labs will be drawn on [**12-26**].
Medications on Admission:
Clotrimazole 10 mg 5x daily
Furosemide 20 mg daily
Propranolol 10 mg QD
Spironolactone 50 mg daily
(Verified with patient. Recent changes in OMR not initiated yet
per patient
Tylenol PM PRN
Discharge Medications:
1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
2. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
follow taper.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
7. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for Pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
HCV
HCC
s/p orthotopic liver transplant
Discharge Condition:
good
alert, oriented
tolerating regular diet
ambulating with supervision
Discharge Instructions:
Please call the Transplant Office [**Telephone/Fax (1) 673**] if have any
danger signs (see below)
Take all medication as prescribed and indicated on your
medication sheet
You will need to have labs drawn every Monday and Thursday am at
[**Last Name (NamePattern1) 439**] lab
Followup Instructions:
[**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2165-12-31**] 8:45
[**Last Name (LF) **],[**First Name3 (LF) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2166-1-2**] 2:30
[**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2166-1-2**] 3:10
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2166-1-9**]
10:00
|
[
"571.5",
"575.11",
"286.7",
"790.29",
"786.8",
"E932.0",
"E870.0",
"998.2",
"E878.0",
"070.54",
"572.3",
"155.0",
"512.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"00.93",
"34.82",
"50.59"
] |
icd9pcs
|
[
[
[]
]
] |
5359, 5365
|
2385, 4389
|
312, 348
|
5449, 5524
|
1868, 2362
|
5849, 6374
|
1503, 1556
|
4630, 5336
|
5386, 5428
|
4415, 4607
|
5548, 5826
|
1571, 1849
|
242, 274
|
376, 1235
|
1257, 1384
|
1400, 1487
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,800
| 111,494
|
46362
|
Discharge summary
|
report
|
Admission Date: [**2162-1-5**] Discharge Date: [**2162-1-15**]
Date of Birth: [**2096-5-9**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
Intubation
Arterial line
Tracheostomy
History of Present Illness:
65-year-old male with history of COPD (FEV1/FVC 28% of
predicted), mild mental retardation with schizophrenia and
recent admission with discharge on [**2161-12-10**] for COPD
exacerbation requiring intubation presenting in respiratory
distress. Patient reported increased cough and O2 requirement
over 1-2 days, completed steroid taper 1 week ago. VNA called
the [**Company 191**] to report found patient to have pOx of 65 % and called
911 for assistance and delivery of patient to [**Hospital1 18**] ED. He was
given a combivent neb at home. Baseline home O2 requirement of 2
L O2.
EMS found patient in respiratory distress, satting 70% RA, given
nebs.
In the ED, initial VS: HR 79 BP 109/69 RR 29 O2 sat 98 % on 40 %
O2 . CXR without clear infiltrate, had received empiric
vancomycin and levofloxacin. Given continuous albuterol,
methylprednisolone. ABG with PCO2 of 82, baseline of 60s. VS:
114/64 69 32 98% CPAP. Repeat ABG unchanged on BiPAP showing
hypercarbia and acidosis. Patient continued to appear somnolent
despite interventions including biPAP and subsequently intubated
with etomidate 20 mg IV and succinycholine 120 mg IV. He was
sedated with fentanyl/versed gtts but stopped in setting of
hypotension (lowest [**Location (un) 1131**] 52/34 HR 64) and given 2 L NS.
Of note, he refused intubation in ED initially. PCP states
patient was not ready for DNR/DNI per clinic note on [**2161-12-15**].
.
On the floor, patient intubated and sedated.
.
Review of systems:
Unable to obtain
.
Past Medical History:
- COPD: FEV1 23% predicted, home 1.5-2L O2 at night only
- Secondary Pulmonary Hypertension (51-66 mm Hg on ECHO
[**2159-9-18**])
- Schizophrenia
- Hx GI bleeding
- Mental Retardation
- Pulmonary Hypertension
- s/p tonsillectomy
Social History:
Lives in [**Location **], unknown if alone. On disability since [**2149**]
for mental health issues. Has home nurse visit every morning and
evening. Reports ~50 pack-year smoking with current smoking.
Denies any ETOH/drug use.
Family History:
Patient unable to provide.
Physical Exam:
Vitals: HR 49 RR 20 BP 84/59 (MAP 65) SaO2 99 on CMV with FiO2
100, PEEP 6 PPeak 32 Vt 0.500
General: sedated
[**Year (4 digits) 4459**]: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: distant breath sounds, end-expiratory wheezes
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:
I. Labs
A. Admission
[**2162-1-5**] 05:28PM BLOOD WBC-7.3 RBC-4.37* Hgb-13.5* Hct-39.8*
MCV-91 MCH-30.9 MCHC-33.9 RDW-13.4 Plt Ct-334
[**2162-1-5**] 05:28PM BLOOD Neuts-57.8 Lymphs-32.3 Monos-5.4 Eos-3.2
Baso-1.3
[**2162-1-5**] 05:28PM BLOOD PT-12.9 PTT-34.7 INR(PT)-1.1
[**2162-1-5**] 05:28PM BLOOD Glucose-121* UreaN-17 Creat-0.9 Na-144
K-4.2 Cl-102 HCO3-34* AnGap-12
[**2162-1-6**] 03:54AM BLOOD Calcium-7.4* Phos-2.0*# Mg-1.4*
[**2162-1-5**] 05:36PM BLOOD Type-ART FiO2-1 pO2-252* pCO2-82*
pH-7.26* calTCO2-39* Base XS-6 Intubat-NOT INTUBA
[**2162-1-7**] 02:10PM BLOOD O2 Sat-98
[**2162-1-5**] 10:20PM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.027
[**2162-1-5**] 10:20PM URINE Blood-NEG Nitrite-NEG Protein-25
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2162-1-5**] 10:20PM URINE RBC-0-2 WBC-[**7-16**]* Bacteri-FEW Yeast-NONE
Epi-0
[**2162-1-5**] 10:20PM URINE Mucous-MANY
B. Micro
[**2162-1-6**] URINE URINE CULTURE-FINAL INPATIENT
[**2162-1-5**] BLOOD CULTURE Blood Culture,
Routine-PENDING EMERGENCY [**Hospital1 **]
[**2162-1-5**] BLOOD CULTURE Blood Culture,
Routine-PENDING EMERGENCY [**Hospital1 **]
C. Discharge
________________________________
________________________________
II. Radiology
A. CXR
XAM: Chest, single frontal view.
CLINICAL INFORMATION: 55-year-old male with history of shortness
of breath.
COMPARISON: Multiple priors including [**2161-12-8**], [**2161-12-6**] and
[**2161-12-4**].
FINDINGS: Subtle right lower lobe patchy opacity appears
slightly more
prominent compared to the study of [**2161-12-8**] but less prominent
compared to
[**2161-12-6**]. Findings could be due to aspiration or infectious
process. Left
infrahilar opacity is again seen. No pleural effusion or
pneumothorax is
seen. Cardiac and mediastinal silhouettes are stable and
unremarkable.
III. Cardiology
A. EKG
Sinus tachycardia. Slight ST-T wave changes are non-specific and
may be within normal limits. Since the previous tracing of
[**2161-11-29**] sinus tachycardia is now present and the marked ST-T
wave abnormalities have decreased
Pending studies
Blood culture x 2, urine culture
Brief Hospital Course:
65-year-old male with mental retardation, history of severe COPD
with multiple admissions for same complaint requiring intubation
presenting with hypercarbic respiratory failure likely secondary
to COPD exacerbation. Goals of care were discussed, and patient
subsequently underwent tracheostomy.
# Hypercarbic Respiratory failure
Etiology thought to be COPD exacerbation given symptoms of cough
in week prior, continued smoking, and absence of leukocytosis,
fever, and definitive infiltrate. He was treated with a 5-day
course of levofloxacin and placed on a prednisone taper.
Multiple pressure support trial were attempted resulting in
worsening hypercarbia and continued intubation. [**Name (NI) **] sister
and patient were involved in discussion regarding goals of care
and decided on undergoing a tracheostomy given multiple
intubations in the recent past for his severe COPD. It was felt
that patient has capacity to make this decision given he
demonstrated understanding risks and benefits of the procedure.
He spiked a fever to 101 on [**1-14**], but felt to be related to
post-procedure. Blood and urine cultures no growth to date and
CXR with no infiltrate. He remained afebrile for 24 hours
afterwards.
# Hypotension
Patient initially hypotensive on admission especially with
sedation after intubation but appeared euvolemic. Attributed to
intubation with sedatives and PEEP. He was treated with a 4 L NS
bolus and continued to produce adequate urine output.
Normotensive throughout rest of MICU course and at time of
dsicharge.
# Pyuria
Patient noted to have pyuria on admission and history of VRE.
Urine culture was negative.
# Glucose intolerance. The patient had elevated blood sugars
during last hospitalization, which may be secondary to steroid
usage vs. hyperglycemia of acute illness vs. a pre-diabetic
state. Patient remained of SSI in house. This should be
monitored closely as an outpt.
# Anemia
Patient noted to have anemia on admission (Hct 39.8). Advise
age-appropriate cancer screening on outpatient basis and
outpatient follow-up.
# Schizophrenia
Patient remained of zyprexa.
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
puffs(s) inhaled twice a day and q 4 hours prn wheeze
FAMOTIDINE - 20 mg Tablet - 1 Tablet(s) by mouth every twelve
(12) hours
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose
Disk
with Device - 1 puff(s) inhaled twice a day
INHALATIONAL SPACING DEVICE [AEROCHAMBER] - Inhaler - use with
inhalers every time
OLANZAPINE [ZYPREXA] - (Prescribed by Other Provider) - 7.5 mg
Tablet - 1 Tablet(s) by mouth once a day
OXYGEN - - 1- 2 liters nasal canula to keep O2 sat above 90%
PREDNISONE - 20 mg Tablet - 2 Tablet(s) by mouth once a day for
7
days
PREDNISONE - 10 mg Tablet - Taper as directed
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - 1 capsule inhaled once a day
Medications - OTC
ACETAMINOPHEN [TYLENOL] - 325 mg Tablet - 1 Tablet(s) by mouth
every four (4) hours as needed for fever or pain
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth once a day
DOCUSATE SODIUM [COLACE] - 100 mg Capsule - 1 Capsule(s) by
mouth
once a day
MULTIVITAMIN WITH MINERALS - Tablet - 1 Tablet(s) by mouth
once
a day
--------------- --------------- --------------- ---------------
Discharge Medications:
1. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler [**Month/Day (4) **]:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing.
2. Advair Diskus 500-50 mcg/dose Disk with Device [**Month/Day (4) **]: One (1)
puff Inhalation twice a day.
3. oxygen
1-2 liters NC to keep O2 sat above 90 %
4. tiotropium bromide 18 mcg Capsule, w/Inhalation Device [**Month/Day (4) **]:
One (1) capsule Inhalation once a day.
5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Month/Day (4) **]:
Two (2) puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
6. olanzapine 7.5 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO once a day.
7. prednisone 10 mg Tablet [**Month/Day (4) **]: Four (4) Tablet PO once a day:
Take 4 tablets daily until [**1-15**], take 3 tablets daily from
[**1-15**] to [**1-20**], take 2 tablets daily from [**1-20**] to [**1-25**]. Take 1
tablet from [**1-25**] to [**1-30**].
.
8. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary: chronic obstructive pulmonary disease exacerbation
Secondary: Mental retardation, schizophrenia
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 treated for a COPD exacerbation with respiratory
failure requiring intubation and mechanical ventilation. It was
decided by you and your sister that a tracheostomy would be a
good option given your recurrent COPD exacerbations requiring
intubation.
Medication changes:
START prednisone taper
START lansoprazole
Followup Instructions:
You should follow-up with your primary care doctor, Dr. [**First Name (STitle) 1022**]
([**Telephone/Fax (1) 250**]), after you leave the rehab.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"790.29",
"416.8",
"491.21",
"285.9",
"295.90",
"317",
"780.62",
"458.9",
"305.1",
"518.84",
"791.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.6",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
9692, 9763
|
5194, 7306
|
330, 369
|
9912, 9912
|
3016, 5171
|
10440, 10724
|
2416, 2444
|
8566, 9669
|
9784, 9891
|
7332, 8543
|
10095, 10354
|
2459, 2997
|
1882, 1902
|
10374, 10417
|
270, 292
|
397, 1863
|
9927, 10071
|
1924, 2155
|
2171, 2400
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,178
| 136,512
|
9958
|
Discharge summary
|
report
|
Admission Date: [**2120-11-13**] Discharge Date: [**2120-11-16**]
Date of Birth: [**2065-9-16**] Sex: F
Service: MEDICINE
Allergies:
Sulfur / Morphine Sulfate
Attending:[**First Name3 (LF) 5266**]
Chief Complaint:
vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Please see initial MICU admission note for details. Briefly,
Ms. [**Known lastname 24344**] is a 55 year old female with history of ankle
fracture 6 weeks ago, HTN, Hyperlipidemia, who presented with a
severe metabolic acidosis, acute pancreatitis, and
transaminitis, likely due to alcohol.
She was taking opiods round the clock for her fracture, but
started having hallucinations and confusion, along with vomiting
and inability to take PO. Was referred to ED by her PCP, [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 5263**]. Was found to have anion gap metabolic acidosis
(Bicarb was 7), without serum or urinary ketones. Etiology felt
likely due to alcohol/starvation acidosis, so was admitted to
MICU. She was treated supportively with IVFs (D51/2NS), and
kept NPO given additional finding of Lipase elevated to 1715.
CT abdomen revealed peri-pancreatic stranding consistent with
acute pancreatitis, fatty liver, and 1 cm cystic lesion at
pancreatic head, ? pseudocyst vs tumor. ERCP team was consulted
and recommended repeat CT scan in 2 weeks and likely EUS to
evaluate this lesion if not resolved.
In the MICU, her electrolytes were agressively repleted. She
did not have abdominal pain. Started on clears on [**2120-11-15**].
She was maintained on CIWA scale because of her etoh history,
although she reports last drink was 1 week prior to admission.
Past Medical History:
HTN
High cholesterol
Social History:
Patient lives with her wife, [**Name (NI) **]. [**Name2 (NI) 1403**] as an optician. Former
smoker, quit 10 years ago (smoke 1/2-1 PPD for 10 years). Etoh
1/week, though reports had history of alcohol abuse.
Family History:
n/a
Physical Exam:
VS: T 98.2, HR 110, BP 150/91, 17 RR , 99% on RA
Gen: appears comfortable
HEENT: PERRL, EOMI, moist mucous membrane
CV: tachy, regular, no m/r/g
Pulm: Clear to auscultation b/l
Abd: +BS, soft, non-tender, non-distended
Ext: trace edema
Neuro: no tremor. AAOx3.
Pertinent Results:
Admission labs:
CBC:
[**2120-11-13**] 03:07PM BLOOD WBC-6.4 RBC-3.87* Hgb-12.6 Hct-37.4#
MCV-97 MCH-32.4* MCHC-33.6 RDW-14.5 Plt Ct-114*
[**2120-11-13**] 03:07PM BLOOD Neuts-86.7* Lymphs-6.7* Monos-5.8 Eos-0.2
Baso-0.5
[**2120-11-15**] 01:05AM BLOOD WBC-3.8* RBC-3.24* Hgb-10.6* Hct-30.2*
MCV-93 MCH-32.5* MCHC-35.0 RDW-14.8 Plt Ct-81*
CHEM 10:
[**2120-11-13**] 03:07PM BLOOD Glucose-89 UreaN-12 Creat-1.2* Na-138
K-3.8 Cl-94* HCO3-7* AnGap-41*
[**2120-11-15**] 12:27PM BLOOD Glucose-104 UreaN-3* Creat-0.6 Na-140
K-3.4 Cl-109* HCO3-21* AnGap-13
[**2120-11-13**] 06:00PM BLOOD Calcium-9.0 Phos-1.4* Mg-1.4*
[**2120-11-15**] 12:27PM BLOOD Calcium-9.0 Phos-2.0* Mg-1.5*
[**2120-11-16**] 07:30AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.7
LFTs/lipase:
[**2120-11-13**] 03:07PM BLOOD ALT-252* AST-324* LD(LDH)-431* AlkPhos-60
TotBili-1.1
[**2120-11-15**] 01:05AM BLOOD ALT-138* AST-121* LD(LDH)-317*
CK(CPK)-156* AlkPhos-47 Amylase-97 TotBili-0.9
[**2120-11-16**] 07:30AM BLOOD ALT-99* AST-87* AlkPhos-48 TotBili-0.6
[**2120-11-13**] 06:00PM BLOOD Lipase-1715*
[**2120-11-15**] 01:05AM BLOOD Lipase-567*
[**2120-11-16**] 07:30AM BLOOD Lipase-426*
[**2120-11-14**] 02:08AM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE IgM
HAV-NEGATIVE
COAGs:
[**2120-11-15**] 01:05AM BLOOD PT-12.9 PTT-30.5 INR(PT)-1.1
Serum tox:
[**2120-11-13**] 03:07PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2120-11-13**] 06:00PM BLOOD Acetmnp-NEG
Misc:
[**2120-11-15**] 01:05AM BLOOD calTIBC-187* Ferritn-1133* TRF-144*
[**2120-11-14**] 02:08AM BLOOD Ret Aut-1.0*
[**2120-11-14**] 11:36AM BLOOD VitB12-GREATER TH Folate-15.1
[**2120-11-13**] 06:00PM BLOOD Acetone-MODERATE Osmolal-299
[**2120-11-15**] 01:05AM BLOOD TSH-3.0
ABG:
[**2120-11-13**] 09:06PM BLOOD Type-[**Last Name (un) **] pO2-73* pCO2-20* pH-7.31*
calTCO2-11* Base XS--13
[**2120-11-13**] 10:30PM BLOOD Type-ART pO2-113* pCO2-22* pH-7.40
calTCO2-14* Base XS--8
[**2120-11-13**] 10:30PM BLOOD Lactate-0.8 Na-136 K-3.3* Cl-104
STUDIES:
1) EKG: Sinus tachycardia. Nonspecific T wave changes. Since
previous tracing of [**2120-9-29**], sinus tachycardia present.
2)KUB: FINDINGS: Upright and supine views of the abdomen are
obtained. There is a paucity of bowel gas with only a small
amount of gas seen within the rectum and loop of bowel in the
left upper quadrant. The stomach also is partially distended
with gas. Findings may be related to small-bowel obstruction
with fluid-filled loops of bowel and clinical correlation is
advised. There is no evidence of free air below the diaphragm.
Lung bases appear clear. The osseous structures appear intact
with a mild rotatory scoliosis noted. Degenerative changes are
also noted in the visualized portions of the lower thoracic
spine.
IMPRESSION:
Paucity of bowel gas, which in the correct clinical setting may
be due to
underlying bowel obstruction. If there is strong clinical
concern, recommend correlation with CT scan. No free air.
3) Abd/pelvic CT: [**First Name9 (NamePattern2) **] [**Location (un) 1131**]-Mild peripancreatic stradning,
may reflect changes of acute pancreatitis. A 1 cm cystic lesion
is present in the pancreatic head, with diagnostic
considerations including a pancreatic pseudocyst, cystic
neoplasm of the pancreas, or an IPMN. Diffusely fatty liver.
Brief Hospital Course:
Ms. [**Known lastname 24344**] is a 55 year old female with HTN, HL, etoh abuse,
recent ankle fx on opiods, presented with anion gap metabolic
acidosis and pancreatitis.
MICU course:
Patient admitted to the MICU with alcohol/starvation acidosis.
In the MICU, she was treated supportively with IVFs (D51/2NS),
and kept NPO given additional finding of Lipase elevated to
1715. CT abdomen revealed peri-pancreatic stranding consistent
with acute pancreatitis, fatty liver, and 1 cm cystic lesion at
pancreatic head, ? pseudocyst vs tumor. ERCP team was consulted
and recommended repeat CT scan in two weeks and likely EUS to
evaluate this lesion if not resolved. Electrolytes were
agressively repleted. She did not have abdominal pain. Started
on clears on [**2120-11-15**]. She was maintained on CIWA scale because
of her etoh history, although she reports last drink was 1 week
prior to admission. Transferred to the floor on [**2120-11-15**].
Medical floor course:
1. Anion gap metabolic acidosis: Etiology of metabolic acidosis
was likely starvation ketosis in the setting of not tolerating
POs for > 2 days and chloride losses from vomiting. Gap closed
after hydration. On the floor, patient was initially put on
clears then advanced to regular diet which she tolerated well
prior to discharge.
2. Nausea/vomiting. History was consistent with opioid
withdrawal given 6 weeks of standing oxycodone 10 mg q 4 hours.
Also was abusing alcohol and was taking ativan daily. Last drink
on saturday [**2120-11-9**]. Given no signs of withdrawal, CIWA scale
was d/c'ed on the floor. Patient continued to remain
asymptomatic- no tremors, diaphoresis, irritability,
palpitations, abdominal pain, nausea or vomiting.
3. Acute pancreatitis. Patient had elevated lipase 1715 on
admission. She denied any abdominal pain. Abdominal CT showed
changes consistent with acute pancreatitis, although also
concerning for pancreatic head mass, ? pseudocyst vs tumor.
Serial abdominal exams remained unremarkable. Lipase slowly
decreased to 426 by time of discharge. Plan for outpt CT scan in
[**12-27**] weeks to be arranged by her PCP and endoscopic ultrasound by
ERCP team (Dr. [**Last Name (STitle) **] was attending)
4. Transaminitis: Patient had nausea, vomiting and highly
elevated LFTs at time of admission. Negative hep c, hep b and
hep A antibodies. Given significant history of alcohol abuse,
alcohol is the most likely etiology of her transaminitis. During
this admission, we obtained daily LFTs which trended downward.
By time of discharge, LFTs greatly improved.
5. Pancytopenia. This was thought to be due to bone marrow
suppression from chronic alcohol consumption. Tox screen was
negative on admission. Hemolysis labs were negative. Retic count
elevated in response to pancytopenia. Iron studies showed
calTIBC 187, Ferritin 1133, TRF 144. No evidence of acute
infection. Patient remained afebrile. No signs of bleeding.
Heparin sc was held given increased risk of bleeding in the
setting of thrombocytopenia. Pt stated that she drinks to
excess, 1 quart vodka. She was initially put on CIWA protocol;
however, this was discontinued in the absence of withdrawal
signs/symptoms. Received thiamine, MVT and folate while in
house. Discharged on folate supplements. Encouraged abstinence
and social work which she can obtain from PCP.
6. Hyperlipidemia: Tricor was held given elevated LFTs, but told
to continue upon discharge when LFTs improved.
7. HTN: BP meds were held per PCP b/c of hypotension. Patient
will follow up with PCP as outpatient.
8. Ankle fracture: Non-weight bearing. Patient will f/u with Dr.
[**Last Name (STitle) 1005**] in early [**Month (only) 1096**]. Narcotics were held given
hallucinations when taking them at home.
9. FEN: cardiac diet, IVF x 1 L, monitored lytes [**Hospital1 **]
10. Ppx: pneumoboots, PPI
11. FULL CODE
Medications on Admission:
Oxycodone 10 mg q 4 hours
Ativan prn (unknown dose)
Tricor 145 mg daily
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
3. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day.
4. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
1) Acute pancreatitis
2) Opiate intoxication
3) Transaminitis- likely due to alcohol
4) Pancytopenia (low blood counts)- most likely due to chronic
alcohol consumption
Secondary diagnoses:
1) Hypertension
2) Hyperlipidemia
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital with nausea, vomiting and
inability to tolerate food. These symptoms were most likely due
to acute pancreatitis (inflammation of the pancreas) and several
lab abnormalities. In addition, you presented with altered
mental status which was thought to have been a side effect of
overusing opiates (pain medications). You were initially
admitted to the intensive care unit and then transferred to the
general medicine floor. A cat scan of your abdomen showed
changes consistent with acute pancreatitis; however, other
pathologies cannot be excluded. You will need a repeat CT in 2
weeks, followed by an endoscopic ultrasound. Please call Dr.
[**Last Name (STitle) 5263**] ([**Telephone/Fax (1) 250**]) to schedule an appointment in the next few
days. Dr. [**Last Name (STitle) 5263**] will order the CT for you. You will then have
an outpatient endoscopic ultrasound with the gastroenterologist.
This will be set up for you.
We encourage that you abtain from drinking alcohol, which has
caused significant effects to your liver and pancreas. You may
ask Dr. [**Last Name (STitle) 5263**] to refer you to a social worker if needed.
Call your doctor if you have any symptoms or concerns.
Followup Instructions:
1) Please call Dr. [**Last Name (STitle) 5263**] ([**Telephone/Fax (1) 250**]) to make an appt in the
next few days. She will order a repeat abdominal CT in the next
2 weeks.
Completed by:[**2120-11-16**]
|
[
"571.8",
"284.1",
"577.0",
"790.4",
"305.00",
"780.97",
"304.00",
"276.2",
"285.9",
"V54.19",
"272.4",
"292.0",
"401.9",
"577.9",
"276.51"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9933, 9939
|
5652, 9511
|
297, 304
|
10226, 10235
|
2344, 2344
|
11503, 11710
|
2041, 2046
|
9634, 9910
|
9960, 10148
|
9537, 9611
|
10259, 11480
|
2061, 2325
|
10169, 10205
|
249, 259
|
332, 1756
|
2361, 5629
|
1778, 1800
|
1816, 2025
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,183
| 166,130
|
34737+57942
|
Discharge summary
|
report+addendum
|
Admission Date: [**2149-9-26**] Discharge Date: [**2149-10-3**]
Date of Birth: [**2083-8-6**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
L IPH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
66M who is well known to Neurosurgery who is s/p left craniotomy
for resection of a Metastatic [**Location (un) 5668**] cell carcinoma in [**8-14**], [**2148**] with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]. He is currently receiving
whole brain radiation and has received 14 out of 15 fractions.
He is currently at [**Hospital3 **] center receiving Lovenox for
a lower extremity DVT which was stopped yesterday when he was
noted
to have decreased mentation and also bloody diarrhea in the
setting on C.Diff colitis with ongoing Vancomycin therapy. He
went was seen by radiation oncology today who sent him to the ED
for evaluation for decreased mental status and fevers.
Past Medical History:
ONCOLOGIC HISTORY:
# neuroendocrine small cell cancer likely [**Location (un) 5668**] cell:
- diagnosed in [**7-/2147**] after patient incidentally found a
left axillary lymph node. FNA was positive for malignant cells,
positive for cytokeratin (AE1/3/CAM 5.2), CK20, synaptophysin,
and chromogranin, negative for CD45, CK7, TTF-1, and S-100. The
immunophenotype suggested a neuroendocrine carcinoma. Imaging
studies showed FDG-avid enlarged left axillary lymph node
without other concerning nodes or masses.
- [**2147-7-19**]: colonoscopy showed an adenomatous ascending colon
polyp
- [**7-/2147**]: derm exam revealed 3 small lesions on the back
consistent with basal cell carcinoma
- [**7-/2147**]: axillary lymph node excision
- [**8-/2147**]/[**2146**]: 4 cycles of cisplatin and etoposide
- [**11/2147**]/[**2147**]: received radiation
- [**4-/2148**]: imaging study showed no evidence of recurrence of
cancer
.
OTHER MEDICAL HISTORY:
1. Neuroendocrine Tumor consistent with [**Location (un) 5668**] cell
2. [**2149-8-14**]: s/p Left parietal-occipital craniotomy for mass
resection. Preliminary pathology report was consistent with a
neuroendocrine tumor.
3. Treated for recent UTI and epididymitis as an outpatient
prior to [**2149-8-12**] admission c/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5668**] cell cancer
4. Basal cell carcinoma
5. Left hip pain
6. H/o shooting pain to the left lower extremity after a fall in
college
Social History:
He is married, lives with his wife. [**Name (NI) **] has two daughters. [**Name (NI) **] is
a dentist. He never smoked. Both his parents died at age 85.
Family History:
His father did have melanoma and developed brain metastases. He
mother had thyroid disease and congestive heart failure. He has
two sisters, all healthy. History of malignant melanoma in his
maternal aunt.
Physical Exam:
Gen: Lethargic
HEENT: Pupils:7mm to 4mm EOMs: unable to asses secondary
to lethargy
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status:
Orientation: Oriented to person, place, and date.
Recall: [**2-5**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,7 to 4mm
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: UA
[**Doctor First Name 81**]: UA
XII: UA
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-9**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
DISCHARGE EXAM:
As Above
Pertinent Results:
[**9-26**] Head CT: IMPRESSION: New 3.8 x 3.1 cm intra-axial
hemorrhage within left temporoparietal lobe in the region of
prior surgical resection of a metastatic lesion, with slight
increase in temporal [**Doctor Last Name 534**] trapping, but stable mild rightward
midline shift as compared to [**2149-8-24**]. No evidence of
transtentorial or uncal herniation.
[**9-27**] Head CT: IMPRESSION: Little change from [**2149-9-26**]
at 16:32 hours in the appearance of large left temporoparietal
intraparenchymal hematoma, with adjacent edema and associated
mass effect. No new hemorrhage is identified.
[**9-27**] Abdominal CT: IMPRESSION: 1. Extensive fecal loading
throughout the colon and rectum, which may account for the
patient's abdominal pain. There is sigmoid diverticulosis,
without evidence for acute diverticulitis or other colonic
inflammatory process. 2. Normal appendix. 3. Bilateral
parapelvic cysts, stable. 4. Distended gallbladder, without
additional findings to suggest acute cholecystitis.
Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
[**2149-9-27**] 1:40 PM
FINDINGS: The PICC line has been re-positioned. The line now
projects with
its tip over the mid SVC, at the level of the azygos vein. No
evidence of
complications. Otherwise unchanged to the previous radiograph
from today,
1237.
The findings were discussed on the telephone with the
responsible IV nurse, [**Doctor First Name **] at the time of dictation.
CT HEAD [**9-29**]
Further organization of a left occipital intraparenchymal
hemorrhage with
decrease in the size of the acute high attenuating blood
products, but
unchanged vasogenic edema and left temporal [**Doctor Last Name 534**] enlargement.
Brief Hospital Course:
Patient was admitted to the ICU for close neurological
monitoring. A repeat Head CT was ordered as well as lower
extremity dopplers and pan culture. It was recommended that he
start 3% saline for his hyponatremia but due to his poor
peripheral access this was not started until [**9-27**] after a PICC
line was placed.
Repeat Head CT revealed slight enlargment in trapped left
temporal [**Doctor Last Name 534**] but the patient's exam remained stable so no
intervention was done at this time. Keppra dose was increased as
well as decadron. Early in the morning of [**9-29**] the patient
developed difficulty speak so a STAT Head CT was obtained. The
CT scan showed interval decrease in the size of the hemorrhage
and stable appearance of the left temporal [**Doctor Last Name 534**] enlargement. On
exam the mornign of [**9-29**] he was noted to stable as he was
oriented to himself and hospital as well as [**2148**] if given
choices. Other then his confusion he was nonfocal and following
simple commands. Given his history of recent DVT of the RLE he
received LENI's, which were negative for DVT. He was also seen
by speech and swallow who cleared him to have a regular diet and
his nasogastric tube was removed.
On [**9-30**] his Na was stable on 3%, therefore salt tabs were added
and the 3% was discontinued. Na cont to be checked q4hrs.
On [**10-1**] his Na was stable and checks were changed to q8hrs. He
was cleared for transfer to the floor. PT and OT were ordered,
and they determined that he met criteria for return to [**Hospital1 **].
On [**10-2**], his daily Na dose was decreased to 3mg TID. His
sodium remained in the high 130s for over 48 hours, and his
sodium was checked once per day.
He was discharged to rehab on [**2149-10-3**].
Medications on Admission:
Dexamethason 4mg tid
Flagyl 500 mg Tid
Nystatin Swish and spit
Prilosec 40mg qd
oxycodone 5mg Q4hrs prn pain
ondansetron 4mg prn Q6h
Anusol-HC 2.5 rectal
Bactrim DS 800mg 160 one tab daily
Dulcolax 10mg rectal prn
Floranex one pack [**Hospital1 **]
keppra 500mg [**Hospital1 **]
Lovenox 80mg/.8ml sub q [**Hospital1 **]
zofran 4mg [**Hospital1 **]
Colace 100mg [**Hospital1 **]
Discharge Medications:
1. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 12 days.
2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
3. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
4. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] (2
times a day).
5. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
6. mineral oil Oil Sig: 15-30 MLs PO DAILY (Daily) as needed
for constipation.
7. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day).
8. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 12 days.
10. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
11. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
12. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
13. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. sodium chloride 1 gram Tablet Sig: Three (3) Tablet PO Q6H
(every 6 hours).
15. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Left intraperenchymal hemorrhage
Hyponatremia - SIADH
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? 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.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Please call ([**Telephone/Fax (1) 11314**] to make an appointment to see Dr.
[**Last Name (STitle) **] in 4 weeks. You WILL need a Head CT prior to this
appointment.
Completed by:[**2149-10-3**] Name: [**Known lastname 12791**],[**Known firstname 126**] Unit No: [**Numeric Identifier 12792**]
Admission Date: [**2149-9-26**] Discharge Date: [**2149-10-3**]
Date of Birth: [**2083-8-6**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 599**]
Addendum:
The patient was also found to have cerebral edema during his
admission.
Chief Complaint:
Cerebral Edema
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Location (un) 42**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 603**] MD [**MD Number(2) 604**]
Completed by:[**2149-11-18**]
|
[
"110.3",
"253.6",
"V10.91",
"V58.61",
"008.45",
"198.3",
"780.61",
"431",
"V12.51",
"348.5",
"V10.83",
"V15.3",
"562.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.29"
] |
icd9pcs
|
[
[
[]
]
] |
12221, 12429
|
5725, 7483
|
324, 331
|
9431, 9431
|
3995, 4006
|
11514, 12165
|
2720, 2927
|
7915, 9240
|
9354, 9410
|
7509, 7892
|
9584, 11491
|
2942, 3151
|
3966, 3976
|
12182, 12198
|
359, 1052
|
3389, 3950
|
4380, 5702
|
9446, 9560
|
1074, 2533
|
2549, 2704
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,709
| 150,693
|
37941
|
Discharge summary
|
report
|
Admission Date: [**2110-11-13**] Discharge Date: [**2110-11-21**]
Date of Birth: [**2050-12-18**] Sex: M
Service: SURGERY
Allergies:
IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Prior Hartmann's procedure for perforative diverticulitis
Major Surgical or Invasive Procedure:
[**2110-11-13**] Reversal of Hartmann's procedure, adhesiolysis,
takedown of colostomy with resection of sigmoid and descending
colon, mobilization of the splenic flexure, primary anastomosis,
open cholecystectomy.
History of Present Illness:
Mr. [**Known lastname 37564**] is a 59 year old male who is status post emergency
Hartmann procedure performed on [**2110-5-18**] for perforated
diverticulitis who presents on [**2110-11-13**] for an elective reversal
of his colostomy. Of note, he had a barium enema study as an
outpatient on [**2110-10-27**] preoperatively. There is scattered
diverticulae in the remaining proximal sigmoid colon and some of
the descending
colon closer to the resection margins. There are no other
masses or strictures identified. In addition, he has a history
of known gallstones, which are planned to be resected during the
procedure.
Past Medical History:
PMHx:
Waldenstrom's macroglobulinemia, RCC T3aNxM0,
hypertension, OCD, basal cell carcinoma, linear IgA, ?Lyme
disease, renal insufficiency, sigmoid diverticulitis.
PSHx:
[**5-/2110**]: sigmoid colectomy with Hartmann procedure for perforated
sigmoid diverticulitis.
R nephrectomy [**3-13**], R knee surgery '[**66**], ?EVD for
hydrocephalus as neonate '[**50**]
Social History:
He is married, lives in [**State 2748**]. Occasional marijuana
smoker, no tobacco, social ETOH
Family History:
no history of colon CA
Physical Exam:
Upon postoperative check:
VS: 100.6-89-119/51-19-94% on 4L NX
Gen: A&O X 3, NAD
Card:RRR
Pulm: Clear to auscultation bilaterally
Abd: soft, nontender, nondistended
wound: c/d/i, JP drain w/ serosang output
Ext: nonedematous, warm and pink
Pertinent Results:
Postop check exam:
100.6-89-119/51-19-94% 4L NC
GEN: A&OX3, NAD
CAR: RRR
PUL: CTAB
ABD: soft, nontender/nondistended
WOUND: c/d/i dressing, JP drain w/ serosang output
EXTR: no edema, pink and warm
Brief Hospital Course:
Mr. [**Known lastname 37564**] was admitted on [**2110-11-13**] under the acute care
surgery service for management after his reversal of hartmann's,
lysis of adhesions, and open cholecystectomy (see operative
report by Dr. [**Last Name (STitle) **] for details).
Neuro: He remained alert and oriented at his baseline mental
status throughout his hospitalization. The acute pain service
was consulted and placed a thoracic epidural for postoperative
pain control. He was also started on a dilaudid PCA. He reported
adequate pain control with this and he was weaned off the PCA,
the epidural was removed, and he transitioned to oral pain
medication by postop day #3. By the day of discharge, Mr.
[**Known lastname 37564**] reported minimal pain and was not requiring any
narcotic pain medication.
Card: The patients vital signs were routinely monitored. On
postop day #3 he became hypertensive with a systolic blood
pressure in the 200's and slightly tachycardic with a HR in the
100's. At this time the patient was also diaphoretic, slightly
nauseated and reported feeling anxious, but denied any shortness
of breath. An ECG was obtained which showed no changes from
baseline (sinus tachycardia) and cardiac enzymes were sent. He
had a slight rise in troponin to 0.7, which came down
subsequently to 0.04 and 0.03 when cycled. The patient was given
IV hydralazine to lower his blood pressure. He had initially
been restarted on his home dose of diltiazem (120 mg ER), and
this was increased at this time to 60 mg QID at this time.
Metoprolol was later added in an attempt to improve his rate
control. His blood pressure began to stabilize, however he
continued to be slightly hypertensive ranging in the 130's-170's
systolic. He remained asymptomatic, but was sent home with VNA
services for blood pressure monitoring and was instructed to
follow up with his PCP after discharge regarding his medications
and hypertension.
Pulm: Mr. [**Known lastname 78048**] oxygen saturation was routinely monitored
with his vital signs. Bibasilar atelectasis was noted on chest
xray on postop day #1. Pulmonary toileting and incentive
spirometry were performed, and he was slowly weaned off
supplemental oxygen. On postop day #7, he began to complain of
waking up "gasping for air" in the middle of the night. No know
history of sleep apnea exists, however, he was placed on
continuous O2 monitoring. He will follow-up for any sleep study
by his primary care provider
GI: An NG tube was placed intraoperatively and he was intially
kept NPO with IV fluids for hydration. On postop day #2, the NG
tube was removed, and on postop day #3, he reported passing
flatus and he was started on a regular diet. However, he
reported intermittent nausea and on postop day #4 he had an
abdominal CT w/out contrast which showed no evidence of bowel
obstruction and no intra-abdominal fluid collections. By postop
day #7, he was able to tolerate a regular diet with minimal
nausea and reported passing flatus and mulitple loose BM's. He
did have episodes of hiccups which were treated with thorazine
and resolution of his hiccups. A sample was sent to check for
c. diff and was negative.
GU: A foley catheter was placed intraoperatively. It was kept in
for urine output monitoring initally. On postop day #5 it was
clear that he was making adequate amounts of urine and it was
removed. He was able to void adequate amounts of urine without
difficulty after removal. A urine culture sent on postop day #5
had no growth.
Musk: Mr. [**Known lastname 37564**] was encouraged to mobilize out of bed and
ambulate as tolerated in the postoperative period. By the time
of discharge, he was out of bed ambulating independently in the
hallway with a steady gait.
Prophyl: He was started on SC heparin for DVT prophylaxis after
the thoracic epidural was removed. He was also started on
protonix for stress ulcer prophylaxis.
Heme/ID: His electrolytes were monitored and repleted as needed.
His WBC was trended for evidence of infection and peaked at 15.7
on postop day #4 when he had the CT scan, and trended downward
and remained within normal limits throughout the remainder of
his hospitalization.
His French drain in the right lower pelvis was discontinued on
POD # 7 and a dry dressing was applied to the site.
He is preparing for discharge home with VNA services to monitor
his blood pressure. He has [**Doctor First Name **] appointment with this primary
care provider and the acute care service.
Medications on Admission:
Diltiazem ER 120 mg daily
Folic acid 2mg daily
Acyclovir 400 TID
Dapsone 100 daily
Vit D3 1000u daily
Discharge Medications:
1. dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] HomeCare
Discharge Diagnosis:
Status post Hartmann's procedure with end descending colostomy
for perforated diverticulitis
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 a reversal of your
colostomy. You are now being discharged home with the following
instructions:
Your blood pressure was elevated while you were in the hospital
and your home medications were changed. You should follow up
with your primary care physician regarding these changes.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than [**10-18**] lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
HOW YOU [**Month (only) **] FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Your staples will be removed next week at your postoperative
visit.
Your incisions may be slightly red around the staples. This is
normal.
You may gently wash away dried material around your incision.
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Ove the next 6-12 months, your incision will fade and become
less prominent.
MEDICATIONS:
Your blood pressure medication was changed as noted above.
Please follow up with your primary care doctor to discuss these
changes. If you have any questions about what medicine to take
or not to take, please call the clinic ([**Telephone/Fax (1) 600**]).
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: TUESDAY [**2110-11-25**] at 9:45 AM
With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 853**] ACUTE CARE CLINIC
Phone: [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: Primary Care
Name: Dr. [**First Name8 (NamePattern2) 3742**] [**Last Name (NamePattern1) 67002**]
When: Wednesday [**2110-11-26**] at 2:30 PM
Location: [**Location 84798**] FAMILY PHYSICIANS
Address: 520 [**Location (un) **] TPKE., STE M, [**Location (un) **] [**Location 84798**],[**Numeric Identifier 82874**]
Phone: [**Telephone/Fax (1) 84799**]
Completed by:[**2110-11-21**]
|
[
"273.3",
"V55.3",
"593.9",
"562.10",
"278.00",
"574.20",
"780.62",
"518.0",
"401.9",
"786.8",
"V10.52",
"E933.1",
"357.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.71",
"46.52",
"51.22"
] |
icd9pcs
|
[
[
[]
]
] |
7452, 7515
|
2258, 6736
|
346, 562
|
7651, 7651
|
2034, 2235
|
10851, 11640
|
1733, 1758
|
6889, 7429
|
7536, 7630
|
6762, 6866
|
7802, 10828
|
1773, 2015
|
249, 308
|
590, 1216
|
7666, 7778
|
1238, 1604
|
1620, 1717
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,718
| 143,321
|
20842
|
Discharge summary
|
report
|
Admission Date: [**2102-7-24**] Discharge Date: [**2102-8-9**]
Date of Birth: [**2027-3-26**] Sex: F
Service: CSU
CHIEF COMPLAINT: Shortness of breath and dyspnea on
exertion.
HISTORY OF PRESENT ILLNESS: 75 year old female who presented
to the Emergency Room at [**Hospital 1474**] Hospital with a chief
complaint of shortness of breath and dyspnea on exertion. The
patient has been having symptoms since Saturday prior to
admission and the patient stated that she had low grade fever
and has been taking Tylenol without any improvement. The
patient denied any and all chest pain, with the exception of
deep coughing and sensation at that time. The patient has
had pulling sensation in the left side of her chest and has
been feeling this only when she is coughing. The patient
denies persistent chest pain and denies any nausea and
vomiting. She does state that she has been having some
difficulty performing her normal activities of daily living
due to shortness of breath. The patient was diagnosed as
having acute coronary syndrome, based on electrocardiogram
which showed a Q wave with ST segment elevation around leads
2, 3 and AVF. The patient was then transferred to the [**Hospital1 1444**] for cardiac catheterization.
PAST MEDICAL HISTORY: History of hypertension, congestive
heart failure, chronic obstructive pulmonary disease, lung
cancer, seizures; status post hysterectomy; status post
appendectomy;s/p lung lobectomy; status post hernia repair.
MEDICATIONS:
1. Multi-vitamin.
2. Prozac.
3. Aspirin.
4. Verapamil.
5. Tegretol.
6. Albuterol inhaler.
7. Diovan.
8. Doxazosin.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: At [**Hospital1 1474**], the patient had a
temperature of 99; heart rate of 98; blood pressure 127/67;
respiration rate of 18; saturating 91 percent. The patient
had a wheezy sound throughout the bilateral lungs on
examination. Heart was regular rhythm and sinus. Abdomen
was soft, nontender, nondistended. No other major physical
examination findings.
LABORATORY DATA: On admission, the patient's white count was
6.8; hematocrit of 31.6 and platelets of 193. Sodium was
136; potassium of 4; chloride of 102; bicarbonate of 23;
glucose of 100; BUN of 11; creatinine 0.7; calcium was 8.9.
Urinalysis was negative. CK was 96. CK MB was 9.7.
Troponin was 6.1.
HOSPITAL COURSE: The patient was transferred to [**Hospital1 346**] cardiology service where the patient
underwent a right coronary artery stent placement. The
patient underwent percutaneous transluminal coronary
angioplasty of the stent. Post procedure, the patient went
into cardiogenic shock with 4 plus mitral regurgitation and
the patient underwent placement of an IABP. Because the
patient did not stabiliz was emergently seen by cardiac t
stabilize, she was taken for emergent mitral valve
replacement. The patient's heart rate was in the 130's and
blood pressure was 90/50 with the intra-aortic balloon pump.
The patient underwent an emergent mitral valve regurgitation
for cardiogenic shock, with low ejection fraction and severe
mitral regurgitation with
rupture of the mitral cords and posterior leaflet
and anterior leaflet. The patient was then transferred to
the CSRU for close monitoring.
Postoperatively, the patient was stable. The patient had a
bout of atrial fibrillation subsequent to surgery. On
postoperative day number one, the patient was on epinephrine,
Dobutamine, Levophed and Propofol and Amiodarone for drips
for management of hemodynamics. The patient remained
afebrile with stable vital signs with cardiac index low at
1.4. MB of 48. The patient's saturations were low at 70
percent. The patient was continued to be intubated on IMV
and the patient was making good urine. The patient was
weaned off the oxygen and the patient was continued to be
n.p.o. until extubation.
On postoperative day number one, the patient was weaned off
of epinephrine, Dobutamine and Levophed and atrial
fibrillation was converted. The intra-aortic balloon pump
was removed. The patient remained afebrile with junctional
heart rate at 60; otherwise, the patient had good gas and
good urine output. The patient was weaned from the
epinephrine and the patient was doing well.
On postoperative day number three, the patient continued to
be intubated. On postoperative day number five, the patient
became really tired on C-Pap at 5 and 5. The patient's
pressure peep was increased to 15. The patient remained
afebrile with stable vital signs, making good urine. The
patient had a chest x-ray which showed some effusion on the
right. The patient was weaned slowly off the ventilator and
aspirin and Lasix were started. On postoperative day number
seven, the patient had increase in agitation and anxiety
overnight. The patient had a stable white count of 11.6 and
was taking in 1600 cc of p.o. and making good urine. Chest x-
ray was reviewed and the patient was continued on tube feeds.
On postoperative day number eight, the patient had increase
in oxygen requirement on the ventilator and increased
ventilatory support. The patient had increase in work of
breathing. The patient had a chest x-ray and the patient's
Lasix was stopped. On postoperative day number nine, the
patient remained in sinus bradycardia with some aspirin and
Amiodarone. The patient's temperature maximum was 103.6 and
the patient was pan cultured. Otherwise, the patient was
doing well. The patient was continued on Propofol and the
Neo drip was decreased and she was doing well and continued
to be intubated. The patient was also seen by infectious
disease for elevated temperature. They questioned the
possibility of development of pneumonia and advised treatment
of the patient with Vancomycin. Overall, the patient was
doing well.
On postoperative day number ten, the patient had the need for
Neo at 1.1, otherwise, the patient was doing well. She had a
low grade temperature of 100.8. Otherwise, she remained
afebrile with stable vital signs. On postoperative day
number 11, the patient was weaned down on the vent and the
patient's Swan was removed and the patient's Neo was stopped.
The patient remained afebrile with stable vital signs. The
patient had right upper quadrant ultrasound which showed
sludge and slightly distended gallbladder and small wall
thickening. Otherwise, the patient was saturating well and
was making good urine.
The patient's sputum culture grew out Methicillin resistant
Staphylococcus aureus and the patient was continued on
Vancomycin and the Zosyn was stopped on postoperative day
number 12. The patient remained afebrile with stable vital
signs and was making good urine. White count was 17.6. The
patient was weaned from the Lasix; however, the patient
required reintubation. On postoperative day number 13, the
patient had no major events. The patient had stable vital
signs and was making good urine. The patient had Amiodarone
run started and was kept n.p.o. with Foley. The patient's
chest tube was removed without any difficulty and repeat
chest x-ray showed that there was no pneumothorax. The
feeding tubes were in good place. The patient underwent
tracheostomy. Please see the procedure note for further
details. The patient tolerated the tracheostomy without any
difficulty.
On postoperative day number 14, the patient continued to
remain afebrile with stable vital signs and was continued on
Amiodarone and aspirin. The patient made good urine. The
patient continued to do well on Percocet and the patient's
tracheostomy collar was weaned. Otherwise, the patient's
medications were continued. Physical therapy evaluated the
patient and recommended rehabilitation placement for the
patient. The patient also obtained a PICC line for long term
Vancomycin treatment per recommendations by infectious
disease for approximately 21 days.
The patient did well postoperatively. The patient was
discharged to the nursing home.
FINAL DIAGNOSES: Mitral regurgitation.
Cardiogenic shock.
Status post emergent mitral valve replacement.
Congestive heart failure.
Chronic obstructive pulmonary disease.
Status post percutaneous transluminal coronary angioplasty
and stent of right coronary artery for acute myocardial
infarction.
Failure to wean from the ventilator.
Status post emergent VR and status post percutaneous
tracheostomy.
MEDICATIONS:
1. Vancomycin 750 mg intravenous q. 12 hours.
2. Percocet, one to two tabs q. Four to six hours prn for
pain.
3. Aspirin 325 mg p.o. q day.
4. Colace 150 mg and 50 ml liquid p.o. twice a day.
5. Fluticasone propionate 110 mcg two puffs twice a day.
6. Albuterol 90 mcg, one to two puffs inhaled.
7. Albuterol 90 mcg at one to two puffs inhaled.
8. Amiodarone 200 mg p.o. q. Day.
9. Plavix 75 mg p.o. q day for three months.
DISPOSITION: Discharged to rehabilitation.
CONDITION ON DISCHARGE: Good.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Doctor Last Name 6052**]
MEDQUIST36
D: [**2102-8-9**] 01:15:08
T: [**2102-8-9**] 05:36:27
Job#: [**Job Number 55510**]
|
[
"424.0",
"785.51",
"410.41",
"518.81",
"427.31",
"428.0",
"496",
"482.41",
"780.39"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.61",
"36.07",
"99.04",
"39.61",
"33.22",
"88.56",
"36.01",
"99.07",
"31.1",
"35.23",
"99.05",
"37.23",
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icd9pcs
|
[
[
[]
]
] |
2368, 7956
|
7974, 8853
|
1683, 2350
|
151, 197
|
226, 1257
|
1280, 1660
|
8878, 9147
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,129
| 182,657
|
1395
|
Discharge summary
|
report
|
Admission Date: [**2176-10-7**] Discharge Date: [**2176-10-15**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4052**]
Chief Complaint:
PNA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
85 y/o with CLL, CAD s/p 3V CABG admitted with 3-5 days of dry,
non-productive cough which did not improve with codeine cough
syrup. Denies fever, chills, CP, sob, dysuria, hemoptysis, HA
but was found to be febrile to 104 rectal in the ED. CXR done in
ED showing RLL PNA. IN ED, systolics dipped into 90's, but
resolved - possibly after pt received 3L NS. Lactates 1.9--1.0.
Admitted for "code sepsis" but never met criteria.
Hemodynamically stable in MICU overnight.
.
Patient says that he has also had [**3-8**] mechanical falls this past
month which he attributes to "hurrying" - denies syncope,
presyncope, dizziness, weakness prior to falls.
Past Medical History:
Acute rheumatic fever, which then required mitral valve
replacement (St. [**Male First Name (un) 1525**])
Three-vessel CABG for coronary artery disease
Hyperlipidemia
Skin cancer
Social History:
Lives at home. Denies tobacco, alcohol or drug use.
Family History:
Non-contributory
Physical Exam:
VS: 116/51 83 20 96%
GEN: elderly man, NAD
HEENT: AT, NC, anicteric, EOMI, OP clear, MMM
CV: RRR, intermittent pronounced harsh click
PULM: diffuse crackles at BL lung bases
ABD: soft, obese, NT, ND, + BS
EXT: no edema
NEURO: no focal deficits
Pertinent Results:
CXR ([**10-8**]):There is a right lower lobe infiltrate. No definite
pleural effusions are identified.
.
Head CT ([**10-8**]): There is no evidence of acute intracranial
hemorrhage, mass effect, shift of normally midline structures,
major vascular territorial infarcts. The [**Doctor Last Name 352**]-white matter
differentiation is preserved. There is prominence of the sulci
and the ventricles, consistent with brain atrophy. There is a
hypodense area within the left cerebellum that likely represents
an old infarct. There is marked mucosal thickening of the
bilateral maxillary sinuses. The visualized portions of the
other paranasal sinuses are normally
aerated. MPRESSION: 1. No evidence of acute intracranial
hemorrhage.
2. Sinus disease, as described above.
.
[**2176-10-7**] 09:58PM LACTATE-1.2
[**2176-10-7**] 07:57PM URINE RBC-0-2 WBC-[**3-9**] BACTERIA-RARE YEAST-NONE
EPI-<1
[**2176-10-7**] 07:29PM GLUCOSE-169* UREA N-61* CREAT-2.3* SODIUM-137
POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-21* ANION GAP-16
[**2176-10-7**] 07:29PM ALT(SGPT)-69* AST(SGOT)-80* CK(CPK)-318* ALK
PHOS-70 AMYLASE-50 TOT BILI-1.8*
[**2176-10-7**] 07:29PM CK-MB-4 cTropnT-0.03*
[**2176-10-7**] 07:29PM ALBUMIN-3.4 CALCIUM-9.2 PHOSPHATE-2.6*
[**2176-10-7**] 07:29PM CORTISOL-88.7*
[**2176-10-7**] 07:29PM WBC-26.9* RBC-2.80* HGB-9.6* HCT-28.1*
MCV-100* MCH-34.4* MCHC-34.4 RDW-15.0
[**2176-10-7**] 07:29PM NEUTS-28* BANDS-0 LYMPHS-71* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2176-10-7**] 07:29PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+
BURR-OCCASIONAL
[**2176-10-7**] 07:29PM PLT SMR-NORMAL PLT COUNT-301#
[**2176-10-7**] 07:29PM PT-24.6* PTT-43.0* INR(PT)-4.4
[**2176-10-7**] 07:28PM LACTATE-1.7 K+-4.7
Brief Hospital Course:
# SOB: Patient received Vancomycin and Levoquin in the ED and
was initially admitted to the MICU for code sepsis and watched
overnight. There was no evidence of sepsis so the patient was
then transferred to medicine. Patient spiked a fever to 101.6
and he was given 500 mg azithromycin to treat presumptive
sinusitis found on CT as well as his pneumonia. He was also
placed on IV ceftriaxone. His symptoms improved significantly
but he continuedto desaturate downt o the 80's with ambulation.
Ceftriaxone was changed to cefpodoxime and Lasix was increased
to 40 mg PO QD. His O2 saturation while ambulating improved and
patient was able to maintain a level greater than 90% without
supplemental oxygen. He was discharged home to complete a full
14 day course of cefpodoxime.
.
# Anemia - Per report baseline is 34-38. He recived one unit of
PRBC for decreased hematocrit in the MICU. Iron studies were
consistent of anemia of chronic disease. Patient was started on
iron supplements.
.
# ARF - Patient was initially admitted with creatinine elevated
from baeline. Patient was treated with gentle hydration and
creatinine returned to baseline.
.
# increaseds LFTS - Patient was found to have elevated LFT's on
admission. Patient has known CLL so there was concern for
malignancy affecting the liver. Patient denied any pain.
Lipitor was held. A right-upper quadrant ultrasound revealed:
"a 1 cm hyperechoic nodule in segment 2 of the left lobe of the
liver, probably representing hemangioma, and small gallstones
with sludge, without evidence of acute cholecystitis" ALT, AST,
and Bilirubin were all trending down by day of discharge.
.
#CAD/CHF: Initially euvolemic on exam there appeared to be some
mild overload later during his stay, likely secondary to the IV
fluid hydration he had been reciving for his ARF in the setting
of decreased diuretics. The volume overload was treated with
lasix and patient was started on a daily dose of oral Lasix.
.
# PPX: Patient was initially supratherapeutic. Coumadin was
titrated to target range between 2.5-3.5 and closely monitored
in the setting of antibiotics.
.
# full code
.
Medications on Admission:
enalapril
atenolol
hctz
lipitor
coumadin
folic acid
Discharge Medications:
1. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [**5-14**]
MLs PO Q6H (every 6 hours) as needed for cough.
Disp:*qs ML(s)* Refills:*0*
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Warfarin 2 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*0*
5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
7. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 11 days: PLease take for 14 days ([**Date range (1) 8406**]).
Disp:*22 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Community Acquired pneumonia
Congestive Heart Failure
Acute Renal Failure
Anemia of Chronic Disease
Discharge Condition:
Stable
Discharge Instructions:
Please take all medications as instructed. Increase your
activity as tolerated. Call your PCP if you develop increased
shortness of breath, fatigue, diarrhea, or recurrent fevers
immediately.
If you develop shortness of breath which does not go away with a
couple of minutes of rest, please call Dr. [**Last Name (STitle) 1266**]
immediately. If he is not available or if the shortness of
breath is severe, please call 911.
We are discharging you with a new medication called Lasix.
Please be sure to mention it to Dr. [**Last Name (STitle) 1266**] at your next
visit.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 1266**] in 1 week after discahrge. You
should have your liver tests rechecked at that time. You also
need to have your INR monitored. The antibiotics have made it
high.
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5026**], MD Phone:[**Telephone/Fax (1) 3237**]
Date/Time:[**2176-10-23**] 1:00
Provider: [**Name10 (NameIs) **],HEM/ONC HEMATOLOGY/ONCOLOGY-CC9
Date/Time:[**2176-10-23**] 1:00
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 4055**]
|
[
"428.0",
"204.10",
"401.9",
"272.4",
"414.00",
"584.9",
"V45.81",
"486",
"V43.3",
"285.29"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6332, 6390
|
3342, 5481
|
267, 274
|
6534, 6543
|
1538, 3319
|
7163, 7751
|
1240, 1258
|
5583, 6309
|
6411, 6513
|
5507, 5560
|
6567, 7140
|
1273, 1519
|
224, 229
|
302, 952
|
974, 1154
|
1170, 1224
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,459
| 158,282
|
25363
|
Discharge summary
|
report
|
Admission Date: [**2177-8-22**] Discharge Date: [**2177-9-15**]
Date of Birth: [**2097-12-19**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine / Penicillins
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
CC:[**CC Contact Info 63438**]
Major Surgical or Invasive Procedure:
RUL, RML, superior seg of RLL resection
History of Present Illness:
79 yo female with hx of HTN, presented to a cardiologist(Dr.
[**Last Name (STitle) 11493**] for a 1 month hx of productive cough. There an EKG
revealed new T-wave inversions and patient was sent to [**Hospital **], where she had elevated Trop I of 0.36. Patient started
on nirto gtt and lovenox. She also had a CT scan that revealed a
RUQ mass, and a bronch was done. There were no endobronchial
lesions, but the R upper lobe revealed easy friability,
bronchial washings were negative for malignant cells, and
bronchial cx were positive for diptheroids. Patient was
imperically treated with Levofloxacin and then switched to
clindamycin. Patient was recommended to have a pneumonectomy,
but wanted a 2nd opinion and no furter work-up had been done.
She was sent to [**Hospital1 18**] for further work-up.
At [**Hospital1 18**] the patient was found to have ischemic EKG changes
(exact same T-wave inversions in anterolateral leads), but
remained asymptomatic. Two sets of cardiac enzymes were
negative. The patient was transferred to Gen Med service for
further work-up of her lung mass.
Upon admission she had a CXR and repeat chest CT showing a
necrotic mass occupying the entire right upper lobe and
occluding the right upper lobe bronchus. The patient's Abx were
stopped due to diarrhea, C.diff toxin was sent, and the patient
was started on Unasyn and flagyl. A PPD was placed and the
patient was put on respiratory contact precautions.
The patients reports not feeling well for several months,
experiencing weakness and occasional fevers. Her cough produces
a white sputum; no hemoptysis. She has SOB at rest. She also
reports a 10 lb weight loss over the last month, and decreased
appetite. She denies chills, sweats, chest pain, or diarrhea.
She is a lifetime non-smoker.
Past Medical History:
PMHx:
1. hypertension
2. Lung Mass
Social History:
SHx:widow, lives with her daughter in [**Name (NI) **], lifetime
non-smoker,
no ETOH, no Hx of TB exposure, active
Family History:
FHx: No CAD and no Cancer
Physical Exam:
PE: 98.9, 150/64, 94, 20, 98% on 2L
NAD, A and O times 3
NCAT, EOMI, OP clear
RRR, no M
CTA with wheexes on R
+BS, soft, NT, ND, guiac negative.
no c/c/e
cn II-XII intact, MAEW
Pertinent Results:
[**2177-8-22**] 07:08PM PT-12.0 PTT-31.2 INR(PT)-0.9
[**2177-8-22**] 07:08PM PLT COUNT-494*
[**2177-8-22**] 07:08PM NEUTS-85.5* LYMPHS-8.8* MONOS-3.4 EOS-2.0
BASOS-0.2
[**2177-8-22**] 07:08PM WBC-13.8* RBC-3.55* HGB-10.2* HCT-31.1*
MCV-88 MCH-28.9 MCHC-33.0 RDW-11.9
[**2177-8-22**] 07:08PM ALBUMIN-3.3* CALCIUM-8.5 PHOSPHATE-2.6*
MAGNESIUM-1.9
[**2177-8-22**] 07:08PM CK-MB-5 cTropnT-0.01
[**2177-8-22**] 07:08PM ALT(SGPT)-22 AST(SGOT)-21 LD(LDH)-263*
CK(CPK)-145* ALK PHOS-77 AMYLASE-57 TOT BILI-0.2
[**2177-8-22**] 07:08PM GLUCOSE-164* UREA N-9 CREAT-0.6 SODIUM-135
POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-26 ANION GAP-14
[**2177-8-22**] 09:44PM URINE RBC-2 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2177-8-22**] 09:44PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2177-8-22**] 09:44PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2177-8-25**] 07:40AM BLOOD Glucose-110* UreaN-7 Creat-0.4 Na-136
K-3.8 Cl-101 HCO3-26 AnGap-13
[**2177-8-27**] 11:00AM BLOOD Glucose-128* UreaN-11 Creat-0.5 Na-131*
K-3.6 Cl-93* HCO3-29 AnGap-13
[**2177-9-2**] 01:10PM BLOOD Glucose-124* UreaN-9 Creat-0.7 Na-136
K-3.2* Cl-99 HCO3-29 AnGap-11
[**2177-9-4**] 02:51AM BLOOD Glucose-107* UreaN-14 Creat-0.8 Na-142
K-3.9 Cl-110* HCO3-22 AnGap-14
[**2177-9-8**] 12:35AM BLOOD Glucose-131* UreaN-23* Creat-0.6 Na-150*
K-4.2 Cl-119* HCO3-27 AnGap-8
[**2177-9-10**] 06:34PM BLOOD K-4.2
[**2177-9-13**] 11:20AM BLOOD UreaN-6 Creat-0.5 K-2.4*
[**2177-9-14**] 05:55AM BLOOD Glucose-115* UreaN-6 Creat-0.5 Na-137
K-3.2* Cl-100 HCO3-28 AnGap-12
[**2177-9-3**] 02:49PM BLOOD WBC-17.9*# RBC-3.24* Hgb-9.7* Hct-27.5*
MCV-85 MCH-30.1 MCHC-35.4* RDW-13.8 Plt Ct-108*#
[**2177-9-4**] 02:51AM BLOOD WBC-9.8 RBC-3.46*# Hgb-10.3*# Hct-29.5*#
MCV-85 MCH-29.6 MCHC-34.7 RDW-14.5 Plt Ct-150#
[**2177-9-5**] 03:45AM BLOOD WBC-15.9* RBC-3.64* Hgb-11.2* Hct-31.6*
MCV-87 MCH-30.6 MCHC-35.3* RDW-15.2 Plt Ct-179
[**2177-9-6**] 02:16AM BLOOD WBC-9.3 RBC-3.47* Hgb-10.4* Hct-30.1*
MCV-87 MCH-30.0 MCHC-34.7 RDW-15.3 Plt Ct-235
[**2177-9-8**] 12:35AM BLOOD WBC-6.4 RBC-3.41* Hgb-10.4* Hct-31.0*
MCV-91 MCH-30.5 MCHC-33.5 RDW-15.0 Plt Ct-281
[**2177-9-10**] 02:47AM BLOOD WBC-13.5*# RBC-3.89* Hgb-11.9* Hct-35.7*
MCV-92 MCH-30.6 MCHC-33.3 RDW-14.6 Plt Ct-308
[**2177-9-11**] 05:06AM BLOOD WBC-9.3 RBC-4.16* Hgb-12.6 Hct-37.5
MCV-90 MCH-30.4 MCHC-33.7 RDW-14.5 Plt Ct-283
[**2177-8-23**] 06:43AM BLOOD Neuts-73* Bands-9* Lymphs-11* Monos-6
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2177-8-29**] 08:35AM BLOOD Neuts-85.8* Lymphs-8.6* Monos-4.1 Eos-1.2
Baso-0.2
[**2177-9-6**] 09:48AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2177-9-10**] 06:34PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2177-9-10**] 06:34PM BLOOD Calcium-8.1* Phos-2.6* Mg-1.8
[**2177-9-14**] 05:55AM BLOOD Calcium-8.2* Phos-1.9* Mg-1.8
[**2177-8-23**] 06:43AM BLOOD Triglyc-69 HDL-38 CHOL/HD-2.8 LDLcalc-54
[**2177-9-8**] 10:21AM BLOOD Type-ART Temp-36.6 Rates-/28 FiO2-50
pO2-102 pCO2-52* pH-7.34* calHCO3-29 Base XS-0 Intubat-NOT
INTUBA
[**2177-9-9**] 05:57AM BLOOD Type-ART pO2-180* pCO2-47* pH-7.39
calHCO3-30 Base XS-3
[**2177-9-9**] 11:25PM BLOOD Glucose-115* Lactate-1.0 K-3.3*
Brief Hospital Course:
Ms [**Known lastname 63439**] was originally admitted to [**Hospital Unit Name 196**] for evaluation of her
ischemic EKG changes. She was stablized and transferred to
Medicine for work-up of her lung mass. She underwent evaluation
by Thoracic Surgery and on HD 13 underwent an uncomplicated RUL,
RML, and superior segment of RLL resection with placement of
chest tubes and JP drain for intercostal flap. AdenoCA of lung
was found on frozen section. Please see OP report for details.
Post-operatively she remained in the ICU intubated. She
gradually improved and was extubated on POD___. She was in
atrial fibrillatin post-operatively and was converted into sinus
rhythm on POD__, and was maintained on amiodarone. She was able
to be transferred to the floor on POD___ and continued to do
very well. Her chest tubes were removed on POD__ and her JP
drian remained. She eventually was weened off of oxygen and
ambulated well. She was able to be dicharged home on POD 12
with home physical therapy and drain managment services.
Medications on Admission:
Medications on Transfer:
1. Lopressor 12.5 mg TID
2. Clindamycin 600mg IV Q6H
3. Lovenox 40mg SQ [**Hospital1 **]
4. ASA 325mg QD
5. Nitro Gtt.
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 days.
Disp:*6 Tablet(s)* Refills:*0*
3. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day:
Start on [**9-19**] after completion of twice a day dosing.
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 3765**] Home Care
Discharge Diagnosis:
s/p RUL, RML, and superior segment RLL resection with chest
tubes
HTN
A Fib s/p conversion
Discharge Condition:
stable, tolerating POs, oxygenating well, afebrile
Discharge Instructions:
No heavy lifting for 4 wks.
No tub bathing for 3 wks, you may shower.
No driving while using narcotics.
Please call Dr.[**Last Name (STitle) 63440**] office for fevers >101.4, chest pain,
shortness of breath, increased productive cough, worsening pain,
redness or drainage from insicion sites, or any concerns.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Doctor Last Name **] [**Telephone/Fax (1) 11650**]
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 2389**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 170**] Call for appointment
in 1 wk
Completed by:[**2177-11-17**]
|
[
"196.1",
"427.31",
"416.8",
"197.2",
"482.81",
"401.9",
"253.6",
"513.0",
"934.1",
"162.8",
"518.5",
"518.0",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"32.4",
"40.3",
"34.91",
"96.6",
"96.72",
"33.48",
"99.04",
"33.24",
"88.56",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
7744, 7805
|
5846, 6884
|
319, 361
|
7940, 7992
|
2627, 5823
|
8351, 8642
|
2388, 2415
|
7078, 7721
|
7826, 7919
|
6910, 6910
|
8016, 8328
|
2430, 2608
|
250, 281
|
389, 2181
|
6935, 7055
|
2203, 2240
|
2256, 2372
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,325
| 118,434
|
38491
|
Discharge summary
|
report
|
Admission Date: [**2106-6-30**] Discharge Date: [**2106-7-5**]
Date of Birth: [**2023-9-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2106-6-30**] AVR(27mm Porcine)/CABGx4(left internal mammary artery to
left anterior descending with vein grafts to diagonal, obtuse
marginal and right coronary artery)
History of Present Illness:
This is an 82 yo male with known aortic stenosis and multivessel
coronary artery disease. Has had increasing SOB and worsening
fatigue. Referred for surgical intervention.
Past Medical History:
aortic stenosis, coronary artery disease
carotid artery disease
polymyalgia rheumatica
hypertension
hyperlipidemia
gout
prior trace rectal bleed
s/p abdominal hernia repair [**2043**]
s/p left 5th finger tendon release [**2097**]
s/p appendectomy [**2045**]
s/p tonsillectomy
Social History:
Lives with: wife
Occupation: retired auto dealer
Tobacco: quit [**2061**]
ETOH: 5 drinks/week
Family History:
Father died of MI at 73. Mother with CVA at 62.
Physical Exam:
Pulse: 61 Resp: 16 O2 sat: 99%RA
B/P Right: 151/80 Left:
Height: 5'[**07**]" Weight: 200lb
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 3/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema- trace edema bilateral ankles
Varicosities- moderate varicosities, left worse than right,
numerous superficial spider veins, venous stasis changes
bilaterally
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit none
Pertinent Results:
[**2106-6-30**] Intraop TEE:
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect 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%).
Right ventricular chamber size and free wall motion are normal.
There are focal calcifications in the aortic arch. There are
complex (mobile) atheroma in the descending aorta.
The aortic valve leaflets (3) 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. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen.
There is no pericardial effusion.
POST-BYPASS:
Preserved biventricular systolic function.
Intact thoracic aorta.
The aortic bioprosthesis is stable and functioning well with a
residual mean gradient of 12mm of HG.
Trivial MR [**First Name (Titles) **] [**Last Name (Titles) **].
[**2106-7-4**] 05:36AM BLOOD WBC-11.3* RBC-3.33* Hgb-10.6* Hct-30.5*
MCV-92 MCH-31.8 MCHC-34.7 RDW-14.6 Plt Ct-145*
[**2106-6-30**] 04:18PM BLOOD PT-15.2* PTT-41.7* INR(PT)-1.3*
[**2106-7-5**] 04:07AM BLOOD Glucose-101* UreaN-32* Creat-1.2 Na-136
K-3.8 Cl-102 HCO3-27 AnGap-11
[**2106-7-4**] 05:36AM BLOOD UreaN-33* Creat-1.2 Na-137 K-4.1 Cl-104
Brief Hospital Course:
Mr. [**Known lastname 85644**] was admitted and underwent an aortic valve
replacement and coronary artery bypass grafting surgery by Dr.
[**Last Name (STitle) 914**]. For surgical details, please see operative note.
Following surgery, he was brought to the CVICU for invasive
monitoring. Within 24 hours, he awoke neurologically intact and
was extubated without incident. His CVICU course was otherwise
uneventful. Beta blocker was initiated and the patient was
gently diuresed toward the preoperative weight. The patient was
transferred to the telemetry floor for further recovery. Chest
tubes and pacing wires were discontinued without complication.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility. He had a brief episode
of afib which converted to SR with beta blocker titration and
amiodarone. By the time of discharge on POD 5 the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged to home in
good condition with appropriate follow up instructions.
Medications on Admission:
HCTZ 25 mg daily
Allopurinol 100 mg daily
ASA 81 mg daily
Lisinopril 20 mg daily
Prednisone 5 mg [**Hospital1 **]
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Psyllium Packet Sig: One (1) Packet PO TID (3 times a
day) as needed for constipation.
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Outpatient Lab Work
Serial PT/INR
dx: atrial fibrillation
goal INR [**2-10**]
Please call results to Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 85645**]
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
12. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: dose
will change daily for goal INR [**2-10**], Dr. [**First Name (STitle) **] to manage,
first lab draw by VNA [**2106-7-6**].
Disp:*30 Tablet(s)* Refills:*2*
13. Lisinopril 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*0*
14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10
days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1376**] [**Hospital3 635**]
Discharge Diagnosis:
Coronary Artery Disease, Aortic Stenosis - s/p AVR (#27
tissue)/CABG x4 on [**2106-6-27**]
Hypertension
Dyslipidemia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage. Edema [**1-9**]+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You have been scheduled to see your surgeon
Dr. [**Last Name (STitle) 914**] on [**2106-8-3**] at 1pm [**Telephone/Fax (1) 170**]
Plaese call and schedule the following appointments
Dr. [**First Name8 (NamePattern2) 4115**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 85645**] in [**1-9**] weeks
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10168**] in [**1-9**] weeks 1-[**Telephone/Fax (1) 70181**]
**VNA to draw INR [**7-6**] and call results to Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 85646**] for management of coumadin dosing**
Completed by:[**2106-7-5**]
|
[
"458.29",
"414.01",
"272.4",
"427.89",
"725",
"599.71",
"427.31",
"424.1",
"401.9",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"36.13",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6529, 6600
|
3496, 4584
|
338, 511
|
6761, 6979
|
1973, 3473
|
7733, 8341
|
1140, 1190
|
4749, 6506
|
6621, 6740
|
4610, 4726
|
7003, 7710
|
1205, 1954
|
279, 300
|
539, 712
|
734, 1012
|
1028, 1124
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,262
| 166,276
|
44343
|
Discharge summary
|
report
|
Admission Date: [**2130-5-4**] Discharge Date: [**2130-5-7**]
Date of Birth: [**2049-8-19**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Placement of subclavian dual chamber pacemaker
History of Present Illness:
80-year-old Russian-speaking woman with aortic stenosis status
post aortic valve repair, presenting with dyspnea and complete
heart block. She underwent aortic valve replacement and septal
myectomy in [**2126**], then subsequently developed aortic
insufficiency and recurrent aortic stenosis. Her activity has
been limited by her AS to about [**Age over 90 **] yards of walking. Today her
home health aide found her dizzy and short of breath. EMS was
called and found her to be in complete heart block on ECG. She
was given atropine and brought to the ED.
In the ED, initial vitals were HR 42, BP 100/80. She was short
of breath at rest, but concious and mentating well. She appeared
somewhat volume overloaded. She was given 2L of IV fluids. EP
was consulted and recommended pacemaker placement in the
morning. A temporary wire was not necessary at this time due to
her narrow complex and hemodynamic stability. On admission, her
vitals were 97.8-38-102/56 to 87/65-20-99% 2LNC.
In the CCU, she is dyspneic with any movement, but comfortable
at rest. She is mentating well. She was given 20mg IV lasix
immediately and a foley was placed for UOP monitoring.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
ankle edema, palpitations, syncope or presyncope
Past Medical History:
Hypertension
Hyperlipidemia
Aortic Stenosis
Osteoporosis
aortic valve replacement for aortic stenosis with a tissue valve
and septal myectomy in [**2126-10-7**] after successful
two-vessel coronary stenting [**2124**] (RCA, LCX into OM)
Social History:
Lives alone with son close.
- [**Name2 (NI) 1139**] history: 2 pack years about 25 years ago, currently
nonsmoker
- ETOH: none
- Illicit drugs: none
Family History:
Father - lung cancer, died 56
Mother - [**Name (NI) 11964**]
[**Name (NI) **] family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission:
VS: 45 115/54 17 94% on 2L
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: blind left eye not responsive to light, Right pupil
reactive
NECK: supple, JVP to the right ear
CARDIAC: bradycardic, regular rhythmm, [**4-11**] holosystolic murmur
LUNGS: bibasilar crackles
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
Discharge:
99.1, 139/57, 63, 16, 97% on RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate. Mentating
HEENT: blind left eye not responsive to light, Right pupil
reactive
NECK: supple, no JVD
CARDIAC: RRR, [**4-11**] holosystolic murmur
LUNGS: CTA b/l
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Warm,
well perfused
Pertinent Results:
Admission:
[**2130-5-4**] 03:40PM BLOOD WBC-9.2 RBC-3.67* Hgb-11.0* Hct-35.5*
MCV-97 MCH-30.0 MCHC-31.0 RDW-12.5 Plt Ct-249
[**2130-5-4**] 03:40PM BLOOD Neuts-73.9* Lymphs-19.4 Monos-5.2 Eos-0.9
Baso-0.6
[**2130-5-4**] 03:40PM BLOOD PT-12.0 PTT-28.8 INR(PT)-1.1
[**2130-5-4**] 03:40PM BLOOD Glucose-138* UreaN-26* Creat-0.9 Na-140
K-3.8 Cl-107 HCO3-24 AnGap-13
[**2130-5-4**] 03:40PM BLOOD proBNP-2298*
[**2130-5-4**] 03:40PM BLOOD cTropnT-0.01
[**2130-5-5**] 02:17AM BLOOD CK-MB-3 cTropnT-0.02*
[**2130-5-5**] 02:17AM BLOOD CK(CPK)-76
[**2130-5-4**] 03:40PM BLOOD Calcium-8.9 Phos-4.4 Mg-2.1
.
EKG on adm: Sinus rhythm. Complete heart block. Junctional
escape rhythm at 42 beast per minute. QRS complexes suggest left
ventricular hypertrophy with repolarization changs. Possible
digoxin effect. Compared to the previous tracing of [**2127-10-28**]
third degree A-V block has appeared. Repolarization changes
secondary to left ventricular hypertrophy are more marked.
Imaging:
[**5-5**] TTE: The left atrium is moderately dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF 70%). Right ventricular chamber size
and free wall motion are normal. A bioprosthetic aortic valve
prosthesis is present. A paravalvular aortic valve leak is
probably present. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. There is severe
mitral annular calcification. There is mild functional mitral
stenosis (mean gradient 8 mmHg) due to mitral annular
calcification. Moderate (2+) mitral regurgitation is seen. [Due
to acoustic shadowing, the severity of mitral regurgitation may
be significantly UNDERestimated.] Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2129-1-14**], mild mitral stenosis is now present.
[**5-5**] CXR: There is small left apical pneumothorax. The pacemaker
leads are
unremarkable. They are projecting over the expected location of
right atrium and right ventricle. No pleural effusion is seen.
Cardiomegaly is stable. Lungs are essentially clear.
.
[**5-7**] CXR: In comparison with the study of [**5-6**], there is little
change.
Pacer leads remain in position. No evidence of acute focal
pneumonia or
vascular congestion. Mild enlargement of the cardiac silhouette
persists
.
Discharge labs:
[**2130-5-7**] 07:39AM BLOOD WBC-8.1 RBC-3.48* Hgb-10.8* Hct-33.2*
MCV-96 MCH-31.1 MCHC-32.5 RDW-12.6 Plt Ct-199
[**2130-5-7**] 07:39AM BLOOD Glucose-90 UreaN-25* Creat-0.7 Na-139
K-3.9 Cl-101 HCO3-30 AnGap-12
[**2130-5-7**] 07:39AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.1
Brief Hospital Course:
SUMMARY: 80-year-old woman with history of HTN, HLD, CAD s/p
stenting [**2124**] and aortic stenosis s/p aortic valve repair [**2126**],
admitted for shortness of breath, found to be in complete heart
block, s/p subclavian dual chamber pacemaker on [**2130-5-5**]
.
# Bradycardia: ECG revealed complete heart block. Initially,
patient was stable, and a non-emergent subclavian dual chamber
ppm was placed on [**2130-5-5**]. Post-procedure course was
complicated by a very small apical pneumothorax, which remained
stable. The patient was given peri-procedure antibiotics, and
will complete a course of keflex for prophylaxis.
.
# SOB: Most likely due to volume overload from fluids given in
the ED and CHF from her complete heart block. Improved with
gentle diuresis and ppm placement. Patient was ambulating with
O2 sats >94% on room air prior to discharge
.
# HTN ?????? was on nifedipine, atenolol and valsartan. Initially
held and were restarted prior to discharge. Could consider
changing atenolol to a different medication on an outpatient
basis.
.
# CAD s/p stenting in [**2124**]: Aspirin, Rosuvastatin were
continued - patient was chest pain free this admission.
.
# Osteoporosis: continued calcium and vitamin d supplementation
.
# HLD: Continued Rosuvastatin Calcium (Crestor) 20mg daily
.
=============
TRANSITIONAL ISSUES:
-Needs f/u in device clinic 1 week after discharge
-Consider changing atenolol to alternative [**Doctor Last Name 360**] as an
outpatient
Medications on Admission:
Aspirin 325mg daily
Atenolol-Chlorthalidone 50-25 qAM
Escitalopram (Lexapro) 10mg daily (not taking, not needed)
Nifedipine 90mg daily
Nitroglycerin PRN
Penciclovir (Denavir) 1% cream
KCl 20mEq [**Hospital1 **]
Rosuvastatin (Crestor) 20mg daily
Valsartan (Diovan) 320mg daily
Zolpidem (Ambien) 5mg 1/2tab PRN insomnia
Calcium carbonate (Calcium 500)
Cholecalciferol
Centrum MVI
Discharge Medications:
1. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. atenolol-chlorthalidone 50-25 mg Tablet Sig: One (1) Tablet
PO once a day.
3. nifedipine 90 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily).
4. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tab
Sublingual every 5 minutes up to 3 tabs as needed for chest
pain: If pain persists after 3 tabs, stop and call your doctor
or go to the emergency room.
5. potassium chloride 20 mEq Packet Sig: One (1) PO twice a
day.
6. valsartan 80 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
7. zolpidem 5 mg Tablet Sig: 0.5 Tablet PO at bedtime as needed
for insomnia.
8. cholecalciferol (vitamin D3) Oral
9. Centrum Oral
10. calcium carbonate Oral
11. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 2 days.
Disp:*8 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
Complete heart block
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 and treated for complete heart
block, which is a delay in the electrial wiring of the heart. We
treated this by having a pacemaker placed. It will be important
to make your follow-up appointments as below.
Please note the following medication changes:
-Please START Keflex (an antibiotic) for 2 more days to prevent
infection
Followup Instructions:
****We are working to schedule you an appointment in [**Hospital **]
clinic' for a routine follow-up in 1 week to check your new
pacemaker. If you do not hear from their office within 24 hours
from discharge, please call to confirm the appointment (([**Telephone/Fax (1) 95083**])****
Department: DERMATOLOGY
When: TUESDAY [**2130-5-9**] at 10:00 AM
With: [**Name6 (MD) 2975**] [**Name8 (MD) 2976**], MD [**Telephone/Fax (1) 2977**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: TUESDAY [**2130-5-16**] at 11:10 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3404**], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: FRIDAY [**2130-7-7**] at 11:40 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2130-5-7**]
|
[
"401.9",
"272.0",
"512.1",
"V42.2",
"428.0",
"424.1",
"V45.82",
"426.0",
"733.00",
"428.33",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.83",
"37.72"
] |
icd9pcs
|
[
[
[]
]
] |
9380, 9466
|
6510, 7835
|
288, 337
|
9531, 9531
|
3713, 6202
|
10068, 11298
|
2442, 2632
|
8423, 9357
|
9487, 9510
|
8021, 8400
|
9682, 9950
|
6219, 6487
|
2647, 3694
|
7856, 7995
|
9970, 10045
|
229, 250
|
365, 1998
|
9546, 9658
|
2020, 2258
|
2274, 2426
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
330
| 184,134
|
20137
|
Discharge summary
|
report
|
Admission Date: [**2132-1-15**] Discharge Date: [**2132-1-17**]
Date of Birth: [**2065-6-10**] Sex: M
Service:
HISTORY: Patient is a 66-year-old gentleman and has a
history of coronary artery disease and CHF, and he had an
abdominal aortic aneurysm, which was found on CT scan. The
aneurysm is approximately 5.6 cm infrarenal in diameter,
infrarenal aortic aneurysm.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Gout.
4. COPD.
5. Smoking history.
MEDICATIONS AT HOME:
1. Digoxin.
2. Coumadin.
3. Toprol.
4. Colchicine.
5. Lipitor.
6. Moexipril.
PAST SURGICAL HISTORY: No past prior surgical history.
HOSPITAL COURSE: Patient was admitted on [**1-15**], and
underwent an endovascular abdominal aortic aneurysm repair.
Postoperatively, patient had some respiratory distress, and
remained intubated in the PACU on postoperative day #1, and
patient appeared to go into CHF intraoperatively, and Lasix
was given. The patient's pulmonary status improved after the
diuresis, and patient subsequently underwent a bronch, which
showed no plugging, no secretions, and no signs of CHF, and
patient was subsequently extubated in the recovery room.
Post extubation, the patient did well, and patient was
transferred to the floor. On chest x-ray, the patient
appeared to have a left lower lobe consolidation, question
pneumonia. Patient was started on Levaquin, and patient was
deemed ready for discharge on postoperative day #2. Prior to
discharge, patient was afebrile and vital signs are stable.
Patient was tolerating p.o. and was voiding without a Foley
catheter. Patient's pulse exam: He has bilateral palpable
DPs and good palpable femoral pulses. Patient's incision was
clean, dry, and intact.
FOLLOW-UP INSTRUCTIONS: Patient will be discharged to home
with instructions to followup with Dr. [**Last Name (STitle) **] in [**12-18**]
weeks, and he will have a follow-up CT angiogram here in
about one month.
The patient is to be discharged on all his preoperative home
medications. Also including Levaquin for 10 days.
DISCHARGE MEDICATIONS:
1. Atorvastatin 20 mg p.o. q.d.
2. Colchicine 0.6 mg p.o. q.d.
3. Digoxin 0.25 mg p.o. q.d.
4. Lasix 120 mg p.o. q.d.
5. Lopressor XL 150 mg p.o. q.d.
6. Moexipril 7.5 mg p.o. q.d.
7. Percocet 1-2 tablets p.o. q.4-6h. prn.
8. Coumadin 5 mg p.o. q.h.s.
9. Levaquin 500 mg p.o. q.d. for 10 days.
DISCHARGE DIAGNOSES:
1. Hypertension.
2. Congestive heart failure.
3. Atrial fibrillation.
4. Gout.
5. Status post endovascular abdominal aortic aneurysm repair.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**]
Dictated By:[**First Name (STitle) 53438**]
MEDQUIST36
D: [**2132-1-17**] 08:52
T: [**2132-1-17**] 09:02
JOB#: [**Job Number 54149**]
(cclist)
|
[
"496",
"401.9",
"997.3",
"274.9",
"518.0",
"997.1",
"272.0",
"441.4",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"96.04",
"33.23",
"39.71"
] |
icd9pcs
|
[
[
[]
]
] |
2414, 2845
|
2098, 2393
|
667, 1747
|
514, 592
|
616, 649
|
1772, 2075
|
412, 493
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,281
| 168,911
|
12022
|
Discharge summary
|
report
|
Admission Date: [**2110-3-1**] Discharge Date: [**2110-3-4**]
Date of Birth: [**2028-11-4**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Altered Mental Status, Shortness of Breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is an 81 yo man with CAD s/p 4V CABG ([**2093**]),
chronic sCHF (EF 20-25%), AF on Coumadin, CHB s/p BiV ICD & PPM,
CKD IV, anemia who initially presented to [**Hospital1 **] [**Location (un) 620**] in moderate
respiratory distress with lethargy, endorsing dyspnea and
fatigue, subsequently intubated out of concern for increased
work of breathing, placed LIJ central line, then transferred
here for further management. Also given ASA in setting of
elevated cardiac biomarkers.
.
In our ED initial vitals were T unknown, 87, 100/51, 17, 100% on
100 % Fi02. Labs revealed troponin of 0.15, BNP of [**Numeric Identifier **].
Hyperkalemia with K of 6.2 treated with Calcium Gluconate, 10U
Insulin, Dextrose. Lasix 40 mg IV given with unclear [**Name2 (NI) 37740**]. CXR
with question of left lower lobe infiltrate versus pulmonary
edema. EKG showed ventricular paced. Ceftriaxone given (received
Levaquin at [**Location (un) 620**]). Vitals prior to transfer were 80, 102/46
(on 0.12 levophed), 100% sat on 100% FiO2.
.
Unable to obtain ROS from patient [**2-26**] intubated, sedated. His
family has also gone home for the day.
Past Medical History:
1. Congestive heart failure.
2. Coronary artery disease, status post myocardial infarction
in [**2082**] and status post coronary artery bypass graft in [**2093**].
3. History of ventricular tachycardia, status post ICD and
pacer.
4. History of hyperthyroidism secondary to Amiodarone.
5. Atrial fibrillation/atrial flutter; status post AVJ
ablation.
6. Gout.
7. Stage IV Chronic Kidney Disease (Creatinine [**3-28**]) on EPO
8. Iron Deficiency Anemia
9. Hyperthyroidism secondary to Amiodarone
Social History:
(per records) Quit smoking in [**2093**]. Prior: 2 PPD x 40 years.
Etoh: none. Retired mail carrier.
Family History:
Father: [**Name (NI) 3730**] (per discharge summary)
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T=98.5 BP=109/54 HR=80 RR=20 O2 sat=100%
GENERAL: intubated, sedated, arousable to tactile stimuli
HEENT: NCAT. Sclera anicteric. PER.
NECK: Unable to appreciate JVP 2/2 habitus/neck mass/lines
CARDIAC: PMI displaced laterally, RR, normal S1, S2. +SEM
loudest at apex radiating to axilla consistent with MR
LUNGS: anterior fields mostly CTAB, RLL with occas crackles
ABDOMEN: Soft, non-tender, non-distended, + LUQ linear scar
EXTREMITIES: + clubbing, no edema, R lateral heel ulcer
SKIN: multiple scattered ecchymoses, confluent on forearms
PULSES: unable to palpate DP & PT, but extremities warm
Pertinent Results:
ADMISSION LABS:
[**2110-3-1**] 08:20PM BLOOD WBC-12.9* RBC-3.22* Hgb-9.5* Hct-29.1*
MCV-90 MCH-29.6 MCHC-32.8 RDW-19.2* Plt Ct-110*
[**2110-3-1**] 08:20PM BLOOD Plt Ct-110*
[**2110-3-1**] 08:20PM BLOOD PT-38.2* PTT-38.3* INR(PT)-4.0*
[**2110-3-2**] 01:07AM BLOOD Glucose-57* UreaN-91* Creat-3.9* Na-130*
K-5.9* Cl-101 HCO3-16* AnGap-19
.
DISCHARGE LABS:
n/a
.
STUDIES:
CXR [**2110-3-1**]:
IMPRESSION:
1. Endotracheal tube in adequate position. Orogastric tube
terminates at the GE junction, and should be advanced for
optimal positioning.
2. Left IJ central line extends only to the region of the left
subclavian.
3. Cardiomegaly, with mild volume overload.
4. Dense left basilar opacity, with small to moderate effusion.
It is
unclear whether there is an underlying parenchymal
consolidation. Clinical correlation is advised.
.
CT HEAD WITHOUT [**2110-3-1**]:
IMPRESSION:
1. No acute intracranial hemorrhage.
2. Findings suggest extensive sequelae of chronic small vessel
ischemic
disease; however, in this setting (and given the lack of prior
studies
available for comparison), a small acute infarct cannot be
excluded and MRI, if feasible, is recommended for further
evaluation if there is clinical concern.
3. Paranasal sinus chronic inflammatory disease, as above.
.
TTE [**2110-3-3**]:
Conclusions
The left atrium is elongated. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is severely
depressed (LVEF= 25 %). with depressed free wall contractility.
The number of aortic valve leaflets cannot be determined. The
aortic valve leaflets are moderately thickened. There is a
minimally increased gradient consistent with minimal aortic
valve stenosis. There is severe mitral annular calcification.
There is mild valvular mitral stenosis (area 1.5-2.0cm2).
Moderate to severe (3+) mitral regurgitation is seen. Moderate
to severe [3+] tricuspid regurgitation is seen. There is
moderate 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 no pericardial effusion.
.
MICRO:
URINE CX [**2110-3-1**]: NO GROWTH
URINE CX [**2110-3-2**]: NO GROWTH
URINE CX [**2110-3-3**]: PENDING
.
BLOOD CX [**2110-3-1**]: PENDING
BLOOD CX [**2110-3-2**]: PENDING
BLOOD CX [**2110-3-3**]: PENDING
Brief Hospital Course:
HOSPITAL COURSE:
81 yo M with multiple medical problems including CAD s/p CABG,
sCHF (EF 20-25%), Chronic AF on Coumadin, CHB s/p BiV ICD & PPM,
Stage IV CKI, and anemia, presenting with lethargy and
respiratory distress, intubated and on on pressors for
hypotension. Pt continued to decompensate, requiring add'l
pressors, and failed to diurese on medical management. Dialysis
was considered, but after discussion with family, pt was made
CMO. Pt was extubated, and expired shortly thereafter with
family at his side.
.
ACTIVE ISSUES:
# Hypoxic/Hypercapnic Respiratory Failure: Most likely
multifactorial including hypercapnea secondary to lethargy given
elevated PCO2's on admission. Pt also with volume overload and
question of infilrate, resulting in hypoxia. CVP's were elevated
in 20's, suggesting volume overload. PE was considered, but pt
was supratherapeutic on Coumadin on admission, making this
unlikely. He was intubated from the outside hospital. Lasix gtt
was started for pulmonary edema. Broad spectrum antibiotics
Vanc/Cefepime were started for HAP. SvO2's were monitored and
remained in the 70's.
He was maintained on the ventilator with settings adjusted based
on ABG's. Pt was made CMO, and was extubated.
.
# Hypotension: Most likely [**2-26**] cardiogenic; differential
included hypovolemia, distributive, or cardiogenic. Pt appeared
volume overloaded rather than hypovolemic, and had no signs of
acute bleeding on admission. A distributive picture was
considered, though initially thought to be less likely given
that he was afebrile and only mild leukocytosis. LLL opacity
suggested possible PNA, and he was started on broad spectrum abx
as above, and pan-cultured. Pt appeared volume overloaded, and
had a known EF of 20-25% from [**2108**] at [**Location (un) 620**]. He had severely
elevated BNP to 22,000 and CXR suggestive of volume overload.
His CVP remained in the low 20's on monitoring. Lasix gtt was
started, but he failed to have good urine output. His SvO2's
remained in the high 70's. He was continued on levophed initally
for pressor support.
He developed a temperature to 100.3 on evening of hospital day
2. Given concern for sepsis, he was re-cultured, and required
higher doses of levophed and phenylephrine briefly. However, his
fever curve downtrended. A stat TTE demonstrated EF 25%, severe
MR [**First Name (Titles) **] [**Last Name (Titles) **]. Given that his CVP's remained elevated, cardiogenic
shock was thought to be the more likely etiology. He was started
on milrinone drip for afterload reduction, and levophed was
weaned down with phenylephrine to maintain BP.
Despite maximum doses of lasix, he failed to put out adequate
urine output, and renal was consulted for dialysis. However, a
family discussion was held regarding goals of care, and pt was
made CMO. All pressors were discontinued and
.
# Acute on chronic systolic CHF: Hx of ischemic cardiomyopathy.
Echo from [**2108**] with EF of 20-25%, and moderate MR, per [**Hospital1 **]
[**Location (un) 620**] notes. Home meds include dig, lasix, ACE-I. As above,
presented with elevated BNP to 22,000 with clinical evidence of
volume overload. Digoxin was held, and ACEI was also held given
hypotension. As above TTE was repeated, and diuresis was
attempted, but failed. (see rest as above)
.
# Elevated cardiac enzymes: Pt presented with trops to 0.14, and
MB flat. Most likely [**2-26**] acute on chronic renal failure as
below. EKG showed v-pacing without change compared to prior. ASA
325mg was continued.
.
# RHYTHM: Hx of chronic A fib and complete heart block, now with
BiVentricular ICD and PPM. Patient [**Name (NI) **] paced so difficult to
appreciate ST-T wave changes. He was monitored on telemetry. On
admission, his INR was supratherapeutic and Coumadin was held.
.
# Stage IV Chronic Kidney Disease: Acute on chronic renal
failure. Prior baseline from 6 months prior demonstrated Cr 4,
not currently on HD. As above, he failed medical diuresis. His
creatinine rose, and renal was consulted. However,
after discussion with the family, pt was made CMO and HD was not
pursued.
.
# Hyperkalemia: Likely [**2-26**] renal insufficiency and acidosis. He
was treated in the ED with IV calcium gluconate, insulin and
dextrose. No peaked T waves on EKG. Electrolytes were monitored,
and the K improved after lasix and kayexalate briefly. However,
as above, renal was consulted for emergent dialsysis. (see
above)
.
# Hyponatremia: Hypervolemic hyponatremia [**2-26**] heart failure and
renal failure. Urine lytes showed UNa of 33, demonstrating that
pt had innappropriate loss of Na in urine given renal failure.
.
# Prolonged PT: [**2-26**] to likely nutritional deficiency prior to
admission and decreased renal excretion. DIC was considered,
though fibrinogen was normal, and PTT normal. His INR remained
elevated, and was reversed with 2 units of FFP. After made CMO,
no further reversal was pursued.
.
# Metabolic encephalopathy: Multifactorial, including hypoxia,
hypercapnea, possible infection, renal failure, and electrolyte
disturbance. CT head without showed chronic ischemic changes.
Gabapentin was held on admission. He remained intubated, but
able to answer questions and respond while intubated. Pt was
extubated, and made CMO. Pt appeared comfortable at time of
expiration.
.
# Anemia: Chronic. Multiple etiologies including CKI,
Fe-deficiency. Per recent notes, receives EPO as outpatient. Of
note, pt had recent admission for melena in [**Month (only) 1096**], received
2U PRBC with no further investigation by GI. Hct was trended and
remained stable. However, he developed hematuria likely [**2-26**]
foley placement and supratherapeutic INR. He was continued on GI
prophylaxis. Expired as above.
.
# Hx of Amiodarone-induced hyperthyroidism: Continued on PTU 50
mg [**Last Name (LF) 2974**], [**First Name3 (LF) 1017**], Tuesday. PTU was re-dosed based on renal
function.
.
INACTIVE ISSUES:
# Gout: Allopurinol 100 qhs held during admission.
.
# Left submandibular neck mass: fleshy consistency, and without
signs of infection. unclear etiology and unlikely contributing
to current clinical status.
.
TRANSITIONAL ISSUES:
N/A. Pt expired after being made CMO.
Medications on Admission:
HOME MEDICATIONS: (from nursing home)
digoxin 125 mcg 4x/week (M, W, F, Sun)
aranesp 50 mcg SC q 2weeks
allopurinol 100 mg daily
nepro 120 mL [**Hospital1 **]
docusate 100 daily
nystatin S&S 10 cc/daily
Gabapentin 300 [**Hospital1 **]
Ipratropium-Albuterol neb PRN
Immodium PRN
Vitamin C 500 [**Hospital1 **]
Zinc sulfate 220 mg daily X 30 days (stop [**2110-3-30**])
Coumadin 1.5/2
Ferrous sulfate 325 daily
Fosinopril 10 daily
Furosemide 80 daily
MVI
Polyethylene glycol
PTU 50 mg [**Last Name (LF) **], [**First Name3 (LF) **], Tues
Spiriva 18 mcg cap daily
Advair 100/50 daily at 9PM
Omeprazole 20 [**Hospital1 **]
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
n/a
Discharge Condition:
n/a
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2110-3-4**]
|
[
"428.0",
"412",
"285.21",
"E942.0",
"428.33",
"V15.82",
"585.4",
"799.02",
"584.9",
"242.80",
"V45.02",
"V58.61",
"348.31",
"427.31",
"274.9",
"458.9",
"486",
"790.92",
"V45.81",
"518.81",
"276.7",
"414.01",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
12294, 12303
|
5402, 5402
|
345, 351
|
12350, 12355
|
2924, 2924
|
12407, 12440
|
2196, 2250
|
12266, 12271
|
12324, 12329
|
11622, 11622
|
5419, 5923
|
12379, 12384
|
3278, 5379
|
2265, 2275
|
11641, 12243
|
2297, 2905
|
11557, 11596
|
8730, 11309
|
263, 307
|
5938, 8713
|
379, 1533
|
11326, 11536
|
2940, 3262
|
1555, 2060
|
2076, 2180
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,348
| 199,705
|
9088
|
Discharge summary
|
report
|
Admission Date: [**2182-1-10**] Discharge Date: [**2182-1-15**]
Date of Birth: [**2130-8-26**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Fentanyl
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
Endoscopy with banding
History of Present Illness:
This is a 51 yof with hx of EtOH cirrhosis, EtOH abuse who
presented to the [**Hospital1 18**] ED after 10 episodes of emesis at home.
Patient states she has never had hematemesis before. She reports
using heroin 1 day prior to admission. Also reports recent
admission to [**Hospital3 **] and was admitted there for N/V, no
hematemesis and was given blood transfusions and then sent home.
.
In the ED: Temp 97.4, HR 102, BP 122/64, RR 20 100% RA. ETOH
level 351. Hct was 30 and she was started on octreotide gtt, IV
protonix and IV cipro and was given 2 L NS and she was
transferred to the MICU.
.
In the MICU, HCT was found to be decreased to 25. She received 2
units PRBCs. GI was notified and performed and endoscospy which
showed 4 cords of grade II-III varices which was treated with 4
bands. She was continued on octreotide gtt and PPI drip was
discontinued. HCT was trended throughout the day and remained
stable and she was transferred to the medical floor.
.
On arrival to the floor the patient reports 4 episodes of N/V
this morning which were non-bloody, no coffe grounds. She
reports +abdominal pain which has been ongoing for about 1 week.
She denies any fevers but does report chills. No diarrhea.
.
Past Medical History:
- Alcoholic cirrhosis (dx: [**2178**])- complicated by varices,
ascites, encephalopathy
- Chronic pancreatitis (dx: [**2172**]) - on pancrease
- EtOH abuse - history of DT
- Low back pain (dx: [**2172**]) - degenerating L4-6 discs, seen in
pain clinic 8 years ago and received fentanyl patch and
oxycodone
- Asthma (since birth) - history of intubation in the past
- Uterine and cervical CA s/p hysterectomy ([**2166**])
Social History:
Former RN. Disabled. Smokes [**12-21**] ppd and drinks daily vodka.
Lives in [**Location 583**] alone. No illicits. Drinks up to a gallon of
vodka at a time, but not every day.
Family History:
Mother died at age 72 from a GIB, "blood clot in stomach" ;
Father died in mid-70s from cancer, possibly mesothelioma
(worked in shipping). Mother, father, paternal grandfather have
history of alcoholism.
Physical Exam:
Vitals: Temp 99.1, BP 126/70, HR 80, RR 18 O2: 95% on 2LNC
Gen: NAD, sitting comfortably in bed
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, +mild distension, +mild tenderness throughout,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis, +1
pitting edema of b/l LE
Pertinent Results:
STUDIES OF RELEVANCE IN CHRONOLOGICAL ORDER:
ABD US [**2182-1-11**]:
HISTORY: 51-year-old female with alcoholic cirrhosis, presenting
with
variceal bleeding. Evaluate for portal vein thrombus.
COMPARISON: Abdominal ultrasound dated [**2181-11-8**].
FINDINGS: The left, right, and main portal veins are well
visualized and
demonstrate normal antegrade flow. Normal flow was also seen in
the left,
middle, and right hepatic veins. Limited views of the liver
parenchyma
demonstrate a nodular, cirrhotic contour, consistent with
provided history. No focal lesions are identified. Spleen
measured 14 cm. There is no ascites. A small right pleural
effusion is noted.
Further evaluation was not possible given patient refusal to
complete this
study.
IMPRESSION:
1. Nodular, cirrhotic liver without focal lesion, however, full
evaluation is limited by patient's refusal to continue exam.
2. Normal flow is seen in the portal vein, hepatic veins, and
splenic vein.
3. Splenomegaly. No ascites.
4. Right pleural effusion.
LABORATORY RESULTS OF RELEVANCE
[**2182-1-10**] 11:05AM BLOOD WBC-6.8# RBC-3.32* Hgb-10.3* Hct-30.0*
MCV-90 MCH-31.0 MCHC-34.3 RDW-19.1* Plt Ct-104*#
[**2182-1-10**] 04:36PM BLOOD Hct-25.8*
[**2182-1-11**] 04:26AM BLOOD WBC-4.1 RBC-3.75* Hgb-11.7* Hct-33.5*#
MCV-89 MCH-31.3 MCHC-35.0 RDW-18.6* Plt Ct-65*
[**2182-1-11**] 11:44AM BLOOD Hct-33.7*
[**2182-1-10**] 11:05AM BLOOD PT-16.8* PTT-34.6 INR(PT)-1.5*
[**2182-1-11**] 04:26AM BLOOD PT-17.4* PTT-35.8* INR(PT)-1.6*
[**2182-1-10**] 11:05AM BLOOD Glucose-108* UreaN-9 Creat-0.7 Na-144
K-3.6 Cl-105 HCO3-28 AnGap-15
[**2182-1-11**] 04:26AM BLOOD Glucose-118* UreaN-7 Creat-0.7 Na-139
K-3.9 Cl-106 HCO3-21* AnGap-16
[**2182-1-10**] 11:05AM BLOOD ALT-22 AST-67* AlkPhos-102 TotBili-1.8*
[**2182-1-11**] 04:26AM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND HAV Ab-PND
[**2182-1-11**] 04:26AM BLOOD AFP-PND
[**2182-1-10**] 11:05AM BLOOD ASA-NEG Ethanol-351* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2182-1-11**] 04:26AM BLOOD HCV Ab-PND
[**2182-1-10**] 04:36PM HCT-25.8*
[**2182-1-10**] 11:50AM URINE HOURS-RANDOM
[**2182-1-10**] 11:50AM URINE bnzodzpn-POS barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2182-1-10**] 11:50AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2182-1-10**] 11:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.0
LEUK-NEG
[**2182-1-10**] 11:05AM GLUCOSE-108* UREA N-9 CREAT-0.7 SODIUM-144
POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-28 ANION GAP-15
[**2182-1-10**] 11:05AM estGFR-Using this
[**2182-1-10**] 11:05AM ALT(SGPT)-22 AST(SGOT)-67* ALK PHOS-102 TOT
BILI-1.8*
[**2182-1-10**] 11:05AM LIPASE-79*
[**2182-1-10**] 11:05AM ALBUMIN-3.7 CALCIUM-8.6 PHOSPHATE-3.7
MAGNESIUM-1.9
[**2182-1-10**] 11:05AM ASA-NEG ETHANOL-351* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2182-1-10**] 11:05AM WBC-6.8# RBC-3.32* HGB-10.3* HCT-30.0* MCV-90
MCH-31.0 MCHC-34.3 RDW-19.1*
[**2182-1-10**] 11:05AM NEUTS-49.5* LYMPHS-38.7 MONOS-6.8 EOS-4.7*
BASOS-0.4
[**2182-1-10**] 11:05AM PLT COUNT-104*#
[**2182-1-10**] 11:05AM PT-16.8* PTT-34.6 INR(PT)-1.5*
Brief Hospital Course:
This 51F with alcoholic cirrhosis presents with hematemesis.
Admitted to MICU on octreotide and PPI drips. Post-GIB
prophylactic cipro was begun. Aggressive IVF at 200cc/hr was
begun. A banana bag was administered. 2 units of packer RBCs
were administered. Upper endoscopy was performed which revealed
varices at the lower third of the esophagus and middle third of
the esophagus (ligated), as well as portal hypertensive
gastropathy. She had no further episodes of hematemesis. Her AM
hematocrit bumped appropriately to the 2 units of blood she
received overnight. Serial hematocrits were stable. She
underwent [**Name (NI) 5283**] sono prior to being called out to the floor which
was limited because the patient refused a full exam, but dod not
show PVT. The hosptial course is further described in brief
below:
.
# Hematemesis: Octreotide, PPI, prophylactic Cipro was begun on
admission. Upper endoscopy was performed which revealed varices
at the lower third of the esophagus and middle third of the
esophagus (ligated), as well as portal hypertensive gastropathy.
She had no further episodes of hematemesis. Her HCT bumped
appropriately to 2 units of blood. She was followed diligently
with q6 HCTs. IVC times 3 were maintained. T and S was
maintained. Patient was hemodynamically stable throughout.
.
# Abd pain: Has history of chronic pancreatitis. Lipase mildly
elevated. No need for imaging currently. Patient was initially
kept NPO. She was given IVFs @ 200cc/hr.
- pain control
.
# EtoH abuse: Monitored on CIWA throughout. Recieved BB daily
(MVT/thiamine/folate) daily. Social work was consulted.
.
# Anemia and thrombocytopenia
Hct above baseline of 25 at recent discharge, but did have
recent transfusion of blood and platelets at [**Hospital3 **].
Baseline deficit likely due to chronic liver disease. Platelts
were trended diligently. No platlet transfusions were required.
.
# Alcoholic cirrhosis: AST/ALT >2 c/w EtoH. Rec'd prophylactic
cipro 400mg IV BID. held lasix and spironolactone in setting of
bleed. Held lactulose while NPO. Abd U/S limited in technical
quality, but no evidence of PVT.
.
Code FULL
Comm: with patient and HCP sister [**Name (NI) **] [**Telephone/Fax (1) 31371**]
DISPO: Home with close follow-up arranged.
Medications on Admission:
Multivitamins PO Daily
Folic Acid 1 mg PO Daily
Thiamine 100mg PO Daily
Lactulose 30 ML PO TID, titrate to 3 BMs daily
Furosemide 80 mg PO Daily
Spironolactone 50 mg PO DAILY
Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Advair 250-50 mcg/Dose [**Hospital1 **]
Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule PO
QID
Albuterol Inhalation Q6H PRN
Ambien 5mg
Morphine SR - only 4 days were dispensed
Discharge Medications:
1. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day) for 2 weeks.
Disp:*56 Tablet(s)* Refills:*0*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Multivitamins Tablet, Chewable Sig: One (1) Tablet PO
DAILY (Daily).
4. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO Q 12H (Every 12 Hours).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. FoLIC Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
9. Albuterol Inhalation
10. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Capsule, Delayed
Release(E.C.) PO four times a day.
11. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
12. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day: Hold
for SBP under 100.
13. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day: Hold for SBP under 100.
Discharge Disposition:
Home
Discharge Diagnosis:
Bleeding esophagael varices
Discharge Condition:
stable
Followup Instructions:
It is critical that you call ([**Telephone/Fax (1) 1582**] to set up an
appointment at the liver clinic to take place within two to
three weeks of your discharge. We have asked the clinic to phone
you, but if you do not hear from them by Thursday the [**11-17**], it is extremely important that you phone them.
Follow-up for your banding and bleeding is critical.
.
Please call your PCP [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 31372**] on Wednesday to set up an
appointment to occur within three weeks of discharge.
Completed by:[**2182-3-26**]
|
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icd9cm
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[
[
[]
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[
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icd9pcs
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[
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2027, 2205
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,490
| 100,499
|
51674
|
Discharge summary
|
report
|
Admission Date: [**2105-11-18**] Discharge Date: [**2105-11-21**]
Date of Birth: [**2080-5-30**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aspirin / Sulfonamides / Latex
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
Dizziness/lightheaded
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
Please see MICU note for full details, briefly 25 yo F w/ Hx of
severe HTN, diagnosed while pregnant (preeclampsia) who
presented on [**11-18**] with chest pain and hypotension. Patient
reports several episodes of N/V/D last weekend but improvement
of symptoms earlier this week. She states medication compliance
as prescribed (900mg labetalol [**Hospital1 **], 90mg nifedipine QD and HCTZ
25mg QD). Prior to presentation she had an episode of SSCP that
radiated down the L arm that was accompanied by dizziness. She
was found to be severely hypotensive and given 6L of NS, 2mg
glucagon X2 for BB overdose, 10mg dexamethasone, 1g calcium
gluconate for CCB overdose, 2g Mg in the ED. EKG--> TWI in III
and aVF (unchanged from prior). A TTE was done while she was
having active CP and this was normal with an EF of 70%. CTA-->
no PE or dissection. Abd U/S--> thickened gall bladder, could be
consistent w/ cardiac or liver disease. She remained
hypotensive, started on peripheral dopamine and admitted to the
MICU.
.
In the MICU, she remained on peripheral dopamine for only a few
hours and has been off pressors for >12hrs with SBP in the
120's. This am she developed acute onset SSCP that was similar
to the episode she had on presentation. She received 3 SLN and
her pain resolved. EKG--> TWI in III, aVF and V1, and TW
flattening in V5-V6 (only new finding). CE's were drawn
initially Trop - <0.01-->0.04-->0.16; CK - 166, 141, 168; MB -
2, 4, 6; likely representing an NSTEMI. Started on heparin gtt,
ASA and statin.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, cough, hemoptysis, black stools or
red stools. She denies recent fevers, chills or rigors. She
denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Hypertension
2. CARDIAC HISTORY: NONE
-CABG: NONE
-PERCUTANEOUS CORONARY INTERVENTIONS: NONE
-PACING/ICD: NONE
Multiple 1st trimester SABs and TABs
- 1 LTCS for NRFHR with intermittent gHTN; no meds postpartum
- 1 VBAC with gHTN postpartum requiring blood pressure meds and
VNA care
- 1 VBAC [**2105-7-31**] 7# 5 oz; 600 mg TID Labetalol; followed by VNA
as outpatient. GDMA2
- PCOS, with HbA1C of 6.1-6.6%.
- Anemia
- Asthma
- Lumbosacral spondylosis
- Transient visual blurriness, chronic s/p MVA in [**2103**];
reportedly
followed by [**Hospital 13128**].
- D+Cs
Social History:
-Tobacco history: Denies
-ETOH: Denies
-Illicit drugs: Denies
Family History:
Father with HTN, DM, leukemia, MI (1st at 30 yo) and CVA
Mother with Parkinsons, sarcoma, G6PD deficiency
Brother with HTN at age 20
Aunt with hx of CVA at age 19
Paternal cousin with cardiovascular death while playing
basketball at age 21.
No family history arrhythmia or cardiomyopathies.
Physical Exam:
VS: T 98.7, BP 129/75, HR 102, RR 20, Sat 100% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of [**5-11**] cm.
CARDIAC: RR, normal S1, S2. No m/r/g. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Trace ankle edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
[**2105-11-18**] 02:20PM BLOOD WBC-11.6* RBC-3.88* Hgb-10.2* Hct-31.3*
MCV-81* MCH-26.2*# MCHC-32.5# RDW-15.8* Plt Ct-237
[**2105-11-19**] 04:26AM BLOOD WBC-11.4* RBC-4.35 Hgb-11.6* Hct-36.0
MCV-83 MCH-26.6* MCHC-32.1 RDW-15.6* Plt Ct-261
[**2105-11-21**] 05:35AM BLOOD WBC-10.2 RBC-4.29 Hgb-11.0* Hct-35.0*
MCV-82 MCH-25.6* MCHC-31.4 RDW-15.3 Plt Ct-273
[**2105-11-18**] 02:20PM BLOOD Neuts-67.5 Lymphs-25.0 Monos-3.0 Eos-4.3*
Baso-0.2
[**2105-11-19**] 04:26AM BLOOD Neuts-87.5* Lymphs-10.7* Monos-0.9*
Eos-0.7 Baso-0.1
[**2105-11-18**] 02:20PM BLOOD PT-13.1 PTT-27.0 INR(PT)-1.1
[**2105-11-18**] 04:45PM BLOOD PT-13.4 PTT-29.7 INR(PT)-1.1
[**2105-11-21**] 05:35AM BLOOD Lupus-NEG
[**2105-11-21**] 05:35AM BLOOD ACA IgG-PND ACA IgM-PND
[**2105-11-18**] 02:20PM BLOOD Glucose-200* UreaN-5* Creat-0.9 Na-141
K-3.5 Cl-110* HCO3-23 AnGap-12
[**2105-11-18**] 08:46PM BLOOD Glucose-136* Na-144 K-3.7 Cl-114*
HCO3-19* AnGap-15
[**2105-11-20**] 07:10AM BLOOD Glucose-93 UreaN-12 Creat-0.7 Na-143
K-4.2 Cl-107 HCO3-24 AnGap-16
[**2105-11-21**] 05:35AM BLOOD Glucose-85 UreaN-18 Creat-0.8 Na-141
K-4.0 Cl-107 HCO3-26 AnGap-12
[**2105-11-18**] 04:45PM BLOOD ALT-19 AST-24 AlkPhos-71 TotBili-0.2
[**2105-11-19**] 04:26AM BLOOD CK(CPK)-168*
[**2105-11-20**] 07:10AM BLOOD CK(CPK)-90
[**2105-11-19**] 03:14PM BLOOD CK(CPK)-133
[**2105-11-18**] 08:46PM BLOOD CK(CPK)-141*
[**2105-11-18**] 04:45PM BLOOD Lipase-9
[**2105-11-18**] 02:20PM BLOOD Lipase-12
[**2105-11-18**] 02:20PM BLOOD CK-MB-2 proBNP-103
[**2105-11-18**] 02:20PM BLOOD cTropnT-<0.01
[**2105-11-19**] 04:26AM BLOOD CK-MB-6 cTropnT-0.16*
[**2105-11-19**] 03:14PM BLOOD CK-MB-4 cTropnT-0.12*
[**2105-11-20**] 07:10AM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2105-11-18**] 02:20PM BLOOD Calcium-8.3* Phos-3.2 Mg-1.4*
[**2105-11-18**] 04:45PM BLOOD Albumin-3.0*
[**2105-11-18**] 08:46PM BLOOD Calcium-8.8 Phos-1.8* Mg-1.8
[**2105-11-20**] 07:10AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.1
[**2105-11-21**] 05:35AM BLOOD Calcium-9.2 Phos-5.0* Mg-2.0
[**2105-11-19**] 04:26AM BLOOD calTIBC-437 VitB12-360 Folate-11.2
Ferritn-24 TRF-336
[**2105-11-21**] 05:35AM BLOOD Homocys-12.3
[**2105-11-19**] 03:14PM BLOOD Triglyc-61 HDL-46 CHOL/HD-3.3 LDLcalc-96
[**2105-11-21**] 05:35AM BLOOD TSH-4.0
[**2105-11-18**] 02:20PM BLOOD Cortsol-26.8*
[**2105-11-19**] 04:26AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2105-11-20**] 07:37AM BLOOD Lactate-1.5
[**2105-11-18**] 10:14PM BLOOD Lactate-2.8*
[**2105-11-18**] 05:00PM BLOOD Lactate-1.9
[**2105-11-18**] 05:00PM BLOOD Hgb-10.5* calcHCT-32
[**2105-11-21**] 05:35AM BLOOD FACTOR V LEIDEN-PND
[**2105-11-18**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.8 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.1 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.7 m/s
Left Atrium - Peak Pulm Vein D: 0.7 m/s
Right Atrium - Four Chamber Length: 4.8 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.2 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.1 cm
Left Ventricle - Fractional Shortening: 0.40 >= 0.29
Left Ventricle - Ejection Fraction: 70% >= 55%
Left Ventricle - Stroke Volume: 65 ml/beat
Left Ventricle - Cardiac Output: 6.59 L/min
Left Ventricle - Cardiac Index: 3.26 >= 2.0 L/min/M2
Left Ventricle - Lateral Peak E': 0.15 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': 0.12 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 11 < 15
Aorta - Sinus Level: 2.7 cm <= 3.6 cm
Aorta - Ascending: 1.7 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.4 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 23
Aortic Valve - LVOT diam: 1.9 cm
Mitral Valve - E Wave: 1.5 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A ratio: 2.50
Mitral Valve - E Wave deceleration time: *132 ms 140-250 ms
Pulmonic Valve - Peak Velocity: 1.2 m/sec <= 1.5 m/sec
Findings
LEFT ATRIUM: Normal LA and RA cavity sizes.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: ?# aortic valve leaflets. Normal AVR leaflets. No
AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No
MVP.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: The patient appears to be in sinus rhythm.
Resting tachycardia (HR>100bpm). Emergency study performed by
the cardiology fellow on call.
Conclusions
The left atrium and right atrium are normal in cavity size. No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The number of
aortic valve leaflets cannot be determined. The prosthetic
aortic valve leaflets appear normal There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. No significant valvular disease seen.
Cardiology Report ECG Study Date of [**2105-11-18**] 2:18:56 PM
Sinus rhythm. Borderline prolonged/upper limits of normal QTc
interval. Low
T wave amplitude. Findings are non-specific but cannot exclude
drug/electrolyte/metabolic effect. Clinical correlation is
suggested. Since the
previous tracing of [**2105-8-9**] there is probably no significant
change.
TRACING #1
Cardiology Report ECG Study Date of [**2105-11-18**] 3:39:34 PM
Sinus rhythm. Prolonged QTc interval. Modest inferolateral lead
ST-T wave
abnormalities. Findings are non-specific but clinical
correlation is suggested.
Since the previous tracing of same date ST-T wave changes are
more prominent.
TRACING #2
Cardiology Report ECG Study Date of [**2105-11-18**] 9:45:00 PM
Sinus tachycardia. Modest inferolateral T wave changes are
non-specific. Since
the previous tracing of the same date sinus tachycardia is now
present and the
QTc interval appears shorter.
TRACING #3
Radiology Report CHEST (PORTABLE AP) Study Date of [**2105-11-18**] 2:20
PM
COMPARISON: None.
FINDINGS: The lungs are clear without focal consolidation. No
appreciable
pleural effusion or evidence of pneumothorax is seen. The carina
is
relatively splayed with relative underlying increased density,
which may be
due to an enlarged left atrium. The cardiac silhouette is
borderline in size,
which may be accentuated by supine, AP technique.
IMPRESSION:
1. Clear lungs.
2. Possible left atrial enlargement.
3. Borderline cardiac silhouette size, which is likely
accentuated by AP
technique and supine position.
Radiology Report CT PELVIS W/CONTRAST Study Date of [**2105-11-18**]
3:14 PM
CT CHEST WITHOUT AND WITH IV CONTRAST: The pulmonary arterial
tree is well
opacified, and there is no pulmonary embolus. The thoracic aorta
is normal in
caliber without dissection, pseudoaneurysm, intramural hematoma
or other acute
abnormality. The great vessels are unremarkable. The heart size
is normal
without pericardial effusion. There is a 1 cm soft tissue
density in the
right hilus, likely reactive lymph node. In the right axilla,
several
prominent lymph nodes measure up to 1 cm in short axis,
demonstrating a normal
configuration with normal fatty hila. Normal appearing left
axillary lymph
nodes are also present. In anterior mediastinum, there is soft
tissue density
material which may be due to residual thymic tissue.
Lungs demonstrate mild dependent atelectasis bilaterally,
without
consolidation or pleural effusion. There is prominence of septal
markings
suggesting fluid overload and mild pulmonary edema. The
tracheobronchial tree
is patent to subsegmental levels.
CT ABDOMEN WITH IV CONTRAST: Assessment of solid organs is
limited given the
arterial phase of the exam, tailored for evaluation of the
aorta. The
abdominal aorta is normal in caliber, without dissection,
pseudoaneurysm, or
other acute abnormality. The major branches are patent.
Incidentally noted
is an accessory right renal artery.
The liver demonstrates increased hypodense material surrounding
the vascular
structures at the porta hepatis and extending towards the
periphery. This
could represent periportal edema, or could indicate periductal
soft tissue
material. At the liver dome (3:81), there is a suggestion of a
6-mm
arterially enhancing focus, although this area is obscured by
metallic
artifact from an object external to the patient. A small amount
of
perihepatic fluid is noted adjacent to the diaphragm.
The gallbladder demonstrates a markedly thickened, hypodense
wall, with
intermediate density intraluminal contents. This pronounced
gallbladder wall
edema is more severe than usually seen in the setting of rapid
rehydration.
Alternatively, this could be seen in gallbladder outlet
obstruction or soft
tissue infiltration of the gallbladder wall. The pancreas
appears slightly
enlarged, although the pancreatic parenchyma enhances uniformly.
There is no
pancreatic ductal dilatation. Surrounding the pancreas, there is
fluid or
soft tissue density material and a mild amount of mesenteric
stranding.
The spleen, adrenal glands, stomach, and duodenum are
unremarkable. The
kidneys are unremarkable without hydronephrosis, stones, or
worrisome renal
masses. Assessment of the mesentery is limited given the
relative lack of
mesenteric fat, but there may be some mesenteric edema. There is
no free air
in the upper abdomen.
CT PELVIS WITH IV CONTRAST: Loops of large and small bowel are
unremarkable.
The appendix is normal. The uterus demonstrates a large
exophytic fibroid
extending off the left fundus. There is no intrauterine device
or vaginal
foreign body seen. The urinary bladder is collapsed around a
Foley catheter,
with small amount of air. There is no free fluid in the pelvis.
There is no
pelvic or inguinal lymphadenopathy by size criteria.
OSSEOUS STRUCTURES: There is no fracture or worrisome bony
lesion.
IMPRESSION:
1. No pulmonary embolus or acute aortic abnormality. No aortic
dissection in
the chest or abdomen.
2. Small amount of fluid along the superior margin of the liver,
surrounding
the pancreas, and gallbladder wall thickening versus edema, and
likely
periportal edema. These findings may be due to rapid
rehydration, but given
the phase of imaging, other etiologies cannot be ruled out.
Serum lipase was
normal making pancreatitis unlikely. This can be further
evaluated with a
non-emergent right upper quadrant ultrasound to evaluate the
gallbladder wall
and for perihepatic lymphadenopathy.
3. Anterior mediastinal soft tissue, most likely consistent with
thymic
tissue, although other mediastinal mass (ie lymphoma) can not be
entirely
excluded. Consider further evaluation with MRI.
4. Mild pulmonary edema.
5. Possible 6mm enhancing hepatic lesion near the hepatic dome.
This can be
further evaluated with nonemergent ultrasound or MRI.
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of [**2105-11-18**]
CT CHEST WITHOUT AND WITH IV CONTRAST: The pulmonary arterial
tree is well
opacified, and there is no pulmonary embolus. The thoracic aorta
is normal in
caliber without dissection, pseudoaneurysm, intramural hematoma
or other acute
abnormality. The great vessels are unremarkable. The heart size
is normal
without pericardial effusion. There is a 1 cm soft tissue
density in the
right hilus, likely reactive lymph node. In the right axilla,
several
prominent lymph nodes measure up to 1 cm in short axis,
demonstrating a normal
configuration with normal fatty hila. Normal appearing left
axillary lymph
nodes are also present. In anterior mediastinum, there is soft
tissue density
material which may be due to residual thymic tissue.
Lungs demonstrate mild dependent atelectasis bilaterally,
without
consolidation or pleural effusion. There is prominence of septal
markings
suggesting fluid overload and mild pulmonary edema. The
tracheobronchial tree
is patent to subsegmental levels.
CT ABDOMEN WITH IV CONTRAST: Assessment of solid organs is
limited given the
arterial phase of the exam, tailored for evaluation of the
aorta. The
abdominal aorta is normal in caliber, without dissection,
pseudoaneurysm, or
other acute abnormality. The major branches are patent.
Incidentally noted
is an accessory right renal artery.
The liver demonstrates increased hypodense material surrounding
the vascular
structures at the porta hepatis and extending towards the
periphery. This
could represent periportal edema, or could indicate periductal
soft tissue
material. At the liver dome (3:81), there is a suggestion of a
6-mm
arterially enhancing focus, although this area is obscured by
metallic
artifact from an object external to the patient. A small amount
of
perihepatic fluid is noted adjacent to the diaphragm.
The gallbladder demonstrates a markedly thickened, hypodense
wall, with
intermediate density intraluminal contents. This pronounced
gallbladder wall
edema is more severe than usually seen in the setting of rapid
rehydration.
Alternatively, this could be seen in gallbladder outlet
obstruction or soft
tissue infiltration of the gallbladder wall. The pancreas
appears slightly
enlarged, although the pancreatic parenchyma enhances uniformly.
There is no
pancreatic ductal dilatation. Surrounding the pancreas, there is
fluid or
soft tissue density material and a mild amount of mesenteric
stranding.
The spleen, adrenal glands, stomach, and duodenum are
unremarkable. The
kidneys are unremarkable without hydronephrosis, stones, or
worrisome renal
masses. Assessment of the mesentery is limited given the
relative lack of
mesenteric fat, but there may be some mesenteric edema. There is
no free air
in the upper abdomen.
CT PELVIS WITH IV CONTRAST: Loops of large and small bowel are
unremarkable.
The appendix is normal. The uterus demonstrates a large
exophytic fibroid
extending off the left fundus. There is no intrauterine device
or vaginal
foreign body seen. The urinary bladder is collapsed around a
Foley catheter,
with small amount of air. There is no free fluid in the pelvis.
There is no
pelvic or inguinal lymphadenopathy by size criteria.
OSSEOUS STRUCTURES: There is no fracture or worrisome bony
lesion.
IMPRESSION:
1. No pulmonary embolus or acute aortic abnormality. No aortic
dissection in
the chest or abdomen.
2. Small amount of fluid along the superior margin of the liver,
surrounding
the pancreas, and gallbladder wall thickening versus edema, and
likely
periportal edema. These findings may be due to rapid
rehydration, but given
the phase of imaging, other etiologies cannot be ruled out.
Serum lipase was
normal making pancreatitis unlikely. This can be further
evaluated with a
non-emergent right upper quadrant ultrasound to evaluate the
gallbladder wall
and for perihepatic lymphadenopathy.
3. Anterior mediastinal soft tissue, most likely consistent with
thymic
tissue, although other mediastinal mass (ie lymphoma) can not be
entirely
excluded. Consider further evaluation with MRI.
4. Mild pulmonary edema.
5. Possible 6mm enhancing hepatic lesion near the hepatic dome.
This can be
further evaluated with nonemergent ultrasound or MRI.
Radiology Report LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT
Study Date of [**2105-11-18**] 6:43 PM
COMPARISON: CT torso obtained approximately four hours earlier.
RIGHT UPPER QUADRANT ULTRASOUND: The liver is normal in
echotexture without
focal abnormalities. There is a small amount of perihepatic
fluid. In the
right upper quadrant, incidentally noted is a tiny right pleural
effusion.
There is no intra- or extra-hepatic biliary ductal dilatation.
The common
duct measures 4 mm. The main portal vein demonstrates normal
hepatopetal
flow.
The gallbladder is not distended, but demonstrates marked
gallbladder wall
edema. The wall measures approximately 1.6 cm. There is no
echogenic debris
are gallstones within the gallbladder. There is no
pericholecystic fluid.
The spleen is normal in size. There is a small amount of
abdominal fluid
tracking around the spleen. Additionally, there is a small left
pleural
effusion. Views of the abdominal midline are limited due to
overlying bowel
gas.
IMPRESSION:
1. Pronounced gallbladder wall edema, without evidence of acute
cholecystitis. This can be seen in the setting of underlying
liver or heart
disease. This can also be seen in aggressive rehydration,
although this
degree of wall edema is somewhat unusual.
2. Trace ascites tracking around the liver and spleen. This may
also be
related to rehydration.
3. Interval development of small bilateral pleural effusions.
Cardiology Report Cardiac Cath Study Date of [**2105-11-20**]
*** Not Signed Out ***
BRIEF HISTORY: This 25 year old female with a history of
hypertension
and strong family history of premature coronary artery disease
referred
for evaluation of atypical chest pain and elevated cardiac
biomarkers.
Chest CT angiogram was negative for pulmonary embolism or aortic
dissection.
INDICATIONS FOR CATHETERIZATION:
Hypertension. Family history of premature coronary disease.
Atypical
chest discomfort. Elevated cardiac biomarkers.
PROCEDURE:
Left Heart Catheterization: was performed by percutaneous entry
of the
right femoral artery, using a 4 French left [**Last Name (un) 2699**] catheter,
advanced
to the ascending aorta through a 4 French introducing sheath.
Coronary Angiography: was performed in multiple projections
using a 4
French JL4 and a 4 French JR4 catheter, with manual contrast
injections.
HEMODYNAMICS RESULTS BODY SURFACE AREA: 2.07 m2
HEMOGLOBIN: 11.1 gms %
REST
**PRESSURES
AORTA {s/d/m} 158/103/128
**CARDIAC OUTPUT
HEART RATE {beats/min} 75
RHYTHM SINUS
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA NORMAL
2) MID RCA NORMAL
2A) ACUTE MARGINAL NORMAL
3) DISTAL RCA NORMAL
4) R-PDA NORMAL
4A) R-POST-LAT NORMAL
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN NORMAL
6) PROXIMAL LAD NORMAL
6A) SEPTAL-1 NORMAL
7) MID-LAD NORMAL
8) DISTAL LAD NORMAL
9) DIAGONAL-1 NORMAL
12) PROXIMAL CX NORMAL
13) MID CX NORMAL
13A) DISTAL CX NORMAL
14) OBTUSE MARGINAL-1 NORMAL
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 24 minutes.
Arterial time = 10 minutes.
Fluoro time = 4.1 minutes.
IRP dose = 543 mGy.
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol 30 ml
Premedications:
Midazolam 0.5 mg IV, 1 mg IV
Fentanyl 25 mcg IV
ASA 325 mg P.O.
Clopidogrel 600 mg PO
Anesthesia:
1% Lidocaine subq.
Cardiac Cath Supplies Used:
- ALLEGIANCE, CUSTOM STERILE PACK
- [**Company **], LEFT HEART KIT
COMMENTS:
1. Coronary angiography in this right dominant system
demonstrated no
angiographically apparent disease in the LMCA, LAD, LCx, or RCA.
2. Resting hemodynamics limited to central aortic pressure
revealed
systolic and diastolic arterial hypertension with SBP 158 mmHg
and DBP
103 mmHg.
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
Brief Hospital Course:
# CORONARIES: Patient presented with chest pain and hypotension.
She was initially admitted to the MICU as her BP remained low
after treatment for BP med overdose and 6 L IVF. Urine and serum
toxicology tests (-). In the MICU she was transiently on
dopamine but this was discontinued after only a few hours. She
has no hx of CAD only risk factors are HTN and family histroy.
Given her age, it was thought that it was unlikely NSTEMI but
given the (+) troponins, that peaked at 0.16, and her multiple
episodes of chest pain a cardaic catheterization was done. Cath
showed normal vessels. A lipid profile was done and found to be
WNL. Oncer her BP strarted to trend up she was re-started on
labetalol and HCTZ. Hypercoagulability testing was ordered prior
to discharge. Some of these results are back today and are (-),
others should be followed up. TSH was WNL.
.
# Hypotension: Patient presented with severe hypotension (SBP
60s-70s) thought to be due to excessive BP med dosing and recent
viral illness causing dehydration. This resolved after
aggressive IV hydration, BP med overdose treatment and brief
treatment with dopamine. Details as above.
.
# PUMP: Patient with no hx of cardiac abnormalities, TTE--> nl.
study with EF of 70%. Not fluid overloaded per exam. BNP WNL.
.
# RHYTHM: Patient in NSR, with no hx of arrhythmias.
.
# Anion gap: Patient with anion gap (16) acidosis, on transfer
from MICU. This resolved without intervention. Lactate was WNL.
.
# G6PD deficiency: Patient states she was told she had this
disease during childhood. No records in system. G6PD testing was
WNL in [**2096**].
.
# Pericholecystic fluid/peripancreatic fluid: This was found on
ED CT abd/pel. Surgery was consulted and concluded that this did
not represent infection/bleeding given stable Hct and completely
normal LFTs/lipase. A RUQ U/S was done which showed same finding
as before and this was thought to be due to aggresive
rehydration. Patient might benefit from reapeat RUQ U/S to
assess for resolution.
.
# Asthma: Stable, asymptomatic.
.
# Anemia: Patient was found to have Hct of 31 on admission. This
trended up throughout admission into the mid-30s range and
remained stable. Iron studies, B12/folate levels WNL.
Medications on Admission:
Labetalol 900mg [**Hospital1 **]
Nifedipine 90mg QD
HCTZ 25mg QD
MVI
Albuterol prn
Discharge Medications:
1. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
3. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
neighborhood health plan
Discharge Diagnosis:
Primary diagnosis: Hypotension
Secondary: preeclampsia, chest pain
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**] because you were having dizziness
and chest pain. In the ED you were found to have very low blood
pressure that was thought to be due to dehydration, because of
your previous stomach sickness, and because of too many blood
pressure mediations. You had chest pain again while in the
hospital and your blood test showed your heart was not getting
enough blood during this episode. You underwent cardiac
catheterization which was normal.
Medication Changes:
STOP: Nifedipine
START: Aspirin 81 mg
No other changes were made to your medications.
Followup Instructions:
Appointment #1
MD: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: Primary Care
Date/ Time: Tuesday, [**12-1**] at 2:40pm
Location: [**Location (un) 2129**] , [**Location (un) 86**]
Phone number: [**Telephone/Fax (1) 32630**]
|
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"458.0",
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icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
26533, 26588
|
23886, 26106
|
329, 355
|
26699, 26699
|
4151, 21752
|
27455, 27717
|
3110, 3403
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26240, 26510
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26609, 26609
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26132, 26217
|
23829, 23863
|
26844, 27324
|
3418, 4132
|
2477, 3014
|
23004, 23812
|
27344, 27432
|
21785, 22985
|
268, 291
|
383, 2397
|
26628, 26678
|
26713, 26820
|
2419, 2457
|
3030, 3094
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,273
| 115,534
|
44582
|
Discharge summary
|
report
|
Admission Date: [**2112-5-8**] Discharge Date: [**2112-5-11**]
Date of Birth: [**2074-10-30**] Sex: M
Service: MICU/GENERAL MEDICINE, [**Location (un) **] FIRM
CHIEF COMPLAINT: DKA.
HISTORY OF THE PRESENT ILLNESS: This is a 37-year-old
gentleman with a history of Hodgkin's disease, status post
XRT and chemotherapy, also with hypercholesterolemia who
presented with new onset DKA. The patient was in his usual
state of health until two weeks prior to the date of
admission when he began experiencing increasing thirst,
polyuria, weight loss, decreased appetite, and blurry vision
for one week. Over the past three days before the day of
admission, the patient also noted increased fatigue which
brought him to the Emergency Department. The patient denied
any intercurrent illness. The patient denied any fevers,
chills, nausea, vomiting, diarrhea, constipation, or swollen
extremities.
In the Emergency Department, the patient was noted to have a
blood sugar of 1,349, also positive anion gap and ketones in
his urine. He was given IV fluids with normal saline, 10
units of IV insulin, and was then started on IV insulin at 6
units an hour before being transferred to the MICU.
PAST MEDICAL HISTORY:
1. Hodgkin's disease in [**2100**], status post chemotherapy and
XRT.
2. Hypercholesterolemia.
3. Obesity.
4. Transaminitis.
5. Palpitations.
ALLERGIES: Contrast dye gives him hives.
ADMISSION MEDICATIONS:
1. Ventolin p.r.n.
2. Claritin p.r.n.
SOCIAL HISTORY: He is happily married. He works as a web
designer and is a musician.
FAMILY HISTORY: The patient's father had CAD and CABG. No
diabetes.
HABITS: He denied any tobacco use. He drinks alcohol very
occasionally and denied any drug use.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
96.4, blood pressure 133/87, pulse 114, oxygen saturation 97%
at room air, respiratory rate 18. General appearance: The
patient was a very pleasant male in no acute distress.
HEENT: Anicteric. The oropharynx was clear. PERRL.
Cardiovascular: Tachycardiac, S1, S2, no rubs, murmurs, or
gallops. Lungs: Clear to auscultation bilaterally.
Abdomen: Obese, soft, nontender, nondistended, with active
bowel sounds. Extremities: No clubbing, cyanosis or edema.
Neurologic: Alert and oriented times three, mentating well.
LABORATORY ON PRESENTATION: CBC revealed a white count of
16.6, hematocrit 48.4, platelets 319,000. Differential:
Polys 87, lymphs 9, monos 3.6, eos 0.2, basophils 0.3.
Chem-7 initially 123, 6.2, 79, 20, 24, 1.5, 1352. Acetone
1GD. U/A: Negative blood. Negative nitrates. Negative
protein, 1,000 glucose, 15 ketones, negative bilirubin.
Otherwise unremarkable.
HOSPITAL COURSE: The patient is a 37-year-old gentleman with
a past medical history of Hodgkin's disease,
hypercholesterolemia, obesity, and transaminitis, who
presented with new onset DKA and diabetes. He had no
previous history of diabetes, however, he had obesity and
hypercholesterolemia which could suggest that his diabetes is
either type 1 or 2. The diabetic ketoacidosis resolved with
an insulin drip and IV fluids. The patient was then started
on subcutaneous insulin. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was called and
they recommended the following subcutaneous insulin dose
which the patient will be discharged on. These will be
listed in the medications on discharge.
Since the patient was now diagnosed with diabetes, he was
also started on an aspirin a day and an ACE inhibitor.
HYPERTENSION: During his hospital stay, the patient was
noted to have hypertension with a blood pressure ranging to
140-160/70-80. He was, therefore, started on an ACE
inhibitor which would have been started anyway because of his
diagnosis of diabetes and the ACE inhibitor which was
lisinopril was eventually increased to 5 mg p.o. q.d. at
discharge.
DISCHARGE DIAGNOSIS:
1. Diabetic ketoacidosis.
2. Diabetes type 1.
3. Hodgkin's disease in [**2100**], status post chemotherapy and
XRT.
4. Hypercholesterolemia.
5. Obesity.
6. Transaminitis.
7. Palpitations.
DISCHARGE CONDITION: Good.
DISCHARGE STATUS: To home.
FOLLOW-UP: The patient is now in the process of calling
[**Last Name (un) **] to make a follow-up appointment with Dr. [**Last Name (STitle) **] who
is the endocrinologist who saw him here. The date of that
follow-up appointment as suggested by Dr. [**Last Name (STitle) **] should be
[**2112-5-18**] at 2:00 p.m. The patient also received teaching
today and will schedule teaching at the [**Last Name (un) **] by taking the
following classes; What can I eat and my weight?
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg p.o. q.d.
2. Lisinopril 5 mg p.o. q.d.
3. Insulin, Glargine 40 units p.o. q. bedtime, Humalog
sliding scale if fingersticks 50, 1-100; breakfast OJ plus 10
units; lunch OJ plus 8 units; dinner OJ plus 8 units; if
fingersticks 101-150, breakfast 10 units; lunch 10 units;
dinner 10 units; bedtime nothing; if fingerstick 151-200,
breakfast 14 units; lunch 12 units; dinner 12 units; bedtime
nothing; if fingerstick 200-250, breakfast 16 units; lunch 14
units; dinner 14 units; bedtime 2 units; if fingerstick
251-300, breakfast 18 units; lunch 16 units; dinner 16 units;
bedtime 4 units; if fingerstick is 300-400, breakfast 20
units; lunch 18 units; dinner 18 units; and bedtime 6 units.
The patient will also make a follow-up appointment with his
new primary care physician, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Last Name (NamePattern1) 6071**]
MEDQUIST36
D: [**2112-5-11**] 10:48
T: [**2112-5-14**] 09:39
JOB#: [**Job Number 95466**]
cc:[**Last Name (NamePattern1) **]
|
[
"278.00",
"V10.72",
"401.9",
"250.12",
"276.1",
"790.4",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4130, 4644
|
1588, 1762
|
4667, 5865
|
3912, 4108
|
2717, 3891
|
1442, 1483
|
195, 1206
|
1777, 2699
|
1228, 1419
|
1500, 1571
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,688
| 194,319
|
6481
|
Discharge summary
|
report
|
Admission Date: [**2164-8-8**] Discharge Date: [**2164-8-12**]
Date of Birth: [**2099-4-21**] Sex: M
Service: MEDICINE
CHIEF COMPLAINT: Change in mental status.
HISTORY OF PRESENT ILLNESS: This is a 65 year old male who
was brought in to the Emergency Department by his wife today
for evaluation of two weeks' history of confusion such that
the patient cannot recall dates or express his wishes. By
report, the patient can no longer shower, feed himself or
stand with a walker secondary to weakness. His family
reports that although he has had these symptoms at baseline,
they have progressed much faster since his discharge from the
[**Hospital Unit Name 196**] Service on [**7-27**].
He had been admitted [**7-24**] through [**7-27**] for a rule out
myocardial infarction and was ruled out by enzymes and by
EKG.
In speaking with the patient's primary care provider, [**Name10 (NameIs) **]
seems that the patient had been mentally declining since
[**2164-1-18**], when he had a stroke and had been more
rapidly declining since his hospital discharge about two
weeks ago.
A visiting nurse found his blood pressure to be 180/70 and
because he had mental status changes per his wife, he was
brought to the Emergency Department.
The patient was unable to give any history.
PAST MEDICAL HISTORY:
1. Diabetes mellitus type 2.
2. End-stage renal disease on hemodialysis secondary to
diabetes mellitus.
3. Hypertension.
4. Peripheral vascular disease.
5. Right pontine infarction.
MEDICATIONS:
1. Metoprolol 75 mg three times a day.
2. Clopidogrel 75 mg p.o. q. day.
3. Atriopeptin 10 mg p.o. q. day.
4. Nifedipine 60 mg p.o. q. day.
5. Sertraline 25 mg p.o. q. day.
6. Diltiazem CD 300 mg p.o. q. day.
7. Temazepam 15 mg p.o. p.r.n.
8. Cevalin 1200 mg three times a day.
9. Insulin NPH 10 units q. a.m.
10. Nephrocaps one capsule per day.
11. Colace 100 mg p.o. twice a day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: No tobacco; occasional alcohol. He lives
with his wife and daughter.
PHYSICAL EXAMINATION: Vital signs with temperature of 97.6
F.; pulse 69; blood pressure 186/79; respiratory rate 12;
oxygen saturation 98% on room air. In general, lying in bed
asleep but arousable in no acute distress. HEENT: Pupils
small and minimally reactive; muddy sclerae. No sinus
tenderness. Mucous membranes were moist. Clear oropharynx.
Neck supple, no lymphadenopathy. Cardiovascular was regular
rate, normal S1, S2. No murmurs, rubs or gallops. Pulmonary
with scant bibasilar crackles with poor inspiratory effort.
Abdomen with normoactive bowel sounds, soft, nontender,
nondistended. Back with no costovertebral angle tenderness
or paraspinal tenderness. Extremities with no edema. Two
plus peripheral pulses. Left upper extremity fistula with
adjacent edema, reportedly chronic. Neurological: Oriented
to self and [**Hospital3 **] Hospital. Not oriented to month or
year. Intermittently able to follow commands. Five out of
five strength bilateral lower extremities.
LABORATORY: CBC with white blood cell count of 7.8,
hematocrit 39.7, platelets 187. Sodium 137, potassium 4.9,
chloride 93, bicarbonate 34, BUN 21, creatinine 6.5, glucose
85. CK 40, troponin T 0.24.
Urinalysis with specific gravity of 1.019, pH 8.0, trace
blood, 500 protein, 100 glucose.
Head CT scan with bilateral cerebral atrophy, diffuse
microvascular infarctions. No acute intracranial hemorrhage.
EKG with sinus bradycardia at 54 beats per minute, left axis
deviation, 3 point elevation V1 through V3, mild T wave
flattening in lead III. No significant changes compared to
EKG of [**2164-7-24**].
HOSPITAL COURSE:
1. MENTAL STATUS CHANGE: Per the patient's primary care
physician, [**Name10 (NameIs) **] patient has been slowly declining since
[**Month (only) 404**] of this year when he had his stroke and much more
rapidly since his most recent admission. He was worked up
for possible etiologies for worsening mental status including
a dementia work-up consisting of Vitamin B12, folate and
syphilis which were all normal or negative; and for infection
as well. He had no signs of infection and his chest x-ray
showed fluid in his lungs which then decreased on repeat
chest x-ray taken after dialysis. He was never febrile and
never had an elevated white count.
Cardiac enzymes were also sent showing the troponin T of
0.24, however, in the absence of chest pain or EKG changes,
and in the light of his previous troponin T levels of 0.18 to
0.27, and speaking with the primary care physician, [**Name10 (NameIs) **] was
felt that these mildly elevated troponin T values may be
falsely influenced by renal insufficiency.
Regarding his renal failure, by Nursing reports, the patient
often improved in mental status after dialysis, although he
had no signs of uremia. During this admission, his mental
status seems stable regardless of hemodialysis.
A head CT scan was negative, showing no acute trauma or
cerebrovascular accident which could explain his altered
mental status as well. His lack of other neurological
findings on examination suggested that he had no acute
intracranial process.
Because he had a mildly elevated bicarbonate on routine
laboratory studies, we obtained two arterial blood gases
which showed that although somewhat hypoxic, the patient was
not retaining excess carbon dioxide to cause his mental
status changes.
Although no concrete etiology was found, his mental status
remained stable and may be secondary to unidentified
metabolic derangements from renal insufficiency on top of
chronic brain atrophy and microvascular infarctions.
The patient had no symptoms to suggest chronic seizure
activity and the Neurology Service felt that an EEG was be
low yield. One other possibility that could have contributed
to his mental status initially was his high blood pressure,
however, on better control of his pressures during admission,
he had no change in his mental status.
Although a diabetic, his sugars were fairly well controlled
in the 100s, which also was not likely to contribute to his
decreased mentation.
2. HYPERTENSION: The patient initially presented very
hypertensive. He had systolic blood pressures to the low
200s, and received extra doses of his Metoprolol, as well as
Hydralazine which decreased his blood pressure. On the
floor, he was continued on Metoprolol, nifedipine and
diltiazem which were his medications listed from a previous
discharge summary.
These decreased his blood pressure to the 120s systolic;
however, on the second day of admission, the patient
developed bradycardia to the low 40s and an EKG and Telemetry
revealed that he was in third degree heart block. Cardiology
was consulted and the patient was transferred briefly to the
Coronary Care Unit overnight for observation.
Cardiology felt that this was secondary to over blockade and
with a dose of Glucagon and calcium gluconate as well as
stopping his anti-hypertensive medications, the patient
returned into normal sinus rhythm with a rate in the 80s by
the next morning, and was transferred back to the Floor. He
had never had any worsening mental status changes with this
episode and had not previously had cardiac changes.
Back on the Floor, he was restarted on a low dose of
Metoprolol as well as Captopril and calcium channel blockers
were avoided. The patient continued to remain in sinus
rhythm with no further episodes of heart block.
3. END-STAGE RENAL DISEASE: The patient received dialysis
on Monday, Wednesday and Friday and was continued on his
nutritional supplements.
4. STATUS POST CEREBROVASCULAR ACCIDENT: We continued his
Plavix and Lipitor.
5. DEPRESSION: There was a question of whether depression
may also be contributing to his decreased mental status;
however, this was difficult to assess during this
hospitalization. His Sertraline was continued.
6. SOCIAL ISSUES: The patient's primary care physician has
been speaking with the family a great deal regarding the
patient's long term care needs and the fact that the
patient's wife feels that she is no longer able to care for
him in their house. She agreed, on this hospitalization, for
the patient to go to rehabilitation and possibly then for
nursing home placement.
He has been [**Street Address(1) 24878**] Place facility.
7. TYPE 2 DIABETES MELLITUS: His fingersticks were well
controlled with NPH and sliding scale insulin.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Altered mental status.
2. Type 2 diabetes mellitus.
3. End-stage renal disease.
4. Hypertension.
5. Peripheral vascular disease.
6. History of cerebrovascular accident.
DISCHARGE MEDICATIONS:
1. Metoprolol 25 mg p.o. twice a day.
2. Captopril 12.5 mg p.o. three times a day.
3. Plavix 75 mg p.o. q. day.
4. Lipitor 10 mg p.o. q. day.
5. Sertraline 25 mg p.o. q. day.
6. Temazepam 50 mg p.o. p.r.n.
7. Renagel 1200 mg p.o. three times a day.
8. NPH insulin 10 units a.c. breakfast.
9. Sliding scale insulin consisting of the following: For
breakfast, lunch and dinner, glucose 201 to 250, give 2
units; 251 to 300, 4 units; 301 to 350, 6 units; 351 to 400,
8 units; greater than 400, 10 units. For bed time for sugars
201 to 250, one unit; 251 to 300, two units; 301 to 350, 3
units; 351 to 400, four units; and greater than 400, five
units of Regular insulin.
10. Nephrocaps one p.o. q. day.
11. Colace 100 mg p.o. twice a day.
DISCHARGE INSTRUCTIONS:
1. The patient will call his primary care physician, [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**] for a follow-up appointment soon after discharge.
Dr. [**First Name (STitle) 1022**] may then adjust his blood pressure medication at that
time.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 16316**]
Dictated By:[**Last Name (NamePattern1) 1606**]
MEDQUIST36
D: [**2164-8-11**] 21:53
T: [**2164-8-11**] 22:09
JOB#: [**Job Number 24879**]
|
[
"V12.59",
"426.0",
"443.9",
"290.41",
"250.40",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
8492, 8671
|
8694, 9443
|
3680, 8437
|
9467, 10075
|
2071, 3663
|
159, 185
|
215, 1304
|
1326, 1958
|
1976, 2047
|
8462, 8471
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,973
| 145,185
|
4034
|
Discharge summary
|
report
|
Admission Date: [**2182-6-15**] Discharge Date: [**2182-6-17**]
Date of Birth: [**2120-10-31**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Imuran / Cephalosporins / Sulfa (Sulfonamide
Antibiotics) / Reglan / Ampicillin / Lactose / Neomycin /
metoclopramide / Doxepin / Doxepin / Doxepin
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
61F with complex med history of failed renal transplant on PD,
numerous hospitalization for sepsis and ICU stays, with severe
immunocompromise ?[**1-24**] ATG and over-immunosuppression, presenting
with lethargy, hypotension, and concern for peritonitis due to
discolored PD fuid. She presents from her rehab with hypotension
and mild changes in mental status. She feels fatigued, but is
alert and oriented. She also endorses 4 days of liquid stools.
.
Arrived to ED with SBPs in 70-80s, awake. Radial pulse not
easily palpable. Dialysate from overnight dwell that arrived
with her is discolored. Abdomen is soft, catheter site is
clean/dry and nonerythematous. Extremities are warm. Her
peritoneal fluid was sent for culture, cell counts did not
indicate an infection. She was bolused 1.5 L of NS total, with
improvement in her BPs to high 90s low 100s.
.
Of note, she was recently admitted from [**5-28**] to [**6-5**] with
hypotension, was aggressively bolused in the ED with 4-5 L, then
had acute decompensated heart failure which improved with fluid
removal from PD. Before that admission, she was admitted with
GNR bacteremia of an unclear source, discharged on a 2 week
course of meropenem, which was completed on [**6-9**].
.
On arrival to the MICU, patient was asymptomatic, comfortable,
blood pressures 109/66, satting 100% 2L.
Past Medical History:
# Ischemic cariomyopathy/CHF; EF 35% in [**4-/2182**]-> 30% [**5-/2182**]
# h/o severe MR s/p repair in [**1-/2182**]
# NSTEMI [**7-/2181**], s/p [**Year (4 digits) **] to LAD [**9-/2181**]
# CABGX5 vessel [**1-/2182**]
# s/p renal transplant ([**2157**])
-- c/b chronic rejection
-- second renal transplant ([**2160**])
# s/p pancreas transplant
-- with allograft pancreatectomy ([**5-/2174**])
-- redo pancreas transplant ([**6-/2175**])
-- admission for acute rejection ([**7-/2180**]), resolved with
increased immunosupression
# Diabetes mellitus type I
-- c/b neuropathy, retinopathy, dysautonomia
-- no longer requires regular insulin after the pancreas
transplant, but has been given SS while on high-dose prednisone
in house
# Autonomic neuropathy
# Sleep disordered breathing
-- Unable to tolerate CPAP; uses oxygen 2L NC at night
# Osteoporosis
# Hypothyroidism
# Pernicious anemia
# Cataracts
# Glaucoma
# Anemia of CKD, on Aranesp in the past
# R foot fracture c/b RLE DVT
# Chronic LLE edema
# Recurrent E. coli pyelonephritis
# s/p anal polypectomy ([**5-/2176**])
# s/p bilateral trigger finger surgery ([**8-/2178**])
# s/p left [**Year (4 digits) 6024**] ([**8-/2179**])
Social History:
Child psychiatrist, on disability. Has been in and out of
hospitals in the last 8 months. Was longest at [**Hospital3 **],
most recently at [**Hospital **] LivingCenter - [**Hospital1 8218**] - [**Location (un) **].
Mobile with wheelchair but unable to do transfers.
- Tobacco: Denies
- Alcohol: Denies
- Illicits: Denies
Family History:
Father with MI at 57.
No family history of arrhythmia, cardiomyopathies, or sudden
cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
[**Location (un) **]: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
DISCHARGE EXAM:
Vitals: HR 70, BP 120/71, RR 14, 99% on RA
General: Alert, oriented x3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
[**Location (un) **]: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
ADMISSION LABS:
[**2182-6-15**] 02:25PM BLOOD WBC-6.5 RBC-2.78* Hgb-9.2* Hct-29.6*
MCV-107* MCH-33.1* MCHC-31.1 RDW-23.2* Plt Ct-250
[**2182-6-15**] 02:25PM BLOOD PT-38.9* PTT-40.7* INR(PT)-3.8*
[**2182-6-15**] 02:25PM BLOOD Glucose-97 UreaN-52* Creat-5.9* Na-135
K-2.9* Cl-91* HCO3-31 AnGap-16
[**2182-6-15**] 02:25PM BLOOD Albumin-2.9* Calcium-7.6* Phos-5.3*
Mg-1.5*
[**2182-6-16**] 04:10AM BLOOD Vanco-25.0*
.
DISCHARGE LABS:
[**2182-6-17**] 03:43AM BLOOD WBC-5.2 RBC-2.62* Hgb-8.8* Hct-27.9*
MCV-107* MCH-33.6* MCHC-31.6 RDW-23.4* Plt Ct-218
[**2182-6-17**] 03:43AM BLOOD PT-24.6* PTT-32.8 INR(PT)-2.4*
[**2182-6-17**] 03:43AM BLOOD Glucose-85 UreaN-57* Creat-6.3* Na-132*
K-3.7 Cl-94* HCO3-26 AnGap-16
[**2182-6-17**] 03:43AM BLOOD Calcium-7.5* Phos-5.9* Mg-2.1
[**2182-6-17**] 03:43AM BLOOD tacroFK-9.6
.
MICRO:
[**2182-6-15**] Peritoneal fluid Cx: no growth
[**2182-6-15**] Blood Cx: no growth to date
[**2182-6-16**] C. diff: negative
.
IMAGING:
[**2182-6-15**] CXR: The patient is status post mitral valve
replacement and probably coronary artery bypass graft surgery.
The heart is mildly enlarged. There is patchy basilar
opacification suggesting a combination of atelectasis and
pleural effusion. Streaky left upper lobe opacity suggests minor
atelectasis or scarring which is unchanged. There is no
pneumothorax. No free air is demonstrated.
IMPRESSION: Patchy left basilar opacity, highly suggestive of
atelectasis in association with a small-to-moderate suspected
pleural effusion, although opacification is not entirely
specific as the etiology.
.
[**2182-6-16**] CT Abd/Pelvis w/o con:
1. Peritoneal dialysis catheter unchanged in position compared
to the prior studies.
2. Small amount of free air in the abdomen, slightly increased
compared to prior study. No clear source identified and this
likely is related to the peritoneal dialysis.
3. Very extensive vascular calcifications.
4. Small shrunken native kidneys consistent with the patient's
end-stage renal failure. A transplant kidney is seen in the left
lower quadrant.
5. Pancreas transplant in the right lower quadrant incompletely
assessed on this non-contrast study.
6. Moderate amount of free fluid in the abdomen and pelvis, but
no hemorrhagic fluid is seen.
Brief Hospital Course:
61 year old woman with diabetes s/p pancreas transplant, ESRD
s/p renal transplant x3, currently on peritoneal dialysis,
presenting with hypotension, lethargy, and diarrhea.
.
# Hypotension: Patient with baseline SBPs in the low 90s,
70s/80s on presentation to the ED with mild lethargy. Now
normotensive above her baseline SBPs > 100 after resuscitation
with 1.5 L NS. Her peritoneal fluid per report was discolored,
however cell count and culture both negative for infection.
Blood cultures negative for growth to date. CXR showed
atalectasis but no evidence of pneumonia. Stool negative for C.
diff infection. She was empirically treated with vancomycin and
meropenem to cover for sepsis, however these were discontinued
after all culture data returned negative. She has had several
days of frequent stools, likely due to a viral gastroenteritis,
which may have contributed to dehydration causing hypovolemia
with her continued PD.
.
# Acute Gastroenteritis: Resolved. C diff negative. Likely due
to a viral gastroenteritis.
.
# ESRD on PD: Patient did not appear volume overloaded on
admission. When she started to dwell on the morning of [**6-16**], the
peritoneal fluid was tinged bright red. The hematocrit on that
fluid was less than two percent. Her Hct was stable at 28. A CT
scan of her abdomen pelvis was obtained and showed that the PD
catheter was in good position and there were no acute
abnormalities. Her subsequent PD fluid has remained clear.
.
# CD4 Count: Patient with recent CD4 count in the 70s, Dr. [**Last Name (STitle) 724**]
(patient's ID doctor) recommended PCP and MAC prophylaxis as
well as HIV test. Patient will need f/u for this as an
outpatient.
.
# Chronic Systolic and Diastolic CHF: Echocardiogram last
admission showed posterior/lateral/inferior/apical hypokinesis
similar to prior but with worsening MR and pulmonary
hypertension. She currently appears euvolemic. She was continued
on amiodarone.
.
# Coronary artery disease: Patient is s/p MI and 5-vessel CABG
in [**1-/2182**] (LIMA-LAD, SVG-D/OM1/OM2/PDA). She also has severe
mitral regurgitation s/p repair in [**2-3**]. Currently without chest
pain. Continued aspirin and statin.
.
# DM1 s/p pancreas transplant and renal transplant: Tacro level
was 9.6, above the goal ([**3-30**]), therefore the tacrolimus dose was
decreased from 1.5mg [**Hospital1 **] to 1mg [**Hospital1 **]. Continued prednisone 5mg
daily.
.
# Atrial fibrillation: History of paroxysmal afib. Currently in
sinus rhythm on amiodarone. INR was supratherapeutic at 3.8 upon
admission so coumadin was held. INR decreased to 2.4 on the day
of discharge so the coumadin was restarted at the patient's home
dose.
.
# Hypothyroidism: Continued levothyroxine.
.
# Vitamin B12 deficiency: Low levels despite PO supplementation
suggesting poor absorption, therefore we stopped the PO vitmain
B12 and started IM 1000 mcg once monthly.
.
# Glaucoma: Continued home eye drops and methazolamide.
Medications on Admission:
1. diltiazem HCl 120 mg Capsule, Extended Release Sig: Three (3)
Capsule, Extended Release PO BID (2 times a day): Take 360mg in
morning and night and 240mg in afternoon.
2. diltiazem HCl 240 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily): Take 360mg in
morning and night and 240mg in afternoon.
3. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: Two (2) Tablet Extended Release 24 hr PO BID (2 times a
day).
4. warfarin 1 mg Tablet Sig: 4.5 Tablets PO once a day: Take
4.5mg daily.
5. amiodarone 200 mg Tablet Sig: One (1) Tablet PO
TUES,[**Hospital1 **],SAT ().
6. fluorouracil 0.5 % Cream Sig: One (1) application Topical
once a day for 2 weeks: apply to face with bactroban.
7. Bactroban 2 % Cream Sig: One (1) application Topical once a
day for 2 weeks: Apply to face with Fluorouracil.
8. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
9. sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
10. Ferrlecit 62.5 mg/5 mL Solution Intravenous
11. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
12. tramadol 50 mg Tablet Sig: 1-2 Tablets PO BID (2 times a
day) as needed for pain.
13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
14. Voltaren 1 % Gel Sig: One (1) application Topical four times
a day: Apply to affected area up to 4times daily.
15. Epogen Injection
16. insulin aspart 100 unit/mL Solution Sig: One (1) injection
Subcutaneous four times a day: Take as directed according to
home sliding scale.
17. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every
3 hours) as needed for Pain.
18. sevelamer carbonate 800 mg Tablet Sig: 1.5 Tablets PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
19. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
20. acetaminophen 650 mg Tablet Sig: Two (2) Tablet PO twice a
day as needed for Pain.
21. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
22. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for Chest pain:
Place 1 tablet under the tongue for chest pressure. Take 1 every
5 minutes, up to three times in a row.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
23. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
24. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
25. doxercalciferol Intravenous
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. Amiodarone 200 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO DAILY
5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
6. Creon 12 2 CAP PO TID W/MEALS
7. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
8. Fluconazole 100 mg PO QMOWEFR
9. Fludrocortisone Acetate 0.1 mg PO DAILY
10. FoLIC Acid 1 mg PO DAILY
11. Gabapentin 100 mg PO QOD
12. Lanthanum 500 mg PO TID W/MEALS
13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
14. Levothyroxine Sodium 125 mcg PO DAILY
15. Methazolamide 50 mg PO TID
16. Midodrine 15 mg PO TID
17. Mycophenolate Mofetil 500 mg PO BID
18. Nephrocaps 1 CAP PO DAILY
19. Omeprazole 20 mg PO DAILY
20. PredniSONE 5 mg PO DAILY
21. Restasis *NF* (cycloSPORINE) 0.05 % OU [**Hospital1 **]
* Patient Taking Own Meds *
22. Simethicone 40-80 mg PO QID:PRN bloating
23. Tacrolimus 1 mg PO Q12H
24. Warfarin 1 mg PO [**Doctor First Name **]/M/W/F/SA
25. Warfarin 2 mg PO TU/TH
26. Acetaminophen 325-650 mg PO Q6H:PRN pain
Do not exceed 4 grams of tylenol per day
27. Loperamide 2 mg PO QID:PRN loose stools
28. Cyanocobalamin 1000 mcg IM/SC ONCE A MONTH
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - [**Hospital1 8218**] - [**Location (un) **]
Discharge Diagnosis:
Hypovolemic hypotension
Gastroenteritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 17759**]:
.
You were admitted to [**Hospital1 18**] with hypotension and diarrhea. Your
dialysate fluid was red. Your hematocrit was stable. Your
hypotension resolved with fluid resuscitation. A CT scan of your
andomen and pelvis showed that the peritoneal dialysis catheter
is in good position.
.
We made the following changes to your medications:
1. DECREASE tacrolimus from 1.5mg twice daily to 1mg twice daily
2. STOP oral vitamin B12 (cyanocobalamin)
3. START intramuscular vitamin B12 (cyanocobalamin) 1000mcg once
a month
.
Please continue to take all of your other medications as
prescribed.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please go to these appointments:
.
Department: DERMATOLOGY AND LASER
When: THURSDAY [**2182-6-20**] at 11:00 AM
With: [**Doctor Last Name **],KATHEEN [**Telephone/Fax (1) 3965**]
Building: [**Location (un) 3966**] ([**Location (un) 55**], MA) [**Location (un) **]
Campus: OFF CAMPUS
Best Parking: Free Parking on Site
.
Department: CARDIAC SERVICES
When: WEDNESDAY [**2182-7-10**] at 10:20 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST
Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: TRANSPLANT CENTER
When: TUESDAY [**2182-9-17**] at 10:20 AM
With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST
Best Parking: [**Hospital Ward Name **] Garage
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2182-6-17**]
|
[
"782.3",
"365.9",
"790.99",
"V43.3",
"518.0",
"V45.81",
"E879.1",
"008.8",
"362.01",
"458.8",
"250.51",
"590.00",
"285.21",
"V49.75",
"E878.0",
"424.0",
"327.23",
"V58.65",
"412",
"276.51",
"337.1",
"414.8",
"414.00",
"V12.51",
"041.49",
"585.6",
"V45.11",
"428.42",
"428.0",
"780.97",
"996.81",
"V15.51",
"244.9",
"V42.83",
"276.52",
"281.0",
"733.00",
"250.61",
"998.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.98"
] |
icd9pcs
|
[
[
[]
]
] |
13828, 13929
|
7113, 10064
|
442, 448
|
14013, 14013
|
4850, 4850
|
14931, 16009
|
3387, 3515
|
12650, 13805
|
13950, 13992
|
10090, 12627
|
14189, 14536
|
5279, 7090
|
3530, 4158
|
4174, 4831
|
14565, 14908
|
391, 404
|
476, 1819
|
4866, 5263
|
14028, 14165
|
1841, 3031
|
3047, 3371
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,608
| 148,436
|
20008
|
Discharge summary
|
report
|
Admission Date: [**2113-1-24**] Discharge Date: [**2113-2-10**]
Service: NEUROLOGY
HISTORY OF PRESENT ILLNESS: In summary, this is an
80-year-old man with past medical history significant for
lymphoma, diabetes mellitus, hypertension, atrial
fibrillation, and COPD, who presented with intractable
emesis, slurred speech, and later obtundation. He was
initially brought to [**Hospital3 628**], where pneumonia was
diagnosed. He was intubated for hypoxia and
unresponsiveness, and then was sent to [**Hospital1 190**] for further management.
Here at [**Hospital3 **], his head CT showed a left cerebellar
infarct. His INR was therapeutic on arrival at [**Location (un) 620**],
however, when he presented here, his INR was actually 5.2. A
MRI was done here at [**Hospital1 **], which confirmed
an infarction in the left superior cerebellar territory. He
was extubated on [**2113-1-26**], and has done well since.
He was transferred to the floor from the ICU on [**2113-1-28**]. He was still on a face mask O2. He denied any
shortness of breath, and says that he felt well. In
discussion with his wife and the patient as per his wishes,
he did not want to be re-intubated for respiratory failure.
PAST MEDICAL HISTORY:
1. Lymphoma.
2. Diabetes mellitus.
3. COPD.
4. Hypertension.
5. Prostate cancer.
6. Hypercholesterolemia.
7. Atrial fibrillation.
ALLERGIES: No known allergies.
MEDICATIONS ON ADMISSION:
1. Albuterol/ipratropium nebulizers.
2. Digoxin.
3. Pepcid.
4. Hydralazine prn.
5. Lopressor 50 mg b.i.d.
6. Coumadin for a goal INR between [**3-7**].
7. Sliding scale insulin.
SOCIAL HISTORY: He smoked one pack per day. He has no
alcohol use. He lives with his wife.
FAMILY HISTORY: Significant only for cardiac disease.
PHYSICAL EXAMINATION: On admission to the floor, he was
afebrile at 97.2, blood pressure is 166/70, heart rate was
78, respiratory rate was 18, and he was satting 99% on a 40%
face mask. He was in no acute distress. He appeared
comfortable. HEENT examination: His oropharynx was clear.
Mucous membranes were moist. His lungs had coarse bilateral
breath sounds with some end expiratory wheezes at the bases.
His heart was irregular with normal S1, S2 with no murmurs.
His abdomen was soft, and extremities were warm.
Neurologically, he was able to follow one step commands. He
showed two fingers. He was able to lift up both legs. He
was able to lift up both arms. He can answer simple
questions appropriately. He was fluent, but no dysarthria
that was obvious. Cranial nerves: Pupils are equal, round,
and reactive to light. Extraocular movements are intact. He
was able to cross the midline with gaze. His fundi were
normal. He had a right facial droop. His tongue protruded
to the midline without vesiculations. On motor examination,
he had normal bulk and tone throughout. He moved his left
arm against gravity. Weaker on the right upper extremity,
however, he was able to lift it against gravity. He had less
spontaneous overall movement on the right arm. His legs: He
was able to lift both of them equally and hold them up. He
had very slight weakness on the right leg compared to the
left leg throughout. His reflexes were 1+ in the upper
extremities. They seem to be decreased on the right side.
He has an upgoing toe on the right side. Sensation: He
withdrew to pain. It was intact to light touch and
temperature, however, the patient not very cooperative with
this examination. Unable to really test coordination again
due to cooperativity, had not been able to test his walk.
LABORATORIES: On presentation to the floor, his laboratories
were a white count of 7.3, platelets of 204, hematocrit 37.4.
His INR was therapeutic, at one point it was complicated with
an INR of 5.2 likely secondary to levofloxacin which was
started for his pneumonia. Coumadin 7.5 mg q.h.s. was held
and then his INR drifted down to normal levels.
His levofloxacin after two days was switched to ceftriaxone
and he was also started on clindamycin IV. He completed 10
days total of levofloxacin plus ceftriaxone and nine days of
clindamycin IV, and his chest x-ray was markedly improved.
His hospital course was complicated only by the pneumonia.
He was very slow to come back appear more alert and oriented,
and after seven days, he was on nasogastric tube feeds, and
eventually a PEG tube was placed on [**2113-2-8**]. He was
started on PEG tube feeds on [**2-9**] a.m. and he has
tolerated those well without complications.
In summary, this is an 80-year-old man with history of
lymphoma, hypertension, diabetes, COPD, who presented with
emesis, slurred speech, and right hemiparesis, who was found
to have a left superior cerebellar artery infarction with
residual deficits. He has mild ataxia and mild hemiparesis
on the right side with a right facial droop. He was
evaluated by Physical Therapy and Occupational Therapy team
here, who deemed that he needed acute rehab services.
After discussion with his PCP, [**Name10 (NameIs) **] was sent out to rehab on
[**2113-2-10**].
MEDICATIONS ON DISCHARGE:
1. Albuterol nebulizers one nebulizer q.4h. prn.
2. Aspirin 325 mg p.o. q.d.
3. Atorvastatin 10 mg p.o. q.d.
4. Captopril 25 mg p.o. t.i.d.
5. Digoxin 0.125 mg p.o. q.d.
6. Sliding scale insulin.
7. Ipratropium bromide nebulizers one nebulizer q.6h. prn.
8. Metoprolol 25 mg p.o. b.i.d.
9. Protonix 40 mg p.o. q.24h.
10. Coumadin 5 mg p.o. q.h.s., his last Coumadin level on
[**2113-2-9**] was 1.7. His [**2113-2-10**] Coumadin level
is still pending.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 12114**]
Dictated By:[**Name8 (MD) 53744**]
MEDQUIST36
D: [**2113-2-10**] 09:08
T: [**2113-2-10**] 09:25
JOB#: [**Job Number 53910**]
|
[
"202.80",
"427.31",
"250.00",
"273.3",
"491.21",
"486",
"434.11",
"790.92",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
1719, 1758
|
5094, 5782
|
1428, 1607
|
1781, 2531
|
123, 1216
|
2548, 5068
|
1238, 1402
|
1624, 1702
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,096
| 109,377
|
10856+10857
|
Discharge summary
|
report+report
|
Admission Date: [**2173-2-2**] Discharge Date: [**2173-2-22**]
Date of Birth: [**2135-2-18**] Sex: M
Service: MEDICINE
CHIEF COMPLAINT: Fever, confusion.
HISTORY OF PRESENT ILLNESS: The patient is a 37-year-old man
with HIV aids, last CD4 count of 22, viral load greater than
750 ......./ml, who is a patient at [**Hospital6 **]
and was referred for admission for fevers and anemia.
It was reported that he had been doing poorly times four
weeks with complaints of fatigue and intermittent diarrhea
since [**Month (only) 1096**]. The fevers began during the first week of
[**Month (only) 404**] with a temperature as high as 104??????. He reported at
that time that he never fully defervesced. His temperature
waxed and waned with severe night sweats, chills, headache
and intermittent photophobia.
The patient also noted watery-brown diarrhea occurring over
the past month, as well as nausea and poor p.o. intake. He
was recently seen by his primary care physician who took
stool cultures. At that time, he was started on Flagyl
empirically for belly pain and diarrhea, but he had to stop
after three doses because of an anaphylactic reaction
requiring Benadryl and steroids in the Emergency Department
on [**2173-1-27**].
The patient presented to his primary care physician's office
on the day of admission because of significant temperatures,
as well as having hallucinations, "seeing fairies on the edge
of his bed," on the morning of admission.
PAST MEDICAL HISTORY: 1. HIV aids times 15 years. The
patient reported poor compliance of his antiretrovirals
secondary to intolerance from side affects. He most recently
was on therapy ................ two weeks prior to admission
when they were stopped for concerns of side affects versus
infection causing the fevers and diarrhea. 2. PCP pneumonia
in [**2171-7-31**], thrush [**2170**]. 3. Anxiety disorder. 4.
Pancytopenia felt secondary to HIV disease. He denied prior
blood transfusions. Per his primary care physician, [**Name10 (NameIs) **]
anemia improved with HAA-RT therapy.
MEDICATIONS ON ADMISSION: Azithromycin, Bactrim, Epivir
.................., Ativan p.r.n. anxiety, Celexa.
ALLERGIES: PENICILLIN CAUSING ANAPHYLAXIS, FLAGYL CAUSING
ANAPHYLAXIS (THE PATIENT ALSO HAD TAKEN TWO DOSES OF
CIPROFLOXACIN WITH THE FLAGYL PRIOR TO HIS ANAPHYLACTIC
REACTION).
FAMILY HISTORY: Maternal aunt and uncle who both reported
died secondary to intracranial aneurysmal bleeds.
SOCIAL HISTORY: No tobacco. No alcohol. The patient as
living alone prior this hospitalization; however, he plans to
move in with his partner. His proxy to his healthcare is
mother, [**Name (NI) **] [**Name (NI) 5025**]. Family is very important to him.
PHYSICAL EXAMINATION: Vital signs: Temperature 103??????, blood
pressure 97/58, pulse 116, respirations 16, oxygen saturation
98% on room air, without ambulatory desaturation per primary
care physician, [**Name Initial (NameIs) 4977**] 172 lbs. General: The patient was a
pleasant, thin, young man in no acute distress. He was
conversing fluently and appropriately. HEENT: Pupils equal,
round and reactive to light. Extraocular movements intact.
Sclerae anicteric. Oropharynx clear. Chest: Clear to
auscultation bilaterally. No wheezes, rhonchi or rales.
Cardiovascular: Tachycardiac, regular rhythm. Normal S1 and
S2. Positive S3 gallop. Abdomen: Soft, nontender,
nondistended. Normoactive bowel sounds. Extremities: No
edema. Neurological: Alert and oriented. Cranial nerves
II-XII intact. Strength 5 out of 5 times four extremities.
Sensation intact to light touch.
LABORATORY DATA: White count 2.2, hematocrit 22.2, platelet
count 94, differential 26% neutrophils, 7% bands, 56% lymphs,
5% monos; PT 13.3, INR 1.2, PTT 35.9; of note, baseline
hematocrit 22-26; sodium 137, potassium 3.7, chloride 105,
bicarb 24, BUN 11, creatinine 0.7; ALT 62, AST 60, LD 550,
...... phos 123, amylase 76, lipase 33, total bilirubin 0.3,
calcium 8.1, phosphate 3.0, magnesium 1.6, albumin 30.1.
HOSPITAL COURSE: The patient was admitted to the General
Medicine Service for further work-up of his fevers and
diarrhea.
1. Infectious disease: In the Emergency Room, the patient
was evaluated first for acute meningitis with lumbar puncture
demonstrating 0-1 white cells, greater than 100,000 red blood
cells, no xanthochromia, protein 256, glucose 47, with
negative gram stain, no polys.
Throat cultures all eventually proved no growth to date, as
well as blood and urine cultures which were unremarkable.
The patient received a single dose of Vancomycin empirically
prior to return of CSF results. Of note, the patient
improved with Vancomycin and fluids.
The patient underwent further work-up for possible source of
infection including full-body scan which was negative for
abscess and unremarkable for lymphadenopathy. His blood
cultures including microcytics continued to be no growth
date. His urine cultures and urinalysis were unremarkable.
His chest x-ray was negative for pneumonia. Induced sputums
were negative for PCP and acid fast bacilli.
The patient underwent further evaluation of his abdomen given
his diarrhea complaints including full set of stool cultures
sent times three which were unremarkable, as well as a
colonic biopsy, including testing for CMV which was again
unremarkable.
The patient's stool viral culture was notable for a positive
adenovirus. The patient continued to be febrile, spiking
temperatures to 103?????? without clear source. Eventually
send-out lab results came back demonstrating a positive urine
histologic antigen.
On [**2-19**], the patient commenced treatment for
histoplasmosis including ................. 3 mg/kg/day,
pretreatment Tylenol, Benadryl, and 500 cc normal saline.
The patient tolerated this treatment well with good response
including complete defervescence.
The patient will continue to complete a 14-day course of
.................. with Itraconazole to be followed. The
patient's dose and course length of treatment of Itraconazole
will be determined by his primary care physician, [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 6164**] in consult with Infectious Disease Service here at
[**Hospital3 **].
Of note, the patient's stool was determined to be positive
for adenovirus, as well as possible nasopharyngeal swab
confirming the presence of adenovirus. Treatment was
considered for this finding, especially given the patient's
new cardiomyopathy; however, given the potential renal
toxicity of treatment, the decision was made to hold on
treatment at this time with further follow-up with the
patient's primary care physician, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6164**], to determine
if treatment in the future is necessary.
2. Neurologic: The patient's confusion persisted throughout
the first two weeks of hospitalization correlating well with
his temperature spikes. He was without hallucinations
throughout his hospital stay. The source of his mental
status changes was felt likely to be ...................
given his infectious source. However, he was also evaluated
for possible HIV encephalopathy, including a lumbar puncture
to test for CSF HIV viral load which demonstrated 6230
...../ml. The case was discussed with Dr. .................
who felt that the elevated viral load in CSF would be
consistent with HIV encephalopathy.
At the time of discharge, he further had CSF TP, PCR and VDRL
pending. Note, serum RPR was negative.
The patient is to follow-up with Dr. ................... in
his clinic with instructions to make an appointment,
[**Telephone/Fax (1) 2343**], for further evaluation.
3. Heme: The patient had persistent pancytopenia requiring
multiple blood transfusions throughout his hospitalization.
He tolerated these without difficulty and had good
symptomatic relief and improvement in his low blood pressure.
The likely source of his pancytopenia is bone marrow
involvement from his HIV disease. Given his long history of
pancytopenia, he will be restarted on ...............
therapy, which has had good result in the past with his blood
count monitored.
This dictation is to be continued.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8184**], M.D. [**MD Number(1) 8185**]
Dictated By:[**Last Name (NamePattern1) 7485**]
MEDQUIST36
D: [**2173-2-22**] 11:37
T: [**2173-2-22**] 12:06
JOB#: [**Job Number 35377**]
Admission Date: [**2173-2-2**] Discharge Date: [**2173-2-22**]
Date of Birth: [**2135-2-18**] Sex: M
Service: CARDIOVASCULAR
CONTINUATION OF HOSPITAL COURSE: On [**2173-2-8**] the patient
developed an episode of shortness of breath, hypoxia with O2
sats up to 91% on room air. The patient underwent further
evaluation. Chest x-ray demonstrated lower lobe and
echocardiogram demonstrated an EF of 15%. The patient
responded well to intravenous Lasix. The etiology of the
patient's heart failure remains unclear with the differential
diagnosis including HIV cardiomyopathy versus a viral
myocarditis. The question of adenovirus in the patient's
stool and possible nasopharyngeal swab may be indication of
an acute viral illness. The patient's volume status was
monitored carefully throughout the rest of his
hospitalization and the congestive heart failure service was
called to assist with management. The patient had repeat
echocardiogram on [**2-19**], which demonstrated an EF of 15 to 30%
of global left ventricular hypokinesis and 3+ mitral
regurgitation. At the time of discharge the patient's heart
failure management included Toprol XL 12.5 mg po q day and
Lasix 20 mg po q day. The patient will need continued follow
up for proper titration of these medications including daily
weights, monitoring of input and output and pulse oximetry.
The patient is to follow up with the congestive heart failure
service in clinic on [**2173-3-15**] at 1:00 p.m. with a Dr. [**First Name (STitle) 2031**].
The patient also was instructed to limit fluids 2 liters per
day. Further investigation of possible adenovirus etiology
and question of further treatment necessary will be deferred
to the outpatient setting with the patient's primary care
physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6164**].
Psychiatric issues, the patient suffers from significant
anxiety for which he was taking Ativan prn at home upwards to
10 mg po q day. Upon hospitalization his anxiety increased
with issues of confusion as well. Psychiatry was consulted
for further management of his medical regimen including
attempts to control his anxiety with Ativan and Haldol, which
were unsuccessful. He was subsequently switched to
intravenous Trilafon b.i.d. with good effect. However, on
[**2-19**] the patient was noted to have significant stiffness,
difficulty moving, speaking and notable right sided weakness
after receiving his dose of Trilafon. Intravenous Benadryl
was administered and in conjunction with the psychiatry team
Cogentin therapy was administered times three days. The
patient's symptoms of stiffness slowly resolved as well as
the strength and sensory deficits. Ischemic event was
excluded with noncontrast head CT and brain MRI. Of note,
the patient is now considered intolerant of all antipsychotic
medications given this reaction. At the time of discharge
the patient was maintained on Valium 5 to 10 mg po q 8 hours
prn.
Renal, the patient experienced acute bump in his creatinine
with results of treatment with Ambazone. With this his
creatinine increased from 0.9 to 1.7 with treatment.
However, upon institution of fluid bolus prior to Ambazom
administration his creatinine decreased and stabilized at
1.5. Should plan to continue pretreatment for all doses of
Ambazome with 500 cc normal saline bolus.
Skin, the patient experienced a generalized erythrodermic
reaction, which he states is chronic and was present on
admission and improved dramatically with holding of the
patient's Bactrim. Upon reinstitution of antibiotics
prophylaxis, the rash reappeared. The patient tolerated this
condition well with no pruritus, no fever and no edema. The
patient was maintained on Benadryl 25 mg intravenous prn.
DISCHARGE CONDITION: Good.
DISCHARGE STATUS: To acute rehab facility.
DISCHARGE MEDICATIONS:
1. Ambazone 250 mg q 24 hours with pretreatment with 500 cc
normal saline bolus as well as 25 mg intravenous Benadryl and
Tylenol 1 gram po.
2. Toprol XL 12.5 mg po q day.
3. Lasix 20 mg po q day (please monitor daily weights and
lower extremity edema and titrate accordingly.).
4. Lamivudine 150 mg po b.i.d.
5. ___________ Disoproxil 300 mg po q day.
6. Ritonavir/Lopinavir three caps po b.i.d.
7. Multivitamin.
8. Loperamide 2 mg po q.i.d. prn.
9. Pantoprazole 40 mg po q day.
10. Azithromycin 1200 mg po one times per week on Saturday.
11. Bactrim double strength one tab po q day.
12. Zofran 2 mg intravenous q 6 hours prn.
13. Percocet one to two tabs po q 6 hours prn.
14. Tylenol 1000 mg po q 6 hours prn.
15. Celexa 20 mg po q day.
16. Acyclovir 800 mg po five times a day times fourteen
days.
17. Diazepam 5 to 10 mg po q 8 hours prn.
Note, the patient should continue Ambazone through [**2173-3-1**].
At that time the patient should begin therapy with
Itraconazole 200 mg po b.i.d. with weekly liver function
testing.
FOLLOW UP APPOINTMENTS: Primary care physician [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6164**]
in one to two weeks. Congestive heart failure clinic [**2173-3-15**]
with Dr. [**First Name (STitle) 2031**] at 9:00 a.m. at [**Hospital1 188**] [**Location (un) 436**] [**Hospital Ward Name 23**] Building.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8184**], M.D. [**MD Number(1) 8185**]
Dictated By:[**Last Name (NamePattern1) 7485**]
MEDQUIST36
D: [**2173-2-22**] 12:54
T: [**2173-2-22**] 13:09
JOB#: [**Job Number 35378**]
|
[
"780.1",
"276.1",
"428.0",
"428.20",
"284.8",
"115.99",
"042",
"584.9",
"425.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.25",
"03.95",
"38.93",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
12338, 12390
|
2387, 2480
|
12413, 13461
|
2108, 2370
|
8684, 12316
|
2763, 4050
|
158, 177
|
13486, 14069
|
206, 1483
|
1506, 2081
|
2497, 2740
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
147
| 103,631
|
24582
|
Discharge summary
|
report
|
Admission Date: [**2158-6-24**] Discharge Date: [**2158-7-21**]
Date of Birth: [**2133-11-1**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
Pt is s/p MVC with multiple facial fractures, left eye injury,
and evidence of small SAH and frontal contusion
Major Surgical or Invasive Procedure:
Left Globe exploration
Facial fracture fixation, with mandibular fixation
Peg and trach placement
History of Present Illness:
PT was involved in MVC and sustained multiple injuries to his
face, Left eye and brain
Physical Exam:
On discharge:
HEENT: Pt with swollen left orbit, arch bars in place, Head
lacerations well healed, Trach removed, dressing over stoma
C/D/I
Cardiac: RRR
Chest: CTAB
Abd:soft NT/ND +BS, PEG tube inplace and without
leakage/erythema or tenderness
Ext: +2 pulses throughout, no edema
Pertinent Results:
[**2158-6-24**] 06:20PM BLOOD WBC-21.6* RBC-4.39* Hgb-13.4* Hct-37.9*
MCV-86 MCH-30.5 MCHC-35.4* RDW-12.1 Plt Ct-130*
[**2158-6-24**] 06:20PM BLOOD PT-12.8 PTT-19.4* INR(PT)-1.1
[**2158-6-24**] 06:20PM BLOOD Plt Ct-130*
[**2158-6-24**] 10:00PM BLOOD Glucose-113* UreaN-15 Creat-1.0 Na-140
K-3.8 Cl-105 HCO3-26 AnGap-13
[**2158-6-24**] 06:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2158-6-24**] 06:31PM BLOOD pO2-38* pCO2-62* pH-7.30* calHCO3-32*
Base XS-1 Comment-GREEN TOP
[**2158-6-24**] 10:07PM BLOOD Type-ART Temp-38.0 Rates-14/ Tidal V-600
PEEP-5 FiO2-70 pO2-331* pCO2-52* pH-7.34* calHCO3-29 Base XS-1
-ASSIST/CON Intubat-INTUBATED
[**2158-6-24**] 11:42PM BLOOD Type-ART Temp-38.0 Rates-18/ Tidal V-600
PEEP-5 FiO2-40 pO2-169* pCO2-41 pH-7.40 calHCO3-26 Base XS-0
-ASSIST/CON Intubat-INTUBATED
[**2158-6-24**] 06:31PM BLOOD Hgb-14.0 calcHCT-42 O2 Sat-65
[**2158-6-28**] 05:03PM BLOOD Hgb-9.9* calcHCT-30
[**2158-6-29**] 01:14AM BLOOD Hgb-10.8* calcHCT-32
Brief Hospital Course:
Pt was admitted to Trauma surgery with multiple facial
fractures, as well as severe trauma to the left eye.
Neurosurgery, Opthomology and Plastics all contributed to the
patients care. The patient developed a CSF leak that was
followed by Neurosurgery that eventually subsided. Nuerosurgery
also followed the patient for a questionable C4-C6 ligamentous
injury for which he was put in a cervical collar. Opthomology
took the patient to the OR for Left globe exploration, they
found no globe rupture but significant corneal abrasion, [**Doctor First Name 2281**]
avulsion with intact lens, and retinal hemorrhages. Plastics
fixed the facial fractures and applied arch bars and was trached
and Peggged [**2158-6-28**]. Patient steadily improved over stay, he
developed some impulsiveness that slowly subsided, he was able
to maintain POs, and achieve daily caloric intake by d/c, and
was cleared by PT and OT for d/c to home with follow up.
Radiology reports:
Head CT showed:
1) Pneumocephalus from multiple facial bone fractures.
2) Subarachnoid versus subdural blood along anterior falx just
above crista
galli.
3) Likely left frontal contusion.
4) Multiple comminuted facial bone fractures. Please see the
dedicated CT
scan of the facial bones for more information.
Facial CT showed:
1. Comminuted fractures involving the outer and inner tables of
the frontal
sinuses with pneumocephalus.
2. Comminuted fractures involving the orbits and maxillary
sinuses
bilaterally. Comminuted fracture of the left zygoma.
3. Right mandibular fracture.
4. Significant subcutaneous emphysema involving the soft tissues
of the
scalp, the orbits and neck. Pansinus opacification.
MRI of spine showed:
Subtle increase in signal intensity adjacent to the spinous
processes of C4
through C6 may represent injury to the interspinous ligament.
CTA head:
IMPRESSION: 1) Slight decrease in prominence of subarachnoid
hemorrhage
anterior to the frontal lobes bilaterally, without evidence of
new mass effect
or new intracranial hemorrhage. Stable pneumocephalus associated
with
multiple comminuted skull fractures.
2) Stable appearance of extensive facial fractures.
3) No evidence of aneurysm or occlusion of the vessels of the
Circle of
[**Location (un) 431**] and its tributaries, or of the cervical portions of the
carotid and
vertebral arteries. Visualization of the small branches of the
external
carotid systems is limited, and if there is clinical interest
for evaluation
of these vessels, standard diagnostic angiography is
recommended. This
recommendation was conveyed to Dr. [**Last Name (STitle) **] at 5:00 p.m. on [**2158-6-25**].
Discharge Medications:
1. Erythromycin 5 mg/g Ointment Sig: One (1) drop Ophthalmic
QID (4 times a day): Administer to left eye.
Disp:*QS for 2wks drop* Refills:*2*
2. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic QID (4 times a day): Apply to Left eye.
Disp:*QS for 2wks * Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*400 ML(s)* Refills:*0*
4. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Boost Liquid Sig: One (1) PO three times a day.
Disp:*30 * Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Multiple Facial Fractures, with CSF leak now resolved
Left eye injury: corneal abrasion, [**Doctor First Name 2281**] avulsion, retinal
hemorrhage
small anterior SAH, left frontal contusion
cervical ligamentous injury
Discharge Condition:
stable
Discharge Instructions:
Take medications as perscribed, be sure to follow up with
plastic surgery, opthomology, orthopaedics, and trauma surgery
clinic. Wear cervical collar at all times. Follow
recommendations of Occupational therapy.
Followup Instructions:
Plastic surgery will call you to arange arch bar removal, you
also have an appointment on [**2158-7-28**] at 1pm at the [**Hospital Ward Name 23**]
Building [**Location (un) 470**] surgical specialties department, cosmetic
clinic call [**Telephone/Fax (1) 274**] with questions
Opthomology: you have an appointment for evaluation on [**2158-7-25**] at
11:15am at the [**Hospital Ward Name 23**] Building [**Location (un) 442**], with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
call [**Telephone/Fax (1) 253**] with questions
Neurosurgery: call [**Telephone/Fax (1) 1272**] for appointment with Dr.
[**Last Name (STitle) 62075**] in 1-2weeks
Trauma Surgery: call [**Telephone/Fax (1) 6439**] to schedule an appointment in
2 weeks
|
[
"871.1",
"802.1",
"518.5",
"801.11",
"847.0",
"802.29",
"802.6",
"958.7",
"E812.0",
"802.4",
"957.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"16.09",
"02.12",
"93.55",
"96.6",
"38.93",
"76.79",
"76.76",
"02.02",
"04.3",
"76.92",
"76.74",
"31.1",
"76.69",
"08.59",
"76.91",
"03.31",
"43.11",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
5281, 5287
|
1984, 4618
|
425, 525
|
5549, 5557
|
960, 1961
|
5818, 6580
|
4641, 5258
|
5308, 5528
|
5581, 5795
|
656, 656
|
671, 941
|
275, 387
|
553, 641
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,349
| 156,046
|
41404
|
Discharge summary
|
report
|
Admission Date: [**2124-2-25**] Discharge Date: [**2124-3-13**]
Date of Birth: [**2065-10-12**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
necrotic small bowel
Major Surgical or Invasive Procedure:
[**2124-2-26**] exlap, washout, ostomy takedown, cholecystostomy tube
[**2124-2-25**] [**3-9**] SBR, ostomy placement
[**2124-2-29**] jejunotransversecolostomy, GJ tube, closure, IVC F
[**2124-3-4**] takedown of jej-colonic [**Last Name (un) 1236**], creation end jejunostomy
History of Present Illness:
This is a 58F with ischemic small bowel s/p large [**Hospital 90097**]
transferred to [**Hospital1 18**] with open abdomen and necrotic ostomy.
Briefly, the patient underwent a laparoscopic right
hemicolectomy
at [**Hospital3 26615**] on [**2124-2-8**] for ruptured appendicitis and SBO who
represented on POD15 ([**2124-2-23**]) with 2 weeks of non-bloody
diarrhea, leukocytosis of 25 with left shift, and poor PO
intake.
She denied abdominal pain and fever. Lactate was 1.8.
Colonoscopy on [**2-23**] revealed pseudomembranes and edema of the
remaining R colon. This was felt to be consistent with either
ischemia or c diff, and she was started on empiric IV flagyl and
PO vancomycin. Biopsies were taken and 2 c diff samples were
sent, which were negative. Stool cultures were also negative.
CT on [**2-24**] revealed a large collection of fluid and air in the
RLQ at the anastamosis, indicating anastamotic leak. Gastroview
enema confirmed the leak. The patient was taken back to the OR
for exploration on [**2-25**]. Infarcted small bowel was found and
resected; a jejunostomy was created. The surgeon estimates that
~[**3-9**] SB was resected and that 6-7ft were left in place. Her
abdomen was left open and towels placed over the wound, with
ioban dressing and suction drainage through towel.
The patient was then transferred to [**Hospital1 18**] for further
management.
She was taken back to the OR for exploration in the AM [**2-26**].
The
ostomy was taken down, a small amount resected, and the end left
stapled in the abdomen. The rest of the small bowel was still
viable, but there only appeared to be ~3 feet. The transverse
colon was healthy, but the rest of the colon was covered in
dense
adhesions. The sigmoid was the only other segment to be clearly
identified. Hydrops of the gallbladder was also found, and a
cholecystostomy tube was placed. Due to increasing acidemia in
the OR, the patient was packed and taken back to the TSICU with
an open abdomen for further resuscitation and stabilization.
Past Medical History:
bipolar disorder, HTN, DVT
Social History:
Has a boyfriend and a daughter. Quit smoking in [**2123**]
after a 25 pack-year history, no E/IVDU. Was at Country Manor
for rehab when she came back to the hospital.
Family History:
NC
Physical Exam:
On admission:
EXAM: intubatd, sedated, MAE.
RRR no MRG appreciated
B/L rales and ronchi
soft, open abdomen. obese. drainaing bilious fluid in ad
around
ostomy appliance.
+ 2 edema B/L
Pertinent Results:
Admission Data:
7.24/41/120/18/-9
7.37/28/92/17/-7
Lactate: 3.0-3.1-3.2-3.2-2.2
150 122 26
-------------- 215
3.9 15 1.2
Ca: 8.0 Mg: 2.7 P: 6.4
38.2 >---< 476
38.4
PT: 14.5 PTT: 25.0 INR: 1.3
CK: 21 MB: 2 Trop-T: <0.01
ALT: 20 AP: 87
Tbili: 0.2 AST: 15
40.1 >---< 519
37.0
N:45 Band:23 L:8 M:1 E:0 Bas:0 Metas: 8 Myelos: 15 Nrbc: 7
Imaging:
CTA abd/pelvis [**2-24**]: 10.6x19x9.9cm fluid collection at
anastamosis. Celiac axis, SMA, [**Female First Name (un) 899**] patent. +Cholelithiasis in
distended gallbladder. Esophagus thickened. Possible pSBO.
Gastroview enema [**2-25**]: Free extravation of contrast from
anastamosis into peritoneal cavity.
Colonoscopy [**2124-2-24**]: colitis of the remaining R side of the
colon, c/w either ischemia or c diff
EGD [**2124-3-4**]: Esophagus and duodenum well examined and no active
bleeding. Area around gastrostomy no active bleeding. Most of
the stomach filled with old clotted blood and could not be well
seen. No active bleeding seen.
Otherwise normal EGD to second part of the duodenum
Brief Hospital Course:
On [**2-26**] the patient was admitted to the TSICU post operatively
for resuscitation from exlap, washout, ostomy takedown,
cholecystostomy tube. On POD 0, the patient had continued acid
base abnormalities, electrolyte abnormalities and she was given
bicarb, and IVFs. She was started on an insulin gtt for control
of her persistent hyperglycemia. Cultures were sent and her
lines from OSH were changed. She had multiple episodes of
desaturation and a CXR was concerning for RML collapse. She was
bronched showing RML mucous plugging. She continued to need
pressors and a bedside echo showed that she was still
hypovolemic. She was bolused fluids. Given her history of PE's
LENIS were ordered. The LENIS showed L common femoral DVT. On
POD 1, she was started on a heparin gtt. The vent was weaned
down. She was given albumin and blood and her pressor
requirement decreased. On POD 2, she started having increased
sodium on labs with dilute urine consistent with DI. She was
given ddAVP and responded appropriately. She went to the OR for
jejuno- transversecolostomy, GJ tube, closure, and IVC Filter.
On POD [**4-4**] she was started on a lasix gtt and 25% albumin. The
free water replacement was stopped as her sodium was improving.
She was still on the heparin gtt and began bleeding from her
rectum, vagina, G tube, and J tube. She was scoped from above
without a source identified. Later on, bowel contents came from
her wound. She was taken back to the operating room, where her
anastamosis was seen to have leaked. THe jejuno-colonic
anastamosis was taken down. The jejunum was unable to be made
to reach the skin; thus it was placed at the base of the wound
as an end jejunostomy. A vac was placed over this area to
control the effluent, but after several days, nothing came out
of the vac. Goals of care were discussed with the family. They
decided to make her CMO. She was extubated and transferred to
the floor, where she passed away several days later on hospital
day 18 of cardiopulmonary arrest. No autopsy was requested by
the family.
Medications on Admission:
zyprexa, depakote, percocet, culturelle, pepto bismol
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
small bowel ischemia
Discharge Condition:
passed away
Discharge Instructions:
none
Followup Instructions:
none
|
[
"276.8",
"401.9",
"518.0",
"453.41",
"038.9",
"934.1",
"276.52",
"569.83",
"995.92",
"276.0",
"276.2",
"997.4",
"568.0",
"V45.72",
"296.80",
"427.5",
"285.1",
"E915",
"V12.51",
"575.3",
"584.5",
"V15.82",
"518.81",
"557.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.94",
"45.93",
"46.51",
"99.15",
"46.75",
"45.13",
"38.7",
"38.91",
"38.93",
"54.62",
"96.6",
"51.03",
"96.72",
"46.93",
"46.11",
"45.62",
"46.39",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
6428, 6437
|
4233, 6294
|
324, 602
|
6502, 6516
|
3144, 4210
|
6569, 6577
|
2918, 2922
|
6399, 6405
|
6458, 6481
|
6320, 6376
|
6540, 6546
|
2937, 2937
|
264, 286
|
630, 2665
|
2951, 3125
|
2687, 2716
|
2732, 2902
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,383
| 100,326
|
35048+57973
|
Discharge summary
|
report+addendum
|
Admission Date: [**2159-8-12**] Discharge Date: [**2159-8-16**]
Service: MEDICINE
Allergies:
Pneumococcal Vaccine / Influenza Virus Vaccine / Sulfa
(Sulfonamides) / Penicillins
Attending:[**First Name3 (LF) 13386**]
Chief Complaint:
BRBPR and coffee ground emesis
Major Surgical or Invasive Procedure:
LIJ was placed
Transfusion of 5 units of PRBCs
History of Present Illness:
[**Age over 90 **] yo F with a history of CAD, CVA, GERD, MRSA UTI, DM, and
dementia (verbal but confused at baseline) presents to ED from
from Heb Reb, with hypotension. She had one episode of emesis
(non bloody [**8-11**]). She then reportedly complained of abd pain on
the day of admission ([**8-12**]), then had 1 episode of coffee ground
emesis, followed by BRBPR with clots. Her BP at the [**Hospital1 1501**] was
60/p.
.
On arrival to the ED her blood pressure was 80/palp. [**Hospital1 **] was 26
(was 33 on [**2158-8-9**]), lactate was 5.5, UA was grossly positive.
FAST was negative. Abd CT revealed 2 cm clot vs mass in
duodenum. GI and surgery were consulted. She was fluid
resucutated, and initially her BP improved to 100 systolic, but
then trended down to 70's.
.
Potassium was initially 7.6, she was given Calcium Cl 1 g,
Insulin 5U.
Code sepsis was called, a L IJ was placed (following a failed
attempt at a R IJ). She was given 3.2L IVF, Vanco/levo/flagyl
and transfused 2 units PRBCs. On transfer to the MICU she was
afebrile HR 110, BP 90-100/40, satting 97% 2L NC.
.
ROS: unable to obtain
.
Past Medical History:
CAD s/p angioplasty [**2143**]
h/o CVA
DM2 with peripheral neuropathy (HgbA1c = 6.6)
CKD (b/l Cr 1.8)
diverticulitis s/p partial colectomy
chronic hypotension (b/l BP = 90)
hyperlipidemia
dementia (oriented x 1 at baseline)
h/o chronic anemia
h/o MRSA UTI
recent CDiff (last dose [**2159-8-10**])
possible chronic renal failure
GERD
SLE
h/o gallstone pancreatitis
COPD
OA
h/o cystitis
low back pain
h/o R knee surgery
s/p sympathectomy
Social History:
From [**Hospital 100**] Rehab, former smoker- [**12-6**] ppd x 80 years. no etoh.
uses a walker. Son [**Name (NI) **] is HCP. requires assistance for
adl's,
Family History:
NC
Physical Exam:
VS - Temp 97.3 F, BP 112/80, HR 102, R 18, O2-sat 96% RA
GEN: sleepy but arousable--lapses back into sleep easily,
oriented x1 to self only. follows simple commands, frail elderly
woman, confused, moaning, very hard of hearing
HEENT: [**Last Name (LF) 12476**], [**First Name3 (LF) 13775**], EOMI, anicteric , dry MM , OP clear
Neck: supple, no JVD, no bruits, no LAD
Heart: RRR, S1, S2, 2/6 SEM at base, no ectopy
Lungs: crackles at b/l bases; no rh/wh, no accessory muscle use
Abd: generally tender/no rebound/no guard. no mass; no
organomegaly; obese; bruisig of skin at site of medication
injection.
Ext: no CCE/erythema (blanching) Rt foot; dp/pt dopplerable
Skin: Stage I-II sacral decub
Neuro: AA&Ox1(to name), 5/5 strength arms; 4/4 strength both
legs; cn2-12 grossly normal except for left hearing loss;
babinski downgoing bilat. reflexes hard to elicit.
Pertinent Results:
EKG: sinus tach at 108, 1st degree AV block, nonspecific stt
changes
.
[**2159-8-14**]: Baseline artifact. Sinus rhythm. Leftward axis. Since
the previous tracing the axis is more leftward.
.
CT pelvis w/o contrast [**8-12**]:
4 cm hyperdense collection in the duodenum is concerning Upper
GI bleed(likely bleeding duodenual ulcer, but cannot rule out
underlying mass). No intraperitoneal free fluid, free air or
obstruction.
.
.
[**2159-8-12**] 02:32PM GLUCOSE-251* UREA N-47* CREAT-1.7* SODIUM-137
POTASSIUM-5.5* CHLORIDE-111* TOTAL CO2-21* ANION GAP-11
[**2159-8-12**] 02:32PM CALCIUM-6.5* PHOSPHATE-4.4 MAGNESIUM-1.4*
[**2159-8-12**] 02:32PM WBC-14.9* RBC-3.10* HGB-9.4* [**Month/Day/Year **]-27.2* MCV-88
MCH-30.3 MCHC-34.5# RDW-15.5
[**2159-8-12**] 02:32PM PLT COUNT-222
[**2159-8-12**] 01:07PM LACTATE-1.5
[**2159-8-12**] 11:27AM LACTATE-2.6*
[**2159-8-12**] 09:45AM LACTATE-2.9*
[**2159-8-12**] 09:30AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.015
[**2159-8-12**] 09:30AM URINE BLOOD-LG NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-MOD
[**2159-8-12**] 09:30AM URINE RBC-[**5-15**]* WBC->50 BACTERIA-MANY
YEAST-NONE EPI-[**2-7**]
[**2159-8-12**] 08:10AM GLUCOSE-267* UREA N-46* CREAT-2.0* SODIUM-138
POTASSIUM-5.6* CHLORIDE-108 TOTAL CO2-25 ANION GAP-11
[**2159-8-12**] 08:10AM estGFR-Using this
[**2159-8-12**] 08:10AM ALT(SGPT)-9 AST(SGOT)-12 CK(CPK)-17* ALK
PHOS-43 TOT BILI-0.3
[**2159-8-12**] 08:10AM LIPASE-16
[**2159-8-12**] 08:10AM CK-MB-NotDone
[**2159-8-12**] 08:10AM ALBUMIN-1.9* CALCIUM-6.0* PHOSPHATE-4.7*
MAGNESIUM-1.5*
[**2159-8-12**] 08:10AM CORTISOL-27.3*
[**2159-8-12**] 08:10AM CORTISOL-27.3*
[**2159-8-12**] 08:10AM CRP-3.4
[**2159-8-12**] 07:19AM LACTATE-5.5* K+-7.6*
[**2159-8-12**] 07:15AM cTropnT-0.03*
[**2159-8-12**] 07:15AM WBC-12.7* RBC-2.93* HGB-8.1* [**Month/Day/Year **]-26.1* MCV-89
MCH-27.8 MCHC-31.2 RDW-16.8*
[**2159-8-12**] 07:15AM NEUTS-81.2* LYMPHS-14.8* MONOS-3.1 EOS-0.1
BASOS-0.8
[**2159-8-12**] 07:15AM PLT COUNT-440
[**2159-8-12**] 07:15AM PT-12.9 PTT-25.7 INR(PT)-1.1
.
COMPLETE BLOOD COUNT WBC RBC Hgb [**Month/Day/Year **] MCV MCH MCHC RDW Plt Ct
[**2159-8-16**] 10:50AM 34.9*
[**2159-8-16**] 05:55AM 7.9 3.82* 11.4* 33.7* 88 29.8 33.8 16.5*
138*
[**2159-8-16**] 04:06AM 8.5 4.02* 11.7* 36.4 90 29.1 32.2 16.3*
155
[**2159-8-15**] 03:40PM 8.4 3.96* 12.1 36.1 91 30.5 33.5 16.2*
154
Source: Line-Central
[**2159-8-15**] 06:10AM 8.3 4.11* 12.2 36.1 88 29.6 33.7 16.4*
188
[**2159-8-15**] 12:18AM 35.3*
Source: Line-CVL
[**2159-8-14**] 03:22PM 35.7*
Source: Line-Central
[**2159-8-14**] 05:56AM 12.3* 3.62* 11.0* 31.6* 87 30.2 34.7
16.2* 203
Source: Line-CVL
[**2159-8-13**] 11:23PM 32.8*
[**2159-8-13**] 07:28PM 33.9*
Source: Line-central
[**2159-8-13**] 04:36PM 17.1* 4.10* 11.9* 35.7* 87 29.1 33.4
16.0* 190
Source: Line-CVL
[**2159-8-13**] 02:23PM 33.3*
Source: Line-left ij
[**2159-8-13**] 09:28AM 35.1*
Source: Line- left ij
[**2159-8-13**] 05:56AM 15.4* 4.17*# 12.3# 35.7* 86 29.5 34.4
15.8* 196
.
.
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2159-8-16**] 05:55AM 101 28* 1.3* 141 4.81 110* 19* 17
[**2159-8-15**] 06:10AM 113* 39* 1.4* 142 4.6 112* 22 13
[**2159-8-14**] 05:56AM 157* 51* 1.5* 141 4.7 112* 20* 14
Source: Line-CVL
[**2159-8-13**] 04:36PM 196* 57* 1.6* 138 5.3* 109* 20* 14
Source: Line-CVL
[**2159-8-13**] 02:23PM 152* 58* 1.5* 137 5.7* 111* 21* 11
Source: Line-left ij
[**2159-8-13**] 09:28AM 5.7*
Source: Line- left ij
[**2159-8-13**] 05:56AM 177* 62* 1.6* 136 5.8* 109* 21* 12
Source: Line-central
[**2159-8-12**] 02:32PM 251* 47* 1.7* 137 5.5* 111* 21* 11
Source: Line-tlc
[**2159-8-12**] 08:10AM 267* 46* 2.0* 138 5.6* 108 25 11
.
.
.
Cortisol [**2159-8-12**] 08:10AM 27.3*1
.
Lactate:
[**2159-8-12**] 01:07PM 1.5
[**2159-8-12**] 11:27AM 2.6*
[**2159-8-12**] 09:45AM 2.9*
[**2159-8-12**] 07:19AM 5.5*
.
ALT AST CK AlkPhos TotBili
[**2159-8-12**] 9 12 17 43 0.3
.
Final [**Year (4 digits) **] on discharge 34.9
.
[**2159-8-15**] CATHETER TIP-IV WOUND CULTURE-PRELIMINARY INPATIENT
[**2159-8-15**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2159-8-14**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2159-8-14**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2159-8-14**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2159-8-12**] URINE URINE CULTURE-FINAL {ESCHERICHIA COLI,
ESCHERICHIA COLI} EMERGENCY [**Hospital1 **]
[**2159-8-12**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2159-8-12**] BLOOD CULTURE Blood Culture, Routine-PRELIMINARY
{LACTOBACILLUS SPECIES}; Aerobic Bottle Gram Stain-FINAL
EMERGENCY [**Hospital1 **]
.
URINE CULTURE (Final [**2159-8-15**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. 2ND
MORPHOLOGY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ 16 I <=2 S
AMPICILLIN/SULBACTAM-- 8 S <=2 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CEFUROXIME------------ 16 I 4 S
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
PIPERACILLIN---------- <=4 S <=4 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
Brief Hospital Course:
[**Age over 90 **]F presents with history of GERD, dementia, MRSA UTI admitted
to MICU from [**Hospital1 1501**] with shock, UTI and GI bleed.
.
# Sepsis/UTI/bacteremia - initially hypotensive in ED, baseline
[**Hospital1 **] per her PCP [**Last Name (NamePattern4) **] 36, down to 26 on admission, thus hypotension
felt most likely hypovolemic from GI bleed, but may have had
septic component as well given +UA on [**8-12**], +leukocytosis (WBC
17.1). CVP = 4. Given 3.2 L IVF, 2 units PRBC's in ED. Never
required pressors in the ICU. She recieved ~4L IVF in the MICU,
and 4U PRBCs. She was treated with broad spectrum abx
vanc/cipro/flagyl for 1d in the ICU. She was transferred to the
floor on [**2159-8-13**]. Vanco and flagyl were discontinued given the
presence of gram negative rods on urine culture, and no other
source of infection. Her Urine speciated E.Coli resistant to
quinolones, and she was switched to oral bactrim based on
sensitivities. She has a history of reported bactrim allergy.
After discussion with her PCP, [**Name10 (NameIs) **] was determined that she has
taken bactrim in the past in [**4-10**] without adverse reaction. She
tolerated bactrim without difficulty.
.
Blood cultures on [**2159-8-12**] were positive for LACTOBACILLUS in 1 of
2 bottles. Subsequent cultures on [**9-8**], [**8-15**] showed no
growth at the time of discharge. Left IJ catheter tip was
cultured and showed no growth at the time of discharge.
ID consult was obtained, and recommended clindamycin iv x 14
days to treat potential lactbacillus bacteremia starting on
[**8-16**]. A PICC line was placed for this antibiotic. She was also
started on a 21 day course of oral vancomycin (starting [**8-16**])
for c. difficile prophylaxis given her recent c. difficille
infection. She was hemodynamically stable upon transfer to the
medical floor and had no further hypotension.
.
She should have follow-up of her bacteremia with either her
primary care physician or the gerontology service at [**Hospital 100**]
Rehab. She does not require surveillence cultures.
.
# GIB bleed - most likely due to duodenal ulcer given CT scan.
GI and surgery were consulted, and given the patient and son's
desire for conservative management, it was agreed upon that no
intervention would be performed unless pt developed life
threatening bleed. Pt received total of 5U PRBCs last on [**8-14**].
Her [**Month/Day (4) **] was stable at 33-35 on discharge on [**8-16**]. She was
tolerating a regular pureed diet with supervision given concern
for aspiration while recovering from UTI. She was discharged
home on omeprazole twice daily. her aspirin and plavix were
discontinued. she should discuss restarting her aspirin with
her primary care physician in the future.
.
.
# Hyperkalemia - K up to 5.8 on [**8-13**], down to 4.8 on [**8-16**] without
intervention. No ekg changes. some question of RTA as source
of chronic hyperkalemia. potassium resolved without
intervention. she will follow-up with her PCP.
.
.
# Recent C Diff - pt finished PO Vancomycin [**8-10**]. She had
melanotic stools this admission, though no diarrhea. She was
started on PO vanco on [**8-16**] for 21 day course to prophylax
against cdiff given that she is starting a new course of bactrim
for UTI and clindamycin for bacteremia.
.
.
# CKD: baseline Cr 1.8 per report, down to 1.3 on [**8-16**].
medications were renally dosed. no evidence of ATN.
.
# DM - pt was covered with sliding scale insulin while
inpatient.
.
# gout - pt continued home regimen of allopurinol.
.
# anemia - baseline Hgb is approximately 12 per discussion with
patients' PCP. [**Name10 (NameIs) **] down to 26 on admission consistent with GIB.
At time of discharge [**Name10 (NameIs) **] 34.9. Iron supplementation was held
in setting of GIB, and can be restarted as outpatient.
.
# CAD - given ongoing GIB as above, decision made to hold
aspirin and plavix. No clear indication for continue plavix
given lack of recent NSTEM, CVA, or PAD. Pt will need to
discuss restarting aspirin with PCP once hematocrit has been
stable.
.
# COPD - pt continued on her home regimen of fluticasone and
spiriva. She was breathing comfortably on room air at the time
of discharge.
.
# Access - L IJ placed in setting of hypotension in ICU. This
was discontinued on [**8-15**], and tip was cultured. PICC was placed
for IV antibiotics which will continue for 14 days, afterwhich
time PICC can be discontinued.
.
# FEN - pt advanced to regular pureed diet on [**8-15**]. Pt kept on
aspiration precautions given that she remains drowsy in setting
of her UTI.
.
# CODE: pt's code status was made DNR/DNI per discussion with
son, HCP in keeping with patient's wishes. Son is HCP.
.
# DISPO: pt being discharged to [**Hospital 100**] Rehab. Plan is to
complete antibiotics as above (bactrim for UTI, clindamycin for
lactobacillus bacteremia), and oral vancomycin for cdiff
prophylaxis. She will readdress aspirin use as above.
Medications on Admission:
tylenol
spiriva
aspirin 81 mg
feso4 daily
plavix 75 mg
fluticasone 220 mcg 1 puff [**Hospital1 **]
milk of mag
trazodone 50 HS PRN
allopurinol 100 mg daily
HISS
prilosec
TUMS [**Hospital1 **]
Vit D 1000U dialy
Maalox prn
lactobacillus [**Hospital1 **]
Discharge Medications:
1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
3. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO once a day.
4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 8 days: Allegy noted. PCP said
that he has never documented a reaction to it.
7. Insulin Lispro 100 unit/mL Solution Sig: One (1) units
Subcutaneous ASDIR (AS DIRECTED).
8. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
9. Maalox 200-200-20 mg/5 mL Suspension Sig: One (1) PO every
4-6 hours as needed for heartburn.
10. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
11. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 21 days: last day [**2159-9-5**].
12. Clindamycin Phosphate 150 mg/mL Solution Sig: One (1) 600mg
Injection Q8H (every 8 hours) for 14 days: 600 mg IV q8hr, last
day [**2159-8-29**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] Center
Discharge Diagnosis:
Primary Diagnosis:
Upper GI Bleed
Urinary Tract Infection
Bacteremia
.
Secondary Diagnosis:
Coronary Artery Disease
Dementia
Discharge Condition:
You are being discharged at your baseline level of functioning.
Your vital signs are stable and you have been assessed by
physical therapy.
Discharge Instructions:
You were admitted after an ulcer in your GI tract bled enough
that your vital signs become unstable and you required admission
to the intensive care unit. After blood transfusions and careful
monitoring, your vital signs stabilized and you were followed on
the regular floors. You were also treated with antibiotics for a
urinary tract infection and an infection in your blood stream.
.
The following changes were made to your medications"
1)You will need to take Bactrim for your urinary tract infetion.
Please take 1 tablet by mouth twice a day for the next 8 days to
end on [**2159-8-15**].
2)We have discontinued your plavix, the milk of magnesia, tums,
and lactobacillus.
3)Please discuss with your rehab doctors when to [**Name5 (PTitle) **] your
aspirin.
4)The prilosec should now be taken twice a day by mouth.
5)Please take Clindamycin 600mg IV every 8 hours for 5 days to
end [**2159-8-20**]. This is the treat the bacteria in your blood.
6)Please take Vancomycin 250mg by mouth 4 times a day for 12
days to end on [**2159-8-28**]. This is to prevent you from getting
diarrhea from your other antibiotics.
.
You will be followed by the doctors [**First Name (Titles) **] [**Last Name (Titles) 100**] Rehab.
.
If you develop any of the following: chest pain, shortness of
breath, palpataion, dizziness, nausea or vomiting, or bloody
stools, please notify the doctors at Rehab [**Name5 (PTitle) **] go to your local
Emergency Room.
Followup Instructions:
The doctors at rehab [**Name5 (PTitle) **] take care of you and will make
recommendations that your should follow.
Completed by:[**2159-8-16**] Name: [**Known lastname 12870**],[**Known firstname **] Unit No: [**Numeric Identifier 12871**]
Admission Date: [**2159-8-12**] Discharge Date: [**2159-8-16**]
Date of Birth: [**2068-12-30**] Sex: F
Service: MEDICINE
Allergies:
Pneumococcal Vaccine / Influenza Virus Vaccine / Sulfa
(Sulfonamides) / Penicillins
Attending:[**First Name3 (LF) 5746**]
Addendum:
pt should have CBC checked on Friday [**8-17**] and Monday, [**2159-8-20**],
and followed by her physician at [**Hospital **] rehab to ensure that her
hematocrit is stable.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 643**] Center
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5747**] MD [**MD Number(1) 5748**]
Completed by:[**2159-8-16**]
|
[
"041.4",
"995.92",
"294.8",
"785.52",
"274.9",
"038.9",
"250.60",
"584.9",
"707.03",
"585.9",
"599.0",
"532.40",
"272.4",
"276.7",
"357.2",
"403.90",
"496",
"530.81",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
18203, 18413
|
9030, 14003
|
323, 371
|
15809, 15951
|
3070, 9007
|
17439, 18180
|
2166, 2170
|
14307, 15567
|
15661, 15661
|
14029, 14284
|
15975, 17416
|
2185, 3051
|
253, 285
|
399, 1516
|
15753, 15788
|
15680, 15732
|
1538, 1976
|
1992, 2150
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,737
| 180,701
|
39381
|
Discharge summary
|
report
|
Admission Date: [**2167-9-30**] Discharge Date: [**2167-10-22**]
Date of Birth: [**2146-11-25**] Sex: F
Service: MEDICINE
Allergies:
Cefaclor
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
hypotension, NSVT
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 20 year old female with history of anorexia nervosa
for 10 years c/b multiple hopsitalizations for self injury,
malnutrition, syncope. She presented voluntarilly to the ED
directly from her PCP for symptoms of light headedness and dark
urine for medical clearance and admission to an eating disorder
clinic.
.
Her history of eating disorder began at age 10, weight loss
became a problem in high school. She has history of anxiety,
depression and PTSD due to assault which have complicated her
eating behaviors. She has restrictive eating patterns and
excessive exercise but does not purge. She first participated
in a treatment program in [**2167-1-9**] since then she has
spent several months in different programs at [**Last Name (un) 3671**], Clarmon at
[**Last Name (un) 34017**]. She has required TF via NGT and GT was also considered
for a time. She was discharged in [**Month (only) 216**] and went to [**State 3908**] to
live with her parents but relapsed and stopped eating for 5
weeks (< 150cal/day), losing 35 lbs in that time. Since that
time she admits to chronic, substernal chest pain, episodes of
syncope, and epistaxis, and mucously reddish BM.
.
She complains of substernal chest pain that is deep similar to
previous episodes without radiation. It is always at rest and
never with exertion (she runs daily), without associated
diaphoresis or nausea. She describes it as a pulling sensation.
Cardiac history is notable for diagnosis of arrythmia during
syncope evaluation which included an echocardiogram which per
patient was normal, tilt table testing for autonomic
dysfunction. At that time she was diagnosed with arrythmia but
cannot remember the type. She was also told that she had a
heart attack while in [**State 3908**]. She has chosen not to follow up
with cardiology despite recommendation to do so.
.
In the ED, initial vs were: 98.7 74 101/66 16 100%. She then
proceded to have three episodes of NSVT, each episode lasting 7
beats, 12 beats, then 9-10 beats most recently at 11:40pm.
Around the times of these episodes her systolic blood pressure
was noted to be in the 50s without change in mental status,
without sx. Her blood pressure would then stablize in the 80s.
She recieved 6L of NS in the ED for blood pressure. She was
also given 4mg IV mag, 1 amp calcium gluconate, and 40meq K in
saline. Initial EKG showed diffuse ST depression with QTC 580,
HR 48. Follow up ECG showed QTC of 450 and HR in 60s. UA was
also done, first sample was dirty, repeat showed no sign of
infection. Vital signs on transfer were 76 83/60 18 100% RA.
.
On the floor, her SBP was initially in the 50s, imporved with
saline bolus to the 80s. She remained asympomatic throughout.
She did not have any NSVT during these episodes. She expresses
that her hospitalization was not her choice, she told she would
otherwise be sectioned.
.
.
Review of systems:
(+) Per HPI, chronic migraines
(-) Denies fever, chills, night sweats. Denies rhinorrhea, cough
or sore throat. Denies shortness of breath, or wheezing. Denies
chest palpitations, or weakness. Denies nausea, vomiting,
diarrhea, abdominal pain. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes. Denies suicidal ideation or depression.
Past Medical History:
Anorexia with restrictive eating and excessive exercise
Anxiety
Depression
PTSD
Osteoporosis
h/o self injury, most recently in [**2167-8-9**]
suicidal behavior - wrist cutting, OD on rx meds
Social History:
- Tobacco: none
- Alcohol: none
- Illicits: used cocaine and speed 1 week prior to admission,
h/o prescribed medication use. denies IVDU.
Family History:
eating disorder - sister ? bulemia
psych history/hopsitalization - father and m grandmother with
substance abuse.
cardiac arrythmia - p grandmother in 30s, ETOH
early MI or sudden death - none
Physical Exam:
Vitals: T:96.3 BP:55/28 -->96/55 P:63 R:13 O2: 97% RA
General: Alert, oriented, cachectic female, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops. tenderness to palpation just superior to xyphoid
process.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: + foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&OX3, CN2-12 intact.
Psych: affect appropriate
Pertinent Results:
[**2167-9-30**] 07:10PM BLOOD WBC-4.1 RBC-3.76* Hgb-10.8* Hct-30.6*
MCV-81* MCH-28.7 MCHC-35.2* RDW-13.3 Plt Ct-331
[**2167-10-1**] 01:17AM BLOOD WBC-3.8* RBC-3.77* Hgb-10.9* Hct-31.4*
MCV-83 MCH-29.0 MCHC-34.8 RDW-13.1 Plt Ct-298
[**2167-10-2**] 08:45AM BLOOD WBC-3.6* RBC-3.40* Hgb-10.0* Hct-28.6*
MCV-84 MCH-29.4 MCHC-35.0 RDW-13.3 Plt Ct-290
[**2167-10-3**] 06:30AM BLOOD WBC-4.0 RBC-3.34* Hgb-9.5* Hct-27.7*
MCV-83 MCH-28.4 MCHC-34.2 RDW-13.5 Plt Ct-299
[**2167-10-4**] 06:35AM BLOOD WBC-4.0 RBC-3.48* Hgb-9.9* Hct-29.2*
MCV-84 MCH-28.5 MCHC-33.9 RDW-13.4 Plt Ct-291
[**2167-9-30**] 07:10PM BLOOD Neuts-38.0* Lymphs-54.9* Monos-4.6
Eos-1.7 Baso-0.8
[**2167-10-1**] 01:17AM BLOOD Neuts-42.8* Lymphs-50.6* Monos-3.3
Eos-1.7 Baso-1.5
[**2167-10-1**] 01:17AM BLOOD PT-15.4* PTT-34.2 INR(PT)-1.4*
[**2167-9-30**] 07:10PM BLOOD Glucose-78 UreaN-5* Creat-0.9 Na-140
K-3.0* Cl-96 HCO3-33* AnGap-14
[**2167-10-1**] 01:17AM BLOOD Glucose-146* UreaN-3* Creat-0.7 Na-145
K-3.0* Cl-113* HCO3-26 AnGap-9
[**2167-10-1**] 06:54AM BLOOD Glucose-51* UreaN-2* Creat-0.5 Na-145
K-3.8 Cl-117* HCO3-24 AnGap-8
[**2167-10-1**] 02:51PM BLOOD Glucose-74 UreaN-2* Creat-0.6 Na-144
K-3.5 Cl-113* HCO3-24 AnGap-11
[**2167-10-2**] 08:45AM BLOOD Glucose-60* UreaN-1* Creat-0.6 Na-142
K-3.6 Cl-110* HCO3-22 AnGap-14
[**2167-10-3**] 06:30AM BLOOD Glucose-75 UreaN-3* Creat-0.5 Na-142
K-3.1* Cl-109* HCO3-27 AnGap-9
[**2167-10-3**] 05:38PM BLOOD Glucose-65* UreaN-3* Creat-0.5 Na-142
K-5.1 Cl-110* HCO3-25 AnGap-12
[**2167-10-4**] 06:35AM BLOOD Glucose-57* UreaN-3* Creat-0.5 Na-143
K-4.2 Cl-109* HCO3-27 AnGap-11
[**2167-10-1**] 01:17AM BLOOD ALT-22 AST-21 LD(LDH)-157 CK(CPK)-100
AlkPhos-38 TotBili-0.8
[**2167-10-3**] 06:30AM BLOOD ALT-56* AST-60* AlkPhos-41 TotBili-1.1
[**2167-9-30**] 07:10PM BLOOD Calcium-9.3 Phos-3.4 Mg-1.6
[**2167-10-1**] 01:17AM BLOOD Albumin-3.5 Calcium-7.6* Phos-1.4*#
Mg-2.4 Iron-40 Cholest-120
[**2167-10-1**] 06:54AM BLOOD Calcium-8.0* Phos-2.5* Mg-1.8
[**2167-10-1**] 02:51PM BLOOD Calcium-8.0* Phos-2.6* Mg-1.6
[**2167-10-2**] 08:45AM BLOOD Calcium-7.6* Phos-3.4 Mg-1.5*
[**2167-10-3**] 06:30AM BLOOD Albumin-3.3* Calcium-8.0* Phos-3.3 Mg-2.1
[**2167-10-3**] 05:38PM BLOOD Calcium-8.8
[**2167-10-4**] 06:35AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.1
.
Other labs
[**2167-10-1**] 01:17AM BLOOD calTIBC-191* Ferritn-68 TRF-147*
[**2167-10-1**] 01:17AM BLOOD Triglyc-68 HDL-63 CHOL/HD-1.9 LDLcalc-43
[**2167-10-1**] 01:17AM BLOOD Prolact-6.4 TSH-0.39
[**2167-9-30**] 07:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2167-10-1**] 01:31AM BLOOD Type-[**Last Name (un) **] Temp-35.7 pH-7.37 Comment-GREEN
TOP
[**2167-10-1**] 01:31AM BLOOD Lactate-1.9
[**2167-10-1**] 01:31AM BLOOD freeCa-1.05*
.
Urine
[**2167-9-30**] 07:00PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.029
[**2167-9-30**] 07:00PM URINE Blood-LG Nitrite-NEG Protein-25
Glucose-NEG Ketone-150 Bilirub-NEG Urobiln-NEG pH-9.0* Leuks-TR
[**2167-9-30**] 07:00PM URINE RBC-[**11-28**]* WBC-[**3-13**] Bacteri-MANY
Yeast-NONE Epi->50
[**2167-9-30**] 07:00PM URINE CastHy-[**3-13**]*
[**2167-9-30**] 07:00PM URINE Mucous-FEW
[**2167-9-30**] 07:00PM URINE UCG-NEG
[**2167-9-30**] 07:00PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2167-9-30**] 11:00PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006
[**2167-9-30**] 11:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-TR Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
.
.
Cardiology
.
Cardiology Report ECG Study Date of [**2167-9-30**] 10:02:42 PM
Normal sinus rhythm. Compared to tracing #1 the Q-T interval has
shortened and
the ST-T wave changes have decreased considerably. The Q-T
interval has also
shortened.
TRACING #2
.
Cardiology Report ECG Study Date of [**2167-9-30**] 11:44:02 PM
Normal sinus rhythm. The Q-T interval has shortened further. The
non-specific ST-T wave changes noted on the prior tracings have
continued to improved.
TRACING #3
Read by: [**Last Name (LF) **],[**First Name3 (LF) 125**] M.
.
Cardiology Report ECG Study Date of [**2167-9-30**] 8:41:02 PM
Sinus bradycardia, rate 48, with occasional ventricular
premature beats.
Q-T interval prolongation. RSR' pattern in lead V2 with QRS
duration
of 86 milliseconds. T wave inversion in leads aVL and V2-V4. No
previous
tracing available for comparison. Consider electrolyte
abnormality.
TRACING #1
Read by: [**Last Name (LF) **],[**First Name3 (LF) 125**] M.
.
ardiology Report ECG Study Date of [**2167-10-1**] 12:02:56 PM
Baseline artifact. Sinus rhythm. Low voltage. Early precordial T
wave
inversions. Since the previous tracing of [**2167-9-30**] the axis is
less vertical.
T waves may be improved.
TRACING #1
Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.
.
Cardiology Report ECG Study Date of [**2167-10-2**] 2:30:50 PM
Sinus rhythm. T wave abnormalities. Since the previous tracing T
wave
abormalities may be more marked. Q-T interval is somewhat
longer. Consider
hypokalemia.
TRACING #2
Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.
.
ECHOCARDIOGRAM:
[**2167-10-1**]
Findings
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). TDI E/e' < 8,
suggesting normal PCWP (<12mmHg). No resting LVOT gradient. No
VSD.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No
MVP. Normal mitral valve supporting structures.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal tricuspid valve supporting structures. No TS. Normal
PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR. Normal main PA. No Doppler evidence for
PDA
PERICARDIUM: No pericardial effusion.
CONCLUSIONS: The left atrium is normal in size. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF 60%). Tissue Doppler imaging suggests
a normal left ventricular filling pressure (PCWP<12mmHg). 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. There is no mitral
valve prolapse. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
IMPRESSION: normal study
.
Radiology
.
CXR [**2167-10-1**]
FINDINGS: There are low lung volumes. The cardiomediastinal
contours are within normal limits. Apparent increased hazy
opacity in the right mid to lower lung zone likely represents a
combination of atelectasis and overlying soft tissues. This
could be further evaluated with dedicated PA and lateral. No
pleural effusion or pneumothorax. The osseous structures are
grossly unremarkable.
.
IMPRESSION: No acute cardiopulmonary process. Right lung hazy
opacity likely represents combination of superimposition of soft
tissues and atelectasis.
.
PORTABLE ABDOMINAL XR [**2167-10-15**]
FINDINGS: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]- or orogastric tube is seen with tip overlying
the region of the stomach. The ascending, transverse and
descending colon are dilated to a maximum diameter of 6.5 cm.
Stool is seen within the colon and rectum. Decubitus film
demonstrates no evidence for free air. Few air-fluid levels are
seen within the colon.
.
IMPRESSION: Dilated air and stool-filled colon suggestive of
ileus.
Brief Hospital Course:
Brief Summary:
The patient was a 20 year old female with a ten year history of
anorexia nervosa who presented voluntarily to the [**Hospital1 18**]
emergency department on [**2167-9-30**] for treatment of malnutrition.
She was noted to have episodes of non-sustained ventricular
tachycardia (NSVT) and hypotension in the setting of abnormal
electrolytes. The patient refused to eat solid foods; thus, the
eating disorder protocol was initiated, necessitating a
nasogastric tube and tube feeds. Early in her hospital stay,
the patient refused her tube feeds. The psychiatry service was
consulted. Legal guardianship documents were filed.
Medical Intensive Care Unit Course: The patient was brought to
the ICU because of hypotension and NSVT. She was fluid
resuscitated with NS, and her electrolytes (potassium,
magnesium, and phosphate) were repleted. An EKG showed a
slightly prolonged QT with no ischemic changes. She was
monitored on telemetry and had no more episodes of NSVT. An
echocardiogram was obtained and showed a normal study.
Nutrition was consulted and she was started on the eating
disorder protocol, on a liquid diet as she refused solid food.
Psychiatry also saw the patient and recommended to continue with
the protocol and to let them know if she refused her feeds to
reassess her capacity to make those decisions. Social work was
involved to help organize a family meeting.
An NG tube was placed and feeding was started via the Eating
Disorders Protocol. Ms. [**Known lastname 45419**] continued to have mild
derangements in her electrolytes which were repleted. She
refused her feeds and psychiatry was involved to obtain
guardianship. There were no further episodes of VT and she
remained hemodynmicaly stable.
Medical Floor Course: The patient was transferred to the medical
floor on hospital day two. On the floor, the patient accepted
her tube feeds. Her weight stabilized at approximately 82
pounds. She complained of nausea and abdominal discomfort with
her tube feeds. Petition for medical guardianship was initiated.
On [**2167-10-12**], her NG tube had to be resited because of damage
from requent use; the abdominal x-ray confirming its proper
placement showed a large volume of stool inside the colon. The
patient estimated it had been 5 weeks since her last bowel
movement, but reported she was passing flatus. That evening she
vomited involuntarily after her tube feed. She vomited again
the following day ([**2167-10-13**]). On [**2167-10-14**], she took in PO calories
successfully. The patient required intermittent supplementation
with oral and intravenous potassium; however, as she began to
take her tube feeds regularly, her potassium levels stabilized.
On [**2167-10-15**], she was approximately 200cc into her AM feed, when
she developed nausea and vomited. When she stood to return to
her bed, she had a vasovagal episode. Vitals were stable. A
repeat abdominal x-ray showed a bowel ileus, involving the
rectum, descending, transverse and ascending colon. Digital
rectal examination revealed no obstruction or fecal impaction.
The patient reported she had not passed flatus for 2 days. The
patient was made NPO except for medications, and her bowel
regimen was expanded to include intravenous metoclopramide and
milk of magnesia around the clock. She declined enemas. On
[**10-18**], she passed flatus and liquid stool; she has continued to
pass stool since that time. On [**10-19**] she restarted her caloric
intake, taking 720cc of Boost PO, without requiring any NG
feeds. As of [**10-20**], her ileus has resolved and she was having
loose bowel movements. The patient gained temporary legal
guardianship (by virtue of her biological father) on the day of
transfer, [**2167-10-22**]. She was transferred to an eating disorder
unit at an outside hospital.
Medications on Admission:
Klonapin 1mg qAM + 1mg prn, 2mg qhs
Clonidine 0.2mg qhs for nightmares
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: Two (2) 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: 1-2 Tablets PO BID (2 times a day).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): This does not need to be
administered if pt is ambulating 3x 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. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO Q 8H (Every 8 Hours).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
10. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
11. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO AM ().
12. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for throat pain.
13. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: [**1-10**] Tablet,
Rapid Dissolves PO Q8H (every 8 hours) as needed for n/v.
14. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily): Please hold if >2 BMs/day.
15. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO three times a day as needed for heart
burn.
16. metoclopramide 5 mg Tablet Sig: One (1) Tablet PO four times
a day: Please titrate to two bowel movements per day.
17. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day): Please titrate to two bowel movements
per day. .
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
Anorexia Nervosa
Secondary:
Electrolyte Abnormalities
Non-Sustained Ventricular Tachycardia
Malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 45419**]:
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
to the hospital because you were malnourished, you electrolytes
were imbalanced, and this was causing your heart to have an
abnormal rhythm. You were placed on an eating disorder protocol
and you were eventually able to tolerate your tube feeds. Your
electrolytes stabilized. Your heart rhythm normalized. You
developed an ileus in which your bowels were paralyzed. You
were given stool softeners, laxatives, and a bowel stimulating
[**Doctor Last Name 360**], which helped you recover from this. You are now healthy
enough to be transferred to an eating disorder unit.
Your medications are attached and will be relayed to the eating
disorder unit.
Followup Instructions:
You will be tranferred to an eating disorder unit.
Completed by:[**2167-11-1**]
|
[
"733.00",
"724.2",
"251.2",
"276.9",
"307.1",
"261",
"300.4",
"564.00",
"784.0",
"560.1",
"305.60",
"560.89",
"V65.3",
"427.89",
"309.81",
"276.51",
"427.1",
"458.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
18332, 18347
|
12698, 16517
|
289, 295
|
18505, 18505
|
4886, 12675
|
19447, 19529
|
4005, 4200
|
16638, 18309
|
18368, 18484
|
16543, 16615
|
18656, 19424
|
4215, 4867
|
3227, 3618
|
232, 251
|
323, 3208
|
18520, 18632
|
3640, 3832
|
3848, 3989
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,307
| 143,979
|
54092
|
Discharge summary
|
report
|
Admission Date: [**2199-3-12**] Discharge Date: [**2199-3-19**]
Date of Birth: [**2134-3-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**2199-3-15**] - Coronary artery bypass grafting times one (Saphenous
vein graft->Obtuse marginal artery)/Aortic Valve Replacement
(21mm St. [**Male First Name (un) 923**] Porcine)
[**2199-3-12**] - Cardiac Catheterization
History of Present Illness:
65 year old male with severe aortic stenosis who has been
referred for evaluation for possible aortic valve replacement.
He reports shortness of breath at rest and on exertion
accompanied by constant chest pressure at rest and on exertion
which feels like a [**4-11**] lb weight on his chest. An
echocardiogram performed by on [**2199-3-5**] revealed severe aortic
stenosis with [**Location (un) 109**] 0.5 cm2/peak grad 85 mmHg/ mean 48. A nuclear
stress test showed no ischemia. He was referred for right and
left heart catheterization.
Past Medical History:
Coronary artery disease
Severe aortic stenosis
Dyslipidemia
Laryngeal cancer treated in [**2184**] with radiation treatment
Back surgery for ruptured disk
Left elbow tendinitis
Heart murmur past 15 years
Tonsillectomy
Social History:
Last Dental Exam:2 weeks ago, Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 110867**]
Lives with:wife
Contact:[**Name (NI) **] [**Name (NI) **] (wife) Phone#[**Telephone/Fax (1) 110868**]
Occupation: Works as consultant at an internet start-up
Cigarettes: Smoked no [x] yes []
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**1-8**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
non contributory
Physical Exam:
Pulse:59 Resp:16 O2 sat:100/RA
B/P Right:124/82 Left:138/82
Height:5'8" Weight:76 kgs
General: NAD
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 [x] grade __3/6____
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [x] _none_
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 1+, right groin ecchymosis Left: 2+
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 2 Left: 2
Carotid Bruit Right: no Left: no
Pertinent Results:
[**2199-3-12**] Cardiac Cath
1. Selective coronary angiography of this right dominant system
demonstrated two vessel coronary disease. The LMCA was patent.
The LAD
was patent. The LCX had a proximal OM1 lesion that was tightly
occluded.
The ramus was tightly occluded proximally as well. The RCA was
patent.
2. Limited resting hemodynamics revealed normal left and
right-sided
filling pressures with RVEDP of 8mmHg and PCWP of 10mmHg. There
was mild
pulmonary arterial hypertension with a PASP of 34mmHg. The
cardiac index
was mildly depressed at 2.2 L/min/m2. There was severe aortic
stenosis
with a mean gradient of 50mmHg and a calculcated valve area of
0.7cm2.
[**2199-3-13**] Carotids
Impression: Right ICA <40% stenosis. Left ICA <40% stenosis.
[**2199-3-13**] Right groing ultrasound
Unremarkable right groin ultrasound with no pseudoaneurysm and
no
AV fistula identified.
.
Intra-op TEE
Conclusions
PRE-CPB:
The left atrium is mildly dilated. No thrombus is seen in the
left atrial appendage. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. The descending thoracic
aorta is mildly dilated. No thoracic aortic dissection is seen.
The aortic valve is bicuspid with a vertical commissure. The
aortic valve leaflets are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0.8cm2). No aortic
regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
Dr. [**Last Name (STitle) **] was notified in person of the results at time of
study.
POST-CPB:
A bioprosthetic valve is seen in the aortic position. The valve
is well-seated with normally mobile leaflets. There are no
paravalvular leaks seen and there is no apparent AI. The peak
gradient across the aortic valve is 31mmHg, the mean gradient is
16mmHg with CO of 4.3L/min.
The LV chamber size is small, consistent with hypovolemic state.
Biventricular function is normal, as in pre-bypass. There are no
changes to other valvular function.
There is no apparent aortic dissection.
.
[**2199-3-18**] 05:25AM BLOOD WBC-7.0 RBC-3.19* Hgb-9.2* Hct-28.8*
MCV-90 MCH-28.7 MCHC-31.8 RDW-14.6 Plt Ct-102*
[**2199-3-17**] 09:05AM BLOOD WBC-8.4 RBC-2.74* Hgb-7.7* Hct-24.4*
MCV-89 MCH-28.1 MCHC-31.6 RDW-13.2 Plt Ct-99*
[**2199-3-19**] 04:55AM BLOOD UreaN-34* Creat-1.3* Na-137 K-5.0 Cl-101
[**2199-3-18**] 05:25AM BLOOD Glucose-154* UreaN-32* Creat-1.4* Na-134
K-4.8 Cl-101 HCO3-24 AnGap-14
Brief Hospital Course:
65 M with aortic stenosis and dyslipidemia, presented with
dyspnea on exertion and chest pressure, and was found to have
severe aortic stenosis and left circumflex disease. Cardiac
surgery was consulted taken to the operating room on [**2199-3-15**]
for coronary artery bypass saphaneous vein graft to the Obtuse
marginal and Aortic valve replacement with [**First Name8 (NamePattern2) 6158**] [**Male First Name (un) 923**]
porcine. Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically
stable, weaned from inotropic and vasopressor support. Beta
blocker was initiated and the patient was gently diuresed toward
the preoperative weight. The patient was transferred to the
telemetry floor for further recovery. Chest tubes and pacing
wires were discontinued without complication. He was transfused
with 1 unit of PRBC on [**2199-3-17**] for a HCT of 24. Renal function
was found to be mildly elevated with CRE 1.4 (base 0.8). Toradol
was discontinued and IV furosemide was changed to PO. The
patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD 4 the patient was ambulating freely, the wound was
healing and pain was controlled with oral analgesics. The
patient was discharged home in good condition with appropriate
follow up instructions.
Medications on Admission:
Simvastatin 20 mg daily
Discharge Medications:
1. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
3. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
4. metoprolol tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2
times a day).
Disp:*15 Tablet(s)* Refills:*2*
5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary artery disease
Severe aortic stenosis
Dyslipidemia
Laryngeal cancer treated in [**2184**] with radiation treatment
Back surgery for ruptured disk
Left elbow tendinitis
Heart murmur past 15 years
Tonsillectomy
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 - healing well, no erythema or drainage.
Edema- trace
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2199-3-26**] 10:15
Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2199-4-17**] 3:00
Cardiologist: Dr. [**First Name (STitle) 7756**] [**Telephone/Fax (1) 71179**] [**2199-4-4**], 2:00pm
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) 5279**] [**Last Name (NamePattern1) 59917**] [**Telephone/Fax (1) 21640**] in [**3-7**] 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:[**2199-3-19**]
|
[
"V10.21",
"V15.3",
"794.4",
"458.29",
"424.1",
"272.4",
"285.9",
"998.12",
"428.0",
"411.1",
"414.01",
"416.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61",
"36.11",
"37.23",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
7458, 7507
|
5191, 6761
|
317, 543
|
7769, 7982
|
2523, 5168
|
8797, 9514
|
1789, 1808
|
6835, 7435
|
7528, 7748
|
6787, 6812
|
8006, 8774
|
1823, 2504
|
270, 279
|
571, 1112
|
1134, 1354
|
1370, 1773
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,258
| 192,384
|
18256
|
Discharge summary
|
report
|
Admission Date: [**2150-11-29**] Discharge Date: [**2150-12-5**]
Date of Birth: [**2094-9-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Vomiting, diarrhea
REASON FOR MICU ADMISSION: fever, hypotension
Major Surgical or Invasive Procedure:
Intubation
Mechanical ventilation
Central venous line placement
History of Present Illness:
56M with CAD s/p CABG, CKD b/l Cr ~2.0 presented to [**Hospital 107**]
Hospital of [**Doctor Last Name 792**]with 3 days of profuse vomiting and
diarrhea. Felt subjective fevers at home but did not take his
temperature. Had mild shortness of breath beginning on the
evening prior to admission. No chills, sweats, headache, neck
stiffness, cough, sore throat, myalgias, arthralgias, chest
pain, palpitations, hematemesis, hematochezia, melena, dysuria,
rash, sick contacts, recent antibiotic use, or recent travel.
Upon arrival at OSH, SBP nadir 69/42 with HR 98. 3L IVF with
improvement in BP to 106/63 HR 102. WBC 10.2 BUN 86 Cr 5.9 CKMB
12.7 (ref range <6.3) %CKMB 1.5 (ref range 0-4), tropI 0.44
(0-0.05). EKG showed sinus tach LAD LAE LVH. Given ASA/heparin
transferred to [**Hospital1 18**] for further cardiac evaluation.
In the ED, triage V/S 102.3 109 106/72 20 100%2L. Tmax 104 PR,
BP nadir 86/57 HR 99. BUN 82 Cr 5.5 K 5.7 CO2 10 AG 15 WBC# 9.8
lactate 1.6. Given vanco 1 g IV, zosyn 4.5 g IV, kayexelate 30
mg, D50 1 amp, insulin 10 U, tylenol, and 5+ liters IVF. EKG
showed ST 110 LAD LAE LVH nonspec IVCD nonspecific <[**Street Address(2) 50379**] depressions. Cardiology evaluated EKGs and recommended
stopping heparin gtt. Vital signs prior to transfer T 102 HR 99
BP 90/54 RR 23 O2sat 97%RA.
Past Medical History:
CAD s/p CABG in [**2144**] (LIMA to LAD, free RIMA from LIMA to OM and
SVG to PDA)
CKD b/l Cr ~2.0 attributed to Buerger's disease
HTN
hyperlipidemia
gout
pituitary tumor diagnosed early [**2131**]
Social History:
Owns a cutlery business. Drinks 2-3 beers/day. Last drink 3 days
prior to admission. Occasional MJ use. No tobacco.
Family History:
Noncontributory.
Physical Exam:
Vitals - T 100.2 BP 90/60 HR 98 RR 25 02sat 96%3L
GENERAL: Ill-appearing obese man appears flushed & diaphoretic
HEENT: OP clear dry MM
NECK: JVD difficult to assess due to habitus
CARDIAC: reg tachy no m/r/g
LUNGS: diminished at bases no w/r/r
ABDOMEN: soft obese nondistended diffusely tender to deep
palpation no rebound, guarding heme+ in ED
EXT: warm, damp +PP no edema
NEURO: awake, alert, conversing appropriately
DERM: no rash
Pertinent Results:
Admission labs:
[**2150-11-29**] 03:25PM WBC-9.8 RBC-4.40*# HGB-13.5*# HCT-40.5#
MCV-92 MCH-30.7 MCHC-33.3 RDW-14.9
[**2150-11-29**] 03:25PM NEUTS-85.0* LYMPHS-9.9* MONOS-3.3 EOS-1.4
BASOS-0.4
[**2150-11-29**] 03:25PM PLT COUNT-195
[**2150-11-29**] 03:25PM GLUCOSE-73 UREA N-82* CREAT-5.5*# SODIUM-136
POTASSIUM-5.7* CHLORIDE-111* TOTAL CO2-10* ANION GAP-21*
[**2150-11-29**] 03:25PM ALT(SGPT)-35 AST(SGOT)-53* ALK PHOS-42 TOT
BILI-0.3
[**2150-11-29**] 03:25PM LIPASE-70*
[**2150-11-29**] 03:43PM LACTATE-1.6 K+-5.7*
[**2150-11-29**] 03:25PM cTropnT-0.26*
Brief Hospital Course:
Mr. [**Known lastname 50378**] is a 56 year old male with CAD s/p CABG who
presented with 3 days of vomiting and diarrhea and was admitted
with shock, respiratory failure, and acute on chronic renal
insufficiency. His hospital course is outlined by problem
below:
.
#1. Multifactorial Shock: This is suspected to be from sepsis.
CT Abd showed +enteritis which was the likely source of his
infection. He was also found to have a LLL pneumonia. He was
treated with vanc/cefepime. He was initially treated wtih
flagyl and po vanc to cover C. diff, and this was discontinued
when he had 3 negative C. diff tests. Vanco IV, Vanco PO and
Flagyl were discontined in the ICU. He was contined on Cefepime
IV for treatment of Enteritis and PNA. He also had adrenal
insufficiency given his empty sellar syndrome and was started on
stress dose hydrocort and fludrocort. Symptoms improved and he
was transferred to the medical floor. He completed a 7 day
course of antibiotics and was discharged home in stable
condition.
.
#2. Panhypopituitarism: Pt was started on stress dose steroids
and continued on his levothyroxine dose. Endocrine was
consulted and recommended Prednisone taper; he was discharged on
5 mg po daily of prednisone to be further tapered by his
endocrinologist as an outpatient.
.
#3. Respiratory failure: Patient was intubated in the ICU for
respiratory failure. This was likely due to underlying metabolic
acidosis. He was extubated [**12-2**] and had no sequelae.
.
#4. Demand ischemia: Patient had positive cardiac biomarkers,
most attributable to subendocardial/demand ischemia in the
setting of obstructive CAD, systemic illness, hypotension, and
decreased renal clearance. He was treated with ASA, statin. No
further issues with this once his infection and associated
hypotension were treated.
.
#5. Vomiting/diarrhea: Pt had negative stool cultures and
serial C. diff toxin assays. Likely [**3-9**] enteritis.
.
#6. Anion gap metabolic acidosis: This improved with volume
resuscitation (with bicarb) and treatment of underlying sepsis.
.
#7. Acute on chronic renal insufficiency: Creatinine elevated
on admission likely in the setting of sepsis and hypotension.
Renal was consulted and diagnosed ATN. He was treated with IVF
and Creatinine trended down to 2.6 on discharge.
.
#8. ETOH use: Pt had some tremors, tachycardia, and
hypertension in the ICU. He was started on a CIWA scale but did
not require medications. He was treated with MVI, folate and
thiamine.
.
#9. Hypertension: Patient became hypertensive in the ICU prior
to transfer to the medical floor. Fludrocortisone was
discontinued and he was started on his home carvedilol. His
lisinopril was held given renal failure. On discharge, his blood
pressure was within normal range.
.
Mr. [**Known lastname 50378**] was deemed medically stable and fit for discharge to
home. He will have close outpatient follow-up within two weeks
of discharge with his primary care provider.
Medications on Admission:
1) ASA 325 mg daily
2) lisinopril dose unknown
3) crestor 20 mg daily
4) allopurinol 100 mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
4. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Amlodipine 5 mg Tablet Sig: 1.5 Tablets PO once a day.
Disp:*45 Tablet(s)* Refills:*2*
8. Imdur 30 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
9. Zoloft Oral
10. BuSpar 5 mg Tablet Sig: One (1) Tablet PO three times a day.
11. Prednisone 5 mg Tablet Sig: One (1) Tablet PO q8AM & q5PM:
Please continue until you see your endocrinologist.
Disp:*60 Tablet(s)* Refills:*2*
12. Dexamethasone Sodium Phosphate 4 mg/mL Solution Sig: Four
(4) mg Injection once a day as needed for fever, nausea,
vomiting, diarrhea.
Disp:*1 dose* Refills:*4*
13. AndroGel 1 % (25 mg/2.5 g) Gel in Packet Sig: One (1)
application Transdermal once a day.
14. Humatrope Injection
Discharge Disposition:
Home
Discharge Diagnosis:
Enteritis
Pneumonia
Discharge Condition:
Stable, normotensive
Discharge Instructions:
You were admitted into the Intensive Care Unit at [**Hospital1 18**] for
treatment of your pneumonia and enteritis. You were intubated
and placed on a breathing machine for treatment of respiratory
failure. Your infection was treated with intravenous
antibiotics and you completed a 7 day course while in the
hospital. As your breathing was improved, you were taken off a
breathing machine and were cared for on the general medicine
floor where you continued to do well until your discharge, save
for some elevated blood pressures that were treated successfully
with medication.
Medications:
1. Lisinopril: Your Lisinopril was STOPPED while in the hospital
as you experienced some kidney failure. Please STOP taking your
Lisinopril for now. It may be restarted by your primary care
doctor if appropriate.
2. Amlodipine: Your Amlodipine was STARTED to 7.5mg a day from
5.0mg a day. Please continue to take this medication as
prescribed for your blood pressure until you follow-up with your
primary care physician.
3. Imdur: You were STARTED on 30mg of Imdur once a day to treat
your blood pressure. Please continue to take this medication as
prescribed until you see your primary care physician.
4. Prednisone: You were STARTED on Prednisone in the hospital.
Please take 5mg of Prednisone, twice a day at 8am and 5pm until
you see your endocrinologist. If you have a fever, diarrhea,
nausea or vomiting, please triple your dose to 15mg every 8am
and 5pm. If you have severe nausea and vomiting, please give
yourself 4mg a one time dose of intramuscular Dexamethasone.
5. Androgel: In the hospital, your Androgel was held. Please
RESTART your regular Androgel dose when you return home.
6. Humatrope: In the hospital, your Humatrope was held. Please
RESTART your regular Humatrope dose when you return home.
.
If you experience any worsening chest pain, shortness of breath,
cough, nausea, vomiting, diarrhea, abdominal pain, chills or
fevers > 101 then please call your doctor or report to the
nearest emergency room.
Followup Instructions:
[**Telephone/Fax (1) 5294**] on Monday to schedule an appointment to be seen
within 1-2 weeks from your discharge. Please ask him to assess
your blood pressure and need for Amlodipine and Imdur.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2150-12-7**]
|
[
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"V45.81",
"274.9",
"038.9",
"276.2",
"414.00",
"558.9",
"584.5",
"518.81",
"486",
"584.9",
"255.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.91",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7634, 7640
|
3240, 6218
|
381, 446
|
7704, 7727
|
2644, 2644
|
9797, 10117
|
2155, 2173
|
6367, 7611
|
7661, 7683
|
6244, 6344
|
7751, 9774
|
2188, 2625
|
276, 343
|
474, 1784
|
2660, 3217
|
1806, 2006
|
2022, 2139
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,411
| 132,076
|
1382
|
Discharge summary
|
report
|
Admission Date: [**2189-8-21**] Discharge Date: [**2189-8-27**]
Date of Birth: [**2122-1-13**] Sex: F
Service: MEDICINE
Allergies:
Tegretol / Codeine
Attending:[**First Name3 (LF) 8367**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 67 y/o F with a PMHx of metastatic melanoma s/p
XRT/resection, metastatic breast CA s/p 7 cycles of herceptin,
recent right malignant pleural effusion s/p recent Pleurex
catheter removal 1 week ago who was due to be taken by EMS to
her outpatient onc appt when she was found to be tachypneic to a
RR of 40, with sats in the low 80s on RA. She was put on a NRB
which improved her sats to the 90s and was brought to [**Hospital1 18**] ED.
In the ED, VS: T101, HR104, BP139/106 RR18, 99% NRB. Pt
received 1g CTX, 1g Vanco.
On ROS, family admits to worsening cough over the past week
along with fevers x1 d. Family denies any c/o by pt of dysuria,
odynophagia, N/V, diarrhea. No recent CP. Pt is bedbound due
to paralysis from XRT/resection of her brain.
Past Medical History:
1. Metastatic melanoma: Initially diagnosed in [**2164**]. Brain
metastases, s/p resection of left parasagittal lesion in [**2174**],
s/p resection of left parietal region in [**2175**], s/p whole brain
radiation.
2. Breast CA s/p masectomy: invasive ductal. s/p IL-2, HER2 +,
s/p 7 cycles of herceptin
3. h/o radiation-induced encephalitis.
4. Partial seizure disorder.
5. Right hemiparesis from surgeries.
6. Diverticular disease.
7. Sigmoid colon perforation, s/p sigmoid colectomy, small bowel
resection and ostomy.
8. h/o pulmonary embolism, s/p IVC filter placement.
9. Anemia.
10. h/o hypercalcemia of unknown cause.
11. Chronic headaches.
12. Dementia [**3-12**] anoxic brain injury from prolonged
hospitalization and craniotomy.
13. Questionable history of obstructive sleep apnea.
14. Osteoporosis, s/p rib and clavicle fractures.
15. Malignant R pleural effusion s/p Pleurex cath placement
[**6-19**], removed [**8-14**] in clinic
Social History:
She lives with her daughter, [**Name (NI) 8368**]. She is wheelchair-bound and
has a 24[**Hospital 8018**] home health aide, [**Last Name (un) 8369**] (who primarily speaks
Portuguese [**Location 7972**]). There is a remote smoking history. Has
eight children.
Family History:
Non-contributory
Physical Exam:
VS: T98.1 BP107/47 HR93 RR23 o2: 97% on NRB
GEN: Elderly female, in NAD, able to give several word answers
without dyspnea
HEENT: Anicteric sclera. MM dry.
NECK: No JVP.
CV: Regular, nml s1,s2. no murmurs
RESP: CTAB, but exam limited by pt effort. +crackles at bases,
? R>L
ABD: Soft, NTND. +BS. No TTP. No rebound/guarding
EXT: 1+ edema
NEURO: Able to answer ?s appropriately, although does answer to
AAO questions.
SKIN: + excoriated 3cm lesions over R chest
Past Medical History:
Pertinent Results:
CXR [**8-21**]:
1. New interstitial opacities in the right upper lung,
suspicious for lymphangitic spread of tumor.
2. Unchanged moderate loculated right pleural effusion.
3. Unchanged right basilar opacity. Superimposed infection
cannot be excluded.
Head CT [**8-21**]: No acute intracranial hemorrhage or change
compared to the most recent examination.
[**2189-8-21**] 02:37PM TYPE-ART PO2-232* PCO2-38 PH-7.45 TOTAL
CO2-27 BASE XS-3
[**2189-8-21**] 01:00PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.022
[**2189-8-21**] 01:00PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-TR
[**2189-8-21**] 01:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0
[**2189-8-21**] 01:00PM URINE HYALINE-<1
[**2189-8-21**] 01:00PM URINE MUCOUS-MOD
[**2189-8-21**] 12:55PM GLUCOSE-103 UREA N-19 CREAT-1.3* SODIUM-146*
POTASSIUM-4.0 CHLORIDE-109* TOTAL CO2-24 ANION GAP-17
[**2189-8-21**] 12:55PM WBC-12.0*# RBC-4.45 HGB-12.4 HCT-37.1 MCV-83
MCH-27.9 MCHC-33.5 RDW-17.3*
[**2189-8-21**] 12:55PM NEUTS-85.8* LYMPHS-8.5* MONOS-4.5 EOS-0.9
BASOS-0.2
[**2189-8-21**] 12:55PM ANISOCYT-1+ MICROCYT-1+
[**2189-8-21**] 12:55PM PLT COUNT-305
[**2189-8-21**] 12:53PM LACTATE-1.9
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2189-8-25**] 9:26 AM
IMPRESSION:
1. Significant increase in the size and number of liver
metastases.
2. Cholelithiasis.
3. Right pleural effusion.
Brief Hospital Course:
67 y/o F with a PMHx of metastatic melanoma s/p XRT/resection,
metastatic breast CA s/p 7 cycles of herceptin, recent right
malignant pleural effusion s/p recent Pleurex catheter removal 1
week ago now here with hypoxia
1. Hypoxia
Pt with a hx of prior lymphangitic spread of malignancy to lungs
with previous malignant effusion and Pleurex catheter
discontinued on [**8-14**]. DDx includes pneumonia vs aspiration
pneumonia vs reaccumulation of pleural effusion vs lymphangitic
spread vs PE vs hypoventilation. Given fever, elevated, WBC and
CXR with ? right basilar opacity, PNA most likely diagnosis,
although unclear whether effusion may be contributing to
hypoxia. Pt. was admitted to MICU for monitoring, placed on NRB
and treated with levaquin/flagyl for CAPNA vs. aspiration PNA.
CTA was negative for PE. IP was consulted regarding
thoracentesis +/- replacement of Pleurex catheter in R pleural
space given reaccumulation of fluid, but as pt.'s oxygenation
status improved and given overall poor prognosis, it was decided
to defer. Her oxygenation improved on levo/flagyl, though could
not be completely weaned, and was sent home on home oxygen.
2. Breast CA: Metastatic, on herceptin as an outpatient, with
very poor prognosis. We held a family discussion in which it
was decided that she would continue herceptin treatment, but
would be brought home and transitioned to hospice care. She
received one dose of herceptin while on floor after family
discussion.
3. Sz d/o : Continued lamictal 200 tid
4. Dementia: Pt with baseline altered MS due to WB XRT,
resection, dementia. Pt intermittently alert and per family was
responsive to her baseline. Pt pleasant, interactive, enjoyed
red sox games.
5. RUQ pain: Pt. with known liver mets, continued RUQ pain,
likely [**3-12**] increasing mets. Liver enzymes not elevated. no e/o
ductal dilatation on U/S. morphine PRN for pain control.
6. FEN - Pt with hx of aspiration risk. Speech/swallow cleared
for pureed and thin liquids. ok for pills
Medications on Admission:
Lamictal 200mg tid
Zyprexa 5 [**Hospital1 **]
Calcium 500 tid c meals
Vit 800
Protonix 40 [**Hospital1 **]
Discharge Medications:
1. Oxygen-Air Delivery Systems Device Sig: One (1) Miscell.
continous: 2L of O2.
Disp:*qs qs* Refills:*0*
2. Lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*2*
4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*8 Tablet(s)* Refills:*0*
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*24 Tablet(s)* Refills:*0*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
7. Zyprexa 5 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Calcium Carbonate 500 mg Tablet Sig: One (1) Tablet PO three
times a day.
9. Vitamin D 400 unit Capsule Sig: Two (2) Capsule PO once a
day.
Disp:*60 Capsule(s)* Refills:*2*
10. Morphine 10 mg/5 mL Solution Sig: One (1) mL PO every six
(6) hours as needed for pain.
Disp:*30 mL* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Community acquired pneumonia
Metastatic Cancer
Pleural effusion
________________
dementia
anemia
seizure disorder
Discharge Condition:
stable
Discharge Instructions:
Please seek medical attention if you develop trouble breathing,
increased shortness of breath or chest pain. Please seek
medical attention if you develop a fever, increased abdominal
pain, or you develop any other worrisome symptoms.
Please take all your medications as prescribed. Take your
antibiotics, levofloxacin once a day for eight more days and
your metronidazole three times a day for eight more days.
Please arrange follow up with Dr. [**Last Name (STitle) **] as you have been doing.
Please attend your appointment with Dr. [**Last Name (STitle) **] and your mammogram
appt outlined below.
Followup Instructions:
Provider: [**Name10 (NameIs) 326**] [**Name11 (NameIs) **] DX RM2 RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2189-8-28**] 11:00
Provider: [**Name10 (NameIs) 306**] [**Name Initial (MD) 307**] [**Name8 (MD) 308**], M.D. Date/Time:[**2189-11-6**] 12:00
Test for consideration post-discharge: Lamotrigine
|
[
"780.39",
"V10.82",
"V10.3",
"197.7",
"197.2",
"507.0",
"285.22",
"294.8",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25"
] |
icd9pcs
|
[
[
[]
]
] |
7548, 7611
|
4366, 6380
|
287, 293
|
7769, 7778
|
2895, 4343
|
8431, 8751
|
2353, 2371
|
6538, 7525
|
7632, 7748
|
6406, 6515
|
7802, 8408
|
2386, 2852
|
240, 249
|
321, 1091
|
2876, 2876
|
2074, 2337
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,255
| 173,865
|
2357
|
Discharge summary
|
report
|
Admission Date: [**2191-1-31**] Discharge Date: [**2191-2-10**]
Date of Birth: [**2129-4-12**] Sex: F
Service: Liver Transplant Surgery
ADMISSION DIAGNOSIS:
End stage renal disease due to alcoholic cirrhosis
complicated by portal hypertension and hepatic
encephalopathy.
End stage renal disease due to alcoholic cirrhosis
complicated by portal hypertension and hepatic
encephalopathy, status post orthotopic liver transplant.
ADMISSION HISTORY AND PHYSICAL: Mrs. [**Known lastname 12271**] is a 62
year-old female with a past medical history significant for
end stage renal disease due to alcoholic cirrhosis
and ascites. She was most recently admitted to the hospital
in late [**2190-12-15**] with mental status changes. She
underwent diagnostic paracentesis of her ascites and was
found to have greater then 500 white blood cells, though she
did not meet criteria for spontaneous bacterial peritonitis,
and gram stain and culture revealed no organisms. She was
started at the time on oral Ciprofloxacin, which she is
currently still taking and her mental status cleared and has
remained stable since that time. She reports no further
issues or problems since this discharge on the [**1-14**]. She now presents to the hospital
preoperatively for an orthotopic liver transplant.
PAST MEDICAL HISTORY:
1. End stage renal disease.
2. Alcoholic cirrhosis.
3. Portal hypertension.
4. Hepatic encephalopathy.
5. Ascites.
6. Hypothyroidism.
7. Type 2 diabetes mellitus.
MEDICATIONS ON ADMISSION:
1. Humalog 75/25 30 units subQ q.a.m.
2. Humalog 75/25 24 units subQ q.p.m.
3. Propanolol 10 mg twice a day.
4. Levothyroxine 75 micrograms once per day.
5. Calcium carbonate 500 mg three times a day.
6. Zantac 150 mg twice a day.
7. Lactulose 60 milliliters twice a day.
8. Folic acid 1 mg once per day.
9. Vitamin D 400 units once per day.
10. Ciprofloxacin 500 mg once per day.
ALLERGIES: Codeine.
SOCIAL HISTORY: Mrs. [**Known lastname 12271**] reports a sixty pack year
tobacco history, which she quit ten years ago. She also
reports a heavy alcohol history, which she quit approximately
two and a half years ago. She currently lives in [**Hospital3 12272**].
FAMILY HISTORY: Noncontributory.
INITIAL PHYSICAL EXAMINATION: Mrs. [**Known lastname 12271**] was found to be
alert and oriented and in no acute distress. Pupils are
equal, round, and reactive to light and accommodation.
Extraocular movements intact. Her neck was supple with
trachea in the midline and no jugulovenous distention. Her
heart showed a regular rate and rhythm with a normal S1 and
S2 and no murmurs, rubs or gallops. Her lungs were clear to
auscultation bilaterally. Abdomen was soft, quite distended
and nontender. Extremities showed 1+ edema bilaterally and
were warm and well perfuse. She had no focal neurological
deficits at that time.
LABORATORIES ON ADMISSION: CBC showed a white blood cell
count of 8.2 with a hematocrit of 28.6 and a platelet count
of 87. PT was 18.7 with a PTT of 40.6 and an INR of 2.3.
Fibrinogen was 133. Chemistries on admission showed a sodium
of 139, with a potassium of 4.2, chloride 113 with a
bicarbonate of 15 and a BUN and creatinine of 48 and 3.0 and
a blood glucose of 205. Liver function tests were
significant for an ALT of 30, AST 43, alkaline phosphatase of
134 with a total bilirubin of 2.6. Amylase was 66, lactate
dehydrogenase was 269 and lipase was 107. The albumin 3.7,
calcium 9.3, phosphate 5.7, magnesium 2.5, and uric acid 9.6.
HOSPITAL COURSE: Mrs. [**Known lastname 12271**] was admitted to the hospital
and subsequently taken to the Operating Room later that night
where she underwent an orthotopic liver transplant. Please
refer to the dictated operative note for full details of this
procedure. She tolerated the procedure well, receiving 6
units of packed red blood cells, 8 units of fresh frozen
platelets, 12 units of platelets, and 3800 cc of crystalloid
in the Operating Room. She was subsequently transferred to
the Surgical Intensive Care Unit in stable condition. She at
this time was on a Propofol drip for sedation and was started
on Fluconazole, Bactrim and insulin drip, Solu-Medrol taper
as well as continuing doses of Unasyn and CellCept. A venous
ultrasound was performed, which showed excellent flow in the
portal arterial and venous systems. She was slowly weaned
from the ventilator during postoperative day number zero.
She was also transfused 5 packs of platelets. She was
subsequently extubated later on postoperative day zero and
tolerated her extubation well. On postoperative day number
one she was started on total parenteral nutrition and had a
continuing insulin drip at 17 units per hour. She was
continuing on CellCept [**Pager number **] mg b.i.d. and she was started on
Cyclosporin 100 mg b.i.d. as well as continuation of her
Solu-Medrol taper. Her platelet count at this time was up to
111,000. Her INR was 1.4. Her ALT and AST were 383 and 323
with an alkaline phosphatase of 98 and a total bilirubin of
4.9. At this time her creatinine was 2.6. She was awake,
alert and doing quite well clinically.
Late on postoperative day number one she was deemed stable
and ready for transfer to the floor. Once on the floor on
postoperative day number two she continued to require an
insulin drip for proper control of her blood glucose,
however, at this time her home doses of Humalog were
reinstated enabling a decrease in her insulin drip to 3 units
per hour. Her creatinine at this time was 3.0. Her AST and
ALT began to decrease, however, she did experience an
increase in her total bilirubin to 6.9 at this time. Due to
this renal function her Cyclosporin dose was decreased to 50
mg b.i.d. She continued on her Solu-Medrol taper as well as
her same dose of CellCept. Secondary to the increase in
total bilirubin, she underwent a repeat ultrasound of her
liver, which again showed normal hepatic portal and arterial
and venous flow. She continued to improve throughout the
rest of her hospital course. By postoperative day number
four she no longer required an insulin drip and was now being
treated with her home doses of Humalog. Her Cyclosporin at
this time continued at 50 mg b.i.d. with a continuing
Solu-Medrol taper and CellCept at 1000 mg b.i.d. Her po
intake continued to improve, as did her urine output. Total
parenteral nutrition was discontinued on postoperative day
number five. It was felt at this time that the patient's
oral intake was adequate to meet her nutritional needs. Her
liver function tests continued to steadily improve and by
postoperative day number five the total bilirubin was down to
1.9 with an ALT of 74 and an AST of 19. Her creatinine also
began to improve at this time decreasing to 2.9. She
continued to improve in terms of mobility getting out of bed
multiple times per day and ambulating with assistance. Her
[**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drains were subsequently discontinued due to
decreasing output.
By postoperative day number eight she was deemed stable and
ready for discharge from the hospital. It was felt at this
time she would benefit from additional time in a acute
rehabilitation facility to further increase her strength and
mobility and improve her nutritional status. On the day of
discharge her creatinine had decreased to 2.4 and her total
bilirubin to 1.5 with a stable hematocrit and platelet count.
She had remained afebrile throughout her postoperative
course and quite alert and oriented.
DISPOSITION: To acute care rehabilitation facility.
DIET: Consistent carbohydrate diabetic diet with Nepro shake
supplementation with breakfast, lunch and dinner.
MEDICATIONS ON DISCHARGE:
1. Fluconazole 200 mg once per day.
2. Bactrim single strength one tablet once per day.
3. Protonix 40 mg once per day.
4. Prednisone 15 mg once per day.
5. CellCept [**Pager number **] mg twice a day.
6. Neoral 50 mg twice a day.
7. Levothyroxine 75 mg once per day.
8. Valcyte 450 mg every other day.
9. Lasix 20 mg once per day.
10. Colace 100 mg twice a day.
11. Humalog 75/25 30 units subQ each morning and 24 units
subQ each evening with dinner.
12. Oxycodone 1.25 mg q 6 hours as needed for pain.
ACTIVITY: As tolerated.
FOLLOW UP: There is a clinic appointment with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] on [**2191-2-16**] at 11:30 in the morning. Follow up
has been detailed to the patient with a schedule from the
Transplant Center at [**Hospital1 69**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366
Dictated By:[**Name8 (MD) 12273**]
MEDQUIST36
D: [**2191-2-10**] 11:10
T: [**2191-2-10**] 11:16
JOB#: [**Job Number 12274**]
|
[
"789.5",
"263.9",
"V15.82",
"287.5",
"303.93",
"250.00",
"571.2",
"572.3",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"50.59"
] |
icd9pcs
|
[
[
[]
]
] |
2225, 2251
|
7756, 8299
|
1526, 1940
|
3541, 7730
|
8311, 8827
|
2274, 2888
|
176, 1307
|
2903, 3523
|
1329, 1500
|
1957, 2208
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,986
| 160,658
|
28523
|
Discharge summary
|
report
|
Admission Date: [**2165-10-13**] [**Month/Day/Year **] Date: [**2165-10-22**]
Date of Birth: [**2100-1-7**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Percutaneous drainage catheter into liver biloma [**2165-10-19**]
IVC filter (Gunther Tulip) placed [**2165-10-13**]
History of Present Illness:
65 yo female s/p CCY ~2 weeks ago; + malaise since surgery;
presents with + SOB to an area hospital; CT performed and
revealed bilatral pulmonary emboli. She was then transferred to
[**Hospital1 18**] for further care.
Past Medical History:
Type II Diabetes
HTN
Depression
Social History:
Lives alone
Family History:
Noncontributory
Pertinent Results:
[**2165-10-13**] 10:34PM HGB-10.5* calcHCT-32
[**2165-10-13**] 09:41AM HGB-10.5* calcHCT-32 O2 SAT-97
[**2165-10-13**] 09:24AM LACTATE-1.9
[**2165-10-13**] 09:00AM GLUCOSE-203* UREA N-12 CREAT-0.8 SODIUM-137
POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-26 ANION GAP-14
[**2165-10-13**] 09:00AM ALT(SGPT)-27 AST(SGOT)-29 ALK PHOS-173* TOT
BILI-0.9
[**2165-10-13**] 09:00AM WBC-10.4 RBC-3.28* HGB-10.5* HCT-29.7* MCV-91
MCH-32.0 MCHC-35.3* RDW-17.2*
[**2165-10-13**] 09:00AM PLT COUNT-248
[**2165-10-13**] 09:00AM PT-13.8* PTT-27.0 INR(PT)-1.2*
[**2165-10-13**] 02:00AM PLT COUNT-268
[**2165-10-13**] 02:00AM PT-13.3* PTT-25.2 INR(PT)-1.2*
C1880 VENA CAVA FILTER [**2165-10-13**] 5:59 AM
Reason: place IVC filter
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
65 year old woman with B PEs
REASON FOR THIS EXAMINATION:
place IVC filter
INDICATION: 65-year-old woman with bilateral pulmonary emboli.
Question of a subcapsular hepatic hematoma. Asked to place an
IVC filter.
RADIOLOGISTS: [**Doctor First Name **] [**Doctor Last Name **] (radiology resident) and [**Doctor First Name 4685**]
[**Doctor Last Name 4686**] (attending radiologist). Dr [**Last Name (STitle) 4686**], the attending
radiologist was present and supervising throughout the
procedure.
TECHNIQUE/FINDINGS: A written informed consent was obtained
prior to the procedure. The patient was brought into the
radiology suite and placed supine on the angiographic table. A
preprocedure timeout was performed. The right groin was prepped
and draped in standard sterile fashion. Under ultrasonographic
guidance, a suitable puncture site was determined. Uneventful
single wall venipuncture of the right common femoral vein was
performed. A 0.035 inch Bentson guidewire was advanced through
the needle into the inferior vena cava. The needle was removed
off the wire and a 5 French Omniflush catheter was steered into
the left external iliac vein. Hand injection demonstrated
appropriate positioning. Subsequently, a power injection
inferior vena cavogram was performed. Review of the images
demonstrated no caval anatomic variations, a single inferior
vena cava, without intraluminal filling defects. The level of
the renal veins was determined.
Based on the diagnostic findings, it was determined that an IVC
filter placement was indicated. The in situ catheter and sheath
were removed over the wire, and the IVC filter sheath was
advanced over the wire. A Gunther Tulip filter was then
delivered uneventfully to the lower margin of the L2 vertebral
body, inferior to the renal veins. It was successfully deployed
and the sheath was removed. Final abdominal radiograph
demonstrated good positioning and deployment of the IVC filter.
Hemostasis was achieved using digital compression for a total of
5 minutes. There was no residual bleeding or hematoma in the
right groin. The patient tolerated the procedure well and there
were no immediate postprocedure complications.
IMPRESSION: Successful placement of a Gunther Tulip IVC filter.
This filter can be removed within 14 days of placement if
medically indicated.
CT ABDOMEN W/O CONTRAST
Reason: please evaluate liver with non-contrast scan
Field of view: 45
[**Hospital 93**] MEDICAL CONDITION:
65 year old woman with B PE, ? liver hematoma
REASON FOR THIS EXAMINATION:
please evaluate liver with non-contrast scan
CONTRAINDICATIONS for IV CONTRAST: recent IV study
INDICATION: History of bilateral pulmonary embolism with ? liver
hematoma.
ABDOMINAL ULTRASOUND WITHOUT CONTRAST: There is right lower lobe
atelectasis versus consolidation. There is a large low density
collection adjacent to the right lobe of the liver that appears
to conform to the liver capsule and produces mass effect upon
the right lobe. Hounsfield unit attenuation values range from 15
to 22. The patient is status post cholecystectomy. Pneumobilia
is noted. There is stranding adjacent to this large collection
extending along the right paracolic gutter.
The spleen and pancreas are unremarkable. The adrenal glands are
normal. There is a 10.6 cm exophytic cystic lesion at the upper
pole of the left kidney that appears to have a high density rim
and possible septation. Contrast material was present within the
kidneys from the patient's recent contrast-enhanced CT scan.
There is no intra-abdominal free air. Visualized loops of bowel
are grossly unremarkable.
Note is made of a spiculated area of soft tissue attenuation in
the left breast that appears to correspond to an area of a
surgical defect anteriorly.
Bone windows reveal no suspicious lytic or sclerotic lesions.
IMPRESSION:
1. Large subcapsular collection producing mass effect upon the
right lobe of the liver with Hounsfield unit attenuation values
ranging from 15 to 22. Considerations include a chronic
subcapsular hematoma, or a subcapsular biloma in this patient
that is status post cholecystectomy.
2. Spiculated soft tissue density in the left breast that
appears to be near surgical defect. Correlation with the
patient's history and mammogram is recommended.
3. 11 mm exophytic lesion at the upper pole of the left kidney
with the suggestion of a high density rim and a possible
septation. Correlation with the patient's other outside imaging
is recommended. Further evaluation with an ultrasound or MRI
could also be performed to further characterize this lesion.
MRI ABDOMEN W/O & W/CONTRAST [**2165-10-17**] 1:30 PM
MRI ABDOMEN W/O & W/CONTRAST
Reason: please perform MRV of HEPATIC VEINS to evaulate for
clot/sou
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
65 year old woman 4 weeks s/p lap Chole with known PE &
subcapsular hematoma. upper and lower US neg for clot
REASON FOR THIS EXAMINATION:
please perform MRV of HEPATIC VEINS to evaulate for clot/source
of PE
INDICATION: Four weeks status post laparoscopic cholecystectomy
with known pulmonary embolism, subcapsular hematoma. Perform MRV
of hepatic veins to evaluate for clot or source of pulmonary
embolism.
TECHNIQUE: Multiplanar MR imaging of the abdomen was performed,
including 2D time-of-flight images through the hepatic veins.
FINDINGS: There is an large subcapsular hematoma along the
lateral aspect of the liver, measuring approximately 17.3 cm AP
x 10 cm TV x 23.4 cm SI, resulting in significant leftward shift
of the hepatic parenchyma and compression upon the IVC. There is
patency and appropriate directional flow of the hepatic veins.
There is no evidence of intra- or extra-hepatic biliary ductal
dilatation. There appears to be a small right-sided pleural
effusion. Visualization of the left adrenal gland and pancreas
appears unremarkable.
Low signal within the inferior vena cava after administration of
gadolinium at the infrarenal level likely represents an IVC
filter.
Evaluation of 3D acquired volumetric images of the abdomen is
degraded by motion.
IMPRESSION:
1. Large lateral subcapsular hematoma along the lateral aspect
of the liver.
2. No evidence of thrombus within the hepatic veins, which show
appropriate directional flow.
Brief Hospital Course:
She was admitted to the Surgical service and transferred to the
ICU for close monitoring. She was placed on a Heparin drip and
later changed to Lovenox; an IVC filter was placed. She did
remain on the Lovenox for several days after IVC filter
placement, but this was eventually stopped. Initially she
required high FIO2 to maintain her oxygen saturations; at one
point endotracheal intubation was being considered. Her FIO2
requirements did decrease and she was transferred to the floor
where she continued to require nasal oxygen. As her activity
increased her oxygen was eventually weaned off and she is
maintaining room air sats at ~93% and is asymptomatic.
Interventional radiology was consulted for the subcapsular
hepatic hematoma noted on abdominal CT imaging; a percutaneous
drainage catheter was placed. Gram stain was negative. She will
be discharged to home with the catheter in place and will follow
up with Dr. [**Last Name (STitle) **] in 2 weeks for repeat abdominal CT scan.
Psychiatry was also consulted for possible depression;
reportedly there has been a history of depression approximately
one month prior to hospitalization. Her Paxil was resumed. She
will follow up with her primary doctor [**First Name (Titles) **] [**Last Name (Titles) **] for
further treatment if necessary.
Physical therapy and Occupational therapy were consulted and
have recommended home with services.
Medications on Admission:
Paxil
Pioglitazone
Glipizide
[**Last Name (Titles) **] Medications:
1. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for loose stools.
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
[**Last Name (Titles) **] Disposition:
Home With Service
Facility:
[**Company 1519**]
[**Company **] Diagnosis:
Bilateral saddle pulmonary emboli
Liver biloma
[**Company **] Condition:
Good
[**Company **] Instructions:
Return to the Emergency room if you develop any fevers, chills,
increased shortness of breath, chest pain, increased abdominal
pain, bloody and/or any unusual drainage materail from your
drainage catheter in your abdomen, nausea, vomiting, diarrhea
and/or any other symptoms that are concerning to you.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in Surgery Clinic in 2 weeks, call
[**Telephone/Fax (1) 6439**] for an appointment. Inform the office that you will
need to have an abdominal CT scan of your abdomen to assess the
fluid collection and that this needs to be compared to previous
CT of your abdomen.
Follow up with your primary doctor in [**12-3**] weeks, you will need
to call for an appointment.
Completed by:[**2165-10-22**]
|
[
"311",
"576.8",
"573.8",
"997.4",
"401.9",
"250.00",
"293.0",
"415.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7",
"51.98"
] |
icd9pcs
|
[
[
[]
]
] |
7916, 9319
|
347, 466
|
850, 1595
|
10536, 10976
|
814, 831
|
6428, 6538
|
9345, 10513
|
288, 309
|
6567, 7893
|
494, 714
|
736, 769
|
785, 798
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
124
| 138,376
|
2577
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 13036**]
Admission Date: [**2165-12-2**]
Discharge Date: [**2166-2-1**]
Date of Birth: [**2090-11-19**]
Sex: M
Service:
ADMISSION DIAGNOSIS:
1. Pneumonia.
2. Colonic pseudo-obstruction/[**Last Name (un) 3696**] syndrome
3. Cerebrovascular disease, history of cerebrovascular
accident, status post bilateral carotid
endarterectomies.
4. Coronary artery disease, status post five-vessel
coronary artery bypass grafting, status post coronary
catheterization.
5. Hypertension.
6. Prostate cancer.
7. Hepatitis C.
8. Hyperlipidemia.
9. Chronic obstructive pulmonary disease/emphysema.
10.History of adenocarcinoma of the lung, status post right
upper lobectomy.
11.Chronic renal insufficiency.
12.History of cavitating pneumonias.
DISCHARGE DIAGNOSES:
1. As above.
2. Sepsis with multisystem organ failure.
3. Respiratory failure.
4. Pneumonia.
5. Colonic perforation, status post extended right
colectomy with end ileostomy.
6. Status post tracheostomy.
7. Status post abdominal wound dehiscence, status post
fascial closure.
8. Acute on chronic renal failure.
9. Malnutrition.
ADMISSION HISTORY AND PHYSICAL: [**Known firstname **] [**Known lastname 13029**] was a 75-year-
old gentleman with multiple comorbidities who was admitted to
a referring institution with severe pneumonia and possible
COPD flare at the beginning of [**2165-12-16**]. He was managed
there with antibiotics and required some degree of steroid
therapy for his severe respiratory disease. During the
treatment of his pneumonia, he developed what was initially
was thought to be a colonic obstruction. This was evaluated
at the referring hospital by the surgical and
gastroenterology services and was found to be a colonic
pseudo-obstruction thought to be related to his pneumonia.
The patient failed to make significant progress in terms of
his colonic pseudo-obstruction. The family request transfer
to the [**Hospital1 69**] for further care.
He was initially transferred to the medical service for
management of his pneumonia and colonic pseudo-obstruction.
Gastroenterology and surgical services were consulted. Both
services concurred with nonoperative management of his
process and treating the underlying illness with correction
of any electrolyte abnormalities and minimization of any
narcotics, anticholinergic agents, which may exacerbate the
pseudo-obstruction. The patient was transferred on [**2165-12-31**].
His symptoms actually resolved on the day of transfer with
resumption of bowel function and passage of gas. This was
visible on his plain radiograph imaging. He did not require
any intervention for this. He was passing gas and having
loose stools first several days, but then began to develop
some increasing abdominal distention on [**2166-1-3**].
This was thought to be possible recurrence of his pseudo-
obstruction and again managed conservatively.
Over the course of the ensuing days, the patient was found to
have free intraperitoneal air on an abdominal x-ray from
[**1-7**] and [**1-8**]. As the patient did not initially
manifest systemic signs of sepsis, given as co-morbidities,
he was managed non operatively with antibiotics. His disease
progressed and he became progressively more ill and was taken
emergently to the operating room on [**1-9**]. Extensive
discussions were undertaken with the family and the patient
highlighting the high risk of the surgery. Given his
extensive co-morbidities and the high risk about morbidity
and mortality, they understood and wished to pursue all
treatment. On [**1-9**] he underwent an extended right
colectomy with an end-ileostomy. Please see the operative
note for further details.
His postoperative course was initially marked by prolonged
ventilator dependence and acute-on-chronic renal
insufficiency. His malnutrition and his immunosuppression
from steroids hampered his initial recovery. He did develop
some degree of pneumonia and pleural effusions and given the
high likelihood that he would require mechanical ventilation
for some period of time, tracheostomy was placed on [**1-14**].
He continued to require full ventilatory nutritional support,
as well as antibiotic therapy for his pneumonia. Nutritional
support was provided with combination of initially TPN and
subsequently enteral feedings. On [**1-20**], he began to have
increasing drainage from his abdominal incision. This was
opened at the bedside and evidenced a fascial dehiscence. He
was taken to emergently back to the operating room for
fascial closure. Notably, at this time, there was no evidence
of healing taking place since the time of operation 10 days
prior, highlighting his severe degree of immunosuppression
and malnutrition.
He was subsequently maintained in the ICU with the narcotics
for pain control and sedation. Full ventilatory support was
required. He failed multiple attempts at weaning despite
aggressive pulmonary toilet and attempts at diuresis. His
hemodynamics were relatively stable with occasional episodes
of atrial fibrillation; but otherwise no significant
hemodynamic instability. His ileostomy continued to function
and never evidenced any ischemia. His renal function
continued to deteriorate somewhat with acute-on-chronic renal
failure developing. Most concerning was the development of
fungal infections in the sputum and urine.
Over the course of the ensuing week, the patient failed to
progress despite maximal medical therapy and nutritional
support. Discussions were had with the family to decide goals
of care with the patient. After several meetings, the family
made the decision to make the patient comfort measures only,
as he was in multisystem organ failure with progressively
worsening infections and with a very low likelihood of any
meaningful recovery. The patient was made CMO on [**2166-1-29**]. He was maintained on ventilatory support per the
family's request. His sedative medications and pain
medications were continued over the course of the ensuing
days. The patient progressively went into worsening renal
failure and this was followed by cardiac arrest on [**2166-2-1**]. The family was at the bedside.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 13037**]
Dictated By:[**Doctor Last Name 3763**]
MEDQUIST36
D: [**2166-2-1**] 07:16:45
T: [**2166-2-1**] 08:56:55
Job#: [**Job Number 13038**]
|
[
"414.00",
"428.33",
"428.0",
"995.92",
"998.31",
"560.89",
"V10.11",
"486",
"427.31",
"403.90",
"569.83",
"585.4",
"V10.46",
"263.9",
"V45.81",
"491.21",
"584.9",
"998.59",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"46.21",
"96.6",
"54.72",
"31.1",
"45.73",
"33.23",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
804, 6423
|
177, 783
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,904
| 167,979
|
39042
|
Discharge summary
|
report
|
Admission Date: [**2179-2-12**] Discharge Date: [**2179-2-15**]
Date of Birth: [**2110-8-25**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
(R)UQ abdominal pain
Major Surgical or Invasive Procedure:
[**2179-2-13**]: ERCP with sphincterotomy, stent placement, and removal
of multiple stones, sludge and pus.
History of Present Illness:
68M presented to [**Hospital **] Hospital on [**2179-2-12**] with RUQ pain and
2-3 episodes of non-bilious, non-bloody emesis. First noticed
this pain two weeks ago. Experienced chills, and mild RUQ
tenderness. Lasted about 30 minutes, not associated with food.
Again on [**2179-2-11**] at 8:00 pm had chills and RUQ tenderness. He
notes that he had a poor appetitite and had not eaten all day.
On [**2179-2-12**], he had a third episode, this time lasting longer,
with more severe pain that radiated into the epigastrum. He
also noted dark [**Location (un) 2452**] urine.
.
He never recorded his temperature, or noted a subjective fever.
He had mild constipation buy no change in stool color, and no
hematochezia.
.
He presented to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] where he was found to be febrile
to 100.4. An abdominal ultrasound showed a distended
gallbladder with stones, sludge c/w acute cholecystitis, and
dilated intrahepatic and common bile duct, concerning for
choledocholithiasis. He was treated with Unasyn 3g IV, Toradol,
Dilaudid, and Zofran prior to transfer.
.
In the [**Hospital1 18**] ED, initial VS were 101.3 101 124/78 16 98%RA.
He was given IV unasyn, 4 mg IV morphine for abd pain & 1L IVF.
Surgery and ERCP were consulted, and recommended ERCP. Patient
was admitted to the [**Hospital Ward Name 332**] ICU in anticipation of ERCP. VS on
transfer were 98.7, 88, 131/75, 16, 99% RA
Past Medical History:
PMHx: Peptic Ulcer Disease, Peripheral Vascular Disease,
Barrett's esophagus, Hypertension, Hypercholesterolemia
.
PSHx: BII Distal gastrectomy [**2140**], Aortobifem bypass [**2172**].
Social History:
Has smoked 1 PPD x 50years. Few drinks on the weekend. Retired;
used to work for GE. Lives alone, daughter living with him now.
Mother, two brothers live in area.
Family History:
CAD in father, sister, paternal grandmother; no h/o ca
Physical Exam:
On Admission:
Vitals: T: 99.2 BP:90/58 P:95 R:17 O2:96/ra
General: Alert, oriented, no acute distress
HEENT: Sclera icteric, MM dry, oropharynx clear
Skin: jaundiced
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, mildly TTP RUQ, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Midline and R subcostal surgical scars
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission labs:
[**2179-2-12**] 08:18PM LACTATE-1.9
[**2179-2-12**] 08:00PM GLUCOSE-120* UREA N-25* CREAT-1.2 SODIUM-141
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-25 ANION GAP-16
[**2179-2-12**] 08:00PM ALT(SGPT)-215* AST(SGOT)-123* ALK PHOS-572*
TOT BILI-6.3*
[**2179-2-12**] 08:00PM LIPASE-23
[**2179-2-12**] 08:00PM ALBUMIN-4.3
[**2179-2-12**] 08:00PM WBC-3.6* RBC-4.36* HGB-13.0* HCT-38.7* MCV-89
MCH-29.7 MCHC-33.5 RDW-13.5
[**2179-2-12**] 08:00PM NEUTS-70 BANDS-16* LYMPHS-12* MONOS-0 EOS-1
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2179-2-12**] 08:00PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2179-2-12**] 08:00PM PLT SMR-NORMAL PLT COUNT-169
.
IMAGING:
[**2179-2-12**] OSH ABD Scan:
Gallbladder stones & sludge, no wall thickening, common hepatic
duct 6mm, CBD 11mm.
.
[**2179-2-13**] AP CXR:
TECHNIQUE: A single upright radiograph of the chest obtained,
without prior study for comparison. The cardiomediastinal
silhouette is within normal limits. The lungs and pleural spaces
are clear. Surgical clips are noted in the region of the
gastroesophageal junction. Otherwise, the visualized upper
abdomen is unremarkable, as are the visualized osseous
structures.
.
MICROBIOLOGY:
[**2179-2-13**] URINE CULTURE-FINAL: NO GROWTH.
[**2179-2-13**] MRSA SCREEN: NEGATIVE.
[**2179-2-12**] BLOOD CULTURE: NO GROWTH TO DATE - PRELIM.
[**2179-2-12**] BLOOD CULTURE: NO GROWTH TO DATE - PRELIM.
Brief Hospital Course:
The patient was transferred from an Outside Hospital (OSH) and
admitted on [**2179-2-12**] with post-prandial (R)UQ pain, nausea,
vomiting, and fever to 101.3 with labs and imaging suggestive of
biliary obstruction and cholangitis for evaluation and
treatment. Initially, he was admitted to the [**Hospital Unit Name 153**], made NPO,
started on IV fluids, a foley catheter was placed, and he was
started on empiric IV Unasyn. Pain was well controlled with
Morphine IV PRN. On [**2179-2-13**], the patient underwent ERCP, which
revealed multiple stones, sludge and large volume of pus which
were extracted to clear the duct. A sphincterotomy was
performed, and a stent was placed. The patient was
hemodynamically stable.
.
On [**2179-2-14**], the patient was transferred to the [**Hospital Ward Name 517**]. He
was given clear liquids, and home medications were restarted.
When tolerating clears, he was converted to oral pain
medications with good effect. He voided adequate amounts of
urine without problem. Bowel function was normal. Urine culture
upon admission revealed no growth. Blood cultures no growth to
date by discharge. Liver enzymes significantly improved after
the ERCP.
.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirrometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. Labwork was routinely followed;
electrolytes were repleted when indicated.
.
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. He was discharged home without services, and will
return later this week for scheduled cholecystectomy. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan.
Medications on Admission:
Nexium 40 mg PO daily
Lipitor 20 mg PO daily
Atenolol 12.5 mg PO daily
Lisinopril 20 mg PO daily
ASA 81mg 1 tab PO daily
MVI 1 tab PO daily
Calcium with Vitamin D
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation: Over-the-counter.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily): Please restart on [**2179-2-20**].
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
10. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO three
times a day for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Cholangitis
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
Do NOT restart preventative aspirin until [**2179-2-20**], otherwise
please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-19**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Followup Instructions:
Please call ([**Telephone/Fax (1) 79758**] to arrange a follow-up appointment
with Dr. [**Name (NI) 70277**] (PCP) in [**1-13**] weeks.
.
You will be contact[**Name (NI) **] by Dr.[**Name (NI) 9886**] Office as to the date and
time to return for planned cholecytectomy surgery as well as
pre-operative intstructions. Nothing to eat or drink after
midnight prior to your surgery date. Please call ([**Telephone/Fax (1) 471**]
with any questions.
|
[
"576.1",
"305.1",
"272.0",
"443.9",
"574.61",
"V17.3",
"401.9",
"V12.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85",
"51.88",
"51.87"
] |
icd9pcs
|
[
[
[]
]
] |
7691, 7697
|
4497, 6480
|
334, 444
|
7753, 7753
|
3012, 3012
|
8576, 9024
|
2334, 2390
|
6693, 7668
|
7718, 7732
|
6506, 6670
|
7901, 8553
|
2405, 2405
|
274, 296
|
472, 1926
|
3029, 4474
|
2419, 2993
|
7768, 7877
|
1948, 2135
|
2151, 2318
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,160
| 156,841
|
54840
|
Discharge summary
|
report
|
Admission Date: [**2123-6-8**] Discharge Date: [**2123-6-14**]
Date of Birth: [**2053-7-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / lisinopril
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Severe Aortic stenosis
Major Surgical or Invasive Procedure:
[**2123-6-8**]: CABG x 4 LIMA-> lad, RSVG-> [**Last Name (LF) **], [**First Name3 (LF) **], PDA, 23 mm
tissue AVR
History of Present Illness:
Mr. [**Known lastname 112060**] is a 69 year old male who presented to Dr. [**Name (NI) 112061**] office on
[**2123-4-22**] with complaints of exertional shortness of breath and
chest pain. that has been occuring over the past few weeks. He
has a known cardiac murmur for years. His recent echo showed
that his AS is now severe with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.9, mean gradient of
44 mmHG. He also complains of shortness of breath not
associated with his chest discomfort. The shortness of breath
occurs with
minimal exertion i.e. bending over to pick up an object. The
chest discomfort occurs with heavy exertion. Wife reports that
she has noticed for the past couple of weeks left lower
extremity swelling.
Past Medical History:
Coronary Artery Disease
IDDM x 8 yrs
High Cholesterol
Hypertension
Muscle cramps
Parkinson's disease 5yrs
? Colitis (40 years ago)pt denies
Gout
Past Surgical History:
Bilateral cataract surgery
Tonsillectomy as a child
Social History:
Lives with:Wife [**Name (NI) **]
Contact: Contact upon discharge: [**First Name8 (NamePattern2) **] [**Name (NI) 112060**] cell
#[**Telephone/Fax (1) 112062**]
Occupation:Retired purchaser
Cigarettes: denies Quit in 1967Smoked no [] yes [] last
cigarette
Other Tobacco use: None
ETOH: Denies < 1
Illicit drug use: denies
Family History:
Non-contributory
Physical Exam:
Physical Exam
Pulse:70 Resp: 18 O2 sat: 100%
B/P Right: 130/60 Left:126/70
Height:5ft 9" Weight:228lbs
Five Meter Walk Test #1_______ #2 _________ #3_________
General:
Skin: Dry [x] intact []
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [xx]
Heart: RRR [] Irregular [] Murmur [x] grade [**1-26**] holosystolic
murmur______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[]
Extremities: Warm [x], well-perfused [] Edema [] _____
Varicosities: None []
Neuro: Grossly intact [x]
Pulses:
Femoral Right:+2 Left:+2
DP Right: doppler Left:Doppler
PT [**Name (NI) 167**]:trace Left:Trace
Radial Right: +2 Left:+2
Carotid Bruit Right: None Left:None
Pertinent Results:
Intra-op TEE [**2123-6-8**]:
Conclusions
PREBYPASS: The left atrium and right atrium are normal in cavity
size. No spontaneous echo contrast or thrombus is seen in the
body of the left atrium/left atrial appendage or the body of the
right atrium/right atrial appendage. There is mild symmetric
left ventricular hypertrophy with normal cavity size. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. There are simple atheroma in the aortic arch and
descending thoracic aorta. There are three aortic valve
leaflets. 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. Mild (1+) mitral
regurgitation is seen. Mild TR, Normal PV. Normal appearing
coronary sinus. Intact interatrial septum.
POSTBYPASS: Normally functioning AV prosthesis with no
significant AS or AI. Otherwise unchanged.
.
[**2123-6-14**] 04:22AM BLOOD WBC-9.8 RBC-3.42* Hgb-9.0* Hct-27.6*
MCV-81* MCH-26.4* MCHC-32.8 RDW-13.9 Plt Ct-301#
[**2123-6-12**] 03:52AM BLOOD WBC-8.9 RBC-3.39* Hgb-9.1* Hct-27.6*
MCV-82 MCH-26.9* MCHC-33.0 RDW-14.3 Plt Ct-163
[**2123-6-14**] 04:22AM BLOOD Glucose-53* UreaN-36* Creat-1.3* Na-134
K-4.0 Cl-96 HCO3-31 AnGap-11
[**2123-6-13**] 04:00AM BLOOD Glucose-69* UreaN-36* Creat-1.3* Na-133
K-4.1 Cl-97 HCO3-29 AnGap-11
[**2123-6-14**] 04:22AM BLOOD Mg-2.6
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2123-6-8**] where the patient underwent Coronary
artery bypass grafting LIMA-LAD, SVG-[**Last Name (LF) **], [**First Name3 (LF) **], PDA and Aortic
Valve replacement (23 mm Porcine). Overall the patient
tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. POD 1 found the patient extubated, alert
and oriented and breathing comfortably. The patient was
neurologically intact and hemodynamically stable on a small
amount of vasopressor support which was discontinued on POD2.
Chest tubes and cardiac pacing wires were removed per protocol.
Respiratory: aggressive pulmonary toilet, nebs and ambulation
his oxygenation improved and he titrated off oxygen with room
air saturations of 93-96%.
Cardiac: low dose beta-blocker was started. On POD5 he had a
brief episode of atrial fibrillation 102-130, amiodarone was
started and he converted to sinus rhythm 60's. He remained
hemodynamically stable with blood pressure 110-116. Statin and
aspirin were restarted.
GI: abdomen soft. Prophylaxis H2 blockers were given. He
tolerated a diabetic diet.
Renal: baseline CRE 1.2. Metolazone and Lasix. Electrolytes
were replete as needed.
Endocrine: His blood sugars were found to be below 60. His home
dose Amaryl was held.
Neuro: Parkinson's medications resumed immediately. Pain well
controlled with acetaminophen and tramadol.
Disposition: He was followed by physical therapy who recommended
rehab. He continued to make steady progress and was discharged
to [**Location (un) 582**] at [**Location (un) 5176**] on POD 6.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Aspirin EC 81 mg PO DAILY
2. Carbidopa-Levodopa (25-100) 1 TAB PO Q4H
3. Carbidopa-Levodopa CR (25-100) 2 TAB PO QPM
4. fenofibrate *NF* 160 mg Oral daily
5. glimepiride *NF* 4 mg Oral daily
6. Lantus *NF* (insulin glargine) 60 u Subcutaneous bedtime
7. Mirapex *NF* (pramipexole) 1.5 mg Oral daily
extended release
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Carbidopa-Levodopa (25-100) 1 TAB PO Q4H
3. Carbidopa-Levodopa CR (25-100) 2 TAB PO QPM
4. fenofibrate *NF* 160 mg Oral daily
5. Acetaminophen 650 mg PO Q4H:PRN pain
6. Amiodarone 400 mg PO BID
start tonight
7. Furosemide 40 mg PO DAILY Duration: 10 Days
8. Heparin 5000 UNIT SC TID
9. Metoprolol Tartrate 25 mg PO BID
Hold for HR < 55 or SBP < 90 and call medical provider.
10. glimepiride *NF* 4 mg ORAL DAILY
11. Mirapex *NF* (pramipexole) 1.5 mg Oral daily
extended release
12. Potassium Chloride 20 mEq PO DAILY Duration: 10 Days
Hold for K+ > 4.5
13. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
14. Glargine 50 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 5176**]
Discharge Diagnosis:
Aortic Stenosis (severe)
Coronary artery disease
IDDM x 8 yrs
High Cholesterol
Hypertension
Muscle cramps Parkinson's disease 5yrs
Colitis (40 years ago)pt denies
Gout Bilateral cataract surgery
Tonsillectomy as a child
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Sternal pain managed with oral analgesics
Edema: 1+ generalized edema
Discharge Instructions:
Shower daily including washing incisions gently with mild soap,
no baths or swimming
NO lotions, cream, powder, or ointments to incisions
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
The following appointments have been scheduled:
Surgeon Dr. [**Name (NI) 5572**] [**Telephone/Fax (1) 170**], [**2123-7-28**] 1:30
Cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**2123-7-1**] 10:30a
Please call to schedule:
Primary Care Dr.[**Name (NI) **] [**Telephone/Fax (1) 22235**] in [**2-25**] weeks
Please call cardiac surgery if need arises for evaluation or
readmission to hospital [**Telephone/Fax (1) 170**]
Completed by:[**2123-6-14**]
|
[
"414.01",
"V58.67",
"357.2",
"332.0",
"458.29",
"276.69",
"427.31",
"424.1",
"401.9",
"511.9",
"272.4",
"250.80",
"250.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"35.21",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
7201, 7279
|
4216, 5912
|
313, 429
|
7543, 7672
|
2627, 4193
|
8043, 8533
|
1807, 1825
|
6385, 7178
|
7300, 7522
|
5938, 6362
|
7696, 8020
|
1398, 1452
|
1840, 2608
|
251, 275
|
1534, 1791
|
457, 1208
|
1230, 1375
|
1468, 1518
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,088
| 172,719
|
47748
|
Discharge summary
|
report
|
Admission Date: [**2179-3-7**] Discharge Date: [**2179-3-18**]
Date of Birth: [**2121-12-23**] Sex: M
Service: MEDICINE
Allergies:
Ibuprofen
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
dyspnea, hyperkalemia
Major Surgical or Invasive Procedure:
Hemodialysis
right Femoral central venous line placement and removal
History of Present Illness:
57 y/o M with hx of ESRD presents after intentionally missing
dialysis for last 9 days. Came to the ED due to the coaxing of
his wife. Complains of SOB and DOE lasting about the last five
days. Also has cough with clear sputum production. Also
complains of bilateral pedal edema, R>L, starting around the
time SOB started. No fevers, chills. No CP, palpitations.
Denies dizziness, fainting, falls. Says he stopped going to
dialysis for no particular reason, although per ED reports after
talking with his wife, it is possible he had passive SI. No
other complaints except for mild nausea.
.
In the ED, his vitals were T 98.0, BP 130/87, HR 92, R 22, 99%
on NRB weaned to room air over course of ED stay. He was noted
to be hyperkalemic to 8.1. There were no EKG changes. He was
treated with Ca, insulin/dextrose, and bicarb. He was given
kayexcelate but did not have a BM by time of arrival to the
floor. He was also found to have a RLL pneumonia and was
treated with azithromycin and ceftriaxone. A L femoral line was
placed for access. Renal team was consulted.
.
On the floor, the patient was feeling well. Had no complaints.
No dizziness, nausea, strange taste in mouth, abdominal pain.
No chest pain, palpitations. Shortness of breath had resolved.
He is confused and a poor historian.
Past Medical History:
- ESRD on HD (TThSa). AV fistula in the right arm with
complications of clot and thrombectomy last in [**2177**]. Now with HD
line in place. Undergoing transplant eval with Dr. [**Last Name (STitle) **], not
yet listed.
- HTN
- DM
- CAD s/p MI in [**2164**]
- A Fib/Flutter s/p ablation in [**2173**]
- Morbid obesity
- Sigmoid diverticulosis
- hx of entercoccus bacteremia associated with line infection
- personality disorder
Social History:
Pt lives at home with wife and 2 sons. [**Name (NI) 1403**] part time [**Street Address(1) 100812**] Bank. 50pack yr h/o tobacco use, quit in [**2160**]. Very
distant marijuana use, no other drugs, no etoh.
Family History:
noncontributory
Physical Exam:
Vitals: T afebrile, P 105, BP 167/86, R 20, 97% on RA
Gen: obese man, resting comfortably, NAD, A+Ox2 although
rambling and not making sense during prolonged interactions
HEENT - ATNC, PERRLA, EOMI, moist mucous membranes, JVD
difficult to assess secondary to size
CV - distant HS, RRR, no m,r,g
Lungs - decreased at bases, otherwise CTA, no crackles, wheezes
Abd - obese, soft, NT, ND, normoactive bowel sounds
Ext - 2+ pedal edema on R, 1+ on L; palp pulses, R foot bandaged
due to heel ulcer, neither leg tender to palpation
Neuro - CN intact, strength 5/5, + asterixis, not cooperating
fully with neuro exam
Pertinent Results:
[**2179-3-7**] 07:30PM GLUCOSE-112* UREA N-137* CREAT-24.1*#
SODIUM-139 POTASSIUM-8.1* CHLORIDE-99 TOTAL CO2-19* ANION
GAP-29*
[**2179-3-7**] 07:30PM estGFR-Using this
[**2179-3-7**] 07:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2179-3-7**] 07:30PM WBC-11.2*# RBC-3.73* HGB-10.7* HCT-32.8*
MCV-88 MCH-28.6 MCHC-32.5 RDW-15.7*
[**2179-3-7**] 07:30PM NEUTS-80.0* LYMPHS-10.0* MONOS-7.1 EOS-2.5
BASOS-0.4
[**2179-3-7**] 07:30PM PLT COUNT-251
[**2179-3-7**] 07:30PM PT-14.1* PTT-37.5* INR(PT)-1.2*
[**3-7**] CXR:
Infiltrate at the right lung base likely indicating infection.
Please ensure followup to clearance.
[**3-8**] R Heel Xray:
Two radiographs of the right heel demonstrate a displaced and
angulated
fracture involving the posterior calcaneal body and the
calcaneal apophysis.
The superior fracture fragment is displaced approximately 3 cm.
Mild to
moderate degenerative change about the osseous structures of the
mid foot is noted. No discrete soft tissue loss is appreciated.
No subcutaneous
emphysema is seen. There is a plantar calcaneal spur.
IMPRESSION:
Displaced calcaneal fracture.
[**3-10**]: ABIs
RIGHT LEG: There is triphasic flow pattern on the femoral,
popliteal and
posterior tibial arteries and monophasic flow pattern on the
dorsalis pedis
artery. The segmental limb pressures are mildly reduced on the
calf and over
DP. The ankle brachial index at rest 0.95.
LEFT LEG: There is triphasic flow pattern on the femoral,
popliteal,
posterior tibial and dorsalis pedis arteries. The segmental limb
pressures
are unremarkable at all levels. The ankle brachial index at rest
1.18.
The patient was not exercised.
IMPRESSION: Mild right tibial distal disease at rest and no
evidence of
peripheral vascular disease on the left leg.
[**3-10**]:
FINDINGS: The right common femoral, superficial femoral, and
popliteal veins show no evidence of deep vein thrombosis. The
patient declined examination of the left groin, so the left
common femoral vein was not assessed. However the left
superficial and popliteal veins appear entirely normal.
IMPRESSION: No evidence of deep vein thrombosis noting that the
patient
declined examination of the left groin by the radiologist.
Discharge Labs:
Brief Hospital Course:
57 y/o M with ESRD on HD presents after missing 9 days of
dialysis, incidentally found to have a right calcaneal beak
fracture.
1. ESRD: The patient was found to be severely hyperkalemic,
uremic and encephalopathic on admission to the ICU. Dialysis
was re-initiated during this admission and these conditions
normalized without permanent sequellae. The patient will return
to Monday/Wednesday/Friday schedule.
2. Right calcaneous fracture: The patient was noted to have R
lower extremity swelling with a superficial ulcer on exam. Heel
x-ray displayed a calcaneal fracture. LENIs negative. Podiatry,
orthopedics & vascular surgery evaluated the patient and
determined that [**Hospital1 **]-valve casting, wound care and non-operative
management was indicated. The patient will follow with Dr. [**First Name (STitle) 3209**]
of podiatry. He should continue prophylactic SC heparin
injections until fully ambulatory to prevent DVT.
3. Diabetes: Patient was initially hypoglycemic for unclear
reasons on initial presentation. During his hospital course,
however, his glucose was persistently elevated and his basal
70/30 insulin was titrated up. His blood sugars should be
monitored four times daily with sliding scale coverage of blood
sugars per the attached sliding scale.
4. Cough: The patient displayed some dyspnea and a cough.
Initial CXR indicated a possible pneumonia for which he was
started on Ceftriaxone and azithromycin. Upon reevaluation on
the medical floor the event was likely aspiration pneumonitis
due to clearing of x-ray and antibiotics were stopped. The
patient was continued on tessalon perles and guaifenisin as
needed.
5. Psych: Throughout the admission the patient intermittently
claimed passive suicidality without true ideation or intention.
His mood rapidly cycled first due to delerium and then due to
baseline pathology. The patient was very labile with frequent
outbursts and demands during his hospital stay. Psychiatry was
consulted and cleared him from 1:1 sitter on which he was
initially placed. He should contact the [**Name2 (NI) **] to set up follow up
with a counselor if he chooses.
6. HTN: The patient was conitnued on metoprolol & lisinopril.
He was normotensive to borderline hypotensive after dialysis.
7. CAD: The patient was continued on Aspirin & metoprolol.
7. Prophylaxis: Patient received heparin SQ during his admission
which should be continued as above.
Medications on Admission:
Humulin 70/30 45 u [**Hospital1 **]
Asa 325 mg daily
Lisinopril 5 mg daily
Hydroxyzine 50 mg tid PRN
Metoprolol SR 25 mg daily
VitB-C complex daily
PhosLo 667 caps, 3 caps tid
Folic Acid 1 mg daily
Discharge Medications:
1. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge
Sig: As directed Units Subcutaneous twice a day: Please take 54
U in the morning and 50 U in the evening.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Hydroxyzine HCl 25 mg Tablet Sig: Two (2) Tablet PO every
eight (8) hours as needed.
5. Metoprolol Tartrate 25 mg Tablet Sig: [**1-15**] Tablet PO BID (2
times a day).
6. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
7. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. INSULIN
Please continue your 70/30 insulin with 54 U in the morning and
50 U at night. This is an increase from your previous dose. You
need to check your blood sugars four times per day.
Please continue humalog sliding scale insulin while at rehab
with the attached sliding scale.
10. Heparin (Porcine) 5,000 unit/mL Syringe Sig: 5000 (5000) U
Injection three times a day: Until fully ambulatory.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Primary Diagnosis:
1. chronic kidney disease stage V, on HD
2. Suicidality, resolved
3. R calcaneal fracture
Secondary Diagnosis
1. Hypertension
2. Diabetes mellitus type II, uncontrolled with complications
3. Personality disorder not otherwise specified
Discharge Condition:
Afebrile, normotensive, comfortable on room air
Discharge Instructions:
1. You have been admitted to the hospital because of an extended
period without hemodialysis. While you were here we reinitated
you on hemodialysis and you will return to a Monday, Wednesday,
Friday Schedule.
2. Also while you were here it was noted that you have developed
a right heel fracture at some point likely within the last two
weeks. Our podiatrists & orthopedic surgeons were consulted and
recommended a cast with regular dressing changes for your ulcer.
No surgery is indicated at this time. You were also evaluated
by the phyical therapists, who recommended that you go to a
rehab facility.
3. Suicidality: You also expressed some suicidality during your
admission and were evaluated by psychiatry. If you develop
worsening feelings of hurting yourself or others, go to your
local Emergency Department or call 911 immediately.
4. Unless otherwise indicated, please resume all of your
medications as taken prior to admission. It is very important
that you take your medications as prescribed.
5. Please follow rehab's instructions regarding your Right foot,
to keep the weight off as directed.
6. Please call your doctor or 911 if you experience suicidal
thoughts, chest pain, shortness of breath or any other
concerning medical symptom.
Followup Instructions:
Hemodialysis as previously scheduled Monday, Wednesday, Friday
Please follow up with Dr. [**First Name (STitle) **] in the the Podiatry department
on [**2179-4-2**]. Provider: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM
Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2179-4-2**] 1:00
Please contact your provider at the VA in [**Location 1268**] if you
desire counseling in the future.
Please contact your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 48975**], for a follow up
appointment within the next two weeks at [**Telephone/Fax (1) 9075**].
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2179-3-18**]
|
[
"E888.9",
"585.6",
"285.21",
"301.9",
"348.39",
"278.01",
"507.0",
"300.9",
"250.62",
"250.42",
"250.82",
"276.52",
"403.10",
"276.7",
"825.0",
"707.22",
"707.07",
"041.19",
"V15.81",
"357.2",
"790.7",
"427.32",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
9141, 9196
|
5342, 7771
|
291, 362
|
9496, 9546
|
3058, 5301
|
10853, 11634
|
2393, 2411
|
8020, 9118
|
9217, 9217
|
7797, 7997
|
9570, 10830
|
5319, 5319
|
2426, 3039
|
230, 253
|
390, 1699
|
9236, 9475
|
1721, 2152
|
2168, 2377
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,181
| 119,509
|
22301
|
Discharge summary
|
report
|
Admission Date: [**2133-1-16**] Discharge Date: [**2133-1-29**]
Date of Birth: [**2050-10-31**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Called by ED to evaluate patient for head mass
Major Surgical or Invasive Procedure:
Cranitomy for removal of brain mass
History of Present Illness:
Pt is an 82 yo female w/ PMHx sig for DM, CAD s/p CABG '[**27**],
and HTN who presents to ER after outpatient MRI showed large
right temporal necrotic mass. The patient was involved in an
MVC
a week and a half ago. She was the driver and her car was
totaled. For reasons that are unclear, she was referred for an
outpatient MRI that showed the above finding.
Past Medical History:
DM, HTN, hypercholesterolemia, CAD s/p CABG
'[**27**], renal stones, hernia repair, varicose veins s/p surgery.
Social History:
Married previously, now lives with male
companion. 3 sons, 1 daughter. Retired in [**2084**] working at a
dry
cleaning business. No tobacco.
Family History:
non-contributory
Physical Exam:
Physical Exam Upon Admission:
Vitals: T 96.9; BP 155/99; P 79; RR 16; O2 sat 98% RA
General: lying in bed NAD
HEENT: NCAT, moist mucous membranes
Pulmonary: CTA b/l
Cardiac: regular rate and rhythm, with no m/r/g
Abdomen: soft, nontender, non distended, normal bowel sounds
Extremities: no c/c/e.
Neurological Exam:
Mental status: Awake, alert. Year - [**2032**], does not know
hospital. Fluent speech with no phonemic or semantic
paraphasias. Adequate comprehension. Repetition intact (no
ifs,
ands or buts). Able to name low and high frequency objects. No
left/right mismatch.
Cranial Nerves:
I: Not tested
II: PERRL, 4-->2mm with light. Left visual field cut.
III, IV, VI: EOMI.
V, VII: facial sensation intact, facial strength
VIII: hearing intact b/l to finger rubbing.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: SCM [**4-21**]
XII: Tongue midline without fasciculations.
Motor: Normal bulk. Normal tone. No pronator drift. Full
strength.
Sensation: intact to light touch.
Reflexes: 1+ symmetric.
Coordination: FNF intact.
Gait: narrow based w/ good arm swing. could walk toe-to-heel.
Upon Discharge:
She is oriented x 1. PERRL, EOMs intact. Face symmetric. Tongue
midline.
The patient is able to follow commands. She can move all
extremities to command and spontaneously. She is a little sleepy
but her blood sugar has been elevated today. Dophoff in place.
Incision clean, dry, intact.
Pertinent Results:
[**2133-1-16**] 05:41PM SODIUM-138
[**2133-1-16**] 05:41PM OSMOLAL-296
[**2133-1-16**] 11:15AM SODIUM-143
[**2133-1-16**] 11:15AM OSMOLAL-297
[**2133-1-16**] 02:27AM SODIUM-136
[**2133-1-16**] 02:27AM GLUCOSE-239* UREA N-13 CREAT-0.6 SODIUM-140
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-27 ANION GAP-13
[**2133-1-16**] 02:27AM ALBUMIN-4.2 CALCIUM-9.2 PHOSPHATE-2.8
MAGNESIUM-2.0
[**2133-1-16**] 02:27AM OSMOLAL-295
[**2133-1-16**] 02:27AM OSMOLAL-302
[**2133-1-16**] 02:27AM PHENYTOIN-11.9
[**2133-1-16**] 02:27AM WBC-9.0 RBC-4.70 HGB-13.8 HCT-39.7 MCV-85
MCH-29.3 MCHC-34.7 RDW-14.7
[**2133-1-16**] 02:27AM PLT COUNT-215
[**2133-1-16**] 02:27AM PT-14.7* PTT-29.1 INR(PT)-1.3*
CT Head:
FINDINGS: Overall, evaluation is limited by motion artifact. The
patient is status post right frontotemporal craniotomy with
persistent postsurgical changes noted in the right temporal
resection bed. A small amount of extra-axial fluid, some of
which appears to represent hyperdense hemorrhage, is unchanged.
Widespread hypodensity in the right MCA territory is unchanged.
Mass effect persists with approximately 7 mm leftward shift of
normally
midline structures, unchanged. No new intracranial hemorrhage is
identified. The size of the ventricles is unchanged. Left
mastoid air cells and paranasal sinuses appear well aerated.
Opacification of multiple right mastoid air cells is again
observed.
IMPRESSION: Unchanged appearance status post right
frontotemporal craniotomy right temporal mass resection.
Extensive hypodensity in the right MCA territory is unchanged
and likely represents evolving infarct.
Video Swallow [**1-27**]:
FINDINGS: Note is made that the patient's level of alertness was
limited,
requiring repeated verbal stimulation to remain participatory.
As such,
textures require mastication were not administered. During the
oral phase,
bolus control was significantly impaired by premature spillover
of thin
liquids into the piriform sinuses. There was also anterior spill
of liquids administered by teaspoon. Anterior to posterior bolus
propulsion and oral transit time were within functional limits
for pureed and thin liquids. During the pharyngeal phase,
swallow initiation was mildly delayed. Laryngeal elevation
appears mildly reduced, and laryngeal valve closure and
epiglottic deflection appeared incomplete. Pharyngeal transit
was timely. Mild residue remained in the valleculae. Aspiration
and penetration were seen with thin liquids due to premature
spillover. Cough which was partially cued did not clear aspirate
material.
IMPRESSION: Moderately severe oral and pharyngeal dysphagia
characterized by premature spillover and incomplete laryngeal
valve closure resulting in
penetration and aspiration of thin liquids. Part of the exam
results may be due to the patient's lethargic status.
Brief Hospital Course:
The patient was taken to the OR for resection of a brain mass
and the she was taken to the ICU post-operatively. She developed
a new facial droop and was less responsive post-operatively. She
was found to have developed an infarct in the area of resection.
The patient improved and was able to be transferred to the step
down unit on [**2133-1-22**]. She was feed via dophoff and speech and
swallow worked with her. On [**2133-1-25**] she was transferred to the
regular floor. She was able to take some pureed food and nectar
thickened liquids prior to discharge.
The patient had blood cultures that grew gram + cocci in
pairs/clusters. She was started on cipro for a UTI.
The patient's steroids are being tapered at this time. She has
has elevated blood sugars and her sliding scale was adjusted.
This should improve as her steroids are decreased as well. On
[**2133-1-28**] the sutures were removed and her incision was clean,
dry, and intact.
The patient was evaluated by PT and OT who agreed with rehab
placement. She was discharged on [**2133-1-29**].
Medications on Admission:
Metformin, Lisinopril, HCTZ, Atorvastatin 40 mg q
day, Glipizide 5 mg [**Hospital1 **], ASA 325 mg q day
Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Phenytoin 125 mg/5 mL Suspension Sig: One (1) PO TID (3
times a day).
13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
14. Sodium Chloride 1 gram Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours).
16. Furosemide 10 mg/mL Solution Sig: One (1) Injection [**Hospital1 **] (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
Brain Mass
Discharge Condition:
Neurologically stable
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
???????????? You may shower before this time using a shower cap to cover
your head while your staples in place
?????? 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 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.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow up at the BTC Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD
Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2133-2-9**] 4:00
Have your staples removed at rehab on [**2133-1-30**]
Completed by:[**2133-1-29**]
|
[
"434.91",
"272.0",
"414.00",
"790.7",
"191.2",
"041.3",
"V45.81",
"401.9",
"599.0",
"997.02",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
7958, 8040
|
5453, 6516
|
367, 405
|
8095, 8119
|
2598, 3297
|
9814, 10075
|
1111, 1129
|
6672, 7935
|
8061, 8074
|
6542, 6649
|
8143, 9791
|
1144, 1160
|
1463, 1463
|
281, 329
|
2290, 2579
|
433, 797
|
1749, 2274
|
3306, 5430
|
1175, 1444
|
1478, 1733
|
819, 933
|
949, 1095
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,492
| 195,784
|
26465
|
Discharge summary
|
report
|
Admission Date: [**2175-7-11**] Discharge Date: [**2175-7-19**]
Date of Birth: [**2109-7-12**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
HCC/HCV
Major Surgical or Invasive Procedure:
liver transplant
History of Present Illness:
The patient is a 65-year-
old male, with a history of hepatitis C-related cirrhosis,
who subsequently developed hepatocellular carcinoma that has
undergone radiofrequency ablation. The patient was evaluated
for liver transplantation and was found to be a suitable
candidate. He was placed on the waiting list. A suitable
donor has become available, and the patient is now brought to
the operating room after informed consent was obtained for
orthotopic deceased donor liver transplant.
Past Medical History:
blindness [**3-2**] retinitis pigmentosa, deafness, HCV/HCC w/ cirr,
arthritis, h/o testicular CA
Social History:
married with 2 children and 2
grandchildren. \
no alcohol no tobacco
Physical Exam:
NAD AOx3
CTA b/l
RRR
soft, NTND
no c/c/e
Pertinent Results:
[**2175-7-11**] 10:45AM BLOOD WBC-5.1 RBC-4.90 Hgb-15.3 Hct-45.8 MCV-94
MCH-31.2 MCHC-33.4 RDW-13.7 Plt Ct-96*
[**2175-7-12**] 02:00AM BLOOD WBC-11.7* RBC-3.67* Hgb-11.5* Hct-33.9*
MCV-92 MCH-31.2 MCHC-33.8 RDW-14.7 Plt Ct-201
[**2175-7-13**] 03:17AM BLOOD WBC-16.9* RBC-3.03* Hgb-9.7* Hct-27.1*
MCV-89 MCH-31.8 MCHC-35.6* RDW-15.4 Plt Ct-117*
[**2175-7-16**] 06:35AM BLOOD WBC-7.2 RBC-3.13* Hgb-9.7* Hct-28.5*
MCV-91 MCH-30.9 MCHC-33.9 RDW-14.6 Plt Ct-110*
[**2175-7-11**] 10:45AM BLOOD PT-12.9 PTT-31.3 INR(PT)-1.1
[**2175-7-12**] 03:20AM BLOOD PT-19.5* PTT-90.0* INR(PT)-1.9*
[**2175-7-18**] 04:35AM BLOOD PT-12.3 PTT-21.1* INR(PT)-1.1
[**2175-7-11**] 10:45AM BLOOD Fibrino-105*
[**2175-7-12**] 05:20AM BLOOD Fibrino-159
[**2175-7-15**] 07:00AM BLOOD Fibrino-302
[**2175-7-13**] 01:00PM BLOOD Glucose-186* UreaN-20 Creat-0.7 Na-140
K-4.4 Cl-106 HCO3-26 AnGap-12
[**2175-7-18**] 04:35AM BLOOD Glucose-147* UreaN-26* Creat-0.8 Na-141
K-4.2 Cl-110* HCO3-23 AnGap-12
[**2175-7-11**] 10:45AM BLOOD ALT-43* AST-86* AlkPhos-308* TotBili-1.0
[**2175-7-12**] 11:55AM BLOOD ALT-511* AST-642* AlkPhos-107 TotBili-0.8
DirBili-0.4* IndBili-0.4
[**2175-7-14**] 04:47AM BLOOD ALT-261* AST-132* AlkPhos-113 TotBili-0.5
[**2175-7-18**] 04:35AM BLOOD ALT-203* AST-51* AlkPhos-187* TotBili-0.4
[**2175-7-12**] 05:20AM BLOOD Albumin-2.6* Calcium-9.3 Phos-1.6* Mg-1.8
[**2175-7-18**] 04:35AM BLOOD Albumin-3.1* Calcium-8.4 Phos-3.5 Mg-1.7
[**2175-7-18**] 04:35AM BLOOD AFP-13.7*
[**2175-7-13**] 07:25AM BLOOD FK506-3.8*
[**2175-7-18**] 04:35AM BLOOD FK506-11.2
[**2175-7-11**] 10:53AM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2175-7-11**] 10:53AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2175-7-11**] 02:04PM URINE RBC-[**4-2**]* WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0
[**2175-7-16**] 10:45 am Immunology (CMV)
**FINAL REPORT [**2175-7-18**]**
CMV Viral Load (Final [**2175-7-18**]):
CMV DNA not detected.
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 65394**],[**Known firstname **] [**2109-7-12**] 65 Male [**-6/2320**] [**Numeric Identifier 65395**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/dif
SPECIMEN SUBMITTED: RECIPIENT LIVER & DONOR LIVER BX.
Procedure date Tissue received Report Date Diagnosed
by
[**2175-7-11**] [**2175-7-12**] [**2175-7-18**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/cma??????
Previous biopsies: [**Numeric Identifier 65396**] Consult slides referred to Dr.
[**Last Name (STitle) **]. [**Doctor Last Name **].
DIAGNOSIS
1. Liver, native hepatectomy (A-J):
a. One nodule (3.0 cm) of moderately differentiated
hepatocellular carcinoma with features consistent with
radiofrequency ablation effect. The tumor is predominantly
(>95%) necrotic with rare microscopic foci of viable component.
b. One focus of venous invasion seen is a portal vein away from
the tumor.
c. Established cirrhosis with grade [**1-30**] inflammation. Trichrome
stain evaluated.
d. Iron stain shows minimal iron deposition in Kupffer cells.
e. Gallbladder with mild chronic cholecystitis.
2. Donor liver, needle biopsy (K):
a. Liver parenchyma with no significant inflammation or fatty
changes seen.
b. Trichrome stain shows no significant fibrosis.
DUPLEX DOPP ABD/PEL [**2175-7-12**] 10:27 AM
LIVER OR GALLBLADDER US (SINGL; -59 DISTINCT PROCEDURAL SERVIC
Reason: S/P LIVER TRANSPLANT ,EVAL FOR VASCULATURE FLOW AND
PATENCY
[**Hospital 93**] MEDICAL CONDITION:
66 year old man s/p liver transplant day 0
REASON FOR THIS EXAMINATION:
DUPLEX - please evaluate vasculature flow and patency
INDICATION: 66-year-old male status post liver transplant.
TECHNIQUE: The liver transplant was performed.
LIVER TRANSPLANT ULTRASOUND:
FINDINGS: The portal vein is patent and has normal direction of
flow. The hepatic artery and its branches are patent. The
hepatic veins are patent. No obvious fluid collections or free
fluid is seen.
IMPRESSION: Normal liver transplant ultrasound.
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2175-7-16**] 2:52 PM
LIVER OR GALLBLADDER US (SINGL; DUPLEX DOPP ABD/PEL
Reason: please do duplex? rejection ?thrombus/clot
[**Hospital 93**] MEDICAL CONDITION:
66 year old man s/p liver transplant with increasing lfts
REASON FOR THIS EXAMINATION:
please do duplex? rejection ?thrombus/clot
INDICATION: 66-year-old man status post liver transplant with
increasing liver function tests. Evaluate.
COMPARISON: [**2174-7-12**].
LIVER ULTRASOUND WITH DOPPLER EXAMINATION: The liver parenchyma
is normal in echogenicity, without focal nodules or masses. A
new 2.9 x 1.1 x 1.4 cm echogenic nodule is seen within the
region of the excluded donor IVC most consistent with thrombus.
Superior extension to the recipient IVC anastomosis is not
clearly identified, and follow-up imaging is recommended. The
adjacent recipient IVC is patent. The right, middle, and left
hepatic veins demonstrate normal direction of flow and
respiratory variation. The main, posterior right, anterior
right, and left portal veins are patent, with appropriate
direction of flow. The main, right, and left hepatic arteries
demonstrate normal systolic upstroke with resistive indices
measuring 0.83, 0.72, and 0.83, respectively.
IMPRESSION:
1. Normal liver Doppler study.
2. New thrombus within excluded donor IVC. Proximal extension
into the recipient IVC is not clearly defined, and follow-up
imaging is recommended for further evaluation.
SPECIMEN SUBMITTED: LIVER BIOPSY (SAME DAY RUSH)
Procedure date Tissue received Report Date Diagnosed
by
[**2175-7-17**] [**2175-7-17**] [**2175-7-17**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/cla
Previous biopsies: [**-6/2320**] RECIPIENT LIVER & DONOR LIVER
BX.
[**Numeric Identifier 65396**] Consult slides referred to Dr. [**Last Name (STitle) **]. [**Doctor Last Name **].
DIAGNOSIS:
Liver, allograft, needle core biopsy:
Liver parenchyma with no significant portal or lobular
inflammation.
No fatty change or features of preservation/ischemic injury are
seen.
No features of acute cellular rejection are seen.
Brief Hospital Course:
Patient was taken to the operating room and underwent an
orthotopic liver transplant; the patient only required 1 unit of
packed cells, 2 units of
platelets, 500-cc of albumin, and 1 unit of cryo intraop. He was
taken to the APCU intubated and in stable condition. Patient did
extremely well and was therefore extubated later that day (ahead
of the pathway). He stayed in the ICU for monitoring for another
24hours, and was then transferred to the floor late on POD1.
From here he made a remarkabel recovery. He continued to make
good urine and LFTs went downward for the first few days. He
ambulated with assitance and tolerated good po pretty early.
Some hampering to his recovery was the fact that he is blind and
somewhat deaf - he was continually claiming to be depressed
because of boredom and lonliness. Duplex on POD1 was normal, and
CXRs continued to be normal. His CVL was removed before he left
the ICU. On POD5 his LFTs bumped up slightly, so he recieved 2
boluses of steroids as a precautionary measure and a repeat US
was performed which showed a mural thrombus in the donor IVC.
Biopsy was done which was normal and without signs of rejection.
After that, LFTs started to decline again and patient continued
to do extremely well.
Medications on Admission:
citracal 600'', mycelox 5x/d, cod liver oil
Discharge Disposition:
Home With Service
Facility:
southern [**Hospital 1727**] medical VNA
Discharge Diagnosis:
HCV/HCC
deaf
blind
Discharge Condition:
stable
Discharge Instructions:
Call Transplant office [**Telephone/Fax (1) 673**] if fevers, chills, nausea,
vomiting, redness/bleeding/drainage from incision or old drain
sites, jaundice, increased abdominal pain or any questions.
Labs every Monday & Thursday for cbc, chem 10, ast, alt, alk
phos, t.bili,albumin and trough prograf level. Fax results to
[**Hospital1 18**] Transplant office attn: [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **] RN [**Telephone/Fax (1) 697**]
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2175-7-26**] 2:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2175-8-2**] 2:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2175-8-9**] 2:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2175-7-26**]
|
[
"112.0",
"715.90",
"575.11",
"155.0",
"V10.47",
"571.5",
"070.54",
"251.8",
"369.00",
"V58.65",
"362.74",
"389.12",
"572.3",
"E932.0",
"V13.01",
"570"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"50.11",
"99.04",
"99.06",
"99.05",
"00.93",
"99.07",
"51.22",
"50.59"
] |
icd9pcs
|
[
[
[]
]
] |
8861, 8932
|
7521, 8767
|
321, 339
|
8995, 9004
|
1138, 4817
|
9521, 10190
|
5574, 5632
|
8953, 8974
|
8793, 8838
|
9028, 9498
|
1077, 1119
|
274, 283
|
5661, 7498
|
367, 855
|
877, 976
|
992, 1062
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
823
| 158,797
|
18307
|
Discharge summary
|
report
|
Admission Date: [**2134-8-29**] Discharge Date: [**2134-8-31**]
Date of Birth: [**2097-1-10**] Sex: F
Service: Trauma Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 37-year-old
female involved a motor vehicle collision against a tree.
She had positive loss of consciousness. It was unknown
whether she was restrained, and she was ethanol intoxicated
at the time. There was airbag deployment. The patient was
combative at the scene with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] Coma Scale of 14.
The patient continued to be combative in the Emergency Room
and was intubated for airway protection.
PAST MEDICAL HISTORY: Bipolar disorder.
MEDICATIONS ON ADMISSION: Lithium and Seroquel.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Positive ethanol use. Positive tobacco use
of one pack per day. No drug use.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed her temperature was 36.3 degrees Celsius, her heart
rate was 77, her blood pressure was 136/80, her respiratory
rate revealed intubated, and her pulse oximetry was 100%. In
general, the patient was combative and confused. [**Location (un) 2611**]
Coma Scale was 14. Head, eyes, ears, nose, and throat
examination revealed pupils were equal, round, and reactive
to light. A scalp laceration measuring approximately 10 cm.
A lower lip laceration. The lungs were clear to auscultation
bilaterally and equal. Cardiovascular examination revealed a
regular rate and rhythm. No murmurs. The abdomen was soft,
nontender, and nondistended. No ecchymosis. Extremity
examination revealed no deformity. No tenderness. Pulses
were 2+ times four. Back examination revealed no stepoff.
No bruising or tenderness. Rectal examination revealed
normal tone. Guaiac-negative. Neurologic examination
revealed the patient was combative. She moved all
extremities. [**Location (un) 2611**] Coma Scale was 14.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
revealed a complete blood count with a white blood cell count
of 12.6, her hematocrit was 42.5, and her platelets were 293.
Chemistry-7 revealed her sodium was 141, potassium was 3.1,
chloride was 11o, bicarbonate was 21, blood urea nitrogen was
8, creatinine was 0.7, and her blood glucose was 124.
Coagulations were within normal limits. Serum toxicology
screen revealed an ethanol level of 286; otherwise negative.
Fibrinogen was 240. Lactate was 3. Amylase was 149.
Urinalysis was negative. FAST examination was negative.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray revealed no
pneumothorax. No effusions.
Pelvic x-ray was negative.
A head computed tomography was negative.
A computed tomography of the cervical spine was negative.
A computed tomography of the abdomen and pelvis was negative.
CONCISE SUMMARY OF HOSPITAL COURSE: An Oral and
Maxillofacial Surgery consultation was obtained, and the
patient's forehead and lip lacerations were sutured in the
Emergency Department.
The patient was transferred to the Surgical Intensive Care
Unit for further management, intubated and on the ventilator
overnight.
The patient was stable on hospital day two and was extubated
without difficulties. The patient's cervical spine was
cleared, and she was placed on a CIWA scale to monitor for
withdrawal. The patient did not require any Ativan as she
exhibited no signs or symptoms of withdrawal.
The patient was transferred to the floor on hospital day two
and was stable overnight. On hospital day three, the patient
was tolerating a regular diet and ambulating well without
difficulty. The patient was passing flatus. The patient's
pain was controlled on by mouth medications.
A Psychiatry consultation was obtained to evaluate the
patient for her bipolar disorder and ethanol dependency who
recommended that we restart her on her previous psychiatric
medications. As there was no evidence of alcohol withdrawal,
depression, suicidal ideation, or suicidal intent with the
motor vehicle accident she was cleared for discharge from a
psychiatric point of view.
DISCHARGE DISPOSITION: The patient was deemed medically
stable and was discharged on [**2134-8-31**].
DISCHARGE DIAGNOSES:
1. Forehead laceration.
2. Lip laceration.
3. Alcohol use.
4. Closed head injury.
5. Status post motor vehicle collision.
6. Bipolar disorder.
MEDICATIONS ON DISCHARGE:
1. Cephalexin 500 mg by mouth q.6h. (times three days).
2. Percocet one to two tablets by mouth q.4-6h. as needed.
3. Tylenol 650 mg by mouth q.4-6h. as needed.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow
up with Oral and Maxillofacial Surgery at [**University/College **] Dental
School on [**Last Name (LF) 2974**], [**2134-9-2**] for suture removal and
evaluation. The patient was to call telephone number
[**Telephone/Fax (1) 27823**] to arrange this appointment.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. 2923
Dictated By:[**Dictator Info 50467**]
MEDQUIST36
D: [**2134-8-31**] 15:14
T: [**2134-8-31**] 16:14
JOB#: [**Job Number 50468**]
|
[
"296.7",
"780.09",
"305.00",
"E815.0",
"873.0",
"873.43"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.59",
"27.51"
] |
icd9pcs
|
[
[
[]
]
] |
4117, 4197
|
4218, 4368
|
4394, 4559
|
720, 781
|
4593, 5127
|
2857, 4093
|
172, 651
|
674, 693
|
798, 2828
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,739
| 174,678
|
9936
|
Discharge summary
|
report
|
Admission Date: [**2120-4-25**] Discharge Date: [**2120-4-26**]
Date of Birth: [**2049-6-24**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor Last Name 4212**]
Chief Complaint:
hyperglycemia
Major Surgical or Invasive Procedure:
Left 5th digit amputation
Left 3rd digit debridement
History of Present Illness:
70M with DM, ESRD on HD, AFib s/p ampuation L 5th digital
amputation and dorsal 3rd digit debridement on [**2120-4-25**] with
hyperglycemia, transferred to [**Hospital Unit Name 153**] for insulin gtt.
Night prior to arrival patient took his usu 18 units of lantus.
AM of surgery FSG was 66 at home so he took no Humalog (usu on
sliding scale). In OR pt received 750cc D5NS. Post-op FSG was
500, persisted to undetectable level despite 12 units regular
insulin given at 15:00, 16:00, and 18:00 (for a total of 36
units regular insulin). On arrival to [**Hospital Unit Name 153**] at 19:30 pt's FSG
still undetectable. He received half a liter of 1/2NS.
Pt states he feels well and has no complaints. Denies f/c, LH,
HA, blurry vision. He states he has had a dry cough. He denies
abd pain, d/c, n/v. He denies rash or tender cellulitis
Past Medical History:
1. Atrial fibrillation, anticoagulation with Coumadin
2. Diabetes since age 40 with neuropathy, nephropathy,
gastoparesis last HgbA1C was 10.7 [**10-25**]
3. End stage renal disease on HD M,W,F since [**10-22**]
4. Peripheral vascular disease
5. Hypertension
6. Hyperlipidemia
PSH:
1. Left AV fistula [**2115**]
2. Left popliteal to dorsalis pedis saphenous vein graft in
[**2116-11-21**] by Dr. [**Last Name (STitle) **]
3. Right popliteal to dorsalis pedis saphenous vein graft
[**2116-12-22**] by Dr. [**Last Name (STitle) **]
4. Right sesamoidectomy and right first MPJ resection in
[**2116-12-22**] following bypass graft by podiatry service
5. Right transmetatarsal amputation on [**2117-6-7**] by Dr.
[**Last Name (STitle) **]
Social History:
The patient quit smoking cigarettes 35 years ago. He does not
drink alcohol. He has a prosthetic limb for his right leg.
He recieves dialysis in [**Hospital1 392**]
Family History:
non-contributory
Physical Exam:
Vitals: 98.4 86 130/92 93%RA
gen- Well appearing NAD
heent- oropharynx clear, mmm, neck supple
pulm- faint R basilar crackles
cv- irreg irreg II/VI syst murmur
abd- s, nt, nd, +bs
ext- R BKA, L no edema, R upper arm fistula with bruit, no
induration or erythema, L hand 5th digit distal amputation, 3rd
digit covered in gauze
neuro- A&O x3 moves all 4, no gross deficits
Pertinent Results:
Admission Labs:
*
CHEM: GLUCOSE-539* UREA N-47* CREAT-5.8* SODIUM-135
POTASSIUM-5.2* CHLORIDE-92* TOTAL CO2-27 ANION GAP-21 Calcium
8.8, Mag 2.0, Phos 5.2
*
CBC: WBC-4.3 RBC-4.17* HGB-13.1* HCT-39.9* MCV-96 PLT 101
DIFF: NEUTS-79.0* LYMPHS-15.8* MONOS-2.4 EOS-2.4 BASOS-0.3
*
COAGS: PT-13.8* PTT-25.7 INR(PT)-1.3
*
Serum Osm: 315, Serum Ketones (acetone): Negative
*
TISSUE Left 5th finger-
*
GRAM STAIN (Final [**2120-4-25**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
CULTURE: Pending at time of discharge
*
5/5 Blood Cx: No growth to date
*
CXR [**4-25**]: Negative for infiltrate or edema. Stable cardiomegaly.
Brief Hospital Course:
This is a 70 y/o Male with h/o DMI, HTN, PVD, who presented for
hyperglycemia s/p amputation of left 5th digit and debridement
of left 3rd digit. On admission to the ICU, his serum blood
glucose was 539 and his anion gap was 16 (with a serum bicarb of
33). His serum ketones were negative and his serum Osm was 315.
Urinalysis was not able to be performed due to the patients ESRD
w/ anuric state. He was asymptomatic at the time of presentation
and his hyperglycemia was felt to be secondary to recieving D5
during his surgical procedure. Stress from the procedure,
although a minor procedure, also may have contributed. Of note
CXR was negative for infiltrate and blood culture was
preliminary negative. EKG was negative for ischemic changes. He
was started on an insulin drip at 5 units per hour for glycemic
control and he was quickly weaned off after 4 hours. Blood
sugars were subsequently well-controlled at <110. He had one
episode of low blood sugar to 38, but he was asymptomatic at the
time and responded to PO sugar intake. His anion gap was reduced
to 12 and his serum Osm decreased to 306. He was re-started on
his outpatient regimen of glarine 17 units qhs with good
glycemic control. After overnight monitoring he was discharged
to home on [**4-26**]. He will resume dialysis on [**4-27**] as discussed with
the renal service.
In regards to his left finger amputation, his wound was dressed
per plastic surgery recommendations. He was started empirically
on Vancomycin given his history of MRSA to complete a 2 week
course (given at hemodialysis). Further antibiotics were held
until final wound culture results returned. These were pending
at the time of discharge. He will follow-up with his PCP for
review of this data.
Medications on Admission:
atenolol 50 mg po daily
coumadin 6 mg daily (last dose 4/4)
lipitor 40 mg daily
nephrocaps two with each meal
renagel two with each meal
phoslo two with each meal
lantus 18 units daily
humalog sliding scale
Discharge Medications:
1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
4. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: Two (2) Cap
PO DAILY (Daily).
6. Vancomycin HCl 10 g Recon Soln Sig: One (1) gram Intravenous
DOSE W/HEMODIALYSIS () for 2 weeks.
7. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18)
units Subcutaneous at bedtime.
8. Warfarin Sodium 6 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Humalog 100 unit/mL Solution Sig: see sliding scale.
Subcutaneous 4 x each day: follow sliding scale as attached .
Discharge Disposition:
Home
Discharge Diagnosis:
1. Left 5th Digit Necrosis
2. Diabetes I
3. Anion Gap Metabolic Acidosis
4. End Stage Renal Disease
5. Hypertension
Discharge Condition:
Good. Afebrile. Hemodynamically stable. Blood sugars well
controlled.
Discharge Instructions:
Please report fever, chills, abdominal pain or blood sugars not
controlled by your current medical regimen to your primary
physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 9006**]. Follow-up with [**Last Name (un) **] as scheduled below.
Please take all prescribed medication. PLease follow your
fingersticks carefully.
Followup Instructions:
1. Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2120-5-2**] 12:10
2. Follow-up at [**Last Name (un) **] with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2489**] NP[**5-9**] at
9:30 am. You will aslo see Dr. [**First Name (STitle) **] in Eye Clinic that same
day.
3. Follow-up with Dr. [**Last Name (STitle) **] on [**2120-7-25**] at 10:30 am.
|
[
"272.4",
"443.9",
"730.04",
"357.2",
"403.91",
"276.2",
"427.31",
"785.4",
"V58.61",
"250.80",
"250.70",
"250.60",
"250.40",
"536.3",
"731.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.22",
"84.3"
] |
icd9pcs
|
[
[
[]
]
] |
6161, 6167
|
3366, 5107
|
333, 388
|
6327, 6398
|
2654, 2654
|
6783, 7293
|
2226, 2244
|
5365, 6138
|
6188, 6306
|
5133, 5342
|
6422, 6760
|
2259, 2635
|
280, 295
|
416, 1254
|
2670, 3343
|
1276, 2024
|
2040, 2210
|
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